|Chapter 11: Historical Development of Dose and Potency
The issues of dose and potency need to be seen in their historical unfolding in order that the remarkable consistency of approach and the underlying principles can be fully appreciated and comprehended. (See also the section Dose and Potency). Part of the history of dose and potency has already been touched on in Chapters 3 and 4 of this Volume as part of the study of the history of dual remedy prescribing. The account in this chapter is a more detailed and complete historical study of the subject.
From the start of his establishment of a true system of Western medicine, in 1796 (Essay on a New Principle), Hahnemann introduced the concept of what we could term the "optimal dose," that is, the dose that is just greater in strength than the natural disease.
The cautious physician, who will go gradually to work, gives the ordinary remedy only in such a dose as will scarcely perceptibly develop the expected artificial disease, (for it acts by virtue of its power to produce such an artificial disease)... (Haehl, Vol. I, p. 265-266, footnote 3)
Hahnemann also mentions repeatedly the use of moderate doses in cure compared to the large often poisonous doses common to his day. This concern with the poisoning effects of larger doses led Hahnemann to seek to reduce the quantity by diluting the medicine in alcohol. At the same time, he undertook to thoroughly shake or succuss the dilution. Here we have the earliest mention of what came to be termed the dynamised dose.
In 1799, Hahnemann first spoke of dilutions.
The first hints of dilutions are to be found in the translation of the second part of the Edinburgh Dispensatorium (1798). Silver Nitrate was recommended by Boerhaave in doses of 2 grains, worked into pills with breadcrumbs and sugar. Hahnemann considered that too strong, and suggested a very diluted preparation. In the same year, in the "Apothecaries Lexicon" he recommends Sabina "in very small doses" and Hyoscyamus also "in very small doses according to my method one-sixtieth to one-thirtieth grain (0.000-0.002 gram) of the concentrated juice given in solution." Stramonium he liked to administer only in the hundredth or even thousandth part of a grain of the concentrated juice. (Haehl. Vol. I, p. 312)
In 1800, Hahnemann stated:
As the physicians of today will not consider giving one ten millionth part [1/10,000,000] of a remedy, therefore Arsenic is not a medicine for them. (Haehl, Vol. I, p. 312)
In 1801, he gave the first detailed description about dilution and succussion in his treatise on scarlet fever (Cure and Prevention of Scarlet Fever). Here we have perhaps the formal start of the dynamised medicine as Hahnemann's use of the term "intimate" to describe the fact that the diluted substance still had a profound effect on the living organism. Contrast the directions for internal use which required "intimate" mixing, and that for external use where only occasional shaking was needed, suggesting Hahnemann's awareness of the dynamic effects of the diluted/shaken medicine on the human being.
For external use I employed a tincture formed by adding one part of finely pulverised crude opium to twenty parts of weak alcohol, letting it stand in a cool place for a week, and shaking it occasionally to promote the solution. For internal use, I take a drop of this tincture and mix it intimately with 500 drops of diluted alcohol, and one drop of this mixture likewise with other 500 drops of diluted alcohol, shaking the whole well. Of this diluted tincture of opium (which contains in every drop one five-millionth part of a grain of opium) one drop given internally was amply sufficient in the case of a child of four years of age,* and two drops in that of a child of ten years, to remove the above state.
The smallness of the dose in which the medicine that acts upon the whole system of the living organism, when it is suitable to the case, produces its desired effect, is incredible, at least is incredible to my colleagues, who think it requisite to give to infants at the breast opium in half-grain doses, and who are ready enough to attribute the sudden death by poisoning that often ensues to a multitude of other causes. The drops for internal use must be intimately mixed with from one to four tablespoons of fluid (water or beer) just before they are administered. (Lesser Writings, p. 375, footnote 3)
He gave similar directions for the other medicines for scarlet fever, Ipecacuahna and Belladonna.
In speaking of the prophylactic action of Belladonna, Hahnemann also gives us very precise directions for a serial dilution that leads to a dilution of 1/24,000,000.
If we now wish to prepare from this the prophylactic remedy, we dissolve a grain of this powder ... in one hundred drops of common distilled water, by rubbing it up in a small mortar; we pour the thick solution into a one-ounce bottle, and rinse the mortar and the pestle with three hundred drops of diluted alcohol (five parts of water to one of spirit), and we then add this to the solution, and render the union perfect, by diligently shaking the liquid. We label the bottle strong solution of belladonna. One drop of this is intimately mixed with three hundred drops of diluted alcohol by shaking it for a minute, and this is marked medium solution of belladonna. Of this second mixture one drop is mixed with two hundred drops of the diluted alcohol, by shaking for a minute, and marked weak solution of belladonna; and this is our prophylactic remedy for scarlet-fever, each drop of which contains the twenty-four millionth part of a grain of the dry belladonna juice. (Lesser Writings, p. 380-381)
This unprecedented dilution and "weakening" of the common doses of his time brought forth immediate criticism from his most prominent medical ally, Hufeland, editor of an influential journal. This caused Hahnemann to write a defense of his new approach in Hufeland's medical journal in 1801, entitled, On the Power of Small Doses of Medicine in General and of Belladonna in particular.
This article has a number of important observations:
- The dry dose is weaker, the liquid dose is stronger.
- The sick person is more sensitive to the similar remedy, so the dose needs to be smaller (more diluted) to avoid an unnecessary homeopathic aggravation.
- The more acute the disease the smaller (more dilute) the dose.
- Use descending dose (that is from more dilute to less dilute) when the person is generally healthy and has only a local affection.
- The action of the diluted dose is purely "dynamical."
- The aggravation from a small dose of the wrongly selected medicine is quickly overcome and leaves no lasting effect (a form of unintended proving).
Here Hahnemann ascribes the effect of the small dose of Belladonna to the fact that it is mixed in water (and intimately shaken) and given to a sick person (who is more sensitive to the medicine) who is or has suffered from a Belladonna-like disease (similars). The degree of sensitivity to dose increases the greater the degree of similitude.
A very hard dry pill of extract of belladonna produces in a robust, perfectly healthy countryman or labourer usually no effect. But from this it by no means follows that a grain of this extract would be a proper, or too weak a dose for this or a similar stout man if he was ill, or if the grain were given in solution certainly not! On this point, let the pseudo-empiricism of the compendiums hold its tongue; let us hear what experience says. The most healthy robust thresher will be affected with the most violent and dangerous symptoms from one grain of extract of belladonna, if this grain be dissolved thoroughly in much (e.g. two pounds of) water by rubbing, the mixture (a little alcohol being added, for all vegetable solutions are rapidly decomposed) made very intimate by shaking the fluid in a bottle for five minutes, and if he be made to take it by spoonfuls within six or eight hours. Those two pounds will contain about 10,000 drops. Now if one of those drops be mixed with other [sic] 2000 drops (six oz.) of water (mixed with a little alcohol), by being vigorously shaken, one tea-spoonful (about 20 drops) of this mixture given every two hours, will produce not much less violent symptoms in a strong man, if he is ill. Such a dose contains about the millionth part of a grain. A few tea-spoonsful of this mixture, will, I assert, bring him back to the brink of the grave, if he was previously regularly ill, and if his disease was of such a description as belladonna is suitable for...
...secondly, because many physicians, ignorant of the purely dynamical action of medicines, are prevented from instituting any experiments of this nature by their invincible prejudiced incredulity [regarding the small doses]...
To the ordinary practitioner it is incredible that a given person, when sick, needs only to take a millionth part of the same drug that he swallowed when well without it having any particular effect, in order to be violently acted on; and yet this is undeniably the case...
Will medical men ever learn, how small, how infinitely small, the doses of medicines may be in order to affect the system powerfully when it is in a morbid state? ... The nearer the disease approaches the acute character, the smaller are the doses of medicines (I mean of the best selected one) it requires in order to disappear. Chronic diseases also combined with debility and general derangement of the health, do not require larger ones. It is only in cases where along with a local affection, the general health seems to be good that we must proceed from the first small doses to larger ones, to the very largest however in those cases where the medicine only can act in a palliative manner. ...
If the appropriate medicine in solution is efficacious in such a small dose, as it assuredly is - how highly important on the other hand is it, that in the event of the remedy being improperly selected, such a small dose can seldom excite such serious symptoms (ordinarily termed aggravations of the disease) as that they shall not soon disappear spontaneously, or be readily removed by some trifling antidote. (Lesser Writings, p. 387-389).
