Category Archives: psychiatry treatment modalities

The City of Lights and Medicine

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Denizens of the 21st century complain of how super-specialized the practice of medicine has become. Few modern medical students aim to be generalists – even the discipline now known as Family Practice is a specialty – as most aim for many additional years of training to become expert in scientific minutiae.

It would appear, however, that our world has nothing on 19th century Paris.

The City of Lights in the epoch between Napoleon and the Franco-Prussian War was an epicenter of medical study, one reason being that French citizens were entitled to free medical care by royal decree. Students and young doctors flocked there from all over the continent, and from across the Atlantic, because of the amazing proliferation of facilities dedicated to very specific conditions and illnesses. No where else could doctors-in-training see so much pathology at the sides of renowned clinicians all in the same place.

Obstetrical complications? That would be Hôpital de la Maternité, with no fewer than a dozen births per day. Gravely sick children? The largest such hospice in the country was Hôpital des Enfants-Malades, sadly filled to capacity. Venereal diseases? There were two: for the women, Hôpital Lourcine, and for the men, Hôpital du Midi – the former being a house of tertiary-staged horrors, and the latter, while equally ghastly, mandating in the earliest years the additional ‘treatment’ of public whippings to teach patients to stay away from strumpets and keep their trousers on.

Lunatic women of childbearing years, idiots and imbeciles and morons of both genders, the terminally ill, the deaf, the blind, the dumb… all had their own specific destinations in the capital. There was a hospital for elderly married couples who wanted to die together in the same room (they could bring their own furniture and effects, the price of admission in part being bequeathment to the facility on joint passing of all personal property).

Lepers, however, were not welcomed, and instead were shipped out of the city limits should any show up at the front doors.

There was even Hôpital des Enfants-Trouvés for homeless children (distinct from an orphanage, as Enfants-Trouvés had physicians on staff to tend to the lesser ailments of the abandoned whose sicknesses didn’t quite require admission to Enfants-Malades). Some of the arrivals were orphaned when their mothers died at la Maternité (1:50), while others were voluntarily surrendered by caretakers unable to provide for their special needs. When these youngsters were deemed medically stable, they were offered for public adoption, though without surprise, many stayed at Enfants-Trouvés until they reached majority and were turned back to the streets by the hundreds.

Enfants-Trouvés had an anonymous drop-zone called le tour d’abandon (‘the desertion tower’) where sliding doors and a small bell would herald to the nurses within the arrival of a new human deposit. The citizens of Paris were encouraged to mark their children so they could potentially be reclaimed, though very few were ever later sought.

The American doctors in town, however, were most astonished by École Pratique d’Anatomie. While not a hospital per se – it was more of a pathology foundation – it allowed any physician, for the equivalent of $6, to access his own personal cadaver for dissection (no doubt many of whom were unfortunate former patients of Paris’ other healing institutions). In the early 19th century, human dissection remained illegal in the U.S., and many practitioners there had to resort to grave robbing to obtain specimens. In Paris, for a modest fee, cadavers were plentiful for the taking.

There was one small catch. The stuffy and warm dissection room often contained two dozen physicians whittling away on unpreserved corpses. The smell was said to be overpowering, and at the end of the day, leftover chunks of the deceased were tossed to packs of snarling street dogs who waited out back.

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[Copyright 2013 @ The Alienist’s Compendium]

PHI and Politicians

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As the political season heats up, there once again have begun the perennial rumblings that the media is “too intrusive” or doesn’t treat one candidate as fairly as another. I don’t worry about this much; there are as many publications on the left as on the right, and if one politician gets heat from a certain sector, you can rest assured that the politician’s opponents will be similarly scrutinized by partisans of the other camps. It can be loud and messy, but I’m convinced it all balances out in the end.

However, and invariably, as the political microscope becomes more focused, there will be more talk about what is ‘fair game’ for journalists. A politician’s family? Dumb things that person may or may not have done in college half-a-century prior?

With HIPAA and Protected Health Information (PHI) in mind… are politicians owed privacy as the rest of us? And if so, to what degree?

Would FDR’s polio be pertinent today to the landmark legislation he championed and his stewardship of the nation through WWII?

Should Thos Eagleton’s history of depression have removed him from contention for the second highest position in the land?

I read recently that, the week following his inauguration in 1961, John F. Kennedy appointed his personal doctor, Janet Travell, M.D., as presidential physician, marking the first time that a woman had held that important post.

This breaking of the glass ceiling, though, came with some additional baggage. Dr Travell had an impressive professional resume, including prestigious academic appointments in pharmacology, orthopedics, and cardiology. She then-already enjoyed an established reputation as a pioneer in the treatment of chronic pain conditions.

[sidebar: it is said to have been her recommendations on ergonomics that later resulted in the iconic images of JFK sitting in rocking chairs]

But when expressly asked about rumors of JFK’s health during the 1960 campaign, she stated that he did not have Addison’s Disease and that she had never treated him for same – both statements found after his death to be inaccurate.

In short, she lied.

Additionally – though this may be a reflection of the times and not as much the clinician – Dr Travell prescribed for JFK an astounding array of potentially habituating agents to treat his pain, including high doses of Luminal, Librium, Miltown, Laudanum, Meperidine, and Dolophine. Add to that his frequent, sometimes nightly, use of Nembutal for sleep. Though the Kennedy family credited Dr Travell with enabling a determined JFK to maintain his punishing schedule in the face of physical difficulties, Dr Jeffrey Kelman, who later researched and published a book on Kennedy’s health, has since stated that the president’s ailments probably would earn him social security disability benefits were he were alive today. And as one who had seen combat, he’d also arguably be 100% service connected through the Veterans’ Administration for such serious and chronic debilities.

All of this occurring concurrently with the Bay of Pigs and the Cuban Missile Crisis!

However, one might say, he successfully navigated those challenges. Yes, others will add, but what if his sensorium had been clouded by that potentially stupifying drug cocktail?

