THE DOCTORS AND THE 'FLU': THE BRITISH MEDICAL PROFESSION'S RESPONSE TO THE INFLUENZA PANDEMIC OF 1918-19






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Publication: International Social Science Review
Author: van Hartesveldt, Fred R
Date published: January 1, 2010

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.' 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 fortúnales 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 1 849. 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."

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 1 900, 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.13

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 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 modern standards for credentials of practitioners. The Conjoint Examination given by the Royal Colleges of Physicians and Surgeons, beginning in 1 885, 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 1 894 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 to £60,000 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 inspectors.24 During World War I, the Board supported research when the necessary medical personnel could be freed from military obligations.25 As the first wave of the pandemic, the most infectious of the three, spread across the British Isles,26 it became clear that a "take two aspirins and call me in the morning" attitude would not serve the public well, and this research began to include studies to treat influenza.

Although the details of the influenza experiments are not important here, an idea of the types of research undertaken and the techniques used is, for such information illustrates how well the medical profession understood the epidemic and how well the lessons of Koch and Pasteur had been assimilated into medical practice. Efforts to develop a cure for influenza faced one key problem: the need for careful controls and rigorous statistical accuracy was not widely understood.27 A good example of this problem can be found in the great effort undertaken to base treatment on Pfeiffer's bacillus, discovered during the pandemic of the early 1 890s, and asserted by the discoverer, Richard Pfeiffer, to be the cause of influenza. Unfortunately, Pfeiffer's claim could not be verified because the state of bacteriology was too weak. As Dr. B. H. Spilsbury remarked in a discussion of influenza at the prestigious Royal Society of Medicine: "...I regard the condition [influenza] as a primary infection of the air passages by Pfeiffer's bacillus, the failure to find this organism in 40 per cent, [sic] of the cases being either because the research was not sufficiently thorough, or because the organism had disappeared before death."28

Since the value of smallpox vaccination was well known, great hope existed for the development of an influenza vaccine. If Pfeiffer's bacillus was the causal agent then it would be the basis for a vaccine, but pneumocci and streptococci were also commonly found in influenza cases. This resulted in mixtures of these bacteria being added to Pfeiffer's bacillus as the basis of most vaccines developed to treat the illness.29 Such vaccines were widely used by the military medical services, the leaders in this research effort, in hopes of stemming manpower "wastage" on the Western Front.30 Small samples and lack of controls resulted in wide-ranging claims of success. In fact, the vaccines could have done nothing to cure or prevent influenza. They might have helped if the patient was lucky enough to get exactly the strain of pneumococus and/or streptococcus that infected him by curing or preventing the pneumonia that was the most common and deadly complication during the pandemic.

Such efforts to develop a vaccine would be laughable at today's Centers for Disease Control, and although they were pervasive in 1918-19, their value was correctly judged by some of the more thoughtful contemporary physicians. According to Dr. M. H. Gordon of the Central Laboratory for C.[erebro] S.fpinal] Fever: "The 'blunderbuss' vaccine composed of Pfeiffer's bacillus, pneumonococus [sic], and streptococcus ... can do no harm, [and] should increase resistance to these microorganisms which play an important part in the pulmonary complications of influenza to which the mortality from it is mainly due. [I]ts value for preventing influenza will probably be found to be limited...."31 He was right; within a decade, serums prepared from the infecting organisms had cut dramatically the death rate in cases of pneumonia. There is, however, no telling how much, if any, good the vaccine treatments did in 1918-19, for the reports of cure and prevention range from one hundred percent to zero.32

There were many other research projects spawned by the pandemic. Studies were made of the overcrowding, diet, climate, the unaccustomed labor and emotional strain resulting from the war, and other factors that might affect the spread and virulence of the malady.33 There were also numerous attempts to analyze post-mortem findings to gain a better understanding of the pathology of influenza.34 The results of such studies were mixed but overall few patterns were recognized. Although it is known today that some of the avenues of inquiry and techniques followed in 1918-19 were completely worthless and others wellfounded, many years would pass before the doctors' knowledge and technology reached a point that allowed for significant treatment of influenza. Even today such treatments are of limited value.35

It is only fair to note that if hindsight guides selection of opinions, a modern picture of influenza can be found in the work of doctors from 1918-19. There were many doctors who argued that the pandemic was caused by a filter-passing virus, was passed from person to person through the air, and frequently caused pneumonia because of an unusually strong tendency to create lesions in the lungs. They associated a number of other diseases now known to be viral with it.36 As in other research efforts, military doctors were prominent among those who had discovered what turned out to be the truth.37 Of course, at the time those who were right and those who were wrong were equally certain that they had found the answers to treat influenza.