11.1 DYNAMIZATION (VERSUS POTENTIZATION)
We can now clearly see between 1796 and 1801 the concept of dynamization, as opposed to simply the idea of dose (one or more granules of a substance), that emerges from this insight into the liquid dose and the serial dilutions. The idea of dynamization is the insight that all medicines act dynamically, an idea that is distinct from that of potentization, that is, a mother tincture can act dynamically, and indeed, must do so for cure of the disease, which is itself dynamic in nature.
Hahnemann meant by dynamization the process of imparting spirit-like activity to the substance, or more accurately, liberating the spirit-like potential of a medicinal substance. In essence, Hahnemann had discovered a way in which to penetrate the veil of natura naturata, past the sensory world of appearances (chemistry) and into the supersensible world of dynamic effect (the realm of natura naturans, the Living Power or Dynamis). It is the succussion or intimate agitation of the liquid solution (or the process of trituration over a long period of time) that Hahnemann discerned as the agent of the spirit-like awakening of the natural substance.
In describing, in 1837, the process of "shaking the liquid" each time a dose (usually a tablespoon) is given to the patient, Hahnemann states that this is the dynamization. Thus, the potency is not altered, as it remains the same potency by the nomenclature usually used (e.g., 30C) but the degree of dynamization is heightened.
This slight change in the degree of dynamization is even affected, if the bottle which contains the solution of one or more pellets is merely shaken five or six times, every time before taking it. (Chronic Diseases, p. 156)
We can also see that succussion alone affects the idea of dose (which is both general and specific - see below), namely through the quality of power of the medicine.
§161.1. a]1 If the doses of the best dynamized medicine (§270) are small enough and if the dose was modified anew each time by succussion, then even medicines of long active duration can be repeated in short time periods even in chronic diseases.
Disease, being dynamic, that is, ground in the generative power of the Living Principle, requires a dynamic agent to be destroyed. Hahnemann talks of taking one drop from a solution and then mixing it vigorously, a process he sees as making the solution (medicine) "intimate," seemingly a generative term (sexual in nature). All through this article, we see without doubt that he is moving away from the idea of quantity and into the idea of quality. In fact, he sees these as being functionally related.
The next reference to dose in his writings is in 1805 in The Medicine of Experience, where he speaks of the heightened sensibility of the sick person to small doses of the similar medicine, as well as, again, to the dynamic nature of the remedies:
With the exception of these few things and the almost purely mechanical operations of surgery on the body, amputation which merely shortens the limb, and blood-letting which merely diminishes the amount of that fluid, together with some mechanically injurious and insoluble substances that may be introduced into the body all other medicinal substances act in a purely dynamic manner, and cure without causing evacuations, without producing any violent or even perceptible revolutions.
This dynamic action of medicines, like the vitality itself, by means of which it is reflected upon the organism, is almost purely spiritual in its nature...
Almost the sole condition necessary for the full and helpful action is that the appropriate remedy should come into contact with the susceptible living fibre; but it is of little, almost no consequence how small the dose is...
If a certain small dose of diluted tincture of opium is capable of removing a certain degree of unnatural sleepiness, the hundredth or even the thousandth part of the same dose of such a solution of opium suffices almost equally well for the same end, and in this way the diminution of the dose may be carried much further without the excessively minute dose ceasing to produce the same curative result as the first...
I have said that the contact of the medicinal substance with the living, sensitive fibre is almost the only condition for its action. This dynamic property is so pervading that it is quite immaterial what sensitive part of the body is touched by the medicine in order to develop it whole action...
...Dry preparations of the medicine in powder act less powerfully through it; its solution acts more powerfully, and still more so if it be applied to a larger surface [here he is talking of external applications of medicine]...
But the diseased organism is altogether much more sensitive for the dynamic power of all medicines, so also is the skin of diseased persons... (Lesser Writings, p. 465-467)
This is confirmed in the final edition of the Organon, when speaking of the LM potency:
§270.9. g]2 It thereby becomes exceedingly probable that the material by means of such dynamizations (evolutions of its true internal, medicinal Genius) finally dissolves itself wholly into its individual spirit-like Entity and thus in its crude state could be considered only actually to consist of this spirit-like Entity.
What we see here clearly is that the energy of the medicine comes from the Dynamis (Genius) of the medicine, a generative power.
11.2 OPTIMAL DOSE (VERSUS INFINITESIMAL DOSE)
Hahnemann very much links the dynamic action of medicine with its quality and quantity. The dynamic nature of medicine allows the true physician to use a very small, infinitesimal (in quantitative terms) dose. This smallness is to be optimal, that is, effectively the amount by which the medicine exceeds the habituation of the living organism to a particular influence. Even where the amount of medicine seems large, it works to the extent that it exceeds in a slight amount the sensitivity of the organism.
The concept of the optimal dose is a qualitative one that informs the qualitative concept of the dynamic medicine. This is different from potency and the idea of infinitesimal doses. An optimal dose may be of a mother tincture or it may be of a very high potency. The determinant is the strength of the disease. Thus, we can have the progressive use of dynamic medicines starting from relatively low potencies, or even material quantities, to higher potencies in order to match the resonance of the disease (which can exist at various levels of intensity).
Thus, the greater the sensitivity to a substance, the smaller the dose required. All medicines work dynamically, even where this does not appear to be the case.
The medicinal power of heat and cold alone seems not to be so exclusively dynamic as that of other medicinal substances. Where these two agents are employed in a positive manner, the smallest possible dose of them does not suffice to produce the desired effect. When it is requisite to obtain relief rapidly they both have to be employed in greater intensity, in a larger dose (up to a certain amount). But this appearance is deceptive; their power is just as dynamically medicinal as that of other medicines, and the difference in given cases depends on the already existing habituation of our body to certain doses of these stimuli, to certain degrees of heat and cold. The heat and cold to be employed in a medicinal manner must surpass this accustomed degree by a little, in order that it may be employed in a positive manner with success (by a great deal, if it is to be used in a negative or palliative manner.) (Lesser Writings, p. 468)
None but the careful observer can have any idea of the height to which the sensitiveness of the body to mechanical irritations is increased in a state of disease. It exceeds all belief, when the disease has attained a great intensity. An insensible, prostrated, comatose typhus patient, unroused by any shaking, deaf to all calling, will be rapidly restored to consciousness by the smallest dose of opium, were it a million times smaller than any mortal ever yet prescribed. [here we see the base for the earlier noted principle that the more acute the disease, the smaller the dose, that is, more dynamic or potentised]
The sensitiveness of the highly diseased body to medicinal irritations increases in many cases to such a degree, that powers commence to act on and excite him, whose very existence has been denied, because they manifest no action on healthy robust bodies, nor in many diseases for which they are not suited. (Lesser Writings, p. 464)
The first edition of the Organon in 1810 produced several aphorisms devoted to dose:
§237 (275 in the 5th and 6th editions):
§275.1 The appropriateness of a medicine for a given case of disease does not rest alone on its apt homeopathic selection, but just as well on the requisite, correct size or, rather smallness of its dosage.
§242. One of the chief maxims of the homeopathic medical system is the following: The counter-disease force (the remedy), chosen as appropriate as possible for the cure of the natural disease, should be made only strong enough to effect our purpose, and should not injure the body in the least by unnecessary strength. (Dudgeon 5th edition of the Organon, p. 220)
In subsequent editions, including the 6th, the following paragraphs of the Organon replace §238-243 of the 1st edition of the Organon.
§276.1. For this reason a medicine, even if it was homeopathically appropriate to the disease case, does damage in every dose that is too large, and in strong doses all the more, the greater the homeopathicity and the higher the potency a] that was selected, and to be sure, far more than every equally large dose of an unhomeopathic (allopathic) medicine bearing no relation to the disease state.
§276.1.a] The more recent praise by some Homeopathists for larger doses is owing partly to the fact that they themselves used low potentizations of the medicine to be administered, dynamized in the hitherto manner (as perhaps I myself did 25 years ago for want of better knowledge), partly to the fact that their medicines were very imperfectly prepared by the manufacturer and partly to the fact that they were not homeopathically selected.
