“For the relief ofPAINthe ‘logical supplanter of opium and other habit-forming drugs’ isPhenalgin. No matter how severe or where located pain is promptly and satisfactorily controlled by this effective anodyne—and without disturbing the digestion, suppressing the secretions, causing constipation or inducing a drug habit.“This is why Phenalgin has superseded opium and its derivatives for relievingHeadaches, Rheumatism, Gout, La Grippe, Lumbago, Neuralgia, Disorders of the Female, Dysmenorrhea, and Painful Conditions generally. To thousands of physicians Phenalgin ‘is the one dependable analgesic—the logical supplanter of opium.’ ”
“For the relief ofPAINthe ‘logical supplanter of opium and other habit-forming drugs’ isPhenalgin. No matter how severe or where located pain is promptly and satisfactorily controlled by this effective anodyne—and without disturbing the digestion, suppressing the secretions, causing constipation or inducing a drug habit.
“This is why Phenalgin has superseded opium and its derivatives for relievingHeadaches, Rheumatism, Gout, La Grippe, Lumbago, Neuralgia, Disorders of the Female, Dysmenorrhea, and Painful Conditions generally. To thousands of physicians Phenalgin ‘is the one dependable analgesic—the logical supplanter of opium.’ ”
If we are to suppose that the composition of Phenalgin is today essentially the same as when it was examined, the claims just quoted are obviously false for, of course, such a mixture must have the properties of acetanilid with all of its drawbacks and limitations. We may contrast the statements made in the advertisement just quoted with those made in Bulletin 126 of the Bureau of Chemistry of the U. S. Department of Agriculture. This bulletin on “The Harmful Effects of Acetanilid, Antipyrin and Phenacetin” summarizes the replies received from 400 physicians to whom a questionnaire had been sent. The information thus gained was tabulated and the figures that follow are from these tables. There were reported no fewer than 614 cases of poisoning by acetanilid with 16 deaths and 112 cases of its habitual use. The larger number of cases of poisoning followed the administration of the drug, by physicians, in doses larger than those now regarded as fairly safe. This large number reported by only 400 physicians indicated an excessively large number in the whole country. Since the questionnaire was sent to nearly a thousand physicians, of whom about 500 failed to reply, it may be assumed that had it been sent to the entire 130,000 physicians in the country, at least 75,000 cases of poisoning would have been reported.
Prior to the passage of the federal Food and Drugs Act (the “Pure Food Law”) many nostrum makers had declared that their preparations contained no acetanilid. When that law went into effect, some of these manufacturers triumphantly pointed to the fact that they were still able to make the same claim without conflicting with the requirements of the law. This was accomplished in fact by changing the formula and substituting acetphenetidin (phenacetin) for the acetanilid. While acetphenetidin is somewhat less toxic than acetanilid, bulk for bulk, the toxicity and therapeutic activity of the two drugs are nearly proportional.
The claim made by many proprietary medicine manufacturers that they are “strictly ethical” because they advertise only to physicians is mere verbal camouflage. There may be no more certain way of insuring the continued use of a nostrum by the public than to have it prescribed by physicians; and none know this better than the makers of nostrums. A proprietary individuality is obtained by giving some special form to the tablets and package or a special coloring to the capsules (“Specify ‘Phenalgin Pink Top Capsules’ ”)so as to indicate the identity of the products in such a way that the patient may in the future procure them without the advice or warning of the physician. When a proprietary preparation with the name or initials stamped on it or attached to it is prescribed, the patient immediately is aware of the fact, and his respect for the physician’s intelligence and wisdom is naturally lessened.
The physician should never place such dangerous drugs as acetanilid and acetphenetidin, or ready made mixtures of them, in the hands of the patient in such a way that they can be employed without his supervision or control. He should never prescribe more than is needed at the time and should not form the habit of using fixed doses or combinations of drugs without a special reference to the particular needs of the individual.
Certain forms of headache yield more readily to a mixture of caffein and acetanilid or caffein and acetphenetidin than to either acetanilid or acetphenetidin alone. When the physician wishes to prescribe such a mixture he may combine 1 grain of caffein or 2 grains of citrated caffein with 3 grains of acetanilid or 4 grains of acetphenetidin in a powder or capsule. Under supervision such a dose may be repeated at intervals of from two to four hours if necessary to control pain. It is necessary to remember, however, that when small doses fail to give relief, increase in the dose is useless. This fact is especially important, and disregard or ignorance of it has been responsible for many cases of poisoning. Further, it should be remembered that while it was taught for many years that the admixture of caffein with acetanilid lessened the effect of the latter drug on the heart, Hale has shown that this is not the case and such mixtures must be used with special caution.—(From The Journal A. M. A., Feb. 2, 1918.)
We hope that it is clear to those who have read the several articles of this series that their purpose is to present evidence that will enable the reader to form a correct estimate of the literature employed in the exploitation of various nostrums. The distinction between mere assertion—however plausible, and from however eminent an authority—and evidence should again be emphasized. Satisfactory evidence rests on careful observation by those who are capable of accurately determining to what extent any changes that may be observed are due to the therapeutic agent employed and not mere accompaniments of such treatment.
