As a terrifyingly lethal influenza virus swept across the globe between 1918 and 1920, history’s deadliest pandemic claimed the lives of approximately 50 million people worldwide and 675,000 in the United States. Nearly 200,000 Americans died from the “Spanish Flu” in October 1918 alone, making it the deadliest month in the country’s history.

With cremation an uncommon practice at the time, the sheer number of bodies overwhelmed the capacity of undertakers, gravediggers and casket makers to keep pace with the arduous task of burying the dead. At the same time, a prohibition on public gatherings that included funerals and wakes compounded the pain of many grief-stricken families who could not properly mourn the loss of their loved ones.

Nancy K. Bristow, a University of Puget Sound history professor and author of American Pandemic: The Lost Worlds of the 1918 Influenza Epidemic, says the United States had been caught unprepared for the outbreak partly because advances in bacteriology made many Americans believe they could control infectious diseases.

“This is not what Americans in 1918 expected to occur,” she says. “An enormous number of people died very quickly, particularly on the Eastern Seaboard where the flu struck first, and they didn’t have an opportunity to prepare in any way.”

The mass mortality led to macabre scenes. Red Cross nurses in Baltimore reported instances of visiting flu-ravaged homes to discover sick patients in bed beside dead bodies. In other cases, corpses were covered in ice and shoved into bedroom corners where they festered for days.

Inundated undertakers stacked caskets in funeral home hallways and even in their living quarters. In New Haven, Connecticut, six-year-old John Delano and his friends played outside of a mortuary, scaling a mountain of caskets piled on a sidewalk, unaware of the contents inside. “We thought—boy, this is great. It’s like climbing the pyramids,” he recalled.

Photos: Innovative Ways People Tried to Protect Themselves From the Flu

Cemeteries struggled to handle the soaring death toll. With gravediggers absent from work—either because they had contracted the flu or were afraid that they would—grieving families were sometimes forced to excavate tombs for their loved ones. In New Brunswick, New Jersey, 15 workhouse inmates were handed spades and picks to dig graves under the watchful eyes of guards. In Baltimore, city employees were called into emergency duty as gravediggers while soldiers from Fort Meade were pressed into service to bury a three-week backlog of 175 bodies at Mount Auburn Cemetery.

Casket companies, already busy supplying coffins for the thousands of doughboys killed in World War I, could not keep up with the demand. Facing a desperate shortage in the nation’s capital, District of Columbia Commissioner Louis Brownlow hijacked two train cars filled with 270 coffins bound for Pittsburgh and rerouted them to the city hospital under armed guard. Gravediggers at Boston’s New Calvary Cemetery were spotted dumping corpses out of caskets into graves so that the coffins could be used again. The War Industries Board ordered casket makers to manufacture only plain caskets and immediately cease production of “all fancy trimmed and couch and split panel varieties.” It limited casket sizes for adults to 5 feet, 9 inches and 6 feet, 3 inches.

The worst horrors were seen in Philadelphia, where the number of deaths approached 1,000 a day at the pandemic’s peak. Entire neighborhoods were draped in crepe that was mounted on front doors to mark deaths inside. Civic leaders recruited the J.G. Brill Company, a streetcar manufacturer, to construct thousands of rudimentary boxes in which to bury the dead, while desperately needed coffins arrived in the city under armed guard.

Five hundred bodies crowded the city morgue, which had a capacity for only 36 corpses. The city scrambled to open six supplementary morgues and placed bodies in cold storage plants. Some Philadelphia residents were unceremoniously tossed into mass graves that had been hollowed out by steam shovels.

“They were primarily poorer and immigrant residents, so there’s a class aspect as the well-to-do were more likely to secure the rites of passage into death in a way that poorer and more recent arrivals were less able to,” Bristow says.

The scenes in Philadelphia appeared to be straight out of the plague-infested Middle Ages. Throughout the day and night, horse-drawn wagons kept a constant parade through the streets of Philadelphia as priests joined the police in collecting corpses draped in sackcloths and blood-stained sheets that were left on porches and sidewalks. The bodies were piled on top of each other in the wagons with limbs protruding from underneath the sheets. The parents of one small boy who succumbed to the flu begged the authorities to allow him the dignity of being buried in a wooden box that had been used to ship macaroni instead of wrapping him a sheet and having him taken away in a patrol wagon.

Public funerals and wakes were banned in cities including Philadelphia and Chicago. Iowa prohibited public funerals and even the opening of caskets. Exceptions were made only for parents or wives identifying soldiers before burial—and even then, they could only open the caskets if family members covered their mouths and noses with masks and refrained from touching the body.

“In many communities, processing the loss of loved ones entails a series of rituals and rites and laying a person to rest in a respectful way,” Bristow says. “In many cities, the restrictions on public events meant that families and communities had those rites interrupted, so grieving didn’t take place in public but became an individual process, which had long-term consequences. Without an opportunity to share it with those around them, that grief was carried around for decades.”

Read more:

Why the Second Wave of the 1918 Spanish Flu Was So Deadly

Spanish Flu - Symptoms, How It Began & Ended

Why October 1918 Was America's Deadliest Month Ever

How the 1957 Flu Pandemic Was Stopped Early in Its Path

Pandemics That Changed History: Timeline