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Spanish Flu

By: History.com Editors

Updated: May 10, 2023 | Original: October 12, 2010

The Spanish flu pandemic of 1918-1919 was the deadliest pandemic in world history, infecting some 500 million people across the globe—roughly one-third of the population—and causing up to 50 million deaths, including some 675,000 deaths in the United States alone. The disease, caused by a new variant of the influenza virus, was spread in part by troop movements during World War I . Though the flu pandemic hit much of Europe during the war, news reports from Spain weren’t subject to wartime censorship, so the misnomer “Spanish flu” entered common usage. With no vaccines or effective treatments, the pandemic caused massive social disruption: Schools, theaters, churches and businesses were forced to close, citizens were ordered to wear masks and bodies piled up in makeshift morgues before the virus ended its deadly worldwide march in early 1920.

What Is the Flu?

Influenza , or flu, is a virus that attacks the respiratory system. The flu virus is highly contagious: When an infected person coughs, sneezes or talks, respiratory droplets are generated and transmitted into the air, and can then can be inhaled by anyone nearby.

Additionally, a person who touches something with the virus on it and then touches his or her mouth, eyes or nose can become infected.

Did you know? During the flu pandemic of 1918, the New York City health commissioner tried to slow the transmission of the flu by ordering businesses to open and close on staggered shifts to avoid overcrowding on the subways.

Flu outbreaks happen every year and vary in severity, depending in part on what type of virus is spreading. (Flu viruses can rapidly mutate.)

In the United States, “flu season” generally runs from late fall into spring. In a typical year, more than 200,000 Americans are hospitalized for flu-related complications, and over the past three decades, there have been some 3,000 to 49,000 flu-related U.S. deaths annually, according to the Centers for Disease Control and Prevention .

Young children, people over age 65, pregnant women and people with certain medical conditions, such as asthma, diabetes or heart disease, face a higher risk of flu-related complications, including pneumonia, ear and sinus infections and bronchitis.

Why the 1918 Flu Pandemic Never Really Ended

After infecting millions of people worldwide, the 1918 flu strain shifted—and then stuck around.

Why Was It Called the ‘Spanish Flu?’

The 1918 influenza pandemic did not, as many people believed, originate in Spain.

How the Flu Pandemic Changed Halloween in 1918

Officials feared Halloween celebrations could spread the virus or disrupt those who were sick or mourning.

A flu pandemic, such as the one in 1918, occurs when an especially virulent new influenza strain for which there’s little or no immunity appears and spreads quickly from person to person around the globe.

Spanish Flu Symptoms

The first wave of the 1918 pandemic occurred in the spring and was generally mild. The sick, who experienced such typical flu symptoms as chills, fever and fatigue, usually recovered after several days, and the number of reported deaths was low.

However, a second, highly contagious wave of influenza appeared with a vengeance in the fall of that same year. Victims died within hours or days of developing symptoms, their skin turning blue and their lungs filling with fluid that caused them to suffocate. In just one year, 1918, the average life expectancy in America plummeted by a dozen years.

What Caused the Spanish Flu?

It’s unknown exactly where the particular strain of influenza that caused the pandemic came from; however, the 1918 flu was first observed in Europe, America and areas of Asia before spreading to almost every other part of the planet within a matter of months.

Despite the fact that the 1918 flu wasn’t isolated to one place, it became known around the world as the Spanish flu, as Spain was hit hard by the disease and was not subject to the wartime news blackouts that affected other European countries. (Even Spain's king, Alfonso XIII, reportedly contracted the flu.)

One unusual aspect of the 1918 flu was that it struck down many previously healthy, young people—a group normally resistant to this type of infectious illness—including a number of World War I servicemen.

In fact, more U.S. soldiers died from the 1918 flu than were killed in battle during the war. Forty percent of the U.S. Navy was hit with the flu, while 36 percent of the Army became ill, and troops moving around the world in crowded ships and trains helped to spread the killer virus.

Although the death toll attributed to the Spanish flu is often estimated at 20 million to 50 million victims worldwide, other estimates run as high as 100 million victims —around 3 percent of the world’s population.  The exact numbers are impossible to know due to a lack of medical record-keeping in many places.

What is known, however, is that few locations were immune to the 1918 flu—in America, victims ranged from residents of major cities to those of remote Alaskan communities. Even President Woodrow Wilson reportedly contracted the flu in early 1919 while negotiating the Treaty of Versailles , which ended World War I.

Why Was The Spanish Flu Called The Spanish Flu?

The Spanish Flu did not originate in Spain , though news coverage of it did. During World War I, Spain was a neutral country with free media that covered the outbreak from the start, first reporting on it in Madrid in late May of 1918. Meanwhile, Allied countries and the Central Powers had wartime censors who covered up news of the flu to keep morale high. Because Spanish news sources were the only ones reporting on the flu, many believed it originated there (the Spanish, meanwhile, believed the virus came from France and called it the “French Flu.”)

Where Did The Spanish Flu Come From?

Scientists still do not know for sure where the Spanish Flu originated, though theories point to France, China, Britain, or the United States, where the first known case was reported at Camp Funston in Fort Riley, Kansas, on March 11, 1918.

Some believe infected soldiers spread the disease to other military camps across the country, then brought it overseas. In March 1918, 84,000 American soldiers headed across the Atlantic and were followed by 118,000 more the following month.

Fighting the Spanish Flu

When the 1918 flu hit, doctors and scientists were unsure what caused it or how to treat it. Unlike today, there were no effective vaccines or antivirals, drugs that treat the flu. (The first licensed flu vaccine appeared in America in the 1940s. By the following decade, vaccine manufacturers could routinely produce vaccines that would help control and prevent future pandemics.)

Complicating matters was the fact that World War I had left parts of America with a shortage of physicians and other health workers. And of the available medical personnel in the U.S., many came down with the flu themselves.

Additionally, hospitals in some areas were so overloaded with flu patients that schools, private homes and other buildings had to be converted into makeshift hospitals, some of which were staffed by medical students.

Officials in some communities imposed quarantines, ordered citizens to wear masks and shut down public places, including schools, churches and theaters. People were advised to avoid shaking hands and to stay indoors, libraries put a halt on lending books and regulations were passed banning spitting.

According to The New York Times , during the pandemic, Boy Scouts in New York City approached people they’d seen spitting on the street and gave them cards that read: “You are in violation of the Sanitary Code.”

Aspirin Poisoning and the Flu

With no cure for the flu, many doctors prescribed medication that they felt would alleviate symptoms… including aspirin , which had been trademarked by Bayer in 1899—a patent that expired in 1917, meaning new companies were able to produce the drug during the Spanish Flu epidemic. 

Before the spike in deaths attributed to the Spanish Flu in 1918, the U.S. Surgeon General, Navy and the Journal of the American Medical Association  had all recommended the use of aspirin. Medical professionals advised patients to take up to 30 grams per day, a dose now known to be toxic. (For comparison’s sake, the medical consensus today is that doses above four grams are unsafe.) Symptoms of aspirin poisoning include hyperventilation and pulmonary edema, or the buildup of fluid in the lungs, and it’s now believed that many of the October deaths were actually caused or hastened by aspirin poisoning.

The Flu Takes Heavy Toll on Society

The flu took a heavy human toll, wiping out entire families and leaving countless widows and orphans in its wake. Funeral parlors were overwhelmed and bodies piled up. Many people had to dig graves for their own family members.

The flu was also detrimental to the economy. In the United States, businesses were forced to shut down because so many employees were sick. Basic services such as mail delivery and garbage collection were hindered due to flu-stricken workers.

In some places there weren’t enough farm workers to harvest crops. Even state and local health departments closed for business, hampering efforts to chronicle the spread of the 1918 flu and provide the public with answers about it.

How U.S. Cities Tried to Stop The 1918 Flu Pandemic

A devastating second wave of the Spanish Flu hit American shores in the summer of 1918, as returning soldiers infected with the disease spread it to the general population—especially in densely-crowded cities. Without a vaccine or approved treatment plan, it fell to local mayors and healthy officials to improvise plans to safeguard the safety of their citizens. With pressure to appear patriotic during wartime and with a censored media downplaying the disease’s spread, many made tragic decisions.

How U.S. Cities Tried to Halt the Spread of the 1918 Spanish Flu

How U.S. city officials responded to the 1918 pandemic played a critical role in how many residents lived—and died.

Why African Americans Were More Likely to Die During the 1918 Flu Pandemic

Most hospitals turned them away—or sent them to the basement for treatment.

When the US Government Tried to Fast‑Track a Flu Vaccine

More than a quarter of the nation was inoculated in 1976 for a pandemic that never materialized.

Philadelphia’s response was too little, too late. Dr. Wilmer Krusen, director of Public Health and Charities for the city, insisted mounting fatalities were not the “Spanish flu,” but rather just the normal flu. So on September 28, the city went forward with a Liberty Loan parade attended by tens of thousands of Philadelphians, spreading the disease like wildfire. In just 10 days, over 1,000 Philadelphians were dead, with another 200,000 sick. Only then did the city close saloons and theaters. By March 1919, over 15,000 citizens of Philadelphia had lost their lives.

St. Louis, Missouri, was different: Schools and movie theaters closed and public gatherings were banned. Consequently, the peak mortality rate in St. Louis was just one-eighth of Philadelphia’s death rate during the peak of the pandemic.

Citizens in San Francisco were fined $5—a significant sum at the time—if they were caught in public without masks and charged with disturbing the peace.

Spanish Flu Pandemic Ends

By the summer of 1919, the flu pandemic came to an end, as those that were infected either died or developed immunity.

Almost 90 years later, in 2008, researchers announced they’d discovered what made the 1918 flu so deadly: A group of three genes enabled the virus to weaken a victim’s bronchial tubes and lungs and clear the way for bacterial pneumonia.

Since 1918, there have been several other influenza pandemics, although none as deadly. A flu pandemic from 1957 to 1958 killed around 2 million people worldwide, including some 70,000 people in the United States, and a pandemic from 1968 to 1969 killed approximately 1 million people, including some 34,000 Americans.

More than 12,000 Americans perished during the H1N1 (or “swine flu”) pandemic that occurred from 2009 to 2010. The COVID-19 pandemic , which started in December 2019, spread around the world before an effective COVID-19 vaccine was made available in December 2020. By May of 2023, when the World Health Organization declared an end to the global coronavirus emergency, almost 7 million people had died of COVID-19.

Each of these modern day pandemics brings renewed interest in and attention to the Spanish Flu, or “forgotten pandemic,” so-named because its spread was overshadowed by the deadliness of World War I and covered up by news blackouts and poor record-keeping.

Salicylates and Pandemic Influenza Mortality, 1918–1919 Pharmacology, Pathology, and Historic Evidence. Clinical Infectious Diseases .

In 1918 Pandemic, Another Possible Killer: Aspirin. The New York Times.

How the Horrific 1918 Flu Spread Across America. Smithsonian Magazine.

What the Spanish Flu Debacle Can Teach Us About Coronavirus. Politico .

WHO declares end to Covid global health emergency. NBC News .

COVID-19 Dashboard. WHO .

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Influenza (“Spanish Flu” Pandemic, 1918-19)

By Thomas Wirth | Reader-Nominated Topic

As World War I drew to a close in November 1918, the influenza virus that took the lives of an estimated 50 million people worldwide in 1918 and 1919 began its deadly ascent. The United States had faced flu pandemic before, in 1889-90 for example, but the 1918 strain represented an altogether new and aggressive mutation that proved unusually resistant to human attempts to curb its lethality. The devastating effects of the virus, known today as H1N1, were first felt in late summer 1918 along the eastern seaboard in a military encampment outside of Boston. From there, influenza propagated ruthlessly across the country, claiming nearly 700,000 lives before running its course in the spring and summer of 1919.

The pandemic hit Philadelphia exceptionally hard after sailors, carrying the virus from Boston, arrived at the Philadelphia Navy Yard in early September 1918. In a city of almost two million people, a half a million or more contracted influenza over the next six months. Equally as startling, over 16,000 perished during this period, with an estimated 12,000 deaths occurring in little more than five weeks between late September and early November 1918. Historians and epidemiologists have identified several critical factors that shaped Philadelphia’s experience with influenza and help explain the peculiarly rapid and catastrophic spread of disease.

First, a severe shortage of medical personnel rendered the city partially defenseless against the pandemic. More than 25 percent of Philadelphia’s doctors, some 850 total, and an even greater share of its nurses were occupied with the war effort. In 1917 and 1918, three-quarters of the staff of Pennsylvania Hospital at Eighth and Spruce Streets was stationed at the Red Cross Base Hospital 10 in Le Tréport, France. Over two dozen physicians, fifty nurses, and nearly 200 aid workers with hospital training were called overseas, depriving the city of a skilled group of men and women on the eve of the pandemic. The absence of vital medical support made the difficult task of containing the flu and healing the sick even more challenging once the virus migrated from the military camps—including the Navy Yard, Camp Dix in New Jersey, and Camp Meade in Maryland—to the civilian population in late September.

Overcrowding’s Toll

The increased demand for labor during the war also compounded matters. While Philadelphia enjoyed a fantastic boom in employment in its shipbuilding, munitions, and steel industries, overcrowding turned the city’s well-documented but often ignored housing deficiencies into a legitimate public health crisis. As African American migrants from the Jim Crow South and immigrants from eastern and southern Europe fled their miserable circumstances in search of a better life, many found the opportunities gained in Philadelphia came at the price of their health and safety. Cramped, dilapidated, and unsanitary living quarters in places like the Seventh Ward —home to a third of the city’s African Americans in 1918—made the slums and tenement districts a fertile source for influenza.

If the city’s execrable living conditions and depleted medical corps made suppressing influenza difficult, its unabated proliferation in the fall of 1918 likely had its origins in the response of city health officials who drastically underestimated the flu’s potency. On September 21, just days after 600 sailors at the Navy Yard fell ill and the first civilian flu cases were confirmed, Philadelphia’s major newspapers reported that Dr. Paul A. Lewis of the Henry Phipps Institute at the University of Pennsylvania had determined the cause of the disease—a bacteria known as Pfeiffer’s B. influenzae. The Philadelphia Inquirer wrote that Lewis’s findings had now “armed the medical profession with absolute knowledge on which to base its campaign against the disease.”

The city’s top health administrators concurred and yet promptly contradicted their own best advice for staving off the grippe: avoid crowds. With virtually no resistance from the city’s leading public health officials at the Department of Public Health and Charities, a rally for the Fourth Liberty Loan Campaign brought 200,000 Philadelphians together into the city’s streets on September 28. A concert at Willow Grove Park featured the music of John Philip Sousa, stoking patriotic fire. Philadelphia raised $600 million in war bonds as a result, but this success immediately revealed a Faustian bargain. Within three days of the event, 635 new civilian cases of influenza signaled the beginning of the single most deadly period of pestilence ever recorded in the city’s history.

Influenza tore through Philadelphia at a ferocious pace in October and early November. During the second week of October 2,600 people succumbed to the flu, and the following week saw that number nearly double. Though the disease knew no gender, racial, or ethnic boundaries, infecting black and white men and women at an equally high rate, the city’s immigrant poor suffered hard. Those born of foreign parents in the Russian, Hungarian, and Italian communities, among others, died at a higher rate, with some 1,500 more total deaths than those born to American mothers. In a war time atmosphere on the eve of the Red Scare, immigrants were the primary target of inflamed nativist sentiment. Public health officials and private citizens alike scrutinized the personal hygiene habits of the foreign born and often linked insalubrious tendencies to the supposedly questionable morals associated with “alien” cultures. One “disgusted woman” wrote to the Public Ledger in October 1918 demanding that “don’t-spit signs be placed in our post-office building in all languages necessary, to reach all foreign men, and with fines for violations.” The city set fines for spitting at $2.50 and in one day, October 23, the Evening Bulletin reported 114 arrests.

Deluge of Corpses

As death stalked the city, unembalmed bodies piled up by the dozens in a lone morgue at Thirteenth and Wood Streets. The extreme circumstances of the pandemic also meant, however, that many bodies simply rotted for days in the streets. Eventually five makeshift morgues, including one at a cold-storage facility on Cambridge and Twentieth Streets, were established to meet the deluge of corpses. Cemeteries lacked the space and manpower to adequately bury the dead, too. At Holy Cross Cemetery in Lansdowne seminarians turned grave-diggers took in an average of 200 bodies a day in October and deposited hundreds of coffins into a large common grave. “On one occasion,” recalled Reverend Thomas C. Brennan of St. Charles Borromeo Seminary, “the students worked on this task until 10:30 p.m. by the light of the October full moon, the long rows of coffins in the trench presenting a weird and impressive picture in the moonlight.”

Those attempting to care for the living at Philadelphia General Hospital on Thirty-Fourth Street faced similarly overwhelming circumstances. Already at its capacity of 2,000 patients when the virus struck, the hospital had to find room for 1,400 more people as it peaked in mid-October. With hospitals inundated and facing a shortage of medical staff, volunteers were culled from religious organizations, civic associations, and, most prominently, the city’s medical and nursing schools. Across Philadelphia these men and women turned parish houses and armories into temporary emergency hospitals, but on the whole extra assistance remained scarce. As one volunteer recalled, “if you asked a neighbor for help, they wouldn’t do so because they weren’t taking any chances…It was a horror-stricken time.”  And yet just as quickly did the horror arrive did it also depart. When 10,000 dosages of a flu vaccine finally arrived in Philadelphia on October 19, the virus was already in the beginning stages of a rapid decline. By the second week of November, deaths caused by influenza and pneumonia were less than a quarter of what they were the week prior, and by the end of the month the death toll had dipped under 100 for the week for the first time since early September. Still, the city’s death rate from influenza, at approximately 407 per 100,000 people, exceeded that of all other American cities in 1918.

