Editorial Remarks On Alternation


Two or more medicinal forces cannot together act upon the economy without so modifying each other that neither shall produce the effect it would if only one were acting.


(1 Suggested by a contribution by Dr. H. to the American Homoeopathic Review, vol. v., February, 1865)

I.

We publish with great pleasure articles which, like the above, though they seem to favor a practice which we deprecate, are, nevertheless, honest expressions of the earnest conviction of men of close observation and faithfully study.

Nothing could be farther from our intention than to undertake to dogmatize on this question, which we admit to be an open question, and on which men of eminence entertain opinions at variance with our own. It may be allowed us, nevertheless, in all courtesy to our contributor, to signify the points on which we take issue with him.

I. We assuredly do entertain the belief that “two or more medicinal forces (or, we prefer to say “morbific forces”) cannot together act upon the economy without so modifying each other that neither shall produce the effect it would if only one were acting.” This belief has prevailed among medical men from the earliest ages. It is the foundation of the practice of polypharmacy in all its varieties, from the complex prescriptions of the seventeenth century to the alternations of our own colleagues. For we hold, with Dr. Sorge (by no means a Hahnemannian, let us add), that “the practice of alternation, as it exists among homoeopathicians, is only another form of mixing remedies with the intention of getting an effect compounded of the action of the two or more drugs that are alternated.”

We say, this belief is the foundation of polypharmacy. The rationale of a compound prescription we take to be the following: the drug which is regarded as the one chiefly indicated possesses, let us suppose, certain properties which would be hurtful to the patient. Another drug is conjoined with it for the purpose of antidoting those hurtful properties. Again, it lacks the power to produce certain effects which are deemed desirable. Another drug is added to supplement this deficiency, and so on, ad infinitum. This entire procedure rests on the belief that these medicinal forces will so modify each other in the economy that neither shall produce the effect it would if only one were acting.

As an example, we mention calomel and opium, a very familiar combination. Certainly the object of giving the opium is that it may modify the action of the calomel, and in a way which conforms to the known action of opium when given alone.

If there were no reason to believe that “two or more morbific force (a drug is a morbific agent exciting a morbific force) could not together act upon the economy, without so modifying each other that neither shall produce the effect it would it only one were acting,” how could we ever cure disease? The morbific force which constitutes the disease is acting upon the economy,, and we bring to bear upon the economy another morbific force, viz., a drug Now, if the latter be properly selected with reference to the former, we know that these forces will so modify each other that, on the one hand, the drug will not produce pathogenetic symptoms as it would on the healthy subject. This statement rests on the basis of such “facts” as our friend invokes. On what other theory than the mutual modification of morbific forces acting together upon the economy could it be explained?

On what other theory could we explain the action of antidotes as homoeopathicians understand and employ them? How else could we explain the action of Belladonna, in large doses, in antidoting poisonous doses of morphine (1 American journal Medical Science, January, 1862) as well as mutual antidoting powers which allopaths have recently discovered, many of the cerebro stimulants and spinant alkaloids to possess? How else, finally could we explain the efficacy claimed for the practice of alternation in general and for certain instances of it particular, such as the cases related by Dr. H., and which we fully credit, where Belladonna and Bryonia in alternation accomplished what neither could do singly, and where Arsenic and China in alternation cured a case which neither alone had cured? How else but by conceding that two or more medicinal forces cannot act together upon the economy without so modifying each other, that neither shall produce the effect it would if only one where acting?

The fact that medicinal or morbific influences must be avoided when we are engaged in proving drugs is universally admitted; even Dr. H. assented to it. But on what other grounds than the belief already stated?

That persons long accustomed to use tobacco or coffee are not easily affected by drugs is accounted for, probably, by the fact that long habit has, in so far as those persons are concerned caused tobacco or coffee to cease to be “medicinal forces.” Use has become “second nature.” That is persons not accustomed to the use of coffee, a dose of it will modify the action of another morbific, or medicinal, force is demonstrated by the effect of coffee antidoting opium, Nux vomica, alcohol, as yell as in neutralizing the beneficial curative action of many drugs, as our clinical observations often satisfy us that it does. The same statements apply to tobacco.

