Hahnemann advises us to base the selection of the remedy upon the totality of the symptoms presented by the patient, as they are the outwardly reflected image of the internal and invisible disease, and the only means by which we can truly apprehend this internal distunement of the bodily forees.
I do not at this point propose to go into the observations and arguments that led Hahnemann to advise that the choice of the remedy should depend almost entirely upon the symptoms, to the practical exclusion of pathology. If these symptoms are to be our guides, what do we include in this terms?Every deviation from perfect health experienced by the patient, or observed by others, including all disturbances of functions and sensations, all alterations in the external appearance of the patient, and also all probable causative conditions. As a rule, in acute disease there is little difficulty in determining the totality of the symptoms, for the deviation form health is usually sharp and well defined. As an acute, supervening disease never forms a complex with a chronic one - the latter being suppressed until the former has run its course - care must be taken when ascertaining the symptoms of the acute disease to exclude from consideration the symptoms of the now latent chronic disease. According to Kent, at times some symptoms of the chronic disease may persist, and be active during the acute disease. Such symptoms are peculiar, because they have not disappeared, and are often guiding in the choice of the remedy for the acute disease. But when we come to deal with chronic diseases the matter is more complicated, for we have to take into account not only the now present symptoms, which often show only a very partial picture of the disease, but must also include many former symptoms that are now active; for even in those patients that have suffered for very long periods, and from many apparently diverse troubles, there always is method and order running through all their illnesses if only we can find the clue. While, theoretically, we should consider all the symptoms experienced by the patient since his birth, excluding those due to acute disease, yet the task is a very difficult one both for patient and physician, and we can only make very cautious use of these bygone symptoms. Even if we could trust to the accuracy of the memory of our patient, or his friends, these old symptoms can only be used with the greatest care, for so many of them may have arisen from faulty environment, the abuse of drugs, or the acquisition of some other miasm, that they would not truly indicate the course and progress of the disease. This is also very often the case when no such question of old bygone symptoms is involved, and those who are guided in the selection of their remedies mainly by the symptoms are in special danger of overlooking such causes, and have to be perpetually on guard lest they fall into the error of ascribing to disease what is really due to other causes.
Dunham, in "The Science of Therapeutics," gives many instances where such mistakes have been made, and only a wide knowledge of drugs, of the habits of the people, and the special conditions under which many occupations are carried on, will enable us to avoid these errors. Such, for example, was the case of a young lady who, for a very considerable time, presented a perfect picture of the classical symptoms of sulphur, and upon whom that remedy, in all potencies, to say nothing of other remedies, failed to produce the slightest effect. It was finally discovered that she was in the habit of suing sulphur to cleanse her teeth, and upon this being stopped the symptoms at once ceased. Or, the case of a maker of crucibles for casting steel ingots, who had suffered for seven years with all the symptoms of graphites gastralgia, and for whom that remedy did no good, until it dawned upon me that I had somewhere read that plumbago was now being used for making these moulds.
When we have excluded all symptoms due to such causes, there is the vast number remaining which can only be ascribed to disease proper, and it is with these in particular I wish to deal to-night.
Theretically, we endeavour to find a remedy whose symptoms correspond exactly - both as regards character and intensity - to those experienced by the patient. This can rarely, if ever, be done, and in chronic cases, at any rate, we have, as a rule, to make a selection from amongst the mass of symptoms, and to base the selection of the remedy mainly upon these. If it were necessary always to select a remedy that corresponded perfectly to every one of the symptoms, our already vast materia medica would be utterly inadequate, and we should require at least 10.000 more fully proven drugs. Who would care to undertake the task of searching for a similimum in such a labyrinth?It is quite bad enough as matters are at present, but we must think of our remedies as complex tools, capable of doing many very different pieces of work, which to the uninitiated would seem to require many diversely shaped ones. Who have made finer cures than the old masters in homoeopathy, with their very limited number of fully proven remedies?But they knew each one through and through, in a way that few of us do nowadays, and in their hands a comparatively few medicines were in the majority of cases sufficient for all their work. It was because they were able to comprehend not only the spirit of each remedy, but also those symptoms that characterized the patient. Following in their footsteps, we must also endeavour to learn to grade the symptoms according to their respective values, and not to act as mere symptom-coverers - an opprobrious name that has at times been only too well deserved.
In every case of disease there are always two classes of symptoms: first, those that pertain to the disease, that is, the common or pathognomonic ones; and, second, those that pertain to the patient; and in all advanced cases a third class that pertains to the ultimates or results of disease. To attempt to select the remedy in accordance with the first and last of these alone is simply to court failure in the majority of cases, for so many remedies will be found to correspond more or less closely to the first, at any rate, that, unless we have some other means of individualizing, we shall be quite unable - except by good luck - to select the correct remedy. Still less can we hope to find a sure basis if we depend upon the pathological condition, for very few drugs have had their provings pushed forward enough to elicit such effects, and consequently we would have to depend mainly upon such cases of accidental poisonings as happened to be available.
Dunham, writing upon this subject, points out that the drugs varying according to the size of the dose may produce three sets of symptoms, viz.: (1) The chemical; (2) the mechanical or revolutionary, consisting chiefly in violent efforts on the part of the organism to eject from its cavities the offending substance; and (3) the dynamic, contingent on the vitality, or resulting from the relation of the peculiar properties of the drug to the susceptibility of the living healthy organism.
He still further subdivides the dynamic ones into the generic - or those common to all members of a certain class of drugs. As an example of this, arsenic in certain doses produces vomiting, diarrhoea, cold perspiration, cramps in the limbs; but cuprum, veratrum, antimonium tartaricum, which belong to the same group, produce identical symptoms.
