The Teaching of Applied Therapeutics at Tufts Medical School

Francis H. McCrudden
1915 Boston Medical and Surgical Journal  
The teaching of therapeutics, one of the most important subjects in the medical curriculum, is one of the weak points in American medical schools. The fundamentals of drug treatment are taught by lectures and laboratory exercises in the department of pharmacology, and the actual details of treatment incidental to the instruction in clinical medicine ; but no systematic instruction is usually given in the general principles of therapeutics as an independent subject. During the past year an
more » ... past year an attempt has been made to strengthen the teaching of therapeutics at Tufts Medical School by giving, in addition to such instruction as is usually given, a course which shall bridge over the gap between pharmacology, physiology, chemistry, and the other fundamental sciences upon which treatment is based, on the one hand, and the actual details of handling patients from day to day, on the other hand ; and shall serve as an introduction to the general principles of applied therapeutics. Though the course is still in an embryonic stage, various expressions of interest on the part of the students, colleagues, and others have» influenced me to make a statement concerning its purposes, scope, and methods in the hope that such a statement might stimulate helpful criticism. It is, of course, true that the forms which any one disease may take,-depending on the severity of the disease and on the fact that different patients react so differently to disease with difference in age, sex, constitutional characteristics, and other factors,-show so many different clinical pictures in different patients, and change so much from day to day in any one patient, that the treatment of every new patient is a new problem, and that, therefore, the actual details of treating sick patients can properly be learned only by long continued bedside observation of many patients under treatment, by the inductive experimental methods now used in teaching the subject in the departments of clinical medicine. We treat individuals rather than diseases. And this is especially true in the case of chronic diseases where the exact details of treatment depend largely on the severity of the disease, on the extent to which function is disturbed, on the condition of the patient as a whole, factors concerning which good judgment is gained,-since exact measurements play but a very small part,-only by long, clinical experience with cases of all grades of severity. But there are, nevertheless, certain general principles relating to the purpose and methods back of the many details which cannot well be taught incidental to the other instruction in clinical medicine and which deserve and need treatment as a separate subject. Pharmacology deals with some of these principles of treatment but not all, for this is not the province of pharmacology. Pharmacology deals with the action of chemical compounds in the body, with the physiological action of substances quite independently of their therapeutic effect; it deals with the action, not only of those substances which are useful in therapeutics, but also those like muscarin, curarin, and saponin, which are not useful in therapeutics and whose action is chiefly harmful ; furthermore, in the case of useful drugs, pharmacology deals not only with those activities which are of therapeutic significance, but also those which are not. Although until very recently this was not strictly true, and pharmacology could hardly be said to exist as a science independent of practical therapeutics, it has now developed to such an extent that it is pursued as an independent science without reference to the practical needs of medicine in the same way, and with the same justification, that chemistry, and physiology,-both of them once a part of practical medicine,-are now pursued as independent sciences. In actual practice, drug treatment is nearly always combined with other forms of treatment; agents such as heat, cold, baths, rest, exercise, posture, diet, massage, electricity, x-rays, high altitude, and sunlight are very extensively used in therapeutics. An intelligent application of these other agents depends upon a knowledge of physiology, physics, chemistry, psychology, and other factors, as well as pharmacology, and the other factors,-even such a one as the personality of the physician,-are, in certain instances, of more importance than the strictly pharmacological knowledge. A knowledge of pathology and clinical medicine, especially, though not necessary for the pharmacologist, is an absolutely necessary pre-requisite for the study of therapeutics; the therapeutically important questions relating to the effect of pathological conditions in altering the action of drugs.-we now have abundant evidence showing that drugs may have a different effect in pathological conditions from what they have in health,-and to when and how to use drugs in disease is outside the province of pharmacology ; furthermore, questions relating to diagnosis and prognosis which have to be taken into consideration in therapeutics, and good judgment in estimating the effect of treatment on the clinical condition require a knowledge of clinical medicine. A knowledge of pharmacology alone, then, is not a sufficient basis_ for the treatment of diseased patients. There is. therefore, a deficiency in the usual medical curriculum and an urgent need for a
doi:10.1056/nejm191510141731603 fatcat:ctevahtwbjflhkcqgzfqvkkq7a