Placebo in history

Placebo in history is the account of the changing understanding of the phenomena of the placebo effect and term "placebo".

The word placebo, Latin for "I shall please", dates back to a Latin translation of the Bible by Jerome.^[1] It first started to be used in a medicinal context in the 18th century but in a different sense to that used at present as an ineffective treatment. In 1785 it was defined as a "commonplace method or medicine" and in 1811 it was defined as "any medicine adapted more to please than to benefit the patient", sometimes with a derogative implication^[2] but not with the implication of no effect.^[3]

In 1961 Kennedy introduced the word nocebo.^[4]

Origin of the word

The word placebo itself originated from the Latin for I shall please.^[1] It is in Latin text in the Bible (Psalm 116:9, Vulgate version by Jerome, “Placebo Domino in regione vivorum”, “I shall please the Lord in the land of the living”). Jerome translated as "I will please" (placebo), the Hebrew word "ethalech", "I will walk with" as in "I will be in step with". This word gave its name, placebo, to the Office of the Dead church service. From that, a singer of placebo became associated with someone who falsely claimed a connection to the deceased to get a share of the funeral meal, and hence a flatterer, and so a deceptive act to please.^[2]

Early medical usage

Placebos were widespread in medicine until the 20th century, and they were sometimes endorsed as necessary deceptions.^[4] In 1903 Richard Cabot said that he was brought up to use placebos,^[4] but he ultimately concluded by saying that "I have not yet found any case in which a lie does not do more harm than good".^[5] In 1961 Henry Beecher found^[6] that patients of surgeons he categorized as enthusiasts relieved their patients' chest pain and heart problems more than skeptic surgeons.^[5]

Hooper’s (1811) Quincy’s Lexicon-Medicum defines placebo as "an epithet given to any medicine adapted more to please than benefit the patient".

In the practice of medicine it had been long understood that, as Ambroise Paré (1510–1590) had expressed it, the physician’s duty was to "cure occasionally, relieve often, console always" ("Guérir quelquefois, soulager souvent, consoler toujours").

According to Jewson, eighteenth century English medicine was gradually moving away from the patient having a considerable interaction with the physician—and, through this consultative relationship, having an equal influence on the construction of the physician’s therapeutic approach—and it was gradually moving towards that of the patient being the recipient of a far more standard form of intervention that was determined by the prevailing opinions of the medical profession of the day. (Jewson 1974; Jewson 1976)

Jewson characterizes this as parallel to the changes that were taking place in the manner in which medical knowledge was being produced; namely, a transition all the way from "bedside medicine", through "hospital medicine", to "laboratory medicine" (Jewson 1976, p.227) (for more on the effect of the development of various types of medical technology see Medical sign#Increased reliance on signs).

From this point of view, the last vestiges of the "consoling" approach to treatment are to be found in the administration – often without any sort of adequate history being taken or any sort of appropriate physical examination being made (Carter 1953, p.823) – of the morale-boosting and pleasing remedies, such as the "sugar pill", electuary or pharmaceutical syrup; all of which had no known pharmacodynamic action.

Those doctors who provided their patients with these sorts of morale-boosting therapies (which, whilst having no pharmacologically active ingredients, provided reassurance and comfort) did so either to reassure their patients whilst the Vis medicatrix naturae (i.e., "the healing power of nature") performed its normalizing task of restoring them to health, or to gratify their patients’ need for an active treatment.

Doctor patient relationships

Some statements about the role of placebos in doctor patient relationship are:

• Cooper (1823, p.259): "[When applying] the compound decoction of the sarsaparilla … [in cases of] irritable ulcer, … some think it placebo; others have a very high opinion of its efficacy … [when it is used] after the use of mercury, it diminishes the irritability of the constitution, and soon soothes the system into peace".
• Shapiro^[2]p.656: "[This use of the term "placebo" is a form of] positioning … Introduction of the word placebo to describe a class of treatments not previously specified was an important development in the history of methodology and medicine."
• Handfield-Jones (1953): "some patients are so unintelligent, neurotic, or inadequate as to be incurable, and life is made easier for them by placebo".
• Platt (1947, p.307): "the frequency with which placebos are used varies inversely with the combined intellligence [sic] of the doctor and his patient".
• Steele (1891, pp 277–278)"To argue with a man, and especially with a woman, that there is little the matter with them might be thought injudicious, and to advise them to return at a more convenient occasion requires more time and resolution than writing out a prescription or administering a placebo."
• But Shapiro^[2]p.679: "If a placebo is prescribed by a physician because it is thought that it will help the patient, then it is a specific [remedy] and therefore not a placebo [at all]."
• An editorial in the British Medical Journal of 19 January 1952 (p.150): "But it is a fallacy to suppose that an inactive medicine can do no harm. If prescribed in a perfunctory way for a patient needing explanation and reassurance it may increase faith in his disease rather than in the remedy, and a doctor who gives a placebo in the wrong spirit may harm the patient."
• Pepper (1945, p.411): "There may be a time when during the carrying out of diagnostic tests it is undesirable to give potent medicine lest it interfere with the tests and yet the patient must be encouraged by treatment. … there is a certain amount of skill in the choice and administration of a placebo. In the first place, it must be nothing more than what the name implies a medicine without any pharmacologic action whatever. Even a mild sedative is not a true placebo. Secondly, its name must be unknown to even the most inveterate patient who knows most drugs by name and is always quick to read the prescription. If the medicines named are familiar, the type of patient who needs a placebo will promptly exclaim that this or that drug had been tried and "had not helped me" or "had upset my stomach". It is well if the drug have a Latin and polysyllabic name; it is wise if it be prescribed with some assurance and emphasis for psychotherapeutic effect. The older physicians each had his favorite placeboic prescriptions—one chose Tincture of Condurango, another the Fluidextract [sic] of Cimicifuga nigra. Certainly this latter by its Latin name might be expected to have more supratentorial action than if one merely wrote for the Black Cohosh, and Condurango would be more effectual than sugar of milk." Pepper's assertion that a placebo "must be nothing more than what the name implies"—namely that it must be "a medicine without any pharmacologic action whatever"—in order for it to be called a placebo, is most significant.
• Findley (1953), p.1826 & p.1824: "[If the placebo is not] used as an instrument of deception, but as a technique for cementing the emotional bond which must attach doctor to patient if any form of treatment is to be really successful… [it was] the most important weapon the physician has … [specifically because] in proportion as this [doctor-patient] bond is firm, the [patient's] need for drugs will likely diminish."
• Leslie (1954, p.854): "Because medicine has been so concerned with its scientific growth, too little attention has been paid to advancing the art of medicine, to which therapy with placebos belongs, and consequently knowledge of the use of placebos has not progressed significantly."
• Carruthers, Hoffman, Melmon & Nierenberg (2000, p.1268): "In clinical practice, where a majority of patient visits are for conditions that cannot be explained on a pathophysiologic basis of for which no specific treatment is available, it is essential that physicians understand the concepts and principles of placebos and placebo effects and, when appropriate, use them correctly".

