Diseases and treatment then and now – Some Reminiscences



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By Dr. V. J. M. de Silva


On September 25th 1955, President Dwight Eisenhower, former Supreme Commander of Allied Forces in World War 2, suffered a heart attack in the middle of the night. His physician, Dr. Howard Snyder, gave him only a morphine injection. No drugs were given specific for a heart attack, falling blood pressure or irregular pulse. His physician told his wife Mamie, in whose family home he was holidaying, to keep him warm. He was allowed to sleep until noon. Dr. Snyder then called a cardiologist to do an electrocardiogram. Later, the president went by car to a hospital. There, he was largely confined for almost seven weeks to bed, chair rest and limited physical activity.


Reading this account a few days ago set me thinking. As an old retired medical person, now in the twilight years of his life, I have often sat back and marvelled at the progress made in medical treatment since the time I entered the Colombo Medical Faculty in 1950. I thought of setting a few facts down in writing as it might interest the general public and the present generation of medical students and young graduates.


Era of Mixtures - The 1950s and 60s decades, the post World War 2 era, saw great advances in almost all branches of medicine. Going back to 1950, if one went to a hospital OPD then, what would have been noticed was that almost all patients carried bottles. Most patients then were treated with mixtures (in addition to tablets and powders). There must have been nearly fifty in the "Ceylon Pharmacopoeia" of that period. The standard decoctions ("stock mixtures") were Mist. Sodi Sal, Mist. Pot. Cit., Mist. Carminative, Mist. Bismuth Sedative etc. All hospital wards had these stock mixtures, which doctors prescribed. Powders were also common. Pulv APC (aspirin, phenacetin, and caffeine) was the commonest, also sold in tablet form – APC tablets were then as popular as present day Paracetamol (Panadol). It was withdrawn when phenacetin was found to have adverse effects; Aspirin then took over, to be replaced once again with Paracetamol. All medical students were taught pharmacy - dispensing mixtures, powders and ointments, and we had to sit for a practical examination as part of pharmacology for the 3rd MBBS. Mixtures were in common use till about the late 1960s.


Antibiotics - As regards antibacterial drugs, the only ones in common use, when we were children (pre 1940), were the sulpha drugs. The first sulpha drug, Prontosil, was discovered by the German chemist, Gerhard Domagk in 1935. Later May & Baker Ltd. produced a new sulpha drug, Sulphapyridine, known at that time as M & B 693. This was followed by other sulpha drugs. The common ones used in the 50s were Sulphadimidine and Sulphaguanidine.


As for antibiotis, in 1928 Sir Alexander Fleming observed that colonies of the bacterium Staphylococcus aureus grown on a culture plate could be destroyed by the mould Penicillium notatum, proving that there was an antibacterial agent there, although it was not recognized at that time. The British scientists Howard Florey and Ernst Chain isolated the active ingredient and developed a powdery form of the medicine in the early 1940s. By 1943, the required clinical trials had been performed, and Penicillin has been shown to be the most effective antibacterial agent to date. Penicillin production was quickly scaled up and made available in quantity to treat Allied soldiers landing in Normandy, France, and wounded on D-Day (June 6, 1944). It was first marketed, I believe, in 1946.


In 1943, American microbiologist Selman Waksman made the drug Streptomycin from soil bacteria, the first of a new class of drugs called aminoglycosides. Streptomycin could treat diseases like tuberculosis; however, the side effects were often severe. Other anti-TB drugs such as Isoniazid, Pyrazinamide, were introduced in the early 50s and 60s. Tetracycline, Chlortetracycline (Aureomycin), Choramphenicol (Chloromycetin) - which became standard treatment for Typhoid (Enteric Fever) and Erythromycin, all came in the latter part of the 1950s. Ampicillin was marketed in 1961; Amoxicillin, I believe, came in 1981. Now, of course, there are so many other antibiotics.


Children’s diseases – Worm infestation and anthelmintics - In the 1950s round worm infestation was very common in pediatric wards. Passing dozens of worms in stools, and vomiting worms was quite common. Most of us of the older generation, would have passed a few worms at some time or other when we were children. The standard treatment then was Oleum Chenopodii (oil of chenopodium) combined with carbon tetrachloride in liquid paraffin, and followed by a purgative such as Mist. Alba (white mixture) or magnesium sulphate. Later tetrachlorethylene (TCE) was introduced and was given with glucose solution. Antepar (piperazine citrate) was introduced when we were medical students in the early 1950s. Today of course there are several drugs which are effective against all ‘worms’ such as roundworms, hookworms, threadworms, tapeworms etc. Unlike in the 1950s, worm infestation is no longer a problem, thanks to regular and effective treatment with safe drugs and of course better sanitation – (worm infestation is spread by soil pollution and the faecal-oral route; in hookworm however, infective larvae enter through the skin of the feet).


