On patent medicines (with Tim Harford)

0:00This is DrugStory. I'm Thomas Gets. Today, we're sharing an episode of one of my favorite podcasts cautionary tales by Tim Hartford. Tim is just super good at explaining complicated things, economics, history, and in this episode, medicine. This show is about Lydia Pinkham's vegetable compound, one of the most popular patent medicines of the late 19th century. Mrs. Pinkham's compound was sold as a women's tonic, ideal for menopause or menstrual pain, and, and I'm quoting here, for all those painful complaints and weaknesses so common to our best female population. It cures bloating, headaches, nervous prostration, general debility, sleeplessness, depression, and indigestion. But did it really? No, no it did not. Lydia Pinkham's compound was the epitome of a cure-all that cured nothing. It was a secret concoction of herbs and roots

1:06and other ambiguous ingredients that promised tremendous benefits without any evidence whatsoever. Eventually, it was outrage over patent medicines like Mrs. Pinkham's that turned into the creation of the FDA, and the evidence-based medicine we enjoy today. I will let Tim tell the whole story, but it's a lovely episode. And just a note before I hand off the mic, I want to thank you all, truly, for listening to this podcast. In just a couple of months, drug story has found a large and enthusiastic audience, for which I am just tremendously grateful. In fact, we are hard at work wrapping up two bonus episodes for this season, including next week's show on a true miracle drug, Ivermectin. That story actually picks up on many ideas that Tim explores in this episode. It is quite the tale, so expect that next week. Thank you for listening. Enjoy the show. A fearful tragedy declared the newspaper, all caps, of course. It was after all the 1880s.

2:22A fearful tragedy, a clergyman of Stanford, Connecticut, killed by his own wife. But why? What were the circumstances? Could the tragedy have been prevented? Never fear, the full explanation is forthcoming, but be warned. This is not actually a news report. It's an advertisement, apparently based on a true story. A fearful tragedy, a clergyman of Stratford, Connecticut, killed by his own wife. Insanity brought on by 16 years of suffering with female complaints, the cause. Lydia E. Pinkham's vegetable compound, the sure cure for these complaints, would have prevented the direful deed. Well, well, it's quite a tale, and quite a claim. Gather round, ladies and gentlemen, and take a comfortable seat. For I am about to tell you a tale of direful deeds aplenty, and of female complaints, and of the most efficacious vegetable

3:27compounds you could wish for. I'm Tim Harford, and you're listening to cautionary tales. Lydia E. Pinkham was born Lydia E. in the city of Lin, Massachusetts, in 1819. The 10th child of a modestly wealthy family of Quakers. If you'd met Lydia as a young woman, you wouldn't have imagined that she'd get into the business of herbal treatments for female complaints. She would have seemed more like a social activist, even an anti-racist.

4:29Lydia, her mother, and some of her sisters were among the founder members of the Lin, female, anti-slavery society. Lydia and her sister Julielma were friends with a great abolitionist activist, Frederick Douglass. He was about their age, and had moved to Lin after escaping slavery, and the girls put their reputation on the line for Frederick Douglass. Lydia stood in the way of a railroad conductor who was trying to send Douglass to the car reserved for blacks and Irish. She left the Quaker faith because it wasn't staunch enough in its demands for the abolition of slavery. Julielma created a scandal after being seen walking arm in arm with Douglass. She was thrown out of her church when she refused to rule out marrying a black man. Color would make no difference to me in a husband. I would look only upon a man's character. Both Lydia and Julielma were founding members of a new debating and lecture society.

5:33No person shall be excluded from full participation in any of the operations of this society on account of sex, complexion, or religious or political opinions. Frederick Douglass became the society's president, and Lydia, its secretary, a debating society upholding feminism, anti-racism, and religious tolerance. It's quite a start to a remarkable career. Then came the second stage of Lydia's life, that of wife and mother. At the age of 24, she married one of her fellow debaters, Isaac Pinkham, a widower, and a gentleman described by a contemporary as kindly but of no great vigor. That seems implausible, for one thing, the Pinkham's had four sons and a daughter. For another, Isaac's problem seemed less to be lack of vigor, but restless activity. He had big dreams and questionable business judgement. Lydia's father had given them a house in the centre of the city, but Isaac,

