History of Medicine, Lilybank House, University of Glasgow, Glasgow

J R Coll Physicians Edinb 2016; 46: 198–205 Paper http://dx.doi.org/10.4997/JRCPE.2016.312 © 2016 Royal College of Physicians of Edinburgh Penicillin: promise, problems and practice in wartime Edinburgh S Gardiner PhD candidate, Centre for the History of Medicine, Lilybank House, University of Glasgow, Glasgow ABSTRACT While medical historians have paid ample attention to the introduction Correspondence to S Gardiner of antibiotics and their impact on hospital-based practice during and after the Centre for the History of Medicine Second World War, the multiple issues surrounding their use in Scottish hospitals Lilybank House are sorely lacking in current discussions. Drawing on an extensive yet underused University of Glasgow range of materials including patient treatment records, oral histories and medical Glasgow G12 8RT correspondence, this paper explores the introduction of penicillin for civilian UK treatment at the Royal Infirmary of Edinburgh during the closing stages of the e-mail [email protected]. War. It highlights the success of the drug in clinical treatment as well as its ac.uk shortcomings, offering an alternative view of its initial impact on surgical practice. KEYWORDS antibiotic resistance, Edinburgh, infection control, penicillin DECLARATION OF INTERESTS No conflicts of interest declared INTRODUCTION the considerable and recognised threat posed by microbial resistance right from the beginning.1,2 Medical historians have paid considerable attention to the introduction of penicillin during the Second World War and its revolutionary impact on surgical practice MANAGING SUPPLIES: THE PENICILLIN and systems for infection control in hospitals worldwide.1,2 COMMITTEE Scholars too have documented and debated the rising rate of wound infection and the emergence of antibiotic Early in August 1944, discussions emerged regarding the resistance as a global phenomenon during the post-war dissemination of penicillin for civilian use in Scotland’s era.3–5 Yet little has been said about the implications of hospitals. Until this point, penicillin had been in use at antibiotic therapy for clinical practice in Scotland and, the RIE for just a few months. It remained under tight more generally, it is recognised that there is a dearth of control and was reserved for the treatment of war historical knowledge of the clinical work undertaken in casualties and for the purposes of clinical trials.7 civilian hospitals during the Second World War.6 However, in early August 1944, the Deans of the four Scottish medical schools of the Universities of Edinburgh, This paper seeks to redress these imbalances within the Aberdeen, Glasgow and St Andrews (in Dundee) met historiography by exploring the introduction of penicillin with officials from the Department of Health for to the Royal Infirmary of Edinburgh (RIE) and examining Scotland (DoHS) to arrange for its incorporation into its impact on the treatment of civilian patients during the civilian treatment.8 The DoHS explained that the Ministry closing stages of the War. This paper utilises a variety of of Supply was providing some 120 million units (120 hospital records including previously unused patient ‘mega’ units) for the treatment of civilians in Scotland in treatment records together with correspondence, August 1944. It was agreed that this sum would be minute books, oral histories and excerpts from the distributed to the four schools as follows: Glasgow, 60 medical press. As in the treatment of war casualties, mega units; Edinburgh, 35 mega units; Aberdeen, 15 mega penicillin achieved great clinical results in civilian units; and Dundee, 10 mega units. At the request of the treatment at the hospital. However, the new therapy was DoHS, each Dean established and led regional penicillin shaped considerably and, in some respects, tainted by ‘committees’ through which supplies and priorities for economic problems with regard to both the quantity use were determined at a regional level.8 That it was and quality of supplies. Indeed, this paper will demonstrate envisaged that the Deans of the four university medical that such considerations exerted a strong influence over schools would play such a crucial role in incorporating the cases chosen for penicillin therapy, methods for penicillin into the Scottish healthcare system is indicative administering the drug and, sometimes, clinical outcomes. of the supremacy of academic medicine in Scotland and its pre-eminence over extra-mural teaching before HISTORY Complicating the traditional view that penicillin was 1948.9 The remit of the new Edinburgh committee was perceived as a ‘wonder drug’ or even a ‘miracle drug’ to distribute the drug to hospitals across the South- when it was first introduced, this paper will