Friday, February 15, 2013

"Weaponized" penicillin to be a frontline Army wound powder and hence the needs of the Navy, Air Force and Civilians are not relevant...

One of the most historic of meetings and dates in the whole extended penicillin saga occurred on September 25 1942 at Portland House in London England .

 In fact one key participant at the meeting sensed this so greatly that he even whispered that history was going to view it that way, into the ear of the chairman as the meeting broke up.

In many ways, this meeting was very odd as well as being very historic.

Mostly because who called it and who it asked to attend.

It was called by one of the powerful of the many British wartime Ministries, the Ministry of Supply (MoS), which  actually only supplied the Army (and perhaps in few things , the other two armed services as well) - but never ever supplied civilian needs.

Ronald Clark in his biography of Ernst Chain says this meeting was proceeded by the Ministers of (army) Supply and  (civilian) Health, Sir Andrew Duncan and Ernest Brown, jointly "taking the idea of the immediate mass production of penicillin to the War Cabinet".

If so, it was possibly informally done via a Ministry "Minute" to the War Cabinet as neither gentlemen were ever members of the small War Cabinet : even in peacetime many many British politicians become ministers, without ever being becoming cabinet ministers.

And significantly, no one from Brown's civilian-oriented department was at this historical meeting.

This is a very important matter to resolve definitely, in part because the peculiar nature of this crucial meeting spelt the doom of  Winston Churchill and his party in the election of June-July 1945.

How on earth did penicillin the universal lifesaver ever come be re-jigged as something only useful to the combat needs of the British Army ?

None of the drug firms summoned to this meeting (which did NOT include the very politically powerful firm of ICI ) had any real political or military influence - they didn't push for the meeting to take place but merely came when they were called.

 But two of the four scientists had the meeting certainly did have good credentials with the Army ( but not Navy or Air Force) medical authorities and were of the correct Tory stamp: Howard Florey and Alec Fleming.

They had pushed for this meeting with the Army's supply department.

So, the army-oriented MoS was there in full force with six top officials along with two top officials from the Army Medical Branch charged with drug procurement for frontline casualties.

Missing in action at this meeting - by design - was the Navy, Air Force and any officials representing the Civilian interest in penicillin production.

Florey and Fleming both strongly saw penicillin as basically a useful supplement to the cheap abundant and systemically-oriented oral sulfas,  with penicillin to be used primarily as in "local applications" for frontline combat wounds.

True, the Navy and Air force casualties were more often treated at large hospitals (and more often simply died in action)  than in the case of the Army.

The Army had to deal with the fact that more of its casualties emerged as alive but wounded ,compared to the other services, which was the good news ---- but the bad news was that their wounds were usually about to get badly infected as a result of the primitive conditions at the front line.

A highly concentrated anti-bacterial drug with a long storage life and stable under almost any conditions as a dry powder (ie highly pure as well as highly concentrated) seemed essential.

Then and only then could it be suitable to sprinkle on open wounds immediately as they occurred on the front lines by barely trained medics or ordinary soldiers themselves.

 Or for a busy front line doctor  in am ambulance tent to inject, with a little sterile water, in or around those open wounds, within hours of the wounding.

Chemically, sulfa was born fulfilling these requirements - but penicillin didn't really meet them until after the six years of war was long over.

But unfortunately, no thorough controlled clinical trials of this claim that a frontline local application anti-bacterial medication would be essential for wounded survival was ever done.

At war's end, the general assessment was that, in fact, the frontline powders and needlefuls of these "local" penicillin and sulfa (ie applied directly into the wound) were not essential.

 Instead, the wonderfully low rate of death from wounds (versus either the much worse record of WWI or of WWII Germany)  was felt to be more due to the Allies' quick thorough debridement (removal) of dead wounded flesh , front line blood transfusions and policy of rapid evacuations of wounded soldiers to clean, quiet ,well equipped base hospitals .

That ---- and the general good health of  wounded Allied troops, because they had been kept well fed and lived in warm sanitary conditions in the months before being wounded.

In the military base hospitals and civilian general hospitals,  wartime sulfas and penicillin did prove to be reliable life savers when given as a systemic, if and when blood poisoning was suspected.

In fact, "crude" liquid penicillin (totally un-concentrated and totally un-purified) injected by needle and prepared in the hospital daily by Dr Duhig, saved lives as a systemic at a Brisbane general hospital --- and could have done so in the military equivalent.

Ooops ! It did do so, at Cairo's largest military hospital, where Dr Pulvertaft treated patients with liquid systemic crude penicillin he made daily in the hospital.

How did the Navy, RAF and the public, along with those politicians sworn to protect these groups of humans beings, react to the idea that penicillin was to be made under the control of the Army and for war casualties only ?

Seemingly with initial indifference - though by the Spring of 1943, a freelancing Navy Surgeon Commander had converted the Admiralty's under-producing vaccine operation to a huge penicillin factory supplying all of the Royal Navy's penicillin needs.

The Admiralty had always 'looked after its own', had always produced its own vaccines and serums so it didn't take long before the Navy medical brass had a look around at the penicillin factory and beam approval.

(Unlike the Army and Air Force, they had won the battle to retain the supplying of their needs by a naval units controlled directly by the Admiralty itself.)

For some rather sad reasons, the Air Force had relatively few wounded, for its size, and for other reasons, the treating of the wounded and returning them to battle was not an operational priority.

