Typhoid Mary—p. 1

The Discovery of Typhoid Mary George Soper, 1907

n the winter of 1906 I was called on to To the first investigators it seemed that investigate a household epidemic of ty- the water must have been contaminated. Iphoid fever which had broken out in the They were unable to ascribe the fever to latter part of August at Oyster Bay, N. Y. food, flies or milk, whereas if they could The epidemic had been studied carefully discover that the water had been contami- immediately after it took place, but its cause nated they would be able to account for the had not been ascertained with as much cer- epidemic. tainty as seemed desirable to the owner of The water supply for the house was from the property. a driven well said to be 167 feet deep. The The essential facts concerning the inves- well was at a distance of 210 feet from the tigation follow: house, within 60 feet of a stable drain, 115 feet from a privy behind the stable, and 224 THE OYSTER BAY OUTBREAK. feet from two cesspools which received the At Oyster Bay in the summer of 1906 six drainage of the house. The cesspools and persons in a household of eleven were at- privy had been cleaned out in April. The tacked with typhoid fever. The house was house was provided with one water closet, large, surrounded with ample grounds, in a situated on the second floor. This was used desirable part of the village, and had been by the family. The sic servants used the rented for the summer by a New York privy. The sewage from the house was car- banker. ried by a tile pipe to the two cesspools just The first person was taken sick on August referred to. The soil is sandy and gravelly 27 and the last on September 3. The diagno- throughout this region. sis of typhoid was positive. Two of the pa- tients were sent to the Nassau hospital at George Soper was a civil engineer Mineola. The others were attended by capa- hired by private citizens of New ble physicians at Oyster Bay. None of the York City to investigate the outbreak subsequent cases apparently resulted from of typhoid in Oyster Bay, New York. the first, although the interval from the first He was known for his experience in to the last might permit of this assumption. investigating typhoid fever epidem- But whether the disease was transmitted ics using epidemiological analyses. from one person to another after the first This paper about his investigation of case occurred was not a matter of great con- Mary Mallon was read before the sequence. The most important question was biological society of Washington, how the first case occurred. D.C., on April 6, 1907. Typhoid fever is an unusual disease in The water was pumped from the well by Oyster Bay, according to the three physi- a gas engine to a covered wooden tank situ- cians who share the medical practice there. ated 186 feet from the stable and 320 feet At the time of the outbreak no other case from the house. Water ran from this outside was known. None followed. tank to an open tank in the attic of the house, The milk supply of this house was the removed from the nearest living rooms by a same as used by most of the other persons in steep and narrow ladder. the village, all of whom [remained well.] Samples of the water were taken and The cream also was from a source which subjected to careful chemical and bacterio- supplied several other families in the vicin- logic analysis. They were collected direct ity. from the pump, from the outside tank and from a faucet in the house. There were five http://skylinecollege.edu/case Typhoid Mary—p. 2 samples taken in all. Four were examined by cleaners who, perhaps, carried typhoid ex- E. E. Smith, M.D., Ph.D., the well-known creta on their boots. It was supposed that a analytic expert, and the other by D. D. Jack- gradual accumulation of organic matter from son, Ph.D., director of the laboratories of the the water and dust from the air, aided by the New York City Department of Water Sup- continued warmth of the summer sun, might ply, Gas and Electricity. have led these germs to multiply until at last The essential facts concerning these they escaped to the water and infected the analyses, including the condensed state- household. ments of the resulting opinions, follow: It did not seem to me that the water the- ory was tenable. The analyses proved that ANALYSIS OF WATER FROM the well was not continuously polluted. The OYSTER BAY fluoresein tests showed that occasional con- 1906 Source of Opinion of tamination was not likely. An inspection of Sample Analyst the premises and inquires concerning they Sept. 12. Faucet in house Sanitarily pure. way the outside tank was cleaned made it Sept. 12. Outside tank Probably safe seem unlikely that this tank became infested Sept. 13. Pump over well No evidence of pollution in the way supposed. Sept. 27. Outside tank Typhoid from It would have been more probable to sup- this source im- pose that the tank in