THE REPETITION OF THE DOSE Part 2 By C W Butler

THE

Medical Advance

A Homoeopathic Magazine

Vol. XXXI          CHICAGO, March, 1894.            No. 3

*SYMPOSIUM OF HOMOEOPATHIC PRESCRIBING

THE REPETITION OF THE DOSE

CLARENCE WILLARD BUTLER, MONTCLAIR, N.J.

Edited By: Dr. Ravinder S. Mann

Part 2

(For Part 1 Click Here)

When the second prescription is a lower potency than that at first employed, or where it is necessary for any reason to again use the original potency, the remedy should be put in water and frequently repeated until effects are not obtained (Rule V).  By frequent repetition of doses I mean, even in chronic cases a dose every hour or two and continued several days if need be.

The patient must be seen at frequent intervals that any produced effect may be detected in its first manifestation and severe aggravations from cumulative action be thus avoided. Although this involves some trouble to a Physician and some expense to the patient it is imperative and the results will amply justify the means. As soon as drug action becomes evident the first business of the Physician is to determine the character of that action (Rule VI).

At times, after a prescription, symptoms peculiar to the drug exhibited will presently appear.

If these are accompanied y neither aggravation nor amelioration of the original conditions it shows that the drug was not Homoeopathic to the case. The effect is always disastrous because it grafts a new (drug) disease upon that which already obtains – is in fact a drug proving and a new and especially careful prescription becomes immediately imperative. The Therapeutist meets few conditions as complicated or as difficult to prescribe fore as this one.

Thus we see that a drug may influence the sick organism in that manner peculiar to itself and without essential modification of the morbid conditions present. But it may also exhibit evidences of a certain amount of influence over the disease present although not enough to establish directly curative action. In other words there are various degrees of the homoeopathicity of drug disease to natural disease. Now the ideal homoeopathic remedy, the similimum, in its curative action proceeds along the same lines as the disease which it annihilates, but conversely. But one less accurately chosen but still similar, while it may not be capable of effecting that immediate and direct cure confidently expected from the similmum, may and frequently does effect a change of the disease type. By disease type I mean that association of symptoms and conditions present through which the Physician recognizes the nature, trend and tendencies of the sickness. All disease being, in respect of the organism diseased, salutary – an effort of the vital energy to remove from it noxious influences, the manner in which it moves toward this end and the channels of elimination or method of annihilation would be presumably those which least seriously disturb the general system. I say presumably because within the animal economy as outside it, the direction of kinetic energy is toward the point of least resistance, and a minimum of resistance insures a minimum of those perturbations which are its direct consequence.

If now for any reason disease has assumed certain type, that accidental influences may serve to change, that type is a fact too well known to demand amplification at this time. Among the most potent factors in effecting such change are drugs, and were illustrations necessary the whole history of suppressant and revulsive treatment might be cited in evidence.

And as drugs this improperly administered may effect unfavorable change of disease type, so too, one may be given which from its partial homoeopathicity to the disease may effect a favorable change of type although it is not sufficiently similar to complete a cure.

Now is such case although the change is a favorable one, the conditions less severe and dangerous, the fact remains that the progress toward health is not such as is observed when the remedy has been accurately chosen – it is a diversion of the vital energy, happily to better avenues of activity, but not to that distinctive action which marks the homoeopathic cure, viz; the gradual disappearance of the symptoms in the reverses order of their appearance.

Indeed a new disease now presents itself i.e. a new complex of symptoms, differing in kind as well as degree from those other and for this reason demanding in kind as well as degree from those other and for this reason demanding a prescription homoeopathic to the status presens (Rule VIII). That unaided nature is usually equal to the cure of this new and milder disease is no excuse for inactivity on the part of the Physician.

All milder types of sickness will usually be cured by the vital energy without remedial aid, but the remedy is needed if the cure is to be made with a “minimum of discomfort, suffering and danger” to the patient.

I have dwelt with perhaps undue length on this subject because I am convinced that much time is lost and much suffering entailed from lack of wise discrimination as to the character of drug action manifest, - indirect aid too often mistaken for that direct curative action which characterizes the ideal homoeopathic cure, and by consequence, the immediate interference most useful in the one case, gives place to the “masterly inactivity” which is the only safe course in the other.