When the Council on Pharmacy and Chemistry was organized in 1905, the greater part of the literature of the nostrums was so palpably misleading, the statements often so ludicrously false, that it was only necessary to call attention to this fact to have those claims collapse. As a result of the Council’s work, the exploiters of worthless nostrums have developed a greater degree of shrewdness in avoiding the easily exploded falsehoods. This has made it increasingly difficult to point out the exact statements on which many of the false claims now rest, even though the exploitation as a whole is as inherently dishonest as before. If a nostrum is worthless, any exploitation must be false and misleading in effect, even though not one single false direct statement is made.
A platitude may be given an appearance of importance if uttered in an impressive manner, and it may be employed to suggest far more than it categorically affirms. These two facts are appreciated by many nostrum exploiters and we find that they have adopted the impressive manner to secure attention, and the platitude to suggest far more than they could defend in direct statement. Thus we have the “lie with circumstance.”
A full page advertisement, which has been appearing regularly for about a year and which must represent a good deal of money, is used to give an appearance of importance to a few words which, if printed in ordinary type, would either pass wholly unnoticed or would lead one to assume that something essential to the full meaning had been omitted. The statement, in full reads:
“Fellows’ Syrup differs from other preparations of the hypophosphites. Leading clinicians in all parts of the world have long recognized this important fact. Have you? To insure results, prescribe the genuine ℞ Syr. Hypophos. Comp. Fellows’. Reject cheap and inefficient substitutes. Reject preparations ‘just as good.’ ”
“Fellows’ Syrup differs from other preparations of the hypophosphites. Leading clinicians in all parts of the world have long recognized this important fact. Have you? To insure results, prescribe the genuine ℞ Syr. Hypophos. Comp. Fellows’. Reject cheap and inefficient substitutes. Reject preparations ‘just as good.’ ”
The only direct statement contained in the advertisement is to the effect that many clinicians have observed that Fellows’ syrup and other preparations of the hypophosphites are not alike. In truth, Fellows’ is not like the better preparations of this type, since after standing it contains a muddy looking deposit that any pharmaceutical tyro would be ashamed of. Technically, then, the statement is true, but it is hardly credible that the manufacturer is paying for an entire page in a medical journal to make this statement without any attempt to suggest something else.
The advertising pages of six medical journals were examined in the order in which they chanced to come to hand. In five of these, the entire advertisement of Fellows’ syrup was in the words just quoted; not a single word more. In one there was the further statement:
“Not a new-born prodigy or an untried experiment, but a remedy whose usefulness has been fully demonstrated during half a century of clinical application.”
“Not a new-born prodigy or an untried experiment, but a remedy whose usefulness has been fully demonstrated during half a century of clinical application.”
These advertisements show that the exploiters of Fellows’ Syrup are spending a great deal of money to induce physicians to prescribe the preparation, and it is equally evident that they wish to convey the impression that the preparation has some therapeutic value. Since we find nothing directly false, in the first mentioned advertisement at least, we must take the evident intent for consideration and determine what therapeutic value, if any, this preparation has, and whether it is advisable for physicians to employ it in any case.
The preparation, according to the statement just cited, has been in use for fifty years. As the exploiter of any preparation cites the most convincing evidence in his possession in support of his views, this claim may be assumed to be the strongest available, and if this evidence fails we must reject the contention as not proved. Here we face a dilemma, for examination of the literature used in the exploitation of Fellows’ Syrup fails to disclose any evidence of the kind that we have described as satisfactory; and we are, therefore, forced to conclude that none has ever been found. By this it is not to be implied that no reputable physician has ever reported favorably concerning the therapeutic effects of this preparation. It is quite possible that an extensive literature of that sort might be found if one examined the older medical journals. But the day has passed when every improvement that follows the administration of a preparation is blindly attributed to the drug in question. Clinical research today is far more exacting.
We will assume that the reader who has investigated the question with an open mind will have come to the decision that the contention that Fellows’ syrup is of especial therapeutic value is not proved. We might rest with that assumption and ask the clinician whether he is prepared to use a nostrum that has been before the medical profession for half a century without any satisfactory evidence having been gained that it possesses therapeutic value. We might ask him whether he would be willing to tell his patients that hewas prescribing such a nostrum for them in the face of the absence of any such evidence of its value.
But we prefer to go even further and show him that not only is there an entire absence of any evidence of its therapeutic value so far as we have been able to learn, but in addition there is an abundance of evidence that the hypophosphites are devoid of any such therapeutic effect as they were formerly reputed to have, and that, in fact, they are, so far as any effect based on their phosphorus content is concerned, singularly inert.
