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Pharmacology Principles and Applications 3rd Edition
Eugenia M. Fulcher Digital Instant Download
Author(s): Eugenia M. Fulcher, Robert M. Fulcher, Cathy Dubeansky Soto
ISBN(s): 9781437722673, 1437722679
Edition: 3rd
File Details: PDF, 48.35 MB
Year: 2011
Language: english
DRUG CATEGORY

CHAPTER BODY SYSTEM DRUG CATEGORY CHAPTER BODY SYSTEM DRUG CATEGORY
15 Medications to treat pain Analgesics and antipyretics 24 Medications used to Antacids
and fever Opioids (narcotics) treat disorders of the Antidiarrheals
Nonopioids gastrointestinal system Antidotes
Anesthetics Antiemetics
General Antiflatulents
Local Anthelmintics
16 Medications used to Antivenoms Antispasmodics
treat disorders of the Immunizations Antiulcer agents
immune system and Immune globulins and antitoxins Digestants
immunizations Immunosuppressants Emetics
17 Medications used to treat Antibiotics Laxatives and cathartics
infectious diseases Antifungals Stool softeners
Antivirals 25 Medications used to Asthma prophylactics
Antiprotozoals treat disorders of the Antihistamines
Antipyretics respiratory system Antitussives
Antituberculars Bronchodilators
18 Medications used to treat Antineoplastics Decongestants
cancer Antimetabolites Expectorants
Mucolytics
Smoking cessation aids
19 Medications used Electrolytes 26 Medications used to treat Antianginals
a nutritional Vitamin and mineral supplements disorders of the Antiarrhythmics
supplements and cardiovascular system Anticoagulants
alternative medicines Antihypertensives
20 Medications used to Hypoglycemics Antihyperlipidemics
treats disorders of the Insulin Cardiotonics and cardiac glycosides
endocrine system Oral hypoglycemics Vasoconstrictors
Insulin antagonists or Vasodilators
hyperglycemics Medications used to Coagulants and hemostatics
Corticosteroids treat disorders of the Platelet inhibitors
Thyroid replacements hematologic conditions Thrombolytics
Antithyroid preparations 27 Medications used to treat Urinary analgesics
21 Medications used to treat urinary system Urinary antiseptics
disorders of the eyes disorders Urinary antispasmodics
and ears Diuretics
Enuretic agents
Eyes Mydriatics
28 Medications used to treat Contraceptives
Miotics
disorders and Fertility enhancers
Ocular antiallergics
conditions of the Hormone replacements
Antiinfectives
reproductive system Androgens
Lubricants
Estrogens
Anesthetics
Progestins
Ears Cerumenolytics
29 Medications used to treat Adrenergics
Antiinfectives
neurologic disorders Adrenergic blockers
22 Medications used to treat Anesthetics
Analgesics
disorders of the Antiparasitics
Opioids (narcotics)
integumentary system Antipruritics
Nonopioids
Antiseptics
Anesthetics
Disinfectants
General
Demulcents (often emollients
Local
and demulcents are
Anticholinergics
classified together)
Antiseizure medications
Keratolytics
Antiparkisonism medications
23 Medications used to treat Antiarthritics
Cholinergics
disorders of the Antigout agents
Hypnotics and sedatives
musculoskeletal Antiinflammatories
Barbiturates
system Bone replacement therapeutics
Nonbarbiturates
Muscle relaxants
Stimulants
30, 31 Medications used to Antianxiety/anxiolytics, minor
treat mental disorders tranquilizers
and substance abuse Antidepressants, mood elevators
Antimanics
Antipsychotics, neuroleptics, major
tranquilizers
Alcohol cessation aids
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This page intentionally left blank
Pharmacology
Principles and Applications

THIRD EDITION

EUGENIA M. FULCHER
RN, BSN, EdD, CMA (AAMA)
Allied Health Instructor

ROBERT M. FULCHER
BS Chem, BSPh, RPh
Pharmacist
CVS Pharmacy
Waynesboro, Georgia

CATHY D. SOTO
PhD, MBA, CMA (AAMA)
Professor and Program Director
Medical Assisting Technology Program
El Paso Community College
El Paso, Texas
3251 Riverport Lane
St. Louis, Missouri 63043

PHARMACOLOGY: PRINCIPLES AND APPLICATIONS, THIRD EDITION ISBN: 978-1-4377-2267-3

Copyright © 2012, 2009, 2003 by Saunders, an imprint of Elsevier Inc.

No part of this publication may be reproduced or transmitted in any form or by any means, electronic
or mechanical, including photocopying, recording, or any information storage and retrieval system,
without permission in writing from the publisher. Details on how to seek permission, further
information about the Publisher’s permissions policies and our arrangements with organizations such
as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website:
www.elsevier.com/permissions.

This book and the individual contributions contained in it are protected under copyright by the
Publisher (other than as may be noted herein).

Notices

Knowledge and best practice in this field are constantly changing. As new research and experience
broaden our understanding, changes in research methods, professional practices, or medical
treatment may become necessary.
Practitioners and researchers must always rely on their own experience and knowledge in
evaluating and using any information, methods, compounds, or experiments described herein. In
using such information or methods they should be mindful of their own safety and the safety of
others, including parties for whom they have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check the
most current information provided (i) on procedures featured or (ii) by the manufacturer of each
product to be administered, to verify the recommended dose or formula, the method and
duration of administration, and contraindications. It is the responsibility of practitioners, relying
on their own experience and knowledge of their patients, to make diagnoses, to determine dosages
and the best treatment for each individual patient, and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors,
assume any liability for any injury and/or damage to persons or property as a matter of products
liability, negligence or otherwise, or from any use or operation of any methods, products,
instructions, or ideas contained in the material herein.

Library of Congress Cataloging-in-Publication Data

Fulcher, Eugenia M.
Pharmacology : principles and applications / Eugenia M. Fulcher, Robert M. Fulcher,
Cathy D. Soto.—3rd ed.
    p. ; cm.
Includes index.
ISBN 978-1-4377-2267-3 (pbk. : alk. paper)
I. Fulcher, Robert M. II. Soto, Cathy Dubeansky. III. Title.
[DNLM: 1. Drug Therapy—Problems and Exercises. 2. Pharmaceutical Preparations—Problems
and Exercises. WB 18.2]
LC classification not assigned
615′.1—dc23
  2011035202

Executive Editor: Susan Cole

Associate Developmental Editor: Laurie Vordtriede
Publishing Services Manager: Catherine Jackson
Senior Project Manager: Mary Pohlman
Senior Book Designer: Amy Buxton
Working together to grow
libraries in developing countries
Printed in the United States www.elsevier.com | www.bookaid.org | www.sabre.org

Last digit is the print number: 9 8 7 6 5 4 3 2

W
e dedicate this third edition to our parents, Harold L. and Rosabel L. Mills and Robert
M. and Lucy F. Fulcher, who gave us dreams and the desire for and the means to
obtain professional educations, only wishing you were here to be proud. To our sons,
Lee and Gene, and our grandchildren, Mac and Allie, we know you have dreams and we hope you
will succeed in reaching them. We thank each of you for the love and support that you have
provided during the preparation of this text. To our extended family, we appreciate all you have
done to assist us. We also thank our students who have been supportive when we needed time to
complete manuscript. To the many friends and instructors who have had suggestions, we have
tried to include as many as possible so your dreams can be found within the text. To all allied
health professionals who will use this text, may you achieve your professional dreams as both of
us have, for almost fifty years—they can come true. You are the reason this text has been written—
to provide the needed educational background for patient safety in health care.
Bobby and Genie Fulcher

I
dedicate this third edition to the two men in my life for whom I will always be deeply grateful
because of their unconditional love, encouragement, and continuous support in both my
professional and personal lifelong journey. It was my father, Edward D. Dubeansky (1928-
2009), a Korean War Veteran and paraplegic before I was born, who taught me to love God and
family, to have dignity and respect toward everyone, to be self-disciplined, and to be a volunteer
throughout life. My husband, Jose Soto III, has been by my side and my moral support for
35 years, who shared with me raising two beautiful daughters (Jenny and June), who drives me
cross country for seminars, workshops, volunteer work, and of course to see our grandbabies
(Victoria Anna, Fernando Miguel, and Murdock Lee), sons-in-law (Fernando and Ed), and all my
siblings and their families. I will always treasure our times together!
Cathy D. Soto
Reviewers
Patricia G. DeBenedetto, CMA-CHI Donna Larson, EdD, MT (ASCP) DLM,
Medical Assistant Program Instructor, CPR Instructor MS, BA, BS
Department of Medical Programs Dean, Allied Health
Medical Career Institute Allied Health Division
Ocean Township, New Jersey Mt. Hood Community College
Gresham, Oregon
Debra Downs, LPN, AAS, RMA (AMT)
Program Director, Instructor Terri L. Levien, PharmD
Department of Medical Assisting Clinical Associate Professor
Okefenokee Technical College Department of Pharmacotherapy
Waycross, Georgia Washington State University College of Pharmacy
Spokane, Washington
Glenda Hatcher, BSN, RN, CMA (AAMA)
Medical Assisting Program Director Ashley Moses, PhD
Department of Allied Health Assistant Professor of Mathematics
Southwest Georgia Technical College Mary Baldwin College
Thomasville, Georgia Staunton, Virginia

MaryAnne Hochadel, PharmD, BCPS Joshua J. Neumiller, PharmD

Clinical Assistant Professor Assistant Professor, Pharmacology
Department of Pharmacy Practice Washington State University
University of Florida Spokane, Washington
Gainesville, Florida;
Clinical Pharmacist Karen Snipe, CPhT, MEd
Department of Pharmacy Services Department Head, Pharmacy Technician,
Bayfront Medical Center Program Coordinator
St. Petersburg, Florida; Departments of Allied Health and Diagnostic &
Editor Emeritus, Gold Standard Imaging Services
Tampa, Florida Trident Technical College
Charleston, South Carolina
Paul Juang, PharmD
Assistant Professor, Pharmacy Practice Rebecca Wright, EdD
St. Louis College of Pharmacy Assistant Professor of Mathematics
St. Louis, Missouri Oakland City University
Oakland City, Indiana
Julie P. Karpinski, PharmD, BCPS
Director, Drug Information Sandra Wright, MEd, PhD
Assistant Professor, Pharmacy Practice Campus President
Concordia University Wisconsin Department of Administration
Mequon, Wisconsin; Atlanta Medical Academy
Drug Information Pharmacist Atlanta, Georgia;
Froedtert Hospital CEO, Moaney Wright & Associates
Milwaukee, Wisconsin Atlanta, Georgia

Renee Koski, PharmD, CACP

Professor, Pharmacy Practice
Ferris State University College of Pharmacy
Marquette, Michigan

vi
Preface

T
he goal of the third edition of Pharmacology: Prin- in the place of employment and with the rules at the site
ciples and Applications is to help the student master of practice. Remember that local requirements may vary
not only the principles of pharmacology but also from those seen in this text, and local requirements
the critical thinking skills necessary to transfer this should always set the basis for practice.
knowledge base to administer medications for patient The organization of material by body system lends
safety. We have sought to achieve this in various ways, itself to the study of disease processes along with the
some of which are found in other pharmacology texts study of medications used to therapeutically and pro-
and others of which are unique to this text. phylactically treat these diseases. This comprehensive
The purpose of this text has remained constant—to study helps students achieve additional competency and
provide an introduction to pharmacology that gives critical thinking skills and helps prepare them for exami-
allied health professionals an in-depth basic knowledge nations that are required for licensure or certification.
about medications that are used on a day-to-day basis in The depth of material is sufficient for critical thinking
the ambulatory and some inpatient care settings. Dose skills that can be readily transferred to patient care and
amounts are shown as a single dose because administra- patient teaching. If a review of materials such as anatomy
tion in these settings would be in that form. The text and physiology are required for understanding, students
includes information on medications used to stabilize a should use an appropriate text for this information.
patient in outpatient emergency situations but not medi- Because pharmacology is a specific science associ-
cations frequently used in inpatient emergency situa- ated with many distinct health care fields, interaction
tions, such as intensive care units. Similarly, because among the professionals who work in these various
medications that are used on a “stat,” or immediate need health care settings is essential to ensure patient safety
basis, in specialized intensive care units, and in surgical and compliance with therapeutic care. This profes-
areas are not typically used in ambulatory care settings, sional intercommunication creates safeguards for the
information about these drugs is not included or only patient as well as checks and balances among profes-
limited information is provided. sionals. It is essential for each professional—health
As the world of medicine has evolved from a predomi- care provider, pharmacist, and allied health profes-
nately inpatient setting for acute and chronic care to sional—to keep his or her medication knowledge as
ambulatory care for many conditions previously seen on current as possible. In addition, communication
an inpatient basis, allied health professionals have inte- among health care workers is important because of the
grated the skills needed to complete tasks ordered by the multitudes of medications released each year and the
health care provider to provide safe, necessary patient increase in indications for usage of established medica-
care in the ambulatory setting. Because the tasks health tions. Having all medications in this text is not realis-
professionals are legally permitted to perform vary from tic; however, the authors have tried to make the list of
state to state, it is important for all health care personnel drugs for this text as current as possible; the constant
to understand state statutes in their particular employ- release of new medications by the Food and Drug
ment setting while being aware of any changes as they Administration and the new indications for older drugs
occur. This text is designed to provide a solid background makes this impossible. Always check current informa-
in pharmacology as well as the necessary skills to admin- tion for any changes that may seem to have occurred.
ister prescription and over-the-counter medications The allied health professional must also be careful to
safely and with in the scope of practice. This is basic ensure that correct medications are being charted in
knowledge for a broad audience so the allied health the medical record and are being relayed to the phar-
professional should keep current with medications used macist as allowed by state laws.

vii
viii Preface

through the skin and mucous membranes), and ending

ORGANIZATION OF THE TEXT with parenteral routes (by injection).
Procedures for drug dose calculation and adminis-
Pharmacology: Principles and Applications has been orga- tration are presented in storyboard format, displaying
nized in a student-friendly manner intended to facilitate illustrations that present specific steps to assist the visual
the study of pharmacology. Each chapter contains special learner. The Procedure Boxes include icons that repre-
elements that help make learning fun and easy. sent OSHA-mandated and methodology-related proto-
cols that should be followed prior to administering
medications. The following icons are presented:
Section I: General Aspects of
Pharmacology
Handwashing required
Section I, an introduction to pharmacology, gives a short
history of the field and how it has changed our world. Gloves required
To ensure safety for both the student and patient, specific
legislation and ethical issues related to pharmacology are Sharps container required as indicated
stressed. The discussion also includes basic pharmacol-
ogy terminology and provides an understanding of how Use the 3 “befores” and 7 “rights”
drugs are used by the body and the skills needed to read of medication administration.
and interpret medication orders and document medica-
tions appropriately.
Section IV: Pharmacology for
Multisystem Application and
Section II: Mathematics for Section V: Medications Related
Pharmacology and Dosage to Body Systems
Calculations
Sections IV and V are directly related to medications.
Section II has a basic math review for the student who Section IV presents medications that affect multiple
needs to practice rudimentary math skills and necessary body systems, such as analgesics, immunizations, anti-
content to calculate drug dosages so that medications are microbials, and antineoplastics. The rapidly growing use
administered safely. The discussion covers the three of herbs and nutritional supplements and their interac-
systems of measurement used to prescribe medications tions with other medications are also addressed. Section
and the conversions needed to change a medication V discusses medications specific to body systems. Tables
order from one system to another. The calculation of are included in these sections that present both generic
dosages for adults and children and other special appli- and trade names for drugs, usual adult dosage, typical
cations are also discussed. routes of administration, and drug interactions.
Check Your Understanding math review boxes Each chapter in these sections lists the Common Signs
allow students to check the application and calculation and Symptoms of Diseases found in the applicable
concepts that they have learned as they work their way body system. These can be compared to the Common
through each math module (answers to these sections Side Effects of Medications commonly prescribed
are found in Appendix A). for the diseases found in that system so that through criti-
Pretests gauge students' knowledge before each math cal thinking skills, the allied health professional will have
chapter material is covered, allowing both instructors the needed background for questioning a patient to
and students to identify areas of weakness. Further review provide the information needed for the evaluation by
of the material can be accomplished by retaking the the health care provider. Using these tools, the allied
pretest before completing the review section. This will health professional can learn to assist in distinguishing
indicate areas that need extra attention prior to complet- between disease progression and medication reactions by
ing the chapter-ending Review Questions that cover asking pertinent questions. This allows the allied health
chapter concepts related to the ambulatory care setting. professional to teach patients which signs and symptoms
must be reported to the health care provider and which
they might expect as side effects—information that is criti-
Section III: Medication Administration
cal for patient education. Medication safety is best rein-
Section III presents the general principles of medication forced when the patient becomes an active member of the
administration. The discussions about routes of medica- medication administration process.
tion administration are organized according to the Easy Working Knowledge tables list medication
CAAHEP/MAERB and ABHES curriculums, starting with classifications used with applicable body systems or sys-
enteral (routes that begin with introduction into the temic medications. This listing, which helps locate dis-
gastrointestinal tract), followed by percutaneous (routes cussions of specific medication types, corresponds to the
 Preface ix

quick reference of drug classifications found inside the questions on how a variety of realistic situations would
text’s cover. The student can learn to group medications be handled safely by the allied health professional.
by systemic disease processes to help with accurate docu-
mentation of medicines. When the student knows the
medications used for specific body systems and specific INSTRUCTOR’S RESOURCE
disease process, the potential for drug errors is reduced. MANUAL WITH TEACH
Icons representing the body systems are located next
to associated medication names. These icons, listed The Instructor’s Resource Manual with TEACH, accessed
below, help students begin to identify drugs as they through the Evolve web site, contains answer keys to the
relate to particular body systems. text and workbook, a test bank and answer key, as well
as detailed lesson plans and lecture outlines. The lesson
Medications used for sensory system disorders plans are linked to each chapter and are divided into
50-minute units in a three-column format. The lecture
Medications used for infectious diseases outlines in PowerPoint pro­vide talking points, thought-
provoking questions, and unique ideas for lectures. The
Medications used for immune system disorders electronic resource includes all the instructor’s resource
manual assets plus the test bank in ExamView, and
Medications used for endocrine PowerPoint slides to help the instructor save valuable
system disorders preparation time and create a learning environment
that fully engages the student.
Medications used for musculoskeletal
disorders
PURPOSE OF THE TEXTBOOK
Medications used for gastrointestinal
system disorders Our goal has been to provide a student-friendly pharma-
cology text that helps the allied health professional
Medications used for respiratory tract disorders administer medications accurately and safely and to
teach patients to administer ambulatory medications
Medications used for circulatory disorders safely at home. The book’s early introduction of drugs to
their corresponding body systems is designed to help the
Medications used for blood disorders student begin to recognize the drugs that are most often
used with a specific body system. The introductory
Medications used for urinary system disorders section on body system and systemic-related medica-
tions is designed to assist the allied health professional
Medications used for reproductive accurately record information about medications admin-
system conditions istered for diseases of that system and to obtain informa-
tion from the patient that will assist the health care
Medications used for mental disorders provider in deciding on the appropriate medications for
the specific patient. This multidisciplinary process must
Medications used for neurological conditions be directed to each individual patient, with the health
care provider, pharmacist, and allied health professional
Medications used for pain management providing a system of checks and balances for patient
safety.
Medications used as antineoplastics As authors, we hope that the third edition of Pharma-
cology: Principles and Applications provides students with
Medications used as nutritional supplements an enjoyable and basic in-depth way to learn how to
administer medications safely, document medications in
Medication used for substance abuse the medical record, and relay needed information to
other health care professionals and patients who are a
part of the medication therapy process.

WORKBOOK Acknowledgments
The Workbook includes multiple review questions and Having worked in the medical field for almost 100 years
practice problems to not only promote continued learn- combined, we have seen the importance of having a
ing, but to also offer thought-provoking, critical thinking strong background in pharmacology to ensure patient
x Preface

safety and education. As health professionals—an have helped you with teaching the information to your
ambulatory care nurse and a pharmacist—we under- students.
stand that safe patient care is only as strong as the indi- We also must thank some special individuals who
viduals involved in medication administration. This have provided background materials and direction, as
book is intended to provide the foundation for that well as moral support when needed. To our personal
knowledge. physicians who provided much guidance in the choice
We give special thanks to some special people at of medications to be presented, thanks. To Don Balasa
Elsevier. To Jamie Augustine and Laurie Vordtriede, our at the American Association for Medical Assistants, we
Developmental Editors, who have been our friends, owe our gratitude for providing information about the
mind-readers, and consultants, we give a big thanks for medical practice acts of the states. To Judy Jondahl at
a job well done. To Susan Cole, Executive Editor, we Medical Assisting Education Review Board, thanks for
acknowledge the time you have taken to ensure the text being a friend who gave us moral support during this
is as it should be. We do appreciate your understanding busy time. To all who have provided encouragement and
of time needed to complete two text revisions at the guidance, a heartfelt thanks. Special kudos to our sons,
same time. To Andrew Allen, Vice President and Pub- Lee and Gene, for their patience and support throughout
lisher, your continuous support of our endeavors is so the entire project. To our grandchildren (and they are
appreciated. You have been a guide that has produced a really grand), Mac and Allie, you have been the light that
light to increase our writing abilities for many years. To made the long days seem shorter. Thanks for being such
Sue Hontscharik, Administrative Assistant—you are great children during the times that we were busy writing
friend in need and a friend indeed. Your encouraging and you were visiting with us. Through the love, under-
words on so many occasions helped us complete this standing, and patience of all who have helped with this
text. To Mary Pohlman in production, you have been book, our dream continues to be a reality—a reality
wonderful to work with; you have spent hours being that we will assist allied health students now and in the
sure the text is the best it could be and we do appreci- future.
ate you. We thank all of the Elsevier staff for being Genie and Bobby Fulcher
there for us when we needed assistance. You are the
greatest! I wish to acknowledge Man Tai Lam, MD, El Paso, Texas,
To our reviewers, we say a big thank you for provid- in Private Practice for Internal Medicine and Infectious
ing guidance throughout the publication of this text. To Diseases, and Medical Director for El Paso Community
those who reviewed previous editions and gave sugges- College’s Medical Assisting Program. For the past 12
tions for the new edition—know that we have tried to years, Dr. Lam has participated in every Advisory Board
incorporate your ideas. To those who reviewed the meeting. Thank you, Dr. Lam for your continued words
chapters during the production of this edition, thank of encouragement and professional support.
you for providing many ideas and guidance for this I would also like to acknowledge my co-authors,
text you are special people to take time to give us the Genie and Bobby, as well as the staff at Elsevier for all
needed assistance. To the instructors who have used their hard work that went into this edition.
the text and have provided guidance we hope that we Cathy D. Soto
 Preface xi

Critical Thinking Scenario

These scenarios stimulate class discussion by introducing the real
g
drug-dru

armaco
logy actions
effect on the receptor
. These
site on i-
es, med
the world aspect of pharmacology to students.
l Aspe cts of Ph ns , or ha
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on how e instanc th at
I Genera ac tio pe nd In so m ug
other dr drugs
s
SECTION n rec- tions de s fit together.
nals ca interac tions of ses,
36 ofessio the drug p the ac other ca locally,
care pr cell and e given to sto the body. In s work
cti on , health e ea ch ns ar to e dr ug ter ac-
of the rea ctions. becaus ffer- catio mental Som g in
causes varies di be detri ralize toxins. lly. Drug-dru e foods
adverse
rea ted and eds and might to neut ica ar
ognize complica different ne gic determi- system so important rug CHAPTER 1 Intro
age is th lo are given others work g. Al trient-d g duction to Phar
Drug us individual wi mes psycho be careful to where as e-threa
ten in m e nu
nes. So n disease-dru • Required pha
macology and
Its Legal and Ethic
is an someti nal mus
t
tailed n be lif medici al Aspects
patient iologic and ofessio must take a de tions ca interfere with ngerous, as
ca
effects associate
rmaceutical firm
s to report all 9
ph ys alt h pr en tal n da adverse
ent ied he l and trim that ca ns can be d with thei • Comprehensiv
The all as an individua ry to avoid de intervals. r drugs at
regular e Drug Abuse
nants. sto tio
interac ns. of 1970 (also Prevention and
patient ogic hi • Required that Control Act
see each d pharmacol s. together, interac
tio all new drugs calle d Controlled
l an reaction e given e before approval be tested for 1970) Substances Act
medica ts and adverse edications ar tion, decreas . toxicity
• Repealed the of
ec e m ac
side eff two or mor other’s 50 laws pass
ed between 1914
When one an Did You Kno 1970 concerni
ng drug control. and
n in crease E S w? • Regulated
they ca C IS ing the manufacture,
EXER ted drink In the late 1930 ing of distribution,
and
K IN G s sulfanilamide, drug s with the pote dispens-
 she star en, although an antibacterial • Indicated
T H IN . Since ris raspberry-flavored agent in a drugs that had ntial for abuse.
IC A L it juice el has ns. base, was a letha potential for
C R IT grapefru olesterol lev the medicatio was not known
to be toxic. With
l elixir because
the base
placed these
medications abus
ch da y with , he r ch ct s of fects? chemicals used no need for appro by potential in five schedule e, and
tions ea ications the effe side ef e in manufacture, val of safe for abuse or s sorted
Scenar
io medica lowering med is to lower tential inks th alcohol base that the company did indi scrim addi ction
ke her ol- juice ving po cause she th was indicated for not use an inate use of to prevent
es to ta g cholester of the t be ha be using an indus an
trial-strength toxic elixir, but made the drug
use. these drugs by
nes lik kin effect nes migh ing her juice
limiting their
Mrs. Jo juice and ta ow n rs . Jo glycol—a major liquid solvent, • Required secu
it d. A kn ine if M urs after drink be your ingredient in antif diethylene rity of control
grapefru s not change de te rm
, what
w ou ld died after inges reeze. More than led substances
t ha ask to ne 2 ho ting less than an 100 children anyone who
dispenses, rece
her die ld you ke her medici respond? the juice excess of 350 more ounc e of ives, by
ns wou ta you inking children were poiso the medicine, and in
controlled subs sells, or destroys
t questio ks if she can How would keep dr tances using
special DEA form
1. Wha as is. tions to ned. show current
inventory.
r medica
s to
. Jones r arthrit • Regulated
2. Mrs ruit helps he t changing he use of controlle
grapef e asks abou • Durham-Hump
hrey Amendm
legitimate han
dlers to help
d substances
to only
n sh _____ ent (1951) repl reduce the wide
3. Whe se? ______
of 1938 aced laws illicit use of thes
e drugs. spread
respon ______ • Indicated regu • Provided for
______ _____ lations for pres prevention of
______ ______ cription orders dependence drug
______
______
______
______ ___
pensing by desi
gnating prescrip or dis- and for treatmen abuse and drug
N S __ ______ __ ______ __ __ ______ ications, with tion and OTC of abusers and t and rehabilit
ation
E S T IO
__ __ __ labeling of pres med- drug-depende
U drug? __ ______
__
______
__
_____ being met by crip • Two importa nt persons.
W Q t? A sa fe
____ __ __
____ __ __
____ __ __ placing an “Rx” tion medications nt agencies had
R E V IE tiv e in gredien __ __ ______ __ __ ______ __ ___ ______ m ost manufacturer’s on the label
of the
ment of this act: a role in the enfo
rce-
ug? An
ac ______
__
______
______
______
______ organ is • Required that
bottle.
The Bureau
t is a dr ______ Which


