"Typhoid Mary, Part 2
Mary Mallon has the distinction of being the first typhoid fever carrier to be identified and charted in North America. An Irish-born cook, Mallon hired out her culinary services to wealthy New York-area families. In the summer of 1906 she found employment in the rented summer home of a New York banker, Charles Henry Warren, in Oyster Bay, Long Island. When typhoid fever struck six people in the household of eleven, the owner of the home, George Thompson of New York City, thinking he would be unable to rent the property again unless the mystery of these cases could be solved, hired George Soper, a civil engineer known for his detailed epidemiological analyses of typhoid fever epidemics, to investigate the outbreak. 17 Soper's inquiry first ruled out the common causes of such outbreaks, contaminated water and milk, and he systematically discarded other possible sources of infection, including clams from the bay and other foodstuffs consumed in the house and any contacts family members had With people outside. When none of these alternatives yielded viable explanations, Soper pressed family members to remember any other distinctive events that might have taken place during the period. Through close scrutiny Soper found his clue: he learned that the family had changed cooks during the weeks in question.18
Believing the cook who left the family three weeks after the outbreak to be a prime suspect, Soper worked next on trying to find her. Although the family claimed that the cook had been in perfect health, Soper, who undoubtedly knew about healthy carriers of other diseases and might have been reading (as he later claimed) literature from Germany and elsewhere in Europe about healthy typhoid fever carriers, expressed confidence that such a person was most likely to have caused this particular household outbreak. 19 By tracing the cook's job history before her arrival in Oyster Bay in August 1906, he found eight families who had previously employed her; in seven of them typhoid fever had followed her stay. 20 Soper was convinced that if Mary Mallon could be found, and her feces and urine tested, he could prove in the laboratory what his epidemiological study had already suggested: that she, although healthy, had transmitted typhoid fever to those who unsuspectingly ate the food she prepared.
ÝMary Mallon's apprehension in March 1907, in the Park Avenue home in which she was then employed, was dramatic and, for her, frightening. George Soper appeared without warning and tried to explain that Mallon was spreading disease and death through her cooking. The story seemed preposterous to the healthy Mallon, who promptly threw him out of the house. 21 But Soper persevered. He convinced the New York City health department, led by Hermann Biggs, that the epidemiological evidence implicating Mallon was strong enough that they should pursue her and gather specimens of her blood, feces, and urine. When approached by city health officer S. Josephine Baker, Mallon still did not understand the demands (how could she, being the first of her kind?) and refused to provide the evidence. Baker called in the police to help, and the officers took Mallon by force and against her will to the Willard Parker Hospital, New York's receiving unit for those suffering from contagious diseases. There they subjected her excreta to careful laboratory analysis. 22 Finding high concentrations of typhoid bacilli in her feces, authorities kept her in health department custody, moving her to an isolation cottage on the grounds of the Riverside Hospital on North Brother Island. In 1909, more than two years after her apprehension, she unsuccessfully sued in court for release; in 1910 a new health commissioner unilaterally decided that the department had kept her long enough and freed her. She was arrested again in 1915 after officials traced a hospital outbreak of typhoid fever to her kitchen. This time she stayed in custody until her death in 1938. She lived in health department-imposed isolation for a total of twenty-six and one-half years.
In some ways Mallon's case epitomized the health benefits that accrued from application of the new science of bacteriology, showing the importance of the laboratory as a supplement to or even substitute for physical examinations. By targeting the attack on typhoid to those individuals who could be identified as dangerous by laboratory methods, the health department streamlined its efforts. By getting Mary Mallon off the streets and out of the homes of citizens, health officials believed that they were protecting the public's health in the best possible way. Yet this protection came at the expense of Mallon, who was denied her liberty for over twenty-six years. This extreme control over the behavior of a single healthy carrier could not, for reasons both practical and political, be repeated for the hundreds of other carriers that would be identified in New York City. As the Medical Record put it: "It is evident that they cannot all be segregated and kept prisoners.... It would be difficult to obtain popular sanction to such interference with the liberty of apparently healthy individuals, and even if the measure were recognized as justifiable the number of bacilli carriers would render it difficult of execution."23 Thus, using what they learned from their experience with Mallon, the health officials developed treatment protocols and regulatory guidelines that could be widely applied. The remainder of this essay examines the laboratory investigations, the treatment procedures and guidelines, and the concept of indefinite isolation to determine whether these activities, based heavily on the science of bacteriology, reduced the scope of health department work.
