THIS WEEK
EDITORIALS
1385 In praise of the physical examination 1386 Secret remedies: 100 years on 1387 World hunger: a reasonable proposal 1388 Where have all the hospital flowers gone?
YEARS LIKE THIS
1390 A journal of the plague year 1392 Sod’s law applied to medicine 1394 Patent medicines and secret remedies 1396 I should cocoa 1397 The Spanish flu through the BMJ’s eyes 1399 BMJ archive: the videos 1400 Ingested foreign bodies and societal wealth: study of swallowed coins
DIAGNOSIS
1402 Fatal alchemy 1404 Lead poisoning at the Swedish House 1406 Stigma and prejudice in Tintin 1408 Animated ophthalmology 1410 Lying obliquely—a sign of cognitive impairment 1413 Darwin’s illness revisited 1416 House calls 1417 George Clooney, the cauliflower, the cardiologist, and phi, the golden ratio
ANAESTHESIA
1418 Painless amputation 1420 Autoappendicectomy in the Antarctic 1422 Prescriber’s narcophobia syndrome
CHRISTMAS FAYRE
1423 Christmas quiz 1424 Santa Claus: a public health pariah? 1426 Ethical dilemma
MUSICAL INTERLUDE
1427 Django’s hand 1429 Listening to Nellie the Elephant during CPR training in lay people
YOUNG AND OLD
1432 Association of early IQ and education with mortality: 65 year longitudinal study 1433 Perceived age as clinically useful biomarker of ageing 1435 Attitudes to ageing in the Economist: apocalyptic demography for opinion formers?
AFTERLIFE
1438 Silent virtuous teachers 1440 From flower graves to breast clinics
PROFESSIONAL MATTERS
1441 Brain maps 1442 Wards of the roses 1444 Selling patients 1447 H-index pathology 1448 Christmas quiz: answers 1449 Evidence based merriment 1450 The Surgical Sieve
BMJ | 19-26 DECEMBER 2009 | VOLUME 339
editor’s choice
rob white
Thinking caps on for the archive issue
When I was a medical student a helpful anaesthetist explained that surgeons wore caps in theatre to stop the bright lights from transilluminating their skulls. Now an anaesthetist has lifted the lid and discovered that surgeons have brains very similar to those of higher primates, with surprisingly complex wiring. Apparently, anaesthetists’ brains differ markedly from surgeons’ (p 1441). Who would have thought? While this is brand new research, readers will discover many articles in this issue with a historical theme—intentionally chosen to mark the year that our complete archive (1840-
2009) was made available online. We’ve included a short description of the nine videos we commissioned to bring to life some of the important figures from the archive (p 1399). They’re viewable free at bmj. com/videos. And we publish the winners of our £1000 prize for the most interesting use of the archive. Tom Jefferson and Eliana Ferroni reviewed what the BMJ published on the Spanish flu 1918-1924, unearthing observations that may have lessons for today (p 1397). A quick glance at our editorials might suggest that this fixation on the past includes an unhealthy dollop of nostalgia—for a time when junior doctors could recognise whispering pectoriloquy (p 1385) and Nurse would gladly stick a bunch of flowers in a vase (p 1388). But David Colquhoun uses the centenary of the publication of Secret Remedies (p 1394) to urge us to look hard at the efficacy of medicines, now (p 1386). His editorial is timely, given that too many at the top of British medicine
seem frozen in the headlights of the complementary medicine bandwagon. He describes a recent session of the House of Commons Science and Technology Committee, devoted to homoeopathy, as “pure comedy gold.” We usually reject articles suggesting diagnoses for the illustrious dead because the hypotheses are untestable, and armchair diagnosticians usually come up with some equally plausible alternative within a year or two. But we’ve made an exception for Charles Darwin in his anniversary year (p 1413). John Hayman’s hypothesis that he had a mitochondrial disorder could be tested by checking descendants of his female relatives for the suspected genetic abnormality. We’ve included articles about possible causes of death of Diane de Poitiers (p 1402) and 17 Norwegian sealers (p 1404) but in these cases there was some tissue to analyse. Both have accompanying videos on bmj.com/videos.
For one year only, we’ve suspended our prohibition against publishing spoofs in the Christmas BMJ. I’m not revealing which article it is, but I can tell you that not all BMJ editors and outside reviewers spotted it. And for those of you who would like to stretch themselves mentally after a heavy Christmas meal, we have a short pathology quiz (p 1423). Tony Delamothe, deputy editor, BMJ
[email protected] Cite this as: BMJ 2009;339:b5471
GRAHAM BIGNELL & RICHARD ARDAGH NEW NORTH PRESS/02077293161
Articles appearing in this print journal have already been published on bmj.com, and the version in print may have been shortened.
Meet the experts. masterclasses.bmj.com
BMJ | 19-26 DECEMBER 2009 | Volume 339
Editorials represent the opinions of the authors and not necessarily those of the BMJ or BMA
EDITORIALS
For the full versions of these articles see bmj.com
In praise of the physical examination
SIMON FRASER/SPL
It provides reason and ritual
Abraham Verghese, professor and senior associate chair for the theory and practice of medicine
[email protected] Ralph I Horwitz, chair of the department of medicine and Arthur Bloomfield professor of medicine, Department of Medicine, S102, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA 94305-5110, USA Competing interests: The authors have both served terms as directors of the American Board of Internal Medicine. Provenance and peer review: Commissioned; not externally peer reviewed. Cite this as: BMJ 2009;339:b5448 doi: 10.1136/bmj.b5448
If an alien anthropologist were to visit a modern teaching hospital, “it” might conclude that, judging by where doctors spend most of their time, the business of an internal medicine service takes place around computer terminals. The alien might assume that the virtual construct of the patient, or the “iPatient”,1 is more important than the flesh and blood human being occupying the bed. But the alien would be wrong—patients are what medical care is all about. Yet the electronic medical record and advanced imaging technology have not only seduced doctors away from the bedside but also devalued the importance of their role there. Indeed, intensive care units exist where consultants conduct their “rounds” on the patients and adjust ventilator settings and drugs via telemetry.2 These trends have left educators and trainees in internal medicine in two camps when it comes to the merits of the bedside examination. In the first camp are those who pine for the old days, bemoan the loss of clinical bedside diagnostic skills, and complain that no one knows Traube’s space or Kronig’s isthmus. In the second camp are those who say good riddance and point out that evidence based studies show that many physical signs are useless; some might even argue that examining the patient is just a waste of time. We believe that the truth is somewhere in between. We argue that clinicians who are skilled at the bedside examination make better use of diagnostic tests and order fewer unnecessary tests. If, for example, you recognise that the patient’s chest pain is confined to a dermatome and is associated with hyperaesthesia, and if you spot a few early vesicles looking like dew drops on rose petals, you have diagnosed varicella zoster and spared the patient the electrocardiography, measurement of cardiac enzymes, chest radiography, spiral computed tomography, and the use of contrast that might otherwise be inevitable. And so many clinical signs, The Stanford 25 1 Funduscopic examination for papilloedema, etc, using panoptic and regular ophthalmoscopes 2 Examination of the pupillary responses and relevant anatomy 3 Examination of the thyroid 4 Examination of neck veins/jugular venous distension for both level (volume) and common abnormal wave forms 5 Examination of the lung, including surface anatomy, percussion technique, identifying upper border of the liver, finding Traube’s space 6 Evaluation of point of maximal cardiac impulse, parasternal heave, and other precordial movements 7 Examination of the liver 8 Palpation and percussion of the spleen 9 Evaluation of common gait abnormalities 10 Eliciting ankle reflexes, including in a recumbent patient 11 Ability to list, identify, and demonstrate stigmata of liver disease, from head to foot
