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~This is the fourth of four guest posts from a class taught by Tom Ewing at Virginia Tech in fall 2017. Read the other parts here: I, II, III. We are grateful to Professor Ewing and his students for sharing their wonderful work with us and allowing us to share it with our readers.

On October 2, 1918, the city of Boston recorded 188 deaths from influenza, the highest daily toll during the epidemic. [1] Just one day later, in an October 3 editorial, the Boston Medical and Surgical Journal conceded “the situation has become serious.” [2]

        The Spanish influenza in 1918 challenged medical experts and public health officials because the scope and severity of the disease exceeded both their expectations for an outbreak and the capacities of available diagnostic, preventive, and treatment measures. This paper examines the response to the epidemic in the New England Journal of Medicine (then called the Boston Medical and Surgical Journal, hereafter BMSJ) from the first reports in late September through the peak death totals in October and ending with the abating epidemic in December 1918. This review is particularly timely now, as the centennial observation of the 1918 flu serves as a reminder of how historical analogies can and should shape epidemiological analysis and health policies. A careful analysis of this journal reveals a growing awareness of the severity of the epidemic, along with consistent efforts to underestimate the danger and make optimistic predictions of improving health conditions.

Figure 1: Deaths from Influenza, Boston, September – November 1918

      The human toll of the epidemic confirms its unprecedented impact. The daily account of deaths due to influenza in Boston (Figures 1 and 2) clearly identifies the first week of October as the peak of the epidemic. A keyword search for “influenza” (Figure 3) and a term frequency chart (Figure 4) both indicate that early October is also when this journal first began reporting on the influenza epidemic. Comparing the daily toll of influenza deaths during the 1918 epidemic deaths from all causes in the fall of 1917 confirms the remarkable costs of this epidemic. [3] Boston’s 3,421 deaths from influenza in fall 1918 were just a fraction of the estimated 15,000 deaths in Massachusetts, 675,000 deaths in the United States, and 50-100 million deaths worldwide during the epidemic. [4]

        The first substantive reporting appeared in the BMSJ on September 19, 1918 in “Medical Notes,” which stated that an “epidemic of influenza prevails” with 350 cases among sailors at the Commonwealth Pier. [5] This article quoted a September 5 statement from Dr. John S. Hitchcock, director of Department of Health’s division of communicable diseases, who combined reassurances about limited dangers with confident endorsements of preventive measures:

Unless precautions are taken, the disease in all probability will spread to the civilian population of the city. The malady appears to be in the nature of old-fashioned grip. No deaths have occurred. The naval medical authorities who have the matter in charge are doing everything possible to control the outbreak. With a focus of infection of this size, it seems probable that the disease will escape into the civil community in spite of all efforts at control. People should be reminded that under these conditions, persons with coughs and colds are not choice companions, and that a good doctor is a friend.

The assertion that “no deaths have occurred” may have been true on September 5, but was certainly not true when the

Figure 2: Influenza and Pneumonia Cases and Deaths in Boston, Table printed in Boston Medical and Surgical Journal, Vol. 179, No. 22, November 29, 1918, p. 688

BMSJ published the statement two weeks later, as the number of deaths had increased to almost fifty each day.

        One week later, a September 26 editorial discussed the epidemic as a serious threat for the first time, yet the tone remains understated, with little evidence of a sense of alarm:

Unfortunately, the number of cases has increased, and the epidemic has now reached important proportions. Although every possible precaution has been taken, the disease has been spreading, especially in Navy cantonments. Furthermore, it has reached the civilian population and has invaded the schools, although not yet to a serious extent. [6]

The editorial explained how influenza was transmitted by droplets spread from person to person, recommended measures for controlling coughing and spitting, advised healthy persons to avoid crowds and sick people to stay home, and raised concerns about securing enough doctors and nurses. Public education campaigns were recommended, as advised by Surgeon General Rupert Blue: “The present outbreak may be controlled to more or less extent only by intelligent action on the part of the public.”

        “Progress of Influenza Epidemic,” an editorial published October 3, included the statement, “the situation has become serious,” cited above:

The epidemic of so-called “Spanish” influenza is still spreading in Boston and in the neighboring districts and towns, Unfortunately, pneumonia has developed in many cases and the mortality list is at present higher than at any previous period since the outbreak of the epidemic. Although every possible precaution is being exercised, the situation has become serious. [7]

While acknowledging the growing toll, the editorial also made the reassuring, yet clearly baseless, claims that the “death rate remains normal although the number of cases has increased.”

Figure 3: Search results, “Influenza,” Boston Medical and Surgical Journal, Vol. 179, July -Dec 1918, from Internet Archive

        The October 10 issue of BMSJ, oddly, contains only one article specifically on influenza, a correction requested by a physician misquoted the previous week. [8] This issue did print death reports for the week ending September 28, 1918, indicating that 992 deaths from all causes represented an increase of more than 400% over the same week in 1917. [9] Even as the death toll reached unprecedented levels, however, the journal did not provide any meaningful explanation of why deaths had more than quadrupled since the previous year.

