REPORT 
on 
MANTENO STATE HOSPITAL 
TYPHOID FEVER EPIDEMIC 
1939 
Fidsllslied by 
Tm Seprtme i: .. fMi mm.. 
J, ERRATA 
The attention of the reader is 
requested to the following.omissions 
and printing errors: 
Page 21: In Table III, 5th column, 
the top figure "So" should 
be 50- 
Page 25: In the last paragraph, the 
first sentence should have 
added to its end the phrase 
"in relatively great numbers," 
Page 55: In the last paragraph, sixth 
line, the word "contrasted" 
is misspelled. 
Page 6C: In the fourth paragraph, 
fourth line, appears the 
word "died" which should 
be changed to "diet." A REPORT ON A 
TYPHOID FEVER EPIDEMIC 
AT MANTENO STATE 
HOSPITAL IN 1939 
Prepared largely from 
the unpublished reports and findings of 
Carl E. Schwob and C. Milton Eberhart, M.D., 
by 
Members of the Staff, 
State Department of Public Health, 
ROLAND R. CROSS, M.D., Director 
Published by Authority of the State of Illinois 
DWIGHT H. GREEN, Governor 
1945 (84775—5M—6-45) INTRODUCTION 
THE following report is concerned with various public-health aspects 
of an epidemic of typhoid fever which occurred in a State hospital for 
the mentally ill at Manteno, Illinois, in 1939, involving 453 cases 
and resulting in 60 deaths. Although the epidemic began early in August, 
and continued into October, the material incorporated in the report was 
gathered, for the most part, subsequent to August 21, and the report covers 
a period of several months after the subsidence of the epidemic. 
The activities described in this report were directed along two major 
lines: (1) determination of the means of transmission of the disease at 
the hospital, and (2) institution of control measures to prevent further 
transmission of the disease there. 
No effort is made in the report to present a full account of the history 
and technicalities of the legal actions and court procedures to which the 
epidemic led. A brief resume is given, however, of those factual points 
in the legal actions that would appear to be of special interest from a public 
health standpoint. 
Although the public-health findings as presented to the Supreme Court 
of Illinois in the course of the legal actions were held by the Court to have 
little probative value, it is hoped that this report may serve a useful purpose 
in recording the development and management of an epidemic of typhoid 
fever in a hospital for the mentally ill. CHAPTER I 
DESCRIPTION OF MANTENO STATE HOSPITAL 
A description of the institution, including location and geology of the 
area, is necessary to provide a proper background for a thorough under- 
standing of the epidemic and the many unusual problems involved in its 
control. 
GENERAL. The Manteno State Hospital is an institution for men- 
tally ill persons. It is located in Kankakee County, approximately 40 miles 
south of Chicago and 10 miles north and east of the City of Kankakee. 
Situated 2 miles from the nearest municipality (Manteno) on a tract of 
ground comprising approximately 1,000 acres, its 100 buildings virtually 
comprise a small municipality. At the time of the epidemic the institution 
generated its own power, furnished its own water supply, and maintained a 
system of sewers and sewage-treatment works. Fig. 1 is a map showing 
general layout of the institution. 
HISTORICAL. Construction on the Manteno State Hospital started 
in the year 1929, additional buildings, utilities, and other facilities being 
provided in the ensuing years up to the time of the outbreak. Building 
construction was in progress at the time the epidemic occurred. The ac- 
companying Table I shows the growth of population for the institution. 
It will be noted that the population at the time of the epidemic was ap- 
proximately 6,200. 
ADMINISTRATION AND OPERATION. Prior to the 1939 
typhoid fever outbreak, the administration and operation of the institution 
were characteristic of procedures followed in other State institutions of this 
kind. The institution was under the direct supervision of a managing 
officer, who was directly responsible to the director of the Department of 
Public Welfare. 
The medical department was under the supervision of a clinical director, 
who supervised the activities of 20 staff physicians and the laboratory tech- 
nicians. The nursing department was directed by a trained nurse, who 
was assisted by a number of supervisors all of whom were untrained lay 
persons. The registered nurses in the administrative plan took their orders 
from the lay supervisors, who, in turn, were responsible for contacting the 
staff physicians. The attendants in this department consisted of lay persons 
who also were responsible for nursing care. 
The dietary department was under the supervision of a dietitian. Ap- 
proximately 85% of the workers in the dietary department were patients, 
the remainder, only, being paid employees. The institution maintained 
it own farms, operated primarily for the growing of vegetables. Most 
of the meat was purchased from packing houses, but a hog farm 
furnished a portion of the meat supply. An institution dairy herd furnished 
about 100 gallons of raw milk daily, which was used only for cooking pur- 
poses, the main milk supply coming from an outside pasteurization plant. 
5 DATE 
PATIENTS 
« 
EMPLOYEES 
Male 
Female 
Total 
Male 
Female 
Total 
Grand Total 
Employee-to- 
Patient Ratio 
1931 (Jan 1) 
100 
0 
100 
63 
10 
73 
173 
1.37 
1932 “ 
410 
414 
824 
108 
74 
182 
1,006 
4.5 
1933 “ 
494 
458 
952 
105 
73 
178 
1,130 
5.34 
1934 “ 
512 
669 
1,181 
87 
91 
178 
1,359 
6.64 
1935 “ 
524 
680 
1,204 
99 
93 
192 
1,396 
6.28 
1936 “ 
1,459 
1,201 
2,660 
207 
184 
391 
3,051 
6.8 
1937 “ 
1,619 
1,202 
2,821 
207 
180 
387 
3,208 
7.3 
1938 “ 
1,915 
1,640 
3,555 
270 
252 
522 
4,077 
6.8 
1939 “ 
2,687 
2,638 
5,325 
350 
380 
730 
6,055 
7.3 
1939 (July 1) 
2,711 
2,673 
5,384 
370 
398 
768 
6,152 
7.0 
1939 
Aug 
2,705 
2,696 
5,401 
370 
398 
768 
6,169 
7.1 
Sept 
2,713 
2,688 
5,401 
426 
455 
881 
6,282 
6.1 
Oct 
2,660 
2,662 
5,322 
469 
471 
940 
6,262 
5.6 
Nov 
2,613 
2,626 
5,239 
488 
481 
969 
6,208 
5.4 
Dec 
1940 
2,580 
2,573 
5,153 
490 
481 
971 
6,124 
5.3 
Jan 
2,518 
2,507 
5,025 
493 
483 
976 
6,001 
5.2 
Feb 
2,566 
2,513 
5,079 
495 
486 
981 
6,060 
5.2 
Mar 
2,616 
2,554 
5,170 
445 
473 
918 
6,088 
5.6 
TABLE I 
MANTENO STATE HOSPITAL 
Population by Years 1931 to 1940 
6 FIG. I 
LEGEND 
POINT OF FLUORESCEIN DOSAGE 
POINT OF FLUORESCEIN fit SALT DOSAGE 
SANITARY SEWERS 
STORM SEWERS 
BUILDING UNDER CONSTRUCTION 
STATE OF ILLINOIS 
DEPARTMENT OF PUBLIC HEALTH 
DIVISION OF SANITARY ENGINEERING 
MANTENO STATE HOSPITAL 
TYPHOID FEVER EPIDEMIC 
I 9 39 
GENERAL LAY-OUT 
BUILDING LOCATION,SEWER SYSTEMS & 
POINTS OF FLUORESCEIN &SALT DOSA&E 
RD. V945 L.0.M.I940 The institution maintained its own bakery. All meals were prepared in 
the central kitchen, except for a few hospital cases requiring special diets. 
At the time of the epidemic approximately 19,815 meals were being served 
daily. Food prepared inAhe central kitchen was transported in aluminum 
food-containers by trucks to the various ward kitchens, from which it was 
usually served in cafeteria style. 
The mechanical department was under the supervision of a master 
mechanic whose responsibilities included the operation of the water supply, 
sewerage, garbage- and rubbish-disposal, and insect- and rodent-control, in 
addition to the maintenance of the power plant, and care of the grounds. 
Table II shows the number and classification of hospital employees from 
the year 1937 to 1940. It will be noticed that the number of employees 
in the mechanical department decreased from 19 in June, 1937, to 14 in 
June, 1939, while Table I shows that the population of the institution in- 
creased during that period from 3,208 to 6,152. 
GEOLOGY. The subsurface formations at the institution are ex- 
tremely important in the study of this epidemic. The area in which the 
institution is located is underlain near the surface with limestone which is 
cracked, creviced, and filled with solution channels. Such formation is 
universally credited by geologists with the character of conveying water and 
likewise pollution for great distances without effecting purification. The 
glacial drift covering the creviced limestone in the area is relatively thin, 
on the institution grounds varying from 0 to about 30 feet in thickness. 
In the southern portion of the institution grounds the rock outcrops, while 
at a distance of several hundred feet north the drift is 20 feet thick. Fig. 2 
gives the depth and thickness of underground formations at the site of one 
of the institution wells. During construction of the institution, some of the 
building foundations had to be excavated in rock; likewise, it was necessary 
to lay some of the sewers in trenches excavated in the rock formation. Ex- 
tensive studies by State geologists were made both before and after the 
epidemic occurred so that the general shallowness of the glacial drift and 
the creviced character of the underlying limestone have been very definitely 
established. 
WATER SUPPLY. The institution water supply was obtained 
from 4 drilled wells, all located within a few hundred feet of each other on 
the institution grounds. The wells all discharged to a concrete ground- 
storage reservoir, from which the water was pumped to the institution dis- 
tribution system on which pressure was maintained by an elevated tank. 
Three of the wells obtained their water solely from the creviced limestone, 
the wells being cased from the surface to only a short distance into the rock 
formation. The other well penetrated deeper rock formations, but that 
portion of the well passing through the creviced limestone was not cased 
out so that this well, likewise, received a portion of its water from the 
creviced limestone formation. Fig. 2 gives the logs and casing records of 
all the wells. For a month prior to the epidemic all water furnished the 
institution was obtained from one well only—that known as “No. 4”— 
which was drilled in 1938 and was located approximately 50 feet north of 
the power plant. This well had a total depth of 225 feet and was cased 
with 14-inch casing from the surface to a depth of only 19 feet, the casing 
7 TABLE II 
MANTENO STATE HOSPITAL 
Number and Classification of Hospital Employees 
During Period 1937 to 1940, 
Date 
Physicians 
Registered 
Nurses 
Attendants 
Mechanical 
Department 
Dietary 
Sanitary 
1937 
June 
9 
3 
358 
19 
6 
1938 
June 
17 
10 
541 
13 
6 
1939 
Jan 
24 
12 
607 
13 
8 
Feb 
23 
14 
621 
13 
9 
Mar. 
24 
22 
606 
14 
9 
Apr 
24 
22 
611 
14 
9 
May 
25 
22 
613 
14 
9 
June 
23 
22 
619 
14 
10 
July 
23 
21 
621 
15 
10 
Aug 
23 
22 
620 
16 
9 
Sept 
- 23 
109 
719 
16 
15 
Oct 
23 
108 
751 
16 
15 
Nov 
22 
86 
709 
18 
14 
Dec 
22 
64 
701 
18 
15 
1940 
Jan 
26 
47 
732 
19 
17 
Feb 
26 
46 
720 
18 
18 
8 
penetrating into the limestone for a depth of only 1 foot. Thus, the glacial 
drift at this well was only 18 feet thick and all water which this well 
supplied was developed from the creviced limestone. The static water level 
was reported at the time of the epidemic at 26 feet below the ground sur- 
face. A sanitary sewer line serving the power house passed only 35 feet 
south of the well casing. This sewer was constructed of vitrified sewer 
pipe, with ordinary cement mortar joints. Fig. 3 is a detailed layout of the 
water supply, and shows the location of sewers with respect to the wells. 
The water consumption at the institution was approximately 1,000,000 
gallons per day. Although water distributed to the hot-water system was 
softened by the zeolite process and boiler water was conditioned by a hot- 
lime process, the remainder of all water furnished the institution was dis- 
tributed without treatment of any kind previous to the epidemic. 
SEWERAGE. The institution was served by a system of separate 
sewers, one for sanitary wastes and the other for storm water. As pre- 
8 Yield - 430 o.pm. 
Oischabse to collecting 
RESERVOIR 
Yield - 15 O.P>. 
Pumped bv airlift 
Discharges to collecting- 
RESERVOIR. 
Yield - 285 o.p.t-i. 
Discharges to collecting- 
SjEseavoiR, 
Yield — 4foO e.P.r*1. 
DISCHARGES TO COLLECTING 
DESECVOlR 
WELL NiO-4 
DaiLUHO 1936 225* DEEP 
Located APPBOif. 50 FeeT 
north of power Mouse 
State Dept, of Public Health 
Division op Sanitary Enoincebins 
WELL. DETAILS 
Mamteno State Hospitau 
inspection NOV 12-iS, 1940 
L o w- ifrto»9-s9 a.O AS 
FIG. 2 
WELL tvJol 
Drilled 1930 - ITGo'dcep 
Located soo ft h.w. or powcc 
HOU&E 
WELL Mo. 2 
isz' ocep 
Located imncoiatClv west 
Ot DLACK.SKH.TH SHOP 
WELL. Mo. 3 
Drilled 193<V 225' Deep 
located aoo feet so. of wbu. t 
amo west of laundry bldg. LAUNDRY 
BUILDING 
5T ATE OF ILLINOIS 
DEPT. OF PUBLIC HEALTH 
DIVISION OF SANITARY ENGINEERING 
LAY-OUT DETAILS 
PUBLIC WATER. SUPPLY 
MANTENO STATE HOSPITAL 
FIG. 3 
9 viously indicated, some of these sewers were laid in creviced limestone be- 
cause of the thin glacial-drift covering at certain points on the institution 
grounds. Sewage from the sanitary sewer system was treated in the insti- 
tution sewage-treatment plant, of the activated sludge type, which was 
built in 1930 and was designed to give complete treatment to the wastes for 
a population of 3,000; however, at the time of the epidemic, the sanitary 
wastes from approximately 6,200 persons were being discharged to the 
plant, which so heavily overloaded it that it was not possible to produce a 
satisfactorily treated effluent. The outlet from the sewage-treatment works 
discharged to a small creek, which flowed through land used for agricultural 
and dairy purposes. Fig. 1 shows the system of sanitary and storm sewers, 
and gives the location of the sewage-treatment plant. 
10 CHAPTER II 
ONSET OF EPIDEMIC 
The official records of the State Department of Public Health show that 
no cases of typhoid fever had been reported from the time the institution 
was opened in 1931, through 1935. However, during the Fall of 1936, 
four inmates of the institution became ill with this disease. There was one 
additional case reported in February, 1937. No cases of typhoid fever were 
reported in 1938. Of the four cases occurring in 1936, the onsets were 
approximately one month apart, and there was nothing to indicate that the 
water supply was involved. The spacing of the cases apparently pointed 
to infection by direct contact with another case or a carrier. No carriers 
were reported found in the institution following the occurrence of these 
cases. 
On July 8, 1939, the first person to become ill with typhoid fever at 
Manteno State Hospital was a male inmate, “J. O.,” who was 30 years of 
age. This patient was admitted to Manteno State Hospital from Elgin 
State Hospital on August 15, 1935. At that time he was placed in one of 
the wards, named Quine Cottage, where he remained until the onset of his 
illness. According to staff physicians, this man had not registered any 
complaints, but on the 8th of July he became delirious and was transferred 
to the hospital proper. The outstanding signs were the abnormal tem- 
perature (which varied between 101 and 104 degrees), a relatively slow 
pulse rate, and rapid loss of weight. The differential diagnosis included 
tuberculosis of the abdomen, and pneumonia. These diseases were ruled 
out on the 10th of July when an X-ray examination was made. 
A maculo-papular eruption was noted and blood specimens were sub- 
mitted for typhoid culture and Widal test. A report from the Division 
of Laboratories dated July 17 indicated that the agglutination test was 
positive in a dilution of 1: 640 with H antigen but negative with O antigen. 
The blood-culture specimen was received July 17, and a report dated July 
24 indicated there had been no growth of any bacteria. The patient died 
on July 15. 
This man first placed in a mental institution in 1928, when he was 
classified as a mentally deteriorated male patient. After being placed in 
Quine Cottage he was not allowed away from this ward; and, consequently, 
lived, ate, and slept in this one building with the exception of those times 
when the patients were taken out for short under the supervision of 
an attendant. With the exception of food that was brought in from outside 
by the patient’s family, all foods which he consumed were prepared in the 
central kitchen of the institution and were served in the ward with the 
assistance of some of the inmates. 
The first case was reported to the Illinois Department of Public Health 
on July 19, and was investigated by one of the district health superintendents 
on July 21. 
11 During the investigation it was recommended to the managing officer 
of the institution that all persons who had been in contact with the case 
should receive typhoid vaccination and also should submit 2 specimens of 
feces and urine, at least 24 hours apart, to be examined for typhoid bacilli, 
as the quarantine regulations of the Illinois Department of Public Health 
required at that time. 
Typhoid-release containers for feces and urine were sent to the insti- 
tution by the Department of Public Health on July 24. In a letter dated 
August 2, the managing officer of the institution gave a list of the contacts 
of this typhoid case and stated that they were receiving typhoid vaccine. 
At that time he also acknowledged that the typhoid-release containers had 
been received; however, the Department of Public Health laboratory did 
not receive feces and urine specimens from the contacts until August 10. 
The reports on these specimens from the laboratory were all negative and 
were dated August 14. 
Later examination of the staff-meeting notes at Manteno State Hospital 
disclosed that on July 15 “E. S.,” a female patient in Adams Cottage, had 
been sent to the hospital with chills, fever, vomiting, and diarrhea. On 
July 16, a male inmate from Billings Cottage had been sent to the hospital 
with similar complaints. On July 21, diarrhea was reported among the 
inmates in Billings Cottage. Other patients were also reported who had 
symptoms suspiciously like those of typhoid, but on whom no definite diag- 
nosis had been made. It should be noted in this connection that widespread 
outbreaks of diarrhea were not uncommon in this institution; and, con- 
sequently, not much importance was attached by the staff physicians to the 
cases of diarrhea occurring in the latter part of July. 
Reference to the graph showing the various dates of onset for patients 
reported as having typhoid fever indicates that apparently the epidemic 
reached a peak on August 15 in the case of employees and other persons 
working on the institution grounds, whereas the peak for inmates on this 
chart apparently is August 23. (See Figs. 5 and 6, Chapter VII.) It 
should be pointed out that sane persons are more apt to complain and apply 
for aid sooner than persons who are mentally ill. In a disease such as 
typhoid fever, in which the onset is insidious, this fact may prove 
to be a complication in compiling epidemiological data. This is also borne 
out by examination of the staff-meeting records for Manteno State Hospital. 
From this record it was noted that one of the staff physicians reported 
on August 20 that he received calls, as officer of the day, from many wards 
about patients’ being ill and having temperatures of 104 and 105 degrees. 
These patients were reported to the physican at the time as all new 
cases, but he found later that they had jll been ill for several days previous 
to the time their conditio?i had been reported to him. Further examination 
of this record shows that the dates of onset for inmates, as reported to the 
Department of Public Health by the institution authorities or gathered 
from patients’ hospital records, were inaccurate. For instance, one female 
patient, “H. M.,” had been rqported to the Department of Public Health 
as having first become ill on August 26, while the staff-meeting record for 
August 22 showed that a physician had seen this patient on that date and at 
that time she had a temperature of 102 and had been sick for 5 days pre- 
12 viously. Likewise, a male patient, “G. McC,” had been reported on the 
patients’ hospital record as becoming ill on August 19. However, the 
staff-meeting record for August 10 showed that the ward physician exam- 
ined this patient on that date and found him to have a temperature of 101, 
with cough, chills, and rales in the chest, which were common typhoid 
prodromal symptoms in this epidemic. 
Early during the month of August, cases of diarrhea with temperature 
were reported from various male and female wards on the hospital grounds. 
Other cases having abnormal temperature only and such generalized symp- 
toms as headache and backache were reported, but apparently no definite 
diagnosis had been made of any of these and they were treated, for the most 
part, while remaining on their respective wards and cottages. It is possible 
that many of these individuals were suffering from typhoid fever in a mild 
form, and, therefore, as possibly missed cases may have constituted a source 
of infection and hazard to other persons on those wards, since no precaution 
was taken in the disposal of feces and urine from these ill inmates and their 
contaminated dishes and linens received no special care. 
The possibility of existence of a typhoid epidemic was apparently not 
recognized by the staff physicians until about August 15, at which time a 
telegraphic request was made to the Department of .Public Health for con- 
tainers in which to submit blood specimens for aggultination tests and 
typhoid cultures. Specimens from 4 patients were received in the Division 
of Laboratories on August 17. Agglutination tests on these were negative 
but E. typhosa was isolated from 3 of the specimens. A telephone report 
was made on August 19 to the assistant managing officer at Manteno State 
Hospital indicating that the results of these blood cultures would probably 
be positive. During this telephone conversation the assistant managing 
officer informed the chief of the Division of Laboratories that there were 
more than 100 cases of suspected typhoid on the institution grounds. It 
was agreed during this telephone conversation that a Department of Public 
Health laboratory-staff member should go to the institution. The remain- 
der of August 19 and Sunday, August 20, were spent in preparing media and 
supplies for an extensive laboratory study of the outbreak. 