The second section of the dynamic symptoms are the specific ones, or those that are peculiar to one remedy and severe to distinguish it from its relatives.
In the vast majority of poisonings little else is produced than the first two classes - viz., the chemical and mechanical - and the symptoms obtained therefrom are of little value in the great majority of cases we are called upon to treat; but our main reliance must ever be placed upon the symptoms that signify the patient, and Hahnemann directs that we should be particularly and almost exclusively attentive to those symptoms that are peculiar or characteristic of the patient, and not to those that are common to the disease. Kent, after many years' experience, states that he regards this advice of Hahnemann's to be the strongest thing that the master ever wrote.
In acute disease there is not much difficulty, as a rule, in recognizing the symptoms that are peculiar to the patient, for the symptoms usually appear in an ordinary manner, and the common or pathognomonic ones are well known; but when we come to deal with chronic diseases our difficulties are greatly increased, for they are often so complex in nature that it is not always easy to separate the symptoms that are peculiar to the patient from those that are common to the disease. In many old-standing chronic cases, especially those that have been long under allopathic treatment, these peculiar and characteristic symptoms have at times so completely disappeared - or have been so utterly forgotten - that our difficulties are greatly increased; nay, it is even the case at times that the characteristic symptoms may never have existed, except in the patient's ancestors, and under these circumstances cure is practically impossible. It is as if, during the exploration of some old city, a coin was discovered which, if we could determine the year of the king during whose reign it was issued, we would be in a position to fix an important date. If the coin were well preserved, any skilled numismatist would promptly furnish us with all the information we desired; but if it were greatly worn or eroded, while he might from the shape or composition of the metal be able to determine the dynasty under which it had been issued, it would be utterly out of his power to state the individual king, to say nothing of the year of his reign.
In this connection let us take a few examples of the symptoms that are peculiar to the patient as distinguished from those that are common to the disease.
The common or pathognomonic symptoms of dysentery are bloody, mucous stools, pain, and tenesmus. From these alone we can determine the group of remedies that corresponds in general to this disease, and in J.B. Bell's classical monograph on this subject over fifty remedies are mentioned; yet from these alone it would be impossible to discover the individual remedy for the case under treatment. If, however, the patient has much thirst, and every time he drinks he shivers, and each drink is followed by a loose stool, then these symptoms, being unusual in the disease, would consequently be peculiar to the patient and guiding to capsicum as the remedy.
Dyspnoea, oedema, and palpitation of the heart, albuminuria, are the common symptoms of many kidney troubles, and from them alone we cannot determine the curative remedy; but if we find in addition there is a strong craving for fat, intensely strong-smelling urine, and a sensation as if the urine were cold when passed, then these would be peculiar to the patient, and point to nitric acid as the remedy.
Or let us turn to characteristic modalities. In a case of spasmodic asthma an aggravation from lying down is so common as to be valueless in the individualizing of the remedy; but if we find there is great relief from lying down, as in psorinum, or from assuming the knee-elbow position, as in medorrhinum, then -these being peculiar and characteristic - will be invaluable.
In hysteria we have an illustration of the danger of prescribing for the symptoms that are common to the disease, and hence not peculiar to the patient. It seems the most natural thing to gather up all the incongruous and peculiar symptoms that characterize this disease, and to prescribe for them; but when we realize that this incongruity is the very essence of the disease - in other words, is pathognomonic of it - we then perceive that we have been prescribing for the symptoms that represent the disease and not for those that characterize the patient. In such cases the true guides to cure, if discoverable, are to be found in the changes of desire, the aversions, the loves and the hates, and these are particularly difficult to find, for the hysterical patient conceals her real hates and loves and relates what is not true.
In the foregoing, stress has been laid on the supreme importance of paying the greatest attention to the symptoms that are peculiar to the patient, but it would be foolish to ignore the symptoms that signify the disease. They must indeed be taken into consideration, but subsequent to, and of much less value than, those that are predicated of the patient. In a very large number of cases no one remedy corresponds to all the peculiar symptoms, but three or four seem to have equal numbers of them, and of approximately the same value. In such a state of affairs the remedy that has also the common symptoms best marked must prevail. It must ever be kept in mind that there must be a general correspondence between all the symptoms of the patient and those of the remedy, and that however helpful the peculiar symptoms may be in calling attention to certain remedies, yet they are not the sole guides; for, after all, it is the totality of the symptoms that determines the choice.
It is true that at times a brilliant cure has been made by a remedy that corresponded only to those symptoms that were peculiar to the patient and was not known to possess any strong resemblance to the common symptoms of the disease; but even in such a case it is almost absolutely certain that further provings will show that the remedy has the common symptoms also. But when using these peculiar and characteristic symptoms as the main guides in the selection of the remedy, it is important to bear in mind that they must be equally well marked both in patient and in remedy; in other words, no matter how peculiar and outstanding a symptom may be, either in the patient or in the remedy, unless it be of equal grade in both we must pay little heed to it. For example, if a patient experiences occasional and slight heat in the soles of the feet at night in bed, this symptom would not be of much importance in selecting sulphur as the remedy, because in that drug this symptom appears in such a vigorous and outstanding way that the provers declare that their feet burn at night as if they had been on fire. Or, take a case of rheumatism, markedly aggravated in dry weather and better in damp; in such a case the selection of phosphorus as the remedy could not be based upon this modality, for, while phosphorus has it, it is only in the lowest degree. Even in a case with, let us say, ten peculiar and characteristic symptoms, of which one remedy has eight, but of a very low rank, while another has only five, but of high rank and corresponding to the rank of the symptoms as experienced by the patient, in such a case it is very improbable that the first medicine will prove to be the curative one, and the second is much more likely to be so. It is this question of the rank of symptoms that is the great objection to the numerical method of selecting the remedy. It seems to have fascinated some minds, for, while it is laborious in the highest degree, it seems to promise certain and exact results; but medicine - even homoeopathic - is not yet an exact science, and even when we have perfect our armamentarium it is extremely improbable it ever will be. Consequently all such mechanical methods are to end in failure, for quality will ever be of infinitely more importance than mere quantity.