        Two subsequent issues, October 17 and 24, by contrast, had numerous articles about the epidemic, including editorials, detailed accounts of specific cities, camps, and states, and statistics about cases and deaths. For the first time, the October 17 editorial acknowledged the actual severity of current conditions: “The epidemic of influenza-pneumonia, which has prevailed in Boston and surrounding districts for over two weeks, is still maintaining unprecedented strength.” [10] The editorial referred to “drastic measures” taken to “stamp out the epidemic,” including closing schools, bowling alleys, bars, and soda fountains, prohibiting public meetings, ordering churches not to hold services, regulating hours of businesses to prevent crowding, and cancelling public events. Yet these detailed accounts of public health measures were accompanied by declarations that “more encouraging conditions” were resulting in “a gratifying decrease in the number of deaths.”

        “Notes on the Influenza Epidemic” in the October 17 issue included a daily list of 2,606 influenza deaths and 662 pneumonia deaths from September 14 to October 11. [11] This detailed list was prefaced with the neutral statement: “The Boston death record is as follows,” without any indication of the unprecedented toll. Detailed accounts of the epidemic elsewhere in the United States, including cases and deaths in military camps and major cities, were framed by a remarkable balance of concerns about the scope of the epidemic and reassurances that the danger was diminishing: “There is at present time very little abatement in the Spanish influenza epidemic, but stringent measures are being taken by every town and city in Massachusetts and elsewhere.” The article’s final paragraph illustrates how acknowledging real costs could be offset by confidence in policy measures: “Brockton’s latest list shows 100 per cent increase in the number of deaths, though the board gave the opinion that the situation is now well in hand with the ample number of doctors and nurses on hand.”

        One week later, “The Waning Influenza Epidemic” continued to report worsening national conditions while

Figure 4: Term Frequency, Boston Medical and Surgical Journal, Vol. 179, July – December 1918, created using Voyant tool for text visualization

highlighting regional improvements: “With the bright, clear days of the past week, the influenza-pneumonia epidemic in the Eastern section has shown a gratifying decrease in the number of new cases as well as in the death rate. But while conditions are improving here, the influenza now has spread to practically every part of the country.” [12] An optimistic tone dominated reports on local conditions where health officials had “the influenza under control” and reported “a return to virtually normal conditions.” Most encouragingly, this editorial called attention to lessons learned by state officials: “Fresh air and sunshine are the most helpful aids…in the treatment of the influenza and the Massachusetts department desires to help all the other States as much as possible.”

        “Notes on the Influenza Epidemic,” from the October 24 issue, amplified this optimism by declaring that “the epidemic is under control” in Worcester, “the influenza situation has improved decidedly” in Lawrence, the “influenza-pneumonia epidemic is on the wane” in Plymouth, conditions were “getting decidedly better” in Milford where “the high water mark” of deaths “is believed to have been reached,” and “the general situation is improving” in Newburyport. [13] Only rarely did more negative reports appear, such as the admission that the “epidemic is at its height [in Westfield] and no relief is in sight,” the “epidemic has broken out anew” in Fitchburg, or a Worcester cemetery could not schedule funerals because grave-diggers were so far behind.

        From this point forward, the editorial tone became increasingly triumphant, even as articles documented the actual toll. The October 31 issue proclaimed “the crest of the epidemic has passed” in Boston, with only a brief recognition that 2,600 deaths “despite the best medical effort to prevent them” indicated “that the reports have not been exaggerated and impresses the seriousness of this disease to the health of the community.” [14] The November 7 issue reported increasing cases across the United States and world, yet also stated: “There is every indication now that the epidemic is disappearing even more rapidly than was expected,” [15] while the November 14 issue proclaimed: “The Spanish influenza is on the wane in New England and surroundings.” [16] In the November 21 issue, “Medical Notes” stated that cases in army and navy facilities near Boston had decreased to single digits, while offering “unstinted praise” for “those who aided in the fight against the recent grip epidemic.” [17] The most significant information contained in the November 28 issue, as discussed above, was the record of daily cases and death, yet this remarkable statistical report lacked any commentary on the unprecedented number of victims. [18]

        “Great Mortality of Influenza Epidemic,” published on December 12, provides hard data that undercuts the consistently optimistic tone of earlier editorials. [19] From September 8 to November 9, American cities reported 83,306 deaths, of which 78,000 were reliably attributed to the epidemic, which “ravaged the country generally from coast to coast,” causing significantly more deaths than losses in the American Expeditionary Forces. The December 26 issue included this blunt statement from state Health Commissioner Eugene R. Kelley:

This epidemic has been a most serious one. It has killed an appalling number of our people and it has directly and indirectly caused the expenditure or loss of large amounts of money and has temporarily halted the progress of many industries. [20]

While these two reports offered direct evidence of the epidemic’s toll, it is perhaps significant that both were republished from other sources, without editorial commentary from this journal.

