The effects of bacteriology on public health theory and practices can be understood vividly through the activities of Charles V. Chapin, whose forty-seven-year career as superintendent of health for Providence, Rhode Island, spanned the turn of the twentieth century. Chapin’s enthusiasm for bacteriology turned him against many of the old practices that had derived from the notion that filth caused disease. Through his one-sided approach, we can best understand the lure of the new science. James H. Cassedy, Chapin’s biographer, has portrayed the excitement of those years for people engaged in efforts to protect and promote the public’s health.25 Laboratory experiments led to frequent announcements of new microbes, which in turn provided links to understanding diseases that had baffled scientists and decimated populations. The hope and promise of these revelations carried Chapin and many public health workers on a wave of optimism, as they scrambled to incorporate the findings into their daily tasks. Chapin became the nation’s leading proponent of using the new science to change the focus of public health work away from broad environmental sanitation to a narrower search for microbes to destroy. In 1902, he wrote an impassioned article claiming that bacteriology “drove the last nail in the coffin” of the old filth theory of disease. Sanitary reforms, such as cleaning streets and collecting garbage, were no longer necessary, Chapin claimed, because it would “make no demonstrable difference in a city’s mortality whether its streets are clean or not, whether the garbage is removed promptly or allowed to accumulate, or whether it has a plumbing law.”26
While today we recognize a link between poor sanitation and germ propagation, Chapin, in his eagerness to get people to accept invisible microorganisms as the single cause of disease (an idea some medical and many lay people initially distrusted), appeared to discard notions about filth—which he agreed might be aesthetically distasteful but not itself dangerous to health—and attacked the old practices one after another. For example, in one of his most influential papers he decried as a “fetich” the common practice of fumigating with steam or formaldehyde the rooms in which the sick had suffered or died.27 Chapin worked to replace city-wide clean-up programs with ones focusing on living human germ carriers (those persons sick or carrying infectious diseases) and encouraging personal habits that would protect individuals from the people around them. While Chapin remained optimistic about what the new science of bacteriology could offer, he never promised that bacteriology alone could “stamp out” disease.28 He understood how hard it would be to implement what were to a large extent changes in personal behavior.
Chapin emphasized a new worry that had been uncovered by recent bacteriological studies: the risk posed by healthy carriers, people who themselves were not sick but who could nonetheless infect others. The Providence health officer became the nation’s preeminent leader in educating the public (and his peers) about these hidden dangers:
Neither you, nor I, nor the Board of Health, know where these [carriers and missed cases] are. The occupant of the next seat may, for all one knows, be a diphtheria carrier, so may the saleslady who ties up the package, the conductor who gives the transfer, or the expressman who leaves a parcel at the door. The dirty man hanging on the car strap may be a typhoid carrier, or it may be that the fashionably dressed woman who used it just before was infected with some loathsome disease. If these people were sick in bed we would avoid them. As it is we cannot. Science has shown this new danger.29
Chapin believed that as experimental and laboratory studies revealed new sources of exposure to infectious diseases, citizens had to assume an increasing responsibility to try to avoid them:
Contact with the fresh secretions, or excretions, of human beings, is the most important source of infection for most of our common contagious diseases. By turning the face from the coughing and loud talking of our neighbors; by putting nothing in the mouth except clean food and drink; by never putting the fingers in the mouth, or nose; most contagious diseases can be avoided. Wash the hands well before eating and always after the use of the toilet. Teach this to the children by precept and especially by example.30
Chapin not only preached the new gospel of individualized public health, he also put the new science into practice by newly prioritizing public health procedures.31 He pleaded with his fellow health officers to adopt a “more rational perspective” by directing their efforts toward the isolation of infectious diseases, medical inspection, vaccination, and laboratory investigation of milk supplies, instead of to abatement of nuisances and municipal housekeeping.32
Over time, other health officers and health departments around the country adopted many of these precepts. The health department in Milwaukee, Wisconsin, for example, had given up control over water and garbage to the department of public works by 1911.33 The emphasis of local health work changed from city-wide sanitation and disease control to closer observation of individuals, their habits, and their potential to carry disease. Most health officers believed that it was possible and even financially necessary to keep many older sanitation activities and adapt them to coexist with the new bacteriological programs rather than to begin anew, as Chapin’s rhetoric suggested. Indeed, since microbes bred in unsanitary environments, the two theories seemed compatible.
