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The St. Louis Diphtheria Tragedy – Podcast #147

As you probably already know, I am not a doctor, but I play one on this podcast. In addition, I have an advanced degree in Geology – aka rocks – where absolutely nothing is alive. Which makes me perfectly qualified to talk about medicine and vaccines – NOT! The reality is that I am not an expert in medicine and since that is the focus of today’s story, I apologize in advance if I make some minor misstatements regarding the science.

Since vaccines have been in the news quite a bit and I am about to get my first covid shot shortly, it got me thinking about some of the more obscure stories that I knew about vaccines. I have chosen a story from the early days of vaccinations and I’m hoping that you will find great interest in what I am about to tell you. This medical tragedy played an essential part in the establishment of federal regulations here within the US that ensures the safety of the vaccines that we use today. And I should point out, that this not meant to be a lesson on avoiding vaccines. It is simply a story about how, even when the greatest of precautions are taken, sometimes things can go horribly wrong.

Today, it is estimated that 3.9% of children will die globally before reaching the age of five, which works out to about fifteen thousand children dying every day. That is a lot of sadness worldwide. Yet, it is a giant ten-fold improvement over the child mortality rate of 1800 when an estimated 40% of all children did not survive to their fifth birthday.

One could make a list of all the reasons why the childhood mortality rate was so high back then, but let’s just focus on one of them: Diphtheria. Nearly unheard of here in the United States today, it was one of the leading killers of children prior to the twentieth century.

Named after the bacterium that causes it, Corynebacterium diphtheriae, it is typically transmitted from person to person by respiratory droplets. Some of the symptoms of Diphtheria seem fairly common: a sore throat, fever, and a loss of appetite. Yet, diphtheria attacks its victim in two ways: First, the bacteria produce a toxin that creates a thick gray pseudomembrane that most noticeably coats the back of the throat, which makes it incredibly difficult to breathe. And, if it did not suffocate the patient, the toxin could cause both heart failure and paralysis. In other words, there was truly little that a 19th-century doctor could do to help those who were infected. Estimates vary, but the mortality rate for those diagnosed with diphtheria was most likely more than 40%.

Two scientists, working independently, Emil von Behring in Germany and Emile Roux in France developed the first diphtheria “antitoxins.” The idea was straightforward: inject an animal with the diphtheria bacteria and let their immune systems work to produce antibodies, which would then be extracted, purified, and finally injected into a human. Of course, to produce a lot of the antitoxin, a lot of blood would be needed. Tests were done on cows and donkeys, but it was found that horses were least affected by the diphtheria injection. They typically only exhibited a low-grade fever.

A biologist injecting a horse with diphtheria bacteria at the New York City Department of Health serum and vaccine farm, Otisville, New York
A biologist injecting a horse with diphtheria bacteria at the New York City Department of Health serum and vaccine farm, Otisville, New York. Library of Congress image.

This diphtheria antitoxin was viewed as a modern miracle. In an age before automobiles, it was easy to acquire horses that were either injured or too old to be of much use. So, instead of putting them down, it made sense for cities like New York and St. Louis to begin using these horses to produce the diphtheria antitoxin.

Fast-forward to October 18, 1901, when Mrs. Mary Keenan took all four of her children to the St. Louis City Hospital because two of them were very sick. The two children were diagnosed with diphtheria and given the antitoxin. And, as was customary at the time, her other two children were given it as a preventative.

Initially, everything seemed to be going well. The antitoxin appeared to be doing its job as the diphtheria symptoms began to subside. But then something peculiar happened: 5-year-old Veronica Keenan, who was initially referred to as Vernie O’Neill in the press, became increasingly ill. She would pass away on Saturday, October 26, 1901.
And what was odd about that?

Veronica was one of the two Keenan children given the antitoxin as a preventative and had never exhibited any diphtheria symptoms. Her death certificate states that the cause of death was spinal meningitis, but there were signs of tetanus (lockjaw).

Veronica Keenan/Veronica O'Neill death certificate.
Veronica Keenan/Veronica O’Neill death certificate.