Doctors' long struggle for professional and social status38 had borne some fruit by the second decade of the twentieth century. Professional claims of scientific skill created high expectations. As a consequence, the failure to meet the pandemic with a cure or even offer its victims dependably helpful treatment led to criticism of medical practice. The doctors' response was a mix of defensiveness and honest evaluation of failure. W Hayes Fisher, president of the Local Government Board answered critics by declaring: "The poverty of medical research in England has long been a reproach." He endorsed the need for investigation of influenza and accepted the government's responsibility for the health of His Majesty's subjects. He insisted that his agency had been working closely with the Medical Research Committee and had been doing all that was possible to find a cure.39 Sir Walter Fletcher, a member of the Medical Research Committee, thought differently. He pointed to a hastily called conference in October 1918, to provide something for use in response to expected questions in Parliament. The conference was the first contact between the two agencies.40 Such problems of coordination and funding led the medical profession to join other groups and individuals in increasing demands for the establishment of a Ministry of Health to oversee efforts to find a cure for influenza.41 The ministry was created, but was in place only to study what had been done and to prepare for the future.42

The research was important, and practicing physicians were more likely to be directly involved in that research than in more recent times. Perhaps the profession can be said to have passed, if not much more, the test of studying the pandemic, but from the patient's perspective, the real proof was caring for the sick. In this regard, the profession did not measure up very well. The arrival of the pandemic's first wave in June 1918, and its two subsequent waves in the fall later that same year and in the spring of the following year, presented Britons with three basic questions all of which it was incumbent on the medical profession to answer: How could one avoid the infection? How did one find a doctor if symptoms appeared and became alarming? How did one effectively treat the symptoms of the illness?

Public health measures such as informing the public of how to handle or avoid infection were the job of the Local Government Board. Although the Ministry of Munitions warned its employees about the impending second wave of the pandemic, the public found out when it arrived in the fall. The Local Government Board did issue practical, though often belated, warnings about isolating oneself if struck by the illness, being careful to use handkerchiefs so as not to spread infection, resting in bed for a week to help avoid complications, and using a wash of potassium permanganate in the nose and mouth. Crowds were to be avoided if possible, but in wartime conditions, reduced public transportation leading to jammed buses and trains and the need for maintaining wartime production meant that some sacrifice of health was expected. People were warned but urged to carry on. The use of gauze masks, popular in the United States, was recommended only for health-care workers.43 Perhaps some lack of alacrity on the part of public health officials is explained in the following remark by Sir Arthur Newsholme, Chief Medical Officer of the Local Government Board: "I know of no public health measure which can resist the progress of pandemic influenza."44 Despair is not a great motivator of action.

When struck with the disease, the sufferer's next problem was to obtain the services of a physician. Doing so was not easy, even for those ready to pay hard cash. At the best of times, the high rate of infection during the pandemic would have strained medical resources. The summer and fall of 1918 were not the best of times. By January 1918, 12,720 doctors, or a more than fifty-two percent of the medical profession, had been assigned to military service. The government's response to expressions of concern about the shortage - in some areas the ratio of physicians to people was one to 5,000 - was that the needs of the army in France transcended the needs of civilians at home. Demands that doctors be released from military service got little satisfaction. The Central Medical War Committee did temporarily withhold from commissioning doctors from regions where the shortage was critical. In addition, some doctors were released from examining recruits, but only because the existing pool was large enough for the time being. Better success was had in asking the Board of Education to divert school doctors from routine tasks to assist general practitioners when the strain became serious. Requests that doctors over the age of forty not be sent overseas to meet growing demand at the front, however, were rejected, worsening the shortage at home.45 In fact, the crisis caused by the German offensives of the spring of 1918 had pushed the conscription age for doctors over fifty, so that few, if any, medical men trained in the twentieth century were left to care for civilians.46 The problem was acute, even in London where doctors were most common. Indeed, in October 1918 the Daily Mail reported that in London there were "only 1,200 doctors... responsible for 1,640,000 insured persons...."47 While the Daily Mail tended toward tabloid exaggeration in its coverage of the pandemic, one block study done in the metropolis after the pandemic found that 62.98% of fatal cases of influenza went unattended by any healthcare professional.48

