Introduction and Background

ROBINSON’S PRESCRIPTION INCOMPATIBILITIES A TREATISE ON PRESCRIPTION INCOMPATIBILITIES AND DIFFICULTIES INCLUDING PRESCRIPTION ODDITIES AND CURIOSITIES FOR PHARMACISTS AND PHYSICIANS AND STUDENTS IN PHARMACY AND MEDICINE BY WILLIAM J. ROBINSON, Pu.G., M.D. EDITOR OF THE CRITIC AND GUIDE AND THE AMERICAN JOURNAL OF UROLOGY AND SEXOLOGY Formerly President New York Board of Pharmacy Institute; Fellow New York Academy of Medicine, American Medical Association, member New York State an County Medical Society, American Association for the Advance- ment of Science, efc., ete. Author; Organic Materia Medica, Posology and Toxicology; Elementary Course in wemistry; Elementary Course in Pharmacy; A Complete Quiz System of harmacy; Practical Druggist Institute Course of Pharmacy; A Practical Course in Pharmacy, Chemistry, Materia Mediza and Tozic ‘and Loce Life; Treatment of Sezuat Author: Sex Knowledge for Men; Woman: Her Impotence and Other Sezual Disorders in Men and Women; Treatment of Gonorrhea; Sezual Problems of Today; Birth Control or The Lim- : Hation of Offspring by the Prevention of Conception; i Never Told Poles; Eugenics ond Marriage, ele., ete. 1919 CRITIC AND GUIDE COMPANY 12 MT. MORRIS PARK WEST NEW YORK BY THE SAME AUTHOR A Pracrican TREATISE ON THE CAUSES, Symproms AND TREaTMEnt or SexuaL Impotence anp Orner Sexuan Dis- orpERS IN Mnn anp WomEN $4.00 TREATMENT OF GONORRHEA AND ITS Compuicarion Iv Men AND Women. 3.00 Sexvua. Propuems or To-pay... + 2.00 Sex Knowtepcs ror MEN.. . 2.00 Sex Knowepcs ror WoMEN. . 1.00 Wouan: Hur Sex anp Love Lirz..... 3.00 Never Toup Tatas... . 1.00 Srorres or Love anp Lirn . 1.50 Birra Conrrot on Limration or Orr SPRING BY THE PREVENTION or Cox: cuprto: 1.50 Sex Moratirr—Past, Preset ND Furure . 1.50 Evaznics ano Marriage 1.00 Sexvuat Trurus. 3.00 PRESCRIPTION INCOMPATIBILITIES...... 3.00 Tue Criric anp Guipg ‘Monthly: $2.00 a year; Single Copies, 25c, Tar Amertcan Journat or Urotocy AND SEXOLOGY ‘Monthly: $5.00 a year; Single Copies, 50c. Tux Sexvan Crisis. Meisel-Hess..... $3.00 Poputation anp Birra Contro Syarostva Swatp or Lance Fanrums. Drysdale and Havelock Elis. Parursxpers iN Mupicte. Dr. eo Robinson. i « 5 Copyright, 1919, By Tue Critic anp Guin Co. aug 18 1919 ©ci.a523600 TO THE MEMORY OF CHARLES RICE Oxe or Tue Nosiest REPRESENTATIVES OF ProressionaL Puarmacy IN THIS COUNTRY A Mopesr anp Unsexrish Man or Sctence I GRATEFULLY AND REVERENTLY DEDICATE THIS VOLUME W.J.R. PREFACE RANKNESS demands the statement that the subject of Prescription Incompatibilities is of considerably less importance now than it was twenty or thirty years ago. It was a rare day then when an editor of a pharma- ceutical journal or one who was considered an expert in solving incompatible riddles did not receive orally or in writ- ing a despairing call for help from some sorely puzzled drug- gist, who in attempting to put up a prescription as written by the doctor, got an unsightly, impossible mass, a strange, unlooked-for color, or perhaps a dangerously explosive mix- ture. And pharmaccutical journals devoted a good deal more space than they do now answering the ‘‘incompatible’’ queries of their subscribers. The flood of new remedies and synthetics was then at its height and the physician still un- weaned from his habit of polypharmacal prescribing insisted on joining together things which the spirits of chemistry, pharmacy and therapeutics intended should be kept asunder. The idea at that time was still pretty general that the value of a prescription increased in direct ratio to the number of its ingredients. And the result was—not infrequently—a spoiled, useless, ludicrous, or even dangerous combination. Things are different now. Our propaganda during the past twenty-five years in favor of simple rational prescriptions has borne fruit. The modern physician does not believe in shotgun prescriptions; he prescribes one, seldom more than two or three active ingredients in a prescription. In fact, the tendency is now towards the other extreme: single reme- dies is the slogan, the physician thus not infrequently de- priving himself of valuable synergistic or corrective combi- 5 6 PREFACE nations. Of course, the fewer the ingredients in a preserip- tion, the fewer the chances for incompatible combinations or impossible absurdities. Nevertheless, the days of incompatible prescriptions and questionable combinations are not entirely over. Not as often as formerly, but still often enough is the author ap- pealed to to clear up difficult points in physicians’ preserip- tions, and it is lack of time, and not lack of opportunity, that prevents him from playing the réle of oracle on in- compatibilities to the pharmaceutical profession. No, the subject of incompatibilities has not yet altogether lost its importance. And every intelligent pharmacist as well as every self-respecting and conscientious physician should be on terms of familiarity with