The laboratory reports formed the central argument in the health officials’ 1909 case as they had for Soper’s initial identification. Without them, the court probably would not have kept Mary 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.”56 Even though the laboratories issued contradictory reports, the seemingly incontrovertible evidence of repeated positive typhoid cultures in the city laboratory data made Mary Mallon’s danger as a carrier palpable.
In concordance with the laboratory evidence, the health department addressed the question of how to eliminate Mallon’s infectiousness. 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 their disappearance.”57 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[.]”58 She indicated the physicians had also tried brewer’s yeast, but “at first I did not take it for I’m 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.” The 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, a suggestion she repeatedly refused.59 Abdominal surgery was associated with a risk of infection, but the physicians urging surgery on Mallon did not inform her of this or of the procedure’s poor record in alleviating the carrier state. Milton J. Rosenau, during the discussion of Park’s earliest paper on the subject at an American Medical Association meeting in 1908, opined that “she is perhaps justified in this conclusion [to refuse to submit to surgical interference.]” Mallon’s skepticism found support in the medical world. William Park himself concluded in 1914, “Medicinal treatment or surgery seems so far to have yielded only slight results. . . . Removal of the gall-bladder cannot be relied upon.”60 By 1921, the department of health admitted that it followed the history of five carriers who had agreed to the removal of their gallbladders, “all of them without success.”61
The emphasis on laboratory findings together with the drug therapy and proposed surgery indicate 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. The energy and commitment of these particular bacteriologically guided health officials was not directed toward social rehabilitation but focused more narrowly on the pathogenic bacilli, illustrating how for them bacteriology reduced the scope of health-related work.
The necessity for keeping Mary Mallon isolated emanated from her laboratory-defined carrier state and from her refusal to accept the authority of bacteriological findings. She persisted in denying that she had ever been sick with typhoid and insisted that she was “in perfect physical condition” and was “not in any way or any degree a menace to the community or any part thereof.”62 Perhaps she denied the validity of the bacteriological findings because her own laboratory informed her that her stools showed no typhoid bacilli, or perhaps because of her rival worldview, one which credited her experience as a healthy woman above a science that defined her as infected. She did not believe the doctors’ claims, she said, at least in part because they kept changing them, sometimes telling her the bacilli lodged in her gallbladder and other times locating them in the muscles of her bowels. Eventually, her denial became part of the indictment against her.
The importance of laboratory analysis to the health department becomes even more evident in the record of Mallon’s second isolation, which began in 1915 and ended with her death in 1938. The health officials monitored Mary Mallon’s feces throughout her life. From the extant records we learn that especially during the 1920s, but periodically during most of the years she was isolated, Mary Mallon continued to provide stool samples to her captors. Only once, on January 3, 1919, did the health department record she “refused to give stools.”63 As offensive and inconvenient as it might have been for a healthy woman regularly to provide stool samples, once as many as fourteen a month and more usually one a week, the process of collection and evaluation continued. The health officers did not permit Mary Mallon to forget why she was isolated, and, more significant, they continued to try to learn through her bodily excretions how carriers’ infection patterns might change over time.
Mallon’s stool cultures continued to demonstrate the intermittent character of the woman’s pathogenicity. The samples for which we can find information—for some years quite complete and for others very scant—indicate a predominance of positive cultures during the second incarceration, among which were occasional negatives. In 1915 and 1916 all of the tests for which we have evidence (fourteen and seven, respectively) proved positive for salmonella typhi. However, of the six recorded during 1917, only two tested positive, and four negative. During 1923, fifty-one of fifty-four tested positive, and during 1924, fifty of fifty-eight samples taken likewise contained the typhoid bacteria. Between 1907 and 1909, Mallon produced 120 positive stool samples and 53 negatives (including the specimens tested by the Ferguson Laboratory); between 1915 and 1936, we have evidence of 207 positives and 23 negatives.64
The laboratory and its ability to identify danger were elevated to new heights of importance in this persistent examination of Mary Mallon’s stools. After 1915 the repeated tests were no longer based on the need to prove that she carried typhoid; that had already been accomplished. The repetitive procedures nonetheless remained important to the laboratory and health department officials. Undoubtedly, the bacteriologists felt it was essential to scientific knowledge to document a long-term record of the carrier state. In more practical terms, without the laboratory proof that Mallon remained contaminated, how could they continue to isolate a healthy woman?
