Volume VII · Winter 1952 · Number 2
Making Diphtheria Antitoxin Serum: An Episode in the Medical History of Rochester
--CHARLES WRIGHT DODGE
[Charles Wright Dodge came to the University as an instructor in biology in 1890, and was elevated to the rank of full professor in 1892. He organized the Biology Department, and remained as its head until his retirement in 1931. His interests extended beyond the campus, and from the very first he took an active part in the movement to promote public health in Rochester. The following account of one of his efforts in that field was read by Professor Dodge before the "Club," (the Pundits) on December 16, 1930. It is here reproduced with the permission of his daughter, Mrs. Adrian Devine.]
This all happened in what some people called "the gay nineties," although I think that no one concerned in what will be related hereafter would think of designating this period by any such expression. We were all too much concerned with our responsibilities and with nervousness over the possible outcome of our efforts to feel in the least gay.
In order to furnish the proper background, I shall have to be more personal than I should wish and to mention some very trivial matters. I learned, soon after I began in 1890 to teach biology in the University of Rochester, that I should probably have in my classes a fair number of young men who proposed to enter medical school after graduation and I cast about to see what training we could give them preparatory to their medical work. It occurred to me that it would be suitable to add to our curriculum a course in elementary bacteriology and in 1893 I told the President, then Dr. David Jayne Hill, that if the University would give me a suitable room for a laboratory and the necessary apparatus and supplies, I would in the following year offer such a course. With their usual generosity, the Board of Trustees set aside a room in Anderson Hall which was equipped with a sink with running cold water, a high-grade Zeiss microscope with compensating eyepieces and apochromatic objectives, an Arnold steam sterilizer of the cylindrical type and so high that I always had to get up on a chair when I put in things to be sterilized or took them out, a hot-air sterilizer, and an incubator.
My knowledge of the subject was not extensive for one who proposed to teach it. I had never had a lesson in bacteriology and realized that I must set about learning something to teach the class. From friends in various laboratories between Boston and Chicago I obtained about a hundred and fifty cultures, not thinking that I might as well undertake to attend personally to the wants of all the animals in the zoo at Bronx Park as to keep all of these cultures in a thrifty condition. They were so fastidious in their food requirements and about the temperature of their living quarters that, with no one to help me care for them, it was not long before, with the aid of starvation, desiccation, blue mold, and natural selection, their number was reduced to one more nearly suited to the possibilities; but before they perished I had time to learn the various habits and naked-eye appearances of some of the more important colonies and to familiarize myself with staining, the reactions of the individuals, and their personal appearance under the twelfth objective.
In the collection I found the clue to a mystery of bacteriological nature, though I did not at the time recognize it as such, that had been a puzzle for the preceding fifteen years. Going into our cellar one warm summer day during my boyhood I had detected a strange odor that I finally traced to a meat safe in which was a partially used roast of beef. On the cut surface of the meat was a small red spot quite like a drop of blood but which on examination proved not to be fluid and plainly enough not blood but, nevertheless, quite as plainly to be the cause of the odor. I had never before seen anything like it. It was evidently some kind of growth on the meat and not an exudation from it. The color and smell of the culture labeled Bacillus prodigiosus identified to my complete satisfaction the strange growth on the meat. This is the only instance that I know of where, presumably, this organism has been noticed growing wild in this country. Of course I do not regard the identification as being scientifically beyond question, but the impression made by the first sight of the growth was very strong, and there is no other organism that I know of that can be mistaken forBacillus prodigiosus. Since then the name of the bacillus has, without benefit of clergy, been changed.
About the time that my course was well under way the City Board of Health, as it was then called, decided to undertake to have examinations made for diphtheria and tuberculosis. None of the hospitals had a bacteriological laboratory, and, having heard of the one at the University, the Board accordingly asked me to undertake the examinations. To this I agreed. A diphtheria inspector was appointed and after October 15, 1894, cultures from suspected cases of diphtheria were insisted upon by the Board of Health as a means of diagnosis. This aroused considerable opposition from many practitioners and resulted in numbers of physicians visiting the laboratory to look at the cultures and the stained smears. In connection with exhibiting these things I delivered a large number of private lectures to my visitors, which resulted in convincing many of them that these really were germ diseases and that the causative organisms could be recognized under the microscope. A number, I think, remained unconvinced to the end of their active days.
