OCT /\tu/\ T TQTOOTOD U1N 3MDI03W jo *«?aan ivnouvn NLM001001061 ^S- AS*. On the Art of Prescribing. A N INTR OD UC TOR Y A DDRE SS. / By JOHN O'REILLY, M. D. AtmEi REPRINTED FROM THE AMERICAN PRACTITIONER FOR APRIL UX^-iXi-t ■ J^ LOUISVILLE: PRINTED BY JOHN P. MORTON AND COMPANY. 1872. \A/BC 1872- /}/m^-22?Sj r)c.2 ON THE ART OF PRESCRIBING. Gentlemen,—I propose this evening to occupy your atten- tion with the art of prescribing in general, but especially in the diseases of infants. I make special reference to this class of sufferers because I think their maladies do not receive from the profession the attention due them, too many dismissing infantile diseases with the remark "that, as a class, we can do little for them any way." To my mind, on the contrary, they offer the most promising field for the practitioner, and many schools of medicine have lately awarded to the subject a distinct lectureship, recognizing the fact that the treatment of infants requires almost a new semeiology, pathology, and therapeutics. But why, you will ask, do they deserve, as a class, such special attention ? If a statistician, examining the records of crime and its causes, finds that in large cities the predisposing as well as the exciting circumstances of vicious- ness are combined, he would infer that there was the field for the reformer; or if an engineer were seeking a new field for his labors, where he might add to his reputation and increase his knowledge and usefulness, he would go to a country where there are mountain ranges, large rivers, and immense mineral resources. There, his judgment would tell him, they must bridge streams, scale mountains, and build railroads— where nature offers her greatest obstacles to science being 4 On the Art of Prescribing. the point that demands skilled mechanism. The same reasons that send the reformer to cities, and the engineer to points where nature builds her barricades to science, should direct the mind of the physician to the study of infantile medica- tion; for it is infants, as a class, that he will be called oftenest to treat. The examination of medical records shows that it is among them that disease comes oftenest, soonest, and with the greatest intensity, that it is among them that death makes the greatest havoc. But, besides its importance, it is, I think, the most interesting in the whole scope of medicine. It is the study of human nature in its simplest, purest form. No malingering, no hysterics, no feigned diseases do we meet in the infant. Its motions, its sighs, every variation of its feat- ures have a significant meaning, and to interpret them is one of your chief concerns. You must learn to think, to feel, and even to talk for your little patient. Its smiles, its cooings, its prattlings must be as intelligible to you as the alphabet, for they constitute a language in which you must find a definition for its diseases. This study is really a medical pantomime, for all information is communicated by gestures and excla- mations. There are two points in the general medication of children to which I wish especially to call your attention. One is the subject of thirst, the other is the intervals at which medicine should be given. In quite a number of infantile diseases the stomach is very capricious, and to keep it quiet is one of our greatest troubles. This difficulty is often caused by the attendant not under- standing the difference between hunger and thirst. The sick child is fretful, and cries and pulls at its mother's breast; and she, willing to do anything that soothes it, permits it to nurse. It sucks, and in a few moments rejects the milk; but cries again, and the mother again yields it the breast only to have the stomach again reject its contents, and thus the fight goes on until the infant is exhausted. The doctor gives medicine On the Art of Prescribing. 5 to quiet the irritable stomach, and the mother counteracts its effect by overfeeding. What I wish to express is the fact that the child is not hungry; it does not want the breast; but is thirsty and wants drink. In health the breast is food and drink, but in disease the craving is that of thirst, not of hunger, and the stomach which rejects the milk because it is unable to digest it would be calmed by a cool beverage. In other words, were water given to the child in place of the breast, the stomach would be relieved, and in many cases the child saved. This difference between thirst and hunger in the in- fant is a point well worth noting. Medicine should be given to infants in small but often- repeated doses. The interval should be only half as long as that for the adult. The reason for this is that the digestive organs of the infant act much more rapidly than those of the adult, and a medicine to have its effect kept up must be sup- plied in accordance with its entrance into and disappearance from the system. Comparing the works on medicine of the present day with those of the last generation, no one can deny that the art of prescribing at this time is on a better footing than it was fifty years ago. But if medicine has improved in every direction, it does not follow that the practice of our forefathers was inefficient or hurtful. No doubt in former times some patients were bled too much, some even were bled who would have been better without it; but, on the other hand, who will deny that to-day many are physicked too much, and that many take medicine who would get along without it? I will venture the statement that our predecessors did no more harm with antimony than we are doing by our abuse of alcohol. In short, we find in practice that a remedy falls into bad repute from abuse; from the character of the hands that use it, and not the character of the remedy itself. If formerly the phy- sician felt lost unless his thumb was on his lancet, are there not many at the present who can see how to diagnose a dis- 6 On the Art of Prescribing. ease only through the speculum, and who have done away with the hobby of hepatic congestion merely to substitute that of uterine irritation? For general purposes, remedies may be divided into two classes: I. Those which are actively medicinal; 2. Placebos. By active remedies I mean those that are used for their effect; by placebos I mean