Dr. H. L. Nietert, superintendent of the hospital, told the press, “I believe that the meningitis was merely coincident; that would have developed had she had been at home. Some of the symptoms did look like tetanus. If the toxine caused tetanus in this instance, why has it not done so in others, for we have administered it to many patients?”
Two days after Veronica’s passing, 5-year-old Bessie Baker would also die from lockjaw. Then, two days after that, Bessie’s 4-year-old sister Viola May would also die from tetanus. Their 2-year-old brother Frankie also exhibited symptoms of lockjaw, but he would survive. Not only that, but all three of the Baker children had developed tetanus shortly after receiving injections of the diphtheria antitoxin.

Dr. R. C. Harris, who had treated the children stated, “I was called in on Oct. 19 by Mrs. Baker to attend to her daughter, Bessie, who was suffering from a severe case of diphtheria. I injected the usual quantity of the anti-toxine in the little girl. As a precautionary measure, frequently adopted in such cases, I also injected a quantity of the anti-toxine in the two smaller children as immunizing doses.

“In three or four days a marked improvement was apparent in the case of the little girl, Bessie, and I concluded that she was out of danger and would soon be entirely well, just as other patients became whom I treated in similar fashion.
“But, about four days later, that was last Sunday, I was hurriedly called to Mrs. Baker’s home, over the confectionery. There I found that the little girl was suffering from tetanus (lockjaw). I could do nothing for her. The poison was injected so thoroughly into her system that she was beyond medical aid. She died at noon Monday.

“Before Bessie died, the second child, May, developed symptoms of the terrible disease. I was called there again but could do nothing. She lingered until Tuesday night at midnight. I called there again Wednesday morning and found that the third child had also developed symptoms of the disease. I fear that she will die too, as her condition is apparently very critical.”

Sidenote: It’s unclear why Dr. Harris referred to the third child as female since the same article states that the boy was named Frankie, which I was able to confirm. This was a common problem in researching this story. Many of the names, dates, and ages were wrong.

Back to the story:

Things would only get worse from here. By the time this story broke in the press on October 30, three more of Mary Keenan’s children had developed lockjaw and it was believed that all would soon die.

The Health Department immediately began an investigation as to what could have gone wrong. The city had recently provided sixty-three doctors with 256 doses of the antitoxin. A number of doctors reported excellent results with no signs of tetanus. The initial belief was that the physicians who had used the suspect serum had used instruments that had not been sterilized properly. Yet, in a precautionary move, the Board of Health announced that they would provide the tetanus antitoxin free-of-charge to any patient who had recently received the diphtheria antitoxin.

Child Receiving the Diphtheria Vaccine in 1895
A child receiving the diphtheria vaccine in 1895 at the Pasteur Institute in 1895. Image appeared on page 8 of the January 3, 1895 publication of Harper’s Weekly.

On November 1, the city issued a recall and announced that they would no longer be in the business of manufacturing the diphtheria antitoxin.

That same day, four more children passed away: 2-year-old Joe Novak, 4-year-old Ettie Simon, 4-year-old Isaac Stein, and 7-year-old Agnes Adele Keenan, the second in her family to die.

As you can imagine, this was an incredibly scary time for parents around the city. Doctors raced to give the tetanus antiserum to those who had received the suspect diphtheria vaccine. But it was too late for others. Doctors began to reexamine the recent deaths of other children to determine if they had also died from tetanus. This added two more children to this growing list: First was 3-year-old Nettie Kammerman, whose two other siblings also developed lockjaw symptoms and survived. The second was 4-year-old Julius Cytron, whose 9-year-old brother Morris had died five weeks earlier after being hit by a streetcar.

But this wasn’t the end of the nightmare. There were numerous reports of children being near death around the city. The press reported daily those near death and kept a running tally on the deceased.

On November 2, 8-year-old Flora Fuerst passed away. Hospital Superintendent Dr. Nietert described the futile attempt to save her life: “In her case, we injected antitoxin into the ventricles of the brain. This was done by reason of the late theory that injecting antitoxin into the nerve cells might save the life. The child died, however.”

