THE DIRECT SALES COMPANY

In determining the effects of any given mode of treatment on a tumor, a variety of criteria may be relied on. Circulatory changes in the tumor, the relief of pain and the restoration of a secondarily impaired function are certain of the criteria on which stress has been laid by the majority of observers in the past. Important as are these criteria in determining the progress of purely inflammatory processes, it is unquestionable that their value in judging of the effects of therapeutic methods when applied to malignant disease is open to criticism. It is a curious and interesting fact that almost every therapeutic claim made in recent years in connection with cancer has included among its virtues the relief of pain. This is true of vaccination with cancer tissue, of Hodenpyl’s method and of many others. In view of this very general effect,not much stress can be laid on this symptom, and it is probably fair to assume that in the great majority of these cases the result is in no small measure psychic. The improvement of function is also largely a subjective phenomenon, and as such requires most careful criticism. Osler relates that he has known a patient with gastric cancer to be relieved of digestive disturbances and to gain 18 pounds in weight as the result simply of the visit of a sanguine consultant who denied the presence of a tumor. Improvement in the ability to chew food, to articulate words or to move a limb are phenomena familiar to those who attempt to treat cases of cancer. The victims of this disease seem to be in a very high degree “suggestible” and impressionable and respond nobly to every therapeutic effort.Circulatory changes in tumors offer an interesting group of clinical symptoms. The observation has often been made, especially in ulcerated new growths, that treatment is associated with swelling, peripheral hyperemia, and an altered character of the discharge. In spite of the fact that there is no reasonable relationship between this congeries of symptoms and the actual cure of the tumor, they generally receive considerable emphasis and are cited as an indication of the specific local action of the agent employed. It is also true, however, that the growth may continue to advance in spite of their presence. It is of some importance to inquire into the mechanism which produces these circulatory changes and into their clinical interpretation. It is a well known fact that many drugs, when introduced into the body either by the mouth or through the skin, are excreted not only by the normal channels of elimination, such as the kidney or the intestine, but also from such ulcerated surfaces as may be present on the body. This is easily shown to be true, for example, of certain of the anilin dyes, which, when introduced by way of the veins, produce an intense discoloration of the dressings over ulcers. It is likewise true of certain of the metals, such as arsenic. In order to understand the series of events previously enumerated it is therefore only necessary to assume that the therapeutic agent is excreted from the ulcerated surface of tumors. If an irritant, it will tend to produce hyperemia of the margins of the ulcer, and an increase of the secretions. If an astringent, however, it may produce just the opposite of these effects. Such a result, however striking, is purely accidental, and has no necessary bearing on the growth or destruction of the tumor itself. It constitutes a symptom on which no reliance should be placed.Excluding from consideration all of these secondary factors, we may conclude that the observation of the size of the tumor itself is the sole criterion on which we can place reliance in judging of the effect of therapeutic measures. This implies, in the first place, that a tumor must be accessible to fairly accurate measurement. Tumors of the uterus, for example, and intra-abdominal growths will only exceptionally fall into this class. In the second place, indirect evidence of a decrease in the size of tumors, such as is afforded by the increased permeability of obstructed passages, as in the case of tumors of the esophagus, pylorus or intestine, must be accepted only with great reserve. Remissions in the obstructive symptoms characteristic of such tumors are a frequent feature of the normal evolution of the clinical history of such growths. The relief of obstruction, however, may be due either to necrosis of the obstructing portions of the tumor, while the remainder continues to grow progressively, or to a relief of the accompanying muscular spasm. Finally, evidence of decrease afforded by the roentgenogram is not sufficiently exact in most cases to afford ground for so important a conclusion as that at present in question.Not only must there be unquestionable evidence, however, of the diminution in size of the tumor, but this diminution must be of a kind not ordinarily attributable to the natural evolution of the tumor.... It is safe to say that multiple tumors offer enormous difficulties in the matter of interpreting therapeutic results. At present we have in the wards of the hospital a patient with multiple metastatic carcinomas of the skin. For several months we have at intervals made accurate measurements of certain of these tumors and have found that some have undergone retrogression, others have entirely disappeared, while still others have continued to grow steadily. In the case which afforded the ascitic fluid used in Hodenpyl’s experiments, many of the lymphaticmetastases underwent complete retrogression, while the metastatic process in the liver, as was demonstrated at necropsy, increased progressively, and ultimately almost destroyed that organ. Thus, in multiple carcinosis, the retrogression of individual nodules is no indication that therapeutic intervention has produced an improvement.I shall not delay to emphasize those variations in the size of solid tumors which accompany hemorrhage and its absorption, edematous swelling, necrosis in the depths, and other familiar factors which clinically simulate, or induce, the softening and the reduction that are so often attributed to therapeutic interference. But it is important to draw attention to a similar feature in that type of superficial epithelioma known as rodent ulcer. These new growths not infrequently advance at one point of the periphery, while they recede at another, and thus cicatrization and contracture may simulate a partial recovery. This effect is due in part to alterations not in the growth itself, but in the accompanying ulcerative process. The secretions from the growths, especially if confined under dressings, may have eroded and destroyed the surrounding skin, and it is tempting to interpret a recession of the associated ulcerative disease as an indication of a favorable effect on the new growth. It is unquestionably this aspect of rodent ulcers which plays so generously into the hands of the numerous venders of nostrums for this disease.In brief, the demonstrable reduction in size of a tumor, of a kind not to be attributed to the natural processes of evolution of that tumor or of its associated lesions, is the one essential feature of effective therapeutic intervention.