A review of four months of reporting on the Spanish influenza demonstrates a trajectory of growing awareness, deepening concern, and policy recommendations, always balanced by optimism, confidence, and eventually triumph. One lesson to be learned from the 1918 influenza epidemic is for medical professionals to ensure that accurate, timely, and realistic information is not distorted, delayed, or diluted by excessive confidence in the efficacy of health policies. In fact, the published statistical evidence makes it possible to follow the 1918 epidemic’s devastating trajectory in the pages of this journal. A close reading clearly indicates, however, that at every stage, from the first cases through the final calculations, these same reports expressed confidence that the medical establishment would protect the health of the population. By the end of the year, the journal could claim victory, but the actual human costs were clearly evident in the toll of deaths that filled these same pages.

Footnotes

1. “Influenza and Pneumonia in Boston,” The Boston Medical and Surgical Journal, Vol. 179, No. 22, November 28, 1918, p. 688. Full text versions of this volume are available from the Internet Archive (link), Google Books (link) and the Hathi Trust library (link).
2. “Progress of Influenza Epidemic,” The Boston Medical and Surgical Journal, Vol. 179, No. 14, October 3, 1918, p. 457.
3. The numbers come from weekly reports, which usually included total deaths for the same week in the previous year.
4. Data for Boston and Massachusetts is for the final months of 1918. Data for the United States and the world covers a broader period of time, from summer 1918 to summer 1920. “Mortality of Influenza in Massachusetts,” The Boston Medical and Surgical Journal, Vol. 179, No. 26, December 26, 1918, p. 808.
5. “Medical Notes,” Boston Medical and Surgical Journal, Vol. 179, No. 14, September 19, 1918, p. 408.
6. “The Epidemic of Influenza,” Boston Medical and Surgical Journal, Vol. 179, No. 15, September 26, 1918, pp. 430-434.
7. “Progress of Influenza Epidemic,” p. 457.
8. “The Grip Situation: A Correction,” The Boston Medical and Surgical Journal, Vol. 179, No. 15, October 10, 1918, p. 492.
9. “Boston and Massachusetts,” The Boston Medical and Surgical Journal, Vol. 179, No. 15, October 10, 1918, p. 493.
10. “Further Developments in the Progress of the Influenza Epidemic,” The Boston Medical and Surgical Journal, Vol. 179, No. 16, October 17, 1918, pp. 511-513.
11. “Notes on the Influenza Epidemic,” The Boston Medical and Surgical Journal, Vol. 179, No. 16, October 17, 1918, pp. 519-520.
12. “The Waning Influenza Epidemic,” The Boston Medical and Surgical Journal, Vol. 179, No. 17, October 24, 1918, pp. 538-540.
13. “Notes on Influenza Epidemic,” The Boston Medical and Surgical Journal, Vol. 179, No. 18, October 24, 1918, pp. 546-549.
14. “Medical Notes,” The Boston Medical and Surgical Journal, Vol. 179, No. 18, October 31, 1918, pp. 571-575.
15. “Progress of the Influenza Epidemic,” The Boston Medical and Surgical Journal, Vol. 179, No. 19, November 7, 1918, pp. 603-605.
16. “Progress of the Spanish Influenza Epidemic,” The Boston Medical and Surgical Journal, Vol. 179, No. 20, November 14, 1918, pp. 633-644.
17. “Progress of the Influenza Epidemic,” The Boston Medical and Surgical Journal, Vol. 179, No. 21, November 21, 1918, p. 659.
18. “Medical Notes,” The Boston Medical and Surgical Journal, Vol. 179, No. 22, November 28, 1918, pp. 687-689.
19. “Great Mortality of Influenza Epidemic,” The Boston Medical and Surgical Journal, Vol. 179, No. 24, December 12, 1918, pp. 743-744.
20. “Delay in Reporting Cases of Influenza,” The Boston Medical and Surgical Journal, Vol. 179, No. 26, December 26, 1918, pp. 807-808.

~This is the third of four guest posts from a class taught by Tom Ewing at Virginia Tech in fall 2017. Read the other parts here: I and II.

The state medical journals can be analyzed using tools and methods from the digital humanities and data analytics to provide unique insights into the historical significance of the 1918 Spanish Influenza. These methods include term frequency, text visualizations, and network analysis of term collocations. The tools used for this analysis, each easily accessible to scholars and students, including Voyant and Google Sheets.

Accessing the full text versions of the state medical journals is possible through the internet archive, which provides links to a full text version of each volume. The text version often includes some additional texts from the digitization process, which can be deleted from a text version of the document, to preserve the integrity of the original. Some visualization tools, such as Voyant, allow users to enter a url, which can be done from the internet archive directly. In this case, the additional text may appear in the visualization, but can be deleted or ignored.

III.1

The six state medical journals for the period most directly related to the Spanish Influenza, 1918 – 1919, include more than four million total words and 86,000 unique terms. Illustration III.1 is a cirrus cloud representation using Voyant showing the one hundred twenty five most common terms (excluding common stop words) across all four million words. Some of the terms are obviously relevant to any medical field (medical, cases, treatment, patient), while others are perhaps more specific to state medical journals (county, state, society, and member). The letter, a^, appears in these texts as a result of optical character recognition software, and thus is not consistent with the original text. While this visualization is useful for showing the most common terms across all the journal texts, it provides little analytical insights into the Spanish flu epidemic (or any other specific topic).

III.2

Using the Contexts and Cirrus Cloud tools in Voyant to analyze the same corpus from six state medical journals does provide a more insightful visualization of texts. The Contexts tool extracts the fifteen words on either side of the keyword, “influenza” (Illustration III.2), thus producing a corpus of 60,000 total words and 6,000 unique words. The advantage of using this tool is to produce a corpus of terms that are all directly related to influenza in the context of these six journals at the most relevant time. The Cirrus cloud of top 125 words produced from this corpus is more insightful in terms of understanding how state medical journals reported on the Spanish flu (Illustration III.3). The two most prominent terms illustrate key aspects of this disease: the widespread impact that led to the frequent designation of an epidemic and the association with pneumonia, which actually caused most deaths during the epidemic. Other medical terms that appear frequently in the same context as influenza, such as d

III.3

isease(s), patient(s), case(s), and hospital, are not specific to the epidemic. By contrast, the frequency of the term “bacillus” reveals how medical journals used this term to explain the causal agent of the influenza. As will be discussed below, the appearance of the term vaccine(s) among the top 125 words is perhaps the most suggestive aspect of this visualization.

III.5

As suggested above, collocation is a useful tool for understanding the meaning of terms within a particular context. Illustration III.4 shows the terms most commonly collocated with the term influenza across all six state medical journals (Pennsylvania, Virginia, Missouri, Indiana, Kansas, and Kentucky). As was evident in the Cirrus cloud discussed above, the most frequent terms include seemingly obvious terms, such as case(s), epidemic, disease(s), and pneumonia. Yet here again, the frequency of the term vaccine(s) is notable, as it suggests that the state medical journals often reported on influenza and vaccines in the same context.

The relative importance of these terms can be documented by seeing the frequency of terms in the context of vaccination (using the truncated term, vaccin*, which includes both vaccine and vaccination). Illustration III.5 identifies medical terms most frequently collocated with vaccin’*, indicating that influenza was the most common term, followed by typhus, with pneumonia, small pox, and tetanus appearing less frequently.

III.6

Illustration III.6 compares how frequently the nine most common disease terms were collocated with vaccin* in the entire corpus of the six state medical journals for 1918-1919. The fact that “influenza” appears most commonly across this corpus indicates that discussion of vaccines during this two year period across these six journals was very much about the influenza — even though no effective vaccination against influenza was available at the time.

Table III.1

This approach has the potential to offer new ways to interpret sample texts extracted from a very large corpus. Starting with the 60,000 words identified as the context for the term influenza across these six medical journals, it then becomes possible to identify contextual phrases surrounding the term “vaccin*” These phrases were then classified as having a positive or negative statement about vaccination, or a meaning that is either neutral or indecipherable. Approximately 20% of the nearly 300 phrases could be identified as either negative or positive; a sample are listed in table III.1 below.  These phrases suggest some important issues related to vaccines during the 1918 Spanish flu, including questions about therapeutic benefits, the quest for preventions and cures, and safety of serums. Terms such as reliability, results, investigation, evidence, recommendations, and laboratory suggest the ways that medical journals engaged the scientific method in testing vaccines. Yet removing these phrases from their context, both in terms of complete sentences or paragraphs and the date and journal title, as well as the additional problems associated with optical character recognition and text encoding, makes these interpretations more suggestive than conclusive. In this sense, the digital humanities tools are more valuable for identifying important phrases and patterns, but actual interpretation of historical significance requires more traditional methods of close reading and analysis.

State medical journals can also be used to examine trends in keywords. Medical Heritage

III.7

Library and the Internet Archive make it possible to examine several volumes of the same journal over a period of years by entering the url’s. Illustration III.7 shows the distribution of the term “influenza” each year from 1916 to 1922, a six year period with several years on either side of the 1918-1919 epidemic for state medical journals from Indiana, Missouri, and Kansas. As clearly indicated in this chart, all three journals provided little reporting on influenza in 1916 and 1917, the years prior to the Spanish influenza epidemic. The frequency of influenza in the Journal of the Indiana State Medical Association increased sharply in 1918. By contrast, the Journal of the Missouri State Medical Association and Journal of the Kansas Medical Society showed slight increases in 1918, followed by much greater increases in 1919. The frequency of influenza decrease in all three journals in 1920, and by 1922, had decreased so only slightly higher rates as were reported in 1916. This distribution of terms suggests two important interpretations of how the medical profession responded to the Spanish influenza: first, the epidemic prompted a period of intense attention to the disease, as reflected by the fact that almost 60% of the times “influenza” appeared was in the years 1918-1919, which accounted for less one-third of the seven years covered in this chart. Yet the second interpretation is equally important, as it appears that attention to influenza quickly dissipated after the epidemic ended, at least as measured by the frequency of these keywords.