also highlight Eastern Defence District, an area probably covering 198 Penicillin usage in wartime Edinburgh Lothian and the Scottish Borders.8 Its membership septicaemia, acute osteomyelitis and severe carbuncles); comprised: Professor Sydney A Smith, Dean of the haemolytic streptococcal, pneumococcal and University’s Medical School; WG Clark, Medical Officer meningococcal infections (especially those resistant to of Health for Edinburgh; TJ Mackie, Professor of sulphonamide treatment); and gas gangrene. Several Bacteriology at Edinburgh University and Bacteriologist conditions merited ‘special consideration’ when supplies to the RIE; and JR Learmonth, Professor of Surgery and allowed for it, such as eye infections; sepsis in burns and Surgeon to the RIE.7,10,11 wounds; sulphonamide-resistant gonorrhoea; traumatic lesions (for example, compound fractures and thoracic Despite the fact that penicillin was still a relatively new injuries); complications associated with tuberculosis technology, the Edinburgh team already possessed (such as acute empyema); and skin infections resistant to considerable knowledge of how to handle, use and even other forms of treatment. The Ministry of Health produce the drug. Mackie’s bacteriological team at granted the local penicillin committees the authority to Edinburgh University had been growing small amounts use penicillin on conditions other than those highlighted of penicillin for clinical use at the RIE since mid-1942.12,13 in the memorandum, again providing supplies were By September 1943, however, the net yield amounted to sufficient.22 only one mega unit, enough to treat just one patient.12This is indicative of the difficulties faced in British university The Ministry of Health advised against the use of laboratories in producing ample quantities of penicillin penicillin to treat conditions caused by organisms which before the US method of mass production by deep-tank were not at that time known to be susceptible to the fermentation was adopted in 1945.2 Learmonth, in drug (such as intestinal infections and ulcerative colitis), collaboration with another bacteriologist, JP Duguid, had while also excluding bacterial endocarditis and syphilis.22 recently conducted an investigation into the drug’s The inclusion of ulcerative colitis on the list of conditions efficacy in treating war wounds inflicted during the inappropriate for treatment highlights the ‘vexed D-Day landings of June 1944.14 Under the new question’ that was the aetiology of this condition during arrangements, from August of that year, penicillin supplies the interwar period.23 Indeed, the medical literature of were kept in Mackie’s University department before the pre-penicillin period was awash with narratives being distributed to hospitals across the region. These about the infectious nature of the condition, with Bacillus hospitals included not only the RIE itself but also the dysenteriae highlighted as a potential cause.24–26 Likewise, City Hospital for Infectious Diseases, Bangour Hospital, while penicillin would eventually revolutionise the the Western General Hospital, the Royal Hospital for treatment of syphilis, during the War there was a delay Sick Children, Leith Hospital and the Princess Margaret in introducing the new treatment as the full extent of its Rose Hospital. In that first month, the RIE obtained the activity against the causative organism in the condition largest share of the supplies reserved for civilian use in remained unknown.27 This allowed one British clinician these hospitals, receiving eight out of 35 mega units.15–17 to state in January 1945 that Paul Ehrlich’s discovery of The total share for civilian treatment in all hospitals Salvarsan in 1907 remained to that day the ‘greatest increased to 50 mega units in January 1945 and 75 mega advance in the treatment of [syphilis]’.28 units in the following month.18,19 Despite these increases, demand continued to considerably outweigh supply. This The memorandum also provided advice regarding how may explain why, for a brief period in early 1945, the to administer the drug both locally and systemically, Penicillin Committee considered issuing ‘sub-standard’ often recommending the size and frequency of dosages. penicillin (defined as penicillin of a potency lower than For example, for burns and deep wounds they encouraged 150 units per milligram) to its hospitals for topical use. the local application of a penicillin cream. For abscesses, These plans were soon abandoned.20,21 they recommended a solution containing sterile water and at least 250 units of penicillin per cubic centimetre. Awareness of the need to ration penicillin became In the treatment of dry wounds, they endorsed the use widely apparent in October 1944, when the Edinburgh of

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