The laboratory to which Mallon's specimens were brought, part of the Division of Pathology, Bacteriology, and Disinfection within the health department, was the dream of Hermann Biggs; Charles Chapin described it as "perhaps the most important step in modernizing public health practice in the United States." Biggs hired William H. Park, a physician trained at Columbia University College of Physicians and Surgeons and in the scientific laboratories of Vienna, to organize the bacteriological laboratory in 1893, and he remained as its director until 1936. Park and his colleagues carried out studies that put New York in the forefront of bacteriological investigation in the United States. Among their more important works were their studies of healthy carriers. 24 Mary Mallon, because of her long stay under department auspices, provided much of their longitudinal data on typhoid fever carriers. 25
ÝMallon's feces received close laboratory attention from 20 March 1907, when she was first brought to the hospital, until she sued for release, the last examination recorded in the courtÝ records occurring on 16 June 1909. More examinations were undoubtedly made after her second incarceration in 1915, but for these the data are not available. In the twenty-eight months for which we have data, health officers collected 162 fecal specimens, an average of more than one a week. In Mallon's words: "When I first came here they took two Blood Cultures and feces went down three times per week say Monday Wednesday & Friday respectfully [sic] until the latter part of June after that they only got the feces once a week which was on Wednesday . . . when I first came here I was so nervous & almost prostrated with grief and trouble."26
The laboratory analyses revealed that Mallon was an intermittent carrier of typhoid fever. Repeatedly over this time her feces contained no typhoid bacilli at all; the laboratory reports were negative for twelve consecutive examinations from 16 September through 14 October 1907. In an on-again, off-again pattern over the twenty-eight months, 119 of the 162 cultures tested positive, 43 negative. Her urine consistently tested negative.
While the city was conducting its laboratory tests, Mallon arranged for her urine and feces to be analyzed by a private company, the Ferguson Laboratories. The specimens were brought to them by Mr. A. Briehof, whose relationship to Mallon I have been unable to learn. George Ferguson conducted ten tests on Mallon's urine and feces between 1 August 1908 and 30 April 1909, concluding. "I would state that none of the specimens submitted by you, of urine and feces, have shown typhoid colonies."27 Comparison of the dates of Ferguson's analysis with those of the health department's analysis reveals that of the ten negatives the private laboratory found, eight were reported during weeks when Mallon's feces tested positive in the city laboratory. Mallon herself, even while denying the validity of the laboratory test to confirm the presence of a disease that she insisted she had never experienced, used the Ferguson Laboratories' negative findings to bolster her case in court. 28
Similarly, the health department used the predominantly positive city laboratory reports to make its legal case, to insist to the court that it was necessary to isolate Mary Mallon. Dr. Fred S. Westmoreland, the resident physician at Riverside Hospital on North Brother Island, in whose care Mallon was placed, offered the following conclusion before the judge:
The laboratory reports formed the central argument in the health officials' case. Without them, the court probably would not have kept Mallon in isolation; with them, the case seemed clear to the Honorable Mitchell L. Erlanger, who ordered that the writ should be dismissed and "that the said petitioner, Mary Mallen [sic], be and she hereby is remanded to the custody of the Board of Health of the City of New York."29 Even though the laboratories had issued contradictory reports, the seemingly incontrovertible evidence of repeated positive typhoid cultures in the city laboratory reports made Mary Mallon's danger palpable.
Given the laboratory evidence, and again illustrating its narrowed focus on that evidence, the health department addressed the question of how to eliminate Mallon's infectiveness. According to Westmoreland's testimony, "Hexamethylenamin in doses gradually increasing from one hundred to one hundred and fifty grains a day has been given frequently with no apparent benefit. Attention to diet and mild laxative has caused the greatest reduction but not [the bacilli's] disappearance." Mallon provided more details of her therapy, which she portrayed as punitive: "In spite of the medical staff Dr. Wilson ordered me Urotropin I got that on & off for a year sometimes the[y] had it & sometimes the[y] did not. I took the Urotropin for about 3 months all told during the whole year if I should have continued it would certainly have Killed me for it was very Severe[.]" Mallon indicated that the physicians had also tried brewer's yeast, but "at first I did not take it for Im a little afraid of the people & I have a good right for when I came to the Department the[y]] said [the bacteria] were in my track later another said they were in the muscels [sic] of my bowels & laterly the[y] thought of the gall Bladder."30 This lack of medical precision convinced Mallon that the doctors did not know what they were doing.
In addition to trying various drugs, health officers urged Mallon to have her gallbladder surgically removed:
Although the physicians urging surgery on Mallon did not inform her of its poor record, in 1921 the department of health had followed five carriers who had agreed to the removal of their gallbladders, "all of them without success." 31 It seems that Mallon's skepticism was warranted.