When it became apparent that an epidemic was occurring, the director 
of the Department of Public Health on his own initiative ordered public- 
health personnel to proceed to the institution. Illinois law charges the 
Department of Public Health with the duty to “ . . . investigate the 
causes of dangerously contagious or infectious diseases, especially when ex- 
isting in epidemic form, and take means to restrict and suppress the 
same . . .” and when “. . . local authorities neglect or refuse to enforce 
efficient measures for its restriction or suppression or to act with sufficient 
promptness or efficiency the Department of Public Health may enforce 
such measures as it deems necessary to protect the public health . . . ” 
Further, the State Civil Administrative Code provides, “The Depart- 
ment of Public Health shall have power:....To make sanitary, 
sewage, health and other inspections and examinations for the charitable, 
penal and reformatory institutions . . In other words, the Department 
of Public Health can make inspections of State institutions and submit 
recommendations for needed improvements, but has no authority to act as 
a control agency until an epidemic actually occurs. As will be disclosed 
in Chapter IV, in which the institution water supply is discussed in detail, 
13 the Department of Public Health had made inspections of the institution 
sanitary facilities and had repeatedly made recommendations to the institu- 
tion authorities for correction of defects in the water-supply system. 
Accordingly, on August 19, the director of the Department of Public 
Health called the director of the Department of Public Welfare by tele- 
phone and advised that Department of Public Health personnel were being 
sent to the institution to assist in controlling the epidemic. The director 
of the Department of Public Welfare then, on that date, authorized the 
installation of an emergency chlorinator on the institution water supply. 
A chlorinator company in Chicago was called by the institution officials, 
and by the late afternoon of August 19 an emergency chlorinator was in- 
stalled. 
A Department of Public Health sanitary engineer arrived at the insti- 
tution on August 21 and proceeded with preliminary surveys on sanitary 
conditions at the institution. A Department of Public Health physician 
and a bacteriologist also arrived at the institution on August 21, and from 
that date through the remainder of the epidemic representatives of the 
Department of Public Health were present at the institution at all times. 
It soon became evident that a thorough and complete investigation of 
the cause of the epidemic, and the development and execution of measures 
to control it, would require the services of many persons experienced in 
public-health work. Additional epidemiologists were sent to the institution 
to collect epidemiological data and to render consultation services in clinical 
diagnosis of typhoid fever cases. An emergency laboratory was established 
at the institution, operated by experienced bacteriologists. Several more 
sanitary engineers were detailed to the institution to conduct surveys on 
pollution and plumbing, and to examine food-handling methods. Milk 
sanitarians were required to check the milk supply. 
There was an insufficient number of registered nurses at the institution 
to carry out isolation technique properly, and considerable difficulty was 
experienced in getting the lay attendants to execute the strict isolation 
measures necessary. Therefore, on September 20 nine Public Health 
Department nurses were sent into the institution to serve on the various 
isolation wards and supervise isolation technique in those places. 
Some administrative difficulty was encountered in obtaining immediate 
execution of control measures by regular institution personnel. Conse- 
quently, by agreement between the director of the Department of Public 
Health and the director of the Department of Public Welfare, on Septem- 
ber 19 an experienced Department of Public Health sanitary engineer was 
loaned to the Department of Public Welfare in order that he might serve 
as assistant managing officer of the institution and in this capacity be in 
direct charge of the control of the epidemic. This transfer greatly facili- 
tated the prompt execution of necessary control measures, because it es- 
tablished a direct liaison between the personnel of the two State depart- 
ments and resulted in a marked improvement in the co-operation of the insti- 
tution employees. 
Many of the Department of Public Health personnel were retained at 
the institution for several months. The estimated cost of the epidemic to 
the State of Illinois for both the Department of Public Health and the 
14 Department of Public Welfare for extra personnel, travel and mainte- 
nance expense, and supplies, occasioned by the outbreak, was $120,000. This 
does not include any cost for time and loss of life by those who contracted 
the disease. 
15 CHAPTER III 
PRELIMINARY OBSERVATIONS 
Upon arrival of the Department of Public Health personnel at the 
institution, a survey was made of the existing control measures in order to 
determine their efficiency and to institute whatever additional measures were 
necessary to control the epidemic. 
WATER SUPPLY. It was found that all of the water for the in- 
stitution was being obtained from Well No. 4, which had its source of 
supply in the shallow Niagaran limestone. This well was cased only 
through 18 feet of drift and 1 foot into the limestone. An emergency 
chlorinator had just been installed. Chlorine was being fed into the pump- 
suction line at a point approximately 15 feet from the high-service pump. 
Due to the fact that the high-service pumps discharged directly into the 
distribution system, the retention period provided between the point of 
application of chlorine and points where the water was consumed was not 
adequate to provide proper disinfection. Analyses of samples of this water 
showed that contamination still persisted after chlorination, 
TYPHOID WARD WASTE DISPOSAL. A survey of the method 
of handling the wastes from the typhoid patients showed that it was not 
satisfactory, because the wastes were in some instances being placed directly 
into the sewer, and, other instances the material was collected in cans and 
hauled to a field for burial. 
No attempt had been made to close off the sewers in the isolation build- 
ings to keep contaminated material from going to the sewer and sewage- 
treatment works. 
TYPHOID WARD LINEN. The handling of linens from the 
typhoid wards was found to be unsatisfactory. Large piles of soiled linens 
were found lying on the porches of the typhoid wards, where they were 
exposed directly to flies. Soiled sheets were lying on the floor in the typhoid 
wards proper and in the bathrooms. 
SEWERAGE. The plumbef was contacted to determine if any serious 
sewer stoppage had occurred. He advised that a sewer stoppage on First 
Avenue in front of Silvis Hall had been remedied a few days before. 
Upon examination and checking with dye, it was found that sewage from 
the sanitary sewer was finding its way to the storm sewer, which sewer 
was approximately 12 feet from the sanitary sewer. It was found, also, 
that there was a stoppage of the sanitary sewer located in the street between 
the power house and Well No. 4, and that sewage was standing to a depth 
of several feet in the manhole located approximately 80 feet from Well 
No. 4, Details on these sewer stoppages will be found in Chapter IV. 
DIETARY DEPARTMENT. A hurried check revealed that 
there was a serious fly situation in the central kitchen and the 
dining rooms and that the kitchen was extremely dirty. Patients .who 
16 were working in the kitchen were dirty. It’was noted that brooms 
used for scrubbing floors were later used for cleaning the cooking uten- 
sils and the meat block where meat was carved. An objectionable odor 
nuisance also existed both inside and outside the kitchen. 
A dishwashing machine in use in the central kitchen provided only a 
12-second interval from the time the dishes entered until they were dis- 
charged. The same method of dishwashing was used in the majority of 
the ward kitchens. In ward kitchens, where no dishwashing machines 
were provided, dishes were washed by hand. No attempt was made to 
sterilize the dishes after washing by either method. Dish towels were 
used throughout the institution by patients in drying the dishes; also, a 
great deal of difficulty was encountered in securing a sufficient number of 
towels. Cans used for transporting food from the central kitchen to the 
ward kitchens were returned, in many instances, to the central kitchen with- 
out having been cleaned. 
Food-handlers, both patients and employees, had not been checked to 
determine whether or not they were carriers of infectious disease. 
Several discarded bathtubs were being used in the basement of the cen- 
tral kitchen as receptacles for vegetables which were being prepared. The 
enamel was badly chipped on these tubs and they were otherwise in a poor 
sanitary condition. The situation prevailing in this room was not satis- 
factory because of overcrowding of inmate workers and the necessity of 
preparing, at times, 100 bushels of potatoes for a meal together with the 
other vegetables which were required. The drainage facilities in the 
peeling room were also inadequate; and, as a result, the floor was flooded 
at times. 
In bringing the vegetables from the peeling room to the central kitchen, 
they were transported around the building, a distance of approximately 
500 feet, by a small hand truck. In the process of transportation these vege- 
tables were-subjected to flies, dust, dirt, and other contaminating substances. 
The milk supply coming to the institution was from an approved milk- 
pasteurization plant; however, there were approximately 100 gallons of 
raw milk produced on the institution farms each day. This raw milk was 
used only for cooking and in a boiled ice-cream mix. 
Dishes used by hospitalized patients and employees, which included 
typhoid patients and typhoid suspects besides the ordinary population, were 
being returned to the hospital kitchen from the bedsides without proper 
disinfection. 
It was found that relatives and friends visiting employees in the hospital 
who were ill with typhoid fever were going from the typhoid patients’ bed- 
sides into the hospital kitchen and were handling dishes, food, etc. 
GARBAGE. Garbage at the institution was being collected by a 
horse-drawn wagon, and the garbage box provided was not watertight. As 
a result, whenever the garbage wagon stopped for collection, pools of gar- 
bage were formed, thereby creating fly-breeding and odor nuisance over the 
entire grounds. Garbage cans from the individual ward kitchens were set 
along the roadway and in most instances the areas around the garbage cans 
were covered with garbage that had been spilled. Also, there was a lack 
of lids for these garbage cans and no attempt was made to wash the cans 
after the garbage* had been collected. 
17 At the central kitchen, garbage was placed in galvanized iron cans on 
the rear platform of the kitchen, and if cans were not available the garbage 
was dumped directly onto the ground. Here again, a serious fly and odor 
nuisance existed. 
RUBBISH. Rubbish from the institution was collected with a horse- 
drawn vehicle and taken to the north farm where it was deposited near the 
garbage dump. On windy days the paper and other material were blown 
over the landscape and presented a very untidy, ill-kept appearance. Tin 
cans from the kitchen were not charred and crushed, and, again, an excellent 
feeding place for flies was created. Attempts were made to burn all com- 
bustible material in the rubbish; however, this was not possible on windy 
days. 
RODENT CONTROL. Very little attention was paid to rodent con- 
trol at the institution and as a result many mice and rats were present. 
An ample food supply for rodents was available around garbage cans and at 
the garbage dump. 
There was a very bad infestation of rats at the sewage-treatment plant, 
where screenings from the barscreen were dumped and not properly covered. 
FLY AND INSECT CONTROL. At the start of the epidemic the 
institution was infested with flies and cockroaches. There was profuse 
fly breeding at the sewage-screenings dump, garbage cans throughout the 
institution, manure piles, and at places where fecal matter had been de- 
posited by patients (particularly behind bushes around the buildings and 
in the grove behind the power house). Probably the worst condition existed 
at the sewage-screenings dump where it was noted that the entire dump 
was literally alive with maggots. Cockroaches were so prevalent that they 
were noted in the sleeping rooms and even in the beds of some of the 
various wards. 
The central kitchen was infested with flies, due partly to the remodeling 
activities which made it impossible to have all openings properly screened 
and partly to the fact that traffic was through one outside door. 
The hospital, including the operating and post-mortem rooms, was over- 
run with flies due to improperly fitted screens. 
18 CHAPTER IV 
WATER-SUPPLY STUDY 
It was noticed early in the investigation that there was no definite 
localization of typhoid fever cases to any one ward or group of wards, a fact 
which indicated that the source of infection must have been associated with 
a factor common to all wards of the institution. This directed suspicion 
toward water, food, milk, and ice cream. Since the water supply had 
always been of questionable sanitary quality, it was deemed advisable to 
make a detailed study of this possible means of transmission. 
PREVIOUS RECORD OF POLLUTION OF WATER SUPPLY. 
As indicated in Chapter I, the institution water supply was secured from 
wells obtaining water from creviced limestone. This limestone, known as 
the Niagaran, is badly cracked and creviced and contains solution channels 
that may carry pollution for great distances. The shallowness and com- 
plete absence in places of the glacial-drift covering at the site of the insti- 
tution further increased the hazard to such a water-supply source. 
Plans and specifications for the institution water supply were not sub- 
mitted to the Department of Public Health for review before the installa- 
tion was made; and, consequently, Department of Public Health approval 
was never issued. When the water supply was first placed in operation, 
early in 1931, a Department of Public Health sanitary engineer made an 
inspection, and samples of water were submitted for analysis on the same 
day. Results of water analyses showed the presence of contamination, and 
the institution officials were immediately informed by telegram of the results, 
wfith the recommendation that all drinking water be boiled and that chlorina- 
tion of the water supply be instituted. This first inspection disclosed that the 
water was being obtained from the creviced limestone. An opinion was 
then requested by the Department of Public Health from the Illinois State 
Geological Survey, which organization made a study and reported in part 
as follows: “Not only will the proximity of the limestone to the present 
surface be dangerous for obtaining water from the Niagaran, but the fact 
that sewers and other constructions extended into the rock makes it im- 
perative that the water from this well be constantly jvatched and 
perhaps treated with chlorine continually.” The managing officer of the 
institution was immediately informed of the State Geological Survey 
opinion, and the hazard of utilizing water obtained from the creviced lime- 
stone was stressed. A formal report was then prepared and submitted to 
the director of the Department of Public Welfare. 
In this first official report of the Department of Public Health on the 
Manteno State Hospital water supply, dated March 31, 1931, the director 
of the Department of Public Welfare was informed that by inspection and 
results of analyses the supply was found to be contaminated, there was possi- 
bility of the entrance of dangerous contamination because of the underlying 
creviced limestone formation, and that continuous and adequate chlorination 
should be adopted or the wells reconstructed in order to case out undesirable 
19 water from the limestone formations. This report was submitted only a 
short time after the new institution was formally opened for occupancy. 
Again, in a formal report dated November 22, 1935, to the director of 
the Department of Public Welfare on the institution water supply, the 
State Department of Public Health repeated its former warnings pertaining 
to the hazard from the shallow creviced limestone and its recommendation 
that chlorination be adopted. Under date of September 21, 1937, a third 
formal water-supply report on the institution was submitted to the director 
of the Department of Public Welfare, again warning of the hazard because 
of the creviced limestone and recommending that a chlorinator be installed. 
The following paragraph was included in this report: 
“These defects in the Manteno State Hospital water supply 
have existed for a number of years and we have previously 
called the attention of the hospital officials to these dangers. 
The Manteno State Hospital officials are not exercising the 
‘reasonable care’ necessary in the maintenance of an institu- 
tional water supply and should an epidemic of water-borne 
illness occur the officials would be responsible for negligence 
in not protecting the water supply.” 
For a period of 8 years from the time the institution was formally 
opened (1931) until the epidemic occurred in August, 1939, the Department 
of Public Health analyzed a total of 241 water samples, collected in 78 
separate sets at intervals varying from a minimum of 5 sets to a maximum 
of 11 sets per year. These water samples were analyzed in the Department 
of Public Health laboratories in conformance with “Standard Methods of 
Water Analysis.” The accompanying Table HI, giving a summary of these 
results, clearly shows the unsatisfactory bacteriological quality of the supply 
for the 8-year period prior to the outbreak. 
From this tabulation, it will be noted that only during the year 1933 
did the supply, from an analytical standpoint, meet the laboratory standards 
for safe drinking water; also, beginning with 1937, the bacterial quality of 
the water supply became progressively worse. Gross pollution of the supply 
is further emphasized by a number of samples collected just prior to and 
following the outbreak, as shown in Tables IV and V. Each of the 3 
consecutive monthly samples from Well No. 4, collected immediately pre- 
ceding the outbreak, had all five 10 ml. portions positive. Maximum coli- 
form indices, determined on samples collected after the epidemic started, 
were 70,000 for water from Well No. 4 and 240,000 for Well No. 1. 
The laboratory results of all analyses of water samples collected from 
the institution over the entire 8-year period were reported as soon as com- 
pleted to the director of the Department of Public Welfare at the State 
Capitol and to the managing officer at the institution. Conclusions 
regarding the safety of a water supply are based primarily on the field 
conditions surrounding the source and the possibilities of pollution through 
such physical surroundings, therefore, ceven when occasional satisfactory 
laboratory results were obtained, the written opinions on these results still 
stated that the water at the institution could not be considered safe for 
drinking because of the possibilities of contamination, and reference was then 
20 TABLE III 
SUMMARY OF RESULTS OF WATER ANALYSES 
Previous to Epidemic 
Year 
Number 
Samples 
Collected 
During Months 
Number 
10 ml. 
Portions 
Tested 
Number 
10 ml 
Portions 
Positive 
% Positive 
Portions 
1931 
40 
Feb., Mar., May, June, July, 
Aug., Sept., Oct., Nov., 
Dec 
•# 
200 
80 
25.0 
1932 
35 
Jan., Feb., Mar., Apr., May, 
June, July, Sept., Oct., 
175 
/ 
37 
21 I 
1933 
15 
Jan., Mar., May, July, Oct. , 
75 
2 
2.7 
1934 
28 
Jan., Mar., Apr., June, Aug., 
Sept., Oct., Nov 
140 
33 
23.6 
1935 
36 
Jan., Feb., Mar., Apr., July, 
Aug., Sept., Nov., Dec. . . 
180 
41 
22.8 
1936 
21 
Feb., Mar., May, June, July, 
Nov., Dec 
105 
20 
19.0 
1937 
26 
Feb., Apr., May, Aug., Sept., 
Oct., Dec 
130 
48 
36.9 
1938 
15 
Feb., Mar., July, Aug., Oct.. 
75 
30 
40.0 
1939 
25 
Jan., Feb., Mar., Apr., May, 
June, July, Aug 
125 
69 
55.3 
made to previously submitted formal reports in which details of the hazards 
and recommendations for correction had been included. When results of 
analyses showed the water to be bacteriologically unsafe, not only did the 
written opinion state this but the opinions on the analyses were so worded 
that the fact that the water supply was not considered safe for drinking 
should have been clearly understood by any lay person. Some of the actual 
phrases used in these laboratory opinions were “Unsafe to drink,” “This 
sample represented a water unsafe for drinking,” “This was not safe to drink 
as represented by this sample,” “This water is subject to dangerous con- 
tamination and not safe to drink,” “So great is the danger that at any 
moment a dangerous water-borne epidemic might result . . . ,” and “The 
fact that no epidemic of illness attributed to the water supply has occurred 
is no indication or proof that such an epidemic may not occur at any time.’* 
21 TABLE IV 
MANTENO STATE HOSPITAL 
Bacteriological Analyses of Water Supply 
From March 23, 1939, to March 31, 1940 
Well No. 4 
(Unchlorinated) 
Month 
No. of 
Samples 
Coliforms in 
10 ml. Portions 
or No. of Samples 
Showing 
Contamination 
Max. Coliforms 
in any 1 Sample 
Average 
Coliforms per 
100 ml. (MPN) 
March 23 
1 
5— 
— 
— 
April 27 
1 
5— 
— 
— 
May 25 
1 
5+ 
— 
— 
June 1 
1 
5+ 
— 
— 
August 2 
1 
5 + 
— 
— 
August 21 
2 
2 
1,300 
620 
August 23 
1 
1 
2,400 
— 
August 26 
1 
1 
2,400 
— 
August 27 
1 
1 - 
2,400 
— 
August 29 
1 
1 
24,000 
— 
August 30 
1 
1 
24,000 
— 
August 31 
1 
1 
13,000 
— 
September 
27 
24 
70,000 
5,889 
October 
16 
11 
620 
156.5 
November 
28 
26 
620 
105 
December 
26 
25 
13,000 
900 
January 
28 
26 
2,400 
220.5 
February 
27 
15 
8.6 
2.2 
March 
12 
4 
2.1 
0.7 
Note: Dilutions not made previous to August 21. Therefore, maximum coliforms 
not available for samples collected before that date. 
SEWER LEAKAGE. Inasmuch as some of the institution sewers were 
known to be laid in the creviced limestone and in view of the above out- 
lined history of pollution of the water supply, an attempt was made to trace 
pollution from the sewers to the water supply. On August 22, a Depart- 
ment of Public Health sanitary engineer learned from a plumber employed 
by the institution that, a short time before, a sanitary-sewer stoppage had 
occurred in the sewer on First Street directly in front of Silvis Hall, and 
that the stoppage had been removed. Upon examination at this approxi- 
mate location, it was found that a storm sewer paralled the sanitary sewer 
at a distance of about 10 to 15 feet, and that domestic sewage was flowing 
in the storm sewer. Both sewers were reported to be laid in creviced 
22 TABLE V 
MANTENO STATE HOSPITAL 
Bacteriological Analyses of Water Supply 
P'rom August 21, 1939, to March 31, 1940 
Month 
No. of 
Samples 
No. Showing 
Contamination 
Max. Coliforms 
in any 
1 Sample 
Average Coliforms 
per 100 ml. 
(MPN) 
Well No. 
1 
Aug. 21-31 
1 
l 
2,400 
2,400 
Sept 
7 
4 
6,200 
3,000 
Oct 
30 
23 
2,400 
528.5 
Nov 
24 
24 
21,000 
1,903 
Dec 
15 
15 
240,000 
23,147 
Jan 
21 
20 
24,000 
2,282 
Feb 
27 
23 
64 
17.2 
Mar 
8 
6 
240 
65.2 
Total Well No. 1 
(Aug. 21-Mar. 31) 
133 
116 
240,000 
3,610 
Well No. 
2 
Total Well No. 2 
(Aug. 21-Mar. 31) 
73 
2 
8.6 
0.23 
Well No. 
3 
Total Well No. 3 
(Aug. 21-Mar. 31) 
153 
4 
17 
0.25 
Well No. 4* 
Total Well No. 4 
(Aug. 21-Mar. 31) 
172 
139 
70,000 
1,461.7 
Distribution System 
(Chlorinated) 
Aug. 21-31 
21 
5 
2,400 
344.40 
Sept 
78 
2 
14.5 
0.21 
Oct 
105 
2 
2.1 
0.02. 
Nov 
100 
0 
0 
0 
Dec 
90 
0 
0 
0 
Jan 
53 
0 
0 
0 
Feb 
55 
0 
0 
0 
Mar 
63 
0 
0 
0 
Total Dist. System 
(Aug. 21-Mar. 31). 
565 
9 
— 
— 
Note: All samples from wells collected before any treatment. Double chlorina- 
tion on water pumped to distribution system began August 25. 
•Monthly breakdown of samples for Well No. 4 given in Table IV. 
