"A desire to take medicine is, perhaps, the great feature which distinguishes man from other animals" - Sir William Osler (1891)
The watershed between the era of traditional but largely ineffectual medicines and the new age of potent and effective drugs was the 1939-45 war. There was already a glimmer of the new dawn when penicillin hit the newspaper headlines in 1942, but penicillin was then in limited supply and reserved for the allied armed services and the few effective drugs were mainly the old standbys: colchicine for gout, digitalis for heart incompetence and opium for severe pain. In a century of tremendous activity in chemical laboratories, there had been only two significant medical breakthroughs: the discovery of insulin by Banting and Best in 1921 and the introduction of the sulphonamides, the first drugs effective in bacterial infections, in the early 1930s. In 1943, when I entered pharmacy, medicine was still firmly in the era of the magic bottle.
The tradition of liquid medicines goes back a long way. Pliny the Elder in his ‘Natural history', published in 55AD, was scathing about the influx of Greek medicine men who were establishing laboratories and concocting their potions in the cities, deriding them as profiteers and deceivers. Pliny favoured natural herbal remedies (although that did not prevent him listing the most bizarre brews and the conditions for which they were recommended), but even he would have had to concede that rarely are the solid parts of plants as effective as the liquid extracts made from them, and down the centuries these formed the basis of the ever popular mixtures. An observer at the outpatient department of St Bartholemew's hospital in 1869, quoted by Roy Porter in his encyclopaedic ‘The greatest benefit to mankind', recorded that the physician saw 120 patients in an hour and 10 minutes, spending 35 seconds per patient, each of whom received a dose of physic from one of several large jugs, the medicine being chosen apparently at random.
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The bottle of medicine has been something of an art form |
Indigestion mixtures were white because the alkalis in them to neutralise excess stomach acid were white: magnesium carbonate and sodium bicarbonate (although this was in solution) for rapid neutralisation, with magnesium trisilicate usually as the slower and longer lasting antacid. Virtually all indigestion cases and, indeed, stomach complaints of any kind were attributed to an excess production of hydrochloric acid produced by the stomach to aid gastric digestion. An advertisement for the most popular indigestion remedy of the time, Maclean's stomach powder, showed a photograph of a carpet with a sizeable hole in it, the caption dramatically pointing out that there was enough acid in the stomach to produce damage on this scale. No doubt this was enough to scare numbers of indigestion sufferers into buying the powder although there was quite a lot of advertisers' licence at work here since the stomach contents are not acidic enough to dissolve carpet or anything else unless they are concentrated into about a teaspoonful.
No attempt was made to measure the level of acid in the indigestion sufferer's stomach or to determine if there was any superfluous acid at all, and every patient was instructed to take the same tablespoonful (15ml) dose of mixture. The main thing was that the mixture was white. If a stomach sufferer was unfortunate enough to be afflicted with the rare condition of achlorhydria, when the stomach produces insufficient acid, the likelihood was that he would be prescribed the standard alkali mixture and his condition made worse until, if he was lucky enough, he was sent to hospital and the condition diagnosed, when he would be given a non-white mixture. This contained hydrochloric acid to remedy the deficiency, together with compound infusion of gentian, a so-called stomach bitter purported to stimulate acid production. This concoction, known as mist gent acid, was the colour of stale urine, had the taste of old battery acid and in the mouth produced the sensation that the surface of the teeth was being eroded into powder.
