PLACEBO: MEDICINE FOR DUMMIES
The term ‘placebo effect’ was coined in the 1950’s when it was observed that the health of patients given sugar pills would often improve. It has since been proposed that the placebo acts as a sort of psychotherapy. It is the experience of healing, caring and attention that a patient receives from a doctor which translates into a positive physiologic response.
Many ancient remedies seem to have taken advantage of the placebo effect. Just 50 years ago, a revolutionary medical therapy called ‘Lidya’s Pink Medicine’ began sale on the market, promising to treat any problem ailing women. Excessive menstrual bleeding? Joint pain? Yeast infection? Never fear… Lidya was there.
In retrospect, it seems absurd to claim that a single potion could cure all types of ailments that are so physiologically diverse. And yet, through history there are numerous examples of therapies that were believed to be effective for a wide range of purposes. In fact, before 1963, US pharmaceuticals only had to prove their drug was safe, not that they were effective! Just imagine how many useless remedies were sold purely on their promises to heal all disease- propaganda that just may have stirred up enough of the placebo effect to make the person believe it was worth the 12¢ a bottle.
Through my presentation, I hope to explore some dubious historical remedies which, oddly enough, were regarded as the holy grail during their heyday. You’ve just entered the world of the placebo effect.
In recent years there has been much discussion surrounding the existence of the placebo-effect. Initial studies in the 1950’s suggested the placebo effect accounted for 30% of the effect of a drug (Beecher, 1955). Patients on placebo exhibited increased brain activity and increased release of endorphins. But despite these findings, there has been more recent evidence that the placebo is only a mild pain-killer that has little ability to alter other physiologic processes and disease. So is taking a placebo worthwhile? People throughout history seem to think so. There are numerous examples of ancient remedies which seemed to be effective despite our current knowledge that these remedies have no physiological effect. One possible explanation for their success is the placebo effect- that is, a person’s health improved simply because they expected it to. In this paper, I will review the evidence for and against the placebo effect and then offer some examples of historical placebos. It is my aim to demonstrate that placebos have been an integral part of medicine since the beginning of time, even though the placebo-effect itself may be very minute.
Evidence in Support of the Placebo Effect
Brody (1982) has defined the placebo effect as “The change in the patient’s condition that is attributable to the symbolic import of the healing intervention rather than to the intervention’s specific pharmacologic or physiologic effects” (Jospe, 1978). The term placebo effect exploded into the academic world in 1955 when Beecher published his famous paper The Powerful Placebo. Through a meta-analysis of 26 clinical trials, Beecher showed that the placebo-effect was responsible for approximately 32% of a drug’s healing power. This study continues to have an immense impact on how society views the placebo. Even today, many student pharmacists are taught that the placebo is responsible for one-third of a drug’s effect.
Following Beecher’s study, many more placebo studies were conducted. In one study, two groups of patients were given a sugar pill. One group was told it was a stimulant, and sure enough, their pulse rate and BP increased. The other group was told it was a tranquilizer and these people experienced the physiological effects of tiredness in addition to a lowered pulse and BP (Jospe, 1978).
In other studies, placebos were shown to cause side-effects, particularly vomiting. Most commonly, these side-effects were pre-existing symptoms that became worse when taking a placebo (Shapiro, 1997). Perhaps even more astonishing are some case reports which describe some patients becoming addicted to placebos (Rich, 2003).
Evidence Disputing the Placebo Effect
Despite the significant volume of evidence in support of the placebo-effect following Beecher’s study, there is a more recent school of thought that argues this effect is very small. This group argues that patients enter studies when they’re feeling the worst. This is either because patients are trying to seek medical attention (and then enrolled in a study), or because investigators seek out sick patients to try and demonstrate a maximal effect of their drug. Unfortunately, this introduces a selection bias. It makes placebos seem more effective than they really are because the natural histories of most diseases show fluctuation such that when people are at their sickest, they will often become better regardless of therapy (Hrobjartsson & Gotzshe, 2001). This is the theory of regression to the mean. If people are entered into the study at their worst, their symptoms will invariably regress to the mean.
The problem is that few studies have both a ‘no treatment’ and ‘placebo’ group to compare between. This is the only way to differentiate between a placebo- induced affect & simply an upstroke in the natural history of the disease.
Hrobjartsson & Gotzshe (2001) realized this and so they analyzed 114 randomized controlled clinical trails that included both a ‘placebo’ group and a ‘no treatment’ group. In most of the healing modalities studied, they did not find that the placebo group improved in comparison to the no treatment group, and hence, concluded that the placebo effect is very small if it exists at all.
The Current View on Placebos
Currently, most experts view placebos as being able to cause some pain relief and perhaps an improved feeling of wellness, but not a powerful force capable of altering physiological processes. Even Hrobjartsson & Gotzshe (2001) admit that the placebo group experienced pain relief in comparison to the no treatment arm. They estimated that the pain relief was 1/3 as effective as NSAIDs (we can tell Tylenol & Motrin they won’t go out of business just yet!). However there may be more to the placebo that just pain relief. After all, Hrobjartsson & Gotzshe’s study may not have been large enough to demonstrate a small but statistically significant placebo effect. Based on the number of successful ancient remedies that have no proven physiological effect, this would seem to be very likely.