1. Wha ______ ______ ______ cretion? ______

____ all prescription of
Drugs (BNDD) Narcotics and Dangero
______ ______ ______ d in ex ______
Federal law s be labeled “Cau
______ ______


______ ______ ______ e involve ______ ___ prohibits disp

ensing without :
tion , in existence us
______ __ __ __ __ ns ar __ __ __ __ prescription.” 1973, with the from 1968 to
______
____
______
____ What or
ga ______ ______ a following resp
______ ______ e they? ______ ______ _ • Designated To onsi bilit
______ ______ ______ regis ies:

the OTC drug ter all persons
______ What ar ______ ______ ______ s that were cons who manufac
______
______ routes. ______ ______ ______ ______
sufficiently safe idered pense, prescrib ture, dis-
ted by four __ __ ______ __ __ ______ __ __ ______ __ __ __ • Required warn not to require a prescription subs
e, or administ
er any
cre __ __ __ __ tances. controlled
Dr ug s are ex __ __ ______ __ __ ______ __ __ ______ __ __ ______ __ __ _ • Kefauver-Har ing labels on
drug packagin
.
lved? __ __ __ ______ To provide for
2. ______ ____ ____

ris Amendment g.
ly invo ______ ______ ______ ? ______ • Was passed (1962) necessary revis
common ______ ______ ______ reaction ______
___ and classes of ion of schedule
______ ______ ______ allergic ______
because drug controlled drug s
______ ______ ______ , and an ______ large profits and companies were 
The Drug Enfo s.
______ __ __ ______ __ __ ______ cti on __ __ __ __ __ __ ___ engaging in misl making rcement Adm
inis
____ ____ rse rea ______ ______ false drug prom eading and even was established tration (DEA)
______ ______ an adve ______ ______ ___ • Required prov otions. in 1973 to cont
______ ______ e effect, ______ ______ ______ and enforcem inue regulatio
______ ong a sid ______ ______ ______ en effectiveness ent of manufac n
______ ______ ______ ______ of a drug befo turin
______ ces am ______ ______ ______ s? Anti- keting, with
old and new re mar- ing of dangero
us and potentia g and dispens-
e differen ______ ______ ______ agonist drugs requiring
W ha t are th __ ______ __ ______ __ ______ ist s? Partial __ ____
testing.
proof
(See section on
DEA that follo
lly abused drug
s.
__ __ __ on __ • Poison Prev
3. ______ ______ ______ es? Antag ______
____ ention Packagin ws.)
______ ______ ______ eptor sit ______ _____ g Act of 1970
______ ______ ______ rk at rec ______ ______
• Created stan
______ _______ ists wo ______ ______ Did You Kno dards to ensu
______ ______ do agon ______ ______ _____ and OTC med re that both pres
______ __ __ ______ . Ho w __ __ __ __ __ __ __ __ __ w? ications were cription
__ ____ ____
______ tor sites ______
______ ______ ______ ___ The manufacturer packages. in child-resistan
______ us recep ______ ______ ______ of thalidomide, t
at vario ? ______ ______ ______ ______ pregnant women a hypnotic that • Drug Listing
s work bolites ______ ______ ______ _ early in pregnancy was taken by Act of 1972
4. Drug rs? Antimeta __ __ ______ __ __ ______ __ ______ __ __ ______ drug for the naus , claimed it was • Established
National Dru
Chela to __ __ ____ __ __ __ __ ea of pregnancy a miracle
dotes? __ __ ______ __ ______ __ __ ______ __ __ ______ ___ __ ___ realizing the asso and a sleeping FDA to identify g Code for use
by
____ ____ __ __ __ __ __ __ __ ciated dangers of aid without a drug’s manufac the
__ __ ______ __ ______ __ __ ______ __ __ ______ __ __ ______ leading to a wave severe deformitie the drug form
ulation and the turer, including
__ __ __ __ __ __ __ s in fetuses,
______ ______ ______ ______ of “thalidomide ing, by using size of the pack
______ ______ ______ ______  born with severe babies.” These infan a unique and ag-
______ ______ ______ ______ deformities, espe ts were permanent code
______ ______ ______ nant women in the cially of limbs. drugs.
______ ______ ______ Northeast were Some for
______ ______
______
______
______ tragedy was more prescribed the drug, preg- • Drug Regulatio
n and Reform Act
______ ______ a “might-have-be but the • Allowed for of 1978
__ __ __ __ widespread, actua en” catastrophe briefer
____ ____
______ tration employee
l one because a
U.S. Food and Drug
than a to allow for faste investigation of new drug
______ r access by the s and
______ information befor
was suspicious
of the drug and
Adminis- • Orphan Drug consumer.
e approving it for wanted more Act of 1983
Sadly, the chem use in the Unite • Established
ist who developed d State in response to
suicide. the drug later comm s. because of pote
ntial dangers
the removal
of drugs
itted • Established or the lack of

End of Chapter Critical Thinking Exercises and Review funding for rese research.
drugs in the arch for use
treatment of of these
through gran rare chronic
t monies and illnesses

Questions
tax incentives
to find

Did You Know? box

End of chapter Critical Thinking Exercises and Review Questions offer
Did You Know? Boxes provide enrichment facts about relevant topics of
challenging, thought-provoking questions on how a variety of realistic
interest, such as new medical trends, history, diagnostics, treatments,
situations would be handled by the allied health professional.
and diseases.
Clinical Tip box
Clinical Tip boxes provide information about the clinical
of Phar
macolog
y
MAJOR
DRUG AC
TIONS administration of medications.
l Aspects 2-5 FOUR E
I Genera TABLE EXAMPL
SECTION ON (Detrol)
28 DEFINITI tolterodine s the urge to
ps ACTION ce s the de presse
n, ste Re du
an t Facts , an d excretio includ- De pre ssant tiv ity of the vo id 56 SECTION I Gene
ac tin)
Import oli sm factor s
, metab t on many gender, and body fun
ction in (Dilan ral Aspects
tribution phenyto s seizure of Pharmacolog
rption, dis dependen y


tion, depresse
• Abso process drugs, are te of administra
used to sta te, rou in the ac tiv ity
mental patient. culating stimulat
e CLINICAL
ing age, l condition of the ount of drug cir Laxatives
TIP
ca am The patient’s diet
the physi od level is the of the Increase or
s body peristalsis mics should be discussed Time of Ad
ministratio
g blo ich half glyce to ascertain if as part of the medi n
• The dru eam. time at wh . Drug half- Stimulan
t
function Oral hypo the pancreas dietary considera cal history
dru g is the va ted selections. tions are signi Drugs should
bloodstr sage of a and ina cti
feren t for activity stimu lat e ficant for drug be taken at the
lf-life do tabolized ge, is dif insulin sician. Some time ordered
• The ha se has been me g the safe dosa to release ex) stomach, whe
drugs need to
be taken on
by the phy-
initial do al in establishin there- cil (Efud reas others requ an empty
nti kidneys; fluoroura skin lesions for testinal tract. ire food in the
life, esse ly via the duces irritates Gender Stimulants shou gastroin-
ch dru g. mo st common se nt. Pro of n of the sleep. Body func ld not be take
n just before
ea
ex cre tion occu
rs
cti on must be
pre
Irritant symptoms n destructio side effect Women may as the body adju
tions change
with the time
• Drug al fun tio a of
uate ren inflamma lesion as ses the medications
react more stron
who work at
sts to periods
of work and rest.
day and
fore adeq ol increa because of thei gly than men to some night and sleep
at site of Ichthamm tion of boils proportion of r smaller size take medicati in the day prob People
n inflamma body fat. Rem and higher ons different ably will
applicatio a reservoir for ember that bod work hours. ly than those
ns e cream with daytime
ru g Actio Hy dro cortison ic skin drugs’ excretio
lipid-soluble
medications,
y fat can be
D allerg
amics— action n. slowing the
Soothing ion, soothes
acodyn works or nt reaction
s Route of Ad
Pharm Body a drug i- Demulce for irritat
oothes cra
cked ministratio
n
for how body’s chem
in the e term
ics is th the body or th ic terms, drug
e usually to Lanolin sm decreases
d Genetics
The nearer the
drug is administ
yn am ski n or ski n an or mucous mem ered
acod
Pharm nism of action pharmacodyn
in am
oc esses in co us tat ion branes, the faste to the blood supply
ha gic pr n mu irri Slight differenc and distributed r the drug is
its mec ugs. In physiolo Drugs ca es es (see Table 2-4) absorbed
on to dr ical or ed by disease. s membran caused by gene in the body’s metabolic .
cal reacti ect biochem dy organ tic predispositio processes
aff ges caus t give bo more sensitive n make som Environment
actions or control chan but they do no or
pharmacokineti resistant to certain medicati
e people
acts,
the body way the body . r local
or cs are affected. ons, and Because local
modify
the function be eithe adminis- weather cond
es a new ug may of vessels, with itions affect the
and tissu of a dr d to the site - heat causing size of blood
action e applica and cold caus dila
ers Th e site of tio n is limite rrounding th n are Diseases ing constriction tion of blood vessels
TIP ics ref l ac su actio temperature of vessels, envi
NING acodynam ic. Loca es immediately ns with local effect is influences drug ronmental
LEAR site. Pharm the body. system d tissu icatio e drug Some diseases less oxygen is effects. At high
n at a in n an of m ed he n th in is- , especially rena available, whic altitudes
explosio e” into action tratio ples
e; exam topical cream st at the site of
s. W adm in blood. For h affects drug
causes an d impair body func l and hepatic the patient with distribution
xplod tion sit nous an disorders,
Dynamite n, as drugs “e d ju tions, including
or rays an dy, not Intrave r tion of medicati metabolism and smoking envi respiratory diso
to drug ac
tio down nasal sp hout the bo stemic action. circulation fo ons. Renal dise
ases reduce excr excre-
ronm ent may be of rders, a


r slow dy ug mic some drugs. If tion effectiven importance in

lly eithe otect the bo felt thro is considered
sy
ch syste eous drugs m
ay dosage is not etion of ess; the patient with medica-
dr ug s usua d pr es th e it ay s rea an be renal insufficie adjusted in a ing prolonged employment
s an ib tration, drugs alw al and subcut me drug may ncy, toxic leve person with stan requir-
e ac tions of cell processe le 2- 5 descr us cu lar sa An low doses of ls may be reac medications for ding may have the need for
Th (Tab intram ereas or l effects. The med hed even with arthritis. One increased
ordinary agents the ect, wh
ect.
local eff psules diseases because ication. The same is true mental factors of the greatest
speed up ns of foreign enters their eff stemic or lo
ca
mic or ca the liver is the of hepatic is economic: environ-
tio ). a drug cted. e sy r syste tured in l use. lism of most major organ for often cannot patients livin
from ac r drug actions tion. When is expe th produc r eithe manufac loca drugs (see Cha metabo- afford medicati g in poverty
four m
ajo gle ac ction wi tured fo which is for topical or pter 2). between med ons and mus
ug has a sin chemical rea s differently, e manufac is Benadryl, am bo dy distant patients do not
ications and
food. t choose
No dr
ictable drug ng. Th e it
exampl ic use and as
a cre th e
a part of have a rem
ote eat an adequate Also, many of these
a pred react to s occurri e ect on administratio diet for safe med
body, viduals emical reaction pected respons m
for syste that has its eff ration is said
to der the Mental Sta n. ication
r, indi aced un ris in te
Howeve predictable ch when the ex y eyes caused A drug e of administ gly ce rin, pl a pe cto
s ter e sit tro The patient with
many un effect happen stopping wa occur that ar m the pl e is ni s of angin Drug Depen
yl at s. fro ex am e sym pt om respond positivel a positive attitude is mor dence
desired ch as Benadr her effects th e side effect effect;
an
the acut e drugs ich
have y and potentia e likely to
occurs,
su
wever,
ot ts ar
dy syste
m, to treat n, som tions. The pati te the effects Physical or
ed effec tongue ic actio hormone, wh r ent of medica- psychologic
ies. Ho
by allerg le but not th
e desir e than one bo e unde- t. system not take medicati who is depressed or despond increased drug drug dependen
ect mor us
may ca th Bena- the hear than having as thyr
oid
d gland
fo on and may not ent may use. The patient ce leads to
predict
ab
ica tions aff specific and wi Rather ac tio n, such in the thyroi Strong emotion
s such as ange
respond to som
e drugs.
tion to achieve
the same effec
consumes mor
e medica-
em ed cu rs of n ts, causing an
Becaus n may not be siness that oc peutic actio
n
specific
sites of actio thyroidism. scribe how worry will have r, fear, jealousy, danger of over
dosage or und increased
ow era g ary site hypo de an effect on met or extreme erdosage.
the actio nses. The dr metimes a th ect. Lowerin ha s a prim lacement in categories that teractions at ologic processe abol
s. A strong belie ism and other physi-
po so eff e e rep into in
sired res pected and is ed side uce sid hormon may also fall or the helpful may f that a drug Pat ien
ex a desir often red be dis- ication ns. influence resu
lts positively; will be t Complian
dryl is mnia as ication will have to Drugs s to med ibes four actio patients with
negative feeli conversely, ce
th inso s respond descr ngs and mist Patient complia
used wi ge of the med s the drug may erse reaction the body lls. Box 2-4
decreased med
icinal effects. rust may have nce in taking
the do
sa m e case ec ts. (Adv er in this ep to r ce affects medicati med
on response. Dos ications as prescribed
so eff d lat rec
but in e
e of sid are discusse taken result in es missed or extra
effects, ca us History of varia
d be
continue to be more
severe Previous Me cooperation with tions in intended response doses
d dications variables as man medical therapy is needed,
. Patient
that ten Long-term use
of ual dexterity, but such
chapter
.) because of accu a drug can result in increase ity, mental state vision, intellect

Learning Tip mulation of the d effects , attitude towa ual capac-

result in a redu drug or alternati economic facto rd medications,
ced response rs (such as abil and socio-
developed a because the indi vely can a major role in ity to pay for
drugs) play
tolerance. In vidual has compliance. Loca
either
Learning Tip boxes give helpful hints about medications and about
need to be adju or far from pha tion—whether
sted for continui case the dosage may be a major
rmacies and pub close to
ng effectiveness. factor in com lic transportatio
pliance for n—can
deprived peop economically
le. In rural area
studying pharmacology. s, transportatio
n problems,
xii Preface

73
Important Facts box
tely

ing and Interpreti

ng Medicati on Labels and
Orders and Docu
menting Appropria
Important Facts boxes contain bulleted summations of previously
CHAPTER 5 Read rmation
and weight info

s
appropriateness,
before administ
dose, allergy,
ering medicati
ons in fillin
g standing
or transfer-
learned material that IIIprovide an at-a-glance resource for students to
206
SECTION
Abbreviation s for the patient Medica
ts about dard protocol tion Admi
consult in reviewing important topics.
stan pati ent has no
Important Fac orde rs and the nistratio
hand. facilities. That ld be such as n
ld be used as short other health rse reactions shou oi
mal or ntments, linim
• Only standard
abbreviations shou d by other health care  ring to would cause adve and standing orders throug
must be understoo condition that s h-th ents, an
The abbreviation ed. Stan dard protocol e, and docu ments Percutan d
eous ro e-skin medica lotions; and tra
ascertain designated plac direct
professionals. “loca l” abbre via- in a oses . After contact utes of adm tions, includi nsde
n is a legal docu
ment, and
ld not be should be kept for legal purp
becaus of the inistratio ng patch r- • Skin
• The prescriptio accepted, shou ed by a physician es, documentation in e of med n es. surfa
not universally eted if should be sign edur temic ad ease of adm ication with are used when crusting ce should be
tions, or those could be misinterpr ration or proc ed immediately. verse rea inistratio
the prescription drug administ ld be perform ference skin is • Skin and cakin thorou
ghly dr
inclu ded beca use reco rd shou s of som ctions. Becaus n and low ris desired surface g of th y to min
the medical system e topica e of ab k of sy should e po imize
not filled locally. viations are a
clear and ic actio l agents, so s- sk in sp be fully wder.
appropriately, abbre n temic di n and this ro rption rate di • Powd read open fo expose
• When used her on a prescriptio seases. so is se
ldom us ute has unrel f- er shou r powd d, with
writing orders, whet those Dr ld er appl folds of
concise means of ab ug s ab ed iab le lea vin be lig ication.
bal and mouth sorbed throug sorbed percu
for treati g a fine, htly du
n order . ts about Ver ng m or th in ste d
Important Facers
or medicatio , rec h muc taneous sy s- e abso layer. A on to the
when slo tum, and lu ous m ly, exce by incre rbent than a thin surfa
Standing Ord
ng
desired w and extende s, are slow ac branes of th
em pt asing ev thick lay layer of powd ce,
to the person who
read back . d med ting an e aporati er,
on of m reducing fricti is
er
should always be on of a ication d ar Soaks,
• Verbal orders ce of misinterpretati administ e used Compr oisture. on
If there is a chan For soak es se
gave the order. ration s,
presses, and Wet Dr
should be spelled. is s, com
ers ard protocols for TOPIC dine, th
Verbal Ord d health professio
nal drug, the drug name
ing orders or stand AL MED e followi and we
t
essing
s
an allie s use stand signe d by • ng po dr es
ician tells the physi- • Physician in writing and ICATI Active ints ap sings su
When the phys s to administer to a patient, . Both should be en ONS in
solutio gredient is
ply: ch as Be
order is for a certain situations followed as if writt Medica ta-
e orders are to be
drug tio
which drug or er (V/O). The such as ns may be ap • Thes n to leave a fil dissolved in
a verbal ord ication to be the physician. Thes idual patient. to reliev e substan m on th
cian is giving es the med for an indiv healt h warmth
pl
e itching ied topically ces e sk water-b
and designat , and route of as a single order cation, the allied (B ing a so
othing, contain a mild in.
ased
specific patient on, time ring any medi the of unsta engay), or fo (calamine lo r local effec
fo
of the med icati y given • Before admi
niste knowledge of used on cooling, astring
have a working r system tion) or t,
given, dose, form ers should not be routinel patches
ble an
gina us • Band bl ist ered or an d an en t, pr
n. Ord r and confu- professional must . Topica ing ni
ic actio
n, such
provide
ages m oozing tipyretic effec
ovid-
administratio ibili ty of erro possibil- reaction lm tro as relief ay be skin ar t when
use of the poss r is given verbally, the medication. ssional there is any s and fo edications ca glycerin oint applied soaked eas.
verbally beca health care profe Types r safety n cause ment to skin in so
, when an orde ld read it back to the • Always ask the of sh sy or be soak .
ed in th If appropriate, lution and
sion. However etation of orders. forms as skin preparati ould be appl stemic adverse
g the order shou ibility of confusion, ity of misinterpr cre ons rang ied as pr plastic e solutio an extre then
person receivin poss ings an am s, ointm escribe wr ap may be n. With a m ity may
gave it. If there is a r drug names, d soak ents, an e from such d. keep it
damp. placed wet
person who ds like othe tions s
such as for wound ca d powders to
common over th dressing, a
drug name soun spelled to reduce the e dressin
especially if the be discussi hormon re and wet dres Cream g to
name should al orders on of e patches s- s, Ointm
the medication ion of all verb Orders The area forms of m replacement for cond Creams ents, G
chance of erro
r. Documentat as possible to prevent Medication professionals of ed ication, th erapy. i- for topi
an d oi ntments el s, and Lo
d as soon allied health clean, sk
dry, an in for medica see (For tions
should be acco
mpl ishe on. “V/O” shou
ld order, telling written but tion ap Chapter 3.)
ca
and Trip l applications e semisolid
ar
n of the medicati A medication er, should be open ar d free preparati
inist ratio that the order drugs to administ ent for eas, an of infec plicatio le Antib ; exam
errors in adm writ ten order to show has which drug or It is not given to the pati being
tre
d dead tion,
tissue un rashes, encru ould be
n sh • Activ iotic Cr
eam
ples in on
clude Ne s used
the documen ted ally. inistra- skin sh ated. Before
e
• Crea ingredients fo or Ointmen
be indicated in any order not may be given
verb is used for adm less a ra sta osporin
n. Lega lly, the orde r cy, but rath er
ities. In ou topi sh or wo tions, ms are r cream t.
was verbally give . To ensure correctness, filling at a pha
rma
ambulatory facil called with wa ld be inspec cal medicatio used to s are in
rmed givin g the itals and ter. The ted for ns are und is skin. deliver
drugs di a water base.
not been perfo by the person of drugs in hosp orders may be before skin sh applied • Crea
tersi gned tion icati on ould be integrity and rectly to

6
coun tion conc ern- ’s office, med health pro- applica , ms are
should then be there is a ques the physician cols. The allied absorp tion be
cause so free of all so cleansed having absorb or into
as possible. If fication before
medica- or standard proto to follow these orders tion.
• Crea a cooling eff
ed into sk
order as soon
r, always get clari standing orders y When ap can ap resid
ues in and
to another the responsibilit s by hydrati applying topi
alter m ms and
ointmen t.
ec vanish,

CHAPTER
ing a verbal orde n or sending the order fessional has tice, which varie edicatio pyretics usually
l scope of prac ication orders
on is ne cal med n ts
tion administ
ratio in his or her lega transde ce • Oint , antimicrobial may be used
with
The six compon
ents of med rmal m ssary. The fas ications, adeq ments to deliv
health professio
nal.
state statute. chest, edicatio test site uate sk in gr are soft, s, and softeni er anti-
an ns is be for abso in edient fatty su ng com
are listed in Box
5-3. absorp d abdomen hi nd the ear. rp tio n ba se.
carried
in an oi
bstance
s
pounds
.
tio are the of
ers forearm n. Slowest sit next m Th • Oint l, lanol with the activ
Standing Ord assigned ICATION ORDERS
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and ste ts deliver drug
in, or pe e
orders that are PONENTS OF MED
sorptio d sites troleum
have standing a standing BOX 5-3 SIX COM
n are th
e thigh of rio s, such
Physicians may An example of in cont ds, to the su
ific instances. tic, such as
and
The ap act longer th rface of as antimicrob
for use in spec specific antipyre is waiting Patien

