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Art and Images in Psychiatry
April 2006

Self-Portrait After Spanish Flu

Arch Gen Psychiatry. 2006;63(4):354-355. doi:10.1001/archpsyc.63.4.354

For as long as I can remember I have suffered from a deep feeling of anxiety which I have tried to express in my art. Without anxiety and illness I would have been like a ship without a rudder.

Munch to his doctor and friend, K. E. Schreiner1(p22)

“Do you find it nauseating?” “What do you mean?” “Don't you recognize the smell?” “The smell?” “Yes, the odor of death—don’t you see I’m on the brink of rotting away?”

Munch in dialogue with Rolf Stenersen about his self-portrait2(p66)

The Spanish flu passed across the North Sea and arrived in Norway in 3 waves in the summer and fall of 1918 and the early months of 1919. Almost half of the Norwegian population of 2.5 million was affected; 15 000 died (5.7/1000).3 Worldwide the death toll was more than 50 million; approximately 675 000 died in the United States (6.5/1000). The Norwegian summer epidemic beginning in mid-June was less severe; most died (8.6/1000) during the second wave from October to December from pulmonary complications and pneumonia. Unlike earlier and later flu epidemics where children and the elderly were the hardest hit, healthy young adults between the ages of 15 and 34 years bore the brunt of this illness in Norway as elsewhere. Not only was the death rate high, but also there were short-term and long-term complications and a reduced birth rate because of the deaths of so many in the prime of life.4

Besides pneumonia, the largest increase in first-time hospitalization in Norway, as in other countries, was in asylums for mental illnesses, especially for psychosis.1,5,6 There also was an increased rate of suicide associated with the pandemic. Sir William Osler, who died of bronchopneumonia in 1919 as a complication of his bout of Spanish flu, wrote, “[A]lmost every form of disease of the nervous system may follow influenza.”7 Another pandemic (1916-1927), encephalitis lethargica (von Economo disease), mainly affecting children, often has been linked to the Spanish flu. However, recent evidence does not confirm a direct association. Influenza RNA has not been found in archival postmortem tissue,8 and studies of contemporary cases suggest that this syndrome may be the result of basal ganglia autoimmunity.9

Edvard Munch (1863-1944), aged 55 years, was among the survivors of the 1918 pandemic and depicted the effects of the illness in a series of self-portraits about his illness and his recovery. Following his successful treatment in Copenhagen in 1908 through 1909 for a mental breakdown brought on by stress and alcohol abuse,10 he returned to Oslo, Norway, and purchased a manor home at Ekely. In 1909, he wrote the following to Sigurd Høst1(p18):

My motto has become ‘Steer clear of everything.’ I now confine myself to nicotine-free cigarettes, alcohol free drinks, and non-poisonous women (either single or married). You're going to find me an extremely boring uncle.

Munch was a reclusive person, rarely going out, but he had frequent visitors, both friends and strangers (Jacobsen, personal communication, 2006). He was preoccupied with his health, having been frequently ill during his childhood. Moreover, he was well acquainted with illness; his father was a physician, and Munch accompanied him on his house calls. He was well aware of respiratory illness; his mother and older sister, Sophie, both died of tuberculosis. Munch's earliest paintings depicted the sick room, particularly Sophie's terminal illness and the shock, in his youth, of witnessing death. His preoccupation with illness was magnified by the severity of the Spanish flu and the loss of a close friend to it. Munch's preparatory drawings for his self-portrait with the flu show him in bed or sitting on the side of his bed. But in Self-Portrait With Spanish Flu (1919), he sits in a chair as Sophie had in his paintings of her (The Sick Child [1885-1886], Spring [1889], Death in the Sickroom [1893]). One preparatory drawing shows him sitting up in bed appearing gaunt with threatening shadows on the wall.11 Other preparatory drawings depict fear and possibly delirium, a common complication of the flu.

Self-Portrait With Spanish Flu captures Munch's sense of debilitation and decay (epigraph) (Figure). Exhausted and pale, he faces the viewer in his sickroom, almost blending into the wall; his eyes peer out, his mouth ajar, his hands weakly placed on his lap. He sits in his yellow wicker chair, wearing a robe with a blanket over his lap, beside a bed with a crumpled duvet that suggests his tossing and turning in bed. The lively bright colors of the yellow chair, red blanket, and blue bedstead strikingly contrast with his lifelessness. The flamelike redness on the wall may be reminiscent of his high fever. There is flatness to the composition, making it appear 2-dimensional; the thin application of the paint suggests a sense of disintegration.11 Still, despite the starkness of Munch's facial appearance, the substantiality of his body and the fact that he is out of bed implies emerging strength.

Self-Portrait With Spanish Flu, 1919. Oil on canvas, 150.3 × 131 cm. © 2006 The Munch Museum/The Munch-Ellingsen Group/Artists Rights Society (ARS), New York, NY.

Self-Portrait With Spanish Flu, 1919. Oil on canvas, 150.3 × 131 cm. © 2006 The Munch Museum/The Munch-Ellingsen Group/Artists Rights Society (ARS), New York, NY.