While we have thus far taken the Fellows’ preparation as the subject of the discussion, we may take a broader view and examine the subject of the hypophosphites in general, and the substitutes containing phosphorus that have been introduced from time to time. It hardly needs to be said that if the hypophosphites are without therapeutic value, it is impossible to give them value by combining them in a muddy-looking, ill-made preparation such as Fellows’ Syrup. Such evidence was submitted to the medical profession in a report of the Council on Pharmacy and Chemistry (J. A. M. A.67:760 [Sept. 2] 1916); and we would strongly advise any one who is disposed to act on the suggestion contained in the advertisements of Fellows’, and other hypophosphite preparations, to read that report in full and to think the matter over before prescribing one of these nostrums. Quoting briefly from the report in question:
“Although the overwhelming weight of evidence was against the probability that the hypophosphite preparations are of value as therapeutic agents, the Council thought it well to investigate the subject. Dr. W. McKim Marriott of Baltimore was therefore requested to review the evidence for and against the therapeutic usefulness of the hypophosphites and to conduct such experiments as seemed necessary.”
“Although the overwhelming weight of evidence was against the probability that the hypophosphite preparations are of value as therapeutic agents, the Council thought it well to investigate the subject. Dr. W. McKim Marriott of Baltimore was therefore requested to review the evidence for and against the therapeutic usefulness of the hypophosphites and to conduct such experiments as seemed necessary.”
The Council was not content to rest on the mere absence of evidence for the value of these preparations or any one of them, but sought to obtain evidence that would fulfil the conditions mentioned above, and in pursuance of this plan it secured the cooperation of a trained investigator, one who would work under the best of conditions for learning the truth. The results of Dr. Marriott’s investigation were published inThe Journal, Feb. 12, 1916, p. 486, and should be read by everyone who has any interest in the problem. Lest some of our readers may fail to refer to the original of Marriott’s paper, we will quote briefly from it:
“None of the subjects of the experiment experienced any effect whatsoever from the administration of the drug... Almost all of the ingested hypophosphite is eliminated unchanged....“These experiments (Forbes) demonstrate conclusively that the hypophosphites possess no specific value as a source of phosphorus for the body.... It is doubtful if there are any conditions in which the body suffers from lack of phosphorus. Even should such conditions exist, phosphorus, in the form that it occurs in the ordinary foods, or as phosphates, is more efficient in supplying the deficit than hypophosphites that must be oxidized before utilization and which are only about 15 per cent. oxidized if at all. For example, half a glass of milk contains more available phosphorus than three large doses of hypophosphites of 15 grains each, as great a dosage as is usually given.“What then, is the therapeutic value of hypophosphites? There is no reliable evidence that they exert a physiologic effect; it has not been demonstrated that they influence any pathologic process; they are not ‘foods.’ If they are of any use, that use has never been discovered.”
“None of the subjects of the experiment experienced any effect whatsoever from the administration of the drug... Almost all of the ingested hypophosphite is eliminated unchanged....
“These experiments (Forbes) demonstrate conclusively that the hypophosphites possess no specific value as a source of phosphorus for the body.... It is doubtful if there are any conditions in which the body suffers from lack of phosphorus. Even should such conditions exist, phosphorus, in the form that it occurs in the ordinary foods, or as phosphates, is more efficient in supplying the deficit than hypophosphites that must be oxidized before utilization and which are only about 15 per cent. oxidized if at all. For example, half a glass of milk contains more available phosphorus than three large doses of hypophosphites of 15 grains each, as great a dosage as is usually given.
“What then, is the therapeutic value of hypophosphites? There is no reliable evidence that they exert a physiologic effect; it has not been demonstrated that they influence any pathologic process; they are not ‘foods.’ If they are of any use, that use has never been discovered.”
The case seems to stand about like this: A nostrum maker spends thousands of dollars to tell physicians that his cloudy preparation is not like other preparations,and physicians are expected to accept that as convincing evidence that they should prescribe and their patients, perforce, take it. This too, in spite of the evidence gained by careful scientific investigators that the hypophosphites in fairly large doses contain less available phosphorus than half a glass of milk, and that there is no evidence available that they exert any therapeutic effects at all.
Should we take the meaningless statement of a nostrum maker, who does not submit evidence of any therapeutic value of his preparation—unless one can call certain careless habits of prescribing evidence—and assume the responsibility of prescribing a nostrum that according to all scientific evidence available is useless, and of no more effect than a few teaspoonfuls of milk, so far as its hypophosphite content is concerned? It may be argued that it possesses some value because of its bitter nature. We will not deny that it is bitter; so is strychnin, so is quinin, so are scores of simple drugs, but what physician would care to admit to his patients that he did not know how to prescribe a simple bitter, such as nearly every layman can select for himself, without recourse to a preparation such as Fellows’ Syrup?
We have felt that it is not wholly satisfactory to discourage the use of a given nostrum without making an effort to assist the physician in choosing wisely in the treatment of the condition for which the nostrum is claimed to be useful. In the present instance, however, we fear that would prove a task beyond our powers, for the hypophosphites have been used in such a variety of conditions that the discussion would have to include nearly the whole materia medica if we were to follow our usual procedure.—(From the Journal A. M. A. Feb. 16, 1918.)
