From the Pit to the Pinnacle – 100 years of fighting death

Author: Valdis Ģībietis

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Have you ever dreamed of being able to time-travel back to some historic moment in time? To see beyond the static black-and-white photograph frame that may be our only way of taking a glimpse into the long-gone times. Wouldn’t it be wonderful to have a few days off, say, 100 years ago, in 1919?

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I would certainly be ready to pay a lot of money if somebody offered me a legitimate return ticket for such an adventure. But during this romantic daydreaming, I remember that I am in fact a medical doctor. When we travel to a foreign land to have a good time, especially if that land is located closer to the equator than we are and we intend to taste some of the local cuisine, it is always a brilliant idea to pack some medical supplies. So that a sudden upset of the tummy, allergic reaction, headache or destruction of the skin on our heels in the unlikely event of our new hiking boots not being as comfy as they were in the shop yesterday can be easily dealt with. However, if a more serious disease took us by surprise, we would be taken to the nearest hospital to hopefully enjoy the benefits of the 21^st century medicine.

What would happen if we got ill during our time-travel in 1919? At that time Europe had just gotten through a four-year long meat grinder called World War I – if bullets and shells could not get the killing job done then dysentery and typhus were there to help. As if that was not bad enough, 1918 greeted the world with an unusually deadly influenza pandemic – the so-called Spanish flu, killing 50 to 100 million people worldwide [1]. The war itself killed mere 15 million [2].

In 1919, Latvia was boiling in the heat of our War of Independence. Whether in the Latvian/German controlled part of our land or the areas occupied by the Red Army, to get seriously ill would be a very unfortunate event. Wartime famine, infectious diseases and disastrous social conditions, as well as hospitals filled with the wounded probably don’t sound too encouraging. But even if we forgot all this insanity of the war and only paid attention to the actual progress of medicine at that time, what would our chances be to survive well-known medical conditions that are among the most common reasons for hospital admissions nowadays?

The ill-fated clinical scenarios are made up according to the latest medical advice suggested in the ninth revised edition of “The Principles and Practice of Medicine” by Sir William Osler and Thomas McCrae, published in 1921 (link – [3]). Sir William Osler aka “Father of Modern Medicine” should be a familiar name to medical students. If not – google him, he is a very famous Canadian physician. Bear in mind that we are talking about what would happen in an up-to-date “modern” medical facility. Let’s begin our graveyard stories.

Pneumonia

What if you suddenly had a fever, productive cough, shortness of breath and pain in the chest when trying to breathe deeply or cough? A doctor in a white gown with a suit underneath it would examine you, hear crackles in your lungs through his stethoscope.

You may get the chance to stand in the invisible beams of an X-ray machine – the doctor would put on his lead gloves and apron to visualize your lungs in real-time. He would see a nasty darker area in one of your lungs, right where the pain is. “Congratulations! I have confirmed that you have a lobar pneumonia,” would be his conclusion. It is an inflammation of the lungs most commonly caused by bacterial infection. We are dealing with a disease aptly called “Captain of the Men of Death” at that time.

One of the leading causative agents was already discovered some 35 years earlier to be a microbe called Streptococcus pneumoniae or pneumococcus. If you found yourself in a rather fancy hospital, your blood and sputum (coughed-up material) would be taken to the lab to check for pneumococcus. They could also do some additional tests to learn its type. These tests would involve injecting your sputum into the tummy of a poor laboratory mouse and extracting fluid out of it a few hours later. The so-called Type I could be rather experimentally treated with a novel method – the antistreptococcic serum. I suppose you wouldn’t receive this treatment in Bolshevik occupied Riga in early 1919.

Generally, you would be put to bed rest, possibly even in the open air to get some fresh breeze into your lungs. Hot-water bag would be put at your feet, but your fever would be relieved by cold sponging and baths of tepid water. Your bowel movements would be ensured by calomel or enema (back in the day they quite emphasized the importance of “keeping bowels open” in most disease states). It is not a good doctor who cannot relieve pain, so your comfort would be assured using ice bags (or hot bags), and if that is not enough – injections of codeine, morphine or even heroin. These drugs would also reduce cough. Nowadays, we usually give intravenous fluids to people with high fever. Back then it was given under the skin (subcutaneously) because peripheral venous catheters were not a thing yet. Some old-school intensive care approaches in case of failing circulation, manifested by low blood pressure and weak pulse, were injections of plant derived drugs – strophanthus, digitalis, atropine, caffeine and the more modern epinephrine, which to this day is a mainstay in many emergency situations. To my surprise, the popular poison from detective novels called strychnine was also considered useful. An injection of hot salt solution in the bowel was also an option to replete some fluid volume for stable circulation. If you developed enough inflammatory or pus-filled fluid around your lung, it would be punctured and drained if needed.