Circulatory changes in tumors offer an interesting group of clinical symptoms. The observation has often been made, especially in ulcerated new growths, that treatment is associated with swelling, peripheral hyperemia, and an altered character of the discharge. In spite of the fact that there is no reasonable relationship between this congeries of symptoms and the actual cure of the tumor, they generally receive considerable emphasis and are cited as an indication of the specific local action of the agent employed. It is also true, however, that the growth may continue to advance in spite of their presence. It is of some importance to inquire into the mechanism which produces these circulatory changes and into their clinical interpretation. It is a well known fact that many drugs, when introduced into the body either by the mouth or through the skin, are excreted not only by the normal channels of elimination, such as the kidney or the intestine, but also from such ulcerated surfaces as may be present on the body. This is easily shown to be true, for example, of certain of the anilin dyes, which, when introduced by way of the veins, produce an intense discoloration of the dressings over ulcers. It is likewise true of certain of the metals, such as arsenic. In order to understand the series of events previously enumerated it is therefore only necessary to assume that the therapeutic agent is excreted from the ulcerated surface of tumors. If an irritant, it will tend to produce hyperemia of the margins of the ulcer, and an increase of the secretions. If an astringent, however, it may produce just the opposite of these effects. Such a result, however striking, is purely accidental, and has no necessary bearing on the growth or destruction of the tumor itself. It constitutes a symptom on which no reliance should be placed.

Excluding from consideration all of these secondary factors, we may conclude that the observation of the size of the tumor itself is the sole criterion on which we can place reliance in judging of the effect of therapeutic measures. This implies, in the first place, that a tumor must be accessible to fairly accurate measurement. Tumors of the uterus, for example, and intra-abdominal growths will only exceptionally fall into this class. In the second place, indirect evidence of a decrease in the size of tumors, such as is afforded by the increased permeability of obstructed passages, as in the case of tumors of the esophagus, pylorus or intestine, must be accepted only with great reserve. Remissions in the obstructive symptoms characteristic of such tumors are a frequent feature of the normal evolution of the clinical history of such growths. The relief of obstruction, however, may be due either to necrosis of the obstructing portions of the tumor, while the remainder continues to grow progressively, or to a relief of the accompanying muscular spasm. Finally, evidence of decrease afforded by the roentgenogram is not sufficiently exact in most cases to afford ground for so important a conclusion as that at present in question.

Not only must there be unquestionable evidence, however, of the diminution in size of the tumor, but this diminution must be of a kind not ordinarily attributable to the natural evolution of the tumor.... It is safe to say that multiple tumors offer enormous difficulties in the matter of interpreting therapeutic results. At present we have in the wards of the hospital a patient with multiple metastatic carcinomas of the skin. For several months we have at intervals made accurate measurements of certain of these tumors and have found that some have undergone retrogression, others have entirely disappeared, while still others have continued to grow steadily. In the case which afforded the ascitic fluid used in Hodenpyl’s experiments, many of the lymphaticmetastases underwent complete retrogression, while the metastatic process in the liver, as was demonstrated at necropsy, increased progressively, and ultimately almost destroyed that organ. Thus, in multiple carcinosis, the retrogression of individual nodules is no indication that therapeutic intervention has produced an improvement.

I shall not delay to emphasize those variations in the size of solid tumors which accompany hemorrhage and its absorption, edematous swelling, necrosis in the depths, and other familiar factors which clinically simulate, or induce, the softening and the reduction that are so often attributed to therapeutic interference. But it is important to draw attention to a similar feature in that type of superficial epithelioma known as rodent ulcer. These new growths not infrequently advance at one point of the periphery, while they recede at another, and thus cicatrization and contracture may simulate a partial recovery. This effect is due in part to alterations not in the growth itself, but in the accompanying ulcerative process. The secretions from the growths, especially if confined under dressings, may have eroded and destroyed the surrounding skin, and it is tempting to interpret a recession of the associated ulcerative disease as an indication of a favorable effect on the new growth. It is unquestionably this aspect of rodent ulcers which plays so generously into the hands of the numerous venders of nostrums for this disease.

In brief, the demonstrable reduction in size of a tumor, of a kind not to be attributed to the natural processes of evolution of that tumor or of its associated lesions, is the one essential feature of effective therapeutic intervention.

When the various methods of treatment which have been discussed in this paper are judged by the standard advocated above, it is apparent that none of them can lay claim to therapeutic effectiveness. The modifications of the disease attributed to them are modifications which occur spontaneously in a very large proportion of cases as a result of the natural evolution of the disease process. This is a fact which cannot be too strongly emphasized. Owing unfortunately to the hopeless character of cancer, men are not prone to study with care all the lesser changes which the disease and the patient present under ordinary conditions; but when a “cure” is under investigation, the patient and his medical attendant note every apparent improvement with painstaking attention and enthusiasm. As a result, some evidence of improvement in treatment is entered on the books.—(From The Journal A. M. A., April 17, 1915.)

During the past four or five years,The Journalhas had inquiries similar in effect to this, just received from Dr. E. P. Jewett of Gardner, Mass.:

“Will you kindly inform me regarding a drug manufacturing company by the name of the Direct Sales Company, Buffalo, New York? Are their products standard and reliable so far as you know?”

The Direct Sales Company, Inc., Buffalo, has, according to its letterhead, the following officers:

Geo. J. Dotterweich, President and Treasurer,C. K. Dotterweich, Vice-President,Louis B. Seufert, Secretary.