Institutional care was also difficult to obtain. In the late nineteenth century less than one-third of sanitary authorities made provision for the isolation of infectious cases.49 Although the number of hospital beds had grown by more than 600 percent during the war, it was often more profitable to fill them with soldiers or reserve them for soldiers than to use them for civilians. Care, particularly during the first two waves of the pandemic, was woefully inadequate, and people, sometimes entire families, were simply left to die.50 In the fall of 1918 and spring of 1919, the rate of infection was lower than during the first wave, but the virulence and rate of complications were much higher, thus making the need for hospital care greater because fewer sufferers of influenza could get by on their own. The profession responded heroically to the crisis. Many doctors saw hundreds of cases a day, made do without nurses, who were also needed by the military, where they got better pay than at home, and made little complaint about their situation. These problems were eased during the third wave of the pandemic in the spring of 1919 because the war was over. The availability of doctors and nurses remained low, however, due to a very high rate of infection and mortality from the pandemic.51

Having reached professional help, most sick people need to trust the care provided and fear damps down questions. By the end of the pandemic, however, questions were being asked. A letter to the Manchester Guardian summarized the worst of patient concerns regarding the lack of uniform treatment to combat influenza:

On March 1[,1919,] you published a letter written by an eminent physician in which he very strongly recommended the use of permanganate of potash for influenza. On February 28, at the Medical Conference on Hygiene, sitting in London, the use of such a solution was [characterized as] a 'horrible remedy' Which of the two is to be believed? The other day I was talking to a district nurse in a suburb only a short distance from Manchester, and was told that she was attending patients prescribed by four medical men, yet each doctor had a different method of dealing with this plague. It is more likely that such differences obtain all over the country. Why do not the medical men in Manchester and district have a meeting, decide what is actually required and have their decision put before the proper authorities.52

Why indeed? For one reason, there was very little agreement within the medical profession about what to do. "We are almost helpless....," lamented one doctor,53 but almost every one was ready to try something. The most commonly prescribed medicine was alcohol - whiskey or brandy -as a stimulant. At St. Bartholomew's Hospital in London, brandy was prescribed as a remedy for influenza more than four times as often as any other drug.54 Demands for grain during the war had resulted in distilling being stopped and the government putting existing supplies of spirits in bond. As rationed amounts of whiskey were issued, the demand for release of larger supplies from physicians and patients became tremendous.55 Candidates for public office were heckled on the subject, and there were discussions in Parliament and the Cabinet before extra amounts were released.56 Although it was believed that the shortage had been responsible for thousands of deaths, alcohol was being erroneously prescribed - it is a depressant not a stimulant. This had been shown scientifically and proclaimed in England some fifty years earlier by Dr. Benjamin Ward Richardson, and confirmed by a government-sponsored study just a few years before the pandemic. Still, the medical profession had and generally continued to dismiss Richardson's ideas no matter how well-confirmed.57 Few doctors stoutly maintained that alcohol was useless against influenza.58

