Friday, February 8, 2013

Re-setting the Allies' moral compass : the acid test of penicillin for wartime endocarditis

Please correct me : but in all my research I could find no indication that in his 15 years of medical research before October 16th 1940, (and he was a world-class expert in the area of strep bacteria) Henry Dawson had never written or spoken one peep - not one peep - on the subject of endocarditis, a very common and deadly disease, usually caused then by a variant of strep bacteria.

Dawson was a scientist who spoke and wrote a lot , so his silence , until October 16th 1940, was surely hardly from lack of opportunity.

Nor was it bureaucratically and professionally easy, in October 1940 anymore than it would be today, to go from being the director of an outpatients' clinic on chronic arthritis to suddenly becoming the lead doctor on a totally new treatment of such an acute cardiac illness as subacute bacterial endocarditis (SBE).

At least not in a big teaching hospital, with all boundary-conscious specialists rigidly defined in each area.

So we are still left with the puzzle explaining why Dawson literally gave his life to suddenly treat and cure this hitherto incurable disease, endocarditis.

It helps to recall that as a paid up member on the side of Social medicine at a time when War medicine was in the ascendancy in the corridors of Columbia Presbyterian Medical Centre that Fall, Dawson's ears must have zeroed in on the disease quickly voted "the absolutely lowest priority disease in all War medicine" : and that SBE.

The overall consensus that that the SBEs consumed endless amounts of medical care, generally only to quickly die anyway.

Or if they did by some weird chance recover - this time - they couldn't much useful war work with their weakened heart and anyway would surely succumb to a second bout of SBE.

Dawson might even have agreed with this assessment , albeit reluctantly, before October 1940 : nothing, not even the much vaunted brand new sulfa drugs, did anything to extend the SBEs' chances.

But to Dawson, if not to any one else in the world,  the written claims about this new , as yet untested, drug penicillin seemed to offer a way out.

It promised activity against SBE's green strep bacteria, good diffusibility and above all , near absolute non-toxicity.

The latter was critical because ("Blood, blood everywhere and not a drop to drink") ironically the heart's values have almost no internal blood supply and must be 'dabbed' by a drug filling the entire blood supply, as it whistles past the heart valves at break neck speed.

An internal "antiseptic" as it were.

Any drug strong enough to instantly push its way through the thick vegetation on the heart valves and quickly kill the strep within , as it rushed on by at 'breaking the speed limit speeds' was also strong enough to be toxic to the entire human body.

SBE was a "disease designed by a committee" : a committee of Devils creating a disease so devilish as to even frustrate God Himself.

SBE seemed an impossible cure -- surely a quick death following upon benign neglect was the most merciful choice ?

But none of the SBE experts seemed to feel as he felt ; none was willing to do the sort of heroic medicine required to at least give crude penicillin and SBE  the old school try.

Did Dawson begin to feel that this indifference to the possibility of curing SBE, "the polio of the poor", was just an excuse?

Did he not buy the claim that the difficulties of preparing penicillin together with all the preparations for war medicine and  for prioritizing medicine for the 1A fit  was the real reason for inactivity on SBE ?

Or was it really just an excuse to roll back New Deal efforts to do something medically for the poorest and weakest (the 4Fs) among us ?

Were there not strong rumours about that the Nazis were also abandoning the poorest and the weakest among the German patients, also using the necessities of war to justify their actions ?

Whatever ethical speculation led him to his decision, it is a fact that on October 16th 1940, Henry Dawson made the wartime treatment of the weakest of the weak, the 4Fs of the 4Fs, the ultimate acid test for the moral compass of the Allied cause.

It took him years - and cost him his life - but he got that moral compass set right, right in the middle of a bloody war.

Finally, treating the SBEs, the least of these, as we would want ourselves to be treated, became the practise of the Allies, not just another plank in their hollow public rhetoric....

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