III.8

A comparison of term frequency between the Journal of the Kansas Medical Society and a newspaper, the Topeka State Journal, available from Chronicling America, provides further evidence of the scholarly value of state medical journals (Illustration III.8). This chart recognizes that the methods of measuring are slightly different: the journal counts all keywords whereas the newspaper counts pages on which the keyword appeared, so the actual count of keywords in the newspaper would likely be higher. Both the state medical journal and the newspaper showed a significant increase in 1918-1919, followed by a gradual decrease over the next several years. Whereas the newspaper showed a dramatic increase in 1918, and almost the same level of reporting in 1919, the increase in term frequency in the journal occurred in 1919, as discussed above. While the newspaper also revealed a decrease in 1920, the relative decrease following the peak of the epidemic was less consistent than the data from the journal, suggesting the possible appearance of advertisements in this popular medium containing the word “influenza.” In each publication, the years 1918-1919 accounted for just over 60% of all the appearances of the term “influenza” in this seven year period.

~This is the second of four guest posts from a class taught by Tom Ewing at Virginia Tech in fall 2017. Read the other parts here: I and III.

Virginia Medical Monthly article

Students enrolled in Virginia Tech’s course, Introduction to Data in Social Context, in fall 2017 were assigned a group project requiring them to complete a case study of a single state during the Spanish influenza using a variety of primary sources. (1) Six states were selected for the groups: Pennsylvania, Virginia, Kentucky, Indiana, Missouri, and Kansas. These states each had a medical journal available from this collection and they were contiguously linked geographically, which allowed for comparisons of regional similarities and differences. The total population of these six states was approximately 20 million, which made up one-fifth of the total United States population (105 million, according to the 1920 census) which means that these states can be considered a broadly representative section of the population. (2) Each group was asked to consider three types of primary sources in preparing their case study: 1) newspapers published in 1918 and available from the Library of Congress Chronicling America collection (3); 2) data from the United States Census on causes of death during the year 1918 (4); and 3) one article from the state medical journal. The assignment was designed to encourage students to think about data as an important aspect of historical analysis, to learn how to find data in original historical documents, and to interpret this data using a combination of written text, visual representations, and oral presentations. The groups spent about four weeks on this project, producing a short presentation (link) and multiple drafts of a short analytical essay.

The six articles from the state medical journals assigned to research teams were selected to illustrate the breadth of reporting on the Spanish influenza available for scholars and students conducting research on the Spanish influenza. (5) The lead article in The Journal of the Indiana State Medical Association in the June 15, 1919 issue, offered a specialized review of bacteriological cultures taken from identified victims of the Spanish influenza. Authored by Virgil H. Moon, a physician in the Department of Pathology at the Indiana University School of Medicine, this article was apparently written for the expert readers of this medical journal, thus demonstrating how medical journals provided a forum for circulating research within the profession with the goal of advancing knowledge about causes of disease. The fact that this article was first presented to the Marion County Medical Society on December 3, 1918 provides further evidence of how state medical journals contributed to the circulation of expert knowledge, as a paper initially presented orally to colleagues became part of the published record available to the medical community throughout Indiana — and now available digitally to scholars and students.

An article published in the Virginia Medical Monthly in December 1918, written by Doctor H. U. Stephenson, also sought to use the forum of a medical journal to spread knowledge about the Spanish influenza. (6) In this article, Dr. Stephenson used his own record of treating influenza patients to make broad claims about the effectiveness of an anti-influenza vaccine. This article suggests that state medical journals also functioned as a way for individual physicians to share their experiences with colleagues and thus disseminate knowledge gained through direct medical practice. In this case, the fact that the article appeared in December 1918, within weeks of the peak of the influenza epidemic, illustrates how state medical journals provided timely reporting on the experience of physicians in ways that might be most useful for the profession. In addition, the fact that Dr. Stephenson practiced in a small town in a rural part of the state indicates that the journal served the function of connecting medical professionals located in a variety of locations that may not have otherwise been served by a medical society or medical school in close proximity.

