Pox
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In early November, word spread in Camden that a sixteen-year-old boy named William Brower had come down with tetanus. Few of life’s hazards caused parents more worry than the infectious disease most folks called lockjaw. The New York writer W. J. Lampton called it “one of the strangest and most horrible maladies known to man.” In 1900, more than 2,200 Americans died from it. The tetanus bacillus was discovered in 1884 in a Göttingen laboratory. Since then, scientists had found germs in hay dust, crumbling masonry, garden soil, and, especially, horse manure. Turn-of-the-century America—from the farms to the cities—crawled with the stuff. Even so, as Army Surgeon General Sternberg noted in his treatise, Infection and Immunity , simply ingesting bacilli-rich filth would not cause infection. Nor was tetanus contagious. The bacilli did not grow in the presence of oxygen. It usually took a traumatic event—a wound of some kind, the narrower and deeper the better—to introduce bacilli into a human body in a way that could cause infection. The classic culprit was a rusty nail—not because of the chemical composition of the rust itself, but because it made the surface of the nail rough enough to hold an abundance of bacilli which the sharp, skinny nail could drive home without much bleeding. Every Fourth of July, hundreds of American boys caught tetanus after cutting their hands with toy pistols.17
The symptoms of lockjaw were terrible. William Brower suffered them all. The son of a plumber, the boy had seemed in fine health until he fell suddenly ill around November 1. He suffered a high fever. He felt the telltale stiffness in his face. His jaws tightened like a vise. Excruciating contractions spread from the jaw and neck to all the muscles of the body. His spine arched, as convulsions racked his body. The doctors administered the tetanus antitoxin, a relatively new product with a low rate of success. No one expected the boy to survive. According to the Philadelphia North American, William’s mother Sarah said, in her grief, “Never, never again shall I have one of my children vaccinated.” William had been vaccinated nineteen days earlier. To his parents there seemed no better explanation for his misery. The trusted family physician who had vaccinated William, Dr. William H. Kensinger, disagreed. “Vaccination doesn’t produce tetanus; that I know,” he said.18
Then came the news that sixteen-year-old Lillian Carty was critically ill with tetanus. The daughter of a railroad clerk, Lillian had been vaccinated twenty-one days earlier by Dr. S. G. Bushey, the city coroner and a prominent member of the Camden Board of Health. Lillian’s parents posted a sign at their front door, asking passersby to keep quiet, because the slightest noise agitated her and sent her into convulsions. Antitoxin was administered. No one expected her to survive.19
Neither Brower nor Carty was the first child to die. On November 11, Thomas B. Hazelton, age eleven, the son of a shipping clerk, was in the street playing when he started to feel ill, with a pronounced stiffness in his jaw. Someone called for Dr. Bushey, who as the Hazeltons’ family physician had vaccinated the boy about three weeks earlier. Never had Bushey seen a patient suffer such “terrible agony.” Less than twenty hours after Thomas took to his bed, he was dead. According to the New York Tribune, now covering the Camden story, Bushey moved to set the record straight. “[T]he boy’s death was not the result of vaccination,” the coroner declared. But Thomas’s parents had doubts. Mr. Hazelton said he might seek legal advice. He wanted to know whether the vaccine used on his boy was pure and, if it was not, whether the manufacturer could be held responsible for his death.20
The next day, November 13, tetanus struck nine-year-old Anna Cochran, the daughter of a teamster. She had been vaccinated about three weeks earlier. The story of little Anna’s courage, as convulsions shook her small frame, was, as the New York Sun told it, “particularly sad.” Just before she died, on November 14, Anna “turned to her parents and whispered through her clenched teeth: ‘Don’t worry, papa and mamma, I’m going to get well.’”21
As parents’ initial suspicions swelled into a panic, Dr. Davis of the board of health made a statement to the press. Camden’s most prominent physician attributed the tetanus cases to a period of unusually dry and dusty weather. “I am satisfied that none of them have been caused by vaccination,” said Davis, “but by the tetanus germs in the air.” Local physicians formed a unified public front with Davis and the board, insisting that the vaccine they had used was safe. But a few expressed doubts. Dr. Dowling Benjamin, considered a local authority on tetanus, broke ranks. “This talk of germs being in the air is all absurd,” he said. “If that were so there would be more lockjaw than there now is. I think it is highly probable the tetanus germs were in the vaccine tubes before they were sealed.”22
Local newspapermen turned up three more dead children whose deaths by tetanus had previously gone unreported. Eleven-year-old Anna Warrington, the only child of an illiterate ship carpenter and his wife, had died on November 8, after suffering in “great agony.” Six-year-old Frank Cavallo, the child of Italian immigrants (his father was an illiterate rag dealer), had been vaccinated in Philadelphia during a visit to his grandmother; he died three weeks later, on November 9. The other new victim, unnamed, lay buried in the Evergreen Cemetery, believed to have died on November 5. A growing distrust of the authorities strengthened the public’s fears. Why hadn’t public health officials reported these cases earlier?23
On the night of November 15, Lillian Carty gave up her fight. The doctors had done all they could, the newspapers said, administering antitoxin and trying to ease her suffering as her muscles contracted. “Conscious through it all,” the New York Tribune reported, “she suffered frightfully for two days.” Her parents, exhausted from the long ordeal at her bedside, were prostrated in their grief. Remarkably, William Brower was still alive, but in critical condition. The bad news kept coming. The day Lillian died, another child had been diagnosed with tetanus following vaccination. Her name was Mamie Winters. She was eight years old.24
Camden was now in a full panic, and regional newspapers had taken notice. With the tetanus outbreak now weighing far more heavily on people’s minds than the continuing smallpox epidemic, city health officials and parents searched, in their own ways, for connections between the lockjaw cases. They found few. The children ranged in age from six to sixteen. No two of them lived in the same ward of the city. None had visited the free vaccination station, and no more than two had been vaccinated by the same physician. As the Camden Board of Health saw things, though, there were significant commonalities. Board representatives observed that most of the children were from “lower class” families (a dubious claim, as Hazelton’s father was a shipping clerk; Brower’s, a plumber; Carty’s, a railroad clerk); that the parents were “ignorant” (also unfair, for most of the parents were at least literate); and that they inhabited a dirty city that had experienced a spell of dusty weather (demonstrably true). For the lay public, the salient commonalities had nothing to do with social status or the weather. All of the children had been healthy until they were vaccinated. Roughly three weeks later each fell ill with lockjaw. Now six of them were dead. Most of the children had received glycerinated vaccine. To these links, the New York Sun, in a November 17 report, added another: most of the vaccine used in Camden had apparently come from a single, trusted Philadelphia firm, H. K. Mulford Company.25
It was probably inevitable that suspicion would fall upon the Mulford Company vaccine farm and laboratory in Glenolden, Pennsylvania, just outside Philadelphia. Mulford marketing materials boasted of the company’s vaccine sales in eastern Pennsylvania and New Jersey. When the Camden Board of Health announced its plan for wholesale vaccination, Mulford and Marietta-based Alexander Vaccine Farm vied to corner the market. According to the Sun, a local chemist who represented Alexander approached the Camden Medical Society and seemed poised to win the contract for the vaccine station. Mulford countered by offering the society a thousand free points. Demand quickly exhausted that gratis supply, and the society bought more vaccine from Mulford, as did many private physicians. Almost all of the afflicted children had
received Mulford virus. Company executives insisted the vaccine was pure. The allegations, they said, had come from pharmacists who served as agents for their rival companies, Alexander and Parke, Davis.26
The parents of Camden demanded a public investigation of the tetanus outbreak. James B. Cochran, Anna’s father, swore that if the authorities did not “fix the blame,” he would “spend his last dollar doing it himself.” Every family in the city had cause for concern. Parents whose sons and daughters had dutifully submitted to vaccination were terrified they would be the next to fall ill. (The children were afraid, too. At Lillian Carty’s funeral, her schoolmates cried for her and worried for themselves.) Parents whose children had not yet been vaccinated feared that submitting now would expose them to an unacceptable risk of lockjaw.27