Statistics such as these provide a tangible sense of the staggering loss of life that occurred in Philadelphia during this short period, though tell us next to nothing about how influenza inflicted widespread fear and distress across the city. For an instant in the fall of 1918 it was as if Philadelphia had been transported back to the fourteenth century to that grisly time when victims stricken with plague were often found dead within twenty four hours of contracting it. Perhaps the words of the renowned cardiologist Isaac Starr, a third-year medical student at the University of Pennsylvania at the time of the outbreak, came closest to encapsulating the ordeal of late 1918 when he noted simply that it was as if “the life of the city had almost stopped.”

Copyright 2011, University of Pennsylvania Press

Philadelphia Fights Back Against the Epidemic

Special Collections Research Center, Temple University Libraries

To combat the influenza epidemic, Philadelphia enacted an extensive anti-spitting ordinance. Practitioners were unclear about the cause of the flu, but they knew that it was an airborne disease and therefore instituted a public campaign against coughing, sneezing, and spitting in public. The Philadelphia Board of Health posted signs like this one in public places and inside public transport vehicles toward the end of 1918 and distributed pamphlets instructing citizens to use handkerchiefs while coughing. Several public places like churches, shops, and libraries closed, but most that remained open displayed such signs. The city’s ordinance made spitting a criminal offense – those found spitting without covering their mouths were fined $2.50 and sometimes even arrested.

Related Topics

• City of Medicine
• Greater Philadelphia
• Philadelphia and the World

Time Periods

• Twentieth Century to 1945
• South Philadelphia
• Children’s Aid Society of Pennsylvania
• Typhoid Fever and Filtered Water
• World War I
• Board of Health (Philadelphia)
• Philadelphia Navy Yard
• Infectious Diseases and Epidemics
• Coronaviruses

Related Reading

Barry, John M. The Great Influenza: The Epic Story of the Deadliest Plague in History . New York: Viking, 2004.

Brennan, Thomas C. “The Story of the Seminarians and their Relief Work during the Influenza Epidemic.” Records of the American Catholic Historical Society of Philadelphia 30 (2) (June, 1919): 115-177.

Crosby, Alfred W. America’s Forgotten Pandemic: The Influenza of 1918 . New York: Cambridge University Press, 1989.

Hardy, Charles. “ I Remember When: What Became of the Influenza Pandemic of 1918 .” Audio recording, January 18, 1983.

Starr, Isaac. “Influenza in 1918: Recollections of the Epidemic in Philadelphia.” Annals of Internal Medicine 85 (4) (October 1, 1976): 516-518.

Wirth, Thomas. “Urban Neglect: The Environment, Public Health, and Influenza in Philadelphia, 1915-1919,” Pennsylvania History 73 (Summer 2006): 316-42.

Related Collections

• Philadelphia Inquirer, North American, and Public Ledger Newspaper Collections Free Library of Philadelphia 1901 Vine Street, Philadelphia.
• Philadelphia Evening Bulletin newsclipping collection and the Housing Association of the Delaware Valley Records, 1908-1975 Urban Archives, Temple University Libraries 1900 N. Thirteenth Street, Philadelphia.

Related Places

Pennsylvania Hospital , 800 Spruce Street, Philadelphia.

Philadelphia Navy Yard , 5100 S. Broad Street, Philadelphia.

Backgrounders

Connecting Headlines with History

• Fear of the sick stranger (WHYY, November 4, 2014)
• Philadelphia News Coverage of the Epidemic (Influenza Encyclopedia, University of Michigan)
• Newspaper clipping, 1920: "Prohibition guards against influenza" (Drexel University College of Medicine Legacy Center)
• The Deadly Virus (National Archives Online Exhibit)
• American During the 1918 Influenza Epidemic (Exhibit, Digital Public Library of America)

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The Spanish Influenza Pandemic: a lesson from history 100 years after 1918

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Mariano Martini, Department of Health Sciences (DISSAL), University of Genoa, largo R. Benzi, University of Genoa, Italy - Tel/Fax +39 010 35385.02 - E-mail: [email protected]

Received 2019 Jan 15; Accepted 2019 Feb 22; Collection date 2019 Mar.

This is an Open Access article distributed under the terms of the Creative Commons Attribution NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) , which permits for noncommercial use, distribution, and reproduction in any digital medium, provided the original work is properly cited and is not altered in any way. For details, please refer to https://creativecommons.org/licenses/by-nc-nd/4.0/

In Europe in 1918, influenza spread through Spain, France, Great Britain and Italy, causing havoc with military operations during the First World War. The influenza pandemic of 1918 killed more than 50 million people worldwide. In addition, its socioeconomic consequences were huge.

“Spanish flu”, as the infection was dubbed, hit different age-groups, displaying a so-called “W-trend”, typically with two spikes in children and the elderly. However, healthy young adults were also affected.

In order to avoid alarming the public, several local health authorities refused to reveal the numbers of people affected and deaths. Consequently, it was very difficult to assess the impact of the disease at the time.

Although official communications issued by health authorities worldwide expressed certainty about the etiology of the infection, in laboratories it was not always possible to isolate the famous Pfeiffer’s bacillus, which was, at that time, deemed to be the cause of influenza.

The first official preventive actions were implemented in August 1918; these included the obligatory notification of suspected cases and the surveillance of communities such as day-schools, boarding schools and barracks.

Identifying suspected cases through surveillance, and voluntary and/or mandatory quarantine or isolation, enabled the spread of Spanish flu to be curbed. At that time, these public health measures were the only effective weapons against the disease, as no vaccines or antivirals were available.

Virological and bacteriological analysis of preserved samples from infected soldiers and other young people who died during the pandemic period is a major step toward a better understanding of this pandemic and of how to prepare for future pandemics.

Key words: History of Pandemic, Flu, Public Health, Mortality rate

War and disease: the spread of the global influenza pandemic

On March 4, 1918, Albert Gitchel, a cook at Camp Fuston in Kansas, was afflicted by coughing, fever and headaches. His was one of the first established cases in the history of the so-called Spanish flu. Within three weeks, 1100 soldiers had been hospitalized, and thousands more were affected [ 1 ].

In Europe, the disease spread through France, Great Britain, Italy and Spain, causing havoc with First World War military operations. Three quarters of French troops and more than half of British troops fell ill in the spring of 1918. In May, the flu hit North Africa, and then Bombay in India; in June, the first cases were recorded in China, and in July in Australia.

This first wave is not universally regarded as influenza; the symptoms were similar to those of flu, but the illness was too mild and short-lasting, and mortality rates were similar to those seen in seasonal outbreaks of influenza [ 2 ].

In August, a deadly second wave of the Spanish pandemic ensued. This was probably caused by a mutated strain of the virus, which was carried from the port city of Plymouth in south-western England by ships bound for Freetown in Sierra Leone and Boston in the United States. From Boston and Freetown, and from Brest in France, it followed the movements of the armies.

This second wave lasted almost six weeks, spreading from North America to Central and South America, from Freetown to West Africa and South Africa in September, and reaching the Horn of Africa in November. By the end of September, the flu had spread to almost all Europe, including Poland and Russia. From Russia the epidemic spread throughout northern Asia, arrived in India in September, and in October it flared up again in China. In New York, the epidemic was declared to be over on 5th November, while in Europe it persisted, owing to the food and fuel shortages caused by the war. Most cases of illness and death due to the pandemic occurred during the second wave [ 3 ].

Deadly clusters of symptoms were recorded, including nasal hemorrhage, pneumonia, encephalitis, temperatures of up to 40°C, nephritis-like blood-streaked urine, and coma [ 4 ]. While the new virus struck military personnel, influencing war strategies, it did not spare those who lived in privileged conditions, one of the most famous cases being that of the King of Spain, Alfonso XIII, who was certainly not afflicted by the privations of the war.

By December 1918, much of the world was once again flu-free, and in early 1919 Australia lifted its quarantine measures. However, in the austral summer of 1918-1919, more than 12,000 Australians were hit by the third wave of the disease. In the last week of January 1919, the third wave reached New York, and Paris was hit during the post-war peace negotiations. Overall, fewer people were affected by the disease during the final influenza wave. Nevertheless, mortality rates are believed to have been just as high as during the second wave [ 5 ]. In May 1919, this third pandemic was declared finished in the northern hemisphere. In Japan, however, the third epidemic broke out at the end of 1919 and ended in 1920.

Looking for the Spanish flu bacillus

Although official communications issued by health authorities worldwide expressed certainty about the etiology of the infection, in laboratories it was not always possible to isolate the famous Pfeiffer’s bacillus, the Haemophilus influenzae bacterium first identified by the renowned German biologist in the nasal mucus of a patient in 1889, which, at the time, was considered to be the causal agent of influenza [ 6 ]. In October 1918, Nicolle and Lebailly, scientists at the Pasteur institute, first advanced the hypothesis that the pathogen responsible for the flu was an infectious agent of infinitesimal dimensions: a virus. Its immuno-pathological effects transiently increased susceptibility to ultimately lethal secondary bacterial pneumonia and other co-infections, such as measles and malaria, or co-morbidities such as malnutrition or obesity [ 7 , 8 ].

The Spanish flu hit different age-groups, displaying a so-called “W-trend”, with infections typically peaking in children and the elderly, with an intermediate spike in healthy young adults. In these last cases, lack of pre-existing virus-specific and/or cross-reactive antibodies and cellular immunity probably contributed to the high attack rate and rapid spread of the 1918 H1N1 virus, and to that “cytokine storm” which ultimately destroyed the lungs.

Only in 1930 was the flu pandemic rightly attributed to a virus, and in 1933 the first human influenza virus was isolated [ 9 ].

Public health measures to control the disease

There was no cure for the disease; it could only be fought with symptomatic treatments and improvised remedies. Moreover, the return of soldiers from the war fronts, the migration of refugees and the mobility of women engaged in extra-domestic activities had favored the rapid spread of the virus since the onset of the first pandemic wave. Preventive public health measures were therefore essential, in order to try to stem the spread of the disease [ 10 ].

The first official preventive measures were implemented in August 1918; these included the obligatory notification of suspected cases, and the surveillance of communities such as day-schools, boarding schools and barracks. In October 1918, local authorities in several European countries strengthened these general provisions by adding further measures, for instance the closure of public meeting places, such as theaters, and the suspension of public meetings. In addition, long church sermons were prohibited and Sunday instruction was to last no more than five minutes.

Street cleaning and the disinfection of public spaces, such as churches, cinemas, theaters and workshops, were considered to be cornerstones in controlling the spread of Spanish flu, in addition to banning crowds outside shops and limiting the number of passengers on public transport. However, they did not prove very effective.

Among public health interventions, local health departments distributed free soap and provided clean water for the less wealthy; services for the removal of human waste, the regulation of toilets, and the inspection of milk and other food products were organized; spitting in the street was forbidden, which determined the spread of pocket spittoons, and announcements in newspapers and leaflets advertised the therapeutic virtues of water.

To simplify mortuary police services, many administrations in the worst affected centers in Italy set up collection points for corpses and abolished all the rituals that accompanied death.

In addition, identifying cases of illness through surveillance, and voluntary and/or mandatory quarantine or isolation, also helped to curb the spread of Spanish flu, in a period in which no effective vaccines or antivirals were available.

The silence of the press: the censored Spanish flu

As Spain was neutral in the First World War, newspapers there were free to report the devastating effects that the 1918 pandemic virus was having in that country. Thus, it was generally perceived that the pandemic had originated in Spain, and the infection was incorrectly dubbed “Spanish flu” [ 2 ]. During the fall of 1918, the front pages of Spanish newspapers were filled with the names of those who had died of the pandemic in the country [ 2 , 3 ].

In other European countries, however, the press refrained from reporting news of the spreading infection, in order to avoid alarming the general population, which was already suffering the privations caused by the First World War. On 22 nd August 1918, the Italian Interior Minister denied the alarming reports of the spread of the flu pandemic, and in the following months, both national and international newspapers followed suit. Nor was censorship restricted to news of the spread of the fearsome infection; it also extended to information and comments that contrasted with the official versions of the nature of the disease.

In order to avoid public alarm, several local hygiene authorities refused to reveal the numbers of people affected and deaths [ 11 ]. Moreover, it was announced that the average duration of the epidemic did not exceed two months. By the middle of October 1918, however, it had become impossible to verify this claim.

Some scientists believed that one of the causes of the epidemic was the poor quality of food, which was rationed at the time of the epidemic crisis. The extent to which the gravity of the pandemic was accentuated by malnutrition among war-tired populations is unclear. However, the fact that the disease, even in serious forms, spread through countries that were neutral or completely uninvolved in the war, such as Spain, seems to suggest that malnutrition was not a key factor.

Another thesis was that the disease had been triggered by a bacteriological war waged by the Austro-German enemy. On the one hand, newspapers were essential to publicizing emergency measures to contain the epidemic, such as closing cinemas and theaters or prohibiting other types of gathering, including funerals. On the other, any mention of the horror that was unfolding was to be avoided. Even sounding death bells was sometimes forbidden, to prevent their continual dismal tolling from revealing the extent of the tragedy that was to be hidden. The unseen enemy mainly attacked young people, causing major social upheaval; if Spanish flu did not take the lives of children, it made them orphans.

A tragic legacy: mortality worldwide

The influenza pandemic of 1918 killed more than 50 million people and caused more than 500 million infections worldwide. In the military camps and trenches during the First World War, the influenza pandemic struck millions of soldiers all over the world, causing the deaths of 100,000 troops. However, it is not clear whether it had an impact on the course of the war [ 12 ]. The highest morbidity rate was among the Americans in France, during the Meuse-Argonne offensive on the Western Front from September 15 to November 15, 1918, when over one million men of the US Army fell sick [ 12 ].

General understanding of the healthcare burden imposed by influenza infections was unclear. Several factors were suspected of increasing the risk of severe flu: length of service in the army, ethnicity, dirty dishes, flies, dust, overcrowding and the weather. In overcrowded camps, the risk of flu, and its principal complication, pneumonia, increased 10-fold [ 13 ]. Bacterial pneumonia secondary to influenza was the overwhelming cause of death, owing to increased susceptibility due to transient immuno-pathological effects and dysregulated, pathological cellular immune responses to infections [ 14 , 15 ].

It is difficult to ascertain the mortality rate of the pandemic, as data on deaths were transmitted in incomplete form to the Central Statistical Office. In Italy, the “Albo d’oro” collected documentation on the number and demographic characteristics of the soldiers who died during the conflict, which enabled more accurate data to be obtained on deaths due to influenza among military personnel [ 16 ].

Military nurses and medical officers were intensively and repeatedly exposed to the influenza A (H1N1) pandemic strain in many areas. However, during the lethal second wave, nurses and medical officers of the Australian Army, and other groups of healthcare workers, displayed influenza-related illness rates similar to those of other occupational groups, and mortality rates that were actually lower. These findings suggest that the occupational group most intensively exposed to the pandemic strain had relatively low influenza-related pneumonia mortality rates [ 17 , 18 ]. The dynamic relationship between the host and the influenza virus during infection, the unusual epidemiological features and the host-specific properties that contributed to the severity of the disease in the pandemic period still remain unknown [ 19 , 20 ].

Conclusions

The 1918 pandemic influenza was a global health catastrophe, determining one of the highest mortality rates due to an infectious disease in history.

Virological analysis of preserved samples from infected soldiers and others who died during the pandemic period is a major step toward a better understanding of this pandemic. Such knowledge may contribute to the discovery of new drugs and the development of preventive strategies, including insights into the appropriate timing of the administration of antivirals and/or antibiotics, thereby providing indications on how to prepare for future pandemics.

The 1918-1919 pandemic led to enormous improvements in public health. Indeed, several strategies, such as health education, isolation, sanitation and surveillance, improved our knowledge of the transmission of influenza, and are still implemented today to stem the spread of a disease that has a heavy burden.

Acknowledgments

Funding sources: this research did not receive any specific grant from funding agencies in the public, commercial, or non-profit sectors.

Conflict of interest statement

None declared.

Authors’ contributions

MM and IB conceived the study, MM and IB drafted the manuscript, VG and NB revised the manuscript. IB, MM, VG and NB performed a search of the literature. All authors critically revised the manuscript. All authors have read and approved the latest version of the manuscript.

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The Spanish Influenza 1918-1920: Devastating for Public Health Essay

Introduction, government and health organizations response, role of influencing factors.

In 1918, the world saw the spread of one of the deadliest global pandemics in history known as the Spanish Influenza. The H1N1 virus was unique as it predominately affected young individuals. The origin of the virus remains unknown to this day, but many believe it to have originated in America, eventually spreading to Europe and Asia (Reid et al., 1999). Due to the lack of vaccinations and effective treatments, the number of flu cases skyrocketed, resulting in devastating public health consequences.