As physicians, we deal with the headaches of HIPAA daily, the near-constant concerns over aspects of privacy – presumed, expressed, implied – that any/ all practitioners can readily appreciate. We worry about minutiae like names on the spines of filed charts being visible from a distance.

The media has no such worries in reporting on the body politic. Or should it?

All points worth keeping in mind as we enter the nominating primaries.

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[Copyright 2013 @ The Alienist’s Compendium]

The Wonder Drug

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A (foreign-born) relative of mine – one with extensive medical training – has chronic difficulty sleeping. X has attempted all of the usual sleep-hygiene techniques. X has also tried the rather traditional drug/ health food store aids (e.g., Tylenol PM, Benadryl, Melatonin, l-Tryptophan) and much of the prescription stuff (e.g., Seroquel, Remeron, Ambien). X often sleeps in fits and spurts regardless, and has become frustrated, tired of going to the family doctor for help that doesn’t actually help.

One day recently, X and I were going through the belongings of another relative who had visited the U.S. and then departed, inadvertently forgetting some personal items and then asking for smalls to be mailed to her. In reviewing what to send and what to keep for the next visit, X came across a small bottle of liquid. X sat down, looking at the label, and smiling.

Corvalol

Corvalol

“What did you find?”

“Ah, this is what we used in [the Old Country]. It’s great stuff.”

“For what?”

“It’s a nerve medication. And a heart medication, for high blood pressure, angina, and tachycardia. It calms you down. It even works for gastrointestinal cramping. But most people also use it for sleep. Old people love it. You mix it with water and maybe some sugar. I used it years ago. It’s great.”

Intrigued by this rather vague and all-inclusive description from a fellow medical professional, I asked for translation, as the label was written in a tongue I do not speak.

C-O-R-V-A-L-O-L

Before I go further, let me remind readers that much-vaunted Western Medicine (and culture) has a long history of employing stuff back in the day that we wouldn’t be caught dead using now. Freud was a vocal proponent of cocaine, a sanguine view shared by the original recipe for Coca Cola. 7-Up at one time contained lithium. The Victorians freely employed alcohol for colicky children. Before it was outlawed in the 1960s, many residency programs employed LSD as a means of teaching budding psychiatrists about psychosis. Benzodiazepines (e.g., Valium and its brethren) were handed out like candy by some practitioners when first on the market, as a “safe” alternative to other sedative-hypnotics. You get the picture.

So, a MedPub search of Corvalol turns up some very interesting information.

It is OTC in many central and eastern European nations and in former Soviet states, and there is a booming market for it in immigrant communities. Usually brought into this country in small amounts as personal Rx (and with labels that can’t be read by customs anyway), it is available as scored tablets, though it is more often found as a (liquid) tincture to be mixed with a beverage of choice before consumption.

It is neither approved nor legal in the U.S. in its traditional formulation. It can be obtained online, but is then missing some of its key ingredients when shipped via approved channels, rendering it, in the words of one disgusted user, “piss water.”

Okay, so what comprises this wonder drug? As brewed by its two manufacturers – Farmak Pharmaceutical Manufactory of Kiev, Ukraine, and Krewel Meuselbach GmbH of Frankfurt, Germany – it contains myriad inactive ingredients (i.e., lactose monohydrate, magnesium stearate, β-cyclodextrin, potassium acesulfam, peppermint oil), and then

• Alcohol (the tincture 96% by volume) which needs no introduction;
• Ethyl ether of α-bromizovalerianate, a combination of bromide and herbal valerian root extract;
• Phenobarbital.

Bromides have been employed as flame retardants, gasoline additives, and pesticides – appetizing, yes? – though in humans, they have a long and storied history as anxiolytics and anticonvulsants starting in the 19th century.

[sidebar: for those readers from Baltimore who are familiar with the city’s landmark Bromo-Seltzer tower, that widely-known medicinal agent lost its namesake ingredient in 1975 by U.S. Food and Drug Administration fiat]

Valerian started as perfume in the 16th century Mediterranean basin. It has been historically used for insomnia and conditions associated with anxiety. It has also been applied in folk medicine for infantile convulsions, epilepsy, attention deficit, chronic fatigue, joint pain, asthma, migraines, menstrual cramps, and symptoms associated with menopause. Despite minimal scientific data that valerian can reduce coronary vessel spasm in certain cases, the remainder of these therapeutic claims are unsupported by any research at present.

As for Phenobarbital, it is an anticonvulsant barbiturate and DEA schedule IV controlled substance. There are no clinical trials supporting its use in cardiovascular or bronchospastic states. It can also alter the metabolism of other Rx when taken in combination – thus, gerontologists oppose its use in the elderly due to the high rate of physical dependence and risk of toxicity even at low doses.

And yet, the lack of controlled studies notwithstanding, in a number of countries, Corvalol is widely available – sometimes even mandated – in first aid kits (e.g., those accessible on public transportation), alongside aspirin, nitroglycerin, and activated charcoal, and freely dispensed as needed.

Sleep tight!

[Have an idea for a post topic? Want to be considered for a guest-author slot? Or better, perhaps you’d like to become a day-sponsor of this blog, and reach thousands of subscribers and Facebook fans? If so, please contact the Alienist at vadocdoc@outlook.com]

[Copyright 2013 @ The Alienist’s Compendium]

The Pink Ladies

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Here’s a quiz: which of the following assertions were uttered by chronically mentally ill individuals at a state psychiatric facility, and which were headlines from a nationally distributed periodical, one that enjoyed a circulation of over 1.2M in its heyday and spawned a hit off-Broadway musical?

“There’s a giant mutant hog monster attacking Georgia!”

“Scientists have found an infant dragon preserved in formaldehyde!”

“Bat Boy to be the next Pope!”

“Elvis’ face appeared in my pancakes!”

“The Founding Fathers were all gay!”

While some/ all of this might have been said at some point by patients suffering from psychotic disorders, the above statements were actually front page ‘news’ from a widely read tabloid. The Weekly World News, bastard cousin of The National Enquirer, to be exact.