§277.1. For the same reason, and since a well-dynamized medicine, presupposing its dose to be properly small, becomes all the more curative and helpful, almost to the point of wonder, the more homeopathically it was searched out, a medicine whose apt selection has been homeopathically hit upon must also be all the more curative the more its dose descends to the appropriate degree of smallness for gentle aid.
§278.1. Here the question arises, as to what were the most appropriate degree of smallness for certain as well as gentle help, as to how small, therefore, for purposes of the best cure, the dose of each single medicine, homeopathically chosen for the disease case, would have to be?
§§for homeopathic curative purposes, yet being so minute that the gentlest and most rapid cure is to be thereby attained, is not the work of theoretical conjecture, as is easily realized; speculating intellect and subtle sophistry give just as little information about it as it is possible to record all conceivable cases in a table in advance.
§278.3. Only pure experiments, careful observation of the arousability of each patient, and correct experience can determine this in each particular case, and it would be foolish to want to advance the large doses of inappropriate (allopathic) medicine of the old practice, which do not homeopathically touch the diseased side of the organism, but only attack the parts unassailed by the disease, against that which pure experience expresses about the smallness of the doses necessary for the purpose of homeopathic cure.
Here we can see a distinction made, from the 2nd edition of the Organon (1819) on (there are some minor changes in the 6th edition), concerning the issue of dose and potency. This distinction is also made in an article written in 1814 on the treatment of typhus (then rampant due to the Napoleonic Wars).
Neither of the medicines can be used in a lower dilution [than 12C] or in a larger dose [one drop on a sugar cube]; they are too strong. (Lesser Writings, p. 634)
The issue of the size of the dose is now addressed in terms of parts of a drop. This becomes clear in the second volume of the Materia Medica Pura (1816) where Hahnemann advises in one case mentioned a drop of Bryonia juice ("one of the strongest homeopathic doses") and in another Pulsatilla in "half a drop of the quadrillionth part of the mother tincture." (Heahl, Vol. I, p. 317)
By the fifth volume, published in 1819, Hahnemann was speaking about "the smallest part of a drop." (Haehl, Vol. I, p. 318)
We also have in the quotes immediately above the emergence of a distinction between dose (quantity) and potency (quality) out of the dynamization of the medicine (through the method of dilution and succussion).
Thus, Hahnemann began to realize that the smallness of the dose was linked both to the size in terms of drops or parts of a drop (quantity) and to the degree of dilution/succussion or dynamization (quality).
Any prescription had to take both into account. The disease, which was dynamic, had to be matched in terms of similarity and dose, and dose meant both quantity and quality. As in the case of the term "symptoms," where Hahnemann had both a narrow and wider meaning, he seems to have used the term dose in the general and more particular sense. We can see this in the following quotes:
...for it holds good and will continue to hold good as a homoeopathic therapeutic maxim not to be refuted by any experience in the world, that the best dose of the properly selected remedy is always the very smallest one in one of the high potencies (X) [30C]...
...one such smallest dose of medicine in our highly potentized dynamization... (Dudgeon edition, p. 123, footnote; from the 5th edition of the Organon)
§25.1. Now, however, in all careful experiments, pure experience, a] the sole and infallible oracle of the Remedial Art, teaches that the medicine which in its impingement on healthy human bodies has proven itself capable of engendering the most symptoms in similarity found in the disease case to be cured, also (in properly potentized and diminished doses) rapidly, thoroughly and permanently lifts and transforms the totality of the symptoms of this disease state...
§221.1. ...selected from the class of the other proven remedies in highly potentized, subtle homeopathic doses, in order to dispatch the acute disease to such an extent that the Psora returns for the present to its previous almost latent state, wherein the patient appears to recover.
It would seem that when Hahnemann referred to "small dose" he had in mind mainly the quantity (in terms of the number of globules or drops, or the frequency of administration "single dose"), whereas the term "dose" by itself could have the more encompassing meaning of quantity and quality (potency).
§234.1. ...the intercurrent use of a very small dose of potentized cinchona bark solution is necessary in order to entirely extinguish their intermittent fever-like Type.
§246.4. And this allows itself also, as the most recent, oft repeated experiences have taught me, to be carried out right happily under the following conditions: firstly, if the medicine selected with all circumspection was aptly homeopathic secondly, if it is highly potentized, dissolved in water and administered in properly small dosage at intervals the most distinctively appropriate according to experience for the best possible acceleration of the treatment, but with the precaution that the degree of potency of each dose should deviate somewhat from the previous and subsequent doses, so that the Living Principle being resonified to the resonant medicinal disease may never feel itself agitated to adverse counter-actions and enraged, as happens with unmodified renewed doses, especially when rapidly repeated one after another.
§247.1. a]2 But by modifying each dose in its of dynamization, as I teach here, no offense takes place, even with more frequent repetition of the doses, no matter how highly potentized the medicine may be with ever so many succussions.
§249.1. a]1 Since according to all experiences almost no dose of a highly potentized, specifically fitting homeopathic medicine can be prepared that is too small to produce a distinct improvement in the disease for which it is suited (§161, 279), we would then be practicing inexpediently and deleteriously, as happens with the hitherto method of treatment, if we wanted to repeat the dose or indeed even augment the same medicine, in cases of non-improvement or small exacerbation, under the delusion that the medicine has not been able to be of service on account of its small quantity (of its all too small dose).
He also referred to the idea of potency by the term "finest dose."
83.1. ...by means of a few, well pondered, simple medicines, in the finest doses,
93.1. a]5 Thus, warmth and cold do not act as remedies in bodily ailments by virtue of their nature (therefore not as warmth and cold per se, not as things detrimental in themselves, as are perhaps the medicines rhubarb, China, etc., even in the finest doses) rather, merely by virtue of their greater or lesser quantity;
§11.1. a]17 That finest dose therefore can contain almost simply and solely the pure, freely unveiled, spirit-like medicinal power, and only dynamically carry out such great actions as could never be achieved by the crude medicinal substance, even taken in a large dose.
At one point between the 4th and 5th editions of the Organon (1828-1833), Hahnemann tried to increase the number of globules in a given dose in order to achieve a speedier cure, but found that this only created an unnecessary aggravation. He noted that using a lower dynamization of the remedy (the rationale being that this would reduce the medicinal effect) in the same large dose also did no good. Hahnemann was initially driven to use larger doses, or lower potencies, by the logic of his position in the first four editions of the Organon on the single dose.
Between the use of a single, small dose of a given potency and the use of large doses of lower potencies, Hahnemann sought and found a "middle path" as he called it, in the use of repeated doses. He felt the need to increase the speed of the cure and recovery from disease and now advised the need for repeated doses, but only once every week or so. The determination of the time interval would depend on the nature of the medicine, the "corporeal constitution of the patient" (vitality) and the "magnitude of disease." The deeper acting the remedy, the lower the vitality, and the more chronic the disease, the longer the interval. (see Dudgeon edition of the Organon, p. 124)
11.3 CHANGES ANNOUNCED IN 1837
It was only a number of years later that Hahnemann developed the idea of the liquid dose, to be divided and given almost daily.
Hahnemann first explained this method in a letter to Constantine Hering, a German homeopath who settled in America.
In 1835 (year 39) Hahnemann wrote to Hering, describing the further diminution of dose by giving portions ("split doses") of a medicinal solution produced by dissolving a medicated centisimal pellet in a volume of water. This reduced dose allowed for more frequent repetition during the gradual amelioration of chronic disease, with gradual ascent of potency by stirring or succussion of the solution prior to each repeated dose. (Will Taylor, The Development of Dose and Potency in the History of Homeopathy, simillibus.com).
The details of this method were then published in the preface to the 3rd part of the 2nd edition of Chronic Diseases (1837).
Experience has shown me...that it is most useful in diseases of any magnitude...to give the patient the powerful homeopathic pellet or pellets only in solution, and this solution in divided doses. In this way we give the medicine, dissolved in seven to twenty tablespoons of water without any addition, in acute and very acute diseases every six, four or two hours; where the danger is urgent, even every hour or half-hour, a tablespoon at a time...