Over the course of the whole war, each of the British armed service got about one third of the money spent on the war. But in terms of manpower, of five people in uniform there were three in the army versus one in the RAF and one in the Navy/Merchant Marine.

This is because the RAF and RN/Merchant Marine had lots of big expensive machines that if  "taken out of action" usually resulted in a 100% loss (aka "sunk" or "crashed"), while except in disastrous retreats, this rarely happened to the Army and its smaller cheaper machines.

The Allied Armies proved very much better, for example, at recovering even badly damaged tanks , as compared to the Germans.

In terms of personnel killed, the story is more complex.

Most of the RAF were never in real danger of dying but among those that flew, rather than maintained aircraft on the ground, the death rate was very high -often as much from operational accidents as enemy fire.

In Bomber Command, 55 of 100 fliers died before finishing their tour of duty.

Again there were relatively few wounded fliers versus a high rate of deaths - with the relatively few that survived their plane being hit only doing so by remaining out of the war, as German POWS.

People losses anyway and quite frankly , were not a big concern to the RAF : it never had a shortage of qualified recruits.

The RAF was seen as very glamorous to those determined to be very brave and seen a very secure place to spend the war to those with peacetime technical and engineering skills and no urge to be brave.

 Manpower sustaining by speeding the recovery of the wounded was never a critical issue for any of WWII's air forces.

Replacing lost machines ( and frequently the training of new flier recruits) was always their obsession instead.

The world's navies were almost as attractive as the air forces, and rarely suffered from manpower worries and wounded recovery worries.

Instead, the sudden loss of entire town-sized machines (battleships or aircraft carriers) with all two thousand on board dead at one stroke, from a single torpedo or bomb, was their admirals more realistic nightmare.

In addition, while the Merchant Marine had particularly high losses of lives, against the relatively small number of its personnel, the merchant marine crews' relatively high pay and lack of onerous military discipline kept manpower replacement issues at bay.

When all factors are combined, at a gross figure level, the three armed services all lost about the same percentage of dead against the total number enlisted in each service, though as I have shown, the chance of death in service fell very unevenly.

In the case of the Army, it fell hardest on the infantry, followed by the tank crews and often the combat engineers.

Because almost no one wanted to join the infantry, it had few volunteers and generally the infantry got those conscripted recruits so totally lacking in useful education and technical skills that no other section of the Army wanted them.

To combine metaphors : incredibly enough, in all the Allied military , the very pointy end of the offensive stick came from the very bottom of the barrel.

In a nutshell, this is why the Germans and Japanese proved so very hard to defeat.

Over the whole war, the death rate varied greatly among the three services - the Navy death rate actually went down as the war progressed, the RAF's deaths peaked in 1943-1944, while in the case of the Army it was expected to rise suddenly and sharply to WWI Western Front levels, following the invasion of Europe.

The Army faced a short sharp period of potentially huge casualties - most wounded and infected but in Allied hands, not POWS.

If they weren't too badly wounded and the right anti-bacterial medication was at hand, the Army might be able to get most of the wounded back into battle formations before the war ended.

Just as well ,as there were no new men hustling to enter the infantry replacement pipeline at the other end.

At the very least, the thought that if and when they got wounded, the Army could heal most of them, would make the infantry less reluctant to rise up and advance against deadly Mortar and Machine Gun fire.

Or so the Army brass fondly believed.

I have tried to make the Fall of 1942 case for the British Army making penicillin just for itself seem as sensible as possible.

But in fact, it was a case going around with its nose full of Coke and Ecstasy.

In the fall of 1942, the really big medical story wasn't the rise of penicillin ; it was the decline of the previous wonder slash miracle drug : the Sulfas.

After five years of ever newer, better sulfas coming on market, that pipeline had died.

It was a double whammy of disaster, because now the current sulfas were proving less useful as more and more bacteria were becoming resistant to them.

Either a disease's bacteria totally failed to respond to sulfa and the patient died, or so large a dose need to be given that some patients again died from sulfa's toxicity at high dose levels.

This was not some sort of a Army front line versus RAF or Navy base hospital versus civilian home GP issue --- the stuff just didn't work as well as it used to ---- anywhere : in the UK , in battlefields world wide, in Germany and in Russia.

Full stop.

Sulfa's improved replacement - and it might be penicillin, who can tell  ? - would face immense pressure to made in sufficient quantities to fulfill all needs all over the world, in civilian systemic use as well as front line local antiseptic use.

This was Florey and Fleming's greatest intellectual failure : the inability to see this.

Now neither of them were conceptual thinkers, as even their most ardent supporters admit in print - they were uniquely tied to the concrete and conventional here and now rather than to abstract speculation.

 By contrast, Rene Dubos didn't have their success in finding a useful anti-bacterial medicine from microbes, (his luck was bad) but he could  clearly see the Big Picture issues in ways those two could never hope to.

I do not know where Dawson stood for sure on this conceptual versus concrete issue since we have no personal papers of his - but the fact that Dubos always felt highly of him suggests a hint.

Certainly if deeds are better than mere words, Dawson never acted at all as if penicillin had to be first weaponized before it could become useful to humanity.

He was the first to give the world a patient successfully treated by a life-saving antibiotic because he saw semi-crude penicillin as more than good enough to inject safely into a human being : Dies Mirabilis, October 16th 1940.....

1 comment: