Addiction Treatment Blog

Tranquillity

Before the second half of the 19th century, the dominant medical and popular notions of disease rested on a humoral theory, first put forward by Hippocrates and Aristotle, and then Galen, later in the 2nd century AD. According to this theory, there were humours – phlegm, choler, bile and sanguine – and diseases resulted from an imbalance between them, or an imbalance between the humoral state of the individual and conditions in the environment (1).

A version of this theory survives to this day in the Chinese notions of yin and yang, which are popular in alternative medicine settings, and in the three dhosas of Ayurvedic medicine. The yin and yang notions and four humours theory are very similar in their trust. In each case what is aimed at is a state of harmony. Treatment consists of efforts to restore balance or internal equilibrium. Until the last century, this was done by regulating diet or by bleeding, purging, inducing vomiting, raising blisters (in which noxious vapours could collect), or giving a variety of tonics – agents that were stimulant or strengthening in some way. Diet and tonics of various sorts remain the most popular methods today.

The idea that masturbation or menstruation might lead to disease or mad therefore entailed a disruption of the internal balance of the humours. As this was being done in an uncontrolled or injudicious way, the outcome was liable to be disharmony. Among the drugs used for psychiatric indications were black hellebore – a drastic purgative – and white veratrum which produced vomiting. Shaving of the head was also employed in order to let the vapours out; assisted by various ‘oleum cephalicums’, which would produce blistering of the shaven scalp. Also in use were iron, literally to strengthen the constitution camphor as a stimulant and bromides as sedatives (2).

Against this background, there flourished a considerable ‘industry’ aimed at satisfying consumer needs (or profiting from their misery), through the provision of tonics, elixirs, etc. The market was almost entirely consumer led as numerous plays, novels and operas, such as Donizetti’s L’Elisir d’Amore attest. It was regular feature of village life that the peddler of medicines would come to the village with a range of potions for sale, and individuals regularly treated themselves with such compounds. Even when quite seriously ill, it was common, until this century, for afflicted individuals to have a go at treating themselves first.

In the 19th century the range of such patient medicines – medicines containing ’secret’ remedies – increased dramatically. Allied with a more vigorous marketing in the emerging popular press, this became an increasing problem which led to concern in orthodox medical circles and among regulators (3). The patent medicine industry still survives today in the over-the-counter (OTC) medicines and most clearly in the health food industry, whose food supplements are ‘drugs’ by another name – a clear example of this is the burgeoning phenomenon of smart drugs outlined in section 5.

The modern pharmaceutical industry took shape in the first half of this century as a reaction to the widespread provision of patent medicines. The newer drug companies which emerged and which survive today termed themselves ‘ethical’ companies in contrast to the patent medicine industry. The term ethical here needs some clarification. These companies saw themselves as being ethical, in the first place, in their attempts to purify the compounds that went into their preparations and secondly in their willingness to specify exactly what a medicine contained.

The Magic Bullet

The development of specific theories of disease was probably the most significant factor affecting the outcome of the competition between the ethical and patent pharmaceutical industries. The discovery by Pasteur of bacteria, and their role in infection, led to a growing belief in specific causes for specific diseases. The most significant breakthrough came with the development of diphtheria antitoxin, in 1896, which led to the eradication of diphteria.

Allied to this, there was during the 19th century an increasing awareness that the herbs and other compounds appeared naturally to be helpful in the treatment of disease all contained specific compounds, and that it was these compounds rather than the whole herb which were the curative factors. For example, it turned out to be the opium in the poppy, rather than the entire poppy, that was helpful, the digitalis in foxglove and the salicyclic acid in the bark of the willow tree (Salix alba). Other developments such as the increasing use of anaesthesia for ever more specific surgical procedures fostered the idea of specific illnesses and correspondingly the idea of specific cures. The growing trend found a notable expression in Paul Ehrlich’s concept of the magic bullet, which ideally was a compound that would enter the body and act on a disease process specifically, leaving all other metabolic processes undisturbed (4).

The antibiotics have come closest to this ideal in practice. The idea, however, has taken hold that all modern drugs are magic bullets of some sort and leads many, if not all, of us who are prescribing or taking any drug to believe that we are using something that will work specifically on just one faulty piece of the human machinery.

The reality, however, is quite different. It is not just that most drugs, particularly psychotropic drugs, may cause side effects, but rather that they may act profoundly on a great number of body systems – for instance, the calcium channel blockers may have therapeutic actions on almost every system in the body. Or the neuroleptics may be used as anxiolytics, antipsychotics, antidepressants, antipruritic agents or anti-emetics. The rationale of the modern drug industry as well as marketing practices (see below) militate against a recognition of this state of affairs.

Initially, the ethical companies aimed at purifying natural compounds, such as digitalis, salicyclic acid, or morphine and a variety of other opiates from the poppy. The great advantage of purification was that the amount of a drug that is given could be controlled. In the case of foxglove, for example, crushing and administering the plant may help cardiac failure, if the dose is right – it may be poisonous if the dose is too high. In principle, if there is an active ingredient in a natural compound it should always be possible to establish what it is and purify it.

The next step was involvement in the manufacture of entirely synthetic organic compounds. The development of the barbiturates were a significant step forward in this regard. The production of chlorpromazine, in this century, was a laboratory-based exercise of this nature that was spectacularly successful. There are a number of potential drawbacks to this enterprise. The escalating with our increasing recognition of an ever greater number of distinct receptors and ability to synthesise compounds that will bind to each of cart is getting put before the horse. An ever increasing number of compounds are being developed – the only problem is it is not clear what illness they are supposed to be treating. We have a range of magic bullets and seem programmed to think that there must be appropriate illnesses for each of them. From this comes the need for companies to market their compounds in what is becoming an ever more crowded marketplace.

References

• Vogel MJ, Rosenberg CE: The therapeutic revolution. Philadelphia PA: University of Pennsylvania Press, 1979.
• Sneader W: The prehistory of psychotherapeutic agents. J Psychopharmacol 1990, 4:115-119.
• Liebenau J: Medical science and medical industry. Basingstoke: Macmillan Press; 1987.
• Pellegrino E: The sociocultural impact of twentieth century therapeutics. In The therapeutic revolution. Edited by Vogel MJ, Rosenberg CE. Philadelphia PA: University of Pennsylvania Press, 1979.