by Daniel Keays

Typhoid Mary

The Sad Saga of Mary Mallon

Serving wholesome meals.

Oh, Mary! So contrary!

Guilty innocence.

 

            History has given us nicknames that have become more famous than the name of the person they represent.  Many will recognize the name “Billy the Kid,” but few would be familiar with his real name, Henry McCarty, or even his alias, William Bonney.  He apparently had a very youthful face and a goatee that made him look something like a billy-goat, a kid goat at that.  “Tokyo Rose” was a familiar radio personality during the Second World War.  She was an American of Japanese descent who graduated from the University of California at Los Angeles.  Late in 1941, she traveled to Japan to attend to a sick relative but was stranded there when the war broke out.  Her real name was Iva Toguri D’Aquino.  “Wild Bill Hickok” reportedly got his nickname because of his large nose, which reminded some of a duck’s bill.  His real name wasn’t William, but James Butler Hickok.  He changed the first part of his nickname from “duck” Bill to “wild” because it sounded better.  “Blackbeard the Pirate” was the name given to a British sailor who developed a reputation for being a ruthless cutthroat. In real life, he relied more on his tactical skills and the art of negotiation.  His real name was Edward Teach.

            The discipline of infectious diseases has its own famous nicknamed person whose real name is obscure to most people.  She was a hard-working woman of Irish ancestry who simply wanted to make a good living and enjoy a few creature comforts now and then.  An intelligent woman with a meager formal education, she became embroiled in some of history's most important medical and legal questions.  Her Christian name was Mary Mallon, but she is mostly referred to by her assigned nickname, “Typhoid Mary.”

 

            Mr. and Mrs. George Thompson were wealthy.  They owned several lavish properties in the northeastern United States, their primary residence being in the upscale neighborhood of Oyster Bay on Long Island, New York.  It was a beautiful home in the middle of a very exclusive, high-class setting.  Not far away was the summer residence of Theodore Roosevelt, and there were equally impressive residents nearby.

            Most years it was the Thompsons' custom to rent their Oyster Bay home for several months and spend the summer in the Catskills.  In the summer of 1906, they rented it to the family of Mr. and Mrs. Charles Warren of New York.  Mr. Warren was a banker to some of the industrial giants of the time, and he and his wife enjoyed the relaxed setting of the Oyster Bay community with their four young children.  Theirs was something of an idyllic summer.

            For some reason, the Warrens lost their cook in early August.  Perhaps she was fired or had some personal issues, but the household needed a cook quickly.  Mrs. Warren did what was commonplace then: she paid a visit to Mrs. Stricker’s Employment Service in New York.  They recommended a cook with impeccable references, one who had worked for some of the most prominent families in New York.  Her name was Mary Mallon.

            Family cooks of that time worked extremely hard and were very talented.  They were the first of the household to arise each morning, and they worked close to 14-hour days.  They were responsible for the entire kitchen, from buying groceries, cleaning ovens and sinks, washing dishes, and cooking.  It was rough, hard work, and the meals had to be varied, engaging, and delicious.  The cook typically prepared meals for the family first, then for the help.  The Warrens had four children, and there were four servants besides Mary.  After breakfast and the kitchen cleaned, it was time to prepare lunch.  A day that began around 6 AM for a cook might end around 8 PM unless there was a party.  Then it might be even longer. Challenging work, but Mary Mallon was up to it.  She was a trained professional at age 37.

            The trouble began in late August 1906.  One of the Warren’s children, Margaret, age 9, became ill.  She had a fever and some diarrhea and felt listless.  “Summer diarrhea” was a common malady of the time and still is today.  Likely, Mrs. Warren didn’t worry too much when her daughter first became ill.  A little castor oil would fix her right up.  But the disease persisted.  Her fever spiked to 105 degrees, and she became delirious.  Her stools became bloody, foul-smelling, and frequent.  The child had become acutely, seriously ill.   Then the tell-tale sign: a rash, or “rose spots,” on her abdomen.  A doctor was promptly summoned, and he confirmed the diagnosis:  typhoid fever.