This concern circularizes physicians and emphasizes that it sells “Only by Mail.” It also features a “profit sharing rebate” scheme, whereby purchasers receive a coupon representing 10 per cent. of the invoice value of each purchase. After $100 worth of merchandise has been purchased the $10 worth of coupons when “presented for redemption at one time” will be “honored as cash”—presumably on the purchase of additional goods.

The Direct Sales Company catalogues have for some years, carried a guaranty, which reads, in part:

“We absolutely guarantee all preparations to be in exact accordance with the National Pure Food and Drugs Act, June 30, 1906.“We also absolutely guarantee all preparations bearing our label to be equal, if not superior, to any on the market.”

“We absolutely guarantee all preparations to be in exact accordance with the National Pure Food and Drugs Act, June 30, 1906.

“We also absolutely guarantee all preparations bearing our label to be equal, if not superior, to any on the market.”

In one of the Quarterly Bulletins of the State Board of Health of New Hampshire, issued last year, this paragraph appeared:

“The Direct Sales Company, Inc., Buffalo, N.Y., is a pharmaceutical concern which until recently has done business direct with New Hampshire physicians. In two or three instances complaints have been received by this department that the preparations sold seemed to be lacking in potency. Some time ago a physician sent us a specimen of codein sulphate tablets, one-fourth grain, concerning which he was suspicious, admission being made that the price paid was very much less than current quotations. The amount of codein sulphate actually found per tablet proved to be but one-sixteenth grain. Later on, having subsequently received a new lot from this source, the same physician sent us a second sample, the composition of which was found to be practically identical with the first. Acting under the federal law, 500 lot packages of the following preparations were next purchased of the company direct, the analytical results indicating serious deficiency in every case, as follows:“Tablets salicylic acid, 5 grains... 1.72 grains found.“Tablets acetylsalicylic acid, 5 grains... 2.31 grains found.“Tablets acetanilid, 3 grains... 1.88 grains found.“Tablets codein sulphate,1⁄4grain...1⁄15grain found.“Tablets nux and pepsin No. 2, claiming pepsin 1 grain, extract nux vomica,1⁄10grain, found to have a gross average weight per tablet of only 1.17 grains, 0.54 grains of which was represented by sugar and other medicinally inert material.“Tablets Infant’s Anodyne (Waugh) showed serious discrepancy from formula.”

“Tablets salicylic acid, 5 grains... 1.72 grains found.“Tablets acetylsalicylic acid, 5 grains... 2.31 grains found.“Tablets acetanilid, 3 grains... 1.88 grains found.“Tablets codein sulphate,1⁄4grain...1⁄15grain found.“Tablets nux and pepsin No. 2, claiming pepsin 1 grain, extract nux vomica,1⁄10grain, found to have a gross average weight per tablet of only 1.17 grains, 0.54 grains of which was represented by sugar and other medicinally inert material.“Tablets Infant’s Anodyne (Waugh) showed serious discrepancy from formula.”

The Bulletin added the statement that, as the company could not be reached under the New Hampshire laws, the federal authorities were appealed to. The result of this appeal appeared inChemical Supplement 54, issued Aug. 21, 1918, by the Bureau of Chemistry of the U. S. Department of Agriculture. This government bulletin contained Notice of Judgment No. 6193, which describes cases of adulteration and misbranding of some of the drugs put out by the Direct Sales Company. Briefly, it may be said that some 2 grain acetanilid tablets sold by this concern were found by the government chemists to contain, roughly, about 12⁄3(1.61) grains; some1⁄4grain calomel tablets were found to contain only about1⁄6(0.163) grain; some 1 grain quinin sulphate tablets were found to have only about2⁄3(0.63) grain; some 21⁄2grain salol tablets contained only about 11⁄3(1.39) grain; some 5 grain sodium salicylate tablets contained less than half that amount (2.32 grain). In addition, the federal chemists found that some Elixir of Iron pyrophosphate Quinin and Strychnin (Elix. Ferr. Pyrophos. Quin. et Strych. N. F.) fell considerably below the standard of strength laid down by the National Formulary by having less than one-eighth the amount of quinin sulphate which the official standard calls for, and only about one-fifth the amount of sugar, saccharine, which is not a normal ingredient of the official preparation, having been substituted for part of the sugar. The chemists found, too, that some hydriodic acid sold by the same concern, instead of containing, as the label declared and as the United States Pharmacopeia requires, 1 per cent. of absolute hydriodic acid, contained less than one half of 1 per cent. The Direct Sales Company pleaded guilty in this case and was fined $700.—(From The Journal A. M. A., Sept. 27, 1919.)

In spite of the wonderful achievements of modern science, it seems impossible to get the public to think in scientific terms. This is doubtless due to a fundamental weakness in our educational system. The tendency still is tothink in terms of the eighteenth century rather than of the twentieth. Many timesThe Journalhas been chided, even by its friends, for failing to take seriously preposterous claims made for alleged discoveries in medicine by well-meaning but self-deluded enthusiasts or by shrewd and conscienceless charlatans. Far too often the attitude is that any alleged discovery in medicine, no matter how bizarre or how humanly improbable, should be taken up in all seriousness and subjected to the tests of modern laboratory methods. It was only a few years ago that a quack of unsavory antecedents brought forth an alleged cure for consumption—a disease that for years has been the subject of study by the best brains in the world—and a medical college spent thousands of dollars “investigating” the “cure,” thereby giving it a standing that it would never have received otherwise and incidentally obtaining for the school an amount of publicity that may or may not have been desired. AsThe Journalsaid at the time, it would have been just as pertinent for a body of astronomers to determine by scientific methods whether or not the moon is really made of green cheese.

