Randi Hutter Epstein M.D. M.P.H.

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A Remedy for Everything

I’m taking a mental health day by avoiding news and immersing myself in medical history. It’s a literary cleanse. I’m reading Sarah Stage’s Female Complaints: Lydia Pinkham and the Business of Women’s Medicine, published by WW. Norton forty years ago, in 1979.

Stage’s book tells the story of Lydia Pinkham’s colossally popular 19th century cure for, well, just about everything. A few sips a day were touted to cure cancer, constipation, menstrual cramps, menopause symptoms, kidney failure and so on and so forth. The target audience was women but men could take it too. The active was alcohol.

Female Complaints delves into the savvy, deceptive marketing.

Remedies that guaranteed cures were all the rage at the turn of the 20th century when lots of people distrusted doctors; when medicine didn’t offer much (this was half a century before antibiotics); when women were embarrassed to talk about female “issues” with their mostly male physicians; when physicians were squeamish to pry into their patients’ womanly complaints.

Not everyone was duped. In the early 1900s, a few muckraking journalists got wind of the false claims such as Lydia Pinkham’s cure and Mrs. Winslow’s Soothing Syrup and wrote a series of articles in Ladies Home Journal. (Mrs. Winslow’s Syrup was a mix of morphine-alcohol touted to cure fussy babies that later became known as a baby killer.) Good for Ladies Home Journal. Other media outlets turned down the pieces because of contracts with drug-makers’ advertisers that stipulated the deal would be cancelled if the publication ran anything detrimental to the products. In those days, according to Professor Stage, some $40 million was spent on these kinds of advertising deals.

In part due to these journalists (but mainly due to Upton Sinclair’s The Jungle, about the horrid conditions in the meat industry), the Pure Food and Drugs Act was passed in June, 1906 and took effect January 1, 1907. (Opponents claimed the law staunched consumer choice.) The Act stated that medicines involved in interstate trade

  1. Meet certain standards of purity
  2. Labels must be truthful
  3. Toxic ingredients must be listed, such as cocaine, opium, morphine, heroin, alcohol, cannibas. (The label need not list all ingredients.)

While doctors and journalists celebrated their victory and pronounced the so-called fake-medicine business dead, hustlers were strategizing. “In the long run the patent medicine manufacturers proved more astute judges of human nature than the reformers,” wrote Stage.

The truth-law only applied to labels so the quack-medicine peddlers promoted their false claims in signs in streetcars; advertisements in newspapers; and mailed pamphlets.

At the same time, the president of the Proprietary Association, the organization of those who sold these so-called patent medicines, issued a seal to anyone who followed the new rules. “Guaranteed Under the Pure Food and Drug Act.” They knew the sticker implied that the product must be safe and effective. In reality, it just meant that the label accurately stated toxins within. The association assumed, perhaps rightly so, that most people would be convinced by the seal of approval and not read the fine print. (The “guarantee system” was halted in 1914.)

The peddlers also hired “testimonial agents,” who procured upbeat blurbs. One broker charged $75 for a senator’s endorsement; $40 for a Congressman. Women were encouraged to write testimonials and were offered free medicine or the cost of a professional photograph. (They were told letters to Mrs. Pinkham would get replies by the maker, herself. Except for one thing, the deal went long into 1890s and early 1900s, years after Pinkham’s death in 1883.)

Sometimes reading about history soothes my soul because 19th century wackiness takes my mind off of 2019 insanity. Back in my grandparents’ day, consumers fell for slick advertising and testimonials. They were lured by claims that preyed on their fears of aging and promises of quick fixes. Can you imagine if people today were just as gullible?

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A New Play Shines Light on Women Long Forgotten

In the years leading up to the Civil War, about a dozen or so female slaves were part of a series of gruesome experiments that culminated in a huge advance in gynecology.