Neither time nor space, now serve for the discussion of the question of palliative treatment. Without argument or elaboration of the theme, I make here the bold statement that the Homoeopathic remedy is the truest, the safest, and most effectual palliative. 

This is in accord with the testimony of the greatest prescribers of our school of medicine, and, incidentally, with my own experience. Assuming the truth of this statement I proceed to the discussion of Rule IX.

Where the remedy is simply palliative in its action, evidence of its efficacy will be the same as curative action (q. v. Rule X). Now if these evidences of drug action are unmistakably present, despite which definite prognostic signs indicate that the sickness is making certain and undoubted progress toward an ultimately fatal termination, it proves conclusively that the disease is incurable by any mode of treatment.

The utmost that can be hoped for then is a reduction of the patient’s sufferings in the greatest possible degree, and in the safest and best possible manner.

Since this is most surely accomplished by the drug selected under the Homoeopathic law and since the evidence is plain that in the case postulated, this drug has been administered and has directed the vital energy to the most favorable lines of action, it follows logically, as it has been proven many times experimentally, that the best possible is already doing.   

Palliation being the utmost of your expectation, and this being already in evidence, any meddlesome interference not only will complicate conditions even now sufficiently serious, but will, too, deprive the patient of the only benefits which may be hoped for from medical aid.

As we have seen when discussing Rule VIII, remedial action may be direct or indirect – and this determined by the degree of homoeopathicity of the selected drug to the natural disease for which it is prescribed.

If indirect action is established its effect is to change the disease type, carrying the patient so to speak, a little way toward recovery and paving the way for another prescription.

No inconsiderable number of our cases are thus, to use the late Dr. C. Hering’s graphic expression, “zig-zagged” back to health. When however, there obtains close similarity between the drug action and the disease action the influence of the former will be directly curative and no change of type will follow, no new tissues will be invaded, no new lines of action be established, but gradually and in regular order will the signs of the sickness all disappear. This is the ideal cure for which every Homoeopathist strives. The first sign of this direct curative action will be either an amelioration or an aggravation of the patient’s symptoms. If it be amelioration steady and progressive, the exact object desired has been attained; the remedy proven to be homoeopathic, and the potency appropriate.

If on the other hand aggravation follows, then, too, is the drug proved to be homoeopathic but the power employed is inappropriate. I say inappropriate – not necessarily too strong.

A crowbar is not too strong to do the work of a cambric needle, but it is quite inappropriate. It will occasionally occur that aggravations thus super-induced will be so prolonged, severe and even dangerous that antidotal treatment will become necessary. In such case another similar remedy, in a potency different from the one already employed, will be found the most effectual antidote.

The inhibition of the aggravation by antidotal treatment may leave the case materially modified in original conditions and no further present interference be necessary, or the case may present itself considerably changed and a new prescription be demanded – a direct curative action having been converted into an indirect.

Care must always be exercised not to mistake complications from drug proving for aggravations from undue remedial action. The onset of symptoms belonging to the drug employed and the appearance of conditions in no way related to the natural course of the disease under treatment, will mark the former; simple exacerbation of conditions already present, the latter.

Aggravation from the Homoeopathic remedy, wisely handled in respect to repetition, are, however, usually transitory and quickly followed by material and satisfactory amelioration.

Amelioration of the disease conditions either direct or indirect because of intervening aggravations, is at once the beginning and unmistakable evidence of the establishment of curative action. If now the only effect which the remedy can have is the promotion of this curative vital motion, and this it has already done, it is obvious that further medication is superfluous, as has already been said.

But not only is it obvious that further medication is superfluous, but it is equally obvious that such medication may be obstructive even to the point of danger, for undoubtedly some new form of motion must be thereby introduced to complicate and modify that already established – to change exactly the action which is most desired at all. Accordingly it is most strenuously insisted (Rule X) that, when curative action is manifest, no interference is permissible so long as this continues.