But allow me to digress for a moment before further explaining.

I was dining with family recently when my foreign-born spouse brought forth a surprise dish we’ve never before enjoyed at our house. Perhaps she thought it was an exotic food worth sharing, one that is absent from both her own memory and her culture’s traditional cuisine. She placed it on the table with a smile and asked, “does anyone know what this is?”

“Yes,” I replied. “That’s pimento cheese spread.”

She looked somewhat surprised that I recognized the edible when she has never seen me eat or talk about it in our decade together. Thus, I felt an explanation to her was in order.

At the University of Virginia, where I completed both medical school and residency, the second half of the 1980s was a period of transition. The drab old hospital, built in the years following WWII, was being replaced by a bright white edifice just across the street. That new building, with an expensive copper roof that shone like jewelry in the sunlight, had a fancy dining facility in keeping with the rest of its aesthetics. The old hospital had a run-down cafeteria in its basement – called The Skylight Inn, even though that was comical since there wasn’t a single window in the place.

And the old hospital had the Pink Ladies.

Most hospitals have a volunteer auxiliary comprised of (usually female) older retired helpers supplemented by bored high-schoolers and those looking to add a few community service brownie points to their upcoming college applications. The former were the Pink Ladies, and the latter were the Candy Stripers.

Both flavors of these volunteers had small carts that they pushed around to patients’ rooms to deliver paperback novels and chocolate bars. But they also served the medical center’s workforce. The Pink Ladies staffed a snackbar, just one flight up from the Skylight Inn in the old hospital. Although its menu was limited – a few simple sandwiches, chips, sodas, candy – it was often preferred by the doctors and nurses to the cafeteria downstairs. Why? Because the Pink Ladies made their sandwiches early each morning en masse, wrapped them in wax paper, and sold them super-cheaply. Plus, you could be in-and-out with your purchase in no time; patronizing the Skylight Inn meant lining up and waiting, and if they didn’t have what you wanted, you’d have to wait longer.

Far from gourmet, Pink Lady sandwiches consisted of nothing more than two pieces of Wonder Bread cut diagonally, usually with some sort of smear on the triangles which were then pressed/ glued together. Tuna. Ham salad. And yes, pimento cheese.

As a medical student and intern, grabbing three or four Pink Lady sandwiches, for the princely sum of approx $2.50 total and then stuffing them, taped wax paper and all, into the huge side pockets of my white coat, could keep me going for the rest of the afternoon and evening, long after the Skylight Inn had closed and the Pink Ladies had gone home to play pinochle and watch Lawrence Welk.

So that was my experience with pimento cheese. But remembering that faux-delicacy soon got me thinking about another long-forgotten aspect of the Pink Ladies, one far more nefarious.

I spent my internship in the main (old) hospital, but as a resident, I moved out to the designated psychiatric facility, Blue Ridge, a freestanding separate complex that was originally a turn-of-the-century TB sanitarium on 100 acres about five miles down Rt 20. The Pink Ladies had an outlet there as well, but it wasn’t their foodstuffs in 1989 that piqued my curiosity.

It’s widely accepted that, when managing patients with disorders of perception and cognition, maintaining predictable routines in structured surroundings with known staff helps reinforce reality-testing. That’s why ward schedules are often the same every day, familiar faces are encouraged to visit, and rooms usually have large windows, bold calendars, seasonal décor, and clocks that are easy to read – it helps those with a tenuous grasp of this dimension keep from further slipping.

Those patients with off-unit privileges were allowed to leave the ward and walk outside to smoke, or else stroll down the hall to the Pink Ladies’ venue for a treat.

sigh...

sigh…

Imagine my amazement when, the first time I visited the Pink Ladies’ satellite at Blue Ridge, my eyes were greeted by issues of the Weekly World News trumpeting the exploits of P’lod (an extraterrestrial famed for his affair with the First Lady), Tonya (the world’s fattest cat at 80lbs) and old fallbacks such as Bigfoot and Nessie. All things supernatural and paranormal do not make the psychiatrist’s job any easier, trust me. Patients would see this drivel, and even if they didn’t purchase the rag, they would come back to afternoon group espousing further paranoid delusions and conspiratorial theories despite the epic amounts of Haldol that I dutifully dispensed.

Was this someone’s idea of a joke? Perhaps the lighthearted satire of WWN was amusing for medical-surgical patients at the main hospital, but at Blue Ridge?!?! It only rendered the task of preserving reality all the more difficult, Rx or no Rx.

I finished residency in 1992. Blue Ridge closed its doors in 1996. The Weekly World News folded in 2007 after a 28 year print-run (it now lives online). And if the Pink Ladies’ shop still exists in the main UVa hospital, I suspect that those sandwiches are much more expensive, and the only periodicals on the rack are Time and Newsweek.

[Have an idea for a post topic? Want to be considered for a guest-author slot? Or better, perhaps you’d like to become a day-sponsor of this blog, and reach thousands of subscribers and Facebook fans? If so, please contact the Alienist at vadocdoc@outlook.com]

[Copyright 2013 @ The Alienist’s Compendium]

Hamilton Beach meets Adam and Eve

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Are you female?

Are you having trouble sleeping?

Are you experiencing fluid retention?

Are you irritable?

Do you have a tendency to “cause trouble”?

If so, based on medical texts from the late 19thc, you are obviously a hysteric. As many as 75% of middle class women in America were then thought to suffer this ailment. And at the time, the standard of care – for those women who couldn’t afford to travel to Europe and lie on Freud’s couch – was a “pelvic massage” resulting in therapeutic “hysterical paroxysms.”

In other words, the patient needed a medical sex surrogate to bring her to climax (weekly was the suggested frequency) and all would be restored to normalcy.

Today, this strangely sexless office sex would almost certainly result in a lawsuit and loss of licensure. Not so in 1900.

Apparently most doctors at the time found the manipulation to be tedious, as literature of the day reported with seeming straight face that it often took hours to accomplish. The good doctor needed something to assist.