Camden families launched a school strike, hundreds of parents declaring that their children would not return to the classroom until the school board rescinded its vaccination order. Some parents also talked about litigation, considering whether to sue the vaccine company or seek a court order to open the schools to unvaccinated children. To a knowledgeable lawyer, neither avenue would have looked promising in 1901. One prevailing principle in tort law (“privity of contract”) insulated manufacturers from liability for injuries to anyone other than those to whom the makers sold the vaccine directly; while another principle (“contributory negligence”) limited a defendant’s liability if he could show that the plaintiff had negligently contributed to his own injury (for example, by carelessly letting dirt enter a vaccination wound). Moreover, under New Jersey’s wrongful death statute, if the plaintiff’s lawyer somehow proved the manufacturer’s liability in court, the child’s next of kin (normally, the father) would have been entitled only to compensation for his direct pecuniary loss: the child’s wages, if any. As for the other legal strategy—seeking a judicial writ to compel school officials to admit their unvaccinated children—two circumstances would have hampered that claim: the school board was acting in accordance with a state law, not merely at its own discretion, and the board had promulgated the order in the midst of an actual smallpox epidemic. In the American legal environment of the era, a school strike was a far more viable option than a lawsuit. But even that option carried a risk: school officials could have had the parents prosecuted for violating the compulsory education law.28
Increasingly, people in Camden asked if the compulsory order had really been necessary. On the day Anna Cochran died, the Camden Board of Health had released its monthly report. There had been just fourteen cases of smallpox since October, with only one fatality. The toll from tetanus was much higher. “Camden people are demanding to know where the benefits of vaccination come in,” said the Sun. According to the Times, some citizens now saw the health board as an “autocratic” institution, unaccountable to the people.29
Events came to a head on November 18, six days after Thomas Hazelton’s death. Camden’s vaccine crisis was no longer just a local or regional story. It was a national event. Reports of isolated postvaccination tetanus deaths—more schoolchildren—surfaced from Atlantic City and Bristol, Pennsylvania. Philadelphia, too, reported “several cases of tetanus following vaccination, but no official action has been taken.” As telegraph wires fed newspapers from Charlotte to San Francisco the latest from Camden, journalists dusted off other stories from the past year. “The tetanus bacillus has admittedly found its way into commercial virus to such an extent as to have given serious trouble in at least five widely separated districts, and probably in isolated cases wherever vaccination is practiced,” said the Times. Cleveland had lost four people to postvaccination tetanus during the past year. Previously, postvaccination tetanus was a rare complication. One investigator would turn up more than sixty U.S. cases from 1901 alone; most had occurred in November. All of those local events and stories seemed connected, like an epidemic, creating a widening sense of collective connectedness and complicity that transcended local political boundaries.30
Also on November 18, the St. Louis coroner announced his verdict regarding the first seven deaths from tetanus that had followed the administration of diphtheria antitoxin to children in that city. Citing bacteriological tests, the coroner said the cause of the deaths was the administration of antitoxin containing tetanus toxin. The city health department, not a private firm, had prepared the antitoxin—an experiment in public production that had won the department no small amount of criticism from private companies and druggists. All of the tainted antitoxin had been produced from the blood of a single animal, a horse named Jim, “stabled at the Poorhouse Farm.” Jim had developed tetanus in October and was put down. But serum had been drawn from Jim before his symptoms became apparent, and the serum had not been destroyed. Compounding the public relations disaster was the revelation that the job of bottling the serum had been entrusted to a janitor. The coroner charged the health department with negligence. American newspapers readily extrapolated from the coroner’s findings to the vaccine cases. “No other suggestion is reasonable,” said the Duluth News-Tribune, “than that the unwelcome bacilli secured a lodging place in the virus and the antitoxin in the laboratory.”31
The tetanus scares triggered opposition to vaccination in many American communities. In Rochester, New York, in the midst of its own small-pox outbreak, parents responded to the news from Camden, 350 miles away, by refusing to allow their children to be vaccinated. Two schools were “practically closed for want of attendance.” In response, the city health officer, according to the New York Tribune, “deprecated the displaying of the Camden news.” His peers in many other American communities shared his frustration.32
