In chronic diseases, when we are sure our selection has been correct, if within a certain period, to be determined by the urgency of the symptoms, no amendment is perceptible, we should repeat the medicine; but if the amendment is going on, we may advantageously leave the patient without medicine for days, and even for weeks; and give him unmedicated powders in the meantime. As a rule, the intervals between the doses may be longer in chronic diseases, and shorter in acute. In the latter, too frequent repetition is not so apt to do harm; whereas, by waiting too long, we may do positive injury, for to lose time in such cases is to lose everything. Change of dose is very requisite even in acute diseases.
In acute diseases the periods of exacerbation must be our guide for the repetition of the medicine: thus in dysentery, vomiting, and cholera, we should repeat the dose after every evacuation; in colic, intermitting faceache, toothache, and such-like pains, the dose should be repeated at every attack; and if the dose acts no longer, we should change the dose, which is a better plan than changing the medicine. A medicine may be its own antidote, as many observation show. Hence, in many cases the success of a well-chosen of a well-chosen remedy may be destroyed by too frequent repetition.
Dr. Trinks, who was one of the first to insist on the necessity of repeating the medicine in both acute and chronic diseases, at a time when such advice was considered by the Hahnemannic purists little better than high treason, considers the subject of the repetition of medicines again at length in his Materia Medica. He says, if after one dose of a medicine the symptoms become altered in their character, the same medicine must not be repeated; but if the symptoms are merely altered in degree, this is an indication for repeating the medicine, and it should be repeated as long as it exercises a beneficial influence on the disease. It is, then only the alteration and diminution in degree of the violence of the symptoms that, according to Trinks, can give a rational empirical indication for the repetition of the same medicine in a disease. Dr. Trinks says, that as no one dose of a medicine, even of powerful action, is capable of producing all its effects on the organism, so one dose is never sufficient to eradicate a deeply -rooted disease, albeit a superficial slight affection, even though it may have lasted some considerable time, will often yield to one dose. The rule Trinks gives for the period of the repetition is, that a second dose should not be given until the improvement effected by the first becomes stationary; and this rule, he says applies to acute as well as chronic diseases. The more the safely of the organism is threatened by the disease, the more rapid should be our repetition of the medicine; in the acutest forms of disease we shall have to give the medicine every four, three, or two hours, or one, half, or quarter of an hour, or even every ten or five minutes; and continue to give it in this way until the danger to life is past. In chronic diseases, he says, we shall much oftener have occasion to repeat the same medicine than in acute, for the changes in the latter are usually so rapid as to demand a change of remedy. In chronic diseases we should continue to repeat the medicine that we are certain is indicated, until either an alteration is effected or we are convinced that no improvement will follow its continuance. In these diseases it is not necessary to give the medicine oftener than every twelve, twenty- four, forty-eight, or seventy-two hours; for in them the medicines act more slowly than in acute diseases, and the frequency of the repetition must also be determined by the nature of the medicine, in regard to its being one of longer or shorter action.
The transient exaltation of the symptoms, often produced by too large and too often repeated doses of the medicine, may often be allayed by giving repeated smaller doses of the same medicine, and per contra the exaltation produced by small doses may be subdued by larger ones. In chronic diseases the susceptibility of the organism is often blunted by giving very frequently repeated doses of the same medicine, but occasionally the reverse happens, and the susceptibility is increased by repeated doses. In the former case we must give stronger doses, in the latter we must descend to smaller and still smaller doses.
Dr. Arnold, in his recent work on homoeopathy, (Idiop. Heilv., 325) gives the following maxims as the deductions from his observations on the subject of the repetition of the remedy:- 1. The smaller the dose is, so much the sooner is an other necessary. This, however, is only true, he says, with respect to a certain strength of dose. Very massive doses are often soon expelled from the organism in consequence of the irritation they produce, and hence their action may be very transient.
2. The shorter the duration of action of a medicine is, the more rapid must be its repetition; the longer its action, the slower must its repetition be. The duration of action of a medicine is very various in different individuals and in different diseases. It is shorter in persons of lively nature, longer in those of a torpid nature; it may run its course in a few hours in acute diseases, while it may last days in chronic maladies.