In chronic diseases, I have found it best to give a dose (e.g., a spoonful) of a solution of the suitable medicine at least every two days, more usually every day. (Chronic Diseases, p. 155-156)
The key to the repetition was:
- the use of the same solution (rather than making a new one up each time of the same potency), so as to divide the dose, and
- the succussing of the main solution each time slightly, which served to prevent resistance in the form of a too-strong counter-action on the part of the Living Power, as well as the succussing of the final daily solution used to give the daily dose - tablespoonful.
But in taking one and the same medicine repeatedly (which is indispensible to secure the cure of a serious, chronic disease), if the dose is in every case varied and modified only a little in its degree of dynamization, then the vital force of the patient will calmly, and as it were willingly receive the same medicine even at brief intervals very many times in succession with the best results, every time increasing the well-being of the patient. (Chronic Diseases, p. 156)
On days, when only the latter [rubbing in] is administered, as also when it is taken internally, the little vial containing the drops must every time be briskly shaken five or six times; so also the drop or drops of medicine with the tablespoonful of water must be well stirred in the cup.
It would be still better if instead of the cup a vial should be used, into which a tablespoonful of water is put, which can then be shaken five or six times and then wholly or half emptied for a dose. (Chronic Diseases, p. 159).
The last quote refers to the use of a slightly different dilution of the stock solution in warmer weather to avoid having to use too much alcohol or charcoal as preservative which "were still objectionable to me with many patients." (Chronic Diseases, p. 159)
At the same time, Hahnemann continued to use the greater "dilution" of the power of the remedy "in cases where a great irritability of the patient is combined with extreme debility" by means of daily olfaction. However, he had to change the potency of the medicine each day in order not to repeat the same dynamization. (Chronic Diseases, p. 159-160)
With this new, divided medicinal dose, approach, Hahnemann was able to repeat the dose daily in chronic diseases. He also noticed that the homeopathic aggravation came at the end of the process, rather than at the beginning, and that this was the signal to shift to a different remedy.
This will be continued so long as the remedy still produces improvement and until new ailments (such as have never yet occurred with other patients in this disease), appear; for in such a case a new remedy will have to be used. (Chronic Diseases, p. 157)
Hahnemann gave new directions for repetition:
- first, where the daily dose produces too strong a reaction (counter-action), the dose should be stopped for a day;
- second, where the symptoms of the disease alone appear and are simply aggravated, the dosing must be suspended for several weeks.
On any day when the remedy has produced too strong an action, the dose should be omitted for a day. If the symptoms of the disease alone appear, but are considerably aggravated even during the more moderate use of the medicine, then the time has come to break off in the use of the medicine for one or two weeks, and to await a considerable improvement. (Chronic Diseases, p. 157)
11.4 DEVELOPMENT OF THE LM OR Q POTENCY
Hahnemann in his final years developed a greater dilution scale. He diluted the remedy on a scale of 1/50,000 (Q scale or now often called the LM scale), which approach he published in the sixth edition of the Organon (which, however, was not made public until 1922, where the change in prescribing was not really noted until the 1950's by Pierre Schmidt, a Swiss homeopath).
Hahnemann gave detailed directions for the preparation of this new potency scale.
- The substance (one grain) is triturated to the 3C level,
- One grain of this is dissolved in 500 drops of water/alcohol (80/20 ratio).
- One drop of this solution is put in another vial with 100 drops of alcohol and succussed 100 times.
- One drop of this solution is then used to moisten 500 fine sugar globules and these are marked as the first potency (I) - LM1.
- One globule is then used to make the next potency, using another 100 drops of alcohol and sucussing 100 times. The 500 globules are then moistened and dried and marked as the second potency (II) - LM2.
§270.1. Now in order to best effect this evolution of potential, a small part of the substance to be dynamized, about one grain, is brought to the one-millionth powdered attenuation by first triturating for three hour-long sessions, three times with 100 grains of milk sugar in the way stated below.
§270.2. For reasons which are further indicated in the footnote [f] below, one grain of this powder is dissolved in 500 drops of existing mixture from one part brandy wine [90 degree grain alcohol] and four parts distilled water, and a single drop of this is put in a vial.
§270.3. One adds to this 100 drops of good wine spirit [95 degree grain alcohol] and then gives the vial with its corked stopper, 100 strong succussions with the hand directed against a hard but elastic body.
§270.4. This is the first degree of dynamization, whereby fine sugar globules are first well moistened then rapidly spread out on blotting paper, dried and saved in a stoppered little vial with the sign of the first degree of potency (I).
§270.5. From this only a single globule is taken for further dynamization, put in a second new vial (with one drop of water in order to dissolve it), and then in the same way with 100 drops of good wine spirit dynamized by means of 100 strong succussions.
§270.5. f]5 On the contrary, the method indicated by me, engenders medicine of the highest evolution of power and gentlest action, which, if well chosen, curatively touches all diseased points. Only in very rare cases, when health is almost already fully restored and with good Living Power, nevertheless, an old troublesome local malady continues, it is not only allowed but even unavoidably necessary to administer in ascending doses the medicine proven to be homeopathically helpful, however, potentized up to a very high degree by means of many hand succussions, whereupon such a local malady disappears very soon in an often wonderful way.
§270.5. f]6 From these far more perfected dynamized medicinal preparations, one can, in acute fevers, repeat also at short intervals the small doses of the lowest degrees of dynamization, even of the medicines of long-lasting action (e.g. Belladonna), as well as best make the beginning in treatment of chronic diseases with the lowest degrees of dynamization, and when necessary pass over to the higher degrees which, although becoming ever more powerful, always act only gently.
§270.6. With this etherized medicinal fluid globules are again dampened, rapidly spread out on filter paper, dried, secured against heat and daylight in a stoppered glass and furnished with the sign of the second potency degree (II).
§270.7. And so continue in this way until one dissolved globule of XXIX [the 29th degree of potency] has formed an etherized medicinal fluid with 100 drops of wine spirit by means of 100 succussions, whereby globules moistened with this and dried are labeled XXX [the 30th] degree of dynamization.
The method of prescription of the new method of dynamization/potentization is the same as that detailed in the Chronic Diseases in 1837.
§248.1. With this intent, the medicinal solution a] is potentized anew each time before it is taken (with about 8 or 10 succussions of the bottle), from which the patient is given one or (ascending) several coffee or teaspoonfuls daily, or every second day in protracted diseases, in acute diseases every 6, 4, 3, or 2 hours, and every hour in the most urgent cases, or even more often.
§248.1. a]1 In 40, 30, 20, 15 or 8 tablespoons of water with the addition of some alcohol or a piece of charcoal to keep the solution from spoiling.
§248.1. a]2 Take charcoal, hung by a thread in the bottle and withdraw it every time when the bottle is to be succussed.
§248.1. a]3 The solution of the medicinal globule (for seldom more than one globule of a properly dynamized medicine is needed) in a very large quantity of water can be replaced by making a solution in only 7 - 8 tablespoons of water, and after the previously indicated vigorous succussion of the bottle, by pouring a tablespoon in a glass of water (containing about 8 - 10 tablespoons), stirring several times vigorously, and then administering the determined dose to the patient.
§248.2. Thus in chronic diseases, each correctly selected homeopathic medicine, even of long acting duration, can be ingested in daily repetition for months with ever increasing success.
In the case of very excitable patients, the process of dilution must be carried even further in order to "thin out" the power of the remedy, using a second or third glass.
§248.1. a]4 If the patient is unusually excitable and sensitive, then take from the glass, vigorously stirred up, a tea or coffee spoonful, which is vigorously stirred into a second glass of water in order to administer a coffee spoonful (or somewhat more) to the patient from it.
§248.1. a]5 There are patients of such high excitability that it is necessary to employ a third or fourth glass to properly thin the medicinal solution for them prepared in a similar way.
§248.1. a]6 Every day after ingestion, pour out the content of this prepared drinking glass (or several), in order to prepare it anew every day.
Thus, the unique nature of Hahnemann's dosing method in the 6th edition of the Organon lies not in the use of liquid, divided doses, nor in the succussing of the stock solution. It lies in the further dilution of the medicine on the basis of 1/50,000 as opposed to 1/100.
Hahnemann referred to the new method of dose and potency, based on starting with a small globule, as "medicaments au globule" compared to the former method which was called "medicaments à la goutte (drop)."
