- Email: [email protected]
THE RELATION BETWEEN THERAPEUTICS AND PHARMACOLOGY.
191
THE LONDON:
LANCET.
SATURDAY, JANUARY 27,
1923.
THE RELATION BETWEEN THERAPEUTICS AND PHARMACOLOGY.
practitioners,
A CERTAIN over-trustfulness among shown by a willingness to attribute peculiar virtue to remedies the administration of which has been followed by recovery among their patients, was the subject of attack at a meeting of the Section of Therapeutics and Pharmacology of the Royal Society of Medicine reported last week in THE LANCET. A vehement endorsement of the criticisms, appearing in our correspondence columns, suggests that the relation of therapeutics to pharmacology, which is by no means so intimate as the union of these two branches of medicine into one section of a society would imply, needs serious readjustment. The art of therapeutics has remained considerably an art, too many of its principles being without sure scientific foundation, though the position has been vastly improved in recent times, and the best workers in this sphere of medicine are giving it grave attention. But the plight in which the practitioner may find himself is still somewhat comparable to that of a navigator before the science of astronomy was well advanced. He has to trust largely to his own ingenuity and his own interpretation of particular problems in many perilous situations. The medical profession wants a record of his experiences. Alas, the practitioner, with an over-full day, does not appear to realise that only the most careful records of cases that have been followed up, and collated with their similars, can advance the art of therapeutics on its scientific side. The progress of the sciences on which therapeutics must eventually be founded is dependent on the cooperation of the man who uses the weapons provided against disease. Over-eagerness to accept as efficacious preparations announced as physiological remedies may hamper that progress. In the course of the discussion at the Section of the Royal Society of Medicine it was said that organotherapy lags considerably behind endocrinology ; would it not have been more correct to say that organotherapy has been exploited so far beyond what is justified by our present knowledge of endocrinology, that professors of the latter branch of science are driven to repudiate their own child ? It is not only in organotherapy, however, that the lack of cooperation between clinician and pharmacologist is evident. It was recently pointed out that the most popular official preparation of ergot in this country is one in which pharmacologists can find little, if any, active principle. Practitioners find it easier to credit anonymous pamphlets than to accept the view of physiologists that much of the activity which colloidal preparations of metals or other powerful drugs can possess may be attributable to the fraction present in true solution or to a protective substance added to ensure stability.l If pharmacology and therapeutics were not mutually dependent, the lack of confidence between 1
The Colloidal State in its Medical and Physiological Aspects. Oxford Medical Publications. London : Henry Frowde and Hodder and Stoughton. 1923. 6s. Also THE LANCET, 1922, i., 40.
By Sir William Bayliss.
workers in either field would not be so serious. But, as Prof. A. G. CLARK points out in the preface to a little book2 expressly designed to bridge the gap between them, experiments upon laboratory animals usually show more or less the immediate effect of a toxic dose of a drug upon a healthy animal, whereas clinical medicine is concerned with the effects produced by therapeutic doses of drugs upon diseased human beings ; such effects are usually produced only after many hours or days. Thus information derived from laboratory experiments requires to be controlled and extended by clinical observation. The question remains as to how a better understanding between groups of workers whose outlook and responsibilities differ so widely is to be achieved. We agree, and all will agree, with much that our correspondent, "A Physician," writes, but demur to his reproach of the clinician who lacks " the courage to use controls. It is more a question of temperament and of a conception of duty to each individual patient. To withhold treatment which he believes to be efficacious from 20 patients, whether suffering from intractable varicose ulcer or from syphilis, while he administers it in 20 parallel cases can hardly be regarded as a duty by a professional man who is treating patients, not conducting experiments. The attitude may be unscientific, but it cannot be condemned, unless, despite the absence of controls, results are published claiming to be conclusive. Even should controls be adequate, there are other variables which may easily vitiate clinical evidence. The typical impartial scientific observer is not popular or successful with patients, while the practitioner can hardly gauge the value of his own sanguine temperament. It is natural enough that laboratory workers who keenly desire to have their experimental conclusions tested in the sick room should be dissatisfied with the results, unclassified, uncontrolled, and insufficiently documented, which may emanate therefrom. But can they devise means whereby the action of a drug in clinical practice can be actually The electrocardiogram is an example measured? of such an instrument, and another designed to record the contractions of the uterus is being tried at Queen Charlotte’s Hospital. Hitherto the clinician has not received sufficient considerationin a dual role ; we are convinced that if his difficulties. are recognised by his scientific colleagues attemptswill be made towards the solution of joint problems in pharmacology and therapeutics which would soon have speedy results.
THE PUBLIC AND TUBERCULOSIS RESEARCH. SCEPTICISM and modesty are the attributes of mind most conducive to useful research. It was WILLIAM HARVEY who counselled his fellows not to rely only on other men’s traditions in the wonderful field of nature, where, he added, performance exceeds what is promised. " Nature her selfe must be our adviser; the path she chalks must be our walk...." We note that the address by Prof. LYLE CUMMINS, printed at the front of our present issue, is frankly Instead of saying that what we interrogatory. " know not is not knowledge," he says: "Does what we know of tuberculosis deserve the name of know" Coupled with his call for research is the ledge ? query, very pertinent in these days, whether every 2 Applied Pharmacology. 1923. 15s.
