PROPRIETORSHIP IN MEDICINE

To the Editor:—I am enclosing a reprint of my article on the “Present Status of Pituitary Extract in Labor,” which appeared in The Journal, June 2, 1917, p. 1601, and also the September issue of Parke, Davis and Company’s Therapeutic Notes, on page 89 of which they quote this article, that you may compare the two. The Therapeutic Notes article is ostensibly a copy, but as a matter of fact, it gives it only in part, which seems to me to be a gross misrepresentation, and one which I do not think should go unnoticed.

Joseph J. Mundell, M.D., Anacostia, D. C.

[Comment.—Therapeutic Notes is one of the house organs of Parke, Davis and Company. A part of each issue is usually devoted to “excerpts” from current literature. The Therapeutic Notes may be judged from the manner of “excerpting” the article of Dr. Mundell. Naturally the interest of Parke, Davis and Company is in those sections of the article which may be expected to promote the use of Parke, Davis and Company’s proprietary preparation of pituitary extract—pituitrin. The following passages from the article of Dr. Mundell were not among those “excerpted” in Therapeutic Notes:

“Used here in properly selected cases, after due consideration by one who has good obstetric judgment, its results are usually happy, and it is a boon to the tired mother and her attendants.”

“To step beyond these narrow confines of indications is indeed entering on dangerous territory. Especially is this true as regards the life of the baby. It is recommended in small doses by some good authorities and is frequently used in cases of slight contraction at the brim with sometimes very good results if the birth occurs within a few minutes, but frequently with disastrous results to the baby if delivery is delayed. In such cases, forceps are urgently indicated. Its use in such cases is risky beyond question. Pituitary extract is recommended in cases of postpartum hemorrhage, but ergot is undoubtedly to be preferred.”

“All means should be exhausted to arrive at a definite diagnosis, and the dangers of its use should be fully appreciated and due consideration given before its administration in any case, for such a powerful drug, used indiscriminately, will surely produce sad results to mother or child or both.”

“During the past two years a number of untoward effects and consequences of severe character have arisen. As far as the maternal accidents and complications are concerned, I firmly believe that were the slogan of the hour “safety first” borne in mind, a number of them could have been prevented, for beyond question this drug has been greatly abused, as it has been given in too large doses, in cases in which its use was strongly contraindicated, and often, I am sorry to say, for no reason other than the accoucheur’s expediency. Its use has been reckless and careless. The many reports of its rapid and safe action have been one of the greatest dangers. DeLee says, ‘It provides for the physician and his brother gynecologist a lot of chronic sufferers, often incurable, even after mutilating operations.’ ”

“An analysis of the detailed reports of all these cases of ruptured uterus with one or two exceptions reveals the fact that pituitary extract was abused, being given to patients who should not have had it. To my mind, to give a dose of pituitary extract to a woman who has a contracted pelvis, mild or severe, when the head has not passed through the pelvis, is criminal and, if the obstetrician is not aware of the contraction, he is still little short of being a criminal.”

In the latter part of his article in The Journal, Dr. Mundell analyzes the reports of twelve cases of rupture of the uterus, thirty-four cases of fetal deaths, and forty-one cases of asphyxia pallida in which “resuscitation was effected only after prolonged and vigorous efforts.” These also were not excerpted.—Ed.]—(Correspondence in The Journal A. M. A., Nov. 24, 1917.)

The Manufacturer’s Protest

To the Editor:—The article in The Journal, November 24, page 1818, on proprietorship in medicine does us a gross injustice, and in reply thereto we beg leave to submit the following:

For reasons which every publisher (yourself included) understands, it is not practicable for us to reproduce in full, in the columns of Therapeutic Notes, all the clinical papers to which we wish to direct the attention of our readers. But that the article of Dr. Mundell was not garbled to make capital for Parke, Davis & Co. is quite apparent on comparison of the omitted portions with a previous paper by the same author, reprinted in the January (1917) issue of the Notes, and herewith submitted together with clippings from other issues of the Notes which prove that we have not hesitated to present to our readers the dangers incidental to the misuse of Pituitrin as well as the advantages of its proper use.