23 limestone at this location. In order to check the possibility that leakage 
was taking place from one sewer to the other by passing through crevices 
in the limestone, flourescein dye was placed in toilet bowls in Silvis Hall and 
the toilets flushed repeatedly for a period of approximately 15 minutes. 
Within a very short time this green dye appeared in the sanitary sewer, and 
in about 15 minutes it was noticed in considerable concentration in the 
parallel storm sewer. Insofar as could be determined at this location and 
upstream from this point, there were no direct sanitary connections to the 
storm sewer. In that there was a time lag of about 15 minutes between 
the appearance of the dye in the sanitary sewer and the storm sewer, the 
test demonstrated with reasonable assurance that sewage was flowing from 
the sanitary sewer through the limestone to the storm sewer. This par- 
ticular location, where the dye test was made, is approximately 2,400 feet 
from Well No. 4; however, sewers are laid in limestone to within approxi- 
mately 400 feet of Well No. 4, 
Further checking of the storm-sewer system revealed that the storm 
sewer from the north (or male) side of the institution was practically dry, 
as it should have been because there had been no recent rain, while the 
storm sewer from the south (or female) side of the institution was carrying 
sewage to a depth of approximately 5 inches above the sewer invert. De- 
termination that the storm sewer was carrying waste of sanitary character 
was made by visual inspection, the flow having the normal appearance of 
domestic sewage. Some of this flow may have originated from the base- 
ment and floor drains, which were known to have been connected to the storm 
sewer at some points below that location where the dye test, above-mentioned, 
was made. However, it is significant that the glacial drift is very thin, and 
entirely absent at several points on the south half of the institution grounds. 
Many of the sewers on this side were laid in or on the creviced limestone, 
while the glacial drift on the north side is somewhat thicker and sewers 
there were generally bedded in clay. 
At the time of this sewer-systern investigation (August 22), a stoppage of 
a sanitary sewer was discovered which sewer was located in the street between 
the power house and Well No. 4 at a distance of approximately 35 feet 
from the; well. This sewer was of ordinary vitrified clay pipe, with cement- 
joint construction. Stoppage at some point downstream in the sanitary 
sewer caused sewage to back up into the sewer until there was a depth of 30 
inches in a manhole approximately 80 feet from Well No. 4. Thus, through 
an inspection by a responsible Department of Public Health sanitary engi- 
neer, it was determined that a sanitary sewer in the near vicinity of Well 
No. 4 (from which the entire institution water supply had been obtained 
for several weeks prior to the epidemic) was surcharged'with sewage under 
considerable pressure; and although the sanitary sewer at this location was 
not laid directly in the limestone, there being approximately 12 feet of clay 
intervening between the invert of the clogged sewer and the top of the 
creviced limestone, this finding gave further substantiation to the probability 
that sewage pollution had entered the institution water supply. 
ISOLATION OF E. TYPHOSA FROM WATER SUPPLY. 
From the above finding it was concluded that sewage pollution might actu- 
ally be then passing from the surcharged sewer directly to the limestone and 
Well No. 4. Therefore, it was determined to make the attempt to isolate 
24 typhoid organisms directly from the raw water produced from Well No. 4. 
In most instances it is not possible to isolate typhoid organisms from water 
supplies suspected of harboring this organism; in fact, this can be done so 
rarely that it is usually not attempted. However, in view of the long rec- 
ord of unsatisfactory bacteriological results obtained on samples collected 
from the supply, which indicated that water from Well No. 4 was grossly 
polluted, it was considered worthwhile to attempt the isolation of E. typhosa 
from this well. This attempt was begun on August 22, the identification 
being completed on August 31, 1939. The method employed being an 
unusual one, we present here the technique and results as given in the 
Department of Public Health bacteriologist’s original report: 
“Approximately 6 quarts of water were obtained from the 
sampling faucet of Well No. 1, and the same amount in two 
instances from Well No. 4, (sterile Erlenmeyer flasks). In 
each instance approximately 6 quarts of water were filtered 
through a Seitz filter pad, size E. K., and this pad was sub- 
sequently broken up in 250 cc. Selenite F. enrichment. Incuba- 
tion time of filter pad from Well No. 1—18 hours. Incubation 
time of filter pad from Well No. 4 was, on my first attempt, 
18 hours and at my second attempt from the same well 8i/£ 
hours, (when typhoid bacilli were isolated). The reason 
for changing incubation time was that after plating on Endo 
agar from the Selenite the Endo plates showed heavy over- 
growth of organisms belonging to colon-aerogenes group. 
“After incubation in Selenite, one 7 mm. loop was streaked 
each time on each of 5 Endo agar plates and incubated over- 
night. In my second attempt with water from Well No. 4, 
two colonies were picked having the following characteristics: 
dextrose acid, mannite acid, arabinose, rhamnose, saccharose, 
lactose no change and xylose acid. The organism was indol 
neg., H2S very pronounced (noticeable after 5 hours) in lead 
Motility agar, Gram neg., motile, agglutinated readily in ty- 
phoid immune serum ( 2 hours at 37.5°C.) in a dilution of 
1:640 (floccular agglutination).” 
The reactions of the organisms as described in the above report are typ- 
ical of those produced by typhoid organisms in every respect. There 
appears to be no doubt, therefore, that typhoid organisms were present in 
the water from Well No. 4 at the time the sample was collected. 
In considering this unusual isolation of typhoid fever organisms from the 
water of Well No. 4, it should be recalled that there is much evidence to 
show that the water was grossly polluted and therefore E. typhosa was 
probably present in the sample collected. Table IV gives bac- 
teriological results of analyses of samples collected from Well 
No. 4 for several months before and after the epidemic. It will be observed 
that coliform indices on August 21 (the day before collection of the samples 
from which E. typhosa was isolated) were 1,300 and 620. On the day 
after, August 23, the coliform index was 2,400. The coliform index reached 
a maximum of 70,000 in September. Unfortunately, dilutions were not 
made on the samples collected previous to August 21, and therefore coli- 
form indices are not available to show the exact numerical degree of pollu- 
tion of Well No. 4 during the period immediately preceding the outbreak; 
25 however, the confirmed positive results (5-f- on 10 ml. portions) for that 
period do show gross pollution. 
ADDITIONAL POLLUTION SURVEY. While the attempt was 
in progress to isolate typhoid fever organisms from the institution water 
supply, Department of Public Health sanitary engineers proceeded to make 
additional investigations to substantiate more fully pollution of the water 
supply. An attempt was made to trace pollution from the sewers into 
Wells No, 1 and No. 4. For purposes of tracing sewage pollution from 
the sanitiary sewers into the wells, the use of salt and fluorescein was adopted. 
These tests were conducted on August 29 and 30. 
Salt was applied to 10 sewer manholes, located at different points on the 
sanitary sewer system. These points are shown on the map of the institution 
which is presented in this report as Fig. 1. At each manhole approximately 
10 pounds of medium-grade granulated salt were added directly to the 
sewer and a 10-pound sack of rock salt was placed in the invert of the 
flowing-through channel of these manholes, thus blocking the normal passage 
and causing the sewage level to rise and pass over and around the salt sack. 
Rock salt was used in order to effect a gradual dosage of chlorides following 
the initial dose of granulated salt. Altogether about 200 pounds of salt 
were added to the sewer system. 
Fluorescein dye was also added to the sanitary sewers at 7 manholes by 
the use of 54-gallon barrels, each equipped with stopcocks so that the solu- 
tion of fluorescein and water could be added over a period of time. Ap- 
proximately 100 grams of dye were added to each 50 gallons of water in the 
barrels, the dye solution being allowed to drip in a steady, thin stream 
directly into the sewer invert channels of the manholes. A total of about 
1 ]/i pounds of fluorescein was added. From Fig. 1, which shows the points 
of application of fluorescein to the sewers, it will be noticed that the fluo- 
rescein was applied principally to the sewers covering the south side of the 
institution, this being done because it was learned that these sewers were 
generally laid directly on or in the creviced limestone formation. 
The tests were conducted for 24 hours, during which period determina- 
tions of both chloride and fluorescein contained in Wells No. 1 and No. 4 
were made. Initial chloride determinations were made prior to the dosing 
of the sewer system, which established the initial chloride content of water 
from both Wells No. 1 and No. 4 as approximately 14 parts per million. 
The general procedure was adopted of collecting samples from both wells 
after one hour of pumping, so that representative results could be obtained. 
Fluorescein determinations were made by use of 100 ml. Nessler tubes, in 
which periodic samples were checked colorimetrically against initial samples. 
Table VI is a complete tabulation of determinations made during these 
tests, and Fig. 4 graphically shows the results of the salt test. 
On the chloride determination made one hour after the sewer system was 
dosed, it will be noted that an increase of approximately 10 parts per million 
of chlorides was determined. This determination was made following the 
starting of pumpage from Well No. 4 and appears to be false since during the 
previous hour difficulty was experienced with the well, and although the 
pump was running no water was being lifted. Immediately prior to the 
sample collection for this determination, the pump was shut down and ap- 
parently a back-siphonage of chlorinated lime into the well was experienced 
26 Mamtcr-4o State Ho»pital 
Goaph Or Water Pollution Survey 
Cesuuts 
Incrftase Of Chloride Concentration 
in Water from Well **-4 subsequent to 
the dosmq of the matilufion sawar 
system with 200 lbs of salt 
Test Conducted Auq 2.9 A 30 1939 
By 
Division Or Sanitaov EnGiuccrimq 
Illinois OlWOrMCNT Or Public Hialtm 
Cblo»-»cie» in PPM. 
FIG. 4 
which gave this false reading. All other determinations were made following 
at least a full hour of pumpage, and a study of Fig. 4 indicates that the most 
positive chloride increase occurred about 14 hours subsequent to the dosing 
of the sewers with salt. After a period of 6 hours had elapsed following the 
salt dosage, an inspection of the sewer manholes in which the bagged rock salt 
had been placed revealed that nearly all of the salt had dissolved and passed 
on into the sewer system; and, since at this time a positive increase of 
chlorides was noted, the fluorescein dye dosage was increased so that the 
remaining dye would pass through the sewers within another hour’s time. 
At no time during the test was the presence of fluorescein found in the 
water from either Well No. 1 or Well No. 4. Results, however, of 
chloride determinations for Well No. 4 showed increases of chloride content, 
particularly at intervals of 1,6, and 14 hours after the dosing of the sewers 
with salt. From these tests it was concluded that a positive increase of 
chlorides in the water pumped from Well No. 4 indicated, beyond reasonable 
doubt, that sewage pollution was entering this well. 
27 Sample 
No. 
lime 
Well 
No. 
Test 
by 
Ml. of 
sample 
Ml. of 
AgNOs 
Chlorides 
ppm 
Fluorescein 
color 
REMARKS 
Initial 
— 
4 
Div. Lab. 
— 
— 
14.0 
— 
August 21, 1939 
— 
4 
i< <« 
— 
— 
16.0 
— 
August 23, 1939 
— 
4 
(( << 
— 
— 
14.5 
— 
August 26, 1939 
— 
4 
“ “ 
— 
— 
22.5 
— 
After starting pump August 27 
— 
4 
RMB 
50 
1.4 
14.0 
0 
August 29, 1939 
— 
4 
50 
1.25 
12.5 
0 
August 29, 1939 
— 
1 
“ 
50 
1.55 
15,5 
0 
August 29’, 1939 
— 
1 
“ 
50 
1.50 
15.0 
0 
August 29, 1939. Initial check 
— 
2 
“ 
50 
1.00 
10.0 
0 
August 29, 1939 
“ 
— 
2 
LEW 
50 
1.05 
10.5 
0 
August 29, 1939. Initial check 
1 
6:00 P.M. 
1 
RMB 
50 
1.30 
13.0 
0 
2 
7:00 P.M. 
4 
50 
2.25 
22.5 
0 
Reading taken after starting pump. Result 
checked 
3 
8:00 P.M. 
1 
“ 
50 
1.35 
13.5 
0 
4 
9:00 P.M. 
4 
LDH 
50 
1.90 
19,0 
c 
5 
10:00 P.M. 
1 
50 
1.5 
15.0 
0 
Wells No. 1 and No. 4 pumped entire hour 
6 
10:00 P.M. 
4 
“ 
50 
1.4 
14.0 
0 
7 
11:00 P.M. 
4 
“ 
50 
1.5 
15,0 
0 
TABLE VI 
MANTENO STATE HOSPITAL 
Water-supply pollution survey to check possible increase of 
chloride concentration and presence of dye in wells following 
dosing of sewer system with salt and fluorescein. 
Tabulation of Results 
28 8 
12:00 A.M. 
4 
“ 
50 
1.6 
16.0 
0 
8 
12:00 A.M. 
4 
“ 
50 
1.7 
17.0 
0 
Result checked 
9 
12:00 A.M. 
1 
“ 
50 
1.4 
14.0 
0 
10 
12:30 A.M. 
4 
“ 
50 
1.6 
16.0 
0 
August 30, 1939 
11 
1:00 A.M. 
4 
(C 
50 
1.6 
16.0 
0 
12 
2:00 A.M. 
1 
“ 
50 
1.35 
13.5 
0 
10 
12:30 A.M. 
4 
RMB 
50 
1.70 
17.0' 
0 
Result checked 
13 
3:00 A.M. 
4 
50 
1.53 
15.3 
0 
Fluorescein dosage increased between 3:10 and 
3:40 A.M. 
14 
4:10 A.M. 
4 
“ 
50 
1.5 
15.0 
0 
15 
8:00 A.M. 
4 
“ 
50 
2.50 
25.0 
0 
16 
8:30 A.M. 
4 
LEW 
50 
2.5 
25.0 
0 
17 
9:00 A.M. 
4 
“ 
50 
2.5 
25.0 
0 
18 
9:30 A.M. 
4 
“ 
50 
1.73 
17.3 
0 
Checked O.K. 
19 
10:00 A.M. 
4 
“ 
50 
1.5 
15.0 
0 
20 
10:30 A.M. 
4 
“ 
50 
1.45 
14.5 
0 
21 
11:30 A.M. 
4 
“ 
50 
1.4 
14.0 
0 
22 
12:30 P.M. 
4 
“ 
50 
1.4 
14.0 
0 
23 
1:00 P.M. 
1 
50 
1.5 
15.0 
0 
Well idle since 4:00 A.M. Two minutes’ 
pumping 
24 
1:30 P.M. 
4 
LDH 
50 
1.65 
16.5 
0 
25 
2:00 P.M. 
1 
“ 
50 
1.4 
14.0 
0 
After 45 minutes of pumping 
26 
2:30 P.M. 
4 
LEW 
50 
1.4 
14.0 
0 
27 
3:30 P.M. 
4 
“ 
50 
1.4 
14.0 
0 
28 
4:30 P.M. 
4 
50 
1.4 
14.0 
0 
29 CHAPTER V 
CONTROL METHODS ADOPTED 
After the preliminary observations had been completed, it was obvious 
that additional control methods would have to be adopted immediately in 
order to prevent the further spread of typhoid fever. The measures which 
were deemed essential were: more stringent isolation of typhoid patients, 
better food-handling methods, proper disposal of typhoid wastes, improved 
methods of handling linen, insect- and rodent-control, adequate chlorination 
of water, chlorination of sewage, immunization, and a carrier finding survey. 
STRICT ISOLATION. In inaugurating control measures at the 
institution, one of the first objectives was to reduce, as far as possible, the 
chances of inmates’ and employees’ contracting typhoid fever as a result 
of direct contact. This, of course, necessitated the adoption of strict iso- 
lation and quarantine measures. Since typhoid fever is a disease which has 
a slow onset with varied symptoms, definite diagnosis often cannot be made 
during the early stages. It was recognized, however, that persons in the early 
stages of the disease are capable of transmitting the disease to other indi- 
viduals; hence, isolation wards were established in the west wing of the 
hospital for the segregation of all persons showing any symptoms whatso- 
ever like those of typhoid. These suspected cases were held in isolation in 
this ward until they were either definitely proved not to have typhoid or 
proved by either clinical or laboratory findings to have the disease. 
Since the general hospital had a capacity of only 200 beds, with 100 of 
these already being used for general medical and surgical cases, it was found 
impossible to care for the large number of typhoid and suspected-typhoid 
inmate patients in this place. Therefore, two of the single-story “I”-type 
cottages were set aside as typhoid wards; namely, Clouston and McDowell, 
used for male and female patients, respectively. Since these cottages were 
not primarily planned for the care of acutely ill patients, there was no hos- 
pital equipment available. Therefore, articles which were essential for the 
care of sick patients, such as hospital beds, rubber sheets, hot-water bottles, 
rectal tubes, and enema and venoclysis apparatus, had to be supplied. Since 
typhoid patients occupied all parts of these buildings, persons other than those 
who had business in the buildings were, of necessity, excluded. 
Hospital employees who became ill with typhoid were hospitalized in 
single and double rooms located on the second floor of the general hospital 
building. These rooms were adjacent to the rooms used for the isolation 
of suspected-typhoid inmate patients; and, therefore, isolation technique was 
applied to the entire area as a unit. Unfortunately, the diet kitchen serving 
the second floor of the hospital building was located within the isolation 
area. Since general medical and surgical patients also located on the 
second floor had to be served from this kitchen, it was essential that this 
room be maintained as a clean area, and much difficulty was experienced in 
the serving of food from this kitchen to both typhoid patients and the 
general medical and surgical patients. This difficulty was overcome by 
30 several means. All persons were excluded from the kitchen except dietary 
personnel who were not allowed to enter the isolation area. The kitchen 
fortunately was provided with two entrances at opposite ends of the room. 
All foods served to the typhoid patients were served through one doorway, 
which was blocked by a serving table. The food was poured from the 
kitchen containers into separate containers wThich were kept for the use of 
the isolated patients. During the transfer of the food from one container 
to another, there was never any contact between them. Dishes from the 
isolation ward were not taken into the diet kitchen without first being 
thoroughly sterilized. The food to be served to the clean area on the second 
floor was transported on a food cart through the outer entrance of the 
kitchen to the general medical and surgical wards without coming in contact 
with the isolation section of the hospital. 
CONCURRENT DISINFECTION. A routine process of con- 
current disinfection was established for all of the isolation wards. Every 
person whose duties required his presence in an isolation unit was required to 
wear a surgical gown to protect his outer clothing. Hand-washing facilities 
were provided and available at the exit from all isolated areas. These facilities 
consisted of a double-basin washstand, the first basin containing 2 quarts of 
water, 2 teaspoonfuls of compound cresol solution, and sufficient green soap 
to provide a good lather. Any person leaving the isolation unit scrubbed 
his hands thoroughly, using a scrubbing or nail brush and cleaning thorough- 
ly under the fingernails in the solution provided in the first basin. In the 
second basin there was a rinse solution, consisting of 2 tablespoonfuls of 
compound cresol to 2 quarts of water. The hands were then dried with 
clean paper towels. Linen towels were not used, since it was considered 
important that each towel be disposed of after being used. After the hands 
were washed, the surgical gown was removed, folded inside in, and hung 
by the shoulders on a hook. This kept the inside of the gown uncontami- 
nated. In putting on the gown, the wearer slipped his hands, palms to- 
gether, between the back edges of the gown and grasped the inside; 
the gown was then removed from the hook and the hands forced through 
the sleeves and cuffs. The hands did not touch the outside of the gown 
during this procedure. Since the door handles were contaminated, paper 
towels were provided at the door for the purpose of grasping the door 
handle. These towels were then disposed of by burning. 
In order to carry out the various duties in the typhoid wards, an attempt 
was made to have a graduate nurse, with special contagious-disease training 
on duty for every shift. This nurse was responsible for the supervision of 
the nursing procedures carried out by the ward attendants. 
All articles used in the care of typhoid patients were carefully disin- 
fected after each use. Rectal tubes, colon tubes, etc., were scrubbed with 
soap and water, then soaked in a 1-200 bichloride of mercury solution for 
20 minutes, and placed in actively boiling water for 20 minutes. Enema 
apparatus was disconnected after each use and the rubber tubes and tips 
were disinfected as mentioned above for rectal tubes. The enema cans were 
disinfected through the use of strong compound cresol solution such as was 
used for the care of bedpans. Both rectal and oral thermometers were 
washed in soap and water and then passed through a 1-1000 mercuric bi- 
chloride solution or a 5% phenol solution with 70% alcohol rinse. These 
31 thermometers were required to remain in either of the above-mentioned 
solutions for 5 minutes, and were thoroughly rinsed with water before they 
were used again. 
Intravenous tubing and needles were stored in the various isolation 
wards and were sterilized after each use by boiling. 
TERMINAL DISINFECTION. All equipment which was to be 
removed from the typhoid wards for any reason received special attention. 
Beds were taken apart, moved outside the isolation unit, there thoroughly 
washed with a 10% compound cresol solution, and allowed to dry in the 
open air for several hours. Contaminated pillows and mattresses were 
rolled in clean sheets, removed from the ward on a special truck, and de- 
livered directly through an outside door into the sterilizing room in the 
basement of the Diagnostic Building, where they were sterilized with steam 
and formaldehyde. Woolen or leather articles, such as patients’ clothing, 
which would be damaged through contact with a strong chlorine solution or 
steam, or by boiling, were disinfected by being exposed to formaldehyde gas 
in a tightly closed container for at least 24 hours. Similar sterilizing pro- 
cedures were carried out by injecting atomized formaldehyde solution into a 
heated steam sterilizer, but without the use of steam in the chamber. 
QUARANTINE. In order to minimize the possibility of infection 
by contact with subclinical cases, all moving-picture shows, dances, church 
services, and gatherings of any kind where patients from the various wards 
came in contact with each other, were stopped. 