            In 1906, there was no specific treatment for typhoid; care was merely palliative.  Just do the best you can, pray, and wait it out.  Shortly thereafter, four others became ill with the same disease:  Margaret’s older sister, two servants, and the gardener.

            It was well known at the time that the primary source of typhoid fever was contaminated water.  Whether you drank the water or it was used to wash fresh produce, most cases could be traced back to the water supply.  How this house, at this time, had contaminated water was anybody’s guess.  Theirs was the only home in the neighborhood affected.  Once the crisis was over, the Warrens did what any typical, thinking family would do.  They high-tailed it back to their residence on the Upper East Side in New York, thanking their lucky stars that their daughters and employees had survived the disease.  Mary, for her own reasons, did not accompany them.

            When the Thompsons returned to their Oyster Bay home in mid-September, they expected to find the Warrens gone and their house in good order.  What they found instead was the scene of a calamity.  Typhoid was something you just didn’t see in an affluent community like Oyster Bay.  It was associated with filth and deprived living conditions.  The Thompsons were now residing in what the locals and others were calling the “typhoid house.”  It was presumed that the disease arose from the water supply in their home, and any who entered there were at risk.  This would not do.  Mrs. Thompson, above all, was incredulous.  She immediately notified the local public health authorities, who thoroughly inspected the entire home and its plumbing.  Nothing.  They interviewed the fruit and vegetable vendors and checked to see if any other cases in the community were noted.  Nothing.  They even considered a nice older woman who sold clams she dug herself in Oyster Bay.  Nothing.  The health workers finally just gave up, assuming the event was idiosyncratic. Case closed.

            Mrs. Thompson was having none of it.  Their standing in the community, let alone their ability to rent the property (who would want to live in the “typhoid house”), set her on a mission to find the best disease investigator available.  Her inquiries led her to a rather unusual little man, Dr. George Soper, the “epidemic fighter.”  The “Dr.” part of his name was somewhat misleading; he was not a medical doctor.  His Ph.D. degree was in mining.  But he liked to read medical literature, especially those articles dealing with disease outbreaks and their causes.  The 36-year-old was officially classified as a “sanitary engineer,” as “epidemiologist” had not yet been coined.  

            People had long known that contaminated water could cause infectious diseases.  The seminal work on the matter was that of an obstetrician named John Snow, who elegantly demonstrated that a common source of contamination caused a cholera epidemic in the Soho district of London in the 1850s.  It took a while for the concept to take hold, but by the early 1900s, it was accepted as fact.  It was also well known that a person ill with an infectious disease could spread it to others.  What wasn’t appreciated, though, was that a perfectly healthy person could also be the source of a communicable disease.

            In the early 1900s, most investigations into infectious disease outbreaks and epidemics involved looking at physical facilities and things like fresh water supplies becoming contaminated by sewage.  In that regard, someone like George Soper, with his expertise in mining, would be a good fit for the job.  Soper went further than most, though, as he kept abreast of the latest scientific literature in the field of medicine, especially articles related to the spread of infectious diseases.  One article intrigued him.  It was written by the eminent German microbiologist Robert Koch.  In it, Koch described a person who was entirely well but could pass viable microbes that could infect other people and make them sick.  It was just a single example that occurred in Europe, but it was nonetheless provocative.

            Dr. Soper did the same inspection of the Oyster Bay house that the local officials did and also came up empty-handed.  But he took it a step further.  He traveled to New York City to interview members of the Warren family.  During the conversation, he learned that the only real change that had taken place between the time the family moved into the home and the outbreak of the disease was the firing of the old cook and the hiring of her replacement.  Using his investigative instincts, he contacted Mrs. Stricker’s Employment Service (which was actually owned and run by a man).  The owner was very cooperative and freely gave Dr. Soper a list of all the families to which his firm had connected Mary Mallon, the Warren family’s cook.  From there, it was plain old gumshoe detective work, paying a visit to each household to see if any incidents had happened when Ms. Mallon was employed.