Journal of the Kansas Medical Society article

Also in December 1918, the Pennsylvania Medical Journal re-published a letter that had first appeared in the Philadelphia Evening Ledger on October 22, 1918, written by Marion E. Smith, Superintendent of University Hospital. (7) The letter, published soon after Philadelphia experienced the most deadly stage of the influenza epidemic, expressed heartfelt gratitude to the entire staff of the hospital for their dedication to patients, colleagues, and the community. Publishing this letter from the newspaper in the state medical journal brought the experience of this hospital to the attention of the broader medical profession in Pennsylvania while also providing historians with a vivid first-hand description of the impact of the disease on medical professionals including nurses, housekeepers, and cooks at a major urban hospital.

In December 1918, the Journal of the Kansas Medical Society published a report on
Spanish influenza at the University of Kansas authored by Noble P. Sherwood of the Department of Bacteriology. (8) The article, published less than two months after the epidemic hit the campus, provided a detailed account of the epidemic, including the number of patients,, leading to the conclusion that the prompt and extensive treatment offered by hospital and university staff explained the “comparatively low death rate.” Articles that examines the course of the disease within a particular community, often written by those with direct experience during the epidemic, provided colleagues with detailed descriptions of patients, physicians, nurses, and hospitals, that can now be used by scholars and students to document both the impact of the influenza and the ways that medical professionals at the time devised, and evaluated, treatment options.

In March 1919, approximately six months after the epidemic, the Journal of the Missouri State Medical Association published a short article about the influenza epidemic at Jefferson Barracks, authored by Major Louis M. Warfield, which provided a detailed account of the number of cases and deaths and the measures taken by the hospital staff. (9) Major Warfield presented this information at the December 9, 1918 meeting of the Missouri State Medical Association, and the version published in the state medical journal included the discussion that followed at the meeting, with extensive comments from one speaker identified only as Dr. Dock. The publication of papers from the state medical association meetings, and particularly the discussions that followed, reveal the important role of state medical journals in promoting scholarly and scientific exchanges within the medical profession, particularly during and immediately after an unexpected and costly health crisis. For historians, these exchanges are especially valuable because they illustrate the evolution of professional understanding of this disease and the measures taken to treat patients.

Kentucky Medical Journal article

In December 1918, the Kentucky Medical Journal published an editorial with the title, “The Influenza Epidemic in Kentucky,” which traced the disease from the first outbreak near the city of Bowling Green following a visit by a battalion of troops on their way to Camp Zachary Taylor. (10) After examining several similar examples of rapid and extensive disease transmission, the editorial concluded with recommendations to prevent similar outbreaks in the future, including a lengthy excerpt from recommendations by the Health Commission of New York. This editorial demonstrates the value of state medical journals for understanding the scope and scale of a disease outbreak within a particular state as well as the important role of journals in re-printing materials from other journals, thus ensuring they reached the important audience of medical practitioners affiliated with state medical associations.

Footnotes

1. The syllabus for this course is available here: http://ethomasewing.org/idisc_f17/.

2. Statistical Abstract of the United States, 1918 (Washington: Government Printing Office, 1919 Table 23: Population of the United States at Each Census, 1790-1920, with Estimates for July 1, 1918 pp. 30-31.

3.  Chronicling America allows for keyword searching by state, which makes it easy to select states with daily newspapers for 1918: https://chroniclingamerica.loc.gov/

4. Mortality Statistics 1918. Nineteenth Annual Report (Washington: Government Printing Office, 1920) Table 8: Deaths (Exclusive of Stillbirths) in the Registration Area…From Each Cause and Class of Causes, by Age of Decedent, 1918, pp. 294-431.

5. Virgil H. Moon, “A Consideration of the Bacteriology and Pathology of the Epidemic of Influenza,” The Journal of the Indiana State Medical Association, Vol. 12, No. 6 (June 15, 1919) pp. 149-152. The student researchers were Stephen Balani, Hannah Brown, Tighe Chemidlin, Jenny Ramsey, and Dylan Waddell.

6. H. U. Stephenson, “Treatment of Pneumonia,” Virginia Medical Monthly, Vol. 45, No. 9, December 1918, p. 240. The student researchers were Larry Hensley, Cece Burgher, Kayla Mizelle, and Grant Ferreri.

7. Marion E. Smith, “How One Hospital Faced the Strain,” Pennsylvania Medical Journal, Vol. 22, No. 3 (December 1918), p. 161. The student researchers were Akhil Mahanti, Devin Holler, Joshua Mosier, Luis Rodriguez, and Zach Polhemus.

8. Noble P. Sherwood, “Spanish Influenza at the University of Kansas,” Journal of the Kansas Medical Society, Vol. 18, No. 12 (December 1918), pp. 294-295. The student researchers were Iulia Voina, Renata Pena, Natille Medawar, Sophia Rademaker.

9. Louis M. Warfield, “The Influenza Epidemic at Jefferson Barracks,” Journal of the Missouri State Medical Association, Vol. 16, No. 3 (March 1919) pp. 100-101. The student researchers were Jessica Beggs, Joseph Ha, Ally Madsen, and Sarah Shinton.

