The Era Prize Essay.—Reprint from the Pharmaceutical Era.
Originally every physician was his own apothecary, and at the present
time probably a majority of medical practitioners dispense their own
medicines, very rarely writing a prescription. These will have but a
languid interest in the subject of this essay, which deeply concerns all
physicians who are not their own apothecaries, and all compounding
pharmacists.
In medical, as in every other science, the increase of knowledge so
widened the field that it became impossible for one mind to grasp all
the facts, and a division of labor took place, the part of the work
which related to the collection, preservation and dispensing of drugs
being assigned to a class of men who had displayed peculiar aptitude for
that branch. Thus was constituted as a distinct occupation, the
specialty of the apothecary, which, beginning as a department of medical
science, is inherently honorable, and has been so developed that it
gives scope for a lifetime of fascinating research, elevating study, and
profitable endeavor, independently of any proper work of the modern
physician. The two callings are, for the purposes of this discussion, as
in their best actual operation, practically distinct; and yet they are
not independent, but interdependent. The greater part of the physician’s
labor would be vainly spent, were it not supplemented by the service of
the pharmacist; the latter’s business would cease to have a reason for
existence but for the vocation of the former.
In this paper it will be taken for granted that the physician is well
educated and experienced in his profession, that the apothecary knows
his business thoroughly, and that both are actuated by high moral
purposes. The grievance of neither, therefore, will result from the
intentional wrong-doing of the other, but from his thoughtlessness or
conservative adherence to long-established custom. The honesty of each
being presupposed, such a charge as the substitution of an inferior
article for some ingredient in a prescription, or the false insinuation
that a mistake in the medicine is due to the compounder’s carelessness
need not be raised. Let us consider the grievances of each against the
other.
The physician complains that the apothecary exceeds his function by
prescribing for the sick. A person applies to the pharmacist for a
remedy for a specified disease. The latter consults the dispensatory,
finds a number of medicines mentioned in the therapeutical index under
the name of that malady, selects one, and sells the article to the
patient. He regards the protest of the doctor merely as the wail of one
who is disappointed at not getting a fee for prescribing. The physician
has a right to complain of those who prescribe for any but the indigent
without a professional fee, for this makes it vastly harder for him to
collect the charges to which he is entitled; but he has higher ground
than this. With him the first step in every case of disease is
diagnosis, without which prescribing is simply drawing a bow at a
venture, with small probability of penetrating a joint of the harness;
and he insists that neither the apothecary nor the patient is qualified
to make a diagnosis. The determination of the character of a disease is
not a simple matter, often baffling the profoundest learning and the
broadest experience, and, in most cases, requiring special knowledge and
discriminating judgment. The most obtrusive symptoms are by no means
necessarily the most characteristic; a given symptom may be the
accompaniment of different diseases, and sometimes attends pathological
changes of diametrically opposite nature. But one who is uninstructed in
this branch has nothing but symptoms to guide him, and therefore
frequently, if not commonly, is led into error, which may produce the
gravest results. The educated physician is the only person who is
equipped to solve the problems of disease; and it is, in the long run,
cheapest, even from the financial point of view, for one who is ill to
obtain competent medical advice. Therefore, considering merely the
welfare of the patient, the physician deplores the custom of
counter-prescribing.
The universal practice among apothecaries of refilling prescriptions
indefinitely, without the sanction of those who wrote them is frequently
the subject of adverse criticism by physicians. “But,” says the
pharmacist, “is not the prescription mine?” Probably the reply will be
affirmative, though this is a question not entirely settled in the minds
of those concerned. Granting, however, for the sake of the argument,
that the apothecary is the rightful owner of the prescription, he
triumphantly asks, “May not one do as he chooses with his own?” Not
always, by any means, unless he elects to use his property in a way
which will not imperil the welfare of others. The law puts many
restrictions on the natural rights of ownership, for the purpose of
shielding society from the ignorance, the malice, and the cupidity of
proprietors. In the matter of prescriptions there are no such
limitations; but in this, as in so many other affairs, we should be
controlled not merely by considerations concerning our legal rights. The
unwritten, but greater, law regards the question from a higher plane;
and from this point of view one sees that there are moral reasons which
should restrain the apothecary in these premises. Let us look at
prescription-refilling in its remote as well as its immediate bearings.
The physician writes his prescription for one occasion and for one only.
