A blast from the BNF’s past

Rags Methanol dips into the contents of the British National Formulary from 1971

“I’ve got something for you,” garbled one of the regulars the other week. “You’ll like it!” With apprehension, I ventured from the dispensary. To my surprise, an intact copy of the 1971 BNF was thrust into my hands. A weekend-long loan was agreed, and I found that much has changed over the past 40 years.

Let me start with the general prescribing information in the front of the book. Prescribers are offered general advice for when the old folk come a-knocking. Under a section subtitled “the patient’s mentality”, is the following excerpt: “Most elderly patients have poor memories and get confused. They may live alone, or with a partner who is no better. They find it difficult to follow even simple instructions, and the complicated schedules sometimes offered . . . are quite beyond them.” In today’s politically oversensitive society, I doubt that such an ageist statement would make the final edit of a respected medical reference.

The political incorrectness continues in the nutrition section. After proudly stating that the “normal” UK diet in the 1970s provided British citizens with adequate vitamins (presumably before we became addicted to burgers), the book accepted that this might not be true for alcoholics, food faddists, psychotics, mental defectives and impoverished solitary old people.

In addition, apparently, starvation is “much less likely” to cause vitamin deficiencies than an “ill-balanced diet of adequate calorie value”. I look forward to reading the scientific studies that prove that no vitamins are better than some.

Questionable logic also reigned supreme in the rheumatic diseases section. Gold salts were hailed as “useful” during the active stage of rheumatoid arthritis. However, the text then goes on to state that they “produce no immediate therapeutic effect but may lead to a decrease in disease activity if given for several months”. Great news for those with joint pain.

The effect of renal insufficiency is an important consideration these days. Experienced renal specialist pharmacists are ten-a-penny in secondary care, as are copies of the Renal Drug Handbook. Back in ’71, however, the kidney was a much simpler organ. As such, the BNF needed only to offer the following advice: “Blood urea is a useful guide to the ability of the kidneys to excrete drugs. When the blood urea is 60mg per 100ml, the dose of drug should be halved. When it is 120mg per 100ml, the dose should be reduced to one quarter.” Simples! In those days, the concept of a renal specialist was someone who could divide by 2 or 4 without a calculator.

Other bizarre practices were noted from 40 years ago. For example:

• Aspirin 10g (yes, grams!) daily was used to treat patients with rheumatic fever (and iron stomachs, I hope)
• The dose of propranolol could vary between 20mg and 1,000mg daily
• Bendrofluazide 10mg daily was used for heart failure
• Pholcodeine had “no obvious advantage over codeine” as a cough suppressant
• A 50/50 mix of industrial methylated spirits and water (so-called “Spirit ear drops”) was a topical treatment for chronic ear infections

Finally, I have often wondered what information the GPs of yesteryear were given about benzodiazepines that led so many old dears to end up being hooked on the stuff. Well, BNF 1971 offers an insight. While barbiturates top the list of potential hypnotics, the book adds: “Patients should be warned not to place their supply of barbiturate tablets at the bedside because of the danger of automatism, in which, without being fully aware of what they are doing, they may take several further doses during the night with resultant poisoning.” On the other hand: “Nitrazepam is rapid in onset, its effect lasts about eight hours and the patient wakens fresh.” With this advice ringing in your ears, which would you choose?

Who knows how the BNF will look in 2052. Perhaps future citizens will mock our primitive paper copy? Perhaps they will chuckle heartily at our continued use of rat poison or baulk at our widespread use of steroids? Only time will tell.

In the meantime, I shall put BNF 63 into the loft and dig it out when I start drawing my pension.