Childhood's Deadly Scourge: The Campaign to Control Diphtheria in New York City, 1880-1930 (review)

Evelynn Maxine Hammonds. Childhood's Deadly Scourge: The Campaign to Control Diphtheria in New York City, 1880-1930. Baltimore: Johns Hopkins University Press, 1999. ix + 299 pp. $39.95.

In this volume Evelynn Hammonds uses as a foil one of the most challenged but enduring narratives of the history of medicine: that which tells how in the first half of this century the age-old scourge of infectious disease was largely conquered by the combination of extraordinary advances in science (most notably in bacteriology, epidemiology, and serology) and skillful political maneuvering by public health officials. But rather than refute the narrative or replace it with another, Hammonds seeks to improve it and to make it more sophisticated and useful as an explanation--most notably by adding the nature of the disease as a third component to the equation, and by analyzing and interpreting that nature in terms that draw from both basic science and cultural theory.

Hammonds's focus is the late-nineteenth- and early-twentieth-century public health campaign to control diphtheria, one of the deadliest and most frightening of the so-called childhood diseases. In particular, she looks at New York City, where Herman Biggs and especially William Park pioneered many of the diagnostic, immunogenic, and political interventions subsequently adopted throughout the nation. Expanding on Charles Rosenberg's assertion that a disease exists only once it is named, Hammonds shows how early attempts to control diphtheria were frustrated by the complex etiology, symptomatic presentation, and mode of transmission of the disease. Although identified as a distinct clinical entity in the mid-nineteenth century, diphtheria presented itself in such varied ways that its clinical diagnosis and definition were highly problematic, which made all but impossible a traditional program of control relying on the identification and isolation of infected individuals. The discovery in the late 1880s of a microorganism associated with the disease, the founding of the New York City Bacteriological Laboratory, and the development by William Park of a simple-to-use "culture kit" held promise that a bacteriological definition of the disease could be fashioned that would allow for a relatively certain diagnosis. However, unlike the tuberculosis bacillus, what came to be known as the Klebs-Loeffler bacillus did not meet developing criteria for proving a microorganism as the etiologic agent of a disease. Most notably, bacilli were found to be present in the throats of individuals who had no clinical manifestations of the disease. This forced bacteriologists to make a distinction between true and false diphtheria; it raised a host of ethical, political, and practical problems concerning the isolation of healthy individuals; and it challenged what for practicing physicians was a bedrock belief: that a disease was concurrent with its symptoms.

Hammonds shows how the tension between clinical and bacteriological definitions and diagnoses of diphtheria served to shape the ways that research into the etiology, transmission, and potential treatment of the disease was promoted and was responded to. In a section describing and analyzing the health department's efforts to convince physicians of the therapeutic value of the antitoxin it was producing, she provides a nuanced interpretation of physician resistance--demonstrating how it did not, as is sometimes claimed, spring from a generalized opposition to the germ theory, but devolved from the increasing conflict between laboratory and clinical knowledge and the fundamental challenges to physicians' judgment and practice that the latter posed. She also describes how the antitoxin's failure to grant long-term immunity necessitated the development and use of active immunization, which, in turn, again required health officials to convince skeptical physicians and meet the public's concerns about surveillance and control.

In part the health department's campaign was facilitated by the development of the Schick test, a simple diagnostic tool that produced a visible skin reaction in those who were susceptible...