Enter the vibrator.

The first vibrator, called a “massage and vibratory apparatus,” was invented and patented in the U.S. by George Taylor MD in 1869. It was steam powered, large, heavy, and sold only to physicians and spas. It was hardly discreet.

One must wonder: did females see the clinician unwrapping said apparatus and feel even fleeting anticipation, or just the kind of dull disinterest one would experience while watching a mechanic change the car’s oil?

The first (smaller) battery powered unit followed from the fertile mind of British physician Joseph Granville a mere eleven years later. Manufactured by the Weiss Company, it was lighter, easier to move, and less expensive than the Taylor machines.

Then homes started to be wired for electricity. By 1900, there were more than a dozen companies in the U.S. and U.K. that were churning out mothers’ little (plug-in) helpers. The Age of Electricity saw the advent of the electric sewing machine, the electric fan, the electric tea kettle, the electric toaster… and these contraptions (which, I might add, predate the electric vacuum cleaner). To our modern eyes, such devices hardly seem alluring. The giant noisy motors. The thick cloth that covered the cords to prevent sparks from flying. The need to add oil occasionally – that last feature yielding the ambience of a bedroom chainsaw.

Marketing was then expanded beyond medical journals. Ads began to appear in Modern Woman and Woman’s Home Companion. These ads remain legendary, promoting such claims as “relieves all suffering,” “wonderfully refreshing,” and “curative of many diseases.” Gushed one, “it can be used by yourself in the privacy of dressing room or boudoir, and will furnish every woman with the essence of perpetual youth!”

And they were economical too. With doctors charging $2 per, er, treatment at the turn of the century, the $5.95 cost of hand-held plug-ins meant that a machine paid for itself after a mere three self-help sessions.

Throughout the 1910s and ’20s, print ads flourished, providing hysterics around the country with relief, courtesy of USPS mail order. Hamilton Beach made such equipment. So did Sears Roebuck, their 1918 catalog vaguely mentioning that the devices were “very useful and satisfactory for home service,” hoping you got the idea and no further explanation was necessary.

Vibro-Life, Eureka Vibrator Co, 1908

Vibro-Life, Eureka Vibrator Co, 1908

There also existed, briefly, pneumatic and hand-cranked models, Macaura’s Pulsocon from the 1890s and the Vibro-Life from 1908 being examples of the latter. Given the relatively recent cultural vogue of total depilation, one cannot help but ponder the cringe-worthy outcomes of applying to one’s self, pre-Brazilian waxes, a metal instrument that twisted not unlike a baker’s mixer.

Even though it was a poorly kept secret – wink wink – once vibrators began to appear in naughty pictures, they were driven almost instantly from the pages of ‘respectable’ publications. They reappeared only during the Sexual Revolution of the ‘60s, and then purely and unabashedly as erotica, where they have remained to this day, their stiff-collared Victorian roots notwithstanding.

Interested in further reading? Google ‘antique vibrator museum’ and be amazed by the collection on display in San Francisco. Better, plan a visit there the next time you’re in town

[Have an idea for a post topic? Want to be considered for a guest-author slot? Or better, perhaps you’d like to become a day-sponsor of this blog, and reach thousands of subscribers and Facebook fans? If so, please contact the Alienist at vadocdoc@outlook.com]

[Copyright 2013 @ The Alienist’s Compendium]

Nellie Bly

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[Today’s post is sponsored by my good friends, Monika Vainoriene MD, and Enrikas Vainorius, MD, of Morrisville, NC. We were talking about this very subject recently, and now here is a bit more detail…]

Though likely apocryphal, there’s a story told by psychiatrists over drinks at happy hour that goes something like this: years ago, an employee of a mental asylum in Johannesburg, South Africa, was transporting twenty patients in a bus from one psychiatric facility to another. He stopped (on company time) for a few drinks while en route, and when he got back to the bus, all of the patients had eloped. Fearing for his job and not wanting to admit to his incompetence, the driver proceeded to a nearby bus stop in town and offered everyone waiting there a free ride. He then delivered these unsuspecting passengers to the second asylum, telling the receiving staff that the ‘patients’ were very excitable and prone to bizarre delusions of abduction. The deception wasn’t discovered for almost a week.

It’s long been a joke amongst psychiatrists that if a healthy person were ever committed to a psychiatric facility, they might have a difficult time getting out, since those predictable statements that they’d make – “I’m not crazy!” – are the same utterances that the truly disturbed would say.

Well, we know of at least one situation where this did, in fact, happen.

Elizabeth Jane Cochran was born in 1864 near Pittsburgh PA. She was one of fifteen children, and was always known as the rebellious one. This made her stand out during an age in which women were meant to be seen and not heard.

Her father died when she was 6 years old, and the family was thrown into poverty. By the age of 14, Elizabeth was having to work outside the home to help support the family. She held brief gigs as a schoolteacher and a maid in a boardinghouse, but nothing seemed too permanent.

Around this time, she read an op-ed piece in the Pittsburgh daily newspaper by one Erasmus Wilson, then a well-known journalist. He wrote that working women were “an abomination,” and should be home, pregnant and tending to their husbands. This annoyed Elizabeth, who knew that many working women – she and her mother amongst them – had no such option. So Elizabeth replied to Wilson with a strongly worded letter about the offensive article. The newspaper loved her chutzpah, and subsequently hired her as a writer and giving her the pen name Nellie Bly.

Elizabeth/ Nellie started writing about the plight facing working women, but the newspaper decided she should be writing about fashion and home economics. Nellie wasn’t interested in that, so she quit and headed to New York. Luckily, her reputation by then proceeded her, and it wasn’t long before she was hired by the New York World. They had a plan for Nellie. On 22 September 1887, Nellie was approached by her new editor to write an article about the state’s notorious Blackwell Island Insane Asylum. They wanted to know what went on behind the barred doors, and Nellie agreed to find out. The editor offered no solid plan to get her out of the institution once her observations were completed, but promised her it would be achieved somehow. Her instructions were simple: “Write up things as you find them, good or bad; give praise and blame as you think best, and tell the truth all the time.”

