As preliminary to an intelligible, discussion of this question, we must briefly define primary and secondary symptoms, respectively, and state how, in our judgment, the discrimination between them bears upon the selection of the remedy. And this, notwithstanding these questions have been elaborately and lucidly discussed by other members of this bureau. For it will not have escaped the reader's observation that these terms are used with different significations by different writers.
Symptoms may be called primary as being first in order of occurrence, in comparison with others which, occurring at a later period, are, with reference to time, secondary to them.
Or, symptoms may be called primary as being, in a sense, the exciting cause of other and opposing symptoms, which are then secondary to, as being contingent upon, the former.
Or, symptoms may me styled primary as being of greater importance or significance than others called, therefore, secondary.
The distinction, then, may be based on considerations of time, of opposition in nature, or of rank. And it is important not to confound or combine these ideas in our discussions. Since most of our traditional notions on this subject originated in Hahnemann's utterances upon it throughout his writings, I will briefly repeat his views before stating my practical conclusions.
In an essay entitled Suggestions for Ascertaining the Curative Powers of Drugs, published 1796 (S. W., 312),
Hahnemann says : "Most medicines have more than one action ; the first a direct action, which gradually changes into the second (which I call the indirect secondary action).
The latter is generally a state exactly the opposite of the former. In this way most vegetables act. But few medicines are exceptions to this rule, e. g., metals and minerals."
He illustrates what he means by the secondary action in the following note : "Under Opium, for example, a fearless elevation of spirit, a sensation of strength and high courage, an imaginative gayety, etc., are part of the direct primary action of a moderate dose ; but after eight or twelve hours an opposite state sets in--2-the indirect secondary action ; there ensue relaxation, dejection, diffidence, fear, loss of memory, etc."
In the preface of the Fragmenta de Vir. Med. Pos., etc., 1805, Hahnemann says : "Simple drugs produce in the healthy body symptoms peculiar to themselves, but not all at once, nor in one and the same series, nor all in each experimenter ; but to-day perhaps these, to-morrow those ; this first one in Caius, the third in Titus, but so that on some other occasion Titus may experience what Caius felt yesterday.
"A certain drug evokes some symptoms earlier and others later, which are somewhat opposed and dissimilar to each other ; indeed may be diametrically opposed. I call the former primary, or of the first order, and the latter secondary, or of the second order.
"For each individual drug has a peculiar and definite period of action in the human body, longer or shorter, and when this has passed, all the symptoms produced by the drug cease together.
"Of the drugs, therefore, the effects of which pass over in a brief space of time, the primary symptoms appear and disappear within a few hours. After these the secondary appear and as quickly disappear. But the exact hour in which any symptoms may be wont to show itself cannot be positively determined, partly because of the diverse nature of men, partly because of different doses. *
"I have observed some drugs the course of whose effects consisted in two, three or more paroxysms, comprising both kinds of symptoms, both the primary and the secondary ; the former, indeed, as I have stated in general terms, appeared first and the latter second. And, sometimes, it seems to me I have seen symptoms of a kind of third order.
"Under the action of moderate or small doses, the symptoms of the first order come chiefly to view ; less frequently those of the second order. I have chiefly preserved the former, as most suitable to the Medical Art and most worthy to be known."
Finally he speaks of a class of symptoms which he denominates "reliquias," generally the effects of very large doses, and which seem to indicate or depend upon more or less permanent alterations of tissue, including the symptoms of the "agony" in fatal cases.
As illustrating these views, I quote remarks prefixed or appended to the symptomatology of several of the drugs mentioned in the Fragmenta.
In a note to Aconite, Hahnemann says : "Through the whole course of action of this plant, its effects of the first and second order were repeated in short paroxysms, two, three, or four times before the whole effect ceased (eight to sixteen hours)." And he describes these effects as follows :
"Coldness of the whole body and dry internal heat. Chilliness. Sense of heat first in the hands, then in the whole body, especially in the thorax, without sensible external heat.
"Alternating paroxysms (during the third, fourth, and fifth hours) ; general sense of heat, with red cheeks and headache, worse on moving the eyeballs upward and laterally, then shivering of the whole body with red cheeks and hot head ; then shivering and lachrymation with pressing headache and red cheeks."
