Chapter V: deals with “The Problem of Legislation.” It is based on the (2)

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

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

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

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

THE DIRECT SALES COMPANY

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

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

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

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

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

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

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

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

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

“The Direct Sales Company, Inc., Buffalo, N.Y., is a pharmaceutical
concern which until recently has done business direct with New
Hampshire physicians. In two or three instances complaints have
been received by this department that the preparations sold seemed
to be lacking in potency. Some time ago a physician sent us a
specimen of codein sulphate tablets, one-fourth grain, concerning
which he was suspicious, admission being made that the price paid
was very much less than current quotations. The amount of codein
sulphate actually found per tablet proved to be but one-sixteenth
grain. Later on, having subsequently received a new lot from this
source, the same physician sent us a second sample, the composition
of which was found to be practically identical with the first.
Acting under the federal law, 500 lot packages of the following
preparations were next purchased of the company direct, the
analytical results indicating serious deficiency in every case, as
follows:

“Tablets salicylic acid, 5 grains ... 1.72 grains found.

“Tablets acetylsalicylic acid, 5 grains ... 2.31 grains found.

“Tablets acetanilid, 3 grains ... 1.88 grains found.

“Tablets codein sulphate, 1/4 grain ... 1/15 grain found.

“Tablets nux and pepsin No. 2, claiming pepsin 1 grain, extract nux
vomica, 1/10 grain, found to have a gross average weight per tablet
of only 1.17 grains, 0.54 grains of which was represented by sugar
and other medicinally inert material.

“Tablets Infant’s Anodyne (Waugh) showed serious discrepancy from
formula.”

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

DISCOVERIES AND DISCOVERERS

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

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

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

Scientific discovery, once an open field for all comers, is today
becoming more and more a matter calling for the most intensive
special qualifications. As the body of human knowledge broadens and
deepens, it becomes increasingly difficult to make any material
addition to it. Any one undertaking such a task must of necessity
bring to it a long and careful training, acquired either in the
refined atmosphere of the laboratory, or in the rougher school
of close contact with the operation of apparatus constructed by
those who have already qualified. In particular, he must possess a
carefully developed power of making accurate observations and drawing
correct conclusions. It is rather the habit to point to men like
Edison and Maxim in refutation of these necessities; but they are not
to be so refuted. These men are examples, raised to the _n_th power,
of the great inventor who has qualified in the University of Hard
Knocks and Long Experience.

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

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

“DRUG REFORM”

As It Appears to the Cleveland Medical Journal

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

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

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

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

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

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

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

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

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

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

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

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

DRUG THERAPY: THE FALLIBILITY OF TEXTBOOKS

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

THOMAS WEBSTER EDGAR

Tired Rabbits for Diabetes; Ring-Tailed Monkeys for Sex Stimulation

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

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

And this from a layman in Pennsylvania:

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

While a physician from Illinois writes:

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

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

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

“I tried the blood of rabbits and found what I wanted. In obtaining
the blood I first put the rabbit upon a treadmill and keep it there
until it reaches a stage of fatigue. Then I draw the blood, and
after heating it to 60 degrees centigrade separate the corpuscles
from the serum. When the serum has been treated after the method I
have discovered, I inject it immediately subcutaneously.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The Journal Receives a Letter Denouncing “Medical Clerks” and
“Biased Sceptres”