Due to the fact that hundreds of friends and relatives swarmed into the 
institution week ends and holidays, it was deemed necessary for the pro- 
tection of these people to ban all visitors from the institution. This was 
accomplished by posting guards and signs at all entrances to the grounds. 
No more committed or voluntary patients were admitted to this institution 
during the epidemic. Also, the importation of all food from the outside by 
individuals was stopped, other than that in the original containers in which 
it was merchandised. 
FOOD HANDLING. Since one of the principal means of trans- 
mission of typhoid fever is contaminated food, one of the very first control 
measures adopted by the Department of Public Health in combating this 
epidemic was the effort to obtain at least two postcathartic specimens of 
feces and urine from each food handler in the institution, to be examined 
for the presence of typhoid or paratyphoid organisms. When any of these 
specimens was found to be positive, the person submitting that specimen was 
promptly removed from any food-handling capacity. 
Special precautions were taken in the handling of food for the two 
typhoid wards and the hospital by having one truck deliver the food to these 
three points. Instructions were given that the truck personnel were not to 
enter the typhoid-isolation-ward kitchen nor to take central-kitchen food 
cans into that room. All food was transferred outside the kitchen door 
from the central-kitchen containers on the truck directly into the ward- 
kitchen containers without their contacting each other. The food containers 
on the truck were then taken to the basement of the central kitchen, where 
they were washed and subjected to live steam for a period of 2 minutes 
before being returned to the central kitchen proper. 
32 As an additional precaution, an attempt was made to maintain the kitchens 
at the isolation wards and the hospital as clean areas. In other words, no 
food containers or materials were allowed to enter the isolation kitchen until 
they had been thoroughly and completely sterilized by chlorine solution. 
Aluminum plates, cups, and other utensils that were used by the typhoid 
patients for eating were cleaned, and then soaked in a chlorine solution 
500 parts per million for 30 minutes before they were taken to the kitchen 
and put through a dishwashing machine which had live steam available for 
sterilization. Milk bottles, pop bottles, and similar containers were kept 
in the typhoid isolation ward and stored in a wooden barrel until the barrel 
was filled. The bottles were placed neck up, and when the barrel became 
full a chlorine solution having 100 parts per million of available chlorine 
was applied; the bottles were left overnight in this solution before they were 
removed from the building. 
Employees in the isolation-ward kitchen, before entering the ward 
or dining room thereof, put on surgical gowns; and, upon returning to 
the kitchen, they were required to remove the gown and thoroughly and 
completely wash their hands with green soap and a compound cresol solu- 
tion. Inmate workers in the isolation-unit kitchen and dining room were 
isolated the same as the workers on the feces-collection detail and were given 
the same treatment as far as clothing, bathing, etc., were concerned. 
Rubbish from the isolation ward, such as papers, paper towels, and 
other combustible material, was burned at the ward, and special precautions 
were taken to see that none of this material was left in the improvised in- 
cinerator at the ward; tin cans were charred before they were removed to 
the rubbish dump. 
FECAL AND WASTE DISPOSAL. No sewage, wash water, bath 
water, or any other waste was allowed to enter the institutional sewer from 
the typhoid-isolation units because of the leakage from the sanitary sewer 
into the creviced limestone and the inadequacy of treatment facilities avail- 
able at the institution sewage works. All body wastes from the typhoid 
patients were collected in bedpans, urinals, or commodes; and, after being 
emptied into the fecal cans located in the utility room, these containers were 
scrubbed with, and placed in, a solution having approximately 500 parts 
per million of free chlorine. After remaining in this solution for a period 
of 30 minutes, the bedpans, urinals, commodes, and bed chambers were 
rinsed and then hung on pegs and allowed to dry. This practice caused 
marked irritation of the skin over the buttocks, thighs, and back; and in 
many instances this irritation, with the combined effect of pressure, resulted 
in decubitus. Upon examination of the bedpans it was found that, regard- 
less of the extent of rinsing, there was a remaining film of lime deposited 
on the rims of the bedpans. To eliminate this difficulty, green soap and 
2% compound cresol were substituted for the chlorine. The solution used 
for this cleansing and sterilizing was composed of one gallon of compound 
cresol, U.S.P., to 50 gallons of water. To this were added 2 cupfuls of 
green soap or a similar quantity of soap chips. 
Whenever this sterilizing solution or the subsequent rinsing solution be- 
came dirty or contained a visible amount of fecal matter these solutions 
were changed, the dirty solution being disposed of in the same manner as 
33 feces, urine, garbage, etc. The substitution of the cresol solution for the 
chlorine solution in the concurrent disinfection of the bedpans, urinals, and 
commodes, resulted in a marked decrease in the decubital ulcers. 
All fecal matter, urine, bath water, uneaten food, and other wastes 
coming from the typhoid patients were collected in 25-gallon galvanized 
iron cans in which 2 cupfuls of chlorinated lime, having 30% available 
chlorine, had been sprinkled on the bottoms of the cans before receiving any 
wastes, and it was a standing order that whenever the lid of a fecal can was 
removed there should always be a strong chlorine odor. This meant that 
several cupfuls of chlorinated lime had to be added to the can before it 
was finally filled. Fecal cans were never filled more than about two-thirds 
full so that they could be easily handled without spilling the material in the 
process of transportation to the fecal-disposal field. 
After treatment with chlorinated lime in the isolation ward and the 
hospital, the fecal cans were removed to a fecal-disposal field where the 
material from the cans was placed in 90-gallon caldrons and was then 
boiled until a thick paste residue was left in the caldron. This material 
was removed from the caldron, thrown directly onto the fire, and burned— 
thereby eliminating any possibility of transmitting typhoid fever from this 
waste material. Fecal cans were cleaned with a strong solution of chlorin- 
ated lime, having 1,000 parts per million of available chlorine. All of the 
fecal material was transported on one truck, used for no other purpose, and 
at the end of the day this truck was washed down with a 10% compound 
cresol solution. Hospital employees were not available for performing 
duties in gathering wastes from the typhoid wards and it was necessary to 
use patient labor; these patients were isolated in the same manner as typhoid 
cases, in a separate building, and they were not allowed to mingle with other 
patients of the institution. Also, the clothing worn by this detail was 
treated in the same manner as soiled linen from the typhoid wards. These 
patients were all bathed and given a change of clean clothing twice a day; 
namely, at noon when they came in to eat, and in the evening before dinner. 
At the fecal-disposal field proper, the work, again, was .done by inmate 
labor under the supervision of an attendant and the same procedure was 
followed with these inmate workers as had been outlined above for the 
fecal detail. 
The efficiency of the measures adopted for the handling of this highly 
infectious material was clearly demonstrated in that at no time during and 
subsequent to the epidemic did any of the inmates or employees working on 
the detail mentioned above develop typhoid fever; however, all had received 
typhoid vaccine. Hand-washing facilities were provided at all points where 
the detail handled fecal cans, and they were compelled to wash their hands 
thoroughly in a compound cresol solution, using green soap, after handling 
the cans. Paper towels were used for drying hands and were disposed of 
by burning. 
LINEN AND LAUNDRY HANDLING. To prevent the exposure 
of soiled laundry to flies, roaches, and other insects, rolling hampers were 
provided so that linens removed from the patients’ beds were placed directly 
in the hampers and not allowed to be left on the floor. The hampers of 
linen were taken to the bathroom, where galvanized iron cans of approxi- 
mately 25-gallon capacity were used for receiving the soiled linen. These 
34 cans were of a different design from those mentioned above for the disposal 
of fecal matter, urine, and other body wastes so that they would not be 
confused with the latter cans. In the 25-gallon cans a chlorine solution 
was provided which had approximately 100 parts per million of free chlo- 
rine; and the linen, after being placed in the can, was submerged and allowed 
to set for a period of 4 hours before it was transferred from the typhoid 
ward to the laundry. During the early part of the epidemic, chlorinated 
lime was placed directly in each can and water added, but it was found that 
this procedure resulted in the disintegration of a large quantity of linen. 
To eliminate this difficulty, a stock solution of chlorinated lime was mixed 
in a 55-gallon barrel so that the solution had 1,000 parts per million of 
available chlorine. The supernatant liquid from this stock chlorine-solution 
barrel was placed in the galvanized iron cans and diluted to approximately 
100 parts per millon. However, during the early part of the epidemic, 
a much stronger chlorine solution was used for the linens, due to the fact 
that the majority of the linens were badly soiled. This resulted in the 
disintegration of a considerable amount of linen. However, it was felt 
that this procedure was justifiable. Checks were made by engineers from 
time to time to ascertion the residual chlorine in the linen cans after a 
4-hour storage period, and the chlorine dosage was reduced in accordance 
with the findings of these check results. 
The linen from the isolation wards was transported to the laundry by 
the laundry detail, one truck being assigned to this duty and used for no 
other purpose. Upon arrival at the laundry, where one washing machine 
was set aside for the washing of linens from all typhoid wards, the galva- 
nized iron cans were removed and their contents discharged directly into the 
washing machine by the laundry detail; the cans were brought out imme- 
diately and placed on the laundry-detail truck without sitting around the 
laundry. All laundry from the typhoid wards was returned to those wards 
after being cleaned. 
The laundry detail was segregated from the rest of the inmates of the 
institution in the same manner as the other patient-help working in con- 
nection with the typhoid wards, and at the close of each day the laundry 
truck was washed down with a 10% compound cresol solution. 
Any colored materials, woolens, or leather goods which would be dam- 
aged by the chorine solution were disinfected by placing them in galvanized 
iron cans with tight-fitting lids. In the bottom of each of these cans 
was placed one ounce of 40% formaldehyde. The articles to be disinfected 
were allowed to remain in the cans in the formaldehyde fumes for 24 hours, 
after which they were removed and placed in clean pillowcases and taken 
from the ward without contacting any contaminated surface. 
INSECT AND RODENT CONTROL. All known fly-breeding 
places were eliminated: (1) by having fly-breeding material removed, 
if possible; (2) by spreading chlorinated lime over the area where the 
objectionable conditions had existed. In the case of the screenings pit near 
the sewage-treatment plant, two loads of straw were deposited on the 
screenings and the maggots killed by burning the straw, then approximately 
8 inches of earth were placed over this material so that there was no or- 
ganic material exposed. 
35 Very little attention had been paid to the elimination of flies in the 
various buildings by spraying or by proper screening, and it was necessary 
to see that all screens, especially those in the typhoid wards and the kitchens 
of the institution were placed in first-class condition. In addition, nightly 
spraying with a good insecticide and the placing of fly strips in all buildings 
of the institution were resorted to with excellent results. 
For some time after killing frosts had occurred at the institution there 
was still need for fly control in the various ward buildings and the kitchens. 
Fly strips were maintained in the wards and kitchens at all , times. 
Large blast fans were purchased and placed in the typhoid isolation 
wards and in the central kitchen so that the blast struck the outside door, 
which assisted in preventing the entrance of flies. 
A contract was made with a commercial exterminating company, and, 
by means of an intensive program, the cockroach nuisance wes eliminated. 
The rodent population at the institution was materially reduced through 
the education of employees, the provision of new garbage cans with tight- 
fittng lids, and the elimination of garbage and sewage-screenings dumps. 
CHLORINATION AND CONTROL OF WATER. A pulso- 
meter-type chlorinator was installed at the institution on Saturday, August 
19. This chlorinator introduced chlorine into the water just ahead of the 
high-service pumps on the suction line from the reservoir. 
Samples of water, collected from the kitchen of the institution, showed 
that the water was still contaminated due to the lack of a sufficient chlorine- 
contact period; and it was necessary to install additional chlorinators so that 
the water would have a retention period sufficient for killing the organisms 
present. Until additional chlorinators were installed, batch chlorination 
of the collecting reservoir was resorted to by using calcium hypochlorite; 
and all samples collected after August 25, when this type of chlorination 
was resorted to, showed that the water was free from coliform organisms 
as it was sent to the distribution system. On August 26, two additional 
chlorinators were installed (one on the discharge of Well No. 4, and the 
other on the discharge of Well No. 1). An exceedingly heavy dose was 
added in both places to compensate for the dilution caused by the water 
coming to the reservoir from Wells No. 2 and No. 3, which wells were 
not provided with individual chlorinators. 
A chlorine-demand determination was made on the water from Well 
No. 4, and found to be 0.936 part per million. 
‘ Residual chlorine determinations were made at hourly intervals at the 
power house. Samples were collected and residual chlorine determinations 
were made daily from fourteen points on the distribution system. The 
residual chlorine was kept between .75 and 1.0 part per million on the 
distribution^system until the danger of amoebic dysentery was recognized. 
(See Chapter VI.) 
It was found that many attendants and employees of the institution 
were bringing water to the grounds in containers from outside sources. 
This practice was ordered stopped because of the possibility of bringing 
in contaminated water and giving it to the patients. 
36 IMMUNIZATION. One of the first recommendations given to the 
authorities at Manteno State Hospital, in order to control the typhoid 
epidemic, was that typhoid immunization should be instituted at once. This 
procedure was most important, inasmuch as no general typhoid-vaccination 
program had ever been instituted at the hospital and practically the entire 
hospital population could be considered susceptible to the disease. Therefore, 
on or about August 23, a program was instituted whereby the patients in the 
various wards and all employees started receiving typhoid vaccination. 
These vaccinations were given by injecting one-half, one, and one ml. portions 
of typhoid vaccine at 5-day intervals. By Septmber 5, practically every 
individual in Manteno State Hospital had received 3 doses of typhoid 
vaccine. Triple vaccine was not used, since it was recognized that this 
particular preparation caused more severe reactions; and, in this epidemic, 
paratyphoid did not seem to be of any importance, as was shown by bac- 
teriological procedures. 
SPECIMEN COLLECTION. In order to maintain bacteriological 
control over this epidemic, specimens of blood for cultures were taken 
from all patients having any symptoms suspiciously like those of ty- 
phoid. In certain cases a Widal agglutination test was also made on these 
blood specimens. The results of this latter test, of course, were not accepted 
as conclusive in proving that a patient did or did not have typhoid fever. 
Some of these individuals had received typhoid vaccine, which produced 
positive results even in the absence of the disease, whereas others who were 
in their first week of illness showed a negative agglutination test but were 
definitely proved later to have the disease. Two feces and urine specimens 
were collected from every person, inmate or employee, in the institution. 
An effort was made to obtain 3 specimens as soon as possible from every 
person employed as a food handler. 
37 CHAPTER VI 
AMOEBIASIS-GONTROL METHODS 
On October 13, there was a case of amoebic dysentery reported in the 
hospital. This case had been proved by a microscopic stool examination. 
The patient was immediately isolated, and all precautions taken to keep the 
body wastes from entering the sewer system. However, there was fairly 
definite evidence of leakage from the sewers into the water supply, which 
was protected only by chlorination. Recognized water works authorities 
indicated that Endamoeha histolytica cysts were killed only by exceedingly 
high dosages of chlorine. Therefore, it was felt that in order to eliminate 
any possibility of an outbreak of amoebic dysentery, drinking water from 
an outside source should be brought into the institution. 
This first patient having amoebic dysentery died on October 16. At a 
post-mortem held on October 17, the pathologist stated that in his opinion 
the individual had contracted the disease not more than 4 to 6 weeks pre- 
vious; and, therefore, since the patient had been in the institution for years, 
it was certain that he had contracted the disease there. 
On October 20, another case of amoebic dysentery was found and the 
patient isolated. - As a result of these two cases all additional persons de- 
veloping diarrhea were isolated in their respective wards for a period of 
48 hours in order to ascertain whether or not the disease would subside 
spontaneously, and also to allow time for miscroscopic stool examinations 
to be made for amoebiasis. 
On October 22, the first water was hauled into the institution from the 
Kankakee public water supply by a truck loaned to the Department of Pub- 
lic Welfare by a large Chicago dairy. In addition to this truck, this dairy 
and one other loaned the institution several hundred milk cans for the 
distribution of water to all wards of the institution. 
Consideration was also given to bringing water in by other methods, 
such as railroad tank cars, and transporting it directly in 10-gallon milk 
cans. A study was also' made of the possibility of filtering the water 
through existing pressure filters used for boiler-feed water; also of raising 
the temperature of all drinking water above the thermal death point of 
Endamoeba histolytica and then cooling with the institutional refrigeration 
equipment. The method of transportation by truck was finally adopted 
because it was the most ecbnomical, sanitary, and flexible. 
Drinking water was dispensed in all buildings by means of 110 wood 
barrels, which had been paraffined inside and were equipped with brass 
faucets. Wood paper-cup dispensers .were built on the sides of the racks 
supporting the barrels, since glass cup dispensers could not be used because 
of the type of patients at the institution. These dispensers were constructed 
by the institution carpenters. 
The Kankakee water supply was taken from the Kankakee River, and 
treated by means of coagulation, sedimentation, filtration, and chlorination. 
The finished water supply-had a residual chlorine of approximately 0.2 part 
38 per million. As an additional precaution each tank truck load of water 
was chlorinated during filling so that there was a residual chlorine of 1 to 
1.5 parts per million in the water when it arrived at the institution. The 
chlorine residual was checked and a sample of water for bacteriological 
analysis was collected from each truck load of water. 
A system of distribution was arranged whereby the 10-gallon milk cans, 
which had been previously placed in the wards, were filled daily directly 
from the tank truck. 
An ample water supply was maintained by having several 10-gallon 
cans full of water in reserve at all wards. A detail of institution employees 
and patients was responsible for filling all of the barrels daily. In order 
to take care of fluctuations in water consumption, a reserve supply was main- 
tained at a central location and was availble upon call, at any time. 
The first day the barrels were used for dispensing water, samples were 
collected from all of the barrels for the purpose of bacteriological analyses. 
The results of these analyses, which were made in the Springfield laboratory 
of the Department of Public Health, revealed that the water in many of 
the barrels was grossly contaminated. Upon investigation, it was found 
that patients were inserting clothing and other material into the water 
through the 2-inch bung provided in the top of the barrels for the purpose 
of filling. As a result it was necessary to protect the water supply by 
placing hasps and locks on the bungs of all barrels. 
In addition, two Department of Public Health engineers collected 
samples from barrels at various locations, and a routine was worked out so 
that each barrel was sampled at least once a week. Residual-chlorine deter- 
minations were made of the water in all of the barrels daily, and each 
engineer was given instructions that whenever a barrel was found which 
had no residual a sample for bacteriological examination was to be collected, 
regardless of when the last sample had been taken. Engineers were also 
instructed to add more chlorine, from the stock .solution which they carried, 
to such barrels in order to raise the residual to at least one part per million. 
Wherever a ward attendant complained of odor or taste in the water, 
that barrel was immediately removed and replaced by another barrel. 
This same practice was followed when any single barrel was responsible 
for more than one contaminated sample of water. A practice was also 
established for the routine cleaning, washing, and disinfection of all barrels. 
A concentrated solution, having at least 1,000 parts per million available 
chlorine, was used for disinfecting the barrels. 
In the beginning it was felt that it would be necessary to supply ap- 
proximately 15,000 gallons of water per day for drinking purposes. This 
figure was grossly in error, and it was found that it was necessary to trans- 
port only 2,100 gallons per day to supply the necessary demand. 
The original institution water supply was- maintained for sanitary pur- 
poses and fire protection; however, all drinking fountains throughout the 
institution were shut off and precautions were taken to see . that drinking 
cups were not provided at any of the distribution-system taps. In addition, 
the chlorine dosage was increased to approximately 5 parts per million to 
discourage the drinking of this water. 
39 The amoebiasis cases and suspects were isolated in a separate section 
of the hospital. Special provisions for carrying out isolation technique for 
these patients were provided and were similar in nature to those used for 
the typhoid patients, with the exception that 10% cresol solution was used 
in place of chlorine for disinfecting body wastes, utensils, etc. 
Because of continued suspicion that amoebiasis was epidemic in the 
institution, a parasitologist from the Division of Laboratories made a Survey 
of 175 specimens during the period of November 17*10 21, inclusive. Many 
different parasites were found, including E. coli in 51 specimens, but E. 
histolytica were demonstrated in only 2. Although only 2 individuals with 
E. histolytica in their stools were found, there existed the possibility that 
other carriers were present in the institution; consequently, the precautions 
already in effect were continued until emergency coagulation and filtration 
equipment could be installed on the institution water supply. This equip- 
ment was placed in operation on March 1, 1940. 
The emergency purification equipment consisted of a battery of 8 pressure 
filters, each 96 inches in diameter. They were inserted in the discharge line 
from the high-service pumps. Alum and acid-treated sodium silicate were 
used to effect coagulation, these chemicals being applied into the pump 
suction line, the agitation in passing through the pumps effecting quick 
mixing. There was a theoretical retention period of approximately 8 
minutes in the high-service pump piping and in the filter space above the 
sand, from the time the water was dosed with coagulant until it passed into 
the filter sand. Laboratory jar tests, conducted while the emergency plant 
was being designed, showed that none of the common coagulants or any 
of their combinations would produce a satisfactory floe; however, alum used 
with acid-treated sodium silicate did produce small-sized floe particles, and 
facilities for this chemical treatment scheme were adopted. 
Because it was evident that some of the wells were periodically re- 
ceiving gross pollution, the institution officials decided to build a 10-mile pipe 
line connecting with the Kankakee public water supply. This 16-inch pipe 
line, some of it requiring rock excavation, cost approximately $240,000, 
The emergency filtration plant, however, remained in operation approxi- 
mately two and one-half years until the pipe line was completed. 