One could well ask why this new dilution scale was necessary. Hahnemann tells us that the use of almost daily doses, with its requirement to alter the degree of dynamization of the stock solution slightly before each dose, produced too strong an effect. It seems that the 1/100 dilution could not accommodate the repeated succussions without creating too great an intensity in the solution. A greater dilution scale allowed the repeated succussions to be absorbed and then released in a gentler fashion.
§270.5. f]1 According to the initial instruction, a full drop of the fluid of the lower degree of potency was always to be added to 100 drops of wine spirit for higher potentization; this proportion of the dilution medium to the medicinal quantity to be dynamized (100 to 1) was much too narrowly limited other than that a quantity of such succussions, without applying great force, would have been able to evolve the powers of the applied medicinal substance properly and in high degree, as laborious tests have convinced me.
§270.5. f]2 However, if a single such globule is taken, of which 100 weigh one grain, in order to dynamize it with one hundred drops (of wine spirit), then the proportion becomes 1 to 50,000, indeed still greater, in that 500 such globules cannot fully absorb one drop.
§270.5. f]3 With this unequally higher proportion between medicine and dilution medium, many succussions of the vial filled to 2/3 with wine spirit can produce a far greater evolution of power.
§270.5. f]4 However, with such a small dilution medium as 100 to 1 of the medicine, very many impacts by means of a powerful machine are, as it were, forced in, thus arise medicines which, especially in the higher degrees of dynamization, almost instantaneously, but with stormy, indeed dangerous intensity, impinge especially on the delicate patient without having as a result a lasting gentle counter-action of the Living Principle.
The LM (Q, fifty-millesimal) potency scale, which Hahnemann referred to only as his "medicaments au globule" as distinct from the centisimal "medicaments a la goutte", was developed in 1838 (year 42, 5 years before his death), with the intention of preparing remedies even better adapted for use in split dose in medicinal solution. (Will Taylor, The Development of Dose and Potency in the History of Homeopathy, simillibus.com/).
11.5 HAHNEMANN'S USE OF DOSE AND POTENCY: 1796-1816
1/18,000 grain of Aconitum; 1/2000 grain of Capsicum; 10 grains of Lathyrus cicera; 1/40,000 grain of Coraria; 1/400,000 grain or 1/1,600,000 grain of Pulsatilla; up to 1/3,840,000,000 of Chamomilla; 1/12,00 grain of Nux vomica.
Veratrum - 1/2000; Mezereum - 1/400,000; Ledum - 1/200,000; Oenanthe - 1/2000; Stramonium - 1/300,000; Nux vomica - 1/2,400; Belladonna - 1/12,000; Aconite - 1/1,800,000,000,000.
Hahnemann apparently returned to lower dilution doses for a time, then began to use the higher dilutions - e.g., Belladonna went from 1/100 to 1/120,00; Nux from 1/24,000 to 1/1,200,000. However, Chamomila remains in the dilution 1/3,840,000,000 (roughly equivalent to 18C). Some medicines were still prescribed in more material doses: Argentum - 4 grains; Ipecacuahna - 2 grains, etc.
Arsenicum in the 18C dilution and Nux in the 9C.
Use of various medicines in the 8C and 12C dilutions.
First reference to the 30C potency in the second volume of the Materia Medica Pura, which also contained for the first time detailed instructions for each substance regarding dose in terms of dilution and quantity of liquid. (Haehl, Vol. I, p. 317)
Although Hahnemann was conscious of the dynamic nature of medicinal action right from the beginning (around 1800, if not somewhat sooner), it was not until he had thoroughly tested different dilutions over another 10-15 years that he felt comfortable in giving the public details as to the extent of these dilutions. He had also developed a more consistent system of dilution, based on the metric system then introduced formally into science in revolutionary France, which he termed the C or centesimal scale.
In the years 1816-1822 Hahnemann continued to use various dilutions/potencies from the Mother Tincture to beyond the 30C in some cases.
11.6 USE OF MEDICATED GLOBULES
In 1821, we have the first formal reference to the fact that Hahnemann used small globules of lactose (about the size of a poppy seed) in order to divide a drop of solution (Haehl, Vol. I, p. 320). One drop could moisten one hundred or more globules. Thus, in addition to the increasing dilution (and, thus, corresponding power of the remedy), he found that he needed to decrease the quantity of the given potency.
In the period 1824-1827, Hahnemann continued to increase the potency use, even recommending Thuja in 60C potency, and also met with increased opposition from the medical establishment. At the same time, Hahnemann still used the entire range of potencies, from MT to the highest dilution, but his more enthusiastic followers went even further than the careful master and soon produced up to a 1.5M potency (1,500C). The main proponents of this high potency movement were Dr. Gross and Schreter in Germany and General Korsakoff in Russia.
The increasing opposition of the medical establishment, rooted as it was in the materialistic paradigm, to the increasing dilution of medicines caused Hahnemann some worry. Although he privately used ever higher dilutions in an attempt to better understand their action, he grew somewhat concerned at the public knowledge of these high potencies without adequate experience on which to base a definite recommendation. If anything, his experience had taught him that firm recommendations regarding potency in a case was almost impossible.
As he noted in the second edition of the Organon (§303), the dilution degree can only be determined by careful observation and accurate experience in a given case (Haehl, Vol. I, p. 318). This spirit of caution regarding the public rendering of his discoveries is a feature that marked his entire scientific life.
As a result, in the case of dilutions, he sought, at least publicly, in the year 1829 to limit the use of potencies to the 30C. He wrote to Dr. Schreter:
I do not approve of your potentising medicines higher than to XII and XXII - there must be a limit to the matter, it cannot go on indefintely. But by definitely deciding that homoeopathic medicine should all be diluted and potentised up to X[30th centesimal - R.H.] a homogenous process arises in the cures of all homoeopaths and if they describe a cure, we are able to work after them in the same degree, since they are operating with the same tools as we are. Then our enemies cannot reproach us with having nothing definite, no fixed standard. (Haehl, Vol I, p. 322)
In the period 1829-1833, Hahnemann embarked on the use, almost exclusively, of the olfaction method. This involved the sniffing of a single medicated globule of the 30C potency. The use of ever higher potencies and also the work of Korsakoff in medicating hundreds, if not thousands of unmedicated globules with one medicated globule, must have impressed on Hahnemann even more the dynamic nature of medicinal action. This experience with the smelling of a single globule or a relatively high potency (for his day) is also an important aspect in the history of the dual remedies (see section Consolidating Heilkunst and Prelude to Dual Remedies).
Hahnemann varied continually the recommendation for the number of succussions of a given dilution. Early on, with the more crude dilutions, he recommended a period of several minutes. Later, this was changed to 100, 10 or even 2 succussions. He realized that there was a medicinal (dynamic) effect from succussions that went beyond simply achieving a homogenous solution. The more the medicine is succussed, the stronger it becomes. Hahnemann first elaborated this understanding in the first edition of the Chronic Diseases (1828). In the 5th edition of the Organon (1833), he advises using two shakes instead of the 10 formerly recommended due to the too strong power developed.
Moreover, the homoeopathic medicine is potentised at every division and diminution by trituration or succussion. This was such a development of the latent powers of medicines never dreamed of before my time, that in later years I have been compelled by convincing experience to reduce the ten succussions, previously prescribed after each dilution, to two. (Note to #280 - Haehl, Vol. I, p. 325)
In 1837, he advises to return to the 10 succussions due to a change in the method of administering the dose. Previously it had been undivided (a globule dissolved in a small quantity of water), but now he prescribed this liquid dose in several parts over a number of days or weeks. The use of the olfactory method is reserved for the most sensitive patients.