the house, which was possible without a cover and accessible to occupants Sept. 29. Outside tank Evidence does of the house, had become polluted. Such not show pol- contamination was not without precedent. lution Had typhoid existed in the house at the time, In addition to these examinations, an ex- it was possible that the tank could have be- perimental study was made of the possibility come contaminated in this way. But there that the typhoid germs might have perco- had been no case. Moreover, inquiry made it lated through the ground to the well from seem unlikely that the tank had been visited some receptacle of excrement. On Septem- all summer. It was much more convenient ber 29 Dr. Smith put fluoresein in the bowl for persons to get water otherwise than by of the water closet in the house, in the cess- climbing the narrow ladder to the attic. It pools, in the stable manure vault, in the seemed more probable that they infectious privy vault on this property and in another material had been carried to the house by on adjacent property and in the bowl of the some person or some article of food. water closet in a neighboring house. He looked for traces of this fluoresein in water I was led from the proper track for a time from the well, obtained after much pumping, by being assured that no person who had had two days and five days later. Six samples of typhoid, at least within many months, had water were collected during this test. They lived in the house or visited it during the entirely failed to reveal pollution. whole summer, and by discovering that the Even this thorough work on the water family was extremely fond of soft clams. supply did not entirely destroy local confi- My suspicion for a time attached to clams. It dence in the theory that the water had been was found that soft clams had frequently the cause of the outbreak. A contamination been obtained in the summer from an old of the outside covered tank of such nature as Indian woman who lived in a tent on the to escape detection by analysis was sus- beach not far from the house. It was impos- pected as offering a possible explanation of sible to find this woman, but I made inspec- the trouble. According to this idea the tank, tions of the sources of soft clams at Oyster which had been cleaned early in the spring, Bay, which showed that they were some- might have received typhoid bacilli from the Typhoid Mary—p. 3 times taken from places where they were daughter of the tenant and, finally, the gar- polluted with sewage. dener who lived permanently at Oyster Bay But if clams had been responsible for the and had worked on the place for years. outbreak it did not seem clear why the fever Believing that some peculiar event might should have been confined to this house. have occurred in the family on or shortly Soft clams form a very common article of before August 20, which, if studied, might diet among the native inhabitants of Oyster give the necessary clue to the cause of the Bay. On inquiring closely into the question epidemic, careful inquiry was made into the of the food eaten before the outbreak it was immediate history of the household at this eventually found that no clams had been time. The key of the situation was thus dis- eaten subsequent to July 15. This removed covered. the possibility that they epidemic had been It was found that the family had changed caused by clams. From July 15 to August cooks on August 4. This was about three 27, six weeks, was too long a period for an weeks before the typhoid epidemic broke outbreak of this character to remain unde- out. A cook who had been with the family veloped. The infectious matter which pro- several years had been discharged and a new duced the epidemic had been taken with one employed. Little was known about the food or drink, in my opinion, on or before new cook’s history. She had been engaged at August 20. an employment bureau which gave her an The supplies of vegetables and fruit were excellent recommendation. She remained in next considered. It was found that they per- the family only a short time, leaving about sons attacked had not eaten any raw fruit or three weeks after the outbreak of typhoid vegetables which had not also been eatene occurred. Her present whereabouts were un- by menay persons who escaped the fever. known. The cook was described as an Irish The history of the house with regard to woman about 40 years of age, tall, heavy, typhoid was inquired into. It was found that single. She seemed to be in perfect health. but one case of typhoid had occurred on the Here was by all means the most important premises or been nursed there in thirteen possibility in the way of a clue which had years. This case occurred in 1901. Care come to my notice. If this woman could be seemed to have been taken to destroy the found and questioned, it seemed likely that infectious nature of the discharges. The case she could