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such as rebound tenderness, lid lag, tremor, clubbing, or hemiparesis cannot be discerned by any imaging test. In the United States, after a three year residency, trainees can become certified by the American Board of Internal Medicine on the basis of a multiple choice test—an examination that has been standardised and well studied. Because the oral clinical examinations of the past, in which external examiners assessed a doctor’s skills at the bedside, were viewed as subjective and not standardised, assessment of such skills was left in the hands of training programme directors, who themselves were ill prepared to conduct the test or be truly objective about their own trainees. Without a high stakes clinical examination looming over them, the bedside skills of trainees atrophy. In short, we now certify internists in the US without an external benchmark that ensures that they can find a spleen, elicit a tendon reflex, detect fluid in a joint, or detect a large pleural effusion by percussion. If the public fully understood this, they would be shocked. The good news is that in our experience, house staff and junior faculty members are eager to improve their skills at the bedside. They recognise that the clinical examination has value and that it is necessary, particularly because so many of our students and residents have some experience in practising abroad in resource poor settings, where the value of such skills is more obvious. Often they understand the theory of a physical diagnostic manoeuvre but their technique is lacking. To this end we have developed the “Stanford 25,” a list of 25 technique dependent physical diagnostic manoeuvres that we teach to our trainees.3 On the list are items such as the funduscopic examination, the thyroid examination, the study of jugular venous pressure and wave forms, and the performance of the Achilles tendon reflex in a bedridden patient—the last is a great example 12 Ability to list, identify, and demonstrate common physical findings in internal capsule stroke 13 Examination of the knee 14 Auscultation of second heart sounds, including splitting, wide splitting, and paradoxical splitting 15 Evaluation of involuntary movements such as tremors 16 The hand in diagnosis: recognise clubbing, cyanosis, and other common nail and hand findings 17 The tongue in diagnosis 18 Examination of the shoulder, specifically testing for rotator cuff tears, the acromioclavicular joint etc 19 Assessment of blood pressure; identifying pulsus paradoxus 20 Assessment of cervical lymph nodes 21 Detection of ascites and abdominal venous flow 22 Rectal examination 23 Evaluation of a scrotal mass 24 Cerebellar testing 25 Bedside ultrasonography
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EDITORIALS
of a technique dependent manoeuvre. It is a skill to get the patient to relax, to position the leg properly, and to strike the tendon correctly to elicit a reflex (and it also takes a tendon hammer, which, unlike the ubiquitous stethoscope, is often missing from the pocket of the trainee’s white coat). The Stanford 25 teaches trainees 25 useful manoeuvres, while helping them recognise how nuanced some of these tests are. It also gives junior faculty members a repertoire of skills to teach when they are at the bedside. A third view of the bedside examination, and one that we advocate, is that it is not just a means of data gathering and hypothesis generation and testing, but is a vital ritual, perhaps the ritual that defines the internist. Rituals are all about transformation. The elaborate rituals of weddings, funerals, or inaugurations of presidents are associated with visible transformation. When viewed in that fashion, the ritual of the bedside examination involves two people meeting in a special place (the hospital or clinic), wearing ritualised garments (patient gowns and white coats for the doctors)
and with ritualised instruments, and most importantly, the patient undresses and allows the doctor to touch them. Disrobing and touching in any other context would be assault, but not as part of this ritual, which dates back to antiquity. We propose that if the ritual is short changed, if it is done in a cursory fashion, if it not done with skill and consideration, if its sacredness seems to be violated, then the transformation (which in this case is the formation of the doctor-patient bond, the beginning of a therapeutic partnership and the healing process) does not take place. We believe that the failure to form that bond could account for a great deal of the dissatisfaction patients express and doctors feel about their encounter. 1 2
3
Verghese A. Culture shock—patient as icon, icon as patient. N Engl J Med 2008;359:2748-51. Breslow MJ, Rosenfeld BA, Doerfler M, Burke G, Yates G, Stone DJ, et al. Effect of a multiple-site intensive care unit telemedicine program on clinical and economic outcomes: an alternative paradigm for intensivist staffing. Crit Care Med 2004;32:31-8. Stanford School of Medicine. Stanford initiative in bedside medicine. http://medicine.stanford.edu/education/stanford_25.html.
Secret remedies: 100 years on Time to look again at the efficacy of remedies
DIAGNOSIS, p 1394
David Colquhoun research professor, Department of Pharmacology, University College London, London WC1E 6BT
[email protected] Competing interests: DC held the AJ Clark chair of pharmacology at UCL from 1985 to 2004. Provenance and peer review: Commissioned; not externally peer reviewed. Cite this as: BMJ 2009;339:b5432 doi: 10.1136/bmj.b5432
In the linked feature, Jeffrey Aronson describes how the BMA, BMJ, and politicians tried a century ago to end the marketing of secret remedies.1 They didn’t have much success. Forty years after their endeavours, A J Clark (professor of pharmacology at University College London and later at Edinburgh) could still write, “the quack medicine vendor can pursue his advertising campaigns in the happy assurance that, whatever lies he tells, he need fear nothing from the interference of British law. The law does much to protect the quack medicine vendor because the laws of slander and libel are so severe.”2 Clark himself was sued by a peddler of a quack cure for tuberculosis for writing that: “‘Cures’ for consumption, cancer, and diabetes may fairly be classed as murderous.” Although he fought the libel case, impending destitution eventually forced him to apologise.3 Clark’s claim in 1927 that: “some travesty of physical science appears to be the most popular form of incantation”4 is even truer today. Homoeopaths regularly talk nonsense about quantum theory, and “nutritional therapists” claim to cure AIDS with vitamin pills. Some of their writing is plain delusional, but much is a parody of scientific writing, in a style that Ben Goldacre calls “sciencey.”5 It reads quite plausibly until you check the references. One hundred years on from the abortive efforts to crack down on patent remedies, we need to look again at the effiGlossary10 • Acupuncture: a rather theatrical placebo, with no real therapeutic benefit in most, if not all, cases • Herbal medicine: giving patients an unknown dose of an ill defined drug, of unknown effectiveness and unknown safety • Homoeopathy: giving patients medicines that contain no medicine whatsoever
1386