Concomitant with the shift in emphasis in public health work, bacteriological laboratories with their microbe-identifying capabilities became the single most crucial tool in identifying the people and the problems to which health departments should attend. During the “golden age of bacteriology,” in the words of one of the country’s leading public health theoreticians, Charles-Edward Amory Winslow, “the laboratory . . . [was] the scientific foundation of the public health campaign in America.”34
Typhoid fever was one of nineteenth-century America’s most serious health problems, and its history illustrates how the new science of bacteriology worked alongside the old filth theories to contribute to curtailing the incidence and deaths caused by the disease. (Today, clean water supplies and antibiotics have made typhoid fever a minor statistic in the full picture of disease dangers.)35 Science’s understanding of microorganisms and their role in disease transmission added to efforts already begun in the pre-bacteriological era to alleviate the worst of typhoid fever’s devastation. In the minds of bacteriologists and medical scientists of the period, the disease provided an excellent example of how science could save lives.
In the mid-nineteenth century, when scientists first distinguished typhoid fever from typhus as two distinct diseases (caused by different microorganisms), the former was already causing significant public health problems in American cities.36 A water- and food-borne systemic bacterial infection, typhoid brought sustained fever, headache, malaise, and gastrointestinal problems (constipation or diarrhea) to its victims. A few days following exposure, the patient experienced headache, loss of appetite, and chills. The body temperature slowly rose—to 104 or 105 degrees—and could remain high for two weeks; with only cold baths to relieve the fever, it often did not disappear for four weeks or more. Victims developed a characteristic rash on the abdomen and chest, which lasted for a few days. Severe cramping, tenderness, and diarrhea added to the patient’s woes. Sick for over a month, the patient weakened and became susceptible to complications. Although many mild cases occurred, typhoid fever carried a case fatality rate of about 10 percent.37
Typhoid struck most harshly in those cities that sent untreated lake or river water through the pipes; thus it responded well to water filtration systems and sanitation efforts instituted in many cities during the last third of the nineteenth century or in the early years of the twentieth century.38 Often it took repeated epidemics to convince legislators or taxpayers to spend the large sums necessary to clean up the water supply. Milwaukee, for example, did not eliminate the “typhoid highball” drawn from the city water pipes until citizens, after suffering from a major bout of diarrhea in 1916, finally approved a bond for a new sewage-treatment plant.39
New York City brought clean water from the
Croton watershed in the 1840s, but by the 1880s population density had severely taxed the system and led to serious pollution problems. Minor patching to the system sufficed until the turn of the century. In 1907, the year of Mary Mallon’s first move to North Brother Island, continuing high typhoid fever rates convinced many New Yorkers that they could wait no longer to filter the water flowing in the city pipes. While advising citizens to boil their water, city leaders put in process plans for a new sewer system and in 1911 finally appropriated almost $9 million to construct a filtration plant.40
Fig. 1.1. Water Filtration and Typhoid Fever Death Rates, U.S., 1900–1913.
Typhoid fever exemplified the effectiveness of sanitation practices based both on the old filth theory of disease and at the same time incorporating the new tenets of bacteriology. When the salmonella typhi bacillus was identified (1880) and traced to contaminated water supplies, it underscored the necessity of providing clean water in urban environments. William T. Sedgwick, the Massachusetts state bacteriologist, and the Lawrence Engineering Laboratory pioneered an effective sand filter in the 1890s and paved the way for safe drinking systems. As more and more cities responded by adding filtration to their water systems in the early twentieth century, typhoid fever diminished nationwide as a major cause of morbidity and mortality (see fig. 1.1).41
Yet typhoid fever did not disappear. In 1900, over 55,000 deaths in the United States were attributed to typhoid.42 In the first decade of the twentieth century, thanks to bacteriological investigations, medical scientists began to understand why there were still cases of typhoid after sanitation efforts had significantly lowered the incidence of the disease. “Residual” typhoid seemed to be caused by apparently healthy persons, either those recovered from a case of the disease or those who could not remember being sick at all but who nevertheless harbored the bacillus and transmitted it to others. Labeled “germ distributors,” “chronic carriers,” or “healthy carriers,” these individuals became important foci for bacteriologically oriented public health officials, potent illustrations of how the new science, by creating a new taxonomy, both aided and complicated the fight against disease. By 1907 when bacteriologists identified Mary Mallon as a healthy typhoid carrier, scientists had already firmly established that healthy people could carry salmonella typhi in their excreta and transmit the disease to others.43
Researchers slowly elaborated the details of how healthy people harbored and transmitted the disease to others. American scientists, familiar with European research on typhoid carriers, shared data from various centers around the country, including San Francisco, St. Louis, Syracuse, Boston, Chicago, Wisconsin, and Minnesota. In the early decades of the twentieth century, American bacteriologists came to understand that the carrier state could follow either mild, even subclinical, cases or acute illnesses; that it seemed to last more than six weeks in approximately 3 percent of recovered cases; and that more women than men seemed to be chronically affected, especially when those women had been infected during their middle years. Salmonella typhi could be isolated from blood, urine, or feces; the bacilli often lodged in the gallbladder. Carriers transmitted the disease in the same ways as typhoid victims might infect others, through water or food contaminated by their feces or urine.44
Many scientists believed that Mary Mallon’s apprehension in 1907 was a momentous event, one in which the new science of bacteriology played a heroic role. They championed bacteriology’s new key function in streamlining the efforts of the health department by reducing the attack on typhoid to those individuals who could be identified by laboratory methods as dangerous. Mallon’s example demonstrated the vital importance of the laboratory as a supplement to or even a substitute for physical examinations. The laboratory would help the health department get people like Mary Mallon off the streets and out of the homes of healthy citizens. Scientists and health officials believed the new science would help protect the public’s health in the best possible way.
