A paper read to the British Homoeopathic Society, June 7, 1923. Reprinted from The British Homoeopathic Journal 1923.
In opening this discussion on the difficulties in homoeopathic prescribing I must, of course, presuppose agreement with the fundamental principles underlying the homoeopathic Law of Cure – so it is like preaching to the converted. But few, if any, pass a single day in practice without being confronted with difficulties as to how to proceed next. We know what homoeopathy can do curatively, and all the more we feel the responsibility of our next prescription – indeed, the future of the patient lies in our hands in a way that does not happen in other methods of treatment. Somehow, lately, we have had very little opportunity of discussing our difficulties; except perhaps in the short time at the end of our meetings. The latest additions to our ranks are faced with the problems that confront those who enter fresh fields of research, with, perhaps, a short apprenticeship. Yet they feel their responsibilities equally with those sojourn has been longer. They are consulted by patients who have had the benefit of experienced prescribers, and very definite results are expected from them. Homoeopathic doctors are often isolated units, deprived of the benefits of conferring with their neighbours, and hence their difficulties have to be shouldered.
Their risk is very great, of getting into wrong ways, and continuing in them, for want of opportunities to discuss their problems. We can all learn from each other; the oldest from the youngest, as well as the other way. It is with this object – mutual helpfulness that I suggested such a meeting as this; where we can all frankly speak of our difficulties, and perhaps get some help as to our future. I thought that the best plan to find out what were the chief difficulties was to invite suggestions, but unfortunately very few replies have come to hand, so that I am rather in the dark as to how to treat the subject. One has written and spoken so often on the subject of Homoeopathic Philosophy that it is impossible to offer anything new. But there are Laws of Cure which must be obeyed.
Hahnemann says: “Unless the physician imitates my method, he cannot expect to solve the highest problems of medical science, that of curing those important chronic diseases, which have remained uncured until I discovered their true character, and proper treatment” (Chr. Dis., p. 156).
“If physicians do not carefully practise which I teach, let them not boast of being my followers, and above all, let them not expect to be successful in their treatment.” (Ibid).
“This doctrine appeals not only chiefly, but solely to the verdict of experience – `repeat the experiments’, it cries aloud, `repeat them carefully and accurately, and you will find the doctrine confirmed at every step’ – and it does what no medical doctrine, no system of physic, no so-called therapeutics ever did or could do, it insists upon being `judged by the results’.” (M.M.P., vol. ii, p. 2).
There are errors of commission more disastrous than those of omission. “It is better to do nothing, than to do something wrong.”
One of our greatest difficulties in homoeopathic prescribing is time – lack of it. And if we are hurried or flurried, that is fatal to good work. The best time-saver is to take your case well the first time. The time thus spent will save much time and worry on subsequent visits. We can all realize, when the patient comes the second time, the mood we were in on his first visit. If the first prescription was good, the second and probably the third should be very easy. On the contrary, if you have missed your first shot, the whole thing has to be reconsidered, and time is lost.
Confidence, born of knowledge and experience, on the part of the doctor, must be unconsciously communicated to the patient; so it behooves us all to do our best, and thus acquire this assurance.
Dr. “A” raises what he calls “The Eternal Question, the choice of Potency”.
The question of potency is an extremely difficult one, so far as dogmatism is concerned.
Men have obtained good results from high, low and medium potencies, provided that the right remedy has been chosen.
You may cure a “Baptisia pneumonia” with a few doses of Baptisia in the mother tincture, or with the highest potency. This is the case in acute disease.
In provings it is found that a crude drug is apt to produce the coarser animal symptoms; and that violent efforts at elimination may put an end to the proving.
That the finer, and especially the mental symptoms of a drug have come out best when the proving started with the higher potencies.
It is matter of experience that in using the lower potencies (the 30th and under) one seldom sees, except in susceptibles, such phenomena as the homoeopathic aggravation, the return of old symptoms, the long amelioration after the initial stimulus. These of course are of great import in the conduct of the case, and in prognosis.
Again, Hahnemann worked up, Kent worked up, Nash worked up – with fear. Nash relates, in his “Leaders”, under Colchicum, how he had carried a case of 200s, given to him by Carroll Dunham, for whole year in his carriage without daring to test them. On one occasion a patient of his was dying of diarrhoeic and bloody stools (she had sixty in the twenty-four hours, and was far through). He searched for a remedy having her very marked symptom, terrible aggravation from the smell of cooking. Colchicum had it, and fitted the case. But he had no Colchicum, except in 200th potency in that case of Carrol Dunham’s. He fetched it from his carriage, put a few globules into a half- tumbler of water, and directed, “Give her a sip after each stool.”
