The 1918 Influenza Pandemic

Tested against the primary record

1. SupportedIn British India no method exists to count the deaths actually due to influenza, and the figure of 7,089,694 is the mean of three excess-mortality estimates.

   Rests on documents from: Government of India; Ministry of Health (Great Britain).

   The Sanitary Commissioner's report states the method and the mean in its own words, and the Ministry of Health's summary, from a second producer, carries the same approximately seven millions and says that in India anything other than approximations is impossible to obtain.

   The 3 extracts it rests on

   1. Sanitary Commissioner with the Government of India, Annual Report of the Sanitary Commissioner with the... (1920)p. 56Exhibit 2

      Influenza . — There is no method by which the deaths actually due to influenza can be calculated. If it be assumed that the excess Mortality. jn the deaths in 1918 over the mean of the previous 5 years was the result — direct or indirect — of influenza, the figure would come to 7,718,307. This is an overestimate owing to the disturbing factor of other epidemic diseases, such as plague, cholera, malaria and relapsing fever, which raised the mortality in various parts of India during the first half of the year. There is no certain evidence that influenza was present in India before June 1st : it is, however, probable that if it were, it had no appreciable influence on the death rate for India as a whole. This suggests that the excess in the mortality from all causes between June 1st and December 31st over the 5 years mean — 6,812,633 — may be a more reliable index. This may, however, be a slight underestimate, for, in the last half of 1918 the mortality from plague was exceptionally low as compared with the quinquennial mean. Another estimate may be obtained by "subtracting from the total mortality from all causes the deaths registered as due to the chief epidemic diseases — - plague, cholera and small-pox, and comparing this figure with one similarly obtained for the previous quinquennium. On this basis the estimate would be 7,304,478. A fourth figure may be estimated by taking the excess in the mortality from “ fevers ” and respiratory diseases over the average for 5 years. In 1918 this excess came to 7,151,971.

   2. Sanitary Commissioner with the Government of India, Annual Report of the Sanitary Commissioner with the... (1920)p. 57

      Without any claim to accuracy it is suggested that the mortality directly hand indirectly due to influenza was in the neighbourhood of the mean of the General Population.] WITH THE GOVERNMENT OF INDIA FOR 1918. 5 last 3 figures, viz. , 7,089,694. This mean is taken for the purpose of this report, and the mortality and death rates for the Local Governments and Administrations are calculated in a similar manner : the figures in this report consequently differ slightly from those given in the provincial sanitary reports, and are given in the following table : —

   3. Great Britain, Ministry of Health (Major Greenwood, Thomas Carnwath, R. Bruce Low, S. P. James and others), Reports on Public Health and Medical Subjects, No. 4 (1920)§ india

      Reports received indicate that no part of the world suffered as severely as did India during the latter half of 1918. A preliminary report by the Sanitary Commissioner with the Government of India estimated that up to the end of November 1918 no fewer than five million deaths were attributable to the influenza pandemic in British India alone (population, 238,000,000). In the native states influenza deaths certainly exceeded one million in the same period. A later report states that between 1st lune and 31st December 1918, the total mortality in British India exceeded the quinquennial mean mortality for the same period by approximately seven millions. The great majority of this excess mortality occurred in the last four months of the year. There was no abnormal prevalence of other communicable disease, so it is justifiable to accept this figure as a rough approximation of the influenza death roll. In view of the conditions pertaining in India, anything other than approximations of this nature is impossible to obtain.

2. QualifiedEngland and Wales lost about 200,000 people to the epidemic.

   Rests on documents from: Ministry of Health (Great Britain); Registrar-General for England and Wales.

   The Registrar-General's 200,000 is a round figure reached by adding deaths allocated to other causes to the 151,446 allocated to influenza; the Ministry of Health, in the same year, puts the loss at upwards of 150,000, which is the allocated count. Two producers, one quantity, two conventions, so the claim holds only with its method attached.

   The 3 extracts it rests on

   1. Registrar-General for England and Wales, Supplement to the Eighty-First Annual Report of the... (1920)§ totalExhibit 1

      In addition to the above there were 7,591 deaths of non-civilian males in this country allocated to influenza in 1918 and 2,899 in 1919 during the epidemic period, or 10,490 in all. This number has to be increased to an uncertain extent, say to 14,000 to allow for deaths really due to influenza but allocated to other causes. The non-civilian mortality of the preceeding years was so small that it may be left out of account. This addition to the civilian deaths brings the total toe 198,000, and in view of the uncertainties of the estimation the round figure of 200,000 deaths attributable to the epidemic (in addition to about 7,000 which the average rate of recent mortality would have accounted for) may be accepted as adequately summing up its results

   2. Registrar-General for England and Wales, Supplement to the Eighty-First Annual Report of the... (1920)§ estimate

      Estimate of total mortality.—The deaths allocated to influenza during 1918 numbered 112,329, 53,883 of males and 58,446 of females. The 53,883 males. included 7,591 non-civilians. Deducting these we are left with 104,738 deaths of civilians, corresponding to a mortality of 3,129 per million civilian population. No such mortality as this has ever before been recorded for any epidemic in this country since registration commenced, except in the case of the cholera epidemic of 1849, when the mortality from that cause rose to 3,033 per million population. None of the previous outbreaks of influenza can compare in mortality with that of 1918-19. During the 46 weeks, June 23rd-May 10th, the total deaths allocated to the disease were 151,446, including 140,989 of civilians, the corresponding civilian death-rate for these 46 weeks being at the annual rate of 4,774 per million population. It is well known that during influenza epidemics the mortality attributed to the disease does not represent the whole of that caused by it. The entries under other headings, especially those of respiratory disease, are always found to increase during an epidemic, and though this has not occurred in 1918 to the same extent as in other recent outbreaks it is still necessary to make allowance for these increases of mortality, allocated to other causes but really attributable to influenza, in endeavouring to measure the loss of life caused by the epidemic.

   3. Great Britain, Ministry of Health (Major Greenwood, Thomas Carnwath, R. Bruce Low, S. P. James and others), Reports on Public Health and Medical Subjects, No. 4 (1920)¶ 2

      2. This document deals with one of the great historic scourges of our time, a pestilence which affected the well-being of millions of men and women and destroyed more human lives in a few months than did the European war in five years, carrying off upwards of 150,000 persons in England and Wales alone.

3. Cannot be tested from the free recordThe pandemic destroyed more lives in the whole world than the European war in five years.

   Rests on an absence in the free record.

   The Ministry asserts the comparison and offers no figure for either side; nothing in the free record here can test it, and it is published as the Ministry's judgment.

   The extract it rests on

   1. Great Britain, Ministry of Health (Major Greenwood, Thomas Carnwath, R. Bruce Low, S. P. James and others), Reports on Public Health and Medical Subjects, No. 4 (1920)¶ 17

      17. Thirdly, the epidemic was remarkable in respect of the mortality. It should be borne in mind that the fatality of influenza is low, but its incidence is so vast that the number of deaths create an excessive mortality. Thus, it comes about that the epidemic destroyed more lives in the whole world than did the European war in five years.

Tested against the primary record

1. SupportedThe recorded statistics of influenza morbidity and mortality are a significant understatement.

   Rests on documents from: Government of India; Registrar-General for England and Wales; United States Public Health Service.

   Three producers say so of their own returns: the Sanitary Commissioner that there is no method by which the deaths actually due to influenza can be calculated, the Registrar-General that the mortality attributed to the disease does not represent the whole of that caused by it, and the Public Health Service statistician that in practically no locality can complete reports of cases be assumed.

   The 3 extracts it rests on

   1. Sanitary Commissioner with the Government of India, Annual Report of the Sanitary Commissioner with the... (1920)p. 56Exhibit 2

      Influenza . — There is no method by which the deaths actually due to influenza can be calculated. If it be assumed that the excess Mortality. jn the deaths in 1918 over the mean of the previous 5 years was the result — direct or indirect — of influenza, the figure would come to 7,718,307. This is an overestimate owing to the disturbing factor of other epidemic diseases, such as plague, cholera, malaria and relapsing fever, which raised the mortality in various parts of India during the first half of the year. There is no certain evidence that influenza was present in India before June 1st : it is, however, probable that if it were, it had no appreciable influence on the death rate for India as a whole. This suggests that the excess in the mortality from all causes between June 1st and December 31st over the 5 years mean — 6,812,633 — may be a more reliable index. This may, however, be a slight underestimate, for, in the last half of 1918 the mortality from plague was exceptionally low as compared with the quinquennial mean. Another estimate may be obtained by "subtracting from the total mortality from all causes the deaths registered as due to the chief epidemic diseases — - plague, cholera and small-pox, and comparing this figure with one similarly obtained for the previous quinquennium. On this basis the estimate would be 7,304,478. A fourth figure may be estimated by taking the excess in the mortality from “ fevers ” and respiratory diseases over the average for 5 years. In 1918 this excess came to 7,151,971.

   2. Registrar-General for England and Wales, Supplement to the Eighty-First Annual Report of the... (1920)§ estimate

      Estimate of total mortality.—The deaths allocated to influenza during 1918 numbered 112,329, 53,883 of males and 58,446 of females. The 53,883 males. included 7,591 non-civilians. Deducting these we are left with 104,738 deaths of civilians, corresponding to a mortality of 3,129 per million civilian population. No such mortality as this has ever before been recorded for any epidemic in this country since registration commenced, except in the case of the cholera epidemic of 1849, when the mortality from that cause rose to 3,033 per million population. None of the previous outbreaks of influenza can compare in mortality with that of 1918-19. During the 46 weeks, June 23rd-May 10th, the total deaths allocated to the disease were 151,446, including 140,989 of civilians, the corresponding civilian death-rate for these 46 weeks being at the annual rate of 4,774 per million population. It is well known that during influenza epidemics the mortality attributed to the disease does not represent the whole of that caused by it. The entries under other headings, especially those of respiratory disease, are always found to increase during an epidemic, and though this has not occurred in 1918 to the same extent as in other recent outbreaks it is still necessary to make allowance for these increases of mortality, allocated to other causes but really attributable to influenza, in endeavouring to measure the loss of life caused by the epidemic.