Diarrhoeal diseases – these were quite common and children were often brought in an acute state of dehydration. Giving intravenous fluids is not easy in children and there was a high mortality.


Oral rehydration – the introduction of oral rehydration in the late 1960s in the treatment of acute diarrhoeal diseases was a significant medical discovery. That glucose orally, enhances the intestinal absorption of salt and water, and thus corrects dehydration was not known in the late 1950s, when I was working in hospitals. Lack of this knowledge caused a lot of unnecessary deaths. Today of course, everybody has heard of ‘Jeevani’ (oral rehydration salts - ORS).


Other diseases – In the pre-immunization era, diseases such as diphtheria, measles, mumps and whooping cough were quite common. As medical students we saw quite a lot of tuberculosis in children, especially TB meningitis. These are of course not seen today. Respiratory infections were also prevalent before the antibiotic era.


Immunization – The earliest vaccine to come into use was that against small pox, developed at the end of the 18th century. This disease has of course now been globally eradicated; so declared by the WHO in 1980. This was the only immunization we were subjected to as children. Typhoid immunizations were carried during epidemic periods. Triple vaccination against diphtheria, pertussis (whooping cough), tetanus (DPT) was introduced in the early 1960s. Routine BCG vaccination of infants also came in about this time. Today, children are also immunized against diseases such as measles, mumps, rubella and hepatitis.


An all-island mass immunization campaign against poliomyelitis, using an oral vaccine, was carried out for the first time, when I was an MOH in early 1960s.


Diseases and Drugs in General Medicine – Oral Antidiabetic drugs – Diabetes mellitus was treated in the early days by diet and insulin. The earliest oral drug to come into use was Rastinon, a sulphonylurea, marketed in Germany in 1956, and later by an American firm as Orinase (Tolbutamide). It was discovered when a new contender for a sulpha drug was found to have drastic blood sugar lowering properties as a side effect. Metformin, the most widely used oral antidiabetic drug in the world today, was introduced into UK in 1958, and US as late as 1995.


Insulin, given by injection was there from 1922.


Anti-hypertensive drugs – One of the first drugs developed for the treatment of hypertension in 1952 was Serpasil, derived from the plant Rauwolfia serpentina. A major breakthrough was the discovery of the diuretic chlorothiazide which came into use in 1958. It increased salt excretion while preventing fluid accumulation. In the early 1960s, the group of drugs known as the beta blockers (like propranolol) came into use; also the introduction of powerful diuretics like furosemide (Lasix). When I was an interne, the standard diuretic was Mersalyl, given by injection twice a week. There are of course now a whole heap of new drugs in treating hypertension.


Asthma – Until the 1960s the commonest used drug was ephedrine. More severe cases were treated with adrenaline injection which was quite effective. Aminophylline, both oral and intravenous was also in use. In the late 1960s salbutamol was introduced, also used in the form of inhaler. This, and the judicious use of steroids, has revolutionized the treatment of this common chronic disease.


Viral Hepatitis - We heard of hepatitis as one disease; today we know that there are about five types with different modes of spread.


Malaria, Filariasis and Leprosy – Following the discovery of DDT, malaria was brought under control in the late 1940s. We went through medical school without seeing malaria cases. It flared up again in the late 1960s. It is under control now, though there are cases still occurring.


Filariasis - The use of Hetrazan (diethylecarbamazine) in the control of filariasis (a type of ‘worm’ infestation found in the blood stream and lymphatics) was also introduced in the 1950s. It is now greatly reduced.


Diseases and treatment then and now – Some Reminiscences ...From page III


Leprosy – this too is no longer a problem thanks to vigorous health education, case finding and adequate treatment


Family Planning – The oral contraceptives were introduced to this country, I believe in late 1950s or early 60s. In 1965, the government decided to accept family planning programme as its responsibility. By early 1960’s, more modern contraceptives such as oral contraceptives, condoms were available at family planning clinics. Intra uterine devices (IUD) and contraceptive injections (depot Provera), came a little later. Today of course the whole set-up has been changed to operate in a more efficient manner.