Twice he stopped his carriage, after leaving, feeling that he must go back and give that poor woman something! But went on.
Next day he found a cheery patient. She had only needed two doses! It was thus that Nash became a high potency man.
Probably, to do the highest curative work in chronic diseases, the high, the highest, potencies are necessary. But each individual is probably most susceptible, at any time, to some particular potency. Happy if we find it.
In severe acute sickness of healthy people, high and highest potencies may cure, and may be safely used.
In advanced stages of such diseases as phthisis and cancer, with profound tissue changes and destructions, the reaction induced by a high potency may be fatal.
When the Emanometer has got beyond its experimental stage, it may have a great deal to teach us in regard to potency. It is still in its childhood – most interesting but not yet convincing.
Dr. “B” asks: “What time must elapse before concluding that a remedy or a potency has failed to act altogether?”
Each drug has, according to repeated observations,its normal length of action, varying, however, according to reactive powers of the patient and the acuteness or chronicity of the disease.
In one’s experience, drugs of long action, like Sepia, may in chronic cases fail to show much or any improvement for periods up to five or six weeks; and one has been so sure of the prescription that one had waited, and been thankful to have waited, because of the sudden, marked improvement.
One has seen Sulphur in the same way hang fire for four to five weeks, and then suddenly got the desired results.
Experience with other polychrests has often been much the same, where patients are irresponsive and exhibit poor reaction.
Hahnemann, on the contrary, says: “If the antipsoric treatment be properly conducted, the strength of the patient ought to increase from the very beginning of the treatment.” Of course where the patient says : “Symptoms the same, but I feel better,” one would not dream of interfering. Reaction is initiated. In acute cases one expects some result almost instantaneously when one has hit the remedy.
In a case of pleurodynia Arnica gave instant relief after many remedies had failed. The patient had hardly swallowed it when she exclaimed: “That’s the first breath I have been able to draw all night,” and promptly fell asleep.
Another case, one of bilious headache, where the patient, a doctor, was so prostrate after twenty-four hours of suffering, in whom remedy after remedy had failed to touch, that he could just crawl to a bottle of Chelidonium; this gave relief in ten minutes.
Another case of pneumonia, after a dose of Phosphorus 200, got such relief of suffering that he was found sitting up in bed reading a newspaper, though temperature was still 103 degree F., and the lung, of course, unresolved. Here the prompt response of the patient proved the correctness of the remedy, which in due course cured.
Hahnemann says: “The condition of the mind and the general behaviour of the patient are among the most certain signs of incipient improvement, or of aggravation, in all diseases, especially in acute ones.
“Incipient improvement, however slight, is indicated by increased sense of comfort; greater tranquillity and freedom of mind; heightened courage and a return of naturalness in the feelings of patient.
“The signs of aggravation, however slight they may be, are the opposite of the preceding, and consist in an embarrassed, helpless state of mind, while the department, attitude, and actions of patients appeal to our sympathy.” (Org., p. 174.)
Dr. “C” writes: “What value must I put on the generals Heat and Cold?”
These generals must be used with care. Be careful, for example, to distinguish between stuffiness and warmth. Also the patient must be very markedly affected by heat or cold. And this susceptibility is far more important when it is a change of condition, due to illness, than when it is the patient’s normal state.
He asks: “Are these generals sufficient to cut out cold or hot drugs, whatever the mentals may be?”
Here the question of Grading of Symptoms comes in. If mental symptoms are well marked, they are of prime importance in prescribing.
He adds: “I have often been disappointed by my second prescription. At end of four or five weeks after a single dose, when patient is going back (after having had a good result) when the repetition of the drug produces no benefit, after waiting a fortnight, how am I to find the new drug or potency?”
Hahnemann meets this question. He says: “The homoeopathic physician ought to examine the symptoms every time he prescribes; otherwise he cannot know whether the same remedy is indicated a second time, or whether a medicine is at all appropriate.” (Chr. Dis., p. 160).
On the other hand, the very fact that a remedy has so helped the patient is a valuable symptom; and it may be unwise to abandon it before trying the effect of a higher potency.
Dr. “D” writes: “My greatest difficulty is in the second and subsequent prescriptions. The generals remain the same; the chief guide therefore is unchanged; and there are only particulars to guide one… on which your method places little value.”