It would be unfair to seek out bizarre and completely unfounded treatments advocated by quacks, or to laugh and damn the medical profession as incompetent in its handling of the influenza pandemic. The fact that some doctors knew and openly said there were no good treatments shows that some were better informed. Nevertheless, doctors engaged in some foolish and scary - even for that day - therapy. The following list is compiled from prominent, respected medical journals. Perhaps most surprising is an advocacy for venesection - bleeding - even though the improvement was admitted to be temporary.59 The British Medical Journal offered the following ideas for treatments: wet packs, cinnamon, massive doses of sallicin, camphor, opium, quinine, and aspirin.60 Articles in The Lancet endorsed some of these treatments and offered several other suggestions: induced sneezing to "rid the nose of infection," a combination of sodium salicylate and strychnine, inhalation of iodine in steam, intravenous injection of garlic oil dissolved in pure ether, tri-menthenal allyic carbide, and purging with castor oil or calomel (mercurous chloride) followed by bicarbonate of soda every four hours.61 For all the assurances in numerous articles about treatment, it is clear that doctors were confused and ill-prepared to either treat influenza or study the effect of such treatment. Modern statistical methods, which would have helped enormously, were not understood by the bulk of doctors. A saving grace is that unlike doctors of a generation or two earlier what they did was usually not seriously harmful to the patient. Yet it is still hard to avoid the sense that there were many self-serving, even dishonest, claims made in hopes of status or profit.

As in all research efforts, there were bright spots in the efforts to help patients - mostly in public health. Although the quality of their work varied - Dr. S.C. Lawrence of Edmonton recommended the old-fashioned drooping mustache, periodically dampened with disinfectant, as a filter for infected air62 - local medical officers often did very valuable work. Perhaps the best example is Dr. James Niven of Manchester. Niven, who had already made a name for himself through his work on the prevention of tuberculosis, was indefatigable in his efforts to improve public health. He found hospital beds for the seriously ill, and arranged home care using local health visitors to supplement regular nurses and maintenance workers. He fought for and secured government money and food to help families that were prostrate due to illness. He worked with local government officials to close schools and public places of entertainment or at least to thoroughly ventilate the latter between shows to reduce the spread of infection. He also organized block surveys to study patterns and discover conditions conducive to the spread of infection. Within the limits of contemporary knowledge and technology, it would have been hard to do more than Niven did. He is one of the unsung heroes of the catastrophe. Although Niven was the best, other medical officers did good work in many places including Wigan, South Shields, York, Newcastle-upon-Tyne, Warrington, and Leicester. The data they collected and the comfort they provided to patients is one chapter in the treatment of the pandemic of which the British medical profession can be proud.63

Overall, however, the British medical profession, as it fought the influenza pandemic of 1918-19, was in disarray. With the beginnings of statistical analysis and thorough laboratory investigation, its best researchers and practitioners were pushing into the twentieth century while the worst were mired in the poor methods and extravagant claims of the nineteenth. Public health in some areas was well-served but nationally it was inefficient and uncoordinated. The greatest price for the profession's disarray was paid by the patient, who usually had to settle for the care of a doctor over the age of forty who, having been trained in the nineteenth century, was most likely to have ill-conceived erroneous ideas in treating illness, particularly influenza. The worst thing is that many doctors who could have known better did not. The medical response to the pandemic demonstrated the need for a Ministry of Health, long sought by medical reformers before 1918, to provide a central organizing agency for public health and coordination of government health programs for British subjects. The establishment of that agency, stimulated by the medical response to the pandemic, would prove crucial to the growth of modern systems of illness prevention and medical treatment for Britons.64

ENDNOTES

1Asa Briggs, "Cholera and Society in the 19th Century," Past and Present XIX (February 1961):76.

2Edwin O. Jordan, Epidemic Influenza: A Survey (Chicago: American Medical Association, 1927), 214-18.

