A Scandalously Short Introduction to the History of Pharmacy

Chapter 6 - Formularies, Herbals & Pharmacopoeias

The problem of trying to get a standard formula for many commonly used and prescribed preparations has occupied physicians and dispensers for hundreds of years. Going back to the Herbal of Pliny who lived from ( AD 23-79), there has been attempts to keep records of the medicines that were used. The Materia Medica of Discorides (AD. 40 - 90) which described 600 plants and animal substances remained the authority on the subject for over 1500 years.

Because it was usually only monks and clerics who could read and write, any reference book had to be hand made and was generally confined to a particular monastery or hospital. Latin was generally used to achieve uniformity but because of the scarcity of books, the library of the average physician or apothecary was meagre.
      
Books of recipes for physicians were often called a Compendium, or an antidotarium , or a Dispensatorium.
       
The production of reference books became much more widespread after the invention of printing , but that in itself posed problems because of the confusion as to which book to use or which formula to compound.

The first attempt to control the proliferation of references was in Florence in Italy, which issued the first official pharmacopoeia the Ricettario Florentino in 1498 and a few years later was translated into Latin so that it could be used throughout Europe. The City of Nuremburg in 1529 was the first community to use a formulary legally binding on the apothecaries of that city.

One of the popular Herbals produced in England was written by Nicholas Culpepper, and its second edition appeared just before his death in 1654.
Culpepper started his career as an apothecary's apprentice, and later claimed a medical qualification and practised as a physician. In 1649 he produced an unauthorised translation from the Latin of the 1618 edition of the London Pharmacopoeia. His Herbal was described as an "astrologo-physical discourse on the common herbs of the nation.

He maintained a large garden at his London house, and he grew many of the plants which he described in his book which was first titled "The English Physician", The book was so popular it was kept in print down to the 19th century.

There are also some other texts that we handle occasionally, and let us look at why they came into use, and who was behind them. The problem that we have to face though, with the multitude of reference books available, which one do we rely on most.?

Pharmacopoeias

A pharmacopoeia (Greek pharmakon, a drug and poieo, I make) is a list of medicinal substances, crude drugs and formulae for preparing various substances from them. Such a list is compiled by recognised authorities, usually appointed by the Government of each country for that purpose. All the principle countries of the world have their national pharmacopoeias.

Pharrnacopoeias however, do not cover the entire field of therapeutics and some countries have found it necessary to supplement the pharmacopoeia with a more comprehensive formulary or codex.. In the United Kingdom, in addition to the British Pharmacopoeia, there is the British Pharmaceutical Codex and the British National Formulary. Products included in these publications are often referred to as standard products These combined formularies however, cover only a pan of modern drug therapy. In some countries this pan is small, 20% or less; the remainder consists of proprietary products, or, to use a more appropriate term, medical specialities. Such has been the progress of the pharmaceutical industry that the pharmacopoeias now include many monographs on important new drugs which are obtainable only in proprietary form.

Since most drugs originate in the large research laboratories of the pharmaceutical industry, it follows that they will first bear registered proprietary names. The proprietary name for the same drug my differ in different countries, or if the drug is not a patented substance, different manufacturers may register different names, This confusion has contributed to the introduction of officially Approved Names. In the United Kingdom, Approved Names are devised or selected by the British Pharmacopoeia Commission. The World Health Organisation was trying to produce International Non-Proprietary Names for new drugs which might prove acceptable to the pharmacopoeial authorities of other countries, and thus prevent further multiplication of nomenclature. There are many practical difficulties to be overcome, but some success has already been achieved.

The French appear to have been particularly industrious with regard to the production of a Pharmacopoeia as their Codex, which has had an unbroken history until now, was first published in the year 1818.

This was followed two years later by the United States Pharmacopoeia, which is also still in existence.

The British Pharmacopoeia (B.P.) is the authoritative collection of standards for medicines in the United Kingdom. It provides essential information for all those concerned with the quality of medicines and its standards are legally enforceable in the UK and most of the Commonwealth, including Australia. It was first published in 1864 as the result of the amalgamation of the pharmacopoeias of London, Edinburgh and Dublin. The preface to the first edition starts with the words " Of the several functions conferred on the General Medical Council of the United Kingdom by the Medical Act of 1858, not one has caused the Council more anxiety than the preparation of the British Pharmacopoeia."

