ImageFrom ‘Street Life in London’, 1877, by John Thomson and Adolphe Smith, courtesy of LSE Library, No known copyright.

Today, we take it for granted that we can walk into any main street pharmacist and buy high quality, safe and effective medications.  Just over a single lifetime ago this was not the case.  How drugs were manufactured, tested, labelled and sold was very different, and the raft of regulation and legislation that protect us now could not even be imagined.

Most people would never have had the money to consult a doctor or an apothecary.  Instead, they would rely upon the drugs they could purchase with their pennies and ha’pennies from street peddlers.  On the streets of Victorian London you may have bought medicines from the sort of peddler shown in the picture above.  This street trader of drugs was photographed by the pioneering Scottish photojournalist John Thomson.  Along with the writer Adolph Smith, he documented London street life from 1876-77 and they published their combinations of pictures and interviews in monthly parts.  Their work has often been hailed as the forerunner of the modern documentary.  Characters like this trader of cough lozenges and healing ointments have been known by many names, including quacks and mountebanks, but when Adolphe Smith interviewed ‘an intelligent member of the fraternity’, he learned what they called themselves.

“Our profession is known, sir, as ‘crocussing’ and our dodges and decoctions as ‘fakes’ or rackets. Many other words make up a sort of dead language that protects us and the public from ignorant impostors.  It don’t do to juggle with drugs, leastwise to them that are ignorant of the business. I was told by a chum of mine, a university man, that ‘crocussing’ is nigh as old as Adam, and that some of our best rackets were copied from Egypshin’ tombs.”

Regarding themselves as members of the medical profession, they communicated with each other in ‘crocus’ Latin and employed a cryptic nomenclature for their remedies.

When asked about the nature of these remedies the crocus made clear his principles.  ‘Pardon me, sir, you may be a licensed surgeon yourself. But I would as soon swallow a brass knocker as some of your drugs. A brass knocker is a safe prescription for opening a door; it’s poison as a pill. I believe it is just the same with the poisons took out of the bowels of the earth, where they should be left to correct disorders. Herbs are the thing, they were intended for man and they grow at his feet, for meat and medicine.’

Of course such crocuses could also turn their hand to selling rat poison and household cleaners as well as remedies.

“A very shady ‘racket’ is the India root for destroying all sorts of vermin including rats. It’s put among clothes like camphor. Any root will answer if it’s scented, but this racket requires sailor’s togs; for the ‘crocus’ must just have come off the ship from foreign parts.  It also requires a couple of tame rats to fight shy of the root. The silver paste is a fatal ‘fake’.  The paste is made of whiting and red ochre. The crocus has a solution of bichloride of mercury, which he mixes with the paste, and rubbing it over a farthing silvers it. He sells it for plating brass candlesticks and such like, but it’s the mercury that does the business, he don’t sell that. The mercury in time gets into his blood and finishes him. I have known two killed this way.”

But it was the sale of medicines that brought the greatest rewards.  “I have been a cough tablet ‘crocus’ for nine years, only in summer I go for the Sarsaparilla ‘fake’. Sometimes this is a regular ‘take-down’—swindle. The ‘Blood Purifier’ is made up of a cheap herb called sassafras, burnt sugar, and water flavoured with a little pine-apple or pear juice. That’s what’s called sarsaparilla by some ‘crocusses’.  If it don’t lengthen the life of the buyer it lengthens the life of the seller. It’s about the same thing in the end.”

The contents of this crocus’s pills, ointments and potions were closely guarded secrets, not least of all because the key ingredients were often worthless.  However, even if you knew what was in the medicine you were using, there was no guarantee of its safety.  The sale of drugs was unregulated and there was no need for any manufacturer to test their products before marketing to ensure their safety, nor indeed was there any compulsion to provide evidence for any claims of efficacy.

This lack of control over the contents and their safety testing meant that you could be giving morphine to your teething child, smoking ‘asthma cigarettes’ for the relief of ‘all diseases of the throat’ (but thankfully ‘not recommended for children under 6’).  You might also sip a cocktail of codeine, cannabis and chloroform to relieve your cough.  If the latter did not do the trick you could simply treat yourself with some over-the-counter heroin—again sold as a cough remedy.

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Today, even with calls to deregulate such drugs, it is hard to imagine that we would sanction the indiscriminate use of high doses of opiates for minor complaints in adults, never mind children.  But, without any form of regulation, manufacturers of such drugs could advertise widely, making often largely unsubstantiated claims for the efficacy of their products. Even if there had been any form of quality assurance exercised during their drug’s manufacture, you would not have been able to check the contents of the product as the seller had no obligation to list the ingredients on the pack.  Drugs sold over-the-counter and prescribed by physicians and apothecaries could, and did, contain anything.

But, think for a moment, what would our world look like if there were no drug treatments?  First, the global population, which has recently passed the 7 billion mark would be less— considerably less.  Deaths from many diseases, but especially infectious diseases would be high.  The population would be on average much younger for the likelihood of reaching old age would be much reduced.  The average number of pregnancies for each woman would be much higher as infant mortality would be high, as of course would be rates of maternal death in childbirth.  Pain would be unrelieved, infections untreated, psychiatric diseases unresolved. Patients with diabetes could expect nothing like a normal life.  Children with asthma would struggle and many would die from their condition.  Sexually transmitted diseases would be rife and often ultimately fatal.  There would be greater dependency on folk remedies and alternative therapies—only they would no longer be alternative, but mainstream.  Medicine as a professional discipline would also look very different: built less upon a scientific foundation and more upon an unstable and shifting edifice of opinion and belief and faith.

We do not have to work too hard to imagine this world for it was our world in the comparatively recent past.  The explosion in drug development has largely been a story written in the last two or three centuries, and this narrative has been driven by many different factors.  Yes, there have been commercial interests but there has also been a genuine desire to improve the health of the population and to relieve suffering.  Lofty words that lose a little of their altitude when we think of drug scandals and the apparent deception and greed of some groups, but words that are nonetheless true.

The development of new drugs is often driven in the first instance by a simple wish to help, and not simply to make money.  Successful drugs will make, for those who develop and manufacture them, enormous riches, but it is also a very risky and expensive business.   Huge speculative investment must be made to find and test the next drug.  Many, if not most, contenders will fall by the wayside and only a tiny minority of new compounds will eventually find their way on to the pharmacy shelves.  But, the regulation of this drug development is comparatively new and was often enacted as a response to scandal or catastrophe.

‘A desire to take medicine is, perhaps, the great feature which distinguishes man from other animals,’ wrote William Osler in 1891.  Our pharmaceutical consumption has continued unabated since, and if we are to be assured that what we take with our glass of water before bedtime is safe and effective, we must thank the complex regulation of clinical research and drug regulation that protects us from crocuses.

© Allan Gaw, 2013

You can read more about the history of clinical research in my book Trial by Fire available from amazon as a kindle download.

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http://www.amazon.co.uk/Trial-Fire-Lessons-Clinical-ebook/dp/B004N84VMS/ref=sr_1_1?ie=UTF8&qid=1364739051&sr=8-1

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Trial by Fire: Lessons from the History of Clinical Trials

Trial by Fire: Lessons from the History of Clinical Trials

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