Hahnemann’s first allusion to it-His first case of aggravation owing to an over-dose-he first taught that it was necessary to the cure-Afterwards that it was only an occasional occurrence-And that it depend on the size of the dose-Duration of aggravation in acute and in chronic diseases-False aggravation by the production of medicinal symptoms- Always indicative of unsuitableness on the part of the medicine-Very slight medicinal symptoms of no importance-Hahnemann’s examples of true aggravation from a too powerful dose-The drosera aggravation examined-Cures with large doses mentioned by Hahnemann without aggravation-Schron denies the reality of the homoeopathic aggravation-Rummel considers it exceptional-Kurtz confounds the true and the false aggravation- Gross considers the quality of the aggravation dependent on the size of the dose-Schmid asserts that it only occurs with too small doses-Kampfer’s critical and non-critical aggravation- Hirschel’s four kinds of aggravation-None of these resemble Hahnemann’s Trinks says true and false aggravations are independent of dose-Schneider says Hahnemann’s aggravation is a phantom, but admits five kinds-Romano’s rule for distinguishing betwixt the homoeopathic aggravation and the natural increase of the disease-Rau’s peculiar aggravation-Griesselich admits and denies the homoeopathic aggravation-Arnold’s definition of it-Is it a reality?-Foundation for the belief in it-Writers have generally confounded the false with the true-General conclusions on the subject- Classes of practitioner who talk most of aggravations-Necessity for examining critically all Hahnemann’s doctrines-A desirable aggravation-Cutaneous diseases.
INTIMATELY connected with Hahnemann’s theory of the mode of action of the homoeopathic medicine is his doctrine of the homoeopathic aggravation, as it is termed, a doctrine that has been very much misunderstood by many of his followers, by whom it has been misstated, and often represented as a terrific bugbear, frightening the timid practitioner and the credulous patient with imaginary dangers and disasters.
This homoeopathic aggravation has played such a great part in the drama of the new medical reform, that it would be unpardonable in me to pass it over cursorily; and I feel it incumbent on me to enter into a thorough examination of the whole subject, whereby we shall see whether, like other phantoms, it does not lose all its terrors when thoroughly examined and exposed to the light.
The first hint we meet with in Hahnemann’s works respecting anything of the kind is in his first Essay on a New Principle. (Lesser Writings, p. 313.)
“If,” say he, “in a case of chronic disease a medicine be given, whose primary action corresponds to the disease, the indirect secondary action is sometimes exactly the state of body sought to be brought about; but sometimes (especially when a wrong dos has been given) there occurs in the secondary action a derangement for some, hours seldom days. Thus a somewhat too large dose of henbane is apt to cause, in its secondary action, great fearfulness” etc.
This, however, it will be observed, does not correspond to his later notions respecting the homoeopathic aggravation, as we shall presently see, but is merely as though he had said when the dose is too strong the remedial agent produces some derangement of the system, over and above its effect upon the disease,’ which, of course, is sufficiently plain and obvious.
In the next page of the essay I have just quoted from he gives the first instance of the actual occurrence of an aggravation. The case was that of a pregnant woman who, in order to cure cramp in her leg, took five drops of the volatile oil of chamomile, whereby the cramp was vastly increased, and a number of other symptoms peculiar to the drug occurred.
But the first very distinct and decided case mentioned by Hahnemann of a real homoeopathic aggravation, followed by a well- marked curative effect, and resulting distinctly from an over- dose, was published by him in the following year, 1797. The case was one which he denominates colicodynia, or spasmodic colic of excessive severity, which had already been treated by himself and others with all imaginable drugs and systems of medication. At length the similarity of the effects of veratrum album on the healthy induced him to try this medicine. He accordingly gave the patient four powders, each containing four grains of veratrum, with orders to take one powder every day. In place of doing so, however, the patient took two powders a day, and when he had finished the whole sixteen grains he was seized with such a dreadful attack of his colic that he seemed almost at the point of death. However, after this he was not again troubled with his complaint; he was perfectly cured of all his morbid symptoms.