those that are used because they produce no effect. Many diseases need active and energetic measures, when we use the first class; but you will often be called to infants whose complaints exist only in the imaginations of their mothers, or else are such as you can not diagnose. In all such cases as these we use the latter class. Of the active remedies I will now make special mention of but one, and that is opium. Of all the articles in the pharmacopoeia this seems to act most strangely on the infantile organization, and unless you use it with the greatest discretion you will rue it. In fact, so uncertain is its action that I avoid it as a rule. True, it is a common remedy with mothers and nurses, but it is also true that when used by such no one records the bad effects. I have seen one grain of Dover's powder completely narcotize an infant when it was scarcely expected to quiet it. I have seen the twelfth of a grain of opium do the same thing, and a professor of obstetrics in this city once informed me that he was confident he had witnessed a death from that dose. I know this is a common dose with physicians; but since no one can foresee when it may act with such power, we should be cautious in all cases. I would advise you always to administer it in substance, a grain divided into twelve parts. In this way you will be more apt to get the exact proportion in each dose. The best druggist, when mixing it with other articles, may get more in one powder than another. All liquid preparations are of uncertain strength. The second class of remedies is a favorite one in general practice as well as in the treatment of infants. Placebos in the cure of disease are what manners are in acquiring business; On the Art of Prescribing. 7 and as I have known several physicians to make a lucrative practice by the suavity of their manners, I have known others make reputation by prescribing at the right time remedies of this class, letting nature rally after the patient had been medicated almost to death by persistent medicine - giving doctors. After all, the science of prescribing for adults as well as infants, but especially the latter, consists largely in knowing when not to give medicine. Be always on your guard, and never dose a child when it can get along without it. A dose or two sometimes may not affect the adult injuriously, but every grain too much is detrimental to the infant. Another rule to be observed is "to let well enough alone." Do not unnecessarily change your prescription at every visit. Remember the saying of Lord Bacon, that a multiplicity of remedies for the same disease is a mark of ignorance. Never change your prescription as long as your patient is improving under it, nor strive to force nature to do better by trying something else. Never give a dose of medicine without con- sidering well its action, nor give anything unless you wish to accomplish a certain definite effect by it. Do not acquire the habit fallen into by so many of giving drugs at random. For instance, when you learn that opium, tannin, lead, etc., are astringents, and sometimes beneficial in diarrhea,- do not, when you are called to a child with this complaint, give the first of the above articles that chances to enter your mind, from the simple fact that you have seen it recommended. Consider well the condition of the particular case before you, and its causes, and then select that remedy which is especially indicated, and you will frequently find that the best astringent in diarrhea is an aperient. In prescribing be not always on the lookout for something new. Seek not to be fashionable prescribers, by which I mean prescribing the latest remedies. Avoid likewise a routine practice; that is, having set prescriptions for every disease. 8 On the Art of Prescribing. Do not conclude that because a certain medicine appears to do well in a few cases you may throw it into the stomach of every patient who presents anything like the same assem- blage of symptoms. Remember that the same disease in different constitutions requires different medication. And above all steer clear of the great error of treating diseases by their names; of diagnosing a disease and then treating it by its title. Let your views of treatment always be based upon general principles. Take physiology and pathology for your groundwork, and predicate your special medication on the symptoms most prominent. On thTArt of Prescribing. AN INTRODUCTORY A DDR/CSS. J * By JOHN O'REILLY, M. D. REPRINTED FROM THE AMERICAN PRACTITIONER FOR APRIL LOUISVILLE: PRINTED BY JOHN P. MORTON AND COMPANY. 1872. The American Practitioner. EDITED BY DAVID W. YANDELL, M. D. Professor of Clinical Surgery in the University of Louisville AND THEOPHILUS PARVIN, M. D. Professor of the Medical and Surgical Diseases of Women in the University of Louisville. PUBLISHED MONTHLY. TERMS $3.00 A YEAR. A journal which stands in the very front rank. We take pleasure in com- mending it to our brethren of the West as an honor to their section of the country, and physicians of the East would do well to have it come monthly to their office tables. It is in every sense of the word a credit to American med- ical journalism.—Journal of Psychological Medicine. The editorial labor which has been expended on this journal during the year has given the work a standard value, and rendered it one of the most attractive and readable journals now published in this country. The plan of the journal is to give especial prominence to therapeutical studies and applications, thus making it directly contributory to the practical every-day work of the physician. It is a journal which is creditable to the medical literature of the country.—New York Medical Journal. One of the best and most practical medical periodicals in this Country.— Chicago Medical Examiner. "A noble journal, and the very thing needed by the busy doctor. "—Prof. G. C. Blackman, M. D. " It comes under the most favorable editorial auspices, and under such man- agement must take rank among the best of the medical monthlies."—The Phar- macist. " Of all our exchanges, it is the freshest."—Nashville Medical Journal. JOHN P. MORTON & CO., Publishers, LOUISVILLE, KY. ■**> •4.. A NATIONAL LIBRARY OF MEDICINE NLM GDlOOlOt. 1 OH NLM001001061