“A. The morbid state undergoes an alteration, or,–
“B. It undergoes no alteration.
“The alternation it undergoes is one of three kinds:
“1. The state alters for the better.
“2. It alters for the worse.
“3. The disease merely alters its totality of symptoms.”
In the first case, we have only to wait without giving any medicine, and see how long the amelioration will go on; and in such a case, however slow the progress made in the improvement, it would be imprudent to disturb it by administering a fresh dose. If, however, the amendment becomes stationary, then, if there be no contra-indication, no remedy is so appropriate to be given as the one that brought the improvement on so far, and it may safely be repeated not only once but often, every seven days, or every four days, or even every other day.
If in place of amelioration we observe aggravation of the morbid symptoms, we are thereby assured of the action of the remedy on the disease, and we either wait till the aggravation has subsided, or, if the symptoms of aggravation are too severe, we give an antidote, and the best antidote in most cases, says Aegidi, is a second dose of the medicine. After this improvement takes place, and when that becomes stationary we must either administer the medicine again (but this time in a smaller, more highly potentized dose), or we must give another medicine more suitable for the actual symptoms.
Where, from the administration of a medicine, the disease is not improved, and the symptoms it presents are only altered, this shows that the selection of the remedy was false, and we should then give a more accurately selected one as speedily as possible.
If after the first dose no alteration is perceptible for better or for worse, and still the selection of the remedy seems to have been accurate, we repeat the dose more or less frequently, according to the susceptibility of the patient, until either a homoeopathic aggravation ensues, whereafter the amendment will proceed vigorously, or until several symptoms peculiar to the remedy show themselves, which were not contained in the original morbid picture, and after which the state often begins to improve, or, if the contrary be the case, an indication is presented for another medicine. Aegidi says that attention to the directions just red will often give us the happiness of seeing chronic diseases cured in a much shorter time than they have hitherto been by the usual mode of treatment.
On a subsequent occasion, (Hyg., ii.201.) Dr. Aegidi advised not only the giving of stronger doses than was usual, but to repeat the remedy much oftener also; “by which continuous assault,” he says, “it is alone possible to effect a powerful and curative reaction, an event that seldom follows from the administration of a single dose.”
At a later period, (Allg.h.Ztg., 27, No. 9.) Aegidi stated that in some cases the repetition of the medicine was inappropriate, whilst in others it was by repetition alone that we could attain our object. The character of the case we had to treat must determine for us the propriety, or the reverse, of repetition. By cautious hesitation we could not lose much, but by a rude and frequent assault we might spoil everything.
Dr. Wolf a (Archiv, xi,1.45.) had already, before Aegidi, touched upon the subject of the repetition of the medicine, and alleged that where the reaction of the organism to the antipsoric medicine was defective, it might be advisable to repeat the dose in rapid succession. A year later, (Ibid., xii.2.) he treats of the subject of the repetition of the medicine at much greater length, and seeks to obtain some fixed rules upon the matter. He says, that a lengthened experience has convinced him that Hahnemann’s advice not to repeat the dose must not be followed in certain cases, for that some were evidently greatly benefited by a repetition; on the other hand, however, he warns against too rapid repetition, which he has often seen to be productive of harm. A consideration of the good effects of the drinking of mineral waters, of the success often attending the allopathic mercurial treatment of syphilis, of the cures effected by the use of certain vegetable extracts and infusions, of the beneficial results often attending the administration of the homoeopathic remedy in allopathic doses–and here he adduces two cases of amaurosis cured by the application of strychnia to a blistered surface, and asks if homoeopathists have ever obtained such good results–all these circumstances Wolf declares point to the necessity for the repetition of the dose in some cases. He admits, however, that we have not distinct rules to guide us in the repetition, because we are still ignorant of the medicines adapted to repetition, of the diseases to which this technicality is applicable, and of the criteria to guide us in fixing the proper periods for the repetition.
There are, he says, three principal methods in which the repetition of the dose may be effected.
1. The repetition of the specific remedy in the smallest dose, in very rapid or somewhat slower sequence, until we may consider that the system is brought under the influence of the medicine, or this influence has shown itself by the development of primary symptoms.
2. Repetition of the specific remedy in constant sequence and proportionally short intervals until amelioration is apparent, with or without distinct evidence of the influence of each dose.
3. Repetition of the specific medicine at long intervals, after one dose has effected amelioration of the state, and the amelioration has become stationary.
