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From lighthouse to hothouse: hospital hygiene, antibiotics and the evolution of infectious disease, 1950–1990

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Abstract

Upon entering clinical medicine in the 1940s, antibiotic therapy seemed to complete a transformation of hospitals that originated in the late nineteenth century. Former death sinks had become harbingers of therapeutic progress. Yet this triumph was short-lived. The arrival of pathologies caused by resistant bacteria, and of nosocomial infections whose spread was helped by antibiotic therapies, seemed to be intimately related to modern anti-infective therapy. The place where such problems culminated were hospitals, which increasingly appeared as dangerous environments where attempts to combat infectious diseases had instead created hothouses of disease evolution. This paper will focus on one aspect of that history. It caused clinical medicine and hospital hygiene in particular to pay attention to a dimension of infectious disease it had previously paid little attention to thus far: The evolution of infectious disease—previously a matter of mostly theoretical interest—came to be useful in explaining many phenomena observed. This did not turn hospital hygienists into geneticists, though it did give them an awareness that the evolution of infectious disease in a broad sense was something that did matter to them. The paper advances its argument by looking at three phases: The growing awareness of the hospital as a dangerous environment in the 1950s, comprehensive attempts at improving antibiotic therapy and hospital hygiene that followed from the 1960s and lastly the framing of such challenges as risk factors from the 1970s. In conclusion, I will argue that hospital hygiene, being inspired in particular by epidemiology and risk factor analysis, discussed its own specific version of disease emergence and therefore contributed to the 1980s debates around such topics. Being loosely connected to more specialized studies, it consisted of a re-interpretation of infectious disease centred around the temporality of such phenomena as they were encountered in day-to-day dealings of clinical wards.

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Notes

  1. For an overview, see Gradmann (2017, pp. 380–383). For a recent analysis of bacteriology’s impact in clinical medicine, see Wall (2013).

  2. Concerning typing, Colebrook and Kenny (1936), Colebrook collaborated with Fred Griffith, a pioneer of research into bacterial typing (Ayliffe and English 2003, p. 136; Méthot 2016).

  3. Ayliffe and English (2003).

  4. Amsterdamska (1987, p. 682) argues about interwar bacteriology that it challenged the ‘Cohn-Koch dogma’ through work on bacterial variation but showed little interest in questions of inheritance. Mendelsohn (2002) makes the more radical point that there probably had never been such a thing as the Cohn-Koch orthodoxy. Instead there was a place for variation and evolution in modern bacteriology for instance in work about virulence. His accent, however, like in the case of Amsterdamska is strongly on studies of variation.

  5. Méthot (2016) is a recent paper that offers an introduction to such work.

  6. Quoted in Méthot and Alizon (2014, p. 781).

  7. Introductions on the use of risk factors in clinical medicine are provided in Marks (1997) and Rothstein (2003).

  8. My approach is inspired by Reinhard Koselleck’s work. This historian developed an anthropology of how time is experienced in history. In historical situations of perceived stability, experience dominates and the present is seen in continuity with the past. In periods of accelerated change, however, it is expectation that dominates, while the present is seen as discontinuous with the past (Koselleck 1979). For an introduction see Bouton (2016).

  9. In her classical analysis of two camps in nineteenth century bacteriology, organized around notions of unitarianism and specificity in microbiology, Mazumdar (1995) emphasized how the dominant school with its emphasis on specificity would downplay the variability of bacteria.

  10. See Bud (2007) for an analysis that emphasizes this.

  11. Ayliffe and English (2003) provides a wealth of detail for those who want more detail. A useful interpretation of the British situation in the 1950 s is Condrau and Kirk (2011). Some insight into the US history can be found in actor’s accounts, including Brachman (1981), Dixon (2011) and Hughes (1987).

  12. The collection by Suter and Vincent (1993) served a s a starting point which focused on journals from the field of hospital hygiene and infection medicine.

  13. Spink (1955, p. 585), as well as the following two quotes. The paper was based on a presentation delivered in 1953.

  14. From the context it is clear that when writing about hospitals,”permitting the survival of people who are less able […] to cope with bacterial infections” was not thinking of racial differences but instead of the patients’ age or the therapies they had undergone (McDermott 1956, p. 64).