The mind boggles at the politics involved in trying to supersede three pharmacopoeias, each of which had long been held in great repute.

The Council was made up of representatives of Royal medical colleges, universities, and the Apothecaries Halls of London and Dublin. There are no pharmacists listed as members of the Council, although the newly formed Pharmaceutical Society of Great Britain had been invited to make a submission to the Council.

The first edition copy sold for ten shillings and sixpence, and interestingly enough the 1914 edition was  also the same price, although the publication was heavily subsidised to keep it affordable, as Britain was just entering the first world war when it was released. The 1998 edition consists of three volumes and a CD ROM, with access to the Pharmacopoeia website, and its price is £595.STG, or for Australian subscribers around $1800 AUD.

Because of the time span between some of the editions of the B.P., various Addenda were issued to try and keep up with the rapid advances that were made in medical science and therapeutics. It was not until the eighth edition in 1953, that English  had precedence over Latin titles.
 
Although it is the legal standard referred to in legislation throughout the Commonwealth, it is no longer a required text to have in a pharmacy in W.A..

Another book that was more useful to the dispenser was the British Pharmaceutical Codex. (B.P.C) It was first published in 1907. It was published by the Council of the Pharmaceutical Society, to make available in one volume, accurate information about all drugs and medicines in common use throughout the Empire, as well as including the principle substances and preparations which were official in the Pharmacopoeias of France, Germany and the U.S.A., as well as in the B.P. itself. In 1979 a major reconstruction of the BPC was undertaken , and the provision of standards was discontinued. The publication is still produced but since the Ninth edition, it is now called the Pharmaceutical Codex: Principles and Practice of Pharmaceutics. The 12th edition was published in 1994.

In 1864, a past president of the British Pharmaceutical Society, Peter Squire, produced a book called A Companion to the British Pharmacopoeia  (Squire). His object in issuing this work was to enable pharmacists and prescribers to readily compare the strengths of the various preparations in the newly published B.P., with those of the London, Edinburgh, Dublin, U.S.A. and other pharmacopoeias. He also indicated suitable doses for drugs he couldn't find in the established formularies, and he listed preparations under the name of the principal drug. It ran to 19 editions, the last being published in 1925.

Squire preferred to indicate quantities by parts, and on every page of the book there is printed the legend, "Solids by Weight and Liquids by Volume".

Hospital Pharmacopoeias

The compilation of a pharmacopoeia by the physicians and the pharmacists of a hospital proved a great convenience to the many resident and consulting physicians treating patients there.

Peter Squire also produced an amalgamation of various private pharmacopoeias from a group of London Hospitals. He certainly was a very busy man, but gave a lot to his profession.St.Bartholomew's Hospital in London, produced its first pharmacopoeia in 1730. The copy in our Society library is dated 1869.Many of the larger Australian hospitals also produced their own pharmacopoeia and formulary, the Melbourne Hospital publication being the standard setter. We have copies of the Perth Public Hospital pharmacopoeia and also the Perth Children's Hospital pharmacopoeia.

One of the reasons for having an "in house" formulary was to save time and expense. The chief pharmacist could purchase the most economical drug packs, and also prescribers could use the briefest title and know exactly what would be supplied. It was a bit complicated though when an out patient visited a community pharmacy seeking a repeat of the preparation supplied in the hospital.

The Extra Pharmacopoeia( Martindale)  (See also Chapter Five)

William Martindale was a practising pharmacist with a flair for the scientific aspects of his profession. His aim was to provide medical men and pharmacists with practical and  up to date information concerning drugs and galenicals to supplement that contained in the B.P. The term "Extra" means in this instance "Outside", because the book aimed to describe drugs that were outside the British Pharmacopoeia.. The first edition appeared in1883 and was immediately successful because it was ahead of the needs of pharmacists at the time. It quickly went to four editions from 1833 to 1835.

After the first edition he had a co-author Dr.Wynn Westcott, and what had started as an unofficial addendum to the B.P., emerged as a work of independent status which included in its scope the whole field of therapeutics and allied sciences. When William Martindale died in 1902, he and Westcott, had produced ten editions of the Extra Pharmacopoeia. One of his sons William Harrison Martindale carried on the business and produced another ten editions. When he died the publication was taken over by the Royal Pharmaceutical Society of Great Britain.
It is still a most useful reference book today, and the 32nd edition is the latest to be produced. It is also available "on line" and on CD Rom.