This rule, as old as Homoeopathy, and appealing in the strongest manner to reason, would be easily followed if disease in its progression or in its retrogression was steadily uniform in its movement.

But unfortunately this is seldom, perhaps never, the case. Periods of improvement will be followed by sharp and distressing aggravations and conversely, periods of seemingly marked retrograde movement will precede most undoubted and satisfactory betterment of all conditions. These “wave like” movements in disease action must be allowed for, and it often becomes a very nice question whether certain changes are those temporary fluctuations which may be expected, or whether they indicate radical loss. To a correct solution of the question must be brought the prescriber’s calmest judgment and most conscientious care, for his action, which this will determine is of gravest importance.

If it becomes evident that curative action has ceased, reexamination will determine whether a change of remedy, of potency, or a repetition of the dose is next needed; if however, it proves to be one of those “wave like” motion of disease – a temporary exacerbation, no change or repetition is indicated. Wait patiently and confidently for reaction and when this comes it will certainly carry your patient to a much higher physical plane, and that rapidly and pleasantly.

It will be especially helpful in making this decision if it is borne always in mind that the patient not the disease, is under treatment. If on the whole your patient is better – especially in the Psychological sphere, even though his disease in its nosological classification is unimproved, you may confidently class the present condition as among the temporary aggravations incidental to all cases. Again as improvement progresses there will frequently appear certain symptoms not present or not remembered as present before, and appeal forcibly to your mind as marked indication for the use of another remedy. If however, the disease type remains unchanged, these should be ignored, at least in so far as they may influence interference on your part. The patient is getting well and no meddlesome medication will hurry nature who moves always according to fixed laws, intolerant of interference and unforgiving of mistakes.

Rule XI is but the expression of an obvious necessity and requires neither explanation nor amplification.

THE REPETITION OF THE DOSE Part 1 - By C W Butler

Published in 

THE

Medical Advance

A Homoeopathic Magazine

Vol. XXXI          CHICAGO, March, 1894.            No. 3

*SYMPOSIUM OF HOMOEOPATHIC PRESCRIBING

THE REPETITION OF THE DOSE

CLARENCE WILLARD BUTLER, MONTCLAIR, N.J.

Edited By: Dr. Ravindra S. Mann

Part 1
(For Part 2 Click Here) 

In the discussion of any scientific question a definite and certain terminology is of prime importance.  

It is probable that more energy has been wasted in profitless polemics from lack of precision and clearness in statement of the premises assumed than because of radical differences in opinion. It is well therefore that I should at the outset make plain my understanding of the terms used in the statement of the subject assigned to me. By a “dose” of medicine I understand any portion of a drug given for therapeutic purposes at a single imbibition; by repetition of doses I understand one or more additional portions of the same drug administered at practically appreciable intervals of time.

If, for example, a physician desires to administer three-eighths of a grain of morphine, and elects to give one-eighth of a grain every fifteen minutes until the whole quantity has been taken, I should say that he had given three doses of morphine of one-eighth grain each, and has repeated the doses every fifteen minutes; and this although the analgesic or hypnotic effect desired in this particular case might have been obtained, or even expected, only from the physiological effect of the total quantity  -  three eighth of a grain.

If a Homoeopathist puts one-half a grain of the third trituration of a drug into six spoonfuls of water and gives one spoonful every hour until all has been taken, I should consider each spoonful of the solution a dose, and would report this case of having received six doses of medicine at hourly intervals of repetition.

I have been thus particular to make my meaning in the use of these terms clear and unmistakable since there has arisen among certain physicians in recent years a fashion of speaking of the “divided dose” as if the total amount of the drug administered was the dose in each particular case. Now that medicines are given in different forms and at stated intervals, in portions smaller than the supposed remedial limit, evidences the fact that different effects are expected by the Therapeutist from these different methods of administration.

That this expectation had sound basis in general experience may be conceded I think, without argument.