   3. Edgar Sydenstricker, Public Health Statistician, United States Public Health Service, Preliminary Statistics of the Influenza Epidemic (1918)p. 2306

      Were there any necessity for demonstrating the utter inadequacy and lack of uniformity of morbidity reporting in the United States, such a demonstration would be fully available in the experience afforded during the present epidemic. The shortcomings of morbidity statistics already are so well known that it is unnecessary to refer to them in detail. Their chief fault — incompleteness— was immeasurably increased by the unusual circumstances that prevailed. Among these circumstances were the magnitude of the epidemic in a large number of localities, the congestion of cases at and near the peak of the epidemic, the tendency to cease reporting toward the end of the epidemic, the breakdown of the more or less elaborate S3^stem of individual card reports which called for unessential as well as essential data, and the depletion of the reporting personnel — the practicing physicians — by service in the armed forces and by the disease itself. In addition to these unusual conditions was the fact that in practically no State or locality had influenza been a reportable disease prior to the 1918 epidemic, and that in perhaps a very large proportion of localities it was not made a reportable disease until the epidemic was well under way. In studying the prevalence of influenza, therefore, we are confronted with serious obstacles, among which may be mentioned the following:. (1) In practically no locality can it bo assumed that complete reports of cases were made; a true prevalence rate can not be computed. (2) Since the disease was not reported with any degree of comparable completeness in different localities, comparisons of localities for prevalence obviously are impossible. (3) For the same reasons, statements of the incidence according to sex, age, or of any other condition with which it might be desirable to attempt correlations are not feasible, except in very general terms. (4) The chronology of the epidemic in perhaps the great majority of localities has not been recorded, and if recorded is subject to serious errors with respect to the beginning of the epidemic and the true height of the peak. (5) Fatality rates manifestly can not be ascertained. With the exception of data obtained from special field studies and from limited areas ami population groups, we must look to mortality reports for our main statistics of the epidemic.

2. Cannot be tested from the free recordGlobal deaths were of the order of 50 million and arguably as high as 100 million.

   Rests on an absence in the free record.

   No artifact here counts the world's dead, and a total built from national estimates cannot be tested against national records that themselves call their counts approximations. The figures stand as their producers' and are set beside the others in the disagreements.

   The 3 extracts it rests on

   1. Jeffery K. Taubenberger and David M. Morens, 1918 Influenza (2006)¶ 2

      An estimated one third of the world's population (or ≈500 million persons) were infected and had clinically apparent illnesses (1,2) during the 1918–1919 influenza pandemic. The disease was exceptionally severe. Case-fatality rates were >2.5%, compared to <0.1% in other influenza pandemics (3,4). Total deaths were estimated at ≈50 million (5–7) and were arguably as high as 100 million (7).

   2. Niall P. A. S. Johnson and Juergen Mueller, Updating the Accounts (2002)abstract

      The influenza pandemic of 1918-20 is recognized as having generally taken place in three waves, starting in the northern spring and summer of 1918. This pattern of three waves, however, was not universal: in some locations influenza seems to have persisted into or returned in 1920. The recorded statistics of influenza morbidity and mortality are likely to be a significant understatement. Limitations of these data can include nonregistration, missing records, misdiagnosis, and nonmedical certification, and may also vary greatly between locations. Further research has seen the consistent upward revision of the estimated global mortality of the pandemic, which a 1920s calculation put in the vicinity of 21.5 million. A 1991 paper revised the mortality as being in the range 24.7-39.3 million. This paper suggests that it was of the order of 50 million.

   3. Great Britain, Ministry of Health (Major Greenwood, Thomas Carnwath, R. Bruce Low, S. P. James and others), Reports on Public Health and Medical Subjects, No. 4 (1920)¶ 17

      17. Thirdly, the epidemic was remarkable in respect of the mortality. It should be borne in mind that the fatality of influenza is low, but its incidence is so vast that the number of deaths create an excessive mortality. Thus, it comes about that the epidemic destroyed more lives in the whole world than did the European war in five years.

Tested against the primary record

1. SupportedBritish India's excess mortality is an outlier at the high end, the hardest-hit country in the sample.

   Rests on documents from: Government of India; Scholarship; Ministry of Health (Great Britain).

   The Ministry of Health wrote in 1920 that no part of the world suffered as severely as India, and the Government of India's own table carries 7,089,694 deaths for 1918; two producers agree with the position on the point it uses India for.

   The 3 extracts it rests on

   1. Great Britain, Ministry of Health (Major Greenwood, Thomas Carnwath, R. Bruce Low, S. P. James and others), Reports on Public Health and Medical Subjects, No. 4 (1920)§ india

      Reports received indicate that no part of the world suffered as severely as did India during the latter half of 1918. A preliminary report by the Sanitary Commissioner with the Government of India estimated that up to the end of November 1918 no fewer than five million deaths were attributable to the influenza pandemic in British India alone (population, 238,000,000). In the native states influenza deaths certainly exceeded one million in the same period. A later report states that between 1st lune and 31st December 1918, the total mortality in British India exceeded the quinquennial mean mortality for the same period by approximately seven millions. The great majority of this excess mortality occurred in the last four months of the year. There was no abnormal prevalence of other communicable disease, so it is justifiable to accept this figure as a rough approximation of the influenza death roll. In view of the conditions pertaining in India, anything other than approximations of this nature is impossible to obtain.

   2. Sanitary Commissioner with the Government of India, Annual Report of the Sanitary Commissioner with the... (1920)§ 57table

      Province. Mortality. Death rate per 1,000 of population. Delhi 23,612 56.6 Bengal 386,572 8.5 Bihar and Orissa 709,976 20.5 Assam 111,340 18.6 United Provinces of Agra and Oudh 2,034,257 43.4 Punjab 898,947 45.4 North-West Frontier Province 89,035 43.6 Central Provinces and Berar 924,949 66.4 Madras 682,169 16.7 Coorg 2,014 11.5 Bombay 1,059,497 54.9 Burma 137,491 13.9 Ajmer-Merwara 29,835 59.5 India 7,089,694

   3. Peter Spreeuwenberg, Madelon Kroneman and John Paget, Reassessing the Global Mortality Burden of the 1918... (2018)¶ 20

      In the present study, the best estimate (including India) for global influenza pandemic deaths is 15 million, with an excess death rate of 788 per 100,000, in 1918; and 2.5 million deaths, with an excess death rate of 128 per 100,000, in 1919.

2. Cannot be tested from the free recordThe global toll of 1918 and 1919 together was about 17.4 million.

   Rests on an absence in the free record.

   A model's output cannot be tested against artifacts that are its inputs, and no independent count of the world exists in this record; the figure is published as the position's, beside the others.

   The 2 extracts it rests on

   1. Peter Spreeuwenberg, Madelon Kroneman and John Paget, Reassessing the Global Mortality Burden of the 1918... (2018)¶ 22

      In conclusion, we have developed an indirect estimation method using vital statistics population data. Our best estimate (a total of 15 million deaths in 1918) is lower than recent estimates (50–100 million) and shows that researchers need to be careful with the methods they choose to make their estimates. For example, researchers must take into account wars and other possible causes of increases in numbers of deaths, and the underlying time trends in mortality. We also show that it is important to test the theoretical feasibility of estimates (e.g., 100 million deaths), because results of such tests suggest the true estimate is very unlikely to be higher than 25 million and probably closer to our final estimate of 17.4 million deaths (1918 and 1919 combined).

   2. Registrar-General for England and Wales, Supplement to the Eighty-First Annual Report of the... (1920)§ totalExhibit 1

      In addition to the above there were 7,591 deaths of non-civilian males in this country allocated to influenza in 1918 and 2,899 in 1919 during the epidemic period, or 10,490 in all. This number has to be increased to an uncertain extent, say to 14,000 to allow for deaths really due to influenza but allocated to other causes. The non-civilian mortality of the preceeding years was so small that it may be left out of account. This addition to the civilian deaths brings the total toe 198,000, and in view of the uncertainties of the estimation the round figure of 200,000 deaths attributable to the epidemic (in addition to about 7,000 which the average rate of recent mortality would have accounted for) may be accepted as adequately summing up its results

Tested against the primary record

1. QualifiedLoring Miner's Haskell County warning was the only reference to influenza in Public Health Reports in the first six months of 1918.

   Rests on documents from: Scholarship; United States Public Health Service.

   The journal's issue of 21 June 1918 reports fevers of April and May from Norfolk to Louisiana that its physicians believed were mainly influenza of mild type, a second reference inside the six months. The Haskell note itself is not held here, and the journal is one producer, so under Rule A the finding is capped at qualified: the claim fails on the journal's own text, but this record holds only one side of the comparison.

   The 2 extracts it rests on

   1. John M. Barry, The site of origin of the 1918 influenza pandemic and... (2004)¶ 26

      The disease did not, however, slip from Miner's thoughts. Influenza was neither a reportable disease, nor a disease that any state or federal public health agency tracked. Yet Miner considered this incarnation of the disease so dangerous that he warned national public health officials about it. Public Health Reports(now Morbidity and Mortality Weekly Report), a weekly journal produced by the U.S. Public Health Service to alert health officials to outbreaks of communicable diseases throughout the world, published his warning. In the first six months of 1918, this would be the only reference in that journal to influenza anywhere in the world.

   2. United States Public Health Service, Influenza a Probable Cause of Fever of Undetermined... (1918)p. 1003

      PUBLIC HEALTH REPORTS VOL. 33 JUNE 21, 1918 No. 25 Influenza a Probable Cause of Fever of Undetermined Nature in Southern States. Fevers of an undetermined nature were reported during April and May at various points from Norfolk to Louisiana. An examination of the records and reports of the physicians who have treated these cases leads to the belief that these fevers were mainly influenza of mild type. It is possible, however, that all cases reported were not of the same disease, and in one locality in Louisiana dengue «may have occurred.

2. QualifiedThe American spring wave began at Camp Funston in March 1918, where more than 1,100 men were hospitalised within three weeks.

   Rests on documents from: Scholarship; Ministry of Health (Great Britain).

   The Ministry of Health dates the mild American epidemic to April and May 1918, Taubenberger and Morens to March 1918; the Funston figures rest on the two scholars and no camp record is held, and the two scholars disagree on the camp's strength, Barry giving an average of 56,222 troops and Dicke roughly twenty-six thousand. One Tier A producer, and it does not name the camp, so the date is borne out only in the season.