When I used to administer medicines undivided, each taken with a little water, at one dose, I found that potentising in phials with ten succussions often acted too strongly (i.e., their medicinal powers were too strongly developed). I therefore advised only two succussions. But as for several years I have been able to give each dose in solution which will not deteriorate, distributing the dose over 15,20 or 30 days and more, now no potency in a vial is too strong if prepared each time with ten succussions. I must therefore take back what I said on this subject three years ago in the first part of this book, p. 186. (Chronic Diseases, preface to third part of the second edition, 1837 - quoted from Haehl, Vol. I, p. 326)
In the preface to the fifth and last volume of Chronic Diseases Hahnemann further states:
But even in the 50th potency...the smallest globules moistened with this medicine and dissolved in water can and must be taken in small parts so as not to produce too violent effects on susceptible patients. (Haehl, Vol. I, p. 326)
This view that the number of succussions affected the dynamic nature of the medicine (that is, its curative power), as well as the use of the olfactory method, seems not to have been accepted by the majority of the homeopaths of the day, including Haehl. (Vol I, p. 326)
11.7.1 SUCCUSSION AND DILUTION
Hahnemann realised that both elements were important in the development of the inner, spirit-like power of the medicine. He also discovered that to some extent, the use of succussion and dilution were interchangeable. In the footnote to Aphorism 270 of the 5th edition of the Organon, he states that the succussion alone raises the dynamisation and potency.
There are, however, homeopathists who carry about with them on their visits to patients the homeopathic medicines in the fluid state, and who yet assert that they do not become more highly potentized in the course of time, but they thereby show their want of ability to observe correctly. I dissolved a grain of soda [Natrum carbonicum] in half an ounce of water mixed with alcohol in a phial, which was thereby filled two-thirds full, and shook this solution continuously for half an hour, and this fluid was in potency and energy equal to the thirtieh development of power. (Dudgeon, p. 135-136, footnote 4)
Indeed, Hahnemann realised that the higher potencies went deeper into the Living Power of man. He also discovered that the higher potencies had a shorter initial action (something that became important in the use of dual remedies - see the section on Consolidating Heilkunst and Prelude to Dual Remedies).
In the 5th edition of the Organon (1833), in a footnote to Aphorism 287 (which was also there from the 2nd edition of 1819), Hahnemann writes:
The higher we carry the attenuation accompanied by dynamization (by two succussion strokes), with so much the more rapid and penetrating action does the preparation seem to affect the vital force [Living Power] and to alter the health, with but slight dimunition of strength even when the operation is carried very far... (Dudgeon, p. 148)
One French homeopath in the latter part of the 19th Century, Gallavardin, set out a means of using succussion alone of a given potency to achieve the same power as a higher potency arrived at by the serial dilution/succussion method.
Gallavardin argued, based on Hahnemann, that the dilution and succussion aspects of potency were partly interchangeable, in that they separated the matter more and more to release the "radiant energy."
To a certain extent, one factor may take the place of the other, provided one obtains the same product, nine hundred [30 dilutions with 30 succussions each time], to bring about the 30th dilution. When the latter is prepared in this manner it has the same strength as when it is prepared by thirty successive dilutions in thirty different vials. This fact...was recognized by Hahnemann...[noting that the experiment Hahnemann undertook amounted to 900 succussions, if once was done every 2 seconds]. (Gallavardin, How to Cure Alcoholism, p. 96)
This seems to be the basis that others used to develop high potencies without the more laborious process of dilution, such as those by Jenichen, who used mainly, if not exclusively succussion to achieve high potencies. Hahnemann apparently himself had some of the Jenichen potencies and must have used them.
Conforming to the experimental teaching of Hahnemann to separate more and more the constituent molecules of each remedy and bring the latter to a more radiant state, Jenichen substitutes a given number of succussions for a given number of dilutions. For instance, to raise Arsenic from the 800 to the 2600 dilution he gives the same vial 51,000 succussions, or about twenty-eight for each intermediate dynamization. (Gallavardin, p. 97)
11.8 WET VERSUS DRY DOSE
Hahnemann, right from the beginning dissolved the medicinal substance in water. In 1798 her recommends that 1/60 - 1/30 grain (0.001-.002 grams, or 1-2 milligrams) be given "in solution." (Haehl, Vol. I, p. 312) In his treatise on scarlet fever, in 1801, Hahnemann speaks of giving one drop doses from a solution of poppy juice (opium) to a child of 4 years, but diluting this one drop in 10 teaspoonfuls of water and giving it only one or several teaspoons, or younger children, according to age. (Haehl, Vol. I, p. 312)
In a footnote, Hahnemann notes that the one drop must be administered as a single dose by mixing it with water and succussing:
The drops administered internally must, immediately before taking, be vigorously stirred with one to four tablespoons of some beverage (water or beer!!). (Haehl, Vol. I, p. 313)
Thus, we also have the idea of the succussed liquid dose. In the prescriptions of 1803, Haehl notes that the medicine is always given in liquid form, even when highly diluted (Vol. I, p. 315).
In the 1st edition of the Organon (1810) Hahnemann gives us the more mature reflection on the use of the liquid dose, essentially in self-limiting, so-called acute diseases.
Every edition of the Organon, up to and including the 4th (1829) contained the following:
As every medicine acts most precisely and effectually in solution, the sensible practitioner will give in solution medicines which do not require to be administered in the form of powder. All other forms in which they have hitherto been used (pills, electuaries, &c.) are to be rejected because the action of the medicine on the living fiber is thereby rendered uncertain and determinate. (Dudgeon, p. 218)
We also find in §248 that "dividing the dose (giving it at several intervals) has a much more powerful effect than the whole dose administered all at once." (Dudgeon edition of the Organon, p. 223) This idea would later form the basis for the divided medicinal dose of the period from 1835-1843.
11.9 SUMMARY: HISTORICAL DEVELOPMENT OF DOSE/POTENCY
- At the start, it seems clear that Hahnemann's focus was on reducing the drug aggravation of the medicinal doses of his day, which were in the form of grains (20 grains to one gram). While he had resurrected the law of similars as the curative principle, he discovered that, because of his understanding of the dual action of medicines (initial and counter-action), remedies could still cause adverse effects that risked engendering a new, drug disease, even as the old, natural disease was removed. Already in 1796, with the first public defense of the principle of similars (Essay on a New Principle), Hahnemann spoke of using "small doses." In a footnote, he notes that this smallness is in principle linked to the ability of the medicine to engender an artificial similar disease over the natural disease:
The cautious physician, who will go gradually to work, gives the ordinary remedy only in such a dose as will scarcely perceptibly develop the expected artificial disease, (for it acts by virtue of its power to produce such an artificial disease)... (Lesser Writings, p. 265-66, fn 3)
Thus, while Hahnemann's conscious mind was more focussed on quantity, he already had the sense of a qualitative factor (optimal dose - namely that small dose that will engender the artificial disease similar to the natural disease, without allowing for a further dissimilar artificial disease to be engendered - adverse drug effect).
- In 1800, he is already speaking of the dynamic, spiritual nature of medicine, even in crude doses. Now he begins in earnest to explore the scope of this "optimum" dose (that is, the dose that is slightly stronger than the disease), from relatively crude doses (though small by the standards of his day) to relatively high dilutions. These dilutions are low by the standards of homeopathic medicines of today, where 30C is seen as a medium potency (1/1,000,000,000,000,000,000,000,000,000,000, 000,000 ,000,000, 000,000,000,000,000,000).
However, for Hahnemann and his contemporaries even dilutions such as 6C (1/1,000,000,000,000) or 12C (1/1,000,000,000,000,000,000,000,000) were so small compared to the material terms they were used to working with and thinking in (chemistry) "that the amount of the drug can scarcely be expressed in fractions, which would give any comprehensible idea to the human mind." (Haehl, Vol. I, p. 330)
In such small amounts it was difficult to measure by the usual method of the apothecary's balance. Thus, already around 1801 Hahnemann explains his idea of mixing and diluting the medicine with either milk sugar or water/alcohol and starts to develop the serial dilution on the centesimal scale with "vigorous shaking" which renders the solution "intimate."
- In 1816, Hahnemann, after extensive experience, started to name the dilutions "potencies," consciously recognizing the dynamic nature of their action and the heightened power of the dilution/succussion process. This was occurring at the same time that Hahnemann was unfolding his dynamic conception of disease.