Therapeutic Notes, in quoting other journals, puts into its readers’ hands the means of investigating the fairness of its quotations. It is a house organ—true enough; but the organ of a house which has always appealed to the honor as well as to the progressiveness of the medical profession. Its publishers could not afford to resort to deception in advertising their products, through this or any other medium.

The profession is indebted to Parke, Davis & Co. for Pituitrin (among other medicaments), and it is to the profession that the manufacturers look for the ultimate verdict. The contraindications are quite as important as the indications, and, as the excerpts submitted show, we have taken account of these, not only in forming our own estimate, but in presenting the evidence to the readers of Therapeutic Notes.

We cite these facts that you may give us a square deal in an early issue of The Journal if so disposed.

Parke, Davis & Co., Detroit.

[Comment.—The Journal has no desire to discuss Parke, Davis and Company’s motives in omitting certain parts of Dr. Mundell’s paper. What The Journal did was to publish those parts of Dr. Mundell’s paper on the “Present Status of Pituitary Extract in Labor” that Parke, Davis and Company left out of their circular. That it is not practicable, as Parke, Davis and Company points out, for the manufacturers of proprietary products to reproduce in full all clinical papers dealing with such products is obvious. It is not so obvious why such concerns in abstracting or quoting papers of this kind should delete those parts that are unfavorable to the products dealt with rather than those that are favorable. Curiously, however, whenever an author is quoted only in part those parts are almost invariably those favorable to the product.—Ed.]—(Correspondence in The Journal A. M. A., Dec. 8, 1917.)

Why Proprietaries Flourish

To the Editor:—The following experiences seem to add one more to the many reasons offered to explain why proprietaries and ready-made preparations flourish at the expense of the official drugs and preparations: A few days ago I prescribed Troches of Ammonium Chloride, U. S. P., for a patient of exceptional perseverance. The next day he had not yet secured the troches and told me that he had submitted the prescription to seven pharmacies, including the largest, and three of the best known and admittedly the best equipped in New York. All told him that these troches were “not being made any more,” and that they were therefore unable to supply him. He thereupon communicated with one of the largest wholesale manufacturing pharmaceutical houses in America and received precisely the same answer. I then took the matter up with a first class pharmacist whom I knew and induced him to prepare this difficult (!) troche, for which the U. S. Pharmacopeia gives the following directions: “Rub the powders together until they are thoroughly mixed; then form a mass with syrup of tolu and divide ...”

Seven pharmacists declined to fill a prescription for an official preparation because they could not buy the preparation from a wholesaler, and it required some persuasion to get the eighth to make the preparation. But even worse, several of the pharmacists offered my patient some ready-made troche more or less resembling the official, or offered compressed tablets of ammonium chlorid.

That this is not an isolated example of what often poses as pharmacy is shown by the fact that I have found it extremely difficult to find a pharmacist who would ex­tem­por­aneously coat pills with gelatin. Most want the physician to alter his prescription so that one of the ready-made gelatin coated pills can be dispensed, if a gelatin coating is necessary. Some gelatin, hot water, a large cork, and a few domestic sewing needles are all that is required for very satisfactory coating of pills with gelatin, yet few pharmacists seem willing to perform this simple procedure.

Two other illustrations, not so recent, have come to me from a colleague. A few years ago he was unable to obtain from either of two pharmacists an emulsion of cod liver oil without the hypo­phosphites because, as both said, “It does not come without hypo­phosphites.” On another occasion four of the best drug stores in Boston were asked for the Compound Laxative Pill, U. S. P., then official in the Pharmacopeia. In every case he was told that he must have meant the compound cathartic pill, which in no way resembles the pill he sought.

With this attitude on the part of the men supposed to be serving the public and the medical profession by the practice of pharmacy, is it any wonder that it is difficult to induce the medical profession to prescribe official preparations or combinations of official drugs in place of ready-made commercial substitutes largely drawn from among the proprietaries or specialties? Real pharmacy by real pharmacists is a necessity if we are to succeed in combating the proprietary evil.

Cary Eggleston, M.D., New York.

—(Correspondence in The Journal A. M. A., Aug. 21, 1920.)