But first, Nellie had to get herself committed, which meant she had to feign insanity convincingly. She decided to pose as a poor girl looking for work at the city’s Temporary Home for Females, under the name Nellie Brown. There, she started displaying ‘insane’ behaviour. She said she was afraid of the other women, spoke vaguely, and spent that first night staring blankly at a wall rather than sleeping. She reported having nightmares of attacking people with a knife.

The plan worked. The ass’t matron called the police and Nellie was hauled away. The next morning, a Judge Duffy ordered a mental examination, and the court’s alienist declared her insane. A second specialist concurred, adding, “[the patient is] positively demented. I consider it a hopeless case. She needs to be put where someone will take care of her.”

Nellie’s first observation: it’s not very difficult to fake mental illness and get admitted to an asylum.

Once at the asylum, Nellie met a number of other women who didn’t seem to have anything wrong with them either. She watched as those women were brought before doctors for follow-up examinations. One woman only had a fever as far as Nellie could tell. Another was German, and as no one at the asylum spoke her language, the staff thought the woman must be crazy. When it was Nellie’s turn, she decided to drop the charade and act/ talk as she did in everyday life; however, the doctor ignored her comments and kept flirting with the nurse instead. Nellie noted that, “the more sanely I talked and acted, the crazier I was thought to be.”

Nellie determined quickly that the food was horrible and sleeping arrangements were chilly and uncomfortable. Asylum life, Nellie soon found, was unsuitable for anyone. She was forced to endure ice-cold baths, freezing nights, both verbal and physical abuse at the hands of the nurses, isolation, and the fear of fire (doors were individually locked from the outside, and windows were barred, so if a fire broke out, it was likely that a majority of the patients would die.) “What, excepting torture, would produce insanity quicker than this treatment? Take a perfectly sane and healthy woman, shut her up and make her sit from 6 a.m. to 8 p.m. on straight-back benches, do not allow her to talk or move during these hours, give her no reading and let her know nothing of the world or its doings, give her bad food and harsh treatment, and see how long it will take to make her insane. Two months [of that] would make her a mental and physical wreck.”

Towards the end of her stay, Nellie pressed the doctors for answers. How could they determine whether or not the women were insane if they didn’t listen to them? She insisted on a full examination to determine her sanity, but the doctors only brushed her aside, thinking she was raving. She wrote that “the insane asylum on Blackwell’s Island is a human rat-trap. It is easy to get in, but once there it is impossible to leave.”

Luckily for the intrepid reporter, her editor made good on his promise to get her out. After ten days in the asylum, she was freed and on her way back to the newspaper’s offices (details of her release remain sketchy). The first installment of Nellie’s report on the conditions in the asylum was published a few days later; the entire expose ran over 17 issues (and was later compiled into a book, Ten Days In A Mad House). Readers were horrified, and Nellie Bly was made a celebrity of sorts, praised for her bravery during her time in the asylum.

an illustration from Nellie Bly's book

an illustration from Nellie Bly’s book

Predictably, the medical staff offered many excuses for the allegations in Nellie’s articles. But the public was outraged. Nellie’s writings produced many changes and better treatment for those institutionalized, including more funding for the Department of Public Charities and Corrections. One involuntary patient later wrote, “ever since [Nellie left], everything is different. The nurses are very kind and we are given plenty to wear. The doctors come to see us often and the food is greatly improved.”

Interestingly, her asylum stint wasn’t the last of Nellie’s adventures. She later traveled solo around the world in 72 days, a much bigger deal for a woman in the late 19th century than it would be today, trying to ‘beat’ other reporters and the 80-day mark set by the Jules Verne novel of the same name. Not only did she succeed in her global circumnavigation, but she actually was able to meet Verne in Paris while passing through town!

[Have an idea for a post topic? Want to be considered for a guest-author slot? Or better, perhaps you’d like to become a day-sponsor of this blog, and reach thousands of subscribers and Facebook fans? If so, please contact the Alienist at vadocdoc@outlook.com]

[Copyright 2013 @ The Alienist’s Compendium]

More On The Placebo Effect

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Sleep difficulties are a common complaint in the population at large and especially amongst psychiatric patients. Unfortunately, the drugs that are readily used to address insomnia are not candy. Many of them can be habit forming, are expensive, produce their own set of undesirable side effects, and can alter deep sleep morphology – producing a less-than-rested sensation upon awakening. There were times in the past when patients of mine would exhibit resistance to every suggestion for healthy sleep practices (e.g., no coffee or soda, moderate exercise, cool bedroom temperatures) and would insist on Rx. These weren’t necessarily people who were abusing drugs… they were just convinced of the all-encompassing Power of Rx to cure their perceived ills, and no amount of redirection seemed to work.

Enter the placebo.

Much has been written about the ethics of dispensing placebo, but I’m convinced that in the right place and at the right time, it is a useful and humane option. Back in the early 1990s as a resident, for select inpatients, a large brightly colored capsule at bedtime – the colors were always blindingly neon, suggesting power far beyond drab greys and whites – produced the subjective perception of sedation and deep restorative slumber, absent both side effects and habituation. Those patients wanted sleep. I gave them an inert intervention that helped them feel better. A true win-win.

“How,” the reader will ask, “did you explain this intervention to the patients without boldfacedly lying to them?” Easy… by telling the truth in ways that were not immediately obvious. One of the main ingredients in the placebo capsules was stearic acid, a type of benign filler and preservative also found in some hard candy. I would tell patients, honestly, that I wanted to give them a capsule containing stearate “because in many cases it has been found to assist patients with problems just like yours.” That is a wholly truthful statement, and yet the patient interpreted the words in the way they wanted to interpret them.

The days of using placebos are over as far as I can tell. This is because patients are constantly reading online, and liability surrounding informed consent has become too risky. Had I used the ‘stearate is good for people with problems just like yours’ line recently, the patients or their families would have looked up the substance on their iPads and then come back to complain that what I was giving them was nothing more than an inert filler.