On the day that Flora died, it was revealed in the press that 10-year-old Jacob Centuria had passed away two days prior. His death certificate described his cause of death as “Cause Unknown at Present.”

Jacob Centuria death certificate.
Jacob Centuria death certificate.

4-year-old Emma Ernst would be the next to pass away on November 3. As sad as this was, doctors were able to offer a glimmer of hope. Based on the known period of incubation for the tetanus toxin, they estimated that there would be no new tetanus cases after Thursday, November 7.

Yet, there were a number of children already suffering and it was feared that at least several more would die.
The one family that we lost track of during this story was the Keenan family, those four children who all had tetanus infections. The two surviving Keenan children continued to suffer greatly. Sadly, 10-year-old Mamie (really Marie) passed away on November 5, 1901. While her father and his two sisters were burying Mamie in Bellefontaine Cemetery, Mrs. Keenan stayed home to care for her only surviving child, Chester. He courageously battled the effects of tetanus for two weeks and miraculously survived. In total, thirteen children had died from tetanus after receiving the diphtheria antitoxin. Veronica Keenan had been the first identified and Mamie Keenan was the last.

Marie (Mamie) Keenan Death Certificate.
Marie (Mamie) Keenan Death Certificate.

But what had caused all of this?

The entire manufacture of the diphtheria antitoxin in St. Louis was done under the charge of Dr. Amand Ravold, the city’s bacteriologist. He did nearly all of the work himself, from the initial injection of diphtheria into the horses, through the collection of the serum, to its purifying and, finally, its distribution and record keeping. A few tasks like testing and bottling were done by others, but it was mostly Dr. Ravold’s baby.

There was one thing that investigators were certain of: all of the children who had developed what was believed to have been tetanus had received doses drawn within a short period of time from the same horse, a horse named Jim.

Dr. Max C. Starkloff, the St. Louis Health Commissioner stated, “He was a bay horse, 16 hands high, weighed over 1600 pounds and named Jim. Originally, he was an ambulance horse, had been injured in the shoulder and was turned over to me by Dr. Jordan, chief dispensary physician, in 1898. He has been under treatment for the production of diphtheria antitoxin for nearly three years, has been bled a number of times and has furnished over thirty (30) quarts of diphtheritic antitoxin. In fact, the greater part of the antitoxin distributed by the health department during the years 1900 and 1901 came from this horse.”

Yet, there was one big problem with Jim. He was no longer alive. Dr. Ravold explained, “Come October 21 to 26 we ran out of serum. On October 18 Mr. Taylor [Henry R. Taylor, a janitor and Dr. Ravold’s assistant] called my attention to the fact that our serum was running low and that an unusual demand was being made for it. I gave instruction that not more than one bottle was to be given to any applicant until a new lot of serum could be obtained.

“On September 22 I again injected Jim with 300 c.c. of strong diphtheria toxin, and on September 30 bled him, taking 8000 units of blood. On October 2 I was notified by telephone that Jim was sick and Dr. Ellis was sent out to see him. He pronounced the horse sick with tetanus and ordered him killed.”

So, could that be the cause of death for all of these children? Dr. Ravold did not think so. First, he explained that he had been in Chicago when he received the call and upon his return from, Mr. Taylor and he poured all of the serum that had recently been drawn from Jim down the sink. Second, the serum previously drawn from Jim and distributed around the city had been purified and carefully sterilized. In addition, samples were taken from each batch of diphtheria antitoxin produced and tested on guinea pigs. If tetanus had been present, the guinea pigs would have certainly died. Dr. Ravold was at a loss to explain where in the tightly controlled and multi-step processing of the serum that tetanus could have been introduced.

Tetanus was not unheard of in the horses used in the production of the diphtheria antitoxin. Dr. Ravold wrote, “It is a well-known fact that horses undergoing treatment for the production of diphtheria antitoxin are highly susceptible to infection with the bacillus of tetanus. We have lost six antitoxin horses with tetanus since 1895.” While it was possible to immunize a horse against tetanus, this was not done because it was thought sufficient to test the antitoxin on guinea pigs.