2. We think we may then assume, as conceded, the fact that “two or more medicinal forces cannot at the same time act upon the human system, without mutual modification.” It is now asked, whether granting this modification, we may not avail ourselves of it to derive, from the alternate use of drugs which modify each other, good effects that we have attained no other way? There can be

not doubt of the possibility of this being done, no doubt that it has been done with advantage; as, indeed, Dr. H. shows by two instances.

But, in the present state of our science, it would be impossible for any one lay down rules for the selection of remedies to be given in alternation, with the view of gaining any desired modification of the action of each. Nor can we conceive of the possibility of arriving at any such law. The rule of the ancient polypharmacy, viz., to select remedies according to the effects which they produce singly, and to combine them with reference to the effect desired, does not always work well in practice. For example, calomel and opium produce a combined effect, which is clearly a modification of the known action of each drug. But on the other hand, the combined action of opium, ipecacuanha and the sulphate of potash in Dover’s powder is quite distinct and different from that of either constituent alone, and is such as could hardly be anticipated from what we know of these constituents.

Arsenic and China produced a combined effect which cured an ague that neither singly would cure. Now, if this fact were to be taken as a guide in selecting a combination for a case of uterine disease, for example, in which we were at a lose of uterine disease, for example, in which we were at a loss to decide between Sepia and Pulsatilla, it might lead us to alternate those two remedies. But it is not three months since one of us took charge of a case in which this alternation, on this very ground, had been employed, but the patient had not recovered. We were led to the conclusion that the Sepia was really the remedy indicated-that it did good, but that its effects were constantly antidoted by the Pulsatilla. We omitted the Pulsatilla, gave Sepia judiciously, and the patient promptly recovered.

When, in addition to this difficulty arising from the fact that alternated drugs do not always produce a morbific action which can be predicated in advance from their known single action, we consider that the various degrees of susceptibility of the organism to drugs indicated with different degrees of accuracy, will cause the modifications by drugs of each other’s action to be different in each individual case, we clearly see that we can never be in a position to predicate, in advance, the effect of the joint administration of several drugs. We can never, therefore, have a scientific indication for such a combination or alternation. If we make it, it must always be the result of “guess-work” of “feeling our way along,” just as Dr. H. did in the cases he relates.

But we claim superiority for Homoeopathy in that it gives us the means of selecting our remedies with a reasonable certainly of their effects, and we rightly claim that medicine should not rest content with anything short of a method which, given the symptoms of a disease, points us to certain remedy if our materia medica contain it; or, given the pathogenesis of a drug, indicates to us, a priori, the complex of symptoms which the drug will remove.

But the method of alternation throws us back from all-such certainty-back to the field of unmethodized clinical experience-back to the trackless wilderness of polypharmacy and allopathy.

For the reasons, briefly and imperfectly stated, from the stand-point of science we hold that homoeopathic medicine cannot countenance nor tolerate alternation. And we have such a faith in the unity of nature as to believe that what sound reasoning shows to be erroneous, accumulated facts will prove to be mischievous and unnecessary.

3. But there is another view of this matter from the practical stand-point. Dr. H. says: “Grant that in a given case of the use of two remedies, some one remedy might have been found that would as well, or better have answered the purpose ** the question is not, Could some other person have done better than I, but Have I done the best I could? Undoubtedly, yes! And, so far as the prescriber’s own conscience is concerned, this answer exonerates him, even though his prescription were a faulty one. And in so far, from the practical point of view, alternation may be justifiable. But will his question, ‘Have I done the best I could?” if affirmatively answered, always justify the prescriber? The practitioner of one year’s experience may commit a sad blunder and yet be fully justified, because being inexperienced and young, bad though his error was, he did ‘the best he could.’ Would this plea justify the same blunder ten years later? Obviously it would not. Yet is it not the tendency of this plea to satisfy a man with the knowledge he has and with the methods he pursues, and thus to blunt his zeal for greater knowledge and better methods? Remonstrate with the allopathist for murdering patients with lancet and purge; he replies, “I act according to my light’ I do the best I can.’ And so through all degrees of error and imperfect knowledge. It is a dangerous plea, unless its complement be always added, ‘I have done the best I can, but please God, I will do better next time!'”

And here we see the advantage of a sound “theory,” which our friend holds in so light esteem.