   The 4 extracts it rests on

   1. John M. Barry, The site of origin of the 1918 influenza pandemic and... (2004)¶ 30

      These men, and probably others unnamed by the paper, were exposed to influenza and would have arrived in Funston between February 26 and March 2. On March 4 the first soldier at the camp reported ill with influenza at sick call. The camp held an average of 56,222 troops. Within three weeks more than eleven hundred others were sick enough to require hospitalization, and thousands more – the precise number was not recorded – needed treatment at infirmaries scattered around the base.

   2. Tom Dicke, Waiting for the Flu (2015)¶ 18b

      What is nearly certain is that this flu spread from there to Camp Funston (now part of Fort Riley), Kansas, where, in March and April, it left eleven hundred of the roughly twenty-six thousand troops training there hospitalized and thirty-eight dead.

   3. Great Britain, Ministry of Health (Major Greenwood, Thomas Carnwath, R. Bruce Low, S. P. James and others), Reports on Public Health and Medical Subjects, No. 4 (1920)¶ 16

      In America, too, influenza had been occurring in greater or less degree in 1915, 1916, and 1917, but it became epidemic in mild form in April and May, 1918, and in September developed more virulent characters and swept over the country, mainly from east to west. In Paris the epidemic broke out in July; in Spain at the end of May; in Italy in April; in Greece in May; in Persia and Mesopotamia in June ; in India in June ; in Australia and New Zealand in July. Such was the universal experience of emergence and the rapid evolution was similar to it. The disease simply had its way. It came like a thief in the night and stole treasure.

   4. Jeffery K. Taubenberger and David M. Morens, 1918 Influenza (2006)¶ 5

      Before and after 1918, most influenza pandemics developed in Asia and spread from there to the rest of the world. Confounding definite assignment of a geographic point of origin, the 1918 pandemic spread more or less simultaneously in 3 distinct waves during an ≈12-month period in 1918–1919, in Europe, Asia, and North America (the first wave was best described in the United States in March 1918). Historical and epidemiologic data are inadequate to identify the geographic origin of the virus (21), and recent phylogenetic analysis of the 1918 viral genome does not place the virus in any geographic context (19).

Tested against the primary record

1. QualifiedPurulent bronchitis with heliotrope cyanosis in the military camps of 1916 and 1917 was probably the same malady as the autumn wave of 1918.

   Rests on documents from: Scholarship; Ministry of Health (Great Britain).

   The Ministry of Health's clinicians wrote in 1920 that the minor epidemics of purulent bronchitis with heliotrope cyanosis in camps in America, England and France in 1916 and 1917 were probably the same malady under a different name; one producer, so capped at qualified, and probably is the Ministry's word.

   The 2 extracts it rests on

   1. Douglas Gill and John Oxford, The 'Spanish' influenza pandemic (2026)¶ 9

      Hammond’s paper describes an exhaustive piece of research. During February and March, 1917, he and his colleagues conducted ‘156 consecutive necropsies’. They discovered thereby the ‘prevalence of bronchitis of a purulent type’. It occurred ‘as a primary condition in 45 and as a secondary condition in 26 of the cases examined. Altogether purulent bronchitis was found in 45.5 per cent of the total cases’.

   2. Great Britain, Ministry of Health (Major Greenwood, Thomas Carnwath, R. Bruce Low, S. P. James and others), Reports on Public Health and Medical Subjects, No. 4 (1920)§ clinical

      Contrasted with the extensive and acute but non-fatal outbreak of June 1918, the world-wide " plague" of influenza of the following autumn and winter, with its millions of deaths, presented very different clinical characters; and in the multitude of severe cases one saw the constantly repeated picture of a dreadful malady which few physicians had seen the like before. Those who had experienced the minor epidemics of " purulent bronchitis with heliotrope cyanosis and fatal ending " that had occurred here and there in military camps in America, England and France during 1916 and 1917 had already become familiar with some of the worst features, especially the dreaded blueness, of what was probably the same malady under a different name ; but now it was a question of seeing hundreds or even thousands of cases in districts in which the fatal " purulent bronchitis " had affected but a few.

2. Cannot be tested from the free recordThe virus spread eastwards to China from Europe.

   Rests on an absence in the free record.

   One line in a September 1918 circular reports influenza in Canton without a date of onset; it neither bears out nor contradicts a direction of spread.

   The 2 extracts it rests on

   1. J. S. Oxford, The so-called Great Spanish Influenza Pandemic of 1918... (2001)abstract

      This discussion piece examines the likely epicentre of the influenza pandemic of 1918-1919. Contrary to previous studies that have proposed a Chinese origin, there is documentation that suggests that, in this instance, the virus spread eastwards to China from Europe. Although more recent oubreaks of influenza have undoubtedly had an Oriental origin, the evidence indicates that future outbreaks could conceivably arise anywhere in the world.

   2. United States Public Health Service (circular signed Rupert Blue, Surgeon General), Measures for the Prevention of the Introduction of... (1918)p. 1540

      On account of a reported pandemic of influenza in various European countries, officers in charge of national quarantine stations have been advised to exercise special care with respect to vessels on which this disease has appeared. The following circular has been issued: Medical Officers in Charge, United States Quarantine Stations. Sirs: You arc especially cautioned to be on the alert in the inspection of vessels from European ports so as to detect any cases of the so-called Spanish influenza. If any such disease is discovered, vessels should not bo released from quarantine until after the local health authorities have been notified in accordance with paragraph 68, United States Quarantine Regulations. Owing to disordered conditions in European countries, the bureau has no authoritative information as to the nature of the disease or its prevalence. It appears, however, to be an infection due to the B. influenza with predilection to lung involvement. If any such cases are discovered upon arrival of a vessel, they should be reported to the local health authorities and the necessary cooperation extended, including fumigation of living quarters with sulphur dioxide, letting personal effects remain in compartments during the fumigation. This circular does not contemplate consideration of cases of ordinary pneumonia or respiratory infections, but only those infections involving a considerable number of the crew and which appear to be highly communicable and suggestive of epidemic influenza. Respectfully, Rupert Blve, Surgeon General. Recently a steamship arrived at one of the southern ports from a port of Great Britain with history of an outbreak of epidemic influenza in the crew. The master of the vessel reported very shortly after his arrival at Great Britain that the entire crew had sickened with the infection, the symptoms being high fever, cough, coryza, and more or less prostration. Upon arrival of the vessel at a port of the United States two of the crew were still suffering from the 1541 September 13, 191S. disease and were isolated in the quarantine hospital, the vessel was disinfected, and other appropriate measures were taken to prevent the introduction of the disease. The disease has been reported as being observed at quarantine in two ports on the Pacific coast. In both instances there were several cases of pneumonia, possibly due to B. influenza although not stated to be. Epidemic influenza has. been reported in several countries in Europe during the summer -of 1918, more especially in Spain. According to press dispatches, 8,000,000 persons have suffered from the disease in that country. Most of the cases reported to the Public Health Service have been from France, England, Norway, and Switzerland, although a mild form has been reported in Canton, China. It has appeared at Prince Edward Island, Canada, and in the Island of Guadeloupe in the West Indies, probably an extension from European ports.

Tested against the primary record

1. QualifiedThe disease was named for Spain because the epidemic was attributed to Spain when its spread over Europe was first recognised, not because it began there.

   Rests on documents from: Ministry of Health (Great Britain); United States Public Health Service.

   The Ministry of Health writes that the source was attributed to Spain and the disease termed Spanish on that account, and that it cannot be admitted that the European epidemic began in Spain; the Public Health Service's circular of September 1918 already writes so-called Spanish influenza. Both bear out the name and the doubt about the origin; neither says who attributed it or why, so the position's mechanism, the press, is not in the artifacts, and the verdict is qualified.

   The 3 extracts it rests on

   1. Great Britain, Ministry of Health (Major Greenwood, Thomas Carnwath, R. Bruce Low, S. P. James and others), Reports on Public Health and Medical Subjects, No. 4 (1920)§ namingExhibit 3

      When it was first recognised that influenza was spreading over Europe in 1918, the source of the epidemic was attributed to Spain, and the disease was, on this account, termed " the Spanish Influenza." Although the presence of epidemic influenza in Spain was recognised in the early months of 1918, it is beyond doubt that at the same time outbreaks were occurring in other European countries, including France and Germany and in the Russian war zones. It cannot, therefore, be admitted that the European epidemic began in Spain. A recent American report contains the statement that: "It seems " probable that the earliest appearance of the 1918 influenza " pandemic was in Eastern Europe, and that by April it was " spreading in the war zones of Western Europe." It may be remembered that the 1889 epidemic was believed to have originated in China, and spread thence to Russia, where it was spoken of as the "Chinese" influenza. From Russia the disease spread westward into Europe, where it was named the " Russian" influenza. From Europe the infection was carried to North America by shipping, and there it was called the "European" influenza; and when it spread from North America across the Pacific to Japan it was known there as the "American" influenza.

   2. United States Public Health Service (circular signed Rupert Blue, Surgeon General), Measures for the Prevention of the Introduction of... (1918)p. 1540

      On account of a reported pandemic of influenza in various European countries, officers in charge of national quarantine stations have been advised to exercise special care with respect to vessels on which this disease has appeared. The following circular has been issued: Medical Officers in Charge, United States Quarantine Stations. Sirs: You arc especially cautioned to be on the alert in the inspection of vessels from European ports so as to detect any cases of the so-called Spanish influenza. If any such disease is discovered, vessels should not bo released from quarantine until after the local health authorities have been notified in accordance with paragraph 68, United States Quarantine Regulations. Owing to disordered conditions in European countries, the bureau has no authoritative information as to the nature of the disease or its prevalence. It appears, however, to be an infection due to the B. influenza with predilection to lung involvement. If any such cases are discovered upon arrival of a vessel, they should be reported to the local health authorities and the necessary cooperation extended, including fumigation of living quarters with sulphur dioxide, letting personal effects remain in compartments during the fumigation. This circular does not contemplate consideration of cases of ordinary pneumonia or respiratory infections, but only those infections involving a considerable number of the crew and which appear to be highly communicable and suggestive of epidemic influenza. Respectfully, Rupert Blve, Surgeon General. Recently a steamship arrived at one of the southern ports from a port of Great Britain with history of an outbreak of epidemic influenza in the crew. The master of the vessel reported very shortly after his arrival at Great Britain that the entire crew had sickened with the infection, the symptoms being high fever, cough, coryza, and more or less prostration. Upon arrival of the vessel at a port of the United States two of the crew were still suffering from the 1541 September 13, 191S. disease and were isolated in the quarantine hospital, the vessel was disinfected, and other appropriate measures were taken to prevent the introduction of the disease. The disease has been reported as being observed at quarantine in two ports on the Pacific coast. In both instances there were several cases of pneumonia, possibly due to B. influenza although not stated to be. Epidemic influenza has. been reported in several countries in Europe during the summer -of 1918, more especially in Spain. According to press dispatches, 8,000,000 persons have suffered from the disease in that country. Most of the cases reported to the Public Health Service have been from France, England, Norway, and Switzerland, although a mild form has been reported in Canton, China. It has appeared at Prince Edward Island, Canada, and in the Island of Guadeloupe in the West Indies, probably an extension from European ports.

   3. Great Britain, Ministry of Health (Major Greenwood, Thomas Carnwath, R. Bruce Low, S. P. James and others), Reports on Public Health and Medical Subjects, No. 4 (1920)§ spaincommission

      In order to meet the many opinions expressed at first as to the true nature of the epidemic, a Spanish Medical Commission was sent to Paris to collect information, particularly as to the identity of the epidemic in Spain with that occurring in France and other countries of Europe. Their conclusions were that the Spanish epidemic and that in France were identical, not only from the clinical, but also from the bacteriological and epidemiological points of view.

2. QualifiedBelligerent governments censored reporting of the epidemic to protect morale.

   Rests on documents from: Scholarship; Ministry of Health (Great Britain).

   The Tier A record here holds no censor's order. It does hold concealment: the Ministry of Health records the allegation that San Sebastian's municipal authorities hid the epidemic to save the summer season, on the neutral side, and that Spain and France each blamed the other. Honigsbaum documents The Times withholding the Prime Minister's bulletins and military censors holding back army sickness rates, which is the position's own evidence. One Tier A producer, and it shows the silence was not only the belligerents'.

   The 3 extracts it rests on

   1. Mark Honigsbaum, Regulating the 1918-19 Pandemic (2013)¶ 14b

      In the meantime, The Times censored several of Milligan’s medical bulletins, waiting until the 18th to report that the Prime Minister was on his way to recovery.

   2. Mark Honigsbaum, Regulating the 1918-19 Pandemic (2013)¶ 15

      Growing concern about the impact the flu was having on army sickness rates also failed to make it past the military censors. The American Expeditionary Force (AEF) first began to note a resurgence of influenza in northern France in early September. The outbreaks were most extensive at Le Mans and Brest and by the end of the month the AEF had recorded some 11,000 new cases. This time, however, the influenza was frequently accompanied by severe pneumonia and sometimes proved fatal.

   3. Great Britain, Ministry of Health (Major Greenwood, Thomas Carnwath, R. Bruce Low, S. P. James and others), Reports on Public Health and Medical Subjects, No. 4 (1920)§ spain

      It is, however, possible that it may have been more prevalent in the early part of 1918 than was admitted at the time, and allegation is made that the municipal authorities of San Sebastian purposely concealed the prevalence of influenza as far as they were able, so as not to prejudice the summer season of this health resort, and stop the coming of the expected visitors. The Spanish authorities strongly maintain that the first epidemic wave of influenza that swept over Spain in May and June 1918, was due to infection introduced from France. The French authorities on the other hand as stoutly contend that France received its infection from Spain. Other experts attributed the origin of the infection of Spain to the Levant, while others again contend that influenza was in the early months of 1918 already epidemic in Central Europe. The first wave of the influenza epidemic of 1918 in Spain was comparatively mild, but very widespread ; one estimate is that some eight millions of persons were attacked during May and June. One of the places that suffered much from this first epidemic wave was the city of Madrid (population 648,760) where it is asserted some 30 per cent, of the population suffered, including King Alfonso and a number of his Cabinet Ministers. The effects of the epidemic were felt severely among the public officials, and some Government Offices had in consequence to be closed, and the municipal tram services suspended.

3. Cannot be tested from the free recordSpain's official count was 147,114 influenza deaths in 1918.

   Rests on an absence in the free record.

   Two scholarly sources recite the same official figure and a third estimate above it; no official Spanish document is held, so the figure is published as theirs.

   The 3 extracts it rests on

   1. Antoni Trilla, Guillem Trilla and Carolyn Daer, The 1918 "Spanish Flu" in Spain (2008)abstract

      The 1918-1919 influenza pandemic was the most devastating epidemic in modern history. Here, we review epidemiological and historical data about the 1918-1919 influenza epidemic in Spain. On 22 May 1918, the epidemic was a headline in Madrid's ABC newspaper. The infectious disease most likely reached Spain from France, perhaps as the result of the heavy railroad traffic of Spanish and Portuguese migrant workers to and from France. The total numbers of persons who died of influenza in Spain were officially estimated to be 147,114 in 1918, 21,235 in 1919, and 17,825 in 1920. However, it is likely that >260,000 Spaniards died of influenza; 75% of these persons died during the second period of the epidemic, and 45% died during October 1918 alone. The Spanish population growth index was negative for 1918 (net loss, 83,121 persons).

   2. Laura Almudéver Campo and Ramón E. Camaño Puig, The demographic impact of the 1918 flu epidemic through... (2025)§ 105

      Para Echeverri 5, en España mueren de gripe 143.930 personas en 1918, 21.094 en 1919 y 17.841 en 1920, un total de 182.865 personas, el 75% de las cuales fallece durante el segundo brote y el 45% de las mismas lo hacen en el mes de octubre de 1918; cifra similar a la planteada por Navarro 16, que estima la mortalidad en 147.114 para el año 1918, 21.235 en 1919 y 17.825 en 1920. Sin embargo, posteriormente Echeverri31 eleva la cifra a 257.082, es decir, el 12‰ de la población española, que ascendía en esa época a 20.880.000 habitantes.

   3. Great Britain, Ministry of Health (Major Greenwood, Thomas Carnwath, R. Bruce Low, S. P. James and others), Reports on Public Health and Medical Subjects, No. 4 (1920)§ spain

      It is, however, possible that it may have been more prevalent in the early part of 1918 than was admitted at the time, and allegation is made that the municipal authorities of San Sebastian purposely concealed the prevalence of influenza as far as they were able, so as not to prejudice the summer season of this health resort, and stop the coming of the expected visitors. The Spanish authorities strongly maintain that the first epidemic wave of influenza that swept over Spain in May and June 1918, was due to infection introduced from France. The French authorities on the other hand as stoutly contend that France received its infection from Spain. Other experts attributed the origin of the infection of Spain to the Levant, while others again contend that influenza was in the early months of 1918 already epidemic in Central Europe. The first wave of the influenza epidemic of 1918 in Spain was comparatively mild, but very widespread ; one estimate is that some eight millions of persons were attacked during May and June. One of the places that suffered much from this first epidemic wave was the city of Madrid (population 648,760) where it is asserted some 30 per cent, of the population suffered, including King Alfonso and a number of his Cabinet Ministers. The effects of the epidemic were felt severely among the public officials, and some Government Offices had in consequence to be closed, and the municipal tram services suspended.

Tested against the primary record

1. QualifiedIn the Punjab 962,937 deaths were attributed to influenza between 1 October and 31 December 1918.

   Rests on documents from: Government of India; Scholarship; United States Public Health Service.

   The Public Health Service, quoting the Punjab sanitary commissioner's report, carries the same 962,937; the Government of India's own table carries 898,947 for the Punjab and says its figures differ slightly from those given in the provincial sanitary reports. Two producers, two figures for the province, and the Government of India explains the difference as its own recalculation.

   The 4 extracts it rests on

   1. David Arnold, Death and the Modern Empire (2019)n. 4

      4 In Bombay Presidency there were 675,222 influenza deaths in October 1918: Annual Report of the Sanitary Commissioner for the Government of Bombay, 1918 (Bombay, 1919), 23. In Punjab 962,937 deaths were attributed to influenza between 1 October and 31 December 1918: Report of the Sanitary Administration of the Punjab, 1918 (Lahore, 1919), app. D, xi.

   2. United States Public Health Service, from the reports of the sanitary commissioners of Assam and the Punjab for 1918, Influenza in India, 1918 (Assam and Punjab) (1919)p. 2300

      Estimates of deaths clue to the epidemic of influenza in Assam, India, in 1918, show 306,452 deaths in a population of 6,246,330, giving a death rate of 17.04 per thousand. The estimates were based on the excess of deaths over those for the preceding five years, and were published by the sanitary commissioner of the Province of Assam. The majority of deaths were of persons in the prime of life. The first wave of the epidemic appeared about the middle of July. In August and September the disease was present. In October the second virulent wave started almost simultaneously throughout the Province, reaching its highest intensity in November, and subsiding for the most part about the end of December. In the district of Sylhet, where the prevalence was of somewhat less intensity than in other parts of the Province, the duratipn of the outbreak was longer, lasting into the early months of the year 1919. Incidence and case mortality of the prevalence of influenza in Assam are not estimable for the general population, but certain figures for sections of the community are available. Thus, in a jail population of 2,381 the number of cases was 836, deaths 14, and the case mortality 1.67 per cent. 2301 October 17, 1919. Punjab. As shown by the report of the sanitary commissioner of the Punjab for the year 1918, influenza was first reported present in the Punjab in July. In August a mild epidemic was recognized at Lahore, Simla, and Amritsar. In Simla the European population was most affected, but at the plains stations the prevalence was mostly among natives. During the month of September the area of infection rapidly increased. During this second epidemic the disease was still mild in type and the death rates for August and September, 1918> werfe the lowest recorded during the year. During the month of October the character of the disease changed completely and the Punjab began to experience the worst epidemic in its history, and one which particularly attacked young adults. A peculiarly fatal type of pneumonia appeared as a concomitant of the disease, and from October 15 to November 8 the epidemic prevalence was very severe, and was universal throughout the Province in rural and urban districts. By November 8 the worst of the epidemic prevalence was passed in the urban area, but throughout the month the prevalence continued to be severe in rural areas. In December the epidemic was practically over except in the Kangra district and the remote hill districts, where it was prevalent in a virulent type. The total mortality attributable to influenza was estimated at 962,937, or 4.77 per cent of the estimated population,

