Published online by Cambridge University Press: 07 December 2011
It has become commonplace in accounts of medicine in the second half of the twentieth-century to ascribe an “antibiotic revolution” to the years when penicillin became widely available from the early 1950s. However, to date there have been hardly any studies that demonstrate a major discontinuity in medical practices after mid-century, let alone that go on to specify their character. There would seem to be two key features of any “antibiotic revolution”: first and foremost that the treatment of diseases was transformed as doctors were able to cure illness caused by infections with specific drugs that eliminated causative bacteria; and second that the ambition of doctors to intervene with drugs in a number of diseases grew, as did the ability of the pharmaceutical industry to supply an increasing range of targeted and effective remedies. In this article we contribute towards an assessment of the first of these key features by discussing the changing management of acute bronchitis from the mid-1940s to the early 1960s. The disease was amongst the most prevalent and important of that period in Britain, being the single largest cause of consultations with general practitioners (GPs) through much of the 1950s. Bronchitis was also the subject of many high profile debates among doctors and health care agencies as concerns about its morbidity and mortality touched on such issues as smoke pollution, the costs of the National Health Service (NHS) and changes in the doctor–patient relationship. The evidence of contemporary studies shows that the treatment of acute bronchitis changed radically after the introduction of antibiotics, such that by the mid-1950s over 80 per cent of patients diagnosed with the condition were prescribed penicillin or another antibacterial drug—a shift that was not supported by any clinical trials or systematic evidence. How and why this change occurred are the questions we set out to answer.
1 See for example, K Brown, Penicillin man: Alexander Fleming and the antibiotic revolution, Stroud, Sutton, 2004. In typical fashion, this book offers a few examples of previously life-threatening diseases that could be effectively treated with penicillin, e.g. endocarditis, meningitis, sepsis, and puerperal fever, p. 193. On changing drug therapies over the century, emphasizing evolutionary change, see M Weatherall, In search of a cure: a history of pharmaceutical discovery, Oxford University Press, 1990.
2 R Bud, ‘Penicillin and the new Elizabethans’, Br. J. Hist. Sci., 1998, 31: 305–33; D Masters, Miracle drug: the inner history of penicillin, London, Eyre & Spottiswoode, 1946; H M Böttcher, Miracle drugs: a history of antibiotics, London, Heinemann, 1963.
3 College of General Practitioners (CGP), ‘Acute chest infection in general practice. A group investigation by 55 general practitioners organized by the research committee of the council of the College of General Practitioners’, Br. med. J., 1956, i: 1516–20, p. 1518.
4 Scottish Intercollegiate Guidelines Network (SIGN), ‘Community management of lower respiratory tract infection in adults’, 2002, 59: 1–29. Accessed by http://www.sign.ac.uk/guidelines; Patient-Orientated Evidence that Matters (POEM), ‘Antibiotics are not needed for lower respiratory tract infection’, Br. med. J., 20 Aug. 2005, 331: 0NN.
5 M Woodhead, D Fleming, R Wise, ‘Antibiotics, resistance and clinical outcomes’, Br. med. J., 2004, 328: 1270–71.
6 The important contribution of viruses did not emerge until the 1960s.
7Chronic bronchitis: an NAPT symposium, London, NAPT, 1958.
8 National Archives, Public Records Office (hereafter NA PRO) MH 132/48, Report of the Minister of Health for the year ending 1958. Part 11. On the state of the public health, being the annual report of the Chief Medical Officer, London, HMSO, Nov. 1959, p. 73.
9 CGP, op. cit., note 3 above, p. 1518.
10 J Pemberton, ‘Illness in general practice’, Br. med. J., 1949, i: 306–7.
11The Times, 16 Sept. 1955, p. 7.
12 Anon., ‘Facts from general practice’, Lancet, 1953, ii: 978–9.
13 J Horder and E Horder, ‘Illness in general practice’, Practitioner, 1954, 173: 177–87, p. 186.
14 CGP, op. cit., note 3 above, p. 1518.
15 E M Backett, J A Heady, J C G Evans, ‘Studies of a general practice (II). A doctor's job in an urban area’, Br. med. J., 1954, i: 109–15, p. 113.