Suppose a practitioner driven, as Dr. H. was driven, to alternate. The patient recovers. He has, nevertheless, a conviction that drugs modify each other’s action in a way that we cannot foretell, and that the action of the entire organism is so harmonious that “two morbid states cannot co-exist independently,” and that, therefore, the morbid state being essentially one, there must be a possibility of one similar drug-disease to oppose it. A sound theory compels him to the belief that alternation is not justifiable nor defensible on scientific grounds, and that it can do nothing to advance our knowledge of Therapeutics, but rather confuses it. He enters in his mind a protest against the practice to which the necessities of practical duty and his limited knowledge of the materia medica have constrained him, and turns with redoubled vigor to the study of materia medica, smarting a little with shame that the exigencies of practice have found him unprepared, and have compelled him to a resort which, though successful, his reason condemns, and determined that the next time he will, if possible, be equally if not more successful, and by a method which shall commend itself to his reason, and shall add to his stock of knowledge for future use.

And if, while “doing the best they can,” as each case presents itself, practitioners will earnestly and systematically study the materia medica, determined to do better and better the next time, we shall have no word of reproach to utter against their temporary expedient of alternating drugs. With broader knowledge they will alternate less and less, and we are very sure that they will see, as we have done, how, in case after case in which they had alternated, the recovery was in truth retarded by the mutual reaction of the drug; and how the careful individualization of the case, and the painstaking selection of the single drug in the manner that Hahnemann advised, will be in their hands the means to a success far beyond any ever reached through alternation. For, though we have admitted and do admit that success is the object of all our labors,” we are nevertheless convinced, through our own experience, for we have alternated in our day, that a much larger measures of success is obtained by adherence to the rule of administering single remedies, and that closer study of the materia medica and sharper investigation of cases will preserve us from those dilemmas in which we are tempted or compelled to resort to alternation.

4. And if we appeal to the experience of Hahnemann, let it be understood that we appeal to the man who both knew materia Medica better than any other man ever knew it, and who had more practical experience than any of us has had. Let us not indulge in the fallacy of supposing that, because we are now practicing in the fifty-ninth year since the Organon was published, we have had fifty-nine years’ experience in homoeopathic practice, and have been studying materia medica fifty-nine years. On the contrary, our own experience is measured only by the actual number of years we have practice; since in this matter of assimilating to one’s own mind the facts of the materia medica, and of seeing the correspondence between these and the facts of the disease, we can borrow but little from the experience of others.

If then we, from our little experience of fifteen, or ten, or five years, appeal to Hahnemann with his venerable experience of more than fifty years of active practice, with his unapproachable knowledge of the materia medica, of which he might justly say like Aeneas, “magna pars fui,” with his unrivalled powers of observation and discrimination; if we appeal to him as “authority” on this question, at once practical and scientific, can it justly be said, that we are seeking some “authority outside of and beyond our own reason?” Our colleague appeals to collections of “facts.” Is not Hahnemann’s statement of his practical conclusions a most stupendous “collection of facts?” Who ever observed so many of them? Who ever observed so well as he? Facts must be received on testimony; who ever reported more graphically and more faithfully than Hahnemann? If we doubt his ability, his capacity, his candor, what are we doing with his materia medica, on the truth of which we risk our patients’ lives?

This outcry against “swearing in the words of the master” has come to have a very different meaning from that of the ancient original protest. It was never meant to intimate that the opinion and testimony of him whose abilities had crowned him “kind of men” should not have a royal weight of influence.

EDITORIAL REMARKS ON ALTERNATION.

(1 Suggested by a contribution by Dr. C. to the American Homoeopathic Review, vol. v., April, 1865.)

II.

This article very justly afirms that the question of alternation, being a practical one, “must be decided by experience;” that no dogmatism will satisfy those differing in opinion. The writer then straightway proceeds to dogmatize on the basis of two assumptions, which he claims to be “established principles in Homoeopathy,” but which very few will concede in the terms in which he has expressed them.

