Typhoid Mary (Lecture 1)

(Updated 1 January 2015)

The Bare Facts

  • Mary Mallon: an immigrant, Irish woman who made her way as a cook
  • Well liked and respected (“good with the children”)
  • Probably exposed to typhoid fever around 1900
  • Between 1900 and 1907, she infected 22 people with typhoid fever; one died
  • Quarantined on North Brother Island (age 37) for three years
  • Released by the new health officer after promising never to cook again
  • Traced to Sloan Maternity Hospital as cook!
    • 25 more people infected
    • 2 died
  • Returned to quarantine on North Brother Island
  • Died of a stroke 23 years later (in 1938)

The Issues we will discuss in this course

  • The priesthood of modern medicine; rise of the clinical worldview
  • Public policy
    • Definitions of truth and necessity
    • What is possible and what is politically agreeable
    • Definitions of “arbitrary” and “scientific”
  • Legal issues of public safety and individual rights
  • Social issues: class, gender, ethnicity
  • Mass media
    • “The right to sell papers” or the right of a free press
    • Shaping a worldview
  • Mary Mallon the person: she had a real name!
  • The modern perspective

Typhoid Fever (a 20th Century Perspective)

  • Symptoms
    • headache, malaise, fever
    • Constipation, sometimes diarrhea
    • later, rash on abdomen and trunk, distended abdomen, tenderness, enlarged spleen
    • white cell count actually decreases (what do white cells do?)
    • sometimes delirium, perforation of the bowel, pneumonia
  • If untreated,
    • by fourth week, symptoms subside, convalescence begins, immunity develops
    • fatal in about 10% of cases
    • some become “healthy carriers”
  • Healthy Carriers
    • Role of white blood cells (phagocytes)
    • engulf bacteria and form a small vesicle (sack)
    • vesicle fuses with lysosome and bacteria are killed and digested
    • Salmonella typhi blocks the fusion so they survive
    • Protected from antibodies of the immune system
  • Spread is by fecal-oral contamination
    • contaminated water
    • contaminated milk or produce
    • dirty hands
  • Water treatment plants eliminated most sources of contamination

Her germ

Salmonella typhi

  • The other player in this story

Salmonella in general

  • Salmonella enterica (typhimurium)
    • nomenclature problems
    • S. mjordan
  • Salmonella typhi
  • facultative aerobe/anaerobe

S. enterica

  • Usually foodborne
    • eggs and poultry
    • how does it get there?
  • Causes gastroenteritis
    • Usually untreated!
    • rapid onset
    • some fever
    • diarrhea and vomiting
    • usually straight through and over in a day or two

S. typhi

  • no good animal model
  • we know surprisingly little about it
  • stomach to blood to intestines (not the direct route)
  • Typhoid fever
    • slower onset
    • rarely diarrhea
    • lasts for a month
  • requires treatment

The Oyster Bay Outbreak (1906)

  • 6 out of 11 members of the Warren household (3 family and 3 staff) had typhoid fever
    • Charles Henry Warren was a New York banker
  • The landlord (George Thompson) hired George Soper (civil engineer) to find the course
    • worried about being able to rent the place!
  • Ruled out all the usual source
    • food, well water, the barn
    • even clams from the bay

Mary Mallon suspected

  • Soper knew about “healthy carriers” from German medical journals
  • He traced her former employment through the employment agency
    • a record of typhoid outbreaks
    • she often left soon after
    • 26 affected in 7 outbreaks (why so FEW?!)
      • immune
  • Needed stool and urine (and blood) samples to be sure

George Soper “visits” Mary Mallon

To read George Soper’s account of his visit to Mary Mallon and his interactions with the New York City Health Authorities, click here.

  • He appeared unannounced and tells her she is spreading typhoid fever
  • He wants her to go to the hospital and give him a stool, urine, and blood sample
  • She throws him out of the house
  • He tries again bringing a doctor
  • She throws him out again

Mary Mallon Apprehended

  • Soper convinces the health dept. that Mary is a likely carrier
  • Hermann Biggs sends S. Josephine Baker who calls in the police
  • Mary escapes and the neighbors hide her
  • Mary dragged away to the Willard Parker Hospital for contagious diseases and samples taken by force
  • typhoid bacilli (Salmonella typhi) found in her stool

Health and Disease in 1900

  • Infectious disease is the major cause of death
  • Epidemic vs. endemic disease
  • Miasmas vs. germs
    • good food, good air, rest
    • the success of sanitary engineering

The germ theory of disease

  • The germ theory is new
    • Koch and Pasteur in the 1880’s and 1890’s
    • Rug dyes and agar
  • Germs and filth
    • Same or different?
    • Major policy issue
  • Germs as a target
  • Depersonalization of disease

Clash of Views

  • Mary said she was healthy, the bacteriological clinic said she was sick
  • Good food or a toxic meal
  • The petri dish imprisoned her — the separation of health and germs

Mary Mallon’s Options

  • Stop cooking
    • She tried. How to make a living?
  • Have her gall bladder removed
    • risk of surgery in 1907
    • by 1914, 5 other carriers had theirs removed — no effect
  • Laxatives and diuretics
    • no effect and not very pleasant

Why so stubborn (Mary) — more details next lecture

  • The Irish Question
  • The contradictions
    • two world views
    • inconsistent stool results
      • her own lab results
  • First contact with Soper
  • Culture clash

Why so stubborn (authorities) — more details next lecture

  • Soper had the first US carrier
  • New York had one of the first municipal bacteriology labs
  • She was a perfect “longitudinal study”
  • “She never would be missed”
    • Irish, woman, unmarried, lowerclass
  • Culture clash

Public Health: Then and now

Boards of Health

  • Since colonial days, but usually transient
    • e.g. Yellow Fever in Philadelphia (1793)
    • “Bring out your dead!”
  • Hospitals not always part of it
  • Enforcement of quarantine and sanitation

Public Acceptance

  • Fear in epidemics (action better than none)
  • Success in public works
    • Water treatment
    • Sewage treatment
    • Garbage and fumigation

Turn of the century

  • Progress
  • Railroads
  • Steel and other Trusts
  • Rise of USA as world power
    • Spanish-American War
    • Teddy Roosevelt
  • Progressive Science

NYC Board granted broad powers

  • Modern lab facility
  • Hermann Biggs (24 years with city, more with state)
  • Record of success

Koch and Pasteur = Confidence

  • Rabies
  • Tuberculosis
  • Anthrax
  • Cholera (John Snow in 1830’s)

Other Typhoid sources disappearing

  • Water and milk kept clean
  • Sick are avoided
  • = increasing percentage caused by carriers

Limits to Public Health Authority

  • Fears of physicians (prevent but don’t cure!)
    • more later (Syphilis)
    • untrained in microscopy
  • Cost
    • upper class resisted taxation
    • more later (Cholera in Hamburg)

The Problems

  • Mary Mallon was only one
    • about 200 new carriers every year in NYC alone!
    • no good way to track them
  • How to find them all?
  • Probable that some were upper class

Could all carriers be found?

  • Typhoid was “reportable”
  • but problems with physicians
    • stigma
    • loss of work and patients
    • opposition to state medicine

Three ways to find

  • Track every case bacteriologically until clear
    • never more than 10 or 20% effective
  • Screen all food personnel
    • expensive (more later, Syphilis)
    • problems with private physicians
  • Epidemiological tracking

Epidemiological tracking

  • finds the important carriers
  • lets the “unimportant” carriers alone
  • only useful AFTER an outbreak
  • does carrier = infectious?

Does carrier = dangerous?