   3. Sanitary Commissioner with the Government of India, Annual Report of the Sanitary Commissioner with the... (1920)§ 57table

      Province. Mortality. Death rate per 1,000 of population. Delhi 23,612 56.6 Bengal 386,572 8.5 Bihar and Orissa 709,976 20.5 Assam 111,340 18.6 United Provinces of Agra and Oudh 2,034,257 43.4 Punjab 898,947 45.4 North-West Frontier Province 89,035 43.6 Central Provinces and Berar 924,949 66.4 Madras 682,169 16.7 Coorg 2,014 11.5 Bombay 1,059,497 54.9 Burma 137,491 13.9 Ajmer-Merwara 29,835 59.5 India 7,089,694

   4. Sanitary Commissioner with the Government of India, Annual Report of the Sanitary Commissioner with the... (1920)p. 57

      Without any claim to accuracy it is suggested that the mortality directly hand indirectly due to influenza was in the neighbourhood of the mean of the General Population.] WITH THE GOVERNMENT OF INDIA FOR 1918. 5 last 3 figures, viz. , 7,089,694. This mean is taken for the purpose of this report, and the mortality and death rates for the Local Governments and Administrations are calculated in a similar manner : the figures in this report consequently differ slightly from those given in the provincial sanitary reports, and are given in the following table : —

2. QualifiedIndia lost at least 12 million lives, more than any other country.

   Rests on documents from: Government of India; Ministry of Health (Great Britain).

   That no country suffered as severely is the Ministry of Health's own sentence and the Government of India's tables bear the scale; the count itself is another matter. The contemporary official figure is 7,089,694 registered-excess deaths for 1918 in British India, the Census of 1921 describes the loss in words and by province and gives no all-India total, and the position's 12 million is a later reconstruction of a different quantity, the whole population loss of 1918 and 1919 including the states. Two producers carry the lower figure; neither disproves the higher, so the verdict is qualified and the two are set out in the disagreements.

   The 3 extracts it rests on

   1. Great Britain, Ministry of Health (Major Greenwood, Thomas Carnwath, R. Bruce Low, S. P. James and others), Reports on Public Health and Medical Subjects, No. 4 (1920)§ india

      Reports received indicate that no part of the world suffered as severely as did India during the latter half of 1918. A preliminary report by the Sanitary Commissioner with the Government of India estimated that up to the end of November 1918 no fewer than five million deaths were attributable to the influenza pandemic in British India alone (population, 238,000,000). In the native states influenza deaths certainly exceeded one million in the same period. A later report states that between 1st lune and 31st December 1918, the total mortality in British India exceeded the quinquennial mean mortality for the same period by approximately seven millions. The great majority of this excess mortality occurred in the last four months of the year. There was no abnormal prevalence of other communicable disease, so it is justifiable to accept this figure as a rough approximation of the influenza death roll. In view of the conditions pertaining in India, anything other than approximations of this nature is impossible to obtain.

   2. Sanitary Commissioner with the Government of India, Annual Report of the Sanitary Commissioner with the... (1920)§ 57table

      Province. Mortality. Death rate per 1,000 of population. Delhi 23,612 56.6 Bengal 386,572 8.5 Bihar and Orissa 709,976 20.5 Assam 111,340 18.6 United Provinces of Agra and Oudh 2,034,257 43.4 Punjab 898,947 45.4 North-West Frontier Province 89,035 43.6 Central Provinces and Berar 924,949 66.4 Madras 682,169 16.7 Coorg 2,014 11.5 Bombay 1,059,497 54.9 Burma 137,491 13.9 Ajmer-Merwara 29,835 59.5 India 7,089,694

   3. J. T. Marten, Census Commissioner for India, Census of India, 1921, Volume I (1924)§ natural

      Assam and Burma again show comparatively high rates of increase. Immigration, is an important factor in the rise in Assam but neither of these two provinces. were exposed to an invasion of the influenza equal in virulence to that which wiped off the whole of the natural increase in the Central Provinces and Berar, Bihar and Orissa and Bombay and substantially reduced the population in the United Provinces, the Rajputana and Central India Agencies and the Hyderabad State.

3. Cannot be tested from the free recordGandhi's illness of 1918 was dysentery and exhaustion, not influenza.

   Rests on an absence in the free record.

   The claim is Arnold's reading of Gandhi's own assertion; nothing in this record carries the assertion, so it is published as the position's.

   The extract it rests on

   1. David Arnold, Death and the Modern Empire (2019)n. 82

      82 I see no reason to doubt Gandhi's own assertion that he was suffering from dysentery and exhaustion and not, as some recent writers claim, from influenza. Nor do I see grounds for arguing that the epidemic ‘pushed India closer to independence’. Spinney, Laura, Pale Rider: The Spanish Flu of 1918 and How It Changed the World (2017), 8, 254–60

Tested against the primary record

1. QualifiedThe Māori death rate in 1918, 4,230 per 100,000, was 7.3 times the European rate.

   Rests on documents from: Scholarship; Ministry of Health (Great Britain).

   The New Zealand commission's figures as the Ministry of Health carries them are 1,130 Māori deaths from 1 October to 31 December 1918, 22.6 per 1,000, against European deaths of about 5 per 1,000 for the year: a ratio near 4.5, not 7.3, on a shorter period and a count the position itself calls an underestimate. Both agree the disease was more fatal to Māori; they disagree on how much, and one Tier A producer caps the verdict.

   The 2 extracts it rests on

   1. Nick Wilson, Lucy Telfar Barnard, Jennifer A. Summers, G. Dennis Shanks and Michael G. Baker, Differential Mortality Rates by Ethnicity in 3 Influenza... (2012)¶ 14

      During the 1918 pandemic, the Māori mortality rate (4,230/100,000 population) was 7.3× the rate for the rest of the population (6), which was nearly all composed of settlers of European origin (Table; Figure 2). This work by Rice (14) was far more comprehensive than previous work that compared rates by ethnicity (15). Nevertheless, Rice noted limitations with data quality and considered that the Māori rate was still an underestimate of the true rate because some Māori deaths were not registered (14). This underestimation of Māori pandemic-related deaths was also a finding in a study of the pandemic in New Zealand’s largest city, Auckland (16).

   2. Great Britain, Ministry of Health (Major Greenwood, Thomas Carnwath, R. Bruce Low, S. P. James and others), Reports on Public Health and Medical Subjects, No. 4 (1920)§ nz

      Mortality. —Among Europeans the deaths recorded as being due to influenza in 1918 numbered 5,559 (about 5 per 1,000 of the population), of which all except 38 occurred during the second wave of the epidemic. There was also from July onwards an abnormal increase in the death rate from all catarrhal diseases other than influenza, and this rise was peculiar to 1918, for, although there is usually a seasonal rise, in the winter months, the rate in most years falls as the Spring advances. Among Natives it was estimated that in 1918 between the 1st October and the 31st December, 1,130 deaths. (22.6 per 1,000 of the population) resulted from the disease. Case Fatality. —In the military camps during the second wave about 4.5 per cent of those attacked died, but there are no figures indicating the fatality among the general population. Influence of Age, Sex, and Race. —In New Zealand, as in other countries, the death rates according to age were not a true indication of the case incidence. Of the total deaths about half were among persons between the ages of 25 and 40; but only 24 per cent of the population are in that age-group. In the Featherstone Training Camp an analysis of over 2,000, hospital cases showed that although men of from, 20 to 25 yielded a high proportion of cases, the death-rate among such, 350 cases was proportionately less than among those aged between 25 and 40. The younger men were perhaps equally susceptible to influenza, but were not equally liable to pneumonic complications, and when such complications developed, they were better able to combat the effects. Thus among the more serious pneumonic cases the fatality among the younger men was 57 per cent., but among the older 72 per cent. The deathrate among males was 6'5 per 1,000 as compared with 3.5 among fema]es, but among children under 15 years of age the proportion of deaths was slightly higher for females than for males, and a similar tendency towards equal figures for both sexes was apparent in the statistics of deaths of persons above 50 years of age. Native races (Maoris) were more susceptible to attack than Europeans and the disease was more fatal among them.

2. QualifiedThe SS Talune brought pneumonic influenza to Western Samoa on 7 November 1918.

   Rests on documents from: Scholarship; Ministry of Health (Great Britain).

   The New Zealand commission, as the Ministry of Health summarises it, found no doubt whatever that the Talune introduced the disease on 7 November 1918; that is one producer, and the commission's own report could not be read, so the verdict is capped at qualified.

   The 2 extracts it rests on

   1. G. Dennis Shanks, The 'Influenza' Vaccine Used during the Samoan Pandemic... (2018)¶ 2

      The tragic narrative of how the SS Talune (Figure 1A) brought influenza and thus mass mortality from Auckland, New Zealand to Fiji, Tonga, and Samoa with a ship captain, who denied knowing that influenza was an infectious disease, has been previously described [5,6,7,8,9].

   2. Great Britain, Ministry of Health (Major Greenwood, Thomas Carnwath, R. Bruce Low, S. P. James and others), Reports on Public Health and Medical Subjects, No. 4 (1920)§ samoa

      A Commission appointed by the Governor-General of New Zealand to inquire into the circumstances and causes of the introduction of epidemic influenza into the Islands of Western Samoa reported that in their opinion there was no doubt whatever that epidemic pneumonic influenza was introduced into Western Samoa by the S.S. " Talune" on the 7th November 1918. This ship left Auckland (where influenza was seriously prevalent) on the 30th October, and influenza broke out among the passengers and crew during the voyage to Samoa. Within seven days after her arrival, pneumonic influenza was epidemic in Upolu. It spread with great rapidity throughout this island and later throughout Savaii, the other island of Western Samoa. It was calculated that up to the 31st December 1918, out of a population of 30,738 in Western Samoa, 7,542 persons had died either directly from influenza or in consequence of its prevalence. 361 The Commission reported that American Samoa (Pago Pago) had entirely escaped the ravages of influenza, and it appears, from their report, that from the 20th November, to avoid the risk of introduction from Apia, the United States Governor at Pago Pago imposed on all ships arriving at this port five days absolute quarantine before discharging or taking on board any mail or cargo.