cacy of remedies. Indeed the effort is well under way, but this time it takes a different form. The initiative has come largely from an “intrepid, ragged band of bloggers” and several journalists, helped by scientific societies. It hasn’t been helped by the silence of the BMA, the royal colleges, the Department of Health, and a few vice chancellors.. Even the National Institute for Health and Clinical Excellence (NICE) and the Medicines and Healthcare Products Regulatory Agency (MRHA) could be helping more. The response of the royal colleges to the resurgence in magic medicine that started in the 1970s looks to me like embarrassment. They avoided the hard questions by setting up committees (often populated with known sympathisers) so as to avoid having to say “baloney.” The Department of Health, equally embarrassed, refers the hard questions to the Prince of Wales’ Foundation for Integrated Health. It was asked to draft “national occupational standards” for make believe subjects like “naturopathy”6). Two recent examples illustrate the problems. Take first the Pittilo recommendations for statutory regulation of acupuncture and herbal and traditional Chinese medicine.7 8 The Pittilo report recommended official recognition by statutory regulation and entry by honours degree. But you cannot start to think about a sensible form of regulation unless you first decide whether or not the thing you are trying to regulate is nonsense. This idea, however, is apparently lost on the Department of Health and the authors of the Pittilo report. Fortunately, consultation on statutory regulation has attracted many submissions that point out the danger to patients of appearing to give official endorsement to treatments that have no proper evidence base. The Royal College of Physicians seems to have experienced a major change of heart: its submission points out with admirable clarity that the statutory regulation of things that don’t work endangers BMJ | 19-26 december 2009 | Volume 339
EDITORIALS
patients (though they still have a blind spot about the evidence for acupuncture, partly as a result of the recent uncharacteristically bad assessment of the evidence by NICE). Such enlightenment doesn’t extend to the Prince of Wales, who made a well publicised intervention on behalf of herbalists after the public consultation closed.9 The other example concerns the recent “evidence check: homeopathy” conducted by the House of Commons Science and Technology Select Committee (SCITECH). Oliver Wendell Holmes said all that needs to be said about medicine-free medicines in his 1842 essay, Homeopathy and its Kindred Delusions11 So it is nothing short of surreal to find the UK parliament still discussing it in 2009. The committee’s proceedings are worth watching, if only to see the admirably honest admission by the professional standards director of Boots that they sell homoeopathic pills without knowing whether they work.12 But for pure comedy gold, there is nothing to beat the final session. The health minister Michael O’Brien was eventually cajoled into admitting that there was no good evidence that homoeopathy worked but defended the idea that the taxpayer should pay for it anyway. The chief scientific advisor in the Department of Health, David Harper, was not so straightforward. After some evasive answers the chairman, Phil Willis, said, “No, that is not what I am asking you. You are the department’s chief scientist. Can you give me one specific reference which supports the use of homoeopathy in terms of government policy on health?” One is tempted to quote Lewis Carroll “but answer came there none.” There were words, but they made no sense. Then at the end of the session Harper said, “homeopathic practitioners would argue that the way randomised clinical trials are set up, they do not lend themselves necessarily to the evaluation and demonstration of efficacy of homeopathic remedies.” Earlier, Kent Woods (chief execu-
tive officer of the MHRA) had said, “the underlying theory does not really give rise to many testable hypotheses.” Why not? The hypotheses are testable, and homeopathy— because it involves pills—is particularly well suited to testing by proper randomised controlled trials.13 It isn’t hard to do better than that. “Imagine going to an NHS hospital for treatment and being sent away with nothing but a bottle of water and some vague promises,” wrote the Sun’s health journalist Jane Symons recently.14 “And no, it’s not a fruitcake fantasy. This is homeopathy and the NHS currently spends around £10m on it.” It isn’t often that a Murdoch tabloid produces a better account of a medical problem than anything the Department of Health’s chief scientific advisor can muster. 1 2 3 4 5 6 7
8 9 10 11 12 13 14
Aronson JK. Patent medicines and secret remedies. BMJ 2009;339:b5415. Colquhoun D. Patent medicines in 1938 and now: AJ Clark’s book. 2008. www.dcscience.net/?p=257. Clark D. Alfred Joseph Clark. A memoir. C & J Clark, 1985. Clark AJ. The historical aspect of quackery. BMJ 1927 October 1. Goldacre B. Bad science. Harper Collins, 2008. Skills for Health. http://bit.ly/6wDdUL. Report to Ministers from the DH Steering Group on the Statutory Regulation of Practitioners of Acupuncture, Herbal Medicine, Traditional Chinese Medicine and other Traditional Medicine Systems Practised in the UK. 2009. www.dh.gov.uk/prod_consum_dh/groups/dh_ digitalassets/@dh/@en/documents/digitalasset/dh_086358.pdf. Colquhoun D. A very bad report: gamma minus for the vice-chancellor. 2008. www.dcscience.net/?p=235. BBC News. Prince Charles: “Herbal medicine must be regulated.” 2009 December 1. http://news.bbc.co.uk/1/hi/health/8388985.stm. Colquhoun D. Patients’ guide to magic medicine. www.dcscience. net/?page_id=733. Holmes OW. Homeopathy and its kindred delusions. 1842. www. homeoint.org/cazalet/holmes/index.htm. House of Commons Science and Technology Committee. Evidence check: homeopathy. 2009. www.viewista.com/s/fywlp2/ez/1 . Goldacre B. A kind of magic. Guardian 2007 November 16. www. guardian.co.uk/science/2007/nov/16/sciencenews.g2. Symons J. Homeopathy is draining resources. Sun 2009 December 3. www.thesun.co.uk/sol/homepage/woman/health/health/2755952/ Homeopathy-is-resources-drain-says-Jane-Symons.html.
World hunger: a reasonable proposal
BRUCE HANDS/GETTY IMAGES
Commodity markets explain why so many are going hungry in a world of plenty
Cite this as: BMJ 2009;339:b5209 doi: 10.1136/bmj.b5209
Last year saw 250 million people added to the ranks of the starving and malnourished, pushing the world total past one billion, or one in every six people on the planet.1 As I read reports of the dramatic upsurge I was reminded of a rainy afternoon in Cambridge two summers ago, when I interviewed Amartya Sen, the Harvard professor who had won the Nobel prize for economics in 1998 for his work on poverty and famine. According to Sen, hunger was not only entirely preventable but profoundly unreasonable. I had come to Amartya Sen’s house to discuss the recent efforts of the Bill and Melinda Gates Foundation and the World Food Programme to help eradicate world hunger by means of a new programme, called Purchase for Progress. And while our discussion began with the specifics of global food aid, it eventually ranged beyond the particulars of poverty. “I believe in reason,” Sen told me. “There are those who want to repress reason: Christian, Muslim, and Hindu fun-
BMJ | 19-26 december 2009 | Volume 339
damentalists, and those who pick a totem market economy, the liberal economic state. These are all anti-reason.” Ironically, at the time of my visit to Cambridge the world’s markets were in the throes of one of the greatest food commodity bubbles of all times, a deeply unreasonable surge of speculation that had already doubled the costs of wheat, rice, corn, cooking oil, and numerous other staples and sparked food riots in 39 countries across the globe. Such price spikes in world food markets had little basis in rationality—the wheat harvest of 2008 eventually proved larger than any wheat harvest in human history. But the damage had been done—a quarter of a billion more people had been relegated to a status the “hungercrats” euphemistically call “food insecurity.” As world hunger numbers rocketed, the Gates Foundation and the World Food Programme continued to back Purchase for Progress, which has made a totem market economy a panacea for starvation. It is common knowledge 1387
EDITORIALS
Frederick Kaufman professor, City University of New York Graduate School of Journalism is 219 West 40th Street, New York, NY 10018, USA
[email protected] Competing interests: None declared. Provenance and peer review: Commissioned; not externally peer reviewed.