3K. David Patterson, Pandemic Influenza, 1700-1900 (Totowa, NJ: Rowan & Littlefield, 1986), 1; John M. Barry, The Great Influenza: The Epic Story of the Deadliest Plague in History (New York: Viking, 2004), 450; Gina Kolata, Flu: The Story of the Great Influenza Pandemic of 1918 and the Search for the Virus that Caused It (New York: Farrar, Straus and Giroux, 1999), 7; I.D. Mills, "1918-1919 Influenza Pandemic-The Indian Experience," Indian Economic and Social History Review 23 (January-March, 1986).T-40. Mills estimates 1 7,000,000 deaths in four months during the fall wave of the pandemic. For the British situation specifically, see Mark Hoingsbaum, Living with Enza: The Forgotten Story of Britain and the Great Flu Pandemic of 1918 (New York: Palgrave Macmillan, 2009). Statistics in this era are a mare's nest. Each person's and agency's count is different on pretty much every number: total number of people, total number sick, total number dead. This is true in all countries. The causes include poor technique (that is, differences in claims of how many people became sick or died from influenza), lack of understanding of the importance of statistics, poor communications, and even deliberation. Few doctors understood the math and statistical methodology involved and often confused correlation with cause, assumed post hoc proctor hoc causal relationships, ignored significant percentages of failure when announcing a successful technique or treatment, and made other relatively simple mistakes. In some cases, they deliberately misstated or suppressed information so that their own cures could be promoted for both fame and fortune. See, for example, Francine King, "Atlanta," in The 1918-1919 Pandemic of Influenza: The Urban Impact in the Western World, ed. Fred R. van Hartesveldt (Lewiston, NY: Edwin Mellen Press, 1992), 108-10, 114.

4 Alfred W. Crosby, Jr., "The Pandemic of 1918," in Influenza in America, 1918-1976, ed. June E. Osborn (New York: Prodist, 1977), 5.

5Sir Felix Semon, The Autobiography of Sir Felix Semon, eds. Henry C. Semon and Thomas A. Mclntyre (London: Jarrolds, [n.d.]), 81.

6Abraham Flexner, Medical Education: A Comparative Study (New York: Macmillan, 1925), 215-16, 224, 230; J.M. MacKintosh, Trends of Opinion about the Public Health, 1901-51 (London: Oxford University Press, 1953), 223; Harry Eckstein, The English Health Service: Its Origins, Structure, and Achievements (Cambridge, MA: Harvard University Press, 1964), 63-64, 81-82, 90; J.S. Collings, "General Practice in England Today: A Reconnaissance," The Lancet I (March 25, 1950):579.

7Registrar General, Supplement to the Eighty-first Annual Report of Births, Deaths, and Marriages in England and Wales. Report on the Mortality from Influenza in England and Wales during the Epidemic of 1918-19 (London: His Majesty's Stationery Office, 1920), 3, 7. Honingsbaum has slightly different figures: case fatality rate of 2.5% resulting in 228,000 deaths, but he offers no source to substantiate these numbers. See Honingsbaum, Living with Enza, 5.

8"More Decline," Birmingham Mail, December 16, 1918, 3.

9Local Government Board, Forty-eighth Annual Report of the Local Government Board, 1918-1919. Supplement Containing the Report of the Medical Department for 1918-1919. Parliamentary Papers (1919), Cmd. 462 (London: His Majesty's Stationery Office, 1919), 163 (hereafter L.G.B., Forty-eighth Report and page number).

10Ministry of Health, Reports on Public Health and Medical Subjects. No. 4: Report on the Pandemic of Influenza, 1918-19 (London: His Majesty's Stationery Office, 1920), 477 (hereafter M. of H., Report on Pandemic and page number).

11For accounts of the earlier plague, see Norman F. Cantor, In the Wake of the Plague: The Black Death and the World It Made (New York: Free Press, 2001); John Kelly, The Great Mortality (New York: HarperCollins, 2005); Joseph P. Byrne, The Black Death (Westport, CT: Greenwood Press, 2004).

l2Quoted in René Dubos and Jean-Paul Escande, Quest: Reflections on Medicine, Science, and Humanity, trans, by Patricia Ranum (New York and London: Harcourt, Brace, Jovanovich, 1980), 45.

l3Harry F. Dowling, Fighting Infection: Conquests of the Twentieth Century (Cambridge, MA: Harvard University Press, 1977), 5, 48-49, 106-07.

l4Lewis Thomas, The Youngest Science: Notes of a Medicine Watcher (New York: Viking, 1983), 13-15, 19-20.

15William A. Brend, Health and Science (London: Constable & Co., Ltd., 1917), 18283; Eckstein, 77ie English Health System, 81-82.

