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How Science Conquered Diphtheria, the Plague Among Children
It was highly contagious, lethal and mysterious. Then medical experts developed treatments and vaccines, and the affliction disappeared—but not entirely
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Even Noah Webster, that master of words, did not have a name for the terrible sickness. “In May 1735,” he wrote in A Brief History of Epidemic and Pestilential Diseases, “in a wet cold season, appeared at Kingston, an inland town in New-Hampshire, situated in a low plain, a disease among children, commonly called the ‘throat distemper,’ of a most malignant kind, and by far the most fatal ever known in this country.” Webster noted the symptoms, including general weakness and a swollen neck. The disease moved through the colonies, he wrote, “and gradually travelled southward, almost stripping the country of children....It was literally the plague among children. Many families lost three and four children—many lost all.” And children who survived generally went on to die young, he wrote from his vantage point of more than half a century later. The “throat distemper” had somehow weakened their bodies.
In 1821, a French physician, Pierre Bretonneau, gave the disease a name: diphtérite. He based it on the Greek word diphthera, for leather—a reference to the affliction’s signature physical feature, a thick, leathery buildup of dead tissue in a patient’s throat, which makes breathing and swallowing difficult, or impossible. And children, with their relatively small airways, were particularly vulnerable.
Throughout the 18th and 19th centuries, diphtheria challenged doctors with the terrible specter of children choked, smothered, snuffed out. It brought terror to the richest and the poorest, blighting famous families and anonymous ones. Queen Victoria’s daughter, Princess Alice, died of diphtheria in 1878 at the age of 35. Five of Alice’s children had also been sick with the disease, along with her husband, the Grand Duke of Hesse-Darmstadt; their youngest child died. The tragedy prompted the Sanitary Journal to warn readers of the “kiss of death” that had most likely spread the disease through the royal family: “The greatest care and thoughtfulness should be exercised in these cases of simple sore throat, as in the severer cases; and it should be constantly borne in mind that the kissing of children at such times is most dangerous.”
While there was some understanding of how the illness spread—by what we would now call respiratory droplet, through coughing or sneezing or kissing—the actual, underlying cause was not yet known. In the meantime, it was a leading cause of death for children around the world. “Diphtheria contributed to that notion that childhood was not a safe time, that many children would die by the age of 10,” says Evelynn M. Hammonds, a professor of the history of science and African and African American studies at Harvard and the author of Childhood’s Deadly Scourge, a chronicle of early efforts to control the disease in New York City.
Then, toward the end of the 19th century, scientists started identifying the bacteria that caused this human misery—giving the pathogen a name and delineating its poisonous weapon. It was diphtheria that led researchers around the world to unite in an unprecedented effort, using laboratory investigations to come up with new treatments for struggling, suffocating victims. And it was diphtheria that prompted doctors and public health officials to coordinate their efforts in cities worldwide, taking much of the terror out of a deadly disease.
In my more than 30 years as a practicing pediatrician, I have never seen a single patient with diphtheria. That’s because vaccination efforts in this country have been so successful. In the 1980s, when I was training, there were only a few cases a year in the United States. Since 2000, there have been only six reported cases in the U.S.
And yet, the diphtheria story isn’t over. A recent analysis led by a researcher at the Centers for Disease Control and Prevention noted some 8,800 cases reported overseas in 2017. In places where people aren’t getting vaccinated, or are slacking off on booster shots, diphtheria is finding its way back. And the standard treatment, little changed in more than a century, is in short supply.
I was inspired to become a doctor partly by Paul de Kruif’s 1926 book, Microbe Hunters, a thrilling, even swashbuckling adventure about the encounters between humans and microbes. Among other things, it describes the French scientist Émile Roux, who had been Louis Pasteur’s assistant, and the German scientist Emil von Behring trying to find a way to keep diphtheria from killing children in the 1880s in Paris: “The wards of the hospitals for sick children were melancholy with a forlorn wailing; there were gurgling coughs foretelling suffocation; on the sad rows of narrow beds were white pillows framing small faces blue with the strangling grip of an unknown hand.”
One of the doctors who walked those wards in New York City around the same time was Abraham Jacobi, often called the father of American pediatrics. A Prussian-born Jew educated at the University of Bonn, Jacobi founded the first free clinic for children in New York City and in 1860 was appointed the first professor of pediatrics at New York Medical College. He was interested in research-based pediatrics and patient-oriented medicine, as well as in what we would now call the social determinants of health—the ways poverty and family circumstances and other realities of children’s living conditions shape their well-being. It’s partly because of Jacobi that this awareness has been included in U.S. pediatric training and practice for more than 100 years.
In January 1860, at a meeting of the New York Academy of Medicine, Jacobi reported seeing 122 children with diphtheria at the Canal Street Dispensary, though other doctors had reported seeing none. Some doctors might have been misdiagnosing diphtheria as a form of croup—a disease we now know as a relatively common and far less deadly infection of the airway.
Twenty years later, Jacobi put his vast clinical experience into A Treatise on Diphtheria, in which he described how he himself “became affected with diphtheritic pharyngitis followed by a tedious catarrh, consequent upon sucking the wound, during the performance of tracheotomy, in an eight-year-old child.” Almost all of his more than 200 attempts at tracheotomy—cutting the neck to open the windpipe—ended in failure. The only reason he made this last-ditch surgical effort was “the utter impossibility of witnessing a child’s dying from asphyxia.”
Jacobi was married to another doctor, the brilliant Mary Putnam, who had trained at the Female Medical College of Pennsylvania and then at the École de Médecine at the Sorbonne, where she was the first-ever female medical student. The couple had a son and a daughter, Ernst and Marjorie. In 1883, both came down with diphtheria. Jacobi would later tell a story about a family resembling his own, blaming the infection on the “trustworthy nurse.” Scholars have speculated that Jacobi may have been unable to face the possibility that he himself may have brought the infection home from the clinic. Marjorie recovered, but Ernst died, at the age of 7. There was nothing doctors could do, even for their own children.....
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