This being true it follows inevitably that some result is expected from each portion given, however minute that portion may be, and for each such portion, for purposes of record and of communication, a definite name is surely required. We must therefore either coin a new one or accept that already recognized. But change in scientific terminology is only justified where the term in use involves ambiguity in expression, or implies an unscientific concept. In the case in question, despite the double meaning and inexact use in which it has been at times employed, the term “dose” does not seem open to either of these objections. I protest therefore against the change and modification of its meaning which the term “divided dose” interjects, because its inevitable effect must be ambiguity and confusion, where exactness and lucidity are imperative; and because it can serve so far as I can perceive no useful purpose.

Whether or not, with the present accumulation of facts any generalization may be made sufficiently wide to deserve recognition as a law for the repetition of the dose it is certain that no such generalization has been made and the question remains one of individual experience.

The opinions expressed, the theories advanced and the suggestions made in this paper, are then, of necessity personal, and for any and all of them the writer alone is responsible. By this statement it is not to be understood that originality is claimed not that any new thing may be expected. The paper is intended to be a practical, not an historical one, and while I gladly acknowledge my indebtedness in respect of the theories held and the practice advocated herein to many writers upon the subject from the time of Hahnemann to the present, any attempt to give due credit to particular individuals would necessitate a prolixity wholly inconsistent with its avowed purpose.

The methods is practice advocated will be first presented in the form of arbitrary rules and such remark or explanation as may seem necessary; together with the theories germane to the subject entertained by the writer, will follow. I desire first of all, however, to state with emphasis that these rules are based not upon the theories which will be presented, but upon many years watchful experience, --- are those relied upon daily in my professional work and for them I bespeak faithful and unprejudiced trial by all earnest practitioners of Homoeopathy.

RULES

I.                   Let the first prescription in each case be a single dose.

II.                Let the single dose of any remedy be given in its dry form.

III.             If no effect is produced by the single dose and the conditions remain the same, the remedy should be repeated.

IV.           When repeating the remedy if a higher potency be employed, a single dose of the new potency should be given dry.

V.              If a lower or the same potency be given, when repeating the remedy, these should be exhibited in a watery solution and the dose frequently repeated.

VI.           When drug action becomes manifest stop all medication and determine at once the character of the action. It will either be curative; or palliative; or it will change the disease type; or produce characteristic symptoms of the drug (a physiologico – pathological proving).

VII.        If a drug proving, i.e. the appearance of specific drug conditions, be in evidence, a new prescription will be called for.

VIII.     If the type of the disease is changed by the medication then too, a new prescription will be needed.

IX.            If the action be palliative, repetition of dose, or remedy (or change of drug or potency) is contra-indicated so long as the patient’s sufferings are thus mitigated.

X.               If the action be curative, under no circumstances may the dose be repeated (nor may remedy or potency be changed) as long as this action continues.

XI.            In all cases before repeating the dose, a re-examination equal in care with that required for any other prescription must always be made.

In stating his theories in respect of his subject and of matters more or less intimately connected therewith, the writer must of necessity encroach somewhat upon fields allotted to other contributors to this symposium. No injustice can be done them however, if it be borne in mind that, as has already been stated, the opinions here presented are his own and for them he alone is responsible. Stated as briefly as possible they are these.

The organized living body always endeavors to free itself from noxious influences. Whether such influences be “matter” or “motion” their elimination or annihilation is accomplished unaided, with much perturbation of the system, and in the animal economy with many discomforts and sufferings which are manifest to the skilled observer through recognizable signs (symptoms). From the practical standpoint the complex of these symptoms (signs) is the disease. The business of the Physician is to aid the system in its endeavors toward the elimination or annihilation of this sick making power with a minimum of discomfort, suffering and danger. This he accomplished in his office of Hygienist, or Sanatarian, by removing the aetiological factor when that is known, which is seldom the case; in his office as Therapeutist he attains the same end by the use of drugs. In the present state of human knowledge the appropriate drug may only be determined by the homeopathic law of selection. Such a drug, one homoeopathic to the case in hand, is curative and appropriately termed a remedy. The expression “homoeopathic remedy” is tautological; there is no other. The use of this term is justified however, by the frequent occurrence of the word “remedy” in all medical literature and indeed it may hardly be discared for the present.

That a drug homoeopathic to the case, does cure the patient by removing the cause and the disease is a fact abundantly proven; how it does this is not known.