that markets do not always behave rationally, but that has not stopped one of the world’s premier capitalists and the world’s largest humanitarian organisation from pursuing various strategies to foster more robust grain markets in the world’s least developed countries. Indeed, one of their chief anti-hunger efforts centres around the creation of commodity markets.2 How can commodity markets resolve the tragedy of world hunger? In theory, the forward contracting methods developed by Purchase for Progress will give small farmers the opportunity to arbitrage—and thus stabilise—prices for their product. Instead of all farmers going to market at the same time of year, and thus driving post-harvest grain prices lower and lower, Purchase for Progress will provide the farmers of least developed countries a guaranteed sales price in advance of their harvest. Such price guarantees will provide a measure of financial security; collatoral for loans from local bankers; and thus the opportunity to purchase fertiliser, farm equipment, and perhaps even some day labour for the upcoming harvest. All this may sound like a pretty good idea, but programmes like Purchase for Progress take for granted the idea that free market dynamics can transform the indigent peasant into a bona fide agribusinessman, and that assured future sales of grain will increase output, help alleviate local conditions, and thus mitigate world hunger. But as the titans of global food aid seek solutions to mankind’s greatest health threat—a hunger related death every four seconds—they may do well to remember Amartya Sen’s warning and retain a healthy scepticism regarding the worship of a totem market economy. Free markets may have worked well for oligopolists like Bill Gates, but the World Food Programme cannot simply will them into existence. In fact, the imposition of commodity markets within the world’s least developed countries has a history of failure.3 It took hundreds of years for modern commodity markets to develop in London, Chicago, and New York, and these markets rode the back of heavy investments in infrastructure, transportation networks, and agricultural education. The Chicago Board of Trade may have facilitated American
farmers, grain storers, and millers in their efforts to produce and manage grain surpluses, but futures markets cannot resolve the intractable political, economic, and social ills of— for example, Uganda or Guatemala, and provide a short cut to food security. Such programmes will benefit bankers more than farmers, and perhaps further alienate the rulers from the ruled, an alienation that lies at the heart of hunger. Indeed, the dirty secret of world hunger is that the creation of a grain surplus is no solution. There is plenty of food on earth, more than double that needed to feed all 6.5 billion of us.4 The problem is not food availability, but price. People starve when the daily pay check doesn’t cover the daily bread. All of which is not to say that small farmers do not need our help. But instead of installing futures markets and teaching the nuances of arbitrage, Bill Gates and the World Food Programme might consider expending their manifold resources on emergency income creation and employment programmes. Perhaps even more important, small farmers and landless peasants need to be supported in their efforts to gain political voice and power. As Amartya Sen has often pointed out, there has never been a famine in a representative democracy.5 A political voice is often the shortest path to a full stomach. Finally—strange as it may seem—the best early warning system for a hunger crisis is not a futures market but a free press. Rulers do not like to see their starving subjects on the front page. Gates and the World Food Programme could spend their money to much better effect than on a programme like Purchase for Progress, because the totemic worship of liberal free market economics is not a reasonable solution to world hunger. And in this particular case, not being reasonable has fatal consequences. 1 2 3 4 5
Food and Agriculture Organization of the United Nations. The state of food insecurity in the world 2009. FAO, 2009. Kaufman F. let them eat cash. Harpers 2009;318:51-9. Adebusuyi BS. The stabilisation of commodity markets of interest to Africa. 2004. www.g24.org/Adebusuyi.pdf. McNeil DG. Malthus redux: is Doomsday upon us again? New York Times 2008 June 15. http://www.nytimes.com/2008/06/15/world/ americas/15iht-15mcneil.13714561.html. Sen A. Nobody need starve. Granta 1995;52:213-20.
Where have all the hospital flowers gone? They have fallen victim to new definitions of care PROFESSIONAL MATTERS, p 1442
Simon Cohn medical anthropologist, General Practice and Primary Care Research Unit, Institute of Public Health, Cambridge University, Cambridge CB2 0SR
[email protected] Competing interests: None declared. Provenance and peer review: Commissioned; not externally peer reviewed. Cite this as: BMJ 2009;339:b5406 doi: 10.1136/bmj.b5406 1388
Christmas is a time for giving, so it is timely to consider the reasoning behind the extensive and growing ban on giving flowers to patients in hospital. The article by Giskin Day and Naiome Carter describes how both individual wards and entire hospitals are using their discretion to prohibit flowers on the ward, in the absence of any official ruling from the Department of Health.1 It is undoubtedly causing consternation for patients and visitors alike. The reasons for such prohibitions are varied, something that should immediately make us curious. As Day and Carter point out, some argue that it is about reducing the risk of injury from broken glass, or avoiding the depletion of oxygen in the air from decomposing
material, or even avoiding water spillage over modern electronic equipment. In addition, some staff cite the inconvenience of changing water regularly and the problems of disposing of dead flowers. Unsurprisingly, in the context of invigorated concern around hospital cleanliness, the most common explanation relates to hygiene—that either the flowers themselves, or the water in their vases, carry a risk of infection. However, none of these explanations has a secure evidence base. Although it is not surprising to learn that flower water can contain bacteria,2 3 rigorous studies have emphatically concluded that bedside flowers pose no particular threat to health.4 But what is of interest is just how widespread the bans are, despite the evidence. BMJ | 19-26 december 2009 | Volume 339
EDITORIALS
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Post hoc rationalisations of practices seem, by definition, logical and sensible—using partial bits of knowledge to mask, often from the protagonists themselves, the fact that an a priori decision was based not on facts but on values. For this reason, even compromises such as those Day and Carter present—for example, specifying the best kind of flowers or designating a shared common place—are no less perplexing, because they indirectly reinforce the idea that flowers are essentially inconvenient or pose some kind of hazard. Of course, this may not seem particularly important for hospital staff in the context of their extensive responsibilities, and we should be sympathetic to this. But the matter is important to patients and their visitors. The point about giving is that it reinforces meaningful relationships of love and friendship.5 And hospital gifts are perhaps even more nuanced than this. Firstly, the gifts are traditionally ephemeral in nature—whether flowers, fruit, or chocolate, there is something reassuring about them lasting a finite period, echoing the hope that soon the patient will recover and head home. Secondly, although giving flowers can be a sign of private intimacy, in a hospital setting the flowers also publically demonstrate social ties beyond visiting hours. A patient looking at a bouquet doesn’t just see the flowers but the person who gave them. And a nurse or doctor is often part of this—remarking on the gifts in small talk, and consequently becoming entangled in a comforting form of interaction. The apparent intransigence of hospital staff in the face of evidence suggests there might be more to this ban than merely the flowers themselves. In anthropological terms, hygiene is not defined by things being essentially “dirty,” but by things being perceived to be in the wrong place6—for example, soil is fine in the garden but dirty when on the carpet. So how is it that although flowers were once fine at a hospital bedside, they are suddenly in the wrong place and therefore unclean? Perhaps it is because flowers can mark out a small personalised space, domestic and non-clinical,
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where a different mode of relating can take place, and it is this that is really out of place on a modern ward. Underlying all the explicit arguments, the decision to ban flowers seems to reflect a much broader shift towards a model of care that has little time or place for more messy and nebulous elements.7 The development is not the articulation of rational science but increased rationalisation in the sociological sense, which equates with technical efficiency coupled with greater bureaucracy and accountability. The practice of healthcare delivery—with more prescriptive guidelines and targets, greater demands on time, and more explicit professional roles—means that there is simply not room for the more vague, apparently superfluous, practices on a well functioning ward. The flowers have been elbowed out. And so, in the context of health priorities, such an apparently inconsequential policy reflects a more general shift in current definitions of care. At this time of year, despite all the calls of commercialisation and trivialisation, in truth most of us still value ritualised contact with loved ones and the demonstration of relationships through giving and receiving. Perhaps, then, now is a good time to think about a broader version of care that increasingly needs to be protected on the ward and within the everyday practices of a hospital. Such a version of care would be thought of not as an outcome that can be delivered but as a relationship that can be exchanged. 1 2
3 4
5 6 7
Day G, Carter N. Wards of the roses. BMJ 2009;339:b5257. Kates S, McGinley K, Larson E, Leyden J. Indigenous multiresistant bacteria from flowers in hospital and nonhospital environments. Am J Infect Control 1991;19:3156-61. Taplin D, Mertz P. Flower vases in hospitals as reservoirs of pathogens. Lancet 1973;302:1279-81. Gould D, Chudleigh J, Gammon J, Ben Salem R. The evidence base and infection risks from flowers in the clinical setting. Br J Infect Control 2005;6:18-20. Mauss M. The gift: forms and functions of exchange in archaic societies. London: Routledge, 1990. Douglas M. Ritual uncleanliness. Purity and danger. London: Routledge, 1966. Mol A. The logic of care: health and the problem of patient choice. London: Routledge, 2008.
