AFTER PENICILLIN
By J. GORDON COOK "Sergeant Harold Holden, of the Cambridge Borough Police, covered the 74 miles from Staines to Cambridge in go minutes with a packet of the drug streptomycin, needed to save a child desperately ill in hospital with pneumonia."—Sunday Express.
TODAY science is equipping -the medical profession with new and more efficient weapons against disease. Every branch of medicine has had its share of progress, and it is impossible to assess the relative importance of the advances which have been made. But there is one development which has undoubtedly contributed more to our human welfare than any ocher during the last century ; that is the discovery of penicillin and the new class of drugs which we now know as the antibiotics. Almost twenty years have passed since the spore of the mould Penicillium notatum floated in through the open window of Alexander Fleming's laboratory in St. Mary's Hospital in London, settled on a dish of growing bacteria and began producing penicillin to destroy them. The development of penicillin from Fleming's original observation has now become past history ; and with penicillin available in every chemist's shop it is no longer even news. But the importance of penicillin goes far beyond the intrinsic value of the drug itself ; of much greater significance is the fact that penicillin was the first important- member of the antibiotics, drugs produced by living organisms which are yet able to destroy bacteria and other forms of life.
The unusual feature about Penicillium notatum which attracted Fleming's attention in 1928 was not simply the fact that it was able to kill off his culture of pathogenic bacteria ; ordinary anti- septics could do that. But here was this growing mould—itself a living thing—producing something which was able to destroy another form of living micro-organism. The penicillin, as he later named the drug manufactured by the mould, was selective in its action against life. To Fleming this was a factor of supreme im- portance. During the Great War he had himself been searching for antiseptics that could destroy bacteria without harming the living cells of the body. And here was something which looked as though it might be able to do that very thing. Fleming's subsequent work showed that his penicillin was, in fact, harmless to the living cells of the human body. Where the ordinary antiseptic could deal with the germ outside the body, penicillin was able to continue the fight within the bloodstream itself.
For a number of years, production of it made little headway. Concentration and extraction of the drug from the medium in which the mould grew was unusually difficult, and the stimulus that was later to be provided by the war was lacking. But research on peni- cillin continued, and large-scale production established itself in America and in Britain during the war. Today we have as much penicillin as we need, and it has become routine medical treatment for a variety of diseases. As our understanding of the significance of penicillin has deepened, research into the new field of antibiotic drugs has increased. Two lines of attack are open to us: first, much work has been done in an attempt to synthesise penicillin in the laboratory ; and, second, the search for new antibiotic drugs is in full swing. Already small amounts of penicillin have been synthesised as a result of the joint work of British and American chemists ; but the process is so complex that it could not compete economically with the mould for large-scale production of the drug. Rather does its importance lie in the possibility of modifying the chemical structure of the penicillin to produce effects different from those of the natural drug itself.
In the general field of antibiotics, research during the last few years has brought to light a number of new drugs of this type. Some have shown sufficient promise to warrant intensive study ; very many others have been abandoned owing to their low antibacterial activity or high toxicity. So far, only one antibiotic other than penicillin has become of real importance ; this is the streptomycin which has received so much publicity during recent months. Streptomycin is a complex chemical manufactured during the life-cycle of Actino- myces griseus, a mould-like micro-organism found in garden soil. Discovered in America in 1944. the drug has already been the subject
of a great deal of experimental research. During this work it soon became apparent that streptomycin could destroy germs that peni- cillin would not affect ; it was carrying on where penicillin had left off. And in particular it was found that streptomycin possessed a degree of activity against the bacillus of tuberculosis in animals. With this discovery, interest in streptomycin became more than academic, and steps were-taken to manufacture it in sufficient quantity to allow for a full evaluation of its properties. Already the drug is being made on a moderately large scale in America and on a smaller scale in this country.
As supplies of streptomycin have become available, it has been possible to carry out experiments to assess its value against human tuberculosis. In America such work has already shown that strepto- mycin treatment is, to some extent, able to influence the course of the disease during its administration. But it does not provide a clinical control of human tuberculosis, nor is it as harmless to the body as penicillin. In Britain experiments are now in progress under the control of the Medical Research Council, and these should furnish us with further information as to the part streptomycin is to play against tuberculosis. But, by its nature, tuberculosis pre- sents unusual difficulties as an experimental problem, and many months of painstaking work are needed to assess the value of such treatment. Tubercular meningitis, like pulmonary tuberculosis, has shown some response to streptomycin treatment ; but, again, success has been tempered by the results it has produced. Deafness, partial paralysis and blindness have followed in a number of cases ; and when the streptomycin treatment is stopped -the disease may again flare up.
Meanwhile, the partial success of this early work with strepto- mycin has received considerable publicity in both Britain and America. Some has been in the form of carefully worded state- ments that would not raise false hopes ; too much has been sensa- tionalised into wildly optimistic promises that may never be fulfilled. At the present time, experimental work continues in the hope that streptomycin will eventually become the second antibiotic of out- standing importance. To the normal healthy person the logic of this scientific approach is simple to accept. But to the patient suffering from a serious disease the slow progress of scientific experiment is less easily borne. Disease to the sufferer is the most important thing in life, and in new drugs like streptomycin he recognises something that may be the answer to his prayers. It is new, and its poten- tialities are unknown ; is it not possible that the drug will be effective in his own particular case?
Today streptomycin is in the position that penicillin found itself in a year or two ago. It is known to be of value against a number of disease-producing germs ; and its possibilities have not yet been finally determined. But the results obtained so far have created a demand for streptomycin that cannot immediately be met. And as more is found out about the drug it is possible that the demand will still increase. At present insufficient streptomycin is being produced in Britain to meet the needs of all these desperate people. To divert supplies from the little that is being used experimentally would be to prejudice the outcome of the work on the success of which count- less lives may ultimately depend. Under such conditions only one solution remains 'to the person who is looking to streptomycin for his life ; that is to appeal to someone possessing supplies of the drug obtained, for example, from abroad. Recently such appeals have been increasing in number, and the drug has sometimes been flown specially from America. But the danger in its indiscriminate use is real, and the Medical Research Council has found it necessary to issue a warning to ensure that the toxicity of streptomycin is appre- ciated by those concerned.
As research continues, other antibiotic drugs will undoubtedly be discovered with activity against disease-producing germs. And with each one we may face the human problem that is provided by strepto- mycin now ; early indications of effectiveness must inevitably create a demand for the drug from patients who have no certain cure for their disease. But at the same time it is essential from the long- term point of view that controlled experiments should be carried out on such material as is available. It can never be easy to with- hold from a fellow human-being his opportunity of life. But there is sometimes no alternative.
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