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ticular agent used in the management of this case ? To this question I can possibly write the answer, "No," using a capital "N.”
If not I, who then? Was it a brother physician? No. Was it some close friend of the patient who had recently recovered from a like disease? No. No, it was the manufacturing chemist who did the prescribing. It was he who designated the compound, as he thought, suited to this patient's case; it was he who knew exactly how big the dose should be and just how often it should be administered, and it was he who drew the largest portion of the net recompense for getting the poor fellow to the end, and it would be difficult often to tell which end he would arrive at first.
To prove the truthfulness of this last statement, I need only to refer you to the rapid increase in the number of manufacturing establishments and physicians' supply houses, and refer you to the fact that not one of them has ever become bankrupt or had to go into the hands of a receiver. If such conditions continue, soon every town of 5000 inhabitants with its half dozen or more of doctors will have a supply house and it do well.
We are letting the manufacturing chemist say just what remedies we may, can or must use. It is he who makes known to us the physiological action of his compounds, not remedies, and suggests their therapeutic applications, and it is he who has taken from our hands the whole rein of practice and makes his regular monthly calls to see-his patients? No; to collect his bills for supplies for the previous month, and we pay them, it we are able.
Admitting, for the sake of argument, that we have been duped, let us look intc the contents of a few of the many compounds we are daily prescribing and dispensing, and see if we are play
ing the part of scientific medication when we prescribe or dispense many of these preparations.
Of the many compounds now on the market, let us take for the first for our consideration one of a number of samples left on my desk by a promoter of the interests of one of these supply houses. One hands it to us as SawPalmetto Compound; another has it marked Trimetto Compound; another Palmo-Santal Compound, and I pect soon some one will come around with the same thing, calling it SantoPalmel Compound. And when we examine into the formula we find them ail to claim them to contain about the same things in nearly the same proportions, viz., saw palmetto, corn silk, couch grass and santal. Do they stop at this? No; they all continue about in the same line, possibly arranging their phraseology a littie differently, but all virtually saying: "It is indicated in chronic disorders of the genito-urinary tract, enlarged prostate, cystitis, troublesome micturitions, incontinence of urine, and relaxed conditions generally;" and I am really surprised that they do not add, "Good for leucorrhea and rhinosis," in order that they might increase their sales.
Is this all they say? No; they adą, “Dose, one or two teaspoonfuls three times a day."
Is it not surprising how those fellows can tell that our patient needs all these remedies in this exact proportion? Is it not surprising that they know without seeing or examing the patient that he needs it in one or two teaspoonful doses three times a day? But is it not more surprising that we as trusted men, the exponents of scientific medicine, will allow Ourselves to be led off after that which we can never hope to obtain--a compound that will cure everything they claim for it?
Let us dissect this compound a lit
tle further. How many of the mem- There are a number of other combers of this compound are U. S. P. pounds I would like to take up, such remedies ? At the present time but as Viburnum Comp., sold also as Aletris two are recognized as being of any Cordial, Hellonicas Cordial, Vio-Vitrue medicinal value, viz., couch grass
burnum mp., etc., and many others and santal. Are we standing on safe equally as irrational and incompatible, footing when prescribe beyond but time will not permit me, and these these?
will serve to show where we are driftLet us look at this still in another ing. way. Do we know the physiological
When we continue to prescribe these and therapeutical action of each of
proprietary compounds, is it any wonthese drugs taken separately? If not,
der that the laity laughingly throw could we know what it would be if
the taunt of "quack" at us? Is it any taken together, and might there not
wonder we have so many self-constibe some conditions present where one tuted doctors in the persons of drugmember of the compound is indicated
gists, when we are telling them just and another contra-indicated ?
what we are prescribing these comLet us examine into another com- pounds for? There is nothing to prepound in tablet or pill form, now on vent the druggist from becoming even the market, and used extensively by more acquainted with the action and physicians, but I hope not by any uses claimed for these different measmember of the Academy of Medicine.
ures, for every container bears its It is sold under the name of "Heart printed label, telling just what the Tonic and Stimulant, or Nitro-Glycer- agents are intended for and the dose iue Compound," and contains digitalis, and manner of administering. We can strophanthus, nitro-glycerine and bel- not censure them for attempting to ladonna, and when we examine into make a diagnosis occasionally when the physiological actions of the differ- there is fair prospects for the sale of ent component parts what do we find? a dollar's worth of the stuff. In it we have two agents that quicken There is still another bad feature the pulse rate and two that slow it. that needs mentioning, and that is, We have three agents that produce we are fast losing sight of the true an accelerated blood pressure and one value of officinal remedies-remedies that lowers. We have two agents that that have been tested and tried and contract the arterioles and two that
found to possess therapeutic value. dilate.