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ecent Years have seen a Catalogue of Plagues and sundry other Contagions. Hard on the scaly Heels of Avian Flu follows Global Warming, Swine Flu, Obesity, and now the Economic Plague. This Litany of Woes has affect’d me deeply, as these few Entries from my Diary this past Year shew.
5th April
Rose early to enjoy reading the latest Bill of Mortality of Estate Agents in the Parish of St. Giles’s, which show’d again a monthly Increase. The Bankers, too, have this past Year been struck low, and it transpires that their Understanding of the term “Bank” has left much to be desired; they have been sinking our Shillings in miscellaneous crackpot Schemes in the Colonies that few understand, and fewer profit from: to wit, Hedge-Funds, Subprime Mortgages, Ponzi schemes, Plans to build golden Stairways to the Moon, and God knows how many other feeble minded Schemes. Fearful of my own Savings, I visited my Bank in the Strand this Morning, only to find to my Dismay the Building lock’d up with a large “X” marked roughly upon the Door. I rapped loudly, and Mr Madoff put his Head out the Window. When I demanded to withdraw my Savings he tossed me a Florin, saying insolently, “This is what is left, Defoe, use it wisely. Remember, past Performance is no Guarantee of future Results—as I told you when you invested, the Value of your Savings can plummet, as well as fall briskly,” and with that he slamm’d the Window with a hollow Laugh. On close Examination I discovered the Coin to be but a poor Fake, bearing the Head not of our beloved Monarch but of one Fred the Shred, who some claim help’d land us up to our Necks in the financial Privy in the first Place.
12th May
Walked deep in Thought to the Tavern. Much Talk there of the Change in the Climate and the dire Consequences for the Publik Health. However the Country’s best Brains are at Work to identify Remedies, and I am heartened to read in a Broad-sheet that the Fashion World has come up with a Solution: viz, new “flood length trousers” which keep the wearer’s Hems out of the rising Waters.1 We need no longer live in fear of Flooding when the Fashion Industry is working so assiduously on our Behalf. (Mem: To Payment to Tailor for Reduction of Trousers to knee Length: 5 shillings) 1390
6th June
Up betimes and stroll’d down the Strand, only to be assail’d by the dismal Sight of formerly prosperous Bankers and Estate Agents begging for Alms. At Aldgate I was approach’d by one in Rags outside the Coffee House, who seiz’d me by the Elbow and hoarsely ask’d for the Price of a skinny venturi decaff soya latte with cream, an extra shot, and coffee on the side. Not to drink, mind, but simply and intransitively “To go.” It would be a harder Heart than mine that could turn down such a low Wretch and I toss’d him a Florin, which he bit to test its Soundness. Would that the Bankers had always been so careful.
7th June
Read in a Broad-sheet that a Banker has choked to Death on a counterfeit Florin in St. Giles’s. 2
3rd July
Remembering that a previous Plague—to wit, the Foot & Mouth—was combat’d by burning all our Cattle, and that we had to wipe our Feet when visiting our Country Estates, I am seiz’d with a Plan: viz, that all avian and porcine Visitors to the Country should wipe their Feet upon entering and that all those already here should be incinerated forthwith. In this latter Endeavour I intend to enlist the help of Britain’s many Fried Pullet and Braised Offal emporia. Three tallow Candles did I exhaust, as many Quills, and a night’s Sleep dismiss, in the fever’d Exposition of my proposal. I dispatched my Opus— extending to ten Quires of copperplate Manuscript—upon the Tea Clipper Sea Difficile bound for the English Colonies in America, for Consideration by their most highly esteem’d New England Medical Intelligencer. My Fortunes assured, I retired in high Spirits to my local Tavern, the Winter Swallow, to partake of a majestic Supper, before which I was entreated by the Victualler, “Goeth ye large? ‘Tis but a Ha’penny more.” The Inn’s recent Refurbishment with sturdy oak Furniture, reinforced against Obesity,3 will be viewed by future Generations as prescient and of much Comfort and Benefit to our expanding Populace. Doctors of Physik today are wont to say that Corpulence, like Plagues before it, is borne of an “obesogenic miasma.” Such an Observation is self evident, and any Man may test its Veracity. I, myself, found recently that after partaking of frequent long Walks in the Highgate Countryside I had need to entreat my Tailor to take in the Waistband of my Breeches. The only rational BMJ | 19-26 DECEMBER 2009 | VOLUME 339
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Explanation must be that the fresh and vital Air of Hampstead Heath is unpolluted by the “portly Odours” of the City.
1st September
Scarcely had the Difficile docked in New England than her sister Ship, C Shanty, return’d to London bearing Missives from the Referees of the Intelligencer. These discharged upon my Paper such Bile that I was sorely tempted to dispatch a quicke Response on the first Schooner at Dawn. The Referees’ Comments moreover were accompanied by an insolent Memorandum to the Effect that they receive many Epistles such as mine, and that unfortunately they can print only a sparse 10 per cent of them, etcetera. I replied by Return, saying that their Gross Inefficiency is not my Concern, and further drew their Attention to the Fact that I receive many such rejection Letters, but unfortunately I, too, can only accept 10 per cent of them.