the salient facts of prescription writing, so that the latter may avoid and the former correct glaring absurdities. It is just a quarter of a century since the author began to teach and to write on the subject of this book. His first Treatise on Prescription Incompatibilities and Difficulties appeared in Merck’s Report, where it ran for several years. In a revised form it was published in The Critic and GuipE for 1903, 1904 and 1905. It is not a mere phrase to state that the Treatise met with exceptional favor. It was claimed that the author was the only writer in the field who suc- eeeded in making a dreary and dry-as-dust subject readable and interesting. And being interesting, the subject became memorizable; it left an impression on the tablets of one’s memory, which a dreary, non-interesting subject rarely does. The requests to reprint the Treatise in a separate volume were quite numerous—but then a busy practice and other, more interesting literary work made compliance with the re- quest a practical impossibility. And with each year that passed the Treatise became more inadequate—because new remedies came into use and with them new incompatibili- ties, and the composition of certain pharmacopeial galenicals became changed, so that explanations and criticisms which PREFACE i held good before, held good no longer. To bring the Treatise on Prescription Incompatibilities up to date required con- siderable additions, a few eliminations and a thorough re- vision. I despaired of ever having the time to devote to it. But I recently achieved some leisure and I have taken the opportunity to subject the Treatise to a thorough revision and to bring it up to date. And I now take pleasure in pre- senting this enlarged and revised Treatise on Prescription Incompatibilities and Difficulties, including Prescription Oddities and Curiosities, to my friends in the pharmaceutical and medical professions. A word on the kind of prescriptions and incompatibilities that are discussed in this Treatise. They are bona fide pre- scriptions and combinations, and the incompatibilities are such as have presented themselves to some druggists and physicians and are apt to present themselves again to others. It is not only superfluous and unnecessarily space-consum- ing, but it is mind-confusing and discouraging to present incompatibilities in prescriptions which never happened and never could happen, because no physician in his wildest flights of fancy would ever think of writing such combinations. Let me illustrate by some examples: Of what use is it to tell a physician or a pharmacist, or a medical or pharma- ceutical student, that mucilage of acacia is precipitated by sodium phosphomolybdate, that acetanilid gives a white pre- cipitate with bromine, that meconic acid gives a precipitate with barium chloride, that urethane give off some ammonia when heated with a solution of potassium or sodium hy- droxide, that cadmium salts are precipitated by alkali car- bonates and chromates, that gamboge with ammonia water gives a yellow colored solution, that a mixture of cocaine and calomel acquires a dark color if the fumes of hydro- chlorie acid are blown over it, that a solution of methyl- thionine hydrochloride is precipitated by potassium bichro- mate, that piperazine explodes when heated to a certain tem- perature with sodium hypochlorite, that potassium salts give 8 PREFACE a yellow precipitate with platinic chloride and hydrochloric acid, that sugar is decomposed with ignition by concentrated sulphuric acid, that thymol is incompatible with chromic acid, ete., ete.—the list could be extended indefinitely. It is not merely superfiuous, but, as stated above, is confus- ing and discouraging to the student. For, seeing that most drugs have dozens and some even hundreds of incompati- bilities, he loses courage and despairs of ever mastering the subject. Why, many of the chemicals given as incompatibles of this, that and the other thing are not even medicinal preparations, are never used in medicine, are never prescribed and consequently can never form the subject of prescription incompatibilities! Who ever heard of a doctor prescribing acacia with sodium phosphomolybdate, acetanilid with bro- mine (elementary bromine!) ? And of what interest is it to a student of incompatibilities to know that meconie acid is incompatible with barium chloride? Have the two ever been prescribed? And has a doctor ever prescribed sugar with concentrated sulphuric acid? Or has anybody ever ordered to blow the fumes of HCl over a mixture of cocaine and calomel? And so on. So what is it all for? The examples I have enumerated are chemical tests and reactions—they are useful in their place, but they have nothing to do with the subject of incompatibilities. This book will be found free from the superfiuities referred to, and will, it is hoped, be found more acceptable and more useful on that account. W. J.B. 12 Mount Morris Park West