In the first place the method is Hahnemann’s, not mine.
If patient is improved give sac. lac., and give this again and again, so long as improvement continues. Even the particulars, unless dependent on a mechanical cause, should disappear. If patient goes back and symptoms remain the same, repeat same remedy and same potency. If it ceases to hold so long, and symptoms return, give same remedy in higher potency. And again, and again placebo, so long as improvement continues, probably for a longer time. If symptoms change, and yet the patient feels better, still give placebo. These may be a return of old symptoms, on the road to cure. Patient may be doing his return journey, especially if they reappear and die away, in the reverse order of their appearing years ago. If the symptoms change, and are not a return of old symptoms, and the patient is not improving, reconsider the case and get the new drug that now fits the altered condition. At the same time do not be too slavish in basing your prescription on ill -marked generals. Marked particulars with modalities, or peculiar symptoms, may be really all there is of the case; and far more important than a host of generals that one has manufactured, and which are not sufficiently marked to exclude remedies from consideration.
Dr. “C” asks further: “Is a knowledge of the drugs that follow well the most important thing?”
The lists of drugs that follow well contain mere suggestions, and are helpful where there are few symptoms to guide you,
He then quotes the case of a child that did well under Calcarea carb. (200 to c.m. potencies) for a year. He improved very much under treatment, but the parents complained that he was only well while taking the medicine.
Hahnemann says where there is no manifest exciting or maintaining cause, one must always have regard to the possibility of the existence of “some miasm.” Probably, to complete the cure, the child needed Tuberculin, or one of the other nosodes.
Dr. “E” raises an important point… “Why did not the well- indicated remedy help this case?”
His excellent results, as you will see, answer his question.
“1923. February 20.-Mrs. O., aged 28; two children. Constipation, getting worse; no desire for stool. Purgatives lose their effect; takes raw fruit, Upset with menses, which last twenty days, with seven days clear. They are copious, bright-red, with clots. Sickness and vomiting for first three days of menses; keeps her in bed generally. No trouble when children born. Patient is tall; thin; fair hair; waxy complexion. (<) cold; warm room; (>) open air. Feels will lose her reason during thunderstorm. (<) on rising; (>) noon. Desire for salt; aversion to meat, to all fats, which upset. (<) pastry. Music her delight; highly strung. (<) dark; alone. No T.B. history. Phosphorus 1m, one dose.
“March 1.-No change. Phosphorus 10m, one dose.
“April 11.-No better. Tuberculinum bov. 1m one dose.
“May 28 – Much better every way till May 18. Eating better. Stronger; more cheerful. Less nervous; no sickness with this M.P. Has had a daily stool till May 18; since then going back in this respect. Says `wonderful wee pills’. Tub, bov. 1m, one dose”.
“Why did not Phos help this case?”
Hahnemann recognizes the stop-spot of treatment by symptoms only. He says: “These alone (with due regard to the possible existence of some miasm) must constitute the medium through which the disease demands and points out its curative agent”.
Sometimes patients declare there is no T.B. history; and later tell us, after inquiry, that statement was not correct.
Allen says: Think of Tuberculinum when the best selected remedy fails to relieve, or permanently improve.” Dr. “E” finds another difficulty “where there are only particulars relating to complaint – no mentals or generals. Patient appears to be in perfect health.”
Here one must be alive to the possibility of some tumour causing pressure symptoms.
On the other hand, there are often cases which present merely particulars, and these, forming the totality of the case, must guide to the prescription. The following is a case in point:-
February, 1913: J.W., a minister, aged 52. Headache for thirty years, every few weeks. These bowl him over for two days. Wakes with slight pain, which increases during the day till he vomits, which relieves. Buries his head in the pillow. He seems to be poisoned with them. Lies like a log, quite dazed, wakes up to vomit, then dozes again. Pain, nail-like; in patches. Better for pressure; lying on sore side; dark; eyes closed; keeping still. Worse for light; noise; sitting up. Gets bilious attacks at changes of the weather. Is faintish on first lying down at night. Vertigo looking up, There were no mental symptoms; no worry or depression.
The drug that worked through best was Sanguinaria ….It had his nail pain; pain right temple in the a.m.
Better dark room; pressure; after vomiting; worse light; noise. Vertigo looking up. He got Sang 200, three doses.
