The second prescription can be defined as the prescription which is made each time the patient comes for follow up. It can be more specifically defined as the prescription which is made after the previous prescription has acted completely. This definition theoretically sounds very simple, but practically this is the most tedious task for the physician. A hurried, wrong second prescription can spoil the whole case, no matter how well it was taken and how well the similimum was selected for the case.
Patience in prescribing the second prescription, confidence in the previous prescription and proper knowledge of Organon are the key factors for second prescription success. Hurriedness in making the second prescription without properly addressing the condition of the patient, is a negligent act on the part of physician.
Clinical Approach For Second Prescription (In chronic diseases): The second prescription can be :
(1) Wait and watch (or prescribe placebo) after the first prescription.
(2) Repetition of the first remedy or
(3) Change of medicine
The above three choices cannot be done practically unless the whole case is restudied very carefully.
(1) Wait and watch (or prescribing placebo) after the first prescription:- The foremost rule of making the second prescription is to give enough time to the previously prescribed medicine so that it can act completely. If the patient comes for the follow up and says that there is no change in his symptoms, or in general condition, restudy the case. If the first prescription was selected properly on the totality of symptoms, have confidence in it, do not change or repeat it unless it is very urgent; just wait and watch or prescribe placebo for the patient’s satisfaction. Chronic disease is of long duration and may be complicated by suppressive treatments, so it may not be possible for the medicine prescribed to produce changes in 6-7 days. Unless the symptoms of the patient demand change, it is always advisable to just wait and give the medicine more time to act. Most well-made prescriptions get spoiled because of hurried second prescriptions (whether that is repetition or change of remedy).
(2) Repetition of first remedy: After the first correct prescription, changes will appear in the patient’s symptoms: Some will increase or decrease or new ones might appear. In such a case, while the symptomatology is in change-mode, the physician has to wait and not repeat. In due time, the physician will observe that the symptoms have returned to their original state, as when the patient first sought help, with the same generals and particulars but in less severe form–or even in more severe form. The time to repeat the first remedy is when the improvement has stopped. If the patient benefitted after the first prescription and now, after an interval has passed, the original symptoms return, the physician can believe that the first prescription was correct and he may repeat it. However, do not repeat a remedy that is still acting. Repetition at that time will disturb the action of the remedy. Also, when the original symptoms reappear, don’t change the remedy.
When the patient says that he has no symptoms, or they are very decreased in intensity but still he is not feeling completely well and not improving further, the case has come to a standstill. In such a case, wait till you get some guiding symptoms to prescribe on. If after waiting no guiding symptoms appear and no further improvement is taking place, the repetition of the remedy will help in further improvement of the patient. A new remedy cannot be given because of lack of any new guiding symptoms.
The same remedy can be repeated many times where the case becomes standstill. The same potency can be repeated until it will not act any longer. A complete range of potencies can be tried, when you are sure that the previous medicine has acted and has benefitted the patient constitutionally. If a remedy has benefitted the patient, never leave it until one or more doses of higher potency has been given.
(3) Change of remedy: The change of remedy can be:
(ii) Selecting new remedy for the case, which can be a completely new remedy or complementary remedy or cognates, or a different antipsoric remedy or an intercurrent remedy.
(i) Antidote: The remedy must be antidoted when there appear lots of new symptoms after the first prescription. But before antidoting, the case must be restudied and it is to be confirmed whether patient has experienced these new symptoms earlier in life. If old symptoms are appearing, better to wait than to antidote, as gradually these new symptoms may disappear. In case the new symptoms are very disturbing and don’t belong to pathogenesis of the remedy or old symptoms, it is better to antidote and take the case again, prescribing on any new and original symptoms. If the symptoms belong to the pathogenesis of the medicine, wait and watch, as long as the symptoms are not very disturbing. These symptoms may pass away and after that you can retake the case and select the more correct simillimum.
(ii) Selecting new remedy:
(a) When striking new groups of symptoms appear. This new group of symptoms demands a change in remedy.
(b) When symptoms of the patient are changed and he is not improving generally, this is also the time to change the remedy.
(c) When after first prescription, you have waited enough but there is no change in any of the symptoms , ( he is the same as when he came the first time) it is advisable to retake the case and select a more correct simillimum.