give facts from which the cause of produced no secondary cases at the time. the epidemic could be ascertained. The house had been occupied every summer When, after much difficulty, she was since without typhoid. found, this hope was destroyed. No infor- Attention was now concentrated for a mation of value was obtainable from her. time on the first cases to determine whether She refused to speak to me or any one about the infection could have occurred during a herself or her history except on matters temporary absence from Oyster Bay. It was which she knew were already well known. found that those persons who were taken It became necessary to work out the sick at the outset had not been on a visit, or cook’s history without her help. This effort picnic, or, in fact, away from Oyster Bay on has been only partially satisfactory. Her any account for several weeks prior to the whereabouts for only a part of the time in onset of the illness. the last ten years have been ascertained. The social position of the persons at- About two years of time among the last five tacked differed decidedly. Among the first years remain unaccounted for. In the last ten to be taken sick were a daughter of the head years she has worked for eight families to of the family and two maid servants, one of my positive knowledge; in seven of thse ty- which was colored. Following in a quick phoid has followed her. She has always es- succession were the wife and then another Typhoid Mary—p. 4 caped in the epidemics with which she had New York Polyclinic. It is unnecessary to been connected. descibe this analysis or the details of Dr. The most interesting features of the other Wilson’s careful investigation. outbreaks of typhoid with which this cook Dr. Wilson’s conclusion was that the epi- has been connected follow: demic must have been caused by the laun- In 1904 a well-known New York family dress. In his opinion, she had probably been on moving to Sands Point, L. I., to spend the infected before entering this employment. summer experienced an epidemic of typhoid Her case, he thought, gave rise to the others. which attracted a considerable among of at- Dr. Wilson tired to find how the laundress tention at the time. The household consisted became infected before joining this family, of eleven persons, seven of whom were ser- but was unsuccessful. vants. The household arrived on June 1. On June 8, or about one week later, typhoid be- EPIDEMIC AT DARK HARBOR, gan to appear. MAINE, IN 1902 The first person to be taken sick was the In 1902 a severe outbreak of typhoid oc- laundress. She had entered the employ of curred in the family of a prominent New this family ten days before for the summer York lawyer who had just taken his house- season. Following this case in irregular suc- hold, consisting of four in family and five cession three other persons were taken sick. servants, to Dark Harbor, Maine, to spend Within three weeks after arrival, there were this summer. Seven members of this house- four persons, in all, all attacked. hold of nine were soon ill of typhoid. In ad- None of the family itself was taken sick. dition, a trained nurse was attacked, as, it is No person was attacked who had been long said, was a woman who was employed to with the family. The new laundress fell ill work by the day. first, then the gardener who had not come The first case occurred two weeks after from the city with the family, but worked on the arrival at Dark Harbor, on June 17. The the place the year round, then the butler’s onset of this case was sudden. In just one wife, and finally the butler’s wife sister. The week another case occurred. Two days later latter was not in the family service, but lived there was a third. The remainder followed with the other servants in a little house sepa- rapidly. The only persons who escaped were rate from the main dwelling. the cook and the head of the family; he had The cook had been in the family nine had an attack of typhoid fever some years months, seemingly without suffering from before. typhoid fever or producing typhoid. All the servants, except the cook, had The Sands Point epidemic was confined been employed in this family for one month to the house where the servants lived. There or more in New York. The cook had been were no other cases in the vicinity. None engaged especially for the summer and had preceded this outbreak and on followed at joined the family three weeks before it left Sands Point. No doubt could be placed on New York. the diagnosis. One of the cases, that of the The outbreak at Dark Harbor was studied laundress, was long and severe. There was by a number of persons and especially by no death. Dr. E. A. Daniels of Boston and Dr. Louis The outbreak was studied by several per- Starr of Philadelphia. The house was new, sons. Finally, Dr. R. L. Wilson of the New never having been occupied before. It has York City Department of Health