In a note to Chamomilla, Hahnemann says : "The course of its action is run in paroxysms of several hours duration, comprising symptoms of each order, free spaces or remissions being interjected, so, nevertheless, that in the earlier paroxysms, the symptoms of the first order, in the later, those of the second order predominate."
In a note to Ignatia, he says : "Ignatia is wont to display the curriculum of its operations in several paroxysms comprising both orders of symptoms, and repeated at intervals of several hours ;" and concerning the mental symptoms : "Inconstancy, impatience, vacillation, quarrelsomeness, wonderful mutability of disposition, now prone to laughter, now to tears," he says : "These mental symptoms are wont to be repeated at intervals of three or four hours."
Hahnemann's teachings on this subject in the Organon (in which all the editions substantially agree) have been so fully given by Dr. C. Wesselhoeft in the preceding section of the report of this bureau, that I am spared the necessity of quoting them.
It appears that Hahnemann, in the Fragmenta and the Organon, teaches that among the symptoms of a drug, there appear series which are opposed to each other in different degrees of diversity, from being "somewhat opposed" to "diametrically opposite ;" and that, of these series, that which occurs first in order of time, is to rank among ?
the primary, and the occurring subsequently among the secondary symptoms. But he calls attention to the fact that there are some kinds of symptoms in every proving, to which there can be no series of an opposite nature, i. e., to which an apposite cannot be predicated ; for, he says, "Our organism always bestirs itself to set up in opposition to this effect [first drug action], the opposite condition, WHERE SUCH A CONDITION CAN EXIST" [ Organon 2d and 3d ed., § 74 ; 4th ed., § 63. ]
In his definition of primary and secondary symptoms, therefore, Hahnemann blended ; the elements of time and of causation or nature (viz., that these classes were opposed in their nature).
The secondary symptoms were not an independent series, but were secondary by virtue of their relation of opposition in nature to a series of preceding symptoms.
And such symptoms as did not in their nature admit of an opposite condition (as, for example, pain, cutaneous eruption, etc.) could not be called primary, because, in the nature of things, they could not be followed by an opposite class of symptoms. Nor could they be called secondary, because, in the nature of things, they could not have been preceded by an opposite series, which could stand to them in the relation of primary symptoms. Hahnemann, then, appears to have recognized in the pathogeneses of drugs, symptoms which being opposed in nature could be arranged into series of primary and secondary, and other symptoms not susceptible of such arrangement.
He distinctly tell us [ Organon, 2d and 3d ed., § 59 ; 4th ed., § 152. ] that the primary or positive symptoms of drugs are those on which we are to base our prescriptions.
These statements in the Organon, as quoted by Dr. Wesselhoeft, embrace not only a description of various classes of symptoms as observed by Hahnemann in drug-proving, but also a theory of the nature and genesis if these various classes. A man's observations of natural phenomena, if he be a keen and accurate observer, as Hahnemann unquestionably was, are generally correct. His theoretical explanation of them is pretty sure to be tinctured with the philosophy of the period in which he wrote, and is not likely to be accepted without qualification by men of a subsequent period.
And at the present day, few would accept Hahnemann's explanation of the genesis of primary and secondary symptoms as. representing respectively a state of passivity followed by a state of intensified activity on the part of the vital force ; this conception of a vital force, in the sense in which Hahnemann used the term, being one which, itself, has been discarded by most physiologists.
But the rejection of the explanation offered by Hahnemann does not involve the rejection of the observations to which he attached it.
Among the symptoms which he called primary (first wirkungen), Hahnemann recognized the occasional occurrence of what he called alternate (Wechselwirkungen), opposed, sometimes contradictory symptoms, which, nevertheless, were not secondary.
He does not tell us how to recognize these, nor how to distinguish them from the secondary symptoms. But he does give us instances of what he regards as secondary symptoms, as follows : [ Organon, 2d. and 3d eds., § 76 ; 4th ed., § 65. ] "The gayety which follows the use of coffee is a primary symptom ; the subsequent drowsiness and lassitude are secondary symptoms. The sleep which follows Opium is a primary and the subsequent insomnia a secondary symptom ; the purging of cathartics is a primary and the subsequent constipation a secondary symptom. The constipation of Opium is a primary and the subsequent diarrhea a secondary symptom." And consistently with Hahnemann's instructions, we should not expect to base our prescriptions on these secondary symptoms.
