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July 6th, 1886.
The above is given as an example of an ordinary compound prescription, but as the result is nearly identical with an official preparation, we might write the prescription simply as follows:
B. Infusi Senna Compos., 3viij.
and this is the manner of prescribing the official compound preparations. It will be noticed that the term "basis" in the analysis of the formula covers two ingredients; but either of the two might be considered the principal agent, and the other one classed as an adjuvant.
As Pareira says, "These four parts of a formula are intended to accomplish the object of Asclepiades, curare cito, tute et jucunde; in other words to enable the basis to cure quickly, safely, and pleasantly.
The Principles of Combination are so well laid down by Dr. H. C. Wood, that his words are appended. verbatim, as follows:
The art of combining medicines is not a difficult one; but in practice certain principles should not be lost sight of. Chief of these are, to prescribe as few remedies as possible, and to use no powerful drug without a very distinct idea of what it is intended to do. Whenever it is desired to give a powerful remedy in increasing doses until its physiological effect is produced, it should always be given by itself. Thus, it may be necessary to give arsenic so as to impress the system, at the same time that iron is indicated; but the two remedies should be given separately, so that the dose of either can be increased or dimin. ished independently of the other.
The principles of combination formulated below were long ago enunciated by Dr. Paris, but are to-day as imperative as ever. Medicines are combined
First. To augment, correct, or modify the action of a medicine. Thus, purgatives act much more kindly when a number of them are united together. The chief reason of this probably is, that as different remedies affect different portions of the gut, the whole intestine is best reached by a union of the diverse substances. It may take an intense irritation of the mucous membrane to purge as actively as does a mild irritation of both the mucous membrane and the muscular coat. In the case of neurotics the principle has a very limited action, because so many of this class of remedies are physiologically more or less antagonistic; yet sometimes the principle can be advantageously applied; thus, the anesthesia of Chloroform or Ether may be prolonged by a hypodermic injection of Morphia; and Chloral and Morphia certainly make a mixture which is much more powerfully hypnotic than is either of the substances separately.
Second. To obtain the joint action of two or more diverse remedies. Thus, in a cough mixture Morphia may be included to quiet the cough, whilst Ipecacuanha and Squill (in accordance with the first principle) are added to affect the mucous membrane. The application of this principle requires caution, or the practitioner will be led into that chief abomination-polypharmacy. It is worse than futile to attempt to prescribe for every symptom. It is the underlying cause of the disorder or the under-stratum of bodily condition which must be sought out and prescribed for simply.
Third. To obtain a special combination, which is really a new remedy, or which expe
rience has shown acts almost as a new remedy. Thus, when to Iodide of Potassium in solution Corrosive Sublimate is added, a new chemical compound is formed, which experience has shown to be of great value in syphilitic diseases. Griffith's antihectic mixture is another instance of the use of chemical changes, the Proto-carbonate of Iron being formed out of the Sulphate of the metal and the Carbonate of Potassium. In the famous Dover's powder no chemical change occurs, but the ordinary action of Opium upon the skin is so enhanced that the combination may be looked upon almost as a new remedy.
Fourth. To afford a suitable form. Thus, Acacia is added to make an emulsion, or Confection of Rose to make a pill. In the choice of excipients care should be exercised to select a substance free from medical properties, having no chemical incompatibility with the medicinal agent, and of suitable physical character. Bread crumbs often make a good basis for pills; but with Nitrate of Silver they are chemically incompatible, on account of the chlorides in them. When writing a prescription, the utmost care should be taken to use such excipients that the combination should not only be attractive to the eye, but also as little repulsive to the palate as may be. Whenever possible, the pill-form should be employed with bitter or disagreeable medicines. The pill may be readily coated with silver-foil; tonic pills may be coated with Iron by shaking or rolling them in Ferri Pulvis whilst soft and sticky. Sugar-coated pills and "compressed pills" are apt to get so hard and insoluble that their use requires caution. In regard to mixtures, flavoring oils should be freely used, and the power of Glycerin to conceal the disagreeable taste of many substances should be remembered.
In Writing an Extemporaneous Prescription, the first step is to put down the superscription, consisting of the name, date, and the sign B. Next the name of each ingredient should be written in Latin and in the genitive case, each one on a separate line. Then the quantity of each article sufficient for one dose should be mentally determined and multiplied by the number of doses which the mixture is to contain, and the result set down in signs and Roman numerals. The directions to pharmacist and to patient being added, and the prescriber's name or initials affixed, the prescription is completed; but when very active agents are used, it is a good plan to go over the calculations a second time before letting it leave the hands of the person most responsible for its action. For pills or powders the same process should be employed, slightly varied according to the requirements of each case. Frequently the ingredients and quantities for but one pill, powder or suppository are named, with instructions to make a certain number after the formula. When an unusually large dose of any poisonous drug is prescribed, it is customary to underline the quantity, so as to call the attention of the compounder to the fact that the prescriber is aware that the dose is above the average.
There is no royal road to prescription-writing; practice, care and knowledge of the whole subject is necessary to enable one to turn out habitually those elegant prescriptions which are properly termed "magistral," being the work of a magister, or master of his business. A fair knowledge of the Latin language is a sine qua non to every professional man, but especially to the physician. It is pitiable to see a Doctor write. ignorantly of even the genitive case-endings of the drug-names which he The teaching of Latin is not within the scope of this work, and
hence this part of the subject will be dismissed with the advice to the physician who is ignorant of that language to write his prescriptions wholly in English if he cannot write them in decent Latin.