But the passing of the Age of Placebo is not necessarily a bad thing, albeit with one caveat.

Too many patients who visit physicians in general, and psychiatrists in particular, view the awarding of a Rx script as a validation of sorts. To visit a shrink and not come away with a pill is perceived by many as having failed in the therapeutic interaction. Faced with taking time and trying to educate patients about proper Rx usage and then having them go away miffed, many doctors will prescribe a consolation prize – antidepressants, anxiolytics, sleep aids, you name it. Yet those consolations are not risk-free, and render us a nation of unnecessary pill-poppers.

It was for these situations that placebos often made sense. In their absence I trust that my fellow physicians will just learn to say ‘no’ more often.

The Placebo Effect is very real, especially when employed for issues with high degrees of subjectivity, such as pain and sleep. If a patient is fragile and already taking (arguably) too much Rx, does a physician give yet another (potentially addictive) Rx that may interact with all of the other Rx… or try an inert sugar pill that could yield relief and cause no harm whatsoever in the long run? Ethicists will debate this endlessly, but I know from my own experiences as a resident in the 1980s that I favor the latter approach in carefully selected cases.

The placebos we could order from the pharmacy back then were HUGE capsules in bright neon colors. They looked powerful. To amuse ourselves when on-call and nothing was pressing, we’d make up names for them. My clinical supervisor at the time labeled his as ‘Obecalp,’ which is ‘Placebo’ backwards. I always preferred ‘Fallacine’ or ‘Fauxene’ for mine. And this is actually how the pharmacy would dispense them when a patient was discharged: “Fauxene one tablet Q6hrs as needed,” and then in parentheses “Stearic Acid” (the generic name of the inert filler/ preservative in the sugar pills).

More times than not, inpatients would greet me at the ward door the next morning – or outpatients would come to our next meeting – and report how soundly they had slept or how their pain seemed much more manageable.

[sidebar: once a patient called me after discharge to say he’d run out of Rx before his upcoming outpatient appointment, asking if I’d refill. Normally I didn’t write Rx for discharged patients, but I asked him what it was that he needed. He replied, “P-L-A-C-E-B-O.” The pharmacy had apparently mislabeled the container. I gladly refilled]

But here’s the really amazing thing: the Placebo Effect doesn’t necessarily rely on ignorance on the part of the patient! Research has shown – repeatedly – that the Placebo Effect still exerts benefit, even when patients KNOW they’re taking placebo!

Case in point: a recent study at Duke University (Ariely et al.) gathered 82 people and gave electric shocks to their wrists. Then, the cohort was divided in half, and each of the test subjects was given one of two pills, shocked again, and asked to compare the pain initially with the pain after taking their respective pill. Of the first group, 85% said the pill reduced the pain. On the other hand, only 61% of the second group said that the pill reduced the pain. Whichever pill the researchers gave their “patients” worked, though the first pill clearly worked better.

It shouldn’t surprise you that some of these test subjects received placebos. What might be surprising, though, is that in this study, ALL of the test subjects received placebos. On top of that, both groups received the exact same thing: sugar pills of identical size, shape, color, &c. So why did the first group feel less pain than the second group?

Apparently it was due to the price. The second group was told that their pills were being sold at a huge discount.

Specifically, as the New York Times reported in 2008

http://www.nytimes.com/2008/03/05/health/research/05placebo.html?_r=1&

the first group was informed that their pills cost $2.50 each. The second group, though, was told that their pills typically sold for $2.50, but the price had been cut dramatically – all the way to ten cents each. Other than that, the two groups went through the same process, the same electrodes, the same pills, the same everything. But news of the discounted price seemingly rattled some of the subjects’ faith in the pills’ quality, and, therefore, reduced the Placebo Effect!

[Have an idea for a post topic? Want to be considered for a guest-author slot? Or better, perhaps you’d like to become a day-sponsor of this blog, and reach thousands of subscribers and Facebook fans? If so, please contact the Alienist at vadocdoc@outlook.com]

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[from the medical records dept] A Bane of My Professional Existence

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[originally posted by the Alienist in early 2012, but worth reexamining]

Last evening, I was reading a periodical before bed, and as I thumbed absent-mindedly through the pages, several large advertisements from pharmaceutical companies caught my eye – Pristiq (antidepressant), Aricept (anti-dementia), and Abilify (antipsychotic sometimes used to augment antidepressant) amongst them.

As a physician, these encounters wouldn’t be unusual… except that I was glancing through Psychology Today, a lay publication written specifically for a mass audience of non-clinicians. And it certainly doesn’t stop there – one only needs to pick up (mostly ladies’) print media to find all manner of colorful Direct-to-Consumer (DTC) drug ads splashed across the pages.

The rise of the Internet, and the explosion of available educational resources via both print and digital outlets, has been a boon in innumerable arenas, not the least of which is health education. But it is a double-edged sword. My heart leaps for joy when a patient arrives for an appointment carrying sheaves of drug print-outs courtesy of self-serve Wikipedia. Undoing mis-information, or mis-interpreted accurate information, takes much longer than just explaining the pertinents from scratch.

I confess that I harbor more than a bit of residual paternalism, and I realized a long time ago that I’m too late to the world of psychiatry (as I would like to see it practiced). But heck, I went to medical school for four years, residency for four years, passed my boards, recertified, and now have logged over two decades of clinical experience. I think I’ve learned a few things along the way re: how to take good care of patients, only to have my job made all the more difficult by the presence of freely available op-ed pieces and data of dubious quality ‘out there.’

