1901 — Oct 19-Nov 7, Tetanus tainted (horse blood) diphtheria antitoxin, St Louis, MO– 13
–13 Philadelphia Times. “Ten Children Die of Lockjaw. Thirteen Deaths…St. Louis.” 11-10-1901, 4.
–13 St. Louis, Oct 19-Nov 7. DeHovitz. “The 1901 St. Louis Incident…” Pediatrics, June 2014.
Narrative Information
From DeHovitz: Children with diphtheria were injected with diphtheria antitoxin developed by Dr. Amand Ravold, “a local physician and trained bacteriologist…hired by the city…” to develop antitoxin. He did this by taking blood from a horse to produce serum. However, on Oct 2nd, after Dr. Ravold took blood from a horse on Sep 30, the horse “became ill with tetanus and was killed.”
“The antiserum obtained on September 30th was ordered to be destroyed.
“On October 26, 1901, the health department was notified by a physician that he had under observation 2 cases of tetanus after the use of diphtheria antiserum…. [both children died shortly thereafter]
“Over the next few days, as more children died, the health department recalled the existing bottles of antitoxin and began an investigation. By November 7th, the 13th death had been reported….
“….the [St. Louis] Tetanus Court of Inquiry began on December 17th. Dr Ravold had insisted that he and Henry Taylor, the…janitor…[he worked with to bleed the horse], had disposed of the September 30th serum after the horse died. But Taylor’s story began to change after he was ‘closeted with the Chief of Detectives by order of Mayor Wells.’ After this prolonged interrogation, Taylor was promptly placed back on the stand where he stated that he did release some of the serum dated September 30th… He released it, he stated, because he thought it was safe and because the August 24th serum was exhausted.[1]
“On February 13, 1902, the commission issued their verdict stating that the 13 children died of tetanus-contaminated vials dated September 30th. Second, the commission found that Henry Taylor, the janitor, bottled the serum but was not fully aware of its poisonous nature. Conversely, Dr Ravold was aware of the dangerous nature of the September 30th serum but was negligent in ensuring that it was destroyed. Last, both Dr Ravold and Taylor were to be dismissed from the Health Department….
“Dr Ravold went on to have a distinguished career as a bacteriologist, and he was elected president of the St Louis Medical Society. When he died at age 83 in 1942, his obituary made no mention of the diphtheria antitoxin incident of 1901….” (DeHovitz, Ross E. “The 1901 St. Louis Incident: The First Modern Medical Disaster.” Pediatrics, Vol. 133, Issue 6, June 2014.)
Newspaper
Nov 9: “Special to The Philadelphia Times. St. Louis, Mo., November 9.–Thirteen deaths following the use of diphtheria antitoxin prepared by the city, ten of the cases showing typical symptoms of tetanus (lock-jaw), have caused surprise among medical men in this city, many of whom had used the serum heretofore, especially in their charity cases, with highly beneficial results. Seven or eight other children similarly treated are suffering the tortures of lock-jaw, and for most of them death alone is expected to bring relief.
“Three expert bacteriologists, acting under the direction of Coroner R. M. Funkhouser, are at work trying to determine the exact cause of the outbreak, which is without a parallel in American medical practice….
“Just how the calamity was brought about and who was responsible, if any avertable error was committed, is not at all clear. The serum which is believed to have been the cause of all the tetanus cases was drawn on August 24 from a horse, Jim, which had been kept at the city poorhouse for two years, and had been treated many times before in order to prepare it for the bleeding which is the first step in the production of the serum. On August 24 the horse was apparently healthy and in the best of spirits. The serum was prepared in the usual way, with all the usual careful precautions to prevent possible infection, and about September 10 was ready for distribution. Two hundred doses of ten cubic centimeters each were sent out as called for by the various physicians and the city institutions….
“On October 28, Dr. R. C. Harris announced that one of his diphtheria patients had died from tetanus, and asserted the belief that the unlooked-for turn of affairs was due to the city anti-toxin. City Bacteriologist Amand Ravold, who personally performed almost every step in the intricate process of manufacturing the anti-toxin, was surprised. He said at first that it could not be possible. But he lost no time in calling in all the serum that had not yet been used, though the amount was small, the last bottle having been issued on October 23.
“Then other deaths were reported. The Board of Health held special sessions to consider the matter, and decided that the city should henceforth manufacture no more anti-toxin. A supply of tetanus anti-toxin was purchased and every physician who had used the suspected serum was urged to apply the only preventive of lock-jaw now known to medical practice. The tetanus anti-toxin was used in several cases where symptoms of tetanus had manifested themselves but without perceptible result. In other cases tetanus developed after the tetanus anti-toxin had been administered, but in each of these the patient now seems to be in a fair way to recover.
The Death List.
