What Should a Druggist Do If a Medicine Is Harming Patients? 1913

"The Druggist's Duty Concerning Coal Tar Derivatives" by F.M. Siggins, from the Dixie Druggist, May 1913, online at UNC Health Sciences Library. Acetanilide, also known as phenylacetamide, acetalil, acetanilid, and Antifebrin, is no longer sold as a drug. It was found to reduce pain and lower fever and introduced under the name of Antifebrin in 1886. Unacceptable toxic effects prompted the search for a less toxic aniline derivative, such as phenacetin. After several conflicting results over 50 years of study, it was found in 1948 that acetanilide was mostly metabolized in the body to paracetamol, which is acetaminophen. Of course, acetaminophen is still sold today, but there is a risk related to high doses of the drug. The FDA today warns that acetaminophen doses over 325 mg might lead to liver damage. Large doses prescribed in 1913 and the fact that acetanilid contains other potentially dangerous substances that are not found in acetaminophen are probably behind the harm suffered by patients in the following story.

 

I am not a physician, I am even ignorant of the simplest forms of disease which many druggists are familiar with, and my excuse for the ignorance is, that I have studiously avoided that line of study that I might have less incentive for the so-called art of counter prescribing.

But if I am weak in the knowledge of disease, I hope I have not spent 30 years behind the drug counter without using my facilities of observation, and in as short a time as possible, I wish to register my emphatic objection to the further open sale and use of coal tar derivatives, and I follow with my reasons.

My first notice of their danger was brought to me 25 years ago, in the early days of Acetanilid, by a physician who gave large doses and was enthusiastic over the results and saw no harm in its use. A few months later I noticed that the doses had been cut down 60 per cent, and I enquired the cause. "Well," says he, "I nearly killed half a dozen of my best friends, and I thought it time to stop."

As the years rolled on, scarcely a month passed by but what some incident occurred that told me we have admitted into common use the most dangerous drugs ever placed upon the pages of our text books. I have taken 1 1/2 grain doses of acetphenetidin with salol at various times for colds and rheumatism, and thought for years that it did me no harm, but now I am reluctantly compelled to acknowledge the contrary. For after two or three days' use, with a dosage of 1 1/2 grains three or four times a day I find myself almost completely benumbed and heart action very weak. And as I recall it I have always had these symptoms, though less pronounced, and yet it has taken years, with all my knowledge of the drug, to tumble to its viciousness. A physician very near to me commented using the same drug in small doses and in a short time could take as high as one dram, but he has quit. Here are the two extremes in dosage.

Another physician gave a colored woman the well-known mixture of soda acetanilid and caffeine and in a short time she was consuming one ounce every two weeks. The physician and the woman are both dead.

Still another M.D. who dispensed about 1,000 3 1/2 grain acetanilid tablets per month died with a bad heart. I do not know how many of them he took himself, but I have always had my convictions, and I am reasonably certain he died without blaming acetanilid for his condition.  Our sales for one year covering our retail trade and wholesale account of about 100 physicians totals 100,000 tablets containing some one of the coal tar products. The patent headache and pain remedies, estimated in 10 cent packages, total 4,000 and the cold cures 700 boxes, while the bulk goods, covering acetanilid, acetphenetidin, hexamethylene, sulfonal, trional, veronal, reaches 15 pounds. The profit on these goods should run about $400, but the public is welcome to any part of it, if they will let coal tar alone, either voluntarily or by compulsion. Now then, with these figures before us and with the facts plainly evident to druggist or physician who uses any powers of discernment, what change have the common people against the wiles of the impertinent manufacturer who repeatedly advertises "Perfectly Harmless."

I must now give you the cases which aroused in me the antagonism to the open sale of all remedies which contain any coal tar derivative, no matter how strongly fortified with correctives.

A close friend of mine had a young son come down with a cold, the physician prescribed 20 powders, two grains each of acetphenetidin. Some time after this, the box came back for a refill. I said to Jones, "Does the doctor want you to have these again?" He replied that he did. This happened several times in the course of a few years, and the boy became old enough to come to the store himself on errands, and I could not help noticing how white and pale he was, and it finally dawned on me what ailed that boy. I went to Jones and said to him, "While it is none of my business, I want to tell you with all the force possible, to quit killing that boy." "Well," he says, "I told my wife what you said, and she replied that she guessed the Doctor knew as much as I did about it, so he had dropped it, but now I believe you are right, and those powders stop right here." The boy today is a fine strapping rosy-cheeked youth.

A young man of this town, a perfect giant in strength, who could pick up my 175 pounds and throw me over his head, became addicted to the use of one of our popular effervescent preparations for headache. Some time after he commenced using it, I began to warn him against the frequent dosage, till he almost quit coming to our counter, not relishing my "preaching" as he styled it. I saw him, however, at all the other stores in town, and knew he was using it regularly. Several years passed, and some prescriptions containing heart remedies were ordered sent to this man, later a nurse was called. I asked the physician "What ails Brown?" "Heart trouble," says he. I told him what I knew, and he thanked me, not knowing the cause.

In a few days this perfect specimen of physical manhood died--died in the prime of life and with a strength that not one man in 10,000 ever attains, died because we men, druggists, doctors, and scientists have been so slow to recognize the slow, sneaking, insidious character of these vicious remedies. No one can make me believe, when I pick up the morning paper and read the same old story day after day, that Jones dropped dead in Texas, Smith in Main and Black in California, that Coal Tar was not at the bottom of 90 per cent of them.

For my part I am in this fight to stay. I have decreased our sales by one half, by my own warnings against their use.

But how much avail am I to the ignorant young rounder who comes out of a night's debauch with a big head and who still half drunk wanders from drug store to drug store and asks for his effervescent? No one guilty because the busy clerk or proprietor did not know that he had had another just 5 minutes previous. With all this knowledge before me I have been guilty of openly pushing the sale by the distribution of literature lauding these remedies, but no more for me.

And I ask my brother druggist not put out any advertising which may contain on one of its pages a recommendation for a coal tar remedy. I also hope to soon see upon the statues of every State a law similar to the one concerning Cocaine of our own State.

For I maintain that Opium or Cocaine are not one half as deadly as Coal Tar, for while they openly show what they can do, the other works silently till the end is near. For our part, we have quit putting up a remedy of our own, and I have in mind the adoption of a label to go on the outside of all packages sold, to read something like this:

"All remedies containing acetanilid, acetphenetidin or the like product of coal tar are dangerous and should be used with caution, in extreme cases only, and never habitually.
Considering the effect on myself, on the people I have sold to, the evidence of many physicians who have found out the pernicious effects and felt themselves compelled to abandon or modify its use, I venture the opinion that, while it is bad medicine for any one for regular use, on those who are extremely susceptible to it, it soon vitiates the blood and deprives them of their full powers of resistance, when sudden shock or disease o'er takes them.