M&B to the Rescue!

(adapted from Nursing Churchill: Wartime Life from the Private Letters of  Winston Churchill’s Nurse, by Jill Rose, Foreword by the Hon Emma Soames. Amberley Press: 15 June 2018)

On 7 February 1943, Prime Minister Winston Churchill returned to England after an exhausting four week journey to North Africa and the Middle East. He was feeling poorly and thought he must have caught a chill. A few days later a cold and sore throat obliged him to lie up. On the evening of 16 February his temperature rose alarmingly and his personal doctor, Sir Charles Wilson, Dean of St Mary’s Hospital Medical School,  was called in. He diagnosed pneumonia, which was confirmed by an X-ray the following day.

Sir Charles summoned Dr Geoffrey Marshall of Guy’s Hospital, an expert in respiratory diseases. The two physicians prescribed a period of bed rest, plenty of fluids and treatment with M&B, a widely-used medicine often hailed as a wonder drug. The patient would need skilled nursing care, and Sir Charles turned to St. Mary’s to send their best. My mother Doris Miles, a recent recipient of the Gold Medal for Excellence in Nursing and the daughter of a former Dean, was the obvious first choice. On the evening of 19 February she was told by Matron to go immediately to the Prime Minister’s residence.

‘I went straight away in a taxi’, Doris wrote in 1982 to Churchill’s official biographer Martin Gilbert, ‘and was met by Sir Charles who said, “Glad to see you, nurse. I must warn you, the Prime Minister doesn’t wear pyjamas” – and neither he did. [Only] a silk vest, velvet jacket with a diamond V on the lapel and slippers of velvet with PM embroidered on the front’.

Doris’s first duty was to give her patient a tepid sponge bath to reduce the fever. Churchill was suffering from a pneumococcal infection caused by bacteria called streptococcus pneumoniae, which infected the lungs and caused fever, loss of appetite, chest pain and difficulty breathing, and could damage the heart. The condition,  called haemolytic strep pneumonia, was potentially life-threatening to the elderly and to people who smoked or were heavy drinkers; Dr Marshall knew that the Prime Minister was a high-risk patient. There was an ever-present risk of pleural empyema (a build-up of pus in the pleural cavity) which could lead to serious lung damage. Edward Fitzroy, Speaker of the House of Commons, five years older than Churchill, was suffering from the same ailment; he was in critical condition and died soon afterwards.

A doctor today has an arsenal of antibiotic drugs he can use in a case of the pneumonia from which Churchill was suffering, but in 1943 the use of such drugs to treat bacterial infections was in its infancy. The antibacterial properties of the penicilliummould had been discovered  in the Pathology Department of St Mary’s Hospital in September 1928 by a Scottish doctor named Alexander Fleming. Returning to his lab after being away on holiday, he observed a bloom of mould on a Petri dish which had inhibited the growth of the Staphylococcusbacteria inadvertently left in there. (The story goes that the mould had blown in through an open window from the Fountains pub and brew-house across the street.)  He made a culture of the active ingredient and called it penicillin.

However, Fleming failed to develop his discovery. He was a bacteriologist and lacked the skill of a chemist to isolate the active ingredient in the mould. In addition, he had a diffident personality and was unable to convince others of  the enormous significance of his discovery.

For over a decade his work and success remained unrecognised. It was not until 1939, when other scientists became involved, that the effectiveness of penicillin became apparent. The American pharmaceutical company Merck began commercial production, and in December 1942 survivors of the devastating Cocoanut Grove nightclub fire in Boston were the first burn victims to be treated with the new drug.Nonetheless, penicillin remained difficult to manufacture and was in limited supply until early 1944, when, with the backing of the US Government, large-scale production became possible. For the remainder of the war it was used with great effect on wounded Allied soldiers, saving many thousands of lives. A  colleague of my parents’ from St Mary’s, Graham Jones, had been taught by Fleming how to grow penicillin cultures, and in a prisoner-of-war camp in Germany he arranged an informal trial of the drug through the International Red Cross, which he used to treat his fellow prisoners during an epidemic of pneumonia.