6:37always with an eye on the next prize, sold up and moved the family eight times. As a career, he tried first shoe-making, then kerosene manufacturing, then produce trading, farming, and building. Lydia's biographer, Sarah Stage, writes that he changed occupations, as often as some people changed clothes. Lydia Pinkham, meanwhile, was trying to keep everything together at home. Lydia's second son, Daniel, died in infancy of gastroenteritis. It must have been terribly hard, but all too common in the 19th century. She also named her next baby, Daniel. Life had to go on, and go on it did. One of Lydia's many house-wifely chores was to brew up a vegetable tonic at home. This wasn't unusual. Home-brewed medicines were ubiquitous, since doctors were expensive and

7:37of doubtful help, and disease was an ever-present threat. Lydia Pinkham's tonic was based on an existing formula, adapted after some kitchen experiments, and a close reading of the American dispensatory, a comprehensive description of herbs and their medical uses. Tonic contained a variety of botanical ingredients, including golden ragwort, unicorn root, fenugreek, butterflyweed, black cahosh, and alcohol. It was, in her opinion, the finest remedy of my experience. Remedy for what? Four female complaints, of course. Painful, irregular, or heavy menstruation, a prolapsed uterus, menopausal symptoms, etc., etc. Lydia gave away pints of the staff to her neighbours. It was only in 1875, after Isaac Pinkham's latest scheme, real estate

8:38catastrophically failed, that Lydia was finally tempted into commerce. She was in her mid-50s. Her father was long dead. The family money long spent, and the Pinkham's desperately needed some cash. The story goes that two strangers rode up to the Pinkham residents in a handsome carriage, said they'd come five miles up the coast from Salem, and offered Lydia five dollars for six bottles of her famous vegetable compound. That was easily a week's wages, and although somewhat embarrassed, Lydia Pinkham accepted the price and made the sale. It was the start of the third and most remarkable phase of Lydia Pinkham's life, that of healer, entrepreneur, and agony all rolled into one. The idea first came from her 27-year-old son, Dan. Mother, if those ladies will come all the way from Salem to get that medicine,

9:40why can't it not be sold to other people? Why can't we go into the business of making it and selling it, same as any other medicine? Lydia Pinkham and her children put Lydia's vegetable compound on the market, promoting it with matronly images of Lydia e Pinkham herself, and promoting the tonic with a four-page pamphlet in which Lydia offered frank health advice, by a woman for women. Dan Pinkham set out to spread the word of his mother's miraculous vegetable compound. He paced the streets of Boston and New York, hustling for sales to drugstores, going door to door handing out leaflets, haggling with printers over the cost of printing those leaflets and writing letters home, asking for money. For God's sake, whose management is it that keeps me from having what I actually need? Now, in consequence of your cussed judgment, I shall have to live upon a cracker diet. There is no use in writing. I actually can't spare three cents to buy a stamp with. Dan's advertising ideas were imaginative but impractical. He littered

10:46New York's parks and graveyards with little cards with faux handwritten notes on them, giving the impression that someone had been meaning to post a message, recommending Lydia e Pinkham's vegetable compound to a friend that had dropped the card before it reached the mailbox, several thousand times. Dan also fantasized about draping a banner from one end of the Brooklyn Bridge to the other. His younger brother Will was working smarter, not harder. After making a big sale to the Boston wholesaler, Weeks and Potter, Will Pinkham swung past the offices of the Boston Herald and asked how much it would cost to put an advertisement with his mother's picture on the front page. $60 came the response. Will Pinkham had $84 in his pocket, so he slapped down the cash and went home to tell his mother what he'd done. To her, it was a disastrous echo of her

11:49rash husband's business gambles. That was like a thunder clap out of a clear sky and we all sat down and had a good cry. But within two days, borders from Boston drugstores emptied the Pinkham stock of vegetable compound. Stores which had bought a dozen bottles at a time now placed orders for a hundred or more. The lesson was clear. It pays to advertise, especially if you advertise with the matronly image of Lydia E. Pinkham. Lydia E. Pinkham's vegetable compound cures female complaints such as dragging sensations, weak back, falling and displacements, inflammation and ulceration and organic diseases and it dissolves and expels tumors at an early stage. Women suffering from any form of female weakness are invited to write Mrs. Pinkham, Lynn Massachusetts for advice. The Pinkham's bought another front page advert the following week