16Thomas, The Youngest Science, 13-15, 19-20.

l7The joke, an example of doctors' attitudes toward changes in scientific practice, was an attempt to sneer at the ideas of Joseph Lister who had dramatically reduced surgical infections with the use of antiseptics.

18H.S. Glasscheib, The March of Medicine: The Emergence and Triumph of Modern Medicine, trans, by Mervyn Small (New York: G. P. Putnam's Sons, 1964), 125; RB. Smith, The People's Health, 1830-1910 (New York: Holmes and Meier, 1979), 108-09,268.

19Samuel Hynes, The Edwardian Turn of Mind (Princeton, NJ: Princeton University Press, 1968), 155. The revolutionary work of doctors such as Robert Koch in bacteriology, Louis Pasteur on infection, and Joseph Lister in antiseptic surgery seemed to suggest the coming of a wave of progress in the treatment of disease. Unfortunately, only an elite in the medical profession embraced these new ideas. Scientific advances were often ridiculed and the everyday practice of medicine changed little.

20Gerald L. Geison, Michael Foster and the Cambridge School of Physiology: The Scientific Enterprise in Late Victorian Society (Princeton, NJ: Princeton University Press, 1978), 4-5, 41, 43-44; Jeanne L. Brand, Doctors and the State: The British Medical Profession and Government Action, 1870-1912 (Baltimore, MD: Johns Hopkins University Press, 1965), 232.

21 [Editorial], British Medical Journal I (January 25, 19 19): 107 (hereafter title of article, B.M.J. , volume number, date, and page number).

22 F.N.L. Poynter, "The Influence of Government Legislation on Medical Practice in Britain," in The Evolution of Medical Practice in Britain, ed. F.N.L Poynter (London: Pitman Medical Publishing Co., 1961), 11-13; Sir Zachary Cope, "The Influence of the Royal College of Surgeons of England Upon the Evolution of Medical Practice in England" in The Evolution of Medical Practice in Britain, ed. Poynter, 49, 53.

23Michael W. Perrin, "The Influence of the Pharmaceutical Industry in the Evolution of British Medical Practice," in The Evolution of Medical Practice in Britain, ed. Poynter, 95-96, 103.

24[Robert] Morant to Secretary of] H[is] Majesty's] Treasury, June 25, 1920, Box 33, folder 10.2, Papers of Christopher Addison, Bodleian Library, Oxford University. See also Hansard's Parliamentary Debates, Commons, 5th ser, vol. XC (October 30, 191 8), col. 146 1 .

25Report on Medical Services in France, PRO/W032/4752, 6; Medical Research Committee, Studies of Influenza in Hospitals of the British Armies in France, 1918, Special Report Series No. 36 (London: His Majesty's Stationery Office, 1919).

26The common pattern of three waves of the pandemic as it occurred in Britain is welldescribed in Honigsbaum, Living with Enza, 35-152.

27Such methods were known as can be seen in the work of the Local Government's Medical Officer, Sir Arthur Newsholme, Fifty Years in Public Health: A Personal Narrative with Comments (London: G. Allen & Unwin, 1935), 99-100.

28"Discussion of Influenza," Proceedings of the Royal Society of Medicine: General Reports, XIl (1919):57 (hereafter Royal Society, "Discussion of Influenza," and page number). See also James Mcintosh, D.D., "The Incidence of Bacillus Influenzae (Pfeiffer) in the Present Influenza Epidemic," The Lancet II (November 23, 1919):695; [Editorial], B.M.J., II (July 27, 1918):91; [Editorial], Daily Mail (London), March 1 1, 1919, 4.

29 For the formula adopted by the Ministry of Health, see M. of H., Report on Pandemic, xx. This is typical although amounts and dosage vary and occasionally other ingrethents were added.

30Director of Medical Services, War Diary, LII (November 20, 1918), PRO/WO 95/4481. See also Royal Society, "Discussion of Influenza," 83.

31M.H. Gordon to Addison, March 3, 1919, Box 4, Folder 115, Addison Papers; "Thomas Harder to Editor," The Lancet II (November 9, 1918):642.