Abbreviations, though very commonly used by physicians in prescribing, are a source of much annoyance to the compounder, and frequently one of great danger to the patient. Physicians who never knew anything of the Latin grammar, or those who have forgotten its rules, are very apt to use abbreviations to conceal their ignorance of case-endings. Many others use them through sheer laziness, and some from force of habit. The educated and conscientious man will take pride in turning out a full and clear prescription, free from cabalistic letters and all elements of uncertainty. In the Appendix will be found a list of the Latin terms used in prescriptions, with the abbreviations in vogue, and the English meaning. Ambiguous contractions may result fatally to the patient, as is readily seen by studying the following list, which gives a few examples of the dangers of careless abbreviation:
Prescription Blanks. After many years' experience in prescribing on blanks furnished by druggists, the writer has come to the conclusion that it is much better, for many reasons, for the physician to have his own blanks, without the address of any drug-store thereon. These blanks should be furnished with stubs on which to write the prescription at first in rough, afterwards copying it out cleanly on the main blank. A careful prescriber always writes a formula twice before letting it go out of his hands. If he does the first writing on the stub of a book of blanks he will always have a copy of such prescription in his possession, for which he will often be thankful. The blank used by the writer measures 44 inches by 34, joined by a perforated edge to a stub 34 inches by 21⁄2 inches. On the main blank the physician's name and address are printed, together with his office hours, and a place for number and date, also the sign B., and a line for signature. On the stub there are printed the
. 189. . For ..
words, "Copy of Prescription No.. and on the back of the main blank occurs the following printed legend in red ink:
A PRESCRIPTION WRITTEN ON THIS SIDE
These blanks are bound up in books of 100 each, with a flexible morocco cover, from which the book of stubs may be slipped and a fresh book inserted as required. The size is ample for all ordinary requirements, and permits of the book being carried in the breast-pocket.
Renewals. It would be advisable for physicians to always write the words "Non Repetatur," or some similar direction, on all prescriptions which should not be repeated without their sanction. By so doing they would doubtless cut off a good many renewal charges from the receipts. of druggists who would fear the legal consequences of disobeying the mandate. This inconvenience to the drug-seller would be more than compensated for in the protection to the drug-taker, who too frequently carries in his pocket-book a stock of recipes for his various complaints; and in protection to the physician, who by giving up the dispensing of his own medicines has placed it in the power of the druggist to connive at a direct robbery of the just reward of professional skill and knowledge.
It is doubtless a fact familiar to every observer, that the old-time confidential relations between the professions of physician and pharmacist have almost passed into oblivion. In fact, the tendency of pharmacy now-a-days is towards the position of a mere money-making trade, instead of in the exalted direction of a profession. The indiscriminate renewing of prescriptions, the open sale of quack nostrums and homoeopathic pellets, the readiness with which counter-prescribing is indulged in, the insinuations too frequently made over the drug-counter in reflection on physicians, and many other similar practices, have caused the noncombatant profession to regard the average druggist with suspicion. If physicians boldly took the dispensing of medicines more into their own hands many of these evils would soon eliminate themselves from the drugstores. Right here, it may be said that there is nothing unprofessional or derogatory in the dispensing of his own medicines by the physician. In England it has been the universal practice for centuries in all places except the largest cities, and it has only been given up by a part of the medical profession as a matter of convenience, not as a right. The homœopaths fought for the reclamation of this practice as a right belonging to the medical profession, and succeeded in its legal establishment, but not from a worthy motive. They dispense their own medicines in order to
cover up the many frauds of which they are daily guilty, and to give them the power of administering full doses of powerful drugs in a form which is apparently "homoeopathic," with no tell-tale prescription on file in a drug-store to give mute but dangerous evidence against their honesty. In this way they administer several grains of Calomel or eighth-grain doses of Morphine, or correspondingly large quantities of active alkaloids, triturated with sugar of milk, or dissolved, as many of the latter may be, in alcohol. Chemistry, by isolating the active principles of plants, and furnishing them to commerce in the form of soluble salts, has enabled the homœopath to practice this fraudulent method of dispensing drugs, which the innocent and ignorant patient, who believes in the power of the minimum dose, supposes to be infinitesimal in amount. But the physician of the regular profession is too apt to think that if he adopts a practice which charlatans have appropriated to themselves, he may be classed with them by his professional competitors. Hence, many regular physicians are absolutely afraid to use such drugs as Aconite, Belladonna, Gelsemium, Arnica, Rhus, etc., all of which are official, and most of which are older than homœopathy in medicine; and avoid pocket-cases, drachm-vials and triturations, as badges of charlatanism. It is high time that we asserted our independence in all these matters, and made use freely of those means which are recommended by our individual judgments as promotive of the best results to our patients and to ourselves. With a small stock of reliable fluid extracts, such as are manufactured by Parke, Davis & Co., of Detroit, or Dr. Edward R. Squibb, of Brooklyn,—an equally moderate supply of gelatin-coated pills and compressed tablets from the best houses, such as McKesson & Robbins, Schieffelin & Co., Warner & Co., Wyeth & Co., physicians could check-mate the unscrupulous practices of many druggists to a great extent, save their patients many dollars, and retain many a dollar for their own pockets, which under the present system goes to their enemies. The homoeopaths understand the money part of the argument well. When their patients' medicine is exhausted, the doctor must be seen for a fresh supply, meaning of course another consultation about symptoms, a change perhaps from Mercurius Dulcis to Mercurius Vivus, and another fee. The expense is nothing, sugar of milk being cheap, and there is no prescription in the patient's pocketbook, to be renewed scores of times (paying toll however every time to the druggist), and finally to be copied by aunts, mothers and friends, as a sovereign remedy for a cough, or a really wonderful receipt in a case of croup.
Filling a Prescription means a combination of operations which requires great care, undivided attention, and a special practical apprenticeship at the dispensing desk. In the following discussion of extempo