40 TYPHOID FEVER 
Manteno State Hospital 
Number Of Cases Occurring Daily Showing Inmates, Employees And Other Cases 
1939 
Inmata Typhoid Casas 
Hospital Employe® Typhoid Fever Casas 
Typhoid Ftvar Cases Occuhrinq Oytsid® 
Mantano State Hospital But Traceable To It 
Typhoid Cases 
July 
August 
Septemsea 
OCToftt® 
D&cEmber, 
FIG. 5 
OES OME.MD. 
S ZI-40 
4*t CHAPTER VII 
EPIDEMIOLOGY 
As complete an epidemiological history as possible was taken of every 
case which was definitely diagnosed either by clinical or laboratory data as 
typhoid fever. This was true for cases occurring outside the institution 
but traceable to it, as well as for those occuring on the institution grounds. 
The data were collected by either a trained epidemiologist or by one of the 
special investigators who had had much epidemiological experience. Much 
difficulty was encountered in collecting these data from inmates of the 
institution; because of their psychotic condition, they were frequently un- 
able to give rational answers to the questions asked. It became necessary, 
therefore, to supplement these histories as far as possible with information 
which could be gleaned from the official institution records. 
ONSET OF EPIDEMIC. The records of the Illinois Department 
of Public Health show that only 5 cases of typhoid fever had been reported 
from Manteno State Hospital from the time it opened in 1930 until July, 
1939. Of these 5 cases, 4 occurred during the Fall and early Winter of 
1936, and the other in February, 1937. The spacing of these cases indi- 
cated the probable source and means of transmission of the causative or- 
ganisms to be direct contact with either another case or a carrier. 
As has been stated before, the next case of typhoid fever was reported to 
the Department of Public Health on July 19, 1939, the onset having been 
on July 8, and the patient having died on July 15. Thereafter, beginning 
on July 31, 1939, additional cases developed almost every day for the next 
two and one-half months among persons at, or who had been in, Manteno 
State Hospital, the last case occurring in a laboratory worker on December 
10, 1939. In all, there occurred in this epidemic 453 cases of typhoid fever 
which could be traced directly to the institution. The distribution of the 
dates of onset of these cases is shown in Fig. 5. Some of the difficulties 
encountered in trying to place dates of onset accurately have been discussed 
in Chapter II. 
Since much of the data concerning the onset of the disease in inmates 
was obviously untrustworthy, Fig. 6 was prepared in order to determine 
as accurately as possible the suddenness of onset of the epidemic proper. 
In this graph are shown data for only those typhoid fever cases occurring in 
persons other than inmates. This graph indicates that the peak of the 
epidemic was reached on August 15. Considering that the incubation 
period of typhoid ranges from 3 to 40 days and that the onset is usually 
insidious, one may consider the initial rise of this epidemic curve as being 
relatively acute. It is interesting to note further in this graph the fact 
that the curve subsides almost to the base line approximately one month 
following the installation of double chlorination of the drinking water. 
Further examination of this fact tends to indicate that the infecting dose of 
E. typhosa was either tremendous or the organisms were extremely virulent, 
for it will be noted that 7 out of the 10 deaths represented occurred in 
persons who became ill prior to the peak of the epidemic. 
41 Reported Order 
of Occurrence 
Onset and 
Initials 
Age 
Sex 
Occupation 
Residence 
Remarks 
1 
7-8 J.O. 
31 
M 
Quine 2 
2 
7-31 H.B. 
24 
M 
Constr 
Kankakee 
3 
8-1 J.B. 
26 
M 
Hosp. Emp 
Worked on Billings 2 
4 
8-1 E.L.A. 
37 
M 
Constr 
Kankakee 
5 
8-1 E.R. 
40 
M 
Constr 
Joliet 
6 
8-3 W.G. 
13 
M 
Son of Hosp. Emp. 
7 
8-3 F.N. 
30 
F 
P. 0. Clerk 
8 
8-3 C.McD. 
21 
M 
Constr 
Palestine 
9 
8-4 O.S. 
27 
F 
Hosp. Emp 
10 
8-5 W.H. 
41 
M 
Hosp. Emp 
11. 
8-5 H.R. 
27 
M 
Hosp. Emp 
Worked on Rush 2 
12... 
8-5 E.S. 
38 
M 
Hosp. Emp 
Worked on Male Rec. 
13 
8-8 R.R. 
34 
F 
Hosp. Emp 
Worked on Female Hy. 
14 
8-8 G.S. 
20 
M 
Constr 
Arlington Hts. 
15 
8-8 W.C. 
30 
M 
Hosp. Emp 
Worked on Kilbourne 
16 
8-8 R.B. 
28 
M 
Inmate 
Quine 2 
17. .. 
8-9 L.S. 
38 
M 
Hosp. Emp 
Pana 
Worked on Quine 2 
18 
8-10 H.C. 
35 
F 
Hosp. Emp 
Worked in Morgan D.R. 
19 
8-10 M.H. 
50 
F 
Hosp. Emp 
Worked on James 2 
20 
8-10 H.K. 
50 
F 
Hosp. Emp 
Worked in Williams D.R. 
21 
8-10 AJ. 
36 
F 
Inmate 
Diag. Int. Th. 
22. 
8-10 M.L. 
27 
F 
Inmate 
Dix 
23 
8-10 A.M. 
70 
F 
Inmate 
Hospital 2 
TABLE VII 
MANTENO STATE HOSPITAL 
Typhoid Epidemic 
First Cases in Order of Occurrence 
42 24 
8-10 
H.R. 
53 
M 
Hosp. Emp 
Sewage Plant Operator 
In M.S.H. Only 3 Davs and Onlv Drank 
25 
8-10 
F.W. 
28 
M 
Dynamiter 
Ottawa 
26 
8-11 
E.M. 
47 
F 
Inmate 
Diag. Int. Th. 
Diag. Int. Th. 
Visitor. 
Water—Ate No Food 
27 
8-11 
A.H. 
62 
F 
Inmate 
Prior to 7-29 Had Been in Adler 1 
28 
29 
8-11 
8-11 
N.H. 
A.W. 
21 
8 
F 
M 
Hosp. Emp. 
Student 
30 
8-12 
c.c. 
45 
F 
Hosp. Emp. 
Worked on Hannah 
31 
8-12 
p.s. 
26 
M 
Hosp. Emp. 
Worked on Diag. Int. Th. 
32 
8-12 
G.S. 
30 
M 
Truck Dr 
Streator 
Made Daily Trips to M.S.H. but Drank Onh 
Water There 
Worked in M.S.H. from 7-24 
3T 
8-12 
W.M. 
M 
Constr 
Chicago (?) 
34 
8-12 
G.Y. 
30 
M 
Truck Dr 
Streator 
Made Daily Trips to M.S.H. 
35 
8-13 
K.B. 
25 
F 
Hosp. Emp. 
Drank Water. 
Worked in Officers’ D.R. 
36 
8-13 
R.P. 
28 
M 
Hosp. Emp. 
Worked on Diag. Male Int. Th. 
37 
38 
8-13 
8-13 
H.G. 
L.K. 
25 
40 
M 
M 
Hosp. Emp. 
Hosp. Emp 
Worked on Quine 2 
39 
8-14 
B.L. 
42 
F 
Hosp. Emp 
Worked on Hosp. 2 
40 
8-14 
J.B. 
J.D. 
L.P. 
E.B. 
32 
M 
Hosp. Emp 
Drove Food Truck 
41 
8-14 
28 
M 
Constr 
Worked Constr. Emp. Bldg. All July and Aug, 
42 
43 
8-14 
8-14 
37 
62 
M 
F 
Constr. 
Inmate 
Mitchell 2 
44 
8-14 
M.U. 
39 
F 
Inmate 
Diag. Int. Th. 
45 
8-14 
M.P. 
68 
F 
Inmate 
Kraeplin 2 
46 
8-14 
C.P. 
39 
F 
Inmate 
Adler 2 
47 
8-14 
D.R. 
68 
F 
Inmate 
Diag. Female Rec. 
48 
8-14 
H.B. 
38 
M 
Inmate 
Meyer 2 
49 
8-14 
T.R. 
25 
M 
Constr 
Kankakee 
50 
8-14 
E.H. 
35 
M 
Constr 
Bradley 
51 
8-14 
F.F. 
18 
M 
Constr 
Joliet 
Lovington 
52 
8-14 
S.S. 
49 
F 
Visitor 
Visited M.S.H. July 20. Ate Ice Cream and 
Drank Water 
43 Manteno State Hospital 
Dates Of OnsetOfT/phoio Fever Occurinc Its 
Hospital Employees, Construction Mem And“ 
Others, Excepting. Inmates 
1939 
Hospital. Employees 58 
Construction Men 28 
Others, «.9. Visitors 
6 
TotauCon»ioebld 92 
Not- Shown 
2. Hospital Emp. Becoming III. 
In OCTOBCBi DECEM0£ft 
2CoNftT.MrN-OfitET Cu-nc UnWhown 
FIG. 6 
Table VII lists chronologically those typhoid cases which occurred prior 
to the assumed peak of the epidemic on August 15. Here it will be noted 
that among these first 52 cases, there were 22 hospital employees, 14 con- 
struction workers, 13 inmates, 2 visitors, and a son of an attendant. Of 
the 14 construction workers, there were none who lived on the institution 
grounds; and furthermore, investigation of these cases disclosed that many 
had eaten no food nor come in contact with any patients in the institution. 
Two of these persons made daily trips driving a brick-truck, between 
Streator and Manteno State Hospital. These men both stated that they 
had never eaten any food at the institution, but since the weather was 
particularly warm and dry, they drank large quantities of water during 
their brief stays at the institution. Another of these men, from Ottawa, 
Illinois, was in the institution only on 3 separate days and drank water 
while there. The exact dates of this man’s visits could not be obtained; 
but it is known, however, that they were during the latter part of July or 
approximately 3 weeks prior to the onset of his illness. There was no other 
known exposure to typhoid fever in this case. 
One of the two visitors was in Manteno State Hospital only on July 
20, 1939, and she stated that while there she ate ice cream at the institution 
commissary and also consumed water from the institution supply. She was 
unable to recall having partaken any other food or drink during her visit. 
There were no other cases of typhoid fever in her home town during the 
summer of 1939. 
Of the first 52 cases, there were 4 employees who handled food. These 
people worked respectively in Morgan Dining Room, Williams Dining 
44 Time. Spent At Manteno State Hospital By 
Vkeious Constbuction Men Who Developed Typhoid Feive.12. 
CON»TOUCTION 
Com panics 
(Each Hobizontal 
Lim«; Rcppcsshts 
Time SptnrAi 
Hanuno State 
Hospital By One. 
Man ) 
FIG. 7 
Room, the Officers’ Dining Room, and on a food truck. On August 15 
and 16, two of the cooks in the central kitchen were reported as having 
typhoid fever. Since it has been adequately shown by previous investiga- 
tions that persons in the incubationary stage of typhoid fever are infectious, 
these latter individuals may have been responsible for some of the cases 
occurring later in August or early September. 
That secondary cases occurred among contacts with the first cases is 
undoubted, inasmuch as some of the early inmate cases came from extremely 
untidy wards where there existed unlimited possibilities for patients to come 
in contact with the body discharges of their fellow patients. 
PERIOD OF INFECTION. If the probable incubation period of 
typhoid fever is taken as 10 to 40 days, then, counting backward this num- 
ber of days from the assumed peak of the epidemic on August 15, we find 
that the probable period of infection would be between July 5 and August 5. 
The records of the various construction companies pertaining to those 
workmen who developed typhoid fever were examined to determine as 
closely as possible the period of employment of these men at Manteno State 
Hospital. The results of this investigation are shown graphically in Fig. 7, 
where it will be noted that most of the construction workers who developed 
typhoid fever were working at the hospital during the computed probable 
period of infection; namely, between July 5 and August 5. 
INCIDENCE. Due to the fact that persons of all classifications work- 
ing in different parts of the institution grounds developed typhoid fever, it 
appeared that there was some common factor operable universally through- 
45 PERCENT OF 1939 INMATE POPULATION ADMITTED 
TO MANTENO STATE HOSPITAL IN A GIVEN YEAR. 
COMPARED WITH PERCENT OF 1939 IMIMATE 
TYPHOID CASES OCCURRING AMONG INMATES IN THE SAME GIVEN YEAR 
YEAR OF ADMISSION 
PERCENT OF \9B9 INNATE POPULATION ADMITTED 
IN A GIVEN YEAR. 
PERCENT OF 1939 INMATE TYPHO\0 CASES OCCURRING 
AMONG INMATES ADMITTED IN A GIVEN YEAR. 
FIG. 8 
CES- CMC \»AO-C.W*94-ET 
out the institution which served as a means of transmission for the typhoid 
infection. Therefore, in searching for an explanation of the additional 
fact that relatively few persons developed typhoid fever in comparison to 
the large number who may have been exposed to infection, the incidence 
was computed for inmates according to the year of admission to the institu- 
tion. This study is shown in Table VIII and Fig. 8, from which it is 
46 TABLE VIII 
Composition of 1939 Inmate Population Showing Year of 
Admission in Relation to Incidence of Typhoid Fever 
Year 
of 
Admission 
No. 
of 
Inmates 
% of 1939 
Inmate 
Population 
Inmate 
Typhoid 
Cases 
% of Inmate 
Typhoid 
Cases 
1930 
66 
1.38 
4 
1.12 
1931 
528 
11.07 
22 
6.16 
1932 
123 
2.58 
6 
1.68 
1933 
159 
3.33 
7 
1.96 
1934 
50 
1.05 
2 
.56 
1935 
1,040 
21.80 
46 
12.89 
1936 
275 
5.76 
8 
2.24 
1937 
667 
13.98 
50 
14.01 
1938 
1,366 
28.63 
121 
33.89 
1939 
497 
10.42 
91 
25.49 
I Total 
4,771 
100.00 
357 
100.00 
apparent that typhoid fever struck most heavily among those who had en- 
tered the hospital in the 2 years preceding the epidemic. Application of 
the Chi-square test of probability to these data, as shown in Table IX, 
indicates that the difference in attack rates was highly significant and would 
not have occurred as often as once in a Hundred times due to pure chance 
alone. Therefore, it appears that, in the absence of typhoid vaccination, 
some common factor may have been in operation over a period of years in 
transmitting small doses of typhoid organisms throughout Manteno State 
Hospital and thereby increasing the immunity of those who had resided 
there for more than 2 years. 
Geographically, the incidence of typhoid cases among inmates of the 
various cottages varied widely from 21.5 to 1.2 per hundred inmates. The 
specific rates for inmates residing in each of the cottages is shown in Table 
X. It is noteworthy that all of the wards with the highest incidence; 
namely, Dix, Diagnostic Female and Male, Williams, Kraepelin, Myer, 
Wines, and White, were those to which newly admitted inmates were 
routinely sent. Therefore, in the light of the preceding study, the high 
incidence in these particular cottages can be explained by the fact that the 
population of these cottages, for the most part, represented those inmates 
who had resided in Manteno State Hospital for the shortest time and had 
little opportunity to acquire herd immunity to typhoid. 
The incidence by place of residence for other than inmates could not be 
determined since the population of the various employees’ dormitories was 
constantly changing and many of the persons in this classification lived off 
the institution grounds. 
47 Adm. 
Year 
(Oi) 
Typhoid 
Cases 
(02) 
No. 
Typhoid 
Total Pop. 
1939 
(Ti) 
(T2) 
Oi-Ti 
02—Ta 
(Oi-Ti)2 
(02-T2)2 
(Oi-Ti)2 
Ti 
(Oi-Ti)2 
Ti 
1930 
4 
62 
66 
4.02 
69.91- 
0.92 
1.09 
.8464 
1.1664 
.172 
.019 
1931 
22 
506 
528 
39.52 
488.63- 
17.52 
17.37 
306.9504 
301.7169 
7.767 
.016 
1932 
6 
117 
123 
9.21 
113.88 — 
3.21 
3.12 
10.3041 
9,7344 
1.119 
.085 
1933X 
7 
152 
159 
11.89 
146.98- 
4.89 
5.02 
23.9121 
25.2004 
2.011 
.171 
1934 
2 
48 
50 
3.75 
46.35- 
1.75 
1.65 
3.0625 
2.7225 
.817 
.059 
1935 
46 
994 
1,040 
77.83 
962.25- 
31.83 
31.75 
1,013.1489 
1,008.0625 
13.017 
1.048 
1936. 
8 
267 
275 
20.56 
254,25- 
12.56 
12.75 
157.7536 
162.5625 
7.673 
.620 
1937 
50 
617 
667 
49.91 
617.08 
0.09- 
0.08 
.0081 
.0064 
.000 
.000 
1938 
121 
1,245 
1,366 
102.21 
1,263.73 
18.79- 
18.73 
353.0641 
350.8129 
3.454 
.278 
1939 
91 
406 
497 
37.20 
459.94 
53.80- 
53.94 
2,894.4400 
2,909.5236 
77.808 
6.326 
Total 
357 
4,414 
4,771 
357.00 
4,414.00 
0.00 
0.00 
113.838 
8.622 
TABLE IX 
Chi-square Test of Significance of Observed Relation Between 
Inmate Typhoid Incidence and Year of Admission to Institution 
o 
VO 
eg 
CNJ 
N 
eg 
eg 
VO 
CO 
+ 
00 
oo 
N 
X 
48 TABLE X 
Incidence of Typhoid Cases by Wards 
Cottage 
Typhoid 
Incidence 
Per 100 
Cottage 
Typhoid 
Incidence 
Per 100 
Dix 
21.5 
Dunne 
5.6 
Diagnostic Female 
18.1 
Todd 
5.4 
Williams 
15.5 
Willis 
5.4 
Kraepelin 
15.0 
Pinel 
4.2 
Meyer 
10.2 
T. B. Sanatorium 
4.0 
Wines 
10.2 
Billings 
3.7 
White 
9.6 
Hunter 
3.7 
Diagnostic Male 
9.5 
Industrial 
3.6 
Adler 
9 0 
3.2 
James 
8.6 
Rush 
3.2 
Cullen 
7.8 
Morgan 
3.1 
Prince 
7.8 
Hannah 
2.8 
Barton 
7.7 
McDowell 
1.8 
Adams 
7.5 
1.7 
Dewey 
6 2 
1.3 
Kilbourne 
5.9 
Hospital 
1.2 
The incidence by age and sex for inmates is given in Table XI. Here 
it will be noted that relatively more cases developed among those in the 
younger age groups, and that the total incidence for females was 7.3 per 
hundred population as compared to 5.0 for males. These latter rates by 
sex represent a reversal of the usually expected greater typhoid incidence 
among males, and therefore should be explained. Referring to Table 
XII, it will be noted that 60% of the 1939 female inmate population had 
been in residence at Manteno State Hospital for less than 2 years, as com- 
pared to only 45% of the male population. Thus, if the previously stated 
hypothesis regarding the development of typhoid immunity as a concurrent 
event to years of residence in the hospital is warranted, it may be 
assymed that approximately one-third again as many female inmates were 
susceptible to typhoid fever in 1939 as there were males. This assumption 
is a possible explanation for the reversal of the expected incidence by sex. 
Table XIII shows the incidence by age and sex for employees of the 
institution and also for the construction men who were employed on the 
grounds. Female employees had a typhoid incidence of 7.3 per hundred 
compared to 8.4 for males. The total employee incidence of 7.8 did not 
differ significantly from that for inmates; i. e., 6.2 per hundred. The rate 
of 5.4 typhoid cases per hundred construction men is only a rough esti- 
mate, since the total number of men exposed could not be accurately de- 
termined. 
CARRIER-DETECTION PROCEDURES. The classification of 
the 453 typhoid fever cases in the Manteno State Hospital epidemic ac- 
49 TABLE XI 
Typhoid Cases and Incidence Among 
Inmates by Age and Sex 
Age 
Female Inmates 
Male Inmates 
Total Inmates 
Total 
Pop. 
Typhoid 
Cases 
% 
Typhoid 
Total 
Pop. 
Typhoid 
Cases 
% 
Typhoid 
Total 
Pop. 
Typhoid 
Cases 
% 
Typhoid 
10-14... 
1 
0 
0.0 
0 
0 
0.0 
1 
0 
0.0 
15-19... 
20 
3 
15.0 
26 
' 3 
11.5 
46 
6 
13.1 
20-24... 
62 
6 
9.7 
76 
7 
9.2 
138 
13 
9.4 
25-29... 
149 
12 
8.0 
174 
12 
6.9 
323 
24 
7.4 
30-34... 
234 
22 
9.4 
322 
23 
7.1 
556 
45 
8.1 
35-39.. . 
335 
36 
10.8 
395 
33 
8.4 
730 
69 
9.4 
40-44.. . 
360 
35 
9.7 
276 
11 
4.0 
636 
46 
7.2 
45-49... 
407 
30 
7.4 
333 
16 
4.8 
740 
46 
6.2 
50-54.., 
324 
21 
6.5 
374 
11 
2.9 
698 
32 
4.6 
55-59... 
302 
23 
7.6 
317 
10 
3.2 
619 
33 
5.3 
60-64... 
249 
7 
2.8 
225 
10 ' 
4.4 
474 
17 
3.6 
65-69... 
174 
7 
4.0 
159 
5 
3.1 
333 
12 
3.6 
70-74... 
104 
7 
6.7 
129 
2 
1.6 
233 
9 
3.9 
75-79... 
90 
2 
2.2 
84 
1 
1.2 
174 
3 
1.7 
80-84... 
41 
0 
0.0 
19 
2 
11.5 
60 
2 
3.3 
Over 85 . 
22 
0 
0.0 
11 
0 
0.0 
33 
0 
0.0 
Total. . . 