It has been stated that this case taught Hahnemann the expediency of at once diminishing the dose to the infinitesimal point; but Hahnemann was not at this period capable of jumping so rapidly to a conclusion from a single observation, and accordingly we find that in the cases published by him for several years after this occurrence the doses of medicine he gave were by no means so small, far less infinitesimal. Several grains of arnica root, two or three grains of ignatia, a third of a grain of opium, fifteen to twenty grains of camphor, six or seven grains of ledum, a drachm and a half of cinchona bark, in the course of the twenty-four hours, which we find him giving ordinarily in 1798, are full doses according to the notions of the old school. Not till three years later do we find him recommending anything like infinitesimals; but even then the homoeopathic aggravation is not yet taught as a doctrine, but merely incidentally alluded to and confounded with the aggravation arising from an improperly-selected medicine. We must turn to the Medicine of Experience, that precursor of the Organon, for a distinct allegation respecting the homoeopathic aggravation and the part it plays in the curative process. We shall there find the following statement:-
“If we have not only selected the right remedy but have also hit upon the proper dose, the remedy causes within the first few hours after the first dose has been taken a kind of slight aggravation, which the patient imagines to be an increase of his disease, but which is nothing more than the primary symptoms of the medicine, which are somewhat superior in intensity to the disease, and which ought to resemble the original malady so closely as to deceive the patient himself in the first hour, until the recovery that ensues after a few hours teaches him his mistake.”(Lesser Writings, pp. 518, 519.)
This is the inevitable corollary from the Hippocratic axiom, or the stronger vanquishes the weaker, which I have shown that Hahnemann adopted for the explanation of the homoeopathic cure; for the stronger power–the medicine–must exhibit its superior strength in the act of superseding the disease, and hence the apparent increases of the disease, which, however, we are told is only apparent, for this increase is medicinal not morbid action.
Immediately after this Hahnemann tells us that if, notwithstanding the administration of the perfectly-adapted remedy, no aggravation occurs, then the dose has been too small, and we shall require to give one or several more doses to make it superior to the disease.
In this same essay he warns against confounding the aggravation just described with the so-called aggravation by the production of new symptoms peculiar to the medicine given. The following are his words:-
“Every aggravation (as it is called) of a disease that occurs during the use of a medicine, in the form of new symptoms, not hitherto proper to the disease, is owing solely to the medicine employed; these symptoms are always the effect of the medicine. An aggravation of the disease by new, violent symptoms during the first few doses of the medicine is never indicative of feebleness of the dose, but it proves the total unfitness and worthlessness of the medicine in this case of disease. (Lesser Writings, pp. 538-9.)
This doctrine of the homoeopathic aggravation was somewhat softened down by Hahnemann afterwards. It was not represented by him as so invariable and necessary a concomitant of the remedial effect of the homoeopathic medicine. I shall now read what he says upon the subject in the last edition of his Organon:-
“But though it is certain that a homoeopathically-selected remedy does, by reason of its appropriateness and the minuteness of the dose, gently remove and annihilate the acute disease analogous to it, without giving expression to its other, unhomoeopathic, symptoms, that is to say, without the production of new, serious disturbances, yet it usually, immediately after ingestion–for the first hour, or for a few hours-causes a kind of slight aggravation (where the dose has been somewhat too large, however, for a considerable number of hours), which has so much resemblance to the original disease, that it seems to the patient to be an aggravation of his disease. But it is, in reality, nothing more than an extremely similar medicinal disease, somewhat exceeding in strength the original affection.
“This slight homoeopathic aggravation during the first hours-a very good prognostication that the acute disease will most probably yield to the first dose-is quite as it ought to be, as the medicinal disease must naturally be somewhat stronger than the malady to be cured, if it is to overpower and extinguish the latter, just as a natural disease can remove and annihilate another one similar to it, only where it is stronger than the letter.
“The smaller the dose of the homoeopathic remedy is, so much the slighter and shorter is this apparent increase of the disease during the first hours.”
“But as the dose of a homoeopathic remedy can scarcely ever be made so small as that it shall not be able to relieve, overpower, indeed completely cure and annihilate, the pure natural disease of not very long standing that is analogous to it, we can understand why a dose of an appropriate homoeopathic medicine, not the very smallest possible, does always, during the first hour after its ingestion, produce a perceptible homoeopathic aggravation of this kind.
“When I here limit the so-called homoeopathic aggravation, or rather the primary action of the homoeopathic medicine that seems to increase in some degree the symptoms of the original disease, to the first or few first hours, this is certainly true with respect to diseases of a more acute character and of recent origin; but where medicines of long action have to combat a malady of considerable or of very long standing, where, consequently, one dose must continue to act for many days, we then see, during the first six, eight or ten days, occasionally some acute primary actions of the medicine; some such apparent increase of the symptoms of the original disease (lasting for one or several hours) makes its appearance, whilst in the intervening hours amelioration of the whole malady is perceptible. After the lapse of these few days, the amelioration resulting from such primary action of the medicine proceeds almost uninterruptedly for several days longer. (Organon, Aphorism clvii-clxi.)