            What he found astounded him.  Six of the seven families on his list for whom Mary Mallon worked as a cook had had a typhoid outbreak while she worked there.  In one family, there were nine people afflicted.  The only ones not sickened were the male head of the house, who had contracted the disease as a young man, and Mary, the cook.  All told, Dr. Soper uncovered twenty-two victims.  The only family not affected was an elderly couple, who probably had caught the disease in their youth and were naturally immune.

            Continuing his search, Dr. Soper tracked Mary to a house on Park Avenue.  Unfortunately, he was too late.  At the home of Mr. Walter Browne and his family, he encountered their 25-year-old daughter, Effie, horribly sickened with typhoid.  She soon died.  Also ill was a household servant.  There were now twenty-four known victims associated with Mary Mallon, which was only from the list he had obtained at the single employment office.  No doubt there were others from jobs Mary had found on her own.  Firm action was indicated.

            Dr. Soper confronted Ms. Mallon in the kitchen of the Browne home in a surprise visit.  In such a situation, tact is essential.  A little charm doesn’t hurt, either.  Dr. Soper displayed neither.  He later wrote that he “bungled the interview.”  Mary became indignant and defensive.  It was the most absurd thing imaginable that she could be making people sick with typhoid when she was perfectly well and didn’t recall ever having the disease.  Dr. Soper explained that he just needed to get a few specimens of her blood and feces.  That would prove it once and for all.  But the more he spoke, the more upset she became.  Finally, she picked up a carving fork and lunged at him, sending him racing out the back door in fear for his life.  The tangled legal case of Mary Mallon had begun.

            Several attempts to get Mary to cooperate were unsuccessful, to say the least.  The more she was implored, the more belligerent she became.  After doing their darndest to get Mary to comply, Dr. Soper and Hermann Biggs, the head of the New York Department of Health, enlisted the services of a female doctor, Dr. Josephine Baker.  The diminutive “Dr. Joe,” as she was called, was one of the few women practicing medicine in the New York area.  She worked for the Public Health Department and was used to attending to poor, working-class people, especially women.  If anyone could turn Mary Mallon, it had to be Dr. Joe.

            She got a more hostile reception than the men did.  On March 19^th, 1907, Dr. Baker, several police officers, and an ambulance showed up at the front door of the house where Mary was working.  Mary saw them coming and bolted out the back door.  After a two-hour search of the neighborhood, they found her hiding behind some trash cans.  The policemen pulled her out and “escorted” her to the ambulance.  Dr. Baker’s description of the episode of Mary’s detention is quite descriptive:

            “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.”

            After basically holding her as a captive at the Willard Parker Hospital in New York, a facility used to treat patients with infectious diseases exclusively, the precious stool specimen was obtained, sent to a microbiology laboratory, and, sure enough, tested positive for the typhoid bacillus.

            The word “quarantine” in the early 1900s was invoked quite frequently.  It comes from the Italian word “quarantena,” referring to 40 days, as in the forty days of Lent.  Centuries ago, it was the custom for ships coming into Italy to be isolated for 40 days so that cases of plague and smallpox could not spread from the crew to the community.  Many areas of the world adopted this approach.  

            New York had a 13-acre island in the middle of the East River, North Brother Island.  The facilities there were referred to as Riverside Hospital.  It was mainly a series of small cottages where residents were given medical attention while they bided their time.  Most patients were quarantined there voluntarily, but not Mary Mallon.  She was effectively a prisoner.

            This raised a serious legal question:  she had committed no crime and was given no trial or legal representation, but here she was being held prisoner by state agents.  One of the founding legal principles of the United States is that of Habeas corpus, which is “A legal term meaning that an accused person must be presented physically before the court with a statement demonstrating sufficient cause for arrest. Thus, no accuser may imprison someone indefinitely without bringing that person and the charges against them into a courtroom. In Latin, habeas corpus means “you shall have the body.”’  But the reality of the situation was apparent: a woman who was a carrier of a deadly disease who worked in a profession that practically guaranteed the transmission of that disease to unsuspecting people.  Her unrepentant and uncooperative nature clearly demanded intervention by those protecting the populace.  It was a genuine conundrum.

