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6 Histology of a Revolution
- Johns Hopkins University Press
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c h a p t e r s i x Histology of a Revolution Histology, of course, depends as much on the mode of presentation of materials as it does on a magnified viewing of its subject. For ease of presentation, I have therefore divided this longest chapter into three chronologically ordered subgroupings , highlighting: the resistance engendered by serum advocates against the abandonment of antipneumococcal serotherapy during the advent of the sulfa drugs; the resultant (if heterogeneous) persistence of antipneumococcal serotherapy to a degree hardly captured by images of wanton rabbit warren and horse farm destruction; and finally, the course of antipneumococcal serotherapy’s ultimate displacement. I hope, in the process, to have made visible the necessary complexity of such a therapeutic transformation while providing a substrate from which to draw more universal principles. Resistance: Therapeutic Control As demonstrated in the previous chapter, by the late 1930s serum was becoming increasingly advocated as the standard of care of the pneumonia patient, embedded in a public health approach to pneumonia and unanimously supported in the medical literature. In October of 1938, a Pennsylvania practitioner encouraged the fellow members of his own decidedly pneumonia-conscious state medical society to advocate for further state funding for serum, “which will surely be needed in larger amounts as specific treatment becomes more popular.”1 The same day, in Indiana, a clinician would note before the Indiana State Medical Society : “It has been stated, and it must be repeated, that pneumonia is one of the great medical emergencies. It demands aggressive attention, just as does the acute appendix, perforated ulcer, diphtheria or coronary occlusion. . . . It is evident that specific type serum therapy of pneumonia is established, and it should be pressed until some better method is developed.”2 As further substantiation of such support, in several prominent trials of the sulfa drugs for pneumonia, only those patients with pneumonia considered less amenable to serotherapy were subjected to the “experimentation” of treatment with the sulfa drugs in the first place.3 Indeed, some still conceived of antipneumococcal serotherapy as a paradigm for the serotherapeutic approach to all infectious diseases.4 Sulfa advocates were certainly present and propagating, however. In 1935 Germany ’s Gerhard Domagk had announced the treatment of murine hemolytic streptococcal infection with the azo dye later named Prontosil; and after initial skepticism, researchers in Great Britain and the United States found that a derivative of Prontosil, sulfanilamide, indeed appeared e¤ective in such streptococcal infections as puerperal fever and erysipelas.5 Through pharmaceutical company and media promotion, sulfanilamide would, over the next several years, indeed initiate the chemotherapeutic revolution.6 As applied to pneumonia in America, proponents from several academic centers (most prominently, the Detroit Receiving Hospital) lent their weight behind the novel agent in the treatment of pneumonia, whether nonspecifically against all pneumococcal serotypes, or either alone or (in anticipation of future trends) in combination with serotherapy against the ominous type III pneumococcus.7 And certainly, clusters of general practitioners did use the novel agent for such a relative of the beta-hemolytic streptococcus as the pneumococcus.8 In general, however, the marginal benefits accorded to sulfanilamide were considered to be outweighed by its novel toxicities (from headaches to life-threatening hemolytic anemias and cyanosis) at pneumonia-level doses, as the sulfa drugs faced the same stigma regarding novel side e¤ects that had plagued the now-familiar serotherapy years earlier. An exchange between Harvard’s Max Finland (an advocate of combination therapy for type III pneumococcal pneumonia) and Wesley Spink (at the University of Minnesota) in late 1937 suggests the contemporary weight given to the novel sulfanilamide’s side e¤ects and eªcacy, vis- à-vis those of serotherapy, by two leading specialists: [Finland to Spink:] [Regarding sulfanilamide,] we have encountered the whole gamut of untoward reactions. In some instances they were so severe and death was experienced so that the workers were very hesitant to use the drug. [Isadore] Snapper in Amsterdam made the blatant remark that the wave of enthusiasm for this drug has long been passed here in Europe [where Finland was visiting].9 [Spink to Finland:] You may be interested to know that we have had on the service recently a mother and her 17-year-old son, both with type 2 lobar pneumonia. The son had also otitis media of the right ear, type 2 pneumococci being recovered and the mother had a type 2 bacteremia. Both recovered with serum therapy. We also...