The point we would make is that the strides made by modern science have practically eliminated the possibility of men without training or special knowledge evolving any epoch-making discovery. In this connection an editorial in theScientific Americanof recent date, dealing with the mechanical sciences rather than the medical, is well worth quoting in part. The editorial discussed the “Garabed” incident. “Garabed,” as Our readers know, was a name given to a device which one Garabed T. K. Giragossian claimed to have developed and which, so far as could be learned from the generalities in which Mr. Giragossian indulged, would take energy out of the cosmos and transfer it directly into mechanical motion. Mr. Giragossian would give no details regarding his “engine,” but was so able to hypnotize Congress into a belief that he had something worth looking into that it passed a joint resolution calling for the appointment of five scientists to pass on the claims for Garabed. The investigation proved, as might have been expected, that the thing was unsound in principle and nonoperative as a device.

The methods by which Garabed was brought before the public savored strongly of those used by quacks in the medical world, the one difference being that Giragossian was apparently perfectly sincere and unequivocally honest. The point that we bring out, however, and which, as we have said before, was so well expressed by theScientific American, is the utter futility of wasting the time of scientific men on alleged inventions or discoveries by men without training who substitute secrecy and glittering generalities for facts and accomplishments. Quoting theScientific American:

Scientific discovery, once an open field for all comers, is today becoming more and more a matter calling for the most intensive special qualifications. As the body of human knowledge broadens and deepens, it becomes increasingly difficult to make any material addition to it. Any one undertaking such a task must of necessity bring to it a long and careful training, acquired either in the refined atmosphere of the laboratory, or in the rougher school of close contact with the operation of apparatus constructed by those who have already qualified. In particular, he must possess a carefully developed power of making accurate observations and drawing correct conclusions. It is rather the habit to point to men like Edison and Maxim in refutation of these necessities; but they are not to be so refuted. These men are examples, raised to thenth power, of the great inventor who has qualified in the University of Hard Knocks and Long Experience.On these grounds, when a man comes before us in the self-assigned rôle of a great inventor, it is incumbent upon him to answer, not necessarily the bald question “Who are you?” but certainly the more searching one, “What are your qualifications to undertake this work?” Only by his answer can we decide whether he possesses a competence deserving of attention, or is but a dilettante playing with fire. Yet this obligation was one which Mr. Giragossian, far from meeting, did not even appear to comprehend. To every effort to ascertain his qualifications he replied in the same terms, that he was an honest man, and could prove it by letters from his technically nondescript collection of friends and sponsors. The very fact that more than personal integrity is necessary in a man who would unravel the secrets of the creation of energy appears to have escaped his comprehension.

On these grounds, when a man comes before us in the self-assigned rôle of a great inventor, it is incumbent upon him to answer, not necessarily the bald question “Who are you?” but certainly the more searching one, “What are your qualifications to undertake this work?” Only by his answer can we decide whether he possesses a competence deserving of attention, or is but a dilettante playing with fire. Yet this obligation was one which Mr. Giragossian, far from meeting, did not even appear to comprehend. To every effort to ascertain his qualifications he replied in the same terms, that he was an honest man, and could prove it by letters from his technically nondescript collection of friends and sponsors. The very fact that more than personal integrity is necessary in a man who would unravel the secrets of the creation of energy appears to have escaped his comprehension.

The fundamentals thus stated apply with equal force to the sphere of medical discovery. At the time when medicine was pure empiricism it was not only possible but also probable that the medicinal value of certain products or combinations of products might be stumbled on by those untrained and unskilled. That time has passed. Today, while it is not impossible, it is so improbable that there is no justification in taking up the time of scientific men in investigating alleged discoveries by men who are utterly lacking in the fundamental qualifications needed for the study of the complex problems of human pathology.—(Editorial from The Journal A. M. A., Aug. 10, 1918.)

The matter which follows appeared originally as an editorial in theCleveland Medical Journal, November, 1915. It expresses, we believe, the attitude of the thinking physician toward the subject discussed:

Physicians have come to the realization that drugs are as a two-edged sword—under proper conditions, striking against the disease; otherwise, against the patient’s health. The first condition for their proper use is adequate knowledge of their composition and purity; of their actions and malefactions; their field and limitations. Slowly and painstakingly—sometimes painfully—this scientific knowledge has been gathered, is still being gathered, by chemists and pharmacists, pharmacologists and clinicians, with increasing thoroughness, care and discrimination.

Where wisdom fears to venture, unwisdom and cupidity find ample room. The wise physician knows that there are ills that drugs cannot cure; that drugs generally only aid or relieve; and that to obtain even this aid efficiently and safely, the existing scientific knowledge is none too great. Not so the unwise. He who sees in disease only a name, to him a name is a sufficient cure. Let there be a mixture with a convenient and suggestive name and a pleasant taste, a compendious index of diseases and symptoms—and a lively imagination—and the cure is accomplished. Few things could be easier, and few more false. It is not surprising that the “man on the street” should fall into these errors; it is sad that any physician should be misled by the sophistry of interested drug vendors.

Physicians have the moral obligation to instruct the public in matters of health. Preaching before practice is of little avail. It behooves the medical profession to make at least a reasonable effort to clean its own house before it passes the broom to the public. Realizing this responsibility, the American Medical Association some years ago established its Council on Pharmacy and Chemistry. This Council is strictly an educational agency—it collects and disseminates knowledge about drugs, especially those drugs that are advertised to physicians and that are not described in the legal pharmacopeias. Physicians are thus put in a position to discriminate. Many have done so; others will, a few may never see the light on this earth.