We have spent hours, yea months, of What can we expect when prescrib- hard study while in school preparing ing such combinations? Would it not for final examination, and as we then make a better showing if our patient thought, to prepare us to follow our had a weak, rapid pulse, with but lit- chosen profession, and now, just as tle pressure, to prescribe digitalis or we are entering upon our career of strophanthus, or possibly the two in practice, we allow the manufacturing combination, since their action is so chemist to come in and make us beDearly identical and there being no lieve we have wasted much valuable physiological incompatibility, or if our time in learning that which is of but patient had a slow, weak pulse, would little or no value to us, and that they it not be better improved by the ad- are prepared to furnish us with every ministration of a dose of belladona, remedy we need in the most attractive or nitro-glycerine, instead of the com- form and combination. pound.
Prescribing and prescription-writing
or compounding medicine, if we choose to dispense our own remedies, is fast becoming a lost art with the medical profession of today, and why? Is it because of the deplorable lack of therapeutic knowledge on the part of the physician? I may answer this question either by yes or no. Yes; if we have allowed the manufacturing chemist to do much of our prescribing, we certainly have forgotten a good portion of our therapeutic knowledge, and "No" when we are led to use proprietary remedies under the erroneous idea of accuracy of dose and purity (?) of drugs, as vouched for by the agent.
The manufacturing chemists are not slow to comprehend our weak points, and they come to our rescue with just the things they consider we need-not because of their brotherly love for the physician; not because of their tender loving mercies extending out to all suffering humanity, but because they see in it an opportunity to enhance their own fortunes. Now what are we to do?
Will we continue to sink deeper and deeper into the nets and finally give up the fight, handing the entire scientific part over to the manufacturing chemist, and we assume the role of hucksters and pill
distributors? It is supposed we have just stepped out of the age of empiricism in medicine and are now getting firmly implanted upon the foundation of science, but if there is any science in this shotgun prescribing, I fail to catch it.
Now, in conclusion, allow me to say I hope I have not drawn the lines so closely that we are not left with sufficient remedies with which to combat diseases, and hope I have not conveyed the idea that I desire to eliminate the manufacturing chemist entirely. Far from that. The manufacturing chemist has a very important place to fill and we as physicians appreciate their efforts at placing many things in our hands in such convenient form, but it seems as if they have ventured a step too far and desire to relieve us of too much.
What, then, is the remedy? A good rule I have found is to select my own remedies from a knowledge of their physiological actions, and if a compound is desired, designate what it shall be and how it shall be given, and, above all, make it a point not to prescribe any patent or semi-patent medicine.
2646 West Pico.
THE FEAR OF INSANITY AS A CAUSE OF INSANITY.
HENRY WALDO COE, M. D., PORTLAND, OREGON, MEDICAL DIRECTOR MT. NERVOUS SANATORIUM; CONSULTING ALIENIST OREGON STATE INSANE ASYLUM ; NEUROLOGIST MULTNOMAH
COUNTY HOSPITAL, ETC.
Case No. 1-A gentleman aged 54, of puwerful physique, with all the vital organs, outside of the nervous system, in normal condition, of good past and present habits. came under mv care for what he called “extreme nervousness." Although a searching examination was made, the cause of this
man's distress did not appear, although he seemed to be suffering mental agong of a degree to almost induce a diagnosis of melancholia with some masked delusion. The patient had none of the stigmata of the defective, and his family and business affairs were, so far as I could judgc, of a
satisfactory character. His father and mother were still living and in the enjoyment of good health for people of their age, and several brothers and sisters
reported in excellent health. One brother had died of some ailment of which I could learn nothing.
One week after first meeting this patient, his wife wrote me that the brother had died six months before in an insane asylum. The patient was much disturbed when he ascertained that I possessed this knowledge, although he said he had upon several occasions tried to impart it to me, but the nervousness into whicb the subject would throw him, when attempted, had deterred him from the consummation of this purpose and from that can. dor which he knew he should display when talking with his doctor. His family physician knew nothing of this Item in the family history. The situation at once appealed to me as forci. bly demonstrating the etiological factor which auto-suggestion so often plays in insanity, a subject which has upon several occasions been brought to my observation during the past few years.