Math Review
th e skin ial
r mig ht be to give a feve r who 1. Date t Educ cream plicatio
n of
an a cre
am. to rem s
orde a high ation is descr
ibed in an antimicr
ain
, to a child with a standard 2. Patient’s name If medic for Com
acetaminophen s may also use ation Nitrogl Proced obial oi
ician. Physician to be used 3. Medication name of medication with gentl is indicated to plianc
e pectoris ycerin ointm ure ntment
to see the phys set of orders nt nistra - e red
heat the strokes. If the dru uce itching, it , is appl ent, us 13-1. or
h is a signed is the use of a
sup- 4. Dosage or amou tion (If no route is given, oral admi up ied ed
protocol, whic es; an example nistra of admin- skin, inc g is rubbe shou pe r arms, di rec in treatmen
proc edur re a colo n- 5. Route of admi t as to the route reasing d vigoro ld be applied tiv or thigh tly to the sk t of
with spec ific
/or an enema
befo e. If there is doub ld always ask the
itching. usly, fric ely free s. The in
site shou on the chest,
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
a laxa tive, and docu men tatio n
professional shou
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the
es- ion, the allied health ment res scar tis ld be dr
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nda rd allied heal th prof istrat the medi catio n.) dose is id su e. an d rel
oscopy. “Sta ical record; the ician who ordered Apply ap ue shou To
ld be rem prevent overd a-
ten inSthe med and performs phys tion ing To istered, plied. When
writIVE ician expects the efollowing
: ency of administra pical ca
drug be re should be troglycerin oi
ni oved be ose,
OB JE CT what the phys be capa
sional knows ter, you as ld are docuble men ing offic
doin
ofted 6. Time or frequ mixed numbers to Powde Medic nt
fore a
new
shouthey the fractions and rs ations ca tak
contact. use a headac en to avoid ment is admin
After studying
specific
chap
this task s exactly
wor should ascertain
ker nt • Converting To use
powders The pr he may contact -
heal th care equ ivale decimals . divid ing m oc with
improper, and
. The ing, and follow
these ste such as thos
ent is de ed oc
scribed ure for applyin cur from accid the
racting, multiply
ualser,
manprop
• Identifying . • Adding, subt ps: e for fu Gels, su in Proc
edure 13 g nitroglycerin ental
ngal co
fractions. mixed numbers decimals. stances ch as
K-Y Jel
g imp rope r fractions to perc ents to decimals. ndition
s, used fo ly, ar
-2. oint-
• Changin st terms. • Changing . drug to r lubrica e
tion or thick water-b
tions to lowe for mals to percents th
for bette e skin. Some
• Reducing frac st common denominator • Changing deci dividing percents. r covera
fo
gels ha r ease of appl ed sub-
as
lowe and
• Finding the • Multiplying percents.
ge that ve an oi
l in
ying ac
tive
tions to figure
lasts fo
fractions. tiplying, and divid
ing
• Using frac perc ents. r longer gredient adde
mul re
Patient Education for Compliance box
ract ing, to figu periods d
• Adding, subt ortions
mixed numbers
.
hs, • Using prop of time.
fractions and le numbers, tent
decimals to who
• Rounding ths.
Patient Education for Compliance boxes contain information pertinent
thou sand
hundredths, and

Proportion
KE Y TE RM
S
Improper frac
tion
Mixed number
Numerator
Proportional
Quotient
method
to instructing patients on medication administration and about possible
mon
Decimal
Denominato
r
Lowest com
denominato
mon
r (LCD)
Percent
Product
Ratio
Reciprocal side effects or adverse reactions.
Dividend Lowest com
) Proper fraction
Divisor multiple (LCM
tion
Equivalent frac

Chapter 6
PRETEST Extensive Math Review
All math chapters begin with a pretest that highlights material covered
37 ____________
 4. =
Mixed Numbersfractions. 4
Fractions and roper
wing as imp 73 ____________
Write the follo
3 ________
5.
9
=

to the lowest
terms. within the chapter. If a student masters the pretest with a 90% or
1. 4 = ____ wing fractions

2. 6 =
4
1 ____________
Simplify the follo le numbers.
Answers will
be who better, the student should then move on to the review questions. If a
144 = ____________ sionally used
student can score 90% or better on both, he or she is ready to move on
2
numbers.
wing to mixedApplication 6. are occa d skin infec- 17 CHAPTER Antimicrobials,
Convert the follo stem 72 lotions an is broader, inclu Antifungals, and
Multisy rs. Skin acne vulgaris, as powd cal
ers ding antibiotics, Antivirals
logy for ____ eal ulce 32atitis____ ics, and drug antifungals, anti 283
to the next chapter. Students are encouraged to go back to the pretest
35 ma co co rn , ________such s such as mer
Phar = ________ and 7. rm = eparations topi parasit-
CTION IV3. 6 the eic de These target cells eith cury. Antimicr sensitivity, the
SE Z-TM P) , for se bo rrh 8
pica l pr burns. (Table er through loca obia ls reach drug
site, and the host ’s ability to penetrate the
296
TM P (SM ot iti s . Ot her to us ed to treat ic absorption at the site of
application (e.g.
lized activity
of the drug infection’s
th Is, tions are stem factors present.
ole wi is used for UT jiroveci, ntments have some sy
when studying the chapter to check for mastery of the chapter’s
mic preparati , topical, otic, therapy occurs The best antimicr
ethoxaz , and oi ons) or through or ophthal- when the infe obial
Sulfam encountered d Pneumocystis mocystis ons do the drug. Dru systemic distr identified and cting organism
action. preparati gs absorbed ibution of is sensitive to has been
mmon
ly llosis, an eu
t of Pn unode- balance of norm systemically can infection’s caus the drug selec
most co onchitis, shige and treatmen ted for the
17-9).
contents.
upset the ative organism
ia, br is qu ire d imm ar e allowing over
al body flora
, eradicating a broad-spectru s. However, in
med hy lax th ac drug s growth of othe some and m some cases
for pr84op tients wi nation imbalance that r organisms, resu the results of testi medication may be prescrib
such as ia (PCP) in pa . The combi The drug causes a seco lting in an ng ed before
on S) effects. ns ferent site and nd, new infection be narrowed once are obtained; drug therapy
pneum me (AID with rare toxic nous solutio ti- with a different at a dif- the results and may then
syndro ve ge quan necessitating sensitivities are
ficiency well tolerated, ns, and intra Z. T ALE
RT st take lar a treatment of the causative orga
nism— known.
lly sio
genera tablets, suspen to five parts SM PATIEN patient mu in the kidneys, Antibiotics are new infection
Drug Sensiti
des, the on enhanced natu .
forms of
e part TM
P sulfonami drug crystallizati thetically form ral substances vity
of on s W hil e taking pre ve nt dil ute . ed
organic sources; substances originally obta
or syn- The likely micr
consist ration fluids to en urine is kept


pa of each antibiotic— ined from obial that is effec

eP re able in tie s gani tive
danger wh
those drugs a term used to sm should be against the micr
namid are avail sulfa- minimal
that treat bact describe considered whe oor-
l Sulfo mides chemical rese erial infection being selected. n the medicati
Topica sulfona ations such as vitis mblance to s—bears a If a
ons of stance. The goal the original organism is diffi tentative identification of the on is
epar uncti chemical sub- cult to make, infective
preparati lmic pr ed for conj of
or suppress grow therapy with antibiotics is otic can be pres a broad-spectru
Topical rms. Ophtha e us th of the infe to destroy cribed, or seve m antibi-
fo ar cting organism scribed to be take ral antibiotics
several amyd) cient time to
allow normal n may be pre-
e (Sul IONS host defenses for suffi- use of more than concurrently. It is widely thou
cetamid TERACT
infection, prov
iding a resultan to control the one antibiotic ght
DRUG IN cannot always t cure. Antibiot may delay the for empiric treat that
produce a cure ics alone rapid increase
IDES R USE in conjunction . These drugs antimicrobial in bacterial resis ment
LFONAM UTE TIONS FO n of with surgical may be used drugs. tance to
-9 SE LECT SU UL T DOSE, RO INDICA rea se s the actio oral
d
and drainage,
débridement
procedures such
as incision
A certain med
ication may
17 AD Inc lants an
TABLE USUAL ION ct infected tissue. of wounds, and such as greater be preferred
INISTRAT Urinary tra be anticoagu cs; decreases excision of efficacy, lower for reasons
ME/ OF ADM infection: y cemi ity of the micr toxicity, or grea
RI C NA pe s of ns ; ma hy po gly of oral oorganisms to ter sensitiv-
GENE M E
Ty
d GI tra ct infectio illin and eff ec tiveness personal facto the medication
NA an the rs as cost. Alte or for such
TRADE d with pe
nic
tives BACTERICI
AGENT 1 g PO combine n for otitis media contracep
required if the rnative agents
ACTING BACTERIOSDAL VERSUS
pati ent is allergic may be
SHORT- le/Gantrisin ery thr om yci
TATIC
because of toxi
c effects.
to the drug of
choice or
sulfisoxazo
Antibiotics may
function as bact
-acting bactericidal agen eriostatic agen CLINICAL
ort
for the sh
ts. By inhibitin ts or as TIP
bacteriostatic g the growth of
Same as des agen bacteria, If therapy must be
sulfonami ism without caus ts inhibit growth of the micr start
G AG ENT ing death, allow oorgan- available, specimen ed before culture and sensitivity
-ACTIN 2 g PO mechanisms ing the body’s defe s for culture shou resul
ld be obtained befor ts are
EDIATE extra time to nse begins. If the labor
INTERM xazole (SMZ)/ Ulcerativ
e infection. Bact control and
eradicate the atory sample is e therapy
infection: se, juvenile
tho ericidal agen started antimicrob obtained after the
sulfame l Types of destruction of ts cause eith ial therapy, infec patient has
nta no hn disea the bacterial cell. er deat
The antimicrobia h or and their identificat ting agents may
Ga colitis, Cro arthritis whether bact
eriostatic or bact l action, ion impeded. be suppressed
ENT id
CTING AG ine 3-4 g rheumato some antibiot
ics because dosa
ericidal, is not
firm with
LONG-A fid centration at ge of the drug
ine/Azul infection site, , drug con-
sulfasalaz inary tra
ct organism all and virulence MEDICATION
ection: Ur al contribute to of the micro- ALERT
pes of inf dia, vagin outright or simp whether the cell


, IV Ty ections, otitis me ly
medications the inhibited in its growth. Thu
is destroyed The goal of antib
ID ES 00 mg SMZ PO inf s for some iotic therapy is
ON AM P/4 same agent may organisms; rathe not to kill all the
NA TIO N SULF 80 mg TM or bactericidal
against the give be either bacteriostatic microorganisms
r, the goal is to
suppress the grow
infecting
COMBI m (TMP)-SMZ/ mg SMZ
PO families of agen n microorganis
m. See the to allow the host’ th of the
pri TMP/800
ts discussed later the infection and s immune syste
Trimetho Septra 160 mg dia effective actio in this chapter resolve the patie m to subdue
Bactrim, Otitis me n of each agai for the disease. nt’s signs and symp
P-SMZ/ er, diarrh
ea, nst microorganis toms of
ength TM uced fev ms.
Double-str DS, Septra DS 0-6 00 mg PO , drug-ind
Bactrim
20 damage
so xa zol e/
nc es , kidney FACTORS IN
erythrom
ycin-sulfi
ID ES : GI distur
ba
OF ANTIBIOT THE CHOICE Patient Fac
e ONAM routes ICS tors
Pediazol IC SULF renteral
SYSTEM or by pa
FECTS OF when taken PO Ophthalm
ologic When treating Patient factors
SIDE EF s infection:
infections the may influence
the choice of
MAJOR , rashes, pruritu Type of
maximal anti
microbial effec
goal is to achi
eve the
of administratio
n, or dosage. drug, route
headache dro in
p infection patient harm. t while caus individual, the In the immuno
IO NS ec ted , usually 1 ski n inf ections Anti
bug and the drug microbial therapy tries to
ing minimal
compromised
immune syste
m is important
suppressed
AT As dir d
L PREPAR Burns an “match the state and drug because the
solution ” while consider s alone may
TOPICA ide ophthalmic eye with affected
area cal condition.
The appropriate ing the patient’s physi-
eases. Pacemak
ers, prosthetic suppress dis-
d ically to
sulfacetam solution/Sulamy Apply top
individual is antibiotic choi objects may
cause attacks
joints, and othe
ointmen
t,
adene
based on the
causative orga
ce for each
of implantatio on healthy cells r foreign
zine/Silv
Patient Alert box
nism, its drug n, at the site
lfa dia prevent an infe requiring the use of anti
silver su ction that mig biotics to
Cream , orally. ht necessitate
enously; PO removal of
l; IV, intrav
Patient Alert boxes highlight important information that the allied
GI, gastro
intestina

Medication Alert box

health professional should communicate to the patient when he or Medication Alert boxes contain facts about specific drugs, the goals of
she is receiving treatment. their administration, and any potential adverse reactions.
Contents

SECTION I
GENERAL ASPECTS OF PHARMACOLOGY
1 Introduction to Pharmacology and its Legal and Ethical Aspects, 2
2 Basics of Pharmacology, 21
3 Drug Information and Drug Forms, 38
4 Understanding Drug Dosages for Special Populations, 53
5 Reading and Interpreting Medication Labels and Orders and Documenting Appropriately, 68

SECTION II
MATHEMATICS FOR PHARMACOLOGY AND DOSAGE CALCULATIONS
6 Math Review, 84
7 Measurement Systems and Their Equivalents, 113
8 Converting Between Measurement Systems, 126
9 Calculating Doses of Nonparenteral Medications, 145
10 Calculating Doses of Parenteral Medications, 169

SECTION III
MEDICATION ADMINISTRATION
11 Safety and Quality Assurance, 186
12 Enteral Routes, 196
13 Percutaneous Routes, 205
14 Parenteral Routes, 218

SECTION IV
PHARMACOLOGY FOR MULTISYSTEM APPLICATION
15 Analgesics and Antipyretics, 240
16 Immunizations and the Immune System, 255
17 Antimicrobials, Antifungals, and Antivirals, 280
18 Antineoplastic Agents, 309
19 Nutritional Supplements and Alternative Medicines, 323

xiii
xiv Contents

SECTION V
MEDICATIONS RELATED TO BODY SYSTEMS
20 Endocrine System Disorders, 344
21 Eye and Ear Disorders, 369
22 Drugs for Skin Conditions, 385
23 Musculoskeletal System Disorders, 402
24 Gastrointestinal System Disorders, 418
25 Respiratory System Disorders, 443
26 Circulatory System and Blood Disorders, 463
27 Urinary System Disorders, 493
28 Reproductive System Disorders, 503
29 Drugs for Neurologic System Disorders, 526
30 Drugs for Mental Health and Behavioral Disorders, 558
31 Misused, Abused, and Addictive Drugs, 580

APPENDIXES
A Check Your Understanding Answers, 597
B Drug-Nutrient and Drug-Drug Interactions, 601

GLOSSARY, 602
INDEX, 619
 SECTION

I
General Aspects of
Pharmacology

CHAPTER 1 Introduction to Pharmacology and Its Legal and Ethical

Aspects
CHAPTER 2 Basics of Pharmacology
CHAPTER 3 Drug Information and Drug Forms
CHAPTER 4 Understanding Drug Dosages for Special Populations
CHAPTER 5 Reading and Interpreting Medication Labels and Orders
and Documenting Appropriately

1
2 SECTION I General Aspects of Pharmacology

CHAPTER 1
Introduction to Pharmacology
and Its Legal and Ethical Aspects

O B J E C T I VES
After studying this chapter, you should be capable of the following:
• Describing the role of the allied health professional • Describing the registration and documentation
in pharmacotherapy and the role of each process for compliance with the Drug Enforcement
participant in medication delivery. Administration with regard to administering,
• Explaining the need of the allied health dispensing, and prescribing controlled drugs.
professional’s knowledge base as a safeguard in • Describing the role of the Food and Drug
medication administration. Administration in medication safety.
• Understanding folk medicine and its effects on • Differentiating among drug dependence, drug
medicine today. abuse, drug misuse, and habituation.
• Differentiating among major governmental • Listing and describing signs of drug abuse and
agencies and the role and regulations of each in ethics involved in addressing these problems with
medication development and delivery. patients and medical professionals.
• Identifying the legal aspects of the Comprehensive • Identifying ethical procedures regarding
Drug Abuse Prevention and Control Act of 1970 prescriptions, including who may prescribe
and describing the five schedules for controlled medications, and the use of protocol to ensure
substances found therein. that these measures are followed.

Judy, a new allied health professional, has little background in pharmacology. Sara, a young mother of a
2 year old, calls and states that her child has a cold with fever. She asks Judy to call in a prescription
to the local pharmacy for the child. Judy does not think that it is necessary to ask any further questions
about the child’s condition because “a cold is a cold.” Judy does pull the medical record and sees that
the child is allergic to penicillin but was given Augmentin previously. So, without consulting the
physician, Judy orders the same antibiotic. The next day Sara calls to say the child has a rash covering
the entire body and cannot breathe properly. Judy tells Sara to continue the medicine because it
sounds like the child has measles and will be fine. Later that day Judy learns that the child is in
intensive care at the local hospital with an adverse reaction.
What are some of the implications for Judy?
What has she done that could be grounds for litigation?
Should she have called in the prescription without consulting the physician? Explain your answer.
What is the physician’s responsibility?
What is the pharmacist’s responsibility?

2
 CHAPTER 1 Introduction to Pharmacology and Its Legal and Ethical Aspects 3

K E Y T E R MS
Administer Drug abuse Food and Drug Physical dependence
Adverse reaction Drug addiction Administration Physiology
Anatomy Drug dependence (FDA) Placebo
Bioequivalence Drug efficacy Generic drug Prescribe
Brand-name drug Drug Enforcement Homeostasis Prescription
Bureau of Narcotics Administration Legend drug Psychologic drug
and Dangerous (DEA) Medication dependence or
Drugs (BNDD) Drug purity Narcotic habituation
Clinical pharmacology Drug quality National Formulary Respondeat superior
Controlled substance Drug sample (NF) Side effect
Dangerous drug Drug standardization Over-the-counter (OTC) Standardization
Dispense Drug standards drug United States
Dosage Drug strength or drug Pathology Pharmacopoeia
Dose potency Pharmacology (USP)

A
n important responsibility of allied health pro- essential information about body parts and normal
fessionals is understanding drugs, their interac- physical body function. Pathology describes changes
tions, and routes of administration. All health from normal structure and function as well as the func-
care professionals should know answers to questions tion of medications when the person is out of homeo-
about medications such as the following: What is the stasis. Psychology provides an understanding of how a
correct dose to be given? Is the dosage within normal person’s mental state and lifestyle influence medication
limits? What are signs of drug overdose? What are the compliance. Allied health professionals must integrate
interactions with the drug? What side effects or adverse established knowledge in the basic health sciences
reactions can occur when drugs are given singly or in with information from the rapidly advancing field of
combination with other drugs? How do routes of admin- pharmacology.
istration affect the drug’s effectiveness? With knowledge
of medications, health care professionals can prepare the
patient for a realistic expectation and safe outcome. Important Facts
• Pharmacology is the study of drugs and their uses.
Did You Know? • Pharmacology draws information from many scientific
disciplines.
The word pharmacology comes from the Greek pharmakon,
which has three related meanings: claim, poison, and remedy.
Why Study Pharmacology?
Pharmacology changed immensely in the last half of Before administering medications safely, health profes-
the twentieth century. Many medications used today sionals must know forms of drugs available and what
were not available as recently as 10 years ago. New medi- patient factors could affect actions of the drugs. The
cines and new uses of older medicines are constantly knowledge includes the expected action and correct
being researched and approved by the Food and Drug dosage of drugs, methods and routes of administration,
Administration (FDA) for use. Developments in phar- symptoms of abnormal reactions, and appropriate
macology require constant and diligent study for safe patient education for safe delivery of the medication.
medication administration. The allied health professional functions as a link in
the health care chain to ensure that the physician is
aware of all medications, both prescription and over-
PHARMACOLOGY AND the-counter (OTC), that the patient is taking (Figure
HEALTH SCIENCES 1-1). A complete history of medication use must be doc-
umented with each patient encounter to assist the physi-
Drawing on many health care disciplines, pharmacol- cian in safely and effectively prescribing medications.
ogy is the study of drugs, their uses, and their interaction Because the names of some medications are spelled
with living systems. Anatomy and physiology provide similarly or sound alike, the professional must ensure
4 SECTION I General Aspects of Pharmacology

Figure 1-1 The allied health professional plays a major role by taking the A B
patient’s complete medication and health history.

accuracy in documentation. Use of alcohol, recreational

drugs, and alternative medications such as herbals and
vitamins should also be recorded. These actions alone
assist in preventing legal and ethical problems for the
physician.

Did You Know?

Sound-alike–look-alike drugs are labeled with high alert warn-
ings for verification at the time of dispensing medication. C

Figure 1-2 The three members of the health care team with direct use
In many cases allied health professionals will rein- of pharmacology for patient safety. A, Pharmacist; B, allied health profes-
sional; C, physician.
force patient teaching about a drug’s purposes, its method
and route of administration, and regimen for medica-
tion efficacy, especially with initial drug prescriptions,
for patient safety. how and when to take the medication (Figure 1-2). To
With the growing number of OTC drugs, the avail- administer a drug means to give the medication by the
ability of information concerning their actions and their route prescribed. Drug administration may be done by
interactions with prescription medications (or legend the patient personally or by a health care professional in
drugs) will prevent reactions detrimental to the patient. a medical facility (see Figure 1-2, B). The patient is the
People today frequently use OTC drugs previously avail- most important figure in the drug administration trian-
able only by prescription, to treat themselves for common gle. Patient safety for all members involved in drug
ailments or illnesses such as allergies, colds, arthritis, and therapy focuses on the patient (Figure 1-3).
gastric conditions, without consulting a physician. These The physician, who is a central figure in drug admin-
OTC items are mandated to be noted in the patient’s istration because he or she determines the specific drug
medical record as medications being taken. therapy required for a specific patient in a specific situa-
tion, may also dispense sample medications or admin-
ister some drugs, such as antipyretics for fever or
Role of Professionals
analgesics for pain, in his or her medical facility.
in Medication Administration
Sixty percent of visits to a physician result in a pre-
According to guidelines of the Drug Enforcement scription; therefore pharmacists are involved not only in
Administration (DEA), each person in the medication providing the correct drug product, but also in helping
pathway has a specific duty. A physician prescribes a to ensure its proper use. The pharmacist ensures that the
drug to be filled by the pharmacy in an outpatient setting course of therapy prescribed is safe, effective, and correct
or an order in an inpatient setting. The pharmacist dis- in every detail. If a question concerning the therapy is
penses or distributes the drug in a correctly labeled evident, the pharmacist will contact the physician for
container with specific instructions for the patient on verification.
 CHAPTER 1 Introduction to Pharmacology and Its Legal and Ethical Aspects 5

Physician

Patient

Allied health Pharmacist

professional

Figure 1-3 Triangulation of health care professionals for patient safety

with medication use. Figure 1-4 Foxglove (Digitalis purpurea), used for cardiac disorders, is an
example of plant materials that have been used as medications for many
centuries.

The allied health professional begins patient educa-

tion in proper drug use while also functioning as a Important Facts—cont’d
liaison between the physician and pharmacist. The allied professionals. Therefore the physician, pharmacist, and
health professional usually is the person who receives allied health professional must cooperate in a system of
phone calls from patients with questions about their checks and balances to ensure patient safety.
prescriptions or is the first person in the team to hear • Allied health professionals must have a working knowledge
that the medication has caused problems or has not had of all medications used at the site of employment, including
the expected results. Most patients discuss medications new drugs and new applications of established drugs.
that have not had the desired effect with other health
care professionals such as a pharmacist or office staff
member rather than the physician. Therefore, important
roles for allied health professionals are to provide knowl- HISTORY OF PHARMACOLOGY
edgeable answers and to include other health care pro-
fessionals such as physicians and pharmacists in safe Ancient civilizations recorded use of drugs more than
patient care. The pathway of medication delivery requires 2000 years ago. Through trial and error, humans discov-
that the entire team know medications and their uses ered which plants might be used for food and which had
and misuses, as well as the patient who will be using the medicinal value. Folk remedies largely did, and still do,
drugs. Just as the physician and staff must know the use herbs and other plants. In previous generations,
medical needs of patients, so the pharmacist must keep serious illnesses were considered to be of supernatural
updated records of all medications being taken by a origin as a result of spells cast on the victim by an enemy,
patient to ensure drug safety. a demon, or an offended god. Ancient medicine men
using frog bile, pig teeth, spider webs, and sour milk
were actually witch doctors, wise men, “root doctors,”
Important Facts curanderos, shamans, or sorcerers who treated the whole
• A complete medication profile, including both prescription body. Herbal treatments for illnesses became a part of
and over-the-counter drugs, must be documented for all every cultural heritage, with many cultural communities
patients. choosing healers and with culture members seeing these
• Allied health professionals must continue to learn about new men as having “cures” because of their special knowl-
medications as they are released and keep current on new edge of plants. Over the years, folk uses of plants and
uses for older drugs. other natural remedies became the basis for certain
• Basically, physicians prescribe, pharmacists dispense, and modern medicines used in pharmacology today. For
allied health professionals (depending on state law) may example, the digitalis plant, also called foxglove (Digitalis
administer medications and be a liaison to other health care purpurea), is the basis of the commonly used cardiac
medication digoxin (Figure 1-4).
6 SECTION I General Aspects of Pharmacology

BOX 1-1 TIME LINE OF MEDICATIONS

Pre–sixteenth century Egyptians collected plants for treatment of specific diseases and used molded bread for treatment of
infection. India’s version of Materia Medica was written as a drug formulary of plants used for
treating diseases.
Sixteenth century Chinese devised a 52-volume formulary of concoctions prepared to restore and maintain body harmony.
Reserpine (Rauwolfia) was prescribed for high blood pressure, and ginseng as a diuretic.
Seventeenth century Greek physicians, and especially Hippocrates, used opium for pain, herbal remedies such as belladonna
(atropine) for nausea and vomiting, and Jesuit’s bark (quinine) for malaria. Greeks used natural cures
for dieting. Romans began use of prescriptions for obtaining patient medications.
Eighteenth century Edward Jenner developed first vaccine for immunity against cowpox (smallpox).
Nineteenth century Morphine (1806), strychnine (1817), quinine (1820), and nicotine (1828) were created.
1865 During American Civil War, carbonic acid was used for surgical asepsis.
1897 During Spanish-American War, typhoid vaccines were administered to troops.
Twentieth century
Early 1900s Prontosil (1908, forerunner of sulfa drugs), Salvarsan (1910, synthetic arsenic for syphilis), and
phenobarbital (1912, for epilepsy) were created.
1916 Insulin was isolated.
1914-1918 (World War I) Tetanus antitoxin was developed and used for military personnel.
1920s Diphtheria vaccine (1922) was created.
1930s Sulfa (antiinfective), phenytoin (Dilantin, for epilepsy), and yellow fever vaccine were created.
1940s (World War II) Penicillin (antiinfective), Benadryl (1945, antihistamine), cortisone (1948, immunosuppressant), antibiotics,
chemotherapeutic agents, and influenza vaccine were introduced.
1950s (Korean War) Medications to treat mental illness were introduced. Salk vaccine (1954, polio vaccine) and oral
contraceptives were introduced.
1960s Sabin oral polio vaccine was introduced. Vaccines for rubella, measles (rubeola), and mumps were
created. Beta blockers were developed to treat hypertension. Clotting factors were developed for
hemophilia.
1970s Cimetidine for treatment of peptic ulcers and ibuprofen for treatment of inflammation were introduced.
1980s DNA-produced insulin (1980) was the first DNA-produced medication.
Chickenpox vaccine, medications for cardiac arrhythmia and benign prostatic hypertrophy, and
angiotensin-converting enzyme (ACE) inhibitors were developed.
1990s Acquired immunodeficiency syndrome (AIDS) medications and chemotherapy developed at a rapid pace
to treat these devastating illnesses. Newer forms of medications were developed to treat peptic
ulcers, impotence, and diabetes, especially newer forms of insulin with fewer reactions.
Twenty-first century New drug administration techniques are being developed, such as insulin delivered via nasal spray,
continuous oral contraception, and inhaled antibiotics. A vaccine for AIDS, microchips for drug
administration, and gene therapy are on the horizon, and antivirals and antibiotics for drug-resistant
microbe are increasing in numbers.