To address this, pandemic health and government officials had to take unprecedented measures and develop new means of containing the inter-community spread of the virus. Public authorities attempted to prevent the transmission of the influenza virus by enforcing quarantine, public education, and the creation of new regulations for public spaces.

The Spanish Influenza was a global pandemic lasting from 1918 up to 1920. It infected at least 500 million people, causing acute illness for 25-30% of the world’s population, resulting in an estimated 40 million deaths (Taubenberger, 2006). Sequencing the virus has been a challenging undertaking by several researchers during the 20th century. Eventually, the technology helped identify that the H1N1 influenza virus caused the Spanish Influenza with genes derived from avian-like and swine influenza virus strains. The specific 1918 H1N1 genome was unique, resulting in a mortality rate of 5-20% higher than usual for influenza, due to a higher proportion of complications of infection in the respiratory tract rather than other organ systems (Taubenberger, 2006).

The infected experienced typical flu symptoms of fatigue, fever, and chills, but as the disease became more deadly, victims began to die in a matter of days, if not hours, with observed cyanosis and fluid filling the lungs. An unusually young age group was most affected by the mortality rate, with many children and healthy young or middle-aged adults dying. Furthermore, waves of influenza activity exacerbated the public health problem, which resulted in three outbreaks in one year that is highly unusual (Taubenberger, 2006).

There are multiple hypotheses regarding the origin of the Spanish Influenza. Historians such as Alfred Crosby (2003) suggested the virus originated in Kansas, U.S.A. One of the first reported cases of the virus had been diagnosed on March 11, 1918, in Fort Riley, with unsanitary conditions leading to outbreaks in the city and later other military installments in the United States. Later, researchers suggested that the Kansas outbreak was much milder, but the study suggested the virus still had North American origins with reassortment occurring in 1915 (Worobey et al., 2019).

Another hypothesis suggests that the source was in China since the country was one of the least affected by the pandemic, supposedly due to the already acquired immunity. Historians argued that the spread occurred through either Chinese immigration to the United States, eventually shifting to Europe, or due to thousands of Chinese laborers behind the frontlines in Europe. However, this theory also seems to have been disapproved, suggesting the epidemic was circulating Europe months if not years before the pandemic began (Worobey et al., 2019).

A major troop camp and hospital for the U.K. in Étaples, France is also considered, if not the origin, then an epicenter of the outbreak. The overcrowded location was ideal for the spread of the virus, and more than 100,000 soldiers passed through the camp as well as having live poultry and pigs for provisions (Worobey et al., 2019). Historians believe that the virus was circulating in European armies, with Étaples serving as the epicenter of the further outbreak in Europe (Worobey et al., 2019).

In either of these scenarios, one of the critical factors of the outbreak was the ongoing World War I at the time, which created optimal conditions in war-torn cities and army installments for the spread of the virus. Furthermore, no matter if the virus originated in the U.S., Europe, or China, it was virally spread through the world most likely as a result of troop transportation and supply chains to the frontlines from virtually all regions of the globe (Erkoreka, 2009).

The first wave of the outbreak in the spring of 1918 was seasonal benign influenza, and only by spreading to the frontlines of WWI, it became a much viral and devastating disease by the fall of 1918, inextricably linked to the soldiers and their conditions. The combination of an international mix of populations in Western Europe, poor quality of life and infrastructure, destruction of war, and numerous other injuries and corpse decay were human factors that may have contributed to transmission. Ecological factors included climate and exposure to elements, as well as an agglomeration of humans contacting with animals, and each other contributed to the extremely high virulence of the Spanish Influenza (Erkoreka, 2009).

At the time, medicine in its present form was only beginning to develop, encouraged by World War I. There were no vaccines and lab tests, with governments and healthcare facilities relying on observations and autopsies to determine the disease and eventual cause of death (Barry, 2020). Meanwhile, government officials had to utilize non-pharmaceutical interventions to manage the disease and prevent transmission, such as imposing quarantine and limits on public gatherings. In general, cities experienced worse outbreaks than rural areas, and there were notable differences at times between infection and mortality rates in various cities (Strochlic & Champine, 2020).

The death rate of St. Louis (385 per 100,000) was half that of Philadelphia (807 per 100,000), one of the hardest-hit cities of North America. American cities responded with restrictions rapidly. New York City, having reacted earliest and with most stringent methods of virtually closing its borders, imposing mandatory quarantines, and regulating strict closures and controls for public gatherings, had one of the lowest mortality rates in the world (Strochlic & Champine, 2020).

Cities that implemented preventive measures early on had up to 50% lower mortality rates than those that did so later or not at all. Furthermore, statistics show that early relaxation of intervention measures could lead to secondary waves of outbreaks and relapses of a stabilizing city, as occurred in St. Louis that relaxed rules after two months (Strochlic & Champine, 2020).

The public health response implemented by New York City will be discussed in this paper as one of the most successful locales to mitigate the 1918 pandemic. NYC approached the epidemic by taking advantage of its robust public health infrastructure, which helped prevent the spread of contagion and increase disease surveillance capacities alongside a large-scale health education campaign (Aimone, 2010).

The city had some experience with epidemics such as tuberculosis in recent history at the time and suggested that public health infrastructure plays a critical role in shaping practices and policies during a health crisis. The city officials declared a modified maritime quarantine, almost a month before the first cases appeared in the city as well as partial land-based quarantine. For New York, one of the busiest seaports, this was significant (Aimone, 2010).

The city utilized its infrastructure by converting various gymnasia, armories, and other facilities into temporary hospitals for the duration of the epidemic. The surveillance capacity for new cases increased through stringent health inspections and physician reporting. The local health department increased its surveillance capacity by utilizing independent inspectors and nongovernmental organizations (Aimone, 2010).

New policies and regulations were explicitly developed for public places to ensure cleanliness. The city made sure to sterilize public infrastructure, such as water fountains. Meanwhiles, public places such as theaters remained open in order to reach a greater population with information about preventive methods. Still, they were forced to adhere to strict regulations and inspections to ensure sanitation (Aimone, 2010).

Other countries, such as Europe, Spain, and the U.K. often imposed similar measures. The rigidity and compliance with these regulations depended on the authority of local governments or health departments. Unfortunately, the measures had only mild effects due to lack of medical treatment and war-time censorship (Martini et al., 2019). These factors resulted in distrust for the government and actions it was implemented to control the pandemic (Martini et al., 2019).

Socio-Cultural

Social factors played an important role regarding the transmission and response to the 1918 influenza pandemic. Similar to modern-day, social distancing was a persistent recommendation by governments around the world at the time. In combination with the strict measures described previously, health officials hoped it would reduce the spread of disease. Social and public health education was unusually prevalent in major cities such as New York, where posters and pamphlets were distributed. While schools remained open, children were educated about the disease and informed of safe health practices to prevent transmission.

Sanitary codes were put into place and enforced throughout American cities (Aimone, 2010). Fines were issued for citizens that did not follow social distancing guidelines and practiced dangerous behaviors such as spitting in public or coughing without covering their faces. Many wore handmade protective masks. New York also established 150 emergency districts that helped manage health service distribution and manage home care and case reporting. Business hours were regulated by the board of health timetables to prevent crowding in public transit and streets (Aimone, 2010).

As discussed earlier, World War I was ongoing when the 1918 pandemic emerged. Governments strongly relied on both domestic economies turned towards war efforts as well as the well-being of their troops. Despite such prevalent death tolls of influenza, it is often overlooked in history in relation to that time. People had little to no understanding of disease and virus contagious. Meanwhile, governments in many places chose to hide or obstruct the fact that there was an ongoing pandemic in order not to upend the war effort (Martini et al., 2019). Governments imposed press censorship in most of the countries involved in WWI, such as Germany, the U.K., France, and the U.S.A.

In many locales, authorities refused to reveal epidemiological statistics and mortality rates, resulting in widespread mistrust of the government since populations were openly devastated by the disease. The 1918 flu pandemic has got its name, the “Spanish Influenza,” due to significant press coverage in Spain which was neutral in the war and did not instill censorship (Martini et al., 2019). Moreover, Spain arguably was taking the most aggressive actions in containing the pathogen (Martini et al., 2019).

Healthcare and Medical

People knew very little about influenza at the time, and many scientists accepted that the Pfeiffer’s bacillus bacteria were the cause. Germ theory by Robert Koch, based on the findings of the French biologist Louis Pasteur in the 1850s, made a connection that disease was caused by micro-organisms (Tognotti, 2003). However, this theory was highly controversial at the time and had no proof. Richard Pfeiffer identified the pathogenic influenza agent in a bacterium, Haemophilus influenza. Researchers attempted to test if the Pfeiffer’s bacillus was the cause of Spanish Influenza. Since they were unable to reject the theory, it remains unknown whether the bacterium had any role (Tognotti, 2003).

However, viruses, unlike bacteria, could not be seen through an optical microscope, although some research existed regarding their role in disease, yet nobody suspected it could be causing the flu. The modern genome classification of the remaining samples showed it was the H1N1 virus. Even so, antibiotics were not discovered until almost a decade later to treat infections accompanying the flu, and hospitals had limited treatment options (Kassraie, 2020).

Significance

In light of the ongoing COVID-19 pandemic, the Spanish Influenza has become a common reference point as the most recent historical pandemic of such global magnitude, drawing numerous parallels. Response by authorities tends to follow similar patterns to identify and prevent transmission. During the infamous bubonic plague in the Middle Ages, patients were put in isolation and encouraged to take precautions. However, there was a large lack of knowledge and awareness about the transmission that resulted in at least a third of the European population being wiped out and continuing pockets of outbreaks for close to 2 centuries (Hsieh et al., 2006).

As evident, during the Spanish Influenza pandemic, governments adopted similar measures with more improved recommendations and stricter enforcement that were based on knowledge of medical science at the time.

Nevertheless, there are eerie parallels between the current COVID-19 pandemic and the Spanish Influenza. In 2020, many of the same approaches help prevent the spread of the virus in a global pandemic (WHO, 2020). Similar to other pandemics, the COVID-19 outbreak sees identical measures. Once the virus began to show spread, areas affected by the virus, especially its origin and epicenter of Wuhan, China, were put into lockdown.

All people, except for those who had the essential professions, were ordered to stay at home. The sick, once tested and identified, were put into isolation (BBC, 2020). To enforce these measures, many countries have increased surveillance and law enforcement capacity. Public events are canceled to minimize person-to-person contact in public gatherings (BBC, 2020). Notably, many countries took these strong measures to prevent transmission too late, when community spread has already been initiated. This resulted in several new epicenters of disease arising and a tremendous peak in cases.

Evidently, approaches used by authorities largely remain the same as the Spanish Influenza, with the emphasis being put on modern medicine and vaccination research to prevent widespread infection and deaths. Public authorities, both in 1918 and today, attempt to prevent the transmission of the influenza virus by enforcing quarantine, public education, and the creation of new regulations for public spaces. Since the risk of influenza and future pandemics is expected, governments and health organizations should invest in effective influenza vaccines and medications as well as take a more competent approach in recognizing outbreaks and limiting their transmission (Hsieh et al., 2006).

One of the main lessons, according to historian John Barry, is that in a pandemic, one has to tell the truth in a public health setting, something that governments have failed to do in the current crisis (Barry, 2020). The COVID-19 outbreak is similar in many ways to the Spanish Influenza, and once the disease passes, there will be significant research and reviews on the ongoing situation. It is necessary to learn from historic, albeit devastating events such as these to develop new methods of response and management, particularly in a modern globalized world.

Aimone, F. (2010). The 1918 influenza epidemic in New York City: A review of the public health response . Public Health Reports (1974-), 125 , 71-79. Web.

Barry, J. M. (2020). The single most important lesson from the 1918 influenza . The New York Times . Web.

BBC. (2020). Coronavirus: How are lockdowns and other measures being enforced? BBC News. Web.

Crosby, A. W. (2003). America’s forgotten pandemic: The influenza of 1918 . Cambridge University Press.

Erkoreka, A. (2009). Origins of the Spanish Influenza pandemic (1918-1920) and its relation to the First World War. Journal of Molecular and Genetic Medicine, 3 (2). Web.

Hsieh, Y. C., Wu, T. Z., Liu, D. P., Shao, P. L., Chang, L. Y., Lu, C. Y., … Huang, L. M. (2006). Influenza pandemics: Past, present and future . Journal of the Formosan Medical Association, 105 (1), 1-6. Web.

Kassraie, A. (2020). Spanish Flu: How America fought a pandemic a century ago . AARP . Web.

Martini, M., Gazzaniga, V., Bragazzi, N. L., & Barberis, I. (2019). The Spanish Influenza Pandemic: A lesson from history 100 years after 1918 . Journal of Preventive Medicine and Hygiene, 60 (1), E64–E67. Web.

Reid, A., Fanning, T., Hultin, J., & Taubenberger, J. (1999). Origin and evolution of the 1918 “Spanish” Influenza virus hemagglutinin gene. Proceedings of the National Academy of Sciences of the United States of America, 96 (4), 1651-1656. Web.

Strochlic, N., & Champine, R.D. (2020). How some cities ‘flattened the curve’ during the 1918 flu pandemic. National Geographic . Web.

Taunbenberger, J. K. (2006). The origin and virulence of the 1918 “Spanish” influenza virus. Proceedings of the American Philosophical Society, 150(1), 86-112. Web.

Tognotti, E. (2003). Scientific triumphalism and learning from facts: Bacteriology and the “Spanish flu” challenge of 1918. Social History of Medicine, 16 (1), 97–110. Web.

World Health Organization. (2020). Report of the WHO-China joint mission on coronavirus disease 2019 . Web.

Worobey, M., Cox, J., & Gill, D. (2019). The origins of the great pandemic. Evolution, Medicine, and Public Health, 2019 (1), 18–25. Web.

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Lesson Plan: Lessons Learned from the 1918 Influenza Pandemic

The 1918 Spanish Flu Pandemic

Historian Nancy Bristow talked about the 1918 influenza pandemic and how it devastated American communities and soldiers during World War I. She explained how this version of the flu was different than previous seasonal versions of the flu at the time.

Description

In 1918, a strain of influenza spread throughout the globe causing 50 million deaths worldwide. Sometimes referred to as the Spanish Flu, this pandemic was unique in its severity and the segments of the population that were affected. This lesson has students hear from historians, scientists and doctors to explore the factors that led to the spread of the disease. With this information, students will develop a list of lessons that can be learned from the 1918 influenza pandemic.

Before beginning class, have the students brainstorm answers to the following questions. Address any misconceptions that student may have about the flu and early 1900s.

• Describe what you know about the flu and how it usually spreads. What are ways that are used to prevent it?
• Describe what was occurring around the world in 1918.

INTRODUCTORY VOCABULARY:

Have the students either define each of the following terms in their own words or provide them with a brief overview of these terms. This vocabulary will be used through the video clips included in this lesson.

• Public Health

INTRODUCTION:

After students have an understanding of the vocabulary terms mentioned above, have them view the following video clip that provides an overview of the 1918 Spanish Flu. Student should answer the questions provided to focus their viewing.

VIDEO CLIP 1: The 1918 Spanish Flu Pandemic (5:15)

What is the common belief about the origin of the 1918 influenza pandemic?

How did World War I help intensify the spread of the Spanish Flu?

How did the Spanish Flu affect certain age groups differently than previous flus? Why was this significant to society?

Describe the symptoms of the Spanish Flu.

• What factors led to the Spanish Flu having a significant impact on society in the United States?

EXPLORATION:

Provide students with the 1918 Influenza Pandemic Handout. Students should watch the video clips provided below to complete the graphic organizer. Students will take notes on the factors that contributed to the spread of the flu and actions taken to stop the spread of the flu.

HANDOUT: 1918 Influenza Pandemic (Google Doc)

VIDEO CLIPS:

VIDEO CLIP 2: The Outbreak of the 1918 Influenza Pandemic (1:52)

VIDEO CLIP 3: The Spanish Flu and World War I (1:49)

VIDEO CLIP 4: Social and Cultural Norms during the 1918 Influenza Pandemic (4:23)

VIDEO CLIP 5: The Spread of 1918 Spanish Flu in Urban Areas (4:01)

VIDEO CLIP 6: Remembering the 1918 Influenza Pandemic (2:33)

• VIDEO CLIP 7: Lessons Learned from the 1918 Spanish Flu Pandemic (2:30)

APPLICATION AND CONCLUSION:

After students have completed their graphic organizer, have them develop a list of 3-5 lessons learned or recommendations that can be taken from the 1918 pandemic. For each, they should explain how these lessons or recommendations could prevent the spread of similar pandemics in the future.

EXTENSION/ALTERNATIVE ACTIVITIES:

Oral Histories: Using the Department of Health and Human Service documentary, We Heard the Bells, The Influenza of 1918 , choose one of the people from the film who witnessed the 1918 pandemic. Provide a summary of their experiences and explain how their story relates to some of the factors that contributed to the spread of the flu.

1918 Influenza Pandemic Memorial- As Professor Bristow mentioned in the video clip, there is not a national memorial to honor the victims of the 1918 influenza pandemic. Using the information provided in the clips and outside research, design a memorial that commemorates the pandemic. In addition to creating a design for the memorial, provide an explanation of where you would locate the memorial and how this memorial symbolizes the 1918 pandemic.