Since 1888, when Charles Chapin established the first municipal laboratory in the United States, the proof of laboratory results had steadily gained significance in public health investigations.65 Laboratory verification had become the hallmark of the new science of bacteriology and vital to what became identified as the “new public health” in the early years of the twentieth century. Writing in 1923, C.-E. A. Winslow claimed, “The laboratory has become the scientific foundation of the public health campaign in America, developed to a point perhaps unequaled in any other country. The activities of the chemist and the bacteriologist . . . impart throughout the whole range of the work of the health department the rigorous spirit of science.”66
Mary Mallon’s capture epitomized what the new laboratory science could provide and the hope for the future. It had now become possible to isolate the germs that caused disease in the laboratory, bacteriology’s major tool. Having done that, it would be possible to discover how the microorganisms were spread and, scientists believed, to stop that dissemination. Those who saw the story of Mallon’s pursuit and capture as a triumph of the new science were convinced that the bacteriological success alone was what made the story important. She could not have been found without Soper’s careful epidemiological work and could not have been isolated without the subsequent laboratory proof of the dangers she posed. It seems probable that she could not have been held twenty-six years in isolation without the continuing laboratory substantiation. Finding and isolating Mary Mallon represented the scientific optimism of the early twentieth century and
the faith that science would serve humanity by curbing disease.
Mary Mallon’s story, when understood from this scientific perspective, is a compelling and clear testimonial to scientific advancement. Hundreds and thousands of other healthy carriers of typhoid fever identified in New York City and around the country in the years following 1907 were found through similar epidemiological studies, with the laboratory adding proof that they shed typhoid bacilli in their feces or urine. Medical science proved its worth in the case of healthy carriers of typhoid fever.
However important the advancements of understanding the carrier state and locating carriers were, these steps did not themselves answer the challenge of disease control. Bacteriology had addressed the question of why typhoid fever continued to threaten the population, but it could not alone provide the means by which people could be protected. Given the sheer volume of hundreds or thousands of carriers in major cities and states around the country, health departments needed to find ways to adapt the scientific findings to practical public health policy. In determining their actions, health officials relied on a combination of factors, including but not limited to scientific findings. If we are to remember and give deeper meaning to Mary Mallon and this important episode in medical history, and to use it to increase our comprehension of present-day health problems, we need to look beyond the “shoe leather” epidemiology and the laboratory findings to uncover other perspectives on her story.
“Extraordinary and Even Arbitrary Powers”
Public Health Policy
CHAPTER TWO
For the city and state officials responsible for developing and executing health policy, Mary Mallon posed a challenge beyond the single individual. Their perspective accepted the bacteriology laboratory findings identifying Mary Mallon as a menace and emphasized the very practical question of how to stop her from endangering the health of others. The public officials who encountered her also needed to determine health policies that would put this one carrier’s story to use against the threat that all healthy carriers seemed to pose to the public. To investigate Mary Mallon’s story in terms of health policy from the perspective of the people officially responsible for the protection of the public’s health, we need to examine public health authority in this period and to try to understand the dimensions of the healthy carrier problem as they saw it.
In the early twentieth century, as now, every state in the nation supported a board of health, whose job was to protect and promote the public health. These departments had evolved over the second half of the nineteenth century, and their actual structures and capabilities, and especially their budgets, varied considerably from state to state by the beginning of the twentieth century. Available funding, in part, defined their duties, and some were extremely limited in what they could accomplish. Those states that contained large cities usually delegated to those cities their own public health work and responsibility. Such was the case in New York.1
The New York City Health Department began operations formally at the turn of the nineteenth century, but it was not until 1866, when the state legislature approved of a new and greatly expanded Metropolitan Board of Health, that real powers passed to the local level. The local board soon became the nation’s leader in terms of defining municipal programs to promote health and prevent disease, and its accomplishments were adopted as models across the country.2 In addition to its vast sanitation projects, like water works and sewer systems, the board successfully launched programs to combat disease, such as vaccinating to prevent smallpox and establishing isolation hospitals. With time and experience, the policy-making board of health and the city department of health, which carried forward board policy, found ways to increase operating budgets and expand services.
