[Article VI]
Fellows’ Syrup, and Other Preparations of the Hypophosphites
We hope that it is clear to those who have read the several articles of this series that their purpose is to present evidence that will enable the reader to form a correct estimate of the literature employed in the exploitation of various nostrums. The distinction between mere assertion—however plausible, and from however eminent an authority—and evidence should again be emphasized. Satisfactory evidence rests on careful observation by those who are capable of accurately determining to what extent any changes that may be observed are due to the therapeutic agent employed and not mere accompaniments of such treatment.
When the Council on Pharmacy and Chemistry was organized in 1905, the greater part of the literature of the nostrums was so palpably misleading, the statements often so ludicrously false, that it was only necessary to call attention to this fact to have those claims collapse. As a result of the Council’s work, the exploiters of worthless nostrums have developed a greater degree of shrewdness in avoiding the easily exploded falsehoods. This has made it increasingly difficult to point out the exact statements on which many of the false claims now rest, even though the exploitation as a whole is as inherently dishonest as before. If a nostrum is worthless, any exploitation must be false and misleading in effect, even though not one single false direct statement is made.
A platitude may be given an appearance of importance if uttered in an impressive manner, and it may be employed to suggest far more than it categorically affirms. These two facts are appreciated by many nostrum exploiters and we find that they have adopted the impressive manner to secure attention, and the platitude to suggest far more than they could defend in direct statement. Thus we have the “lie with circumstance.”
FELLOWS’ SYRUP
A full page advertisement, which has been appearing regularly for about a year and which must represent a good deal of money, is used to give an appearance of importance to a few words which, if printed in ordinary type, would either pass wholly unnoticed or would lead one to assume that something essential to the full meaning had been omitted. The statement, in full reads:
“Fellows’ Syrup differs from other preparations of the hypophosphites. Leading clinicians in all parts of the world have long recognized this important fact. Have you? To insure results, prescribe the genuine ℞ Syr. Hypophos. Comp. Fellows’. Reject cheap and inefficient substitutes. Reject preparations ‘just as good.’ ”
The only direct statement contained in the advertisement is to the effect that many clinicians have observed that Fellows’ syrup and other preparations of the hypophosphites are not alike. In truth, Fellows’ is not like the better preparations of this type, since after standing it contains a muddy looking deposit that any pharmaceutical tyro would be ashamed of. Technically, then, the statement is true, but it is hardly credible that the manufacturer is paying for an entire page in a medical journal to make this statement without any attempt to suggest something else.
The advertising pages of six medical journals were examined in the order in which they chanced to come to hand. In five of these, the entire advertisement of Fellows’ syrup was in the words just quoted; not a single word more. In one there was the further statement:
“Not a new-born prodigy or an untried experiment, but a remedy whose usefulness has been fully demonstrated during half a century of clinical application.”
These advertisements show that the exploiters of Fellows’ Syrup are spending a great deal of money to induce physicians to prescribe the preparation, and it is equally evident that they wish to convey the impression that the preparation has some therapeutic value. Since we find nothing directly false, in the first mentioned advertisement at least, we must take the evident intent for consideration and determine what therapeutic value, if any, this preparation has, and whether it is advisable for physicians to employ it in any case.
The preparation, according to the statement just cited, has been in use for fifty years. As the exploiter of any preparation cites the most convincing evidence in his possession in support of his views, this claim may be assumed to be the strongest available, and if this evidence fails we must reject the contention as not proved. Here we face a dilemma, for examination of the literature used in the exploitation of Fellows’ Syrup fails to disclose any evidence of the kind that we have described as satisfactory; and we are, therefore, forced to conclude that none has ever been found. By this it is not to be implied that no reputable physician has ever reported favorably concerning the therapeutic effects of this preparation. It is quite possible that an extensive literature of that sort might be found if one examined the older medical journals. But the day has passed when every improvement that follows the administration of a preparation is blindly attributed to the drug in question. Clinical research today is far more exacting.
We will assume that the reader who has investigated the question with an open mind will have come to the decision that the contention that Fellows’ syrup is of especial therapeutic value is not proved. We might rest with that assumption and ask the clinician whether he is prepared to use a nostrum that has been before the medical profession for half a century without any satisfactory evidence having been gained that it possesses therapeutic value. We might ask him whether he would be willing to tell his patients that he was prescribing such a nostrum for them in the face of the absence of any such evidence of its value.
