THE PRINCIPLES OF THERAPEUTICS

PART I

THE ART OF WRITING PRESCRIPTIONS

INTRODUCTION

Until recent years therapy was the most studied branch of medicine. It was first surrounded by mysticism of all kinds, but embodied, even in earlier times, management as well as the actual giving of drugs. All good results, however, were accredited to the ingested or applied remedy, and, like the "lack of sufficient faith" plea of the Christian Scientists for their unsuccessful cases, failure to cure in these times was ascribed to the special devil or special devilishness of the disease. After this period of amulets, talismans, and elaborate mixtures of almost everything available, and the wonderful panaceas and cures by all kinds of mental impression, came the chemical age, then the age of wonderful cures by multitudinous dilutions of nothing, and its wonderful success on the mind, next came Magendie, the Nestor of physiologic investigation of drugs, and finally more scientific medication.

Rational therapy is the hardest of the practical subjects to master, and it is safe to say that the young physician, even after a hospital course, is less prepared in the bedside management and the office treatment of disease than in any other branch of medicine. In hospital and dispensary cases the treatment necessarily is much restricted to general routine and to formulary preparations; the patient is not individualized, and other therapeutic measures are not often available, especially in dispensary cases. Students rarely learn in this manner fine individualized scientific therapy for private practice. In the hospital, the diet, bathing, electricity, massage, drugs and preparations are always given and used according to some one

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rule which can not well be varied in these institutions to suit an individual taste or need. Hence the graduate, and even the post-graduate, unless he has especially studied therapy, starts his individual practice of medicine positively handicapped. He has no resources if his first dogmatic treatment has failed or has not been suited to the patient.

Each and every clinician well knows that it is only the consultant who can ignore the treatment of troublesome symptoms. All successful quackeries succeed because of their ability to relieve symptoms or to cause such mental suggestion as will relieve overtaxed minds, and many a loyal patient is driven to employ quackery by scientific neglect.

The physician must carefully study his patients, their symptoms, and the result of his treatment, and especially the results of medication. He must never confound his patient with the disease; it is the patient who has the disease that he is called upon to treat. Hence the therapist must individualize the man, woman or child who comes to him for treatment.

Fred Shattuck, of Boston, once said, "The surgeon's knife is in reality a confession of failure in so far as it is used for the relief of pathological surgery." We should go a step farther and still call it therapy when the physician decides that operative intervention is needed and is advisable. But the internist should not wholly release his patient to the operating surgeon, but should control and manage his pre-operative, post-operative, and convalescent periods with, of course, consultation with the surgeon. Surgeons are often not alert to physiologic disturbances in their operated cases, and hence do not properly manage such disturbances, and many a surgical patient gets well in spite of the post-operative treatment rather than on account of it. Also, the operated patient is often a "case" to the skilled, busy operator; but it is a fact that proper medical care after the operation will very many times prevent long, tedious convalescence, and may even prevent permanent invalidism.

We hear of natural born physicians, of intuitive sense, and of great success in medicine without much medical education, and often without even accurate diagnoses. This is true; a very

scientific practitioner may fail at the bedside, while a man with broad, keen, intuitive sense will succeed. "Common sense" as it has been termed, or slangly "horse sense," is that ability to visualize all the knowledge applicable to the given case and then to note all of the individualities of the patient and to modify the treatment accordingly.

In spite of all diagnostic acumen and diagnostic measures, many a patient gets well without a diagnosis, and some die with negative autopsy findings.

Good therapy is an art. It requires high training, stored knowledge, and good judgment to decide the proper hygiene, diet, exercise, rest, eliminative or antidotal treatment, and the physical measures, drugs, or surgery needed to cure a given patient. It also requires good judgment to decide that a patient needs only psychic treatment. Also, after the diagnosis is made, no two patients can be successfully treated in exactly the same way.

We have not sufficiently studied the various "pathies" and appropriated to our own use the modicum of value which each may possess.

Unfortunately for the determination of what is rational and scientific therapy, we cannot dissociate ourselves from a deeply imbeded belief in mystery in the treatment and cure of disease, hence mankind, and the physician is no exception, is impressed by cures by physical methods and by multiple or secret mixtures, when the cure is really caused by mental impression.

A cure for a great evil to-day would be to compel every mental healer, Christian scientist, osteopath, chiropractor, or pseudopractitioner of any other fraud or cult, to pass an examination in pathology and bacteriology. No one of these people, unless he were a rascal and subject to prosecution for trifling with human life, could study gross and microscopical pathology and bacteriology, and then make grossly absurd statements to their patients and to the public as to the cause and method of cure of disease, or could promise to cure incurable diseases. Also they would not use methods of treatment that either neglect or aggravate a diseased condition.

The old hobby of letting Nature cure the patient has been

ridden too long. Nature is a good mother, but she will do just as much to propagate a pathologic germ as she will do to promote the welfare of the human being infected by that germ. Consequently, neglect will not cure a patient. On the other hand, because a patient has an incurable disease, or has a disease for which there is no specific treatment, is no excuse for neglecting every other discomfort that he may be enduring. Neither should a complaining individual be neglected because we find nothing the matter with him as far as we with our limitations can determine. Such an individual needs mental, moral, or physical aid of some kind.

Besides all sanitary and hygienic advice, providing proper nourishment for the baby, advice for the proper management of the child, and protective vaccinations and serum treatment, there still remains a large field for the proper use of proper drugs, given in a proper manner, not only to prevent the progress of disease, but to improve the physiology, to correct and aid elimination, and to modify the various disturbances to which human flesh is heir.

We have not yet eliminated mystery from medical practice, and still have a belief, unless we very carefully eliminate it, in a multiple mixture, although it may not be a mythical mixture, we may know its contents. It is so easy to believe when we are told that a drug in this particular combination has a particularly pleasant and efficient activity, or that this particular kind of a drug or preparation will not cause the disturbance that the well-known and well-tried basic drug causes.

We rarely need mixtures, whether Pharmacopoeial, National Formulary, or proprietary. Such mixtures may have value, but the active drug of the mixture can generally be given in a very simple manner and the results obtained be perfectly satisfactory, and the treatment be much more scientific.

A part of good therapy consists in the right use of the right preparation of the right drug. This object can only be obtained by a knowledge of the pharmacologic and toxic action of the best drugs, by a knowledge of their best preparations, and by a knowledge of how to administer them in proper doses. Consequently, Part I of this book aims to briefly teach good pre