Dr. Wolf then gives a long list of medicines which, he says, he has found it useful to repeat, which I need not weary you by enumerating.
Dr. Hering of Philadelphia wrote an article upon the repetition of the remedy about the same time. (Archiv, xiii.3.) Hahnemann, as we have seen in the first edition of the Chronic Diseases, set his face against the repetition of the remedy in successive doses. Still, with respect to some medicines, such as causticum, natrum muriaticum, and sepia, he admitted that it was occasionally useful to repeat the remedy, interposing, however, some other remedies betwixt the two doses of the antipsoric. This Hering calls “repetition after other medicines.” When the repetition is made after only one interposed medicine, Dr. Hering calls this “repetition in alternation.”
He contends that repetition is useful when, on account of defective reaction, the medicines, must be given again and again; in very painful disease the interval that elapses betwixt the doses should not be great. Thus he is in the habit of repeating the dose every two, four, seven, eleven, sixteen days, until reaction or new symptoms supervene. Likewise when the homoeopathic aggravation is too strong he finds it advantageous to repeat the medicine, but in this case once only, and in many cases it is best to give the antidote; but he has often observed that the second dose of the remedy is its own best antidote. Another case for repetition is when the reaction is too short, in this case the second dose may be given the following day. Another case for repetition is when the curative action has commenced, continued, but again come to an end; this he terms renewal of the dose.
Dr. Hering’s paper on this subject is extremely interesting, and I regret time will not permit me to give a more extended analysis of it.
At the Homoeopathic Congress held at Leipzic, in 1832, (Ibid., xii.2.) several members discussed the subject of the repetition of the remedy. Dr. Gross mentioned several cases of cures with repeated doses of belladonna, mercurius, antimonium tart., sepia, etc. Dr. Kretschmar removed a spasmodic affection with repeated doses of causticum; and Dr. Rau stated as follows:-“The more I think of the subject, the less reason do I see for not repeating a medicine several successive times. It is well known, “he continues (though this is not the general knowledge on the subject, I fear), “that the more acute the case is the greater necessity have we to give only the higher potencies, but that the action of the remedies is transient in proportion to their dilution. The first dose, on account of its very transient character, only takes away a portion of the symptoms; the second and third, if they are still indicated, act still more favourably.”
In another place (Werth d. hom. Heilv., 169) Dr. Rau expresses the following conclusions with regard to the repetitions of medicines:-
“Repetitions are useful-
“1. In all diseases where the remedy administered has mitigated the violence of the symptoms, but caused no further change. The proper time for repeating is when the amelioration has come to an evident pause.
“2. In cases where a perfectly indicated medicine has, after the lapse of the time in which it ought to have displayed its action, remained without any action at all. In such cases several repetitions are often necessary, in order to rouse the prostrate power of reaction. Such cases are met with among both acute and chronic diseases, and particularly where there is a well-marked topical disease, either alone or in combination with more general morbid symptoms. Hence,” he continues, “in incarcerated hernias I give a dose of nux vomica every two hours, and also in violent inflammations of the lungs I repeat the medicine indicated every two or three hours until the anticipated reaction appears. In obstinate diseases of the vegetative system, e.g. syphilis and itch, atonic gout and dropsy, old skin diseases and products of irregular plastic action, where the object is to effect a retrograde action of the formative process, it will be difficult to effect anything without repetition of the medicine.
“Repetitions are hurtful–
“1. On the occurrence of homoeopathic aggravations, which, when they are too violent and dangerous, or at least cause us to feel uneasy, demand the administration of an antidote, or, at all events, should be allowed to pass off, in order to permit the curative reaction to come into play. After such aggravations have passed off, if the same remedy is still indicated, it should be given in a higher dilution, in order to avoid a repetition of the aggravation.
“2. On the occurrence of an alteration of the morbid picture, which must always be an indication for the employment of another medicine. Such a case is chiefly met with in hysteria and hypochondriasis, but also in many other diseases, especially when they are passing into other stage, where, on account of the alteration of their general character, the previous indications can no longer exist. In such cases the administration of the former medicine would certainly not be so injurious as during the continuance of a homoeopathic aggravation; but at the same time it would not be of the slightest use.”
