Typhoid Mary

by Judith Walzer Leavitt

  Dr. Hoobler and I described the situation with as much tact and judgment as we possessed. . . . We wanted a small sample of urine, one of feces and one of blood. . . . Indignant and peremptory denials met our appeals. We were unable to make any headway. Mary’s position was like that of the lawyer who, on being told by the judge that the facts were all against his client, said that he proposed to deny the facts. Mary denied that she was a carrier. . . . Nothing could alter her position. As Mary’s attitude toward us at this point could in no sense be interpreted as cordial, we were glad to close the interview and get down to the street. We concluded that it would be hopeless to try again.11

  Soper later described this second encounter even more starkly: “Mary was angry at the unexpected sight of me,” he wrote. Insisting she knew nothing about typhoid and had not caused it, “she would not allow anybody to accuse her.” Soper left her, “followed by a volley of imprecations from the head of the stairs.”12

  Believing that his epidemiological evidence implicated Mallon in the transmission of typhoid fever, Soper reported his findings to Hermann Biggs and the New York City Health Department, who, he felt, had the authority to take the case further. The city’s public health officials, convinced by Soper’s data, immediately investigated. Dr. Walter Bensel, sanitary superintendent, sent his assistant, Dr. S. Josephine Baker, to the Bowens’ Park Avenue house to collect specimens of Mary Mallon’s blood and urine.13

  Baker had been born and raised in Poughkeepsie, New York, in a privileged family. Her father’s death (from typhoid fever) when she was sixteen, however, put some brakes on her ambitions. Although unable to attend Vassar as originally planned, she persevered in getting a medical education with her mother’s support. She graduated from the New York Infirmary Medical College in 1898, at a time when not quite 5 percent of American physicians were women.14 She interned at the New England Hospital for Women and Children in Boston for one year and returned to New York to set up her medical practice. Baker joined the health department in 1901, when it became evident that she, like other medical women in this period, would have difficulty attracting enough patients to make a living in a private practice. In 1907 she was a medical inspector and had not yet begun the work that would make her one of the most influential public health physicians in the country, as head of the division of child hygiene within the health department.15 (See fig. 2.1.)

  The health department showed some sensitivity in sending a woman to collect Mary Mallon’s specimens. Soper described Baker as “gentle,” but Mallon saw in her only the “red flag” of government authority.16 She quickly showed Baker the door.

  Fig. 2.1. S. Josephine Baker, 1922.

  Bensel sent Baker back the next day with curt directions, as Baker later recalled being told: “I expect you to get the specimens or to take Mary to the hospital.”17 Worrying how she “would face Dr. Bensel” if she failed in the mission, Baker persisted, accompanied by five police officers and an ambulance. Baker later wrote that when she arrived at the Bowen house the second day,

  Mary was on the lookout and peered out, a long kitchen fork in her hand like a rapier. As she lunged at me with the fork, I stepped back, recoiled on the policeman and so confused matters that, by the time we got through the door, Mary had disappeared. “Disappear” is too matter-of-fact a word; she had completely vanished.18

  The other servants in the house, showing what Baker recognized as “class solidarity,” denied any knowledge of Mallon’s whereabouts. Baker and the police looked everywhere. They spotted footprints in the snow leading to a chair set up near the fence separating the Bowen property from the neighbor’s grounds, and so they searched the neighbor’s house as well. For five hours they “went through every closet and nook and cranny in those two houses. It was utter defeat.” Finally “a tiny scrap of blue calico caught in the door of the areaway closet under the high outside stairway leading to the front door” betrayed Mallon’s hiding place. The police had not previously looked there because of the “dozen filled ash cans . . . heaped up in front of this door; another evidence of class solidarity.” Baker described the scene:

  She came out fighting and swearing, both of which she could do with appalling efficiency and vigor. I made another effort to talk to her sensibly and asked her again to let me have the specimens, but it was of no use. By that time she was convinced that the law was wantonly persecuting her, when she had done nothing wrong. She knew she had never had typhoid fever; she was maniacal in her integrity There was nothing I could do but take her with us. The policemen lifted her into the ambulance and I literally sat on her all the way to the hospital; it was like being in a cage with an angry lion.19

  At the Willard Parker Hospital, bacteriologists examined Mallon’s feces and discovered a high concentration of typhoid bacilli, proving in the laboratory that Soper’s epidemiological study had been correct. On the basis of this evidence, the health department soon removed Mary Mallon from the hospital to North Brother Island, where she remained for almost three years.