June he reported: “Very bad the first few days, and scarcely a headache since. Nothing to even stop me from reading. No vertigo no faintness. Not feeling the changes of the weather. No medicine.
September: One bad headache the beginning of July. Sanguinaria 200, three doses.
February, 1914: Only slightest traces of headache till this week. Sanguinaria 200, three doses.
May, 1914: Perfectly well. No headache. Some years later I heard that patient was still well.
Dr. “F” feels more and more the importance of getting all the modalities of the physical stage before entering on mental symptoms. Recently good result in case of duodenal ulcer from Chelidonium given because of relief lying on left side, with legs flexed. A cholecystitis (probably) has had relief (great) from Calcarea, given because of relief lying on back. Drugs selected according to mental symptoms had failed.”
In this regard one must remember that “a number of strong particulars must not be neglected on account of one, or even more, weak generals.” Strong particulars with modalities are very important in the working out of any case. One must also remember that not all drugs are equally well represented in the repertory.
Many very important drugs appear, perhaps only once, but in highest type, in some small rubric. They have come into too recent use, or are not sufficiently proved, to find a place in the work. In such cases one has to go to the materia medica to realize whether the drug truly fits the case.
Again he asks: “How can one get mental symptoms without asking leading questions?”
Dr. Gibson Miller says: “These symptoms are naturally the most difficult to elicit, for people, as a rule, shrink from revealing their inmost thoughts and motives, their hatreds and yearnings, their evil tendencies, and their delusions, , and it requires the greatest tact and a full knowledge of human nature, before we can hope to win the confidence of our patient and to understand his deepest thoughts”.
Here, also, the friends of the patient may help us much, specially in regard to important changes of disposition; besides that, we are helped by our own observation. The mental symptoms we generally leave to the last, till the patient is familiar with our methods, and we have had time to gain his confidence.
He asks further, “Must I take all mental symptoms without reference to attending circumstances, i.e., a girl with intense fear of thunder, whose mother has also fear of thunder , and hides during a storm. Am I to include fear of thunder?”
All the more! You do not refuse to take phthisis into consideration, because her mother or her grandmother had died of it. On the contrary, very often the same peculiarities and the same drugs run in families.
And once again: “Patient has had certain mental symptoms for years before the development of physical illness… am I to take that symptom?”
Organon (par. 213) says, “We must pay attention to the change that has taken place in mind and body”.
Whilst all symptoms must be taken into consideration in a case,yet the last appearing or more recent symptoms are the most important for the first prescription.
Dr. “G” writes: “My greatest difficulty is myself, how to get proper knowledge of materia medica”. KNOWLEDGE OF MATERIA MEDICA
Read a drug a day in different books, so as to get different presentments by men of different minds, and different experiences. Some can tell you about one drug, some about another. Read such books as give briefly the characteristics of drugs. You do not need all the small details – the symptoms common to innumerable drugs. You want the broad, characteristic outline – the peculiarities – the strange mentalities For quick work, you want to know especially, what makes this drug quite unlike all others, say “Allen’s Keynotes” or “Nash’s Leaders” if you are too rushed or tired for “Kent”. Or read the black type and italics in “Allen’s Cyclopaedia,” or the black type of “Hahnemann’s Materia Medica Pura”. These give you a wonderful perception of drugs.
Also, when you have worked out a case, glance through your drug in the materia medica before prescribing, to see that it not only fits the patient as a whole (several drugs may seem to do this) but that it is also on the spot with what the patient complains of. In this way you learn your drugs far better than in merely working them out; it will also save you from tediously working through small particulars, which may not be well represented in the repertory.
For instance, Sepia, Nitric acid. and Natrum mur. might work out more or less. But if the patient is complaining of uterine symptoms, probably, if you turn up Sepia, you will find a picture of the whole trouble;if it is anal or buccal, you might possibly find your picture detailed in the provings of Nitric acid, or the headache complained of may be absolutely Natrum mur. There is not only the general and mental picture to be dealt with; but also the regional. We sometimes forget this. Prescribers say that Kent rather neglected the regional. But it is a fact that drugs pick out each its own locality or tissue, as Silicea, , connective tissue; Arnica, Carbo veg., Lachesis, Pulsatilla veins; Chelidonium, Podophyllum, , liver; Bryonia, Ruta, , serous tissues.
He says, “two types worry me”.
Patient “who has a respect for doctors, and tells you plenty. When he has gone, you find nothing but an impenetrable verbal forest.”