12:53and got much the same result. As they sank more money into advertising, sales continued to saw. Mrs. Pinkham was on her way to having one of the most famous faces in America. Hair in a bun, slightly graying, neck concealed by a starchy rough, fastened centrally by a simple brooch. She was the very picture of middle-aged respectability and wisdom. Her vegetable compound would soon become legendary. It's the all-American rags to rich history. But there is one nagging question. Did the vegetable compound cure anything? The tonic consisted of a few herbs preserved with a generous splash of booze. The advertising claimed it was so efficacious for female complaints that it would prevent menstruating or menopausal women from direfully murdering their husbands, even that it would prevent cancer. Was that actually true? It wasn't a question that people seemed to be interested

13:57in asking. Cautionary tales will return after the break. Mrs. Pinkham was not the first entrepreneur to make money selling unusual concoctions. The wave of enthusiasm for such remedies had begun before she was born. Oddly, these remedies were called patent medicines, although no patents were involved. Instead, entrepreneurs used trademarks to protect their brand image, which is telling in its own right. This was a world of style and snake oil over substance, and fakes and quacks prospered. As a newspaper editor complained as early as 1800, the vendors of patent medicines in almost every capital town in the United States are fattening on the weakness and folly of a deluded public. One of those vendors was Thomas Diet, a penniless immigrant from England looking to make a

14:57mark on Philadelphia. By day, he polished shoes. By night, he manufactured the black shoe polish. He soon had more shoe polish than he could use. Opened a store, then a warehouse, then a bottle factory, before finally realizing that if he was to spend his days putting gloop into bottles, medicinal gloop would be far more profitable. Even at the time, there were many critics of such tonics and potions. They would be dismissed as Trumpery by which they meant fraud or showy nonsense. It's a good word. But the critics didn't dampen the vigorous demand, and Thomas Diet took full advantage. Diet sold a wide variety of cures, his own concoctions, the popular medicines of his rivals, and above all, treatments perfected by his grandfather, the noted Dr. Robertson of Edinburgh. Dr. Robertson's vegetable nervous cordial. Dr. Robertson's gout and rheumatic drops.

16:02Dr. Robertson's infallible, worm-destroying lozenges. And Dr. Robertson's cure for a certain disease, presumably something or everything involving the male-neather regions. Diet was proud of his ancestor, Dr. Robertson, despite the fact that the Philadelphia medical journal scathingly explained that there had been no noted Dr. Robertson in Edinburgh for two centuries. No matter. Thomas Diet was soon claiming to be a physician himself, and more to the point, by the 1830s, he was enormously wealthy, making the equivalent of $10 million a year. He kept a grand estate and was driven around in a fine English coach with half a dozen outtriders. He kept expanding his operations, even setting up a bank. Why was he so successful? Certainly because he was a master of vivid, clever advertising,

17:05but was it because his worm-destroying lozenges actually were infallible? Not a chance. And when Diet's fortunes turned, which they did in 1837, it wasn't because people stopped buying useless treatments from a fake doctor with an imaginary grandfather. It was because Diet's bank collapsed in the midst of a nationwide banking panic. If it stuck to selling the non-existent Dr. Robertson's far-from-infallible worm-destroying lozenges, he'd have been fine. Why do people buy treatments without any evidence that they work? In some ways, it's a timeless question. As Lydia Pinkham was perfecting her vegetable compound in the 1870s, Western Egyptologists had just obtained papyrus, which contained detailed accounts of Egyptian medical practice, from 1500 BCE, three and a half thousand years ago. And as one medical

18:08historian explains, Quackery is an ancient tradition. These papyrus, the oldest proper medical instructions of our species, contained potions and salves and drugs whose effectiveness was a fantasy. The first doctors in the world were frauds. For the next three and a half thousand years, little changed. Even today, there are plenty of phony cures, especially when conventional medicine can't help. Quackery abhors a vacuum, so when the SARS-CoV-2 virus was discovered in early 2020 and no proven treatment or vaccine was available for COVID within weeks, people were on social media recommending special red soap or treatments for malaria or even using a USB flash drive as a bio shield. There's a lot of money to be made by selling snake oil to the fearful or desperate.