Cough mixtures were dark brown because most of them contained ingredients such as chloroform and morphine tincture (chlorodyne) which, when diluted with water — the water content of mixtures varied from about 80 to 98 per cent - produced an off-putting muddy appearance which, to preserve the patient's confidence in the magic bottle, was transformed to a rich, dark brown by the addition of liquorice extract. The variety of substances believed to be of value in the treatment of coughs was almost limitless. Ammonium chloride, a vile tasting compound, was a common ingredient of cough mixtures, although it was described in the pharmacopoeias of the time as a diaphoretic (sweat producer) and diuretic (urine producer) with the caution that large doses caused nausea and vomiting. This unpleasant side effect was in fact the reason for the inclusion of ammonium chloride and a whole range of other nauseants in cough medicines due to the popularity at that time of the theory that gastric irritants produced a reflex irritation of the adjacent bronchi, stimulating mucus production and coughing. Had this hypothesis possessed any physiological basis and had Indian food been generally available at the time, clearly the most effective cough treatments would have been vindaloos! However as the culinary revolution had not yet reached Britain, patients with coughs were obliged to go on imbibing mixtures containing gastric irritants such as ipecacuanha (still used in its rightful role as an emetic), senega root, euphorbia (Australian snake weed) and antimony salts, with their spectactular poisonous properties.
Creosote, whose smell is familiar to us still each spring when our conscientious neighbour sets about preserving his garden shed, was featured in the formularies as an internal disinfectant (a ludicrous idea since the point of the intestines is that they are swarming with the bacteria needed to break down food residues) but was also an ingredient of cough mixtures on the vindaloo principle.
According to a prestigious authority of the time, Martindale's Extra Pharmacopoeia, cocillana bark was the equal of ipecacuanha in its expectorant properties and was also effective as a tonic and laxative, but since the liquid extract was a brown colour it was only ever used for coughs. Cough mixtures are still popular, but with a little more justification since the first question asked of a cougher now is whether any phlegm is produced or if the cough is irritant and dry, so that an expectorant or cough suppressant can be supplied. There were no such refinements in the heyday of cough mixtures. The one most popularly prescribed was mist morph et ipecac (also known as mist tussis nig, black cough mixture), containing morphine in the form of chlorodyne to suppress the cough reflex and ipecacuanha tincture to aid expectoration, the two antagonists being left to fight it out.
Nowadays we are knowledgeable - and some would say cynical - enough to be aware that there is no such thing as a tonic medicine, but for those who lived in more innocent times life without recourse to a bottle of tonic would have been unthinkable. Tonics were taken when one felt off-colour - that is to say before one got ill - and again after one had been ill to aid recuperation. In between times, tonics were taken just to be on the safe side.
No explanantion as to why virtually all tonics had to be red has been offered as far as I know but there may be a clue in the assumption in those days that anyone needing a tonic was lacking in iron, together with an awareness of the importance of the role of iron in haemoglobin in effecting oxygenation of the blood; as is well known, oxygenated blood is bright red. Symbolism becomes important when medicines are based on faith rather than therapeutics and it seems likely that the coloration of tonics was a symbolic gesture towards healthy red-bloodedness.
This is supported by the fact that the iron salts obligatorily included in tonics were green or yellowish and that the red colour came from added dyes. Apart from its reputation as a blood booster, iron compounds satisfied another requirement of the ingredients of tonic mixtures in that they had an astringent and obnoxious taste, satisfying the golden rule of those times that anything meant to do you good must taste bad.
Most children growing up in the first half of the 20th century were regularly dosed with an iron tonic whose reputation rested on its diabolical taste and even more impressive name, Parrish's Chemical Food. Any child not clearing up his or her dinner plate, or showing any signs of languishing, was put on a course of chemical food, although the subsequent return of appetite and energy may have had more to do with a desire to avoid further dosing with Mr Parrish's pick-me-up than with its tonic properties.
There was a third requirement of tonic ingredients that iron only partially fulfilled, and that was toxicity. Not only had tonics to taste revolting but it was preferable that their ingredients were serious poisons. Although iron salts are quite toxic in doses not far in excess of those prescribed, there were obviously more credible candidates and those favourites of poisoners over the ages, arsenic and strychnine, featured prominently in tonic formulae. One of the most prescribed tonics for adults was Easton's Syrup, which contained quinine and strychnine in addition to the obligatory iron.