was called been impossible to rent it since. as expert to investigate it. Dr. Wilson ex- Because of its newness, the water supply amined the water supply, drainage and other of the house was not in every way satisfac- sanitary conditions. He caused an analysis of tory. A tank on the top floor of the house the water to be made by Dr. Jeffreys of the had not been cleaned since it was set in Typhoid Mary—p. 5 place. Until this cleaning was accomplished tack was not, apparently, investigated at the drinking water was obtained from a spring. time, and fuller information concerning it Water was never believed to have been has so far been difficult to obtain. the original cause of the outbreak. Two analyses of the water were made; one at the OUTBREAK AT MAMARONECK Massachusetts Institute of Technology in IN 1900. Boston and one in New York. They con- My earliest record of the cook’s employ- firmed the opinion that the water was safe. ment is in a New York family which has a It was suspected that the household sup- summer residence at Mamaroneck, N. Y. In ply later became contaminated. A pitcher this instance, a young man who made a visit from a room in which the first typhoid case to the family was attacked, his illness dating was nursed was supposed to have been filled from Sept. 4, 1900. The circumstances in at an open tank on the same floor, this in- this case were such as to lead to the impres- fecting the household supply. But the epi- sion at the time that the infection occurred demic had already broken out when this on Long Island. He had spent two weeks at event was believed to have occurred. Ty- East Hampton within a few miles of a fever- phoid fever was scarcely known in Dark ridden camp occupied by U. S. soldiers at Harbor at the time of this outbreak and had Montauk Point. It was thought that me might been exceedingly rare since. No case imme- have been infected from water or by drink- diately preceded or succeeded it. ing from a cup used by some typhoid pa- It was believed by some that the original tient, or in some other way not known. cause of the epidemic was the sickness of a Inasmuch as the patient lived in the footmanÐthe first case. The theory was that Mamaroneck household for at least ten days the footman contracted his illness before before the onset of his illness, and, as his going to Dark Harbor, either in New York or supposed exposure to typhoid on Long Is- on the way. Dr. Daniels was of opinion that land was by no means reasonably clear, it the first three cases received their infection seems to me probable that he was infected in this way at the same time and place. by the cook. The cook left within a few days On making a careful study of the facts, after the onset of this illness. She had been both views seem to me untenable. The pe- in the family for three years without, appar- riod of time which elapsed from the first to ently, being connected in any way with ty- the second case was too short to agree with phoid. the theory that the first case led to the others. The incubation period required to be cov- OUTBREAK IN TUXEDO, N. Y., ered in the event that the first three cases IN 1906. were infected before reaching Dark Harbor Subsequent to her employment at Oyster was too long. Beside, for the most part, Bay, the cook went to live in a family at these three persons had not shared the same Tuxedo Park, N. Y. She remained there from food for a long time. Sept. 21 to October 27, 1906. On October 5, fourteen days after her arrival, a laundress OUTBREAK IN NEW YORK IN 1901. was taken sick with typhoid fever and re- The history of the cook before going to moved to St. Joseph’s Hospital, N. J. Dark Harbor is not entirely clear. In 1901-2, According to Dr. E. C. Rushmore, who she lived about eleven months in one family. saw this case, no other case of typhoid had Here a laundress was taken ill and removed been known in Tuxedo for several years. to Roosevelt Hospital, Dec. 9, 1901, one Excepting the cook, all the servants had month after the cook’s arrival. This case was been in the family for two months or more. seen by Dr. R. J. Carlisle of New York. The The cause of the laundress’ illness was not diagnosis was positive. The cause of the at- made clear at the time. Typhoid Mary—p. 6