To the explanation of human life...the principles by which we explain other phenomena are quite inapplicable. ..Human life is in no respect regulated by purely physical laws...they are regulated by the laws peculiar to vitality alone, they are themselves animated just as the whole system is animated. Here a nameless fundamental power reigns omnipotent, which suspends all the tendency of the component parts of the body to obey the laws of gravitation, of momentum, of the vis inertiae, of fermentation, of putrefaction, &c, and brings them under the wonderful laws of life alone, -- in other words, maintains them in the condition of sensibility and activity necessary to the preservation of the living whole, a condition almost spiritually dynamic. (Lesser Writings, p. 618) (Bold added)
...it is impossible that [the morbific injurious agencies] can immediately either mechanically disturb or derange...The exciting causes of disease rather act by means of their special properties on the state of our life (on our health), only in a dynamic manner, very similar to a spiritual manner, and inasmuch as they first derange the organs of the higher rank and of the vital force, there occurs from this state of derangement, from this dynamic alteration of the living whole, an altered sensation (uneasiness, pains) and an altered activity (abnormal functions) of each individual organ and of all of them collectively [leading to changes at the tissue level]. (Lesser Writings, p. 618-619) (Bold added)
Hence it is obvious that the diseases excited by the dynamic and special influence of morbific injurious agents can be originally only dynamical (caused almost solely by a spiritual process) derangements of the vital character of our organism. (Lesser Writings, p. 619) (Bold added)
Now because diseases are only dynamic derangements of our health and vital character, they cannot be removed by man otherwise than by means of agents and powers which also are capable of producing dynamical derangements of the human health, that is to say, diseases are cured virtually and dynamically by medicines. (Lesser Writings, p. 620) (Bold added)
Between 1816 and 1828 Hahnemann worked on uncovering the chronic miasms. Hahnemann continued to give one liquid dose and to wait until the full action of the remedy ended. However, the more he treated the chronic diseases, the longer the counter-action. (See section Consolidating Heilkunst and Prelude to Dual Remedies) This meant extended waits between doses of the same remedy, or new remedies.
Eventually he considered that it must be possible to make the process of cure and healing more rapid. Likely, as he became more comfortable with the prolonged and significant counter-actions, he explored the possibility of more frequent doses.
In the fifth edition of the Organon (1833), he recommended the greater repetition of dose. However, this was still a repetition of once per week or longer with no change in dynamization. Thus, he saw the need to give intervenient doses of Nux or Sulphur. The dose was the liquid dose, but for very sensitive patients, the use of smelling of a single globule of 30C in a vial.
In 1837, Hahnemann published the use of the divided liquid dose, with succussion of the stock bottle each time. Hahnemann had come to the conclusion, from observation, that it was the too frequent repetition of the same potency that created an apparent resistance on the part of the Living Power. The homeopathicity of the remedy is as much due to its similarity in terms of dynamization to the disease as to its similarity on the basis of the symptoms or image of the disease. Thus, once the disease had been cured at one level of dynamization, a repeated dose was no longer homeopathic. Hahnemann's earlier advice to not repeat a dose for fear of undue adverse reactions was sound, but he now saw that it was linked to the issue of dynamization. But altering the dynamization of the remedy slightly each time, by succussion of the stock bottle and by dilution of the dose into a glass of water (with vigorous stirring), it was possible to give a dose daily.
Between 1837 and 1843, Hahnemann discovered that the almost daily repetition was still causing problems with sensitive and weak patients. Although he used the olfactory method with such patients, this method did not allow for the same degree of flexibility and fineness of adjustment as did the liquid, divided dose. He discovered that the degree of dilution had to be greater, the greater the rate of repetition. This led to the use of the 1/50,000 dilution instead of the 1/100 dilution, creating the Q or LM scale.
11.10 REPETITION OF DOSE
The issue of repetition of dose is closely linked to the issue of dose and potency. Hahnemann addressed this matter right from the beginning as the practice of his day in medicine was to use not only large doses, but frequent ones.
1796: "Its direct action lasts twelve, twenty-four, and forty-eight hours. Hence, a dose should not be repeated sooner than after two days. A more rapid repetition of ever so small a dose must resemble in its (dangerous) effects the administration of a large dose. Experience teaches this. (Lesser Writings, p. 275)
He got nux vomica, in increasing doses, one daily, and improved. (Lesser Writings, p. 279)
As the direct action of foxglove lasts occasionally several days...A dose is necessary only every three, or at most every two days, but the more rarely the longer it has been used. (Lesser Writings, p. 280-281)
In such cases, a dose is necessary every twelve or twenty-four hours. (Lesser Writings, p. 284)
As its action lasts several days...If, then it be found necessary to give a dose daily, each successive dose should be at least a third smaller than the previous one. (Lesser Writings, p. 288)
The doses must, however, be sufficiently large to produce the appearance of a still greater insensibility and depression, but given seldom, only about every thirty-six or forty-eight hours. (Lesser Writings, p. 296)
The mania resembling that peculiar to veratrum, the firm fibre of the patient, and the symptoms...induced me to prescribe three grains of it every morning, which he continued for four weeks, with the gradual cessation of all his sufferings...
The duration of its action is short; limited to about five, at most eight or ten hours, inclusive of the secondary action; except in the case of serious effects from large doses. (Lesser Writings, p. 301-302)
1801: It is unnecessary to repeat these doses oftener than every four or eight hours, in some cases not more than every twenty-four hours, and that sometimes only a couple of times throughout the whole fever... (Lesser Writings, p. 375)
I therefore gave this girl of ten years of age...a dose...The following day...I gave her another dose and she remained well, perfectly well...whilst two other children of the family fell ill...I gave my convalescent a smaller dose of belladonna every three or four days, and she remained in perfect health. (Lesser Writings, p. 379)
...a dose every seventy-two hours (well stirred for a minute with a teaspoon in any kind of drink) as long as the epidemic lasts, and four (to five) weeks thereafter.
Should the epidemic be very violent, it would be safer, if the children could bear it, to let the second dose be taken twenty-four hours after the first, the third dose thrity-six hours after the second, the fourth forty-eight hours after the third, and thereafter to let the subsequent doses be taken every seventy-two hours until the end... (Lesser Writings, p. 381)
1805: The repetition of dose of a medicine is regulated by the duration of the action of each medicine. If the remedy acts in a positive (curative) manner, the amendment is still perceptible after the duration of its action has expired, and then another dose of the suitable remedy destroys the remainder of the disease. The good work will not be interrupted if the second dose be not given before the lapse of some hours after the cessation of the action of the remedy. The portion of the disease already annihilated cannot in the meantime be renewed; and even should we leave the patient several days without medicine, the amelioration resulting from the first dose of the curative medicine will always remain manifest.
So far from the good effect being delayed by not repeating the dose until after the medicine has exhausted its action, the cure may on the contrary be frustrated by its too rapid repetition, for this reason, because a dose prescribed before the cessation of the term of action of the positive medicine [basically the initial action] is to be regarded as an augmentation of the first dose, which from ignorance of this circumstance may thereby be increased to an enormous degree, and then prove hurtful by reason of its excess. (Lesser Writings, p. 472)
It is important to note here that the reference by Hahnemann at this stage to the action of the remedy is essentially the initial action, the secondary action in most self-limiting and acute diseases being very short or insignificant.
Its direct action lasts twelve, twenty-four, and forty-eight hours. Hence, a dose should not be repeated sooner than after two days. A more rapid repetition of ever so small a dose must resemble in its (dangerous) effects the administration of a large dose. Experience teaches this. (Lesser Writings, p. 275 - 1796).
In the following passage from 1805, Hahnemann gives further guidance as to when a repeat of the remedy is sanctioned, namely, when there is improvement, but not a complete cure of the disease.
After the expiry of the term of the action of the first dose of the medicine employed in a curative manner, we judge whether it will be useful to give a second dose of the same remedy. If the disease have diminished in almost its whole extent, not merely in the first half-hour after taking the medicine, but later, and during the whole duration of the action of the first dose; and if this diminution have increased all the more, the nearer the period of the action of the remedy approached its termination - or even if, as happens in very chronic diseases, or in maladies the return of whose paroxysm could not have been expected during this time, no perceptible amelioration of the disease have indeed occurred, but yet not new symptoms of importance, no hitherto unfelt suffering deserving of attention have appeared, then it is in the former case almost invariably certain, and in the latter highly probable, that the medicine was the curatively helpful, the positively appropriate one, and, if requisite, ought to be followed up by a second and finally even, after the favourable termination of the action of the second, by a third dose if it be necessary and the disease be not in the mean time completely cured, - as it often is, in the case of acute diseases, by the very first dose. (Lesser Writings, p. 473)
All through these early writings, one is struck by the insistence on the smallest dose possible (both in terms of dynamization and quantity) and on not repeating a dose too frequently.
