Circulating Now welcomes guest blogger E. Thomas Ewing, PhD, Professor of History and Associate Dean in the College of Liberal Arts and Human Sciences at Virginia Polytechnic Institute and State University. Professor Ewing offers a comparison of health recommendations during the Spanish Influenza epidemic of 1918 and today.
The term “flattening the curve” circulated widely in early 2020 to explain the important social distancing measures to control the spread of COVID-19. Did medical experts during the 1918 epidemic also understand the concept of “flattening the curve”? An article by the eminent physician, Dr. James Herrick in 1919, suggests that this strategy was part of the public health response to that historic epidemic. First published in the Journal of the American Medical Association in 1919 and then reprinted as a brochure available from the National Library of Medicine’s digital collection, this article illustrates how a leading physician drew on direct experience treating influenza during the epidemic to educate the medical community and the public about this disease. Herrick’s record directing the influenza ward of Presbyterian Hospital in Chicago can be evaluated using statistics from its Annual Report. Herrick’s article also reveals how a leading medical researcher understood treatment options and made recommendations still relevant in the present.
Herrick’s approach to “flattening the curve” began with “segregation of those who are ill” and “prohibiting public gatherings” to “lessen the number of contact infections.” Such measures “lessen the rapidity of the spread of the disease by lessening the concentration of exposures.” He argued that steps to limit contact within the population, such as prohibiting meetings, should “spread the disease more thinly over a longer space of time.” Such measures may also “postpone” the spread of the disease “until such time as the less virulent type is prevalent.” Herrick’s conclusion directly anticipates similar outcomes predicted as a result of social distancing in 2020: “By this diluent action fewer fatalities may result.” These are “desirable ends, and so these measures are to be encouraged.” Herrick’s description was thus consistent with the public health measures implemented in Chicago in 1918, which may have contributed to lower death rates, and certainly anticipate current discussions on how to “flatten the curve” in response to Covid-19.
A Fight Against the 1918 Epidemic
Did Presbyterian Hospital succeed in “flattening the curve”? Its 1918 Annual Report claims that “positive action was taken” as soon as “it became evident” that influenza “was spreading through the city.” Early in October, at a time when the number of deaths was still low, the Chicago Health Department ordered that hospitals isolate all influenza patients, prohibited family visits, and required attending nurses to wear masks. With all “ordinary cases” removed from the entire floor of the Jones Memorial Building devoted to influenza and all surgical cases, except emergencies, postponed or cancelled, the hospital “settled down to a fight against the pandemic.” Many nurses fell ill, as many as six a day, with the total reaching eighty-three during the epidemic. Only one nurse, Gladys Foster, “a senior pupil of much promise, could not rally.” Kitchen and laundry staff also fell ill, which “crippled” the hospital. In the early days of the epidemic, many cases were “desperate when received, generally with serious pneumonia, and for a few days the mortality was large.” As the epidemic progressed, however, “we were fortunate in saving practically all that came to us.”
The Annual Report provides striking statistical evidence of a successful response to the epidemic: 9,852 patients admitted and 293 deaths, for a rate of approximately 3% in 1918. This rate was similar to the 3% death rate reported in 1916, 1917, 1919, and. The Annual Report’s concession that “mortality was large” suggests that any spike in deaths was temporary, and may have been offset by decreases in mortality at other times, although the data is not detailed enough to make that judgment. The claim of only one death from influenza is repeated in Herrick’s article, which does provide some credibility to this striking claim.
Dr. James Herrick was among the best known American physicians of the early twentieth century, whose most important contribution was discovery of sickle cell anemia in a West Indies patient, Walter Clement Noel, published in 1910. Given his prominence in medical fields seemingly distant from respiratory diseases, the fact that Herrick took charge of the influenza ward in fall 1918 confirms the remarkable danger presented by this epidemic. The title of the article, “Treatment of Influenza by Means Other Than Vaccines and Serums,” is certainly suggestive of the situation in spring 2020, as health officials, doctors, and the public figure out how to deal with a new viral threat without either vaccines or treatments specific to the disease. In fact, Herrick conceded that physicians treating influenza have “no generally accepted plan of treatment” and “no one remedy of sovereign value.” The “one feature of the treatment of influenza on which all agree” was having patients rest until fever, cough, and other symptoms have disappeared. Herrick also recommended a “sunlit room, plenty of fresh air and light diet with a liberal amount of liquids.” Most influenza patients, according to Herrick, “do not need a single dose of medicine,” as treatment is “really expectant, symptomatic, and individualistic.” Given current debates about treatments and preventives for Covid-19, Herrick’s warning to professional colleagues will sound familiar: “The self-restraint of the level-headed physician is likely to be swept aside by the thought of the possible grave consequences of the malady, and his accustomed good judgement is apt to be smothered in the semi hysterical atmosphere of alarm that pervades the community during the visitations of the epidemic.”
At Presbyterian Hospital, “no prophylactic vaccine or use of serum” was used for any patients, who instead were treated with rest and liquids. Offering a pointed commentary on professional rivalries and public clamor, Herrick wrote: “I have wondered whether if I had used some vaccine or serum or other supposed specific I might not now be eager to get into print with my record of only 0.6 per cent mortality.” Instead of rushing into print, Herrick declared his satisfaction with “knowing that no lives were taken by drugs” and that “cautious conservatism gave Nature a chance to work a cure.” Where drugs were used to treat symptoms, Herrick found that digitalis was the “remedy that seemed of greatest value,” averting “dangerous or even fatal heart failure,” with nausea as the only side effect. Herrick found that the next most helpful treatment, however, was opium, administered as heroin or codeine, to alleviate “pain, sleeplessness and severe cough.” Other successful treatments included camphorated oil, epinephrin and, in Herrick’s own words, “I think I saved one life by bleeding.”
Herrick’s words are certainly worth remembering today:
“One ought not to be a nihilist as regards drugs in this disease; but no apology is needed for being a good deal of a skeptic as to the value of much of the therapy that is prevalent…How much harm may be done by overdrugging no one can estimate. But the danger is real and not imaginary.”
Even with his cautions about preventives and treatments, and even after the epidemic took 8,000 lives in Chicago in just eight weeks, Herrick seems confident that his profession had taken the proper steps, learned the correct lessons, and succeeded in their mission. Understanding Herrick’s perspective illustrates how medical history can inform understanding of preventive measures, treatment options, and the importance of accurate statistics today.
Dr. Ewing’s research in the historical collections of the National Library of Medicine includes using new methods of analyzing textual information to discover information about public health communication. In April 2020, students in his course Topics in the History of Data in Social Context presented a symposium Reporting, Recording, and Remembering the 1918 Influenza Epidemic sponsored by the NLM History of Medicine Division in cooperation with the National Endowment (NEH) for the Humanities Office of Digital Humanities-as part of the ongoing NLM/NEH partnership to collaborate on research, education, and career initiatives. Follow Dr. Ewing on Twitter at @EThomasEwing.