19:10But while Quackery began at least three and a half thousand years ago and continues to the present day, its golden age may have been the 19th and early 20th centuries. The age of Dr. Robertson's worm-destroying lozenges and Mrs. Lydia E. Pinkham's vegetable compound. A few years ago, the economist Werner Trusken published a study of the US market for unproven concoctions in this golden age. He concluded that even after adjusting for inflation, people spent more than a hundred times as much on these dubious patent medicines in 1939, firmly in the modern age, than they had back in 1810 when Thomas Diet was just starting out. Across that period, demand for patent medicines grew 20 times faster than the economy as a whole, and these strange potions became a major industry in their own right. So why did people buy them?

20:12The simple answer? Sometimes they made people feel better. There were two reasons for that. One is the placebo effect. People do often benefit simply from the belief that they're being treated. Many Quack medicines included ingredients such as chili, alcohol, and opium, producing plausible highs, lows, and tingles. The chili was fine. The opium was a problem. Parents could, and tragically sometimes did, medicate their own children to death. Lydia Pinkham's vegetable compound contained neither chili nor opium, but it was 20% alcohol, making it a drink as strong as port or cherry. A small glass of that, and well, you might indeed relax and feel a little differently about your female complaints. And then there's the fact that most people who feel bad feel better in due course. If they're suffering from an infection, the immune system kicks in. Period pains pass with each

21:14monthly cycle. The symptoms of menopause usually fade after a few years. And if you happen to be taking medicine when your sufferings abate, well, perhaps you'll give the medicine the benefit of the doubt and tell your friends. There was another reason for the popularity of patent medicines. People bought them because they didn't trust the doctors. The doctors of the day had a habit of prescribing calomel, a compound of mercury, which was distinctly toxic and caused inflamed gums and ashen complexion, and in extreme cases, a rotting away of the jaw. Women in particular had reason to be wary of doctors in the 19th century. Evidence was slowly emerging that physicians were accidentally killing their female patients by attending births while their hands were contaminated from disease from other patients or from dissecting corpses. The medical profession, however, was outraged at this suggestion and refused to consider the evidence that it was true.

22:19Charles D. Meigs, an American obstetrician, spotted that doctors are gentlemen and gentlemen's hands are clean. If the alternative was jaw rotting calomel, crude surgery, or death from infection, after a doctor prodded your uterus with cadaver juice under his fingernails, all at vast expense, well, small wonder that people flocked to the patent medicine sellers, especially those like Lydia Pinkham, who offered relief for female complaints. It's hard to read the economist Werner Trusken's research, without thinking not just of the Trumpery of patent medicines, but Trumpery of the more political kind. All across the world, left and particularly right-wing populists have been in the ascendancy while old-fashioned centrists have been out of fashion. The parallels are inescapable, populists, like patent medicine sellers, often suggest approaches which offer a short-term

23:20pick-me-up, even if they only make things worse over time. Populists, like patent medicine sellers, thrive when the establishment has let people down. The doctors of the 19th century talked confidently but looked down on their clients and offered their own ineffective remedies. Are political centrists so different today? Populists, like patent medicine sellers rely on marketing, huge adverts, bold claims, attention-grabbing stunts. In the 19th century, it was common for quack medicine sellers to operate alongside a circus. Modern populists try to generate a circus all of their own. And populists, like patent medicine sellers, are quick to claim that the people are on their side. Consider this newspaper editorial from 1881. There is no such thing as medical authority. The people are and are obliged to be the only judges of medicine and of physicians. The people are the only true judges,

24:27and the people have had enough of experts. If people like what's on offer, whether it's tough talk about immigration or a vegetable compound, well, isn't that all the proof of effectiveness that anyone would need? It was attempting claim about patent medicines then, and it's attempting claim about politics today. Because one thing that infuriates people, whether the reactionary voters of today or the suffering patients of the 19th century, it's feeling that you're not being listened to by the people who should be looking after you. Listening to people was something Lydia Pinkham did very well indeed. Dear Mrs. Pinkham, I have been afflicted with amality that my physician frankly tells me that he has never met with before, and I write to ask you the cause and what the cure is. It is an affection of the gums and mucus membrane of the mouth. The gums turn white and a layer easily rubs off, leaving them very red and angry. The inside of my cheeks and corners of my jaw are white

