Wow! They don’t write journal articles like that anymore. It sounds like an opening from a Sherlock Holmes story, or some other detective or investigator dreamed up by H.P. Lovecraft. Instead, it’s the opening sentence of a scientific article entitled “The work of a chronic typhoid germ distributor” from the Journal of the American Medical Association (JAMA) way back in 1907, by a chap called George Soper (the hero of our story), and it deals with one of the most famous/infamous outbreaks of typhoid of modern times.
Cue dramatic music…!
The house in Oyster Bay where the outbreak occurred had been rented for the summer by a New York banker, General William Henry Warren, 3 members of his family and their 7 servants (!); 6 of the 11 people staying there were sick. The first case occurred on the 27th August and the last on the 3rd September. Our “hero” George Soper remarks that it doesn’t matter if the people affected were all infected at the same time or if the first person (index case) affected others (secondary cases), he was concerned how “anyone” was infected in the first place… No one else in Oyster Bay was affected, and in fact typhoid was a rare diagnosis in Oyster Bay. So he was right, why did they get infected in the first place?
The original investigators had blamed the water supply, but George Soper found no evidence that the well, supplying water to the house, had been contaminated. In fact he even looked for “the possibility that the typhoidal germs might have percolated through the ground to the well from some receptacle of excrement”!
Despite local people continuing to blame the water supply despite no evidence of this (sound familiar - Covid-19 and research laboratories!) George Soper began to suspect that the “infectious material had been carried to the house by some person or some article of food”.
Unfortunately, our hero George then got led (literally) down the garden path when local people kept telling him the affected family were very fond of eating clams. This theory was reinforced by George’s own observations that clams were often sourced locally from a site close to where sewerage was dumped into the sea. Eventually George discovered that no clams had actually been eaten since the middle of July, so he rejected that theory.
George then looked at vegetables and fruit, picnics and holidays, social standing and even whether there had been previous outbreaks in the house… nothing!
The more he looked into the outbreak George became convinced that something had occurred in or around the 20th August that had exposed the family to the infection. The only thing George could find was that the family had changed their cook of many years to a new cook who had joined the household three weeks before the outbreak occurred but that she had left 3 weeks after it occurred. She was described as “an Irish woman about 40 years of age, tall, heavy, single” and she was apparently in good health.
George was also able to pinpoint the likely moment when people were infected by taking a detailed dietary history. Most of the food eaten at Oyster Bay had been thoroughly cooked, therefore destroying any probable bacteria, however there was a particular dessert “of which everyone present was particularly fond”, it was “ice-cream with fresh peaches cut up and frozen in it”; yet George concluded that it wasn’t just fresh peaches that had been added to the ice-cream!
George Soper finally managed to track the cook down after much searching to a house on Park Avenue where she was working again as a cook. The fact that two people in the Park Avenue household were also extremely sick with typhoid fever in a local hospital might also have had something to do with it. She however was completely unhelpful, and she refused to talk to George… although given the way he describes her, I suspect his bedside manner left a lot to be desired!! Her response was to “seize a carving fork and advanced in his direction” forcing George to make his escape through “the tall iron gate” and back onto the sidewalk!
In the end George had to work out the cook’s history himself. His investigation was incomplete, but he was able to discover that she had worked for at least eight families since 1900, of which seven had experienced typhoid outbreaks! George makes the excellent observation that the cook had never been ill during any of the outbreaks. In total George found 26 cases and 1 death associated with the cook.
It is an amazing piece of detective work as the germ theory of disease was still relatively new, and the ability of bacteria to transmit between people causing disease was only just starting to be recognised. Even in modern days, Microbiologists can seem “reluctant” to initiate investigations and find the source of an outbreak! It is even more striking that George was able to work out the common factor and likely source of infection as he was not a Doctor, and in fact had no medical qualifications at all, he was an engineer.
In case you haven’t already guessed, the cook’s name was Mary Mallon, although history has remembered her as “Typhoid Mary”.
What happened next?
Despite managing to upset Mary so much that she attacked him with a carving fork, George Soper didn’t give up trying to prove beyond doubt that Mary was the focus of the infections. (NB Hmmm… sometimes I feel I have daggers pointed at me when I walk onto a ward with my “I think we have a problem attitude”). He managed to find out that she was visiting a rooming house and spending her evenings with a “disreputable looking man” who showed George his rooms, which George later describes as “a place of dirt and disorder… not improved by the presence of a large dog” and which he would “not care to see another like it”. It sounds grim but it could just be our George’s social prejudices coming out again!
George then waited in secret for Mary to turn up. Strangely George was surprised that Mary got angry when she found him there… George really had a way with people. Mary chased George away again with a flea in his ear!
George then turned to the New York City Health Department and made them aware of his concerns about Mary, calling Mary “a living culture tube and chronic typhoid germ producer” and a “proved menace to the community” …there you go again George!