Journals can no longer claim that they mislead their readers in good faith. Some—theCleveland Medical Journalamong the first—have frankly acknowledged their obligations, and sacrificed a lucrative income from advertisements; others are still occupied in compounding the matter with their conscience. Manufacturers are in a similar position. Those who are on the side of scientific progress—or to put it materially, those who realize that honesty is the best policy—are taking the opportunity to separate themselves from the dishonest and ignorant.

Altogether, the medical profession may safely advise the public on the subject of drugs without laying itself open to the charge that it preaches what it is unwilling to practice.

Meantime, the public itself has had a somewhat similar awakening. The progress of the profession has necessarily spread more or less to the laymen. All sorts of educational agencies have been working to convince the public that individual and national health is too precious an asset to be entrusted to any quack who may spell his praise in printer’s ink. Legislators have passed food, drug, and antinarcotic laws which have aroused interest and discussion. Even the “drugless cults” have somewhat offset their harm by causing the public to reflect that drugging is not a panacea for all ills. All this has not been without effect. The public is in a receptive mood; it is not convinced, but wishes to learn. Legislators are prepared to follow public opinion. The purveyors of patent medicines are watching events.

What, under these conditions, should be the attitude of the medical profession? Plainly, it should continue to be what it always has been: to stand aggressively for the protection of the public health, without any compromise. In doing so, it is true, physicians will expose themselves to the imputation of selfish motives. Selfishly commercial minds cannot or will not understand the unselfish ideals of a profession—that is their loss. Physicians, however, must be careful not to give a semblance of reason to the charge; for that would diminish the effect of their attitude. They must confine themselves to informing the public of the facts; and to guarding the health of the public at large, and of their own patients in particular.

No one, in a free country, can force a diseased individual to seek effective treatment or prevent him from using an ineffective treatment, unless his disease imperils the health of others. At that point, and not before, the government can and should take personal measures. However, it is a well recognized function of the government to protect individuals against their own ignorance. It does this when it forces the child to go to school; it does this when it places the swindler in jail.

On exactly the same principle, the government has the right and the duty to protect the uninformed public against the flagrant evil of the patent medicine traffic—and the patent medicine traffic as now carried on is a flagrant evil and series of evils. The government should protect the public against advertisements that are framed to suggest or create imaginary ailments, with their attendant miseries; it should protect the public against being deluded by false promises of cure; against the specious relief that merely hides the disease and blinds the patient to its dangers; against drugs that may and do work positive harm; against the veil of mystery that makes these abuses possible.

The individual layman cannot protect himself against these dangers, and has a right to expect that the government will prohibit the indiscriminate sale of any medicine that may be harmful to him. He has a right to expect, when the government permits the sale of a patent medicine, that the medicine will do him no harm; just as he has a right to expect that any physician whom the government permits to practice, should be competent.

These are some of the reasons why physicians oppose patent medicines as they are now exploited; and for these reasons, physicians should take an absolutely uncompromising attitude, and use every opportunity to educate the public. The patent medicine interests naturally try to obscure the issue. By the art in which they are so skilful, they aim to suggest to the public that physicians are opposed to patent medicines, in order to drive patients to their offices. They “forget” to mention that physicians have never conducted a “campaign” against really efficient preventive public-health measures, no matter howmany prospective patients were involved. No physician has ever refused to give diphtheria antitoxin because this would diminish the number of his visits. A short memory is a very convenient asset for self-interested persons. It is not so convenient for the public—but it is all too frequent. Physicians must, therefore, make it plain that their stand is not against patent medicines, but for the protection of the health of the public.—(From The Journal A. M. A., March 4, 1916.)

Until very recently, we were compelled to acknowledge that little, if any, progress was being made in internal medicine so far as drug therapy was concerned. Everybody knows of the progress made in other branches—in bacteriology, in pathology, in biologic chemistry, in surgery, in etiology and in application of technical methods to diagnosis. Recently, however, pharmacologic research and the application of scientific methods in the study of the physiologic action of drugs are resulting in definite, positive progress. An important lesson, incidentally learned through this scientific investigation, is the fallibility of the drug therapy described in textbooks. The explanation is, of course, that many of these textbooks are mere compilations containing false statements, unproved theories, and unverified clinical evidence representing the guesswork of ancient uncritical observers. Many drugs have been, and still are, vaunted in textbooks as valuable in a variety of conditions, whereas scientific investigation and controlled clinical observation have proved them to be totally worthless; others are proving to be of value in an extremely limited number of conditions. The sooner writers of textbooks realize this fact and enter into the spirit of the new era, the better for the public and for scientific medicine.—(Editorial from The Journal A. M. A., May 27, 1916.)

During the last two or three yearsThe Journalhas received inquiries regarding one Thomas Webster Edgar, M.D., of New York City, first, relative to his alleged treatment for diabetes and more recently about his “monkey gland” treatment for sex stimulation. Here is one from a physician in Washington:

“Have you any knowledge of the efficacy of a serum made from the pancreas of rabbits for the relief or cure of diabetes? It is made by Dr. T. W. Edgar of 766 West End Ave., New York City.”