Formerly it was customary to prescribe mixtures of many drugs on the assumption that if one of the ingredients missed the mark another might be expected to hit it, just as a poor marksman is more likely to hit a target at short range with a blunderbuss than with a high powered rifle. Increased precision in every branch of science has become the outstanding feature of civilization. The soldier today must shoot straight with a rifle that sends a single ball. There is none of the disposition to rely on chance as when the blunderbuss was used. A capable physician directs his drug straight at the seat of the trouble, and we now have many drugs that can be depended on to exert definite actions. The complex mixture is just as preposterous in modern therapeutics as the blunderbuss would be on a modern battlefield.
Every drug exerts undesired side actions, and it is the aim of the modern physician to try to select the one which will have a maximum of therapeutic with a minimum of undesired actions. When a complex mixture is employed, it is obvious that only the best is utilized, whereas all the undesired side actions come into play. We do not pretend that even the best studied drug has not much to be learned about it; but the nostrum maker who exploits a complex mixture either knows practically nothing of the side actions that it will exert, or, if he knows, he conceals that knowledge. He knows that massive doses of hydrated chloral combined with various narcotics can be relied on to cause unconsciousness in nearly all cases, but he prefers to speak of this as a hypnotic action. This is plain gambling with human life. When the patient dies, it is difficult to prove that death was caused by the mixture alone.
The Council on Pharmacy and Chemistry has expended a great deal of time and energy in combating the “shotgun” nostrum evil. It is easy tounderstand the disadvantages of such mixtures but it is not so easy to demonstrate the misleading character of the claims made, with an entire disregard of the truth, for these mixtures. No one believes that a pot of gold lies at the end of the rainbow, but no one has actually gone there to see for himself.
There are many types of “shotgun” nostrum. Some are dangerous, as in the case of “Bromidia”; some are preposterous, therapeutic monstrosities which excite the contempt of educated physicians, as in the case of “Tongaline”; some are merely useless mixtures of well known drugs, sold under grotesquely exaggerated claims, as in the case of “Peacock’s Bromides.”
Various formulas have been given for Bromidia. The manufacturers appear to be more cautious under those circumstances in which falsehood might lead them into collision with the federal authorities, than when giving reign to fancy and considering only the best means of winning the favor of the physician. It is said to consist of hydrated chloral, potassium bromid, Indian cannabis, and hyoscyamus. It is impossible to determine from the published formulas just how much hydrated chloral and potassium bromid it contains, but is probable that there are about 15 grains of each of these two drugs to the fluidram, and variable amounts of Indian cannabis and a small amount of either extract or tincture of hyoscyamus.
This much is certain: Bromidia is a distinctly dangerous mixture for indiscriminate use. The claim of the manufacturers, implied, rather than directly stated, that it is superior to an extemporaneously prepared mixture of those drugs is especially reprehensible because it tends to create the impression that the nostrum is safer in effective doses, conducing to a false sense of security on the part of those who are deluded into prescribing it in larger doses than they would a mixture of the same drugs prepared extemporaneously.
A report of the Council on Pharmacy and Chemistry published inThe Journal, May 16, 1914, p. 1573, mentions three instances in which death is reported to have followed the use of Bromidia. The manufacturers of Bromidia have no magic power to render hydrated chloral harmless, while it retains its hypnotic action. It depresses the central nervous system, and it is nothing less than monstrous for any one to pretend to rob this drug of its dangerous properties while it retains its hypnotic effects. If the patient requires a hypnotic, the physician should choose that one which his judgment and experience dictate as the best for that particular patient. If he needs hydrated chloral, the physician should prescribe exactly as much as he believes the patient needs. If the effect is slightly greater or slightly less than anticipated, no harm is done and the physician has gained experience that will be valuable in future prescribing. If Bromidia is prescribed and unexpected effects are induced, it is impossible to know whether these were due to the hydrated chloral or to one of the other narcotics or to a synergistic action; and there is nothing to guide in the further use of the nostrum, for mixtures of narcotics commonly have much less uniformity of action than a single drug.
The irritant action of hydrated chloral on the stomach can be avoided by the use of bland fluids or dilute solutions. The following serves as an example of the way in which it may be prescribed conveniently:
Gm. or c.c.Hydrated chloral2│6gr. xlSyrup of orange peel│Water of each30│fl ℥ i
Hydrated chloral
Syrup of orange peel
Water of each
A tablespoonful (15.0 c.c.) of this mixture, containing 10 grains (0.65 gm.) of hydrated chloral, will often induce sleep in the absence of severe pain or serious disturbance, and seldom does this dose have to be repeated more thanonce in such simple cases. Hydrated chloral is often used in somewhat smaller doses in combination with potassium bromid, which may be prescribed in a mixture such as the following:
Gm. or c.c.Hydrated chloral1│3gr. xxPotassium bromid3│9gr. lxSyrup of orange peel│Water of each30│fl ℥ i
Hydrated chloral
Potassium bromid
Syrup of orange peel
Water of each
In producing sleep when severe pain is absent this is as effective as the preceding, in similar doses. The use of repeated doses of hydrated chloral in such a mixture as this, or in the form of Bromidia or other nostrum when sleeplessness is due to severe pain is highly dangerous. It should be remembered that while hydrated chloral is an effective hypnotic in case of simple sleeplessness, it is not actively analgesic except in distinctly dangerous doses. Bromidia in repeated doses will induce sleep even in the presence of pain, of course; but any active narcotic does that, and it is correspondingly dangerous. Small doses of morphin given alone are preferable when sleeplessness is due to severe pain.
