The Sulfonamide Revolution and Children’s Health Care Delivery in the U.S.

Cynthia Connolly, PhD, RN, FAAN, will speak on Thursday, October 15, 2020 at 2:00 PM ET. This program will be live-streamed globally, and archived, by NIH VideoCasting. Dr. Connolly is Professor of Nursing, Rosemarie B. Greco Endowed Term Chair in Advocacy, and Associate Director, Barbara Bates Center for the Study of the History of Nursing, University of Pennsylvania School of Nursing. Circulating Now interviewed her about her upcoming talk.

Circulating Now: Tell us a little about yourself. Where are you from? What do you do? What is your typical workday like?

Cynthia Connolly: I am from Camp Hill, PA (a small town outside of Harrisburg). I have been a pediatric nurse for 40 years and have worked in settings ranging from neonatal intensive care to pediatric primary care  In the early 1990s, I returned to get a PhD in nursing history and the history of health care because I could not figure out how it was that we had built a health care system that seemed to work so inefficiently and so poorly for so many children.  After completing a dissertation on the history of children and tuberculosis (a study that ultimately became my first book) I served as a Legislative Fellow in the office of the late Senator from Minnesota, Paul Wellstone.  In my role as a professor at Penn’s nursing school, I teach nursing to undergraduate students, mentor doctoral students, and teach a history of health care elective course.  I also try and bring my clinical, policy, and historical backgrounds together in my role as a Faculty Director at Penn’s Field Center for Policy, Practice, and Research.

CN: Your upcoming talk is titled “New Drugs, Old Problems: The Sulfonamide Revolution and Children’s Health Care Delivery in the United States, 1933–1949.” What are sulfonamides and how were they developed?

CC: Until the advent of the synthetic organic compounds known as the sulfonamides in the mid-1930s, the treatment for infectious disease, where one existed, was known as serum therapy. Its administration could be challenging and the outcomes were often poor. Serum worked in one of two ways: Some, such as diphtheria antitoxin, worked against the poisons produced in the body by bacteria, others contained antibodies that destroyed the bacteria itself. The production of antibacterial serum therapy was labor intensive and expensive: First, it required a laboratory for identification of the bacteria afflicting the ill person. Next, a skilled technician needed to inoculate an animal with the bacteria (typically horses or rabbits), then harvest the resulting antibodies they developed from the liquid portion of blood, which would then be injected into the child to help fight the infection. Additionally, the serum was highly perishable and often produced serious side effects, including fever, joint pain, rash, and even fatal allergic reactions.

CN: Your focus here is on child health, did the treatment have a particular impact on children?

CC: Because serum was administered subcutaneously, intravenously, or injected into the spine, it was an uncomfortable procedure. The treatment also posed challenges unique to the pediatric patient. Its administration almost certainly frightened young children who could not understand what was happening to them, which undoubtedly would be upsetting to their parents as well. Moreover, infants and very young children who experienced an allergic reaction to serum could become critically ill much more rapidly than adults. Their smaller blood vessels also made serum administration more challenging than for adults.

CN: Why did the introduction of a new drug have such an impact on the way Baltimore’s Sydenham Hospital cared for patients?

CC: Great question! As I hope to explain in my talk, first and foremost the availability of sulfa drugs meant that many children who would have died survived. Everyone celebrated this of course, but a seemingly unanticipated consequence in the short term was that this outcome increased the pace and intensity of medical and nursing work because youngsters remained critically ill for days, sometimes weeks.

The ways in which the sulfonamides altered the care of children with infectious diseases at Sydenham, for example, was dramatic. While nurses prepared serum for administration and assisted physicians in its once-a-day infusion for these two conditions, sulfonamides could be taken orally (the preferred route of administration). So getting the drug into children every three to four hours became a nursing responsibility as did administering bicarbonate to prevent acidosis.  For children too young or too sick to swallow pills, nurses ground them up and mixed them with fluid or honey to get the patients to swallow the medication. If children refused some of the medication or vomited after administration, nurses needed to calculate how much they had received and administer the rest of the dose.  A particular challenge, the patient records reveal, was ascertaining whether the clinical response to the drug was a sign of toxicity or a drug reaction, both of which were common side effects to sulfonamide treatment. Or was the drug just not working for that bacteria? Nurses had always observed children for the side effects of serum so monitoring children who received sulfa drugs was not a new demand. What was new was the level of detail and clinical acumen required to perform that monitoring and the nursing assessment afterwards in terms of trying to unravel whether negative reaction the infection or the drug side effects.

CN: What is special for you about working with the pediatric patient records in the Sydenham Hospital, Baltimore records, 1909-1962 collection?

CC: With patient records you can see nursing and medical care “on the ground” as it is happening and as clinicians try and figure out how to experiment with novel therapies in order to save children’s lives.  And you can see their joy and amazement when children who would have died survive and thrive.  As a nurse, I can relate to that and I really feel it connects me to my forebears.

And you can also see, in granular detail, how the sulfonamides began a transformation that continued with penicillin. Along with improved public health measures, they helped change American childhood, parenting, and societal expectations for child well-being in the United States.

Cynthia Connolly’s presentation is part of our NLM History Talks, which promote awareness and use of the National Library of Medicine and other historical collections for research, education, and public service in biomedicine, the social sciences, and the humanities. All talks are live-streamed globally, and subsequently archived, by NIH VideoCasting. Stay informed about the lecture series on Twitter at #NLMHistTalk.