One of the first things that needed to be determined was whether the children had, in fact, died from tetanus infections. This would require testing on guinea pigs, which the city had an unusual shortage of at that moment. It was explained that they had received a shipment of fifty guinea pigs earlier, but they were all double the size that was required for testing. A new batch of guinea pigs was ordered from a breeder in Philadelphia, but in the days before overnight shipping was possible, it took days for the guinea pigs to get to St. Louis.

A big concern among health officials was that people would now fear injection with the antitoxin and there would be an increase in deaths from diphtheria. Dr. H. N. Chapman of the Board of Health publicly expressed his concern: “The really gravest danger now is that people will become afraid to permit the use of antitoxin. Beyond the shadow of a doubt, antitoxin has saved hundreds of lives in the city, and when properly prepared, is one of the safest things that any physician can use. There is no more danger from antitoxin than from any drug prescribed by a physician.” Luckily, officials did not see an increase in deaths while this was unfolding. Parents continued to allow their children to receive the antitoxin. This was not true in Chicago, however. By the end of November 1901, vaccine hesitancy caused a one-third increase in the diphtheria mortality rate.

On November 8, 1901, bacteriologist C. A. Snodgras was the first to release the results of his tests. He found absolutely no tetanus bacilli in any of the samples that he had tested. To which Dr. Ravold commented, “I contended all along that the serum contained no germs.” Yet, it was quickly pointed out by other experts that Snodgras had only tested for the bacilli, not the presence of the potent tetanus toxin, which is among the world’s most deadly of toxins.

After reviewing the data obtained by a number of experts working independently and interviewing nearly one hundred witnesses, the coroner issued his report on November 18. While it didn’t place blame on any one individual, it held the health department responsible for the deaths of seven of the children by tetanus. It concluded that the tainted antitoxin drawn from Jim had somehow been mislabeled and, at least in part, distributed to doctors around the city.
Blood had been drawn from Jim on a nearly monthly basis. The batch of antiserum originally produced on August 24 was proven to be non-toxic. The next batch, labeled September 30, had been drawn one day prior to Jim’s tetanus diagnosis and was supposedly never distributed. Yet, some of the September 30 samples were somehow mislabeled as August 24 and supplied to doctors. This was proven by the fact that all of the tainted samples, whether they be dated August 24 or September 30, were identical in every way, including potency, specific gravity, toxicity, spectral analysis and more.

Dr. Amand Ravold.
Dr. Amand Ravold. Image appeared on page 15 of the October 26, 1942 publication of the St. Louis Post-Dispatch.

Dr. Ravold expressed puzzlement in these findings. “How those bacteriologists arrived at their conclusion that the diphtheria antitoxin drawn on September 30 was distributed for use is more than I can understand. This opinion is directly at variance with every statement I have made regarding that point. I know that the serum of September 30 was destroyed without being tested. I do not believe that any of this serum could possibly have been placed in small bottles and distributed without my knowledge.”

Yet, the science was clear. Somehow, that tainted serum had wound up being injected into those innocent children.
Meanwhile, a similar situation had been developing in Camden, New Jersey. In October 1901, the Camden school board decided to vaccinate their entire student body against smallpox. By the end of the month, an estimated 5,000 students had been inoculated. Then, on November 1, 16-year-old William Brower died from tetanus, nineteen days after having received the smallpox vaccine at school. Soon, eight additional students would die. Soon after, five more who received the same smallpox vaccine would die of tetanus in Philadelphia. Instead of placing blame on the vaccine, which was believed to be safe, the cause was attributed to neglect on the part of the parents. Basically, all of the infected children were poor and stereotypically believed to live in dirty homes, so it was concluded that the parents had exposed their children to unsanitary conditions resulting in exposure to the tetanus toxin.