But when we examine Hahnemann's remarks on the individual drugs of the Materia Medica Pura, we find deviations from his definitions and illustrations as given in the Organon. In the preface to Belladonna we read : [ Materia Medias Pura, 1st ed. ] "There is no known drug of long action which expresses itself in so manifold (two and three fold) alternate conditions as Belladonna.
Only compare symptom 15 with 16 and this with 17, 56 with 58, and this with 60, 61 and 114, and these with 113 and 152 ; again, 62 with 63, 64, and these with 70, and 62 with 72, 158 with 159, and this with 160 and 165, and this with 163 ; and 172 with 174 and 175, and these with 176. Of none of these alternate conditions (Wechselivirkungen) can it be said that they are beyond the primary action."
The symptoms thus referred to describe opposite conditions as follows :
Contracted pupils and dilated pupils.
Abdominal pains compelling to bend backward and to sit still, to move forward and not admitting of motion.
Suppressed stool and urine and involuntary stool and micturition, and constant tenesmus.
Sleeplessness and deep slumber.
Raging delirium and wild fear, and foolish madness, etc.
It is evidently Hahnemann's meaning, and surely experience justifies him, that Belladonna may be given (other symptoms corresponding) when either the one or the other (the opposite) of these conditions is present. And these opposites belong to the class described in the Organon as secondary, and on which we are told, we are not to base our prescriptions.
In the introduction to Nux vomica (Materia Medica Pura, 1st ed.) Hahnemann says :
"The symptoms of a single dose of Nux vomica are wont to recur several days in succession, at the same time of day, even at the same hour, or every other day. Hence the usefulness of this drug in some typical diseases when the symptoms otherwise correspond. Besides this periodicity of the symptoms, and besides the alternation of heat and cold, there follow also upon one another, here and there (as is the case also with other drugs), symptoms which differ very much from one another, and (*pear to be opposed to each other, although they all belong to the primary action of the drug. We may call these alternate actions (Wechselwirkungen)."
And among the symptoms of Nux vomica, Hahnemann calls attention to 232 and 233 "anorexia," as contrasted with 236-238, "great appetite," and says these are alternate actions, and belong to the primary symptoms, and are, therefore, to be used as bases of prescriptions. He refers also to 369-374, "Constipation with tenesmus," etc. ; and to 357-359, "Diarrhea with desire and tenesmus ;" etc. ; and says, in a note, "Diarrhea, constant, abundant, strictly so called, is not, according to my observation, to be expected in the primary action of Nux vomica ; and that which here appears among the symptoms as diarrhea is partly very small, mostly mucous discharges with tenesmus and pain," etc.
Again, in a note to 456, he says : "Discharge of mucus from the nose is an alternate action with dry obstructions of the nose." There is, clearly, a discrepancy between Hahnemann's general propositions in the Organon and his practical instructions in the Materia Medica Pura. For we find from the latter that Belladonna, for instance, may be given for the primary symptom, "sopor," as well as for what in the Organon is called the secondary, but in the Materia Medica Pura the alternate symptom "sleeplessness," and that Nux vomica may be given for the primary symptom "constipation," and likewise for what is called in the Organon the secondary, but in the Materia Medica Pura the alternate symptom "diarrhea."
The very terms primary and secondary, as thus illustrated, seem to imply a succession of symptoms, more or less opposed in character, and all of them differing from the equilibrium of function which we recognize as health. The instances given, and, indeed, the only possible instances, relate to functions of which a "more" or "less," or an "opposite," may be predicated ; as, for example, temperature, sleep, certain mental conditions, and the secretions and excretions generally.
Thus we may have an unnaturally prolonged sleep or wakefulness, gayety, or despondency, and a plus or minus of sweat, alvine discharge, urine, etc., etc.
But how could we have an opposite condition to any specified pain or subjective sensation, to parenchymatous deposit, to cutaneous eruption, etc., etc. ? The absence of these phenomena would be pro tanto a state of health ; it would not be an opposed morbid condition or sensation.