In Self-Portrait After Spanish Flu (cover), he stands in the foreground fully dressed, a looming mass, shoulders sagging, perhaps looking into a mirror to survey the impact of his recent sickness.11 The rich coloration of his face betrays the residua of his illness. His sunken eyes are now prominent and his mouth firm. Haggard and unshaven with long, tousled hair, his face is unsettling, apparitional, even ghostlike, but some color has returned to his face and his gaze is intense. The wicker chair is now empty, and the room is flooded with daylight, the carpet is brightly colored, and books on the table suggest a return to normalcy. The window frame forms a Tau cross.12

Edvard Munch (1863-1944), Norwegian. Cover: Self-Portrait After Spanish Flu, 1919-1920. Oil on canvas, 59 × 73 cm. © 2006 The Munch Museum/The Munch-Ellingsen Group/ Artists Rights Society (ARS), New York, NY.

Edvard Munch (1863-1944), Norwegian. Cover: Self-Portrait After Spanish Flu, 1919-1920. Oil on canvas, 59 × 73 cm. © 2006 The Munch Museum/The Munch-Ellingsen Group/ Artists Rights Society (ARS), New York, NY.

Another painting, Self-Portrait in Turmoil, completed around the same time, shows him sleepless and agitated. Munch complained to friends about the sleeplessness that accompanied the flu. Although Munch may have been delirious and hallucinatory during his illness,13 afterwards there seems to have been no mental residua. Following his recovery in 1919, he began to build a new studio in Ekely. The following winter, he became ill again and spent many months in bed, painting Self-Portrait With Bronchitis at that time. These illnesses passed and his success continued. In 1930, he had an intraocular hemorrhage in his right eye and feared blindness, but this too resolved and Munch continued to paint throughout the rest of his life.

Others were not as fortunate as Munch in their recovery from the Spanish flu. The relationship to psychiatric illness intrigued Karl Menninger5 at the Boston Psychopathic Hospital. Menninger reported on 80 cases of mental disturbance in cases admitted in the 3-month period from September 15 to December 15, 1918. He described 4 groups ranging in age from 16 to 69 years: delirium (16 cases), frank dementia praecox (schizophrenia) (25 cases), other forms of psychosis (23 cases), and unclassified (16 cases). He noted an unexpectedly high frequency of hallucinations and/or delusions in the majority of cases, generally with onset 2 to 8 days after the termination of influenza; acutely, depression was relatively infrequent. Initially Menninger thought that the flu was an etiologic factor in schizophrenia, independent of delirium; he found no predisposing factors and no suggestive family history in many of these cases. The average age at onset of these cases was 23 years. In follow-up at 1 to 5 years,6 he reported that in the majority of cases (40/50) symptoms had remitted; Menninger now referred to these cases as reversible or symptomatic schizophrenia and questioned its specificity to Spanish flu.

More recent links of influenza to schizophrenia involve studies of gestational exposure. Archived maternal serum was assayed for influenza antibody in pregnancies giving rise to offspring with schizophrenia. These cases were compared with matched control offspring in a case-control study of a large birth cohort born from 1959 through 1966 and followed up for psychiatric disorders 30 to 38 years later.14 There was a 7-fold increased risk of schizophrenia for influenza exposure during the first trimester but not with exposure beginning in the second or third trimester. The authors also summarized evidence for the effects of influenza virus on behavior in mouse models.

Further investigation of the effects of the Spanish flu virus on brain functioning in animal models is now possible with identification of the 1918 influenza virus coding sequence. Reverse genetics (from viral RNA to complementary DNA to DNA amplification and sequencing) has been used to generate an influenza virus bearing all 8 gene segments of the 1918 pandemic virus.15,16 Unlike contemporary human influenza H1(hemagglutinin) and N1 (neuraminidase) viruses, the 1918 pandemic virus causes rapid death in mice and embryonated chicken eggs and grows readily in human bronchial epithelial cells. No other human influenza virus is as pathogenic for mice 3 to 4 days after infection. Fortunately, approved antiviral drugs oseltamivir and amantadine are effective against viruses carrying the 1918 neuraminidase and the 1918 matrix gene, respectively.16 Moreover, vaccines containing the 1918 hemagglutinin and neuraminidase genes are protective in mice.

Besides its effects on individuals, the Spanish flu had historical impact. The US Congressional elections of 1918 took place during the pandemic as did the peace negotiations that followed World War I. At the peace conference in Paris on April 2, 1919, Woodrow Wilson, who had insisted on making peace based on certain principles, his 14 points, was preparing to abandon the talks because the parties could not reach an agreement. On April 3, he was seized by violent paroxysms of coughing that interfered with his breathing and had a fever of 103°F. He was severely ill with Spanish flu. Crosby17 writes that as the physical symptoms abated, Wilson seemed different psychologically, lacking in mental agility and tiring easily. More disturbing, his chief usher reported strange ideas, that Wilson was suspicious, worrying that all the servants were French spies.17(p193) Still ill, only days after threatening to leave the conference, and without discussion with his staff, Wilson abruptly was no longer intent on the principles he had insisted on earlier and yielded to French demands that he had firmly opposed. Wilson's illness seemed to have affected his will to negotiate. The Versailles Treaty was signed but was not ratified by the US Senate. Historians continue to question whether Wilson, hypertensive with known atherosclerosis, also had a small stroke at that time that affected his personality during the negotiations. And historians speculate about the impact of Wilson's Spanish flu and a possible stroke on his decision-making17,18 on the settlement that was reached at the end of the first World War and its subsequent effects on world history in the 20th century.

Please Note: The exhibit “Edvard Munch: The Modern Life of the Soul,” is at the Museum of Modern Art; New York, NY; February 19 to May 8, 2006.

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