The reputation of quinine as a wonder drug was forged on its remarkable antimalarial properties. But it also satisfied two of the requirements of tonics in that it has an intensely bitter taste and is toxic in moderate dosage. Repeated administration causes cinchonism, characterised by tinnitus, headache, nausea, abdominal pain and skin rashes.
In severe and prolonged malaria, quinine frequently had to be given in quantities that approached toxic levels and, in malaria caused by the Plasmodium falciparum parasite, quinine could precipitate the potentially lethal blackwater fever. When quinine was freely available over the counter in pharmacies, it was sold ostensibly for the treatment of colds and fevers, although it was widely known that it was mostly taken as an abortifacient. To have any effect on the uterus, quinine had to be taken in dangerously high dosage and it was this consideration that led to the present ban on sales in the United Kingdom. Probably because of its availability, in Greece until recent times quinine was the most commonly used agent in suicides. The only and dubious therapeutic justification for the inclusion of quinine in tonics was the widespread belief at the time that to do any good a medicine had to taste unpleasant.
Strychnine had the most impressive credentials as a tonic since it is a central nervous system stimulant and one of the most toxic alkaloids found in nature, a favourite of poisoners and still (regrettably) sold by country pharmacists to farmers for killing moles. Strychnine had the added advantage that weight for weight it is one of the bitterest substances known.
Arsenic too was a famed tonic in its day, appearing along with iron in mixtures and pills. Arsenic was widely used as a weed-killer and in sheep dips, quite apart from being the agent of choice in a whole series of poisoning cases resulting in sensational trials, and its inclusion in tonics can only have been on the principle (more seriously adopted by Samuel Hahnemann as the basis for homoeopathy) that a little of what does you harm does you good.
The advantage of arsenic as a poison is that it acts slowly, accumulating gradually in the body tissues, so that it can be given in subtoxic doses over a prolonged period before any noxious effects become apparent. Even then the nausea, diarrhoea and stomach cramps which precede death conveniently mimic the symptoms of food poisoning. This made arsenic the favourite with poisoners until the introduction of the extremely sensitive Marsh test in the early 20th century, which in developed countries at least has made the detection of arsenic poisoning a virtual certainty.
It was a different story in those parts of the world where science lagged behind and Dr (later Sir) Sydney Smith, who was appointed the principal medicolegal officer in Egypt in 1917 recorded in his fascinating autobiography, ‘Mostly murder', that arsenic poisoning was then so common there that he had a battery of Marsh tests constantly on the go in his laboratory. There are those who became convinced that arsenic poisoning went on undetected in the very out-of-the-way island of Saint Helena during the stay of its most famous inhabitant since, after exhumation of Napoleon's corpse, the hair and nails revealed an arsenic content high enough possibly to have been lethal. The argument over whether or not Napoleon was deliberately poisoned by his British captors has been regularly aired over the years in the medical journals, the rebutters mostly basing their case on the fact that arsenic compounds were widely used for colouring paints and wallpapers until their toxicity was generally recognised and that Napoleon like many others at the time absorbed the arsenic from the green wallpaper used to decorate his quarters.
So deeply held was the idea that poisons have tonic properties that between the two world wars research chemists were employed to create combinations of the most lethal substances, resulting in such bizarre compounds as strychnine cacodylate, an amalgam of strychnine and organic arsenic (then the most effective treatment for syphilis) that was administered to its unfortunate recipients by intravenous injection. The respected British company Allen & Hanburys devised a ferruginous neurasthenic serum (FNS injection) which contained strychnine cacodylate with iron and several worthless glycerophosphates. The preparation did contain iron and neurasthenia was a fashionable diagnosis of the time, probably because it was vague enough to cover most neurotic manifestations. Serums were also highly regarded - but this injection was not a serum. In the United States they invented a chemical combination of iron and organic arsenic called ferric cacodylate and in Portugal they came up with a solution of cacodylic acid as a means of giving arsenic by rectal injection.