16 This pattern was confirmed by the General Register Office 1952–1954 study of 37,000 consultations.
17 J Fry, Common diseases: their nature, incidence, and care, Lancaster, Medical and Technical Publishing, 1974, ch. 2 ‘Influenza’, pp. 16–26.
18The Times, 12 Jul. 1947, p. 6; 15 Jan. 1949, p. 3.
19The Times, 11 Feb. 1952, p. 6.
20The Times, 16 Sept. 1955, p. 7.
21The Times,17 Jan. 1951, p. 2. Dr John Fry, a GP from Beckingham, who was a pivotal figure in the early days of primary care research and published widely on acute bronchitis and chest infections, put it another way, “‘flu’ can become a convenient garbage-can type of loose and imprecise diagnostic term that offers a quick and ready label for the victims of a multitude of common respiratory infections”. Fry, op. cit., note 17 above, p. 22.
22 ‘All about ‘flu’, Family Doctor, 1954, 4: 84–5, p. 84.
23The Times, 31 Jan. 1953, p. 3.
24 NA PRO MH 132/36, Report of the Minister of Health for the year ending 31 Dec 1952. Part 11. On the state of the public health, being the annual report of the Chief Medical Officer for the year 1952, London, HMSO, Dec 1953, p. 76.
25 J G R Howie, I M Richardson, G Gill, D Durno, ‘Respiratory illness and antibiotic use in general practice’, J. R. Coll. General Practitioners, 1971, 21: 657–63.
26 J S Collings, ‘General practice in England today’, Lancet, 1950, i: 555–85.
27 Anthony Ryle, letter to the Lancet, 1950, i: 885.
28 British Medical Association, General practice and the training of the general practitioner, London, British Medical Association, 1950, pp. 82–4; P A Tyser, ‘Training for general practice’, Lancet, 1950, i: 1091.
29 G Rivett, From cradle to grave: fifty years of the NHS, London, King's Fund, 1998, p. 90.
30The Times, 24 Oct. 1962, p. 15.
31 We have been unable to track down any extant copies of Prescribers’ Notes. It was produced between 1952 and 1958 and was the forerunner of the Prescribers’ Journal, which replaced it in 1961 on the recommendation of the Hinchcliffe Committee. See, Department of Health, Final report of the Committee on Cost of Prescribing, Hinchcliffe Committee report, London, HMSO, 1959, p. 49.
32 Royal College of General Practitioners, Archives (hereafter RCGPA), ACE J8–1, The cost of prescribing. A memorandum from the Council of the College of General Practitioners, 1958, p. 3.
33 Ibid., p. 4.
34 D M Dunlop, L S P Davidson, J W McNee, Textbook of medical treatment, 3rd ed., Edinburgh, Livingstone, 1944, pp. 861–71.
35 A B Christie, ‘Refresher course for general practitioners: acute bronchitis’, Br. med. J., 1951, i: 82–5.
36 J D Comrie, H A Clegg, Black's medical dictionary, 18th ed., London, Adam and Charles Black, 1946, pp. 145–9.
37 M Worboys, ‘Treatments for pneumonia in Britain, 1910–1940’, in I Löwy (ed.), Medicine and change: historical and sociological studies of medical innovation, Montrouge, John Libbey Eurotext; and Paris, INSERM, 1993, pp. 317–26; I Loudon, ‘Puerperal fever, the streptococcus, and the sulphonamides, 1911–1945’, Br. med. J., 1987, 295: 485–9.
38 Christie, op. cit., note 35 above, p. 84. University of Nottingham Hallward Library manuscripts and special collections material (hereafter UNHL) MCH 1/10/1, Minutes of the address by Professor Sir Derrick Dunlop to the Nottingham Medico-Chirurgical Society on ‘Modern concepts in therapeutics’, on 30 Nov. 1949, pp. 116–17.
39 T Anderson, ‘The newer antibiotics in respiratory infections’, Practitioner, 1952, 169: 589–95, p. 592.
40 Ministry of Health, National War Formulary, 1st ed., London, HMSO, 1941, p. 5.
41 Ministry of Health, National [War] Formulary, 2nd ed., London, HMSO, 1947, p. 5.
42 D M Dunlop, L S P Davidson, J W McNee (eds), Textbook of medical treatment, 5th ed., Edinburgh, Livingstone, 1949, pp. 86–8, on p. 86.