From the beginning of the crisis, Camden health officials and doctors had maintained a united front in defense of vaccination. But with six children dead so far, the schools half-empty, and a national scandal brewing, the board of health called a halt. On the night of November 18, the members passed a resolution ordering physicians to cease vaccination until further notice. The board advised the school board to suspend enforcement of the vaccination law, which that body did the following day. The health board launched a scientific investigation to determine the causes of the tetanus outbreak and, as James Cochran had demanded, fix the blame. The Mulford Company promised its full cooperation.33
The board members were not the only medical men determined to settle these same questions. Working on their own, three other men had quietly begun their own investigations—inquiries that would push the limits of medical science. Two of them, Robert Willson and Joseph McFarland, were physicians from neighboring Philadelphia. Willson had recently lost a patient to postvaccination tetanus. McFarland was one of America’s leading bacteriologists; his work with diphtheria antitoxin had put Mulford on the map, but he had left the company for academia and a consulting job with Mulford’s rival, Parke, Davis. The third investigator, Milton J. Rosenau, was an officer of the federal government, working in a small Washington laboratory, within the U.S. Marine-Hospital Service, that would one day be known as the National Institutes of Health.
All three men believed vaccination was medical science’s greatest gift to humanity. All sought an answer to the crisis that had discredited that operation during the most serious visitation of smallpox the nation had seen in years. Their investigations ensured that the Camden Board of Health would not have the last word on the matter.
The Camden tragedy cast unwanted light upon a hitherto little-known sector of the U.S. economy. Part animal husbandry, part laboratory science, the vaccine industry exemplified the distinctive historical inbetweenness of life at the century’s turn. On city streets, automobiles and streetcars vied for the road with horse-drawn carriages. In the public sphere, a new scientific rhetoric of social statistics and structures pressed against the older Protestant moralism of individuals and strictures. And in one of the most profitable manufacturing sectors of the U.S. economy, future giants of the nation’s pharmaceutical industry—companies such as Wyeth and Parke, Davis—were
making names for themselves by harvesting pus from the undersides of barnyard animals. Poised between the stable and the laboratory, the farm and the firm, the vaccine industry embodied a world in transition. Of course, the vaccine makers had no way of knowing what their industry would one day become, but the most innovative among them dared to dream big. They forged close ties with government health departments and universities. And they embraced medical science—not just for the technical innovations that science enabled but for the credibility it offered to an industry built upon incredible promises.34
Although vaccination arrived in America in 1800, vaccine manufacturing did not emerge as a commercial industry until the 1870s, with the shift from “humanized” to “bovine” virus. Of course, Edward Jenner had obtained his original vaccine material from a cow, albeit by an indirect method: he took the “lymph” from a pustule on the hand of a milkmaid infected with cowpox. Uncertain about the origin of this disease, the doctor named it “variolae vaccinae,” smallpox of the cow. And though Jenner speculated that the disease might have originated in an affliction of horses (and he may have been right), the name vaccine stuck.35
Naturally occurring cases of cowpox were rare. Fortunately, Jenner established that vaccine could be serially reproduced in humans. The method entailed taking fluid directly from the vaccination vesicle on the arm of a donor (“vaccinifier”), usually a healthy young child, and applying the virus to the scratched arms of an assembly of recipients. Humanized virus: vaccine without the vache. The possibilities were breathtaking, as the Balmis expedition showed the world in 1803–5, transporting vaccine in the arms of orphans to the Spanish colonies of the Americas and the Philippines. In England, the National Vaccine Establishment assumed responsibility in 1808 for maintaining a supply of humanized virus, through serial “arm-to-arm” transfers. The virus could also be preserved and transported by drying the fluid on pieces of thread, quills, or ivory points; or by peeling the crust from a vaccination sore. The lymph-saturated crust could be carried or even sent in the mail; the vaccinator would triturate (crush) and moisten the crust, producing a pasty vaccine material, and then set to work. A North Carolina physician recalled vaccinating his entire town in 1854 with a “very ugly little scab” that he received by post from Wilmington.36