There are other specialist formularies that you will see as you visit various dispensaries, although the need for the written word has greatly diminished with the facilities that are available though the dispensary computer.
 
One that is in every approved pharmacy is "The Prescriber's List" , published by the Commonwealth of Australia as the formulary for the Pharmaceutical Benefits Scheme. Fifty years ago when the Pharmaceutical Benefits scheme was first introduced, the medical profession didn't want to participate in the scheme for various reasons, one of them being the formulary of preparations which they claimed restricted their prescribing freedom.

This argument was eventually settled, and if you look at the Prescriber's List in the PBS Yellow Book today, it reflects current practice with very few extemporaneous preparations still listed.

Other Pharmacopoeias that were in common use during the war years in Australia and England were brought out to guide pharmacists and physicians on what substances could be safely substituted for many of the common drugs which were unavailable because of the war. Things like  Glycerin and Alcohol were vital to the war effort, and substitutes had to be allowed for.

Even common drugs like "Aspirin" were all imported from Europe and when supplies were cut off Australia had to start from scratch and find suitable substitutes from their own resources. This in itself was not a bad thing for Australian industry.

The prize to market an Australian equivalent of "Aspirin" was won by a Melbourne Pharmacist George Rich Nicholas, and his partner Harry Woolf Smith, a manufacturing chemist.
Nicholas called his product "Aspro" and he marketed it around the world. Today the company Kiwi Nicholas is still a multinational of Australian origin.

Australian Pharmaceutical Formulary ( A.P.F. )

Originating in Victoria, the publication was sponsored by the State Pharmaceutical Societies and it first appeared in 1902. It was a very slim volume, designed to be carried in the pocket by "medical men". The preface to the first edition stated that the APF was.. "an endeavour to counteract the increasing practice by medical men of ordering proprietary articles, the composition and strength of which are alike unknown to the prescriber and dispenser. It is believed that the publication of a book of formulae for non official preparations in general demand for dispensing, placed in the hands of the medical profession with an invitation to adopt the printed formulae whenever practicable, would meet with general approval. (Note the deference in the tone of the language)

It is thought that that such a publication would be of considerable value to pharmacists, as in the absence of specific instructions for definite preparations, those made from the published formulae would invariably be used."  It then concludes…. "In ordering preparations in this formulary, medical men are asked to mark their prescriptions A.P.F."

A special edition was brought out during the war years, and it was seen as a protest against the power of the drug manufacturers and all factory made medicines, and it also promoted the manipulative skills of the pharmacist.

You are all familiar with the book, the latest being the 18th edition, that is no longer a "pocket reference", and with the advent of computer based references, one wonders just how long the APF will last. Maybe it just won't make a centenary edition, Also it now his to face competition from the new Australian Medicines Handbook, which appears to have reverted to the original concept behind the APF in providing a reference to both pharmacists and prescribers.

Another area that affects pharmacy greatly is an extension of the principle of protecting the public interest, and that is the utilisation of recognised standards for drugs and preparations made from those drugs, so that there is a consistency across pharmacy and medicine with regard to dosage and form. We have a classic example of the effects of lack of standards today among the drug culture in our society. How often do we see reported in the media the dire consequences of addicts using substances of unknown strength, and because street drugs are adulterated by a whole variety of means, no one knows what the effects are likely to be. In the days of the industrial revolution in England, a similar situation existed. Narcotics were almost universally employed, not only to dull the boredom of the workers, but also to pacify infants so that mothers could return to the looms immediately after confinement. A very popular nostrum that was made by almost every pharmacy was known as Godfrey's Cordial. This was made from Laudanum (Tincture of Opium) sweetened with Syrup and flavoured with an essential oil or spice. The problem was, that there was no formulary or reference book for the preparation and mothers could easily overdose their children if they purchased their "Mother's Quietness" or Soothing 'Syrup" from different pharmacies. In  1840 a Manchester newspaper reported that 48% of the deaths in the area were children under five years of age.

With the universal use of computers in pharmacy practice, the information contained in .  .the books on the dispensary library shelf is available in an electronic form which enables the pharmacist to access up to date information quickly and efficiently.

Clients themselves also have access to a host of information through their home computers and many enquiries directed at health professionals today relate to the interpretation of the information they have accessed.