“Tongaline” is an example of the type of “shotgun” nostrum that would be merely ludicrous if we could look on anything that degrades therapeutics so lightly. A report was made to the Council on Pharmacy and Chemistry, and published inThe Journal, July 17, 1915, p. 269, and in this report it is stated that Tongaline is said to consist of tonga, cimicifuga racemosa, sodium salicylate, colchicum, and pilocarpin. Whether the formula was cut short just there because the office boy ran out of breath at that point, or because the discoverers of this wonderful combination had not heard of the eminently potent substances that the witches added to their cauldron, we can leave to the reader’s imagination, for it is manifestly impossible to present an orderly discussion of the pharmacology and therapeutics of such a preposterous jumble of drugs.
“Peacock’s Bromides” belongs to a slightly different class. It is said to consist of the bromids of sodium, potassium, ammonium, calcium and lithium. In the absence of a logical explanation of the pretended superiority of this mixture over one that is made extemporaneously, the exploiters seem to have been driven to the necessity of pretending that its freedom from contaminating chlorids explains its claimed advantages over mixtures of the official or commercial bromids. The truth is that the chlorids are used as antidotes in bromid poisoning.
Disregard the claims made for Peacock’s Bromides, and ask yourself the question whether you have ever actually seen any ill results following the use of the official bromids that you could reasonably attribute to contaminating chlorids. Furthermore, carefully consider the relative advantage of a single bromid (say the bromid of potassium, or bromid of sodium, if you prefer it), with the opportunity of observing its effects and adjusting the dose in accordance with the results of your experience, and a mixture such as Peacock’s Bromides, the composition of which you do not know, and which the manufacturer can alter to suit his own convenience.
While it is true that the therapeutic art will not degenerate in its entirety merely because some physicians continue to use the most fraudulent and worthless nostrums, yet, on the other hand, to the extent that a physician continues to be guided by the false teachings of nostrum venders who have no therapeutic training, he is plunged into therapeutic chaos.—(From The Journal A. M. A., March 2, 1918.)
It may seem paradoxic to say that recent progress in the medical sciences has made therapeutic chaos possible, but it is true nevertheless. Revolutions are sometimes slow and orderly, sometimes sudden and attended with confusion. The revolutionary changes in the medical sciences have been so numerous and so rapid that the general practitioner has been unable to keep pace with them, and in the resulting confusion the nostrum maker has seen his opportunity for exploiting his useless, dangerous or unscientific preparations. The greater the confusion, the greater his opportunity; and it is no exaggeration to say that he has been the most potent factor in maintaining the chaos of therapeutics.
The majority of our readers would probably say that the existing scientific medical literature insures the permanence of established beliefs, but every one who has delved into the literature has found instances of truths that had been established and forgotten—buried under the ever-increasing avalanche of contributions to that literature.
Typical half-page Tyree advertisement appearing in medical journals.
Typical half-page Tyree advertisement appearing in medical journals.
Rapid advances are still being made in the medical sciences and unless constant vigilance is exercised therapeutics will return to the chaotic condition from which it has so recently emerged. It was in recognition of these facts—the danger of this return to chaos, and the difficulty, in fact, impossibility, of any individual’s keeping pace with all of the medical sciences—that the American Medical Association secured the cooperation of men in various branches of medicine in the Council on Pharmacy and Chemistry, in order that it may place the results of therapeutic progress before the readers ofThe Journalin an impartial manner.
Are you profiting by this work, or are you still depending on your unaided efforts to distinguish the false teachings of the nostrum venders from that of scientific medicine? Are you prescribing “Antikamnia” and “Ammonol” or a simple member of the group, such as acetanilid or phenacetin? Are you depending on “Tyree’s Antiseptic,” so called, or are you using an antiseptic about which there is no mystery, for which no false claims are made, and one which is really effective? In short, are you using drugs of unquestioned value,such as are described in “Useful Drugs,” or are you taking your therapeutic instructions from nostrum makers’ circulars?
Perhaps you have been led to believe that the Council on Pharmacy and Chemistry is composed of “theorists” and that the nostrums represent the work of “practical men.” Every one should strive to be practical, of course, and it is worth while to inquire whether scientific experimenters, who so largely mold medical literature, should be termed theorists, or practical men. A practical man practices that which is useful in the treatment of the sick, and he must determine who is capable of furnishing him with a better materia medica. A perusal of medical literature will convince any unbiased mind that medical science progresses only by means of experiment, hence experimenters must be considered the really practical men while those who cling to outworn theories are really the “theorists.”
Typical Aseptinol advertisement.
Typical Aseptinol advertisement.