25:33and look and feel hot. Such letters to Mrs. Pinkham were common. Adverts for the Pinkham Company actively encouraged suffering women to write in for advice. No man would ever read their letter, they were assured. In this case, Lydia Pinkham's response was to the point. You have taken virulent poisons in the form of medicine that has caused disease of the mucus membranes. It's the typical response of the quack healer, blame mainstream medicine for the affliction, but given that these symptoms were typical of calumel poisoning, Pinkham was probably right. Mrs. Pinkham recommended instead the dry form of her compound, which was alcohol-free, supplemented by some healthy living. Bay yourself all over every night in hot water, eat farenacious food and broths, ride out and walk out, dig, use the trowel, take the compound according to instructions and let doctors alone. That might work or it might not, but it sounds

26:40better than calumel. Unlike the doctors, Mrs. Pinkham seemed to be listening, and she was listening with the benefit of her own experience as one of the Pinkham companies advice books explained. It takes a woman to understand a woman, take for instance the long list of diseases and discomforts which come directly from some deraidagement of the female generative organs. Do you think it possible for a man to understand these things? That still doesn't answer the question of whether Lydia E. Pinkham's vegetable compound actually worked. But then, what did the doctors have to offer that was better? Nothing. The Pinkham company was set up as a partnership between Lydia Pinkham's four children, and it remained within the family for decades. But at the start of the 20th century, the Pinkham's became a tempting target for a backlash against patent medicine in general.

27:41In 1905, Edward Bach, the editor of the Ladies Home Journal, launched a ferocious attack on the Pinkham's. He published a discomforting pair of contrasting images on the left. A recent advertisement for Lydia Pinkham's vegetable compound, urging women to write to Mrs. Pinkham for advice on the right, a photograph of an ornate monument in a cemetery in Lin, Massachusetts to Lydia E. Pinkham, showing that she had died on May 17, 1883, 22 years earlier. The implication was clear, the Pinkham's were liars. Corsary tales will return after the break. Edward Bach's attack was an uncomfortable moment for the Pinkham family business,

28:44which was being run by Lydia's son, Charles. They were encouraging people to write to Mrs. Pinkham, but Mrs. Pinkham had been dead since the early years of the company. The Pinkham defence was to brazen it out. They issued a statement noting that the Mrs. Pinkham mentioned in the advertisement was Lydia's daughter-in-law, Jenny, and she supervised the company's correspondence with female customers. The company explained that they had never claimed that Lydia E. Pinkham answered all the letters and declared optimistically that the general public understands this very well. But why were prominent commentators such as Edward Bach so keen to attack the Pinkham operation? Not because there was any suggestion that the vegetable compound did not work. Nobody seemed to care about that. Instead, just as Thomas Diet had been undone not by selling phony cures that because of a bank run, campaigners such as Bach worried less about whether patron

29:47medicines helped women and more that they contained alcohol. One of Bach's articles was titled The Patent Medicine Curse. It included a table showing the alcohol content of Lydia Pinkham's vegetable compound and three dozen other patron medicines. No woman has a moral right to give a medicine to her child or to any member of her family or to take the medicine herself, the ingredients of which either she does not know or has not the assurance of a responsible physician to be harmless. Bach finished with a flourish, arguing that to give a medicine containing alcohol to a child would be to strike at his very soul, planting the seed of a future drunkard. As for the women themselves, Bach sneered at their symptoms. They feel sluggish after the all winter indoor confinement. They feel that their symptoms need a toning up.

30:48The idea that some women might be suffering agonizing, disabling pain doesn't seem to have occurred to Edward Bach. But then despite the fact that he edited the lady's home journal, he was almost proud to declare weirdly in the third person that he knew nothing about them. It is a curious fact that Edward Bach's instinctive attitude towards women was one of avoidance. They had never interested him, of women therefore he knew little, of their needs less. Nor had he the slightest desire even as an editor to know them better or seek to understand them. Three things, however, he did understand. First, the medicine contained alcohol. Second, in the opinion of Edward Bach, women were inventing their symptoms. And third, the pinkum company was inviting women to write to Mrs. Pinkum, even though Mrs. Pinkum was dead. What more did anyone want? Well, if you were suffering from female complaints, perhaps a cure?