Many medications have been introduced during times Important Facts

of war or as technology has advanced. See Box 1-1 for • By trial and error, early civilizations found plant sources that
an annotated history of pharmacology. could be used to treat disease processes. This was a precur-
In the twenty-first century, transdermal patches and sor to folk medicine.
small dots are increasingly being used for medication • In the sixteenth century, the Chinese created the first phar-
administration for smoking cessation, hormone replace- macopoeia, which listed drugs of animal, vegetable, and
ment therapy, contraception, and even treatment of mineral origin that were used to maintain body harmony.
attention-deficit/hyperactivity disorder (ADHD) because • At the end of the nineteenth century and beginning of the
of convenience. Insulin pumps for type 1 diabetes mel- twentieth century, many laws were enacted in the field of
litus and nasal sprays for treating acute or chronic ill- pharmacy to protect the public.
nesses are commonly used. Inhalation medications • Medications for previously fatal chronic illnesses were intro-
using aerosol particles are used to treat bronchial duced during the first half of the twentieth century. Many of
diseases.
 CHAPTER 1 Introduction to Pharmacology and Its Legal and Ethical Aspects 7

drug interactions, and other negative effects are required

Important Facts—cont’d
to be given equal coverage so people are given sufficient
these medications arose out of the needs of uniformed mili- information to make informed choices about the value
tary personnel, especially those serving in combat. of the therapeutic agent. Because of today’s information
• The pharmaceutical field developed rapidly in the last half of highways such as the Internet, the U.S. government con-
the twentieth century. This period saw the introduction of tinues to investigate ways to ensure that information
oral contraceptives, medications for hypertension, insulin gathered from computer sources is accurate and
produced by recombinant DNA technology, drugs to treat complete.
erectile dysfunction, and chemotherapeutic drugs, as well as Controls for ensuring safety and promoting informed
new administration techniques. choices have been a direct result of legislation at federal,
• At the start of the twenty-first century, medication delivery state, and local levels. State and local regulations, such
systems that result in a prolonged effect and do not neces- as classification of certain controlled drugs, are usually
sitate frequent application are available. Among these deliv- more stringent and precise than federal regulations.
ery systems are patches and insulin pumps with silicone Restrictions found in policy and procedure manuals of
microchips under investigation for use. individual offices or medical facilities may be even more
stringent than government regulations. Allied health
professionals must have a working knowledge of regula-
tions at all levels to comply with all restrictions.
Society and the Need
for Drug Regulation
DRUG STANDARDS AND
Throughout history, some members of societies have PATIENT SAFETY
chosen to misuse or even abuse medicinal substances
from herbs to chemicals. As societies became more pro- Drug standards assure consumers that they are receiv-
gressive, governing bodies saw the need to establish regu- ing safe medications. Legislation requires that all drugs
lations to control use of these substances by enacting with the same name and dosage be of uniform strength,
laws and regulations. quality, and purity so each prescription filled for a
Government has also taken steps to ensure that the given medication is the same in all pharmacies. Drug
consumer has high-quality drugs providing the expected manufacturers must meet standards set in the United
therapeutic properties. Before the twentieth century, drug States Pharmacopeia–National Formulary (USP-NF)
legislation would have been almost impossible—detailed for quality, efficacy, strength or potency, and purity
information about drugs was not available because there of a drug. Drug purity specifies the type and concentra-
was no means to analyze drugs as they were developed. tion of a chemical substance present in a drug. Most
A drug’s potency or strength, or concentration of products are combinations of active ingredients with the
active ingredients, varied with the conditions under fillers, buffers, and solvents necessary to give form to
which the drug was prepared. The drug consistency tablets and capsules, to make the product more palat-
might vary from one bottle of medication to the next; able, or to change the absorption rate of the medication.
thus patients’ reactions to medication also varied, affect- Purity standards also ensure that excessive contaminants
ing even patient safety. Since the beginning of the twen- are not found in the medication. Drug potency or
tieth century, however, research methods mandated by strength is the concentration of active ingredients in
legislation have resulted in consistent manufacture of the preparation measured by chemical analysis. Drug
medications and thus safety in their preparation and quality ensures that consumers receive medications that
effectiveness. Legislation now also requires that all new achieve the standards required by the federally approved
medications undergo stringent testing before release to USP-NF. Drug efficacy refers to the ability of a drug to
ensure drug standardization of these therapeutic agents produce the desired chemical change in the body. Clini-
and therefore consistency with use. Over the past quarter cal trials are used to compare the response of volunteer
century the public has become more knowledgeable individuals to the drug with other volunteers’ response
about medications as the number of OTC medications to a placebo.
has increased, making patient education about drug
interactions and adverse reactions an important patient
issue.
Pharmaceutical companies spend vast amounts of
money on drug development and advertising. Therefore Did You Know?
legislation is necessary to protect consumers and com- Because of the strict regulation of safety standards for new
panies and to enforce quality control of the medication. drugs in the market, drugs are often available in other countries
Advertisements for medication stress their positive effects before they are found in the United States.
to increase sales. However, by law, adverse reactions,
8 SECTION I General Aspects of Pharmacology

Even OTC drugs are studied to make sure they are safe Before the twentieth century, many drugs containing
for administration without professional guidance if the opium and the new miracle drug morphine did not
manufacturer’s directions are followed and that labels require a prescription, and pharmacists and physicians
bear sufficient warnings and instructions. By 1983 OTC were not required to hold a license. Labeling of ingredi-
medications were either found safe or were removed ents on medication bottles was not a requirement. Use
from sale except by prescription. One of the problems in of many nonstandardized dangerous drugs resulted in
medicine today is that vitamin and herbal supplement injury or death from their use, addiction, or inconsis-
standards are not enforced by the FDA; rather, these tency in manufacture.
supplements are supervised as food products according
to the less strenuous restrictions of the Department of
Agriculture. These supplements may not have the same Did You Know?
purity and quality with each manufacturer or batch;
therefore consumers must be careful to choose reputable Before 1906, patent medicines were sold by medicine men in
companies and to carefully read labels to lower risks of traveling shows, by mail order, in stores, by trained physicians,
taking poor-quality supplements. and even by individuals who just called themselves “doctors.”
In the illicit drug market, the consumer does not Medications with names like Dr. Smith’s Miraculous Cough
enjoy the protection of these standards, resulting in Medicine or New Age Miracle Soothing Syrup were popular. For
inherent dangers similar to those found in the time of example, John S. Pemberton, a pharmacist in Atlanta, first made
the medicine man. The use of illegal drugs has resulted French Wine Coca—Ideal Nerve and Tonic Stimulant in 1885. In
in overdoses and death among those willing to take the 1886 Pemberton used coca leaves and caffeine from the African
risks involved. kola nut as ingredients in a product called Coca-Cola. Advertised
as a “therapeutic agent” and “sovereign remedy,” the “quicker
picker-upper” became known by the nicknames “Dope” and
Important Facts “Coke.”
• Drug standards ensure that consumers will receive safe
medications that are the drugs that were expected.
• Drug purity specifies that the correct active ingredient is
Federal Legislation Related to Drugs
present and manufactured without excessive contaminents.
• Drug potency or strength is the concentration of active • Pure Food and Drug Act of 1906
ingredient. • Earliest regulation included many loopholes and
• Drug quality ensures that the consumer receives drugs that lack of enforcement abilities.
meet the standards published in the United States Pharma- • Drugs found in interstate commerce could not be
copeia–National Formulary. labeled as curative if the claims were false and mis-
• Drug efficacy is the ability of the drug to produce the desired leading, but advertisement by word of mouth or
chemical change in the body. printed materials was not covered.
• Over-the-counter medications must meet the same standards • The USP and the NF were created as the compendia
as legend drugs. containing the official standards for strength and
purity during manufacturing, including a label
showing the eleven specific dangerous chemicals
present that may cause drug addiction.
International, Federal, and
• Shirley Amendment of 1912
State Statutes for the Regulation
• Prevented fraudulent therapeutic claims by drug
of Medications
manufacturers.
The international control of medications comes under • Harrison Narcotic Act or Federal Narcotic Drug Act of
the authority of the World Health Organization of the 1914
United Nations. This group provides technical assistance • Established the word narcotic and required the use
in the drug field and promotes research on drug abuse. of a stamp on the containers of these drugs.
Because no world judicial groups enforce laws concern- • For patient safety, regulated the importation, man-
ing drugs, drug control varies from country to country. ufacture, sale, and use of opium, codeine, and their
Some nations have more stringent laws than statutes of derivatives and compounds.
the United States. Harsh punishments including long • Food, Drug, and Cosmetic Act of 1938
prison sentences and even death are imposed for posses- • Provided safety testing on all drugs.
sion of illegal drugs or drug trafficking in some countries. • The FDA was formed to enforce the laws, seize
Other countries have lenient laws and enforcement con- goods that were improperly manufactured or pack-
cerning drug possession, even to the point of allowing aged, and undertake criminal prosecution of the
use of some drugs that are illegal in the United States. responsible persons or firms.
 CHAPTER 1 Introduction to Pharmacology and Its Legal and Ethical Aspects 9

• Required pharmaceutical firms to report all adverse • Comprehensive Drug Abuse Prevention and Control Act
effects associated with their drugs at regular of 1970 (also called Controlled Substances Act of
intervals. 1970)
• Required that all new drugs be tested for toxicity • Repealed the 50 laws passed between 1914 and
before approval. 1970 concerning drug control.
• Regulated manufacture, distribution, and dispens-
ing of drugs with the potential for abuse.
Did You Know?
• Indicated drugs that had potential for abuse, and
In the late 1930s sulfanilamide, an antibacterial agent in a placed these medications in five schedules sorted
raspberry-flavored base, was a lethal elixir because the base by potential for abuse or addiction to prevent
was not known to be toxic. With no need for approval of safe indiscriminate use of these drugs by limiting their
chemicals used in manufacture, the company did not use an use.
alcohol base that was indicated for an elixir, but made the drug • Required security of controlled substances by
using an industrial-strength toxic liquid solvent, diethylene anyone who dispenses, receives, sells, or destroys
glycol—a major ingredient in antifreeze. More than 100 children controlled substances using special DEA forms to
died after ingesting less than an ounce of the medicine, and in show current inventory.
excess of 350 more children were poisoned. • Regulated use of controlled substances to only
legitimate handlers to help reduce the widespread
illicit use of these drugs.
• Durham-Humphrey Amendment (1951) replaced laws • Provided for prevention of drug abuse and drug
of 1938 dependence and for treatment and rehabilitation
• Indicated regulations for prescription orders or dis- of abusers and drug-dependent persons.
pensing by designating prescription and OTC med- • Two important agencies had a role in the enforce-
ications, with labeling of prescription medications ment of this act:
being met by placing an “Rx” on the label of the  The Bureau of Narcotics and Dangerous
manufacturer’s bottle. Drugs (BNDD), in existence from 1968 to
• Required that all prescriptions be labeled “Caution: 1973, with the following responsibilities:
Federal law prohibits dispensing without a  To register all persons who manufacture, dis-
prescription.” pense, prescribe, or administer any controlled
• Designated the OTC drugs that were considered substances.
sufficiently safe not to require a prescription.  To provide for necessary revision of schedules
• Required warning labels on drug packaging. and classes of controlled drugs.
• Kefauver-Harris Amendment (1962)  The Drug Enforcement Administration (DEA)
• Was passed because drug companies were making was established in 1973 to continue regulation
large profits and engaging in misleading and even and enforcement of manufacturing and dispens-
false drug promotions. ing of dangerous and potentially abused drugs.
• Required proven effectiveness of a drug before mar- (See section on DEA that follows.)
keting, with old and new drugs requiring proof • Poison Prevention Packaging Act of 1970
testing. • Created standards to ensure that both prescription
and OTC medications were in child-resistant
packages.
Did You Know? • Drug Listing Act of 1972
The manufacturer of thalidomide, a hypnotic that was taken by • Established National Drug Code for use by the
pregnant women early in pregnancy, claimed it was a miracle FDA to identify a drug’s manufacturer, including
drug for the nausea of pregnancy and a sleeping aid without the drug formulation and the size of the packag-
realizing the associated dangers of severe deformities in fetuses, ing, by using a unique and permanent code for
leading to a wave of “thalidomide babies.” These infants were drugs.
born with severe deformities, especially of limbs. Some preg- • Drug Regulation and Reform Act of 1978
nant women in the Northeast were prescribed the drug, but the • Allowed for briefer investigation of new drugs and
tragedy was more a “might-have-been” catastrophe than a to allow for faster access by the consumer.
widespread, actual one because a U.S. Food and Drug Adminis- • Orphan Drug Act of 1983
tration employee was suspicious of the drug and wanted more • Established in response to the removal of drugs
information before approving it for use in the United States. because of potential dangers or the lack of research.
Sadly, the chemist who developed the drug later committed • Established funding for research for use of these
suicide. drugs in the treatment of rare chronic illnesses
through grant monies and tax incentives to find
10 SECTION I General Aspects of Pharmacology

new drugs and new uses for older drugs for condi- medications have been tested and found effective with
tions with so few patients that the manufacturer minimal adverse reactions and that all prescriptions for
would be unlikely to recoup expenses once the the same medication will contain the same therapeutic
drug could be marketed. ingredients.

Did You Know? Did You Know?

Thalidomide, which caused severe birth defects in the 1960s, The use of the Internet for medications has brought ethical and
has been found today to be effective for leprosy, multiple safety dilemmas of its own. New consumer safety regulations
myeloma, acquired immunodeficiency syndrome, and other rare are being put into place to ensure safety for patients who fill
conditions because of the enactment of the Orphan Drug Act. medication prescriptions by using the Internet or providers in
other countries. The government is even looking into ways to
ensure that such Internet sites provide patient safety and that
• Drug Price Competition and Patent Term Restoration Act the medications are those specified and protected by regulations
(1984) pertaining to the manufacture and distribution of the drugs.
• Eased requirements for marketing generic drugs by
allowing generic drug companies to prove bio-
equivalence without having to duplicate trials.
• Extended length of time of patents to compensate At the state level, almost all states have laws governed
for the time lost in premarketing trials. by the state boards of pharmacy concerning the substitu-
• Omnibus Budget Reconciliation Act of 1990 (OBRA tion of generic drugs for brand-name drugs. Some
1990) states and some insurance companies permit generic
• Mandated that OTC drugs be considered an impor- substitution by the pharmacist, although the person pre-
tant part of the medical record and that they be scribing the medication, usually a physician, retains the
documented. right to require the dispensing of a brand-name drug by
• Anabolic Steroids Control Act of 1990 writing “brand necessary” on the prescription. If the state
• Placed anabolic steroids under umbrella of the has mandatory substitution, the pharmacist is required
Controlled Substances Act of 1970. to use less expensive generic drugs for dispensing. If a
• Prescription Drug Amendments of 1992 generic name is used on the prescription, the pharmacist
• Allowed rapid approval of medications by the FDA, may use his or her discretion to select the drug with a
especially for life-threatening diseases and debili- bioequivalence to the brand-name medication. A generic
tating conditions. medication must go through testing to ensure that the
• Food and Drug Administration Modernization Act (1997) inert ingredients provide bioequivalence and that the
• Allowed rapid approval of medications by the FDA, active ingredients have not changed from those in
especially for life-threatening diseases and debili- the trademarked drug.
tating conditions.
Other laws may come from regulatory agencies such
as the Federal Trade Commission, which regulates busi- THE FOOD AND DRUG
ness practices in the medical field, and the Consumer ADMINISTRATION AND THE
Products Safety Commission, which has a routine that INTRODUCTION OF NEW DRUGS
must be followed, such as for drug packaging to prevent
poisoning in children. As an agency of the U.S. Department of Health and
Human Services, the FDA is responsible for reviewing the
testing of all drugs before they are released to the public
Did You Know? (Table 1-1). The development process is lengthy, taking
6 to 12 years, and is expensive. At the end, only about
During the widespread outbreak of H1N1 influenza in 2009, the one drug emerges for each 5000 to 10,000 different com-
FDA allowed emergency use of the experimental drug peramivir pounds tested. (See Box 1-2 for the drug testing process.)
for hospitalized patients who had not responded to the FDA- At any time during the process or even after approval,
approved antivirals. the FDA may ask for additional information from the
manufacturer, for revisions in the trials, or for the medi-
cation to be returned to the company for further research
Over the years, federal legislation has established or testing. Therefore manufacturers that develop a drug
standards for medicines that provide patient safety. Citi- are given a 20-year patent on the medication to cover the
zens of the United States can feel assured that their time and expense of trials necessary to show that the
 CHAPTER 1 Introduction to Pharmacology and Its Legal and Ethical Aspects 11

TABLE 1-1 AGENCIES RESPONSIBLE FOR DRUG SURVEILLANCE

AGENCY AND
SUPERVISING
DEPARTMENT OF U.S.
GOVERNMENT CONCERN RESPONSIBILITY
Food and Drug General safety Approves and removes products on the market
Administration (FDA) standards in the Regulates labeling and advertising of prescription drugs; cooperates
under Department of production of drugs, with Federal Trade Commission on regulation of nonprescription
Health and Human foods, and cosmetics drugs
Services Regulates drug manufacturing practices
Engages in postmarketing surveillance to detect unanticipated
adverse and therapeutic effects of drugs
Drug Enforcement Controlled substances Enforces laws against unlawful drug activities
Administration (DEA) only Assigns identification numbers (DEA numbers) for those entities that
under Department of prescribe, dispense, and manufacture scheduled drugs
Justice Monitors scheduled drugs for need to change possible abuse level

BOX 1-2 STEPS IN THE DEVELOPMENT OF NEW DRUGS

Development of a New Compound Phase 3 trials—experimental study of drug or treatment to

by a Pharmaceutical Company larger group of people (1000-3000) to confirm effectiveness,
↓ monitor side effects, compare to commonly used treatments
Preclinical Testing in Animals and collect information that will drug or treatment to be used
Drugs are tested for toxicity, use of drug in the body, and possible safely
useful effects. Phase 4 trials—post-marketing studies delineate additional infor-
Animal testing: range of 1 to 3 years, usually 18 months mation including the drug’s risks, benefits, and optimal use
↓ ↓
Food and Drug Administration (FDA) safety review of testing New Drug Application (NDA) Sent to FDA
results FDA review: Range of 2 months to 7 years, usually 24 months
↓ ↓
Investigational New Drug Status if Approved FDA Approval of NDA
(Go back to earliest research if not approved.) (If not approved, return to manufacturer for further initial testing
↓ or further research.)
Clinical Trials in Humans ↓
Range of 2 to 7 years, usually 5 years Postmarketing Surveillance
Testing for safety, effectiveness, dosage range, and therapeutic Drug is released for use, permitting observation in large numbers
use of patients.
Phase 1 trials—test of an experimental drug or treatment in a Surveys, sampling, and inspections by FDA and physicians using
small group of people (20-80) for evaluation of safety, safe the medication are performed.
dosage range, and identify side effects Adverse reactions are reported to FDA for analysis and
Phase 2 trials—experimental study of drug or treatment to larger reevaluation.
group of people (100-300) to further evaluate effectiveness and
safety

drug has the intended therapeutic purpose in humans.

The process of FDA approval uses up to half of the patent Did You Know?
time, leaving the company with about 10 years of mar- Many brand names may be available for the same generic drug.
ketability under patent, or trade name. At the end of that For example, ibuprofen is sold under the brand names Motrin,
time, another company may manufacture the drug under Nuprin, and Advil, and naproxen is sold as Naprosyn at prescrip-
another brand name or use the generic name that has tion strength and as Aleve at over-the-counter strength.
been assigned by the USP.
12 SECTION I General Aspects of Pharmacology

The FDA also reviews proposals for new indications potential to be addictive or habit forming, such as ste-
for already approved drugs, with the clinical testing roids, depressants, and stimulants. Criteria for placement
process being performed as for a new drug. A new indi- on the list include the following:
cation for an already patented drug extends the time of • Evidence that the substance is being used in suffi-
the patent on the medication. Conversely, if a drug cient amounts to pose a medical threat to individu-
appears to be associated with too many adverse reac- als or a hazard to the community
tions, the FDA or manufacturer has the right to with- • Significant diversion of the substance from legiti-
draw the drug from the market after approval has been mate use to illegal drug trafficking
granted. • Tendency of consumers to take the substance on
their own initiative rather than on medical advice
• A new drug with an action related to the action of
Did You Know? a drug already on the controlled substances list
until a decision is made concerning its abuse
Drugs that are deemed unsafe may be removed from the market, potential
as occurred with the voluntary withdrawal of the cyclooxygenase-2 The controlled substances are grouped into five cate-
(COX-2) inhibitors Vioxx and Bextra, after they were found to gories, or schedules, each with its own prescription and
increase the risk of multiple adverse reactions such as heart dispensing restrictions (Table 1-2). Medications with
attack and stroke. highest potential for abuse and with no accepted medical
use are placed on Schedule I. Those with least abuse
potential are placed on Schedule V. A drug may be moved
Many prescription medications are becoming OTC from one schedule to another or may be removed from
drugs at strengths decreased below the legend strength. the list on reevaluation of abuse potential by the DEA.
An OTC drug is a medication, and as such, the consumer Any revision of the list is sent to practitioners to keep
must use it as the FDA has approved it for OTC use. the health professional’s knowledge current.
Educating the patient to follow directions is an impor- Because the DEA strictly enforces regulations pertain-
tant element in the safe use of OTC drugs. See Table 1-1 ing to scheduled medications, precise and complete
for the role of the FDA in drug regulations. records are required for Schedule II medications. These
records must indicate the flow of the medicines
from time of arrival at the facility until they are
administered.
Important Facts
• The DEA, an agency of the U.S. Department of Justice, is
responsible for monitoring controlled substances. The Food
and Drug Administration (FDA), an agency of the U.S. Depart- Important Facts
ment of Health and Human Services, is responsible for regu-
lating the manufacture and safety of drugs. • Controlled substances are placed in one of five groups, or
• The development of a new drug is a lengthy process, taking schedules, each with restrictions on prescribing and dispens-
up to 12 years, and only one of up to 10,000 compounds ing, based on the danger of abuse or misuse.
tested may reach the stage of a new drug. • DEA controlled substances may be moved between sched-
• A company introducing a new drug has approximately 10 ules on the controlled substances list. A current inventory of
years of exclusive use of the drug. all Schedule II medications should be kept; if Schedule III
• Preclinical and clinical testing must be done on a new medi- medications are dispensed by the facility, an inventory of
cation to ensure its safety. Any adverse reactions to medica- those is also necessary.
tions, especially newly marketed drugs, should be reported • Controlled substances can be abused and misused with or
to the FDA. without prescription use.