Dr. Kampfer (Allg., h. Ztg., xx.) has considered the subject of the repetition of medicine at considerable length. Hahnemann, he alleges, has ascribed to all medicines a much longer duration of action than they actually possess. Kampfer considers that the size and the repetition of the dose stand in a certain relation to one another, which he seeks to ascertain. In acute diseases, or when the intervals betwixt the several doses are very considerable, we may, he says continue to give the medicine at equal intervals and in unaltered doses to the end of the disease, but such cases are not, he says, of frequent occurrence; the continued repetition demands an alteration in the intervals and in the size of the dose. The receptivity becomes deadened, and where, as in chronic diseases, it is necessary to continue the medicine for a long time, the repeated doses must be given stronger; the quicker the repetition the more rapidly susceptibility for the impression of the remedy blunted. It is very rare that the susceptibility is exalted by repetition of the dose, especially in the case of small doses, but that this happens in some cases, he brings forward examples to prove. But, he adds, there are plenty of patients whose irritability remains for years in the same degree, provided intervals are allowed to occur without their taking medicine. As the duration of the action of medicines is shorter in acute than in chronic diseases, repetition is more demanded by the former than the latter. He also admits that some medicines have a longer action than others. In acute diseases it is, he alleges, necessary to repeat the shorter-acting medicines every four hours, every two hours, every hour, every half-hour, or quarter hour, but the longer – acting medicines every two to twelve and even twenty-four hours. In such cases, after giving a few doses quickly, we may make a pause of some hours duration. In chronic diseases, the long- acting medicines should be given only every twenty-four hours, some times even seldomer; the short-acting ones require to be given often several times in the twenty-four hours: it is seldom requisite to give several doses of the longer-acting medicines in one day. Kampfer disapproves of waiting too long as much as of repeating too hurriedly. The degree of the amendment is his guide in general for the repetition. When the critical reactions are strong enough he advises to pause in the repetition, after they are past decided amendment will follow; but if such reactions require to be supported, we must give the medicine in the same or a still larger dose; in this case it appears that the doses latterly given act in an antidotal manner to those first administered, by which the critical reaction, i.e., the curative homoeopathic aggravation, was produced; if this aggravation has become too strong, it may often be subdued by smaller doses of the same remedy, and thus this curative action expedited, in this case there is also an antidotal relation. In the repetition of larger doses of medicine Kampfer recommends us to be very cautious, lest we should produce a medicinal disease.
Dr. Attomyr, (N. Archiv, i. 2.) as I mentioned in a former lecture, has treated of the subject of the repetition of the medicine along with that of the dose. As with the dose so with the repetition, he seeks to obtain rules for it from the provings of medicines on the healthy. It is not the sick-bed but the Materia Medica that must furnish us with rules for the repetition of the medicine. He starts with the following examples: a bottle of wine will intoxicate a man if he drinks it all at once, but he may drink four bottles of wine at twenty times without being a bit the worse for it. Of course, it is requisite that these twenty times should be at some distance from each other, for he would get drunk enough if he drank his twenty draughts in twenty minutes; but if he took twenty days to drink the twenty draughts, the wine would have no effect on him. In like manner, says Attomyr, the difference in the action of medicines is to a certain extent dependent on the intervals at which the successive doses are administered.
On this subject the provings of medicines teach us-
1. That two identical doses given in rapid succession mutually increase one another’s medicinal action.
2. Two identical doses given at long intervals repeat the medicinal action without increasing it.
3. If a small dose be given a short time after a large one it increase the action of the latter.
4. If a small dose be given a long time after a large one it neither increases nor repeats the action of the latter.
5. If a large dose be given shortly after a small one the action of the latter is thereby increased.
6. If a large dose be given a long time after a small one the action of the latter is thereby neither increased nor repeated.
From the repetition of the medicinal doses therefore only two different kinds of action are observed-1, increase, or 2, repetition of the medicinal action; the former by the renewal of the doses at short intervals, the latter by their renewal at long intervals. The Homoeopathic therapeutic principle can derive no service from the increase of the medicinal action; the repetition of the medicinal action at long intervals is the only kind of repetition which seems to be required by the present state of things, as far as practice is concerned. The repetition of the medicine is, he contends, not an improvement or perfectioning of the art, but a mere pis-aller shift, occasioned by defective knowledge of the active sphere of action of most medicines; by the innumerable complications of most diseases; by the frequent selection of the improper remedy; by the improper dose; by dietetic disturbances of the medicinal action, etc., etc.