(d) When a higher potency of the remedy (which benefitted the patient) has been tried, but now it is not showing any benefit, this implies that the medicine has done all the good it can, and this is the time to change the medicine.
(e) Complementary medicine: The first prescribed medicine is an acute one, and it relieves the patient for a time, but repeatedly the same symptoms with the same intensity appear. In such a case the acute remedy is to be complemented with some complementary remedy. E.g. Calcarea carb is chronic of Belladonna, Silicea is chronic of Pulsatilla.
(f) Cognates: The cognate medicines are closely related to each other. These medicines are so closely related to each other that a medicine always leads to one of its cognates. E.g. Sulphur, Calcarea carb, Lycopodium follow each other, Causticum, Colocynth, Staphysagria follow each other
(g) Change of plan of treatment: It is applicable during the antimiasmatic treatments of chronic diseases. The patient’s symptoms indicate psoric miasm and so an antipsoric remedy was prescribed. After the prescription the patient’s psoric symptoms are better and now the symptoms are showing syphilitic or sycotic predominance. This is the time to change the plan of treatment and a new antimiasmatic (antisyphilitic or antisycotic) remedy is to be selected on the basis of new symptoms of the patient.
(h) Intercurrent remedy: Sometime even after careful selection, the remedy is unable to produce any favourable effect on the patient. Under such circumstances a suitable antimiasmatic remedy may help to remove the miasmatic obstacle to cure. E.g. In acute cases when a well selected remedy fails to give a favourable result Sulphur often clears the case, while in chronic cases Psorinum clears the case. In cases where there is a family history of tuberculosis, Tuberculinum as an intercurrent remedy may prove helpful.
Clinical Approach for Second Prescription (In acute diseases):
In acute disease where the symptoms are very disturbing and increase in intensity very rapidly, quick relief for the patient in the shortest time is urgent. In that case, the wait and watch rule is to be avoided. Here the remedy can be repeated many times at frequent intervals, even in minutes if needed urgently.
If in acute disease the patient is not improving rapidly, but rather is worsening, retake the case and try to select the a more accurate simillimum.
Case example showing the importance of a well selected second prescription:
CASE OF WARTS
Mr. Mahesh, 21 years of age, OPD no 3588 presented with warts on the back of his hands since last 1 year.
Bowels- Regular and clear
Past History: Nothing significant
Family History: Nothing significant
1st prescription: Because of paucity of symptoms, the medicine was just selected on the basis of the symptom: warts on back of hand.
Dulcamara 30C/t.d.s./7 days followed by Sac Lac 30C/t.d.s./10 days.
2nd prescription: No change in any of the warts. Same remedy repeated but in higher potency.
Dulcamara 200C/tds/1 day followed by Sac Lac 30C/tds/15 days. Again after 2 weeks there appeared no change in any wart.
After waiting and watching and trying a higher potency there is no change in the patient, so it is advisable to retake the case and change the remedy.
3rd prescription:- After retaking the case it was found that the warts first appeared on the right hand and then the left hand. On the basis of this symptom and desire sweets the medicine prescribed was:
Lycopodium 30C/t.d.s./3days, followed by Sac Lac 30C/t.d.s./10 days.
4th prescription:- Now there appeared a small change in a few of the warts. So Sac Lac 30C/t.d.s./ 7 days prescribed.
5th prescription: No further change in size of warts, case is standstill. Same remedy repeated but in higher potency.
Lycopodium1M/2 doses, followed by Sac Lac 30C/t.d.s./15 days.
6th prescription: This time there was significant change in the warts, so waiting and watching applied.
Sac Lac 30C prescribed and gradually in few days all the warts vanished.
Conclusion: Wait and watch, repetition, or change of remedy at the proper time helps in furthering treatment of the patient. Thinking that early repetition will hasten the action of remedy, is a big mistake. Early repetition or changing the remedy without restudying the case, not only spoils the progress of the case, but also makes it more complicated.
- Kent J.T., second prescription, Lectures on Homoeopathic philosophy, 7th edition, B Jain publishers pvt. Ltd.-2007.
- O’ Reilly Wenda Brewster, section 245-258, Organon of medical art by Dr. Samuel Hahnemann, Birdcage books – 1998
- Sarkar B.K., Organon of Medicine (5th & 6th edition) by Samuel Hahnemann, M. Bhattacharyya % Co (P) ltd. – 1987