In opposition to this numerical method, some physicians have gone to the other extreme, and have been content to be guided in the selection of the remedy by one or two peculiar and outstanding symptoms, practically ignoring all the others, because they have overlooked the fact that - unless there be a general correspondence between the symptoms of the patient and those of the remedy - it is not reasonable to expect a cure. This so-called "keynote" system of prescribing is very attractive, as it seems so easy, and saves all the laborious comparison of competing drugs that is involved in the numerical method, and also because by means of it many brilliant cures have been made; but it is from its very nature a wrong method, and in the great majority of cases is doomed to failure, because it ranks one or two symptoms very high and practically ignores the others.(To be concluded.)
N°3
On the comparative value of symptoms in the selection of the remedy 2
By Robert Gibson Miller, M.B.
(Continued from p. 80)
Having discussed the difference in value, so far as the selection of the remedy is concerned, between the symptoms that signify the patient, and those that signify the disease, we would turn to the other great division of symptoms - viz., the generals and the particulars.
The general symptoms are those that affect the patient as a whole and, because of this very fact, are naturally of higher value than the particulars, which only affect a given organ. What the patient predicates of himself is usually general, as when he says: "I am thirsty," "I am sleepy" - thereby indicating that his whole being is so affected, and not merely one or two particular organs. So much higher may a general symptom rank that if it be a strong and well-marked one it can overrule any number of even strong particulars. Let us take a case of gastric catarrh, with semi-lateral headache, roaring in the ears, greasy taste, aversion to fat and butter which aggravate greatly, fulness and pressure of the stomach after eating, flatulence, chilliness, vomiting of the food. So far pulsatilla and cyclamen compete equally; but if we have in addition diarrhoea only at night, nausea from hot but not from cold drink, palpitation when lying on the left side, then the balance would turn towards puls. But, if we find that the patient has the greatest aversion to the cold open air, and is always aggravated by the least cold, then this one strong, general symptom would overrule the marked particulars that puls. alone has, and declare plainly that puls. could not be the remedy, not withstanding the fact that it alone had the three strong particulars. But, on the other hand, a number of strong particulars must not be neglected on account of one or even more weak generals. Let us take another case of gastric catarrh, with severe pain over the right eye, bitter eructations, pain in the stomach - worse from cold and better from hot drinks, one cold and one hot foot. So far lycopodium and chelidonium correspond about equally to the case; but if there is in addition a constant pain under the inferior angle of the right scapula, a yellow-coated tongue with indented margins, and clay-coloured stools, no one would hesitate to give the preference to chel. But if, on still farther examining the case, we find that the patient always feels worse all over - though not in a very marked degree - after eating, also that he feels better moving about than when sitting, these generals would be against chel. and in favour of lyc., but they are only weak and not strongly-marked generals, and consequently should not be allowed to overrule the strong particulars that indicate chel.
Amongst general symptoms are to be included the mental state, which, reflecting the condition of the inmost part of man, is bound to be of the utmost importance, and - as Hahnemman so strongly insists - must always, if well marked, take the highest rank in the selection of the remedy. These symptoms are naturally the most difficult to elicit, for people, as a rule, shrink from revealing their inmost thoughts and motives, their hatreds and yearnings, their evil tendencies, and their delusions, and c., and it requires the greatest tact and a full knowledge of human nature before we can hope to win the confidence of our patient and so understand his deepest thoughts.
Of course, we are all aware of the value of the more common mental states, and these influence us, consciously or unconsciously, in the choice of our remedies. We all recognize, for example, the fastidiousness of arsenic, "the gentleman with the gold-headed cane", the irritability of bryonia, chamomilla, and nux-vomica, the gentle, yielding lachrymose puls., the ever-varying moods of ignatia, the hauteur of platina, the lack of self-confidence of silicea; but there are many less apparent conditions, which have to be deeply probed for, though when found are invaluable. Such is the presentiment of death of apis., the lack of natural affection of sepia and phosphorus, the strange impulses to kill those dearest to them of mercurius and nux., the suicidal promptings of china. - not open and obvious like those of natrum.- sulph, but hidden, shamefaced, and mixed with fear. These latter, in the early stages, few patients care to allude to, yet their value to us is inexpressible. Even amongst the mental symptoms there are various ranks, and consequently they vary greatly in their value. All symptoms of the will and affections, including desires and aversions, are the most important, as they relate to the inmost in man. Of less value are those relating to the intellect, while those of memory are to be ranked lowest of this group.
Amongst our other generals are the effects of sleep and dreams, such as the aggravation after sleep of lachesis and sulphur, the aggravation from loss of sleep of cocculus, and the great relief from sleep of phos. aNd sepia.
Again, how often has the study of the dreams revealed the hidden key to the remedy!For in sleep man is off his guard and his subconscious self can assert itself, and under such circumstances the veil is often lifted a little, so that we are able to apprehend in some degree the deep and hidden mysteries of that disordered life we call disease. Of course, such dreams must be regular and persistent to make them of value, and great care must be taken to eliminate the effect of all external influence.
I recall a case of aortic aneurysm, giving rise to much pain and many other pressure symptoms. The patient had not the slightest idea what his disease was, yet he dreamed night after night of pools and seas of blood, and so distressing was this that sleep was one wild nightmare. The other symptoms were valueless so far as the selection of the remedy was concerned; but, taking the dreams as my guide, I gave solanum tuberosum aegrotans, which completely removed the dreams, and so releived the pains that he went down to his grave in peace.