The Materia Medica must be referred to, to ascertain what is a long, what a short interval. We have short and long-acting medicines. In all medicines some parts of their action come on quickly and last but a short time; others appear late and last longer. The duration of action varies from one hour to several weeks, or even months. In like manner, the morbific agencies produce at one time a shorter, at another a longer lasting disease, and the health-restoring agencies-the medicines- must, by the different duration of their actions, resemble this property of the diseases.
It would, he contends, be contrary to the principle of similarity to give slow-acting medicines and doses in rapid diseases, and equally opposed to this principle would it be to give slow and long-acting medicines at short intervals, and vice-versa. it betrays, he alleges, but a scanty acquaintance with Hahnemann’s doctrines to say that the smallness of the dose does not appertain to the essentials of homoeopathy, for the homoeopathic therapeutic principle is not capable of being carried into practice without both smallness of the doses and rarity of their administration. (This is going a little too far, as homoeopathic cures, it is admitted on all hands, were effected before Hahnemann or small doses were known.) The force of habit is a powerful enemy, continues Attomyr, to repetition, the organism becomes in time blunted even to the action of poisons. It was an experience of this that first led to the introduction of inter-current remedies. It has, Dr. Attomyr remarks, been stated that the size and the repetition of the dose are to be determined by the age, sex, temperament of the patient, the character and duration of the disease, and so forth. But all this appears to him erroneous. The repetition is determined by the size of the dose. As the action of large doses-so he says, contrary to the opinion of homoeopathists- lasts- but a short time, they may be repeated at short intervals. The 30th of aconite cannot be repeated every hour, even in an acute pneumonia, but the 3rd may: the treatment of this disease with large doses often repeated corresponds, he thinks, more to the homoeopathic principle than with high potencies at long intervals. I need hardly remark that in all this Attomyr, who is reputed Hahnemannist, is quite at variance with Hahnemann, who directs that the acutest diseases shall be treated with the 30th dilution repeated frequently, in some cases as often as every five minutes. Hahnemann also ascribed to the higher dilutions a more transitory action.
When, says Attomyr, we are about to prescribe for a patient, the first question is-What medicine according to the homoeopathic principle? the next-In what dose according to the homoeopathic principle? The answer to the second question determines the question of the repetition. If we determine for a larger dose, this involves the necessity of more frequent repetition, and vice versa.
Dr. Attomyr appears to me to be a framer of pretty hypothesis, which, however, like the houses that children build of cards, require but a very superficial inspection to convince us of their hollowness, and need no very vigorous assault to overthrow them completely.
Dr. Koch, in his work On Homoeopathy, (Die homoeopathie, 587. so often referred to in the course of these lectures, thus formulizes what he has to say respecting the repetition of the medicines.
1. The more similar the medicinal agent, the less requisite is its repetition. Repetitions in very small quantities is its repetition. Repetitions in very small quantities not only do no harm, but on the contrary, are essential to the certainty of the cure.
2. The less similar the medicine, the oftener must the dose be repeated.
3. The more extensive the morbid process, the oftener is the repetition of the medicine required.
4. The more acute the morbid process, the more frequent must be the repetition; the more chronic the morbid process the more rare must be the repetition.
5.The more similar the medicine, the more hurtful is the repetition of large doses.
Dr. Griesselich (Handbuch, 258.) subjects the recorded opinions of Hahnemann and his followers upon the repetition of the medicines, to a searching criticism distinguished by his usual sarcastic and genial talent. He says it is impossible to give fixed rules to give rules for the repetition of the dose for all cases; the characteristics of each case must be well considered, and must be our guide upon the subject. It is, says he, absurd to speak of the duration of the action of a medicine, we can only speak properly of the duration of the action of a dose; to say that arsenic, for example, acts for thirty or forty days is incorrect; we might just as well say it acts for ten minutes or for five years. In cases of cholera, arsenic may be given every ten minutes and still action of the former dose be explained before the next is given, whereas a slow arsenical poisoning may last for years. There is, he says an incontrovertible rule for the repetition, and that is this: the dose of the properly selected remedy should not be repeated as long as a beneficial action is observed to continue from its administration. The repetition of the medicine, he says, is a real and important improvement in the method of administering it. The object of repetition is to retain the diseased organism in the state necessary to allow it to effect the cure. The repetition of the medicine renders its impression more lasting. The repetition of the medicine often repairs the error of a too feeble dose, it frequently effects what might have been accomplished by a first, more appropriate and more powerful dose.