'Placebo effect'

Graves was possibly the first to mention the "placebo effect", when he spoke in 1920 of "the placebo effects of drugs" being manifested in those cases where "a real psychotherapeutic effect appears to have been produced". (Graves 1920, p.1135)

In the 1930s Evans and Hoyle (1933), (using 90 subjects), and Gold, Kwit and Otto (1937), (using 700 subjects), published studies which compared the outcomes from the administration of an active drug and a dummy simulator (which both research groups called a "placebo") in the same trial. Neither experiment displayed any significant difference between drug treatment and placebo treatment;^{[citation needed]} leading the researchers to conclude that the drug exerted no specific effects in relation to the conditions being treated.

In 1946, the Yale biostatistician and physiologist E. Morton Jellinek was the first to mention either a "placebo reaction" or a "placebo response". He spoke of a "response to placebo" (p.88), those who "responded to placebo" (p.88), a "reaction to placebo" (p.89), and of "reactors to placebo" (p.90). This suggests that to Jellinek the terms "placebo response" and "placebo reaction"—or the terms "placebo responder" and "placebo reactor"—were identical and interchangeable.

The first used of the term "placebo effect" is attributed to Henry K. Beecher's 1955 paper The Powerful Placebo, where, however, he only speaks of placebo effects when he is contrasting them with drug effects. Otherwise, he always speaks of "placebo reactors" and "placebo non-reactors". Beecher (1952), Beecher et al. (1953), Beecher (1959), consistently speak of "placebo reactors" and "placebo non-reactors"; they never speak of any "placebo effect". Beecher (1970) simply speaks of "placebos".

The word obecalp, "placebo" spelled backwards was coined by an Australian doctor in 1998 when he recognised the need for a freely available placebo.^[7] The word is sometimes used to make the use or prescription of fake medicine less obvious to the patient.^[8]

It has been suggested that a distinction exists between the placebo effect (which applies to a group) and the placebo response (which is individual).^[9]

References

1. ^ ^{a b} Jacobs B (April 2000). "Biblical origins of placebo". J R Soc Med 93 (4): 213–4. PMC 1297986. PMID 10844895. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=1297986. 
2. ^ ^{a b c d} Shapiro AK (1968). "Semantics of the placebo". Psychiatr Q 42 (4): 653–95. doi:10.1007/BF01564309. PMID 4891851. 
3. ^ Kaptchuk TJ (June 1998). "Powerful placebo: the dark side of the randomised controlled trial". Lancet 351 (9117): 1722–5. doi:10.1016/S0140-6736(97)10111-8. PMID 9734904. http://linkinghub.elsevier.com/retrieve/pii/S0140-6736(97)10111-8. 
4. ^ ^{a b c} de Craen AJ, Kaptchuk TJ, Tijssen JG, Kleijnen J (October 1999). "Placebos and placebo effects in medicine: historical overview". J R Soc Med 92 (10): 511–5. PMC 1297390. PMID 10692902. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=1297390. 
5. ^ ^{a b} David H. Newman. Hippocrates' Shadow. Scribner (2008). p. 134–159. ISBN 1-4165-5153-0. 
6. ^ Beecher HK (July 1961). "Surgery as placebo. A quantitative study of bias". JAMA 176: 1102–7. PMID 13688614. 
7. ^ Axtens, Michael (1998-08-08). "Letters to editor: Mind Games". New Scientist. http://www.newscientist.com/article/mg15921467.300-mind-games.html. 
8. ^ E.g. see Gulf War Veteran Gets Placebos Instead Of Real Medicine or BehindTheMedspeak: Obecalp.
9. ^ Hoffman GA, Harrington A, Fields HL (2005). "Pain and the placebo: what we have learned". Perspect. Biol. Med. 48 (2): 248–65. doi:10.1353/pbm.2005.0054. PMID 15834197. http://muse.jhu.edu/cgi-bin/resolve_openurl.cgi?issn=0031-5982&volume=48&issue=2&spage=248&aulast=Hoffman. 

See also

• History of medicine