But one grand general - viz., the effect of different temperatures upon the patient as a whole - is often of the greatest service in calling our attention to special groups of remedies and excluding other groups, so that the labour of selection is thereby greatly lessened. It is by no means always an easy general to use - in fact, I am more careful in questioning patients with regard to this than with regard to anything else. How often, in response to our question as to how they are affected by heat and cold, they will reply: "Oh! I can't stand heat!"But on inquiry you discover that they hate cold, but cannot stand a close, stuffy place - or perhaps they may say so because they are worse in summer - which is not necessarily the same as aggravation from heat, for summer, in this climate at any rate, means more than heat.
Another frequent source of error is the tendency to mistake any undue readiness to perspire as an indication that heat aggravates. On the other hand, many confuse an undue tendency to catch cold with aggravation from cold; but when we have eliminated these errors and find the patient markedly aggravated as a whole by heat or cold, we are greatly aided in our choice of remedy.
This question of temperature is often very valuable when the body as a whole is markedly affected by one temperature, and some special organ by the opposite; for example, we find a general shrinking from cold under ammonium carb. and carbo vegetabilis, yet their respiration is releived by cold air. Cycl. has the same aggravation, except with regard to its headache and catarrh; magnesia phos., except for its cough and some headaches; china., except for its stomach symptoms; or phosphorus, except for its headache and stomach symptoms. Or, as a patient suffering from headache and general rheumatism of the body remarked, if he could only have his body in a bath and his head in an ice-tub, he would be supremely happy. Conversely, the general aggravation of heat of lycop., except for its stomach and some rheumatic symptoms; or secale, except for some headaches and neuralgias, illustrates the value of this general. The exquisite sensitiveness of the mercurial condition to both extremes of temperature, only finding comfort at a medium temperature, is doubtless known to all of us, and must often have served us in good stead when the other mercurial symptoms were absent.
There is little need to call attention to the general effect of the various weathers, but many a valuable hint is obtainable from them, not only in a positive but also in a negative way. In many conditions such as rheumatism, where we expect as a rule to have an aggravation from weather changes, the absence of such an aggravation becomes peculiar and characteristic, and enables us to throw out of consideration whole groups of remedies. For example, where change of weather does not influence a rheumatism, we can safely exclude dulcamra, nux. Moschata, phos., ranunculus bulbosus, rhododendron, rhus, sil., tuberc.; or, if wet weather does not affect, we can eliminate calc., merc., natrum carb., natr. Sulph. and ruta. Such negative conditions are not sufficiently made use of -for, while the mere absence of particular symptoms that strongly characterize a remedy cannot be relied on as excluding that medicine, yet when strong generals that characterize the remedy are absent we can, with a fair degree of confidence, exclude that remedy, simply because each drug is a unity, and such characteristic generals are their very web and woof.
Amongst the generals must be included the influence of the various positions, such as the great aggravation of most symptoms by standing of sulphur and valerian, the aggravation of lying on the right side of merc., the peculiar aggravation of phos. when lying on the left, yet with aggravation of the head symptoms when lying on the right. To be of any value as a general symptom, the patient as a whole must be markedly influenced by these, and if only one organ is so affected they can only take low rank, being particulars. The tendency of disease to affect particular parts of the body is often well marked and may be a general of considerable value. Such, for example, is the semi-lateral nature of many illnesses that require alumina, kali carb, phos. acid; or, if the right side is mainly affected, apis, bell. And lyc.; or, if it be left-sided, argentum nit., lach. And phos. Again, how often has the oblique appearance of symptoms led to the choice of agaricus or asclepias tuberosa as the remedy, and even more frequently the appearance of symptoms on alternate sides has led to a cure by lac. caninum.
But let us consider how profoundly time influences our diseases, and how common it is to find the symptoms aggravated regularly at particular hours. Here, indeed, is a valuable and great general whose proper use will enable us many a time to decide which is the true remedy. It may be the morning aggravation of chel., natr. mur. or nux, or the evening one of bry., bell., or puls. - perhaps coupled in the latter remedy with the exceptional aggravation of the stomach symptoms in the morning. Or if we find the cases characterized by periodic return of the symptoms - whether it be daily, as in aranea, or on alternate days, as in chininum sulph. or lyc., or every two weeks, as in ars. or lach. - we here, again, have a general of the greatest value. But it is worthy of note that the less the disease that happens to be under consideration is itself normally characterized by periodicity, the more does this periodic return of symptoms indicate special remedies which have this characteristic in a marked degree. This is well exemplified in the case of ague, which is normally characterized by the periodic return of the paroxysm at fixed intervals, due as we are all now aware to the segmentation of each variety of the parasite at definite times; but the mere fact that this periodicity is common to the disease, and hence not peculiar to the individual patient, has led the most successful prescribers for this disease to base their prescription on other factors that are present rather than on the periodicity, though of course by no means excluding it from consideration.
The various cravings for, and aversions to, various substances are as a rule general symptoms, for they depend upon some deep need in the body as a whole, and, if outstanding and definite, must always take high rank. It is easy to understand many of these, such as the aversion to fat of puls., for it also disagrees, or perhaps also the craving for salt of natr. m.; but the reason for many others is utterly beyond our ken at present. For example, an intense craving for pork in a case of rheumatoid arthritis, which presented no symptoms beyond those common to this disease, put me upon the track of crotalus and led to the cure of the case, though the patient had been bedridden for over six months.