32Royal Society, "Discussion of Influenza," 83-84.

33 "Robert Hill, "Influenza in the Grand Fleet," Journal of the Royal Naval Medical Service V (April 1919):142; M. of H., Report on Pandemic, 169, 172; L.G.B., Fortyeighth Report, 18; "Ministry of Health," The Lancet II (November 2, 1918):595.

34 See, for example, [Editorial], B.M.J. II (July 27, 1918):3; Geoffrey Bourne, "Influenzal Empyema," Saint Bartholomew's Hospital Journal XXVI (March 1919):64.

35 William Beveridge, Influenza: The Last Great Plague, rev. ed. (New York: Prodist, 1978), 36-38.

36TH. G. Shore, "The Morbid Anatomy and Pathology of Influenza Based Upon 177 Post-Mortem Examinations," Saint Bartholomew's Hospital Reports LIV (1922):35; L.G.B., Forty-eighth Report, 13; [Editorial], B.M.J. I (March 22, 1919): 331-35.

37 Major H. Graeme Gibson, R.A.M.C, Major FB. Bowman, C.A.M.C, Captain J.I. Connor, A.A.M.C, "A Filtrable Virus as the Cause of the Early Stage of the Present Epidemic of Influenza," B.M.J. II (December 14, 1918):645.

38The struggle for professional status, superseding concern for patients, can be followed in M. Jeanne Peterson, The Medical Profession in Mid- Victorian London (Berkeley, CA: University of California Press, 1978); Ivan Waddington, The Medical Profession in the Industrial Revolution (Dublin: Gill and Macmillan Hunanities Press, 1984); Eliot Freidson, Profession of Medicine: A Study of the Sociology of Applied Knowledge (New York: Harper and Row, 1970).

39"Medical Research," Daily Mail (London), October 28, 1 9 1 8, 3 . For another example, see Sir Arthur Newsholme 's remarks in Royal Society, "Discussion of Influenza," 11-12.

40Walter Fletcher to [Waldorf] Astor, October 29, 1918, copy in Fletcher to Addison, October 30, 1918, Box 21, Item 10.2, Addison Papers.

41 Ministry of Health," The Lancet II (November 2, 1918):595.

42Ministry of Health, Annual Report of the Chief Medical Officer, 1919-20, Parliamentary Papers (1920), Cmd. 978, 47-48.

43Local Government Board, Memorandum on Prevention of Influenza (February 1919), copy in Box 4, Bundle 102-03, Addison Papers; [Editorial], B. MJ. II (November 30, 1918):620.

44"Royal Society, "Discussion of Influenza," 3.

45Report on Medical Services in France, PRO/WO 32/4752, 6; Brian Abel-Smith, The Hospitals, 1800-1948 (London: Heinemann, 1964), 279; Hansard's Parliamentary Debates, Commons, vol. XC (October 29, 1918), cols. 1291-93; [Editorial], B.M.J. II (November 2, 1918):495.

46 Trevor Wilson, The Myriad Faces of War: Britain and the Great War, 1914-1918 (Cambridge: Polity Press, 1986), 644-45.

47 "People Dying Without Doctor's Aid," Daily Mail (London), October 30, 1918, 3.

48 Metropolitan Borough of St. Paneras, Annual Report of Medical Officer of Health for 1918 (London: His Majesty's Stationery Office, 1919), 42.

49 Anthony S. Wohl, Endangered Lives: Public Health in Victorian Britain (Cambridge, MA: Harvard University Press, 1983), 138-40.

50Abel-Smith, The Hospitals, 1800-1948, 264, 267-68, 281.

51 [Editorial], BMJ II (November 30, 1918):495-96; [Editorial], B.M.J. I (February 1, 1919):133.

52 "Viajante [sic] Editor," Manchester Guardian, March 11, 1919, 4.

53 "Epidemic Now Over Whole Country," Daily Mail (London), October 23, 1918, 4.