And this from a layman in Pennsylvania:

“Last year there was published in theNew YorkHerald an account of the new treatment for diabetes in which a serum was injected in the veins and as a result it was claimed that over sixty-five per cent. of the treatments made were successful. The account further stated that they proposed to establish some sort of a sanitarium in New York City used especially for the treatment. The writer having mislaid the account, wrote theNew York Heraldas to the doctor who had charge of it and in return was given the name and address. Dr. Edgar in a letter under date of last year stated that the cost of the treatment was $300.00, payable beginning of the treatment, and he gave very little information as to the success of it, with the exception that if the treatment did not give the desired effect after the end of three months, it would be continued without any further cost. The writer wrote and asked him the names of one or two of the patients who had been cured, because it seemed rather unusual that if the treatment were a success, it was necessary for a patient to pay the cost of the treatment in advance. To that letter I have never received a reply.”

While a physician from Illinois writes:

“I am enclosing a clipping from a Chicago paper relative to Dr. Thomas Webster Edgar of New York and his operation for transplanting the glands of ring-tailed monkey. I note that he is a member of the New York County Medical Society! What is there to this? I have seen no mention of these wonders inThe Journal.”

Thomas Webster Edgar was born in 1889. The records show that he was graduated in medicine by the University and Bellevue Hospital Medical College in 1913, and was licensed to practice medicine in the State of New York the same year. In March, 1919, an article by T. Webster Edgar appeared in theNew York Medical Journalon “Diabetes Mellitus.” In this Edgar gave a theory of the cause of diabetes mellitus and stated that he had “treated successfully, twenty cases of definite diabetes.” In the article he spoke positively of the successful results he had obtained by the “intramuscular injections of my diabetic serum.” No information was given regarding this serum except that he mentioned vaguely that it was “prepared from normal blood after the animal is exercised to the point of fatigue.”

Photographic reproduction (reduced) of a few of the newspaper items that appeared in various parts of the country regarding Thomas Webster Edgar’s alleged serum for diabetes.

A few days after the appearance of this article in theNew York Medical Journal, newspaper articles appeared regarding a cure for diabetes perfected by “Dr. Thomas Webster Edgar, 766 West End Avenue, New York City.” According to these reports, Edgar said:

“I tried the blood of rabbits and found what I wanted. In obtaining the blood I first put the rabbit upon a treadmill and keep it there until it reaches a stage of fatigue. Then I draw the blood, and after heating it to 60 degrees centigrade separate the corpuscles from the serum. When the serum has been treated after the method I have discovered, I inject it immediately subcutaneously.“I have attained success in 65 per cent. of my cases and I have had 100 cases. I do not say that the cure is infallible, but I am now certain that it will work in most cases, particularly when the patient observes the rules laid down and undergoes faithful treatment.”

“I have attained success in 65 per cent. of my cases and I have had 100 cases. I do not say that the cure is infallible, but I am now certain that it will work in most cases, particularly when the patient observes the rules laid down and undergoes faithful treatment.”

In April, 1919, a physician in Kansas wrote to Edgar at the request of a diabetic patient asking for information about the “serum.” Edgar replied that it would be impossible to send the physician any of the serum for administration unless the “patient is willing to pay me for the cost of same, which will be approximately the sum of $25.” He stated further that, in a few months’ time, he hoped to be able to manufacture the serum in larger quantities which would “more than cut the expense in half.”

In the same month a layman in Chicago who read the newspaper story wrote to Edgar and asked for details regarding terms and the arrangements that would have to be made to take the “treatment.” Edgar replied that he expected to be in Chicago in a few weeks’ time and would see the man in consultation with his regular physician, that he would administer the first injection and give instructions to the physician as to subsequent injections. Edgar added:

“My custom is to have all fees paid in advance and my charge is $200.00 by certified cheque or money-order.”

A layman in one of the smaller cities of New York wrote to Edgar in May, 1919, and received a reply from Edgar’s secretary stating that the treatment extends “over a period of three months, cost $150.” He was also told that the serum could be sent to his physician for administration “for the sum of $25 prepaid by money-order.” The letter closed with the statement that Edgar “has been very successful with the serum.”

Photographic reproduction (greatly reduced) of small portion of the publicity that has been given to Edgar relative to his operation for “sex stimulation” by the transplantation of the glands of ring-tailed monkeys!

A layman in South Carolina who wrote to Edgar in June, 1919, was told that the treatment as administered by Edgar “extends over a period of two months; fee $300” and that if he wanted the serum administered by his own physician the cost would be “$50 prepaid.”

In May, 1920, Edgar had another article on diabetes, also in theNew York Medical Journal. In this, too, he refers to his serum in the following words:

“In conclusion I may state that I have been able to produce some rather startling results by the use of my serum, which is prepared from the blood of rabbits after they have undergone a series of maneuvres capable of activating the various internal secretory glands to increased action. The serum contains the internal secretions in hormone form.”

Gradually the newspaper publicity on Edgar’s diabetic “serum” died down. Then, in November, 1920, there appeared—again in theNew York Medical Journal—an article by Edgar on “Sterility, Sex Stimulation and Endocrines.” Edgar there stated that he wished to place himself “on record as being interested in sex stimulation” and that he wanted to notify the profession that hehad another serum which he was using “with success in the treatment of this condition.” Thus:

“... I feel entitled to state that I have a distinctly beneficial serum for the alleviation of presenile and senile deficiency; and that my product is capable of producing a new lease of life in those whose functions have been reduced to a minimum.”