The health department’s bacteriology laboratory where Mary Mallon’s fecal samples were examined was the most influential public laboratory in the country, and, amid much publicity, gained the cooperation of physicians in reporting infectious diseases, even cases of the controversial tuberculosis.3 Hermann Biggs, who trained at Cornell University and the Bellevue Medical College as well as in the scientific laboratories of Berlin before joining the department in the 1880s, became New York’s chief of the division of bacteriology and disinfection in 1892. He hired William Hallock Park to run the laboratory and assumed the position of general medical officer in 1902, a position he held until he moved to the state health department in 1913. His twenty-six years with the city department and his later career as state commissioner of health during the crucial early years of bacteriology made Biggs, along with people like Charles Chapin who served in Rhode Island for forty-seven years, one of the most important health officers in the country.4
Biggs understood what was possible in health department work. He maneuvered the politics of city health work and succeeded as an effective bridge between the private physicians and the politicians. His vision was perhaps best epitomized in the oft-repeated health department motto, “Public health is purchasable. Within natural limitations a community can determine its own death-rate.” He summed up his philosophy:
Disease is largely a removable evil. It continues to afflict humanity . . . because it is extensively fostered by harsh economic and industrial conditions and by wretched housing in congested communities. These conditions and consequently the diseases which spring from them can be removed by better social organization. No duty of society, acting through its governmental agencies, is paramount to this obligation to attack the removable causes of disease. The duty of leading this attack and bringing home to public opinion the fact that the community can buy its own health protection is laid upon all health officers. . . . It means the saving and lengthening of the lives of thousands of citizens, the extension of the vigorous working period well into old age, and the prevention of inefficiency, misery and suffering.5
Biggs’s philosophy combined older hygienic ideas with the newer bacteriological concepts. He defined the goals of public health work in the early twentieth century and at the same time illustrated the optimism of health workers in this period. Human intervention could make the world a healthier place. Typhoid fever appeared to be one disease that approached, in the words of another public health optimist, “absolute preventability.”6
Biggs held an expansive view of the importance of public health; he also espoused an expansive idea of health officials’ authority to accomplish the goal of protecting the public from preventable diseases. When he traveled to Edinburgh to read a paper at an international tuberculosis conference in July, 1910, three years after Mary Mallon’s first apprehension and four months after her release, Biggs described for his international colleagues the broad scope of health authority in New York City:
The Board of Health of New York City has legislative, judicial, and executive powers. Its regulations on all matters pertaining to the public health are final, and there does not exist in any individual or in any body any power of review or revision of the action of the Board of Health excepting in the courts. . . . I do not think that any sanitary authorities anywhere have had granted to them such extraordinary and even arbitrary powers as rest in the hands of the Board of Health of New York City.7
Even allowing for some hyperbole in Biggs’s address before an international audience, his statement provides a context in which to examine the policies developed to cope with Mary Mallon and other healthy carriers in New York City. New York health officials did have substantial authority to determine public health actions, in the definition of the problem, in executing its solutions, and in its presentation to the public.
Noting Biggs’s political skills in working well with both Tammany and reform governments, Johns Hopkins physician William Welch wrote that Biggs had “unsurpassed persuasiveness and skill in the presentation of his arguments to the authorities in power. Not less skilful was he in securing the support of the press and of the general public. . . . Biggs had a genius for leadership and has been justly called a sanitary statesman.”8 In the hands of
Biggs and his colleagues, New York City Health Department activities aimed at stemming the damage from typhoid fever and its carriers can be seen to represent the most (and perhaps the best) of what was possible in American public health policy.
Before health authorities apprehended Mary Mallon in 1907, public health officials had not implicated healthy people in causing outbreaks of typhoid fever; as we have seen, their activity had centered upon the environment and the sick as possible causal agents. Even the decade-old bacteriological knowledge that recovered typhoid patients could harbor the bacilli in their urine and feces for years after recovery had not yet in the United States been applied to an actual carrier, and the general public was not aware of this knowledge at all. Thus, when George Soper appeared on Mary Mallon’s doorstep convinced that she was a carrier, a new interaction was taking place.
Soper described what happened when he located Mary Mallon in the Walter Bowen home at 688 Park Avenue in March, 1907:
I had my first talk with Mary in the kitchen of this house. . . . I was as diplomatic as possible, but I had to say I suspected her of making people sick and that I wanted specimens of her urine, feces and blood. It did not take Mary long to react to this suggestion. She seized a carving fork and advanced in my direction. I passed rapidly down the long narrow hall, through the tall iron gate, . . . and so to the sidewalk. I felt rather lucky to escape.9
Unable to obtain Mallon’s cooperation at her place of work, Soper tried her at home in an encounter which, he said, he “staged more deliberately.” Soper and an assistant, Dr. Bert Raymond Hoobler, “waited at the head of the stairs in the Third Avenue house.”10 When Mary Mallon arrived,
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