  The extant records do not directly reveal the thinking of health officials about this initial isolation of Mary Mallon. Why was quarantine the first response of the New York officials instead of the position of last resort? It seems that Mallon’s resistance to being captured defined her as trouble. Certainly cooperation did not mark her behavior. On the other hand, the record is mute on attempts by officials to convince Mallon that what they were doing was reasonable. There is no suggestion that health department officials tried to persuade Mallon that they would release her after either retraining or finding her new employment—an omission Mary Mallon herself noted.20

  New York City health officials probably regarded their initial isolation of Mary Mallon as a temporary measure that would give them time to determine what long-term procedures could be applied. In 1907, when they first remanded her to North Brother Island, they knew enough to question what they should do, but not yet enough to have developed a policy. As William Park, director of the city’s hygiene laboratory, wrote sixteen months into her isolation: “Has the city a right to deprive her of her liberty for perhaps her whole life? The alternative is to turn loose on the public a woman who is known to have infected at least twenty-eight [sic] persons.” In framing the question Park considered the large number of people who potentially could be affected, and concluded:

  What can we do under these circumstances? It seems to me that any attempt to isolate and treat on bacteriologic examinations . . . is impracticable. When we consider that the presence of the bacilli in the feces of these persons is often only occasional, that numerous contact cases having never had typhoid fever would not come under suspicion, and finally, the impracticability of isolating for life so many persons, we are forced to consider isolation utterly impracticable.21

  The scope of the problem immediately became clear not only to Park, but to most public health officials who began to grapple with the issue in the early years of the twentieth century. Health departments simply did not have the wherewithal to find and round up all carriers and keep them separate from the general population. Nor would people easily have accepted such mass isolation. Early studies indicated that 2 to 5 percent of all of those people who had suffered from typhoid fever became chronic carriers.22 If the ill had been reported to health departments, as most jurisdictions required, they could, with adequate budgets and personnel, be followed after recovery. But if their cases were not reported, or if the infected had never identified their illness as typhoid fever (like Mary Mallon), the carriers would be much more difficult to find. Furthermore, many recovered typhoid fever patients would never infect others, so they did not need to be considered as part of a disease prevention program. Perhaps most important, if isolation was to be considered part of the solution, health departments needed to determine if they had the legal authority to incarcerate healthy individuals and, if so, for how long.

  Mary Mallon’s situation thus illustrated the immediate need for developing a public health
policy that would address the problem of stopping transmission of typhoid fever through carriers yet at the same time be feasible in terms of health department budgets and staff abilities and also not overreach the boundaries of health department authority. How could the considerable, but by no means absolute, powers of public health departments be applied to the specific task of regulating the behavior of healthy typhoid fever carriers?

  In addressing this basic question, officials needed to determine how many people like Mary Mallon existed in a given population. Health authorities offered wide-ranging estimates of the numbers of typhoid fever healthy carriers, and through these we have an idea of the scope of the problem as it was viewed early in the twentieth century. The number of new carriers was directly related to the number of people ill with typhoid fever, although the total number of carriers in any given population was impossible to estimate accurately because the disease often presents in mild form as a flu-like illness, if it is noticed at all. The numbers of reported sick are always an understatement of the actual numbers of those infected. For estimation purposes, however, the case reports provide a basis for defining the problem.

  After studying European and American reports of typhoid fever carriers, Charles Chapin had concluded that the number of new carriers added to a population should be calculated at 3 percent of cases. He suggested in 1910 that there were “probably 200,000 cases of typhoid fever in the United States each year, and 3 per cent of these would be 6,000.”23 Milton J. Rosenau, director of the National Hygienic Laboratory, and later professor of preventive medicine and hygiene at Harvard University, estimated 350,000 cases nationwide in 1900, putting the number of new carriers added each year over 9,000.24

  On the local level, the numbers of healthy carriers seemed staggering. The state epidemiologist in New Jersey, for example, reasoned that the state of New Jersey alone harbored about 9,000 typhoid carriers at any one time, although in the 1920s, officials knew of only 26.25 In California, between the years 1913 and 1919, over 9,000 cases of typhoid fever were reported to the state health department; calculating at the rate of 3 percent, 272 new carriers were added to those thousands who already lived in the state. Health authorities tracked only sixteen of them.26 In Washington, D.C., in 1910, officials believed there might be 1,568 carriers per 100,000 population.27 The editors of the American Journal of Public Health concluded:

  The magnitude of the problem [of healthy typhoid fever carriers] is apparent when we consider that even in a healthy city like New York, where nearly 3,000 cases of typhoid fever occur each year, this means the addition of over one hundred typhoid carriers annually. Allowing each carrier only twenty years of life, certainly a conservative estimate, it follows that there must now be over two thousand typhoid carriers at large in New York City.28

  The problem in New York City, where officials were coping with Mary Mallon, was indeed challenging. In 1907, the year of Mary Mallon’s identification, New Yorkers reported 4,426 new cases of typhoid fever (two of which were attributable to Mallon); in 1908, another 3,058. These two years alone, according to the widely accepted formula, combined to generate almost 200 new chronic carriers. The years 1909, 1910, and 1911 followed inexorably with their own high numbers approximating 3,500 new cases each year, each adding close to 100 new carriers.29

  No one believed it would be possible to find all the healthy carriers of typhoid fever in the population. But health officials, realizing that the dangers from healthy carriers could be greater than from the sick—because susceptible people knew to avoid the sick or to be careful when caring for them, but could not know when they might be at risk of being infected from a seemingly healthy person—determined to find a way to bring most of the carriers within their purview.