2nd September, post meridian
With renewed Spirit, I consider’d the Views of my New World Critics and set down to draft again my Manuscript. Deftly, I filleted the Piece to one twelfth its original Length while introducing a fanciful Conclusion—to wit, that the Swine Flu might be attenuated through Variolation of the Sort that has been used to curb the Small Pox in Asia since the first Millennium. My Revision includes many clear Messages for Policymakers, Practitioners, Quacksalvers, Mountebanks, Poultry-keepers, Pill Merchants, and sundry other Busybodies, as required. To avoid any Delay by His Majesty’s Royal Mail—I admit, a most unlikely Eventuality—I dispatch my Footman, Lance, to Camden Lock, where a prestigious Journal— yet one of somewhat less Standing than the Intelligencer— has its Offices.
3rd September, ante meridian
I find this morning that my latest modest proposal too has been rejected by the onion-eyed Hedge Pigs4 who run this Penny Dreadful, and I repair to The Polar Bear & Wellingtons to mull over the sundry global Catastrophes which befall us and, more pressingly, to consider whether they afford me any Opportunity for Publication. I dash off a short Missive of Appeal for Consideration of my Paper.
20th December
Christmas draws nigh, and since my last Intervention, nothing but Silence from the Sots at the Journal, who no doubt are in their festive Cups instead of inking the Printing Presses. I repair to The Pig and Tamiflu for a small Cordial and to consider my few remaining Options.
21st December, ante meridian
A great Anxiousness afflicts me after a Night of diabolical Fever and I fear that I am finally succumbing to that most dreaded Distemper, the swine Pestilence, or, as it is now widely known, “The Pink Death.” From my Sick
Bed I draft my Obituary, in which, with sincerest Modesty, I detail my glorious Achievements, Laudations and major Contributions to the World. I enclose a small woodcut Likeness of my Visage, seal the whole with Wax, and dispatch it to a local but respectable Journal—though a modest one of considerable less Impackt, again—the Provincial Medical and Surgical Journal.
21st December, post meridian
Feeling much the better. Perchance the increasingly unseasonal meteorological Conditions, in which the Temperature of London has reached 80 degrees Fahrenheit in the Shade, accounted for my Feverishness; for it seems I am to be spared. While taking Afternoon Tea, a Messenger from the Provincial Medical and Surgical Journal is shewn into my Study, bearing a dainty folded vellum Notelet. Its Message can barely be deciphered having, it appears, been impressed by a very worn India rubber Stamp and not written out, proper. “Thank you for taking the Time to consider our Journal for your Obituary,” its single Sentence begins, “But we feel there would be insufficient Interest among our Readers for your Artickle.”
23rd December
I console myself by spending my last 12 shillings in The Sty in Quarantine; and thankfully after downing the first two Pints of Port, much of the Rest of the Evening, and indeed this sorry Year, remains a Blur. (I have a discomfiting Memory of a semi-naked Man lying in Russell Square Fountain holding a half empty Port Bottle, and singing “Deck the halls” or a Version thereof).
24th December
Mem: To purchase of Tincture of Willow Bark: 2 shillings; Laundry of sundry Items of wet and soil’d Clothing: 6 shillings; To postage of numerous Letters of Apology to Residents of Russell Sq: £0-12-6. Mark Petticrew chair in public health evaluation, London School of Hygiene and Tropical Medicine, London WC1E 7HT David Morrison director, West of Scotland Cancer Surveillance Unit, Section of Public Health and Health Policy, University of Glasgow, Glasgow G 8RZ References are in the version on bmj.com
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Modern medicine has failed to take account of one of history’s most fundamental rules and the lessons of a neglected 16th century philosopher, write Tony Hope and Dominic Wilkinson Iudico potere essere vero che la fortuna sia arbitra della metà delle azioni nostre, ma che etiam lei ne lasci governare l’altra metà, o presso, a noi. [I believe that it is probably the case that fortune controls half of what we do, but she allows the other half to be controlled by ourselves.] Niccolò Machiavelli, 1513 (published 1532) Modern medicine attempts to exert control over outcomes. It is the intellectual descendant of Machiavelli. But are such attempts to manipulate and minimise chance futile, do they risk making the worst outcome more likely? Such questions were anticipated and debated five centuries ago by a contemporary of Machiavelli, now largely forgotten, the Italian philosopher Girolamo Di Sod.
Girolamo Di Sod Di Sod was born in Florence to a poor aristocratic family, towards the end of the 15th century. He was almost certainly in correspondence with Machiavelli before the age of 20.2 With Machiavelli’s support, he was invited to take part in the literary gatherings at the Oricellari Gardens, where he engaged with some of the finest political thinkers of the age. Although none of Di Sod’s works has survived, descriptions by other members of Orti Oricellari suggest that he was both brilliant and eccentric. He studied with the Franciscan Luca Pacioli who 1392
NUNEZ DE VILLAVICENZO: BOYS PLAYING DICE/PC/CHRISTIE’S/BAL
Will it all go wrong? Sod’s law applied to medicine
DI Sod, not playing dice
had, a decade earlier, written the first printed work to discuss probability.3 However, Di Sod quickly transcended his teacher in his efforts to quantify and control the element of chance. One of Di Sod’s most distinctive views related to the conservation of personal fortune—episodes of fortune must be balanced by episodes of misfortune. He developed a pathological fear of gambling, convinced that good luck in such games might hasten his death. This fear, commented on by his contemporaries, gave rise to a common aphorism in the 16th century (later misquoted by Einstein), “Di Sod does not play dice.” Di Sod’s behaviour became progressively more extreme, including the imposition of severe dietary restrictions (he ate only plain bread) and insistence on wearing weatherproof clothing in the height of summer.4 In his last years he wore a metal helmet while riding his horse in case of falls. The circumstances of his early death in his late 20s are unclear, but one report suggests that he may have been the victim of a lightning strike.5 If so, his customary head covering may have contributed to his demise—a striking confirmation of his famous law.
What is Di Sod’s law? None of Di Sod’s writings survives. The sad irony is that Di Sod, determined that his writings should survive beyond his death, stored them in a fireproof box
in a locked safe at the centre of his house. However, it seems that the manuscripts were lost during the siege of Florence in 1529, two years after his death. The keys to Di Sod’s strong box (which he had stored in several hidden locations in the house) could not be found in time to save the work before the house was demolished.4 Di Sod’s major work “In un’istanza di sventura” (On the instantiation of misfortune) has been lost. What we know of his famous law comes from secondary sources. What we find are references to examples of its operation, and we must infer its content from these examples. Modern statements of the law do not do justice to the depth of Di Sod’s thinking. None deals with the important issues with which Di Sod and his contemporaries were struggling: the epistemological status of the law; the underlying causal mechanisms of the law; and, crucially, the limits of human agency in the events of history.
Di Sod and Machiavelli Any analysis of the law must start from an understanding of Di Sod as a critic and intellectual combatant of Niccolò Machiavelli. Machiavelli had seen his beloved Florence decline from a powerful and independent city state to become a second rate power under domination from Spain and later France. He sought to understand the role of human agency in such changes: specifically how BMJ | 19-26 december 2009 | Volume 339
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LORENZO LOTTO: PORTRAIT OF A GENTLEMAN, GALLERIA DELL ACCADEMIA, VENICE/BAL
makers (Fratellanza dei costruttori di ombrelli), who, in the 18th century, marketed their leather umbrellas to farmers citing Di Sod and claiming that the purchase and use of an umbrella would ensure long periods of sunshine.