ADDITIONAL PROMPTS:

Should the federal government take a more active role in preventing epidemics and pandemics?

How did World War I contribute to the spread of the Spanish Flu?

How did the Spanish Flu impact World War I?

In what ways did the social and racial divisions impact the severity of the 1918 influenza?

• Why do you think the 1918 influenza pandemic is not remembered as much as other events?

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• World War I

Social and Economic Impacts of the 1918 Influenza Epidemic

India lost 16.7 million people. Five hundred and fifty thousand died in the US. Spain’s death rate was low, but the disease was called “Spanish flu” because the press there was first to report it.

A n estimated 40 million people, or 2.1 percent of the global population, died in the Great Influenza Pandemic of 1918–20. If a similar pandemic occurred today, it would result in 150 million deaths worldwide. In The Coronavirus and the Great Influenza Pandemic: Lessons from the “Spanish Flu” for the Coronavirus’s Potential Effects on Mortality and Economic Activity (NBER Working Paper 26866 ), Robert J. Barro , José F. Ursúa , and Joanna Weng study the cross-country differences in the death rate associated with the virus outbreak, and the associated impacts on economic activity.

The flu spread in three waves: the first in the spring of 1918, the second and most deadly from September 1918 to January 1919, and the third from February 1919 through the end of the year. The first two waves were intensified by the final years of World War I; the authors work to distinguish the effect of the flu on the death rate from the effect of the war. The flu was particularly deadly for young adults without pre-existing conditions, which increased its economic impact relative to a disease that mostly affects the very young and the very old.

The researchers analyze mortality data from more than 40 countries, accounting for 92 percent of the world’s population in 1918 and an even larger share of its GDP. The mortality rate varied from 0.3 percent in Australia, which imposed a quarantine in 1918, to 5.8 percent in Kenya and 5.2 percent in India, which lost 16.7 million people over the three years of the pandemic. The flu killed 550,000 in the United States, or 0.5 percent of the population. In Spain, 300,000 died for a death rate of 1.4 percent, around average. There is no consensus as to where the flu originated; it became associated with Spain because the press there was first to report it.

There is little reliable data on how many people were infected by the virus. The most common estimate, one third of the population, is based on a 1919 study of 11 US cities; it may not be representative of the US population, let alone the global population.

The researchers estimate that in the typical country, the pandemic reduced real per capita GDP by 6 percent and private consumption by 8 percent, declines comparable to those seen in the Great Recession of 2008–2009. In the United States, the flu’s toll was much lower: a 1.5 percent decline in GDP and a 2.1 percent drop in consumption.

The decline in economic activity combined with elevated inflation resulted in large declines in the real returns on stocks and short-term government bonds. For example, countries experiencing the average death rate of 2 percent saw real stock returns drop by 26 percentage points. The estimated drop in the United States was much smaller, 7 percentage points.

The researchers note that “the probability that COVID-19 reaches anything close to the Great Influenza Pandemic seems remote, given advances in public health care and measures that are being taken to mitigate propagation.” They note, however, that some of the mitigation efforts that are currently underway, particularly those affecting commerce and travel, are likely to amplify the virus’s impact on economic activity.

In a related study, Non-Pharmaceutical Interventions and Mortality in US Cities during the Great Influenza Pandemic, 1918–19 (NBER Working Paper 27049 ), Robert Barro analyzes data on the mitigation policies pursued by US cities as they confronted the flu epidemic. There were substantial cross-sectional differences in the policies that were adopted. Relative to the average number of flu deaths per week over the course of the epidemic, the number of flu deaths at the peak was lower in cities that pursued more aggressive policies, such as school closing and prohibition of public gatherings. However, the estimated effect of these policies on the total number of deaths was modest and statistically indistinguishable from zero. One potential explanation of this finding is that the interventions had a mean duration of only around one month.

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National Archives News

The Flu Pandemic of 1918

Red Cross workers make anti-influenza masks for soldiers, Boston, Massachusetts. (National Archives Identifier  45499341 )

Before COVID-19, the most severe pandemic in recent history was the 1918 influenza virus, often called “the Spanish Flu.” The virus infected roughly 500 million people—one-third of the world’s population—and caused  50 million deaths worldwide (double the number of deaths in World War I). In the United States, a quarter of the population caught the virus, 675,000 died, and life expectancy dropped by 12 years. With no vaccine to protect against the virus, people were urged to isolate, quarantine, practice good personal hygiene, and limit social interaction. Until February 2020, the 1918 epidemic was largely overlooked in the teaching of American history, despite the ample documentation at the National Archives and elsewhere of the disease and its devastation. The 100-year-old pictures from 1918 that just months ago seemed quaint and dated now seem oddly prescient. We make these records more widely available in hopes that they contain lessons about what to expect over the coming months and ideas about ways to avoid a repeat and prepare for what may follow.

Online Exhibit

A selection of photographs and documents from the National Archives' nationwide holdings tell the story of the 1918 influenza pandemic.

Photographs

(Click image to view gallery)

Images from the 1918 Flu Pandemic

Female clerks in New York City wear masks at work. (National Archives Identifier  45499337 )

Department of the Navy: Precautions Against Influenza. (National Archives Identifier 6861947 )

Traffic "cop" in New York City wearing gauze mask. (National Archives Identifier 45499301 ) 

New York City "conductorettes" wearing masks. (National Archives Identifier 45499323 )

Letter carrier in New York City wearing mask. (National Archives Identifier 45499319 )

To prevent the spread of Spanish Influenza, Cincinnati barbers are wearing masks. (National Archives Identifier 45499317 )

Additional Photographs

• Red Cross volunteer nurses in Eureka, CA
• Red Cross Women’s Motor Corps aids injured patients
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Author Lecture

Dr. Jeremy Brown, Director of Emergency Care Research, National Institutes of Health, spoke about his book Influenza: The Hundred-Year Hunt to Cure the Deadliest Disease in History, at the National Archives in Washington, DC, on March 5, 2019.

Archival Film

Nurses make bandages for flu epidemic (stock newsreel footage from CBS)

Blogs and Social Media Posts

Forward with Roosevelt: One of the Millions: FDR and the Flu Pandemic of 1918–1920

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For Educators

Influenza Directive from DC re: treatment and procedures , 9/26/1918

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Memo Re: Sanitary Precautions, 9/12/1918  

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At the Presidential Libraries

Truman Library:  Letter from Harry to Bess , referencing the influenza epidemic, and expressing relief that Bess has recovered from it.

Ford Library:  Remarks Upon the Signing of National Swine Flu Immunization Program of 1976

Ford Library:  President Asks Congress for $135 Million for Swine Flu Vaccine Ford Library:  Fact Sheet on Swine Influenza Immunization Program

George W. Bush Library:  Pandemic Flu: Preparing and Protecting against Avian Influenza

Barack Obama Library:  Declaration of Nat’l Emergency - 2009 H1N1 Influenza Pandemic

Barack Obama Library:  Press Briefing On Swine Influenza

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Spanish Flu Pandemic of 1918

The deadliest virus in modern history, perhaps of all time, was the 1918 Spanish Flu. It killed about 20 to 50 million people worldwide, perhaps more. The total death toll is unknown because medical records were not kept in many areas.

The pandemic hit during World War I and devastated military troops. In the United States, for instance, more servicemen were killed from the flu than from the war itself. The Spanish flu was fatal to a higher proportion of young adults than most flu viruses.

The pandemic started mildly, in the spring of 1918, but was followed by a much more severe wave in the fall of 1918. The war likely contributed to the devastating mortality numbers, as large outbreaks occurred in military forces living in close quarters. Poor nutrition and the unsanitary conditions of war camps had an effect.

A third wave occurred in the winter and spring of 1919, and a fourth, smaller wave occurred in a few areas in spring 1920. Initial symptoms of the flu were typical: sore throat, headache, and fever. The flu often progressed rapidly to cause severe pneumonia and sometimes hemorrhage in the lungs and mucus membranes. A characteristic feature of severe cases of the Spanish Flu was heliotrope cyanosis, where the patient’s face turned blue from lack of oxygen in the cells. Death usually followed within hours or days.

Modern medicine such as vaccines, antivirals, and antibiotics for secondary infections were not available at that time, so medical personnel couldn’t do much more than try to relieve symptoms.

The flu ended when it had infected enough people that those who were susceptible had either died or developed immunity.

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Home — Essay Samples — Nursing & Health — Influenza — Understanding the Impact of the 1918 Spanish Flu Epidemic

Understanding The Impact of The 1918 Spanish Flu Epidemic

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The 1918 Spanish Flu

Before the 20 th  century, the world had experienced some of the deadliest pandemics in its history. For example, the world experienced the sixth cholera pandemic (1910-1911), which claimed more than 800,000 persons, the flu pandemic (1889-1890), which killed about 1 million persons globally, and the third cholera pandemic (1852-1860), which also killed close to 1 million persons globally (MPH online, 2021). However, at the start of the 20 th  century, the world experienced one of the deadliest pandemics in its history. The Spanish Flu, also known as the1918 influenza pandemic, or the Great Influenza pandemic, remains one of the most significant pandemics that hit the globe in the 20 th  century. According to Taubenberger and Morens (2006), the Flu was caused by the H1N1 virus. During the pandemic (1918-1919), more than 500 million people globally were infected (about a third of the world’s population during that time) (Taubenberger & Morens, 2006). Generally, due to the number of persons who got infected and succumbed to the virus, the pandemic was considered the deadliest pandemic in the 20 th  century.

The mystery surrounding the origin of the virus remains unsolved up to date. Some medical historians aiming to explain the source of the virus had theorized that the virus might have originated from Asia, particularly in China, because China had experienced a lethal outbreak of a pulmonary disease before the pandemic began. The medical historians suggest that the virus might have spread to other parts of the world through the migration of Vietnamese or Chinese laborers working in France or traversing through the United States of America (Barry, 2004). On the other hand, a British scientist J.S. Oxford hypothesized that the virus might have originated in a British Army post in France because, in 1916, British physicians had discovered a disease they named “purulent bronchitis,” whose symptoms were similar to those of the Influenza pandemic (Oxford, 2001). The pandemic significantly disrupted major global economies due to its transmissibility. For example, in the United States of America, the pandemic reduced the manufacturing output by 18% (Bishop, 2020). In general, the pandemic disrupted major global economies, leading to a reduced GDP in most countries.

Biocultural perspectives of the Spanish Flu

Understanding biocultural perspectives is significant for medical anthropologists. According to Wiley (2018), biocultural perspectives enable scientists and researchers to understand variations in diseases across human populations. In addition, researchers use biocultural perspectives to understand the relationship between culture and biology, as they play a crucial role in health and diseases affecting human populations. Wiley (2018) affirms that some vital methods in biocultural analyses include biomarkers, environmental effects, and social and cultural data. Collectively, these perspectives influence the variation in health and diseases across human populations.

Biological aspects of the Spanish Flu

The devastating impacts, such as the loss of millions of lives globally, left behind by the Spanish Flu spurred scientists to research more about the virus because little information about it was known then. The virus victims experienced lung inflammation, fluid-filled lungs, and severe pneumonia (Jordan, 2020). Therefore, scientists researched, for example, the possible strains of the virus and its transmissibility, as they tried to uncover the mystery surrounding the virus given that it was one of the deadliest pandemics the world experienced in the 20 th  century. Jordan (2020) affirms that the involved researchers aimed to answer questions like why the virus was so fatal, its origin, and lessons learned from the pandemic, which could play a significant role in the world’s preparation for similar situations pandemics should they occur in the future. Around the mid-20 th  century, researchers successfully began finding answers regarding the virus. In the late 1930s, researchers who had analyzed the antibody titers of the pandemic’s survivors suggested that the 1918 Spanish Flu was caused by the HIN1-subtype influenza A virus (Dowdle, 1999). According to Taubenberger (2006), the virus might have contained a hemagglutinin gene encoding, which most populations during that period lacked protective immunity. Taubenberger (2006) further affirms that based on the data released by Jordan (1927; as cited in Taubenberger, 2006) regarding influenza infection rates globally before the 1918 pandemic, the 5-15 age group accounted for approximately 11% of the influenza cases, while age group of above 65% accounted for 6% of the overall cases of the influenza infections between 1900 to 1917. However, during the 1918 influenza pandemic, the virus’s infection rates among the age group5-15 rose to approximately 25%, while that for the age group of greater than 65% reduced to about 0.6%, implying that persons within the age group 5-15 years were more susceptible to the virus. It was suggested that persons in the past 65 years might have developed pre-existing H1-antibodies, which reduced their susceptibility to the virus during the 1918 pandemic (Taubenberger, 2006).

Researchers hypothesized that persons born before 1889 might have been subjected to the H1-like virus strain that existed during that period, thus enabling their bodies to develop the H1-antibodies that partially protected them against the 1918 virus strain (Taubenberger et al., 1997). Microbiologists derived the virus sequence from multiple victims. They found that the sequence of the 1918 H.A. and that of the A/swine/lowa/30 virus had many avian features though they were closely related (Taubenberger, 2006). In addition, a study by Weis et al. (1988) revealed that for the influenza virus to survive in the host cell surface, the H.A. protein must bind to the sialic acid receptors, preferentially to receptors with α (2–6) linkages. Generally, based on the reviewed studies, sequencing and analyses of the RNA of the 1918 influenza pandemic strongly reveal that the virus was a strain of both swine and HINI lineage, giving ground for further studies, including testing of the 1918 influenza’s virulence.

Cultural aspects of the 1918 Spanish flu

The 1918 Spanish Flu remains one of the worst pandemics of the 20 th  century due to the high number of people who succumbed to it. Researchers estimate that the pandemic infected more than 500 million persons and left more than 50 million persons dead (Taubenberger & Morens, 2006). The pandemic happened during the period when the world was recovering from the devastating aftermaths of the first world war, which had left at least 20 million persons dead and more than 40 million persons wounded globally (“World War 1 Causalities,” n.d.). Based on the number of persons that succumbed during these two significant events of the early 20 th  century, it is evident that the Spanish Flu killed more people than the first world war. According to Shanks (2014), the influenza pandemic killed more people than the first world war, bringing a critical transition point towards scientific medicine. Shanks (2014) affirms that the pandemic’s aftermath and its devastating impacts revealed how much remained beyond scientists’ and doctors’ capability to handle infectious diseases during the first world war because researchers believed that the first world war escalated the spread of the virus. For example, Byerly (2010) affirms that crowding conditions in the U.S. military camps and other camps in the Western Front in Europe during the first world war significantly intensified the spread of the virus because it was airborne. Byerly (2010) reports that 20% to 40% of American personnel, specifically U.S. Navy and U.S. Army personnel, got infected by the virus. These statistics reveal how the first world war contributed to the spread of the virus.

The influenza pandemic happened in two waves. The first wave, also known as the spring wave, happened around March 1918. The second wave, also known as the fall wave, occurred between September to November 1918. The second wave was the deadliest because many people died (Taubenberger & Morens, 2006). The second wave was characterized by severe illnesses, although scientists failed to uncover why the virus generated repeated waves of illnesses. One factor contributing to high mortality rates during the influenza pandemic was the lack of antibiotics in 1918 (Taubenberger & Morens, 2006). In general, the first world war and limited medical inventions contributed to the devastating impacts of the influenza pandemic, laying a foundation for researchers to invest in research involving infectious diseases.

Barry, J. M. (2004). The site of origin of the 1918 influenza pandemic and its public health implications.  Journal of Translational Medicine ,  2 (1), 3. https://doi.org/10.1186/1479-5876-2-3

Byerly, C. R. (2010). The U.S. military and the influenza pandemic of 1918–1919.  Public Health Reports ,  125 (3_suppl), 81-91. https://doi.org/10.1177/00333549101250s311

Oxford, J. S. (2001). The so-called great Spanish influenza pandemic of 1918 may have originated in France in 1916.  Philosophical Transactions of the Royal Society of London. Series B: Biological Sciences ,  356 (1416), 1857-1859. https://doi.org/10.1098/rstb.2001.1012

Shanks, G. D. (2014). How World War 1 changed global attitudes to war and infectious diseases.  The Lancet ,  384 (9955), 1699-1707. https://doi.org/10.1016/s0140-6736(14)61786-4

Taubenberger, J. K., & Morens, D. M. (2006). 1918 influenza: The mother of all pandemics.  Emerging Infectious Diseases ,  12 (1), 15-22. https://doi.org/10.3201/eid1209.05-0979

Wiley, A. S. (2018). Medical anthropology methods: Biocultural perspectives.  The International Encyclopedia of Anthropology , 1-8. https://doi.org/10.1002/9781118924396.wbiea2080

World War 1 Causalities . (n.d.). Maison de l’Europe à Scy-Chazelles – CERS. https://www.centre-robert-schuman.org/userfiles/files/REPERES%20%E2%80%93%20module%201-1-1%20-%20explanatory%20notes%20%E2%80%93%20World%20War%20I%20casualties%20%E2%80%93%20EN.pdf

Taubenberger, J. K. (2006). The origin and virulence of the 1918 “Spanish” influenza virus.  Proceedings of the American Philosophical Society ,  150 (1), 86.

Dowdle, W. R. (1999). Influenza A virus recycling revisited.  Bulletin of the World Health Organization ,  77 (10), 820.