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

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

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

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

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

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

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

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

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

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

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

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

“Very truly yours,

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

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

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

GLYCEROPHOSPHATES

Physicians who prescribe on definite principles must often be puzzled by the number and variety of glycerophosphates on the market. All available evidence indicates that, as sources of phosphorus to the animal organism, the glycerophosphates possess no advantages over the ordinary inorganic phosphates.[290] The glycerophosphates are split up in the intestine, and liberate inorganic phosphates. In this form they are absorbed and utilized, if they are utilized at all. There is no evidence that glycerophosphates have any pharmacologic action to warrant the belief that they are of use as therapeutic agents. The theory that organic phosphorus compounds are more readily assimilable than inorganic compounds and hence a better means of introducing phosphorus into the system is still kept alive in the promotion of certain proprietary mixtures, in spite of the scientific evidence that the organism can assimilate phosphorus quite as readily from inorganic as from organic phosphorus compounds.[291] The glycerophosphates will continue to be manufactured until physicians refuse to prescribe them. A chemist in the “research laboratory” of a well known manufacturing firm has recently given a rather interesting reason for the use of glycerophosphates--from the manufacturers’ point of view. He is quoted as saying: “On account of the instability of phosphorus in elixir of phosphorus, nux vomica and damiana we have quite recently replaced the phosphorus by glycerophosphates. Such a preparation is apparently equally as effective, for we continue to have a great demand for it.” This is doubtless a sufficient reason for the substitution from the manufacturers’ point of view; but how about the patient, who, after all, is the one to be considered? Is it not a matter of considerable importance to the patient whether he receives phosphorus, one of the most powerful drugs known, or the inert glycerophosphates? The chemist’s statement seems to imply that it is not. It may be of interest to recall that a member of the firm whose chemist gives this “reason” for the use of glycerophosphates, in a recent address, was rather severe in his condemnation of institutions of learning, hospitals, etc., for their lack of cooperation with manufacturers: he said that “they should welcome an opportunity to let any manufacturer try out or test his products in their clinics, laboratories, etc.” A test as to whether there is a difference between the action of glycerophosphates and ordinary poisonous yellow phosphorus, especially when the former are mixed with extracts of nux vomica and damiana, would not be likely to appeal to many hospitals and laboratories as a very promising field of research at this day since, as has been stated, the scientific evidence at present available does not furnish any warrant for the therapeutic use of glycerophosphates.--(_Editorial from The Journal A. M. A., April 15, 1916._) [290] Organic Phosphorus Compounds, Editorial, J. A. M. A. 40: 1958 (June 21) 1913. Marshall, E. K.: The Therapeutic Value of Organic Phosphorus Compounds, J. A. M. A. 44: 573 (Feb. 13) 1915.

[291] Marshall, E. K.: The Therapeutic Value of Organic Phosphorus Compounds, J. A. M. A. 44: 573 (Feb. 13) 1915.

INFLUENZA VACCINES

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

1. The evidence at hand affords no trustworthy basis for regarding
prophylactic vaccination against influenza as of value in
preventing the spread of the disease, or of reducing its severity.
The evidence from the present epidemic, though meager, suggests
that the incidence of the disease among the vaccinated is smaller
than among the nonvaccinated. The board, therefore, concludes that
further experimental evidence should be collected.

2. The evidence at hand convinces the board that the vaccines
we have considered have no specific value in the treatment of
influenza.

3. There is evidence that no unfavorable results have followed the
use of the vaccines.

The second committee, known as the Special Board of Statistical Investigation, consisted of Dr. George C. Whipple, chairman, William H. Davis and F. C. Crum. This committee reported:

1. The weight of such statistical evidence as we have been able to
accumulate indicates that the use of the influenza vaccine which we
have investigated is without therapeutic benefit. Exceptional cases
where apparent benefit has resulted from the use of the vaccine can
be matched by other cases where similar recoveries have been made
without vaccination.

2. The statistical evidence, as far as it goes, indicates a
probability that the use of this influenza vaccine has some
prophylactic value.

3. There is also some evidence to the effect that other methods
of protection, such as open-air treatment and the use of proper
masks, are effective in protecting exposed attendants, and the
use of vaccine should not be taken as an excuse for omitting such
safeguards.

As a result, the following recommendations were made:

That the state encourage the distribution of influenza vaccine
intended for prophylactic use, but in such manner as will secure
scientific evidence of the possible value of the agent. The use of
such vaccine is to be regarded as experimental.

That the state shall neither furnish nor endorse any vaccine at
present in use for the treatment of influenza.