In 1810, with the publication of the Organon, his more formal and public statement of the new system of medicine, Hahnemann repeated, but in somewhat stricter language, his caution from 1805 not to give a second dose so long as the previous dose is working visibly. He also had in mind his earlier cautions regarding too frequent repetition of even small doses, which experience had taught him was damaging. The following quote is from the 5th edition of the Organon, but is essentially the same from the fourth, and the idea of one dose and wait is there from the 1st edition and, as noted above, from the precursor to the Organon, The Medicine of Experience of 1805.
Every perceptibly progressive and strikingly increasing amelioration in a transient (acute) or persistent (chronic) disease, is a condition which, as long as it lasts, completely precludes every repetition of the administration of any medicine whatsoever, because all the good the medicine taken continues to effect is new hastening towards its completion. Every new dose of any medicine whatsoever, even of the one last administered, that has hitherto shown itself to be salutary, would in this case disturb the work of amelioration. (Dudgeon, p. 122)
In 1814, Hahnemann strongly recommends against giving a second dose so long as the first is acting.
...as long as the improvement goes on, we give him no other medicine, nor even repeat the same one.. (Lesser Writings, p. 633)
Thus, almost from the beginning, Hahnemann held that the repetition of dose was to be based on principles.
The first, established in 1796, is that to repeat a dose of a remedy within the "direct" (initial) action of that remedy would only lead to the problem of injurious large doses, as several small doses within the initial action amount to one larger dose.
he second, established in 1805, is that there should be no repeat of a dose so long as the previous dose is visibly acting to improve the health of the patient.
In the period following the release of the Organon (1810), Hahnemann began to come to grips with the more chronic diseases, finding remedies that acted more deeply in such cases. He then discovered that the "secondary" (counter) action from the giving of a remedy was much longer and more significant than he had previously realized, when treating more acutely and with non-miasmatic remedies. This led him to wait for this action, the full action of the first dose of the remedy, not just the direct or primary action (which was a matter of hours, if days) to complete itself, so long as it seemed to be still acting positively.
In 1828, Hahnemann published strict instructions in this regard in his Chronic Diseases.
313.1 In this respect, it is a fundamental rule in the treatment of chronic diseases: To let the dose of the remedy, selected in a mode homeopathically appropriate to the case of disease which has been carefully investigated as to its symptoms, come to an undisturbed conclusion, so long as it visibly advances the cure and while improvement of the malady noticeably increases. This process forbids any new prescription, any interruption by another medicine and forbids as well the direct repetition of the same remedy.
313.2 Nor can there be anything more desirable for the physician than to see the improvement of the patient nearing completion unhindered and noticeably.
313.3 There are not a few cases, where the practiced, careful Homeopath sees a single dose of his remedy, selected so as to be perfectly homeopathic, even in a very difficult chronic disease, continue uninterruptedly to diminish the malady for several weeks, yea, months, up to recovery - a thing not to have been expected better in any other way, and not to have been replaced by treating with several doses or with several remedies.
However, the period of time for the full action of a dose of a given remedy was weeks or months in some cases. Hahnemann then sought for a way to speed up the remedial process without interfering with the desired amelioration, and keeping to the principles he had earlier established.
What emerged was a refocusing on the earlier distinction between the initial action and the counter-action and the first principle that had emerged from this distinction. Thus, Hahnemann began to repeat the remedies within the full action of the first dose, but making sure that he did not repeat the dose within the period of the initial action, which was usually a matter of hours or days. We now enter the period of simultaneity of action that preceded the dual remedy period (simultaneity of ingestion). (See the section Volume I, Section A, Chapter 7: Simultaneity of Action versus Simultaneity of Ingestion)
Already in the Chronic Diseases, Hahnemann allowed for exceptions to his seemingly strict rule regarding no repetition of dose within the full action of the remedy.
316.1 Nevertheless there are cases which prove exceptions to the rule, but which not every beginner may trust himself to find out.*
317.1 The only admissible exception for a direct repetition of the same medicine is when the dose of a well-selected and in every way suitable and beneficial medicine has made some beginning toward an improvement, but its action ceases too quickly, its power is too soon exhausted, and the cure does not proceed any further. This is rare in chronic diseases, but in acute diseases and in chronic diseases that rise up into an acute state it is frequently the case.
317.2 It is only then, - as a practiced observer may recognize - when the peculiar symptoms of the disease to be treated, after fourteen, ten, seven, and even fewer days, visibly cease to diminish, so that the improvement manifestly comes to a halt, without the mind getting worse and without the addition of any troublesome new symptoms (meaning that the former medicine would still be perfectly homeopathically suitable), only then, I say, is it expedient, and probably even necessary to give a dose of the same medicine in the same small amount, but most safely in a different degree of dynamic potency.*
This exception emerged in more expanded form in the 5th edition of the Organon. Here we find a reference to repetition "at suitable intervals, which experience shall have pronounced to be the best adapted for accelerating the cure to the utmost extent, yet without the vital force, which it is sought to influence to the production of a similar medicinal disease, being able to feel itself excited and roused to adverse reactions." (Dudgeon, p. 123-124)
I perceive that in order to discover this true middle path [between no repetition until the full action of the previous dose is over and increase in the quantity of the single dose] we must be guided here as well by the nature of the different medicinal substances, as also by the corporeal constitution of the patient and the magnitude of his disease, so that to give an example from the use of sulphur in chronic (psoric) diseases the smallest dose of it (tinct. Sulph X) can seldom be repeated with advantage, even in robust patients and in fully developed psora, oftener than every seven days, a period of time which must be proportionately lengthened when we have to treat weaker and more excitable patients of this kind; in such cases we would do well to give such a dose only every nine, twelve, or fourteen days, and continue to repeat the medicine until it ceases to be of service.(Dudgeon, p. 124, footnote)
Hahnemann then came across a new problem. The repetition within the full action still created a certain resistance in the form of a stronger counter-action in certain patients. While this was fine in terms of greater eventual health, it was at times too discomforting for the patients, particularly the more sensitive ones. So, he eventually had to search for a way to overcome this new problem.
One approach was in the form of the potency (going to higher potencies) and another was in the form of the dose (moderating it - either by using the olfaction method, or by splitting the drop dose into fine globules, one drop moistening many hundreds of granules). Initially, from about 1829-1833, Hahnemann concentrated on the use of the smelling method (olfaction). In a preface to Boenninghausen's "List of symptoms of the anti-psoric medicines," written in 1832, he wrote:
It is impossible for me to impart anything to the world unless I am convinced of it. I was convinced of the reasonableness of the contents of this interpolation only quite recently, so that I can not only obtain the mastery of the severest cases of chronic diseases by letting the patients smell but I can do it in an incredibly short space of time. (Haehl, Vol. I, p. 323)
However, Hahnemann must have felt the need to adjust the dose even more than was possible with the olfactory method. With this method, the amount of a given potency could be adjusted by smelling more or less and more or less frequently, but then to go further required a change in potency. So, it seems that he returned to his clinical trials of the liquid dose.
From this came the divided medicinal dose method that was first described in 1835 and then again in 1837. However, we can see the germ of this more intensive use of the divided dose in the first edition of the Organon (and in writings earlier).
The fact that usually not much more than a single dose of a certain homoeopathically selected medicine overpowers and annihilates the morbid state for which it is appropriate and that every superfluosly stronger dose affects the body more than is necessary, explains the important, universally valid observation that dividing the dose (giving it at several intervals) has a much more powerful effect than the whole dose administered all at once. (Dudgeon, p. 222-223)
This divided dose approach worked well according to Hahnemann, allowing more frequent repetitions, in most cases daily. However, a new problem emerged from these much more frequent repetitions of dose using also regular succussions of the stock potency bottle and the glass used to further dilute and divide the dose.
Thus, a third approach Hahnemann developed was to dilute the stock potency on a greater scale (1/50,000 instead of 1/1000) to allow it to absorb the energy of the more frequent succussions, which led to the development of the LM potency scale described in the 6th edition of the Organon.
What we see here is a progression of an approach to potency and dose. There are no abrupt breaks or changes, but a gradual evolution against experience informed by principle.
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