***AFTER studying a chronic case and after deciding on the remedy, having given each symptom its proper evaluation, and having administered the *simillimum, we expect some action, some response. After the patient shows the desired reaction, there may and probably will come a time when the physician is called upon to meet a symptom picture once more. This is the time when he must consider the second prescription.
Strictly speaking, the first prescription is the prescription that first reacts. A physician may make a mistake and not select a remedy that is similar, consequently with no reaction. Thus while we;may seem to be looking for a second prescription, we are in reality looking for a first prescription to which the patient will react. In other words, the prescription must be considered as the *simillimum. Unless the patient reacts to the administration of a remedy and it has produced an effect, it is not a true prescription, for it is quite evident that it is not the *simillimum. It is really bungling.
The second prescription may be a repetition of the first. On the other hand, the reaction may have been such that an antidote is required; or the first remedy having taken care of a part of the symptoms, a complement of the first prescription may be demanded. In order to meet the situation intelligently, after the remedy has reacted, the case must be thoroughly restudied.
In general, if the first prescription has had a beneficial reaction, that remedy should be allowed to complete its work to the fullest extent. In such conditions, the second prescription would be a repetition of the first; and since a remedy should not be changed without very good reasons, it is probable that the remedy may be repeated at the necessary intervals through a whole range of potencies, securing the full amount of good from each potency before passing on to the next.
The reaction to the correct prescription is that the striking features, the peculiar features, the concomitant symptoms on which the choice of the remedy was based, are the first symptoms to be removed; thus the guiding symptoms of the case have been obliterated. The picture has been almost erased, and only the trivial symptoms are left. Now if the remedy is repeated at this stage, the cycle of cure is broken; for the guiding symptoms will surely return only when the action of the remedy is exhausted. If there is no interference with the action of the remedy, the indications which give us the clue to our next step will present themselves. One of the hardest things for a physician to do is to keep his hands off a this stage. If the remedy is administered at this stage we will find an intermingling of drug symptoms, so that no intelligent prescription can be made.
If the first prescription has not acted curatively, or it has not been permitted to act to its fullest extent, it is impossible to get second observations; but suppose that the first prescription was correct, and that it has been given plenty of time to act without interference:-
If the case has come to a standstill or if the first prescription has caused changes in the symptomatology that remain, that do not vary greatly for some little time, it is time to go over the case again with the second prescription in mind. While these changes are going on, no orderly symptoms can be gathered and no rational observations made. If we have given time for the proper reaction and the fuller development of the case, having allowed the natural period of rest, the time has come to make a minute observation upon the return of the original symptoms, which should be our first consideration.
They may not return as strong or marked as they appeared before the first prescription, but we must look carefully for the return of the original symptoms. It is while the action of the remedy is going on that the vital principle is re-established in the economy; and while this process is going on we will not find the return of the original symptoms. The length of time varies in different individuals and in different remedies; it may be a few weeks and it may be months.
Now what are we to do at this time? Without symptoms we cannot prescribe intelligently. Symptoms are the only guide to the remedy. The duty of the physician is plainly marked: to await the return of the symptom picture. In chronic conditions we may be quite sure that the symptoms will return, for it is very rarely that we can cure a case with one prescription. When the symptoms return, they may be changed as to their intensity; sometimes they return in a less intense form and sometimes they are increased in intensity. The fact that the first prescription was correct. In this case there is very little that we need in the way of information beyond this, because we know that the remedy was right and the patient can be cured. In this case the remedy must be a repetition of the first prescription.
Another class of cases we must consider are those that present a number of new symptoms which appear to take the place of the old symptoms. The old symptoms do not return, but are replaced by an entirely different symptom group. In these conditions we must restudy the case entirely in the pathogenesis of the remedy we have already given, and find if the new symptoms that have appeared are in the pathogenesis of the remedy. If this is so, we may find that this condition comes from a partial proving of the remedy, or we may find that these appear from a different cause. This is an important point. We must determine from the patient whether he has ever had any of these symptoms before in any former sickness or under any other conditions. We must go over these points carefully to see if we cannot elicit from the patient the history of these symptoms. Sometimes we get these relationships from the patient and sometimes from the family.
If these are old symptoms, we not only chose our first prescription correctly but it has eliminated the newest symptoms and uncovered an older layer, in the proper order of cure; but if we can get no history of the patient having had these symptoms before, and if they are not in the pathogenesis of the remedy, we have made a mistake in the first prescription, and it has changed the direction of the disease. Here, if it is possible, we must antidote the remedy.