54Saint Bartholomew's Hospital, Medial Register - Male, 1(1919), Saint Bartholomew's Hospital Archives, MR 16/80. This pattern of prescription was also seen in the United States, although not as strongly. See Dorothy A. Pettit and Janice Bailie, A Cruel Wind: Pandemic Flu in America, 1918-1920 (Murfeesboro, TN: Timberlane Books, 2008), 12931,209-10.

55"Edmund W. Williamson, M.R.C.S., L.R.C.P., to Editor," Birmingham Mail, March 6, 1919, 6; "Whiskey for Influenza Care," Manchester Guardian, March 14, 1919, 7.

56"Need for Whiskey," Daily Mail (London), December 10, 1918, 6; "War Cabinet Considering Releasing More Whiskey," Daily Mail (London), February 21, 1919, 3; [Editorial], Birmingham Mail, March 4, 1919, 4; [Editorial], Manchester Guardian, December 14, 1918,6.

57Newsholme, Fifty Years in Public Health, 106; Michael E. Rose, "The Success of Social Reform? The Central Control Board (Liquor Traffic), 1915-21," in War and Society, ed. M.R.D. Foot (London: Paul Elek, 1973), 75; Wohl, Endangered Lives, 58-59.

58"More Whiskey Released," Manchester Guardian, February 26, 1919, 10; "Letter from Doctors," Manchester Guardian, March 14, 1919, 12; "Scarcity of Whiskey," Daily Mail (London), February 20, 1919, 3.

59Bourne, "Influenza Empyema," 63.

60WC. Philip, "The Wet Pack in Influenza," B.M.J. I (March 8, 1918):278; [Editorial], B.M.J. II (October 19, 1918):440; RL. Guiseppi, M.D., Lond., F.R.C.S. to Editor, B.M.J. II (December 28, 1918):716; "Captain L. Bensted, R.A.M.C, to Editor," B.M.J. II (December 14, 1918):614; [Editorial], B.M.J. II (July 13, 1918):39.

61"Dr. R. W. Allen to Editor," The Lancet II (November 2, 1918):603; "Isabel Ormiston to Editor," The Lancet II (November 2, 1918):604; "Treatments Recommended Based on Letters from Surgeon R. Murray Burrow, Dr. Walter Kidd, Dr. R. W. Allen, and Walter Allingham, M.R.C.S.," The Lancet II (November 9, 1 9 1 8):644; "Treatments Recommended Based on Letters from Dr. C. Muthu, Dr. H. O. Butler, and Dr. WC. Minehin," The Lancet II (December 7, 1918):796.

62 [Editorial], Daily Mail (London), February 19, 1919, 3. On the general lack of preparation of medical officers in the late nineteenth century, see Wohl, Endangered Lives, 182-83.

63Niven's work is detailed in James Niven, Observations on the History of Public Health Efforts in Manchester (Manchester: John Heywood, Ltd., 1923), passim, esp. 17, 36; Brand, Doctors and the State, 134; M. of H., Report on Pandemic, Appendix IV, passim, esp. 445-54. For efforts to improve public health in Wigan, South Shields, York, Newcastle-upon-Tyne, Warrington, and Leicester, see L. G. B., Forty-eighth Report, 15964; M. of H., Report on Pandemic, Appendix IX, Report on Wigan by RJ. Hutchinson, 264-65, and passim; City of York Health Committee, Report on Influenza and Influenza Epidemics of 1918 (York: City Government, 1919), 1-2, 4, 13, and passim.

64For information on the Ministry of Health's connection to the flu pandemic of 19181 9 as well as its growth and function, see Eckstein, The English Health Service, 49-60, 62-71, 84-85; Maurice Bruce, The Coming of the Welfare State, rev. ed. (New York: Schochen Books, 1966), 2 1 1 ; Brend, Health and the State, 1 87; A. W. Russell, "A Ministry of Health," The Practitioner C (January 1918):75, 77-78; Caroline E. Playne, Britain Holds On, 1917-1918 (London: George Allen & Unwin, 1933), 377.

Author affiliation:

FRED R. van HARTESVELDT is a professor of history at Fort Valley State University in Fort Valley, Georgia.

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