One more of these general symptoms I would allude to - viz., the influence of eating. Of course, so far as it affects the stomach directly, it is only a particular, and we do not as a rule find it to be of much help in the selection of the remedy; but when the man as a whole is thereby influenced, and states that he feels better, or worse, all over, by eating, then it becomes a general of high rank. Especially is this the case when symptoms in parts far distant from the stomach are so influenced, such as the aggravation of the pains in the limbs of indigo, or the amelioration of natrum carb., or kali. bichromicum. The effect of special foods is at times general, affecting the man as a whole; but as a rule they only affect the digestive organs, and in that case are merely particulars, it is through forgetting this distinction that all of us at times rank their influence too high, and are disappointed when remedies selected more or less in accordance with them fail to cure the case.
The special senses are often so closely related to the whole man that many of their symptoms are general. For example, when the patient states that the smell of food sickens him, this is a general; but if he only experiences a subjective, offensive smell in the nose, this would merely relate to the one organ and consequently would be only a particular, and of comparatively low rank.
General symptoms are not always recognized at once to be so, but on examining a series of particular organs we find that a symptom or modality runs so strongly through them all that it may be predicated of the patient himself. Here we have a general made up of a series of particulars. For example, if we take a case in which, wherever the pain happens to be felt, whether in head, or chest, or limbs, there is relief from lying on the pain-ful side, this becomes so common as to characterize the patient as a whole, or if we find that in all organs and tissues affected the pains are boring from within out-wards, as is found under asafoetida, then this symptom can be raised from being an ordinary particular to a general of low rank; or, if the pains, wherever they may chance to be located, are always associated with numbness, as in cases requiring plat. or cham., then this may also be regarded as a general, though, of course, of a comparatively low rank. But there is a real danger of overdoing this dependence on generals in the selection of the remedy, and a glaring example of this is seen in Boenninghausen's "Pocket Book."In this he overdid the generals, for he generalized many rubrics that were only particulars. For example, writing is a rubric of particulars, and in no instance is the patient himself worse from writing; but in some cases it is the eyes, from looking; in others the hand, from exertion; or in others the back from sitting bent. If we are searching for the remedy for a headache aggravated by writing, a rubric composed after this manner would be useless. But the rubric aggravation from motion is on quite a different footing, for, if we have a case requiring, say, bryonia, we find so many particulars aggravated by motion that it appears that the very patient himself is worse from motion, and consequently in this case motion is a general.
But there is one other general - the greatest of them all - which I must not omit, for it is created by the blending of all the generals and particulars into one harmonious whole. For lack of a better word we speak of, let us say, the "sepia" constitution, meaning thereby that special diseased condition of mind and body for which that remedy has so often proved itself curative, that we come to look upon it almost as an entity. At times it is plainly discernible by all, and capable of being described in words, such as the leuco-phlegmatic constitution of calc., the tall, thin, narrow-chested one of phosphorus, or "the lean, stooping, regged philosopher," as Hering called the sulphur patient; but far oftener it is something much more subtle, such as that of arg. nit., with its fears and anxieties and hidden, irrational motives for all it does. To very few of us is it given to penetrate into these secrets and to understand that almost indefinite something which often lies behind the mere symptoms, modifying and characterizing them all, and so becoming the governing element in the whole case. he masters in our art are those who have had the power to understand this great general, and we stand amazed at their skill in penetrating right into the heart of the most complex cases and evolving order and consequent cure out of seeming chaos.
But while the general symptoms are of the highest rank as a rule, simply because they relate to the man as a whole, yet we must on no account undervalue the particulars, and, in fact, many cases seem to be composed only of particulars, and have few or no generals of any importance. In such a case, where no one remedy corresponds to the case as a whole, we must base our selection upon those particulars that are most characteristic and peculiar, for it must be borne in mind that both generals and particulars may either be characteristic and peculiar, such as, say, a vague aggravation from cold and damp, an indefinite depression of spirits, or an irritability without any qualifying conditions, or not of much intensity, then the characteristic particulars must lead.
There is one matter in connection with prescribing the particulars that may give rise to a difficulty in selecting the remedy. In alternating complaints, such as of eye and stomach, we may find that, say, euphrasia is more sharply related to the eye symptoms than the deep-acting remedy that best fits the whole case, and that puls. corresponds to the stomach ones better than the deep-acting one does; yet we must ever remember that there is one deep-acting remedy that is more similar to the whole patient than these special remedies, because it corresponds better to the general symptoms. I have previously quoted Hahnemann and Kent with regard to the importance of paying heed mainly to the symptoms that are peculiar, but this is only one aspect of the truth, for the highest rank of all belongs to those symptoms that not only are peculiar but are also general. A very good example of this is a case with very high fever, let us say, of 105°, yet without the least thirst. Here we have without doubt a very peculiar symptom, for the absence of thirst with such a temperature is a most unusual thing, and this thirstlessness is a general, for it is the whole man that is thirstless. Of course, if we had only temperature of, say, 101° this symptom would not be specially characteristic, and consequently of comparatively low rank.
But before we pass from the consideration of particulars, I would call attention to the fact that common particulars may in certain circumstances assume a comparatively high rank. When two common symptoms which, if they appeared alone, would be of little importance, yet when associated at once become of considerable value - the coryza with polyuria of calc. is a good example of this. In this connection it is worth noting that a remedy can cure groups of symptoms, even where they did not appear as concomitants in the proving; and this is even the case when the components of the group were observed by quite separate provers. Kent, in his great repertory, has left out the majority of concomitants, and has only retained those few that abundant clinical experience has demonstrated to be frequently associated.
Other examples of this raising of the rank of common symptoms are where the common symptom is associated with a peculiar modality, such as the chilliness of puls., worse near the fire, or a special localization may emphasize a quite common symptom, such as the aching pain at the inferior angle of the right scapula of chel., or finally, the mere intensity of a common symptom such as the overwhelming sleepiness of nux. m. gives it a value that otherwise it would not possess.