“Those children who have died from tetanus, or with titanic symptoms are:
Veronica Keenan, 5 years old…
Agnes Adele Keenan, 7 years old, same address.
Mamie Keenan, 10 years old, same address.
Frank Novak, 3 years old…
Ettie Simon, 5 years old…
Ike Stein, 4 years old…
Flora Fuerst, 8 years old…
Emma Mary Ernst, 4 years old…
Bessie Baker, 6 years old…
May Baker, 4 years old, same address
Jacob Centurio, 11 years old…
Charles Cytron, 11 years old…
Nettie Kammerman….
“The children now suffering from marked cases of tetanus and who may not recover are Chester Keenan, the only surviving child of the Keenan family; Mary Kammerman, a sister of Nettie Kammerman; Blima, Max and Emma Goldstein…; Margaret and Mabel Hayden…; Frank Baker, the only surviving child of the Baker family; and Amanda Schlegel…
“Health Commissioner Starkloff says he does not believe that any more cases will develop. Ten days have elapsed since the last dose was administered to any patient, and that is considered ample time for the cases to become acute.
“The practice of making the anti-toxin at the expense of the city began here six years ago, when the cost of the serum was $15 for a 10 cent bottle. The mortality rate in diphtheria cases dropped almost at once from 35 per cent, to a fraction more than 6 per cent., and the average rate of mortality in cases treated with the city anti-toxin for the last six years has been little more than 8 per cent. No charge was made for the serum, and it was given in unlimited quantities to any physician who asked for it.
“Heretofore the results had been uniformly satisfactory, alike to the practitioners, to the Board of Health and to Dr. Ravold, upon whom the burden of the responsibility rested. Dr. Ravold is almost beside himself with grief and surprise over the unfortunate turn of affairs. ‘I do not dare think about it,’ he said to-day. ‘I have other work to occupy my mind. If I did not, I would go crazy. I have been saving lives almost daily by this work, and my heart and soul were in the effort to save the little ones from suffering and death. Now comes this awful thing — it is horrible. To save my life I could not tell how this happened.’
“Health Commissioner Starkloff fears the effect on the public mind in relation to the use of anti-toxin in the treatment of diphtheria. He said:
Whatever may have been the cause of these deaths, it was no fault of the serum treatment. That is still the most efficacious method of treating diphtheria, and the unthinking, the ignorant, I greatly fear, will become afraid of the name of anti-toxin and physicians will have great difficulty in making use of the treatment.
“Experiments so far made, and Dr. Ravold’s description of his methods of making the anti-toxin, have led to the belief that no tetanus bacilli or germs were in the serum when it was distributed, but that the toxins produced by the bacilli may have been present. These toxins are among the most powerful known to the bacteriological experts. The dose of the pure toxin necessary to produce death in a mouse is said to be .00000005 of a gram, a quantity too small for human comprehension.
“Whether such an occurrence might occur in ordinary practice probably would depend on the care used in the manufacture of the serum and physiological tests made with it before distribution. Doctor Ravold made tests on at least a dozen guinea pigs before he allowed any of his product to leave the laboratory. If the tests resulted doubtfully in a single instance, the entire lot went into the sink. Doctor Walden, who makes the anti-toxin for the trade, makes an injection into his own body the supreme test of the quality of the serum he has in preparation If the slightest soreness results, the entire quantity is destroyed.
“Another unexplained point is the length of time a horse may have tetanus without displaying perceptible indications of the presence of the disease. If the tetanus toxins were really in the serum from the beginning, the horse must have been diseased on August 24, although the symptoms did not appear until October 2. If this should prove to be the case, horses will have to be subjected to a more careful scrutiny than ever before if the diphtheria anti-toxin is to be made perfectly safe.
“Only once before this time has any such calamity followed the use of anti-toxin. This was in Italy last winter, when several deaths followed the use of serum from a horse which was afterwards attacked with lockjaw….” (Philadelphia Times. “Ten Children Die of Lockjaw. Thirteen Deaths Follow…Administration of Diphtheria Anti-Toxin in St. Louis.” 11-10-1901, 4.)
Sources
DeHovitz, Ross E. “The 1901 St. Louis Incident: The First Modern Medical Disaster.” Pediatrics, Vol. 133, Issue 6, June 2014. Accessed 11-5-2017 at: http://pediatrics.aappublications.org/content/133/6/964
Philadelphia Times. “Ten Children Die of Lockjaw. Thirteen Deaths Follow the Administration of Diphtheria Anti-Toxin in St. Louis.” 11-10-1901, p. 4. Accessed 11-5-2017 at: https://newspaperarchive.com/philadelphia-times-nov-10-1901-p-4/
[1] Cited is St. Louis Republic. Dec 27, 1901 and Feb 13, 1902.