            After some legal battles, the health authorities prevailed.  Mary Mallon was held in a small bungalow on the island's edge.  Her residence was pretty decent, with a living room, a kitchen, and a bathroom.  She even had a small fox terrier for company, and she reportedly made a few friends and was permitted to have visitors.  But she wasn’t allowed to leave, and she certainly wasn’t allowed to prepare meals for the other island residents.

 

            Today in the United States and many countries, we have laws to protect the identity of patients and their personal information.  In the U.S., we often refer to these rights as the HIPAA regulation, which stands for “Health Insurance Portability and Accountability Act.”  Everyone in the healthcare industry is familiar with the letter and the spirit of the HIPAA regulations:  you never breathe a word about any patient to anybody outside of their immediate family.  These regulations didn’t exist in the early 1900s. Even though one would think patient privacy is a moral and ethical imperative, private information of a sensational nature was often leaked to the press.  Adding to the maelstrom was the pervasiveness of what was known as “yellow journalism,” a contest between publications to see who could come up with the most electrifying story (and sell the most newspapers).  In June of 1909, Mary opened a copy of New York American, a newspaper owned by William Randolph Hearst. She saw banner headlines giving her name and calling her “the most dangerous woman in America.”  It went on to list details of her predicament and suggested she could remain “a prisoner for life.”

            Controversy and legal battles ensued.  Somehow, Mary got an attorney, who argued a perfect legal case, but the court sided with the health department.  While acknowledging they couldn’t lock up every typhoid carrier, this case was unique.  Everyone seemed to sympathize with her, but Mary Mallon was condemned.

            Finally, in February 1910, Mary relented.  She signed a paper promising to report to the health department for monthly testing and never work as a cook again.  She was free from her island confinement, but more problems were just beginning.  Her image, name, and story were plastered in the mainstream press.  Who would hire the “typhoid carrier,” even if it was a laundress or a maid? In 1910, there was no unemployment compensation, government assistance, or social security disability.  Find a job or become a charity case.  She was unmarried, and at age 40, her prospects were minimal.

            Mary faithfully reported to the health department for testing for the first year.  Then she just faded away.

            During this time, one might be justified in feeling somewhat sorry for Mary Mallon, perhaps even taking a devil’s advocate position for her.  She wasn’t sick, did not intend to hurt anyone, and was the victim of a miserable biological situation.  Her life was in turmoil through no fault of her own.  But any humane feelings for her evaporated in early 1915.  A typhoid epidemic occurred at the prestigious Sloan Hospital for Women in Manhattan.  Twenty-five cases of typhoid fever had broken out, with 24 victims being doctors, nurses, or other hospital staff and one patient.  Two died.  This was unheard of at a hospital like Sloan, well known for its impeccable attention to hygiene.  Hospital officials were distraught and perplexed, so they called in “the epidemic fighter,” Dr. George Soper.

            Three months before the outbreak, the hospital had hired a new cook, Miss Mary Brown.  She was very good at her work, well-liked by the staff, and dependable.  Take three guesses about the true identity of “Miss Mary Brown.”  She must have known something was up because she disappeared right before being summoned for an interview by Dr. Soper.  Some good police work found her hiding in a bathroom at a friend’s house, and several policemen once again took her into custody.  At age 46, she had cooked her last meal and infected her last person.

            Mary Mallon lived out her days on North Brother Island.  She liked to read, had a few friends, and eventually got a job preparing specimens in the laboratory at Riverside Hospital.  On December 4^th, 1932, Mary didn’t show up for work.  She had suffered a stroke in her cottage, completely paralyzed on her right side.  For the last six years of her life, she remained bedridden in Riverside Hospital, and on November 11, 1938, she died of pneumonia.

            One might say that Mary Mallon gives testament to the oft-quoted phrase of historian Laurel Thatcher Ulrich that “well-behaved women seldom make history.”  If she had been more interested, concerned, and willing to assist during that first encounter with Dr. Soper, we would have never heard of her or her famous nickname.  (The name “Typhoid Mary” originated during a medical conference concerning typhoid carriers.  During the discussion period after a lecture on the subject, one of the physicians attending the conference referred to the woman discussed by that moniker.  The name stuck).  However, she chose a different path; as they say, the rest is history.
 

