Antiquated medical practices can be hilarious and at times, terrifying. Thank goodness those times are in the past - aren’t they? 04/08/2021
If your baby was fussy in the late 1800s, you might have tried a spoonful of Mrs. Winslow’s soothing syrup - a combo of morphine and alcohol, along with essential oils of dill or caraway (Br Med, 1912). This “patent medicine” was marketed toward teething babies (and, presumably, their mothers) for that special kind of pain relief that only morphine can bring (unless it was the dill essential oil that packed such a wallop).
Unfortunately, this “miracle-in-a-bottle” was often tragically lethal, and was banned in the 1930s.
Thirsty and in need of a pick-me-up? What about a nice cold Coca-Cola, complete with actual cocaine? That’ll put some pep in your step! (Das, 1993)
Mercury, heroin, radium, and arsenic - all used to be commonly available for a whole host of ailments and conveniently, right at your corner store. Well, at least they’re natural!
Fortunately, modern medicine has made legitimate advances - many of them, significant and life-saving. So can we conclude that modern medicine has moved away from medical practices that offer no net benefit and may do harm?
“Identifying medical practices that do not work is necessary” (Prasad et. al, 2013)
While it’s entertaining to giggle about the misguided efforts of old-time physicians, sometimes the gaffes aren’t quite as antiquated as one may hope - indeed, some of today’s common medical practices may be just as laughable in the near future.
The phenomenon of finding a medical practice to be inferior to some less-used or prior standard of care is referred to as a medical reversal. Today, ideally, this occurs when new, better studies contradict current practice (Prasad, 2011).
After all, when we are advised by our physicians about potential courses of treatment for any medical issue, we “expect that new medical practices gain popularity over standards of care on the basis of robust evidence indicating clinical superiority or … easier administration and fewer adverse effects. The history of medicine, however, reveals numerous exceptions to this rule” (Prasad et. al, 2013).
Here are some recent medical reversals. Some are well known, others may surprise you.
Hormone therapy to improve cardiovascular outcomes for post-menopausal women was a common yet controversial treatment based largely on observational evidence (not randomized controlled trials, the optimal study design). Large-scale studies started popping up to assess the safety of this treatment, such as The Women’s Health Initiative study, which began in 1991.
That study’s initial design was to spend eight and a half years assessing the benefit and risk of the commonly used combined hormones estrogen and progestin. However, after the test statistics for invasive breast cancer exceeded the stopping boundary, the trial’s safety board recommended ending the trial early, as the risk for intervention exceeded the benefit - risks such as coronary events, strokes, cancer, and fractures.
Even with these findings, hormone therapy remains an accessible treatment that may still offer some benefits in certain cases, according to the Mayo Clinic – but now, with a greater understanding of the risks it may carry (Roussouw, 2002) (Hormone Therapy – Is It Right for You? 2020).
Stents - not so straightforward
Percutaneous coronary intervention - also known as inserting a stent - is a routine treatment for patients with stable coronary artery disease (Bhatt, 2018).
Surely this multibillion-dollar-per-year invasive intervention must be superior to medical management for patients (Prasad et. al, 2013)?
Not according to a four-year study which showed no significant differences between the stent group and the medical-therapy group when it comes to death, heart attack or stroke (Boden, 2007).
A longer and larger trial, called the ISCHEMIA trial, offered further confirmation. It examined the difference between medicine-management and stents in coronary patients. It indicated that for most, managing stable coronary artery disease with medications alone was as effective as the more invasive strategy of stent insertion (Lopes et. al, 2020).
Shockingly unnecessary catheterization
Routine usage of a pulmonary artery catheter, invented in the 1970s and popular in the 1980s for elderly patients in shock, was also by the early 2000s discovered to provide no benefit and was actually inferior to less-invasive management strategies. Patients on whom a pulmonary catheter was used had higher rates of pulmonary embolism (a blood clot in the lung).
How long did it take before a randomized-controlled trial that examined the benefit risk of pulmonary-artery catheters was conducted?
Before that, the observational studies had been inconsistent. The increased risk of blood clot was not statistically shocking in the trial itself, which had about 1,000 participants in the intervention group versus placebo group.
Yet according to the study authors, that level “must be interpreted in the light of the 1.5 million patients who receive pulmonary-artery catheters in North America annually.” When magnified to this eye-popping number, “the use of these catheters could potentially translate into 12,000 additional pulmonary embolisms annually” (Sandham et. al, 2003). It is now used only in rare circumstances.
Medical Reversal: Second Verse, Same As The First
While the term “medical reversal” inspires hope that once a practice is determined to be inferior, it’s no longer implemented - it’s not exactly that simple. These evaluations have become a topic of greater interest among medical researchers as “the continued use of such practices wastes resources, jeopardizes patient health, and undermines trust in medicine” (Prasad, 2013).