In many stories about medieval medicine, it seems that they employed a one-size-fits-all approach by using bloodletting for virtually any disease or complaint. This delightful method was still a popular one in 1919. The authors of “The Principles and Practice of Medicine” state that “we employ it much more than we did a few years ago, but more often late in the disease than early” with marked dilatation of the heart being a common reason. Indeed, when your lungs are clogged up with a lot of stuff that should not be there, it is hard for the right side of the heart to pump blood towards it, so reducing blood volume may give a short relief by decreasing the blood traffic jam. Nowadays, diuretic drugs (drugs that increase urination to get rid of extra fluid in your body) would do the trick.

As of now, you may have noticed that there is one key treatment modality missing – you would not receive antibiotics to kill the bacteria in your lungs because they were not discovered yet. It took 20 more years until the introduction of the first effective antibacterial drugs for pneumococcal pneumonia – sulfapyridine and penicillin – a perfect timing for World War II. Until then treatment of bacterial pneumonia was mainly supportive, although antistreptococcic serum if started early could reduce mortality in Type I for up to 50% by the mid-1930s.

Anyway, what were the odds of leaving the hospital on your own feet 100 years ago? The textbook clearly sums it up – “pneumonia is one of the most fatal of all acute diseases”.

In leading American and British hospitals mortality was 20% in people aged 21 to 30 and as much as one half above the age of 60. To make our time-travel less pessimistic, the textbook states that “pneumonia is a self-limited disease and even under the most unfavourable circumstances it may terminate abruptly and naturally. So also, under the favouring circumstances of good nursing and careful diet, the experience of many physicians in different lands has shown that pneumonia runs its course in a definite time, terminating sometimes spontaneously on the third or the fifth day, or continuing until the tenth or twelfth”. In its natural course pneumonia resolved with the so-called crisis – an abrupt drop of fever.

Nowadays, mortality in community-acquired pneumonia ranges from 1 percent in ambulatory patients to 20 – 25 percent in severe hospitalized cases [4]. It is still a leading cause of hospital admission and even though we have effective antibacterial drugs, pneumonia may be a life-threatening condition, especially in older, co-morbid and immunosuppressed patients. Antibacterial resistance is a major concern in the 21^st century. Bloodletting is not expected to return though.

Still, 1919 was a rather bad year to catch pneumonia. Interestingly, most of the 50 – 100 million deaths in 1918-1919 influenza pandemic are thought to be caused by its deadliest complication – our friend bacterial pneumonia [5]. It also took the life of Sir William Osler in December 29, 1919.

Myocardial infarction

What if during your stroll through the remains of war-ravaged European streets or maybe while running from Bolshevik or Bermontian bullets in Riga you felt a sudden, very strong crushing sensation behind your chest bone. This pain would radiate to your left arm, neck and jaw. It would not stop upon rest. Cold sweat would pour down your skin, you would be terrified and scared to death. If that was not a horrifying enough experience, the thought that you are in 1919 not 2019 would add an additional element of terror to your state of affairs. Knowing the demographic of SA readers, it is quite unlikely for you to develop this condition anytime soon but let’s imagine the worst.

There is no chapter for Myocardial infarction in Osler’s textbook. There is a relatively short description of Angina Pectoris (Stenocardia, Breast Pang) – a disease associated with coronary artery disease – atherosclerotic narrowing or blockage of the coronary arteries of the heart – the ones that supply blood to the heart muscle itself. Both its stable and acute forms are discussed in this chapter with the worst-case scenario named “severe angina” or “Angina Major”, which would be called acute coronary syndrome nowadays – a syndrome of decreased blood supply to the heart muscle. One of its principal manifestations is myocardial infarction (MI) – death of heart muscle cells.