How long Edgar has been featuring his “serum” for “sex stimulation” it is difficult to determine, but during the last year the newspapers have carried sporadic reports of alleged remarkable results produced by “Dr. Thomas Webster Edgar of 766 West End Ave., New York,” through the transplantation of the “interstitial gland” taken from “a special species of orangoutang.” A layman who wrote Edgar some months ago regarding this “gland implantation” received a letter from Edgar’s secretary stating that the treatment “has been most successful in all cases” and assuring him that “the experimental stage had been passed, and the operation is advised in all cases presenting symptoms of presenility or age.” A week later the same man received a letter written by Edgar himself in which he reiterated the claim that all of the operations had been successful. Edgar added that he was now treating all cases “by operation instead of the serum,” and that “the fee for operation is $500, inclusive of the sanitarium,” the patients remaining in the “sanitarium” “for from two to three days.” A month or two later the prospective patient received another letter signed, “Thomas Webster Edgar, M.D.,” assuring him that “the effect is permanent, and does not wear off. No ill effects can possibly result.”

Commencing, Oct. 1, 1921, a series of sensational articles appeared regarding one of Edgar’s alleged monkey gland implantations performed on an individual described as “one time lawyer and then a writer.” These articles purport to be written partly by one of the newspaper staff, partly by the man undergoing the “operation” and at least one by Thomas Webster Edgar. The material is played up in the style typical of yellow journalism. In addition to repeated pictures of the individual who is being operated on, there also are given pictures of Thomas Webster Edgar and one of his “ring-tailed monkeys.” Doubtless the “story” has sold many newspapers. Its sensational character, the element of mystery and above all its sex slant will appeal to that large class of newspaper readers that hunger for stuff of this sort. Doubtless, too, it has proved a large advertising asset for Thomas Webster Edgar.

The statement that appears in the series to the effect that Edgar “is a member of the County Medical Society of New York” is incorrect. Edgar is not a member.

The further newspaper claim that Edgar is “an authority on glandular transplantation” should also be accepted with reservations. “Authorities” are created with ease in the pages of newspapers. Edgar may possibly be termed an authority in a newspaper or, shall we say, Pickwickian sense.—(From The Journal A. M. A., Oct. 15, 1921.)

The Journalrecently published in this department some inquiries regarding Thomas Webster Edgar, M.D., of New York City, relative to some alleged serums that Dr. Edgar had developed for diabetes and sex stimulation, respectively, and relative also to the newspaper publicity given Dr. Edgar in connection with the alleged transplantation of glands from “ring-tailed monkeys.”

We are in receipt of a letter signed, “Thomas Webster Edgar, M.D.,” and reading as follows. It is givenverbatim et literatim:

“Gentlemen:—I have read with great interest your editorial regarding the publicity given my work in metabolism, and gland implantation.“Yourpseudo, expose,and distinctly libelous insinuations are unjust, and they lead me to believe that you are going to be called to account at a very early date.“My profession is the practice of medicine, and the policy of my practice is not controlled by the editorial department of the journal. I am progressive, and a firm believer that legitiment medicine and surgery can not be practiced if the physician be governed by a set of medical clerks, who disdainfully boast that they control, and govern the healing art through out the breadth of the land, with a sceptre that is biased and steeped in the unadulterated commercialism of a certain medical clique.“Aside from the fact that I am an associate editor on a medical publication, it is disgraceful, as well as unjust that you have written such an editorial with out first investigating the therapeutic value of my serum, and implantation operation.“The psychology of your editorial, only reflects on your editorial department, and will tend to belittle some of the greatest surgeons in the country.“It may be to your advantage to know, that this very afternoon, I was on the program with the following men.“Dr. Lewis Gregory Cole—New York“Dr. Charles H. Mayo—Rochester, Minn.“Dr. John B. Deaver—Philadelphia“Dr. Charles Peck—New York.“My paper was entitled—Senility, its etiology and treatment by gland implantation. I am sure the above mentioned gentlemen are thoroughly ashamed of your actions in the matter, as well as thoroughly disgusted with the baby like attitude you have displayed. You have no sense of fair play, and if it is with in my power to undue the wrong which you have wrought me, I shall endeavor to vindicate myself in the eyes of the clear thinking members of the profession.“I sincerely trust you will publish this communication, in order that my brethren shall understand and appreciate that your thrust has not gone unnoticed.“It is my hope that the various medical societies through out the country, will call upon me to read a paper on my work, so that I may be able to offer substantial evidence to the fact that you have done me an injustice.“Very truly yours,TWE/AEL[Signed] “Thomas Webster Edgar, M.D.”

“Gentlemen:—I have read with great interest your editorial regarding the publicity given my work in metabolism, and gland implantation.

“Yourpseudo, expose,and distinctly libelous insinuations are unjust, and they lead me to believe that you are going to be called to account at a very early date.

“My profession is the practice of medicine, and the policy of my practice is not controlled by the editorial department of the journal. I am progressive, and a firm believer that legitiment medicine and surgery can not be practiced if the physician be governed by a set of medical clerks, who disdainfully boast that they control, and govern the healing art through out the breadth of the land, with a sceptre that is biased and steeped in the unadulterated commercialism of a certain medical clique.

“Aside from the fact that I am an associate editor on a medical publication, it is disgraceful, as well as unjust that you have written such an editorial with out first investigating the therapeutic value of my serum, and implantation operation.

“The psychology of your editorial, only reflects on your editorial department, and will tend to belittle some of the greatest surgeons in the country.

“It may be to your advantage to know, that this very afternoon, I was on the program with the following men.

“Dr. Lewis Gregory Cole—New York“Dr. Charles H. Mayo—Rochester, Minn.“Dr. John B. Deaver—Philadelphia“Dr. Charles Peck—New York.