The cook has escaped sickness in every FINAL OUTBREAK IN NEW YORK instance. In only one instance is it known IN 1907. that she has worked in a family where no When, at last, the cook’s final where- typhoid has occurred. This family consisted abouts were ascertained, it was found that of two people of advanced age and one old two cases of typhoid fever had broken out in servant. the household where she was employed. In all there have been twenty-six cases These occurred a few weeks after her arri- and one death. Twenty-four of these cases val. One patient, a chambermaid, was taken have occurred within the last five years. sick Jan. 23, 1907, and removed on January 29 to the Presbyterian Hospital, New York. THE CAPTURE OF The doctor was first called to see the other TYPHOID MARY* patient, a daughter of the owner of the n 1907 Sara Josephine Baker, a physician house, on February 8. This second case re- and New Your City medical inspector, sulted fatally on Feb 23, 1907, the only fatal Iwas dispatched to visit Mary Mallon, the case in this whole record. famous cook who became known as "Ty- A period of two months elapsed between phoid Mary." George Soper at the [New the beginning of the employment of the York City] Department of Health Laborato- cook and the beginning of the first case of ries had investigated seven family epidemics illness in this household. The New York of typhoid going back to 1900. He found City Department of Health officially inves- that they were all linked to the cook in each tigated the first of these two cases at the family. Baker was sent to collect specimens time it was reported by the attending physi- for culture. On her first visit, Baker had the cian and, in the absence of evidence to the door slammed in her face. The next day, contrary, ascribed it to the public water sup- when she returned with several policemen, ply. Mary answered the door and against tried to The foregoing records by no means all slam it shut, but a policeman's food was in the cases with which this cook may have the door. Mary ran into the house and could been associated. As already mentioned, I not be found in a search of the house. But have been able to trace but fragments of her looking out the rear window, Dr. Baker no- history through the last ten years. ticed a chair against the fence and footprints There is a remarkable resemblance be- in the snow. Mary was found next door tween these seven fragments. In each in- hiding in a closet. She was most uncoopera- stance one or more cases of typhoid have tive and fought against having blood taken occurred in households from ten days to a so she was forcibly transported in an ambu- few weeks after the cook has arrived or lance to a hospital where specimens were among people who have, within that period, obtained. come to live near her and eaten the food Dr. M. Goodwin did the bacteriological which she has prepared. work under Dr. Park’s direction. It was ex- In every instance the families have been pected by me that germs might be found in of ample means and accustomed to living the urine, but more probably in the stools. well. In each household there have been four None was found in the urine. The stools or five in the family and from five to seven contained the germs in great numbers. Daily servants. Four of the persons attacked have examinations made for over two weeks have been laundresses. Two have been gardeners, permanently attached to the country places * O'Hern, E. M. "Sara Josephine Baker." In Profiles where the typhoid has broken out. All but of Women Scientists. Washington, D.C.: Acropo- two of the outbreaks have occurred in the lis Books, 1985. country. Bourdain, Anthony. Typhoid Mary: An Urban Historical. New York City: Bloomsbury, 2001 Typhoid Mary—p. 7 failed only twice to reveal the presence of the Bacillus typosus, and on these occasions The bacterium that causes ty- the sample taken was perhaps too small to phoid fever is Salmonella en- reveal them. The blood gave a positive Wi- terica Typhi. dal reaction. The cook appeared to be in per- fect health. The Widal test is a serological We have here, in my [Soper] judgement, test to detect antibodies against a case of a chronic typhoid germ distributor, the S. enterica Typhi in a pa- or, as the Germans say, a "typhusbazillen- tient's serum. Bacteria are trägerin." placed on a slide and patient Captured on March 20, 1907, Mary serum is added. Agglutination Mallon was confined to Willard Parker Hos- of the bacteria indicates the pital for two years and 11 months during presence of antibodies. which time every available remedy was tried to rid her of the typhoid organisms., All ef- forts failed. On the promise that she would return every three months to the laboratory and take up some occupation other than cooking, Mary was released. She promptly disappeared. For the next five years Mary worked in homes and institutions in and around New York, often under assumed names. In Febru- ary 1915, a devastating outbreak of typhoid (1,300 reported cases) was traced to her. She was apprehended and made no struggle against the second capture. This time she was sent to North Brother Island where she remained for 23 years, to the end of her life in 1938, a special guest of New York City. Discussions of the ethics of her case, the morality of depriving her of liberty, had commenced at the annual meeting of the American Medical Association in Chicago in 1910. Concurrently there was consterna- tion of the probability that many more ty- phoid carriers must be at liberty in many communities. ²