43 L S P Davidson, The principles and practice of medicine: a textbook for students and doctors, 1st ed., Edinburgh, Livingstone, 1952, pp. 58–61.
44 Maurice Davidson, A practical manual of diseases of the chest, London, Geoffrey Cumberlege, Oxford University Press, 1954, p. 117.
45 Miller, ‘Penicillin mist for sinus trouble’, Readers’ Digest, April 1948: 59–61.
46 See Christie op. cit., note 35 above, pp. 82–5.
47 R L Cecil, R F Loeb, A textbook of medicine, 8th ed., Philadelphia and London, Saunders, 1951, pp. 822–4.
48 Davidson, op. cit., note 43 above, pp. 58–61.
49 UNHL, MCH 1/11, Minutes of the address by Professor Stuart-Harris to the Nottingham Medico-Chirurgical Society, ‘Pneumonia’, on 13 Feb. 1952, p.21.
50 J Fry, ‘Primary atypical pneumonia’, Br. med. J., 1951, ii: 1217.
51 Ministry of Health, National Formulary, 2nd ed., London, HMSO, 1952, p. 16.
52 T I Williams, Howard Florey: penicillin and after, Oxford University Press, 1984, pp. 148–9.
53 Ministry of Health, National Formulary, 3rd. ed., London, HMSO, 1955.
54 C Wilson, ‘Chloramphenicol’, Practitioner, 1956, 176: 14–17, on p. 17.
55 K R Capper, ‘Preparations of penicillin’, Practitioner, 1955, 174: 12–20.
56 Joint Meeting of the Section of General Practice with the Section of Medicine, ‘Discussion on the use and abuse of antibiotics’, Proc. R.. Soc. Med., 1955, 48: 355–64, on p. 363.
57 NA PRO, MH 133/193, Standing Nursing Advisory Committee meeting 24 July 1951, p. 12.
58 ‘Doctor answers, “Painful injections”’, Family Doctor, 1960, 10: 128.
59 On crystapen tablets see, Br. med. J., 4 Apr. 1953, i: 7.
60 CGP, op. cit., note 3 above, p. 1518.
61 Joint Meeting, op. cit., note 56 above, p. 360.
62 L S P Davidson, The principles and practice of medicine: a textbook for students and doctors, 3rd ed., Edinburgh, Livingstone, 1956, pp. 272–5.
63 D M Dunlop, S Davidson, S Alstead (eds), Textbook of medical treatment, 7th ed., Edinburgh, Livingstone, 1958, pp. 653–5.
64 K Robson, ‘Acute bronchitis’, Practitioner, 1958, 181: 681–5, p. 684.
65 Ibid., p. 683.
66 M Davidson, op. cit., note 44 above, p. 106.
67 Combined Study Group, ‘Some aspects of the recent epidemic of influenza in Dundee’, Br. med. J., 1958, i: 908–13, p. 912.
68 A U Mackinnon, ‘Winter ailments in general practice’, Practitioner, 1960, 185: 764–9, on p. 768.
69 CGP, op. cit., note 3 above, pp. 1516–20.
70 The British Medical Association and the Pharmaceutical Society of Great Britain), British National Formulary (alternative edition), London, British Medical Association and the Pharmaceutical Society of Great Britain, 1957, pp. 151–61.
71 Ibid., pp. 106, 103.
72 Ibid., pp. 152.
73 D M Dunlop, L S P Davidson, S Alstead (eds), Textbook of medical treatment, 9th ed., Edinburgh, Livingstone, 1964, pp. 678–80, on p. 678.
74 D M Dunlop, L S P Davidson, J W McNee (eds), Textbook of medical treatment, 2nd ed., Edinburgh, E and S Livingstone, 1942, p. 817.
75 L S P Davidson, The principles and practice of medicine: a textbook for students and doctors, 8th ed., Edinburgh, Livingstone, 1966, pp. 341–3, on p. 342.
76 A Batty Shaw and J Fry, ‘Acute infections of the chest in general practice’. Br. med. J., 1955, ii: 1577–86, p. 1584.
77 Robson op. cit., note 64 above, pp. 684–5.
78 J Horder, N Oswald and J Fry, ‘The acute chest’, Medical World, Sept. 1963: 380–7, on p. 384.
79 Ministry of Health, British National Formulary, 9th ed., London, HMSO, 1971, pp. 108–9.
80 Anon., ‘The month’, Practitioner, 1956, 176: 1–2, commentary accompanying a symposium on antibiotics printed, pp. 5–65.