Apart from the clinical picture, today the first-line diagnostic tool for MI is electrocardiogram (ECG). Back then it most likely would not be done because the characteristic ECG changes in MI were first described in the following decade [6]. It would also be very inconvenient during a heart attack to force you to sit in a chair with your hands and left foot immersed in salt-water buckets because self-adhesive electrodes (the things that you put on the chest and limbs when recording ECG) did not exist yet.

If you managed to survive until hospital admission, every effort would be made to keep you at rest and reduce any anxiety. For pain relief you would receive inhalations of amyl nitrite or a morphine injection if the former fails. If you were very short of breath and started to turn bluish, you could even receive oxygen inhalations. Also, chloroform – a classic anaesthetic – could help. Interestingly, these methods are not far from what an emergency medicine physician would do for a patient with acute coronary syndrome in the 21^st century – the first-line drugs that are given, according to modern treatment algorithms, are abbreviated as MONA – Morphine, Oxygen if needed and nitrates. “A” stands for antiplatelets. By 1919, an antiplatelet agent called aspirin had been available in pharmacies for 20 years. Unfortunately, nobody knew that it had antithrombotic properties until 1950s. Anticoagulants were also not there yet.

To get rid of the blood clot that is blocking a coronary artery and thus restore the blood flow, i.e., revascularize it, we either need to dissolve the clot by administering a thrombolytic agent – firstly used in MI in 1958 – or to pass through the blockage from the inside of the vessel and open it using a long catheter and a balloon. A procedure like that is called percutaneous coronary intervention (PCI), first performed in 1977. In 1986 a special tube called “stent” was developed to be left inside the previously blocked vessel to keep it open. Back in 1919 none of that was possible. If you didn’t get much better, you would be placed in a more distant part of the hospital ward and nurses would repeatedly come to feel your pulse – as a sort of old-school living and breathing monitor system – to check if you are still alive. If you survived the attack, chances are that you would develop severe heart failure soon after. If any signs of insufficiency of the heart would appear, doctors would quite likely give you a course of digitalis – a drug that nowadays would not be advisable in the setting of myocardial infarction because it has been shown to increase mortality.

It seems that early 20^th century definitely was not the best time to experience a myocardial infarction. Despite the advances in medicine, it is still far from a pleasant experience today, so don’t smoke, eat healthy and do sports! Fun fact – for chest pain characteristic of angina pectoris in men under 40 syphilis would have been suspected as a probable cause back then.

Now I will give you a short rest, dear reader. To be continued soon…

P.S. The next two medical treats for you will involve something sweet and something liquid. Stay tuned!

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Sources

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Article sources:

1. Johnson NPAS, Mueller J: Updating the Accounts: Global Mortality of the 1918-1920 Spanish Influenza Pandemic. Bull Hist Med 2002;76:105–115
2. White M: Source List and Detailed Death Tolls for the Primary Megadeaths of the Twentieth Century 2011 [cited 2019 Apr 9]; Available from: http://necrometrics.com/20c5m.htm
3. Osler W, McRae T: The Principles and Practice of Medicine. 1921. Available from: https://archive.org/details/principlesandpr00mccrgoog
4. Ramirez JA: Overview of community-acquired pneumonia in adults 2019 [cited 2019 Apr 9]; Available from: https://www.uptodate.com/contents/overview-of-community-acquired-pneumonia-in-adults
5. Morens D, Taubenberger J, Fauci A: Predominant Role of Bacterial Pneumonia as a Cause of Death in Pandemic Influenza: Implications for Pandemic Influenza Preparedness. J Infect Dis 2008;198:962–970.6
6. Cervellin G, Lippi G: Of MIs and Men-A historical perspective on the diagnostics of acute myocardial infarction. Semin Thromb Hemost 2014;40:535–543.

Photo sources:

1. Cover picture – https://www.nlm.nih.gov/exhibition/aframsurgeons/history.html
2. https://www.ancienthistorylists.com/world-war-1/top-10-diseases-that-were-spread-in-world-war-1/
3. http://www.kumc.edu/wwi/base-hospital-28/clinical-services/radiology.html
4. https://www.kansasww1.org/aspirin-the-flu-pandemic-and-ww1/