The doctors and the 'flu': the British medical profession's response to the influenza pandemic of 1918-19.

Authorvan Hartesveldt, Fred R.
PositionReport

The development of medicine and its practitioners is a continuous process. In order to assess its state at any particular time, one must find a way to bring all of its activities, theoretical and practical, into focus. Asa Briggs, one of the preeminent British historians of the last half century, has correctly suggested that epidemics provide a lens that does this. (1) Doctors, whether in public service, private practice, or engaged in research, must face the crisis. Their very best efforts and tools are required and tested. Under such circumstances, particular talents are highlighted. At the same time, inadequacies in efficiency, skill, and learning that might easily go unnoticed under normal conditions become glaring faults.

The influenza pandemic of 1918-19, due to its unusual virulence, gave a particularly clear focus to the status of the medical profession worldwide. Our understanding of just how terrible it was has grown significantly in recent analyses. The initial, and long trusted, estimate of twenty million deaths made by University of Chicago bacteriologist Edwin O. Jordan in 1927 is really based on the impact of the pandemic on the economically developed Western world. (2) Recent studies have made clear that Jordan's figure should at least be doubled, possibly quadrupled. (3) Alfred Crosby, an American historian of the pandemic, asserts that "[b]y conservative estimate, a fifth of the human race endured the fever and aches of influenza in 1918 and 1919, and serologic [now more commonly serological; concerning blood fluids] evidence indicates that an enormous majority of those fortunates who did not suffer the discomforts of flu did, however, have sub-clinical cases of the infection." (4) This paper examines how the British medical profession handled the situation in 1918-19 as an example of how medical institutions in one of the leading industrial and scientific nations of the early twentieth century reacted to this medical crisis. As this study will show, although much knowledge needed to respond to the pandemic simply was not available, British doctors had access to much more information than most medical professionals in other countries--some exceptions will be noted--to combat this health crisis.

Although it had been a leader in the practice of medicine during the eighteenth century, the British medical profession had not kept up with developments and practices in the nineteenth century. Its members were slower than Continental physicians to adopt innovations, even those of its own Joseph Lister who pioneered antiseptic surgery. (5) Medical education and general practice remained outdated. Teaching hospitals lacked modern equipment and muddled varying types of cases together in their wards. Hospitals tended to be small and underfunded, and lacked laboratories to conduct their own pathology and bacteriology. The first modern hospital properly prepared for teaching, thanks to its reconstruction in 1912, was University College Hospital in London. Conditions outside the British capital were far worse. The offices of medical practitioners were cluttered and poorly equipped as well, a situation that lasted well into the twentieth century. Much was learned by the Royal Army Medical Corps during World War I, but little of that medical knowledge had been disseminated by the time of the outbreak of the pandemic. (6)

Large numbers of Britons died during the forty-six weeks--June 23, 1918, to May 10, 1919--that were officially declared the period of the flu epidemic in Great Britain. During that time, 184,000 civilians and 10,490 non-civilians died in addition to the approximately 7,000 who would have normally been killed by influenza. The civilian death rate in 1918 was 3,129 per million population, a rate approached only by the cholera epidemic of 1849. For the entire period of this health crisis, the civilian death rate in Great Britain was the equivalent of an annual rate of 44,774 per million. (7) Of course, the impact of the disease was not uniform, but on a local level it was often devastating. Birmingham, for example, experienced a death rate of 44.3 per 1,000 residents for the week ending November 30, 1918. (8) Over the course of the epidemic, influenza struck 55.8% of households in Leicester. (9) At the worst peaks, bodies in Manchester went as much as two weeks without burial, and soldiers had to be pressed into service as grave diggers and coffin makers. (10) Problems of disposal of bodies occurred in a number of other districts as well. Nineteen-eighteen was certainly not the Middle Ages, but mass graves and panic were at least for moments reminders of the horrors of the Black Death in the fourteenth century. (11)

Treatment had changed for the better, but cure was still rare. The early nineteenth century marked the end of the era when powerful purges and emetics combined with copious bleeding and heroic--often poisonous--doses of chemicals such as mercury made doctors more killers than healers. By 1900, in the words of the French chemist and bacteriologist Louis Pasteur, doctors began to understand that "the microbe causes the illness. Look for the microbe and you'll understand the illness." (12) By then, twenty-one specific diseases were known to be caused by specific bacteria. (13) Yet, despite a few successes, for instance with syphilis and the still hesitant use of serums to treat pneumonia, effective treatments were rare. Speaking of the doctor in the 1920s, Lewis Thomas, a physician and long-time director of the Sloan-Kettering Cancer Center, observes, "[a]ll he had in the bag was a handful of things. Morphine was the most important, the only really indispensable drug in the whole pharmacopoeia." (14) Viruses, although suspected, could not yet be filtered or grown, let alone treated. Furthermore, as of 1918 the typical medical practitioner lacked the modern training and equipment necessary for effective treatment of diseases. This was particularly true in rural areas where the medicine practiced was often a generation behind the times. (15)

From the mid-nineteenth through the early twentieth century, the best doctors focused their attention on diagnosis and prognosis with treatment being a distant secondary concern. Potions were dispensed to patients because they were expected, even demanded. If the patient was lucky, these were harmless vegetable mixtures, which recipients commonly rated by how bad they tasted. (16) What is known and what is practiced, however, are not necessarily the same. As late as the 1890s, a common English hospital joke involved keeping the operating theater door closed lest Lister's microbes sneak into the room. (17) Clinical evidence was often simply ignored. At the beginning of World War I, many surgeons still operated in old coats or aprons, the fashion of wearing antiseptic cotton gloves, masks, and easily washable clothing having faded. (18) The failure of Edwardian science to make good on the promises made for it had led to skepticism even among those trained as doctors and scientists. (19)

There were, however, areas of significant improvement in the British medical profession. The study of physiology in British universities, which had reached a nadir in the mid-nineteenth century, made a dramatic comeback under the influence of Sir Michael Foster and his students at Cambridge, though it had not caught up with that of the Germans. (20) Between 1908 and 1914, the Board of Education issued grants totaling 40,000 [pounds sterling] to support the reform of medical schools, but it made little effort to prescribe in any specific way what those reforms should be. Sir George Newman, head of the Board's medical section, sought additional grants but expressed concern about the wisdom of their use. The British Medical Journal voiced some concern about what would now be called 'academic freedom' but supported the Board's reform efforts. (21) The Apothecaries Act of 1815, and, more importantly, the Medical Act of 1858 had begun the process of establishing modem standards for credentials of practitioners. The Conjoint Examination given by the Royal Colleges of Physicians and Surgeons, beginning in 1885, was the most popular but not a universal or the only qualification for practicing medicine. By modern standards, certification to practice medicine was still a loose process in the early twentieth century. (22)

By the late nineteenth century, medical research began taking on its modern, expensive appearance. Private industry was involved with the Wellcome Physiological Research Laboratories, which had been founded in 1894 to investigate the potentially highly profitable production of serums. (23) The National Insurance Act of 1911 allowed Insurance Commissioners to pocket one penny per year for each insured person to fund the Medical Research Committee, which raised 50,000 [pounds sterling] to 60,000 [pounds sterling] annually. The Local Government Board assumed responsibility for public health and also produced auxiliary scientific studies concerning health and sanitation. By 1918, it had a staff consisting of a medical officer, Sir Arthur Newsholme, four assistant medical officers, and twenty medical...

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