Without striving to solve this problem we may safely assert that the drug itself is only indirectly the curative agent. The potent and only direct curative power is within the animal economy, and is its vital energy – that is, that portion of the universal energy appropriated by and acting through the organism at the time. As in the locomotive engine it is the steam which furnishes the motive power, not the lever, the proper adjustment of which admits the heated vapor to those appointed channels in the machine where its energy may be expanded in performing the desired work; as in an electrical apparatus it is the electricity which is effectual to the desired end, not the “switch” which directs the current, so in this wondrously complex machine, the living organism, the remedy is a factor in the cure only as it frees the vital energy and directs its only office, it is obvious that when this is accomplished further medication is superfluous.

All that the remedy can affect it has effected. Now experience teaches us that this effect may usually be had from a single dose of the appropriate drug.

Hence the first rule “Let the first prescription in each case be a single dose.” At two or three different times I have instituted series of experiments with the use of the single dose given in a watery solution, but they have been speedily abandoned, partly possibly, because favorable experience with the dry dose has prejudiced me in its favor, but mostly I think, because I saw nothing gained by this method and at times thought I marked distinct loss. I am free to confess however, that these experiments were never sufficiently exhaustive to form a reliable basis for a fixed rule of practice. But my experience with the method advocated has been so favorable that I have advised that (Rule II) the single dose of any remedy be given in its dry form.

I have said that curative action may usually be inaugurated by the single dose of the indicated remedy, and it is probable that this would be effected in all cases if in every instance we could choose exactly the remedy and the potency. So difficult is it to choose with certainty the most similar remedy even with the guidance of the unerring law of homoeopathy; so difficult is it to select the more appropriate potency since so little is known of the nice relations which should obtain between the drug energy and the vital energy, and no known law is here applicable. This ideal perfection of choice is often impossible to human and fallible judgment. Probably for these reasons, certainly for some reason, in a not inconsiderable number of cases the single dose will be followed by no appreciable modification of the conditions prescribed for. Under such circumstances and when the always imperative re-examination reveals the same conditions still present and by consequence the same drug called for, the remedy must be again exhibited. Rule III.

But this may not be done in any case until after a period of observation sufficiently long to leave no reasonable doubt of the failure of the former prescription. Unfortunately no rule, even approximate, can be given as to the proper period of observation, i.e. the time which one should await evidences of drug action. It is, and will probably always remain, a question of personal judgment in each individual case.

The nature and severity of the sickness, the constitution and temperament of the patient, the known promptitude in action of the remedy employed, are all factors which will enable the prescriber to form that basis or reasonable expectation upon which his action must depend. Acute suffering or imminent danger may call for frequent repetition, while in cases of long standing, especially such as depend upon or are modified by the deep-seated dyscrasia, (“Chronic miasms”), remedial action may only appear after days or weeks have elapsed, and the temptation to repeat the remedy or the dose must be religiously guarded against.

In cases of doubt always remember that the vis a tergo is toward the “fatal error” of rash precipitancy and in no case allow the judgment to be clouded by the restlessness of the patient, the insistence of his friends, nor your own anxiety. In therapeutics it is preeminently true that most wisely do “They also serve who also stand and wait.”

If, however, repetition of the remedy becomes necessary it may only be done in a higher, a lower or the same potency. The fact that the remedy in the form and strength of its original administration was impotent indicates that it should be repeated either in another power of the drug, or another method of exhibition.

If now the drug potency be changed, and this I earnestly recommend as the course usually most efficacious, that change should be marked and material. If your former prescription has been a very high potency, not only should you now give a lower, but a very much lower one; if a low or medium potency was first used, not only should you now use a higher, but a very much higher one – a change from a CM  to a 100 or vice versa.

Where it is practicable to make this marked change from a lower to higher potency, let this be done and a single dose dry, be given. (Rule IV). It will hardly be denied by the Therapeutist of experience that repetition of doses in these high powers too frequently induces troublesome aggravations or more troublesome complications in the way of drug symptoms and conditions.

Of these complications something further will be found in the discussion of Rule VII. 

Part 2