The possibility, then, of classifying symptoms into primary and secondary on the basis of the relative nature of the symptoms, is not co-extensive with symptomatology ; it is partial, confined to a moderate number of conceivable morbid phenomena.
Shall we, then, in the second place, base the distinction on the element of time, and call the symptoms which first occur primary, and those which come later, secondary ? Where then shall we draw the line ? how many hours or days shall we allow for the development of primary symptoms ?
In view of the immense differences in the rapidity with which the curriculum of action of different drugs is run, it is obvious that a special rule must be established for each drug.
Nor is this the only difficulty.
The results of different doses on the same provers, and of different doses or even of the same dose on different provers, are so various that, 1st, as Hahnemann intimates in the preface to the Fragmenta, the symptom which appears in one prover to-day will not appear for several days in another prover ; and, 2d, a very small dose may produce only one series of symptoms ; a larger dose two series of opposed symptoms ; a still larger dose two series differently opposed ; and a very large dose again only one series.
This point has been so well illustrated by Prof. Allen with whose views I am glad to express my entire concurrence, that I need not dwell upon it, but may content myself with two illustrations from our Materia Medica.
On looking over the register of symptoms of Argentum nitricum, [ Oest. Zeit. I. ] we find reported as occurring early in the proving, irritation of the bladder and urethra and increased frequency and quantity of urine, and as occurring later in the proving, diminution in frequency of "micturition and in the quantity of urine. Surely one might pronounce the former to be primary and the latter secondary symptoms. But on examining the provers day-books we find that the majority of the provers (being those who took large doses) report the former and not the latter symptoms. It was the prover who took the 30th who reported diminished urine, and he did not report any, increase at any time.
These symptoms, therefore, which appear in the register to be opposed, and properly distinguishable as primary and secondary, did not bear to each other any relation of apposition or correlation, as they might have done had they occurred in the same individual. They are different, unrelated, independent effects of different doses in different individuals.
And let me suggest, in passing, that the beautiful pictures of primary and secondary effects of drugs which we find in works of Old-School writers, and which have been made the basis of "laws of the dose" by writers of our own school, are composite pictures made up from a variety of observations on patients and from cases of poisoning, and bear no more resemblance to a pathogenesis on a single individual, than the composition of an artist which has the mountains of Ecuador covered with the forests of Oregon and decked with the flowers of Java presents to a faithful landscape from nature.
Most of the provers of Tellurium taking the 3d trit. had, on the first and subsequent days, symptoms of the general sensibility, of sweat, of the skin, of the bladder, etc., etc.
But one prover who took the 4th trit. had no symptoms at all until the fourteenth or fifteenth day, when cutaneous symptoms affecting the ear appeared and were very persistent and troublesome. Were these symptoms secondary because they came later than other symptoms in other provers ? And secondary to what ? How can John's lumbago be secondary to James's toothache ?
But during the second month this same prover, his ear symptoms having vanished, had symptoms referred to the dorsal spine.
Were these secondary to the ear symptoms because they came later ? Certainly as regards time they were secondary, because later. But being in nature wholly unrelated, neither opposite nor similar, they cannot be called secondary as regards nature nor as regards rank or value. Both have been repeatedly verified in practice.
Again, we are told [ The Dose," by E. M. Hale, M. D., N. A. J., IX. 265. ] that coldness, a condition corresponding to the chilly stage of fevers, is the primary effect of Aconite, and that a state corresponding to the hot stage of fever is the secondary effect of that drug. Let us hear Hahnemann.
In the introduction to Aconite he says :
"Aconite is one of ' a few drugs whose primary action. consists in several alternating conditions of chill or coldness and heat."
And now let us study the day-books of the Austrian provers of Aconite.
Rothaus [ Mat. Med. Pura, 1st ed.] took tincture of Aconite in doses regularly increasing from six drops daily to fifteen drops daily for nine days, when, feeling powerful effects, he ceased taking it and noted his symptoms.
From the second to the eighth day inclusive, he had the following constantly recurring symptoms : restlessness at night ; bad dreams ; unnatural heat of body ; rawness and increased secretion in the larynx ; cough ; vertigo ; headache.