The Drug Enforcement Administration

and Controlled Substances The Drug Enforcement Administration
and Controlled Substances
Controlled substances became regulated by the DEA
in the Medical Office
through the Controlled Substances Act, Title II of the
Comprehensive Drug Abuse Prevention and Control Act Controlled substances are labeled so that they can be
of 1970 (see Table 1-1). The drugs are classified accord- easily identified. A large C shows that the drug is a con-
ing to their established abuse potential, which applies trolled drug, with the Roman numeral of the schedule
not only to pain relievers but also to drugs with the (I through V) appearing within the C. For example, a
 CHAPTER 1 Introduction to Pharmacology and Its Legal and Ethical Aspects 13

TABLE 1-2 DRUG CLASSIFICATIONS ACCORDING TO THE CONTROLLED SUBSTANCES ACT OF 1970

DRUG SCHEDULE CHARACTERISTICS PRESCRIPTION REGULATIONS EXAMPLES

Schedule I High potential for abuse, severe No accepted use in United States Narcotics—heroin
physical or psychologic Marijuana may be used in cancer Hallucinogens—peyote mescaline,
dependence and glaucoma for research and PCP, hashish, amphetamine
For research use only may be obtained for patients in variants, LSD
research situations Cannabis—marijuana, THC
Designer drugs—ecstasy, crack,
crystal meth
Schedule II High potential for abuse, severe Dispensed by prescription only Narcotics—opium, codeine.
physical or psychologic Oral emergency orders for morphine, methadone,
dependence Schedule II drugs may be given, hydromorphone (Dilaudid),
Accepted medicinal use with but physician must supply meperidine (Demerol), oxycodone
specific restrictions written prescription within 72 hr (Oxycotin), fentanyl (Duragesic),
Refills require a new written pentobarbital (Nembutal)
prescription from physician Stimulants—amphetamines,
amphetamine salts (Adderall),
methylphenidate (Ritalin)
Depressants-pentobarbital
(Nembutal)
Schedule III Moderate potential for Dispensed by prescription only Narcotics—paregoric (opium
abuse, high psychologic May be refilled five times in 6 mo derivative), certain codeine
dependence, low physical with prescription authorization combinations (with
dependence by physician acetaminophen)
Accepted medicinal uses Prescription may be phoned to Depressants—pentobarbital
pharmacy (Nembutal) (rectal route)
Stimulants—benzophetamine
(Didrex)
Schedule IV Lower potential for abuse than Dispensed by prescription only Narcotics—pentazocine (Talwin)
Schedule III drugs May be refilled five times in 6 mo Depressants—chloral hydrate
Limited psychologic and with physician authorization (Noctec), phenobarbital, diazepam
physical dependence Prescription may be phoned to (Valium), chlordiazepoxide
Accepted medicinal uses pharmacy (Librium), alprazolam (Xanax),
clorazepate (Tranxene),
benzodiazepines (lorazepam
[Ativan], flurazepam [Dalmane]),
midazolam (Versed), meprobamate
(Equanil), temazepam (Restoril),
Stimulants—phentermine (Adipex-P)
Schedule V Low potential for abuse OTC narcotic drugs may be sold Preparations containing limited
Abuse may lead to limited by registered pharmacist quantities of narcotics, generally
physical or psychologic depending on state laws cough and antidiarrheal
dependence Buyer must be 18 years of age, preparations—cough syrups
Accepted medicinal uses show identification, and sign for with codeine, diphenoxylate
medications hydrochloride with atropine
sulfate (Lomotil) and attapulgite
(Parepectolin)
From the Drug Enforcement Administration (DEA), U.S. Department of Justice, Washington DC. Local DEA offices can provide current lists of medications
on these schedules.
LSD, Lysergic acid diethylamide; OTC, over the counter; PCP, phencyclidine hydrochloride; THC, tetrahydrocannabinol.
14 SECTION I General Aspects of Pharmacology

of the administration of the medication must be kept for

2 years.
Schedule II controlled substances must be kept sepa-
rate from other drugs and be placed in a securely locked
area. Some states require a double lock on opioid prod-
Figure 1-5 Symbol that indicates a drug is a controlled substance in ucts. The stock of controlled substances should be kept
Class II (Schedule II). to a minimum. For the office needing large amounts of
controlled substances, higher security measures such as
an alarm system, should be in place. The physician or
his or her designee should keep the key. The statutes of
Schedule II medication would be shown as appears in each state provide guidelines on the handling of con-
Figure 1-5. trolled substances.
Physicians or other health professionals (such as den- If theft of inventory occurs, it is significant and the
tists) who administer, dispense, or prescribe controlled local DEA office must be notified. If theft has occurred,
substances must have a current state license, must regis- it is required that the local police department be
ter with the DEA and be assigned a DEA number, and notified first, as well as the state bureau of narcotic
in some states must have a state controlled-substance enforcement. If damage to or contamination of signifi-
license. Exceptions to this ruling are physicians who are cant amounts of controlled substances occurs, the local
interns, residents, in the armed services, from a foreign DEA office should be contacted for appropriate disposal
country, or on the staff of a Veterans Administration instructions.
facility, who dispense and prescribe using a special code
under the registration of the hospital or institution. At
the appropriate time for renewal (every 3 years), the DEA
Record Keeping and Inventory Control
will automatically send a renewal form 45 days before
the renewal date. If this form is not received, it is the As controlled substances are received, the medication
responsibility of the physician to notify the DEA. should be recorded on a special inventory form (Figure
1-6). The receipt should be signed by two employees and
should show the exact amount of stock medication
received. To take an inventory count, the allied health
Ordering and Securing
professional counts the amount of the medication on
Controlled Substances
hand and compares this with the amount ordered and
Schedule II substances for use in the medical office or in the amount either administered or dispensed to patients.
the physician’s medical bag must be ordered from sup- The total of the medications on hand plus the dispensed
pliers using the Federal Triplicate Order (DEA Form medications should equal the inventory received.
222). When scheduled medications are ordered, one An inventory with invoices or copies of invoices
copy of the form goes to the DEA, the second copy goes from the drug suppliers is required by the DEA every 2
to the supplier, and the third copy is retained by the years. This inventory must contain the following
physician. On receipt of the drugs, the physician attaches information:
the documentation showing receipt of the medication to • The name and quantity of each controlled
the retained copy. This documentation could be a packing substance
slip with cash receipt showing payment for the medica- • The name, address, and DEA registration number
tion or invoice and a copy of the check showing payment. of the physician
Good record keeping not only is invaluable to the physi- • The date and time of the inventory process
cian, but also assists the physician in following state and • The signature of the person(s) taking the inven-
federal regulations related to controlled substances. tory; preferably two persons should take the
Schedule II drug records must be kept separate from inventory
other medical records and must be readily available for If a medication for controlled substances is adminis-
at least 5 years for inspection by the DEA or government tered in the facility and none is dispensed, then the
agencies interested in drug administration. Records of medical record of the patient must show medication
other scheduled drugs may either be kept separately or administration and must be easily available for DEA
be easily retrievable from professional records. review. If controlled substances are administered and
To purchase controlled substances on Schedules III dispensed, records must be maintained separate from
through V, the physician does not use Form 222 but may medical charts and must be readily available for inspec-
purchase these medications through local pharmacies. tion. States vary as to the exact requirements of record
However, the records of the suppliers’ invoices with date keeping, and allied health professionals should be aware
of receipt and quantity of drug received and a logbook of the state regulations where they practice.
 CHAPTER 1 Introduction to Pharmacology and Its Legal and Ethical Aspects 15

Registrant Name: DEA Reg #:

Lawrence Merry, M.D. AD0000000

Address:
4th Street and Jones Ave. Inventory of Schedule: II III,IV,V

e
City/St. Zip: Inventory Date: 11/01/01
Holly, GA 00111

l
Inventory Time: Opening of business
Close of business

p
Drug/Preparation # Containers Contents* CS Contents**
morphine sulfate bottle 100 tabs 15 mg
Demerol HC1 ampule 10 1.0 mL 25 mg
Percocet 1 bottle 50 tabs 5/325 mg

a m
The above stock controlled substances was inventoried by the person(s) signed below, who
attest that the above inventory is maintained at the location appearing at the top of this
inventory and has been maintained at the location appearing at the top of this inventory for
at least two years.

S
Inventoried by Inventoried by

* Number of grams, tables, ounces, or other units per container.

** Controlled substance content of each unit.

Drug Name Patient Dose Date Hour MD MA

Reviewed by Reviewed by

, CMA , MD

Figure 1-6 Typical form for inventory of controlled substances.

Disposing of Scheduled public. Incineration may be necessary for medications

and Nonscheduled Drugs such as topicals or injectables that are difficult to
destroy.
To dispose of controlled drugs, such as expired drugs,
call the nearest DEA office for instructions. If the drug Important Facts
must be mailed, the allied health professional should be
• Stock labels for controlled substances are marked with C,
sure that registered mail is used to ensure safe shipment.
with the schedule number (in Roman numerals) within the
Once drugs have been destroyed, the DEA will issue a
letter.
receipt that the physician must place with controlled
• DEA has specific forms that must be used when applying for
substance records.
a DEA number. Forms obtained from the DEA must be used
Outdated, noncontrolled medications do not come
to order Schedule II medications. Medications on Schedules
under these stringent regulations. Depending on the
III through V do not require the special form.
state law, they may be flushed down the toilet, washed
• The physician has the specific responsibility of renewing his
down a sink, or placed in the trash. If placed in the
or her DEA registration every 3 years.
trash, the physician should maintain security to ensure
Continued
these medications do not fall into the hands of the
16 SECTION I General Aspects of Pharmacology

and is not satisfied without that specific drug. Drug

Important Facts—cont’d
abusers, or those with drug-seeking behaviors, usually
• Any loss or theft of controlled substances must be reported know which drugs they want and will continue to ask
to the DEA. If theft has occurred, the local police department, for a specific drug rather than accept the medical care
state bureau of narcotic enforcement, and DEA must be offered by the physician. Many times a drug-seeking
notified. person will state that he or she has lost a previously
• Specific record keeping, including inventories and verification obtained prescription or lost the medication after the
of administration of the medication, is necessary when han- prescription was filled and therefore needs a new pre-
dling controlled substances. Each state may require other scription. The health care professional should follow
specific record-keeping techniques. office protocol exactly by checking medical records for
• Specific guidelines for disposal of scheduled medications signs of possible misuse of medications, such as repeated
exist. Instructions are sent by the DEA and must be followed prescriptions for pain medications, sedatives, or behavior-
exactly. altering medications. Documenting all prescriptions pre-
cisely is of utmost importance for all patients so that the
physician can detect early signs of possible misuse.
Finally, prescription pads should be safeguarded at all
Preventing Drug Dependence
times. Prescription pads should never be used as note
and Drug Abuse
pads or for orders other than those for prescription med-
Substance abuse is a national and international problem ications. Signature lines may have the imprint of the
that affects all of us. Health care workers have a respon- health care professional’s signature, and drug abusers
sibility to patients and society to assess the chances for may copy the imprint made by signing multiple times
abuse or misuse of medications. A patient’s frequent and forge a prescription. A prescription pad should never
request for a given drug and “doctor-hopping” may be be left in an examining room unattended. The patient
signs of potential abuse or misuse. A pharmacist may who abuses medications may be able to obtain drugs
make the medical office aware of the patient’s use of more easily by stealing prescription blanks. Although all
multiple medical facilities for prescriptions and will prescriptions should be documented in the medical
provide the information to prevent further abuse. The record, another safeguard is to copy all prescriptions
medical office professional should be sure the physician leaving the medical office and place copies in the medical
is aware of any information provided by other health records. The patient seeing this procedure would cer-
care professionals. Other signs that may indicate sub- tainly be less likely to forge a prescription because the
stance abuse include pinpoint pupils, lethargy, or a pharmacist could easily confirm that the prescription
change in or unusual behavior. had been written. Medical office personnel are an impor-
Drug dependence may be both physical dependence tant link in preventing drug abuse and misuse by partici-
and psychological drug dependence, or habituation. pating in the checks-and-balances system between the
The physical dependence begins with use of a medica- physician and pharmacist. This system often is the first
tion over a prolonged period of time and is a normal line of defense as early warning signs are observed and
adaptation to continued drug use. The medication may proper action is taken.
involve a drug used to relieve pain or to control physical
or emotional problems, or it may be one used for such
conditions as blood pressure or respiratory disease. Psy- ROLE OF ALLIED HEALTH
chologic drug dependence is a craving of a drug for PROFESSIONALS IN MEDICATION
pleasure or to relieve discomfort and a psychologic ADMINISTRATION
crutch used to relieve anxiety. However, drug addiction
is compulsive use of a drug despite physical harm and is The medical practice act of each state in compliance with
therefore a dysfunctional behavior. federal regulations provides the guidelines for prescrib-
Drug abuse depends in part on why a drug is taken ing, administering, storing, and dispensing of medica-
and what is culturally defined as acceptable drug use. tions by allied health professionals. Because some allied
What is considered abuse in one culture may not be health professionals perform tasks under the legal
considered abuse in another. Drug abuse is use of a drug premise of respondeat superior, the physician also
in a way that is not consistent with medical or social needs a working understanding of state and federal laws
reasoning or administration of drugs in quantities over governing legal job performances in his or her state of
an excessive time that is inconsistent with accepted practice. Any legal interpretation of the law must come
medical practice. (See Chapter 31 for a discussion of drug from the agency in each state that enforces the medical
abuse and misuse.) practice act. As agents or representatives of the physician,
Some actions by patients may indicate possible abuse, allied health professionals work under the laws of the
as with the patient who asks for a particular medication state in which they practice their profession and have a
 CHAPTER 1 Introduction to Pharmacology and Its Legal and Ethical Aspects 17

legal and ethical responsibility to know what is allowed safeguard confidentiality. The procedure will vary among
under that state’s medical practice act. When federal and medical offices, but it must be in place to protect the
state laws concerning medications differ, which law pre- provider against the possibility of legal actions and inva-
vails? The stricter laws, whether they are federal or state, sion of privacy.
prevail. The office policy and protocol concerning who
may handle prescriptions and administer medicines in Drug Samples and Ethics
the medical office must be in compliance with state and Drug samples are a manufacturer’s way of promoting
national laws. sales by providing free supplies of medications to health
Some states allow allied health professionals to write care professionals; drug samples should not be sold.
prescriptions for a physician’s signature or allow a physi- Sample drugs requiring a prescription are marked
cian’s agent, such as a nurse practitioner, to sign. In other “sample” and bear the federal legend . These medica-
states this practice is illegal. Some states allow medica- tions must be inventoried before being left with the
tion administration by allied health workers; other states physician. Manufacturers may also supply drug coupons
do not. Because many medications have similar names, for a discounted price of prescribed drugs. These coupons
health care professionals should be sure that their knowl- may not be sold or traded for use on a drug other than
edge of medications is adequate to perform telephone the one identified on the coupon.
transmittal of prescriptions with accuracy. (See the Evolve Samples are distributed to health care professionals
site for sound-alike and look-alike names.) For com- (prescribers) only when the physician provides a written
monly prescribed medications, health care professionals request for any sample and identifies the desired quan-
should know indications, normal dosage, side effects, tity of the drug, manufacturer’s name, and prescriber’s
adverse reactions, and what patient education is neces- name. Medical personnel in the physician’s office may
sary before handling telephone orders. New medications not sign for samples; the physician must sign the required
should be researched before health care professionals form to receive samples. (Box 1-3 outlines the protocol
administers or relays orders for these. for receiving drug samples and the DEA surveillance of
controlled substances.)
Important Facts
• The allied health worker must understand laws as they
pertain to the medical practice in the state where he or she BOX 1-3 DRUG SAMPLES AND DRUG ENFORCEMENT
is employed. ADMINISTRATION (DEA) SURVEILLANCE
• Federal and state laws concerning medications and prescrip-
tions must be followed. Responsibilities of Manufacturer
• Supply samples.
• Provide documentation to DEA for scheduled medications.

Ethics of the Health Professional Responsibilities of Sales Representative

in Medication Management • Inventory drugs on receipt and yearly.
• Show place for safe storage.
Ethically, the person administering a medication must
• Maintain records of distribution.
also have a working knowledge of the medication—its
• Report theft or loss.
dosage, strength, physical appearance, side effects, and
• Verify current valid DEA registration of health care profes-
adverse reactions. If there is any doubt about the physi-
sionals receiving samples.
cian or health care professional’s order, the person
administering the medication should ask for clarifica-
Responsibilities of Medical Office
tion. With a written or phoned prescription, this account-
• Provide prescription or representative’s form signed by the
ability becomes a responsibility of the pharmacist. The
health care professional.
ultimate goal in medication administration is safety of
• Safeguard against theft and misuse by storing in secure area
the patient and reduction of possible mistakes.
not accessible to patients.
All health professionals must use confidentiality in all
• Document that samples are supplied to patients.
areas of medications and their administration. Some
• Dispose of unused or outdated samples properly.
drugs indicate certain conditions such as a human
• Retain samples at office once signed for; do not return to
immunodeficiency virus (HIV) infection, and the health
manufacturer’s representative.
professional must carefully protect prescription informa-
• Obtain authorization from health care professional to use
tion from anyone who does not have a need or does not
prescription samples.
have the patient’s permission to see them. If prescrip-
• Do not repackage samples.
tions are sent by facsimile equipment or electronically
• Do not charge for samples.
sent to pharmacies, a protocol must be in place to
18 SECTION I General Aspects of Pharmacology

Samples should be immediately stored in an area that

Important Facts—cont’d
is not accessible to patients and should be organized by
indication of use or disease process and expiration date. • Know the signs of drug abuse, and work within a legal frame-
Samples approaching their expiration date should be work to be sure you do not provide a way for drug abuse with
placed toward the front of the storage area so they are the medical office staff or with patients.
used first. Office personnel should assist the physician in • Work with pharmaceutical sales representatives to gain
being sure that only those medications that will be used knowledge of new medications, new uses for medicines, and
are left by the sales representative. Destruction of medi- information on drug samples left at the office.
cations that are not used or distributed by expiration • Drug samples should be suitable for the physician’s practice
date may be accomplished by flushing the medication and should be organized by their use for disease processes
down the toilet, pouring liquid medications into sink or drug categories. All similar drugs should be grouped
drains (followed by flushing with water), or incinerating. together; those with the nearest expiration date placed in
Drug destruction requires time and effort and should be front.
avoided if at all possible. Distributed drugs may not be • Health care professionals are at risk of drug abuse or misuse
returned to sales representatives. because of the ready availability of medicinal agents, such
Finally, drug samples must be provided to the patient as drug samples, and the tensions of the profession.
in the manufacturer’s package. • Drug abuse or misuse by health care professionals is a physi-
Medical personnel should always ask permission cal issue but more importantly an ethical problem because
from the physician, and office protocol should be fol- of the impact on patient care.
lowed before distribution to patients or for personal use.

Ethics of Medications with Medical Personnel

Because of the easy availability of medicines in the
medical office, health care workers are at risk for drug SUMMARY
abuse and misuse. Many medications, especially sample
medications, are found in the outpatient setting, which As partners with pharmacists and physicians, allied
can lead to the indiscriminate use of drugs. Career pres- health professionals are a major link in the medication
sures such as stress and lower back pain place profession- delivery pathway in today’s health care environment. The
als at greater risk of drug abuse and misuse. Many people administrative assistant must know medications in order
begin the road to drug abuse by having medications to refer medication questions appropriately to other
prescribed for legitimate health problems, only to find members of the health care team. Knowledge of drugs,
they have become chemically-dependent health care their actions, their interactions, their side effects, and
workers. their adverse reactions is necessary for appropriate
The impaired health care professional is a danger not patient care. Depending on the laws of individual states,
only to himself or herself but to the patient. The patient allied health professionals may administer medications,
is in danger because of erratic behavior that causes errors whereas physicians prescribe and pharmacists dispense.
in judgment and accidents. The impaired health care The ideal working relationship among all of these pro-
worker is also a problem for co-workers because they fessionals provides a system of checks and balances for
cannot depend on the person to perform assigned duties. patient safety. All medications, whether prescription or
How the problem is handled is an ethical matter (and OTC, should be documented in the medical record to
in some states a legal issue) that must be faced with each prevent overdosing or adverse reactions from multiple
situation. When the problem is confronted head-on, medications from multiple providers. Through educa-
patient safety is protected and the impaired worker has tion about the importance of providing information to
the opportunity to receive needed care. all physicians and taking medications as ordered, the
patient becomes an active participant in pharmacologic
therapy, and this role will only increase in the future.
Today’s health market has come a long way from the
early twentieth century, when medicine men hawked
Important Facts their wares from wagons. Those wares were not subject
• Allied health professionals must have a working knowledge to quality assurance oversight for ingredients or the man-
of all medications used in the office of employment. Health ufacture of the drug. One bottle of medication might do
professionals with questions about a drug should investigate wonders, but the next might be ineffective or deadly.
the drug prior to any administration. Today with federal and state legislation, people can be
• Have a working knowledge of drug samples. Be sure to assured that the medication prescribed and dispensed
follow office protocol when distributing these samples. will be of the same strength and purity every time they
fill the prescription or receive the medicine in the
 CHAPTER 1 Introduction to Pharmacology and Its Legal and Ethical Aspects 19

physician’s office. Through multiple statutes, the FDA these controlled substances, the public should be aware
continues to follow previously recognized drugs and of potentially abusive or dependent drugs and signs of
studies proposals of new uses of medications by manu- abuse or dependency.
facturers while watching closely as new medications are Health care workers must know federal and state laws
developed. The process is long, time-consuming, and because ignorance of the law is not a defense in court if
expensive, but the public can feel reassured that drugs mishandling or poor administration of drugs occurs. The
are safe. If for any reason safety is questioned, drugs are allied health professional must know the laws in the
recalled or taken off the market until their quality and state of employment, because medical practice acts vary
safety can be established. from state to state. Allied health personnel often work
Controlled substances have the potential to be abused, under the doctrine of respondeat superior, with the physi-
and through stringent laws these drugs are watched cian assigning a protocol that is appropriate to a given
closely by drug enforcement agencies. Written prescrip- situation.
tions are required for drugs with the greatest potential Ethics in the medical office requires ensuring confi-
for abuse, and it is unlawful for a person to possess a dentiality for the patient, safeguarding prescription pads,
controlled substance without a valid prescription. The and handling drug samples properly. By working with
1970 Controlled Substances Act was designed to provide other health care professionals such as physicians and
increased research into prevention of drug abuse and pharmacists, the allied health professional can be effec-
drug dependence. It also required special labels for drugs tive for patient safety. Because drugs are readily available
with potential for abuse, dependence, or both to ensure in the medical field, the allied health professional should
they would be administered or dispensed by legal drug be extremely careful about drug misuse and drug abuse
handlers and not used illicitly. To avoid illegal use of and be observant for early signs and symptoms of misuse.

C R I T I C A L THINKING EXERCISES

Scenario
Mary Ann, an administrative allied health professional, is manning the phone at Dr. Merry’s office.
Janelee calls to say that she has been to the pharmacy to get her medication and has read on the
patient information sheet that the drug prescribed should not be taken with aspirin, which she takes
daily.
1. What should Mary Ann do first?
2. Should she make a decision, or should she ask Dr. Merry?
3. The pharmacist had called earlier and asked to speak to Dr. Merry, but Mary Ann took a message
and did not give the message to Dr. Merry. Why is it important that the information be given to the
physician as soon as possible?
4. What should be provided to the physician at the time the message is relayed?

R E V I E W QUESTIONS
1. Define:
Pharmacology _____________________________________________________________________________________
___________________________________________________________________________________________________
Drug _____________________________________________________________________________________________
__________________________________________________________________________________________________
Medication ________________________________________________________________________________________
__________________________________________________________________________________________________
OTC _____________________________________________________________________________________________
__________________________________________________________________________________________________
Dispense __________________________________________________________________________________________
__________________________________________________________________________________________________
20 SECTION I General Aspects of Pharmacology

Prescribe __________________________________________________________________________________________
__________________________________________________________________________________________________
Administer ________________________________________________________________________________________
__________________________________________________________________________________________________
Prescription drugs __________________________________________________________________________________
__________________________________________________________________________________________________
Legend drugs ______________________________________________________________________________________
__________________________________________________________________________________________________
Drug abuse ________________________________________________________________________________________
__________________________________________________________________________________________________
Drug dependence ___________________________________________________________________________________
__________________________________________________________________________________________________
Drug standards ____________________________________________________________________________________
__________________________________________________________________________________________________
Drug Enforcement Administration (DEA) ______________________________________________________________
___________________________________________________________________________________________________
Food and Drug Administration (FDA) _________________________________________________________________
__________________________________________________________________________________________________
2. The three health professionals in the medication pathway are ________________, _________________, and
_______________. Describe the role of each in the system of checks and balances for safe medication use. _____
__________________________________________________________________________________________________
___________________________________________________________________________________________________
3. Name and define the five schedules found in the Controlled Substances Act. Place common medications that fall
under this legislation in the correct schedule. __________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
___________________________________________________________________________________________________
4. Drug abuse, drug dependence, and habituation are real problems in the medical office. Describe signs that patients
are abusers or are dependent on certain drugs. What measures can the medical office take to assist the patient yet
ensure that the office does not aid in further abuse or dependency? _______________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
___________________________________________________________________________________________________
5. Why are ethics in handling and dispensing of medication samples so important to health care workers? _______
__________________________________________________________________________________________________
___________________________________________________________________________________________________
 CHAPTER 2
Basics of Pharmacology

O B J E C T I VES
After studying this chapter, you should be capable of doing the following:
• Providing definitions of the keywords using the • Describing the five fundamental categories of
glossary or a medical dictionary. pharmacology and how these factors influence
• Stating health care workers’ responsibility with medications.
regard to adverse reactions, side effects, and toxic • Describing indications for medicines.
reactions. • Explaining drug interactions with other drugs,
• Defining drug. nutrients, and diseases.