They were operated on over and over in a ramshackle shed in Dr. J. Marion Sims’ Alabama backyard. Sims was determined to figure out a way to heal vaginal tears caused by long labors.

He succeeded and became world famous. In addition to his surgical cure—a technique that would spare women worldwide some of the ravaging consequences of giving birth—Sims also invented the speculum and founded a woman’s hospital in New York. For more than a century he was hailed as one of the great humanitarian physicians.

For years, the story of J. Marion Sims focused on his achievements. But lately, his story has been revived without glossing over his journey to prominence, culminating not only in heated discussions.

Yet, however the story is told, the spotlight has always been on Dr. Sims. Harriet A. Washington wrote about him in Medical Apartheid. Her book along with subsequent articles prompted protests that resulted in the removal of a Sims statue that had been on Fifth Avenue in New York City. Deborah Kuhn McGregor wrote about him in From Midwives to Medicine. I also wrote about Sims and his legacy in Get Me Out: A History of Childbirth from the Garden of Eden to the Sperm Bank.

But who are these women? There are no diaries, nothing about what they had to say. We know the names of three of them. Lucy. Betsey. Anarcha. So when we write, they become two-dimensional, lumped together in one group: “The slave women.” To be sure, Washington dug deep to bring a voice to Anarcha Wescott, but so many of the women have remained anonymous because we just don’t have the information.

Now, Charly Evon Simpson, a playwright, has given voice to the voiceless. Her new play, Behind the Sheet, is inspired by the real events allowing her to shift the spotlight from Simms to the slaves.

We meet these young pregnant slaves who endured operations—some of them had up to 30 surgeries. But for the first time we are forced to imagine them in three dimensions, as yearning, bonding, compassionate, jealous, hurting women. Simpson gives these women agency.

Ben Brantley in the New York Times said the production “takes on cumulative power in its steady, clear eyed depiction of a time when it was a given that pain would be borne uncomplainingly by human beings regarded as chattel.”

While some of the dialogue is lifted right from J. Marion Sim’s autobiography, Simpson adds a plot twist.

In her play, the doctor is George Barry. We also meet Philomena, his assistant/pregnant mistress/slave. In real life, there was no Philomena. Or rather, there’s no record of Sims having a mistress or impregnating a slave. I found the injected storyline added heft to the play—we see his own mistress suffering and we see happens to her after her child with him causes her to suffer from tears. We see what happens to her after Sims finds his cure and heads north.

Harriet Washington, the Medical Apartheid author, ethicist and historian, applauded the play as a must-see—but, as she wrote in Nature,  the Philomena addition “muddies the already murky ethical waters of volition, coercion, sentiment and motivations.”

The night I went, there were audible gasps from the audience. The woman behind me sobbed. I assumed people went for the reason I did. We knew the story and were curious to know how this fictionalized version would come alive on stage. But perhaps this was news to some of them. And that’s a good thing. This is an important chapter in medical history that needs to be debated in wide circles outside of academia.

Simpson, in an interview with Science Friday, said that her goal was not to bring what has been written to the stage but to infuse life to the women, long forgotten. “I’m a black woman and have ancestors who were enslaved,” Simpson said. “I wanted to give them back the humanity that society at the time stripped way.”

Behind the Sheet had sold-out performances at the Ensemble Studio Theatre and is now extended until March 10th. Here’s more information about the show.

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Predicting Criminal Behavior

In 1924, two rich teenagers from the suburbs of Chicago murdered a kid in their neighborhood. They were caught right away and the trial became known as the crime of the century. The gruesome story of Richard Loeb and Nathan Leopold became fodder for national newspapers and would inspire four films, several books and one play.