On the ninth day, after midnight, severe chill in paroxysms of shivering, starting from the precordia lasting two hours, followed by burning, dry heat, with frequent, feverish pulse ; and this followed by moderate sweat.
For the next six days he had various troublesome symptoms affecting the chest and limbs, and on the sixteenth day of the proving he had again, at night, a febrile paroxysm consisting of chill, heat and sweat, the first less severe, the last more abundant than on the ninth day.
On the seventeenth day, at night, a similar febrile paroxysm. Then for seven days symptoms of increasing severity in the head and chest, ending with hemoptysis on the nineteenth day, and finally, on the twenty-fourth day, a very severe and well marked and defined neuralgic head and face ache.
How can the ingenuity of the most ambitious lawgiver find a pretext for dividing the symptoms (especially the febrile symptoms) of this excellent proving into primary and secondary ?
A febrile paroxysm occurred on the ninth, the sixteenth and the seventeenth days ; before it and after it were well-marked symptoms of the chest and extremities. Which shall be primary and which secondary if date of occurrence determine the question ? Which, if nature or if rank determine it ?
Certainly, if lateness of occurrence stamp a symptom as secondary, then the neuralgic head and face ache, the very last symptom reported by Rothaus [ Mat. Med. Pura, 1st ed.], must be classed as secondary.
Not so fast, however ! In the proving of Aconite by Zlatarovich with the second decimal, which he took in increasing and very large doses for seven days without effect, the very first symptom was a violent neuralgic head and face ache, almost identical with that described by Rothaus on his twenty-fourth day.
It appears, then, that Rothaus’s last symptom was Zlatarovich's first. If the time of occurrence determines the class, we must rank Rothaus's headache among the secondary, and Zlatarovich's identical headache among the primary, and thus we have the same symptom in each class, which is a reductio ad absurdum.
It will be noticed that these identical symptoms, produced at different times in different provers of Aconite, were produced by different doses. The opposite symptoms of Argentum nitricum in different provers resulted from different doses.
Prof. T. F. Allen has shown how greatly the results of different doses vary. Dr. Sharp shows that, in the same prover, Aconite has four different kinds of action on the heart, as shown by the radial pulse, depending on the dose, and that in only two of these is one series of symptoms followed by an opposite series.
Hahnemann, who, it must be remembered, had an immense experience as a drug-prover, and who brought to the work a devotion and powers of observation and analysis rarely equaled, was well aware of the fact that the appearance of apparently contradictory symptoms in a proving is greatly dependent on the dose, as appears from § 66 of the Organon (4th ed.), in which, for this reason, he recommends the use of small doses in proving.
Passing for a moment to the second division of the subject, the value of primary and secondary symptoms as guides in selecting the remedy, there are many drugs which, having certain constant characteristic symptoms, have also series of alternating symptoms relating chiefly to the secretions.
Among them we may mention Veratrum album, which has (122-124) "Thin stool passing unnoticed with flatus. Frequent liquid stools. Liquid stools unnoticed with flatus. Diarrhea of acrid faces, etc." And also (127-139), "Constipation from thickness and hardness of faces.
A desire and compulsion to stool in the upper abdomen, and yet no stool, or a very difficult one, as if from inactivity of the rectum, and as if the rectum took no part in the peristaltic motion of the upper intestines." Also Hahnemann quotes from Greding, "Diarrhea with copious sweat" and "long-continued constipation."
The efficacy of Veratrum in the treatment of diarrhea of an appropriate character is universally conceded in our school. And in my own practice, Veratrum has for many years been a frequently used and highly valued remedy for constipation in persons of all ages, but especially in infants and young children, in whom digestion appearing to be well performed, the evacuation of faces appears nevertheless to be impossible because of the inertia of the rectum — a fact demonstrated by the circumstance that a healthy stool can be procured almost at will by irritation of the rectum, as by the common practice of introducing into the anus a piece of soap or an oiled paper, or a rubber bougie.
We have here the apparent anomaly of the same remedy equally efficacious in diarrhea and constipation.
Nux vomica furnishes a similar example. Its efficacy in certain forms of constipation as well as of dysenteric diarrhea is well known.
Let us now, for a moment, examine a little more closely the nature of the functions affecting which the alternate series of opposed conditions, which have been called primary and secondary, are mostly observed in drug-proving.