2,874 
211 
7.3 
2,920 
146 
5.0 
5,794 
357 
6.2 
TABLE XII 
1939 Inmate Population According to Sex 
and Time Spent in Institution 
Years Residence 
Females 
Males 
Total 
More than 2 
944 
39.42% 
1,297 
54.59% 
2,241 
Less than 2 
1.451 
60.58% 
1,079 
45.41% 
2,530 
Total 
2,395 
100,00% 
2,376 
100.00% 
4,771 
50 cording to sex, occupation', place of hospitalization, and ultimate termina- 
tion is shown in Tables XIV and XV. It should be noted that only 411 
typhoid patients were hospitalized at Manteno State Hospital; therefore, 
this study on the discovery of carriers is confined to this group and the 
6,100 contacts living at the hospitals. 
The rules and regulations for the control of communicable diseases in 
the State of Illinois1 required in 1939 that all contacts with a case of typhoid 
fever submit 2 specimens of feces and urine (each collected from the second 
or third bowel movement following a cholagogue cathartic) taken at least 
24 hours apart, for examination for the presence of typhoid organisms. 
Since all of the 6,100 inmates and employees of Manteno had been in contact 
with typhoid cases, it was necessary to have feces and urine specimens from 
each of them examined according to the State Department of Public Health 
rules. For additional safety, all food handlers within the institution were 
required to submit at least 1 additional specimen. 
The 700 institutional employees were instructed as to the requirements 
and allowed to collect their specimens of feces and urine without super- 
vision. However, 2 details of nurses and attendants were delegated for 
the collection of specimens from inmates. One of these details, consisting 
of 2 attendants, systematically collected specimens in all male cottages, 
whereas the other, consisting of a registered nurse, visited all the female 
cottages for the same purpose. By this means the identification and proper 
collection of specimens from all inmates was facilitated. 
From one-half to one ounce of magnesium sulphate was given to the 
patients in the morning, and the second or third resulting bowel movement 
was deposited in a sterile bedpan or commode chamber, from which a very 
small particle of feces and about 1 dram of urine were taken and placed 
in a sterile specimen bottle for delivery to the laboratory. No preservative 
was added to the specimen, since it usually arrived at the laboratory from 
1 to 12 hours after collection. 
Through these methods specimens were collected from 4,900 inmates 
and approximately 600 employees, the remainder of the total of 6,100 
persons either having developed typhoid or having fled in panic from the 
institution and the epidemic. In the entire group of approximately 5,500 
employees and inmates, positive specimens were reported in the cases of 29 
females and 26 males, or a total of 55 persons. Of these, only 6 had a 
definite history of previously having had typhoid fever. 
Among the 53 inmates represented, 4 showed the presence of S. paratyphi 
B organisms in the specimens submitted. Two of the 4 never again had 
a positive specimen out of the several submitted at weekly intervals over a 
period of 6 months. One of the S. paratyphi B cultures was isolated from 
an 8-month-old girl, whose blood serum failed to agglutinate the organisms 
isolated from the stool. Consideration of this finding, together with the 
fact that 7 feces specimens were reported as negative over a period of 2 
months, finally eliminated this patient from the carrier classification. The 
remaining inmate, found to have S. paratyphi B organisms in her stool 
specimen, in time was found to be a carrier of E. typhosa, also. These 
persons were all isolated in a separate cottage and subjected to further study 
of fecal and urine specimens. 
1 State of Illinois: Manual and Outline of Procedure for Health Officers for the Control of Com- 
municable Diseases. 1935. P. 125. 
51 TABLE XIII 
Typhoid Cases Among Non-inmates 
by Age and Sex 
Hospital Employees 
Construe- 
Age 
Females 
Males 
Total 
tion 
Men 
Others 
Total 
5-9.... 
0 
0 
0 
0 
3 
3 
10-14.... 
0 
0 
0 
0 
1 
1 
15-19.... 
0 
0 
0 
1 
0 
1 
20-24.... 
5 
3 
8 
5 
1 
14 
25-29.... 
6 
7 
13 
6 
0 
19 
30-34.... 
4 
8 
12 
2 
0 
14 
35-39.... 
4 
6 
10 
8 
0 
18 
40-44.... 
3 
4 
7 
2 
0 
9 
45-49.... 
2 
1 
3 
2 
1 
6 
50-54.... 
2 
2 
4 
0 
0 
4 
55-59.... 
2 
0 
2 
0 
0 
2 
60-64.... 
0 
0 
0 
1 
0 
1 
65-69.... 
0 
0 
0 
0 
0 
0 
70-74.... 
1 
0 
0 
0 
0 
1 
Unknown. 
0 
0 
0 
3 
0 
3 
Total. . 
29 
31 
60 
30 
6 
96 
Population 
396 
370 
768 
555 
- 
- 
% 
Typhoid.. 
7.3 
8.4 
7.8 
5.4 
Of the 2 employees found to have positive specimens, 1 was reported at 
first as harboring only paratyphoid B organisms, but later was found 
to be a typhoid carrier. Both these persons were placed under a typhoid- 
carrier agreement. 
Of the 55 carriers found on survey of the contacts, 9 were employed in 
food-handling capacities. However, only 3 of these were employed in the 
central kitchen, the remaining 6 working in ward kitchens where they 
could only possibly contribute to the spread of typhoid in their respective 
wards. In the central kitchen there were 6 different menus prepared; 
namely, officers’ dining room menu, employees’ dining room menu, indus- 
trial menu, regular menu, infirm-patients’ menu, and special hospital diets. 
It is improbable that the 3 carriers working in the central kitchen came in 
contact with all the 6 different menus served to the entire institutional 
population, yet there was no cottage in the institution which was spared 
of typhoid fever. 
For release from the quarantine for typhoid fever, the Illinois rules 
and regulations2 required in 1939 that the patient submit 2 successive neg- 
52 TABLE XIV 
Typhoid Patients Hospitalized at Manteno 
Case 
Termina- 
tion 
Inmates 
Hospital 
Employees 
Others 
M 
F 
M 
F 
Constr. 
Men 
M 
F 
Total 
Released. . 
Chronic 
112 
136 
22 
1 
17 
7 
1 
0 
295 
Carriers. 
14 
44 
0 
4 
0 
0 
0 
62 
Died 
Typhoid. 
18 
30 
2 
0 
1 
0 
0 
51 
Died Other 
V 1 
Causes. . 
2 
1 
1 
0 
0 
0 
3 
Total 
146 
211 
24 
21 
8 
1 
0 
411 
TABLE XV 
Typhoid Patients Hospitalized Outside Manteno 
Case 
Termination 
Hospital Employees 
Constric- 
tion 
Men 
Others 
Total 
Male 
Female 
M 
F 
Released 
4 
7 
15 
3 
1 
30 
Chronic Carriers. 
1 
1 
0 
0 
1 
3 
Died Typhoid . . 
2 
0 
7 
0 
0 
9 
Total 
7 
8 
22 
3 
2 
42 
TABLE XVI 
Chronic Typhoid Carriers and Chronic-Carrier Rates 
Discovered by Examination of 
Initial Survey and Release 
Specimens 
Persons 
Examined 
Carriers 
Found 
Carrier 
Rate 
5,500* 
55 
45 
100% 
10.95% 
411 
5,911 
100 
•Approximate number. 
53 ative specimens of feces and urine, the first being taken 10 days after the 
temperature became normal, and the second 1 week after the first. A 
third specimen was required from the majority of the 411 Manteno patients 
before release was granted, and this additional specimen was taken 1 week 
after the second. No cathartic could be given before collecting these re- 
lease specimens due to the friable condition of the small bowel. 
The release specimens were all collected in the typhoid wards under 
the supervision of trained public-health nurses. The specimen was deposited 
in a sterile bedpan or commode chamber under the observation of the nurse, 
who then transferred a sample of the fecal mass and a sample of the urine 
to a sterile specimen bottle, using an uncontaminated wooden tongue blade 
and a sterilized spoon. In most instances these specimens received no 
preservative and were delivered to the laboratory within 6 hours after 
collection. 
In some cases as many as 7 release specimens were submitted, and out 
of the entire group of 411 typhoid cases at least 1 of the release specimens 
from each of 87 patients showed the presence of E. typhosa. These persons 
were classified as convalescent carriers, and represented a convalescent 
carrier rate of 21.2%. Forty-two of these persons, however, managed to 
submit at least 3 successive negative specimens subsequently at weekly in- 
tervals before 3 months frorn the time of onset. This left 45. who, ac- 
cording to the rules and regulations, were classified as chronic carriers, giving 
a chronic carrier rate of 10.95 per hundred cases. These carriers were 
isolated in the same cottage as the carriers found among the contacts and 
were subjected to further study of their fecal and urine specimens. Three 
of the forty-five were employees, two of who were released under typhoid- 
carrier agreement, but the third suffered a typhoid psychosis and was placed 
in isolation with the inmate carriers. 
Table XVI summarizes the results of both the carrier survey among 
contacts, and release specimens. 
All laboratory work was conducted either in the emergency laboratory 
maintained at the hospital during the period of August through December, 
1939, or in the Chicago or Springfield laboratories of the Illinois Depart- 
ment of Public Health. The total number of specimens and the results 
from each place are recorded in Table XVII. With the completion of 
the original survey among contacts for carriers, most of the work was done 
in the Chicago laboratory. 'Phis fact accounts for the seemingly dispro- 
portionate number of positive specimens discovered in this laboratory as 
shown in the table, for most of the specimens examined there were from 
known carriers. 
The standard procedure followed in making these bacteriological analy- 
ses was to plate the specimen on either Wilson-Blair bismuth sulphite bril- 
liant green agar or desoxycholate-citrate agar, or both (in Chicago and 
Springfield both were used at times, but in the emergency laboratory the 
Wilson-Blair medium alone was used almost exclusively). Suspicious colonies 
were then picked frdm the differential media and inoculated into at least 7 
carbohydrate sugar broths where the characteristic reactions of intestinal 
pathogens were sought. Indole tests, hydrogen sulphide production, mo- 
1 State of Illinois: Manual and Outline of Procedure for Health Officers for the Control of Com- 
municable Diseases. 1935. P. 124. 
54 TABLE XVII 
Total Bacteriological Analyses of Fecal 
and Urine Specimens and Positive 
Results Reported from State 
Laboratories from August, 
1939, through June, 1941 
Laboratory 
Total 
Specimens 
Examined 
Total 
Specimens 
Positive 
Emergency (Manteno) 
13,974 
330 
Chicago 
12,837 
2,031 
Springfield 
246 
6 
Total 
27,057 
2,367 
tility, and Gram-staining characteristics were also recorded. Agglutination 
tests were used to confirm all cultures showing positive results in these 
tests. All interpretations of these findings were made by bacteriologists 
thoroughly experienced in enteric-disease work. 
Specimens shipped to the Chicago or Springfield laboratories were pro- 
tected against overgrowth of the ordinary fecal bacterial flora by a sterile 
buffered 30% glycerine solution. The time interval between collection and 
plating of the shipped specimens was in most instances not over 48 hours and 
usually much less. 
TYPHOID-CARRIER INCIDENCE. As was mentioned above, 
positive stool and urine specimens were found in.the case of 55 persons, who 
at no time during the epidemic had any subjective or objective signs of 
typhoid fever. These individuals were. classified as contact carriers, and 
represented a carrier rate of approximately 1 per 100 total population. 
Klinger, in 1906, isolated E. typhosa from the excreta of 15 cases out of a 
total of 1,700 examined in an area in which typhoid fever was epidemic.3 
This is a carrier rate of 0.85%. Gill4 found a carrier rate of 5.1% in 
1,076 milk handlers in an endemic area in Alabama. 
Among the 411 cases of typhoid fever, 87, or 21.2%, continued as fecal 
carriers after their temperatures reached normal. Only 45, or 10.95% 
of the total, however, continued persistently to excrete typhoid organisms 
in the feces and urine at the end of 3 months from the time of onset of illness, 
thereby automatically becoming chronic convalescent carriers. These 
figures may be constrasted with those of Garbat5, who found 32% of 164 
cases of typhoid continuing as fecal carriers after subsidence of the symptoms. 
In his series of cases, which were studied over a period of 4 months or 
longer, as were those in our series, only 3 or 4% became chronic carriers. 
The chief difference observed between these two studies is that about three 
5 Klinger, P.: Arb. Reichsgesundh. Ant. 25; 223, 1906. 
4 Gill, D. G.; J. A. M. A., 89; 1198, 1927. 
5 Garbat, A. L.: Rockefeller Inst, for Med. Research, Monograph #16, 5-10-22. 
55 times as many chronic carriers persisted in the Manteno epidemic as in that 
reported by Garbat. 
The figures taken more or less as standard today for carrier rates among 
convalescing typhoid patients, are 2 to 5% as reported by Bigelow and 
Anderson" and Park7. It must be recognized, however, that these former 
carrier studies were made prior to the time that greatly improved isolation 
media such as Wilson and Blair’s bismuth sulphite agar and Leifson’s 
desoxycholate-citrate agar came into general use as differential media in 
typhoid-culture work. It has been shown by Mayfield and Gober8, among 
others, that the use of these 2 media vastly facilitates the isolation of E. 
typhosa from fecal specimens. 
The age distribution of the contact carriers and the convalescent carriers 
was found to be not significantly different from that of the institution 
population and the typhoid cases, respectively. These distributions are 
shown in Table XVIII. 
Table XIX lists the sex distribution of the typhoid carriers. It should 
be noted that approximately one-third of the total were males, an observation 
that tallies very closely with the sex distribution of typhoid carriers in New 
York State as reported by Senftner and Coughlin9, who found 120 males 
out of a total of 368 carriers. Gowen10, in a similar study for the State of 
Illinois, found a higher percentage of males; namely, 46 out of 110 carriers. 
It is interesting to note further, in Table XIX, that the sex distribution of 
contact carriers is in proportion to that of the institutional population, 
whereas among the chronic carriers the proportion of males to typhoid cases 
is significantly lower. 
Three additional cases of typhoid fever occurred at Manteno State 
Hospital during the latter part of March, 1940, at least 2 months after the 
last patient of the epidemic had been released. At this time the water 
supply was of a safe and sanitary quality, and had been so for at least 1 
month. No suspicion was. attached to the milk supply, all foodstuffs were 
being obtained from reliable wholesalers, and all food handlers had had 
3 to 5 fecal and urine cultures found negative for typhoid. As a result, 
there was a strong suspicion that these 3 new cases had obtained their infec- 
tion through direct contact with an undiscovered typhoid carrier. All 3 of the 
typhoid cases had had negative fecal and urine cultures at the time of the 
initial survey. 
Following the administration of magnesium sulphate two fecal and urine 
specimens were examined from all contacts with the recent typhoid 
cases and also from all persons who had been released by the usual procedure 
after having had typhoid fever during the epidemic. This new survey, 
conducted in April, 1940, resulted in the discovery of 17 new typhoid car- 
riers, only 3 of whom had been in contact with the recent cases. Thirteen 
of these carriers had had typhoid fever during the recent epidemic, and 
only 3 of the 13 had shown a positive result during the examination of their 
release specimens in 1939. 
6 Bigelow, G. H., and Anderson, G. W.: J. A. M. A. 101 ; 348, 1933. 
7 Park, W. H.: J. A. M. A. 51; 981, 1908. 
8 Mayfield, C. R., and Gober, M.: Am. J. Pub. Health, 30; 69, 1940. 
9 Senftner, H. F., and Coughlin, F. E.: Am. J. Hyg. 17; 71 1, 1933. 
w Gowen, G. Howard: 111. Med. J. 73; 38, 1938. 
56 TABLE XVIII 
Age Distribution of Population, Contact 
Carriers, Typhoid Cases, and Chronic 
Carriers Among Inmates 
1939 
Age 
Inmate 
Population 
Inmate 
Contact 
Carriers 
Inmate 
Typhoid 
Cases 
Inmate 
Chronic 
Carriers 
10-14 
1 
0 
0 
0 
15-19 
46 
0 
6 
0 
20-24 
138 
1 
13 
0 
25-29 
323 
6 
24 
2 
30-34 
556 
6 
45 
6 
35-39 
730 
4 
69 
4 
40-44 
636 
6 
46 
. 7 
45-49 
740 
4 
46 
7 
50-54 
698 
9 
32 
7 
55-59 
619 
7 
33 
7 
60-64 
474 
2 
17 
0 
65-69 
333 . 
4 
12 
1 
70-74 
233 
2 
9 
1 
75-79 
174 
1 
3 
0 
80-84 
60 
0 
2 
0 
Over 80 
33 
0 
0 
0 
Total 
5,794 
52* 
357 
42 
Mean age 
48.84 
47.50 
44.11 
46.19 
*Case of eight-month infant omitted, 
TABLE XIX 
Sex Distribution of Typhoid Carriers 
(Inmates and Employees) 
1939 
Sex 
Contact 
Carriers 
Total 
Population 
Chronic 
Carriers 
Typhoid . 
Cases 
Total 
Carriers 
Male 
26 
3,290 
8 
179 
34 
Female.... 
29 
3,272 
37 
232 
66 
Total 
55 
6,562 
45 
411 
100 
57 This survey was then extended, and monthly post cathartic fecal and 
urine specimens were cultured from all inmates who had had typhoid fever 
in the 1939 epidemic and had been released upon the obtaining of 3 or more 
successively negative specimens. From April, 1940, to April, 1941, four 
additional chronic carriers were discovered among these released patients, 
bringing the total of additional carriers to 17. These 17 carriers, added 
to the original 45, produced a total of 62 chronic typhoid carriers out of 
411 cases, or a carrier rate of 15 per hundred. This is the highest chronic 
convalescent-carrier rate ever reported. 
The finding of typhoid carriers among former typhoid patients several 
months to a year or more after occurrence of the disease is not unusual. 
Leach, Dehler, and Havens11 found 10.3% to be carriers out of 156 in- 
dividuals who had recovered from typhoid fever within 6 months to 2 years 
previously. Gill12 reported 9.48% carriers among a similar sample of 348 
persons. Reports of other similar findings are described by Topley and 
Wilson13. 
From these observations it appeared that the quarantine rules allowing 
release of typhoid cases on only 2 specimens during the period of convales- 
cense was too lax, for if only 2 specimens had been required for release of 
patients in this epidemic there would have been discovered only 20 carriers, 
or the usual 5%. In other words, 42 of the 62 chronic carriers found 
satisfied the release requirements of only 2 negative specimens during con- 
valescence and were not discovered until further specimens were examined, 
the period covered being more than a year after the subsidence of the 
epidemic. 
These observations also indicate that specimens taken following a chol- 
ogogue cathartic are probably more likely to yield positive cultures than non- 
cathartic specimens. As indicated elsewhere in this report, post cathartic 
specimens could not be collected safely from those who had just recovered 
from the disease. The Department of Public Health rules for release of 
cases have now been modified to require post cathartic specimens from 
typhoid convalescents after the danger of causing damage to weakened bowel 
tissue has passed. 
BACTERIOPHAGE TYPING OF CULTURES. During the 
epidemic all of the laboratory facilities available were concentrated on the 
huge task of examining more than 27,000 feces and urine specimens and 
nearly a thousand blood specimens. It was therefore impossible to classify 
the cultures isolated by the then newly discovered procedure of bacteriophage 
(or phage) typing. Cultures were preserved and at a later date these, as 
well as cultures recently isolated from carriers, were tested for phage sus- 
ceptibility. Unfortunately, many of the strains isolated during the outbreak 
had become resistant and non typable. A sufficient number could be typed, 
however, to indicate that the cultures were of many phage types. Further- 
more, the cultures isolated from different individuals in a given cottage 
were of different types. 
These findings indicate that there was no single original source, such as 
one case or carrier, for the epidemic. Instead, a situation must have oc- 
11 Leach, C. N., Dehler, S. A., and Havens, L. C.: Am. J. Pub. Health 16; 391, 1926. 
12 Gill, D. G.: Op. cit. 
12 Topley, W. W. C., and Wilson, G. S.: Principles of Bacteriology and Immunity, Baltimore 
Williams and Wilkins, P. 1219, 1938. 
58 curred in which typhoid bacilli contributed by several different cases or 
carriers, each shedding typhoid organisms of a different phage type, were 
distributed throughout the institution. It would appear that the most 
plausible theory which would account for these facts is that the outbreak 
was water-borne and that human excreta carrying typhoid bacilli from many 
individuals, and thus of many phage types, had contaminated the water. 
Drinking water heavily contaminated with fresh sewage (including fecas 
of typhoid carriers or cases) would, of course, cause the observed distribution 
of nonidentical typhoid strains. 
59 CHAPTER VIII 
DISCUSSION 
From the foregoing data, and from all that is known scientifically of 
the natural history of typhoid fever, it is possible to arrive at reasonably 
accurate public-health conclusions as to the means of transmission of the 
typhoid organisms involved in the institutional epidemic described. It is well 
to bear in mind, however, that, as presented during the litigation and ad- 
mitted in evidence by the Illinois State Supreme Court, such findings and 
conclusions did not constitute legal proof as to the means of transmission. 
It is generally accepted as a scientific fact that most typhoid fever 
epidemics owe their spread either (1) to infection by direct contact with 
human cases or carriers, or (2) to infection from one or more of the fol- 
lowing vectors: food, water, or milk. 
With regard to the question as to whether the epidemic at Manteno 
State Hospital in 1939 might have been due to direct contact, it may be 
said that many of the early cases occurred in persons who had had no contact 
with one another, and that these persons had neither had universal contact 
with the first case in July nor with anyone concerned with the first case. 
This is especially clear with reference to the construction men who were 
employed on the various building projects about the grounds, and certainly 
had no contact with untidy patients (such as the first case), and who, 
nevertheless, contracted typhoid fever. 