During the trial, the killers’ parents hired doctors who tried to convince the judge that the boys weren’t responsible for their own actions. Their faulty hormones made them do it. One doctor, using state-of-the-art tools of the time said he spotted a defective pineal (a gland in the brain) that triggered a lack of inhibition. Today we know the pineal gland emits bursts of melatonin that control our circadian rhythm, our internal clock. In other words, it has nothing to do with compelling someone to kill. In Leopold and Loeb’s time, it was connected ever-so-tentatively to sex and intellect. The doctor explained that because of Leopold’s hard pineal, he had too much libido, even for a 19-year-old boy, and not enough inhibition.

The judge said he was intrigued by this new field of endocrinology (the study of hormones), but these insights were not going to keep two murderers out of jail. The boys were each sentenced to life in prison.

For nearly a century, we have tried to use all kinds of tests to predict human behavior. Around the same time as the trial, Dr. Louis Berman, a New York City doctor, claimed he could look at people and figure out which of their many hormone-spewing glands controlled them. He labeled people “thyroid types” or “adrenal types” based on some dubious assessment. He also said he could forecast their future—whether, based on their hormones, they’d become leaders or movie stars, or criminals. Berman’s ambitions were lofty: he wanted to use his “skills” to evaluate school children and predict their futures. If a kid were destined for a wayward life, he’d prescribe preventive hormone therapy. He wrote books that the public adored and his colleagues loathed. Still, like many ideas based on conjure rather than data, his theory faded away.

We’ve tried for nearly a century to figure out ways to predict who is likely to be a killer, and then take extra cautions with those people. Last week, during a news conference about the flu epidemic, Alex M. Azar, the U.S. Department of Health and Human Services Secretary began by addressing the recent Florida massacre saying the administration needs to be “laser-focused on getting Americans with mental illness the help they need.”

That’s a nice idea. Those with mental health issues should get the therapy they deserve. We don’t need to stigmatize mental illness even further by assuming that anyone suffering from mental illness is a potential murderer. In a scientific article in 2105 published in the American Journal of Public Health, the authors write that the mentally ill are “far more likely to be assaulted by others or shot by the police than to commit violent crimes themselves.”

I’ve spent the past seven years exploring the history of hormones and the science of hormones and behavior. We’ve made great strides. We have more insight into the ways that hormones can make us moody or hungry or tired. We have hormone medicines that can help people with dysfunctional glands. But our notions of predicting a “killer instinct” are, at best, wishy-washy.

We are kidding ourselves if we think we can predict the next killer with tests based on hormones or surveys or any kind of chemical assessments. Politicians and others may look to these studies because they provide a good sound bite, but we need to reread the history of medicine and the recent history of killing sprees to appreciate that it’s highly unlikely we are going to find the sure-fire predictive test and then provide all of the best preventive care necessary to prevent the next massacre.

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Fake News, Silicon Valley and Our Health

In today’s New York Times, Emily Parker writes about something that we all sort of know but don’t want to face: When it comes to fake news going viral, Facebook, Twitter, and Google aren’t the entire problem. We are. As she writes, we are the ones spreading the information; we are the ones who find it much easier to digest news that’s fed to us in bite-sized, easy-to-digest portions. She calls complex debate the vegetables (good for you/not appealing) while fake stuff is candy (junk/super-tempting).

Funny that she went for the health side of it, because the whole time I was reading about fake news and politics, I was thinking that the same could be said for health news. We want a quick fix rather than a nuanced discussion of the pros and cons.

We complain that doctors keep changing their minds. Fifty years ago, hormone therapy for menopausal women was great, a few decades later it was dangerous, and now it’s good for some women, not others. Fifty years ago, natural growth hormone (from the brains of cadavers) was better than synthetic, then we were told the laboratory-made stuff was better.

Does that mean scientists were wrong? That we have to worry they are spreading fake news? No, it means we have to recognize that medicine is an uncertain art.

  • Don’t read every scientific study as the final word.
  • Be wary of people that tout quick fixes.
  • Appreciate that gleaning health information is often complex and takes more than a quick nod to understand. If you care about your health, care enough to read the whole story.
  • Understand that our knowledge of the human body is evolving.