THE INERTNESS OF THE HYPOPHOSPHITES
But we prefer to go even further and show him that not only is there an entire absence of any evidence of its therapeutic value so far as we have been able to learn, but in addition there is an abundance of evidence that the hypophosphites are devoid of any such therapeutic effect as they were formerly reputed to have, and that, in fact, they are, so far as any effect based on their phosphorus content is concerned, singularly inert.
While we have thus far taken the Fellows’ preparation as the subject of the discussion, we may take a broader view and examine the subject of the hypophosphites in general, and the substitutes containing phosphorus that have been introduced from time to time. It hardly needs to be said that if the hypophosphites are without therapeutic value, it is impossible to give them value by combining them in a muddy-looking, ill-made preparation such as Fellows’ Syrup. Such evidence was submitted to the medical profession in a report of the Council on Pharmacy and Chemistry (J. A. M. A. 67:760 [Sept. 2] 1916); and we would strongly advise any one who is disposed to act on the suggestion contained in the advertisements of Fellows’, and other hypophosphite preparations, to read that report in full and to think the matter over before prescribing one of these nostrums. Quoting briefly from the report in question:
“Although the overwhelming weight of evidence was against the probability that the hypophosphite preparations are of value as therapeutic agents, the Council thought it well to investigate the subject. Dr. W. McKim Marriott of Baltimore was therefore requested to review the evidence for and against the therapeutic usefulness of the hypophosphites and to conduct such experiments as seemed necessary.”
The Council was not content to rest on the mere absence of evidence for the value of these preparations or any one of them, but sought to obtain evidence that would fulfil the conditions mentioned above, and in pursuance of this plan it secured the cooperation of a trained investigator, one who would work under the best of conditions for learning the truth. The results of Dr. Marriott’s investigation were published in The Journal, Feb. 12, 1916, p. 486, and should be read by everyone who has any interest in the problem. Lest some of our readers may fail to refer to the original of Marriott’s paper, we will quote briefly from it:
“None of the subjects of the experiment experienced any effect whatsoever from the administration of the drug ... Almost all of the ingested hypophosphite is eliminated unchanged....
“These experiments (Forbes) demonstrate conclusively that the hypophosphites possess no specific value as a source of phosphorus for the body.... It is doubtful if there are any conditions in which the body suffers from lack of phosphorus. Even should such conditions exist, phosphorus, in the form that it occurs in the ordinary foods, or as phosphates, is more efficient in supplying the deficit than hypophosphites that must be oxidized before utilization and which are only about 15 per cent. oxidized if at all. For example, half a glass of milk contains more available phosphorus than three large doses of hypophosphites of 15 grains each, as great a dosage as is usually given.
“What then, is the therapeutic value of hypophosphites? There is no reliable evidence that they exert a physiologic effect; it has not been demonstrated that they influence any pathologic process; they are not ‘foods.’ If they are of any use, that use has never been discovered.”
The case seems to stand about like this: A nostrum maker spends thousands of dollars to tell physicians that his cloudy preparation is not like other preparations, and physicians are expected to accept that as convincing evidence that they should prescribe and their patients, perforce, take it. This too, in spite of the evidence gained by careful scientific investigators that the hypophosphites in fairly large doses contain less available phosphorus than half a glass of milk, and that there is no evidence available that they exert any therapeutic effects at all.
Should we take the meaningless statement of a nostrum maker, who does not submit evidence of any therapeutic value of his preparation—unless one can call certain careless habits of prescribing evidence—and assume the responsibility of prescribing a nostrum that according to all scientific evidence available is useless, and of no more effect than a few teaspoonfuls of milk, so far as its hypophosphite content is concerned? It may be argued that it possesses some value because of its bitter nature. We will not deny that it is bitter; so is strychnin, so is quinin, so are scores of simple drugs, but what physician would care to admit to his patients that he did not know how to prescribe a simple bitter, such as nearly every layman can select for himself, without recourse to a preparation such as Fellows’ Syrup?
We have felt that it is not wholly satisfactory to discourage the use of a given nostrum without making an effort to assist the physician in choosing wisely in the treatment of the condition for which the nostrum is claimed to be useful. In the present instance, however, we fear that would prove a task beyond our powers, for the hypophosphites have been used in such a variety of conditions that the discussion would have to include nearly the whole materia medica if we were to follow our usual procedure.—(From the Journal A. M. A. Feb. 16, 1918.)