INTRODUCTION HE subject of incompatibilities has always been the béte noire of the pharmacist and physician. Whether it is because the subject is really a difficult one, or because it has not received proper and satisfactory treat- ment in our text-books, in our pharmaceutical and medical journals, or because the educational standard of the pharma- cist and physician is not high enough, not. broad enough to enable them to master the subject thoroughly, certain it is that the number of pharmacists and physicians who are able to grapple successfully with all the intricacies of prescrip- tion incompatibilities is a very limited one. It shall be the purpose of this treatise to solve the many mysteries of incom- patibilities. It is the author’s conviction, based upon an expe- rience of many years, that there is no subject, no matter how apparently intricate and complicated, that cannot be mas- tered by a person of average intelligence, provided it be presented in the proper light and in a proper manner; that there is no subject, no matter how dry, that cannot be made interesting and attractive. The author’s opportunities for seeing and analyzing incom- patible prescriptions have always been exceptionally favor- able ones. Besides the large collections he has made in his quondam drug-store practice, he is constantly receiving in- quiries from pharmacists in various parts of the city and country, regarding some mooted points. He is also fre- quently honored with letters from physicians, who, on getting untoward effects from some combinations, ask for enlighten- ment. They frequently inquire whether it is the fault of the combinations, or whether the druggist had perhaps sub- 9 10 PRESCRIPTION INCOMPATIBILITIES stituted something else for what had been prescribed. Finally, the author had been for a number of years regular “‘consultant”’ to a number of pharmaceutical journals and in this capacity he has had to analyze and explain incom- patible prescriptions almost daily. As to why I consider the subject of prescription incompati- bilities of such paramount importance to the pharmacist, I can do no better than to quote from a paper of mine on the subject, read at the Twenty-second Annual Convention of the New York State Pharmaceutical Association. I started that paper by stating that the business of the retail pharma- cist of the present day consisted of three branches: that of manufacturing galenical preparations, that of selling patent medicines, druggists’ sundries, ete. and that of dispensing physicians’ prescriptions. The first two departments have been encroached upon to a very great extent. The large manufacturing houses with limitless facilities, improved machinery, immense capital and modern methods have been able to offer certain classes of preparations to the retail druggist at such a price as to take away from him every incentive to do his own manufactur- ing. And there is no help for that. No matter how we may deplore the fact that the druggist of the present day is unable to spread a plaster or roll a pill so dexterously as did the apothecary of a generation or two ago, you cannot change the tendency of the times. For the sake of sentiment no druggist will spend several hours in making a preparation, which he can purchase ready made and as well made at a lower price. The sale of patent medicines, etc., is being every day more and more monopolized by the department stores. This is also inevitable, as will be admitted by any one who has given the subject some thought and who can read the signs of the times. But there is one department which is still the pharmacist’s own—a department which distinguishes him as a profes- PRESCRIPTION INCOMPATIBILITIES ll sional man and elevates him above the ordinary merchant. I refer to the prescription department. That is a depart- ment which nobody can take away from the pharmacist; be- cause, while no law can be passed to prevent people from selling ordinary drugs and patent medicines, the dispensing of prescriptions can be limited to qualified pharmacists only. And to the development of this department the pharmacist should devote his best energies. To do this successfully he must become a master prescriptionist and be familiar with all the intricacies of prescription incompatibilities. Nothing will more securely hold your physician’s patronage than his confidence in your ability as a prescriptionist, in your abil- ity to dispose of difficulties and to prevent untoward results. Tt has always been a source of wonder to me why the sub- ject of incompatibilities has been so sadly neglected in our college curricula. The student is taught the various steps of preparing sulphuric acid, or of the preparation of soda by the Leblane process (things of which he will never make any practical application), but he is left in ignorance as to how to mix Fowler’s solution and Magendie’s solution without precipitation. He is taught the difference between cast