But his opinion respecting the other or false sort of aggravation he expresses with even greater force in the Organon than in his previous essays. I shall now read what he there says on that point:-
“Every medicine prescribed for a case of disease, which, in the course of its action, produces new and troublesome symptoms not appertaining to the disease to be cured, is not capable of effecting real improvement, and cannot be considered as homoeopathically selected; it must therefore either, if the aggravation be considerable, be first neutralized in part as soon as possible by an antidote, before giving the next remedy chosen from a more accurate similarity of action; or if the troublesome symptoms be not very violent, the next remedy must be given immediately, in order to take the place of the ill-selected one.” (Organon, aphorism ccxlix).
And he adds more emphatically in a note:-
“Every aggravation by the production of new symptoms-when nothing untoward has occurred in the mental or physical regimen- invariably proves unsuitableness on the part of the medicine formerly given in the case of disease before us, but never indicates that the dose has been too weak.”
We are, it would seem from the following passage, not even to take the patient’s word for any improvement, if the pathogenetic effects of the remedy given show themselves:-
“If the patient mentions the occurrence of some fresh accidents and symptoms of importance-signs that the medicine has not been homoeopathically chosen-even though he should good-naturally assure us that he feels better, we must not believe this assurance, but regard his state as worse than it was, as it will soon be perfectly apparent it is.”(Ibid., Aphorism cclvi.)
Unless the medicinal symptoms are serious or numerous however, they are not to be regarded as always indicative of an erroneous selection, for he says, in another place:-
“There is almost no homoeopathic medicinal substance, be it ever so suitably chosen, that, especially if it be given in an insufficiently minute dose, will not produce, in very irritable and sensitive patients, at least one trifling unusual disturbance, some slight new symptom, whilst its action lasts, for it is next to impossible that medicine and disease should cover one another as exactly as two triangles with equal sides and equal angles. But this (in a good case) unimportant difference will be easily done away with by the power of action (energy) of the living organism, and is not perceptible to patients not extremely delicate; the restoration goes forwards, notwithstanding, to the goal of perfect recovery, if it be not prevented by the action of heterogeneous medicinal influences upon the patient, by errors of regimen or by passions. (Organon, Aphorism clvi).
From these passages it is perfectly obvious what Hahnemann understands by the homoeopathic aggravation, and what he does not mean by that term. The true homoeopathic aggravation is, according to him, an increase of the actual symptoms of the disease shortly after the administrations of the medicine, and the cause of it is the dose of the medicine being too powerful. It is an inconvenient and unnecessary accompaniment of the curative action, and is to be got rid of by diminishing sufficiently the size of the dose.
The first distinct instance of this homoeopathic aggravation Hahnemann gives us is, as I before stated in the case of the individual affected with colicodynia, (Lesser Writings, p.353.) and the violent increase of the disease was evidently caused by the enormous doses of veratrum swallowed. The next occasion on which we find him giving examples of this homoeopathic aggravation is in the Organon, (Organon, 238, note.) where he states, on the authority of Leroy, that viola tricolor given for the crusta lactea of infants primarily increases the eruption before it cures it; and, on the authority of Lysons, that the skin diseases cured by elm-bark are primarily aggravated by it; and he asserts that in both these instances the apparent aggravation was owing to the medicine being given in too large doses, and that had it been given in smaller doses no such aggravation would have been observed.
The next example of homoeopathic aggravation we meet with in his writings is to be found in his essay On the Power of Small Doses. (Lesser Writings, p.823.) The aggravation in this case is stated to result not from a too large dose-in as far as quantity is concerned-but from a too powerful dose, the excessive power being communicated to it by a too prolonged succussion. He states, for example, that a drop of drosera, in the 30th dilution, each successive dilution having been prepared with twenty succussions, would endanger the life of a child affected with whooping-cough, owing to the enormous aggravation it would cause, whereas the same dilution prepared with only two shakes for each dilution, would only effect a mild cure. This case, though stated as if it had actually occurred, is, as I have elsewhere, shown, (Lesser Writings, p.823.) a purely hypothetical one, and we have no evidence to show that there is any probability that it would occur, so that we may safely pass it over. The only other instance I can meet with in Hahnemann’s works, which is anything like a homoeopathic aggravation, did not occur from the employment of an excessively large, but of an unusually small dose of the medicine. It is the case of an epileptic lady, to whom he gave a drop of the 90th dilution of sulphur, and within one hour after its ingestion an epileptic fit occurred. (Ibid., p.857) I know not whether this would be considered by him as an example of aggravation, but it is probable it would, and if so, it is one occasioned by a much smaller in place of a much larger dose than usual.
