Small doses of mercury given by Hahnemann before his discovery of homoeopathy. After his discovery he gave other medicine in ordinary doses- First indications of small doses-His doses in scarlet fever-Had the apothecaries persecution an influence on his doses?-Reasons for his sudden change to small doses-Rules he gives for the selection of the dose -Later he alleges that the dose cannot be too small-Examples of various doses he recommended of various medicines-Appreciable doses of some medicines given by him-The doses prescribed in the Materia Medica-He did not always go on diminishing his doses, but sometimes gave larger doses than he had previously ordered- Remarkable influence of the psora-theory on his doses-He makes the 30th dilution his standard dose-He often departed from his own standard-Expresses his disapprobation of higher attenuations- Approves of higher attenuations-If the medicine be repeated the dose should be increased-Various doses in a pocket-case used by Hahnemann just before his death- Hartlaub advises small doses for acute, larger for chronic diseases-Wolf recommends a variety of doses-Rau advises small doses for acute, larger for chronic diseases–Werber contends for various doses -AEgidi prefers the lower dilutions, but admits the power of all-Rummel opposes the idea of a standard dose-He says some medicines do not act in the higher dilutions-He attempts to lay down some rules for the doses- He allows that the 200th dilution still acts-Stapf says the insolubles are best in high dilutions-He prefers the lower dilutions in acute diseases-He treats itch and syphilis with low triturations-He approves of Jenichen’s preparations-Gross’s inconsistencies-He finally fails into the Jenichen trap-And recognises the apparent insanity of his conduct.
IN this and the next lecture it will be my endeavour to lay before you the principal opinions that have been expressed by Hahnemann and his disciples relative to the quantity of medicine requisite to be administered in disease, and to ascertain if there is any rule to guide us in the selection of the appropriate dose for each individual case; or, supposing no such rule can be found, if experience teaches us that there is one uniform appropriate dose for each medicine and for every disease, or that some forms or cases of diseases are most appropriately treated with larger, others with smaller doses.
And as I have proceeded in the case of the other doctrinal points of the homoeopathic system, so I shall commence my inquiry into the present question, by laying before you a historical exposition of Hahnemann’s opinions and practice on the subject.
In one of Hahnemann’s earliest works, that, namely, On the Nature and Treatment of Venereal Diseases, published in 1786, accordingly long before he had any notion of a general therapeutic rule for the employment of remedies in diseases; long before he had thought of any of those pharmaceutic processes that he subsequently held to increase the potency of the drug, and long before he thought it necessary, for the sake of obtained a uniformity of result, to advise one uniform dose for all medicines in all diseases-in this work, I say, we already find some peculiarities in reference to the doses of medicine he prescribed, especially in reference to the dose of the new preparation of mercury, to which his name is attached. It is well known that about the time when Hahnemann wrote this work, towards the end of the last century, the common treatment of syphilis consisted in giving enormous and repeated doses of mercury, so as to bring the system, as it was thought, as quickly as possible under the influence of this drug, with influence was believed to be only duly exerted when the patient presented those well-known but now happily more rarely seen symptoms of mercurial poisoning-salivation, spongy gums, foetid breath, swollen tongue, glandular enlargements, extremely febrile and wasted condition, racking pains in the bones, etc. etc.
Hahnemann’s treatment offers a very remarkable contrast to this heroic practice. He tells us that for the complete eradication of lues venerea, he has sometimes not had occasion to give more than one grain of his soluble mercury, and that the average quantity he requires for the treatment of moderately severe syphilis is not more than eight grains. He here talks of half a grain, of one, two, and three grains of this mercurial preparation as large doses, and the doses he commonly employs are a quarter, third, half, three-quarters, and one grain of the remedy. These comparatively small doses which he at this period prescribed, though they relate but to one medicine and to one disease, seem, however, to show the tendency of his mind to rebel against the enormous doses of ordinary practice, to give remedy in doses sufficient to produce its curative but not its pathogenetic action.