These reports are conservative, and offer to other health commissioners and their communities a reliable guide as to procedures that should be adopted before subjecting or trying out on the public any method of prevention or treatment that may be offered. These matters are the domain of medical science, and medical scientists of recognized ability should be called on to make the decision.--(_Editorial from The Journal A. M. A., Oct. 19, 1918._)

Serums and Vaccines

With respect to serums and vaccines in influenza, there are certain simple facts and considerations that physicians will do well to keep in mind at this times. The main point to keep always in sight is that unfortunately we as yet have no specific serum or other specific means for the cure of influenza, and no specific vaccine or vaccines for its prevention. Such is the fact, all claims and propagandist statements in the newspapers and elsewhere to the contrary notwithstanding. This being the case, efforts at treatment and prevention by serums and vaccines, now hurriedly undertaken, are simply experiments in a new field, and the true value of the results cannot be predicted by any one. Indeed, the exact results can be determined if at all only after a time, in most cases probably not until the epidemic is past and all the returns fully canvassed. Consequently, the physician must keep his head level and not allow himself to be led into making more promises than the facts warrant. This warning applies especially to health officers in their public relations.

As to serum treatment, the only noteworthy new method so far is the injection in severe cases of influenzal pneumonia of the serum of patients who have recovered from such pneumonia.[292] The principle of this method is rational; analogous procedures have given seemingly good results in scarlet fever and other diseases; and the results reported in influenzal pneumonia appear promising. Further trial of this treatment under proper conditions consequently seems to be warranted. It should be borne in mind, however, that McGuire and Redden[292] made their observations in the declining phase of the epidemic when the organism or organisms concerned appeared to be losing virulence. For this and other reasons, the expectations as to what may be accomplished by this method must be kept within reasonable bounds. Influenza is a self-limited disease with variable complications and of variable severity in different places, thus offering great difficulties in the way of evaluation of different methods of treatment.

[292] McGuire, L. W., and Redden, W. R.: Treatment of Influenza Pneumonia by the Use of Convalescent Human Serum: Preliminary Report, J. A. M. A. =71=:1311 (Oct. 19) 1918.

At least two kinds of vaccine are in use in the hope that they may have preventive effects. One consists solely of killed influenza bacilli; it being extensively used in the East. We have as yet no decisive figures as to its effects, but there is an impression that it may have some value. The other vaccine is a mixed vaccine of the more important bacteria in the respiratory tract in influenza, principally pneumonococci, streptococci and influenza bacilli. It appears that vaccines of this nature are in extensive use, but we have no evidence that any benefit will be derived from them. To say that thousands have been vaccinated with apparently good results means nothing at all, simply because we are still in the midst of the outbreak, in many places even in the earlier stages. How slender the basis of this anti-influenzal vaccination when it is considered that the real nature of influenza is still unknown! In any event, it will require many carefully elaborated and controlled observations before anything definite may be learned in regard to the effect of these vaccines, and it is probably safe to say that nothing on which to rely in the future can be learned from the indiscriminate vaccination now going on. There is, therefore, no basis on which promise of protection from vaccines may be made. They may be harmless, and they may or may not be of preventive value.--(_Editorial from The Journal A. M. A., Oct. 26, 1918._)

INTRAVENOUS THERAPY

The intravenous administration of drugs is a new departure in therapy, but one which is rapidly increasing in use. Among its reputed advantages are that it is the quickest means of obtaining the effects of a drug, the effects are obtained with a certainty not obtained by other methods, and they are so marked that they cannot fail to impress the observer. These advantages in many cases are apparent rather than real; but even were they real advantages, they should not blind us to the various and serious dangers which this method involves. The technic, although not difficult, must be thoroughly mastered, or undue pain, infection, air embolism, or even death may result. Such accidents, however, are ordinarily easily avoided, and should be considered quite inexcusable. More serious is the fact that the drugs given intravenously reach the system, and especially the heart, in a different manner and concentration from that to which physicians are accustomed with ordinary methods of administration. Pharmacologists have long practiced intravenous administration, when studying acute effects of drugs, and they have observed that frequently the immediate result of such injections is a prompt fall of blood pressure, not obtained when the same drugs are given by mouth or even hypodermically. This fall in blood pressure is commonly attributed to irritation of the endocardium. It is usually of short duration, but is certainly undesirable and sometimes may have serious results.