On the other hand, among all the examples he cites from the works of allopathic authors of the administration of medicines on the homoeopathic principle with good effect, there is no evidence that the dose, which was in every case enormous when compared with those he himself advised, produced the slightest aggravation.
Again, in his own practice, we find instances where he gave considerable doses without the production of any aggravation.
In the first Essay on a New Therapeutic Principled (Ibid., p.349) a case of spasmodic asthma with head symptoms of a grave character is related, where a gradual cure without aggravation was effected by means of three grains of veratrum album, given every morning for four weeks. In the same essay another case is related of puerperal mania and convulsions, where the patient was cured by means of several half-grain doses of veratrum, which seemed to produce no aggravation of the disease, though a few of the pathogenetic effects of the drug were observed. In the essay On the Obstacles to Certainty and Simplicity in Practical Medicine,(Ibid., p.386) a case of spasmodic asthma is detailed, where four grains of nux vomica, exhibited twice daily for some time, removed the complaint gradually, but perceptibly and permanently, without any aggravation.
In Hahnemann’s two essays, On Continued and Remittent Fevers, and On Hebdomadal Complaints, the remedies administered, most of them in full doses according to old-school notions, cured the diseases for which they were employed, without the production of any aggravation.
Again, in the essay upon Scarlet Fever, (Lesser Writings, p.425) no aggravation is stated as having followed the administration of the various remedies employed.
Passing over the intermediate period, let us turn to the history of those two cases he first published about 1817, and which he republished in 1833, as good specimens of homoeopathic cures. The first case (Ibid., p.864) is one of gastralgia, which was treated with a drop of the pure juice of bryonia, a dose which certainly ought to have caused a violent aggravation, if aggravation was a necessary consequence of an unnecessarily large dose, which Hahnemann tells us in a note this was; but no aggravation whatsoever occurred. The other case (Ibid., p.866) was an attack of dyspepsia, cured by half a drop of the 12th dilution of pulsatilla, likewise far too large a dose according to Hahnemann’s later views, but no aggravation ensued, only a rapid and effectual cure.
Only two more cases of affections treated by Hahnemann are no record, these I have given in the collected edition of his Lesser Writings, (Ibid., p.869) and though the diseases in these two cases got better and worse several times, yet Hahnemann does not attribute this alternation, nor is it in fact attributable, to anything like the so-called homoeopathic aggravation, but it is perfectly evident that it is due to the natural course of the disease, and is what we observe every day in chronic affections treated by any method whatsoever.
Thus we perceive that, notwithstanding the decided manner in which Hahnemann speaks of the occurrence of the homoeopathic aggravation, and the readiness with which he attributes its occurrences to the unnecessary largeness of the dose, we have no evidence from the cases treated by himself that it ever occurs from a moderately large or an immoderately small dose; and the only case in which it did unequivocally occur among all those cases he has recorded, it happened as the consequence of a very immoderately large dose, such a dose indeed as would have been amply sufficient to develop the same or similar symptoms in a healthy individual.
The question we have to resolve then is this:-Is or is not the homoeopathic aggravation, such as Hahnemann depicts it a reality? And to assist us to answer this question, I shall pass in review what has been written about it by homoeopathic authors.
Schron,(Naturheilprocesse, ii.177) than whom none has brought a greater power of what we may call sceptical criticism to bear upon homoeopathy, denies in to to Hahnemann’s views regarding the homoeopathic aggravation, which he hesitates not to term an “unfortunate dogma;” and ascribes the idea to an insufficient acquaintance with the natural history of diseases on the part of those especially who have magnified the homoeopathic aggravation into a terrible bug-bear.
Rummel,(Allg. h. Ztg., ix.No.3;xxxi.No.19) while he admits the occasional occurrence of the homoeopathic aggravation, considers it as the exception not the rule, and that what is called by that name is frequently only the natural course of the disease. Kurtz (Hygea, v.134) believes that the occurrence of homoeopathic aggravations is impossible if the remedy were perfectly homoeopathic, but that they might occur if the remedy were not well chosen, or if it were given in too strong or too weak doses; but he evidently confounds the homoeopathic aggravation with the natural crisis of the disease, and with the pathogenetic effects that frequently result from the medicine administered.