In Hahnemann’s earlier essays on his therapeutic principle we do not, however, find that he carried out the principle he had in his allopathic days laid down with respect to the administration of mercury in syphilis to other medicaments and other diseases. On the contrary, we find that his doses, even after his recognition of the great principal with which his name is for ever connected, differed little, if at all, from those in common use. Thus, in his first homoeopathic essay, (Lesser Writings, p. 295 et seq.) published in 1796, that is to say, six years after those experiments of his with bark, which led to the discovery of the homoeopathic law, we find him prescribing arnica root in powder for dysentery, in the following doses: to children of four years of age he gave at first four grains daily, then seven, eight, and nine grains daily; for children of six or seven years old, he began with six grains, and gradually increased the dose to twelve and fourteen grains; to a child of three quarters of a year old he gave first two grains, and afterwards increased the quantity to six grains. An infusion of ten grains of ledum palustre is, he says, a sufficient dose for a child six years old. Three grains of veratrum album, every morning for four weeks, was the dose he prescribed, and with which he cured a case of severe spasmodic asthma. For a case of delirium after parturition he prescribed with success two doses of veratrum, of half a grain each, during the day. The following year, (Lesser Writings, p. 353.) 1797, we find him giving veratrum for a case of colicodynia, in doses of four grains once a day. The same year we learn from another essay (Ibid., p. 369.) that his doses were- of ipecacuanha five grains, of submuriate of antimony and sulphate of copper a quarter of a grain, of nux vomica four grains twice a day.
In two other essays, (Ibid., pp. 382, 395.) written the following year, we find the doses prescribed by Hahnemann equal to those in ordinary use. Thus he gave ignatia every twelve hours, to children form nine months to three years old, a half to two- thirds of a grain; from four to six years, one to one and a half grain; from seven to twelve years, two to three grains; to an adult, as much as eight grains for a dose. Opium he prescribed in doses of one-fifth of a grain to a child of five years; three- tenths of a grain to children of seven and eight years; seven- twentieths of a grain to one of ten years; to an adult half a grain. Camphor he considered he was using cautiously when he gave it to adults in doses from fifteen to twenty grains per diem, but he found it necessary to increase the dose thirty and forty grains. This medicine he gave to a child of twelve, in the dose of fifteen grains a day for a fortnight. Ledum palustre he employed in the dose of six or seven grains three times a day. Cinchona bark he gave in drachm and half-drachm doses.
In his essay On the Cure and Prevention of Scarlet Fever, m (Lesser Writings, p. 425.) published in 1801, but referring to his treatment in 1799, we have the first indications of the infinitesimal posology which is now vulgarly looked upon as forming as essential part of the homoeopathic system. The preparation of opium he three recommends for the treatment of scarlet fever is prepared by adding one part of pulverized opium to twenty parts of weak alcohol, letting it stand in a cool place for a week and shaking it occasionally to promote the solution. A drop of this tincture is to be added to five hundred drops of diluted alcohol, and well shaken; and of this last, one drop is added to other five hundred drops of alcohol. Of this diluted, tincture, which contains in every drop the five- millionth part of a grain of opium, one drop sufficed for a child for four years of age, and two drops for one of ten years. For still younger children, one drop of this dilution was mixed with ten teaspoonfuls of water, and one, two, or more spoonfuls given.
The mode in which Hahnemann exhibited another remedy for scarlet fever he recommends in this essay, viz., ipecacuanha, was as follows:- A tincture was prepared by digesting in the cold for some days one part of ipecacuanha with twenty parts of alcohol, and of this tincture one drop was mixed with one hundred drops of diluted alcohol; for very young children, one drop of this dilution, containing the two-thousandth part of a grain of the medicine, was enough; older children got more drops, up to ten drops, or the hundredth part of a grain, for a dose.
For the cure of the first stage of scarlet fever, the dose of belladonna prescribed was only the 432,000th part of a grain of the extract, a quantity intermediate betwixt our 2nd and 3rd dilutions. For prophylactic purpose the preparation of belladonna used was thus made:- A grain of the powdered extract was mixed up in a mortar with one hundred drops of distilled water; three hundred drops of diluted alcohol were then added, and the whole well shaken up in a little. One drop of this strong solution was added to three hundred drops of diluted alcohol and shaken for a minute, and of this one drop was added to two hundred drops of alcohol, and this again shaken for a minute. Each drop of this last solution, which is the prophylactic preparation, contains accordingly the twenty-four millionth part of a grain of extract of belladonna; accordingly, twenty-four drops of it are equal to one drop of the 3rd dilution of the co-called centesimal scale.