  15. R. Dubos (1959); cf Moberg (1999).

  16. On Barber see (Tansey 2000, p. 5). According to Graham Ayliffe (ibid, p. 36), her work at Hammersmith Hospital resulted in the first antibiotic hospital policy in the UK.

  17. Health personnel had been ruled out as carriers of resistant strains (Barber et al. 1960, p. 16).

  18. Podolsky (2010); on 2nd generation antibiotics: (Bud 2007, pp. 116–139; Greenwood 2008, pp. 119–136).

  19. See Dixon (2011). The authors name the CDC as a starting point for the US.

  20. Hillier (2006); according to Ayliffe and English (2003, p. 193), Colebrook proposed the position of an infection control nurse in 1955. Wise et al. (1989) report its invention for the US in the late 1950 s. .

  21. For a graphic description, see Wise et al. (1989).

  22. One in the UK, one in the US; see Eickhoff (1991) for references and a sketch of the situation around 1970.

  23. Quoted in Maki et al. (1982).

  24. On risk and risk factor analysis: Aronowitz (2015), Rothstein (2003), Schlich and Tröhler (2006), Timmermann (2012).

  25. This first and fairly simple system was followed by increasingly sophisticated classifications of patients that used pathophysiological markers as risk factors. In parallel textbooks from the period could contain chapters that attempted to educate hospital hygienists in risk factor epidemiology (Wenzel 1987, pp. 581–584).

  26. Quoted in Daly (2005, p. 55), see also Timmermanns and Berg (2003).

  27. Scott H. Podolsky (2010) argues this as the example of why the randomized controlled clinical trial, a core tool of evidence-based medicine, was embraced by critical antibiotics researchers.

  28. Casadevall and Pirofski (2003) discussed this from an immunological perspective. In reply, Méthot and Alizon (2014) proposed an ecological explanation, in which virulence, which is customarily regarded as a trait of a microbe, is seen as context-dependent. Looking at the debates this paper follows, the question of diverging rates of hospital infection was resolved by focusing on circumstance rather than cause: the rates of infections that differed between hospitals became comparable when risk was calculated per device and intervention (Hospital Infections Programme 1991).

  29. Serratia became a classic in hospital infections: Hejazi and Falkiner (1997).

  30. As introductions (King 2004; Snowden 2008). See (Ewald 1994). It seems that the origins of the term do lie in epidemiology rather than genetics, in this case denoting an increase of incidence of human infections. For a contemporary discussion see (Grmek 1993). For a recent historical analysis (Méthot and Fantini 2014).

  31. Lederberg et al. (1992), see Morrens and Fauci (2012).

  32. This can be interpreted in different directions. Outside of the scope of this paper it seems to represent the outcome of a struggle concerning social and professional hierarchies in hospitals—between, for instance, surgeons and microbiologists, doctors and nurses. Of the initial subscribers (in 1980) of the journal, Infection Control and Hospital Epidemiology, 90% seem to have been non-physicians (Wenzel 2009).

  33. A search in Pubmed (30.1.2017), the main bibliographic database for medicine, delivers hardly any (25) hits for the index term “Theobald Smith”, most of which are obituaries or scholarly contributions by historians. A search for René Jules Dubos, again as an index term, delivers 225 returns, including quite a few from the period under study here.

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Acknowledgements

This paper is a much revised version of a presentation on the conference “Making Microbes Complex: Parasites, Epidemics and the Origins of Disease Ecology” held at QMUL July 7–8, 2016. I wish to thank the conference organizers Mark Honigsbaum (QMUL) and Pierre-Olivier Méthot (Université Laval, Québec) for inviting me. Both of them also gave valuable comments on the paper in its various stages of completion. Mathias Grote (HU Berlin) supplied a much appreciated critical reading of the manuscript.

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Gradmann, C. From lighthouse to hothouse: hospital hygiene, antibiotics and the evolution of infectious disease, 1950–1990. HPLS 40, 8 (2018). https://doi.org/10.1007/s40656-017-0176-8

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