Bad Medicine

 As I have been reading, scanning, and transcribing letters written by the Edward McCarty Armstrong family in the last three decades of the nineteenth century, I have been struck by the descriptions of disease and death. The letters are full of references to epidemics of yellow fever and scarlet fever, to the deaths of neighbors, friends, and relatives, and to medicine administered to aid the sick, the depressed, the fatigued. My husband's great-grandfather, Baker White Armstrong (Sr.), was a practicing pharmacist in the last two decades of the 1800s, and his older half-brother William Dillon Armstrong was a physician, as is noted on his tombstone. "Brother Will" was often called out to the Armstrong farm, "Edgewood," to administer aid when a family member was ill. And in our collection of family letters, clippings, and photographs is a pocket notebook of Baker Armstrong's, full of handwritten recipes for pharmaceutical concoctions. We look at those drug recipes today and may think they represent magical thinking more than medicine, but perhaps we aren't so far removed from that magical thinking ourselves.

In the summer of 1883, James (Jimmie), one of Edward's sons from his first marriage to Hannah Pancake, was very ill and went to the home of his father and stepmother for care. His wife, Agnes, pregnant with a son who was to be born three months after his father's death, was there with him. The letters of the family to Baker, who was then living in Baltimore, Maryland, reference Jimmie's illness. Louisa, Baker's mother and Jimmie's stepmother, described some of the details in a letter of June, 1883:

Jimmie is a little easier. William drove him to town for a little while on Friday. The ride did not hurt him we think but he has been much worse since Saturday -- not able to be out of bed. He suffers terribly at times & can be relieved only by Opium. To-day he had been suffering from nausea & vomiting but is somewhat relieved now. William has been with him since 2 o'clock Saturday except for a few hours yesterday evening. He is so changeable -- we do not know one hour what he will be the next. We fear he is in a critical condition; but do not say so to any one but Robert.

In the back of her Bible, Louisa Tapscott White Armstrong recorded the death of her stepson: "James A. Armstrong died July 14th, 1883, about 5 p.m."

In January of 1885, Katie Armstrong, youngest daughter of Edward and Louisa Armstrong, insisted on attending a church "protracted" meeting even though she hadn't been feeling well.  Her father describes the result in a letter of January 27, 1885, to his son Baker, then living in Bryan, Texas.

Mr. Gordon was holding a protracted meeting in Salem and [Katie] and Janie went down to attend it on Tuesday the 13th day of this month and was to return on Thursday to let Fannie and Nettie go down, but the sleet prevented, and they did not go down or get home, until Friday. Katie complained much of her headache and backache when she started to town but was so anxious to attend the meeting, that she went. She attended all the meetings but two, and came home much complaining on Friday. William saw her and gave her some medicine and thought she would be well in a day or two, but she did not get better and William sent her more medicine, and came out to see her on Tuesday the 20th. He treated her but did not think her case serious. That night he got a telegram calling him to see Mrs. Robert Glasgow, who was critically ill. He went, supposing Katie would be all right when he returned, but for fear he might be mistaken, he saw Dr. Bruffey  before leaving, and Bruffey came up in his stead (when we sent for William [the] next day). William returned Thursday night . . . . but nothing they could do seemed to arrest the disease. Delirium came on, and blood poisoning commenced and continued to the end and no remedy seemed to prove efficacious and she quietly and peacefully passed away last night . . . Her dissolution was very rapid . . . I had no idea she would pass away during the night, but her strength gave way, and she breathed her last. O so peacefully and calmly, her life seemed to ebb away, just like the going out of a candle. . .

Katie Armstrong was nineteen years old when she died. Her mother recorded her daughter's death in her Bible: "My dear Katie died Jan. 26th, 1885, at 20 min. past nine P. M. We sorrow not as those who have no hope. She had given herself to Christ some years before."

Many of the Armstrong letters also reference Louisa Armstrong's illness, which lingered for over a decade of letter-writing. What she suffered from is not clear from the descriptions, but she spent weeks at Yellow Sulphur Springs, Virginia, seeking respite from her illness in 1874, and in the years up to her death in 1887, various siblings update Baker on how well or how badly their mother is feeling.

Who knows how many of these family members would have survived their illnesses if they had had access to modern medicine, perhaps to penicillin, which wasn't distributed in significant amounts until World War II. Other illnesses might have been caused by the very medicines being prescribed by doctors and pharmacists. In her letters, Louisa Armstrong mentions the "blue mass" pill, a popular medicine at the time that was administered for illnesses ranging from depression to tuberculosis to toothache to the pains of childbirth. In a letter to her son Baker, dated July 15, 1874, Louisa writes that she is "anxious about [your Pa]" and advises Baker to tell his father "he had better take some more blue mass."