After having given the antidotal remedy and a little time for the patient to rest, we should study the case again from the beginning; and the second remedy should correspond more particularly to the new symptoms than to the old, but both the present symptoms and the former symptoms must be considered. If we do our work carefully, this second prescription will cause the new symptoms to disappear and it will probably remove the old symptoms as well.
We may have to repeat the process several times before we really overcome the difficulty, but each time that it is done makes the next step more difficult and we must proceed with increasing caution after having made the mistake.
After the first prescription has been made sometimes the patient will come to a standstill. The symptoms have changed in an orderly way; new symptoms have come up; but finally the symptoms have all retired in the reverse order to a former state and are hardly of sufficient importance to be considered. The patient will acknowledge that the troublesome symptoms have disappeared, and that he has little in the way of symptoms to report, but he does not feel well; there is no general sense of well-being, yet he can scarcely tell you why and where he does not feel well.
In such states we should wait until we are quite sure the remedy has ceased to act. There are remedies that have a “do nothing” stage in their unfolding, and we must be sure, before repeating the remedy, that the first prescription has entirely run out its cycle. If we have found a “do nothing” stage, it may be put a part of the remedy cycle; if so, the remedy is still acting and to repeat the remedy at this time could do no good and might do harm. In other words, this “do nothing” stage is an expression of the pathogenesis of the remedy as manifesting itself in the curative process, and by a a little more patient waiting the patient will be ready for the next prescription. In these “do nothing” states no other remedy can fill in, because there are no strong indications for another remedy and the symptomatology has not altered to any marked degree except by lessening in intensity, and since there has been little change and no marked new symptoms have arisen, we have no guides for another remedy.
Then we must consider when to change the remedy for the second prescription. Besides the condition we have already spoken if, where new symptoms have appeared and there is an entire change, if the marked symptoms have disappeared and a new group of symptoms have appeared, with no relation to the former history of the patient, a new remedy must be considered.
Suppose in a chronic case these constitutional symptoms have been correctly met, and have gone through a range of potencies form the lowest up to the highest, and that they have all acted curatively, and the case has come to a standstill. After repeating the remedy we get no reaction. This constitutional remedy should be allowed to continue its curative action as long as it can be maintained and even if the symptoms have changed somewhat do not change the remedy as long as the patient shows improvement; but on the other hand, if the patient is not improving and there has been a change in the symptoms we can safely retake the case for the consideration of another remedy. We must make sure, however, that these symptoms are different from those the patient felt earlier, or have not been covered up by later developments, for a patient tends to become accustomed to certain symptoms and almost forgets that he has had them. If asked about them, he often replies that “they are nothing; he has always had them”, but these may be an important part of the symptomatology and we may elicit the fact that these are just a return of old symptoms that have not been previously noticed or reported. On the other hand, it may be that we have really had all the action we can expect from the remedy that has been administered, and it is time to consider another remedy, since the first one has carried the patient as far as possible. A safe rule for procedure is: ***WHEN IN DOUBT, WAIT. In other words, never leave a constitutional remedy, that has proven *simillimum for a considerable period, until you have extracted from it all the benefit that the remedy can contribute. Then, and only then, are you justified in changing the remedy.
It is quite possible that in making a second prescription we may find the *simillimum to be complementary to the first. This is particularly well illustrated in the sickness of child life. There are often repeated tendencies for colds. The patient seems to be getting colds all the while, and a remedy like *Belladonna may seem to be indicated and will cure the acute condition promptly. We may do this two or three times before we realize that these recurrences are an acute exacerbation of a chronic condition, and while *Belladonna acts promptly and effectively, it is only because it is a complementary remedy to the underlying chronic *Calcarea state. *Pulsatilla may be as effective in acute manifestations while the constitutional condition calls for *Silica. It is so with many remedies.
Then we may find constitutional conditions that require, for a complete cure, a succession of remedies, one remedy following another to good advantage. This may be a process of zigzagging a case to a cure because of lack of knowledge of our remedies or because the case does not unfold before us when we first consider
There is another possible reason for the successful succession of remedies. The first prescription may remove all the symptoms of one miasmatic condition, when suddenly a condition will arise which shows a basic condition of one of the other miasms. One miasm may have been submerged under another, and after the first has been removed by the *simillimum, the second shows, and the plan of attack must be changed to include as weapons another group of stigmatic remedies. We cannot expect to eradicate any stigma with a single dose of any remedy, but we may so improve the manifestations that the underlying condition may show itself, perhaps later to return to the first miasm again.
In these chronic conditions, no prescription, either first or second, can be made without careful, thorough study of the case and the sequence of symptoms. It is only by working out the case with the repertories that we are able to see clearly the indicated constitutional remedy in the light of the symptoms that have been cured or relieved. It is only then that we can administer another remedy intelligently and with confidence.