and wrought iron, but he is left in ignorance as to why a pre- cipitate occurs on the addition of potassium iodide to syrup of ferrous iodide and how to prevent it. To me the subject of prescription incompatibilities has always seemed of paramount importance. It is practically more useful than botany, more useful than pharmacognosy, and even more useful than manufacturing chemistry—and I hope the time is not far distant when it will occupy the first rank in the curriculum of every school of pharmacy in the United States. THE MEANING OF ‘‘INCOMPATIBLE’”’ The word “incompatible,” according to the definition of the various dictionaries, means incapable of existing together in agreement or harmony. We call a prescription incompati- 12 PRESCRIPTION INCOMPATIBILITIES ble when its ingredients are of such a nature that, if brought together, one or more of the following changes would take place: (1) Mutual decomposition of the ingredients, with the formation of a new compound; (2) precipitation, chemical or physical; (3) explosion; (4) deflagration; (5) liquefae- tion, when the ingredients are prescribed in powders; (6) the deterioration or destruction of one or more of the ingredients. But it would be a mistake to suppose that the word incom- patible is synonymous with ‘‘non-dispensable.’’ On the con- trary, as will be seen later, there are many combinations which, broadly speaking, are incompatible, but not only may they be dispensed without any hesitation, the incompatibility is intentional and distinctly desirable. Incompatibilities are generally divided into three classes: (1) Chemical incompatibility, where the change is the result of a true chemical reaction, e. g., when sodium salicylate is prescribed with diluted sulphuric acid, salicylic acid precipi- tates out, and sodium sulphate is in solution; (2) pharma- ceutical, when the change is the result of a physical condi- tion, i. e., when the menstruum is unsuitable, e. g., when fluid extract of cannabis indica is added to water and the resin is thrown out of solution; and (3) therapeutic, where the drugs prescribed have antagonistic medicinal properties (as when chloral and strychnine are prescribed together, or digitalis and aconite). With the latter variety, therapeutic incompatibility, the pharmacist has absolutely nothing to do, nor is he to permit himself to make any suggestions to the physician in that direction. The pharmacist is not compe- tent to judge of what constitutes therapeutic incompatibility ; it is none of his affair; two drugs may be antagonistic in one respect and synergistic in another, and it is for the latter effect that the physician prescribes them. The author’s classification of incompatibilities, which he introduced several years ago and which has been found both useful and practical, is as follows: (1) Permissible and desirable incompatibility, when the PRESCRIPTION INCOMPATIBILITIES 13 resulting change is of no significance, or where the new com- pound is expressly desired by the physician. (2) Preventable incompatibility, where the incompatibil- ity can easily be prevented, either by a change in the order of mixing the ingredients, or by the addition of acid, ete., and (3) Absolute, or true, incompatibility, where the preserip- tion cannot possibly be dispensed in its original form and where one or more ingredients must be left out altogether or other ingredients substituted. It is this last kind of in- compatibility which is practically synonymous with non- dispensability. This classification I have found especially useful for students. PRESCRIPTIONS O master the subject of incompatibilities, each preserip- th tion should be read carefully. It is not necessary to attempt to memorize all incompatibilities; but it is im- portant to try to understand the general principles. At the end of the volume, the incompatibilities will be summarized and classified alphabetically, so that they can be easily re- ferred to. 1. Morphinae Sulphatis +. gr. iv Ac, Tanniei gr. viii Aquae Destillatae 33 Inject with ear syringe. I start this series of incompatible, difficult and odd preserip- tions with the above, because it is so very common. With all that has been written on prescription incompatibilities one would think that such a combination would not present any difficulty to any pharmacist. But such, it appears, is not the case. The druggist seemed to be very much surprised and indignant at the fact that a “‘precipitate formed when he added the tannic acid to the solution of morphine, which did not dissolve on long shaking.’’ Well, a precipitate does form when tannic acid is added to morphine, and not only to morphine, but to all other alkaloids. This is one of the commonest kind of incompatibility that we encounter in the drug store practice. ALKALows Are IncoMPATIBLE wiTH TaNNIc AcID OR WITH Sussrances Contamina TANNIN. The alkaloid is precipitated out of its solution as a tan- nate. In the above prescription we