The main ingredient in the blue mass pill was mercury, and, according to an article on the National Geographic News website, this pill "[i]f taken at the normally prescribed dose of the time—one pill two or three times a day—. . .would deliver nearly 9,000 times the amount of mercury that is deemed safe for people by current health standards" ["Did Mercury in 'Little Blue Pills' Make Abraham Lincoln Erratic?," Hillary Mayell, for National Geographic News, 17 July 2001]. A typical U. S. pharmaceutical recipe for the blue mass pill contained "mercury (33 parts), powdered liquorice (5 parts), althaea (root of the marshmallow)(25 parts), glycerin (3 parts), honey of rose (34 parts)" ["UK Lab Reveals Shocking Mercury Level in Lincoln's Blue Pills," Royal Society of Chemistry press release, 22 March 2010]. According to Dr. Norbert Hirschhorn, a New York medical historian, the blue mass pill was "really the Prozac-plus of the time because [doctors] used it to treat a lot of conditions . . . for anything they thought was related to the liver."  But the blue mass pill "only poisoned you," and its effects could include "decreased brain-wave activity, irritability, depression, memory loss, and impaired kidney function." [Jeremy Manier, "For Lincoln, ancient cure worse than his malady," Chicago Tribune, 17 July 2001]

Reading of how frequently such poisonous concoctions were prescribed and ingested may horrify us, but then we may wonder what medical procedures touted as effective today will be proven just as ineffective by researchers in the future. Recent studies indicate we may be at the mercy of ineffectively administered cures just as our ancestors were. In his book, Bad Pharma: How Drug Companies Mislead Doctors and Harm Patients, Ben Goldacre, British physician and science writer, explores how the pharmaceutical industry manipulates the science of drug research, with a deleterious effect on the practice of medicine. In an excerpt from the book published in Salon, Goldacre describes how clinical tests supported by pharmaceutical companies usually conclude positively in favor of the method or drug that the pharmaceutical company is promoting. These positive conclusions can result from conducting faulty research, from suppressing negative results, from choosing participants who are more likely to respond favorably to the treatment being tested,  from halting research before it yields negative results, or just from failing to publish negative results.

Dr. Goldacre writes:

Because researchers are free to bury any result they please, patients are exposed to harm on a staggering scale throughout the whole of medicine, from research to practice. Doctors can have no idea about the true effects of the treatments they give. Does this drug really work best, or have I simply been deprived of half the data? Nobody can tell. Is this expensive drug worth the money, or have the data simply been massaged? No one can tell. Will this drug kill patients? Is there any evidence that it’s dangerous? No one can tell. ["Bad Pharma: Drug research riddled with half truths, omissions, and lies,", in Salon, 27 January 2013.]

The result is that doctors--with the best of intentions but unaware of the full medical research--prescribe medicines and treatments that are no more effective, and perhaps just as injurious, as the blue mass pill.

photocopy of a page from Baker Armstrong, Sr.'s pharmacy notebook

Not a Health Care Soundbite

Jerome Groopman, Chief of Experimental Medicine at Beth Israel Deaconess Medical Center in Boston and author of How Doctors Think has an interesting article online at The New York Review of Books website about how medical "best practices" might be included in government health care legislation and how that inclusion might play out in the decisions of doctors and their patients. Groopman provides two viewpoints of how "best practices" might be legislated in health care reform, one that uses the established best practices as a "nudge" to get doctors to choose governmentally-approved health decisions, another that more aggressively promotes these "best practices" by providing financial incentives or negative consequences. President Obama's friend and advisor, Cass Sunstein, favors the first (providing doctors with some leeway not to choose always the established "best practice" method in dealing with a patient's health issue) and Peter Orszag, another of Obama's advisors and director of the Office of Management and Budget, prefers the more strong-armed approach:

Doctors and hospitals that follow "best practices," as defined by government-approved standards, are to receive more money and favorable public assessments. Those who deviate from federal standards would suffer financial loss and would be designated as providers of poor care. In contrast [to the Senate bill], the House bill has explicit language repudiating such coercive measures and protecting the autonomy of the decisions of doctors and patients.

I didn't know much about this debate until I read Groopman's article this afternoon, and I was fascinated by Groopman's discussion of how established "best practices" sometimes turn out to be wrong or not the best health choice for certain individuals. Thus, there are problems with aggressively pushing doctors to choose the "best practice" standard at all times in all situations. This situation reminds me of the debate over mandatory-sentencing laws.  When judges do not have any discretion over sentencing criminals, serious injustice sometimes results, for instance, first-time drug offenders given long jail sentences when they could have been put on parole, provided with rehabilitation, and given the opportunity to change the course of their lives (and thus not cluttering up the prison system and costing the taxpayers huge amounts of money).

What really struck me was the anecdote of Groopman's personal contribution to a "best practice" standard that proved to be wrong. You just got to listen to folks who are willing to admit their mistakes.

Anyway, it's a long article, published in another one of those magazines that some people sneer at for being "elitist," and thus won't be part of any health care soundbite--but it's worth reading: Jerome Groopman, "Health Care: Who Knows 'Best'?," The New York Review of Books, February 11, 2010 edition.