In the 1930s, however, the treatment of choice forbacterial infections such as cerebrospinal meningitis, septicaemia and pneumonia were the so-called sulpha drugs. Antibiotics such as penicillin, which are derived from micro-organisms, kill the disease-causing bacteria directly, while sulpha drugs, being chemical compounds, act by inhibiting their growth, thus helping the body’s natural defences to rally and mop them up.

Gerhard Domagk, a German scientist working for the Bayer pharmaceutical giant in the early 1930s, had  found a promising anti-bacterial compound contained in a red dye. In December 1934 Bayer was granted a patent for their new product, which they called Prontosil. French researchers subsequently showed that the active ingredient in the dye-based Prontosil was a group of chemical compounds called sulphonamides. The venerable British chemical and pharmaceutical company May & Baker, founded almost a hundred years earlier,  got into the action in 1936 to find a patentable sulphonamide. They enlisted Dr Lionel Whitby, pathologist at the Middlesex Hospital in London, who isolated a variation called sulphapyridine. It was given the number 693 in the May&Baker series, and was thereafter always known as M&B693.

By March 1938 large-scale clinical trials had proved the effectiveness of the new drug, and the following year a more powerful and less toxic variation, sulphathiazole, was introduced as M&B760. This was the drug which Churchill’s doctors, in consultation with Dr Whitby,  chose to use in 1943.

Doris later wrote to Martin Gilbert that on her first night with the Prime Minister, ‘Geoffrey Marshall put him on a course of M&B760. Chemotherapy had only just started with the sulphonamides, and the results, though good on the whole, were still uncontrolled . .  . WC was fascinated by this and demanded to know exactly how the drug worked so that he could recount it to all his visitors’.

Painful urination was one of the more distressing side effects of the drug, so potassium was given at the same time to prevent crystals of uric acid forming in the kidneys. Doris administered this in the form of potassium citrate (Pot Cit). He complained of head pains, so each night she would rub his head with oil of wintergreen (methyl salicylate), a compound related to aspirin which could help reduce the fever. ‘This became something of a ritual every evening’, Doris wrote, ‘and he would sing an old music-hall song while I was doing it’.

To maximise the effectiveness of the drug, it was important to take it at regular intervals and to maintain a constant level in the blood. Tracking the white count daily is an indication of how well the infection is coming under control, particularly the levels of two specific components, neutrophils (often called polymorphs) and eosinophils. Churchill’s blood count was closely monitored.

Churchill took a keen interest in his illness and always wanted the doctors and nurses to explain what they were doing. He found the composition of his blood particularly intriguing; in late night conversations with Doris, when he was relaxed and chatty, he would talk about the ‘pollywogs’ and ‘eowins’ which were his names for the two types of indicator cells. (Churchill loved to play with words and often made up his own. ‘When I use a word . . . it means just what I choose it to mean’, said Lewis Carroll’s Humpty Dumpty; Churchill might well have said the same thing. ‘Pollywog’ is an old-fashioned term for a tadpole; ‘Eowin’ is his own invention.)

Churchill suffered from two more bouts of pneumonia before the end of the war, and each time M&B worked its magic. ‘I personally have never failed to pay my tribute of respect and gratitude to M&B;’ he told the Royal College of Physicians in 1944, ‘although I am not competent to give you an exact description of how it works, it certainly has in my case always been attended by highly beneficial results’.

But already the sulpha drugs were being superseded by the newer, more powerful antibiotics, which had fewer side effects. Fifteen years after his chance discovery of the life-giving mould, Alexander Fleming was made a Fellow of the Royal Society in March 1943. Many awards followed later in recognition of his work: he was knighted in 1944 and was co-winner of the Nobel Prize for Medicine in 1945.

The May & Baker company was absorbed into Bayer and Aventis; today only a Nigerian subsidiary retains the once-illustrious name.