3. The duration of the action of a medicine is different in the same person in health and in disease. It is generally shorter in the diseased than in the healthy body. The more rapid the course of the disease is, the more frequent must the repetition be, and vice versa. In acute diseases the dose must be repeated till crises appear; in chronic affections, until symptoms of reaction occur.
4. When anything occurs to disturb or stop the action of the medicine administered, the more frequent repetition of the medicine will be demanded. The more strict the diet, the more rarely is it requisite to repeat the medicine, and vice versa. It is a good plan to give two or three strong doses of a remedy and then a dose of its antidote, in cases of deeply-rooted diseases and little excitability of the organism.
There are many others whom I might have cited as having written with more or less learning on the subject of the repetition of medicines, but I believe I have, in what I have read to you, detailed the principal opinions that have been broached on the subject; and it would be a useless waste of your time to give you the details of those recorded opinions of other homoeopathists of less note, which would be mostly mere repetitions of what you have already heard. I shall therefore bring this lecture to a conclusion by making a few observations on the subject of the repetition of the dose; a question, only second (if second) in importance to that of the selection of the dose itself.
It is evident to my mind that Hahnemann was influenced entirely by the theoretical notions he had adopted relative to the supposed curative action of the homoeopathic agent, in the advice he at one time gave to administer one, and only one, dose of the medicine. His theory was, as you are aware, that the disease yielded to the medicine in virtue of the medicinal disease being the stronger of the two; and further, such was his opinion of the enormous superiority of the medicinal disease in point of strength, that he held that the medicine could not possibly be given in so small a dose as that it should not possibly be given in so small a dose as that it should not be more powerful than the natural disease. Holding these views, it is evident that he must consider more than one dose as not only superfluous but injurious, as apt to disturb the operations of the medicinal disease already set up by the first dose. His direction not to give another dose before the action of the first is expended, which was the next modification of his teaching on the subject of the repetition, was also founded in error, or at least led to an almost impracticable practice, owing to his belief in the absolute duration of the action of the various medicines. It is certainly possible that a dose of calcarea will in some cases act for forty or sixty days, or even longer; but we can readily conceive cases where its action will not last longer than as many hours, or even minutes. Hahnemann did not at first take into consideration that the duration of the action of a medicine was entirely relative and conditional; and here again we find the great individualizer of disease dealing in the most extensive generalizations, in defiance of his own injunctions to individualize all cases of disease. As well might it be said that each medicine could only cure a disease of a certain duration. The repetition of the medicine cannot therefore be said to be determinable by the supposed duration of the action of the remedy. Hahnemann, indeed, practically abandoned this notion in his later years and prescribed the repetition of the medicine, irrespective of its supposed duration of action. The standard he then fixed was one of a very arbitrary character The duration and intensity of the disease was to be our guide. It seems to have been some practical acquaintance with that most fearful and intense of diseases, cholera, that first led him to break through his former rule; for the whole duration of the disease, from its invasion to its termination by death or recovery, often did not amount to one-tenth part of the supposed duration of the action of the medicine; accordingly, the medicine was to be prescribed in some cases as often as every five minutes.