It has also been observed that several drugs, for instance, quinin and potassium, depress the cardiac muscle when given intravenously much more than when given in other ways. Furthermore, any substance which tends to precipitate proteins must be injected slowly and with extreme caution, or it will produce intravascular clotting and sudden death. Deaths have resulted not only from a lack of knowledge of the technic of intravenous therapy, but also from a lack of knowledge of drugs which may be so administered. Sudden death has been reported following the injection of an iron preparation containing peptone, and also following intravenous injection of ether. Intravenous injections, while sometimes superior to the slower methods, are distinctly inferior when a continuous, rather than a sudden, action is desired. Drugs leave the blood system with great rapidity, and therefore their action on the circulation will cease promptly unless they are continuously supplied. It would be undesirable to inject intravenously such drugs as iodids, nitrites, iron or salicylates.

With these dangers and disadvantages in mind, it seems unwise to resort to promiscuous intravenous medication until the effects of this method have been studied in detail for the drugs employed, and unless there are distinct advantages to be secured. This is the case when an immediate action is necessary in emergencies, as in the use of strophanthin for cardiac collapse, quinin in pernicious malaria, etc., or if the drug would be destroyed in the stomach or tissues as in the case of salvarsan, or when the drug is not adequately absorbed by any other channel, as in the case of epinephrin.

Intravenous therapy will be most securely advanced if its employment is restricted to such well defined fields. These fields can be satisfactorily determined only by a scientific pharmacologic study of the action of these drugs when so administered in animals, as well as in man, under conditions in which the results are carefully controlled. The intravenous method is an impressive one, approaching in preparation almost to that which goes with a surgical operation. The patient is usually interested and impressed by this new, and to him, mysterious method. There is a psychic element in his reaction to the injection which is not a factor in his reaction to the same drug when given by mouth. The intravenous injection of a complex mixture would appear to be particularly reprehensible. Little is known, as has been stated, of the results to be expected from intravenous therapy, even with simple substances. The use of complex mixtures will without doubt react against the proper use of the method.--(_Editorial from The Journal A. M. A., Nov. 11, 1916._)

IODIN FUMES

One of the important factors connected with therapeutics as a science is the method of administration of medicinal substances. Drugs may be given by mouth, by hypodermic or intravenous injection, by inhalation, by inunction or, less frequently, by the use of other entrances into the body. In choosing a method, the physical characters of the substance to be administered and the immediate effects of the substance on the body tissues with which it may come in contact must be especially taken into consideration.

These factors apply particularly in the case of substances like iodin, arsenic, mercury or the biologic products in which the mode of administration radically modifies the action. For some time, manufacturers have urged substitutes for tincture of iodin, claiming that their substitutes were free from the undesirable properties of the tincture, and, at the same time, possessed special virtues which the tincture could not possess. More recently, attention has been directed to the administration of iodin in the form of vapor. The diffusing and penetrating powers of gases have particularly attracted the attention of therapeutists, since by this method drugs may be applied to rather inaccessible portions of the body, such as the lining of the lungs, the throat and the mucous membranes of the genito-urinary tract. Furthermore, it has been asserted that iodin in the form of fumes has increased combining powers, and is thus far more potent in effect than iodin administered by any other route. There do not seem to have been any adequate scientific investigations of the subject, however, until the recently published results of Luckhardt and his collaborators[293] at the University of Chicago. In their experiments, both on man and on animals, accurately determined quantities of iodin were vaporized in a special device, and the fumes applied to the skin. At the same time, the tincture was applied to the skin of other persons as a control. Iodin was also applied to the skin of dogs with hyperplastic thyroid glands; and the effects on the gland, before and after administration, studied. Dogs were also used to determine whether iodin fumes were absorbed from the lungs. As a result of these investigations, which are reported in great detail, it was found that iodin, when deposited on the skin in the form of fumes, is absorbed. More iodin was recovered from the urine, following the application of the tincture, than was recovered following the use of the fumes. This result is explained by the authors on the ground that probably more iodin was actually applied, and that the iodin so deposited was held in combination with the protein during the process of coagulation of the latter by the alcohol of the tincture, leading to a state of continuous absorption. It is probable, furthermore, that the iodin deposited on the skin in the form of fumes is revaporized to some extent by the heat of the body.

[293] Luckhardt, A. B.; Koch, F. C.; Schroeder, W. F.; and Weiland, A. H.: The Physiological Action of Fumes of Iodin, J. Pharmacol & Exper. Therap. 15: 1 (March) 1920.