Taubenberger, J. K., Reid, A. H., Krafft, A. E., Bijwaard, K. E., & Fanning, T. G. (1997). Initial genetic characterization of the 1918 “Spanish” influenza virus.  science ,  275 (5307), 1793-1796.

Weis, W., Brown, J. H., Cusack, S., Paulson, J. C., Skehel, J. J., & Wiley, D. C. (1988). Structure of the influenza virus haemagglutinin complexed with its receptor, sialic acid.  Nature ,  333 (6172), 426-431.

Jordan, D. (2020, June 16).  The discovery and reconstruction of the 1918 pandemic virus . Centers for Disease Control and Prevention. https://www.cdc.gov/flu/pandemic-resources/reconstruction-1918-virus.html

Bishop, J. (2020, June 18).  Economic Effects of the Spanish Flu . Reserve Bank of Australia. https://10.3386/w26866

MPH online. (2021, April 7).  Outbreak: 10 of the worst pandemics in history . MPH Online. https://www.mphonline.org/worst-pandemics-in-history/

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The Spanish Flu Epidemic in 1918

One of the deadliest occurrences of human history is the 1918 “Spanish Flu” epidemic. Influenza spread to almost every part of the world and appeared in the United States, Britain, and France in the same year. Overall, the virus affected three to five percent of the world’s population, including the Arctic region and drastically decreased life expectancy (Tsoucalas et al., 2016). Thus, the pandemic’s massive influence on the world requires comprehending its origins and effects on the United States, specifically the army soldiers affected by it the most.

During the same period, Europe was recovering from severe damages caused by the First World War. However, Spain remained neutral and promptly dealt with the consequences of the epidemic (Tsoucalas et al., 2016). Therefore, the most reputable scientific data regarding the flu was gathered in Spain, which created a false impression that it is the most infected country. Thus, the origins of the pandemic are not determined by that day, as various scientists have been debating the topic ever since.

Furthermore, after the end of the war, the American troops were deployed home. The soldiers also brought the unique illness to the United States, which had not been encountered before by medical specialists. Therefore, a few months after the First World War was over, over twenty million American citizens have contracted the virus (Corbett et al., 2017). Overall, before the beginning of 1919, over 650,000 Americans died from the “Spanish Flu” (Corbett et al., 2017). The pandemic influenced the country’s lifestyle, as people started to avoid crowds, and surgical masks were worn in public places.

In conclusion, the “Spanish Flu” epidemic that originated in 1918 quickly spread around the globe. Many countries, devastated by the damages from the First World War, were not able to cope with the virus sufficiently. However, as a neutral country, Spain had the advantage of dealing with the illness’s negative consequences. Lastly, American soldiers brought the disease to the United States, which sufficiently changed people’s typical way of living.

Corbett, P. S., Janssen, V., Lund, J. M., Pfannestiel, T. J., & Vickery, P. S. (2017). U.S. history. OpenStax College; Rice University.

Tsoucalas, G., Kousoulis, A. A., & Sgantzos, M. (2016). The 1918 Spanish Flu pandemic, the origins of the H1N1-virus strain, a glance in history . European Journal of Clinical and Biomedical Sciences (EJCBS), 2(4), 23-28. Web.

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The Spanish Flu of 1919

Written by: david pietrusza, independent historian, by the end of this section, you will:.

• Explain the causes and effects of international and internal migration patterns over time

Suggested Sequencing

Use this Narrative at the beginning of Chapter 11 to explore the Spanish flu’s effect on the United States.

Mercifully, many of the diseases that once plagued humanity, such as polio, tuberculosis, and smallpox, have been brought under better control or even eradicated through innovative science. One disease – influenza or “the flu” – still flares periodically, but in 1918 it really was a plague, a raging pandemic called the Spanish flu that killed tens of millions worldwide in just a few months.

The world had plenty of trouble in 1918. World War I had raged since August 1914. Between nine million and 11 million soldiers died in the conflict, millions more were taken captive, and five million to six million civilians perished. Yet those numbers paled in comparison to the toll of the influenza pandemic. Between 50 and 100 million people died worldwide about 5 percent of the world’s population and the equivalent of more than 400 million based on today’s higher population levels. It was the worst pandemic since the Middle Age’s bubonic plague (“the Black Death”) killed 30 to 60 percent of Europe’s population in the 1300s.

The Spanish flu hit some areas such as the Pacific Islands, Iran, and India far harder than others. More than a quarter of the U.S. population became sick, and at least half a million Americans died in a population of fewer than 100 million. Men, women, and children wore surgical masks on the streets to avoid infection, and movie theaters and vaudeville houses closed. In Canada, the Stanley Cup hockey championship playoff was cancelled. Fear stalked every school, factory, and home.

Police officers in Seattle wore face masks provided by the Red Cross to help protect against the flu epidemic of 1918.

In New York, the cities of Rochester and Buffalo closed schools, theaters, pool halls, and saloons. The city of Buffalo went into the coffin business. On October, 10, 1918, Philadelphia was particularly hard hit 528 persons died in a single day. A doctor travelling 12 miles to his home each day reported seeing no people or cars on the road. As author A. A. Hoehling wrote of conditions in that city: “The dead lay sometimes for more than a day besides the gutters, and yet longer in half-abandoned, chill rooming houses. A mixed fear and revulsion had frustrated calls for stretcher-bearers and gravediggers.” An anonymous army doctor at Fort Devens near Boston observed that “it takes special trains to carry away the dead. For several days there were not enough coffins and the bodies piled up something fierce.” Dr. Victor C. Vaughan, former president of the American Medical Association and head of the Army’s Division of Communicable Disease, warned, “If the epidemic continues its mathematical rate of acceleration, civilization could easily have disappeared from the face of the earth within a matter of a few more weeks.”

The strain of flu that raged in 1918 is still known as the Spanish flu for a couple of reasons. First, it infected (but did not kill) the Spanish king, Alfonso XIII – a very high-profile victim. Second, Spain was one of the very few neutral nations in World War I. Wartime censorship was not in force, and developments there, including the spread of flu, could be more freely revealed than where the war raged.

Ordinary flu is painful and weakens people, but it is not usually deadly. The Spanish flu was amazingly harsh. High fevers caused hallucinations. People coughed violently and suffered excruciating pain. They turned black. They bled – not just from the mouth and nose but also from the ears and even, rarely, the eyes. Lungs became so weakened that they crackled when flu victims turned over in their beds. A person could be perfectly healthy in the morning and dead that night.

The worst flu mortality rates usually occur among the very young and the very old, whereas healthy young adults are best able to produce natural antibodies to fight the disease and survive fairly easily. That was not the case in 1918. Very young children did suffer a great deal. In the two years that the Spanish flu raged, the excess deaths for children one to four years of age equaled the normal number of such dead over 20 years. But those 65 years and older suffered an increase of less than 1 percent in excess mortality. Shockingly, more than half the dead were in what was normally the safest group: healthy young adults aged 18 to 45 years. One of the possible reasons is that these flu victims produced far too many antibodies, which overwhelmed not only the flu virus but their own bodies, causing death. If this is true, nature’s “cure” was truly worse than the disease.

Dorothy Deming, a nurse at New York City’s Columbia Presbyterian Hospital, observed that “until the epidemic, death had seemed kindly, coming to the very old, the incurably suffering, or striking suddenly without the knowledge of its victims. Now, we saw death clutch cruelly and ruthlessly at vigorous, well-muscled young women in the prime of Life. Flu dull[s] their resistance, choke[s] their lungs, swamp[s] their hearts. . . . There was nothing but sadness and horror to this senseless waste of human life”.

Nurses at the Red Cross Emergency Ambulance Station in Washington, DC, demonstrated how to help victims of the Spanish flu. Note the face masks they wear.

The Spanish flu pandemic was not entirely understood at the time. Its origin was unclear, as were the reasons it was so hard to treat and so deadly. Some believed the flu began at the U.S. Army’s huge base at Fort Riley, Kansas. Some said it originated abroad. But wherever it came from, it spread like wildfire. The war only worsened matters, given that soldiers from America, Asia, and Europe, all with different immune systems, had fought side by side in Europe. They lived in close quarters in tents, in barracks, on ships, and in the trenches of France’s western front. They were weakened from the stress of living under fire, and some had lung damage from the poison gas enemy forces lobbed at each other. And, of course, the same ships and trains that carried men and women across the country and around the world in record numbers also transported the microbes that transmitted this deadly strain of disease. In France, the U.S. 88th division counted 444 dead from the flu, but just 90 were killed, wounded, or captured in combat.

“The conditions cannot be visualized by anyone who has not actually seen them,” wrote Colonel E. W. Gibson of Vermont’s 57th Pioneer Division, who witnessed the worsening situation on the troopship Leviathan . “Pools of blood from severe nasal hemorrhages of many patients were scattered throughout the compartments, and the attendants were powerless to escape tracking through the mess, because of the narrow passages between the bunks. The decks became wet and slippery, groans and cries of the terrified added to the confusion of the applicants clamoring for treatment, and altogether a true Inferno reign[ed] supreme.”

Wartime censorship complicated the crisis. In 1918, Woodrow Wilson and Congress enacted an amendment to the 1917 Espionage Act (known as the Sedition Act), which decreed that “whoever, when the United States is at war, shall willfully utter, print, write, or publish any disloyal, profane, scurrilous, or abusive language about the form of government of the United States . . . shall be punished by a fine of not more than $10,000 or imprisonment for not more than twenty years, or both.” This Act made fighting the disease even more difficult because it choked off much honest conversation (and even reporting) about the situation.

As Chicago’s Public Health Commissioner John Dill Robertson stated, “It is our duty to keep the people from fear. Worry kills more people than the epidemic.” Actually, people had good reason for fear. At Chicago’s Cook County Hospital, 40 percent of all influenza patients died.

Eventually, the deadly pandemic ran its course and life returned to normal. A similar pandemic may return to wreak havoc on humanity, particularly with the frequency of international travel. And if it does, censorship will not help the situation any more than it did in 1918.

Review Questions

1. The 1918 Spanish flu outbreak was the worst pandemic since

• smallpox in the nineteenth century
• the bubonic plague in the fourteenth century
• polio in the nineteenth century
• tuberculosis in the eighteenth century

2. As the Spanish flu progressed across the United States, a unique characteristic that emerged was that the disease

• seemed to be without symptoms until the end
• killed a disproportionate number of women
• struck a disproportionate number of people in New England
• killed mostly young, healthy adults

3. A major effect of the Spanish flu on U.S. society was

• the collapse of the economy
• an immediate demand that immigration be halted
• a temporary closure of schools and businesses
• a decline in the medical industry

4. The quote “it is our duty to keep the people from fear. Worry kills more people than the epidemic” from Chicago Public Health Commissioner John Dill Robertson is related to what policy of the U.S. government?

• Wartime censorship of news concerning the Spanish flu
• The need for the medical profession to bring an end to the epidemic
• Encouragement of accurate reporting regarding the epidemic
• Temporary halting of migration

5. The passage of the Sedition Act made it even more difficult to fight the flu pandemic because

• it stifled honest discussion and reporting of the disease
• it allowed the arrest of many of the health-care workers fighting the disease
• it increased immigration and thus the flow of disease carriers into the United States
• it reopened schools and businesses that had been closed to control the contagion

Free Response Questions

• Explain the impact of Spanish influenza on commerce in the United States.
• Analyze the role that censorship of free speech played in the nation’s ability to fight the Spanish flu pandemic.
• Compare society’s response to the Spanish flu pandemic in 1919 with the COVID-19 pandemic of 2020. What similarities do you notice?

AP Practice Questions

A 1919 public health broadside provides information on the Spanish flu pandemic.

1. The information presented in the broadside at the provided link could be used to support which of the following conclusions?

• The government developed public policies for fighting the disease.
• Private business banned individuals on the basis of their health status.
• Censorship impeded the spread of information about the disease.
• Widespread panic set in because there was little understanding of the way the disease spread.

2. The publication of this broadside most likely indicates

• an expansion of the role of the federal government
• the widespread health concerns caused by the epidemic
• the national government’s concern about the effects of the epidemic on trade
• the ignorance of most citizens of the time about healthy habits

3. The situation that prompted the broadside can be best described as

• the Red Scare created a fear of socialism in America
• people feared America becoming involved in another European war if the United States joined the League of Nations
• the rebirth of the Ku Klux Klan led a fear that personal freedoms would be lost
• a devastating Spanish flu epidemic spread fear, misery, and death around the world

Primary Sources

Price, George M. “Influenza-Destroyer and Teacher: A General Confession by the Public Health Authorities of a Continent.” The Survey 41, no. 12 (1918): 367-369.

“Quarantine and Isolation in Influenza.” Journal of the American Medical Association 71, no. 15 (1918): 1220.

“Spanish Influenza the Way to Treat It and to Avoid It.” A Vicks VapoRub advertisement. Portland Morning Oregonian . January 8, 1919, p. 6. https://oregonnews.uoregon.edu/lccn/sn83025138/1919-01-08/ed-1/seq-6/

Suggested Resources

Barry, John M. The Great Influenza . New York: Viking, 2004.

Hoehling, A. A. The Great Epidemic . Boston: Little, Brown and Company, 1961.

Iezzoni, Lynette. Influenza 1918: The Worst Epidemic in American History . New York: TV Books, 1999.

Kolata, Gina. 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.

Tucker, Spencer and Priscilla Mary Roberts (eds.). World War I: A Student Encyclopedia . Santa Barbara, CA: ABC-CLIO, 2006.

Withington, John. Disaster!: A History of Earthquakes, Floods, Plagues, and Other Catastrophes . New York: Skyhorse Publishing, 2010.

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• The Spanish influenza pandemic seen through the BMJ’s eyes: observations and unanswered questions

The Spanish influenza pandemic seen through the BMJ ’s eyes: observations and unanswered questions

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• Peer review
• Tom Jefferson , researcher ,
• Eliana Ferroni , researcher
• 1 Acute Respiratory Infections Group, Cochrane Collaboration, Rome, Italy
• Correspondence to: T Jefferson jefferson.tom{at}gmail.com

Does the “Spanish flu” of 1918-9 have anything new to teach us about future pandemics? Tom Jefferson and Eliana Ferroni have investigated contemporary accounts in the BMJ archives to find out

Introduction

The great Spanish influenza of 1918-9 is perhaps the best known of all pandemics. A vast number of books have been written on the topic, and “Spanish flu” still represents a rich topic of discussion and research. 1 Although many scientific questions posed at the time have been answered by nearly a century of subsequent discoveries, some puzzles remain—such as the reason for the high case fatality rate (>2.5% according to some estimates), 2 the high incidence in young adults, 3 and the role played by the first world war and its aftermath. 4 At the time, the aetiology was not known and the disease’s mode of transmission could only be hypothesised by careful observation. In addition the effects of preventive measures remained largely unevaluated. A high number of descriptions of the event seem to be based on secondary sources—that is, they are not direct eyewitness accounts—although recently efforts to go back to primary sources have been made. 4

Reliance on secondary sources is a potential source of selection bias: the reader gets a selected view of events, and some of the contemporary observations and explanations are lost. Interpretation of events and actions of a bygone era from a modern perspective is another perilous activity.

We exploited the opportunity to consult the newly digitised BMJ archives to carry out a review of what was published at the time. We tried to look at the pandemic through the eyes of contemporary BMJ contributors and readers and give them their voice back. We chose the Spanish influenza pandemic because we believed some of the observations and issues raised at the time may still be relevant to the events of today, although some have been forgotten.

We carried out a search of the BMJ archives using the keywords “influenza,” “flu,” “pandemic,” and “Spanish influenza” for the period 1918 to 1924. We read the content of each article, looking for unusual or forgotten observations and still unresolved questions. We excluded well known facts (such as clinical descriptions and presentation of the disease), and we did not carry out a detailed analysis of observations that are explicable with today’s knowledge (such as the contemporary conclusion of the presence of “filterable virus,” which was then invisible and unidentified).

We grouped the findings by broad headings covering the capricious nature of the spread of disease and its relation to climatic conditions, the possible multifactorial nature of the high case fatality rate, the unusual effects of poison gas on munitions workers’ health, and possible causality and preventive measures.

We did not carry out a systematic review but selected items that we consider still highly relevant today but largely forgotten. We make no claims as to the completeness or fairness of our selection, but we have listed our search yield and sources in the appendix on bmj.com to encourage readers to consult the original records.

We found 55 articles of varying nature—including studies, reports, and letters—published between July 1918 and October 1920.