The first cultures submitted for examination, fortunately, contained only unmistakable types and I made the diagnosis without any trouble whatever. In later cultures some doubtful forms were found and I sent the cultures and smears to the Albany and New York laboratories for confirmation of my findings. When the report arrived corroborating my results, I carried on the work with more confidence. Reports of the remarkable results obtained in the treatment of diphtheria by injection of diphtheria antitoxin serum produced by the method of von Behring in company with Kitasato in 1890 aroused the attention of medical men all over the civilized world and led to the hope that this medicine was a practically certain remedy for the disease. The work which led to the discovery of the diphtheria antitoxin was the final outcome of the researches of a number of investigators extending over a period of years from the time of Davaine to that of the men named. Reports from private practice and from hospitals showed that, in cases in which the serum was used early, the death rate was lowered from 20 per cent to 50 per cent below that which prevailed in cases in which the serum was not used. With such a saving of human life it at once became evident that this miraculous fluid should be made available to every person who was so unfortunate as to contract the disease. The Berlin laboratories were besieged with so many applications for the serum that it was impossible to manufacture it in sufficient quantities to grant all requests. It thus became necessary to manufacture it elsewhere.
For some time the Rochester Health Bureau had purchased it from dealers who in turn obtained it from Berlin, but the supply was inadequate in amount and uncertain in arrival. When matters became desperate, Dr. Herman Biggs, the Health Officer of New York City, visited the von Behring laboratories and learned the method of manufacturing the serum. Returning to New York he, with the assistance of Dr. William H. Park, the eminent bacteriologist of the New York City Board of Health, and with one horse given them by Dr. T. M. Prudden, began making the serum and the Rochester Health Bureau then tried to buy its supply from the Park laboratory, but found it impossible to do so. The amount produced by the laboratory was limited, in fact, sufficient only for the needs of New York City. Dr. Park, however, agreed to show us how to make our own supply, so the Health Officer of Rochester, then Dr. Wallace Sibley, a political appointee, as was the custom of the time, and I decided to go to New York to consult Dr. Park. I had by this time been appointed City Biologist, my duties being chiefly bacteriological.
The weather was quite wintry when we left Rochester one evening travelling on passes over the West Shore Railroad. The conductor gave me much more than the once-over, which I could not understand, until I learned that my pass was made out to John Desmond, a very well known officer on the Rochester Police Force, and our resemblance to each other was about as close as that between Barnum's Jumbo and myself. We learned on arrival that we could not see Dr. Biggs until early evening. During our interview, in which my companion showed that his education had been more along the lines of practical politics than of practical bacteriology, we were invited to visit the laboratories and stables the next morning. We spent the night at the Hotel Bartholdi, a hang-out for third class politicians and now only a memory. My room contained a frost-bitten radiator into which the steam rarely, if ever, came, and the frost on the window was almost as thick as the panes of glass. In those days liquid air and Einstein were quite unknown, but in any case I doubt very much whether I should have warmed to the thought that the air would have boiled on the radiator, or that what is cold to a New Yorker would seem quite balmy to an inhabitant of Little America.
In the morning we went to call on Dr. Park and found that we had not chosen a very auspicious day, nothing being under way except the inoculation of one or two horses. No testing of the toxin or of the antitoxin was being done at the time of our visit and we consequently missed seeing some of the most important phases of the work. We were unable to arrange for purchasing the amount needed for our cases (we had about two hundred and fifty deaths that year) but Dr. Park generously agreed to test the toxin and antitoxin for us if we would procure an incubator in which to grow the toxin and supply guinea pigs for testing the antitoxin and furthermore to use our own horses and attend to the inoculating and bleeding.
On our return to Rochester the City Fire Department loaned to the Health Bureau four horses which had been retired from active service because of lameness, but were otherwise perfectly sound, as a variety of tests demonstrated. They were not only called sound, but were also said to be of good moral character. One of the New York horses had kicked a goat to death and we wished to have no catastrophies connected with our work. One of the horses, however, in the absence of a goat, kicked Dr. Tegg so badly that he was disabled for several days but finally recovered. The toxin for the inoculation was provided by Dr. W. H. Park of the Health Department of New York City and was administered by Dr. Albert Tegg, veterinarian of the Rochester Fire Department.
