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THERAPEUTIC STRATEGIES TO COMBAT PNEUMOCOCCAL DISEASE: REPEATED FAILURE OF PHYSICIANS TO ADOPT PNEUMOCOCCAL VACCINE, 1900-1945 PETER C. ENGLISH* In recent months, American physicians have witnessed another round in the debate, now in its seventh decade, over whether physicians should immunize their patients against the pneumococcus [1, 2]. Doubts about the vaccine's efficacy, which populations require immunization, possible harmful effects, and whether immunization is the proper method of eliminating pneumococcal disease continue to prompt discussion. Robert Austrian has led the battle for acceptance in this most recent (1978) introduction of pneumococcal vaccine [3—6], and he has focused historical attention on the several past attempts to introduce pneumococcal vaccine into practice [7-11]. What has not been so clearly presented is that physicians debated and rejected accepting pneumococcal vaccine each time it was proposed. It is the purpose of this paper to analyze this debate and rejection from the late nineteenth century to the end of World War II. For the medical historian, the history of therapeutics often presents difficulties in interpretation. On the one hand, there are remedies of the past with little possible value, such as bleeding, purging, and a variety of botanical recipes. Yet patients actively sought them; physicians enthusiastically prescribed them; and both were equally satisfied with the results . It is too easy to dismiss such behavior by claiming that physicians in former times were less thoughtful or less rational. This is simply not the case. While all times have had their share of quacks, charlatans, and Supported in part by the Josiah Macy, Jr., Foundation and the General Pediatric Academic Program of the Robert Wood Johnson Foundation. The author extends appreciation to Ms. Connie Patterson for secretarial help. *P.O. Box 3420, Duke University Medical Center, Durham, North Carolina 27710.© 1987 by The University of Chicago. AU rights reserved. 003 1 -5982/87/3002-0498$0 1 .00 1 70 J Peter C. English ¦ To Combat Pneumococcal Disease mountebanks (ours included), in most instances physicians have been a dedicated, discerning group [12]. On the other hand, there have been remedies of considerable value, such as Joseph Lister's antiseptic principle in surgery, that were actively opposed by educated physicians or simply ignored [13, 14]. At first glance, the case of the pneumococcal vaccine might seem to fit into this category. To understand how one type of therapy is accepted, another is rejected, and still others are ignored requires placing the remedy into its own particular historical context. Concentrating on the early years of the pneumococcal vaccine, this article asks why physicians, despite widespread understanding that the immunization worked, failed to adopt pneumococcal vaccine as a routine part of their therapeutic regimen. Pneumonia in the Early Twentieth Century William Osier, in his widely read textbook, argued in 1892 that pneumonia was one of the most thoroughly understood of diseases [15, pp. 511—531]. Although declining in incidence, pneumonia still accounted for nearly 3 percent of all admissions during the initial 16 years of The Johns Hopkins Hospital, or 658 patients with a 30 percent mortality [16]. Beginning with René Laennec's classic description of 1826, Osier noted, physicians recognized pneumonia's rapid onset, as characterized by fever, chills, splinting, and rusty sputum. They were familiar with clinical signs gained from percussion and auscultation, and they fully comprehended the sequence of the pathological events going on within the lungs of the stricken patients: engorgement, red hepatization, and gray hepatization. Osier claimed that physicians seldom made mistakes in diagnosing pneumonia. To the clinicopathological picture, Osier added a discussion of bacterial etiology. Osier, the first historian of pneumonia and the pneumococcus , was particularly interested in sorting out who first identified the pneumococcus. He gave the priority to George Sternberg [17], the former surgeon general of the United States, a conclusion that most recent historians still accept [18]. It was a close call: Sternberg had injected his own saliva into a rabbit in 1880 and earlier that year Louis Pasteur had published a similar experiment in which he injected the saliva of a young girl dying from rabies [19]; but Osier rightly contended that Pasteur's experiment actually took place after Sternberg's demonstration. In his classic description of...

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