“My paper was entitled—Senility, its etiology and treatment by gland implantation. I am sure the above mentioned gentlemen are thoroughly ashamed of your actions in the matter, as well as thoroughly disgusted with the baby like attitude you have displayed. You have no sense of fair play, and if it is with in my power to undue the wrong which you have wrought me, I shall endeavor to vindicate myself in the eyes of the clear thinking members of the profession.

“I sincerely trust you will publish this communication, in order that my brethren shall understand and appreciate that your thrust has not gone unnoticed.

“It is my hope that the various medical societies through out the country, will call upon me to read a paper on my work, so that I may be able to offer substantial evidence to the fact that you have done me an injustice.

“Very truly yours,

TWE/AEL[Signed] “Thomas Webster Edgar, M.D.”

Dr. Edgar’s statement that he had been on the program with Drs. Cole, Mayo, Deaver and Peck was sufficiently startling to prompt further investigation. It was found that the program in question was that of the annual meeting of the New York and New England Association of Railway Surgeons. It was further found that Edgar’s name did appear on some of the printed programs but not on others. It was rather naturally assumed that the name had been put on the program before the officers of this organization had seen the crude publicity to whichThe Journalrecently called attention. It was found, however, that after several hundred programs had been printed about 150 more were needed and “in the meantime, Dr. Edgar had come into the limelight” in his ring-tailed monkey gland transplantation rôle and “was invited to read a paper on the subject.” While he accepted this invitation the secretary of the organization tells us that Edgar did not read his paper but, when the paper was called, declined, saying it was time for him to be in his office!

As for the rest of Dr. Edgar’s communication,The Journalappreciates that courtesy is due “an associate editor on a medical publication”—referring doubtless to theWestern Medical Times. Dr. Edgar’s pronouncement that “legitimate medicine and surgery can not be practiced if the physician be governed by a set of medical clerks” seems reasonable—if cryptic. But it is when he charges that these “clerks” govern the healing art “with a sceptre that is biased and steeped in the unadulterated commercialism of a certain medical clique,” that he really shines. Whatever opinion one may hold of Dr. Edgar’s ability to compound serums, surely no one can question his skill as a mixer of metaphors. His reference to “sceptres” deserves to be embalmed in every textbook on rhetoric with the classic of the Hibernian statesman who passionately declared: “I smell a rat! I see it floating in the air! But, mark you, Sir, I shall nip it in the bud!”—(From The Journal A. M. A., Dec. 3, 1921.)

Physicians who prescribe on definite principles must often be puzzled by the number and variety of glycerophosphates on the market. All available evidence indicates that, as sources of phosphorus to the animal organism, the glycerophosphates possess no advantages over the ordinary inorganic phosphates.290The glycerophosphates are split up in the intestine, and liberate inorganic phosphates. In this form they are absorbed and utilized, if they are utilized at all. There is no evidence that glycerophosphates have any pharmacologic action to warrant the belief that they are of use as therapeutic agents. The theory that organic phosphorus compounds are more readily assimilable than inorganic compounds and hence a better means of introducing phosphorus into the system is still kept alive in the promotion of certain proprietary mixtures, in spite of the scientific evidence that the organism can assimilate phosphorus quite as readily from inorganic as from organic phosphorus compounds.291The glycerophosphates will continue to be manufactured until physicians refuse to prescribe them. A chemist in the “research laboratory” of a well known manufacturing firm has recently given a rather interesting reason for the use of glycerophosphates—from the manufacturers’ point of view. He is quoted as saying: “On account of the instability of phosphorus in elixir of phosphorus, nux vomica and damiana we have quite recently replaced the phosphorus by glycerophosphates. Such a preparation is apparently equally as effective, for we continue to have a great demand for it.” This is doubtless a sufficient reason for the substitution from the manufacturers’ point of view; but how about the patient, who, after all, is the one to be considered? Is it not a matter of considerable importance to the patient whether he receives phosphorus, one of the most powerful drugs known, or the inert glycerophosphates? The chemist’s statement seems to imply that it is not. It may be of interest to recall that a member of the firm whose chemist gives this “reason” for the use of glycerophosphates, in a recent address, was rather severe in his condemnation of institutions of learning, hospitals, etc., for their lack of cooperation with manufacturers: he said that “they should welcome an opportunity to let any manufacturer try out or test his products in their clinics, laboratories, etc.” A test as to whether there is a difference between the action of glycerophosphates and ordinary poisonous yellow phosphorus, especially when the former are mixed with extracts of nux vomica and damiana, would not be likely to appeal to many hospitals and laboratories as a very promising field of research at this day since, as has been stated, the scientific evidence at present available does not furnish any warrant for the therapeutic use of glycerophosphates.—(Editorial from The Journal A. M. A., April 15, 1916.)

With the appearance of the epidemic of influenza, reports began to appear, chiefly in newspapers, as to new serums, vaccines, drugs and other methods for checking and even for curing the disease. A few samples of such as have come toThe Journalappear in our Tonics and Sedatives Department this week. In Massachusetts, Commissioner E. R. Kelly appointed two committees to investigate the value of influenza vaccines as a preventive agent and as a treatment of the disease. The first committee, a special board for scientific investigation, consisting of Dr. M. J. Rosenau, chairman, and Frederick P. Gay and George W. McCoy, was appointed to consider the evidence available onthe prophylactic and therapeutic use of vaccines against influenza. This committee presented the following conclusions:

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