Of this weak solution of belladonna Hahnemann recommends us to give-to a child below one year, one drop; to a child of one year old, two drops; to one of two years, three drops; to one of three years, four drops; to one of four years, five or six drops; to one of five years, six or seven drops; to one of six years, seven or eight drops; seven years; nine or ten drops; eight years, eleven to thirteen drops; nine years, fourteen to sixteen; and with each successive year up to the twentieth, two drops more; from the twentieth to the thirtieth year, not above forty drops; to each a dose every seventy-two hours (as the action of belladonna, he alleges, only lasts three days), well stirred with teaspoon in any kind of drink, as long as the epidemic lasts, and for four or five weeks thereafter.
Half of the dose recommended as a prophylactic, given every three hours, will, he says, often suffice to suppress the scarlet fever in its first germ. For some of the after-sufferings of scarlet fever, the same doses of belladonna recommended for prophylactic purposes, given frequently, are recommended.
The dose of chamomilla for some of the after-sufferings of scarlatina, and its preparation, differed somewhat from that of belladonna. One grain of the dry extract was dissolved in five hundred drops of water and five drops of alcohol, and of this solution one drop was mixed with eight hundred drops of diluted alcohol. A drop of this, containing the 800,000th part of a few years old; two drops for one of ten years, and so forth.
Such, then, were the first infinitesimal doses mentioned by Hahnemann in his work. We cannot fail to be struck with the sudden transition from the massive doses he prescribed in 1798 t the unheard-of minuteness of his doses only one year later, and we can but guess the causes for this sudden and extreme change. He nowhere assigns any reasons for this abrupt transition, and still less does he give us any details respecting the steps by which he descended from the massive doses we saw him administering in 1798 to the real infinitesimal of 1799.
In this paper on scarlatina he indeed says, respecting opium, that larger doses than those he prescribes occasion raving, hiccough, peevishness, weeping, etc., but he does not state now much larger they must be to have these awkward effects.
You will recollect that in my introductory lecture I mentioned that it was about this time, viz., in 1799, that the persecution of the apothecaries began, and it was probably a desire to evade their harassing annoyance that led Hahnemann to try if, on diminishing the dose to such an extent that it was beyond the ken of chemical or other research, the medicine still possessed the power of influencing the organism. No doubt he was encouraged to make those experiments by certain analogies that must have presented themselves to his mind, and particularly by the theoretical views he began at this time to entertain respecting the purely dynamic character of diseases; but these of themselves would hardly, one would think, have sufficed to make him drop so suddenly from grains to millionths of grains. Having however, from whatever cause, found that these infinitesimal quantities did act, and that more certainly and effectually than the grosser doses, he was not slow of adopting them, and he soon began to find reason for their superiority in medicinal power; and as we saw in my last lecture but one, he ascribes in this very essay great virtues to the process of succussion in the preparation of the dilutions, as a means of making the medicine present more points of contact to the living organism.
It was but natural to expect that practice so extra-ordinary and doses so minute should be strongly commented on by his allopathic colleagues. This was accordingly the case. Among others, Hahnemann’s friend Hufeland demanded a public reply to the objections formally made to this new posology. Hahnemann was not long in giving the reply (Lesser Writings, p. 443.) so imperatively called for; but I should be stating what is contrary to the fact if I said that this reply gives my satisfactory solution of the question that now interests us, viz., how it was that Hahnemann fell so suddenly, as it would seem, from palpable grain and scruple doses of medicines to ten-thousandths, hundred-thousandths, and millionths of a grain.
In the article I allude to as being the reply to the question of Hufeland, Hahnemann refers to the greater power of medicines in solution than in the hard dry state, to the more severe effects developed by giving the same quantity, in divided doses, to the greater susceptibility of the diseased organism for its medicinal stimulus, but he does not mention what it was that produced the violent and complete revolution in his own posological notions. We are, after all, then, only left to infer the reasons for this sudden change. These reasons I conceive to be as follows:-
1. An observation of the greater power of a medicine when given in solution than when taken in the dry state.
2. An observation of the greater power of a certain quantity of medicine when given in divided doses than all at once.
3. An observation of the greater susceptibility of the diseased organism for the medicine having a special or homoeopathic relation to the affected part or parts.