You will get gradually to know what Clarke calls “good symptoms”, that is, symptoms valuable in the finding of drugs, also symptoms that you feel must form a part of the case. Underline these with red pencil, as you read through what you have written, or as the patient gives the symptoms. They will then stand out in their order of importance, and save you much work.
Hahnemann suffered from just the same difficulty. For he says, “observe and discount the temperament of your patient. Some, “he says, “particularly hypochondriacs, and other sensitive and intolerant persons, are apt to represent their complaints in too strong a light, hoping thereby to induce the physician to redouble his efforts.
“But the shy, the modest, or timid and bashful will state their case in obscure terms; or may consider many of their symptoms too insignificant to mention.” (Org. p. 1, 6.)
Again, “Patient with chronic complaint, doing well, has had a recent repeat, and comes in with an acute condition…(?) not related to the chronic one”.
Here Hahnemann says…”The physician must be on his guard against interrupting the action of the antipsoric remedy which he has given to the patient. Let him not exhibit an intermediate remedy on account of a little headache which may perhaps come the day after the remedy was given; or another remedy for a sore throat, or diarrhoea, or a little pain, The rule is that the carefully selected homoeopathic remedy should act until it has completed its effect.” (Chr,. Dis., p. 150.)
Dr. “H”, referring to the treatment of mental cases, says:
“I am up against the difficulty of working on a scarcity of material facts.
“I must judge by the patient’s expression and what he chooses to tell me, which consists mostly of delusions.
“I have come to the conclusion that to prescribe on delusions or delirium or mania in this type of case is hopeless”.
Dr. Burnett used to say: “With infants, lunatics, and liars you have to form your own judgment” re: choice of remedy.
The patient may be unable to give symptoms by word of mouth, or may lie when giving them. But there are other even more sure of ways of arriving at what you want.
Your observation, expression of face may help you, especially in cases of insanity, where, perhaps, the one idea has stamped itself upon the patient. You may see pictured anxiety, fear, suspicion, the lineless face of Sepia, the deeply-lined face of Arsenic. The face may express stupidity, foolishness, may be old-looking, sickly, suffering. Kent has rubrics for these under “Face” (Repertory, pp. 378, 379 besides the rubrics in mentals. You will observe the behaviour of the patient – restlessness; ceaseless movement of hands or feet; desire to escape, Or dull, phlegmatic appearance.
The reports of attendants are invaluable. The patient may be sly, spiteful, cruel, weeping, shrieking. His appetite – hungry or greedy; aversion to food; refusal of food. Aversion to or desire for different foods. Unnatural cravings. May eat lime, earth, his own excrement. His fears – alone, in the dark, of people. Symptoms of paranoia or megalomania. Dr. Tyler has more or less grouped these into two of her repertory cards, “delusions of persecution” and “delusions of grandeur”. Very important, too, are the reports of friends as to changes of disposition. You may find, on inquiry, that a kindly person has become cruel; that there are cravings for things once loathed, or a loathing of things once craved; that there is indifference to, or hatred of persons once loved. All these things are of the utmost importance in dealing with insanity. Never forget the nosodes in mental diseases and maldevelopments.
Tuberculinum is wonderful mental remedy or stimulus. Apart from its symptoms, the indication is a family history of tuberculosis, or previous T.B. history of patient, or, as Allen puts it, “when the best indicated remedies have failed to produce improvement.”
Also Syphilinum : one would think of this where the patient is sleepless, or when his sufferings, mental or physical, are always worse at night. Queer things have been cured by this drug, on that nightly aggravation indication, where other symptoms have not been available, or have not helped (as a case of nightly vomiting). Incessantly washing the hands is one of the peculiar symptoms of Syphilinum, and has been verified clinically. And there is a mental symptom – dreads the night.
Also Medorrhinum. This has some very insane mental symptoms. Far-away sensations; seems to herself to make wrong statements; thinks someone behind her; hears whispering; sees faces peer at her from behind furniture; sees large rats running; large people in the room, feels a delicate hand smoothing her head; all life seems unreal; sure she is going to die; wild and desperate feeling, as of incipient insanity; suicidal; feels matters before they occur, and generally correctly; fear in the dark; has committed the unpardonable sin and is going to hell. A useful symptom, “likes to lie on abdomen”.
Do not forget the effects of blows and fall on head and neck. Arnica, Hypericum, Cicuta, must be here thought of. In America they are said to be doing a great work on asylum patients with manipulations of neck.