1st. They are such as, in the nature of things are periodic, and not continuous ; characterized by periods of repose and activity, and susceptible of quantitative and qualitative correlative interchange among themselves.
Thus sleep is periodic, and capable of being supplemented to a degree by other forms of repose to the nervous system. The intestinal canal, the genito-urinary apparatus, the skin, in so far as secretion and excretion are concerned, have periods of activity and repose ; and the inactivity of one may be made up by increased activity of another.
And thus the function of any one of these apparatus may vary widely at different times without a conditions of opposition being established. For this reason, then, the mere quantity of one of the excretions, or the degree in which any one of these periodic and convertible functions is performed, does not rank first among the indications on which the selection of a drug is to be based. If we now analyze the prescriptions of Veratrum and Nux vomica referred to, we shall find certain constant phenomena characterizing both the constipation and the diarrhea, and which would determine the prescription almost without reference to the excretion.
The Veratrum diarrhea is uncontrolled and almost unnoticed by the patient, liquid faces escaping with the flatus. Here we have a paretic and anaesthesic state of the rectum and sphincter.
The Veratrum constipation exists solely because the rectum does not perform its expulsive function, and is not, as normally it should be, irritated thereto by the presence of faces. Here likewise is a paretic and anaesthesic condition.
But Veratrum is not fully indicated in either case without the characteristic general symptoms : general depression of vitality ; predominant coldness of the body ; pallor and cold sweat of the forehead, or of the whole body, on slight emotion or exertion, as, for example, on having a diarrheic stool, or making the ineffectual effort to have a stool, if constipated.
Both the constipation and the diarrhea of Nux vomica are characterized by increased but uncoordinated activity of the intestine, evinced by tormina and tenesmus, and frequent insufficient stools ; so that the condition of intestinal action is the same, whether there be, as in one case a minus, and as in the other, a plus of excretion ; and, indeed, in the Nux vomica patient these conditions often alternate. These remarks and instances will sufficiently illustrate my conclusions, viz. :
That the appearance or non-appearance of opposed series among the symptoms of a drug depends chiefly, if not altogether, upon the dose in which the drug was proved ; and that the question of the constant and necessary appearance of such series cannot be determined until experiments with a uniform and the least possible dose shall have been made by many provers with the same drug, and in the case of many drugs, and therefore that, 1st, Although in our Materia Medica, as it now exists, pathogeneses do present certain series of symptoms more or less opposed, nevertheless (excluding the symptoms of the agony which are not available in practice), inasmuch as these series of symptoms occur in different orders in different provers according to dose or idiosyncrasy, no sound practical distinction can be drawn between them, based on assumed difference of nature ; by virtue of which they can be designated respectively as primary and secondary.
2d : That symptoms, apparently opposed (not including these of the agony), occurring in a drug-proving are equally available as guides in the selection or remedies.
Coming now to the special subject of this paper, I justify the length at which the preliminary subjects have been discussed by the suggestion that, if I have shown that there is no basis for a division of drug-symptoms into primary and secondary, I have thereby shown the impossibility of a law of dose based on such a division.
Or, if admitting that in pathogeneses there do appear groups of symptoms apparently opposed, I have shown that these refer only to certain functions, and by no means embrace, or could be made to include, the symptoms of the entire organism. I have thereby shown that an alleged law of dose based on the existence of these groups, must necessarily be partial, and therefore devoid of that generality of application to the entire pathogenesis which alone would justify the appellation "LAW ;" and I claim to have shown these things.
In 1844, Dr. C. Hering in a letter to the German Central Vertin in session at Magdeburgh (N. Archives., 21, 3, 166) rejects Hahnemann's explanation of primary and secondary symptoms. He admits that there are in every proving primary and secondary symptoms, in the sense that some symptoms appear earlier and others later in the course of the proving, but affirms that although these may appear to be opposed to each other, they are all to be regarded as drug-symptoms, and as such are to be made the basis of prescriptions.