It is easy now to deride such therapies but, as throughout the history of medicine, these were mostly genuine attempts by mistaken but conscientious workers to benefit the sick. However, there is a lesson to be learnt from all this and that is to question the actual merits of even the most widely adopted and sacrosanct treatments. Now we think that medicine is so much more scientific that we are safe. But then so did the recipients of ferruginous neurasthenic serum.
The most popular tonic mixture dispensed on prescription rejoiced in the (abbreviated Latin) title of mist pot brom et nucis vom. It contained potassium bromide and tincture of nux vomica with, as was the case with most mixtures then, the addition of chloroform as a preservative and amaranth as a colorant since, purporting to be a tonic, it had to be coloured red. The potassium bromide was included as a sedative on the basis that those in need of a tonic were frequently anxious or agitated, akin to the assumption later that any woman attending a surgery who was not suffering from a fracture or acute infection was a neurotic with psychosomatic symptoms and needed Valium. The bromide in the mixture had virtually no effect at the dosage included although, since bromine accumulates in the body, if the mixture were taken for long enough the patient could develop bromism which caused slurred speech, apathy, anorexia, constipation and loss of sensitivity to pain.
The other main ingredient was a tincture made from the seeds produced by a southern Asian tree named Strychnos nux vomica because the seeds contain strychnine. Nux vomica seeds had the additional qualification for inclusion in a tonic of being exceptionally bitter, the name deriving from the Latin for vomiting nut. The strychnine supposedly provided the stimulant properties of the mixture and its popularity with prescribers was doubtless due to their belief that it would calm the nervous and pep up the depressed - that and the fact that in appearance it was a most impressive deep red.
At the height of its popularity in the middle decades of the the 20th century the bottle of medicine was something of an art form. The nicely shouldered, clear glass bottle, perhaps owing something to its origins in the period of art deco, was designed to show off the white, brown or red contents to the best effect. The label was carefully placed at the aesthetically correct one third of the way down from the shoulder and the whole appearance enhanced by the final act of wrapping in heavy glossed white demi paper. The paper fold was required to be dead centre and the taper above the shoulders achieved by symmetrical indentations topped by the triangular flap over the cork that was held by a blob of sealing wax melted in a special gas jet over the dispensary bench. The final touch was the impressing of the pharmacy seal in the wax while it was still molten. An exercise in the art of packaging it certainly was, but impressive packaging at that.
The doctor contributed to the mystique of the medicine bottle by writing the prescription in what the patient believed to be Latin but was really a hotchpotch of Latin abbreviations including directions for dosage such as bd or bid and tds or tid, indicating twice or thrice daily, respectively. Since pharmacopoeial titles were latinised, new products needed to be given pseudo-Latin names and as drug molecules became increasingly complex this led to difficulties. It was reasonable for penicillin to become penicillium, although slightly unreal since this was the name of the mould (Penicillium notatum) from which the antibiotic was extracted. But the convention lost credibility when a compound such as neostigmine methylsulphate had to be rendered as neostigminae methylsulphas and during the late 1950s latinisation of drug names was abandoned.
But during the heyday of the magic bottle, prescription Latin was all part of the convention that the identity of medicines had to be kept secret from the patient. This was on the basis that it would not do for the cough sufferer to discover that the ingredients of his black cough mixture were the familiar chlorodyne and ipecacacuanha that he could buy over the counter. For this reason, medicines were anonymously labelled "The Mixture" and if a customer had the temerity to ask what was in the bottle that had been prescribed, the pharmacist was obliged to reply, so as not to undermine the patient's faith in his doctor, that this was confidential.
In those days, the white coat of the pharmacist, the immaculate wrapping of the bottle and the impressive colour of the contents once it was opened were invariably enough to deter curiosity and to preserve the customer's faith in the magic bottle.
Ray Sturgess is a pharmacist from Knaresborough, North Yorkshire, with experience in the pharmacy industry and in community pharmacy. He has now retired and writes on health related matters