Joyce works in a physician’s office that has several patients who do not think that going to a physician
is necessary until an illness becomes life-threatening. These patients often see folk healers and use
herbal supplements and over-the-counter (OTC) preparations rather than prescription medications.
Joyce does not think it is necessary to document herbal supplements and OTC medications in the
medical record.
What harm may Joyce cause these patients?
Thinking that the patient is taking medications as ordered, the physician cannot understand why the
maintenance dose is not working and increases the dosage. What are the dangers of cumulation
(accumulation), synergism, and antagonism?

K E Y T E R MS
Absorption Chelator Drug blood level Local action
Active ingredient Clinical pharmacology Drug half-life Metabolism
Addiction Contraindication Drug interaction Mucosal
Adverse reaction Cumulation Enteral Pharmacodynamics
Agonist (accumulation) Excretion Pharmacognosy
Alkaloid Curative (healing) First-pass effect Pharmacokinetics
Allergic reaction medication Free or unbound drug Pharmacotherapeutics
Analgesic Demulcent Habituation Potentiation
Anaphylaxis Dependence Hypersensitivity Prophylactic
Antagonism Depressant reaction Receptor site
Antagonist Desired therapeutic Ideal drug Recombinant DNA
Antidote effect or desired Idiosyncratic drug technology
Antiinflammatory effect reaction Safe drug
Antimetabolite Destructive agent Indication Side effect
Antipyretic Distribution Inert ingredient Solubility
Biotransformation Drug Irritant Summation

21
22 SECTION I General Aspects of Pharmacology

K E Y T E R MS— cont’d
Supportive Synthetic or Therapeutics Toxicology
medication manufactured drug Tolerance Usage
Synergism Systemic action Toxic

W
ith the possible exception of computers, in no Most drugs contain various components—active and
area of life during the twentieth and twenty- inactive (or inert) ingredients. An active ingredient is the
first centuries has technology transformed pure, undiluted form of chemical that produces an effect
everyday living more than with pharmacology. Drugs are but is rarely given alone. Usually it is combined with one
not new; they have been used since prehistoric times or more inert ingredients (or vehicles) that assist in the
through all eras of civilization. With the introduction of drug’s action and may also contain ingredients such as
many new drugs and new uses for older drugs, the allied preservatives, colorings, and flavorings.
health professional is responsible for being current on An ideal drug, a theoretical construct, is one that has
the action of drugs within the body; routes of adminis- only qualities of effectiveness and safety and produces
tration; forms of drugs for administration; desired side no side effects or adverse reactions. Although no ideal
effects; and toxic effects and adverse reactions of drugs drug exists, some characteristics, such as the following,
on patients of all ages. The allied health professional’s help a drug draw near to ideal:
understanding of pharmacology can be critical to the • Predictability—Drug will produce the same effect
patient–health professional relationship, as well as to each time the same dose is given.
the employer–employee relationship. • Ease of administration—Drug is simple to admin-
A drug assists in maintaining or restoring homeostasis ister, convenient to use, and requires only one dose
after a decline in body functions caused by illness. Drugs a day, to help the patient follow the directions for
can become dangerous if they are used to create unneces- the medication.
sary dependence or irreversible harm, but when used • Inexpensive—Low cost will help lighten the finan-
intelligently they provide a lifesaving benefit. cial burden of taking medications over prolonged
When patients and prescribers use medications appro-
priately, medications can restore health, prolong life, and
increase quality of life for patients. BOX 2-1 FOUR BASIC TERMS IN PHARMACOLOGY

1. Drug—Any chemical that can affect living processes. Under

this broad definition, all chemicals are considered drugs
WHAT IS A DRUG?
when given in amounts large enough to alter or affect life.
2. Pharmacology—Study of drugs and their interactions with
The word drug comes from the Dutch word droge,
living systems. The definition includes the study of physical
meaning dry. The term is appropriate because for centu-
and chemical properties of drugs, as well as their effects on
ries most drugs used for treatment came from dried
the body. It also includes the history of drugs, their sources
plants. Today a drug is considered to be any substance
and uses, and how they are used by the body. This is a broad
that causes chemical changes within the body. Virtually
field, and this book will consider only those areas of pharma-
all chemicals, including such substances as tea and
cology relevant to an ambulatory medical setting.
coffee, may be classified as drugs. In this book, a drug
3. Clinical pharmacology—Study of drug absorption and
is any chemical used for a therapeutic application such
metabolism in humans, including those who are healthy as
as treating an illness or relieving a symptom or for diag-
well as those who are not in homeostasis.
nostic testing. Drugs are chemical substances that can
4. Therapeutics—Use of drugs to diagnose disease (diagnos-
help or harm individuals, altering the biochemical func-
tic agents), prevent disease or a condition such as pregnancy
tion in the body.
(prophylactic agents), or treat disease (therapeutic drugs).
Researchers today build on the accumulated knowl-
This definition, simply stated, is the medical use of drugs,
edge of the past to produce major new advances. Through
even though some may cause adverse reactions. (Adverse
the years, increasing knowledge about disease processes
reactions are those effects that are undesirable or unin-
has led to the need for refined medications and to rapid
tended.) The term therapeutics also encompasses the basic
changes in the field of pharmacology. Pharmacology
reasons for giving a particular drug to a particular patient, in
will continue to change rapidly in the future as medical
a particular dosage, by a particular route, and on a particular
research makes innovative studies. However, the four
schedule. Knowledge of pharmacology helps show what
basic terms used in pharmacology—drug, pharmacology,
strategies will promote beneficial drug effect while minimiz-
clinical pharmacology, and therapeutics—will remain
ing undesired effects.
the same (Box 2-1).
 CHAPTER 2 Basics of Pharmacology 23

periods. Because of ongoing expense, even moder-

Pharmacognosy—Origins of Drugs
ately priced drugs can be financially devastating.
• Identification—a name that is easy to pronounce Drugs come from basically five sources: plants, animals
and remember. (including humans), minerals or mineral products, syn-
No drug is completely safe, because all drugs have side thetic or chemical substances, and modern engineering.
effects, but selectivity in prescribing reduces the chance No longer is the drug industry bound to natural sub-
of side effects and possible injury. A safe drug produces stances in either crude or natural states. Today, chemicals
only the response for which it is given, causing no and even human tissues, such as in stem cell therapy, can
harmful effects when taken over a long period of time. be manipulated to increase drug sources.
The drug response may be difficult to predict from person The early crude drugs came from all dried plant parts
to person and may change if the patient takes other and had unknown purity and varying strength. Often,
medications. The health care team should work together undesired materials entered the plants and produced
to ensure that medications are producing the desired toxic effects. Later, active ingredients were separated from
effect, or intended results, to minimize the chance of a the plant, resulting in more reliable substance adminis-
drug-induced injury. tration. (Table 2-1 shows examples of plant sources.)
Minerals from the earth and soil are used as they
Important Facts occur in nature or combined with other ingredients for
drugs. An example is coal tar, an acid that yields salicylic
• Medications aid in keeping the body in homeostasis and are acid, which was first used to manufacture aspirin (see
of lifesaving benefit when used correctly and with discrimi- Table 2-1).
nation. If used incorrectly, drugs can cause irreparable harm. Drugs can be derived from animal sources including
• No ideal drug exists. All drugs cause some side effects or vaccines, oils, and fats used in treatment of endocrine
adverse reactions. The allied health professional must be system diseases and for immunizations. Human extracts
aware of these effects and acquire an adequate medication such as enzymes and hormones, may be used for
knowledge base for patient safety. treating diseases or potential conditions—for example,
• Safe drugs are those that can be taken in adequate doses RhoGAM for possible erythroblastosis fetalis (see Table
over long periods of time with no harmful effects. 2-1).
Chemists are producing drugs from living organisms
(organic substances) or nonliving materials (inorganic
FIVE BASIC CATEGORIES substances) in ever-increasing numbers. Chemically
OF PHARMACOLOGY developed drugs are free of the impurities found in
natural substances and are called synthetic or manu-
Medicines are foreign matter to the body and are capable factured drugs. Some drugs are both organic and inor-
of causing unexpected results, as well as desired thera- ganic (e.g., propylthiouracil, an antithyroid hormone)
peutic effects. Medications change body chemistry or (see Table 2-1).
function to diminish disease processes causing the symp-
toms rather than eliminating the cause of the symptoms.
Did You Know?
Terms used in pharmacology are pharmacognosy, or
origins of drugs; pharmacokinetics, or how drugs are Infection was the leading cause of death before the isolation
processed; pharmacodynamics, or actions of drugs; and production of penicillin in a laboratory in 1942.
pharmacotherapeutics, or effects of drugs; and toxicol-
ogy, or the study of toxic or poisonous effects of drugs.
Recombinant DNA technology, the fastest growing
area in the pharmaceutical world, uses artificially manip-
ulated DNA segments from different organic sources by
Important Facts transferring a cell from a different species to a host cell
The fundamental divisions in pharmacology are as follows: to change the way the cell reproduces. In effect, the cell
• Pharmacognosy—Origin of drugs becomes a small-scale protein factory that creates genetic
• Pharmacokinetics—How the body processes drugs (what instructions leading the organism to produce chemical
the body does to the drug) substances for use as drugs. These medications are spe-
• Pharmacodynamics—Drug actions on the body (what the cifically targeted outside cells, although the source of the
drug does to the body) disease proteins is inside cells where the disease begins
• Pharmacotherapeutics—Effect of drugs in treatment of (Figure 2-1). DNA research is now focusing on finding
disease ways to deliver enzymes and proteins inside the cell for
• Toxicology—Poisonous effects of drugs on the body repair of diseased cells. The newer forms of insulin have
been produced by this technique, as have skin grafts for
24 SECTION I General Aspects of Pharmacology

Step 1 Step 2
TABLE 2-1 DRUG SOURCES

SOURCE DRUG
PLANTS
Purple foxglove (digitalis) digoxin
Rose hips vitamin C
GENE IS SPLICED CELLS EXTRACTED
Cinchona bark quinidine Genes for a disease-fighting The cells containing the new
Opium poppy morphine, codeine, paregoric protein are inserted into the protein are then removed
cells of a living organism. from the organism.
Periwinkle (vinca) vinCRIStine
Snakeroot reserpine Step 3 Step 4
Grapefruit methylcellulose
Belladonna atropine, scopolamine
Willow bark aspirin
Castor bean castor oil

MINERALS
Gold Solganal, auranofin
COPIES MADE HARVESTED
Zinc zinc oxide The cells multiply slowly at The desired proteins are
Calcium Os-Cal, Cal-Bid, Citracal, Rolaids, first, then in increasingly larger extracted from the rest of
quantities to supply amounts the cell, purified, and made
Tums needed for manufacturing into biologic medicines.
Magnesium milk of magnesia, Mylanta, of medications.
Maalox Figure 2-1 Making of DNA technologic medications and substances.
Aluminum Amphojel, Gelusil (Redrawn from Marsiglio D: New miracle drugs, AARP The Magazine,
Nov-Dec 2009.)
ANIMALS
Codfish cod liver oil as hepatitis C have been introduced. Many others will be
Urine of mares conjugated estrogen brought to market in the future through methods such
Stomachs of hogs pepsin as cloning of salivary gland cells to produce insulin to
treat diabetes (see Table 2-1).
Animal thyroid glands thyroid hormone
Placenta hair products
Did You Know?
SYNTHETICS AND SEMISYNTHETICS
Inorganic sulfonamides, oral The reason that DNA-technology–produced biologic drugs and
contraceptives, barbiturates grafts are not used more often is that these medicines are so
meperidine (Demerol) expensive—sometimes over $100,000 per year—and patients
cannot afford the price. It is predicted that by 2014, many of the
Organic penicillin, cephalosporins
top 100 drugs will be biologics.
RECOMBINANT DNA TECHNOLOGY
Drugs such as insulin Humulin
Important Facts
Erythropoietin Epogen
The origin of drugs that began with use of natural plant and
animal substances has now moved into the laboratory, where
burns and other wounds that are produced from the scientists manufacture drugs synthetically from chemical
foreskin of the penis (Apligraf). compounds.
Another biotechnologic method of drug production
is use of cells from animals with antigens to produce
hybrid cells that produce antibodies to attack tumors
Pharmacokinetics—How the Body
and permit diagnosis of many conditions, from anemia
Processes Drugs
to syphilis. These drugs are also used as antirejection
medications after organ transplantation. Through bio- The word pharmacokinetics comes from the Greek words
technology, drugs to promote blood clotting in hemo- pharmako, meaning drugs, and kinesis, meaning motion;
philiacs and interferons to combat viral infections such hence, pharmacokinetics refers to the movement of drugs
 CHAPTER 2 Basics of Pharmacology 25

BOX 2-2 FACTORS THAT AFFECT DRUG ACTIVITY

Drug administration—Patient compliance or medication errors Route:

Disintegration or dissolution of drug—Availability of drug for 40 mg orally
absorption administered drug
Pharmacokinetics—How body processes drugs
Pharmacodynamics—Drug-receptor cell interactions
Route:
Intensity of response—Individual differences in response to
2 mg of same
drugs related to physiologic (e.g., age, gender), psychologic, drug administered
Heart
genetic, and dietary factors; disease states; and interactions intravenously
with other drugs
Stomach

BOX 2-3 FOUR BASIC PROCESSES Liver

OF PHARMACOKINETICS
Excretion
Absorption
• Active ingredients are absorbed and transported to sites of
action.
• Amount of absorption depends on drug’s ability to cross cell Figure 2-2 Pharmacokinesis is the movement of drugs through the body
membranes. via absorption, distribution, metabolism, and excretion. (From Klieger DM:
Saunders essentials of medical assisting, ed 2, St Louis, 2010, Elsevier.)
Distribution
• Drug molecules are transported to various body areas via
circulating body fluids.
TABLE 2-2 RATE OF DRUG ABSORPTION BY ROUTE OF
• Permeability of capillaries to the drug determines rate of
ADMINISTRATION
distribution.
RATE OF ABSORPTION* FROM
Metabolism (Biotransformation) ROUTE FASTEST TO SLOWEST
• Drug is chemically altered by the action of enzymes in the
blood, liver, lungs, kidneys, and intestines to convert drug Enteral Rectal → Nasogastric → Oral
molecules into water-soluble compounds or metabolites for Parenteral Intravenous → Intramuscular →
the body’s use or elimination. Subcutaneous → Intradermal
Percutaneous or mucosal Inhalation (lungs) → Sublingual
Excretion (tongue) → Transdermal
• Unused drug molecules are removed from their sites of (through skin) → Topical
action, usually through the urinary tract, respiratory tract, (on skin)
gastrointestinal tract, or skin.
*Rate of absorption is specific to each route of administration.

through the body. The four processes involved in phar-

macokinetics are absorption, movement of a drug from Absorption
its site of administration into the blood; distribution, The rate of absorption of a medication is directly related
movement of a drug from the blood into the tissues and to the route of administration and the drug’s solubility
cells; metabolism (or biotransformation), physical or its ability to dissolve (Tables 2-2 and 2-3). Absorption
and chemical alteration of the drug in the body; and is dependent on the form of the drug and the amount
excretion (or elimination), removal of waste products of blood flow in the area; some medications dissolve
of drug metabolism from the body (Figure 2-2; Boxes rapidly, whereas others dissolve slowly. Primary sites of
2-2 and 2-3). absorption are the mucosa of the mouth, lungs, stomach,
small intestines, and rectum and blood vessels in the
muscles and subcutaneous tissues. Examples include
LEARNING TIP nitroglycerin, placed under the tongue next to blood
Kinesis means motion or movement (recall “kinetic exercises”). vessels; albuterol (Ventolin HFA), taken into the lungs
Pharmacokinetics is the way drugs move through the body. by inhalation; and dextrose in water, administered intra-
venously directly into the bloodstream (see Box 2-3).
26 SECTION I General Aspects of Pharmacology

Table 2-4 shows routes of administration versus time for

TABLE 2-3 ORAL PREPARATIONS AND THEIR
absorption of medications.
ABSORPTION RATES
Other factors that may cause variation in the absorp-
PREPARATION RATE tion rate include the following:
Incorrect administration—Poor technique in giving a
Syrups, elixirs, liquids Fastest medication may destroy the drug before it reaches
Suspensions the bloodstream or its site of action. Specific direc-
Powders tions for administration must be given and fol-
Capsules lowed to enhance absorption.
Tablets pH—Drugs of an acidic pH such as aspirin are easily
Coated tablets absorbed in the acidic surroundings of the stomach,
Enteric-coated tablets whereas alkaline medications such as Maalox are
Timed-release capsules Slowest more readily absorbed in the alkaline environment
of the small intestine.

TABLE 2-4 DRUG ADMINISTRATION ROUTE AND RATE OF ABSORPTION OR ACTION

ROUTE TIME INVOLVED WHEN USED EXAMPLES

ENTERAL ROUTES
Oral 30-60 min As often as possible Most medications
Safest and most convenient Tablets, capsules
Sublingual Several sec to several min Rapid effect Nitroglycerin for angina
Buccal Several min Rapid effect Fentanyl for pain
Rectal 15-30 min, depending on When oral medications cannot be used Suppositories for nausea/
contents of rectum (e.g., with nausea/vomiting) and vomiting or for constipation
parenteral route is not indicated
For local effect Preparation H for hemorrhoids

PARENTERAL ROUTES
Subcutaneous (SC) Several min; 20-30 min Medications inactivated by Insulin, vaccines
gastrointestinal tract or when fast
absorption is not indicated
Intramuscular (IM) Several min, shorter than Medications with poor absorption or Narcotics for pain, antibiotics,
SC route; 15-25 min when more rapid effects are desired— hormones
higher blood levels are obtained faster
Intravenous (IV) Approximately 1 min; When immediate effects are necessary; Cancer medications, cytotoxics
administered directly into when absorption in muscles is not
bloodstream adequate or is damaging to tissues
Intraarterial Approximately 1 min Local effects within an internal organ Select cancer medications

PERCUTANEOUS OR MUCOSAL ROUTES

Transdermal 30-60 min Convenient to provide continuous Nitroglycerin, estrogen, and
absorption and systemic effects over fentanyl
hours
Intrathecal Several min Local effects in spinal cord Spinal anesthesia, epidurals
Inhalation Approximately 1 min Local effects on respiratory tract Medications for asthma, chronic
obstructive pulmonary disease;
oxygen
Topical Approximately 1 hr Local effects on skin, ears, eyes Creams, ointments, drops
Vaginal 15-30 min Local effects Creams, foams, suppositories
Urethral 15-30 min Local effects Gels, jellies
Min; Minute(s), Sec; second(s).
 CHAPTER 2 Basics of Pharmacology 27

Food in stomach—Food in the stomach slows the body with antiinfective action for longer periods of time
absorption rate and decreases irritation, whereas than other antibiotics.
an empty stomach increases the rate of absorption Some drugs cannot pass through certain types of cell
and irritation in most medications. Some drugs membranes. With the blood-brain barrier, the brain is
require food in the intestinal tract for absorption protected by the barrier’s restriction of entry of water-
to take place. soluble electrolytes, but lipid-soluble drugs are allowed
Fat or lipid solubility—Drugs that are highly soluble in distribution into the brain and cerebrospinal fluid
fats or lipids, such as alcohol and alcohol- because the brain is composed of many lipids. The pla-
containing substances, are readily absorbed in the cental barrier, another membrane, is less selective in the
gastrointestinal tract, whereas those with low lipid distribution of medications, allowing water- and lipid-
solubility are better absorbed when given by other soluble drugs to cross. Many medications given to a
routes. mother may also reach the fetus, producing either a
Length of contact—Absorption of topical drugs is influ- therapeutic effect (such as cardiac drugs that may be
enced by the length of contact time with the skin, necessary for the fetus) or harmful effects (such as anes-
size of contact area, skin thickness, and hydration thetics, alcohol, and narcotics). Other drugs may be dis-
of tissues at the site of application. tributed to selected specific sites—for example, sending
Inhalation factors—Depth of respirations, surface area human chorionic gonadotropin (hCG) to the ovaries to
of mucous membranes, hydration of the patient, treat infertility (see Box 2-3).
blood supply to the lungs, and drug concentration
influence the rapidity of absorption. Inhalation is
actually one of the most rapid forms for medica- Metabolism or Biotransformation
tion absorption. Metabolism, or biotransformation, is a series of chemical
Drug concentration—High concentrations of drugs reactions that alter and convert drugs into water-soluble
tend to be absorbed more rapidly; thus initial or compounds for excretion. Most drugs are detoxified, or
first doses may be larger than maintenance or daily turned into a relatively harmless substance, to allow the
doses (see Box 2-3). body to rid itself of the drug. Without metabolism, the
drug would continue to have an effect on the body and
could eventually cause harm to the person by accumula-
Distribution tion to toxic levels.
Drug blood level is the amount of drug circulating in Although other organs can contribute to metabolism
the bloodstream ready to travel through body fluids to of drugs, the liver is the primary site for drug metabo-
its site of action or distribution. Areas with an extensive lism. The amount of the drug that may be metabolized
blood supply receive a drug rapidly, whereas areas with during an initial pass through the liver varies from a
less blood supply have a delay in distribution. Although small amount to a substantial portion of the drug,
a drug is delivered to the organ or tissues through blood vessels leaving only a limited amount of the medication to reach
and capillaries, the effect of the drug is in the tissues, not in the site of action. This is called the first-pass effect.
the blood vessels. The rate at which a drug enters different Drugs that are administered parenterally or sublingually
areas of the body depends on the permeability of the do not undergo a first-pass effect; therefore lower doses
capillaries to the drug’s molecules and to the chemical may be required than for drugs given by enteral routes
makeup of the drug, amount given, size of the person, (see Figure 2-2).
and amount of protein in blood. The rate of metabolism is an important issue in drug
Two factors that influence drug distribution are fat dosage. The drug half-life is the time the body takes to
solubility and protein binding. A sustained pharmaco- metabolize half of the available drug. Older adults or
logic effect is the result of the body providing storage persons with impaired liver or renal function may have
reservoirs in the fatty tissues for fat-soluble drug accu- inefficient or insufficient metabolism of the drug and
mulation. Because little blood flows through fat tissue, may be at risk for drug toxicity because the drug’s half-
the storage site for the drug is established and a relatively life is prolonged (see Box 2-2).
stable reserve of the drug is maintained. Lipid-soluble
drugs, such as hormones given by injection in an oil
base, tend to have a longer-lasting effect. Excretion or Elimination
Plasma protein binding is attaching of drugs to pro- The rate of excretion or elimination depends on the
teins in the blood, decreasing the amount of free or chemical composition of the drug, rate of metabolism,
unbound drug circulating in the body and thus limiting and route of administration (see Tables 2-2, 2-3, and
the amount of drug at the site of action. As the body uses 2-4). The functionality of excreting organs such as the
the free drug, the protein-bound drug breaks down for kidneys also determines how quickly and completely
use. Because of this process, sulfa drugs remain in the excretion occurs.
28 SECTION I General Aspects of Pharmacology

Important Facts TABLE 2-5 FOUR MAJOR DRUG ACTIONS

• Absorption, distribution, metabolism, and excretion, steps ACTION DEFINITION EXAMPLE
used to process drugs, are dependent on many factors includ-
ing age, mental state, route of administration, gender, and Depressant Reduces the tolterodine (Detrol)
the physical condition of the patient. activity of the depresses the urge to
• The drug blood level is the amount of drug circulating in the body function void
bloodstream. phenytoin (Dilantin)
• The half-life dosage of a drug is the time at which half of the depresses seizure
initial dose has been metabolized and inactivated. Drug half- activity
life, essential in establishing the safe dosage, is different for Stimulant Increases body Laxatives stimulate
each drug. function or peristalsis
• Drug excretion occurs most commonly via the kidneys; there- activity Oral hypoglycemics
fore adequate renal function must be present. stimulate the pancreas
to release insulin
Irritant Produces fluorouracil (Efudex)
symptoms of irritates skin lesions for
Pharmacodynamics—Drug Actions inflammation destruction of the
in the Body at site of lesion as a side effect
application Ichthammol increases the
Pharmacodynamics is the term for how a drug works or inflammation of boils
its mechanism of action in the body or the body’s chemi- Demulcent Soothing action Hydrocortisone cream
cal reaction to drugs. In pharmacodynamic terms, drug for irritation, soothes allergic skin
actions affect biochemical or physiologic processes in usually to reactions
the body or control changes caused by disease. Drugs can skin or Lanolin smoothes cracked
modify the way the body acts, but they do not give body organs mucous skin and decreases
and tissues a new function. membranes irritation