The Rx problems in my profession seemingly began with fluoxetine. Most of you know it as Prozac, and it came on the market in the United States in 1988, the year I graduated from medical school. A tiny amount of DTC pharma advertising existed prior to Prozac – at least one branded form of ibuprofen as well as Pneumovax were hawked thus – but it wasn’t until the late 1980s that the world of psychotropic Rx was really impacted by Madison Avenue. Before Prozac, I suspect that if persons on the street had been asked to name an antidepressant, they would have had difficulty doing so unless a prescription had been written for them personally or for someone in their immediate family. But once Prozac hit the market and was pitched to the public, it became a household name (along, shortly thereafter, with all of its closely-related chemical brethren), discussed at length by armchair psychiatrists at water coolers, over PTA coffees, and in late night TV monologues.

The ads got glitzier, the people on the glossy pages looked happier, and anyone who wasn’t totally contented in life would be forgiven for thinking that the pill being marketed would make existence an endless summer afternoon garden party too.

Prozac ad (reprinted courtesy of MindFreedom.org)

Prozac ad (reprinted courtesy of MindFreedom.org)

With all of this unfiltered talk on the airwaves and in ink, it just added fuel to the fire of self-diagnosis and, in my opinion, drug seeking behaviors. The health professions in general, and Pharma in particular, are unfortunately responsible for the ever-increasing ‘A Pill Exists For Every Ill And Can Fix Anything’ school of thought.

Accordingly, as front-line clinicians, it is now our responsibility to do a better job explaining what Rx can and cannot do, regardless of what the paid models and cute little cartoon characters in the magazine ads might suggest.

[Have an idea for a post topic? Want to be considered for a guest-author slot? Or better, perhaps you’d like to become a day-sponsor of this blog, and reach thousands of subscribers and Facebook fans? If so, please contact the Alienist at vadocdoc@outlook.com]

[Copyright 2013 @ The Alienist’s Compendium]

[from the medical records dept] Sorcery, Body Parts, and Pharmaceuticals

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[some of the following was originally posted by the Alienist last summer, but you really can’t get enough of this stuff]

In keeping with April’s mummy theme – soap cadavers, artists’ corpses – I now complete the trifecta with observations on the use of dead people as medicinals and ingestibles.

Cannibalism has existed for as long as there have been humans, and probably longer. It’s the societal revulsion at such behavior, and not the actual metabolic issues of the consumption, that renders the subject anathema. But the proscribed always fosters lurid fascination, and makes for good press.

Take, for example, the British Gazetteer on 3 May 1718, wherein was reported:

“We have intelligence from Lincoln [of] a man being hanged there … [who] within three days after his execution, [had] … apothecaries contract[] with a butcher for a sum of money, to take the body out of the grave, and cut off all the flesh, fit for them to make a skeleton of; which flesh he sold for venison to an inn-keeper; who making it into a pasty, invited many of his neighbors to the eating of it; but sometime after the villainy being detected, the butcher and the two apothecaries were committed to [the] Lincoln [jail].”

Accurate? I’m not certain. And with apologies to honest druggists everywhere, and even the Demon Barber of Fleet Street, this is not really the flavor – pun intended – of today’s post. Instead, I wish to talk about the odd and surprisingly common archaic belief that noshing on the dead was somehow therapeutic, not just delicious. And we start with blood.

In order to restore vigor and youth, some medical practitioners of the late Middle Ages recommended drinking the blood of those not so aged. The physician Marsilio Ficino, in the 15th century, wrote, “why shouldn’t our old people, namely those who have no [other] recourse… suck the blood of a youth? A youth who is willing, healthy, happy and temperate, [and] whose blood is of the best but perhaps too abundant. They will suck, therefore, like leeches, an ounce or two from a scarcely- opened vein of the left arm; they will immediately take an equal amount of sugar and wine; they will do this when hungry and thirsty and when the moon is waxing. If they have difficulty digesting raw blood, let it first be cooked together with sugar; or let it be mixed with sugar and moderately distilled over hot water and then drunk.”

Blood therapy was not a rare recommendation it appears.

Edward Taylor (c.1658–1702), a Puritan minister and lay physician in New England, wrote that “human blood, drunk warm and new is held good in the falling sickness [epilepsy].” In Denmark, the use of blood as a cure for epilepsy was widespread; it is documented that the sick and infirmed would gather under a scaffold hoping to catch the spilt blood of a freshly executed criminal for this very purpose. Many English physicians, too, believed in the curative potency of blood, and recommended it to patients as late as 1747.

Regarding other parts of the human corpus, physician [Nicholas] Lemery recommended mother’s milk for inflamed eyes, feces to heal sores, and skull, brain, fat, nails and “all the parts of man” to cure a variety of conditions in 16th century France.

axungia hominis (human fat)

axungia hominis (human fat)

In The Marrow of Physick (1669), Scotsman Thomas Brugis wrote, “a man’s skull that hath been dead but one yeare, bury it in the ashes behinde the fire, and let it burne untill it be very white, and easie to be broken with your finger; then take off all the uppermost part of the head to the top of the crowne, and beat it as small as is possible; then grate a nutmeg, and put to it, and the blood of a dog dryed, and powdered; mingle them all together, and give the sick to drinke, first and last, both when he is sick, and also when he is well, the quantity of halfe a dram at a time in white wine.”

Though a few formulas called for fresh, when fresh wasn’t available, dessicated would do; one of the most commonly advertised apothecary substances at that time was ground mummy, a preparation of the ancient remains of an embalmed or dried body from the distant sands of Araby. One 16th century surgeon, Ambrose Paré, noted that mummy was “the very first and last medicine of almost all our practitioners.”

Mummy heads were used to create plasters to assist with wound healing as late as 1750. Many practitioners were also prescribing “three drams of [crushed] human skull” for epilepsy, or “two ounces of mummy in a plaster against ruptures.” These forms of therapy, though, were beginning to fall from favor by the early 18th century as public opinion – not necessarily ‘science’ – turned against the practices.

That said, the best is never cheap, and mummy in 1678 was selling in London for 5s 4d for a pound! Thus, many apothecaries substituted, for a genuine Bedouin, cheap imitations that typically came from the corpses of east-side beggars, lepers, and plague victims.