“There is wisdom in the acceptance of uncertainty,” wrote Dr. Sherwin Nuland, my former medical school professor in an essay in the New York Times, six years before his death. Wisdom that isn’t easy to digest but it is good for you. That’s for sure.

For further reading on accepting uncertainty in medicine, I recommend this piece in the New England Journal of Medicine by Dr. David J. Hunter, professor emeritus of cancer prevention at Harvard T. H. Chan School of Public Health.

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Payoffs of Snooping

The Birth of Forceps Offers Insight to Birth Today

There’s an upside to being a snooping guest—you could find a long-lost treasure as this nosey 19th century mother-in-law did.

In 1813, Dr. William Codd’s mother-in-law was poking around he and his wife’s home in Essex, England. She noticed a crack in the floorboard, pried it open, and hoisted a box of metal trinkets. She must have thought the stuff looked scientific because she ran the box over to her friend, a retired surgeon who lived nearby. He knew immediately that she found a medical treasure. One that had been missing for a hundred years.

Inside the box were the world’s first usable forceps. They were created in the 1500s by the Chamberlens, passed down from generation to generation until Peter Chamberlen retired and hid them in the floor of his estate.

The story of forceps is one of a huge medical advance. Before forceps, babies stuck in the birth canal died, and sometimes so did the expectant mother. But it’s so much more. It’s a story of fierce competition and bitter debates.

The Chamberlen men developed this lifesaving device and then refused to share the secret because they figured (rightly so) it would give them an edge in the childbirth business. They became the male-midwives to aristocrats and royalty. And to make sure no one stole their idea, they stored the forceps in box the size of a coffin (so there were no clues about its size or shape) and then blindfolded the laboring women so she couldn’t sneak a peak, either. (As if a woman about to deliver a baby is going to grab a pen and paper—or quill and parchment—and jot down notes).

Eventually in the mid 1700s, Peter Chamberlen, a great-great nephew of the inventor, realized he could make money selling the design. So he did so to Dutch and then British doctors. When he retired, he buried the original forceps in the floor of his house. And there they remained until the nosey mother-in-law of the next home’s owner happened upon them.

I was telling the tale of the eccentric Chamberlens this week when I was interviewed on KWMR radio by Christina Lucas, a nurse in Point Reyes, California about the history of childbirth. I thought I knew the story pretty well until she said, “Where are the forceps now?”

I was stumped during the show, but promised I’d do some searching afterwards. Like most things in life, the answer was one Google click away. The forceps are now on display at the museum of the Royal College of Obstetricians & Gynaecologists.

Since the Chamberlen days—or really starting with the Chamberlen’s, forceps have instigated some of the most contentious childbirth debates. Women worried about the safety of high-tech birth (forceps) versus natural birth (sans forceps). The concerns are reminiscent of the cesarean section versus no-cesarean section debates today.

Today forceps fit into the natural category and many obstetricians believe that the art of using them (it takes a bit of skill) needs to be re-introduced to minimize the high rates of c-sections. There are also initiatives to teach forceps skills to women in developing countries, where surgical births may not be an option.

In any event, if you’re as curious about childbirth history as I am—and if you happen to be in London—it’s worth a stop at the Royal College of Obstetricians and Gynaecologist’s museum. You have to make an appointment. The College is near Regent’s Park, a lovely part of town.

And if you’re really curious, you can hop on a train from Liverpool street to Hatfield Peverel in Essex and see the Chamberlen’s former home. It’s called Woodham Mortimer Hall. There’s a blue plaque on the door that rehashes the history in a few sentences. The Hall is now private, but you can see if from the outside and visit the cemetery nearby. (It’s also a lovely area of the English countryside…where I got my first puppy, a Golden Retriever.)

I’m glad that Christina pushed me to get to the end of the mystery. But the one thing we’ll never know is what Dr. Codd said when he got home that afternoon and found his mother-in-law dismantling his flooring.