When Lister introduced antiseptic methods into surgery he inaugurated a veritable revolution, which afforded the nostrum makers opportunities for reaping rich harvests through the exploitation—under extraordinary claims—of cheap mixtures of little, or no, value. There is no lack of antiseptics of extraordinary activity in the test tube that are practically harmless to man, and it would seem natural to suppose that such antiseptics could be used to control the development of bacteria in such diseases as typhoid fever, but, unfortunately, such hopes have not been fulfilled. Ehrlich experimented with many phenol derivatives that showed decided antiseptic activity in the test tube, in the hope that he might find some that could be used to combat such common diseases as diphtheria and typhoid fever, but while many of these are of low toxicity for man, he was unable to find even one that could be used effectively in the treatment of any of these diseases. His discovery of arsphenamin (“salvarsan”) resulted from quite another type of investigation.
Many practitioners lose sight of the essential difference between antiseptics and disinfectants and employ antiseptics in cases in which only a disinfectant action would be of value. An antiseptic does not destroy bacteria, it merely inhibits their growth; and when it is diluted too much, it loses its effects and the bacteria may begin to multiply as though no antiseptic had been used.This is especially true after the use of weak antiseptics in the mouth. These are soon diluted or removed by the saliva, and the bacteria continue to multiply with only a momentary interruption at best; hence to advise the use of an oral antiseptic as an effective means of treating diphtheria is little short of criminal.
“Tyree’s Antiseptic Powder” was submitted to the Council nearly twelve years ago. The label on the package stated:
“This preparation is a scientific combination of borate of sodium, alumen, carbolic acid, glycerin and the crystallized principles of thyme, eucalyptus, gaultheria and mentha in the form of a powder.”
“This preparation is a scientific combination of borate of sodium, alumen, carbolic acid, glycerin and the crystallized principles of thyme, eucalyptus, gaultheria and mentha in the form of a powder.”
One of the older newspaper advertisements of Tyree’s Antiseptic Powder.
One of the older newspaper advertisements of Tyree’s Antiseptic Powder.
A leaflet issued several years ago by the Aseptinol Manufacturing Company states that “Pulv. Aseptinol Comp.” combines in an elegant form boric acid, the salts of aluminum, crystallized phenol, and the active crystalline principles of thymus, mentha and gaultheria.
A comparison of these formulas would justify the designation of the two preparations as twins, but even one twin may have a wart where the other lacks it. The formula of Pulv. Aseptinol Comp. given in the leaflet also includesHydrastis canadensis, but we believe that a wart should be quite as much of an addition to the anatomy of man as the hydrastis is to this already preposterous formula. Similar as the formulas of these two nostrums were said to be, the general methods of exploiting them were even more similar. A partial list of the diseases for which each has been recommended by its exploiters shows the similarity of methods pursued:
Tyree’s was Said to be Useful in theTreatment of:Pulv. Aseptinol Comp. was Said to beUseful in the Treatment of:LeucorrheaLeucorrheaGonorrheaGonorrheaVaginitisVaginal inflammationPruritusPruritusUlcerated conditions of the mucous membraneUlceration of vagina or cervixScrofulous ulcersChronic ulcersSyphilitic ulcersProphylactic against specific diseaseDisinfecting offensive cavitiesCleansing pus cavitiesDeodorantDeodorantProfuse and offensive perspirationChecks abnormal secretion
We stated that the formula furnished by Tyree was that given above, but the Council was never able to learn when Tyree actually employed the formula except for advertising purposes; and analysis of the powder showed that Tyree’s Antiseptic Powder was essentially a mixture of boric acid and zinc sulphate, with insignificant amounts of odorous principles.
A remarkable fact brought out in the course of the consideration of the preparation by the Council was that Tyree admitted that he had changed the formula without having published the new one. The Council then showed that a specimen of the “antiseptic” that had been kept in a retail drug store for several years was essentially similar to that sold at the later date. Thus it would seem that Mr. Tyree had been making his powder by one formula and publishing an entirely different one for years before the Council published the facts in the case.
If Tyree found it necessary to change the formula of his powder—if indeed, he ever used the published formula—why did the Aseptinol Manufacturing Company adopt it, or one so closely resembling it?
It is obvious that both of these twin nostrums are utterly unfit for treating the various conditions for which they are or have been recommended; and in view of the misrepresentation in one case, it is difficult to understand why it should be taken as the model for the other. Do physicians believe that a simple mixture of boric acid and zinc sulphate, or a mixture such as that given in the formula of “Aseptinol” powder, is in any way superior to a prescription such as any physician could write?
There is a far more important question to consider than the relative merits of such nostrums and a prescription of the physician’s own devising. That question is whether the medical profession is going to help perpetuate the chaotic conditions that the use of such nostrums fosters or to assist in therapeutic progress by maintaining its independence of such false teachers, and seeking to aid in the establishment of a rational use of drugs and remedial measures.—(From The Journal A. M. A., March 30, 1918.)