3. SupportedWestern Samoa's dead of the epidemic numbered 7,542.

   Rests on documents from: Scholarship; Ministry of Health (Great Britain); United States Public Health Service.

   The Ministry of Health, from the commission, and the Public Health Service, from the Department of Native Affairs at Apia, both carry 7,542 deaths to 31 December 1918. Two producers, one count; they differ on the population it is a share of, 30,738 against 38,178, and that difference is a finding below.

   The 3 extracts it rests on

   1. Great Britain, Ministry of Health (Major Greenwood, Thomas Carnwath, R. Bruce Low, S. P. James and others), Reports on Public Health and Medical Subjects, No. 4 (1920)§ samoa

      A Commission appointed by the Governor-General of New Zealand to inquire into the circumstances and causes of the introduction of epidemic influenza into the Islands of Western Samoa reported that in their opinion there was no doubt whatever that epidemic pneumonic influenza was introduced into Western Samoa by the S.S. " Talune" on the 7th November 1918. This ship left Auckland (where influenza was seriously prevalent) on the 30th October, and influenza broke out among the passengers and crew during the voyage to Samoa. Within seven days after her arrival, pneumonic influenza was epidemic in Upolu. It spread with great rapidity throughout this island and later throughout Savaii, the other island of Western Samoa. It was calculated that up to the 31st December 1918, out of a population of 30,738 in Western Samoa, 7,542 persons had died either directly from influenza or in consequence of its prevalence. 361 The Commission reported that American Samoa (Pago Pago) had entirely escaped the ravages of influenza, and it appears, from their report, that from the 20th November, to avoid the risk of introduction from Apia, the United States Governor at Pago Pago imposed on all ships arriving at this port five days absolute quarantine before discharging or taking on board any mail or cargo.

   2. United States Public Health Service, from a report of the Department of Native Affairs, Apia, Influenza Mortality in Samoa, September to December, 1918 (1919)p. 2303Exhibit 5

      A report compiled by the Department of Native Affairs, Apia, Samoa, shows the decrease of the population in the islands of Upola and Savaii during the three months ended December 31, 1918, the period of the epidemic of influenza. The figures are startling. The following tables are taken from the report: Decrease of population in the islands of Upola and Savaii, Samoa. Population before epidemic. Population after epidemie Total loss in population Men. 10,988 7,723 3,265 12,327 9,623 2,704 Children. 14,863 13,290 1,573 38,178 30,636 7,542 Percentages of deailis of men, women, and children, respectively, to the number of each class in the population. December quarter, 1918. Men. Women. Children. 30.448 28.609 29.478 22. Oil 21.803 21.907 11.027

   3. G. Dennis Shanks, The 'Influenza' Vaccine Used during the Samoan Pandemic... (2018)¶ 2

      The tragic narrative of how the SS Talune (Figure 1A) brought influenza and thus mass mortality from Auckland, New Zealand to Fiji, Tonga, and Samoa with a ship captain, who denied knowing that influenza was an infectious disease, has been previously described [5,6,7,8,9].

Tested against the primary record

1. Cannot be tested from the free recordPhiladelphia's authorities allowed a city-wide parade on 28 September 1918 and did not close schools until 3 October.

   Rests on an absence in the free record.

   No artifact here records the parade or the closure order; the one contemporary document on Pennsylvania in that week counts cases, not decisions.

   The 2 extracts it rests on

   1. Richard J. Hatchett, Carter E. Mecher and Marc Lipsitch, Public health interventions and epidemic intensity... (2007)¶ 4a

      The contrast of mortality outcomes between Philadelphia and St. Louis is particularly striking (Fig. 1). The first cases of disease among civilians in Philadelphia were reported on September 17, 1918, but authorities downplayed their significance and allowed large public gatherings, notably a city-wide parade on September 28, 1918, to continue. School closures, bans on public gatherings, and other social distancing interventions were not implemented until October 3, when disease spread had already begun to overwhelm local medical and public health resources. In contrast, the first cases of disease among civilians in St. Louis were reported on October 5, and authorities moved rapidly to introduce a broad series of measures designed to promote social distancing, implementing these on October 7.

   2. United States Public Health Service, Epidemic Influenza ("Spanish Influenza") (1918)p. 1625

      As influenza is not a reportable disease in most of the States, it is impossible to secure complete reports of its prevalence among civilians. The Surgeon General of the United States Public Health Service sent telegrams to State health officers and to officers of the Public Health Service requesting telegraphic reports of the prevalence of the disease. The following is a summary of the reports received up to the time of going to press: California. — Cases have been reported at Belvedere and at San Gabriel, Los Angeles County. Colorado.— Thirty-three cases of suspected influenza in drafted men from other States were reported at the University of Colorado. Connecticut. — Influenza is prevalent throughout the eastern and southern parts of the State and appears to be increasing. About 2,000 cases of the disease had been reported in New London and vicinity on September 23. Delaware,— A few cases have been reported which were diagnosed as "Spanish influenza." Florida. — Cases have appeared at Key West. On September 23 the epidemic was said to be declining. Georgia. — Cases have been reported at Augusta and at Macon. Illinois. — Cases have appeared in Chicago and vicinity. Kentucky. — At Louisville some cases were reported which might be influenza. Louisiana. — On September 14, 1918, the steamship Harold Walker arrived at the New Orleans Quarantine Station from Tampico, Mexico. The vessel sailed from Boston September 1 . Three deaths had occurred on board the ship since she left Boston, and there had been a total of 15 cases of illness. Six members of the crew were ill on arrival. They showed considerable elevation of temperature, ranging from 37.6° to 39.6° C. They all complained of pain in the head, cough, pains in the chest, back, and extremities. 78780°— 18— 1 (1C25) .September 27, 1918. 1626 Massachusetts. — The disease appeared in Massachusetts in August. The State health officer telegraphed September 24 that cases and deaths had been reported as follows: Everett, 698 cases, 7 deaths; Arlington, 160 cases, 1 death; Lynn, 14 deaths; Middleboro, 100 cases, 1 death; Fall River, 102 cases; Lowell, 110 cases; Salem, 1,500 cases, 10 deaths; Provincetown, 415 cases, no deaths; Haverhill, 500 cases, no deaths; Natick, 78 cases; Chelsea, 1,193 cases, 13 deaths. The health officer further stated that Lynn, Quincy, Boston, and Haverhill have large numbers of cases, but the totals are not available. The disease has also been reported from Ayer, Gloucester, and other Massachusetts towns. In Boston from September 16 to 23, inclusive, 333 deaths from influenza were registered, and 121 deaths from pneumonia. Michigan. — Very few cases have been reported. Mississippi. — A few cases have been reported from Montgomery and Leake Counties, and suspected cases from Meridian. New Hampshire. — A number of cases have been reported in Portsmouth and vicinity. New Jersey. — The State health officer telegraphed September 23 that influenza was unusually prevalent. New York. — A report dated September 21 stated that 61 cases had been reported in New York City. North Carolina. — Cases have been reported from Raleigh. Four hundred cases were reported from Wilmington. All the hospitals are crowded. Pennsylvania. — Comparatively few cases have been reported among the civil population. A few cases have occurred at Hog Island, and some are said to have been found in Pittsburgh.

2. Cannot be tested from the free recordEarly, layered closures were associated with peak death rates about 50 per cent lower.

   Rests on an absence in the free record.

   The comparison is a later reconstruction from weekly returns this record does not hold in usable form; the contemporary record shows the closures existed and were fought over, and its own statistician declined the correlation. Absence of a contemporary test is not disproof, so the finding stands as the position's.

   The 3 extracts it rests on

   1. Richard J. Hatchett, Carter E. Mecher and Marc Lipsitch, Public health interventions and epidemic intensity... (2007)abstract

      Nonpharmaceutical interventions (NPIs) intended to reduce infectious contacts between persons form an integral part of plans to mitigate the impact of the next influenza pandemic. Although the potential benefits of NPIs are supported by mathematical models, the historical evidence for the impact of such interventions in past pandemics has not been systematically examined. We obtained data on the timing of 19 classes of NPI in 17 U.S. cities during the 1918 pandemic and tested the hypothesis that early implementation of multiple interventions was associated with reduced disease transmission. Consistent with this hypothesis, cities in which multiple interventions were implemented at an early phase of the epidemic had peak death rates ≈50% lower than those that did not and had less-steep epidemic curves.

   2. Edgar Sydenstricker, Public Health Statistician, United States Public Health Service, Preliminary Statistics of the Influenza Epidemic (1918)p. 2309

      Pathometrical analyses have not been attempted for the obvious reason that the data at present available are not accurate or complete enough for anything more than very general consideration. For the same reason it has not been deemed advisable at this time to attempt any correlation of the types of epidemic curves in various localities with facts concerning the previous prevalence of respiratory or other diseases or with methods employed in attempts to control the epidemic or to mitigate its effects.

   3. United States Public Health Service, Closing of Schools and Theaters during Influenza Epidemic (1919)p. 1377

      In a recent Arizona case * the supreme court of that State decided that a local board of health can order the schools to be closed during an epidemic to prevent the spread of the disease. The board of school trustees of the city of Globe sought to enjoin the enforcement of regulations of the city board of health closing the schools during the epidemic of influenza. It was contended that it was beyond the power of the health board to take such action. The regulations in question declared certain things to be nuisances, among these being holding sessions of schools during the influenza epidemic, and prohibited the same. The court treats very fully of i Globe School Dist. No. 1, of Globe, Gila County, v. Board of Health of City of Globe, 179 Pao. 55. 1377 June 20, 1919. the powers of local boards of health and declares that the action of the health board, in so far as defining and declaring what were nuisances, was void, as being an exercise of the legislative power. The power of the board of health, however, to close the schools daring the epidemic was conceded. In treating of this the court said: * * * The local boards of. health, are granted the power to determine the fact whether the emergency exists for the making of rules and regulations and the adoption of health measures, but such powers are administrative — not legislative. The adoption by the city local board of health of section 11, the order closing the public schools during the rage of the said epidemic of Spanish influenza, for the purpose of preventing the spread of such epidemic, was a valid measure, adopted within the power of the local city board under the authority of subdivision 3 of paragraph 4370 and on the approval of the State superintendent of public health. Necessity is the law of time and place, and the emergency calls into life the necessity for the operation of the law.