Ranking close behind, or even at times taking precedence of the peculiar and general symptoms of a case. These symptoms to be of any real importance, must of course be outstanding and definite, and if so they are always of the first important in the choice of the remedy. So much is this the case that where no remedy can be discovered that corresponds to the case as a whole, it is at times necessary to be guided almost exclusively by them. When so prescribing it is not to be expected that the remedy will influence the case very deeply, or cause any markedly curative results; but it will modify the symptoms and open up the way for other remedies.
The foregoing refers to the symptoms that have been the last to appear, before homoeopathic treatment was instituted; but even when the appropriate homoeopathic remedy has been given and modified the case, and new symptoms have appeared, the same law holds good. Hering, however, cautions us to note that these new symptoms will generally be found amongst the symptoms of the last given remedy, but only of low rank and not guiding in the choice of the second remedy. These new or last-appearing symptoms may be old ones which had disappeared many years ago and have now returned through the action of the first remedy. Accordingly, before using them as guides in the selection of the second remedy, we must have patience and make sure that their return is permanent, and not merely a temporary reappearance while on the way to final extinction.
Another very important rule of Hering's, the observance of which will often prevent many mistakes and save much study, is - that the second remedy must bear a complementary relation to the first, and hence the last remedy that has ACTED, either homoeopathic or allopathic, forms one of the most important guides in the selection of the second. The knowledge of this rule is a great time and trouble saver, for in the majority of cases a reference to the tables of related medicine would enable us to select with ease the remedy that is to follow.
Towards the beginning of this lecture, I made passing mention of the value of old symptoms which had long ago disappeared, pointing out that for many reasons they were often of very uncertain value; but while it is seldom advisable to give them any very high rank in the selection of the remedy, yet they are of the utmost value in confirming the choice of remedy, or in differentiating between competing remedies selected in accordance with the now active symptoms. As an example of this, Kent mentions the case of a man who had long suffered from neuritis of the limbs, and whose present symptoms did not point decisively to any one of five or six competing remedies. It was discovered that in infancy he had been affected by eczema capitis, very similar to that caused by mezereum, one of the competing remedies, and on examination of the pains in the limbs produced by that remedy it was found that they closely resembled those now experienced by the patient. This remedy proved curative and reproduced the original eruption.
Dunham's well-known cure of deafness by the same remedy is another example of this use of old symptoms.
In the cases just mentioned, the diseases cured were not characterized by any marked pathological changes, but even in cases where these changes have become quite definite it is useless in the majority of cases to prescribe upon the symptoms that now present themselves. We must here also seek to discover the primitive symptoms that the patient experienced long before any definite pathological change took place, and though the task, as I stated, is difficult, yet we can often obtain enough data upon which to base our prescription.
I need hardly say that no one, even when he has been able to obtain the fullest and most accurate description of these old symptoms, expects to be able to cure diseases that have advanced so far as to lead to practical destruction of organs and tissues. It is only the beginnings of such processes that are amenable to medicines, so far as positive cure is concerned. Even in comparatively recent and uncomplicated cases of chronic disease, when the symptoms have been suppressed and the whole character of the disease changed, the symptoms that now present themselves must in the great majority of cases be our guides, though at times it may be necessary to select from amongst the competing remedies one that is known to have an antidotal relation to the suppressing drug. This is not, however, invariably the case, and it is at times necessary to give the original symptoms the higher rank and to be guided by them, to the exclusion of those now present. As an example of this, an otherwise healthy young man, who had suffered for over a year from sciatica, presented himself with stitching, cutting pains in the calf, worse at night, better from heat, worse in motion, releived by flexing the limb. Coloc. and other drugs failed to give relief. It was found that the disease, which was originally located in the upper part of the nerve, had been vigorously treated by external applications, with the result that not only was the situation of the pain altered, but its character and modalities had been completely changed. The original pain was of a tearing nature, and was greatly aggravated by sitting - not quite so severely felt while walking - and there was almost complete relief when lying down. Ammonium mur., selected in accordance with these old symptoms, promptly cured.
To-night I can only make passing reference to the so-called primary and secondary effects of drugs, to which some good prescribers have assigned different values in the selection of the remedy. So far as my experience goes, it does not seem to matter in what order the symptoms may appear in a proving - if the remedy can produce them it will also cure them, irrespective of their position in the disease, and consequently so far as rank is concerned we cannot differentiate between them.