Two of the horses showed by their reactions that they were useless for our purposes and were discarded. After several weeks of inoculation of the other horses Dr. Park announced that as they showed no increase in the amount of the antitoxin formed the time had come to bleed the horses and to collect the antitoxin serum. This raised the question as to where and how the serum would be collected. It was decided that the atmosphere of the horse hospital was not favorable for the handling of the blood in the open and also that in transporting the blood in the containers from the horse hospital to the University (a distance of about two miles), the shaking would stir up the serum to such an extent as to render it cloudy from the red corpuscles shaken out of the clot. It was therefore decided to collect the blood at the University.
On the basement floor of Anderson Hall there was a large room only one step above the ground into which docile and well-trained horses could easily be taken without frightening them. This was near the room in which the operation of transferring the serum from the flasks in which the blood was caught to the smaller bottles in which the serum would be distributed to the physicians would have to be carried on. The Health Bureau provided a number of racks, each having spaces for four Erlenmeyer flasks of one-liter capacity, each flask resting on a bed of cotton in its own compartment, one above the other. At one side of each compartment a semi-circular cut was made to hold the neck of the inclined flask to prevent rolling about when the rack was handled. The flasks were prepared by a thorough washing, then plugged with cotton over which was tied, rather loosely, a circular filter paper covering the cotton and above this, more loosely, a second filter paper which protected the lower one from dust. The flasks were then baked for two hours in the hot-air sterilizer after which they were put in the racks and taken to the room where the bleeding was to be carried on. Supplies of bichloride of mercury solution and of alcohol were provided for disinfecting the skin of the horses' necks over the area in which the incision would be made for withdrawing the blood from the jugular vein. A piece of sterile rubber tubing a few feet long to be used in conveying the blood to the flask was made ready by inserting a hollow needle at one end and a piece of glass tubing at the other and sterilizing the outfit in the autoclave for an hour.
When everything was ready for the operation the horses were brought up to the University from the horse hospital and allowed to rest for over an hour, as they had been for some time inactive and without exercise on account of the treatment they had undergone. With these preparations finished, Dr. Tegg sterilized the area of operation, very deftly exposed the jugular vein and inserted the needle. Each of the Erlenmeyer flasks was filled nearly half full of blood; the flask was then laid on its side in its compartment in the rack and clotting very quickly occurred. From the two horses about twenty partially-filled flasks of blood were prepared. After standing an hour or two the racks were transferred with the utmost care against shaking to the smaller room whose preparation I will later describe and the horses taken back to the hospital. On the way one of them, overcome by fatigue, lay down in the middle of the street to the great embarrassment of its caretakers, and stayed there obstructing traffic to a considerable extent and causing a great deal of profanity from passing drivers, to which it remained quite indifferent, but at the end of an hour or two it felt sufficiently revived to get up and continue its journey.
When the bleeding was over I realized that from that time on most of the responsibility of handling the blood rested upon me and that every precaution must be taken to prevent its being contaminated from the air. I had recently read Dr. Prudden's little book on Dust and its Dangers and like a great many others, was properly horrified as to the possibilities.
The transfer of the serum from the flasks to the dispensing bottles would expose the fluid to some risks of contamination, even under the best of circumstances and proper precautions against this danger had to be devised. The place in which the operation must of necessity be carried on was a part of the original cellar of Anderson Hall which had never been finished off as a room. It was situated under the front steps of the building and while it was sufficiently commodious and well-lighted from windows high up at each end of the room, it had been used for many years as a catch-all for odds and ends of lumber, discarded household furniture, and appliances from the homes of the janitors who had successively lived in the apartments in the building. I distinctly recall that besides the lumber there was a dilapidated ice box, a broken-down washing machine, several barrels and kegs ready to fall to pieces from dryness and rust, an old couch whose surface resembled a raised map of a very mountainous region and would have been the envy of Procrustes, had he lived in the right time of the world's history. Over all of these things was a considerable layer of the dust of many years and from the rafters hung cobwebs made by misguided spiders who had probably expected to catch flies in the secluded space where there was no food to attract them. The floor of the room was a combination of clay and sand, dusty when dry and slippery when wet.