Expecting the worst, and not disappointed
the behaviour of rulers can affect outcomes for good or for bad. Di Sod’s reading of history profoundly opposed that of Machiavelli. Where Machiavelli saw failure of proper leadership, Di Sod saw the unrolling of events outside human control. Where Machiavelli saw examples of successful leadership, Di Sod saw only temporary success followed by disaster. Di Sod came to two central conclusions: the powerlessness of human agency and a general pessimism about the effects of events on human aspirations. All historians since Di Sod, whether they agree with him or oppose him, have had to take a view on both these matters.
How should Di Sod’s law be understood? So where does this leave us with regard to an understanding of Di Sod’s law? There have been, broadly, four interpretations. Empirical prediction “Each individual misfortune, to be sure, seems an exceptional occurrence; but misfortune in general is the rule.”6 A common example of Sod’s law is that toast will usually fall butter side down. This is a testable empirical prediction.7 The generalised form of this interpretation is that if there are two or more possible outcomes the most likely is the one that is judged to be the worst.
What humans notice According to this interpretation, Sod’s law tells us more about ourselves than about the external world. We notice when the toast falls butter side down in a way that we do not notice when it falls butter side up: we are more aware of bad outcomes than of good ones.8 Human judgment According to this view we tend to judge whatever happens in a negative way.9 If toast usually falls butter side down then we judge this to be the worse side for it to fall. We could have considered it better for toast to fall butter side down because, if it does, we notice the accumulated detritus (dog hairs, grit, nail parings) and throw it away, thereby avoiding any risks to health. According to this interpretation, the toast falling butter side up would be the worse outcome because we would probably make some ineffectual attempt to brush the toast and then eat it, thereby exposing ourselves to the risk of disease. As an exhortation to prepare for the worst According to this interpretation, Di Sod’s law is an elliptical way of stating how we should think or behave. If we prepare for the worst, the worst will be less likely to happen, and if it does, we will be less psychologically affected by it. This is the interpretation of the Italian guild of umbrella
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Implications of Di Sod’s law for medicine As will be clear there are two profoundly opposed conclusions to be drawn from these interpretations—that bad outcomes can be reduced by appropriate preparation (the last interpretation above) or that we can do nothing to reduce bad outcomes (the other three interpretations). The first conclusion, favoured by Leibniz, implies that a systematic scientific approach to medicine may enable us to create the best possible world10: assiduous attention to the latest evidence averts misfortune for our patients. The second conclusion, favoured by Schopenhauer,11 is that misfortune is inevitable. This implies that seeking the best evidence to guide medical treatments is at best useless and at worst may increase the chances that we will get it wrong. For example, antihypertensives may produce clear benefits in trials, but in clinical practice they may lead to worse outcomes—for example, causing patients to fall and fracture their hips. Conclusion Attention to his pessimistic outlook gives credibility to the view that the correct interpretation of Di Sod’s law is that misfortune is inevitable. If this view is correct it has profound implications for epistemology. It implies that if we view knowledge as providing us with tools to change outcomes, then no true knowledge exists. Evidence based medicine is an illusion that has no valuable effect on the care of patients. In other words, in the end we know Di Sod all. As a footnote we would like to emphasise the irony that Di Sod has virtually been written out of history. It is only in Britain, Australasia, and a few other places that his famous law is known by his name. Even in his native Italy it is named after the American engineer, Murphy, who lived four hundred years later.12 Modern uses of Murphy’s law lack completely the profundity of Di Sod’s law and are little more than cocktail party banter. Tony Hope professor of medical ethics and honorary consultant psychiatrist, Ethox Centre, Department of Public Health, University of Oxford, Oxford OX3 7LF
[email protected] Dominic Wilkinson Oxford Nuffield medical research fellow, Oxford Uehiro Centre for Practical Ethics, Department of Philosophy, University of Oxford OX1 1PT Competing interests: None declared. Provenance and peer review: Not commissioned; externally peer reviewed. This paper arose from speculation over a theinated beverage about the origin and meaning of Sod’s law. Neither of the authors is a medieval scholar or Italian speaker, and it is possible that they may have misunderstood or just made up some of the details about Di Sod’s life. Contemporary references are more reliable. Tony Hope is the guarantor, and guarantees that it will rain if he forgets his umbrella. References are in the version on bmj.com Cite this as: BMJ 2009;339:b5299 1393
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Patent medicines and secret remedies As arguments between doctors and advocates of alternative medicine continue, Jeff aronson describes how the secret ingredients of patent medicines were uncovered a century ago
P
atent means open (box 1), but patent medicines have traditionally contained secret ingredients. The Oxford English Dictionary defines a patent medicine as “a proprietary medicine manufactured under patent and available without prescription.” However, the term and its current definition are historically misleading. From the start, the hallmarks of patent medicines were that they were advertised direct to the public and sold over the counter. They were rarely patented because it was advantageous to be secretive about ingredients that were often ineffective and even hazardous. If a product had a patent it was generally because the remedy was effective—Epsom salts, marketed by Nehemiah Grew in the late 17th century, contained magnesium sulphate as a purgative. Patent medicines could be purveyed by physicians and apothecaries or by unqualified quacks, mountebanks, and charlatans (boxes 1 and 2). Historian Roy Porter suggested that between 1600 and 1850 there were more similarities than differences between quacks (“less cheats than zealots”) and regular practitioners,2 an assertion that is borne out by the history of patent medicines. Sales of patent medicines burgeoned during the 18th century. They were often named after their inventor (Swaim’s Panacea, Turlington’s Balsam of Life); after a famous, but often conveniently dead, practitioner (Dr Boerhaave’s red pills, Dr Radcliffe’s drops), or after the place of origin (Epsom salts, California vinegar bitters). The name might include the source of the
medicine (Clark Stanley’s snake oil liniment) or its supposed indication (Dr D Jayne’s expectorant, Mayr’s wonderful stomach remedy). Exoticism could be an advantage (Indian panacea, Green Mountain magic pain remover). Advertisements for such products, promoting (?) their value in wide ranges of conditions, indeed often for all conditions, might be accompanied by recommendations from patrons—Dr Scott’s bilious pills had benefited “the Dukes of Devonshire, Northumberland and Wellington, the Marquesses of Salisbury, Angelsea, and Hastings, the Earls of Pembroke, Essex and Oxford and the Bishops of London, Exeter and Gloucester.”4 Testimonials from grateful patients were also cited— an advertisement for Lydia Pinkham’s vegetable compound for women stated, “Lydia Pinkham’s private letters from ladies in all parts of the world average one hundred per day.”5
Secret remedies yesterday Regular practitioners have always been critical of patent medicines. In 1790, for example, James Adair, a Scottish physician, published a scathing indictment.6 “Many persons have been destroyed by quack drugs,” he wrote, “but dead men tell no tales.” He and others pointed out that quack medicines contained conventional treatments (such as opium and ipecacuanha in Dover’s powder), poisons (such as hemlock), or nothing of value whatsoever. However, during the second half of the 19th century, with the rise of the chemicals industry and the consequent beginnings of drug com-