The emphasis on laboratory findings, together with the drug therapy and proposed surgery, indicates the extent to which health department thinking concentrated on the bacteria themselves rather than on a more comprehensive approach to eliminating the dangers Mary Mallon posed. Health officers asked how they could kill the bacilli that Mallon was transmitting; they did not ask how to stop a carrier cook from cooking. If they had considered the second question, they might have focused on teaching Mallon ways to cut her infectivity by washing her hands thoroughly and by not preparing raw food for anyone else and on helping her learn new skills. She was literate and spunky; her talents presumably could have been turned to other uses if health officials had put their minds to it. By the time of Mallon's second incarceration there was precedent for moving in this direction rather than insisting on strict isolation of healthy typhoid carriers. At the Pasteur Institute in Paris the bacteriologist Ilya Metchnikoff had found employment in a library for a healthy carrier whose case interested him. In 1918 New York State began subsidizing the incomes of those carriers who were having difficulty finding adequate employment outside the food industry. Indeed, the New York City health department itself maintained the numerous carriers it identified outside of isolation, with an increasingly elaborate set of guidelines governing their behavior. 32
Health officials outside of New York City--including, most significantly, Charles Chapin of Providence and Milton L. Rosenau of the U.S. Public Health Service's hygienic laboratory, both advocates for bacteriologically based changes in public health activity--objected to the stringent isolation of Mary Mallon. As Rosenau stated at the very first meeting at which George Soper had revealed Mallon's capture and isolation, in April 1907, "It is not necessary to imprison the bacillus carrier; it is sufficient to restrict the activities of such an individual." Chapin concluded his 1910 analysis of how healthy carriers should be handled with an indictment of the incarceration of Mallon: "What result is secured by keeping her in confinement, other than the placing of discredit on public health work, it is difficult to see." 33 Both believed isolation too strong a penalty, as well as an impractical remedy, for healthy carriers. For these two prominent public health officials, bacteriology, while emphasizing the importance of germ hosts, did not reduce the problem to one of removing such carriers from society. 34
Yet Mary Mallon herself remained in lifelong isolation. Walking the streets of New York City, she would have posed no health hazard; working in an occupation other than cooking food for others, she would not have been a "constant menace to the public health." Nonetheless, there is no evidence that health officers tried to retrain Mallon until the final years of her isolation. When the new health commissioner released Mallon in 1910, he helped her find work in a laundry, but he did not succeed in tapping her interest or potential, and the change in occupation did not stick. Only in the last years of her life, immediately before her paralyzing stroke in 1932, did a physician at Riverside Hospital train Mallon to work in the hospital laboratory. 35 The energy and commitment of the particular bacteriologically guided health officials who supervised her isolation rested not with social rehabilitation but with the pathogenic bacilli?clearly indicating a narrowing of the focus of health-related work.
Elsewhere in New York's health department activity there is evidence of broader thinking about the problems that healthy carriers posed. Soon after Mallon's apprehension the city health department discovered many other healthy carriers of typhoid fever, most of whom were working in food-handling occupations. The numbers grew with the years: in 1908, the city watched only five carriers (including Mallon); by 1920, eighty-five were under observation; and by 1938, the year of Mallon's death, the health department listed 394 healthy typhoid fever carriers in the city. 36 In its efforts to limit the potential dangers such people posed, the health department implemented guidelines for their regulation, intended to curtail behaviors that might be dangerous to the public health. In 1916, the year following Mary Mallon's final incarceration, the rules were in place, although modifications continued over the years. The guidelines bear close examination. Through them we can understand how health officials, after almost ten years of experience with healthy carriers of typhoid fever, came to interpret the problems they posed. In these guidelines we add another dimension to our understanding of how germ theory affected public health work.
Health department rules forbade any person sick with an infectious disease to handle food. Although rarely enforced in the period before healthy carriers were known to exist, no doubt because of the enormity of the problem, this precept provided the precedent upon which regulation of healthy carriers rested. After Mallon's second incarceration, health inspectors took the potential danger of healthy carriers more seriously than they had previously. In 1916 the rules that had been written to curtail the activity of the sick began to be applied also to healthy carriers of infectious diseases. The health department Bureau of Preventable Diseases, through its occupational clinic, began requiring that the estimated ninety thousand food handlers in the city's hotels and restaurants produce "certificates of freedom from infectious disease" before they could be employed. This regulation included the mandate that fecal specimens of healthy people must be free from pathogenic bacteria. 37