A closer examination of what now seemed the prime underlying cause of this man's distress demonstrated that he was in that borderland between the sane and the insane, the result of an ever-present terror, which was driving its victim along the road of mental misery into the realm of mental darkness. He had worried much over the subject while his brother was sick, and had finally gone East to see the invalid, who was in his last illness, an inmate of a crowded State asylum. The surroundings and associations made a powerful impression upon his already troubled brain, and the anxiety which he had previously felt now became a belief that "insanity was in the family," and that he was destined to go
the same way that his brother was then going. An influence in this case most detrimental, and from which the patient could not escape, was a disposition to keep within his own breast this fear. Before it was directly charged to him, he had never spoken to anyone about the distressing belief which was slowly destroying his rea son.
Reassuring him as well as could be done and seeking to establish the highest possible degree of confidence in his physician, the full history of the brother's case was sought. From the family physician and the asylum records it was learned that the man had been a drunkard, that he was syphilitic, and to add to these, had received an injury to the head which had left a depression in thą skull well marked up to the time of his death, and that for some years previous he had been subject to epilepsy, dying in seizure.
The sturdy character of the family and the absence of nervous or mentai weakness therein, with the personal history of the patient and the apparent absence of any hereditary influence in the case, permitted me, as it would have done any other physician, to present such proofs upon the subject that there was little trouble in expelling from the patient's mind the needless fear which was the source of all his trouble.
Case No. 2-This patient's grandfather and father had been insane. He had reached the age of 55 with much credit to himself in public life. As a boy he had witnessed the mental unbalancement of his grandfather, who was for two years under his father's care and under his own daily observation. Twenty-two years later he became the care-taker of his own father, who, after a year's illness and in spite of the closest surveillance, succeeded in effecting a suicide. This third patient in this family, when he came under my care, was a marked melancholia, and gave the history of the family, as to insanity, with almost painful detail.
The grandfather had sprung from two large Southern families, in which for two generations, at least, and as far back as could be determined, no other mental disturbances had ever existed. He had eight children, one of these being my patient's father, upon whom had devolved the care of this first mental invalid. During the time of such care and after the death of the grandfather, my pationt's father had worried without ceasing up to the time of his own illness, being constantly harrassed by the dread of a like ending. He had in the meantime raised a family of three sons and four daughters. One of these, my patient, undertook and maintained in his own home the care of his father through his illness and up to the time of his death.
The collapse of his father, the distressing character of the ailment, and the constant repetition from his unfortunate charge of the statements regarding hereditary influences, together with the tragic character of his father's death, started my patient into a condition of mental dread which had grown worse and worse, as his own age approached that at which his grandfather and father had become insane. This age was upon him when he came under my observation. This patient stated that his own case was identical with those of his grandfather and father. If this was true, and it doubtless was, the suffering which he and his father had experienced in the care of the former cases must have been extreme, for it is not one's lot to witness a more difficult case to manage than was his. The psychic influence upon one caring for such a father could not help but be powerful and lasting.
He was under my care for a short time, during which he improved, but slightly, if at all, and I afterwards understood that a general terminal dementia had supervened. This man also had a large family of children, including several gifted young men. Of all the children, grandchildren and great-grandchildren of the first insane individual of the family, there is no history of a case of imbecility or idiocy, epilepsy, chores, insanity, or any serious nervous disturbance, except in the cases here given.
Cases Nos. 3 and 4–These were so much alike that they may briefly be referred together. Both were women. One a married lady aged 38, with one child, and the other unmarried, aged 28. The family history in both cases was good, except for an insane aunt in either. In each case the aunt had had much to do with my patient while younger. In each, some thoughtless friend had pointed out some traits of character similar in aunt and niece and the fear of insanity had then been firmly implanted. In both instances this dread had at first been looked upon as a needless fear, not worthy of discussion, and an atttempt had been made for years to stifle the same. The very habit of secretiveness about the fear had evidently tended to magnify the evil. The puerperal state in one instance, and excessive mental activity in school work in the other, finally produced a breakdown. Insanity was present in neither case, but speedily approaching. The removal from home, the change of climate, the absence of the voices formerly heard, and the faces and objects usually seen, with appropriate treatment and a normal influence leading the mind away from its accustomed broodings, and as rational a discussion from time to time as circumstances warranted of the general and individual probabilities against the theories formed in the patient's mind upon the subject