I stated at the beginning of this lecture that Hahnemann insisted that we must be guided in the choice of the remedy almost exclusively by the symptoms, to the practical exclusion of pathology; but I think there is a good deal of conclusion with regard to this matter. So far as I can see, Hahnemann did not object to the use of the pathological changes as guides for theoretical reasons, but only for practical ones. It is true that to a limited extend it is practical to use pathology as our guide, and we all do so use it. Whenever we have to prescribe for eruptions or ulcers - which are, after all, pathological changes - we do not hesitate to be governed by anything that is peculiar or characteristic about them, such as their colour, shape, and position, because by means of these peculiarities we can differentiate. But when we come to deal with gross pathological changes in the deeper organs, we meet with two difficulties. In the first place, we are unable in the living patient to determine those minute differences - though doubtless they do exist - which, if discernible, would enable us to differentiate; and, in the second place, very few of our remedies have had their provings pushed far enough to cause corresponding pathological changes. These, I take it, are the practical reasons that led Hahnemann to ignore pathology; and though our knowledge of this subject has enormously advanced since his day, his reasons still hold good. But we cannot, even in the selection of the remedy - to say nothing of its absolute necessity in all questions of diagnosis and prognosis - ignore pathology, for without it we cannot understand the true course and progress of a disease. Only by means of it can we know the symptoms that are common to the disease, and hence those that are peculiar to the patient. We also thereby know at certain stages of some diseases that no matter how similar the symptoms produced by certain remedies may appear to those of the patient, yet that, owing to the superficial character of their action, it is not possible for them to prove curative. For example, in pneumonia, in the stage of exudation, while the symptoms may apparently call for acon., we know that this remedy, owing to the superficial nature of its action, cannot produce such a condition, and closer examination will reveal that some deeper-acting remedy, such as sulphur or lyc., is needed. Pathology enables us to decide when new symptoms arise whether they are due to the natural progress of the disease or to the action of the remedy. We must clearly understand that it is the patient that is curable, and not the disease, and without a proper understanding of pathology we are liable to err. Take a case of inflammation of a joint that has gone to ankylosis - the suitable remedy will cure the inflammation, but will be powerless to break down the adhesions, and surgical aid must be sought. The same holds good with regard to tumours, for when the patient is cured the tumour will cease to grow and perhaps may be absorbed, but very often it persists, and must be removed by the knife. Pathology also warms us that it is dangerous to attempt to cure certain conditions of disease, such as advanced phthisis, or deeply situated abscesses, or where foreign bodies are encysted near vital organs. In such cases Nature can only cure by ulcerating out the foreign substance, and the exhaustion entailed by such an operation is often fatal. Of course in such cases, if a surgical operation is not deemed advisable, we can do much to relieve by means of short-acting remedies which have no tendency to excite Nature to get rid of the foreign body or dead tissue by suppuration.
I now come to a matter which has given rise to the sharpest controversy in the past, and which many have absolutely rejected, viz., Hahnemann's doctrine of psora. I would not have alluded to it this evening, after having spoken of so many things that I cannot expect all to accept, unless it had been that the discussion of the comparative rank of symptoms would not be complete unless this matter was considered. All are agreed, at any rate, on the existence of the two other chronic diseases, viz., syphilis and sycosis, and I would like to indicate before closing the views of the man who more than anyone - even more than Boenninghausen - has elucidated the course and progress of these diseases - I mean of course James T. Kent. Kent holds that these chronic diseases may exist either in an active or a latent condition, and may present themselves in three ways, viz., as a single miasm; two or three miasms co-existing or separate, but only one active at a time; two or three miasms forming a complex. But, to come to the point we are interested in this evening, both Hahnemann and Kent teach that we must attack the one that is upper-most at the time, and ignore the symptoms of those that are latent, except in the last monstrous phase, where two or three form a complex, which is a rare thing, and seldom brought about except by the prolonged abuse of unsuitable remedies. Where two miasms, say syphilis and sycosis, co-exist, it is not uncommon to find them alternating, though only one is active at a time. In such a state of affairs we naturally will select the remedy solely in accordance with the symptoms of the now active miasm, and ignore those of the that has become temporarily latent - in other words, only the symptoms of the active one have any value in the selection of the remedy that is required at the moment.
Such, gentlemen, is a very imperfect sketch of the rules that must guide us in determining the comparative value of the different classes of symptoms, a matter of the utmost practical importance in connection with the problem of the cure of complex chronic diseases.
And it is solely by our success in the treatment of this class of disease that we can hope to convince our brethren of the old school that the true and only law of cure is that of similia simillibus curantur.
Dr Ord (in the clair), said the Society had listened to an exceedingly valuable and very profound paper, one that had been long needed. When they had carefully studied the paper in print and considered the immense number of points of extreme importance in it, he felt sure they would be all the better for it.
Dr. Berridge (a visitor) thanked Dr. Miller for his paper, with which he fully agreed, and quoted a case of disease of the liver and gall-bladder, for whom chelidonium in the 100,000th attenuation (Fincke), had been given with much benefit, selected on the keynote, "icy coldness of the tips of the fingers," as a characteristic symptom. As there were beginners in homoeopathy present, Dr. Berridge wished to make to them a confession of faith, or rather, of knowledge. For over forty years he had, to the best of his ability, practised homoeopathy strictly according to Hahnemann's rule, and he had never once found Hahnemann's judgement or statements to be wrong.
Dr. Newbery mentioned the case of an old friend of his nearly 70 years of age who had suffered for some time from liver trouble with jaundice and intense irritation of the skin, so that he could not sleep, and was in a constant state of scratch. In response to a request for his advice, in consultation with the medical man in attendance, Dr. Newbery suggested from the symptom of irritation alone, which was the main factor in causing the insomnia and increasing weakness, dolichos pruriens, a plant commonly called "cow-itch", from the intense irritation it was known to cause, which was given. Within a short time improvement began, which by the end of a fortnight was marked, and at the end of a month the patient was completely cured. The irritation of the skin which gave the indication in this case was relieved by dolichos pruriens, and the whole condition was practically cured by the same remedy.
Dr. Ridpath referred to the importance of paying attention to the individual; treating the patient, and not the disease. For instance, in a case of pneumonia it was not necessary to take, say, the hepatization of the left or right lung; if one took the fever, restlessness, difficulty of breathing, and relief or aggravation from lying on the painful side, thirst, and all those symptoms indicative of an affection of the individual himself, they would find the remedy, and if it had not gone too far, the hepatized lung would clear up.
Dr. Goldsbrough referred to a point which was very much insisted upon by Hahnemann, that there should be an accurate record of the symptoms as they were observed in patients. For his own part, he felt he had lacked a good deal in the true observation of symptoms, and in an accurate description and record of them, so that he could classify them according to the method that Dr. Miller had brought forward. Again, to be convincing, a cure must be such that the patient could not have got well if left to himself; that was to say, that in a given case they must have been dealing with a disease in regard to which the recuperative power in nature would have little effect until aided by the remedies given. He thought homoeopaths were apt to lose sight of that point. He had heard it said, that as a rule homoeopaths did not care for numbers of cases; they were too ready to bring forward single ones, and to adduce those as illustrations of the method which, as a matter of fact, they taught was practically universal. He thought there was some ground for that statement.