Since 1978, over a million "test-tube babies" would have born into the world, and "in-vitro fertilization" is now available in this country for sub-fertile couples.


Obstetrics – Most people of my generation would have been born in their parents’ homes. There were few hospitals and no nursing homes. Even in the early 1960s, home delivery by public health midwives was encouraged (in selected cases of course). There were PHMs who did about 5 or more home deliveries a month. Today, home deliveries are almost unheard of. At that time there were qualified obstetricians only in provincial hospitals and ambulances to transfer patients were not easily available. DMOs tackled most emergencies. Conditions have of course changed today; I believe for the better.


Surgery – Surgery of course has undergone a lot of changes since 1950. There were only a few specialities then (orthopaedics, thoracic, neuro-surgery). Most were general surgeons – (in my time Professor Milroy Paul, Professor M.V.P. Peiris, Drs. G.S.Sinnatamby, P.R.Anthonis, Noel Batholomeuz, L.D.C. Austin and others) and they did all types of surgery. Modern surgery has several sub-specialities - gastro-enterology, genito-urinary, plastic, vascular etc.


Today of course there are so many new procedures such as colonoscopy, fiber optic surgery to peer into inaccessible areas, artificial joints implanted into hips and knees, video monitors and laparoscopic instruments. Transplant surgery has now become routine.


Cataract surgery then needed about ten days’ hospitalisation, with sandbags to keep the head immobile for several days. Today, phacoemulsification with lens implantation is an OPD procedure.


Disease pattern- then and now – When I entered the medical faculty, the common diseases carrying a high mortality were infections of the respiratory system and diarrhoeal diseases. Heart disease was of course common, especially disease of the heart valves as sequelae to rheumatic fever and streptococcal throat infection. This has now been recognized and is treated. We saw epidemics of typhoid, occasional cholera scare, and even small pox. Plague had been brought under control. These have now been replaced by dengue fever, other viral fevers, not yet controlled, and sporadic cases of Japanese encephalitis and Chikengunya, now disappearing.


The leading causes of death today are Ischaemic heart disease, Cancers, Pulmonary heart disease, Cerebrovascular disease. Degenerative diseases have gradually replaced parasitic and infectious disease. There is an increase in diabetes, asthma and diseases of the liver. Deaths due to road accidents have greatly increased. Mental disease too has increased and we have high suicide rate. Today the non-communicable diseases count for about 85% of ill-health.


Conclusion – President Eisenhower’s care, related at the beginning of this article, shows how little doctors could do for heart attacks in 1955. Today, such patients are advised immediate hospitalisation; there are drugs to dissolve blood clots, correct abnormal heart rhythms and round-the-clock coronary care units. There is angioplasty to clear arteries, stent devises and by-pass surgery. It is still, as then, a leading cause of death. All what we were taught in medical school is almost completely outdated today. In medicine of course, one never ceases learning. Our professors could not have known how powerful the advances that followed would be. Technology has improved laboratory testing; allowed for the development of CT scans, magnetic resonance imaging (MRI) scans and positron emission tomography, or PET imaging to improve diagnostic accuracy; and produced new drugs and devices. Basic science, too, has deepened our understanding of disease, and much of that work depends on technology. There were very few diagnostic laboratory tests then. We were taught bed-side diagnosis by eliciting physical signs – palpation, percussion, and auscultation was stressed. Above all, our teachers like Professors P.B.Fernando, John Blaze, Drs. Cyril Fernando, E.M. Wijerama and others, taught us to treat patients, not "organs"! Today, most doctors have no time to talk to patients. It was not so then.


The population has increased about four fold. Life expectancy (55 then) has increased to about 75 today. People now live longer (those over 65 will be about 13% in 2025), and they have fewer children- most families then had five or more. The gains that have led to the prolongation of life have also led to new challenges, like the risk of developing Alzheimer’s disease, strokes, arthritis and other ailments that increase in frequency with age. The medicine of the future might be all about geriatrics.


Today, we may be amused over President Eisenhower’s treatment. But, I can imagine the laughter in 2050 as people then look back at the brand of medicine and public health that we consider so "advanced" today!


 
 
 
 
 
 
 
 
 
 
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