3. QualifiedIn Alaska some local units escaped the first wave by travel restrictions and quarantine, while communities the virus entered lost most of their people.

   Rests on documents from: Scholarship; United States Senate, Committee on Appropriations.

   The Senate record carries the Bureau of Education's telegram of 2 January 1919 from Nome, three villages wiped out entirely and others averaging 85 per cent deaths, and its table of approximately 2,000 deaths, so the second half of the claim is borne out by the federal record; the escapes, 8 local units in the scholars' abstract, rest on their newspaper work, and one producer caps the verdict.

   The 4 extracts it rests on

   1. Uddhav Khakurel, Lisa Sattenspiel and Svenn-Erik Mamelund, Role of Nonpharmaceutical Interventions during 1918-1920... (2025)abstract

      Previous studies investigating the 1918–1920 influenza pandemic have provided a comprehensive overview of the spread of the pandemic and possible explanations for high mortality rates in Alaska, USA. Our understanding of the role of nonpharmaceutical interventions (NPIs) is limited, however. To gain an overview of various agencies’ efforts to protect communities during the pandemic, we conducted a mixed-method assessment of a large pool of digitized historical newspapers and archival materials covering Alaska’s local and territorial responses to the pandemic. The study encompassed 14 local units of Alaska that implemented NPIs during October 1918–January 1919. Analyses indicated that 8 local units avoided the outbreak by implementing NPIs and that the other 6 units controlled the spread of influenza by implementing NPIs after the virus was introduced. In addition, some Indigenous communities escaped the pandemic by implementing mandatory and voluntary restrictions. Information on the effects NPI of could guide future influenza pandemic preparedness and response.

   2. Uddhav Khakurel, Lisa Sattenspiel and Svenn-Erik Mamelund, Role of Nonpharmaceutical Interventions during 1918-1920... (2025)¶ 6

      During the 1918–1920 influenza pandemic, Alaska was a US territory. The territorial government of Alaska was forewarned about the risk for an influenza outbreak and implemented quarantine regulations to prevent the introduction of the disease (11). The territorial governor ordered all communities to establish quarantines and to create cordon sanitaire (protective buffer zones), by limiting travel at trailheads and along rivers (12–15). A previous report showed that communities and residents adopted different community-level NPIs to control the spread of influenza (8). Those interventions included travel restrictions, quarantine of travelers, isolation, prohibition of public gatherings and native festivals, fumigation of public places, and school closures. However, implementing NPIs did not prevent introduction of influenza into Alaska (8). The 1918–1920 influenza pandemic killed at least 50 million persons worldwide, including 675,000 persons in the United States (12). In Alaska, the average influenza mortality rate ranged from 1% to 38% at the regional level, and some local communities reported mortality rates of >90% (8,16).

   3. United States Senate, Committee on Appropriations (testimony of Governor Thomas Riggs and Commissioner P. P. Claxton, with telegrams from Nome), Influenza in Alaska (1919)p. 5

      Here is a telegram from Mr. Evans, who is the assistant superintendent of the Bureau of Education at Nome. The superintendent of the Bureau of Education at Nome died of influenza. This is addressed to Hon. P. P. Claxton, Commissioner of Education, Washington, D. C., and is dated Nome, Alaska, January 2, 1919 : Ten villages this district affected. Three wiped out entirely ; others average 85 per cent deaths. Majority of children of affected villages saved by relief parties sent by the Bureau of Education. Teachers in stricken villages all sick; two dead; rest recovering. Total number of deaths reported 750; probably 25 per cent ; this number frozen to death before help arrived. Over 300 children to be cared for, majority of whom are orphans. Am feeding and caring for surviving population of live large villages. Seven relief hospitals operated in affected villages ; no trained nurses or physicians available, 6 INFLUENZA IN ALASKA. but splendid work done by white people in charge. Cost to date estimated $70,000 for native relief alone; will need about $15,000 this month. May be necessary send relief several quarantined villages owing to regulations preventing natives from trapping and can not purchase necessities. Impossible at this time to lift quarantine zones in outlying affected villages. Appalling and beyond description. Am giving 90 orphans to mission at Nome to care for at $10 per month, but hope department will plan for large industrial training school this district next summer. Splendid opportunity for educational advancement for the Eskimos.

   4. United States Senate, Committee on Appropriations (testimony of Governor Thomas Riggs and Commissioner P. P. Claxton, with telegrams from Nome), Influenza in Alaska (1919)p. 40

      Approximately 2,000 deaths in all. Solomon, Teller, and Mary Igloo-wiped out.

Tested against the primary record

1. QualifiedIn Brazil the authorities first announced that the epidemic was mild, and many deaths followed.

   Rests on documents from: Scholarship; Ministry of Health (Great Britain).

   The Ministry of Health's Brazil section says of Rio de Janeiro that the authorities at first announced the type of the malady was mild, that many deaths occurred, and that the official returns for October and November give smaller figures than the city's estimate of 15,000; that is Rio, not Diamantina, and one producer, so the pattern the position describes is borne out for the capital and capped at qualified.

   The 3 extracts it rests on

   1. Ramon Feliphe Souza, O trem e a "senhorita espanhola" (2023)¶ 23

      A lentidão e a negação do estado de doença não é um fenômeno neutro ( Goulart, 2005 , p.104-105). Alves do Couto procurou amenizar as manifestações da epidemia na cidade destacando a doença como de caráter benigno e o clima local como salubre, visto que o reconhecimento do estado epidêmico poderia contrastar com a imagem regional historicamente ostentada acerca da salubridade de seu clima. Essa questão parecia tão cara que, no final de seu discurso, Alves do Couto afirmou que, por conta de seu clima, Diamantina deveria ser aconselhada pelos médicos como refúgio de pessoas doentes vindas de outras partes do país.

   2. Great Britain, Ministry of Health (Major Greenwood, Thomas Carnwath, R. Bruce Low, S. P. James and others), Reports on Public Health and Medical Subjects, No. 4 (1920)§ brazil

      Early in October 1918 influenza began to be epidemic in Rio de Janeiro and spread rapidly over the whole city, attacking, it was said, more than half of the total inhabitants. The precise source from which Rio de Janeiro was infected has not yet been stated. In the early days of the epidemic, influenza was known to have caused the death of 20 of the crew of a United States ship of war lying in the harbour. Although it was at first announced by the authorities that the type of the epidemic malady in the city was mild, many deaths occurred and a panic developed among the inhabitants. The sanitary administration broke down, business was at a standstill, the food supplies ran short, and what articles were available were sold at such exorbitant prices as to place them beyond the reach of the poorer classes. Many shops were closed and the streets were almost deserted. Restaurants and places of amusement also closed their doors. Owing to the amount of illness among the men, the railway services were greatly reduced, and communication by telegraph or telephone was almost suspended for the same reason, the operators being Buenos Aires Herald, 13th December 1919. 339 largely on the sick list. At some of the public relief stations no medical stores were available and medical assistance in many instances could not be obtained. The druggists raised their prices enormously, making such drugs as quinine quite unobtainable by the lower classes. Some of the newspapers added to the panic by printing alarming accounts of the ravages of the epidemic, and attacked with bitterness the sanitary authorities of the city, an attitude that led to the resignation of the Director of Public Health.

   3. Great Britain, Ministry of Health (Major Greenwood, Thomas Carnwath, R. Bruce Low, S. P. James and others), Reports on Public Health and Medical Subjects, No. 4 (1920)§ brazilcount

      It is estimated that from 600,000 to 700,000 of the inhabitants were attacked by influenza in a period of some six weeks, out of a population of about 915,000 ; the mortality caused by the epidemic in the city is given approximately as 15,000. But the official mortality returns for October and November 1918 give smaller figures, namely deaths from all causes in October 11,291, of which 8,876 are ascribed to influenza, and in November 5,705 deaths from all causes, 3,287 being attributed to influenza.

Tested against the primary record

1. QualifiedInfluenza reached Persia in 1918 and found a population already weakened by typhus, relapsing fever and two failed harvests.

   Rests on documents from: Scholarship; Ministry of Health (Great Britain).

   The Ministry of Health's notes from Dr Neligan of the Tehran legation say exactly this: epidemics of typhus and relapsing fever in the winter and spring before, and the dry years 1916 and 1917 with crops failed. One producer, capped at qualified.

   The 2 extracts it rests on

   1. Amir Afkhami, Compromised Constitutions (2003)abstract

      The global demographic impact of the 1918-19 influenza pandemic continues to fascinate researchers and scholars. This paper examines the social and demographic effects of this outbreak on Iranian society, through a comprehensive investigation of the modes of transmission and propagation, mortality rates, and other distinctive features of the region, and reveals the importance of taking a country's unique sociopolitical settings into account. Iran was one of the regions hit hardest by the pandemic, with mortality rates significantly higher than in most regions of the world. Though globally the victims of influenza lived primarily in urban areas, it was Iran's rural regions that suffered the most casualties. In addition, contrary to the prevailing notion that the 1918 influenza targeted the young and healthy, this paper suggests that famine, opium consumption, malaria, and anemia were fundamentally responsible for the high mortality in Iran.

   2. Great Britain, Ministry of Health (Major Greenwood, Thomas Carnwath, R. Bruce Low, S. P. James and others), Reports on Public Health and Medical Subjects, No. 4 (1920)§ persia

      The following notes are extracted from a report by Dr. A. R. Neligan, Physician to His Majesty's Legation, Tehran. When influenza appeared in Persia during 1918 it found the population already much weakened by two previous epidemics of typhus and relapsing fever which ravaged the country in the winter of 1917-1918 and the spring of 1918 respectively. Moreover, the years 1916 and 1917 had been unusually dry, so that crops failed and there was a food shortage. The epidemic is said to have invaded Persia at several points.

2. Cannot be tested from the free recordIran's mortality was among the highest in the world.

   Rests on an absence in the free record.

   No document here counts Iran's dead; the claim is published as the position's.