With regard to symptoms, the emphasis Dr. Miller had laid on the emotional as distinct from the mental symptoms was important. It was not so much mental symptoms strictly, in the modern sense of the word, that had to be taken into account, but symptoms of the personality, such as emotion or disposition, which was a more subtle and more hidden thing as far as its symptomatology was concerned than the actual intellect and memory symptoms.
Dr. Blackley said that in all his professional life he had been a very strong advocate for the pathological method of prescribing. He mentioned a case in point of pneumonia which had been mistaken for typhoid fever where the case cleared up rapidly under the remedies for pneumonia, and the typhoid symptoms also disappeared. Undoubtedly, all pathological conditions had their subjective and objective symptoms: that is, the deep pathological state is always accompanied by symptoms, if one knew how to look for them.
Dr. Miller Neatby enquired of Dr. Blackley what were the ordinary remedies for pneumonia which he prescribed for the case he had just mentioned, because, for instance, phosphorus might be indicated both in typhoid fever and in pneumonia. With regard to the diagnosis, of course the subsequent career of the case might have shown that Dr. Blackley was justified, but pneumonia was not at all an unknown factor in typhoid.
Dr. Blackley, in reply, said the remedies that were administered after he (Dr. Blackley) saw the case were bryonia, phosphorus, hepar sulp., and lycopodium. He could not remember any others, but they were absolutely and entirely the remedies usually prescribed in pneumonia.
The PRESIDENT remarked he was glad that emphasis had been laid on the fact that although there might only be one remedy that would cure a patient, there were several ways of arriving at that remedy. In some cases one could select the remedy almost immediately, and very often a remedy selected on first seeing the case was confirmed by a subsequent study of the repertory. On the other hand, there were a number of cases where the remedy could not possibly be discovered except by a laborious and lengthy process, and in such cases nothing but a careful examination of the symptoms, in such a way as had been so admirably put before the members that evening by Dr. Miller, could lead to the correct result.
Dr. Miller, in reply, said he had not lost sight of the importance of pathology; in fact he had pointed out in his paper that without pathological knowledge and without proper diagnosis there was a tremendous liability to error. It was quite true a number of so-called strict homoeopaths had for a time derided pathology, but those of the more modern school did not do so. He begged the members not to be under the impression that the man who prescribed mainly on symptoms was so foolish as to ignore pathology. The question of the graduation of symptoms, which he had striven to put before the members that evening, seemed an elaborate and complicated thing. But that was not the case, and the subject was not really complicated when one came to study it. There were many cases which did not require to be troubled about at all, and in which there was no question of the comparative value of symptoms. He had spoken that evening of complex cases. Dr. Goldsbrough had referred to the necessity of keeping records of cases. All the men who had been most successful in complex cases, had been most particular in keeping records of their cases; they were of the utmost value. Statements might appear very different when read over afterwards from what they did when first made, and if one did not carefully record his cases he could not grade his symptoms. He (Dr. Miller) regarded syphillinum as an extremely good prescription on the symptomatic basis, when the pains were markedly aggravated at night and from heat.
[In reference to the foregoing paper and discussion, the following communication has been received from Dr. J. Weir. -(Editors.)]
On the evening following the reading of Dr. Miller's paper, Dr. Miller consented to meet those interested who had questions to ask or difficulties to be explained. In response to open invitation a well-attended gathering was held. The following were the points chiefly brought out:-
Generals. - Hitherto, when keeping too rigidly to general symptoms, and discarding a drug because it did not come under each rubric, it was found that almost invariably one of the polycrests was indicated. More elasticity must be given in the choice of medicine. It is not by exclusion, but by considering the drug which comes nearest to or has most of the symptoms present, which will lead to the right one. Of course, one strong general would overrule any particulars. In this connection much help can be obtained by dividing remedies into those producing symptoms markedly affected by heat or cold. If this is a striking symptom it saves much time and anxiety by only considering those which fall into its class.
Repetition of Dose - Whilst the duration of effects of remedies is approximately known, the true guide is to wait till the patient feels hardly so well - as long as he feel "well in himself" the medicine must not be repeated even if it be months since the last dose.
Incurable Cases - Dr. Miller pointed out that great care must be exercised here. In advanced phthisis the lower dilutions only ought to be used, e.g. , 30th, else there is a possibility that the reaction is too violent or that no favourable response to the remedy is induced, and the patient gradually sinks. In some cases of phthisis were puls. seems indicated, especially in later stages, the ought which may have been loose is apt to become dry consequently distressing to the patient. Stannum often antidotes this and makes things easier.
Aggravation from Remedies - The true way to antidote is to prescribe for the outstanding symptoms now present. Many drugs are known to antidote each other, and the one best indicated by the present condition should be selected. Often, however, a very high, or sometimes lower, potency of the same drug has the effect of an antidote.
Tumours - Unless mechanically affecting the patient, tumours ought not to be removed. The patient should be cured of his disease first, and the tumour removed if possible afterwards.
A vote of thanks to Dr. Miller brought to an end a meeting characterized by deep interest.
It was felt that such gatherings should be held monthly to discuss at greater length than is possible at the General Society Meeting questions bearing on the philosophy and selection of the remedy. Permission has been granted by the authorities for these being held in Hospital, on dates which will not interfere with any other existing arrangements. The most suitable times seems to be 5.30 p.m. Due notice will be posted.
SOURCE- HOMOEOPATHIC JOURNAL
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