The laboratory to which Mallon’s specimens were brought, part of the division of pathology, bacteriology, and disinfection within the health department, had been the dream of Hermann Biggs, probably the premier public health officer in the country.45 It early achieved a national reputation. Charles Chapin described the New York laboratory as “perhaps the most important step in modernizing public health practice in the United States.”46 In 1895 Biggs had hired William Hallock Park, a physician trained at Columbia University College of Physicians and Surgeons and in the scientific laboratories of Vienna, to organize the bacteriological laboratory, and Park remained as its director until 1956. He and his colleagues carried out studies that put New York in the forefront of bacteriological investigations in the United States. Among their more important works were their studies of healthy carriers.47 Mary Mallon, because of her long stay under department auspices, provided much of their longitudinal data on typhoid fever carriers. As Charles F. Bolduan, Park’s associate at the laboratory, put it, Mallon “gave Park a splendid opportunity to develop laboratory methods for the detection and isolation of typhoid bacilli in stools.”48
Mary Mallon’s feces received close laboratory scrutiny from March 20, 1907, the day after she was first brought to the hospital, until she sued for release, the last examination recorded in the court records occurring on June 16, 1909. More examinations were made after her second incarceration in 1915; unfortunately the data from these are less detailed and probably incomplete. The laboratory investigations proved of major importance in the legal investigation and the health department’s public justification of subsequent events. They were basic to the bacteriologists’ claim that Mallon was a “menace” to the public’s health.
During the twenty-eight months between March 1907 and June 1909, health officers collected 165 fecal specimens from Mallon, an average of more than one a week.49 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.”50
The laboratory analyses revealed that Mallon was an intermittent carrier of typhoid fever. Repeatedly over these months, her feces contained no typhoid bacilli at all, the laboratory reports showing negative for twelve consecutive examinations, from September 16 through October 14, 1907. In a sporadic pattern over the twenty-eight months, 120 of the 163 cultures tested positive, 43 negative in this period. Her urine consistently tested negative.
Soper, no doubt trying to make his case stronger, somewhat misrepresented the laboratory results in his accounts. He claimed that the 1907 examinations revealed “only a few instances [when] the typhoid organisms [were] not found.”51 In fact the year’s totals indicated fifty-five positive cultures and thirty-four 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, a friend of Mallon’s, with whom she lived before her detention.52 George Ferguson conducted ten tests on Mallon’s urine and feces between August 1, 1908, and April 30, 1909, concluding, “I would state that none of the specimens submitted by you, of urine and feces, have shown typhoid colonies.”53
Comparing the dates of Ferguson’s analysis with 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. There are a number of possible explanations for the discrepancy between the city and private laboratory reports. We do not know the manner in which Mallon’s feces were transported to the private laboratory, and it is possible that the specimens were not fresh when they reached the laboratory. There is also the possibility that the laboratory did not itself carry out the work expeditiously or carefully, or that it had incentives to carelessness. Since Mallon was an intermittent carrier, there were bound to be both times during whic
h her feces carried the bacteria and times when they did not.54
Mallon denied the validity of the health department’s laboratory tests when they confirmed the presence of bacteria associated with a disease that she insisted she had never suffered. She repeatedly voiced her skepticism about the reliability of these positive bacteriological findings. Nonetheless, she accepted and used the negative laboratory results from the Ferguson Laboratory to bolster her case in court. Although she may have felt herself to be a victim of bacteriology, she apparently did not mind enlisting the laboratory—the emblem of the new science—to present her side and fight for her liberty.
The health department used its predominantly positive laboratory reports to make its 1909 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:
A bacteriological examination revealed the fact that fully thirty per cent of the bacteria voided with the feces were of typhoid bacilli; the urine was negative. . . . Weekly examinations of the stools have usually revealed large numbers of bacilli. . . . In view of the foregoing and owing to the large quantities of typhoid bacilli existing in the alimentary tract, or gall bladder of the patient and her occupation as a cook or the fact that she may at any time come in contact with people wherein they would be likely to be infected with the typhoid bacilli, the Department of Health concluded that the patient would be a dangerous person and a constant menace to the public health to be at large; and, consequently, . . . decided, after careful consideration and acting upon their examination of the patient, to place her in a contagious hospital and isolate her from the general public.55
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