It was also learned that a similar tragedy had occurred in Italy in January of that year. Twelve people died from tetanus after receiving the diphtheria antitoxin. Investigators there failed to make the connection between the serum and the tetanus fatalities.

But, this was not the case in St. Louis. It was clear that all of the tetanus infections could be traced back to Jim the horse. Now that the coroner had submitted his formal report, the St. Louis Board of Health opened an inquiry on where to lay blame.

While Dr. Ravold remained unwavering in his testimony, the story that two of his assistants told, changed.
On November 30, 1901, Dr. Martin Schmidt, the assistant city bacteriologist revealed for the first time that he had never tested the last batch of antitoxin derived from Jim due to the fact that they didn’t have any guinea pigs to test on. “The infected diphtheria antitoxin, which killed several St. Louis children, was not tested before its distribution on guinea pigs by the city bacteriological department.

“The serum was entrusted to Henry R. Taylor, a Negro janitor in the city chemist’s office, and he had charge of the supply drawn on August 24 and also that taken from the horse a month later.

‘Some of the bottles, containing the serum, were not labeled, and Taylor was the only person who could distinguish them.

“Other bottles contained two labels, and Taylor was about the only one who could tell which was the correct one.”
He added, “I did not care to tell all I knew at the original inquest because Dr. Ravold is a personal friend of mine and for the further reason that I did not want to show disloyalty to the department.”

Then, on December 26, it was Henry Taylor’s turn to spill the beans. He revealed that they had not destroyed the supposed tainted serum until after it was publicly reported that children may have died from it. “The serum of September 30 was not destroyed on October 11, and the serum of September 30 did go out.” Basically, the supply of diphtheria antitoxin had become depleted in early October and he had distributed eighteen bottles of the tainted serum because, at the time, he didn’t believe that it was “bad enough to kill children.”

Dr. Ravold disagreed with Henry Taylor’s claim. “The serum was destroyed on October 11. I have my book, in which I made a note. I can’t understand why the man made such a statement.”

On February 12, 1902, the Board of Health officially held Dr. Ravold responsible for the deaths of all thirteen children. They then voted to terminate the employment of both Dr. Ravold and Henry Taylor.

Dr. Ravold had other employment in both private practice and in the medical department at Washington University, so he could afford the loss of this appointment. He expressed greater concern for Henry Taylor. “If I had been here the fearful mistake would not have happened. The Board of Health should have had a trained assistant for me to leave in charge. Taylor, a man of 65, honest and faithful, was not supposed to be competent to look after the professional affairs of the office. He was simply a good servant, an old soldier, and this discharge will leave him in hard lines.”
On May 12, 1902, Dr. Ravold resigned from the faculty at Washington University. His intent was to spend a year studying in Berlin before moving on to other cities. Based on newspaper headlines, it does not appear that this ever happened nor did the tainted diphtheria vaccines seem to have any lasting effect on his career. He was unanimously chosen to be the President of the St. Louis Medical Society in 1926 and gained a reputation as one of the world’s foremost bacteriologists. His death on October 26, 1942, at the age of eighty-three was front-page news, yet there was not a single mention of the diphtheria incident.

As for monetary compensation for the deaths of the thirteen children, it was ruled that the city could not be held responsible for the deaths. Lawsuits were then filed against the individuals responsible, but little was mentioned in the press. A jury did render a verdict against Dr. Ravold, awarding $1,000 (about $30,000 today) to Jacob Ernst for the death of his daughter Emma. Dr. Ravold appealed the case, so it is unknown if anything was paid in that case. After that, the St. Louis newspapers stopped following the story.

As tragic as this story was, there was one good thing that came from it. In 1902, the United States Congress passed the Biologics Control Act to regulate, inspect, and license anyone involved in the production of biologic products such as vaccines. Today, the Center for Biologics Evaluation and Research, which is part of the FDA is responsible for biologic regulation. My guess is that they are quite busy right now monitoring the safety of the various Covid-19 vaccines as they roll out.

Useless? Useful? I’ll leave that for you to decide.

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