   The extract it rests on

   1. Amir Afkhami, Compromised Constitutions (2003)abstract

      The global demographic impact of the 1918-19 influenza pandemic continues to fascinate researchers and scholars. This paper examines the social and demographic effects of this outbreak on Iranian society, through a comprehensive investigation of the modes of transmission and propagation, mortality rates, and other distinctive features of the region, and reveals the importance of taking a country's unique sociopolitical settings into account. Iran was one of the regions hit hardest by the pandemic, with mortality rates significantly higher than in most regions of the world. Though globally the victims of influenza lived primarily in urban areas, it was Iran's rural regions that suffered the most casualties. In addition, contrary to the prevailing notion that the 1918 influenza targeted the young and healthy, this paper suggests that famine, opium consumption, malaria, and anemia were fundamentally responsible for the high mortality in Iran.

Tested against the primary record

1. QualifiedAt Camp Devens in late September 1918 deaths ran at about 100 a day.

   Rests on documents from: Scholarship; United States Public Health Service.

   Two letters the same article reproduces give about 20 deaths a day on 24 September and about 100 a day on 29 September; the Public Health Service's report of 27 September records the disease in Massachusetts from August and 333 influenza deaths in Boston in the week of 16 to 23 September, and does not count the camp. The witnesses agree on the direction and differ by the day; one Tier A producer, and it is silent on the camp.

   The 4 extracts it rests on

   1. Peter C. Wever and Leo van Bergen, Death from 1918 pandemic influenza during the First... (2014)¶ 45

      On September 29, 1918, a U.S. Army physician described the rapid clinical course of fatal influenza at Fort Devens. “These men start with what appears to be an ordinary attack of LaGrippe or Influenza, and when brought to the Hosp. they very rapidly develop the most viscious [sic] type of Pneumonia that has ever been seen. Two hours after admission they have the Mahogony spots over the cheek bones, and a few hours later you can begin to see the Cyanosis extending from their ears and spreading all over the face, until it is hard to distinguish the colored men from the white. It is only a matter of a few hours then until death comes, and it is simply a struggle for air until they suffocate. It is horrible.

   2. Peter C. Wever and Leo van Bergen, Death from 1918 pandemic influenza during the First... (2014)¶ 45b

      One can stand it to see one, two or twenty men die, but to see these poor devils dropping out like flies sort of gets on your nerves. We have been averaging about 100 deaths per day, and still keeping it up.

   3. Peter C. Wever and Leo van Bergen, Death from 1918 pandemic influenza during the First... (2014)¶ 35

      Have not had too [sic] go too [sic] the hospital though I have been sick enough too [sic] be there, but anyones chances are pretty slim, that goes there so I keep quiet about my being sick and done my own doctoring and think I am better off than most of them. The doctors say that they have got it checked now. I hope so, as every day there has been an average of about twenty deaths here a day, some toll for a camp.”

   4. United States Public Health Service, Epidemic Influenza ("Spanish Influenza") (1918)p. 1625

      As influenza is not a reportable disease in most of the States, it is impossible to secure complete reports of its prevalence among civilians. The Surgeon General of the United States Public Health Service sent telegrams to State health officers and to officers of the Public Health Service requesting telegraphic reports of the prevalence of the disease. The following is a summary of the reports received up to the time of going to press: California. — Cases have been reported at Belvedere and at San Gabriel, Los Angeles County. Colorado.— Thirty-three cases of suspected influenza in drafted men from other States were reported at the University of Colorado. Connecticut. — Influenza is prevalent throughout the eastern and southern parts of the State and appears to be increasing. About 2,000 cases of the disease had been reported in New London and vicinity on September 23. Delaware,— A few cases have been reported which were diagnosed as "Spanish influenza." Florida. — Cases have appeared at Key West. On September 23 the epidemic was said to be declining. Georgia. — Cases have been reported at Augusta and at Macon. Illinois. — Cases have appeared in Chicago and vicinity. Kentucky. — At Louisville some cases were reported which might be influenza. Louisiana. — On September 14, 1918, the steamship Harold Walker arrived at the New Orleans Quarantine Station from Tampico, Mexico. The vessel sailed from Boston September 1 . Three deaths had occurred on board the ship since she left Boston, and there had been a total of 15 cases of illness. Six members of the crew were ill on arrival. They showed considerable elevation of temperature, ranging from 37.6° to 39.6° C. They all complained of pain in the head, cough, pains in the chest, back, and extremities. 78780°— 18— 1 (1C25) .September 27, 1918. 1626 Massachusetts. — The disease appeared in Massachusetts in August. The State health officer telegraphed September 24 that cases and deaths had been reported as follows: Everett, 698 cases, 7 deaths; Arlington, 160 cases, 1 death; Lynn, 14 deaths; Middleboro, 100 cases, 1 death; Fall River, 102 cases; Lowell, 110 cases; Salem, 1,500 cases, 10 deaths; Provincetown, 415 cases, no deaths; Haverhill, 500 cases, no deaths; Natick, 78 cases; Chelsea, 1,193 cases, 13 deaths. The health officer further stated that Lynn, Quincy, Boston, and Haverhill have large numbers of cases, but the totals are not available. The disease has also been reported from Ayer, Gloucester, and other Massachusetts towns. In Boston from September 16 to 23, inclusive, 333 deaths from influenza were registered, and 121 deaths from pneumonia. Michigan. — Very few cases have been reported. Mississippi. — A few cases have been reported from Montgomery and Leake Counties, and suspected cases from Meridian. New Hampshire. — A number of cases have been reported in Portsmouth and vicinity. New Jersey. — The State health officer telegraphed September 23 that influenza was unusually prevalent. New York. — A report dated September 21 stated that 61 cases had been reported in New York City. North Carolina. — Cases have been reported from Raleigh. Four hundred cases were reported from Wilmington. All the hospitals are crowded. Pennsylvania. — Comparatively few cases have been reported among the civil population. A few cases have occurred at Hog Island, and some are said to have been found in Pittsburgh.

Tested against the primary record

1. QualifiedThe epidemic fell on the United Provinces along the Ganges with a severity the official record confirms.

   Rests on documents from: Government of India; Survivor memoirs.

   The memoir names the influenza and the Ganges and no year; the Government of India's table gives the United Provinces 2,034,257 deaths, the largest provincial count, at 43.4 per 1,000, and the Census of 1921 says the population of the United Provinces was substantially reduced. One producer, so qualified: the province's dead are in the record, the poet's family is not, and the year of his scene is the biographers'.

   The 4 extracts it rests on

   1. Suryakant Tripathi 'Nirala', Kulli Bhat (undated in the scanned copy)p. 79

      इसी समय इनफ्लुएंजा का प्रकोप हुआ । पिताजी एक साल पहले गुज़र चुके थे । इसीलिये नौकरी की थी । नहीं तो हर लड़के की तरह दुनिया को सुखमय देखते रहने के स्वप्न लिए रहता ; कम-से-कम लिए रहूँगा, यही सोचता था। तार आया—“तुम्हारी स्त्री सख़्त बीमार है, अंतिम मुलाकात के लिये आओ ।” मेरी उम्र तब बाईस साल थी। स्त्री का प्यार उसी समय मालूम दिया, जब वह स्त्रीत्व छोड़ने को थी। अखबारों से मृत्यु की सर्यफरता मालूम हो चुकी थी । गंगा के किनारे आकर प्रत्यक्ष की । गंगा में लाशों का ही जैसे प्रवाह हो । ससुराल जाने पर मालूम हुआ, स्त्री गुज़र चुकी है;

      Void translation, not a published quotationAt this same time the influenza broke out. My father had died a year before. That is why I had taken a job; otherwise, like every boy, I would have gone on holding the dream of seeing the world as a happy place; at least I would hold on to it, so I thought. A telegram came: “Your wife is gravely ill, come for the last meeting.” I was then twenty-two years old. I came to know a wife's love at the very moment when she was about to leave her womanhood behind. From the newspapers I had already learned of death's reach. Coming to the bank of the Ganges I saw it with my own eyes. In the Ganges it was as if there flowed nothing but corpses. On reaching my in-laws' house I learned that my wife had died;

   2. Suryakant Tripathi 'Nirala', Kulli Bhat (undated in the scanned copy)p. 80

      दादा के गुज़रने के तीसरे दिन भाभी गुज़रीं । उनकी दूधपीती लड़की बीमार थी। रात को उसे साथ लेकर सोया। बिल्ली रात-भर आफ़त किए रही। सुबह उसके प्राण निकल गए। नदी के किनारे उसे ले जाकर गाड़ा । फिर चाचाजी ने प्रयाण किया। गाड़ी गंगा को जैसे लाश ही ढोती रही । भाभी के तीन लड़के बीमार पड़े । किसी तरह सेवा-शुश्रुषा से अच्छे हुए। इस समय का अनुभव जीवन का विचित्र अनुभव है।

      Void translation, not a published quotationOn the third day after my elder cousin's passing, my sister-in-law passed away. Her breast-fed daughter was ill. At night I slept with her beside me. A cat made trouble the whole night. In the morning her life went out of her. I took her to the riverbank and buried her. Then my uncle departed this life. It was as if the cart carried nothing but corpses to the Ganges. My sister-in-law's three sons fell ill. With nursing, somehow, they recovered. The experience of this time is the strangest experience of my life.

   3. Sanitary Commissioner with the Government of India, Annual Report of the Sanitary Commissioner with the... (1920)§ 57table

      Province. Mortality. Death rate per 1,000 of population. Delhi 23,612 56.6 Bengal 386,572 8.5 Bihar and Orissa 709,976 20.5 Assam 111,340 18.6 United Provinces of Agra and Oudh 2,034,257 43.4 Punjab 898,947 45.4 North-West Frontier Province 89,035 43.6 Central Provinces and Berar 924,949 66.4 Madras 682,169 16.7 Coorg 2,014 11.5 Bombay 1,059,497 54.9 Burma 137,491 13.9 Ajmer-Merwara 29,835 59.5 India 7,089,694

   4. J. T. Marten, Census Commissioner for India, Census of India, 1921, Volume I (1924)§ natural

      Assam and Burma again show comparatively high rates of increase. Immigration, is an important factor in the rise in Assam but neither of these two provinces. were exposed to an invasion of the influenza equal in virulence to that which wiped off the whole of the natural increase in the Central Provinces and Berar, Bihar and Orissa and Bombay and substantially reduced the population in the United Provinces, the Rajputana and Central India Agencies and the Hyderabad State.