With regard to the question as to whether, in this particular outbreak, 
food might have served as a means of transmission of the organisms, it may 
be said that the men employed on construction projects did not eat food 
prepared at the institution, and that the same died was not served 
to everyone in the institution, and that even though the foods were 
prepared in the same central kitchen many of them were handled by different 
individuals. 
With regard to the question as to whether milk and milk products might 
have played a role in the spread of typhoid fever at Manteno State Hospital 
in 1939, it may be said that the milk supply delivered to the institution was 
received from approved pasteurization plants, and that the raw milk pro- 
duced on the institution farm was used only for cooking. Milk from the 
pasteurizing plant was delivered to the institution in sealed 10-gallon con- 
tainers and was distributed in these original sealed containers to the in- 
dividual wards. Therefore, if the epidemic was caused by milk contami- 
nation after delivery, one would expect the inmates of one particular ward 
or several individual wards served by one kitchen only, to have been stricken. 
If the point of contamination for the milk supply had been central, then 
one would expect the characteristics of the epidemic to be different, such as 
a much more acute onset, a lower mortality rate, etc. Again, in this case, the 
construction men working at the institution did not partake of the institution 
milk supply, and those who did consume milk either brought the product 
with them or purchased it at the institution commissary, which brought milk 
60 from a different source and sold it in individual pint and quart containers, 
the seals of which were not broken. This latter supply was also from an 
approved pasteurization plant. 
Water, however, was consumed by all persons on the institution grounds 
regardless of their classification as inmates, institutional employees, con- 
struction men, or visitors. It has been shown in the foregoing account that 
for many years this water supply,' which was derived from 4 wells that 
secured their water from the creviced limestone, had been subject to con- 
tamination. It was further shown, by placing dyes and salt in various 
points of the sewer system, that this application was accompanied within a 
few hours by a very significant increase in the chloride content of the raw 
well-water. Further evidence of sanitary sewer leakage into the creviced 
limestone is shown by the fact that application of fluorescein dye to the 
sanitary sewage through certain toilets was accompanied by the appearance 
of this dye not only in the sanitary sewers but also in the storm sewers, 
both of which are laid in creviced limestone and were reported to have no 
direct physical connections. 
As a result of these investigations, it appears that there was not only an 
outright leakage of sewage from the sanitary sewers into the creviced lime- 
stone, but also that this sewage seeped through the limestone and found its 
way into the wells which supplied the institution with water. Up until 
August 19, the water from these wells was pumped directly into the insti- 
tution distribution system without treatment. In further support of the 
contention that sewage at the time of the investigation was directly contam- 
inating the water supply through sewer leakage and seepage in the limestone, 
there is the investiagtion on the raw water from Well No, 4, made by an 
experienced bacteriologist, from which he was able to isolate Eberthella 
typhosa. Water from this well was used exclusively for several weeks 
preceding the outbreak. Crowning the foregoing evidence is the phage 
typing of cultures obtained from many fecal and urine specimens collected 
from the typhoid patients and carriers, which showed that many phage 
types were represented in the epidemic, suggesting that the causative or- 
ganisms had been transmitted to the patients from many individual sources 
rather than by direct contact with a single patient or carrier. From this 
accumulation of evidence it would seem likely that the water supply was 
receiving direct contamination from the institution sewer system. 
It has been commonly stated that one of the charactristics of a water- 
borne epidemic of any disease is the explosiveness of the onset of the 
epidemic. In the case of typhoid fever, however, it is well known that the 
incubationary period may extend from 2 or 3 days to as many as 40 it 
is also recognized that the onset of typhoid fever is generally insidious and is 
accompanied, at first, by the appearance of many general prodromal symp- 
toms, such as fever, headache, backache, and chills, that are not peculiar to 
any one disease; it is clear, furthermore, that where typhoid fever involves 
individuals who are mentally ill, the onset of the individual case often can- 
not be definitely placed on any certain date. 
It appears reasonable to assume that typhoid carriers were present in 
the institution previous to the onset, since, on the routine survey, many 
persons were found to be typhoid carriers and were subsequently proved, by 
repeated examinations, to be permanent carriers of typhoid-fever organisms. 
61 In some of these instances a definite history was obtained of these individuals’ 
having had typhoid fever several years prior to the epidemic. 
Since the body wastes of these persons found to be carriers after the 
onset of the epidemic and the body wastes of the first typhoid patient re- 
ported were being discharged without special treatment into the sewer 
system of the institution, any possible contamination of the water supply 
from the sewer system might readily have involved the infection of the 
water with a variety of phage types. 
The fact that most of the persons who developed typhoid fever during 
the epidemic under discussion had not been in the institution long suggests 
the possibility that, in some of the persons who had been there longer, active 
immunity to the disease may have been produced without clinical disease. 
Although control measures were instituted during the latter part of 
August, the occurrence of new cases continued for a period of 2 months. 
This phenomenon was to be expected inasmuch as many of the inmates’ 
cases were not discovered until the illness became obvious. Furthermore, 
many persons were afflicted with mild undiagnosed illnesses that may have 
been missed cases of typhoid fever. It is well known that missed cases and 
persons in the incubation stage of typhoid fever are capable of transmitting 
the disease. In spite of rigid precautions which were taken in public- 
health control of carriers and known cases to prevent the spread of the 
epidemic, it was impossible to insure against many close contacts such as 
could happen in any institution for the insane. 
Another factor in the incidence of secondary cases was the lack of 
adequate continuous supervision over the public-health control of typhoid 
fever at the institution until September 20, when the Department of Public 
Health nurses were stationed at the institution for the purpose of supervising 
the carrying out of strict isolation technique at the hospital and in the ty- 
phoid-isolation wards. 
Before the known typhoid cases were released from quarantine, 3 speci- 
mens of feces and urine were required to be taken for examination at weekly 
intervals, the first not sooner than 10 days following the disappearance of 
fever. Even though this release procedure was more rigid than that which was 
then ordinarily required by the rules and regulations of the Illinois Depart- 
ment of Public Health, subsequent examination of specimens submitted by 
persons who suffered with typhoid fever during the epidemic revealed that 
17 who had been released as cured had actually become permanent typhoid 
carriers. It may, therefore, be concluded that the examination of 2 speci- 
mens of feces and urine for typhoid is not sufficient evidence upon which to 
base the criterion of cure. 
From the experience gathered in this epidemic, it may be concluded that 
much more stringent control measures must be practiced in the case of an 
epidemic in an institution for the mentally ill than would be considered neces- 
sary elsewhere. Persons confined in this type of institution frequently 
cannot be held responsible for the practice of personal hygiene, even to the 
extent of exercising control over the rectum or bladder. Consequently, 
any disease which can be transmitted through body wastes is particularly 
difficult to control among such patients. 
62 In order to ensure that the necessary procedures are carried out adequate- 
ly, the experience in this epidemic would lead to the recommendation that 
only persons specially trained in the care of communicable diseases supervise 
the work. 
In order to co-ordinate all control procedures, it was found effective in 
this epidemic to have all aspects of the public-health control work under the 
supervision of orte experienced person charged with the necessary authority 
and having available reliable personnel for rapid and thorough execution of 
the control work. 
The experience in this epidemic emphasizes also the value of giving full 
explanations to the people in the institution of the control procedures and of 
the reasons for instituting these procedures. If no explanation is forth- 
coming, the mass reaction on the part of institution personnel may border on 
panic. 
63 CHAPTER IX 
LEGAL ACTION RESULTING FROM THE EPIDEMIC 
Following the epidemic, indictments were brought in Kankakee 
County, Illinois, against 3 persons concerned with the management and 
operation of Manteno State Hospital: the managing officer, the dietitian, 
and the director of the State Department of Public Welfare. The charges 
against the first two were eventually dismissed. The director of Public 
Welfare was brought to trial in the circuit court of Kankakee County, 
Illinois, Indictment No. 1847, People of the State of Illinois v, Archie 
Leonard Bowen. The jury was unable to reach a decision, and mutual 
agreement between the defendant and the State placed the decision in the 
hands of the judge. The decision rendered by the judge found the de- 
fendant guilty of omission of duty as charged, but this decision was sub- 
sequently reversed by the Illinois State Supreme Court. The opinions of the 
lower and the Supreme Courts are given in full at the end of this report. 
An interesting controversy developed in the lower-court trial in connection with 
the introduction as evidence of the Department of Public Health results of analyses 
of water samples, together with the written opinions issifcd thereon. The prosecu- 
tion contended that the analytical reports and written opinions of the State Depart- 
ment of Public Health should be given full weight as evidence. The defense, 
however, argued that these opinions on the analytical results gave no greater notice 
of danger than did the results themselves, contending that these opinions were 
merely those of persons giving them based on the facts disclosed by the laboratory 
results themselves, from which laboratory results or facts it argued that the de- 
fendant could as well formulate his own opinion, which would be as much entitled 
to weight and authority as the opinions given on these results by the Department 
of Public Health. In other words, the defense contended that the opinions written 
concerning the analytical results or facts added nothing legally that was not shown 
by the results themselves. It also contended that the State Department of Public 
Health in its analyses did not claim to find disease germs but merely the presence 
of B. coli, which, it pointed out, in themselves are harmless organisms. Further, 
that no differentiation was made in the reports between fecal and nonfecal types of 
coli. It was also pointed out by the defense attorneys that the defendant knew no 
disease germs had been found by the analyses, and, particularly, that no typhoid 
organisms had been isolated (previous to the epidemic). Furthermore, that he 
(the defendant) drank the water each month when visiting the institution and 
from a taste standpoint the supply was excellent, that the water was cold, and 
that he was justified in believing that it was safe. On this matter of the written 
opinions, analyses and field-inspection reports of the State Department of Public 
Health, the lower court ruled that reports or analyses be admitted in the record 
solely for the purpose of showing that the defendant was being informed that the 
water was unsafe and that an epidemic might occur at any time but not as sub- 
stantive proof. The court with these restrictions admitted the reports and analyses 
as evidence, stating that they were true and correct insofar as the results of the 
analyses were shown and constituted legal evidence inasmuch as the officials charged 
with the responsibility of making these examinations and reports were all present 
for cross-examination and to testify as to their correctness. 
Another interesting public-health point involved in the trial was the question 
regarding admission as evidence of the salt tests showing the seepage from the 
64 sewer to the well and the isolation of the typhoid organisms from the water supply. 
The defense contended that inasmuch as these tests were made after the onset of 
the epidemic it would be necessary to prove that conditions in both the sewer lines 
and the water supply underground were the same at the time of the salt tests 
(August 29-30) as preceding the outbreak of the epidemic, which was dated 
August 19. The burden of this proof rested on the prosecution and while testimony 
was given to show that no changes had been made or were known to have occurred 
in either the sewer system or the water supply over this period, the prosecution 
admitted that it was humanly impossible to prove that all conditions underground 
were exactly the same on the days the tests were made as they were a few days 
previous when the outbreak started. The court ruled that neither the results of 
the salt tests nor the isolation of the typhoid-fever organisms could be admitted 
as evidence, inasmuch as these tests were made after the date of the onset of the 
epidemic and there was not sufficient evidence to show that underground con- 
ditions were the same. 
The defense contended that the epidemic was caused by direct contact with a 
carrier, one Mary Ores, who died of the disease. Evidence was introduced - to 
show that “Mary” had been moved repeatedly from one ward to another and that 
at such times she would have had direct contact with all early cases. 
Civil action suits for damages, all eventually dismissed, were brought 
into the district court of the United States for the Northern District of 
Illinois, Eastern Division, against surety companies providing bonds for the 
managing officer of Manteno State Hospital, the director and the as- 
sistant director of the State Department of Public Welfare, and the dir- 
ector of the State Department of Public Health. When these cases were 
dismissed in the lower court, they were appealed to the United States Cir- 
cuit Court of Appeals, Seventh Circuit, which upheld the motions for dis- 
missal. 
STATE OF ILLINOIS 
COUNTY OF KANKAKEE 
ss. 
IN THE CIRCUIT COURT OF KANKAKEE COUNTY 
THE PEOPLE OF THE 
STATE OF ILLINOIS 
VS. 
ARCHIE LEONARD BOWEN 
INDICTMENT FOR MALFEASANCE 
NO. 1B47 
OPINION OF THE COURT 
The defendant, Archie Leonard Bowen, was indicted by a special Grand Jury 
of Kankakee County. The indictment was returned and filed on November 21, 
1939. This indictment consisted of three counts: the first charged the defendant 
with unlawfully, willfully and corruptly being guilty of a palpable omission of 
duty; the second charged him with being guilty of willful and corrupt malfeasance 
in office; and the third count charged him with maltreating a certain insane person. 
The case was tried with a jury commencing February 13, 1940, and the jury 
after being out a considerable length of time, having failed to agree, was discharged 
by the Court. However, it not appearing to the Court from the evidence that the 
defendant was guilty of any affirmative acts of malfeasance or of maltreatment 
directed a verdict as to the second and third counts; so that there is remaining only 
for further consideration the charge made in the first count of the indictment. 
65 The charge made in this first count was a violation of Section 208 of the 
Criminal Code. This Section provides in part as follows: 
“Every person holding any public office (whether State, county or municipal) 
trust or employment, who shall be guilty of any palpable omission of duty, 
* * * or who shall be guilty of willful and corrupt oppression, malfeasance or 
partiality, where no special provision shall have been made for the punishment 
thereof, shall be fined not exceeding $10,000 and may be removed from his 
office, trust or employment.” 
This case was again set for trial before a jury on May 20, 1940, and after the 
selection of the jury to try the case, on May 21, 1940, The People and the defendant 
agreed to waive a jury and agreed to submit the case to the Court without a jury 
upon the evidence taken in the first trial. At the time it was agreed that briefs 
would be submitted and there was a request by the Court that both The People and 
the defendant point out any alleged errors in the record, so that the Court might 
have an opportunity of passing on the same and correcting any that should be 
corrected. 
The parties have filed their briefs and pointed out various alleged errors. The 
Court will endeavor to pass upon them or such of them as he deems necessary to 
pass upon. 
At the original trial of the case, after proof having been first made of the 
correctness of the information contained therein a large number of reports that 
the Department of Public Health sent to the defendant was admitted in evidence, 
which purported to show over a period from 1931 to the time of the epidemic in 
question, according to well known and accepted health standards, the water 
furnished the patients at Manteno State Hospital, Manteno, Illinois, was unfit for 
drinking purposes. On the back of these reports were warnings from the Depart- 
ment of Public Health to the effect that the water was unsafe for drinking pur- 
poses and advising that a dangerous water-borne epidemic might result at any 
time. The warnings contained on the backs of the reports, or in letters sent, was 
admitted in evidence by the Court with the restriction that they were being ad- 
mitted solely for the purpose of showing that the defendant was being told that 
the water was unsafe and that an epidemic might occur at any time but not as 
substantive proof. The State’s Attorney contends that the warnings shoyld have 
been admitted as substantive proof. The Court is still of the opinion that he was 
right in his rulings in this respect. If the warnings were admissable as substantive 
evidence as opinon evidence the person making them would have to have been 
present with the right of cross examination. They simply amounted to a warining 
like a statement to one under a chimney, that the chimney is about to fall and, 
therefore, look out. 
The State’s Attorney also says that the Court should have admitted in evidence 
the making of a certain salt test and proof of the alleged isolation of a certain 
typhoid germ. The evidence showed that this alleged salt test and alleged isolation 
of a typhoid germ was long after the alleged offense was committed, and after the 
epidemic had reached its peak and there was no sufficient showing, in the opinion 
of the Court, that the conditions were the same as they were at the time of the 
alleged offense. The Court is, therefore, of the opinion that his ruling in this 
respect was correct. 
The State’s Attorney also says that the Court should not have admitted in 
evidence certain reports made by the Dearborn Chemical Company (two or four 
reports I have forgotten which) some years back stating that the water was safe 
to drink. These reports offered by the defendant were admitted with the same 
qualifications as those admited on behalf of the State. And the Court still feels 
that his view was correct, for the reasons heretofore expressed. They were ex- 
pressions that the chimney was not about to fall. 
66 The defendant first argues that the indictment is insufficient to charge a crime. 
Judge South passed on a motion to quash the indictment and overruled the 
same. This Court concurs in the conclusion reached by Judge South. 
Stripped of all surplusage, the first count of the indictment charges the de- 
fendant with being guilty of unlawful, willful and corrupt palpable omission of 
duty in failing to exercise reasonable care to furnish reasonably safe drinking 
water to the patients at the Manteno State Hospital, Manteno, Illinois. The 
evidence and the statutes clearly show that the defendant was charged with a duty 
of supervising and executively administering the Hospital. Being charged with 
that responsibility, can anyone say that he was not bound to exercise reasonable 
care to see to it that the patients had reasonably safe drinking water? To state 
the question is to answer it. All human life depends on safe drinking water. 
The defense alleges that the venue is not properly laid in Kankakee County, 
because it is said that Mr. Bowen’s office was in Springfield. It seems to me that 
the case of the People vs. Johnson, (66 App. 103) is conclusive on this Court as to 
that question, the Court on page 107 says: 
“But it is to be observed that the personal presence of the offender is not 
always an indispensable element in fixing the local jurisdiction of a criminal 
offense. A crime is, in legal contemplation, committed in the place where 
the doer’s act takes effect, whether he is himself in such place or not; in this 
way one may even perpetrate an offense against a State or county upon whose 
soil he never set foot.” 
Moreover, the evidence in this case shows that the defendant personally super- 
vised and inspected the Manteno State Hospital at its location, and on at least one 
occasion the condition of the water was a matter of discussion between himself, 
Dr. Hinton, and Dr. Hinton’s secretary. 
It is argued that the statute is unconstitutional because it imposes as a possible 
penalty a removal from office, and that this could only be done by the Governor 
and not as a judicial act. Even though the Governor may have power to remove 
an officer, I see no reason why that removal may not also follow as a part of the 
punishment for an offense, if an offense has been or is committed. The one is 
power vested in the Governor, the other is a penalty which may or may not be 
imposed and which is fixed by the Legislature. 
It is argued by the defense that the Grand Jury was illegally constituted, be- 
cause it is said the entire Grand Jury was hand-picked; and that the regular 
Grand Jury was in session. Judge South, however, passed on both of the objections 
and overruled them. Moreover, I find nothing in the record to show that the 
Grand Jury was hand-picked. As to the other question the Supreme Court in the 
case of The People v. Graydon, (333 111. 429) settled the law in Illinois that a 
special grand jury may return indictments even though the regular grand jury is 
in session. 
It is also argued that the venire was not under the hand and seal of the Clerk. 
It seems to me that the only essential was that the grand jury was selected in 
accordance with the law and was present even though the venire had never been 
returned. In the case of The People v. Kramer (352 111. 304) the court held that 
even though a clerk omitted to attest the return before the grand jury it made no 
difference. The court says at page 306; 
“The grand jurors, so far as appears, were lawfully selected. Though the 
venire was void, its only service was to notify the grand jurors that they were 
required to appear at the time fixed. They were so notified and were present 
in court when, according to the law, they should have been. Being there, there 
was no reason to inquire when or how they were notified,, and the court properly 
proceeded to empanel them for the purpose for which they had been selected.” 
67 The defense argues that the reports of the Department of Public Health should 
not have been admitted in evidence. The evidence showed that the reports were 
true and correct in so far as the results of the analyses were shown. I see no 
reason, therefore, why these reports were not competent. The officials, who were 
charged with the responsibility of making the examinations and having the reports 
made, were all present for cross-examination and testified to their correctness. 
I come now to the question as to whether the proofs show beyond a reasonable 
doubt that the defendant is guilty as charged. The charge being, as I view it, 
that he willfully, intentionally and corruptly failed to furnish reasonably safe 
drinking water to the patients of the Manteno State Hospital, and was, therefore, 
guilty of a palpable omission of duty within the meaning of the law. (The People 
vs. Mays, 17 App. 361). In that case considering a statute of identical language 
here, the Appellate Court in speaking of what is meant by palpable omission of 
duty, says on page 366; 
“The finding that through intoxication he has at various times been guilty 
of neglecting his duties is tantamount to a finding of “palpable” omission of duty. 
We quite agree with counsel that the word “palpable,” as here used in the statute, 
embraces the idea of an intentional and substantial failure to perform the duties 
imposed by law, partaking of the nature of a willful or gross neglect of the 
officer to attend to his duties. It would be a too restricted use of the word to 
give it the sense only of “easily perceived”, “plain”, or “obvious”, as such a 
construction would make the officer liable to removal when he had omitted to 
perform any of the duties of the office, although his failure to perform the same 
may have occurred through accident, mistake or some personal inability, arising 
from illness or other cause, for which he might not be in any degree responsible, 
which certainly could not have been contemplated by the legislature as a cause 
for removing him. Through a mistake, that anyone is liable to make, he may 
present an erroneous report to the county board, showing his receipts and dis- 
bursements, and such report therefore be untrue as a matter of fact, and an 
examination of his books would plainly show the incorrectness of it, yet if it 
should also appear that the error was not intentional, but the result of a mistake 
of the officer it would certainly not be contended that he would thereby render 
himself liable to be removed by the board. But if it appeared to be a willful 
act, upon his part, done with the design to wrong the county, there could be 
no question that the board not only could, but should, remove him.” 
This case was afterwards affirmed by the Supreme Court in the case of John 
Henderson vs. The People of the State of Illinois. 117 111. 265. 