10. “The Influenza Epidemic in Kentucky,” Kentucky Medical Journal, Vol. 16, No. 12 (December 1918), pp. 533-535. The student researchers were Jaime Wheaton, Carly Rettie, Lisa Davis, and Brighid Castello.

~This is the first of four guest posts from a class taught by Tom Ewing at Virginia Tech in fall 2017. Read the other posts here: II and III.

The Spanish Influenza of 1918 demonstrates the unique scholarly value of the state medical journal collection from the Medical Heritage Library (link). The Spanish flu affected the entire United States (as well as the world) in ways that challenged the current state of medical knowledge, required mobilization of all available resources, and shaped future understanding of epidemic influenza. State medical journals were part of this history, as they disseminated expert knowledge, reported on cases, and evaluated the impact of the disease on communities and the medical profession at the local and state level.

Illustration I.1

Illustration I.2

The state medical journal collection in Medical Heritage Library includes journals from 34 states for the years 1918-1919 (See Table I.1.) The available states are marked in the map below (Illustration I.1); in the online version, available here, each state is linked to the journal’s page in Medical Heritage Library and the Internet Archive. In most cases, these two years were published as two separate volumes; in some cases, years were combined or the volumes covered part of a year. Most journals include a table of contents for each volume, which allows searching by author, topic, or article title. The full text search feature in Medical Heritage Library allows for broader searches for keywords. A search for the word, “influenza” in the state medical journal collection for the years 1918-1919 produces 35 results from 21 titles. This search across all titles is less complete than searching individual titles; the Virginia Medical Monthly, for example, does not yield results in the search across the collection even though this keyword appears more than one hundred times in the combined 1918-1919 volume. The “search inside” function of the Internet archive makes it possible to search within a specific volume of each medical journal, as shown in the example for the Journal of the Iowa State Medical Society (Illustration I.2). Because this search is for keywords, however, it highlights every instance of the word appearing, which then requires a review of each page to determine relevance.

State medical journals provide insights into key questions about the 1918 Spanish influenza epidemic related to the severity of the epidemic, the extent of cases and deaths, and the potential effectiveness of preventive measures. The journals are especially valuable for addressing this question because they wrote from a position of authority, their audience included physicians as well as public health officials, and the monthly format allowed for some distance to evaluate the effectiveness of specific measures. The editorials that most journals published each month are an especially useful source for understanding how professionals understood the epidemic and what measures, if any, they recommended to deal with this threat to public health. These editorials can be located using the full text search for each journal or by reviewing each month during the epidemic, as the editorials usually appear in the same location of each issue of the journal. A review of editorials from a small sample of journals suggests important common themes as well as distinctive perspectives on the disease.

In October 1918, the Texas State Journal of Medicine published an editorial that began with the statement, “Influenza is now epidemic in every State east of the Mississippi and in many Western and Pacific Coast States. At this writing, seventy-seven counties in Texas have reported influenza as epidemic.”(1) After reviewing the number of cases reported across Texas, the editorial offered this sweeping criticism of public health readiness to deal with the epidemic: “The present crisis emphasizes the utterly unprepared condition of our communities. We have no surplus hospital facilities, even in our municipal institutions, and our health department is so poorly financed as to have no material assistance to offer. Added to this is our present shortage of doctors and nurses.” The editorial reviewed current understanding of disease transmission and then concluded with a lengthy quotation form the Journal of the American Medical Association based on a physician’s first-hand study of cases at a Massachusetts military base.

The Journal of the South Carolina Medical Association also published an editorial, signed by J. Heyard Gibbs, in its October 1918 issue, which also began with a statement of the scope and severity of the epidemic: “At present time the physicians of South Carolina, in common with members of the profession generally throughout the country, are having their mental and physical energies taxed to the utmost through the unprecedented demands made upon them by the prevailing epidemic of influenza.” (2) The demands of military service had deprived many communities of doctors and nurses, but the editorial praised those who serve the population of South Carolina: “The physicians generally have responded in heroic fashion to the increased demands made upon them, and lay women have exhibited a commendable spirit in their desire to aid in the nursing of these patients.” After an extensive review of symptoms, the editorial provided an outline of recommended treatments for individual patients, including rest in bed, simple diet, and measures directed to relief of symptoms. The editorial concluded with a prediction of a lengthy period of epidemic disease — although with no mention of the likely scale of deaths: “Each of our communities may look forward to approximately six weeks of an active epidemic, the disease usually requiring from two to three weeks to reach its height and a corresponding length of time for the decline. But at the end of this time we shall not be through with our difficulties. We shall probably have epidemic influenza throughout the winter months, and we cannot give too much attention to our preparation for handling this disease.”

