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c h a p t e r f i v e The New Standard, the New Deal, and the Pneumonia Control Programs By the late 1930s, many of the tensions exposed and further engendered by antipneumococcal serotherapy over the previous two decades (as discussed in chapter 3) seemed to be resolving in the wake of contingent technological improvements on the one hand, and a continued therapeutic reorientation toward the use and evaluation of the specific in medicine on the other. Yet as discussed in chapter 4, the application of such an expensive, labor-intensive specific as antipneumococcal serotherapy would by this time create a new set of tensions, which at the national level would evolve amid the competing influences of the attempted ascendance of the United States Public Health System (in the setting of the New Deal and the emerging suggestion of health care as a fundamental right), versus the decided ascendance of an organized medical profession championing the cause of the autonomous practitioner. This chapter explores the technological and professional context of pneumonia’s reconstitution as a national public health concern in the late 1930s on the basis of the exigencies of antipneumococcal serotherapy, in the form of a nationwide proliferation of state pneumonia control programs and on the eve of the chemotherapeutic antimicrobial “revolution” itself. The New Standard Antipneumococcal serotherapy was widely considered a powerful tool for the practitioner by this time. Continuing the trend begun earlier in the decade and buoyed by the apparent successes of the Massachusetts and New York state programs , serotherapy would garner further support to the point of being considered “the standard procedure by all investigators in the field” for the treatment of pneumococcal pneumonia, a triumphant specific mandating that the practitioner employ it—and the community pay for it.1 Again, the treatment of type I pneumo- coccal pneumonia served as the standard of eªcacy. Russell Cecil, resplendent with the success of the New York program, could again edit the history of the field, claiming: “I cannot recall a single skeptical article since the introduction of Felton ’s concentrated serum.”2 Lending further urgency to the early recognition of the symptoms of pneumonia and the prompt administration of serum, he would report a 5 percent overall mortality among patients su¤ering from type I pneumonia treated within twenty-four hours of the onset of disease.3 No longer satisfied with relative reductions in mortality, Cecil could advance a cure.4 Still more dramatically, a group at Cincinnati General Hospital reported that not a single type I pneumococcal pneumonia patient had died among fifty treated with monovalent serum “early and adequately.”5 A failed treatment thus implied improper typing or a preexisting complication.6 Parallel with the deepening of confidence in the established type I and II sera came the realized expansion of serotherapy’s range as well. By 1937, Jesse Bullowa could report before the California Medical Association that sera for types V, VII, VIII, XIV, and XVIII pneumococci were already as e¤ective as that for type I.7 It appeared that before long similar results would be extended against all thirtytwo types of pneumococcal pneumonia.8 Moreover, by 1937 such eªcacy and range were enhanced yet again through the discovery at both the Rockefeller Institute and the Lederle Laboratories that rabbits could be successfully substituted for horses in the production of monovalent therapeutic antisera.9 The Rockefeller team soon reported that rabbit serum could be generated far more cheaply than horse serum and could be administered as a single curative dose in the majority of cases with an apparent further reduction in the number of untoward reactions .10 Within a year, they would further detail the successful use of such monovalent serum against nine types of pneumococci, with a combined mortality of 3.4 percent when cases of the ever-tenacious type III pneumococci were excluded from the analysis.11 By the late 1930s, with the dramatic rise of the antipneumococcal sulfa drugs still on the therapeutic horizon (sulfapyridine would be introduced in America during the 1938–39 winter pneumonia season, as will be extensively detailed in chapter 6), the treatment of pneumonia with type-specific antiserum could be cited as one of medicine’s crowning achievements.12 Hailed as a therapeutic “revolution ,”13 it was explicitly compared to such contemporary scientific achievements as the treatment of diphtheria with antitoxin, diabetes with insulin, and pernicious anemia with liver extract.14...

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