How we got from 18th-century tinctures to the opioid crisis

Americans have always loved their medicines and sought them out actively to cure whatever ailed them. Their interest ranged all the way from “staying well” to “feeling better.” Productivity in this hard-charging, pull yourself up by the bootstraps society required activity, and it’s hard to be active when you’re sick.

In the 18th-century in Germany, England, France, and Switzerland, men practicing pharmacy saw their retail operations as the cornerstone of a potential wholesale gold mine. Handmade pills and boluses, macerated and percolated tinctures, infusions and ointments delivered by mortars and pestles were everyday fare. Few chemists and druggists were content with just dispensing. They wanted their “own lines” — “a soothing cough mixture, a worm eradicator, an ointment for scabies, but not too griping purge” might turn a fortune. And America was a rapidly expanding market.

A single pharmacy in Birkenshaw, Yorkshire, had a handwritten formulary that included 534 discreet formulas — 316 medicinal, 69 cosmetic, 68 veterinary, and 81 “domestic.” Among the lot were compressed tablets, cold creams, lotions, essence of smelling salts, powders of all types, and brandy. But of course, there were other offerings considerably more exotic like cockroach bait, glove cleaner, and non-mercurial plate powder.

Simple discoveries in delivery systems expanded the market. Cocoa butter introduced in 1852 launched a worldwide surge in suppositories. The soft gelatin capsule opened all new possibilities in 1834. Subcutaneous injections followed in 1855. By then, some medicines were described as patent or proprietary, but most were simple “secret formula” concoctions that were not registered. As one expert noted, “The “quack” medicines would have had little, if any, therapeutic value, but then neither had most of those prescribed by physician or surgeon apothecary; indeed there was often little to tell between them. The “patent” medicine trade at least had the merit of passing on the knowledge of how to manipulate equipment and mix ingredients in bulk.”

These larger scale and more methodical chemists became increasingly prominent in Europe, and to a much lesser extent in America, in the second half of the 19th century. But they were often accompanied by the likes of German immigrant William Radam, who saw in America the “Wild West,” and the opportunity to make a killing. And he literally did, marketing a dilute solution of sulfuric acid colored with red wine, his “Microbe Killer.” Widely advertised and sold often in religious/theatrical “fire and brimstone” revival sessions (promising to “Cure All Diseases” — a phrase embossed on its glass bottle), it made him a quick fortune. Taken in high doses, it also killed a few people.

William Radam’s “Microbe Killer,” and other variations of mistreatment, was mainly what instigated two hundred and fifty physician delegates from 28 states to coalesce at the founding meeting of the American Medical Association in Philadelphia, Pennsylvania on May 7, 1847. The meeting had been triggered by a motion from Nathan S. Davis, a young New York physician and member of the New York Medical Association in 1845, calling for a national convention.

At that 1847 meeting, the delegates approved the establishment of the organization, elected Nathaniel Chapman its first president, approved a Code of Ethics, established nationwide standards for preliminary education and the degree of MD — and then called it a day.

But then, over the next 24 months, this young organization, according to its official history, “analyzed quack remedies and nostrums to enlighten the public in regard to the nature and danger of such remedies”; “recommended that the value of anesthetic agents in medicine, surgery, and obstetrics be determined”; “noted the dangers of universal traffic in secret remedies and patent medicines”; and “recommended that state governments register births, marriage, and deaths.”

Of course, they also painted their competitors, homeopathic physicians, and osteopathic physicians, with a broad negative stroke. Over the next half-century, homeopathic physicians would disappear, and osteopathic medicine would be repeatedly labeled as a “cult.” It would take over 100 years for the AMA to grudgingly agree to the equivalency of an MD and a DO.

For the young immigrant cousins, Charles Pfizer and Charles Erhardt, who arrived in Brooklyn in 1849 — the timing couldn’t have been better. They intended to produce chemicals and medicinals that were safe and effective. And they saw these new physicians, certified and focused on routing out their “quack” competitors as an asset, a “learned intermediary” that would deliver their product reliably and with implied professional endorsement to patients far and wide. What could be better?

The sales vehicle that would close the deal, a prescription, became commonplace after 1914, when the Harrison Narcotic Act “required prescriptions for products exceeding the allowable limit of narcotics and mandates increased record-keeping for physicians and pharmacists who dispense narcotics.”

That single stroke of the pen had enormous ramifications that we are arguably still negotiating today. The boundaries it established included: separation of duties for physicians and pharmacists; separation of disciplines of pharmacy and pharmaceutical manufacturer; legal cover from some liability for pharmaceutical manufacturers, who once their drug is “approved” by the FDA, hand it — and its liability — over to the physician “learned intermediary” to prescribe; separation of product that exists behind the counter and requires a prescription, from product that is “over the counter”; and separation of product that is still under patent protection from “generic” product which is not protected.

The AMA would jealously protect the “right to prescribe,” and in so doing hold competing practitioners, and increasingly educated patients, at bay for most of the next 100 years. They would turn a blind eye to “sloppy prescribing” and willingly accept the ad dollars and physician masterfile database revenue from pharmaceutical companies that would power prescription profiling and help ignite a deadly opioid epidemic a century later.

And they would do all this with the very active support of Charles Pfizer, Charles Erhardt, and their pharmaceutical colleagues, who would grow very, very rich in the process.

Mike Magee is a medical historian and journalist.

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