panies, such as Hoechst and Bayer in Germany and Burroughs–Wellcome in the UK,7 the criticism became more intense and evidence based. Pharmacology (the word dates from the start of the 18th century8) was becoming scientific. In America, concern about adulterated and misbranded foods and drugs culminated in the publication of 11 articles by Samuel Hopkins Adams in Collier’s Weekly in 1905, titled “The Great American Fraud,” in which he exposed many of the false claims made about patent medicines. This led directly to the 1906 Pure Food and Drugs Act. Doctors, supported by the American Medical Association, then published robust criticisms of the purveyors of patent medicines. They were met by a riposte in the form of a pamphlet, published by the Proprietary Association.9 The Proprietary Association collected newspaper reports of adverse events, including deaths that had been attributed to various medicines, and claimed that patent medicines were less dangerous than other medicines. Something of the flavour of this report emerges from the data on whiskey and alcohol (84 cases, 61 deaths) and Cannabis indica (one case, no deaths). In the UK, patent medicines had been specifically excluded from the Pharmacy Act of 1868 and the Sale of Food and Drugs Act of 1875, and their contents could therefore be kept secret.10 11 Many of them, such as Battley’s
Box 1 | Etymologies Patent comes from the hypothetical Indo-European root PET, to spread or open out. Petals spread out; patellas, spatulas, and spades look like open dishes; space is an open area; and paella is cooked in an open pan. According to the Oxford English Dictionary, letters patent (Latin litterae patentes) were originally open letters from a monarch or government, intended “to record a contract, authorize or command an action, or confer a privilege, right, office, title, or property”; the term then came to mean documents that grant “for a set period the sole right to make, use, or sell some process, invention, or commodity.” It was subsequently shortened to patent. Quacks, originally quacksalvers, supposedly quacked or boasted about their salves; a mountebank was a man who would mount a soapbox (Italian: montare in banco) to shout his wares at a fair; charlatans were wont to prattle (Italian: ciarlare) about their medicines1
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Box 2 | History of apothecaries Apothecaries were originally members of the grocers’ livery company. However, during the late 16th and early 17th centuries, under the leadership of Francis Bacon and the Huguenot refugees Gideon de Laune and Théodore Turquet de Mayerne, they sought to secede. Eventually, the Worshipful Society of Apothecaries of London was incorporated by royal charter of James I on 6 December 1617, although it continued to be allied to the Society of Grocers. The grocers stocked perishable goods, the apothecaries non-perishable ones, including spices, sweetmeats, preserves, and medicines. Apothecaries purveyed and compounded drugs, dispensed physicians’ prescriptions, and charged for medicines. Physicians employed apothecaries or used them as required and charged for consultation and advice. The decision of the House of Lords in 1704 in the case that the College of Physicians brought against an apothecary called William Rose, accusing him of administering medicines without licence from the college, without the direction of any physician, and without taking or demanding any fee for his advice, established that apothecaries could independently prescribe and dispense medicines. The college’s monopoly was broken.3 In 1711, the Worshipful Society of Apothecaries was established as a separate livery company.
the hallmarks of patent medicines were that they were advertised direct to the public and sold over the counter. they were rarely patented because it was advantageous to be secretive about ingredients that were often ineffective and even hazardous
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sedative solution, Daffy’s elixir, and Godfrey’s cordial, contained opium, and their sales increased. In the 1880s, therefore, doctors, supported by Ernest Hart, editor of the British Medical Journal, started to campaign against this abuse. A Patent Medicine Bill in 1884, which would have controlled these products, failed because of pressure from the Society of Chemists and Druggists. Undaunted, the campaigners used as a test case Dr Collis Browne’s chlorodyne, which contained chloroform, morphia, tincture of Indian hemp, and prussic acid and was responsible for a large number of cases of poisoning. The chairman of the parliamentary bills committee of the British Medical Association sent a memorandum to the Pharmaceutical Society, the Society of Apothecaries, and the General Medical Council, attacking patent medicines in general and chlorodyne in particular. Questions were asked in the House of Commons in 1891, to no avail. However, the parliamentary bills committee then persuaded the Treasury’s solicitor to prosecute the manufacturers of chlorodyne. The magistrate defined a patent medicine as one that was issued with a government patent. Chlorodyne, having no such patent, therefore came under the 1868 Pharmacy Act. What had once been secret became open. The manufacturers were fined for marketing a scheduled poison. Other similar patent medicines were thus brought under the act
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Although the ingredients of UK patent medicines are now stated on packets, the information will mean little to most consumers, and important information may in any case not be available Although a select parliamentary committee was subsequently appointed to investigate patent medicines, it published its report on 4 August 1914, when public attention was focused not on Dr Boschee’s German Syrup, but on Germany itself; its recommendations were not pursued.18
Secret remedies today Two Latin tags summarise the success of patent medicines, even today. The first, omne ignotum pro magnifico (ignorance makes everything look superb), was quoted in the preface to the first volume of Secret Remedies. The second, populus vult decipi (the public wants to be deceived), appeared as the legend to an early 17th century engraving by the Dutch artist Jan van de Velde, showing eager customers clustering around a quack and his wares. In 2007, American adults spent $12bn consulting practitioners of
complementary and alternative medicine and $22bn buying their products.19 Although the ingredients of UK patent medicines are now stated on packets, the information will mean little to most consumers, and important information may in any case not be available. The two volumes of Secret Remedies constituted a landmark publication in the control of over the counter medicines. Their story has modern resonances. Nostrums are still available over the counter. Perhaps another edition of Secret Remedies is needed. Jeffrey K Aronson clinical pharmacologist, Department of Primary Health Care, University of Oxford, Oxford OX3 7LF
[email protected] This article is based on JKA’s Gideon de Laune Lecture, given to the Society of Apothecaries in 2008. Competing interests: JKA is president of the British Pharmacological Society, a member of a NICE technology appraisal committee, and a member of the formulary committees of the British National Formulary and the British National Formulary for Children. The views expressed here are not necessarily shared by those organisations. Provenance and peer review: Commissioned; not externally peer reviewed. References are in the version on bmj.com Cite this as: BMJ 2009;339:b5415
See editorial, p 1386
Examples of secret remedies16 17 Product Blair’s gout and rheumatic pills
Claim “Immediate relief and cure of acute and chronic gout, rheumatism, suppressed gout, rheumatic gout, gouty skin diseases, bronchitis and asthma, sciatica, lumbago, and neuralgia” Damaroids “A safe and sure remedy for general weakness, spinal exhaustion, neurasthenia, physical decay, and loss of nerve power” Pink Pills for Pale “When the muscles and nerves are tortured by poisons in the blood, be People the result rheumatism, sciatica, or lumbago … anaemia, indigestion, palpitations, influenza’s after-effects, eczema, sciatica, St Vitus’ dance, spinal weakness, the many forms of nervous disorders dreaded by men; also the special ailments of women” “Professor” O Phelps “For the positive and speedy cure of epilepsy or fits, dyspepsia, Brown’s vervain indigestion, all derangements of the stomach and bowels, and for every restorative assimilant form of debility” Wood’s cure for “Tobacco habit conquered in 3 days” tobacco habit
Stated contents Powdered Colchicum corm, burnt alum
Price (cost of manufacture)* 1s 1½d(