81 M Finland, ‘Changing patterns of resistance of certain pathogenic bacteria to antimicrobial agents’, N. Engl. J. Med., 1955, 252: 570–80.
82 Joint Meeting, op. cit., note 56 above, p. 361.
83The Times, 16 July 1953, p. 3.
84 Dr A Christie of Fazakerley Hospital, Liverpool, in a review for GPs on acute bronchitis in 1951, noted that most cases would eventually clear up without specific treatment, but only, “at the cost of several weeks’ ambulant illness, during which time the patients are a nuisance and danger to themselves and to other people”. Christie, op. cit., note 35 above, p. 84.
85 NA PRO, MH 132/48, Report of the Minister of Health for the year ending 1958. Part 11. On the state of the public health, being the annual report of the Chief Medical Officer. HMSO, London, Nov. 1959, p. 73.
86 P B Beeson, Walsh McDermott (eds), Cecil–Loeb textbook of medicine, Philadelphia, W B Saunders, 1971, pp. 361–2.
87 S Alstead, A G Macgregor, R H Gridgwood (eds), Textbook of medical treatment, 12th ed., Edinburgh, E & S Livingstone, 1971, p. 193. The 1st to 11th editions were edited by D Dunlop and others.
88 C Webster, The health services since the war: Volume 1: Problems of health care: the National Health Service before 1957, London, HMSO, 1988; idem, The health services since the war: Volume 2: Government and health care: The National Health Service 1958–1979, London, HMSO, 1996; Rivett, op. cit., note 29 above; V Berridge and K Loughlin (eds), Medicine, the market and the mass media: producing health in the twentieth century, London, Routledge, 2005.
89 NA PRO MH 132/30, Report of the Minister of Health for the year ending 31. Mar. 1950 including the report of the Chief Medical Officer on the state of the public health, HMSO, London, Sept. 1951, pp. 24–5.
90 NA PRO MH128/283, Report of the Cohen Committee on General Practice under the National Health Service, London, HMSO, 1954, p. 9.
91 C Webster, The National Health Service: a political history, Oxford University Press, 1998, p. 46.
92 J P Martin, Social aspects of prescribing, London, Heinemann, 1957. p. 109.
93The Times, 4 July 1962, p. 5.
94The Times, 20 Apr. 1957, p. 3.
95 Department of Health, Final Report of the Committee on Cost of Prescribing, London, HMSO, 1959, pp. 28–33, esp. p. 31.
96 Webster, vol. 1, op. cit., note 88 above, pp. 222–3.
97 NA PRO MH 135/709, Ministry of Health, England, Joint Pricing Committee for England, ‘Prescribing Investigation Unit: formation and rates of pay’, 1949–1961; NA PRO MH 123/293, Department of Health, Scotland, Report of the Scottish Committee on Prescribing Costs, Edinburgh, HMSO, 1959.
98The Times, 3 Jan. 1959, p. 7.
99 H Davis, ‘The National Health Service and pharmacy’, J. Pharm. Pharmacol., 1954, 6: 761–72.
100 NA PRO, MH 132/49, Report of the Minister of Health for the year ending 1959. Part 1. The National Health Service, London, HMSO, July 1960.
101 Webster, op. cit., note 88 above, vol. 2, pp. 349–57.
102 S Taylor, Good general practice, London, Nuffield Provincial Hospitals Trust, Oxford University Press, 1954, pp. 64–7.
103 Martin, op. cit., note 92 above, pp. 15–16, 30–1; Anon, ‘Five years pricing’, Pharmaceutical J., 1954, 173: 61–2; Taylor, op. cit., note 102 above pp. 64–5.
104 L Johnston, ‘Preparing for general practice’, Lancet, 1950, ii: 824. Italics in original.
105 Taylor, op. cit., note 102 above, p. 183.
106 G Strong, ‘General practice today’, Lancet, 1950, i: 928–9, on p. 928.
107 RCGPA, op. cit., note 32 above, p. 4–5.
108 NA PRO, MH132/39, Report of the Minister of Health for the year ended 31 Dec 1954. Part I. The National Health Service, London, HMSO, 1955, p. 117.
