The monster came with many names in the fall of 1918 - Spanish influenza, the Great Pandemic, La Grippe, the flu.

This November is the 90th anniversary of the worst worldwide epidemic in modern times, which coincides with the ending of World War I. This overwhelming event is one important reason why Central Texans roll up their sleeves each year for flu shots.

Texas’ rainy autumn months nine decades ago were tough - killer influenza and a devastating, brutal war. In all, 50 million worldwide died of influenza, compared to the 9 million who died during actual combat. Influenza was no respecter of persons - rich and poor, mother and child, soldier and civilian.

The 1918 influenza epidemic was “a plague so deadly that if a similar virus was to strike today, it would kill more people in a single year than heart disease, cancers, strokes, chronic pulmonary disease, AIDS and Alzheimer’s disease combined,” wrote Gina Kolata in her history, “Flu: The Story of the Great Influenza Pandemic of 1918 and the Search for the Virus That Caused It.” “The epidemic affected the course of history and was a terrifying presence at the end of World War I, killing more Americans in a single year than died in battle in World War I, World War II, the Korean War, and the Vietnam War.”

Bell County was considered what one newspaper called “the nest of the influenza epidemic.”

The disease spread early to Temple because it was a commercial and transportation center, which brought the disease quicker to the state’s interior. Temple also had most of the physicians and four hospitals: Besides King’s Daughters and Scott & White hospitals, Temple also had the Santa Fe Hospital for railway employees and a hospital for African-Americans that opened in May 1917. Thus, the sick flocked to the city for help.

Physicians and hospitals were unprepared. Bell was among the few counties with an active public health department. Equally significant is that responsibility for dealing with crises of such magnitude lay in the hands of local authorities and physicians. The state had little authority and infrastructure to handle health emergencies.

The monster disease’s encroachment was insidious. The first case was in a soldier at a Kansas military post in the early morning of March 11, 1918. By noon, 100 soldiers reported sick. Within a week, 500 soldiers were stricken. Not until July did Philadelphia health officials name the disease “Spanish influenza,” erroneously attributed to its origin. By August, influenza broadened throughout the Northeast, especially among military in close quarters, such as aboard ships.

Texas newspapers in the first week of September, including the Temple Daily Telegram, reported an epidemic was likely. The U.S. Surgeon General issued press releases, recommending sufferers get bed rest, good food, quinine and aspirin. Within a week, Texas newspapers reported spotty occurrences, expressing fears that the disease was spreading.

Meanwhile, Bell County physicians started seeing the cases in greater numbers. By Sept. 27, the state health department required counties to report cases, but little else.

The next week, on Oct. 6, Wilma Carlton, R.N., director of Scott & White nurses and chairwoman of Bell County nursing services, appealed for mobilization of “all women and girls with nursing experience of any kind to be undertaken at once.” She reported that she personally was handling between 50 and 60 cases at once.

That same week, county health officer Milton Perry McElhannon, M.D., of Belton issued an order to close all schools, churches, picture shows and theaters in Bell County. He forbade all public gatherings, including sporting and social events.

Similarly, Milam and McLennan county officials ordered closings of all “picture shows, pool halls, cold drink places” as well as schools and churches. Camp MacArthur in Waco, where so many Bell County soldiers took basic training, tallied 50 deaths in one week.

King’s Daughters, Scott & White and the Santa Fe all housed patients in tents and outbuildings - called contagion wards - to prevent the disease’s spread. The Bell County Red Cross organized a volunteer nursing corps to assist in caring for the home-bound.

By mid-October, Bell County was in deep crisis. “The situation grows more serious here every day,” McElhannon said. “Every precaution is being taken to get it under control.”

Meanwhile, workers and volunteers stacked coffins along railroad loading docks “like cord wood,” waiting to be shipped home for burial.

To boost lagging business, Temple and Belton merchants launched special sales and extended hours, but McElhannon ordered stores to close early and churches to cancel Sunday services. Those who did venture out in public wore face masks to prevent spreading or catching the disease.

Construction projects halted as workers were too sick to report or were afraid of catching the disease. Lumber mills and manufacturing companies announced their closings. Fields ready for fall planting laid fallow because able-bodied workers were either serving in the war or prostrate with influenza.

Cases were so numerous and Bell County so overwhelmed that health officials quit reporting. The Galveston Daily News on Oct. 20 described Bell County as “located in the nest of the influenza epidemic.”

To help ease the crisis, Congress approved a special $1 million fund to recruit more than 1,000 physicians and 700 nurses for the U.S. Public Health Service to deal with the growing epidemic. However, with so many already serving in the war effort, the Health Service recruited in places like old-age homes and rehabilitation centers.

By Oct. 29, Texas reported 106,978 cases and more than 2,181 dead. Complicating the statistics was a second epidemic of mosquito-borne dengue fever, triggered by an unusually rainy fall. Thus, because the state health department was so overwhelmed, officials admitted the numbers were underreported and probably much higher.

Bell County’s death toll will never be known. Burial logs at Hillcrest Cemetery in Temple offer a glimpse into the emergency. The cemetery ranged from two to 10 funerals per month up to September 1918, about two each week. However, in October, the cemetery had 31 funerals, sometimes as many as five per day. The number of funerals eased slightly - to 17 - in November and December 1918 and January 1919 before leveling off to its previous numbers.

The cemetery, then technically outside the city limits, also contained the city’s pauper graves. Deaths among the poor were so high, the city in December 1918 purchased an additional 1.5 acres. Many of those burials remain unmarked and undocumented.

Despite the sickness and death, some managed semblances of normalcy. Thelbert F. Bunkley, M.D., had recently joined Scott & White and the Santa Fe Hospital as a staff physician. He and his wife had married just as the epidemic began. The Sisters of Charity of the Incarnate Word, who ran the Santa Fe, allowed him a hospital room so that the newlyweds could spend a short honeymoon before he returned to tending to patients.

Also undeterred, the Temple Stag Party, a raucous, men-only annual gala with skits and jokes, went on as usual on Nov. 28 in the Carnegie Library, albeit subdued “in deference to war conditions.”

By early February, the influenza had run its course. As the weather warmed, cases waned. A second epidemic returned in the fall 1919, but not with the virulence of the previous year. Within 18 months, the strain disappeared.

Influenza was not gone for good. Smaller outbreaks were common. During the first week in January 1944, another smaller influenza epidemic affected 126,000 nationwide and 24,000 in Texas.

Not until 1933 did scientists discover that influenza was transmitted by a virus.

For the survivors, the influenza pandemic yielded a curious medical benefit. The August issue of Nature magazine reported Vanderbilt University researchers discovered that those who lived through the 1918 pandemic were still producing antibodies to the virus 90 years later. The Centers for Disease Control recently reconstructed the 1918 virus while studying remains preserved by the Alaskan permafrost.

Could the 1918 epidemic happen again? Maybe. That’s why medical researchers remain vigilant for each viral mutation, new vaccines are formulated each year and physicians stress annual flu shots.

Still, nature can pull surprises. In 2002, public health officials feared the worse when passengers on a plane from China spread severe acute respiratory syndrome to 26 countries around the world, causing 8,500 infections and killing 916 people.

For now, flu shots and flu mist nasal spray are the best deterrents, as are frequent hand washing and generally good hygiene.

Editor’s note: Today marks the last of a series on events of the year 1918. From a war’s end to a pestilence that spread worldwide, it was a year of joy and great sorrow.