The word “corrupt”, in my opinion, means nothing more than willful and in- 
tentional. (Chicago City Ry. Co. v. Olis, 192 111. 514). On page 516, the court said: 
“The modification complained of consists in the insertion of the words 
‘intentionally, corruptly,’ between the words ‘has’ and ‘willfully,’ so that, as 
given, the instruction reads that if ‘any witness has intentionally, corruptly, 
willfully and knowingly sworn falsely,’ etc. It is substantially conceded that 
‘intentionally’ is synonymous with ‘willfully,’ and such reiteration ought not to 
make the instruction vicious. But as to the word ‘corruptly’ it is insisted that 
its use was equivalent to saying to the jury that although they should believe, 
from the evidence, that any witness had intentionally, willfully and knowingly 
sworn falsely to any material point in the case, yet they had no right to reject 
his testimony, when not corroborated, unless they should also believe, from the 
evidence, that such witness had been bribed or was to receive some sort of gain 
or reward. We are unable to agree with counsel in such respect. In such 
connection, ‘corruptly’ refers to the motive of the witness rather than to the 
means by which his testimony is obtained. So in OVERTOOM V. CHICAGO 
AND EASTERN ILLINOIS RAILROAD CO., 181 111. 323, it Is said: ‘It is the 
68 corrupt motive, or the giving of false testimony knowing it to be false, that 
authorizes a jury to disregard the testimony of a witness.’ Again, in 1 Bouvier’s 
Law Dictionary it is said: ‘An act may be corruptly done though the advantage 
derived from it be not offered by another.’ And that learned author defines 
‘corruption’ as being something against law, and illustrates its application by 
the case of a contract for usurious interest, wherein it was ‘corruptly agreed,’ 
etc. It would seem that a witness who should testify ‘willfully and for the 
purpose of concealing the truth’ would bring himself within the meaning of 
‘corruptly’ testifying.” 
In charging a criminal intent as a matter of law, one is presumed to intend all 
natural and probable consequences which flow from his own deliberate act. He 
must not be charged alone by what he actually intendes, but how that act would 
be construed by a reasonable person. The intent may be inferred by the acts he 
did. An intentional disregard of a known duty necessary to the safety of the 
person or property of another, and an entire absence of care for the life, person, 
or property of others, such as exhibits a conscious indifference to consequences, 
make a case of constructive or legal willfullness. A sane person cannot utterly 
disregard consequences and then say that he intended to do no wrong. These 
principles are too well settled to require the citations of authorities. Just about 
all law violations justify themselves by a philosophy that they are right, the law 
is wrong, or that they intended no wrong. 
I come now to a brief discussion as to what the evidence shows. A terrific 
epidemic broke out at the Manteno State Hospital as a result of which some 450 
patients of the Manteno State Hospital became ill with typhoid and some 60 lost 
their lives. To me this is only important as showing the terrible effect of the 
thing, if an offense was otherwise committed. 
The sewage plant was originaly built for a population of 2500, and was required 
to serve at times some 6000. No conclusion can be drawn from the evidence 
except that the sewage plant was grossly inadequate. 
The entire area where the Hospital was located was underlaid with creviced 
limestone. As a result of this it is clear that if the sewage escaped from the pipes 
which carried it, it would find its way into the drinking water, unless all pipes were 
securely incased down for a sufficient depth to prevent seepage; and the evidence 
shows that this was not so. The evidence shows that commencing in 1931 and until 
the epidemic, tests were made from time to time by the Department of Public Health 
that owing to the large quantity of Coli-type bacteria that the water was not fit, 
according to the known standards, for drinking purposes, and that up to the time 
of the epidemic and from time to time the Department rtotified the defendant that 
a serious epidemic might occur at any time. 
The State’s Attorney has summarized the percentages of positive portions of 
drinking water during the years 1931 to 1939. They are as follows: (Taken from 
the original brief of the State’s Attorney on page 25) 
1931 17.3% 
1932 21.8% 
1933 2.7% 
1934 23.6% 
1935 18.0% 
1936 19.0% 
1937 36.9% 
1938 40.0% 
1939 55.3% 
It is a known fact and the evidence shows that typhoid originates in the human 
body and is carried about by excretion and that typhoid epidmics may be and at 
times are water-borne. Only in one year, according to known standards, did this 
water appear safe for drinking purposes. 
The evidence in this case shows beyond all reasonable doubt that the defendant 
paid no attention whatever to the reports of the Department of Public Health, and 
on the contrary shows that on one occasion when the water situation was being 
69 discussed while he was engaged in his duties at Manteno and the reports of the 
Department of Public Health were being presented to him, he said that the water 
would have to wait, that there were more important things to take care of. The 
epidemic broke out after repeated warnings; that it was water-borne, there is no 
doubt in my mind. The conditions to make it were all there. Visiting truck 
drivers drank the water and became ill with typhoid. Mr. Bowen himself testified 
before the grand jury that he was convinced as well as everybody else that the 
typhoid was due to the water, but that if he had the thing to do over again he 
would do just as he did; and that the only reason for not chlorinating the water, 
which the evidence shows would have avoided the epidemic and make the water 
reasonably safe, was the cost which the record shows is no more than ten to 
fifteen thousand dollars. Why Mr. Bowen refused to heed the warnings of the 
State Health Department, I cannot understand. 
The defense adopts a theory that the epidemic was caused by a patient, Mary 
Ores. I do not believe that this Mary Ores had anything whatever to do with 
the epidemic. Her people visited her from time to time in close contact and nothing 
resulted. As to her (Mary Ores) Mr. Bowen when on the witness stand and when 
asked when he first learned of her and that she was the cause of the epidemic 
stated that it was after he had got into trouble and was looking for an out. 
I must conclude that the evidence shows beyond all reasonable doubt that the 
defendant is guilty in a manner and form as charged in the first count of the 
indictment. The only extenuating circumstance that I can see is the tremendous 
burdens that either the law placed upon him or that Mr. Bowen took upon himself. 
Mr. Bowen is a man approximately seventy (70) years of age and with the ex- 
ception of eight (8) years, has been in the State service since 1909; and to quote 
from the brief of the defendant on page 55, and which is shown by the evidence: 
“As director of Public Welfare he exercised an executive and administrative 
supervision over 25 public, charitable and penal institutions of the State of 
Illinois containing 56,000 patients, inmates or prisoners. These were scattered 
over the State of Illinois from Chicago to Anna and included institutions at 
Alton, Jacksonville, Kankakee, Dwight, Manteno, Menard, Peoria, and Joliet. 
He had supervision of the Board of Pardons and Paroles including supervision 
of parole prisoners. In the penal institutions of the State there were 13,000 
prisoners. In addition to this there were 7,000 persons on parole. In the 
charitable institutions there were 56,000 patients and 2,000 on parole from the 
hospital. In southern Illinois there were held five clinics for tracoma. In the 
Institute for Juvenile Research in Chicago there was held the largest research 
clinic in the world. Five hundred hospital beds are constantly kept and 500 or 
600 persons daily go through the dispensary. 350,000 people a year are treated 
in these public institutions. In addition to this service as Director of Public 
Welfare he was in charge of investigations of and allowance of old age assist- 
ance for which at the commencement of the service there were 138,000 appli- 
cations and now are approximately 225,000. In this old age assistance service 
about $3,000,000 a month is paid out under his supervision. In addition to this 
service he is supervisor of the Federal Social Security Service for handicapped 
children involving about 20,000 crippled children and in addition to this about 
4,000 or 5,000 dependent children placed in homes came under his supervisory 
jurisdiction. There are also 3,000 world war veterans that come within the 
jurisdiction of his service.” 
Through arrangements with the State’s Attorney and Mr. Bowen and his 
counsel, I understand that indictments against Dr. Hinton and Miss Williams are 
to be dismissed on the decision of this case having been made, which understanding 
was reached upon Mr. Bowen having as far as within his power permanently 
removed these people from State service. Their indictments are somewhat similar 
70 offenses of Mr. Bowen’s. Dr. Hinton’s position was local superintendent and Miss 
Williams was the dietitian. 
The judgment of the court, therefore, is, and the clerk is ordered to enter the 
same: The defendant is found guilty in the manner and form as charged in the 
first count of the indictment. 
June 27, 1940 
• ILLINOIS STATE SUPREME COURT 
Docket No. 25947—Agenda 5—October, 1940. 
The People of the State of Illinois, Defendant in Error, v. 
Archie Leonard Bowen, Plaintiff in Error. 
Mr. Justice Shaw delivered the opinion of the court: 
Archie Leonard Bowen, then director of the Department of Public Welfare of 
the State of Illinois, was indicted by a special grand jury in the circuit court of 
Kankakee county for the alleged violation of section 208 of the Criminal Code. 
(111. Rev. Stat. 1939, chap. 38, par. 449.) This act provides a penalty of a fine 
not exceeding $10,000 and removal from office for every person holding any public 
office, who shall be guilty of any palpable omission of duty, etc. It was charged 
that the plaintiff in error failed to take proper measures to render the drinking 
water at the Manteno State Hospital fit for drinking purposes and that, by reason 
thereof, an epidemic of typhoid fever occurred, resulting in many serious illnesses 
and deaths. The cause was first heard by a jury which failed to agree. The 
second trial was before the court without a jury and, by stipulation, was had upon 
a transcript of the same evidence which had been heard by the jury in the first 
trial. The court found the defendant guilty, imposed a fine of $1000 and removed 
him from his office as Director of the Department of Public Welfare, and that is 
the judgment reviewed by this writ of error. 
The plaintiff in error makes a number of contentions, only one of which needs 
to be considered. He urges (1) that the evidence is insufficient to sustain the 
judgment, (2) that the statute under which he was indicted is unconstitutional, (3) 
that the venue was improperly laid in Kankakee county and (4) that the grand 
jury which indicted him was illegally selected. A consideration of the first point 
only disposes of the case. 
It is to be noted at the very outset that Bowen is not a doctor, bacteriologist, 
nor any kind of a scientist, and that for such technical matters he was dependent 
upon the advice of the doctors in the Department of Public Health. He started in 
life as a newspaper man, having been born in 1869, and is now seventy-two years 
of age. From newspaper work he went into public charitable work and thereafter 
into supervising State charitable institutions in which capacity he served under 
five Governors, namely, Dunne, Deneen, Lowden, Emmerson and Horner. He 
served the State of Illinois from 1909 to 1921 and again from 1929 until 1940. Since 
1909, he has served under every Governor except Governor Small, and his original 
commission was obtained under the Civil Service law. 
At the time of the unfortunate events at Manteno State Hospital, which are 
hereinafter set forth, Bowen’s duties were very extensive. The Department of 
Public Welfare, of which he was in charge, had more than ten thousand employees 
under his direction and supervision and these, in turn, had direct supervison over 
the following State Institutions: Ten Insane Hospitals, with 32,000 patients, five 
penal institutions with 14,000 inmates, two institutions for juvenile research, two 
schools for technical education of the blind and deaf, three institutions for veterans, 
an infirmary in Chicago, treating 350,000 patients per year, five clinics for control 
71 of trachoma, treating 4000 to 5000 patients per year, a division of child welfare, the 
State Board of Pardons and Paroles, with supervision of all paroled prisoners 
during their period of rehabilitation, and the division of old age assistance, caring 
for approximately 138,000 pensioners. Without any effort at a detailed statement 
of the entire record, it is apparent from a mere recital of the foregoing facts, that 
the Manteno State Hospital could not have been expected to receive more than a 
small portion of the time of the director and the appropriations for the department. 
The first case of typhoid fever at the Manteno State Hospital occurred in July, 
1939, which was approximately the period of incubation for the typhoid bacillus 
after the admission of one Mary Ores, whose case will be noted later in this opinion. 
The next case was on or about August 15, 1939, and others followed swiftly there- 
after until a total of 411 cases had developed. Nothing out of the ordinary, in 
the way of an epidemic, took place prior to August IS, 1939, at which time Bowen 
was taken rather desperately sick with a streptococcus infection, and, for several 
weeks and during the height of the epidemic, was so far disabled as to not know, 
except by hearsay, during part of the time, as to what the Department of Health 
was doing at the Manteno State Hospital. 
It was the theory of the People that the epidemic was caused by pollution of 
the drinking water at the hospital, which came from four deep wells. The record 
indicates that the terrain at that place is underlaid with a creviced niagaran lime- 
stone, which is of such a character as to permit the sub-surface drainage of water 
to get through without being filtered. There were four wells, varying in depth 
from 227 feet to 1760 feet, and these were cased from the surface of the ground 
to varying depths. It is a further theory of the People that sewage escaped from 
the sewage disposal system of the hospital and, percolating through this creviced 
limestone, entered the various wells and thereby caused a pollution which brought 
about the epidemic of typhoid. It is contended that it was the defendant’s duty 
to have a chlorinating plant installed, or by some other means to have prevented 
this alleged contamination. In this connection, it is. to be noted that it was neither 
alleged nor proved that the defendant had any authority to expend the necessary 
eight or ten thousand dollars for a chlorination plant, nor that the Department of 
Health of the State of Illinois had ever recommended it. 
It appears from the record that the State Department of Health has laboratories 
at Springfield, which regularly, at approximately monthly intervals, examines 
samples of drinking water from the various State institutions, and that this depart- 
ment has a series of stock-form recommendations numbered from 1 to 14 which are 
stamped on the back of the reports sent to the various institutions. These analyses 
of drinking water are made by chemists or bacteriologists and not by doctors nor 
by any one qualified to express any medical opinion. It seems that the routine pro- 
cedure is for the examiner, who is sometimes a recently graduated chemical student, 
to note form number so and so to be stamped on the back of the report, which is 
done accordingly. Some of these forms say “the above analyses shows that the 
water is contaminated at the time samples were taken and was not entirely safe for 
drinking purposes.” Other forms are “the above result shows that the water at 
the time of sampling was safe to drink. The continued safety of the supply is not 
assumed however. See previous reports and correspondence.” The court admitted 
in evidence about 158 of these periodic reports, ranging in time from March, 1931 
to October, 1938, and ranging in results from a statement of contamination in some 
of them to a statement in the latest of them that the water was safe for drinking 
purposes. There is no report of any examination within 7 or 8 months of the out- 
break of this epidemic. 
It is fully apparent from the record that no miscroscopic examination was ever 
made for the presence of typhoid bacillus and there is no evidence to indicate that 
typhoid bacillus was ever mentioned to the defendant until after the outbreak of 
this epidemic. The recommendations and opinions written or stamped on these 
72 reports were clearly not admissible in evidence for a number of reasons: They did 
not show who made the examination, they did not show that the person who made 
the examination was qualified to make any recommendation and they constituted 
merely a voluntary comment by an unqualified person not present to testify in 
person nor subject to cross-examination. The most that can be said for any of 
these 158 exhibits, is that it showed the water to be either positive or negative as to 
colt aerogenes. 
It appears from the record that colt aerogenes or colon bacillus may be friendly 
or inimical, and that the mere presence of the colon bacillus in water proves exactly 
nothing so far as typhoid fever is concerned. The tests seem to have been made 
by a method of broth fermentation, and determined nothing more than the presence 
or absence of some kind of colon bacillus. It further appears that this type of 
bacillus is present in the air one breathes, in milk, on fruits and practically every- 
where. 
It is further apparent that colon bacillus may be of the fecal or non-fecal type 
and that so far as typhoid is concerned it is only the fecal type from man alone 
(not from animals) that can spread the disease. The typhoid bacillus could not 
possibly have been identified by the laboratory means used in any of these reports 
and none of them is of any value to the People in an attempt to prove the guilt of 
the defendant. It should again be noted as above, that Bowen was not a doctor 
nor a bacteriologist, and that all of these reports passed through the hands of Dr. 
Andy Hall or Dr. Frank Jerka or Dr. Baxter in the Department of Health and that 
none of them either directly or indirectly ever mentioned typhoid to Bowen. 
Even if these reports were of any probative value they would necessarily tend 
to disprove, rather than prove a case against the defendant. The water from 
these wells was consumed by all the inhabitants of Manteno for more than eight 
years prior to this epidemic. This test over a period of eight years, if looked upon 
as a laboratory experiment, would go a long way toward proving that the water 
actually was safe for human consumption, because there is no evidence of any 
abnormal condition as to typhoid occurring during that period of time. It is diffi- 
cult to think of any better proof that could be offered that the water was free from 
typhoid bacillus and that the epidemic was not water-borne. The conclusion that it 
was not water-borne was also proved by an exceptionally well-qualified and ex- 
perienced expert witness, who based his conclusion on the People’s own exhibits. 
Still another reason for thinking that the epidemic was not water-borne is neces- 
sarily inferred from a total failure to prove that there existed any defect or leak 
in the sewage system. 
The People offered the expert testimony of a young doctor employed by the De- 
partment of Public Health. This witness prepared a number of charts showing such 
essential points as the number of cases beginning on particular days during the 
epidemic, whether the afflicted person was an employee or patient, the age group 
of the various patients, their sex, whether or not they were food-handlers, the lo- 
cation of the patients within the numerous buildings, constituting the entire hos- 
pital, the number of cases in each separate building, with dates of incidence of 
the disease and other pertinent facts. This doctor was neither asked nor expressed 
any opinion as to whether the disease came from the water supply. The record 
discloses that at least ten qualified physicians in the employ of the Department of 
Public Health were at Manteno during the epidemic and not one of them was even 
asked by the People to express an opinion as to whether or not the epidemic had 
been caused by the drinking water. In fact, only two or three of them were called 
at all as witnesses, and one of these, Dr. Baxter, was later called by the defendant 
and testified that in his opinion the disease was not caused by the water. There 
is thus a total failure to prove, even by the opinion of experts, that the disease 
was caused by the drinking water as charged in the indictment. 
73 At this point it is desirable to consider the case of Mary Ores, who has hereto- 
fore been mentioned in this opinion. This patient was admitted to the hospital 
June 12, 1939, which, according to the medical evidence, was about the normal 
period of incubation for typhoid bacillus before the first case of that disease oc- 
curred in the institution. She was so insane as to require feeding by tube through 
her nose, and refused to remain in bed, getting up continuously and roaming about 
the ward in which she was a patient. Physically, she was gross and filthy. She 
weighed approximately two hundred pounds, ran a constant temperature of from 
99 to 103 degrees, suffered from a large carbuncle on her neck which required 
surgical treatment, and had an uncontrollable diarrhea, which she either did not 
or could not restrain. As a result, her person, clothes and her bed were constantly 
defiled with bodily excretions. At that time no one either had or could have 
diagnosed her case as typhoid, and she was, therefore, constantly and by the 
most virulent methods, exposing others in the ward, her nurses, attendants and 
those who handled her food and laundry. She was taken from her ward to a surgi- 
cal ward for treatment and from the surgical to the non-surgical part of the hos- 
pital for a time, and later on returned to a different ward. She was moved several 
times and there is in evidence a large plat showing the exact places in the institu- 
tion where she was from time to time. Her symptoms did not become such as to 
permit a diagnosis of typhoid to be made until two or three weeks after her ad- 
mission and she died of that disease on August 30, 1939. Without detailing the 
testimony, it is sufficient to state that the first twenty-six cases of typhoid were 
medically directly traceable to this woman and that it is also true, from a medical 
standpoint, that all of the cases might be accounted for by either direct or indirect 
exposure to her and to those whom she infected. 
The defendant offered the expert testimony of Dr. L. Loyd Arnold, who testi- 
fied without compensation and whose testimony is in no manner impaired or im- 
peached. In addition to the usual medical degrees, this witness had studied four 
years in Europe at the University of London, University of Oxford, at the Institute 
of Tropical Medicine in Hamburg, Germany, at the University of Goettingen, at 
the University of Munich and the University of Quebingen. His experience in- 
cluded service as biochemist at the Barnes Hospital in St. Louis, as pathologist at 
Nashville City Hospital and other such employments. At the time of his testimony, 
he was professor of Bacteriology and Public Health at the College of Medicine at 
the University of Illinois, Professor of Bacteriology in the College of Dentistry at 
the University of Illinois, and also in the College of Pharmacy of that institution. 
He had previously served as professor of Pathology, Bacteriology and Public Health 
for five years' at Loyola University, School of Medicine, and as director of labora- 
tories for seven large Chicago hospitals. For eleven years he served as bac- 
teriologist in the Illinois Department of Public Health, in charge of its Chicago 
laboratory and was also, at the time of his testimony, a member of the Chicago 
Board of Health. During all of his experience, he had specialized in public health 
matters and epidemics. His experience with the latter included several studies in 
the field in the examination of actual epidemics which had occured in various 
places. This witness considered, analyzed and explained the various charts above 
referred to, which had been made by Dr. Eberhard and as to which Dr. Eberhard 
had expressed no opinion. It is the opinion of this witness that Mary Ores was 
suffering from a latent and not yet developed typhoid when she entered and while 
she was in the hospital, and that the epidemic was traceable to her. His reasons 
for this opinion are not only reasonable, but clear and convincing. He was quite 
positive that this was not a water-borne epidemic and we think the record proves 
this to be the fact. 
It would unnecessarily prolong this opinion to make any further or more detailed 
analysis of the testimony of the great number of witnesses who were called. From 
what we have already said it is fully apparent that the People failed to prove the 
74 defendant guilty and that no guilt could even be assumed, unless at the same time 
many facts not proved by the record were also assumed. It was not proved, and 
we cannot assume that any typhoid bacillus was ever found in the drinking water. 
It was not proved and we cannot assume that there was ever any leak or defect 
in the system of plumbing and sewage disposal, or that any such contamination 
entered either of the wells. In the face of the testimony of Dr. Arnold, it would 
be extremely presumptuous for any layman to assume that the infection came from 
any other place than the body of Mary Ores. On the other hand, we think the 
evidence clearly and satisfactorily establishes that the infection did come from that 
person and that the record, fully considered and properly construed, shows nothing 
at all to indicate any guilt on the part of this defendant. 
In view of our opinion of this matter, it is unnecessary to consider any other 
errors assigned and it is not necessary to remand the cause for any further pro- 
ceedings. 
The judgment is reversed. 
Judgment Reversed. 
75