On September 27th, the state reported to the PHS that "two suspicious cases were reported at Memphis." By October 1st, there were 95 cases in Memphis, and ten days later it was reported to PHS that there had been at least seventy-six deaths in Nashville. Between October 4th and October 10th, there were at least 27 deaths in Chattanooga. On October 15th, there were 27 deaths in Knoxville. By the 25th, the state was reporting that "conditions are greatly improved in nearly all cities and towns, but the disease is slowly spreading in rural districts and mining regions." On October 27th, "conditions were better in mining camps generally and...reports from rural communities in a few counties indicated that the disease is not yet prevalent at these points."

Noon hour Knoxville Cotton Mill. c. 1910 [Credit: The Library of Congress]

While numbers are difficult to predict, one historian has put Nashville's cases at approximately 40,000 cases and 468 deaths. Although the state did not report to the PHS until late September, it appears that the disease appeared in Nashville in early September, becoming noticeable on September 16th. By the 26th, the disease had reached epidemic proportions. The epidemic began in South Nashville, a densely populated part of the city which had many industrial workers. From there it spread into East Nashville and the center of the city. Eventually, the disease hit the less densely populated areas of North and West Nashville. Ultimately, North and West Nashville became the centers of highest incidence.

The city was ill-prepared to deal with the pandemic. There were only about 250 doctors present in the city at the time as many were fulfilling an active-duty role with the military. Compounding the problem, many of the physicians in the city contracted influenza and were unable to work. Nashville recognized early on that relief measures had to be implemented, landing the responsibility on the city's public health nurses, who were given the task of classifying and treating cases by severity.

Establishment of emergency hospitals was ruled out as there were too few physicians and nurses to staff them. Patients were isolated in their homes, forcing medical practitioners to travel to patients' homes in order to administer care. Admission to a hospital required certification by a physician.

The bear pit. Memphis Tennessee. c. between 1900-1920. [Credit: The Library of Congress]

PHS sent two additional physicians and several nurses to Nashville. The Red Cross, the Nashville Golf and Country Club, and the Centennial Club, provided aid in the form of transportation and supplies.

On October 7th, proprietors of nonessential businesses were told to close. County schools were closed on the 8th. The city schools remained open because public health officials were under the false impression that the epidemic had crested. Students were, however, each given an individual drinking cup to prevent spreading the disease and teachers were instructed to send suspicious cases home. During the afternoon of the 8th, school officials decided that the situation was dire enough to warrant closing the schools despite the recommendations of public health officials to keep them open. That same day, ministers were told to close their churches, and the Nashville Street Railway and Light Company was instructed to run their cars with the windows open to allow the cars to air out. Sewage accumulated in the streets raising concerns about other types of disease.

Writing in a medical journal, one Tennessee physician summed up the situation in saying "The man who dug his neighbor's grave today might head the funeral procession next week. No telling who would be next." In one instance, a physician informed his patient, a father with a family of eleven, that the father had contracted influenza. When asked who would take responsibility of the family upon his death, the father did not know. Although no official quarantine was imposed, families such as these were isolated by their neighbors, who refused to come to their assistance even when no one was able to care for family members.

By November 1st, the situation had abated to some extent and schools and places of amusement were reopened in Nashville.