It seems to me that no rule for determining the repetition of the medicine can be deduced, either from the supposed duration of the medicine’s action, or from the intensity of the disease, or from the so-called potency of the medicinal preparation as some have proposed. I believe, it will ultimately be found that the repetition of the dose will be determinable by the periods of exacerbation of the disease. In chronic diseases, I believe, if we attend to their manifestations, we shall observe a certain amount of periodicity in them all. Some, for example, have regular periods of exacerbation and intermission; others there are which still exhibit exacerbations or intermissions, but these are of an irregular character. Others, again, though not presenting any complete intermissions, will be found to offer at least remissions, corresponding it may be to different periods of the day, of the week, or even of the lunar month. I think our repetition of the medicine in chronic diseases should be in a manner regulated by this periodicity of the disease. In regularly intermitting diseases we should give our medicine at some fixed period, anterior to, during, or subsequent to the fit, whichever experience shall determine to be the most appropriate time. When the fits of disease are irregular, as for instance, in many cases of neuralgia, the medicine should be given during the attack. When there are merely remissions and aggravations at certain periods of the day, as is the case in most chronic diseases, our remedy should be given at some time having a stated relation to the period of the exacerbation, to be determined likewise by experience. In acute diseases, the frequency of our repetition of the dose must be determined by the rapidity of the disease, or by the danger attending it, or by the irregular exacerbations that occur in it; thus it is a good plan in diarrhoea to repeat the medicine after every evacuation; in whooping-cough to give a dose after every fit, and so forth. (Similar ideas respecting the repetition of the medicine are expressed in a paper by Dr. Scott, which I have perused in manuscript while these sheets were going through the press. As this lecture was first delivered nearly two these sheets were going through the press. As this lecture was first delivered nearly two years ago, the views expressed in it similar to those entertained by Dr. Scott were not suggested to me by his essay; in fact, I have merely followed up the hints given by Griesselich (v. antea, p. 467)). By this plan, as regards both the chronic and acute diseases, we shall make the action of the medicine bear a certain relation to the disease, not only in point of homoeopathic character, but also as regards the periods of the development of the medicinal influence.
I cannot see how the dose of the medicine can influence us in regard to its repetition, although this has been adduced by some homoeopathists as a determining motive. Thus Attomyr states that the smaller the dose the rarer must be its repetition; whereas, as the object of repetition is only to supply the deficiency of power in the original dose, we should naturally be induced to draw an exactly opposite conclusion from that given by Attomyr. and rather say with Arnold, the smaller the dose the weaker it must be, and the more occasion, must there be for eking out this want of power by frequent repetition. True, practically, we almost all act upon Attomyr’s rule, and we generally repeat the smallest doses more rarely than the largest, but the reason of this is not that given by Attomyr, but this-viz., that we usually prescribe the smallest doses in the most chronic diseases, where frequent repetition is inapplicable for other reasons, and we give the larger doses in acute diseases, and by repetition increase the power of the medicine. Thus we observe that Hahnemann, who had a uniform dose for all diseases, did not hesitate to prescribe the 30th dilution as often as every quarter of an hour in very acute diseases.
The object we have in view by the repetition of the medicine, viz., the increase of its power, could not in most cases, though it might in some, be gained by giving a much larger dose at once, for I have shown that, with regard to most medicines, the effects of a larger dose are totally different from those of a small one; the former giving rise to the irritant or chemical effects of the medicine, the latter acting specifically, and as it is this specific action alone we wish to increase in the treatment of diseases, we can only effect it by repeating the medicinal dose with more or less frequency.
A great deal of needless fear prevails among some homoeopathic practitioners with respect to destroying the effect of the first dose by repeating the remedy. This fear was undoubtedly first raised by Hahnemann himself, who spoke strongly of the bad effects that must inevitably result if the medicine were repeated before it had exhausted its action; but though by advice and practice he subsequently recommended a very frequent repetition of the medicine, some of his disciples have proved more Hahnemannian than Hahnemann himself, and have continued, long after his disavowal, to maintain the injuriousness of repeating the medicine within ten, twenty, thirty, or sixty days. The most notable of these repetition-dreaders is Boenninghausen, who years, after Hahnemann’s adoption of the frequent repetitions of medicine, and in the face of two cases which he details from Hahnemann’s practice, where repetitions were practised, refers back to Hahnemann’s injunctions against repetition as being the ne plus ultra of the Hahnemannian system of treatment. (N. Archiv, i. 1, 95 et seq.) If the medicine be given once a day, in the majority of chronic diseases, I believe no accidents will occur that can be traceable to too frequent repetition, and I further believe that by this plan the good service that it is in the power of the remedy to render will be sooner effected, than if we give the dose less frequently. In acute diseases, I have never yet met with any disagreeable effects from giving the remedy at the exacerbation-periods previously alluded to, and though we do undoubtedly find that our medicine sometimes acts too violently, the amount of it given, more than the frequency of its repetition, will be found to be at fault.