            The cases of Mary Mallon and others bring up many interesting questions in medicine and law.  It also highlights the critical field of epidemiology.  The term comes from two Greek words, epi, meaning “among or upon,” and demos, meaning “people.”  The term epidemic, an outbreak of disease not usually seen in an area or group of individuals, is contrasted with endemic, indicating the condition exclusively belongs to a particular region or place.  The description and study of disease outbreaks, some of them of monumental proportions like the bubonic plague, have captivated humans for millennia.  But only in the last 150 years or so has the discipline of epidemiology become the straightforward practice it now is.

            The epidemiologist must be a natural multi-tasker.  As seen in the case of Mary Mallon, things to consider include the science of the organism(s) involved, physical facilities, geography, statistics, and pharmacology.  Beyond the science and engineering components, it is often necessary to consider history, sociology, criminology, and psychology.  Finding out why an epidemic occurred is one thing.  Getting people to cooperate to eliminate it can be something else entirely.

            Today, epidemiologists work in two main areas:  governmental public health departments and healthcare facilities. The two very often overlap in their work.

            Many diseases are, by law, reportable to the public health department.  Attending physicians, medical laboratories, and hospital infection control departments file reports of the occurrence of listed severe, communicable diseases.  These reports include the patients’ names, addresses, diagnoses, and laboratory findings.  The public health epidemiologist then takes the information and, much like a detective, follows up on two major themes:  determine where the patient got the illness, and keep it from spreading.  Most often, the information about the disease outbreak is not widely disseminated, mainly because there is no imminent danger of disease spread.  For instance, if someone returns from a trip to a foreign country with a case of shigellosis, a communicable intestinal infection, there is not much to be done other than informing the patient of the threat of possible spread and going over good hygiene practices.

            Sometimes, however, the appearance of a disease, especially when multiple persons are involved, is concerning enough that public notification is necessary.  Sometimes this means press releases and product recalls.  Listeriosis is a relatively rare disease in the U.S., but it can be dire to some people, especially the elderly, immunocompromised, and pregnant.  So, a complete health department offensive is required when it turns up in cantaloupes all over the country.  Press releases, news conferences, product recalls, on-sight investigations, and statistics gathering are in full swing.  The information about individual patients is scrupulously guarded, but the public must be given as much accurate information as possible.  Lives are at stake.

            Public health epidemiologists get most of their initial information from medical laboratories, usually those based in hospitals.  Identifying the organism causing an infectious disease is very helpful to the physician treating the patient, but it can also benefit the public health department.  The finding of a couple of patients with Salmonella may not seem much out of the ordinary to the individual lab worker. Still, the plot thickens when several other medical labs in the same geographic area report similar findings.  That is especially true if all the isolates are of the same serotype, the same strain.  That would indicate a common source, and it’s a clue to the public health epidemiologists that something is afoot.

            Clinical laboratories are known as sentinel labs in the public health context.  The formal name given to the system is Laboratory Response Network or LRN.  Prompt isolation and reporting of critical infectious organisms and good communication channels are essential for public health.

            (It is speculated that the outbreak traced to Mary Mallon on Long Island was caused by some homemade ice cream she prepared. She sliced fresh peaches by hand and left them in the cream mix for several hours while preparing the ice machine.  In the warm August afternoon, that would have been an ideal way to cultivate S. typhi, which likely would have gotten onto the peaches from her hands).  

 

            The practice of good sanitation, the discovery of anti-microbial agents like antibiotics, the development of vaccines, and the employment of tools to make us aware of the presence and extent of infectious diseases have combined to provide a phenomenal decrease in the suffering of people around the world.  Gifted pioneering workers like Florence Nightingale, Louis Pasteur, Paul Ehrlich, Gerhard Domagk, Edward Jenner, and so many more have laid the foundation for a field of science that not long ago was not known to exist.  The road to success was not straightforward, with trials, tribulations, heartache, and exultation paving the way.  We will never eliminate infectious diseases, but the knowledge and wisdom gained from experience aid greatly.

 

 

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