One problem was to sterilize the room, and it was this feature of the procedure which prevented the transfer of the serum from being done in the bacteriology laboratory with its calcimined and plastered walls. I recalled Tyndall's process of ridding the air from dust in connection with an experiment in physics in which he coated the inside of a box with glycerine and laid it away in a quiet place so that he might, after a while, feel reasonably confident that in the interval of rest the dust particles in the box had settled down on the glycerine and been held in place by this liquid so that by passing a beam of light through the box through holes at each end, he determined, by the absence of gleaming particles, that the air was dust-free. But glycerine was expensive, impossible to apply, and difficult to remove when its function had been performed. I therefore decided upon water, which was cheaper, easily applied through a hose, and removed by the ordinary process of drying. So long as the room remained wet, the dust particles would be held in place and the air would be dust-free and presumably germ-free. So on the afternoon of the day before I expected to work in this place I arranged with the janitor to take the hose and to give everything in the room -- walls, ceiling, floor, and all the articles a thorough drenching. Being an ardent Baptist, he had great confidence in immersion and when he got through with his job, everything in the room was dripping with moisture, while the floor was inches deep with mud and looked very much like a large box of mortar. The door of the room was locked so that no gusts of germ-laden air could blow in from outside, should anyone open the door, and was left until the next morning to permit all dust particles to stick to the wet surfaces with which they came in contact, and the air presumably would be germ-free at the time I should want to enter the room to transfer the serum.
The sterilization of the implements used was a simple matter and had been attended to, but to prepare myself for the work needed some thought and kept me awake the most of the night preceding the operation. I must make myself free from dust particles, both my garments and such portions of my body as were exposed to the air. This was impossible, so I had instead to cover myself so that I should not give off any germs. To do this I finally decided to cover myself as completely as possible and for this purpose procured from Sibley's department store one of the largest nightshirts that they had in stock. This I put into the laboratory dish pan and wet it thoroughly with water, then folded it loosely, wrapped it in two damp towels, one outside the other, and sterilized it in the autoclave. With another damp towel and a couple of pins I made a turban to cover my head and also had a pair of rubbers to protect my shoes from the muddy floor. With these sterilized packages all prepared, I descended to the cellar, to which I had previously taken the bottles and other appliances, and set them on a sterilized table outside the room, covered with sterilized towels dampened in bichloride solution. Outside the door I put on the rubbers, struggled into the nightshirt, put on my turban, put rubber bands around my wrists to hold the sleeves of the nightshirt closely, and entered the room locking the door behind me to prevent anyone from coming in, as well as the entrance of any other dust particles that came in with me.
I saw that in a few instances the clots had torn loose from the walls of the flasks and the serum had become reddened from the presence of floating corpuscles squeezed out of the shrinking clots. By using a 100 cc. pipette, previously sterilized, and with my hands flooded with bichloride solution, I transferred the serum into sterilized liter graduates. There was a little more than a liter in all, and I mixed it thoroughly by pouring from one graduate into the other. With a pipette I transferred about 10 cc. into each dispensing bottle, into which previously, after sterilization of the bottle, I had put a small piece of camphor and reheated the bottles so that such part of the camphor as had not been dissipated by the heating had re-crystallized on the walls of the bottle where it presumably acted as a mild disinfectant. I found that I had about a hundred and twenty-five bottles of the serum, not counting that which was spilled on the top of the table and on the floor. In order to determine whether the bottles of serum were germ-free, they were placed, in the absence of a sufficiently large incubator, in a warm room to permit the development of any organisms that may have got into them. After several days during which the contents of one bottle became cloudy and the bottle was consequently discarded, the others were taken to the Health Bureau to be dispensed as needed. The serum was never as strong as the best grade, but was at least efficacious and when I heard that the last bottle had been used and that no patient had given any evidence of sepsis, I felt that the load that had weighed upon me ever since the horses were bled had been lifted and decided that the making of diphtheria antitoxin serum was finished, so far as I was concerned and never again would I undertake it, not even for the sake of writing a paper to please Dr. Corner and Dr. Bayne-Jones, for whom I would, ordinarily, do a great deal.