London :
J.
and
A.
Churchill.
THE LONDON:
LANCET.
SATURDAY, JANUARY 27,
1923.
THE RELATION BETWEEN THERAPEUTICS AND PHARMACOLOGY.
practitioners,
A CERTAIN over-trustfulness among shown by a willingness to attribute peculiar virtue to remedies the administration of which has been followed by recovery among their patients, was the subject of attack at a meeting of the Section of Therapeutics and Pharmacology of the Royal Society of Medicine reported last week in THE LANCET. A vehement endorsement of the criticisms, appearing in our correspondence columns, suggests that the relation of therapeutics to pharmacology, which is by no means so intimate as the union of these two branches of medicine into one section of a society would imply, needs serious readjustment. The art of therapeutics has remained considerably an art, too many of its principles being without sure scientific foundation, though the position has been vastly improved in recent times, and the best workers in this sphere of medicine are giving it grave attention. But the plight in which the practitioner may find himself is still somewhat comparable to that of a navigator before the science of astronomy was well advanced. He has to trust largely to his own ingenuity and his own interpretation of particular problems in many perilous situations. The medical profession wants a record of his experiences. Alas, the practitioner, with an over-full day, does not appear to realise that only the most careful records of cases that have been followed up, and collated with their similars, can advance the art of therapeutics on its scientific side. The progress of the sciences on which therapeutics must eventually be founded is dependent on the cooperation of the man who uses the weapons provided against disease. Over-eagerness to accept as efficacious preparations announced as physiological remedies may hamper that progress. In the course of the discussion at the Section of the Royal Society of Medicine it was said that organotherapy lags considerably behind endocrinology ; would it not have been more correct to say that organotherapy has been exploited so far beyond what is justified by our present knowledge of endocrinology, that professors of the latter branch of science are driven to repudiate their own child ? It is not only in organotherapy, however, that the lack of cooperation between clinician and pharmacologist is evident. It was recently pointed out that the most popular official preparation of ergot in this country is one in which pharmacologists can find little, if any, active principle. Practitioners find it easier to credit anonymous pamphlets than to accept the view of physiologists that much of the activity which colloidal preparations of metals or other powerful drugs can possess may be attributable to the fraction present in true solution or to a protective substance added to ensure stability.l If pharmacology and therapeutics were not mutually dependent, the lack of confidence between 1
The Colloidal State in its Medical and Physiological Aspects. Oxford Medical Publications. London : Henry Frowde and Hodder and Stoughton. 1923. 6s. Also THE LANCET, 1922, i., 40.
By Sir William Bayliss.
workers in either field would not be so serious. But, as Prof. A. G. CLARK points out in the preface to a little book2 expressly designed to bridge the gap between them, experiments upon laboratory animals usually show more or less the immediate effect of a toxic dose of a drug upon a healthy animal, whereas clinical medicine is concerned with the effects produced by therapeutic doses of drugs upon diseased human beings ; such effects are usually produced only after many hours or days. Thus information derived from laboratory experiments requires to be controlled and extended by clinical observation. The question remains as to how a better understanding between groups of workers whose outlook and responsibilities differ so widely is to be achieved. We agree, and all will agree, with much that our correspondent, "A Physician," writes, but demur to his reproach of the clinician who lacks " the courage to use controls. It is more a question of temperament and of a conception of duty to each individual patient. To withhold treatment which he believes to be efficacious from 20 patients, whether suffering from intractable varicose ulcer or from syphilis, while he administers it in 20 parallel cases can hardly be regarded as a duty by a professional man who is treating patients, not conducting experiments. The attitude may be unscientific, but it cannot be condemned, unless, despite the absence of controls, results are published claiming to be conclusive. Even should controls be adequate, there are other variables which may easily vitiate clinical evidence. The typical impartial scientific observer is not popular or successful with patients, while the practitioner can hardly gauge the value of his own sanguine temperament. It is natural enough that laboratory workers who keenly desire to have their experimental conclusions tested in the sick room should be dissatisfied with the results, unclassified, uncontrolled, and insufficiently documented, which may emanate therefrom. But can they devise means whereby the action of a drug in clinical practice can be actually The electrocardiogram is an example measured? of such an instrument, and another designed to record the contractions of the uterus is being tried at Queen Charlotte’s Hospital. Hitherto the clinician has not received sufficient considerationin a dual role ; we are convinced that if his difficulties. are recognised by his scientific colleagues attemptswill be made towards the solution of joint problems in pharmacology and therapeutics which would soon have speedy results.
THE PUBLIC AND TUBERCULOSIS RESEARCH. SCEPTICISM and modesty are the attributes of mind most conducive to useful research. It was WILLIAM HARVEY who counselled his fellows not to rely only on other men’s traditions in the wonderful field of nature, where, he added, performance exceeds what is promised. " Nature her selfe must be our adviser; the path she chalks must be our walk...." We note that the address by Prof. LYLE CUMMINS, printed at the front of our present issue, is frankly Instead of saying that what we interrogatory. " know not is not knowledge," he says: "Does what we know of tuberculosis deserve the name of know" Coupled with his call for research is the ledge ? query, very pertinent in these days, whether every 2 Applied Pharmacology. 1923. 15s.
London :
J.
and
A.
Churchill.