We called attention recently to the skill which the nostrum vender displays in avoiding the particular thorn that pricks him, and his development of the art of impressively saying, “Nothing in General,” as exemplified in the advertisements of Fellows’ Syrup. Nostrum sellers are more canny than original; and when once an idea finds lodgment with one of them, it is made to serve many masters. Formerly exploiters of either vicious or worthless nostrums were wont to boast that their preparations were exploited in a “strictly ethical manner.” Recent perusal of as choice a lot of advertisements as can be found in the most degraded of medical journals failed to disclose this claimin a single instance, although the claim that a preparation is “advertised only to physicians” is still common.
The advertisement of “Neurosine,” which we reproduce, was the first one which came to our attention when we searched through some medical journals for one that would illustrate a discussion of the “original package” evil. This is the only reason for selecting Neurosine rather than another. Such half page advertisements and others of similar size in various medical journals cost a good deal of money and they presuppose that the Dios Chemical Company is interested in having original bottles of Neurosine dispensed every time that nostrum is prescribed.
Why should the firm have any such deep interest in seeing that an originalbottlegets to the patient? Why should it be necessary to do anything more than see that the genuinemixturereaches the patient? Does it seem within the bounds of reason that substitution is so commonly practiced by pharmacists that this firm must go to large expense to prevent the substitution of spurious mixtures for its product? Is dishonesty the rule among pharmacists? Common sense rejects the plea as placing too great a strain on one’s credulity. Obviously, then, the advertisement does not tell the whole truth, though it does indeed tell exactly what the nostrum maker wishes to have done, that is, to have onlyoriginal bottlesdispensed when physicians prescribe that nostrum. The fact we have; the reason is not far to seek.
When the pharmacist puts up an ordinary, nonproprietary prescription, the patient gets no clue from the package as to the nature of the prescription employed. But when an original bottle of Neurosine is dispensed, even though the pharmacist puts his own prescription label on it, the patient sees the difference at once and knows just why the usual prescription bottle was not employed. He also knows that he can get the medicine with its original wrapper or label by merely showing the bottle to the druggist, for the words “Neurosine” and “Dios Chemical Co.” are blown in the glass. Here, then, may be a plausible reason for desiring that only original bottles be dispensed.
You may ask, “What difference does it make if the patient does learn the name of the nostrum, he must go to his physician for advice concerning its use?” Having learned the name of the remedy that has been prescribed forsleeplessness, let us say, he proceeds to use it whenever he imagines that he needs it; and that need, real or imaginary, has a way of increasing in frequency. As a result, the patient takes far more Neurosine than the physician would think of permitting if the matter had not passed entirely beyond his control.
Not only has the patient acquired a dangerous habit of self-prescribing, but he takes especial delight in recommending his favorite remedy to friends whose symptoms, real and imaginary, seem to resemble his own. This offers him an opportunity to prescribe with an air of authority. It was prescribed for him by Dr. Blank, and it gave relief,ergoit may be depended on to give relief to others! Thus is the basis laid for its general use by the laity, when this process is multiplied sufficiently. The statement is susceptible of easy proof by any one who cares to investigate the matter for himself. There is probably no physician worthy of the name who will attempt to deny that the promiscuous use of hypnotics and narcotics is dangerous, and certainly no careful physician will deliberately place a narcotic in the hands of patients to be used freely and without control.
Since we have selected Neurosine at random, so far as this particular discussion is concerned, it is worth while to inquire into its composition, the claims that have been made for it and the evidence, if any exists, for or against its therapeutic value. Even the most active of hypnotics are worse than useless if they are inferior to other readily available hypnotics, or if they have undesired side-actions that outweigh any advantages that they might otherwise have.
The Council on Pharmacy and Chemistry investigated the literature relating to Neurosine and published its report in The Journal, Jan. 9, 1915, p. 165. According to this report the manufacturers of Neurosine claimed that each fluidounce contained:
Bromid of potassium, C. P.40grainsBromid of sodium, C. P.40grainsBromid of ammonium, C. P.40grainsBromid of zinc1grainExtract lupulin32grainsCascara sagrada, fl. ex.40minimsExtract henbane0.075grainExtract belladonna0.075grainExtract cannabis indica0.60grainOil bitter almonds0.60grainAromatic elixir
Bromid of potassium, C. P.
Bromid of sodium, C. P.
Bromid of ammonium, C. P.
Bromid of zinc
Extract lupulin
Cascara sagrada, fl. ex.
Extract henbane
Extract belladonna
Extract cannabis indica
Oil bitter almonds
This chemical blunderbuss was recommended for use in insomnia, hysteria, neurasthenia, migraine, neuralgia, delirium tremens, epilepsy and many other conditions. Also it was called an ideal calmative for children suffering from chorea, the exploiters claiming that “All authorities recommend the bromids, hyoscyamus and cannabis indica in this disease.” Oliver T. Osborne, professor of therapeutics in Yale Medical School, does not mention one of these three drugs in his discussion of the Medicinal Treatment of Chorea, in the Handbook of Therapy, though he quotes several authorities in this article. Indeed, he does not mention one of the ten drugs included in the above formula of Neurosine in connection with the treatment of this disease. It is a curious fact that Osborne gives the greatest prominence to the use of that drug which is claimed to be wanting in the formula of Neurosine, namely, hydrated chloral.