Historical Remedies and the Placebo-effect
For the remainder of this paper, I will discuss some historical remedies which seemed to be effective despite our current knowledge that these remedies had no physiological effect. Why were they effective? Well, one explanation is the placebo effect. In his book The Powerful Placebo, Shapiro (1997) claims that “until recently, the history of medical treatment was essentially the history of the placebo effect.” Of course, this is not strictly correct since many ancient remedies such as digitalis, withering, and opium have proven physiologic influences (Koren, 1998). And yet, many old therapies were probably just placebos. One just has to remember that before 1963, US pharmaceuticals only had to prove their drug was safe, not that they were effective!(Jospe, 1978) One can only imagine how many ridiculous therapies were sold under the umbrella of the placebo-effect.
The cure-all “glyoxylide”
In 1919, Dr. Koch discovered a potion that could cure any known disease including cancer, tuberculosis and leprosy. This so called ‘catalyst’ could cause complete recovery in 80 per cent of cases by churning the body into such a fury that the body would manufacture its own remedies. By the 1940’s Koch was collecting $25 per injection and earning an estimated annual income of $100,000. It wasn’t until 1943 when government chemists studied the fluid that it was revealed for what it really was: a simple placebo. These chemists testified that the potion was in fact indistinguishable from distilled water. And despite this evidence, many people continued to believe in Koch’s medicine though he was banned from advertising it as a cure in the US (Gardner, 1957).
“Vrilium” radiation therapy
Another medication that could only have been successful via the placebo effect is Dr. Kay’s vrilium. It is a mysterious substance that projects radioactive waves. During the twenties, a business man by the name of Robert Nelson sold small brass cylinders containing vrilium that could be worn about the neck. Nelson claimed that it could radiate for 20 ft and kill bacteria and germs in and around the body. The cylinders were sold for $300 each and created a frenzy among the rich. The former mayor of Chicago wore one and he is quoted saying, “I don’t pretend to know how it works, but it relieves pain. It has helped me and my wife.” In 1950, the US government took action against the company and testing revealed that the cylinders contained nothing but cheap rat poison. Ever the businessman, Nelson’s response was, “I believe we have an unrecognized form of radioactivity” (Gardner, 1957).
Brown-Sequard Elixir: The Fountain of Youth
In the 1850’s, Brown-Sequard invented an elixir from the testicular blood and seminal fluid of dogs and guinea pigs. After a very precise method of preparation including maceration and mincing, the elixir was injected into the blood. Brown-Sequard claimed that it improved mental concentration, induced greater physical strength and endurance, and increased sexual function. This medication became instantly popular, largely through the press, and for a time was used throughout the world. Clearly this potion must have been placebo. After all, the study which purportedly demonstrated its effectiveness included only one subject! What’s more is the subject, the inventor, and the data-analyzer were all Brown-Sequard! Sure enough, the popularity of the elixir eventually waned (Heather Eliason, 1999), proving that the placebo effect can only carry a drug so far!
This therapy is perhaps the most profound example of a placebo simply because it was so universally practiced and lasted for so long. Blood letting dates back as far as the Stone Ages and only died out as late as the 19th century (Brain, 1986). Medical paradigm during this period considered one’s health to be a balance of the four humors (phlegm, yellow bile, black bile, blood). Sickness was often interpreted as having an excess of blood, so it was drawn out to restore balance. Some physicians actually viewed it as being capable of curing absolutely any illness. Perhaps even more absurd is that some physicians considered pregnancy to be one of the indications in the early 19th century. At this time pregnancy and the coinciding cessation of menstruation was considered abnormal, so blood letting was performed (Kerridge, I.H. and Lowe, M., 1995). With our current medical knowledge, it is difficult explain how this therapy could possibly have been effective (although some have tried). Ten points for the placebo effect!
Today, placebos are used primarily as a control in clinical trials. It is no longer legal for doctors to prescribe placebos, although there are probably still placebo-like medications being used. Vitamins such as B12 and C are potential examples. Some people faithfully take 500mg of vitamin C every day even though the body can only absorb about 30mg/day!
Although doctors would rarely have use for placebos these days given the market saturation of drugs (and the availability of alternative medicine), an ethical debate still exists concerning placebo prescription. Some argue that truth-telling and doctor patient trust are important enough to negate any instance in which a placebo may be of use. On the other side of the fence there are people who believe that a placebo can be a benevolent deception in circumstances where nothing else can be done or in some psychogenic conditions where medication is not actually required (Jospe, 1978). At least for now, truth-telling has been the choice of the medical profession. And yet, every time a doctor prescribes a medication and then adjusts his stethoscope on his shoulders while smiling at his patient, he is in fact harnessing just a little bit of that good ol’ placebo effect.
Proceedings of the 13h Annual History of Medicine Days ~ 170 ~ WA Whitelaw - March 2004