Report on Outbreak of Typhoid Fever in the State Hospital, Trenton.

BY HENRY MITCHELL, M.D., SECRETARY.

The State Hospital for the Insane, located about two and onehalf miles from the City Hall, but just within the boundary limits of the city of Trenton, was established in 1847, and until last spring no case of typhoid fever had developed on the hospital premises. The site was originally selected because of the spring which was located there, and this spring furnished all of the water used in the institution until about the year 1896, when three wells were drilled to increase the supply of water. Water was pumped from the spring and from the wells into a standpipe, and distributing mains and branches conveyed it to all of the various buildings on the hospital premises. Because the persons who were first attacked with typhoid fever were located in a wing of the main building nearest to the spring, and because the pipe supplying water to that wing also carried the water from the spring to the standpipe, a theory was considered early in the course of the inquiry which was made to trace the source of the infection, that the spring water was the medium through which the disease was being conveyed, but when the epidemic ceased, and all of the facts relating to the outbreak were on record, it was found that the disease did not attack persons who were not, either directly or indirectly, in contact with the sick or convalescent fever patients. The water which was obtained from the spring reached the standpipe without doubt, and it was there thoroughly mixed with the water pumped from the wells, and all of the buildings were connected with the mains through which the standpipe water was dis- . tributed, but no case of typhoid fever occurred in the annex, in which 400 inmates were confined. The deductions drawn from these facts and from negative investigations directed to the food

supply are stated in the reports which follow, copies of all of which were forwarded to the managers of the hospital.

To the Board of Health of the State of New Jersey:

GENTLEMEN-Recent inquiries show that new cases of typhoid fever have continued to occur among the inmates of the State Hospital, Trenton, at the average rate of about one each day, up to and including August 13th, and among the conditions which at present favor the spread of the disease in the institution the following have been noted:

1. Convalescents freely mingle with the other inmates in the wards and dining-rooms, and through this agency infection and reinfection of dishes, doorknobs, chair-backs, &c., is constantly occurring.

2. Insane inmates are still retained in service in the kitchens and diningrooms, and therefore there can be no assurance that orders and instructions requiring sterilization of spoons, forks, cups, &c., will be faithfully carried out. In view of these facts it is recommended that measures be at once taken to separate all convalescents from other inmates, and to immediately discontinue to permit any patient in the institution to assist in the kitchens or diningrooms, or to have access to any portion of the building where the food is prepared or where the dishes are washed.

Very respectfully,

August 16th, 1907.

HENRY MITCHELL,

Secretary.

To the Board of Health of the State of New Jersey:

GENTLEMEN-During a visit to the State Hospital, Trenton, made this day, it was learned that no new case of typhoid fever has occurred in the institution since August 13th, a period of nine days. In the course of an inspection of the central kitchen, the kitchen in the west wing and the kitchen in the annex, certain defects in location, construction, arrangement, lighting, ventilation and management were observed, and attention is particularly called to the following conditions: The central kitchen is located in the basement of the main building. The ceilings are low, the window space is small, one cell-like room containing two steam kettles has no window, artificial light being depended upon entirely. The sinks are made of wood and are worn out, the floors are constructed of wood, the refrigerator is worn out. The west kitchen is better located and better lighted than the one just described and it is conducted in a more cleanly manner, but in its location and construction it is not well adapted to the cleanly preparation of food. The kitchen in the annex is superior in construction to those above referred to, but it also is defective in certain particulars (wooden floors and sinks). The dishes, spoons, forks, &c., used by the insane inmates are washed by the inmates in wooden sinks in the dining-rooms. No reliance can be placed upon the faithfulness of these persons, and there is good reason to believe that the dish-washing performed by them cannot be depended upon to remove infective substances from the dining-room utensils.

Accumulations of dirt from the hands of the patients and attendants were found to be encrusted upon the doors of the kitchens and dining-rooms, and appearances indicate that these surfaces are never washed. Upon inquiry information was given by Mr. Fleitchman showing that neither the warden nor the medical officers of the hospital have accepted responsibility for cleanliness in the dining-rooms, and consequently there has been gross neglect in this

department. In the annex, where 400 inmates are fed, only three paid employes are provided, and the inmates are depended upon to render all of the additional service which may be required.

The inspection also shows that the polluted spring, located near the laundry, has not yet been filled with earth and rendered inaccessible as a source of watersupply.

August 22d, 1907.

Very respectfully,

HENRY MITCHELL,

Secretary.