Having referred the question to experience, he makes no appeal to experience, whether his own or his neighbor’s. If he have experience which can throw light on this question, it ought to be comparative experience. He ought to be able to say: “For a certain period of times I avoided alternation, selecting may remedies as Hahnemann directs; then, for a period I alternated. My success under the latter method was the greater.” Such a statement as this would carry weight. But we gather from this article that the author has always practiced alternation, deriving his ideas of its propriety and necessity from the assumed :”established principles” upon which he bases his arguments, and upon the assumed imperfections of the materia medica.

If our conjecture be correct, then his experience, being confined to the practice of alteration and not bearing upon the opposite method, can have only a negative value. It merely shows that a measure of success does attend this faulty form practice, a point which was freely conceded to Dr., H.(2 See previous paper) But inasmuch as no advocate of alternation claims invariable success, the question remains, “Might not the success have been greater if alternation had been avoided?” Not having any comparative experience by the light of which to answer this question, the alternator ab initio, could not reply.

Our editorial note to Dr. H.’s paper expressly referred to Hahnemann’s experience, and to the experience of the writer, as being of this comparative character, and as, therefore, bearing on this question, and as showing, so far as they go, that the results of adherence to the single remedy are more satisfactory than those of alternation.

Some of the points touched by Dr. C. are too important to be treated in this annotation. They will be discussed in a future number of the Review. (1 See “Alternation of Remedies,” Nos. 1 and 2)

Suffice it now to say that, when he states that “the only reason why he practices alternation is the want of perfection of the materia medica,” he concedes (if he will allow us to add one other analogous reason, viz., “want of perfection in the knowledge possessed by practitioners of the materia medica which we already have”) all that the opponents of alternation contend for. For this position admits that alternation is wrong in principle, and is only necessitated by a temporary emergency. We contend that the emergency, instead of being common, is rare, if not altogether imaginary, and we appeal to our practice.

How dangerous it is to discuss a questions of science with rhetorical figures!

Dr. C. makes merry over his imagined double-headed monster, for each head of which he provides a club, and he grows happy at the thought that by his two- handed energy he will have destroyed this figurative disease much more quickly than the luckless editor could do it, whom he restricts to the use of a single club to be applied to but one head at a time.

Now, we have always supposed that the efficacy of an armament depended not so much upon the number of efficient weapons as upon the skill with which the weapons existing were used, and one club in a vigorous right hand might do more execution even on a double-headed monster than two clubs even in the hands of our ambidextrous correspondent. But why restrict the monster to the “two-headed” form? If we are to admit the dual or multiple independent co-existence of disease, why not liken it to a centipede, each foot “possessing independent vitality?” With what armament now will our friend cope with his antagonist? Shall he call Briareus in consultation, and arm him with one hundred clubs? We do not believe in the multiple co-existence of disease. Leaving out of view traumatic affections which may supervene during idiopathic sickness, as Drysdale shows, we believe in the unity of disease, and we expect to find one remedy of which the characteristic symptoms cover the whole case.

The figure of the two-headed monster is, therefore, in our view, defective, but, admitting the figure, why must we use clubs at all? In the days when brute force reigned supreme they were well enough. But surely in this day of enlightenment “clubs are not trumps.”

Hercules was the embodiment of brute strength as distinguished from intellectual acuteness and skill. Surely his subjugation of the Lernean Hydra should not serve us as an example in treating disease. We cannot afford to spend so much time as the club treatment requires; for both the experience of Hercules, and that of our Irish friends at Donnybrook Fair, prove that the breaking of heads by clubs is a tedious and uncertain affair. We decline to enter into competition with our friend in the use of his favorite therapeutic agent, the club, whether he use if single, double, or a hundred fold. But, if he insist on a mechanical figure, we will suggest that, while he is counting the heads of the monster and is casting about in his club-room for a bludgeon adapted to each head, and is fitting his hand, for the arduous effort, and is so getting his balance as to make sure that the complex wielding of his numerous weapons shall not trip him up, we shall humbly survey the monstrous form with the intent to study the controlling characteristics of his anatomical structure, and when we shall have learned to what type he belongs and what are his characteristics as an individual, then with one single weapon (a slender sword, it may be, or a bodkin, or a drop of prussic acid), we shall touch the vital part (the heart, or the medulla, or a delicate mucous membrane) on whose integrity depends the life of all the heads and all the rest-and presto-before the ponderous clubs have time to fall on those devoted heads “belaboring them simultaneously” the work is done!

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