Pneumonia before Antibiotics: Therapeutic Evolution and Evaluation in Twentieth-Century America
http://www.100md.com
《新英格兰医药杂志》
In Pneumonia before Antibiotics, Scott H. Podolsky demonstrates remarkable scholarship as he examines the philosophical and sociologic implications of the introduction of serotherapy and the sulfa drugs for treating pneumonia in the first part of the 20th century. He considers both of these important kinds of treatment with a philosophical insight that leads him to emphasize the tension between the claims of scientific discovery and the individualism of practitioners — "between an emerging universal biometric science and traditional notions of individual judgment."
Most interesting to me was the tension between the continued use of antipneumococcal antiserum and the adoption of the newly discovered sulfa drugs, especially once sulfapyridine was recognized as being much safer than sulfanilamide. Podolsky's thoughtful analysis resonates in the contemporary climate. Because the use of placebo controls was considered unethical, researchers compared the effects of sulfapyridine alone or together with antiserum in alternate patients; the results seemed to show that the sulfa drug alone was as effective as the two treatments together. If I understand Podolsky correctly, Maxwell Finland refused to participate in such studies because he regarded the patient selection as biased, and he supported this view by discussing factors that determined the inclusion of cases with interns who made the decisions. Finland also rejected statistical analysis of such data because, he said, when "unequivocal value . . . is not definitely apparent, the application of statistical analyses serves only to salve the conscience of the person who presents the data." Clearly, the concept of double-blind prospective studies was awaiting discovery. But Finland's views are relevant to today's practice. When I read the results of randomized, controlled drug trials, I always wonder about all the patients who were not considered for inclusion and the bias that may have resulted. And, in direct opposition to Finland's approach, marketplace competition within the pharmaceutical industry has led to huge studies with intense statistical analysis of relatively tiny differences.
Some of Podolsky's other insights are also relevant to present-day thinking and practice. For example, current recommendations for immediate, empirical treatment of pneumonia without attempting to determine its cause are reminiscent of what Harlow Brooks said about the disease in 1922: "There are several, even many kinds of acute pneumonia," but insofar as the therapeutist is concerned, "much of this detailed knowledge is unnecessary, even inadvisable, if it be secured at the sacrifice of the patient's rest, through a delay in treatment." This anti-intellectual view was rejected at the time by good researchers and practitioners, and we would do well to reject the modern tendency to regress to that point of view. Just because there are so many recognized causes of pneumonia, with such varied therapeutic options, it seems to me that there should be even greater emphasis on establishing a correct etiologic diagnosis rather than on empirical therapy, as is implied in recently published guidelines.
Using Massachusetts and New York as examples, Podolsky shows how pneumonia became a public health concern. In the late 1920s, the Massachusetts State Board of Health undertook a program to monitor the epidemiology of pneumonia, educate practicing physicians about antipneumococcal antiserum, and distribute the serum free of charge, asking in return only that physicians complete a case record form. This program was subsequently modified to reduce the perception of encroachment by public authorities on the private practice of medicine, another topic that remains of current concern.
I had great difficulty reading Pneumonia before Antibiotics. The prose is overly complicated. Some sentences contain up to 93 words. Others, I simply could not understand: "Instead countered with a deterministic methodology dependent — rather than on comparisons of mortality tables — on individually rationalizing each of an expected efficacious therapy's failures." Good editing, which one would have expected from Johns Hopkins University Press, should have corrected such problems, removed elaborate phrases (such as "paradigmatic example" and "positivistically pardoned"), and eliminated mixed metaphors ("Sulfapyridine's arrival was thus less a tornado sweeping away the rabbit warrens than a driving, steady breeze altering the murky therapeutic waters"). Still, Podolsky's scholarship is awesome, and his grasp of the philosophical and sociologic context of the issues considered makes this an important work. But it is not an easy read, and it will take a determined reader to get through it.
Daniel M. Musher, M.D.
Michael E. DeBakey Veterans Affairs Medical Center
Houston, TX 77030(By Scott H. Podolsky. 254)
Most interesting to me was the tension between the continued use of antipneumococcal antiserum and the adoption of the newly discovered sulfa drugs, especially once sulfapyridine was recognized as being much safer than sulfanilamide. Podolsky's thoughtful analysis resonates in the contemporary climate. Because the use of placebo controls was considered unethical, researchers compared the effects of sulfapyridine alone or together with antiserum in alternate patients; the results seemed to show that the sulfa drug alone was as effective as the two treatments together. If I understand Podolsky correctly, Maxwell Finland refused to participate in such studies because he regarded the patient selection as biased, and he supported this view by discussing factors that determined the inclusion of cases with interns who made the decisions. Finland also rejected statistical analysis of such data because, he said, when "unequivocal value . . . is not definitely apparent, the application of statistical analyses serves only to salve the conscience of the person who presents the data." Clearly, the concept of double-blind prospective studies was awaiting discovery. But Finland's views are relevant to today's practice. When I read the results of randomized, controlled drug trials, I always wonder about all the patients who were not considered for inclusion and the bias that may have resulted. And, in direct opposition to Finland's approach, marketplace competition within the pharmaceutical industry has led to huge studies with intense statistical analysis of relatively tiny differences.
Some of Podolsky's other insights are also relevant to present-day thinking and practice. For example, current recommendations for immediate, empirical treatment of pneumonia without attempting to determine its cause are reminiscent of what Harlow Brooks said about the disease in 1922: "There are several, even many kinds of acute pneumonia," but insofar as the therapeutist is concerned, "much of this detailed knowledge is unnecessary, even inadvisable, if it be secured at the sacrifice of the patient's rest, through a delay in treatment." This anti-intellectual view was rejected at the time by good researchers and practitioners, and we would do well to reject the modern tendency to regress to that point of view. Just because there are so many recognized causes of pneumonia, with such varied therapeutic options, it seems to me that there should be even greater emphasis on establishing a correct etiologic diagnosis rather than on empirical therapy, as is implied in recently published guidelines.
Using Massachusetts and New York as examples, Podolsky shows how pneumonia became a public health concern. In the late 1920s, the Massachusetts State Board of Health undertook a program to monitor the epidemiology of pneumonia, educate practicing physicians about antipneumococcal antiserum, and distribute the serum free of charge, asking in return only that physicians complete a case record form. This program was subsequently modified to reduce the perception of encroachment by public authorities on the private practice of medicine, another topic that remains of current concern.
I had great difficulty reading Pneumonia before Antibiotics. The prose is overly complicated. Some sentences contain up to 93 words. Others, I simply could not understand: "Instead countered with a deterministic methodology dependent — rather than on comparisons of mortality tables — on individually rationalizing each of an expected efficacious therapy's failures." Good editing, which one would have expected from Johns Hopkins University Press, should have corrected such problems, removed elaborate phrases (such as "paradigmatic example" and "positivistically pardoned"), and eliminated mixed metaphors ("Sulfapyridine's arrival was thus less a tornado sweeping away the rabbit warrens than a driving, steady breeze altering the murky therapeutic waters"). Still, Podolsky's scholarship is awesome, and his grasp of the philosophical and sociologic context of the issues considered makes this an important work. But it is not an easy read, and it will take a determined reader to get through it.
Daniel M. Musher, M.D.
Michael E. DeBakey Veterans Affairs Medical Center
Houston, TX 77030(By Scott H. Podolsky. 254)