Spread of disease and its relation to climatic conditions

One of the least studied aspects of the pandemic was the appearance of synchronous cases or clusters of cases either apparently unconnected or a great distance apart. This had also been a feature of the 1789 and 1889 pandemics (and would be again in 1957 and 1968). 5

Dr Andrew Garvie, a general practitioner in Halifax describes the conundrum: “But why the first case in the household was, on the average, more serious than the sporadic, and why the ‘clumping’ should occur, is difficult to understand. Casual observation might lead one to suppose that the spread was due to actual contagion from one house to another. At first I regarded it simply as due to ‘neighbourliness,’ but later on became convinced that this could only be a partial explanation of the spread. In many of the households affected in a ‘clump,’ a suggestion of being in any of the other affected houses was absolutely denied. It will further be noticed that within one particular ‘clump’ two or three houses commenced on the same date, and further, owing to the general fear of the epidemic, spread by newspaper reports and other methods, if the epidemic was known to be present in a house, the house was usually shunned by neighbours. In many cases the houses were not in direct contact but separated by the breadth of the street or by garden walls ... but why people within small radii of one another, of all ages, of different occupations, not coming in actual contact with one another, should develop synchronous attacks, still remains a mystery to me.” 6

Dr Major Greenwood, later first professor of epidemiology and vital statistics at the London School of Hygiene and Tropical Medicine, writing arguably the most complete description of the UK pandemic in the autumn of 1919, had the following explanation for the observation: “A mass attack, indeed, forms an invariable link in the chain of events, but scattered individual cases are antecedent. This observation removes the most formidable objection to a belief that influenza is contagious, and it is easy to understand why we discover no confirmation in historical records. In such epidemic diseases as plague the preceding sporadic cases are recorded because their high fatality leads to illusion in bills of mortality; but in consequence of the very low fatality of primary epidemic influenza early mortality records are wanting. The mass phenomenon strikes the imagination of the recorder and an illusion of suddenness and simultaneity is produced.” 7

In other words ascertainment bias was the most likely explanation for the observation.

Greenwood and other BMJ contributors (such as Dr Mercer Watson writing in 1919 8 ) dedicated a lot of time to describing the prevailing atmospheric conditions in relation to the subsequent waves of the pandemic. This may be a relic of the old miasma versus contagion debate of previous centuries.

High case fatality rate

A hallmark of the Spanish influenza pandemic was its high case fatality rate. Greenwood described its causes in the spring and summer of 1918 period as “excessive mortality being mainly due to the accident of season, aided by the special circumstances of overcrowding and fuel shortage which are due to the war. In a word, this is not essentially a war epidemic.” 7 The role of wartime shortages and troop concentrations and movements has always been a moot point with historians and epidemiologists. Those who refute these as factors cite the example of whole countries or isolated communities not involved in the war being virtually wiped out—that is, being fatal exceptions to the theory. 9 However, a closer look at the description of conditions by BMJ contributors shows the importance of studying context in the devastation.

Surgeon Lieutenant Francis Temple Grey in charge of the Samoa relief expedition is cited by the BMJ in 1918 explaining the high native mortality compared with the white population: “The incidence among the natives was 80 per cent. Out of a population of 36,405 the deaths numbered 7,264.” Surgeon Lieutenant Grey attributes the high mortality partly to the fact that natives, although apparently of fine physique, have generally a poor chest expansion, and to their habits. “The native house has a raised floor of coral and lava pebbles, a thatched roof supported on poles, and no walls, but at the beginning of the epidemic, when a native fell ill he lay down in his hut, and his family, having pulled down the blinds, which are usually lowered only in wet weather, lay down with him in sympathy. When the fever was at its height, on the third day, the natives cast off their clothes, pulled the blinds up, and many of the men went into the sea to cool themselves. This was often followed by pneumonia, although, except in children, few cases, even with precautions, escaped bronchopneumonia. At the height of the epidemic many lives were lost owing to want of food consequent on the cessation of its collection. On December 8th, 1918, food collecting was resumed, and the decline of the epidemic was popularly dated from that.… Among the whites the incidence was put at 60 per cent, and the case mortality at 2 per cent.” 10

Writing in 1920, Dr A H Macklin, formerly of the Imperial Trans-Antarctic Expedition, helps us to understand some of the reasons behind the often quoted devastation in Lapland: “The Laplanders had a very thorough if unsympathetic way of dealing with their cases. The settlements were composed of wooden huts, small, but generally well made and warm. A common type consisted of but one room used by the family for all purposes. Better class Lapps had better huts, with two or three rooms. In each settlement one of the single-room huts had been set apart, and into this each case of sickness as it arose was unceremoniously pushed; and none were permitted to return to their own huts until completely recovered. Whilst there they received practically no attention, and no healthy person ever entered to attend to their wants. Occasionally a bowl of water or reindeer milk was hastily passed in at the door, or a huge chunk of reindeer meat thrown in, uncooked and uncarved… Constipation was a constant factor, and many cases had not had their bowels opened since the onset of their illness—in some cases seven to ten days. Others had voided urine and faeces just as they lay. In some huts those of the patients who had passed the worst stages of their illness assisted and looked after those more acutely ill.” 11

The effects of poison gas on munitions workers’ health

By 1918 the use of poison gas, first introduced in 1915, was routine when bombarding enemy trenches. A great number of workers were assigned by the Ministry of Munitions to produce shells filled with the noxious substances. Numerous BMJ authors remark on the apparent protection afforded by all types of gas production except phosgene (table 1 ⇓ )

  BMJ reports of associations between exposure to poison gas and other gases and influenza and other acute respiratory illness

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Dr Gregor, writing in 1919, informs us that it was apparently “custom to take children suffering from whooping cough to the nearest gasworks and expose them to the fumes emanating from the oxide of the iron purifiers during the process of cleansing, and the parents of these children firmly believe that by doing so the attack is much mitigated”. 14 He goes on to report a comparative cohort analysis of the incidence of influenza in populations with different exposure levels to gases (table 2 ⇓ ). Assuming that uniformed personnel were the fittest population, the difference in incidence is striking.

 Exposure to gas and incidence of influenza (adapted from Gregor, 1919 14 ). (Values are numbers of subjects unless stated otherwise)

Causality and prevention

By 1919 Dr Benjafield of the British Expeditionary Force in Egypt thought that “In this case it is more than possible that the primary etiological agent is ultramicroscopic and is a filterable virus, which renders the individuals infected hypersensitive to organisms which formerly only possessed a low degree of pathogenicity.” 15 This was also the conclusion of Rose Bradford et al of the British armies in France. 16

If this hypothesis were true, experimental vaccines against a collection of bacteria would be expected to achieve at least partial effectiveness. This is exactly what Sir William Leishman experimented with, using it on troops during the closing stages of the war. 17 The vaccine contained a mixture of Bacillus influenzae ( Haemophilus influenzae type b), streptococci, and pneumococci. Leishman’s BMJ paper does not report details of methods, but his observation of effectiveness against influenza, pulmonary complications, and deaths is upheld by our reanalyses. For example, the odds ratio for pulmonary complications was 0.12 (95% confidence interval 0.08 to 0.18) (table 3 ⇓ ).

 Effects of influenza vaccines in British troops in 1918-9 (adapted from Leishman, 1920 17 ). (Values are numbers of subjects unless stated otherwise)

The views on the effectiveness of other interventions such as masks and distancing were varied.

We found several articles reporting unusual observations. Even today many of these have no explanation. We feel that the observations should first be corroborated and perhaps explored further. The idea that exposure to gaseous fumes (even potentially toxic) prevented or ameliorated respiratory disease seemed established at the time. Today, however, that is flatly contradicted by unreferenced statements in publicly available documents. 18

The causes of the high case fatality rate are still unclear, but modern research suggests that the pandemic was a lot more than just a “one germ-one disease” affair 19 This view is supported by the apparent success of antibacterial vaccines against influenza and its complications (with all the probable methodological shortcomings of Leishman’s study).

Agents other than the influenza virus probably played a part. Above all, the environmental explanations of the high Samoan and Lapp mortality rates indicate the peril of generalising across contexts and simplifying causation models. The origin and spread of the pandemic are also far from clear, but the repeated reporting of multiple synchronous foci should be investigated in today’s pandemic. This may give us an indication of the means of seeding, trigger, and possible spread of respiratory viruses.

Cite this as: BMJ 2009;339:b5313

We acknowledge the keen interest and accurate reporting of our predecessors, who kept their nerve in the midst of an ugly pandemic and the carnage of war.

Funding: None.

Competing interests: None declared.

• ↵ Alcabes P. Dread. How fears and fantasy have fuelled epidemics from the Black Death to avian flu . Public Affairs, 2009 .
• ↵ Taubenberger JK, Morens DM. 1918 influenza: the mother of all pandemics. Emerg Infect Dis 2006 ; 12 : 15 -22. OpenUrl PubMed Web of Science
• ↵ Glezen WP. Emerging infections: pandemic influenza. Epidemiol Rev 1996 ; 18 : 64 -76. OpenUrl FREE Full Text
• ↵ Mark Honigsbaum. Living with enza: the forgotten story of Britain and the great influenza pandemic of 1918. Macmillan Science, 2008 .
• ↵ Shope RE. Influenza: history, epidemiology and speculation. Public Health Reports 1958 ; 73 : 165 -78. OpenUrl PubMed Web of Science
• ↵ Garvie A. The spread of influenza in an industrial area. BMJ 1919 ; 2 : 519 -23. OpenUrl FREE Full Text
• ↵ Greenwood M. The epidemiology of influenza. BMJ 1918 ; 2 : 563 -6. OpenUrl FREE Full Text
• ↵ Mercer Watson A. Influenza epidemic in Q.M.A.A.C. hostel, Edinburgh. BMJ 1919 ; 1 : 40 -1. OpenUrl FREE Full Text
• ↵ Horder T. Preventive treatment in influenza: a British Medical Association lecture given to the southern branch, at Southampton, November 13th, 1919. BMJ 1919 ; 2 : 695 -8. OpenUrl FREE Full Text
• ↵ Influenza in Samoa: value of vaccines. BMJ 1919 ; 2 : 499 -500. OpenUrl FREE Full Text
• ↵ Macklin AH. Influenza amongst the Lapps. BMJ 1920 ; 1 : 465 -6. OpenUrl FREE Full Text
• Ball EJ. The epidemiology of influenza among workers. BMJ 1919 ; 1 : 358 . OpenUrl FREE Full Text
• Shufflebotham F. Influenza among poison gas workers. BMJ 1919 ; 1 : 478 -9. OpenUrl FREE Full Text
• ↵ Gregor A. A note on the epidemiology of influenza among workers: in gas works, in a cordite factory, and in a tin mine. BMJ 1919 ; 1 : 242 -3. OpenUrl FREE Full Text
• ↵ Benjafield JD. Notes on the influenza epidemic in the Egyptian Expeditionary Force. BMJ 1919 ; 2 : 167 -9. OpenUrl FREE Full Text
• ↵ Rose Bradford J, Bashford EF, Wilson JA. Preliminary report on the presence of a “filter passing” virus in certain diseases: with especial reference to trench fever, influenza, and nephritis. BMJ 1919 ; 1 : 127 -8. OpenUrl FREE Full Text
• ↵ Leishman WB. The results of protective inoculation against influenza in the army at home, 1918-1919. BMJ 1920 ; 1 : 214 -5. OpenUrl FREE Full Text
• ↵ IPCS INCHEM. Mustard gas. www.inchem.org/documents/pims/chemical/mustardg.htm (accessed 12 Sep 2009).
• ↵ Brundage JF. Interactions between influenza and bacterial respiratory pathogens: implications for pandemic preparedness. Lancet Infect Dis 2006 ; 6 : 303 -12. OpenUrl CrossRef PubMed Web of Science

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The Spanish flu and the fiction literature

La gripe española de 1918 y la literatura de ficción, emma vázquez-espinosa, claudio laganà, fernando vazquez.

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Correspondence: Fernando Vázquez Valdés Servicio de Microbiología. Hospital Universitario Central de Asturias, Avda. de Roma s/n, 33011 Oviedo, España. Tfno.: 630243480 E-mail: [email protected]

Received 2020 May 17; Revised 2020 Jun 18; Revised 2020 Jun 18; Accepted 2020 Jun 24; Issue date 2020.

This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International (CC BY-NC 4.0)( https://creativecommons.org/licenses/by-nc/4.0/ ).

This review focuses on the fictional literature in which the Spanish flu is represented either as an anecdotal or as a historical aspect and the effect on the author or fictional character. We examine this sociocultural period in the press and mainly in Anglo-Saxon literary works and from other countries, including Spanish and Latin American literature that is not very represented in some international reviews on the subject. Also, we include books about the previous and subsequent influenza pandemics to the Spanish flu.

Key words: Spanish flu, Influenza, pandemic, medicine in literature

Esta revisión se centra en la literatura de ficción en la que la gripe española se representa como un aspecto anecdótico o histórico y el efecto sobre el autor o el personaje ficticio. Examinamos este período sociocultural en la prensa y principalmente en obras literarias anglosajonas y de otros países, incluida la literatura española y latinoamericana que no está muy representada en algunas revisiones internacionales sobre el tema. Además, incluimos libros sobre las pandemias de influenza anteriores y posteriores a la gripe española.

Palabras clave: Gripe española, gripe, Pandemia, medicina en la literatura

INTRODUCTION

“I had a little bird . Its name was Enza . I opened up the window , And in flew Enza.” (Old nursery rhyme)

Flu has caused global pandemics over the centuries. In the 18th century, the influenza pandemic between 1708-1709 was not fairly assessed [ 1 ]. During epidemics and pandemics in 1847–1848 and 1889–1893, it was recognized that the respiratory complications of flu could greatly elevate the death rate [ 2 ]. Another pandemic has been in 2005, the avian flu, with the emerging cultural patterns and interpretative repertoires and metaphors [ 3 ].

The Spanish flu, in 1918, killed 50-100 million people in the World and, in Spain, caused as many deaths as in the Spanish Civil War. About the Spanish flu, there are different studies, this is not an exhaustive list, in the world [ 4 - 13 ] and in Spain [ 14 - 17 ] with its spatial-temporal patterns [ 18 ].

This pandemic has been reviewed from different points of view: sociological or historical and the origin of the flu [ 19 - 21 ].

This review focuses on the fictional literature in which influenza is represented either as an anecdotal or as a historical aspect and the effect on the author or fictional character. In neither case it is an exhaustive review, but it focuses mainly on Anglo-Saxon literary work and from other countries, including Spanish and Latin American literature that is not very represented in some international reviews on the subject. All literature books are cited in the Tables with authors and their books in English and Spanish and we include books about the previous and subsequent influenza pandemics to the Spanish flu.

The name of influenza . The name of influenza is believed to have been used in the city of Florence in the 14th century (by Villani in 1358), considering that the disease was due to the « influenza di freddo » (to the cold) or « di stelle » (to the stars, by the astrological theories in those times) [ 22 - 23 ]. In 1742, Sauvage use the name « grippe ». The terms « gripper » (French), « to grip » (English) or « greifen » (German) mean in Spanish « agarrar, atrapar ».

Perhaps the abrupt way of presenting this disease on many occasions has justified the name « grippe », that in Spanish it was written « grippe » until at least 1925, and then with a single p . At the beginning of the Tolstoi´s book, “ War and Peace ” (1869), a novel that is the chronicles of the French invasion of Russia and the impact of the Napoleonic era on Tsarist society, Tolstoi writes that: “ On a July day in 1805… Anna Pávlovna had been coughing for a few days; it was a “grippe”, as she said (“grippe” was a new word then, that very few used ”).

Another word in Spanish was “ trancazo ” (“ strike with a bar ”), “ tranca ” means “ iron or wood bar ” and from this word derives “ trancazo ” that is a colloquial name for flu.

Other nicknames were Spanish flu or Spanish Lady , also French flu . It appears that French journalists had, initially, called it the “ American flu ”; but the fact that the American soldiers were his allies in the warlike conflict advised not to assign such a link to them; and as there were also cases of influenza in Spain, it was decided to generalize the use of this expression, which was later assumed by Germans and others [ 22 ].

Another most popular name in Madrid, was the “ Soldado de Nápoles ” (“ Naples soldier ”), a popular song in the zarzuela (popular musical genre or “ género chico ” in Spain) called La canción del olvido ( The forgotten song ) due both, were “ highly contagious ”.

Today, there are many authors who avoid such a name (the Spanish flu) and they aptly refer to it as the “19181819 influenza pandemic”.

The origin of the Spanish flu pandemic . There are several theories about the origin: a) the origin could be in China and after in Philippines and the USA and the army in Europe. b) English soldiers in France in 1916, the disease soon spread to other neighboring countries (England, Italy, Spain) and to more distant ones (the USA) as a consequence of the displacement of the troops [ 22 ]. c) the regular arrival of Chinese workers to Africa and Europe, throughout those years, could have been the origin of an earlier introduction (coinciding with the war). And this is a very plausible interpretation due to the circumstance that the Spanish Royal Family and the Spanish ministers suffered the flu, in the month of May 1918, and could contribute to this unjustified name [ 21 ].

The flu in the Spanish King is debated, the majority of scholars think that it was a flu. For Cervera C [ 24 ] was scarlet fever: between September and October 1918, Alfonso XIII had to interrupt this work and his conversations with Germany to stop sinking Spanish ships in the Atlantic. The “ ABC ” newspaper reported on September 30, 1918 that « H. M. the King is sick with the flu. The attack is mild, and although his majesty has a fever, so far the ailment is of no importance ”. On October 4, however, the official party pointed out a fact that indicates that the King did not suffer from the flu: a series of “ scarlet fever eruptions of normal evolution ” on his body. Skin rashes that do not fit with the usual symptoms of the Spanish flu, in the same way that the fact that ten days later the press continued to report mild fever and more skin problems does not coincide with the picture of this disease for Cervera C [ 24 ]. The first signs of scarlet fever can be flu-like symptoms, including a high temperature of 38 ºC or above, a sore throat and swollen neck glands.