109 NA PRO, FD 23/1934, Proposed Therapeutic Trail of Antibiotics in General Practice. Correspondence between Dr J Fry and the Medical Research Council, 1957.
110The Times, 21 Feb. 1955, p. 9.
111 See Martin, op. cit., 92 above, p. 11.
112The Times, 28 March 1952, p. 4.
113 Association of British Pharmaceutical Industry (hereafter ABPI), Annual report. 1964–5, London, ABPI, 1965, p. 13.
114 NA PRO, MH 135/61, Letter from Dr Charles Brooke to Mr Aneurin Bevan, 10 Nov. 1949.
115 See ABPI op. cit., note 113 above, p. 13.
116 ABPI, Annual report. 1966–7, London, ABPI, 1967, p. 10.
117 RCGPA, op. cit., note 32 above, p. 3.
118 Joint Meeting, op. cit., note 56 above, p. 359.
119 Boots plc Archives (hereafter BA) 3322/85, ‘Boots Penicillin Oral Tablets’, for the information of the Medical Profession, Nottingham, Boots Pure Drug Company Limited, 1950c. BA A126/1, Boots Information Leaflet, No. 39, ‘Cold and coughs’, for the information of the Pharmaceutical Staff, Nottingham, Boots Pure Drug Company Limited, 1950c.
120 ABPI, Annual report 1966–7, London, ABPI, 1967, pp. 15–16.
121 RCGPA, op. cit., note 32 above, p. 3.
122The Times, 15 Apr., 1950, p. 4.
123Good Housekeeping's encyclopaedia of family health: a modern illustrated home doctor, London, National Magazine, 1956, pp. 57–8.
124 G Somerville (ed.), Newnes family health encyclopaedia, London, George Newnes, 1959, p. 112; R L Clark, R W Cumley (eds), The book of health: a medical encyclopedia for everyone, Princeton, Van Nostrand, 1962, p. 135.
125 W A R Thomson, Black's medical dictionary, 22nd ed., London, Adam and Charles Black, 1955, pp. 143–5.
126 W Edwards, ‘Is your medicine really necessary?’, Family Doctor, 1951, 1: 259–61, p. 261.
127 C Brogan, ‘Are you a human medicine bottle?’ Family Doctor, 1952, 2: 428–30, p. 429.
128 D Tavistock, ‘Family doctor speaking about bronchitis’, Family Doctor, 1952, 2: 600–1; ‘All about bronchitis’, Family Doctor, 1953, 3: 158–9.
129 Tavistock, ‘Family doctor speaking about bronchitis’, op. cit., note 128 above, pp. 600–1.
130 RCGPA, ACE J 8–1, Letter from Dr Byrne to the Council of the College of General Practitioners, 14 Oct. 1957.
131 Ibid., Letter from Dr Ashworth to the Council of the College of General Practitioners, 15 Oct. 1957.
132 J T Macfarlane, W F Holmes, R M Macfarlane, N Britten, ‘Influence of patients’ expectations on antibiotic management of acute lower respiratory tract illness in general practice: questionnaire study’, Br. med. J., 1997, 315: 1211–14.
133 A Lake, ‘Are you overdosing with antibiotics?’, Reader's Digest, July 1953, pp. 23–5.
134 K C Hutchin, Coughs, colds and bronchitis, London, W & G Foyle, 1961, pp. 59–64.
135 There were no studies or trials that demonstrated the efficacy of antibiotics in acute bronchitis, as there was with streptomycin and tuberculosis. A Yoshioka, ‘Use of randomisation in the Medical Research Council's clinical trial of streptomycin in pulmonary tuberculosis in the 1940s’, Br. med. J., 1998, 317: 1220–23.
136 B Arroll, T Kenealy, ‘Antibiotics for acute bronchitis’, Br. med. J., 2001, 322: 939–40, and Audit Commission, A prescription for improvement. Towards more rational prescribing in general practice, London, HMSO, 1994.
137 Woodhead, Fleming, Wise, op. cit., note 5 above, pp. 1270–71.
138 Committee of the British Thoracic Society and British Infection Society, Health Protection Agency acting on behalf of the Department of Health. Clinical guidelines for patients with an influenza-like illness during an influenza pandemic (http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4121753), Version 10.5, 5 March 2006.