He designs it to fulfil the indications in a particular case at a given
visit. It is often in the highest degree improbable that the conditions
of the case will remain the same for a given length of time; and, when
they change materially, another prescription is needed to satisfy the
altered requirements. Of these things many patients and apparently, all
apothecaries are accustomed to take no note; and, therefore, the
prescription is refilled for the same person on many occasions, when
something very different ought to be furnished, the expected improvement
does not occur, and the physician is blamed for the failure. The
prescription, intended for the treatment of a certain condition afforded
relief and changed the state of affairs. Thereupon, further advice
should have been sought by the patient, his physical condition
investigated anew, and another recipe given by the physician, if he
deemed it desirable. To hold the doctor responsible for the ill effect
or lack of effect of his prescription in circumstances unlike those for
which it was designed is obviously unjust. Yet this is done habitually,
both in the case just supposed and in those other instances, quite as
common, in which the recipe is compounded, not for whom it was written,
but for some other person, who supposes (on what slender evidence it is
appalling to contemplate), that his ailment is identical with that of
the original patient. The refilling really amounts to the apothecary’s
abetting the patient in self-treatment. There is a trite remark to the
effect that he who undertakes to be his own lawyer is sure of a fool for
a client. In legal actions the matters at stake mostly relate to
property; in medical affairs, health and life are involved. Can anything
better be said of the wisdom of him who, without adequate training,
undertakes to settle questions in which his very existence is concerned,
than of the sagacity of the man who, with no competent knowledge of law
and the methods of the courts, presumes to manage a case in which merely
a sum of money may be lost?
But undesirable as is the custom of pharmacists in this respect, it is
unreasonable in physicians to grumble at it, until they reform a habit
of their own, which encourages the practice which they deprecate. When a
physician finds a sick man improving with a certain plan of treatment,
and wishes the same medication continued, usually he simply tells the
patient to have his bottle refilled at the apothecary’s. The latter,
knowing that this is the usage of the medical profession, is accustomed
to suppose—constructively, at least—that, when the bottle is returned to
be replenished, it is brought at the desire of the doctor; and he again
compounds the medicine, as he would not be justified in doing, if the
method of physicians was different. If the latter would habitually
rewrite their prescriptions, or indite orders for repetition, whenever
they wish a continuance of treatment, apothecaries would have the best
possible sanction for supplying medicines to patients a second or a
thousandth time, and would have no moral warrant for such action without
the written direction of the authors of the recipes. When the doctors
adopt the plan suggested, a violation of their request that their
prescriptions shall not be repeated without their written order will
furnish abundant ground for complaint; until such change of method is
established, the consistency of their protest does not conspicuously
appear. By the practice proposed, the apothecaries would lose some
business, indeed, but the community would experience an immeasurable
gain.
The sale of so-called patent medicines by pharmacists is a continual
irritant to doctors. Their objections have the same basis as in the
preceding case, namely, that apothecaries ought not to encourage the
people to prescribe for themselves. A distinguished physician once said
that drugs do more harm than good—a statement which will not be disputed
by those most conversant with the facts. But this is no argument against
the employment of medicinal remedies in any proper way. Drugs taken by
advice of educated, competent physicians do an immense amount of good;
the injury comes almost altogether from their administration
independently of the recommendation of qualified medical men. Concocted,
not to benefit humanity, but to enrich their manufacturers, advertised
as positive cures of diseases which the utmost skill of the medical
profession cannot control, sometimes inert, sometimes dangerous from the
poisons which they contain, pressed upon the attention of the people
with impudent persistence and colossal mendacity, the infamous
compounds, called patent medicines, are purchased by the credulous
public in almost incredible amounts. Nobody knows as well as the
pharmacist what quantities of drugs are sold in this form; nobody knows
as fully as the physician the enormously baneful effects which they
produce. If apothecaries would refuse to handle this class of goods,
they would confer a wonderful blessing on humanity, by demonstrating
their belief in the injuriousness of these articles, and thus bringing
them into disrepute; and they would vastly dignify their profession by
displaying its sense of moral obligation, even at the sacrifice of a
lucrative part of its business.
Apothecaries complain that, to meet the demands of prescriptions, they
are obliged, at great expense, to keep in stock a large number of
whimsical preparations, and also many brands of the same standard
medicines, when really one is practically as eligible as another. There
is force in this complaint. As a rule, the former class of preparations
has but an ephemeral popularity, and, as for the latter, there cannot
often be need of specifying the goods of a particular manufacturer; for
a worldly-wise, not to say honorable, pharmacist certainly may be
trusted to furnish only fine articles, that he may keep the favor of
those upon whose good-will his legitimate business depends. If a special
brand is deemed necessary by the doctor, he can request a convenient
apothecary to procure a quantity, and then can send to his shop the
patients who require this article. Thoughtful consideration of this
grievance will dictate some such course and effect its redress.
Occasionally, in places where apothecaries are accessible, physicians
furnish their patients with medicines. This the pharmacist rightly
regards with disfavor, as diminishing his legitimate business. The truly
wise physician shuns this practice, perceiving that he cannot be as
competent a pharmacist as is one who is nothing else, and furthermore,
preferring to avoid the suspicion of administering medicines
unnecessarily for the purpose of making a profit on them. Enlightened
selfishness prompts him to encourage scientific pharmacy as a specialty.