It could be probable that these two theories may be both true, the flu can later in the course of the disease be complicated by scarlet fever in a percentage of patients. Scarlet fever circulating with chickenpox or influenza can be particularly dangerous. Another explanation is, although infrequently, the flu can take with an exanthematous skin rash.

The treatment and vaccines of the Spanish flu pandemic . The treatment was based in several substances and bacterial vaccines in relationship with the belief in the bacterial theory of disease: “ Bacterial vaccines, some were derived exclusively from the Pfeiffer’s bacillus, the presumed cause of influenza, were widely used, while others contained one or more other organisms found in the lungs of victims ” [ 25 ].

The treatment included “ symptomatic therapy with salicylates and quinine and codeine, for pneumoniae intramuscular or intravenous silver or platinum colloid, digitalis, alcamphor oil, or adrenaline, and bleeding ” [ 26 ].

In the Espasa encyclopedia (popular Spanish Encyclopedia), it was cited that “ the serums and vaccines inspired by bacterial associations are now abandoned ”; and that “ strychnine, oxygen inhalations, arsenicals, salicylates and bleeding are prescribed ” [ 27 ].

Other treatments were vapors from aromatic plants, purgatives, sweats, medicinal plants, and hydrotherapy, strong showers with alternating hot and cold water, iodine, leeches, cardenal brand water filter to trap all microbes. Marañón advocated to use a light antiseptic nasal douches twice a day [ 19 ].

Loeb L [ 28 ] found “ striking similarities between orthodox and commercial suggestions for treating influenza ” in The Lancet and the British Medical Journal between 1889 and 1919.

THE SPANISH FLU AND THE PRESS

The first reference in the Spanish press to an epidemic outbreak in the Spring of 1918 can be found in the Madrid newspapers “ ABC ” and “El Sol” (The Sun) , the latter one published its first headline about the subject on 22 May 1918 [ 18 ]: “What is the cause? An epidemic in Madrid . In June 2 of 1918, “ The Times ” in Madrid, talked about an epidemic with the name the Spanish flu and this name began to circulate and in August the ‘Journal of the American Medical Association’ dedicated its number to the “Spanish flu” [ 18 ]. An important book about the Spanish flu and the press is that of Davis RA [ 19 ].

In the Spanish press, it was the subject of attention with different comic strips that are not included in this work but that can be found in the digital newspaper archives [29a]. These comic strips remember the previous coloured engraved satires, in the Wellcome collection, such as “ An Address of thanks from the Faculty to the Right Hon.ble Mr. Influenzy for his kind visit to this country “ (by Temple West) ( https://wellcomecollection.org/ works/kn2xshu9 ) [29b].

THE SPANISH FLU AND THE RELIGION

The God punishes is a typical approach to the plagues and pandemics. This is just one example: In León, Spain, during the Spanish flu in his prayer “ Pro tempore pestilentiae ” (“ For the times of pestilence ”), the bishop: “ exhorts their parishioners to repent of their guilt because sins are the cause of scourging with that God punishes us” . Among the reasons cited by the bishop to explain the incidence of influenza are the desecration of holidays, blasphemy, obscene and immoral amusements and debauchery [29a]. And in Zamora (city in Castilla), with one of the highest mortality, there were a lots of Mass and the consequent spreading of the flu.

WHY DOES THE LITERATURE IS SCARCE IN THE INFLUENZAE?

Instead the literature of the plague (Bocaccio´s Decamerone , Camus´s The plague ), or tuberculosis (such as Thomas Mann´s The Magic Mountain ), the 1918-1919 pandemic have hardly been the subject of novel or realistic descriptions by writers. Could it be the coincidence in the time of the First World War with the most fatal stages of the pandemic that contributed to the desire not to insist more on the evocation of so many sufferings, and thus favor a deliberate forgetfulness? Stalin said: “ a single death is a tragedy; a million deaths is a statistic ”, the little literature in the 1918 pandemic, perhaps was due to the “ flu overwhelmed language in ways that World War I did not ” [ 31 ]. The Spanish flu is called a “ forgotten pandemic ” [ 31 ], that’s the difference for example, between literature of the Spanish flu and the literature of the World War I and the poets of the war. Or for F. Scott Fitzgerald, Gertrude Stein, Ernest Hemingway and John Dos Passos, the flu did not represent a topic in their novels, the Great War could represent the newness material to build your novels, whereas the pandemic represented historical continuity of the past plagues and this matter was not modern for their literature [ 32 ].

In the essay “ On Being Ill ” (1926), Virginia Woolf lamented that flu hadn’t become a central theme in literature [ 33 ].

Susan Sontag pointed out, “ novelists tend to focus on illnesses that can be “used” as metaphors, plague with its medieval aura, cancer with its mysterious provenance, tuberculosis with its rosy-cheeked energy and Dickensian associations. These illnesses, unlike influenzae, carry built-in mythologies primed for literary appropriation ” [ 33 ].

For Hovanec [34a]. “ The flu acts as metaphor for the dehumanizing and denaturalizing aspects of modern life, which take on many forms ”.

But, since Woolf first complained about the lack of novels devoted to influenza, a small body of English, Spanish -language literature and other languages about the virus has arisen, some of them in relationship with the World War I. “ The resurgence of interest in the flu during the 1930s may have been influenced by new developments in virology and influenza research ” [34a].

ENGLISH LITERATURE ( TABLES 1 - 3 )

American and British authors and their books (in chronological order) about the 1918 influenza pandemic (The Spanish flu)

American authors and their books (in chronological order) about the influenza pandemic (genetic manipulation of the virus and bioterrorism)

Belling [ 31 ] divides fiction representing the pandemic in two groups: the authors with “ experienced ” disease, or autobiographical works, and those with “ registered rather than experienced ” motifs.

The first group: authors who were alive at the time (“experienced”) ( table 1 )

The best known is Katherine Anne Porter’s novella Pale Horse, Pale Rider .

a) At the beginning, was considered not a serious infection. On 24 June 1918, the war poet Wilfred Owen composed an ironic letter to his mother and considered the flu something of a joke: “ STAND BACK FROM THE PAGE! and disinfect yourself ” [ 35 ].

b) T. S. Eliot makes a possible reference to the Spanish flu in his poem Sweeney among the Nightingale : “ The person in the Spanish cape ”. Elliot and Vivien (his wife) caught the disease in November 1918 and he was working in his masterpiece poem “ The waste land” .

c) D.H. Lawrence suffered influenza in 1919, the flu nearly killed him, in a town in the United Kingdom, after the end of the World War I. In his book, The Fox , the soldiers begin to return home, and the shadow of the Spanish flu glides in the environment.

d) F. Scott Fitzgerald. He fell ill while finishing his novel This side of the paradise (1920):

“—He represented Beatrice’s immortality, also love-affairs of numerous dead men who surely had never thought of him... if it wasn’t appendicitis, influenza maybe” .

e) Michael Arlen, in The green hat , the protagonist was inspired in the heiress Nancy Cunard, who caught the flu in 1919 with pneumonia and depression.

f) Virginia Woolf wrote an essay on flu, On being ill , and she describes the mental effects of disease. Her mother had died of influenza in 1895. In her diary writes: “ Influenza, which rages all over the place, has come next door .” “ Rain for the first time for weeks today and a funeral next door; dead of influenza ”. She had several bouts of influenza: in 1918 was kept in bed 8 days, in 1920, 1922, 1923 and 1925.

In her book, Mrs. Dalloway , there are two flu quotations: “ For having lived in Westminster—how many years now? Over twenty, —one feels even in the midst of the traffic, or waking at night, Clarissa was positive, a particular hush, or solemnity; an indescribable pause; a suspense (but that might be her heart, affected, they said, by influenza) before Big Ben strikes ”.

“ Thus, when she said in her offhand way “How’s Clarissa?” husbands had difficulty in persuading their wives and indeed, however devoted, were secretly doubtful themselves, of her interest in women who often got in their husbands’ way, prevented them from accepting posts abroad, and had to be taken to the seaside in the middle of the session to recover from influenza ”.

g) Thomas Wolfe, Look homeward, Angel; A story of the buried . This is his first novel, a semi autographic story, covers the span of time from Eugene’s birth in 1900 to his definitive departure from home at the age of 19. The setting is a fictionalization of his home town of Asheville, North Carolina, called Altamont, Catawba in the novel. Brother´s writer died with influenza.

h) John O´Hara, in a short story The doctor´s son . His father worked during the flu outbreak in the Pennsylvania mining and O´Hara accompanied his father on house calls. Here, O´Hara, as the narrator, adopts a point of view of observer not such as a personal or familiar victim also dramatizes another major public health risk: the gathering of crowds [ 34 ].

i) While Pale Horse, Pale Rider represents the best literature of the flu and perhaps the paradigm of the Spanish flu, there was a lack the interest on it, maybe the reason is the traumatic experience just of a person [ 36 ] and without importance in comparison to the World War I. Katherine Anne Porter, the author, suffered influenza at twenty eight years old in 1918, and her father had planned in advance her funeral. Twenty years later, she published Pale Horse, Pale Rider , a novella in which her autobiographical protagonist, Miranda, almost dies of the flu. The story closely follows an account of Porter’s own illness and recovery during the pandemic, when she was working as a reporter in Denver.

j) William Keepers Maxwell wrote They came like swallows . A novel about a Midwestern family that falls ill when the flu reaches their town. Maxwell describes the fever and the sleep. Mother´s writer died by influenza and pneumonia and he caught the flu in 1918: “ My aunt put her hand on my forehead and got up from the table and took me upstairs and put me to bed because I had a high fever. And I think what happened was that I slept and slept and slept and slept ”. That is revisited too in other Maxwell´s books: Ancestors, So Long, See You Tomorrow , and Time Will Darken It . Uncle Wilfred, in They came like swallows , insists that the flu was purposely spread by Germans in U-boats, and seems familiar for us now, with the SARS Cov-2 and China.

k) William Carlos Williams, The autobiography of William Carlos Williams . Poet and doctor during the time he turned to the exercise of his profession wrote that, we doctors made up to sixty visits a day. Several of us lost consciousness, one of the young people died, others were infected and we had nothing that was effective in controlling “ the potent poison that was sweeping the world ”. “ The war and the influenza epidemic, in particular, provided a collective trauma, Williams infected twelve people in his immediate family, including his wife and children ” [ 37 ].

l) Mary McCarthy wrote Memories of a catholic girlhood . She suffered influenza at six years, in 1918, and her deceased grandmother, mother and father.

m) Anthony Burgess, in Anthony Burgess, Little Wilson and Big God: being the first part of the confessions of Anthony wrote: “ In early 1919 my father, not yet demobilized, came on one of his regular, probably irregular, furloughs to Carisbrook Street to find both my mother and sister dead. The Spanish Influenza pandemic had struck Harpurhey. There was no doubt of the existence of a God: only the supreme being could contrive so brilliant an afterpiece to four years of unprecedented suffering and devastation. I apparently, was chuckling in my cot while my mother and sister lay dead on a bed in the same room ”.

The second group: “registered rather than experienced”) ( table 1 )

They are authors with recent historical fictions that attempt to reconstruct accounts of the pandemic such as in 2006: Thomas Mullen’s The Last Town on Earth and Myla Goldberg’s Wickett’s Remedy .

a) Willa Sibert Cather, One of ours (Pulitzer Prize in 1923). She suffered influenza. The book is a contemporaneous literary accounts of the 1918 pandemic, on American soldiers aboard the fictional troop ship Anchises, bound for France.

b) Craig Dilouie, The Thin White Line . Fictionally documented history of an avian flu pandemic in 2012. He describes the fever and the sleep: “… unconscious. I felt like Rip Van Winkle, sleeping through history .”

c) Thomas Mullen, in The Last Town on Earth , describes the bleeding, cyanosis and the quarantine in Commonwealth, a small town in the Pacific Northwest, to keep the influenza out of the town.

d) Myla Goldberg, Wickett’s Remedy . She describes the death of her family. Both Goldberg and Mullen describe pulmonary congestion as a creature inhabiting the lungs.

e) Ernest Hemingway, Death in the Afternoon . He describes a Spanish flu death choking on snot.

f) W. H. Auden wrote Letter to Lord Byron , poem in Letters from Iceland , and another poem The fall of Rome : “ Unendowed with wealth or pity,/ Little birds with scarlet legs,/ Sitting on their speckled eggs,/ Eye each flu-infected city” .

Auden was thinking in the Spanish flu.

g) Wallace Stegner, The Big Rock Candy Mountain , is a semi autographic novel. In 1916 he was trapped one day in the school due to the low temperatures.

h) Christopher Isherwood in Goodbye to Berlin : “ The whole city lay under an epidemic of discreet, infectious fear. I could feel it, like influence in my bones ”. Christopher Isherwood’s time in 1930s Berlin, describes the pre-Nazi Germany. The book was adapted into the musical and the film Cabaret .

In your diaries, The sixties. Diaries volume two: 19601969 : “ I found Dorothy well but shaken by flu...Gerald and Michael had flu …” (January 1962). “… but Michael won´t let me see him because I might give Gerald flu …” (March 1966). i) Agatha Christie, The Case of the Caretaker (Miss Marple´s novel) and Hallowe’en Party (Hercule Poirot´s novel). Finding A. Christie in bed with influenza, her mother suggested she write down the stories she was so fond of telling. And so, began her literary career.

The Case of the Caretaker (Miss Marple cases): “ Miss Marple smiled at him wanly from pillows. ‘I suppose, really, that I’m better,’ she admitted, ‘but I feel so terribly depressed. I can’t help feeling how much better it would have been if I had died. After all, I’m an old woman. Nobody wants me or cares about me.’

Doctor Haydock interrupted with his usual brusqueness. ‘Yes, yes, typical after-reaction of this type of flu. What you need is something to take you out of yourself. A mental tonic.’ ”

Hallowe’en Party (Hercule Poirot novel) : “ He has not got ’flu,’ said Hercule Poirot. ‘He has only a nasty cold. Everyone always thinks they have ’flu. It sounds more important. One gets more sympathy. The trouble with a catarrhal cold is that it is hard to glean the proper amount of sympathetic consideration from one’s friends .”

-Kevin Kerr, Unity (1918) , a theatre work about the return of the soldiers in the World War I and the presence of the Spanish flu

-James Reina, This time of dying and October mourning

-Ellen Bryant Voight, Kyrie , cycle of poems, is part of the 2007 poetry compilation “ Messenger ” that gives voice to American victims of the Spanish flu.

k) Below is a short list of other writers with an experience with the Spanish flu:

-Raymond Chandler Chandler was sent to the infirmary twice in England, in July and October 1918. Each time, he recovered after six days. The digitized military records reveal two bouts with influenza during the peak of the deadly pandemic ( http://www.thekeptgirl.com/2017/07/the-clews-from-raymond-chandlers-war.html ) .

-Arthur Conan Doyle stopped writing fiction, after losing his son with the Spanish flu, and went to spiritual ism.

-Hilda Doolittle was nearly to die with the Spanish flu

-John Dos Passos perhaps saved his life, as he con tracted it on a military transport while crossing the Atlan- tic to fight in Europe.

-Dashiell Hammett enlisted in the United States Army, and in 1918 was afflicted during that time with the Spanish flu and later contracted tuberculosis.

-W. B. Yeast took care of his pregnant wife through the illness

l) Writers died in the Spanish flu pandemic:

-Randolph Bourne, American progressive writer and public intellectual, (December 22, 1918)

-Bernard Capes, British Victorian novelist (2 November 1918)

-Stephen Sydney Reynolds, English writer, (February 14, 1919)

In tables 2A and 2B , we show a list the other authors and books, and in table 3 books in relationship with the genetic manipulation and bioterrorism.