At a meeting of the State Board of Health, held September 11th, 1907, the following action was taken:

WHEREAS, A report on file in this office, dated August 22d, 1907, draws attention to certain defects in the construction, equipment and management of the kitchens and dining-rooms of the State Hospital, Trenton.

'Resolved, That in the judgment of this board the kitchens in the main building, because of their lack of light and ventilation, and because of their location and construction, are unsuitable for the preparation of food. All kitchens should be provided with ample openings for light and air; the floors should be impervious to water; the sink should not be made of wood or other absorbent material, and all openings should be screened against the entrance of flies.

Resolved, That in the opinion of this board the health of the inmates of the hospital is jeopardized by permitting the insane patients of the institution to aid in the performance of any duties which relate to the preparation, distribution or handling of the food, and we recommend that none but paid employes shall be entrusted with this service.

Resolved, That we further recommend that one capable and reliable person shall be fully authorized to have supervision over all storerooms, kitchens and dining-rooms, and that all employes in those departments be placed directly under his control; that said supervisor be held responsible for the maintenance of cleanly conditions and practices in and about said kitchens, storerooms and dining-rooms.

Resolved, That this board advises that there be no further delay in permanently closing the polluted spring, located near the laundry, by filling said spring with clean earth.

FINAL REPORT.

To the Board of Health of the State of New Jersey:

GENTLEMEN-Twenty-eight days have now elapsed since a new case of typhoid fever has been reported from the State Hospital, Trenton, and we may therefore conclude that the epidemic which recently prevailed in that institution has finally ceased.

To briefly review the important facts having relation to this outbreak it may be stated that the first case occurred April 8th, 1907, in the person of an inmate of the hospital, located in the west wing of the building, who probably contracted the disease in the city of Trenton. Subsequent cases occurred in the same wing, and up to August 13th eighty cases had appeared in the hospital with sixteen deaths. All of these cases were located in the main building of the institution and no cases occurred in the annex, notwithstanding that more than 400 of the inmates of the institution are cared for in that building.

Twenty-three employes and other residents in dwellings on the hospital premises were affected with the disease. Investigations concerning the food-supply, including milk and water, were negative, except that colon bacilli were found in the water of the spring from which a portion of the water provided for the hospital premises was obtained. Suspicion was at first directed to the water of this spring as the medium through which the infection was spread, but in the light of later developments it now appears improbable that the spring water had any influence whatever in conveying the infection, and we are led to the final conclusion that the disease was transmitted directly from patient to patient and through the agency of utensils and food infected within the building. This conclusion is justified for the following reasons:

1. The disease first appeared in the west wing of the main building and spread to other inmates in this wing, and as facilities were not provided for the isolation of convalescents, the infection was communicated by them to other susceptible inmates.

2. The spoons, forks, cups, &c., used in the dining-rooms were washed by the insane inmates, without boiling, and, in the course of the epidemic, every utensil in the building probably became infected, thereby exposing the food which entered the building to infection as soon as it was received.

3. The filthy habits of many of the insane inmates of the hospital probably caused infected discharges to be generally distributed in the bathroom, upon the furniture, door-knobs and other surfaces touched by the hands of the infected persons.

4. From the west wing the infection was carried to other portions of the main building, but as above stated not a single case occurred in the annex, indicating that the infection was not conveyed by milk or water, for the supply of both of these articles was from the same sources for both buildings. The water-supply for all of the buildings on the hospital premises was taken from the same piping system, and in the standpipe, located near the annex, the water which was pumped into the mains from the spring and from the wells was undoubtedly thoroughly mixed before distribution to the various branches and service lines.

5. Inquiry has shown that communication between the infected kitchens of the main building and the dwellings of employes, where cases of typhoid fever occurred, was frequent.

RESTATEMENT.

1. Typhoid fever was brought to the State Hospital, Trenton, by an inmate who was admitted February 16, 1907, the diagnosis being made April 8th. This patient was located in the west wing.

2. The room-mate of the first patient contracted the disease, and also numerous other inmates in the same wing.

3. These persons were not isolated during their convalescence, and new cases continued to appear in the west wing and the disease was undoubtedly spread from patient to patient.

4. The disease did not attack the inmates located in the annex because they were not brought into contact with infected persons.

5. The disease finally subsided when all susceptible persons who were exposed to the infection had suffered an attack.

Very respectfully,

TRENTON, N. J., September 11th, 1907.

HENRY MITCHELL,

Secretary.