Finally, a Dr Josephine Baker and 3 policemen were sent to detain Mary, who on seeing the policemen escaped through a rear window of the house, scaled the back fence, and ran off into the snow! After a 3-hour search, she was eventually found hiding in the “outside closet” of a neighbouring house. Mary put up quite a fight until eventually she was forced into a waiting ambulance by the policemen. Apparently the ambulance’s “ride down to the hospital was quite a wild one”!
Mary was detained in the hospital from March 20th until November 16th and lots of samples were taken to try and isolate the cause of typhoid. In particular George tells us that stool samples were taken 3 times a week and on only a few occasions did they fail to isolate the “Bacillus typhosus” or what we would now call Salmonella typhi.
During this time George, whose bedside manner hadn’t improved at all, visited Mary in her “hospital room”; a room with white walls, ceiling and floor and white bed, were she was dressed in a white bathrobe. George writes:
“Mary,” I said, I’ve come to talk with you and see if between us we cannot get you out of here. When I asked you to help me before, you have refused and when others have asked you, you have refused them also. You would not be where you are now if you had not been so obstinate. So throw off your wrong-headed idea and be reasonable. Nobody wants to harm you. You say you have never caused a case of typhoid, but I know you have done so. Nobody thinks you have done it purposely. But you have done so just the same. Many people have been sick and have suffered a great deal; some have died. You refused to give specimens which would help to clear up the trouble. So you were arrested and brought here and the specimens taken in spite of your resistance. They proved what I charged. Now you must surely see how mistaken you were. Don’t you acknowledge it?”
Mary looked at me steadily, but neither spoke nor moved. Her eyes gleamed angrily.
“Well,” I continued, “I will tell you how you do it. When you go to the toilet, the germs which grow within your body get upon your fingers, and when you handle food in cooking they get on the food. People who eat this food swallow the germs and get sick. If you would wash your hands after leaving the toilet and before cooking, there might be no trouble. You don’t keep your hands clean enough.”
Oh, that old chestnut AGAIN!!!!
…Mary’s expression did not change nor did she utter a word. I was bound to tell her all that I had come to say, so I continued.
“The germs are probably growing in your gallbladder. The best way to get rid of them is to get rid of the gallbladder. You don’t need a gallbladder any more than you need an appendix. There are many people living without them.”
“Mary,” I continued, “I don’t know how long the Department of Health intends to keep you here. I believe that depends partly on you. I can help you. If you will answer my questions, I will do everything I possibly can to get you out. I will do more than you think. I will write a book about your case. I will not mention your real name; I will carefully hide your identity. I will guarantee that you will get all the profits. It will be easy for you to answer my questions. You know what I want to find out. Above all, I want to know if and when you have had typhoid fever, and how many outbreaks and cases you have seen.”
As I finished Mary stood, pulled her bathrobe about her and, not taking her eyes off mine, slowly opened the door of her toilet and vanished within. The door slammed.
Wow! George! You really know how to talk to patients!!! Unbelievable!?
After two years of forced “imprisonment” in hospital against her will, without charge, trial or representation, Mary tried to sue New York City to get released. In the end the Supreme Court rejected her case saying, “they were unwilling to take the responsibility of releasing her”. Poor old Mary!
After nearly 3 years, Mary was eventually released having promised never to handle the food of others again, and to report to the Health Department every 3 months. Mary continued to refuse to have her gallbladder removed… and surprisingly given all of the other abuses done to her this wasn’t forcibly done… I suspect they were (quite rightly) worried the operation might actually kill her!
She was eventually caught again after an outbreak of more than 20 cases of typhoid fever at the Sloane Hospital for Women. George was called in to identify if the cook was in fact Mary Mallon… by a curious coincidence the staff at the Women’s Hospital had been calling her “Typhoid Mary”, despite the fact that she had changed her name!
This time Mary didn’t put up a fight, and the Health Department kept Mary locked up in “hospital” for another 23 years. George says “she had lost something of that remarkable energy and activity which had characterised her young days” he also remarked that “the world had not been very kind to Mary” although he never acknowledges his own part in this.
So, what does Mary’s story tell us about the pathology of typhoid fever?
What George and Mary had shown was that some people infected with Salmonella spp. go on to develop a carrier state in which the infected person appears perfectly well, but in whom bacteria live within the gallbladder. These people intermittently excrete bacteria in their stool and can therefore infect others causing sporadic outbreaks. It is an important observation and one which has allowed Public Health Departments to track outbreaks back to their source and prevent further cases.
In the next blog I’ll tell you more about typhoid fever in the current age of medicine, how it presents, how it is diagnosed, and how we treat it. Until then I’ll leave the last words to George:
“It was to be Mary Mallon’s fate to clear away much of the mystery which surrounded the transmission of typhoid fever and to call attention to the fact that it was often persons rather than things who offered the proper explanation when the disease occurred in endemic, sporadic and epidemic form”.
- The work of a chronic typhoid germ distributor. George Soper, JAMA June 15 1907, 2019-2022
- Address to the Surgeons of the Sixth Division on Mary Mallon by George Soper, published in The Military Surgeon July 1919
- The Curious Career of Typhoid Mary. George Soper, Bull N Y Acad Med. 1939 Oct; 15(10): 698–712