LEARNING TIP
Dynamite causes an explosion at a site. Pharmacodynamics refers
to drug action, as drugs “explode” into action in the body. The site of action of a drug may be either local or
systemic. Local action is limited to the site of adminis-
tration and tissues immediately surrounding the applica-
The actions of drugs usually either slow down or tion site; examples of medications with local action are
speed up ordinary cell processes and protect the body nasal sprays and topical creams. When the drug effect is
from actions of foreign agents (Table 2-5 describes the felt throughout the body, not just at the site of adminis-
four major drug actions). tration, it is considered systemic action. Intravenous and
No drug has a single action. When a drug enters the intramuscular drugs always reach systemic circulation for
body, a predictable chemical reaction is expected. their effect, whereas oral and subcutaneous drugs may
However, individuals react to drugs differently, with produce systemic or local effects. The same drug may be
many unpredictable chemical reactions occurring. The manufactured for either systemic or local effect. An
desired effect happens when the expected response example it is Benadryl, which is manufactured in capsules
occurs, such as Benadryl stopping watery eyes caused for systemic use and as a cream for topical or local use.
by allergies. However, other effects that occur that are A drug that has its effect on a part of the body distant
predictable but not the desired effects are side effects. from the site of administration is said to have a remote
Because medications affect more than one body system, effect; an example is nitroglycerin, placed under the
the action may not be specific and may cause unde- tongue to treat the acute symptoms of angina pectoris in
sired responses. The drowsiness that occurs with Bena- the heart.
dryl is expected and is sometimes a therapeutic action Rather than having systemic action, some drugs have
used with insomnia as a desired side effect. Lowering specific sites of action, such as thyroid hormone, which
the dosage of the medication will often reduce side has a primary site of action in the thyroid gland for
effects, but in some cases the drug may have to be dis- hormone replacement in hypothyroidism.
continued because of side effects. (Adverse reactions Drugs may also fall into categories that describe how
that tend to be more severe are discussed later in this the body responds to medication or the interactions at
chapter.) receptor cells. Box 2-4 describes four actions.
 CHAPTER 2 Basics of Pharmacology 29

Drug therapy is one part of the physician’s total

BOX 2-4 FOUR MAJOR CATEGORIES OF DRUG ACTIONS
treatment plan for the medical condition, but it does
• Depressant—A lessening or suppression of some body func- not stand on its own. Illnesses manifest with signs and
tion or activity (e.g., omeprazole [Prilosec] to suppress gastric symptoms, which may then become indications, or
acid secretions) reasons, for treatment with certain medications, or
• Stimulant—An increase in or stimulation of some body func- pharmacotherapy for the specific condition. Usage is
tion or activity (e.g., bisacodyl [Dulcolax] to increase peristal- prescribing and applying or administering a medication
sis in the colon for excretion of waste) for a given purpose. Many drugs produce therapeutic
• Irritant—The production of inflammation, generally by drugs effects in several ways while still having the same indi-
applied to mucous membranes or the skin (e.g., fluorouracil cations and usage. For example, aspirin is used as an
[Efudex], used topically to irritate keratosis for destruction of analgesic and antipyretic, but it is also used to slow
proliferating cells) blood clotting and as an antiinflammatory agent.
• Demulcent—Relief of irritation or the production of a sooth- Diuretics may be used both to relieve edema and to
ing effect (e.g., calamine lotion to relieve itching and irrita- lower blood pressure, in this way affecting both the
tion of chickenpox) urinary and circulatory systems. A final example is ibu-
profen, which was first introduced for the relief of
arthritic pain and is also used as an antipyretic and
analgesic.
As the field of pharmacology has evolved, a new
Important Facts classification of indications for medication use has
• Drugs do not have a single action, although each drug has come into being. The broad terms therapeutic, diagnostic,
an expected action or desired effect. Because drugs may not destructive, pharmacodynamic, and prophylactic represent
be specific to a single body system, side effects may occur the spectrum of drug indications (see Table 2-6 for an
when another system is influenced. explanation of these terms).
• Drug action is also related to the site of action. A drug that When a drug enters the body, a predictable chemical
is not absorbed into the bloodstream but works at the site of reaction is expected. This intended response and expected
application is said to act locally. Systemic action refers to a therapeutic result is called the desired effect.
total-body effect of a drug that is absorbed into the blood- Because a medication may influence more than one
stream. Remote action refers to the effect of a drug on the body system at a time, it may produce unpredictable
body at a site distant from the site of administration. reactions, called side effects, which are usually mild but
• Four major drug actions are stimulant, depressant, irritant, sometimes annoying responses to the medication. In
and demulcent. some therapeutic cases, medications are used for the
side effects—for example, minoxidil (Rogaine), with its
side effect of hair growth, or drowsiness caused by anti-
histamines. The incidence of side effects may decrease
when the medication is taken over an extended period
Pharmacotherapeutics—Indications
of time. Lowering the dosage of the drug may reduce
for or Effects of Medication Use
some side effects. In some instances, the drug must be
Different from drug action of how and where a drug acts discontinued or stopped because of the annoying
in various body systems, the effect of a drug is the sum response.
of the biologic, physical, and psychologic changes that
occur in the body, or the result of the drug’s action.
Effects that are not part of the desired therapeutic
response do occur with drugs given systemically because
more than one type of body tissue, not just the target Important Facts
receptor site, can be affected. • The effect of a drug in the treatment of disease is referred
to as pharmacotherapeutics or pharmacotherapy and is a
combination of the biologic, physical, and psychologic
changes induced as a result of the drug’s action.
LEARNING TIP • Drugs do not have a single action, although each drug has
If we have therapy of any kind, we expect it to affect or change our an expected action or desired effect. Because drugs may not
body in some way. Pharmacotherapeutics refers to how a drug be specific to a single body system, side effects may occur
changes what is occurring in the body or the therapeutic effect of when another system is influenced.
the medication to treat symptoms or diseases such as a headache • Side effects may be annoying responses to a medication or
or cough. may be an indication for the medication’s use.
Other documents randomly have
different content
circulation through it, returns by the umbilical vein directly to the
heart. The circulation continues until respiration is established,
when it ceases spontaneously, and any interruption of it, before the
latter process has commenced, is immediately fatal. From these facts
we are warranted in inferring that a change necessary to life
(probably oxygenation) is produced in the placenta, although the
nature of that change is obscure, and the relative properties of the
blood in the umbilical arteries and veins not at all known. That the
organ in question not only revivifies the blood, but also elaborates
new vital fluid, thus performing a function analogous to that of the
stomach, can only be inferred from the absence of any other source
from whence the fetus could obtain materials for growth and
support.”
 THE MEMBRANES.
These are expanded from the edge of the placenta, in connection
with which they form a complete involucrum of the fetus and waters,
and at the same time a lining for the uterus. The membranes grow
and expand in the same proportion as the fetus, and when expelled
after the birth has taken place, are, in connection with the placenta,
termed the secundines.
There are three of these membranes, which are found surrounding
the fetus. “There is first the outer, or connecting membrane, which is
flocculent, spongy, and extremely vascular, completely investing the
whole ovum, and lining the uterus; secondly, the middle membrane,
which is nearly pellucid, with a very few small blood-vessels
scattered over it, and which form a covering to the placenta and
funis, but does not pass between the placenta and uterus; thirdly, the
inner membrane, which is transparent, of a firmer texture than the
others, and lines the whole ovum, making, like the middle
membrane, a covering for the placenta and funis. With the two last
the ovum is clothed when it passes from the ovarium into the uterus,
where the first is provided for its reception. These membranes, in the
advanced state of pregnancy, cohere slightly to each other, though in
some ova there is a considerable quantity of fluid collected between
them, which being discharged when one of the outer membranes is
broken, forms one of the circumstances which has been
distinguished by the name of by, or false waters.”
It seemed necessary that I should make these preliminary remarks
concerning the physiology of the placenta and the membranes, in
order that you might the better understand the third process of
labor, or that which consists in the expulsion of these growths, the
secundines, as they are called.
I have now some practical remarks to make, which I hope you will
study faithfully, for it not unfrequently happens that a child is born
before you can obtain the assistance of a physician; and after the
child has been expelled, what to do in reference to the after-birth;
that is a question which, under such circumstances, puzzles your sex
more a great deal than it need or ought to do.
Suppose, then, that a child is born suddenly, or at least before the
medical man or woman whom you would employ, comes to your aid,
and the placenta remains undelivered.
I shall tell you, in another place, not to be in such a flurry, as
women too often are, in regard to separating the umbilical cord. So,
too, I say in regard to the after-birth; be in no hurry.
Have you not often heard people say that the after-birth has grown
fast and sticks? Women sometimes say this, and so do the doctors,
some of them; such, for example, as are not honest enough to tell the
truth, if they know it, and would make you believe that they are
doing a great thing when they get away the after-birth, if it sticks.
Now please remember that it is right that the placenta should grow
fast to the womb; that is, to its inner surface. It is always grown fast,
and should be; but it is possible for it to adhere more firmly in some
cases than in others; and in some cases, too, the uterus seems to be
so weak that it has not power sufficient to expel it.
In cases when the womb is very active after the birth of the child,
the placenta may be expelled very quickly.
But it is more commonly the case that after the uterine
contractions have forced the child into the world, the womb reposes
itself for a half hour, less or more. After this, periodical pains begin
to occur, so that the after-birth may be completely thrown forth into
the world; but far oftener it is either wholly, or in part only, into the
vagina, where it remains for a time at least.
At what time, and under what rules, should manual aid be
administered in helping away the after-birth? By different
practitioners different rules have been instituted. A rule of Dr.
Hunter’s was to wait till four hours after the birth of the child. If the
placenta come away of itself, before this time have elapsed, it is well;
but if, on the other hand, it still remain in the cavity of the uterus,
manual aid may become necessary.
Another rule is, to judge by the pains, without any regard to the
length of time that has elapsed since the delivery of the child; pains,
it is said, accompany the contractions; the contractions expel the
placenta; the pains, therefore, indicate the time at which artificial
assistance should be interposed.
Another rule is, first to determine the situation of the womb before
any manual attempt is made for helping away the after-birth. If, on
examination, the placenta is found lying in the upper part of the
vagina, and through the os uteri, and more especially if the union of
the umbilical cord with the placenta can be felt, it is considered
proper to remove it. But if the umbilical cord ascend high into the
womb, and no part of the placenta can be felt, it is considered best to
wait.
Still another rule is, to act according to the feeling and condition of
the uterus, without any regard to the length of time after the birth,
the pains, or the situation of the placenta. If, on examination
externally, it is found that the womb is yet large, uncontracted, and
pulpy, the placenta should not, according to this rule, be interfered
with. But if, on the other hand, there is an opposite state of things—
that is, if the uterus is found hard and contracted, feeling like a
child’s head in the abdomen, and if it remain so for some time
permanently, it is considered safe and best at once, in a proper
manner, to remove the viscus. A skillful practitioner will bear in
mind all these circumstances, and form a rule out of all of them, as it
were, to guide him in each individual case; and I wish you to
remember, that although you may consider the principal part of
delivery is accomplished at the time when the child comes into the
world, it is to be remembered that its real danger has not yet
commenced, and that the birth of the placenta is a most important
part of the process.
Into all the niceties and difficulties of this part of the accoucheur’s
art, I do not, you will remember, attempt to induct you. It is my
object to give you some general ideas of the matter, such as may be of
use to you in an emergency, and prevent a great deal of unnecessary
anxiety and alarm in some cases. My remarks will also, I trust, go to
impress upon your minds how very necessary it is, under such
circumstances, to have the aid of a physician—a man or woman, I
care not which—who understands well the art. You may say that
nature is sufficient in most cases to perform her own tasks unaided
and alone. That, I admit, may all be true, especially with those who
have good constitutions, and who observe well the laws of life. But
remember that these circumstances do not always exist. Any one of
you would rather incur the expense of having a physician a thousand
times, when he is not needed, than to suffer danger for his want in a
single instance.
 OF FLOODING AFTER DELIVERY.
Hemorrhage is one of the most dangerous of all circumstances
connected with labor. Fortunately, however, this does not often
happen; and in those cases when it does occur, it may generally be
very soon arrested, provided the proper means are adopted.
This form of uterine hemorrhage not unfrequently occurs when
the physician is absent. For this reason, it is necessary that I should
make some remarks on the subject.
Flooding may be either external or internal. When the blood
passes from the vagina, we call it external; when it does not thus pass
off, but remains within the cavity of the uterus, causing the abdomen
to swell and the patient to faint, we call it internal.
Here is a remarkable fact in nature. Women, in consequence of
possessing the menstrual function, and being exposed to the
accidents of childbirth, are more subject to hemorrhage than men. In
striking accordance with this fact, it appears to have been a
benevolent intention of the Creator to form the female system in
such a manner that it more readily recovers from profuse loss of
blood than that of the opposite sex. Under the effects of severe loss of
blood, the system of a man remains pale and enfeebled for months,
perhaps, while that of a woman regains its strength and color in half
the time. Many a time, before I was aware of these facts, I have been
fearful, and sometimes greatly alarmed at the amount of blood lost at
the birth of a child, and when, to my great surprise, in a day or two
the patient was up, and apparently almost as well as ever. This, then,
is an important practical fact, and one well worth remembering.
In regard to the treatment of flooding after delivery, I refer you to
what I have already said under the head of uterine hemorrhage. Cold,
remember, is the great agent here, as all acknowledge.
If the woman faints from loss of blood—and she may also faint
from mere debility—you should not be alarmed at the circumstance.
People generally make a great deal too much ado when a patient
faints. It should be remembered that the object nature has in causing
a person to faint from loss of blood, is to arrest the heart’s action, for
the most part, so that the blood may, as it were, cease its movement
in the uterus, and a coagulum or plug be formed in the orifice of the
bleeding vessel or vessels. This is nature’s method of arresting an
hemorrhage. This being so, it is no doubt often the case that bringing
a person to, is the cause of more harm than good. There should be no
hurry; give the patient good air to breathe, and nature will, as a
general thing, do her own work better than we can do it for her in
these cases.
 LETTER XXVII.
ADVICE CONCERNING LABOR.

The Medical Attendant—State of Mind—The Room—State of the Bowels—The

Dress—The Bed—The Position, Exercise, Food, and Drink.

It will be inferred, from what I have already said in these letters,

that I am in favor of employing a physician, male or female, in all
cases of parturition. Most cases, I admit, will get along well without
any medical aid whatever; but, as you are well aware, there are
exceptions to all rules; and it is for these exceptions that a physician
is needed.
In the first place, then, it is always advisable in labor that you call
your medical attendant early. If it is worth your while to have aid at
all, it is best to have it in good season. The physician himself always
prefers to be called early.
Once you have fixed upon your medical attendant, resolve to be
guided by him in every particular, and follow his directions faithfully.
If you have, from necessity or otherwise, chosen a man-midwife, you
need have none of those foolish whims which some among the so-
called reformers of the present day would have you to believe.
It is always an unpleasant duty for one to attend a woman in
childbed; and be assured that, of all places in the world, a delivery is
the last one in which lascivious or lustful excitement is experienced. I
wish you, then, one and all, to remember that if it is unpleasant for
you to be attended by a man under such circumstances, it is equally
so to him. If he is a conscientious and benevolent physician, he will
cheerfully do that which he considers his duty to do; but as far as his
own personal self is concerned, he would much rather be at home,
enjoying its quiet and its sleep, if need be.
 In regard to your preparation for labor, I will suppose that you
have done all in your power to maintain an equable and healthful
state of both mind and body, and that you are resigned to encounter
whatever God in His mercy may see fit to bring upon you. If you have
done all that you could for yourself, and are still willing and
determined to do so, surely you should feel contented; you can do no
more.
The Room.—As to the apartment in which you are to be confined,
you should take the best one in the house. If possible, you should
have one which is well lighted and aired, and which can be readily
warmed, if there is need of raising the temperature. If it is in a city, a
back room should be preferred in preference to one in front, on
account of the noise of the street.
If the labor is to be a tedious one, it is particularly necessary that
the air of the apartment be kept as pure as possible. Not only should
the strictest attention be paid to ventilation, but all odors and
perfumes should be dispensed with. These do no good, for mere
hiding the bad air is not destroying it, and they always do more or
less harm.
There should not be too many persons in the room when the
woman is to be confined. In the country it is by far too much the
fashion for a large company of women to get together on such
occasions. This always renders the air of the apartment more foul
than it otherwise would be, and for other reasons it ought not to be
permitted.
I have many a time pitied the condition of women whom I have
attended, who had but one room to live in, cook, wash, iron, and at
last to be confined in; and yet those women have in general got along
better than such as live in a more sumptuous way. Such women are,
in fact, workers, and employment, as I have before remarked, is a
most blessed thing in regard to preparing the system for the
important function of labor.
The Bowels.—If the bowels should be constipated at the time when
labor is about to come on—and such is likely to be the case—the
woman should use clysters freely. This practice is, in fact, advisable
in all cases, inasmuch as it can do no harm. If there is fecal matter in
the colon, it is better that it be removed before the birth is about to
take place. Hardened excrementitious matters in the lower bowel are
always a hindrance to labor.
The Dress.—Formerly it was considered a matter of importance as
to how a woman was dressed in labor. Different countries and
provinces had their particular forms of gowns, jackets, chemises, and
head-dresses. The great thing, however, to be observed, is simplicity;
that is, nothing should be worn which at all interferes with the body
in any of its functions or parts. If the dress is such as causes no
constriction of the abdomen, the chest, or the neck, such as gives free
motion to the limbs, and is of such material that it makes the body
neither too hot nor too cold, it is all that is required. Generally too
much clothing is worn at the time of labor. It is safer to be on the side
of too great coolness than of the opposite extreme.
The Bed.—This has been called by different names; the lying-in
bed, bed of labor, bed of pain, bed of misery, little bed, etc.
Some women will not make use of any sort of couch whatever. I
know a lady in this city who has borne a pretty large family of
children, who affirms that she gets along much better upon her
hands and knees on the floor than in any other way. Some are
delivered standing up, the elbows resting on some object, as the
mantle-piece, bureau, the back of a chair, or some other piece of
furniture, or perhaps upon the shoulders of a friend. “A strong and
well-formed woman,” says Velpeau, “may be delivered in any
posture, on a chair, on the floor, a bundle of straw, on foot, and on all
the kinds of beds that have been proposed; so that it is only in the
cases where nothing interferes with the accoucheur’s doing just what
he thinks best, that he ought to attach some value to the composition
of the lying-in bed; further, the only essential matter is, that the
woman should lie as comfortable as possible, that she should not be
incommoded, neither during the pains nor the intervals between
them, and that the perineum may have room to dilate.”
Oftener than otherwise in this country, the woman is delivered on
the same bed on which she sleeps. Sometimes, also, a cot is used,
which also is a very convenient contrivance, since it allows of the free
passing of the physician and others about it. It is, likewise, a
healthful plan to move from one bed to another after labor; but this
is by no means strictly necessary. Cleanliness, comfort, and good air
—these are the great requisites in regard to the bed.
 The Position.—If the patient is to lie upon a bed, which is doubtless
the preferable plan in the majority of cases, what shall be her
position?
This, like many other things, is a matter somewhat of fashion. In
Great Britain the woman is always placed upon the left side, with the
thighs flexed, that is drawn up toward the body, and the hips brought
close to the right side of the bed. The same position is usually
adopted in this country; but on the Continent, the woman is placed
on her back to be delivered. This, I am inclined to think, is the most
favorable, as well as most agreeable position, although perhaps not
the most convenient for the medical attendant.
Exercise.—During a considerable portion of an ordinary labor, it is
doubtless better for the patient, especially if she feel inclined to it, to
sit up, and walk about a little from time to time. This not only affords
some relief, but likewise aids in causing more efficient contraction of
the uterus.
Food and Drink.—It would always be better, so far as food is
concerned, for the patient to fast a meal or two before labor comes
on. She should, however, be allowed all the drink she desires, pure
soft water being the best she can have. If she drink pretty freely, it
will be of essential service to her in keeping off feverishness, and in
helping the renal organs to act properly. If the pains are tardy, taking
now and then a drink of cold water, even against the inclination, will
help on the pains. Even ice is used with good effect for this purpose.
 LETTER XXVIII.
MANAGEMENT AFTER DELIVERY.

Importance of Attention to this Period—Evils of too much Company—Bathing—

The Bandages, Compresses, etc.—Sleep—Sitting up soon after the Birth—Walking
about—The Food and Drink.

Supposing that the mother has been safely delivered, the child
separated, and the after-birth cast off, what advice have we to give in
regard to her recovery?
I have before remarked that the birth of the secundines is the most
dangerous part of labor, although not the most painful. I have now to
remark, that the real danger in midwifery does not commence until
after the whole birth is completed. Childbed fever, inflammation and
abscess of the breasts, these are the sad mishaps which we have to
fear in these circumstances, and for which I feel an anxious solicitude
in your behalf.
You may think me strange when I inform you, that I have had
more trouble in the practice of midwifery from the one circumstance
of the woman having too much mental excitement within a few days
after delivery, than from all other things combined. I am sure I am
not mistaken when I assert that I have known more accidents and
mishaps to occur from this one cause of seeing company too soon
after the birth, than from all other causes put together. So important
do I consider it for you to keep, as it were, quiet in this respect, I
should think my labor in writing these letters a hundred-fold
rewarded, if I could be successful in warning you of the danger of
over-excitement at the time when you are getting up from
confinement. As the most important advice, then, which I can give in
regard to all the subjects connected with midwifery, Do not allow
yourself to see company for many days after the birth.
“Most of the diseases which affect a woman in childbed,” says the
great Velpeau, “may be attributed to the thousands of visits of
friends, neighbors, or acquaintances, or the ceremony with which she
is too often oppressed; she wishes to keep up the conversation; her
mind becomes excited, the fruit of which is headache and agitation;
the slightest indiscreet word worries her; the slightest emotions of
joy agitate her in the extreme; the least opposition instantly makes
her uneasy, and I can affirm, that among the numerous cases of
peritonitis met with at the Hospital de Perfectionnement, there are
very few whose origin is unconnected with some moral commotion.”
Is it not possible to change the fashion in regard to this matter?
This remains wholly with yourselves; for we of the masculine gender
have nothing to do with it. Are you not all sisters? Why, then, be
offended with each other if you do not go to see the sick woman for a
whole month after her child is born. Could you not write her now and
then a friendly note, or send her some little delicacy to eat, which
would be evidence enough that you had not forgotten her? I am
aware there are among your sex a certain set of gossiping idlers, who
do not know how to kill time in any better way than to be gadding
abroad when they are least needed. If one is really sick and needs aid,
they are the last persons in the world to leave their homes; they are
good for nothing among the sick. To such women I care to say but
little, for I consider the task of reforming them a very hopeless one,
as all experience proves. Especially where a new method of
treatment, as, for example, the water-cure, is practiced, do these
twattlers gad about, making mischief wherever they go.
Bathing.—It is no new thing for a woman to be bathed, and that in
cold water, soon after delivery. It was practiced among the Romans,
and, as we have seen in another part of these letters, is still the
custom among several of the savage nations.
I need not remind you, however, that this practice has, for a long
time at least, found no place among the more enlightened portions of
our race; that instead of cold water being regarded as a most
estimable remedy in childbirth, it has been considered as a very
dangerous agent, which, in truth, it is when improperly
administered. Many of you can but too easily call to mind the old
notions which were instilled into your minds on this subject; notions
which you now know to be not only erroneous, but sadly mischievous
when carried out in practice.
More than ten years ago, and while I was yet a student in
medicine, and had never heard of the water-cure as practiced by the
great Priessnitz, I was in the habit of revolving these matters in my
mind. It occurred to me often, that if the Roman women, and the
Indian women of different nations, could reap so great a benefit as
appeared to be derived from ablutions performed soon after
childbirth, that our own females too, weakly although they are many
of them, could gain similar advantages from pursuing a like course.
It was thus that I was led, as far back as 1843, to strike out a course
of treatment for myself in these cases, having no medical authority or
precedent to go by. The result of this treatment is now, fortunately,
getting to be pretty well understood, and the merits of the new
method appreciated in almost all parts of our country. In Europe
they are altogether behind us in the improvement to which I allude.
I need not here go into any lengthy details concerning the methods
of bathing that are proper to be adopted in the parturient state. The
numerous cases which I have given will serve as a sufficient guide, I
trust, to all of you who are concerned. I may remark, however, in
general terms, that there is no need of doing any violence in the way
of a bath; and those who have not access to the personal advice and
superintendence of a physician who understands the practice, may
always act safely by washing the patient in her bed. Thus, if a blanket
or some other extra article is placed beneath her, she may easily be
washed over the whole surface, piecemeal, a practice which, though
it is neither so thorough nor useful in most cases, as it would be to go
at once into the tub, is yet a good one, and productive of great
comfort.
The Binder, Compresses, etc.—As to the use of the wet bandage,
the compresses, etc., a few words will here be in place. If a dry
bandage is ever needed as a support, the wet one is much to be
preferred to it. As a general thing, however, we put no bandage upon
the woman soon after the birth, as will be seen by reference to the
cases given in this work; we wish to change and rewet the application
frequently, and for this reason the simple compresses are the most
convenient. But when the patient is to sit up or walk about, the wet
girdle, if properly arranged with tapes to secure it, and made pretty
tight at the lower part of the abdomen, affords a good deal of
support. The wet bandage does not slip upward and get out of place
near so readily as the dry one.
It will naturally occur to you, whether the going without the old-
fashioned belly-bandage will not be likely to prove injurious to the
woman’s form. The sum and substance of this whole matter is just
this: whatever tends to weaken the constitution in general, and the
abdominal muscles in particular, must have a tendency to produce
laxity of the fibers, thus rendering the part more pendulous. On the
other hand, whatever tends to strengthen the system and to give tone
to its fibers, must have a contrary effect. Now, the dry belly-band,
even when it is so arranged as to keep its place—which it generally is
not—is too apt to become heating, and, of course, a source of debility
under such circumstances. For this reason it is plain that a cold wet
girdle is altogether better than a dry one. Nor should this even be left
on too long a time without changing and rewetting it. This should be
done, as a general thing, every three or four hours at farthest, and in
warm weather oftener.
The Repose.—Some have feared to allow the woman to go to sleep
for some hours after delivery, fearing that she might be taken in
hemorrhage as a consequence. It is possible that a patient under
such circumstances may wake suddenly with a flooding upon her,
particularly if she be too warmly covered up in bed. But by all of the
best authorities it is regarded that the sooner the woman sleeps after
she has passed through the agony of labor the better. Sleep is,
indeed, no less “nature’s sweet restorer” under such circumstances
than at other times; and it would be most cruel to deny a patient this
privilege, when it would be so grateful and refreshing to her.
Sitting up soon after the Birth.—I have proved satisfactorily to
myself, that there is great error abroad in this country generally in
regard to the parturient woman rising soon after the labor is past. It
appears to be the belief of physicians generally in this country, that it
is highly dangerous for a woman to sit up before some days after
accouchement. The common saying concerning the ninth day you
have all of you heard.
Velpeau, of Paris, who is higher authority by far than any old-
school man in this country, says: “After this first sleep—that is to say,
after the lapse of two or three hours—the patient should sit up in
bed, and take a little broth; this position seems to rest her, and
allows the lochia which had accumulated in the vagina to flow
readily off.” That is the point: it serves to REST her; that is, when a
woman is tired of lying down, both common sense and instinct
declare that she should change her position; in other words, sit up.
This very same thing I have taught strenuously for these seven or
eight years, as many of you know; and just now, while I am writing, I
find that Velpeau long ago recommended the same thing.
Walking About.—Precisely the same principle holds good in regard
to walking and all other modes of exercise as in sitting up. A little
and often should be the rule. The cases which I shall give you will
form a sufficient guide on this point.
I have known a great many more persons to be injured by
inactivity, remaining too much in bed and in overheated rooms, than
by walking about too much and too soon.
The Food and Drink.—I have but a word here to say on this
subject. The patient should begin directly after birth with the same
kinds of food and drink which she intends to use during the period of
nursing. If she is to eat fruit, which I consider good for her, she
should take it from the first. Prudence should, of course, be exercised
in regard to quantity as well as quality of food under these
circumstances.
One of the greatest and most common errors in regard to the diet
soon after labor, is that of partaking of articles which are of too fine
and concentrated a nature. The bowels tend naturally to sluggishness
for some days after confinement; hence the diet should be of an
opening nature, such as brown bread, cracked-wheat mush, good
fruit in its season, and good vegetables. It is a poor practice to keep
the patient for nine days on tea, superfine bread, toast and butter,
and the like articles. It is no wonder that women dieted in this way
become constipated, nervous, low-spirited, and feverish.
 LETTER XXIX.
MANAGEMENT OF THE CHILD.