31:57The medical term for one particular form of female complaint is dysmenorrhea. We usually just call it period pain, and it can be incapacitating in its severity. The doctors of the late 19th and early 20th century didn't have much to offer, beyond suggesting that pregnancy was the natural cure. But surely we can do better in the 21st century, can we? If you search the medical literature, you won't find many treatments for severe period pain. Exercise might help a bit, maybe? The same is true for the contraceptive pill, anti-inflammatories such as ibuprofen can help, ginger might help. That's about it. But intriguingly, a small study conducted in 2013 reported that a safe and widely used drug might provide total pain relief over four consecutive hours for women suffering dysmenorrhea. Before you rush to get yourself a packet of this miracle drug,

32:59I'm afraid the study wasn't big enough to rely upon the researchers ran out of money, and they've struggled to get funding since. You can read more about this in Caroline Criado Perez's book, Invisible Women. She interviewed the lead researcher who told her simply that he thought he'd never get funding for a full trial. So that's annoying. If you're curious about what this promising little drug is, well, it was originally tested in 1989 as a treatment for angina, it did not work. However, all of the trial participants were men, and they reported an intriguing side effect, magnificent directions, and so the drug, Sildenafil, was repurposed and put on the market as the wander drug, Viagra. You can't help but wander that if women had been on the original trial, we might also have fortuitously discovered that elusive treatment for severe period pain.

34:01As it was, men got their miracle drug, but women are still waiting. Given this performance from the medical mainstream, it's really no wonder that treatments such as Lydia Pinkham's vegetable compound thrive. Whether the Pinkham's really believed in the power of their own medicine is unclear. Letters from Lydia's sons, Dan and Will suggest a certain degree of cynicism about that, but Lydia herself seems to have kept the faith in herbal remedies when the most testing times came. Here's her diary from 1879, not long after the vegetable compound had become a best-selling sensation. Daniel Sick in New York recommended to take three of my liver pills, then steep one-half ounce of pleurcy root and bugleweed, and one-half ounce of marshmallows, taken one-half cup at a time, three or four times per day. Dan Pinkham rallied, but only for a time.

35:08In October 1880, Dan Pinkham died, stricken by tuberculosis. He was just 32. His brother Will had the same illness and was too sick to attend Dan's funeral. Will died at the age of 28, just two months later. Lydia Pinkham had lost three of her sons. Dan, Will, and the infant Daniel, and in all three cases the cause had been illnesses which are easily treatable today. Medicine can make progress. That progress doesn't come from over-confident doctoring, and it doesn't come from a herbal tonic, cleverly packaged up with some grand motherly wisdom. Medical progress requires proper testing of treatments. The tests which weren't done on Kalamal, and which still haven't been properly conducted, to see if Viagra really can treat severe period pain. But you don't need scientific tests to make money out of people

36:12who are desperate for relief, and Lydia E Pinkham's vegetable compound made plenty. Like the image of her old friend, Frederick Douglass, Lydia's portrait became one of the most reproduced images in the world. Indeed, when Queen Victoria died in 1901, newspaper editors across America often lacked a portrait of the monarch, so they decorated their reports and obituaries with the next best thing. A picture of the late Lydia E Pinkham, close enough. If you don't have the real thing, you'll find something to fill the gap.

37:15The best history of Lydia Pinkham and the business of women's medicine is female complaints by Sarah Stage. For a full list of our sources, see the show notes at TimHalford.com. Corsionary Tales is written by me, Tim Halford, with Andrew Wright. It's produced by Alice Fines, with support from Edith Ruslo. The sound design and original music is the work of Pascal Wise. The show wouldn't have been possible without the work of Jacob Weisberg, Ryan Dilly, Julia Barton, Greta Cohn, Little Malade, John Schnarrs, Carly Migliori, Eric Sandler, Maggie Taylor, Nicole Marano and Morgan Ratner. Corsionary Tales is a production of Pushkin Industries. If you like the show, please remember to share, rate and review. It helps us for, you know, the serious reasons. And if you want to hear the show add free, sign up for Pushkin Plus on the show page and Apple podcasts or at pushkin.fm slash plus.