Assuming one could afford it, perhaps the palate craved mummy with sweetener? Then mellified man, or human mummy confection, was for you. This was a legendary substance created by steeping a human cadaver in honey. Interestingly, it is only mentioned in a single Chinese source from the 16th century by one Li Shizhen, a pharmacologist relying on second hand hearsay (sound reliable?) Li wrote in his reference work, Bencao Gangmu, in the chapter entitled ‘Man as Medicine,’ that in the deserts far to the west, there were elderly men who would volunteer to undergo mummification in honey to create a medicinal suspension that would help their descendants. What separated this mellification process from simple body donation was that it had to commence ante-mortem. It was reported that the donor would stop eating all food other than honey. The donor would even bathe daily in honey. Soon, his feces became mellified, and even his sweat was said to be sweet and thick. When the diet or other illness finally proved fatal, the donor’s corpse would be placed in a stone coffin filled with honey… for about a century. By then, the contents would have turned into a thick rich yellowish goo that was said to be capable of healing broken bones and curing other ailments. Li claimed that this was available in Middle Eastern bazaars at a very hefty price.

Maybe one desired mummy, with sweetener or without, but just couldn’t afford it? Fear not, for you too could still partake of the goodness of the body tissues of others. In one 17th century French kabbalist’s magic book (the genre often doubling as a medical text), there is listed what we would call today a sedative, tranquilizer, or anxiolytic, one guaranteed to defuse those with short tempers and violent tendencies.

It involved scraping and collecting the white skin from the tongue of a newborn on a clean piece of linen, and then secretly placing it under the infant’s bonnet during baptism. The tongue, with its ability to curse or bless, was considered a potent anatomical part. Thus activated, the tissue was said to calm the angry, though whether it had to be ingested or just placed in close proximity to a potential outburst remains vague.

At first glance, quack practices such as these seem far removed from our own advanced healthcare. However, the utilization of body parts in therapy still persists. Though blood transfusions and organ transplantations are dramatically different than drinking blood or eating flesh, such interventions do share a core belief in the human body as an instrument of healing.

[Have an idea for a post topic? Want to be considered for a guest-author slot? Or better, perhaps you’d like to become a day-sponsor of this blog, and reach thousands of subscribers and Facebook fans? If so, please contact the Alienist at vadocdoc@outlook.com]

[Copyright 2013 @ The Alienist’s Compendium]

Sigmund and Nose Candy

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Above-average intelligence and the ability to ‘think outside the box’ may in some cases be facilitated by recreational drug use. Proponents of substance decriminalization have held this, and while it’s an interesting hypothesis, it is not one without tremendous controversy and public health ramifications. Nevertheless, history illustrates a number of drug users who over their lives forged new and creative paths, whether related to chemical use or not.

One drug dilettante was none other than Sigmund Freud, originator of the concept of the subconscious and, amongst other honorifics, the Father of Psychoanalysis.

Freud was a trailblazer of his day, whether or not you subscribe to his approach to the human psyche. And he was also a big fan of cocaine, and advocated its use for a wide variety of conditions.

coca

coca

In a letter written to his fiancée Martha in 1883, Freud opined, “if all goes well, I will write an essay [on cocaine] and I expect it will win its place in therapeutics by the side of morphine and superior to it…. I take very small doses of it regularly against depression and against indigestion and with the most brilliant of success.”

Freud did in fact publish just such a review:

“Über Coca,” Von Dr. Sigm. Freud, house officer of the General Hospital of Vienna. Centrallblatt für die ges. Therapie. 2, 289-314, July 1884.

He began his treatise with a description of the South American coca plant, erythroxylon coca, which is a bush that grows to a maximum of 6’ height and has ovoid shaped leaves. Though cocaine was chemically isolated by Gardeke only as late as 1855, Freud noted that Andean natives were known to have used coca leaves as early as 600 CE when “faced with a difficult journey, when [attempting to satisfy] a woman, or… whenever strength is more than usually taxed.”

Freud postulated cocaine’s benefits for a host of conditions, including asthma, migraine headaches, indigestion, pain, and as a stimulant in wasting diseases. However, like most physicians of his day, he held that cocaine’s greatest therapeutic effects would be seen in psychiatry, in no small part because of the drug’s ability to control melancholia and sexual dysfunction. Interestingly, Freud’s paper was also one of the first to propose substitution as a therapeutic treatment for addiction. While replacing morphine or alcohol with cocaine is something we now know to be counter-productive to recovery, the concept of substitution persists to this day (think Methadone clinics, and Xanax detox using Klonopin).

It is true, Freud conceded, that there can be ill effects from over-use. Commonly were seen dry mouth, dizziness, elevated pulse, and oddly, eructation. Anorexia was also noted, though Freud hastened to add that survivors of the siege of La Paz in 1781 were those who had taken cocaine in lieu of food when there was nothing to eat. He did describe in some individuals a “moral depravity” that arises when these immoderate users become “complete[ly] apath[etic] toward anything not concerned with coca.”

Freud took cocaine himself about a dozen times, employing 50 mg orally on each occasion. Afterward, he claimed, he had no craving for the substance. As far as psychic effects, he did report exhilaration which was the same as the “normal euphoria of a healthy person.” He felt “more vigorous and capable of work,” but he said the overall feeling was “simply normal” and he found it hard to believe that he was under the influence of a drug at all. He did observe a lack of desire for both food and sleep for several hours after ingesting cocaine. Following several trials, he hypothesized that the psychological benefits of cocaine were not due to stimulating effects, but rather “the disappearance of element in one’s general state… which cause depression.”

Freud did not recognize the addictive potential of cocaine, in large part because it was believed in the 19th century that only depressants – morphine, alcohol, laudanum – were habit-forming. Most clinicians felt that cocaine was then better classified with caffeine.

[Have an idea for a post topic? Want to be considered for a guest-author slot? Or better, perhaps you’d like to become a day-sponsor of this blog, and reach thousands of subscribers and Facebook fans? If so, please contact the Alienist at vadocdoc@outlook.com]

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