Of Separating the Umbilical Cord—Practices of different Nations—Of Still-Birth,

and Resuscitation of the Child—Washing and Dressing it.

It was necessary, in describing the three stages of labor, to pass

over for the time an important matter, namely, that which relates to
our attention to the umbilical cord. In treating of this subject, it will
be necessary for me to repeat some things which I have said in
another volume, a “Treatise on the Management and Diseases of
Children.”
Soon after the birth of the child, separating the umbilical cord
requires our attention. How shall this be done? Shall we use a sharp
or a dull instrument in making the division? Shall we apply a
ligature? where, and in what manner to the cord?
It is reported of the aborigines of Brazil, that they merely bite or
chew off the cord, as many of the animal tribes are found to do. This
is imitating nature closely enough, certainly, and more so, perhaps,
than the usages of civilized society would warrant us in doing at the
present day.
Dr. William Hunter, in 1752, remarked in his manuscript lectures
concerning the method which the instinct of animals leads them to
adopt, as follows:
“I will give you an idea of their method of procedure, by describing
what I saw in a little she dog of Mr. Douglass’. The pains came on,
the membranes were protruded; in a pain or two more they burst,
and the puppy followed. You cannot imagine with what eagerness the
mother lapped up the waters, and then taking hold of the
membranes with her teeth, drew out the secundines; these she
devoured also, licking the little puppy as dry as she could. As soon as
she had done, I took it up, and saw the navel-string much bruised
and lacerated. However, a second labor coming on, I watched more
narrowly, and as soon as the little creature was come into the world,
I cut the navel-string, and the arteries immediately spouted out
profusely. Fearing the poor thing would die, I held the cord to its
mother, who, drawing it several times through her mouth, bruised
and lacerated it, after which it bled no more.”
This chewing, bruising, or tearing a part in which blood-vessels
exist, causes them to contract in such a way as to prevent the
occurrence of hemorrhage. This fact we see exemplified in cases
where an arm or other limb is torn off with machinery, in which it is
found that no bleeding of consequence takes place. But if a limb is
severed with a sharp-cutting instrument, the arteries must be
secured.
The New Zealanders, I am informed by a medical friend who spent
some time among that people, cut, or rather tear off the umbilical
cord with the edge of a shell, something like that of the clam or
oyster of our own country.
It matters little, however, what instrument or material is used to
effect the object in question. The cord being immediately after birth a
dead substance, possessing no sensibility whatever, we may bite it
off, or we may use a shell, a sharp knife, or a pair of good scissors or
shears, whichever method we choose, remembering always that it is
of little consequence how we do it, and that it is as natural, precisely,
for a man to exercise his ingenuity in making and using a convenient
instrument as it is for a brute to use his teeth.
In the time of Hippocrates, it was not customary to divide the
umbilical cord previously to the expulsion of the placenta. If this was
slow in coming away, the child was placed upon a pile of wool, or on
a leather bottle with a small hole in it, so that by the gradual
subsidence of the skin or pile of wool, the weight of the child might
draw almost by insensible degrees upon the placenta. In this way it
was extracted without violence.
In modern times, it has been almost universally the custom to
separate the child very soon after delivery, and before the after-birth
has come away. “As soon as the child cries lustily, proceed at once to
separate the cord,” is the common doctrine among medical
practitioners. But it is better, evidently, to wait, before this is done,
until all pulsation has ceased in the cord. If we take the cord between
the thumb and finger, we readily ascertain when its pulsation has
ceased. It has a large vein in it for the transmission of blood from the
mother to the child, and two small arteries, which return the impure
or worn-out blood after it has gone the rounds of the fetal
circulation. Blood is the only nourishment the child has while it is in
the mother’s womb. Hence it would be manifestly improper to rob
the child of any portion of the fluid coming from the mother to it.
The ancients not only waited for the expulsion of the after-birth
before tying the cord, but if the child was at all feeble or dead at
birth, the placenta, when expelled, was laid upon its belly as a
comforting and restoring application. This practice, singular as it
may appear to us in modern times, is not altogether without its
philosophy; the mild, genial warmth of the after-birth was supposed
to act favorably on the feeble powers of life, if such existed, or if it
was dead, it was supposed the infant might thus be recovered.
Speaking of later methods, Dr. Denman observes: “It has been the
practice to divide the funis (cord) immediately after the birth of the
child; and the weaker this was, the more expedition it was thought
necessary to use; for the child being supposed to be in a state similar
to that of an apoplectic patient, a certain portion of blood might, by
this means, be discharged from the divided funis, and the imminent
danger instantly removed. There is another method which I have
seen practiced, the very reverse of the preceding; for in this the loss
of any quantity of blood being considered as injurious, the navel-
string was not divided, but the blood contained in its vessels was
repeatedly stroked from the placenta toward the body of the child. In
all these different methods, and many others founded on caprice, or
on directly contrary principles, children have been treated in
different times and countries, and yet they have generally done well;
the operations of nature being very stubborn, and, happily, admitting
of considerable deviation and interruption, without the prevention of
her ends.”
“There is yet, in all things,” continues this author, “a perfectly right
as well as a wrong method; and, though the advantage or
disadvantage of either may be overlooked, the propriety and
advantage of the right method must be evidently proved by
individual cases, and of course by the general result of practice. In
this, as well as in many other points, we have been too fond of
interfering with art, and have consigned too little to nature, as if the
human race had been destined to wretchedness and disaster, from
the moment of birth, beyond the allotment of other creatures.”
It is the testimony of this author, however, that some children,
after they had began to breathe, had respiration checked, and died
after the cord was divided in consequence, this having been done too
soon. Beyond a doubt, many children have been destroyed in this
way, and in this, as in many other things in the healing art, medical
men have been too much in the habit of interfering with nature, and
thwarting her in her operations.
It is the order of nature, and moreover a truly wonderful
phenomenon, that in proportion as respiration becomes established
in the new-born child, the pulsation in the umbilical cord begins to
cease, first at the placenta, and so gradually onward to the child;
physiologists are puzzled to explain the circumstance, but the fact is
plain.
Hence it follows, that if the cord were left to itself, without any
ligature, it would not expose the child to hemorrhage, or other
accidents, even though it should be cut clean, and not contused or
torn; some little blood might flow from the cut end, but every thing
being left to nature, this could amount to but little, and such as
would do no harm. But for the sake of cleanliness, it is proper that a
ligature should be applied.
But it will be objected, that in some cases—though very rare—
children have been known to bleed to death at the umbilicus. This
has, indeed, happened in some few cases, in spite of ligatures, and
every thing else in the way of styptics that could be applied. But these
extreme cases are not to serve as guides in forming rules of practice.
Nature has exceptions to all her rules. Besides, we may account for
many of these occurrences, by the fact that the natural operations are
often perverted by improper treatment. Thus, if children are swathed
tightly, as has been too often the case in civilized society,
compressing the chest and the abdomen, and causing them to cry
from distress, the embarrassed state of the viscera suffices to
disorder the general circulation, and enable the blood again to pass
out of the navel.
 Hence, as a matter of practical safety, although it is not necessary,
as a rule, to apply a ligature to the umbilical cord, even when we cut
it very near the abdomen of the child, we had better do it, as no harm
can come from the procedure; it is possible for it to do good, even to
save the life of the child; properly applied, it is not possible for it to
do harm.
As to the point at which we divide the cord—whether at a half an
inch or an inch and a half from the abdomen—every one must be his
own judge. It is an old woman’s notion, both in this country and in
the old, which was derived from the physiology of the ancients, and
which requires that the cord should be cut very near the umbilicus if
the child was a girl, and very far from it if it is a boy; such a mode of
cutting being supposed to exert a great influence upon the
development of the generative organs.
Notwithstanding the objections of some of the old women, I have
separated the cord very near—say within half an inch of the
abdomen. This is a much neater and more cleanly mode than it is to
leave two or three inches of a dead substance to putrefy upon the
child; besides, the more cleanly the part is kept, the more quick does
the healing process take place.
“As to the ligature itself,” says Velpeau, “De la Motte advises us to
apply it at the distance of one inch, Deventer, Levret, and the
moderns, at the distance of two fingers’ breadths, others at three,
four, five, six, and even twelve inches from the abdomen. Some
persons have recommended the application of two, and in such a way
that the one nearest the abdomen should not be so tight as the other.
Sometimes it has been recommended to draw it very tightly, at
others very loosely. One person is content with a single turn, and a
single knot; and another thinks there should be two turns, and a
double knot; a third, like Planck and M. Desormeaux, makes first one
turn and one knot, and then bends the cord into a noose to tie
another knot upon it.”
“A majority of the Philadelphia accoucheurs,” says Professor
Meigs, of that city, “in tying the navel-cord, pass two strong ligatures
each twice around it, securing them with two knots; the one an inch
and a half, and the other two inches and a half from the abdomen,
and divide it between the two with a pair of sharp scissors. This is a
cleanly practice in all cases, and prudent, if not essential, in twins;”
cleanly, that is, because, as the professor means the second ligature—
that is, the one that is nearest the mother—prevents the blood
coming from the placenta, and soiling the bed; the same principle I
usually adopt, only the first ligature is placed half an inch, instead of
an inch and a half from the abdomen. Sometimes, however, as in the
night, it is perhaps better to leave the cord an inch or two long, and
the next day tie it nearer the body. The ligature, since we use it at all,
should be drawn very tightly; the cord being a dead animal substance
after birth, very soon shrinks; hence if the ligature is not very tightly
drawn, it may slip off in a day or two. In tying the ligature, we should
be careful not to pull at the child, for in so doing we might cause a
rupture, or a tendency to such an occurrence.
In making the division—which is usually done with a pair of good
shears or scissors—we must be careful to avoid cutting off a finger,
toe, or the private member. The infant, in its struggles, is very apt to
get some of these parts in the way just as one is making the cut.
As to the kind of ligature: some think they must always have a
narrow tape; and hence we often find, in attending a case, that the
mother has already prepared herself with this material. But a
common round thread is to be preferred; we can draw this more
tightly than we can a flat ligature. A strong linen thread, doubled and
twisted if we think it necessary, I consider the best. “Some would not
dare to use any thing except tape,” says Velpeau; “whereas wiser
persons make use of whatever they can find at hand.”
One circumstance should be particularly noticed in regard to tying
the cord. It is said that it is possible for umbilical hernia to take place
before the child’s birth. In such case a portion of its intestine must
have protruded into cord. Hence, in such case, if we were to tie a
ligature about the cord near the body, and where the intestine is—a
fact that we can know by the cord being bulged out, or enlarged at
the part—and should cut it off so as to sever the intestine, we should
inevitably kill the child. Few practitioners have ever seen such a case;
but inasmuch as it is said that such hernia may possibly exist, we
should always watch for it. It would be easy to detect, but if one
should have any doubt as to whether there is hernia or not, he may
apply the ligature an inch or two from the child’s body, and thus
make sure of doing no harm.
 It is important to remember, that at the time of, and before making
the separation, the child should be so placed as to allow the most free
respiration; it has just begun to breathe for the first time in life; it is
just as important that it has good air as it is for any of us. Many a
tender infant has been injured at the very beginning by being
smothered among the bed-clothes as soon as born. People
everywhere, think it will take cold as soon as it is exposed to the air;
but think, you who understand the anatomy and physiology of the
human system, how exceedingly delicate the fine internal net-work
of its little lungs is! And think you that the external skin is less able
to bear the new impression of the atmosphere than the lungs are?
As to difficulties at the child’s navel, I have never had them. It is
certainly a very simple thing to leave it altogether to itself, with the
exception, the second day and onward, of laying upon it a soft, clean,
wet compress, of four or five thicknesses, so that it remains
constantly moist. This water-dressing, often renewed, and kept
thoroughly clean, heals the navel more quickly than can be done in
any other known way.
From what I have been able to learn, I infer that with water-
dressing this healing is effected from one fourth to one third less
time than by the usual methods.
The period of the natural separation of the cord varies
considerably in different cases. According to M. Gardien, it usually
falls off on the fourth or fifth day. M. Orfila says the fourth, fifth, or
sixth day. M. Dennis the fifth, sixth, seventh, or eighth day. M.
Billard remarks, that the desiccation is complete toward the third
day, and it is on the fourth or fifth day that the cord is separated
from the abdomen.
Dr. Churchill, of Dublin, kept an account of the period of its
decadence in 200 cases, and it occurred as follows:
 In 1 case it fell on the 2d day.
„ 4 cases „ 3d „
„ 20 „ „ 4th „
„ 52 „ „ 5th „
„ 81 „ „ 6th „
„ 24 „ „ 7th „
„ 10 „ „ 8th „
„ 7 „ „ 9th „
„ 1 case „ 10th „

According to Dr. Churchill, then, it would appear, that the fifth and
sixth days are the ordinary periods of the detachment. The cord has
been known to remain undetached as long as fifteen days; but such
cases must be very rare.
Complete cicatrization is commonly effected by the end of the
second week. The healing powers vary somewhat in different cases.
In one case, where both the father and the mother were of scrofulous
tendency, it was a number of weeks before the healing process was
fully completed. The child, however, in the end did well.
 OF STILL-BIRTH.
The child may be born still, from its not having passed to its full
period, or from various causes it may not have vital stamina enough
to enable it to live. In some cases the child is born without any
manifestations of life whatever appearing. The face is swollen and
livid, the body flaccid, and the navel-string does not pulsate.
In such cases we should not at once wholly despair of life, although
there is not usually much to hope for; yet, inasmuch as cases of this
kind are now and then recovered, they ought not to be immediately
abandoned without making suitable efforts for the resuscitation of
the vital powers.
A frequent cause of the absence of respiration in the new-born
infant is, separating the umbilical cord too soon after birth. Such is
the opinion of Denman, Burns, Baudeloque, Dewees, Elberle, etc.,
etc., and there can be no doubt that many a child has been destroyed
by this inconsiderate practice. By all well-qualified and skillful
practitioners it is laid down as a rule, “that the cord is not to be tied
until the pulsations in its arteries have ceased;” and this any person
of ordinary understanding, and without medical knowledge, can
easily ascertain, by simply taking the cord between the thumb and
forefinger.
In consequence of the neglect of this rule, Doctor Dewees tells us
that he had reason to believe he had seen several instances of death,
and this of a painful and protracted kind. “And that this is probably
one of the causes of the many deaths, in the hands of ignorant
midwives and practitioners,” this author observes, “we have too
much reason to suppose.” The practice with many is, to apply a
ligature to the cord the instant the child is born, without any regard
whatever to its pulsation, or the state of the child’s respiration.
Treatment.—In the cases of asphyxia, to which I have referred,
various methods of treatment have been adopted, some of which are,
no doubt, valuable, while others are meddlesome, and worse than
useless.
 If the child is livid and dark-colored, it has been recommended to
abstract blood. This is best done at the umbilical cord; that is, by
separating it. If the blood will not flow, it is recommended to strip
some blood from it. It is, however, admitted that, in general, very
little, if any, can be obtained in this way.
It has also been recommended to apply a cupping-glass to the
umbilicus, so that by exhausting the air from the part the blood may
be brought into motion, and thus made to flow, and this even after
the heart has ceased to act. I know of no author, however, who has
succeeded in this method.
The object of abstracting blood in any of these various ways is to
set the vital fluid in motion, and to relieve the congested parts. But it
appears to me that there is a far better method than this, and that is
simply by friction with the wet hand. The child has in no case too
much blood; it is only in the wrong place. The wet hand does not at
all injure the skin; the cold water—for cold only should be used here
—acts as a stimulus to the vital power, and the motion of the hand
and the pressure will set a hundred-fold more blood in circulation
than the mere separating of the umbilical cord could do. Hence it is
that I would depend much upon friction, and very little, if any, upon
the abstraction of blood. This latter practice is destined to become as
obsolete in time, as that of bleeding in a severe injury or shock of the
system—a method which has deservedly gone out of date among all
scientific practitioners of the medical art.
In conjunction with the measure which I have just recommended,
there is another of importance, which should be faithfully made; and
that is, an effort to excite the respiratory function by artificial
inflation of the lungs, and compression of the chest with the hands,
so as to imitate in a measure the natural acts of inspiration and
expiration. In doing this the operator must apply his mouth to that of
the infant—the latter having been first freed of the mucus that
attaches to it—at the same time closing its nostrils, and endeavor by
a moderate but uniform force of expelling the air from the mouth, to
fill the lungs of the child. As the air is thrown into the lungs, the
chest of the child must be allowed to expand as much as it will; and
then, as this act is discontinued, the chest should be compressed a
little, carefully, so as to imitate the natural motion of these parts.
 Authors disagree as to the amount of force allowable in forcing air
into the lungs of a new-born child. Some have recommended a
“forcible insufflation,” while others contend that such a practice is
fraught with danger to the child. It appears from a series of
experiments that have been made in France on animals, and from
observations relative to the human subject, that no very great force of
insufflation is necessary to rupture the delicate air-cells, and cause a
fatal emphysema of the pulmonary structure. In sheep, and in the
dead human subject, the air-cells were ruptured by a force of
insufflation not greater than that which may be made by a person of
ordinary respiratory vigor, without any very violent effort.
To obviate the unfortunate accident of rupturing the air-cells of
the lungs, the air should be thrown into the respiratory passage
through a silk handkerchief folded double, or a fine napkin laid over
the mouth of the infant.
In all cases of retarded, impeded, or suspended respiration
immediately after birth, care should be promptly paid to the removal
of the viscid mucus, which is usually to be found lodged in the mouth
and throat of new-born infants. In some instances the quantity of
mucus is so great, and its quality so tough, that it is believed the child
could not possibly breathe if the obstruction was not removed from
the parts. In all cases, therefore, if there appears to be any difficulty
whatever in regard to respiration, it is best to remove this mucus by
means of the finger, surrounded by a handkerchief or piece of soft
linen. If there is reason to believe that the mucus is also lodged in the
throat and beyond the reach of the finger, it has been recommended
that the child should be turned with its face downward, and the body
raised higher than the head. In this position, the child’s back,
between the shoulders, is to be patted with the hand, and its body
gently shaken, so as to disengage any matters that may be lodged in
the trachea, and permitting it to flow out of the mouth by making
this the depending part. At the same time, if the back is rubbed with
the hand wet in cold water, the stimulating effect will aid in the
expulsion of the offending cause from the throat.
Infants are sometimes born in a state of asphyxia, when, instead of
lividity and swelling of the countenance, there is the opposite
extreme, the face and surface of the body, generally, being pale,
exhibiting a want of vitality. In such cases, it is of the utmost
importance that the cord be not divided too hastily; on no account,
indeed, should this be done until the pulsation has ceased. The viscid
mucus should at once be removed from the mouth and fauces by the
methods before mentioned; and it has been recommended to apply
brandy, spirits of camphor, hartshorn, etc., to the mouth and
nostrils, with the view of exciting the respiratory function. It is
doubtful, however, if such articles do any permanent good whatever,
and they are certainly liable to harm. At any rate, it is better, I am
confident, to sprinkle cold water upon the surface, and to make
friction with the cold wet hand. This will set the blood in motion, and
aid the vital powers incomparably more than the stimulants
mentioned.
It is also advisable in these cases, if respiration is particularly
tardy, to inflate the lungs carefully, according to the method before
recommended. But the applying hot brandy, flannels wrung out of
hot spirits, etc., which have often been used on such occasions, are
worse than useless, and ought never to be resorted to.
Infants, in this condition, should not be given up too hastily.
Numbers of cases have happened in which a half hour or more has
elapsed before respiration has been established. Even a much longer
period than thirty minutes has transpired in some cases before the
breathing has been established.
The time will come, probably, when electricity will become so well
understood as to enable us to make it a valuable agent in cases of
still-birth and suspended animation. In the present state of
knowledge, however, it is better, I think, to depend on the stimulus
of cold water, frictions, and the other means to which I have already
referred. But great care is necessary in the management of all such
cases; and I have no doubt that many more infants have been killed
by too meddlesome and injudicious management, than have been
saved by the use of artificial means. The tendency in cases of this
kind always has been to do too much. It is one of the greatest
acquirements in art to learn when not to do.
 WASHING AND DRESSING THE CHILD.
I have a few words to say here on these topics; but I must refer you
to my Treatise on Children for a much more full and explicit
explanation of them than the limits of this work would admit of. You
can all of you who have need obtain that work, I trust; and surely,
after you have borne a child, you will feel the greatest interest in
learning all that it is possible for you to know respecting the best
modes of rearing it.
In general terms, then, I remark, that a child should, soon after its
birth, be carefully cleansed by means of pure water and the addition
of a little mild soap. The water should not be either too warm or too
cold; a moderate temperature, as from 70° to 80° Fah., will be found
best. The child should be carefully washed, I said; and in all that is
done in handling it, you should remember that it is a frail, delicate
thing. Nor need I hint to a mother that inasmuch as some one had to
perform all of these small yet multiform offices for us, so should we
be willing to perform them for others.
The dress should be loose, and merely sufficient for the purposes
of warmth. The child should not be in any way bound with its
clothing; nor should a binder or bandage be used.
 LETTER XXX.
HYGIENE OF NURSING.

Lactation a Natural and Healthful Process—Rules for Nursing—At what time

should Lactation cease?—Food and Drink proper during the Period.

You who reside in the country—as, indeed, most of you do—can

hardly credit me when I tell you that it is getting to be quite
fashionable in our large cities for a woman not to nurse her own
child.
There is in some cases policy on the part of the physician, which
lies at the root of this matter. “Why, madam, you are too weak,” the
fashionable pill-monger sagely says. “It will injure your constitution,
and you cannot raise your child; you must have a wet-nurse.”
Now, all this is very easy for a man to declare. Some say it from
ignorance, no doubt, and some from other motives; for physicians,
although as a body of men they are as honest as any other, are yet
sometimes selfish, and do that which is dishonest and wrong. The
selfish doctor knows, of course, very well where his money comes
from. He knows—if he is not an ignoramus—that the mother, if she
does not nurse her child, is more apt to become sick, so that she will
need his services; and, what is more, she is more apt to become
pregnant, in which case he will look for another job at midwifery,
which pays well.
I would have every one of you to understand that the health of the
unnatural mother, who will not nurse her child, suffers from her not
fulfilling the order of nature in giving suck. Her system must
inevitably get harm from not allowing it to go through the period of
lactation naturally. Her life of dissipation, too, is poorly calculated to
contribute to health, compared with staying at home and fulfilling
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