  As cities’ water and milk supplies improved in the early twentieth century, it became increasingly important to formulate a policy for carriers, who as a group emerged as the single most dangerous factor in disease transmission. The Bockefeller Institute for Medical Research concluded that as many as 44 percent of all new cases of typhoid fever reported nationwide were due to carriers.30 In a five-year study during the 1930s, the state of New York health authorities attributed no typhoid outbreaks to contaminated water, but found carriers responsible for the large proportion of cases.31 Some investigators concluded that by the 1930s as much as 96 percent of typhoid distribution originated with carriers. A policy to control the danger from healthy carriers became essential: “the difficulty in the eradication of typhoid is not the sick bed patient but rather the healthy carrier who goes blithely on his way distributing his infection.”32

  There were various ways officials could systematically locate carriers. The most promising, although ultimately not the most successful, was to follow recovered sufferers until their stools and urine tested bacilli free. State and local health departments had long required physicians and hospitals to report typhoid fever cases and deaths; thus it was possible to require follow-up laboratory analysis of convalescents’ stools and urine and to place restrictions on those persons who carried the bacilli longer than one year. Many health departments followed this path in the early twentieth century, but the success rate for discovering healthy carriers using this method remained small. By following such post-typhoid cases, California officials discovered less than 10 percent of its registered carriers, and New York State almost 20 percent.33

  A more successful route to locating healthy carriers of typhoid fever was through investigations of actual outbreaks of the disease, either family or community centered. New York found 75 percent of its registered carriers between 1911 and 1932 from such epidemiological investigations.34 For example, in August, 1909, a “sudden increase in the number of cases of typhoid fever reported from the boroughs of Manhattan and the Bronx attracted attention, and led to an investigation to ascertain the cause of the infections.” Investigators implicated a single milk supply in Camden, New York. Officials found the dairy “exceptionally clean and well kept,” although it was also home to a recent case of typhoid fever. “With such a history,” wrote Charles Bolduan, assistant to Biggs, and W. Carey Noble, city bacteriologist, “one could not help but suspect the presence of a chronic bacillus-carrier.” Indeed, stool examinations revealed that the dairyman harbored typhoid bacilli, and the health department connected him to the contaminated milk supply and stopped his work in the dairy. The investigators concluded, “The occurrence of repeated infections in this case shows the danger of having bacillus-carriers in a dairy.”35

  Stephen M. Friedman, in his retrospective study of the 1,004 chronic fecal typhoid fever carriers identified in New York City between 1907 and 1975, reports that such investigation of cases of typhoid fever was the most common method of identifying healthy carriers, accounting for one-third to one-half of all carriers in every decade since 1916.36 Connecting healthy people to actual cases of typhoid fever identified those already implicated in transmitting disease, the ones the health departments most needed to regulate. Not only was this group already shown to threaten others, but the people found this way often did not know they had ever suffered from typhoid or had had it many years before being connected to an outbreak; thus they would have eluded health regulations based only on following the sick. George Soper followed this method of discovery to find Mary Mallon.

  A third method of identifying healthy carriers was one for which health departments had a great optimism: the systematic examination of the stools and urine of food handlers. Once bacteriology established that typhoid could be transmitted by healthy people who prepared the food that others ate, it seemed obvious that if all people who prepared food for others could be examined before they were allowed to handle food outside their own families, epidemics could be stopped. New York City began such a program to identify dangerous food handlers in 1915, the year of Mary Mallon’s second incarceration, and made annual medical examinations of food handlers compulsory in 1925.37 But health departments tracked fewer than 5 percent of carriers in New York
and California through this type of program.38

  Not only was the routine examination program relatively ineffective at identifying potential carriers, it was expensive and cumbersome. Examining the thousands of food handlers annually, officials estimated, cost the city more than $100,000 each year. New York City Deputy Health Commissioner William Best indicated that even if the legislature wanted to increase the department budget to accommodate the certification program, he did not support spending money in this way: “I submit, is such a cost commensurate with the public health benefits obtained?”39

  The food handler examination policy had even more problems. Private physicians who tested their own patients were reluctant to label them with the stigma of chronic carrier and submitted very few positive identifications to the department. In order for the program to be effective, handlers needed repeated examinations, and even if they could be processed more often than once a year, healthy handlers could still become infected soon after certification. (There is an obvious analogy to HIV testing today.) With all the difficulties associated with the program, New York City discontinued routine testing in 1934.40

  Health departments were never successful at locating all typhoid fever carriers within their jurisdictions. And the people who were identified presented health authorities with a big question. What should health officials do with them? How could health authorities stop as many carriers as possible from transmitting disease to others? Was isolation necessary or desirable? Embedded within these questions is, of course, the experience of Mary Mallon herself.

  Policy developers needed to keep in mind that typhoid carriers menaced other people’s health only when susceptible people ingested the pathogenic bacteria that the carriers harbored within their bodies. Passing carriers in the street, sharing public transportation, or sitting beside them in school or at the theater were not dangerous activities. As the state health authorities in New York wrote, “A person of intelligence who is a carrier of typhoid bacilli, but who is willing to observe strictly certain essential precautions, may live and mingle with others and still need not be a source of danger to those about him.” The formulation of rules, the officials concluded, thus should “restrict the activities of such persons to the smallest degree consistent with the protection of public health.”41