He gives instances of such prescriptions in the cases of Conium, Opium, and Mercury. Indeed, he says that the longer-lasting, more permanent and more apposed to the earlier these later symptoms are, the more useful are they in practice. He says further, that "the course of the drug-,disease (in proving) must correspond with that of the disease to be treated." Hering further states that "all symptoms which arise in provings of the higher potencies are similar to the later effects of the lower or so-called stronger doses, and are not like the first effects of strong doses." He adds that the great characteristics of remedies [as we have seen in the eases of Nux vomica, Veratrum, etc.] accompany both the earlier and later symptoms, e. g., the burning of Arsenic.
From these considerations, Hering deduces the following last of dose :
"Having chosen the remedy according to the symptoms of a case from the complete correspondence of the characteristics in disease and drug, we have only to consider whether the symptoms of the case generally have more resemblance to the earlier (primary) symptoms of the drug, and then we give the lower potencies ; or more resemblance to the later (secondary) effects, that is to the symptoms produced by the higher, potency provings, and when we give the higher."
It may be said that this is simply saying : Prescribe doses analogous to those which produced, in the proving, the symptoms presented by the case under treatment. But it amounts to a great deal more, for by showing that the symptoms produced in provings by small doses correspond with the later, effects of large doses, it enables us to infer the effects of small doses in cases where provings have been conducted with large doses only.
In 1860, Dr. E. M. Hale published an elaborate article in the N. A. F. of H., vol. IX., on "The Dose," in which he expresses the belief that he has discovered the long-desired law by which "the proper dose for each case may be selected with as much certainty as the proper remedy," as follows :
"In any case of disease we must select a remedy whose primary and secondary symptoms correspond with those of the malady to be treated," and
"If the primary symptoms of a disease are present, and we are combating them with a remedy whose primary symptoms correspond, we must make the dose the smallest compatible with reason ; and if we are treating the secondary. symptoms of a 'malady with a remedy whose secondary symptoms correspond, we must use as large a dose as we can with safety"
These propositions rest on the assumption that all drugs produce, and all diseases present, two series of symptoms, primary and secondary, and that in one or other of these classes is embraced every symptom of drug or disease.
I have expressed my dissent from this view, and given reasons for thinking that a distinction between primary and secondary symptoms, if ever justifiable, is, at most, applicable to but a portion of the symptoms of each drug.
It cannot, if I am correct, be made the basis of a general law.
Dr. Hale illustrates his meaning by referring to Aconite, the primary symptoms of which, he says, "correspond perfectly with the chilly stage of all fevers," while the secondary symptoms of Aconite "correspond with the hot stage of fever." He therefore recommends a small dose of a dilution of Aconite during the chilly stage, and large doses of the tincture or 1st decimal during the hot stage, and relates results of such treatment, which seem to have satisfied him, but would hardly have satisfied me.
Again, he tells us that the primary symptoms of a group of remedies, of which Cinchona, Ferrum, Conium, Nux vomica, and Ignatia are members, are such as to denote that these drugs first "increase the tone and strength of the muscular or nervous system, impart vitality and vigor to the functions of the vital organs ;" and that their secondary effects are to cause "a peculiar atony, a condition of deficient vitality, and a cachexia of a more or less obstinate character."
And, stating further, that an outbreak of intermittent fever is always preceded by "an era of good feeling," a condition of exalted muscular and nervous tone and vigor, he regards this as the primary stage of that disease, to be treated, when recognized, therefore, by small doses of Cinchona. The outbreak of paroxysmal fever is regarded by Hale as belonging to the secondary series of symptoms, and therefore to be treated by as large doses of Cinchona as may safely be given.
In a paper presented to this Institute in 1874, Dr. Hale reiterates these views in substance and re-affirms this alleged "law of dose." He illustrates the two alleged series of symptoms in disease, called primary and secondary, by the instance of inflammation of the urinary passages, in which congestion and arrested secretion with fever and pain appear first, and are succeeded by profuse secretion or suppuration, prostration and cessation of pain, etc. And he affirms that the group of cognate drugs, of which Cantharis may be the representative, presents similar series of primary and secondary symptoms.
Considering, first of all, the last illustration, it is true that the process of inflammation consists of several successive steps, "accelerated and increased circulation, followed by retarded and diminished circulation, exudation of liquor sanguinis, emigration of leucocytes and stasis," and it is true that the earlier steps are prior to the later, but they are equally successive and necessary steps in a uniform and definite process, and nothing justifies the drawing a line anywhere in the process, and affirming that all that lies behind the line belongs to a different and opposite series to that which lies in front of it. Nor can I recognize in drug provings any such opposed series.