Medical professional societies have started circulating polls, requesting input on the top five practices thought to be unhelpful or damaging. A prestigious medical journal has created an ongoing feature called, “Less is More” (Grady, 2010).
A recent review analyzed each original article from 2000-2010 in the New England Journal of Medicine that referred to an existing clinical practice. After zeroing in on 363 out of those 2044 articles, an astonishing 146 of them – fully 40 percent! - found that the new practice was less effective than the previous standard. Another 27.3 percent were found to be inconclusive (Prasad, 2013).
Now consider that there were only 363 articles reviewed. Imagine if this level of continuous review and critique were applied to every medical procedure we accept as routine without question.
How do we know what we “know”? Asking the hard questions.
If you have ever been in a difficult conversation with a loved one, you know how challenging and rare it is for either party to stop in the heat of the moment and ask: “Could I be wrong about this?” Like a miracle, the moment you ask yourself that is also the moment your perspective can shift away from defensive to constructive. Suddenly, being right or proving a point is less important than beginning to heal.
The publication of peer-reviewed scientific research can be a thing of beauty - particularly when it asks uncomfortable, humbling questions such as “Is this even working?” or “Am I wrong about this?” Our minds are capable of incredible feats - and fortunately, the ability to change one’s mind or course of action when presented with new, correct information is something that will eventually lead to the discovery of facts and truths.
In the meantime, however, one antiquated axiom continues to be more relevant than ever, especially with regard to medicine: “An ounce of prevention is worth a pound of cure” (Ben Franklin, 1735).
- George S. Bause; Mrs. Winslow's Soothing Syrup. Anesthesiology 2012; 116:8 doi: https://doi.org/10.1097/ALN.0b013e318244c10a
- Bhatt D. L. (2018). Percutaneous Coronary Intervention in 2018. JAMA, 319(20), 2127–2128. https://doi.org/10.1001/jama.2018.5281
- Br Med J 1912;1:683
- Boden WE, O’Rourke RA, Teo KK, et al. Optimal medical therapy with or without PCI for stable coronary disease. N Engl J Med. 2007;356(15):1503-1516.
- Das G. (1993). Cocaine abuse in North America: a milestone in history. Journal of clinical pharmacology, 33(4), 296–310. https://doi.org/10.1002/j.1552-4604.1993.tb04661.x
- Christen, A. G., & Christen, J. A. (2000). Sozodont powder dentifrice and Mrs. Winslow's Soothing Syrup: dental nostrums. Journal of the history of dentistry, 48(3), 99–105.
- Grady D, Redberg RF. Less is more: how less health care can result in better health. Arch Intern Med. 2010;170(9):749-750.
- Hormone therapy: Is it right for you? (2020, June 09). Retrieved April 05, 2021, from https://www.mayoclinic.org/diseases-conditions/menopause/in-depth/hormone-therapy/ART-20046372
- Lopes RD, Alexander KP, Stevens SR, et al. Initial Invasive versus Conservative Management of Stable Ischemic Heart Disease Patients With a History of Heart Failure or Left Ventricular Dysfunction: Insights From the ISCHEMIA Trial. Circulation 2020;142:1725-35.
- “On Protection of Towns from Fire, 4 February 1735,” Founders Online, National Archives, https://founders.archives.gov/documents/Franklin/01-02-02-0002. [Original source: The Papers of Benjamin Franklin, vol. 2, January 1, 1735, through December 31, 1744, ed. Leonard W. Labaree. New Haven: Yale University Press, 1961, pp. 12–15.]
- Prasad V, Gall V, Cifu A. The frequency of medical reversal. Arch Intern Med. 2011;171(18):1675
- Prasad, V., Vandross, A., Toomey, C., Cheung, M., Rho, J., Quinn, S., Chacko, S. J., Borkar, D., Gall, V., Selvaraj, S., Ho, N., & Cifu, A. (2013). A decade of reversal: an analysis of 146 contradicted medical practices. Mayo Clinic proceedings, 88(8), 790–798. https://doi.org/10.1016/j.mayocp.2013.05.012
- Rossouw JE, Anderson GL, Prentice RL, et al; Writing Group for the Women’s Health Initiative Investigators. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results from the Women’s Health Initiative randomized controlled trial. JAMA. 2002;288(3): 321-333.
- Sandham, J. D., Hull, R. D., Brant, R. F., Knox, L., Pineo, G. F., Doig, C. J., Laporta, D. P., Viner, S., Passerini, L., Devitt, H., Kirby, A., Jacka, M., & Canadian Critical Care Clinical Trials Group (2003). A randomized, controlled trial of the use of pulmonary-artery catheters in high-risk surgical patients. The New England journal of medicine, 348(1), 5–14. https://doi.org/10.1056/NEJMoa021108