An editorial, also with the simple title, “Influenza,” in the Illinois Medical Journal in December 1918, began with a frank admission of the limited understanding of the disease even after two months of epidemic conditions: “The fact that a well informed medical man will make a clear positive statement regarding the disease and immediately another well informed medical man disputes the truth of such a statement and takes an exactly opposite view, indicates that really there is little known about it.” (3) After reviewing conflicting opinions from doctors and other experts about the value of quarantine, masks, and vaccines, the editorial came to the same conclusion as other journals about the limits of knowledge even after several months of dealing with the epidemic: “The reading of the influenza literature which has appeared until now, thoroughly convinces one that comparatively little is known about it. Many statements now widely published will be subjects of ridicule shortly….The wearing of face masks in hospitals when done intelligently is probably advantageous, but really the recommendation of a face mask for a pedestrian or charwoman is about equal in intelligence to that of advising a manipulation of the spine.”

In November 1918, the California State Journal of Medicine published an editorial stating that “Epidemic influenza has reached the Pacific Coast in its pandemic progress from Eastern Europe around the world.” (4) After reviewing the history of epidemic influenza as well as the death rates from related diseases, especially pneumonia, in past and current epidemics, the editorial cautiously predicted that “there is reason for believing that this mortality will be lower in California.” After reviewing specific symptoms of the current disease, the editorial connected the limited knowledge about the disease to the need for a cautious approach among medical professionals: “No specific treatment for influenza is available but because of the near-hysteria attending the popular interest in this epidemic, numerous sure-cures are receiving publicity in both medical and lay circles. Physicians should be conservative, yet open-minded, on this subject.” The editorial offered a detailed description of the “most successful symptomatic treatment,” which included salicylic acid, high fluid intake, rest, good diet, and attention to complications. Asserting that “prophylaxis is of utmost importance,” the editorial offered this confident statement: “Absolute quarantine will prevent introduction of influenza,” including hanging sheets between hospital beds, making doctors, nurses, and attendants wear masks at all times, careful washing of hands, use of disposable tissues in place of handkerchiefs, and finally a series of steps easily implemented by the public: “Prophylaxis should include sufficient sleep, rest, open air, and sunshine. Crowded street cars and indoor gatherings of all sorts must be eschewed. Sneezing or coughing without the face protected by a handkerchief is a sanitary crime. Spitting should be similarly repressed. Gauze masks should be worn in public by all persons where influenza is epidemic.”

An editorial in the November 1918 issue of Northwest Medicine, serving the states of Oregon, Washington, Idaho, and Utah, reported that the cities of the Northwest had also experienced “the full effect of the influenza epidemic which progressed with great speed from the Atlantic coast.” (5) The impact of the “influenza scourge” has been felt most severely in army camps, but also in among civilian populations, with “the most appalling feature” being the high death rates from pneumonia, leading to this evaluative comment: From a medical standpoint te most appalling feature of the epidemic has been the fatalities from a form of pneumonia with which the average practitioner was totally unfamiliar. In spite of all efforts to check its advances, in many cases the medical attendant has been practically helpless in face of the rapid and unopposed progress to a fatality.” The fact that “the epidemic appears to have created less havoc in the cities of this section” led the journal to praise the prophylactic measures, such as closing schools, churches, theatres, and other places of assembly, implemented by public health officials and generally accepted by the population: “The few individual objectors to wearing of gauze masks and other sanitary provisions have been negligible in comparison with the unanimous compliance with the stringent requirements to check the spread of the disease.” The editorial concluded that these measures had been generally successful in the Northwest states, even as it looked forward to the end of the epidemic: “The fact that the epidemic appears to have created less havoc in the cities of this section than in some others in the country would lead one to place some confidence in the effectiveness of these various measures of prophylaxis which were enforced with considerable degree of severity. At this time it appears that the epidemic is wearing itself out and it is hoped that it will soon be a thing of the past.”

An examination of these five editorials across journals provides some sense of how medical professionals made sense of an unprecedented challenge to public health. The influenza in 1918 seemed familiar, yet the mortality associated with this epidemic, particularly from pneumonia, puzzled physicians and medical researchers. The prophylactic measures were generally endorsed by the medical journals even as they acknowledged the limits of such measures. These editorials suggest that the editorial staff of medical journals, like the profession more generally and indeed the nation as a whole, looked ahead to the end of the epidemic even as they admitted that the disease was poorly understood and thus difficult to control in the present or prevent in the future.

Footnotes

1. Editorial, Texas State Journal of Medicine, Vol. 14, No. 6 (October 1918) pp. 217-218 (link).
2. “Influenza,” Editorial, The Journal of the South Carolina Medical Association, Vol. 14, No. 10 (October 1918) pp. 247-248 (link).
3. “Influenza,” Editorial, Illinois Medical Journal, Vol. 34, No. 6, December 1918, pp. 337-338 (link).
4. “Influenza,” Editorial, California State Journal of Medicine, Vol. 16, No. 11 (November 1918), pp. 479-481 (link)
5. “The Influenza Scourge,” Northwest Medicine, Vol. 17, No. 11, November 1918, p. 320 (link).