Other English books (in chronological order) about the 1918 influenza pandemic (The Spanish flu) and flu in general

WORLDWIDE LITERATURE ( TABLE 4 )

Other worldwide authors and their books (in chronological order) about the influenza

a) Johan Olof Wallin, Swedish minister, orator and poet, in his poem The Angel of Death : “ Those plagues of night and of desolation ”.

b) Leon Tolstoi, War and Peace . The plot is in July 1805

c) Sforim, Tales of Mendele , describes the flu in Odessa 1st October 1886. In 1918, the first wave of flu affected Russia in May, but it went unnoticed except in Odessa, where with the ongoing Russian civil war, it had a major problem of food shortages and the existence of gangster gangs. Due to its strategic position and suffering from different infections throughout history with quarantines since the time of Catherine the Great, Iliá Mechnikov chose Odessa in 1886 as the first center of disease control (Bacteriological Institute) of Russia with vaccinations against the rage. His assistant Yakóv Bardakh continued his work investigating anthrax, typhoid, cholera, malaria and tuberculosis. Bardakh’s Jewish origin led to his dismissal and one of his students, Stefansky, was put in his place, but his fame was so great that he was the most famous doctor in southern Russia. The arrival of the Spanish flu (ispanka ) and other infections such as cholera and typhus made Odesa a chaotic city and many did not want to listen to the rational explanations for the reason for that epidemic, so on October 1 was celebrated the first black wedding ( shvartze khasene in Yiddish). Sforim recounts the first black wedding in his book: It was a Jewish ritual to protect themselves from deadly epidemics, consisting of looking for a boyfriend and girlfriend among the most disadvantaged in the city (crippled or destitute) and marrying them in a cemetery [ 20 ].

d) Géza Csáth, Hungary writer, in the short story The red- haired girl : “ I had taken to my bed. I had contracted influenza. In the evening, fever developed. At such times it is as though the air has become as dense as oil, and everything seems to be swimming in a soft warm fluid…. I saw my father hurrying to my bedside as soon as he was awake. He feels my pulse, examines my eyes and throat and then leaves to wash his hands… Having no appetite, I did not eat any lunch, yet my tempera- ture went up again in the afternoon. I was gazing with tired , feverish eyes at the grey winter sky above the blank wall .”

e) Franz Kafka, Czech Republic, in Letters to Felice (19121917). He contracted the flu in Prague on October 14, 1918 and while in his sickbed he witnessed the fall of the Austro-Hungarian Empire from his window. “ Getting the fever as a subject of the Habsburg monarchy and recovering from it as a citizen of a Czech democracy was certainly overwhelming , but also a little comical ” wrote his biographer. In: Letters to Felice (18-19, XII, 12) : “ But, my love, I am writing so calmly here and perhaps you are ill. In the next letter to Schillings Flucht you get to mention the possibility of a flu. By God, my love to whom my life belongs, take care of yourself! I con- fess that when I think you are sick the first idea that comes to mind is not that you are suffering, but that I may not receive news from you, and immediately, under the harassment of de- spair, I feel mortified by everything around me. On Tuesday the sore throat gave way to a cold, which certainly represents an improvement in these chills totally unknown to me. Do you still have migraines, though? I am seeing how after closing the last letter you go looking for aspirin and you swallow it: I get chills

https://www.granadahoy.com/ocio/Ano-Lorca-Federico-Residencia-Estudiantes-Madrid_0_1358564641.html f) Ernst Jünger, Storm of Steel

https://www.granadahoy.com/ocio/Ano-Lorca-Federico-Residencia-Estudiantes-Madrid_0_1358564641.html g) Stefan Zweig, Letter from an Unknown Woman :” My son died yesterday. For three days and three nights I have had to fight with the death that surrounded that small and fragile life. I sat next to her bed for forty hours, while the flu stirred her poor burning body. I held cold cloths over his boiling tem- ple and, day and night, I held his uneasy hands .

I think I have a fever, maybe I even have the flu, which now goes door to door”

h) Jaroslaw Iwaszkiewicz, The Wilko Girls’ , about the Spanish flu. The story of an ex-military man (Wiktor) who, after fighting in World War I, quelling the communist revolt in Russia, decided to return to his town, where he had a relationship with six sisters who each represent a different type of love. His cousin, the Polish composer Karol Szymanowski composed his opera King Roger in a Black Sea resort in the autumn of 1918 when he contracted the Spanish flu and composed this opera: “ a sleepless Spanish night came to mind ” [ 20 ].

i) Saneatsu Mushanok ji, member of the Japanese avant-garde Shirakaba, in Love and death , described the death by flu of a young´s girlfriend.

j) Suryakant Tripathi (Nirala) (first modern Hindi poet of India). In 1918 many members of Nirala´s family died of flu and there was not enough wood to cremate them. “ My family disappeared in the blink of an eye” [ 20 ].

k) Orhan Pamuk, Cevdet and sons , in the 30s and flu: “ 29, Wednesday

On Monday afternoon my fever rose to forty. I fell back into bed. Doctor Izak came. It seems like I’m having a bad flu . Than disaster being here, in bed, tied its own hands!

–He has been with the flu for ten days and it still hasn’t passed. It worries me .

I hope it’s not the flu ... What do they call it? Spanish , Asian or than?”

l) Sjón (Sigurjón Birgir Sigurðsson), Moonstone – The Boy Who Never Was . The Spanish flu

m) Sigmund Freud, who in 1920 wrote an essay entitled Beyond the Pleasure Principle (1920), in which he introduced the concept of the death drive alongside the sexual drive. At the time, he denied that, the death from the Spanish flu of his daughter Sophie pregnant with their third child (she died of septic pneumonia as a result of the flu), had any influence, but later admitted that perhaps it had something to do with it. The “ fear of contagion ” possibly affecting his scientific reasoning and resulting theories [ 38 ].

n) Writers died in the Spanish flu pandemic:

-French poet and proto-surrealist Guillaume Apollinaire (November 9, 1918)

-French witer Edmond Rostand, Cyrano de Bergerac ´s author (December 2, 1918)

-Margit Kaffka, Hungarian writer and poet, (December 1, 1918)

-Ivan Cankar, Slovenian Writer, (December 11, 1918)

SPANISH AND LATIN AMERICAN LITERATURE ( TABLE 5 )

Spanish and Latin Americans authors and their works (in chronological order) about the influenza

The authors talk about the facts: “ I caught the flu ” in their diaries and letters, while mainly about the consequences of the flu in the novels and poems. The most important Spanish writers in this period and the Spanish flu are Josep Plá, Rosa Chacel and Miguel Delibes

The first group: authors who were alive at the time (“experienced”)

a) Ramón de ValleInclán, an Spanish playwright, poet and novelist, Letters : ” Letter to Don Julio Romero de Torres (a famous Spanish painter):

... I beg your pardon that I did not write to you before thanking you. The cause has been not having Josefina, in all this time, with a health day. All this as a result of a “flu” that left her very delicate ” [ 39 ]. b) Josep Plá, The Gray Notebook . Josep Plá´s dietary wrote between March 1918 and November 1919. Plá caught the flu that year. Spanish flu caused the faculties to close and Plá returns to his town, Palafrugell, to the family home: “ Since there is so much flu they have had to close the College… The flu continues to relentlessly kill people. In these last days I have had to attend various burials ”.

There are extensive references in the text.

c) Juan Pérez Zúñiga, The fashionable illness (Poem). He was a writer, journalist and humorist. He wrote this poem about the Spanish flu that makes us think about the SARS Cov-2 pandemic (different types of theories: a bacillus, causes such as works or the water, a threat coming from outside, politics, and extravagant treatments). In two different centuries the reaction to them has not changed and for this reason we include the complete poem:

“ There is no other way, gentlemen, / to talk a bit today too / of this evil, whose rigors / has all Madrid crazy. / The bacillus of the grip / has sneaked in everywhere, / like, with impudence, / we were talk yesterday. / But it is nonsense the number/ of causes that are blamed, / without rhyme or reason/ the evil that so bends us. / Many are not satisfied / if they don’t blame the insane / bug to the works they do / for, the Metropolitan./ Another seriously say / that is in the water; divine/ pretext of many people to gorge themselves on wine!./ Someone, like Don Felipe, says (and not using your head) / that the grippe bug comes from a part of France/ and war has brought him . / But I don’t know how./ They wouldn’t have allowed, cross the border! / They also say with grace / that the tiny bug / is floating in the air / such as a zeppelin. / And you don’t know who do you blame / the cause of evil Juan Creso! / Well, to the strike committee since he is in Congress. / And there are those who blame the bug/ of Lola Turrón’s little toilet /, which, according to her boyfriend, / she is a filthy like herself / and she scare/ with soap and water / from the same day of/ his first communion. / And if regarding the origin / of evil lies so much today, / ¡The remedies that rule are/ its healing a charm! / People full of fear / say every nonsense .../ Ones, there is nothing better / than cod with tomato./ Others take the job, / for the good of his skin, /sleeping upside down / inside an old closet, / and others heal with gum, / and others with hard asphalt./ Me, taking the evil as a joke / prevent it with bromide./ even when to sweat / I know there is nothing better / what to do verses incessantly / when you don’t have humor ...”

d) Luis Buñuel, the Spanish film director, in his autobiography My Last sigh : “ During the influenza epidemic of 1919, the terrible Spanish flu that killed so many people, we were practically alone in the Residence (Buñuel and Moreno Villa )”

e) Ramón López-Montenegro and Ramón Peña, El trancazo ( The flu ) (1918) and Pulmonía doble ( Double pneumonia ) (1919). These are two comic players in three and one act, both respectively, about the Spanish flu.

f) Elena Fortún, Letter of Encarna (Elena Fortún) to Mercedes, since Santander, 8th November 1918) . María de la Encarnación Gertrudis Jacoba Aragoneses y de Urquijo was a Spanish author of children’s literature who wrote under the pen name Elena Fortún. She became famous for Celia (“ What Celia Says ”), the first in the series of children’s novels which were a collection of short stories first published in magazines in 1929. The series were both popular and successful during the time of their publications and are today considered classics of Spanish literature. “ The flu epidemic continues, and at times we are very overwhelmed and very sad and wanting to escape .

Nothing serious happens to me, but what has been happening to me since the flu in. More and more cough, pain in the side, more and fatigue, and, in the last week, fever and a hundred beats a minute ”.

“ With such a terrible pain in her side, she took her to a radiologist, and to have blood tests done, and then she was seen by Dr. Ribas Sobera, with whom Asita worked, who said she had pleurisy in her right lung ”.

g) Gregorio Torres Nebrera, The spaces of memory (The literary work of María Teresa León) . Evocation by Rosa Chacel of the figure of María Teresa León in Berlin in 1932. Rafael is Rafael Alberti, the Spanish poet: “ That girl who had developed so much beauty was there, in a hotel room, dressed elementally, typing hours and hours, during a long Rafael´s flu

https://www.granadahoy.com/ocio/Ano-Lorca-Federico-Residencia-Estudiantes-Madrid_0_1358564641.html h) Julio Cortázar, Letter to Damián Bayón (March 18th 1956 in Paris) : “ And that’s what we were doing when Glop gives up on not accepting the cold snap (16 below zero) and catches a fierce flu, complicated by liver .”

i) Francisco Ayala García-Duarte, in his Epistolary , there are 10 letters dated between 1957 and 1968 in which he writes that he has caught the flu (years 1957, 1961, 1964, 1965, 1966 and 1968)

j) Rosa Chacel, her novel Acropolis is a look at women and their stage of growth in a generation that lived the Spanish flu. It covers the period of the Spanish flu until the proclamation of the Second Republic (“ Segunda República ”) in 1931: “ It was not enough with the date, from 15 to 18, the years of the Spanish flu that we have just gone through ... Why Spanish? Who knows, but there’s no smoke without fire… And after all, whether there’s no smoke without fire or not, whether or not it is Spanish, the flu, ours, the one that we live here, in our neighborhood, in our house, was Spanish, authentic. The bug has a foreign name .. . “

“... in this Madrid life, with all its bugs. Because the one with the flu is striking and he is listened to, he is treated, but Madrid life survives by force of ignorance ...”

“ Timothy told me something that had happened in the months of his flu… He had suffered one flu after another during the previous year and the persistence of the feverish state and other symptoms had made him fear that it was a serious lung condition ”.

In the second group (“registered rather than experienced”)

a) Federico García Lorca went to the Student Residence in Madrid in November 1919 but occupies it in February 1920, the delay could be due to the flu in 1919.

( https://www.granadahoy.com/ocio/Ano-Lorca-Feder-ico-Residencia-Estudiantes-Madrid_0_1358564641.html ).

b) Pio Baroja, with several books: Weed, The resources of cunning, The nights of the Buen Retiro, The priest of Monleón, Follies of carnival , and Family, childhood and youth . In The Search : “ Manuel, the protagonist, I do not know if because of the flu or what he fell ill with and “he was close to two weeks with a very high fever, delusional .”

The Cape of Storms: Juanito Vélez, a character linked to the plots and union agitations in Catalonia, he died, far from Barcelona in Tuy: “There he caught the flu and soon after, tuberculosis manifested itself with very high fevers and vomiting of blood and in a short time died . “

c) Mariano de Cavia y Lac, Spanish journalist that in your journalistic column entitled: Against the epidemics: People beg for the veil! , in El Sol (“The Sun”) newspaper (October 24, 1918), he echoes the song of the “ zarzuela ” of Barbieri “ Gloria and Wig ” ( Gloria y Peluca ): “ Do not cover your face/ pretty girl,/ that whoever hides the good/ God takes it away ” and he changed it: “ If you cover your face,/ pretty girl/ you will get rid of flu/ and scarlet fever ”. He was following Professor Marchoux´s advice, in the Pasteur Institute, advocated wearing mask for the flu [ 19 ].

d) Ramón Gómez de la Serna, a Spanish writer, dramatist and avant-garde agitator especially known for “ Greguerías ” (a short form of poetry that roughly corresponds to the one-liner in comedy): “The flu is the fog of death, that little smoke that she also throws on the harsh days of winter”

“Some guys on the fringes of life, who seem to go down unspecified sidewalks, are household disinfectants. They pass with their big appliances on their backs talking about indifferent things to avoid the contagion of the epidemics that have just died out. They know that their path had to be secret so as not to startle the life of the street, which is neglected of all the problems and on which they are cast as shadows. They leave a wake of fallen microbes, but they are looked upon with benevolence, since they are heroic soldiers who enter the house where there has been a flu, and close the doors of the fateful rooms, and are inexorable executioners of evil in the hermetic rooms” .

In The bullfighter Caracho (1926): “ The sensible man maintained that if those misfortunes were exorbitant it is because he had been focused with a telescope in agony and that of a tuberculosis patient or that of a carpentry officer who dies of the flu calling his mother cannot be focused in this way ”).

In Social gatherings in the café (Pombo): “Salvador sometimes has long absences. Pombo misses the little Satan who sniffs everything and is distracted from ideas by sniffing things, sensual and dissolute. It is that Salvador always has the flu, his grip is temporary, so Bartolozzi and Flu are also savior ”.

“ Crespo: “If I had not said that the great Savior is Lucifer, I would say that this man is Mephistopheles, although of course Salvador is that in a very serious way with a black coat ”.

He also alludes to his chronic flu in one of his characteristic humorous notes (in The Pombo´s holy crypt ).

e) Carlos Arniches, a Spanish playwright. His prolific work, drawing on the traditions of the “ género chico ”, the zarzuela and the grotesque, came to dominate the Spanish comic theatre in the early twentieth century. In this theater comedy, The caciques , released in Madrid on February 13, 1920, he alludes to the high mortality in old people: “ MORRONES. — There is no abundance of the elderly with the flu; but “ou” will see later the best I have found. And the boys are picking them up for me, my wife. I have told him to pay them six pesetas for half a dozen ... I was already nine when I came; but the nine of both sexes, as “ou” wanted ”.

f) Ramón Pérez de Ayala, in his Epistolary between Pérez de Ayala and Jesús Pabón: “ I did not answer immediately because a whole month I suffered from the flu, which had me perfectly asthenic. The South American flus are very impertinent. I have not recovered yet, but I am improving ”.

g) Miguel Delibes, My idolized son Sisi . The novel recreates the situation experienced in a province by the flu and the quarantine. The novel in three parts (the first one between 1917-1920):

“-Oh, the flu! Said Cecilio Rubes. Since when is the flu a major disease?

Valentine said:

This one right now is not a joke, Mr. Rubes. It is a flu that does not go away with two days of bed and an aspirin seal” .

h) Julio Cortázar, Hopscotch (Rayuela) : “ I will explode from an intestinal occlusion, the Asian flu, or a Peugeot 403… ”

Julio Cortázar, The pursuer (El perseguidor ) (short story): “ You had the flu. Your better now?

It wasn´t flu. The doc arrived and right away began telling me he liked jazz …”

i) Anxel Fole, How the tailor Bieito returned to hell (short story):

“ the gravedigger, seeing that the tailor apparently dead of the flu, rises, exhorts him to return to hell:

-Don’t you see that I’m alive?

-Alive? You died of the flu complicated with pneumonia. Or do you want to know more than the doctor who issued you the death certificate?”

j) Luis Fernando Verissimo, The club of angels . Spanish flu or bird flu:

“ When someone asked about Samuel’s parents, he replied that they had died of the Spanish flu. And if someone remembered that it was impossible, since the Spanish flu epidemic had reached Brazil at the beginning of the century, he said: “Then it was Asian flu, I did not ask for documentation ”.

k) Mario Levrero, The luminous novel : “ Many years ago, a relative dentist expressed in my presence the theory of that flu lasting three, seven or twenty-one days. The numbers are too cabalistic to trust them too much ”.

l) Elías Rubio Marcos, The year of the flu and other stories . Book about the causes that motivated the depopulation in Ochate (Treviño County, Spain), during the Spanish Flu.

m) Gabriela Mistral and Victoria Ocampo, This America of ours. Correspondence 1926-1956 . Correspondence, where the flu contagion is counted

“ I stay in bed with my second flu ..”

Pablo Caralps, Mortal flu . Use of a Spanish influenza strain, its spread and create one vaccine and two influenza drugs

-José Manuel Echevarria, Pandemic alert? . A new flu virus in a pandemic in Guatemala.

Empar Fernández, The spring epidemia . The Spanish flu

Yolanda Guerrero, Mariela . Spanish nurse in Paris, in 1918

Finally, in table 6 we correlate the Spanish flu topics and the authors.

The Spanish flu topics in the books and authors

In conclusion, we show the different literary works about the Spanish flu and an extensive list of them. All these works show the wrong idea of Virginia Woolf complained about the lack of novels devoted to influenza and we have contextualized the works with the historical situation of the Spanish flu.

None to declare

CONFLICT OF INTEREST

The authors declare that they have no conflicts of interest

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