Neither Hahnemann's provings of Cinchona and Ferrum, nor Hahnemann's and Harley's proving of Conium, nor Hahnemann's provings of Nux vomica and Ignatia seem to me to support the allegations of Dr. Hale.
Alluding now to Hale's remarks upon Aconite, I refer to my quotations of Hahnemann, Rothausl, Zlatarovich and Sharp, which show that Aconite does not produce a distinct chilly stage first, followed by continued heat, but, as Hahnemann says, "alternating conditions made up of shivering or cold and heat ; and recurring frequently or at longer intervals."
So that while I will not deny that Dr. Hale prescribed as he says he did, and with the results which he describes, I do affirm that the pathogenesis of Aconite affords no ground for the theory on which he says he acted, or which he deduced from his action.
And, if I may deviate for an instant from the subject strictly under discussion, these statements about Aconite and it application suggest the fact that many prescriptions professedly homeopathic are really made ex tusu in morbis, and are not based on a strict individualization of the case, and a selection of the drug whose symptoms correspond to it. Aconite, having early acquired a reputation as a remedy in febrile conditions, is too often given in routine fashion, "in all fevers" (to use Dr. Hale's phrase), and therefore in many cases in which the symptom's do not at all indicate it. For, as even Hahnemann warned us, "it is not in every case presenting febrile symptoms that Aconite is homeopathically indicated ;" and therefore it cannot truly be said to correspond to the "chilly" or any other "stage of all fevers."
Given when the patient is quiet, lies still, is tranquil in mind and hopeful or patient, it will not remove the symptoms as a Homeopathically selected remedy would do.
Nor is it indicated by a similarity of symptoms in any save a small minority, if in any, of the intermittent, remittent or continued fevers which so often prevail in different parts of our country, nor in the febrile condition which persists when parenchymatous inflammation is established in any important organ.
It was my purpose to follow and analyze the statements and arguments of this writer on this important subject, but I find that I cannot do so. His premises consist of citations from allopathic writers, which seem to me to be statements based on observations of the action of drugs in large doses on the sick, and on theoretical deductions from these observations, and which certainly bear little or no resemblance to the pathogeneses of the Materia Medica Pura, on which I have been wont to rely for a knowledge of drug-effects, but to which my colleague rarely refers.
His allusions to treatment seem to me to be of a very generic character, based on assumptions of the pathological nature of the disease in question, and consisting of an application of drugs according to a vague and general resemblance of assumed pathological conditions. In all of this I fail to see any allusion to, or any place for, the strict individualization of cases, which is the very essence of sound homoeopathic treatment. In studying these papers, in fact, I hardly realize that I am perusing the works of a practical homoeopathist, according to my conception of Hahnemann's idea of homoeopathic practice, and I perceive, to my dismay, that I do not stand on common ground with the author to the extent necessary to make possible a further discussion of his treatment of the question at issue.
I must content myself, therefore, "with the simple statement that my own observation and experience do not enable me to corroborate Dr. Hale's statement of the "Law of the Dose," based on the distinction of primary and secondary symptoms. Where Aconite has been truly indicated by the symptoms of the case, I have seen prompt relief follow the administration of a high potency, given when the patient was in the hot stage, and likewise when in the chilly stage ; and in both the effect has appeared in a much shorter time than Dr. Hale's remarks would lead one to anticipate.
In the treatment both of constipation and of dysenteric diarrhea by Nux vomica in cases in which the characteristics of Nux vomica were present, the higher potencies have been equally efficient, leaving nothing to be desired, and the same may be said of Veratrum album in diarrhea and in constipation, when the characteristics of that drug were present.
It may be, and I am inclined to believe, that the law proposed by Dr. Hering may be found to represent the facts ; but for its demonstration and its general application in practice, we need a much more complete Materia Medica than has yet been furnished us.
In conclusion of this branch of the subject, I think that no, law for the determination of the dose can be deduced from the relation of opposition or contrariety on the basis of which symptoms have been divided into series of primary and secondary.
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