4. some still obscure notions with regard to the increase in power of a medicine by thorough admixture of it with a non- medicinal vehicle, by means of succussion-a foreshadowing of the dynamization-theory.
5. A desire to avoid aggravation of the disease by the larger doses; for he says, if any aggravations occur during the use of a small dose they will not last long, and are easily removable by some antidote.
6. A desire to evade the persecutions of the apothecaries, who had begun to institute legal proceedings against him for infringing on their privileges by dispensing his own medicaments.
That he was not successful in evading the penalty against the infraction of the apothecaries’ privileges by this maneuver, has sudden flight from Konigslutter to Hamburg and his fierce tirade against the apothecary system a few years later, in his Aesculapius in the Balance, (Lesser Writings, p. 492.) amply testify.
These considerations, and probably others of which we are ignorant, no doubt induced Hahnemann to diminish his doses with considerable rapidity; and finding that his medicines still acted, though removed beyond the reach of chemical analysis, he adopted such minute doses as his rule, whereby this advantage was obtained-that the dose was not sufficient to cause any disagreeable or dangerous effects, an advantage not attached to the large doses of the old school-that his enemies, the apothecaries, could not prove that the white powder he administered contained any medicinal substance whatever.
In the essay to which I have just referred, that, namely, where he replies to Hufeland’s question relative to the action of very minute of very minute doses, he gives us some rules for the selection of the appropriate dose for different diseases, which are worth recording.
“The nearer the disease approaches the acute character,” says he, “the smaller are the doses of the medicine it requires in order to disappear. Chronic diseases also, combined with debility and general derangement of the health, do not require larger ones. It is only in cases where, along with a local affection, the general health seems to be good, that we must proceed from the at first small doses to larger ones; to the very largest, however, in those cases where the medicine can only act in a palliative manner.” (Ibid., p. 446.)
The rules laid down at this period are, we see, as follows:-
1. In the most acute disease, and in chronic diseases combined with debility, in which the general derangement of the organism is obvious the smallest doses are to be given.
2. These smallest doses are equivalent, in the amount of medicinal substance they contain, to the 2nd and 3rd dilution of the ordinary or centesimal scale.
3. In what are called local diseases-those chronic diseases, to wit, where the morbid affection is localized and the general system does not seem to be much implicated-the doses must be gradually increased in strength.
4. It does not appear what Hahnemann understood by these stronger doses, but as he wrote for the ordinary practitioners in a journal of general medicine, I presume he meant by this expression such doses as were commonly in use.
5. It is evident that at this time he did not contemplate the exclusive treatment of diseases by means of specific or homoeopathic medicines, but that he admitted the propriety of the palliative or antipathic treatment in certain cases, and that for such treatment he considered the very largest doses used in ordinary practice to be necessary.
The next work of Hahnemann’s where the subject of the dose is touched upon is that remarkable essay, the forerunner of the Organon, entitled the Medicine of Experience. He there says: (Lesser Writings, p. 525.)
“A medicine of a positive and curative character may, without any fault on its part, do just the opposite of what is ought, if given in too large a dose; in that case it produces a greater disease than that already present.” He illustrates this by the various effects of different degrees of cold and of heat, applied on homoeopathic and antipathic principles.
Although he does not define in this essay that quantity he means by the small doses he speaks of, it is evident he implies doses of extreme minuteness, for he says the smallest possible dose suffices; and “as the sole condition for the full and helpful action of the remedy is that it should come in contact with the susceptible living fibre, it is of little or no importance how small the dose is.”
As as illustration of this, he says, that if a certain quantity of diluted tincture of opium will remove a certain array of morbid symptoms, the hundredth or thousandth part of that quantity suffices almost equally well, and the diminution may even be carried much farther without the medicine losing its effect. He now tells us that action of the medicine is almost spiritual, and therefore gives us to infer that no material portion of it is required. As he talks in this essay of giving opium in doses a million times less than those in ordinary use, it is probably that he meant by the smallest possible dose one not exceeding in minuteness what we now understand by the 3rd or 4th dilution. It is, however, not probable that he confined his doses to these very minute quantities; indeed, we shall presently find that ten years and more after this he gave medicine in appreciable quantities.