Unlocking History

1918 pandemic tests prison medical staff

Seven men in lab coats pose for a photo in a prison doctor's office.
San Quentin Dr. Leo Stanley, seated in the center, and his staff battled the influenza pandemic of 1918-19. (Betty Weitz Cook collection, Stanford Medical History Center.)

A deadly influenza pandemic swept across the globe a century ago in 1918, claiming more lives than all those lost in World War I. Hospitals were jammed with patients, overwhelming doctors and nurses. California’s prisons, despite being in fairly remote locations, were not spared.

The rapid spread of what was called Spanish influenza is attributed to the massive transport of troops, the first time in history such a large number of people were moved at one time. The first cases in the U.S. were found in 1918 in soldiers returning from World War I.

According to the Centers for Disease Control (CDC), “It is estimated that about 500 million people or one-third of the world’s population became infected with this virus. The number of deaths was estimated to be at least 50 million worldwide with about 675,000 occurring in the United States. Mortality was high in people younger than 5 years old, 20-40 years old and 65 years and older. The high mortality in healthy people, including those in the 20-40 year age group, was a unique feature of this pandemic.”

It was still a decade before antibiotics were discovered, which are used to treat flu-driven secondary bacterial infections. A vaccine against influenza wasn’t created until 1938.

“Control efforts worldwide were limited to non-pharmaceutical interventions such as isolation, quarantine, good personal hygiene, use of disinfectants, and limitations of public gatherings, which were applied unevenly,” according to the CDC.

As the outside world dealt with the highly contagious illness, California’s two prisons were faced with containing the deadly virus in confined environments.

San Quentin doctor quells 1918 outbreak

Four years before the global pandemic, Dr. Leo Stanley outlined improvements he’d overseen in the prison’s medical department.

In a 1914 report to the warden, Stanley also mentioned the flu and the lack of any serious outbreaks. “Medically there have been no epidemics and very few serious illnesses. Influenza is the disease which attacks the (incarcerated population) mostly,” he wrote.

Little did he know how different things were to become by 1918.

On April 13, 1918, an incarcerated person was transferred to San Quentin from the Los Angeles County Jail. Stanley later identified this individual as the one who introduced the deadly virus into the prison. Commonly called Spanish flu, it was the first of two pandemics of the H1N1 virus. The second pandemic was in 2009 with what’s known as swine flu.

Outbreak traced to county-to-state transfer

“(The new arrival) stated that a number of others had been ill (at the jail),” recalled Stanley in a report after the outbreak. “This man himself had been sick before he came here, having had pains over his body accompanied by fever. On his entrance to this prison, he mingled with the 1,900 men who were in the yard on Sunday, April 14, ate in the general mess with them, and at night was locked in the receiving room with about 20 other newcomers. His illness returned the following day, or at least was aggravated, for he was admitted to the hospital with a fever of 101, chills and an aching sensation in the back and bones.”

From April 15 until May 26, “there was an epidemic of unusual severity, with 101 patients admitted to the hospital, of whom seven developed bronchopneumonia and three died.”

At one point during that first outbreak, “about one-half of the prison population of 1,900 men was ill.”

During the outbreak’s peak, the number of incarcerated people seeking treatment quadrupled in a two-day period. When normally 150 to 200 sought medical help on any regular day, the first day of the peak saw 700 and the second day saw 750. The sheer volume overwhelmed the small prison staff.

“They should have been placed in the hospital but it was impossible to put them there on account of lack of facilities,” Dr. Stanley wrote. “They were allowed to stay in the open air and were not permitted to go to their cells until evening because it was believed that this unusual disease might be increased by confinement in stuffy rooms during the day.”

Large gatherings identified as source of spread

According to Stanley, the disease spread quickly through gatherings such as the Sunday night movies. By Wednesday, previously healthy men who watched the movie came down with fever, fatigue, chills and vomiting. Quarantine and banning large congregations quelled the outbreak for a while.

“A second epidemic broke out in the prison on the third of October, when it was probably reintroduced by a new arrival,” Stanley recalled. “This prisoner stated that one of the deputies who brought him to the penitentiary and who occupied a compartment with him on the night train had complained of feeling ill, with cough, restlessness and thirst.”

That first day, the new arrival spent time with 10 men in the receiving room, took his meal with 1,900 others, and had been interviewed by many old-timers eager to learn what was happening in the outside world. The next day, the new arrival began exhibiting flu-like symptoms and was admitted to the hospital. The cycle started again.

“The epidemic reached its height on Oct. 21,” Dr. Stanley wrote. “In all, there were 69 cases with 8 to 12 percent developing pneumonia, and two deaths.”

Prison’s holiday celebrations spread flu virus

Shortly before Thanksgiving, the prison found itself again battling an outbreak of the flu.

“On Sunday, Nov. 24, the picture shows were allowed to be opened after having been closed for over six weeks. Of course there was a large attendance at both shows,” Dr. Stanley wrote.

The annual Thanksgiving Day track-and-field meet went on as usual, packing an audience of 1,600 on the sidelines to watch 200 competitors. The gatherings contributed to a rapid spread of the illness.

“The sudden flare up after the apparent obliteration of the disease (indicated), the disease had been reintroduced and had been spread in the Sunday show and during the field meet,” he wrote. “It was found that (an incarcerated person) on Nov. 21 arrived by train from Colusa County, where the epidemic was raging. He became ill the following day but not did report at sick call. He (also) had been assigned to the receiving room with 10 or 12 other prisoners. Even though ill, he attended the Sunday morning show. (He) was admitted to the hospital that evening with a temperature of 102 and unmistakable signs of influenza.”

Because San Quentin’s women’s ward was kept separate, none of the women contracted influenza at any time during the three outbreaks.

Masks required for incarcerated population

The prison implemented strict controls to help prevent further outbreaks, including requiring the incarcerated population to wear masks during visits with family or friends. When the moving picture shows were reopened, they were required to wear “six-ply gauze masks.”

“To (prevent flu spread from) possible carriers, it was (also) arranged to place all new arrivals in isolation for at least four days before allowing them in the yard,” he wrote. “Probably as a result of these precautions there was no return of the epidemic, although surrounding cities had many cases after December.”

Folsom Prison struck at year’s end

It took a while for Folsom State Prison to be hit with the flu. Avoiding the first few outbreaks, the prison’s luck ran out by the end of 1918.

“Folsom prison had been free from Spanish influenza until Dec. 23. A prisoner arrived that evening from San Quentin with a temperature of 102.6 and unmistakable signs of influenza,” Stanley wrote. “This prisoner had been in quarantine in San Quentin for four days. When he left for Folsom on the morning of Dec. 23, his temperature was normal and he had no symptoms.”

After two days, one of the correctional officers who transported that prisoner became ill.

“Within two weeks there were over 100 cases there including the resident physician, the pharmacist and three nurses,” he wrote.

Stanley carefully examined all three outbreaks of 1918-1919.

“The most effective means for combating the spread were hospitalization, quarantine, isolation and closure of congregating places,” he wrote.

While the doctor’s work to contain the pandemic was successful when compared to other prisons, his research work was controversial.

Learn more about Dr. Leo Stanley.

By Don Chaddock, Inside CDCR editor

The 1918 pandemic in photos

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