Perhaps you may have seen temporary relief follow the administration of Neurosine in chorea, and may argue that theorizing is of little value in the face of personal experience. We shall not deny that some may have had that experience, for Osborne calls attention to the fact that the success of any medicinal treatment must be judged in the light of the fact that chorea is self-limited, and the intensity of the symptoms will abate in from two to four weeks. In view of this, we would hardly dispute the claim that one mayadminister narcotics, such as those contained in Neurosine, and the symptoms of chorea may abate in spite of such mistreatment. In all the years that Neurosine has been exploited to physicians with such remarkable claims, we have never seen a report of a careful clinical study in which the product has been used under the conditions which scientific investigation demands. Would you prescribe any nonproprietary preparations which had never been studied clinically, if a horse-shoer or grocer’s boy told you it would cure epilepsy or malaria?
According to an editorial note appended to the report of the Council on Neurosine, the Dios Chemical Company consisted at that time (1915) of J. H. Chambers, his wife and two sons. It appeared that Chambers never claimed to have any special knowledge of chemistry, pharmacy or medicine, yet we find that he arrogated to himself or to his employees the right to offer therapeutic advice to the medical profession, and even to direct them as to how they should prescribe a given mixture.
We sometimes fail to see the forest because of the trees. It may help us to obtain a better perspective, in a problem that concerns us intimately, by resorting to a hypothetic case, if a close analogy is maintained. In order that we may see ourselves as others see us in such a situation, let us consider the following imaginary case: You become involved in a lawsuit in which an effort is made to deprive you of your property and your liberty. You seek what you had reason to believe was competent legal advice; but, nevertheless, you lose your case and find yourself deprived of your property and your liberty. Now let us suppose further that you discover, when too late to permit you to correct your mistake, that your legal adviser (we can hardly call such a man a lawyer) had been acting all along under the guidance of a plumber who made no pretense of knowing anything about law. How would you feel regarding that pretended lawyer? Would you feel that you had been treated fairly? Would you feel disposed to speak with all charity of him, to recommend him to those in need of legal advice?
You would probably feel toward such a lawyer as patients must feel toward physicians who prescribe proprietary nostrums based on information and advice offered by those who, though without any special knowledge of chemistry, pharmacy or medicine, will be benefited financially if their information and advice are accepted and acted on.—(From The Journal A. M. A., April 27, 1918.)
To the Editor:—As an old Fellow of the A. M. A. I beg to present the following facts to you, and to ask if anything can be done by you to expose the methods of these people: A concern calling itself “The Anasarcin Chem. Co.” of Winchester, Tenn., has caused to be sent to physicians a chart on the subject of “Diagnostics of Renal Diseases.” This chart contains eighteen plates, which were all taken without knowledge or permission of either myself or my publishers, William Wood & Co., from the third edition of my book on “Urinary Analysis and Diagnosis.” The plates are partly composite plates, but mostly portions of plates, exactly reproduced from my book. I at once caused my publishers to write to the Anasarcin Company; and a few days ago I received a letter from a Dr. H. Elliott Bates of 118 East Twenty-Eighth Street, New York, whose letterhead says, “Medical Advertising.” In this letter the writer says that it was he who suggested the sending of such a chart, and admits that all the plates were taken from my book. In this letter he offers to have a letter sent to every physician of the country “in which it is explicitly statedthat the cuts on the chart were taken from your book, and that complete information regarding the matters treated on the chart can be found in your book.” In other words he offers to advertise my book free of cost to me, so that I should take no further steps in the matter. I consider this entire matter an outrage, and thought it best to write to you for advice, since my publishers seem to think that in spite of the violation of the copyright nothing can be done.
Besides the cuts, some of the text on the chart is bodily taken from my book, while some of the other text, not taken from my book, but apparently compiled from different articles, is in part entirely wrong, so much so that I must be ashamed of its being associated with any of my own work.
By giving this letter your early consideration, and advising me what you think it best for me to do, you would greatly oblige
Louis Heitzman, M.D., New York.
[Comment.—Readers ofThe Journalare, of course, familiar with thearticles246that have been published on “Anasarcin,” the “dropsy cure”! Knowing the standard of ethics that the Anasarcin concern adopts in the exploitation of its ridiculous squill mixture, our readers will not be surprised at the standard of commercial ethics which would justify the appropriation of copyrighted scientific material for nostrum advertising purposes. The statement of Dr. Heitzmann’s publishers that “in spite of a violation of copyright nothing can be done” is, of course, incorrect. Somethingcanbe done by those who hold the copyright.—Ed.]—(From The Journal A. M. A., Oct. 18, 1919.)
Some, possibly many, of our readers have received a letter from Cologne, Germany, from the “Bakteriologisch-Chemisches Laboratorium Wolfgang Schmidt.” The letter contains a circular directing the attention of American physicians to “Antimeristem-Schmidt.” It also contains some advertising leaflets. One physician in sending this material toThe Journalwrites: