BY CARROLL DUNHAM, M. D., NEW YORK.

The following remarks upon the interesting, but, in our judgment, unsound paper on this subject by Dr. J. R. Coxe, jr., published in the February number of the current volume of The AMERICAN HOMOEOPATHIC REVIEW may serve at least, it is hoped, to call attention to this very important approach to Polypharmacy in the customary method of prescribing, and perhaps to stimulate a discussion of its necessity and propriety.

In admitting that the alternation of remedies is incompatible with the theory of a true homoeopathic prescription, our colleague has granted all that the opponents of alternation could reasonably ask. That our practice has not yet come up to our theory, and that we are not yet fully possessed of the means and knowledge to bring it up to that degree of perfection, and that therefore some prescribers may feel constrained sometimes to alternate remedies, as it were under protest, may not be denied. But to urge that because our practice lags thus behind our theory, we are to rest satisfied with it, nay, to defend it and to conform our theory to it, is a position that would be fatal to all progress, and which we can not think of conceding. Nor is the appeal to experience in the sense in which our colleague uses it, valid. He “has alternated remedies in a practice of twenty-five years, and his practice has been generally successful.” We do not doubt this. But we believe his respected father practiced Allopathy for a much longer period and was a successful practitioner; would this fact be a valid argument in favor of Allopathy?

Alternation and succession of remedies are not generally understood to be identical processes. By alternation, we think, practitioners generally understand the prescription, at one and the same time, of two or more remedies to follow each other at short intervals, the symptoms of these remedies taken altogether being thought to cover the symptoms of the case more completely than those of either remedy alone would do. The prescription is the result of one single examination of the patient and of one single comparison of the symptoms with the Materia Medica.

But when a succession of remedies is given, in either an acute or a chronic disease, the understanding is, that, the first remedy, having been carefully selected, is allowed to exhaust its action alone, and then a collection of the symptoms which the patient then presents is made, and the case is prescribed for afresh, almost as if it were a new case; and this process is repeated, each new prescription being the subject of a special study, until the case is cured. Such a process is equivalent to prescribing for a number of new and independent cases, and it is evidently not incompatible with the theory of a true homoeopathic prescription.

The very thoughtful article by Dr. Payne to which reference is made by Dr. Coxe, contains nothing incompatible with these views. He instances cases in which a remedy which had covered all the symptoms, acts well for a time, then ceases to act, and leaves the case still uncured. He advises then a fresh study of the case and especially a study of the previous history of the patient and the prescription of a suitable antipsoric or antisyphilitic — in fact, a strictly homoeopathic prescription de novo. Now, in many such cases, acute though they appeared at the outset, if the prescriber had studied thus carefully at the very beginning, not only the present symptoms, but also the previous history of the patient, a single antipsoric prescribed at first might have sufficed for the case. For although chronic diseases may be incurable except by an antipsoric, antisyphilitic or antisycotic, yet these remedies may also be required in the very beginning of diseases that appear to be most acute. I can certainly testify, from repeated observation, to the efficacy of Sulph.³⁰ in most violent puerperal peritonitis, that remedy being all that was required to bring the cases to a speedy and favorable issue. This calls to mind Hahnemann's admonition — Organon, §257. * * The physician “should never lose sight of this great truth, that of all known remedies, there is but one that merits a preference before all others, viz.: that, whose symptoms bear the closest resemblance to the totality of those which characterize the malady.” *[Experiments have been made by some Homoeopathists in cases where, imagining that one part of the symptoms of a disease required one remedy, and that another remedy was more suitable to the other part, they have given both remedies at the same time or nearly so; but I earnestly caution all my adherents against such a hazardous practice, which never will be necessary, though, in some instances, it may appear serviceable.]

Be this as it may, Dr. Payne's advice clearly contemplates a new study of the case for every new prescription, and if this plan be pursued the treatment will be strictly homoeopathic, even though a dozen remedies were required in succession before the case is cured.

Alternation, however, as generally understood and practiced, does not contemplate this new study of the case before a second remedy is administered or before every change of remedies; and herein it fails to come up to the requirements of a true homoeopathic prescription. And this is the kernel of the whole controversy.

Suppose a case of pleurisy. Bryonia covers all the symptoms. The patient improves for a time and then ceases to improve. The case is studied anew. Some symptoms are found to have vanished; some new ones have appeared. The physician studies the previous history of the patient more closely; he may or may not conclude that there is a psoric taint. At all events he perceives that Sulphur corresponds to the symptoms better than any other remedy. He prescribes Sulphur, therefore, just as though this were a new case that had just come under his treatment. This is an instance of succession of remedies. But each prescription is a strictly homoeopathic one and in every respect commendable.

Suppose another case. A patient has acute tonsillitis. The physician collects his symptoms and prescribes “Belladonna, to be followed in four hours by Mercurius, and that again in four hours by Belladonna and so on.” These two steady nags, so familiar to all, in this relation, are sometimes enlivened by the company of Aconite and Coffea (pro re nata) where the prescriber has no scruples about driving “four in hand.”

This is an example of alternation of remedies and is objectionable on the following grounds: Suppose the first dose of Belladonna to have been a judicious prescription and to have had an effect. How can the prescriber know before hand, that this effect will be just such as to cause the totality of the symptoms at the end of four hours, to correspond exactly to Mercurius, and, what would be still more wonderful, how can he foresee that the effect of the Mercurius will be just such as to cause Belladonna to be better indicated than any other remedy, at the end of another period of four hours? The second remedy (a fortiori a third or fourth!) in such cases must always be prescribed without a preliminary study of the actual condition of the patient, as modified by the action of the first remedy. It cannot therefore be an exact homoeopathic prescription.

Hahnemann has expressed himself fully on this subject in the Organon (fourth edition, British translation), as follows:

Sec. 272. “In no instance is it requisite to employ more than one simple medicine at a time.”*

Sec. 169. “It may easily occur, on examining a disease for the first time and also on selecting for the first time the remedy that is to combat it, that the totality of the symptoms of the disease is found not to be sufficiently covered by the morbific symptoms of a single medicine, and that two remedies dispute the preference as to eligibility in the present instance, the one being homoeopathic to one part of the disease and the other still more so to another. It is then by no means advisable after using the preferable of the two remedies, to take the other without examination, because the medicine given as the inferior of the two, under the change of circumstances, may not be proper for the remaining symptoms; in which case, it follows, that a suitable homoeopathic remedy for the new set of symptoms should be selected in its stead.”

Sec. 167. “In short, if the application of an imperfect homoeopathic remedy used, in the first instance, cause any accessory symptoms of some importance, the action of the first dose is not allowed to exhaust itself in acute diseases; the altered state of the patient is then to be examined and the remainder of the primitive symptoms to be joined to those which have been recently discovered, to form of the whole a new image of the disease.”

Sec. 168. “A new remedy that is analogous may then be easily discovered among the medicines that are known, a single application of which will suffice, if not to destroy the disease entirely, at least to facilitate the cure in a great degree. If this new remedy is not sufficient to restore the health completely, then examine what yet remains of the diseased state and select the homoeopathic remedy that is most suitable to the new image that results from it. In this manner, the physician must continue until he attains his object — that is to say, until he has fully restored the health of the patient.”

The name and practice of Hahnemann, Boenninghausen and Hering have been adduced in support of alternation. Hahnemann's views on the subject we have already quoted from the Organon. The case to which Dr. Coxe refers, as cured by Hahnemann by “the alternate use of Bryonia tincture and Pulsatilla” has escaped our notice, and we should esteem it a favor if Dr. Coxe would inform us whereabouts in homoeopathic literature it is recorded.

Hahnemann published very few cases. In Vol. II of the Materia Medica Pura, third edition, 1838, he relates two cases, one of which was cured by a single dose of Bryonia tincture, and the other by a single dose of Pulsatilla. May Dr. Coxe have, possibly, referred inaccurately to these cases and, by a fault of memory, blended them?

It is often stated, however, that Hahnemann used Bryonia and Rhus tox. alternately in his very successful treatment of the typhus or hospital fever which prevailed so extensively in Northern Germany, in 1813-14, after the French invasion. A reference to his article on the “Treatment of the Typhus or Hospital Fever at present prevailing,” originally published in the Allgem. Anzeig. der Deutschen number six, 1814, and translated by Dr. Dudgeon among “Hahnemann's Lesser Writings” (pp. 631 et seq. American edition) will show how erroneous this statement is.

He says, “this fever has two principal stages,” of which he gives the distinguishing symptoms; the first stage being characterized by “pains and consciousness;” the second stage by “delirium, and mania.”

“In the first stage,” he continues, “two vegetable substances are of use and generally quite remove the disease at the commencement — the Bryonia alb. and the Rhus tox.”

He proceeds to give the special indications for each of these remedies. “If the patient complains of dizziness, shooting (or jerking-tearing) pains in the head, throat, chest, abdomen, etc., which are felt particularly on moving the part — in addition to the other symptoms, the hemorrhages, the vomiting, the heat, the thirst, the nocturnal restlessness, etc., we give a single drop of Bryonia¹². Improvement takes place in the course of four and twenty hours, and as long as the improvement goes on, we give him no other medicine, nor even repeat the same dose.

“If now the amendment produced by the single dose of Bryonia goes off in the course of two, three or four days, that is to say, if the patient then complains of shooting pains in one or other parts of the body whilst the part is at rest; if the prostration and anorexia are greater, if there is harassing cough or such a debility of certain parts as to threaten paralysis we give a single drop of Rhus tox.¹² and no more, nor any other medicine so long as the improvement is mani fest and continued.” “Or, if the symptoms I have just described occur at the very commencement of the attack, we give at its very commencement a drop of Rhus tox.¹²”

“The whole disease will generally be removed by a single dose of the first or of the second medicine (according as the one or the other is indicated, without the addition of any other).”

“If, notwithstanding, the disease should pass into the 'second stage' of delirium and mania, then Hyoscyamusniger meets all the indications of the case.”

These detailed directions for the treatment of an epidemic disease, give a perfect picture of a true homoeopathic treatment. They state, in substance that the generic symptoms of the disease are always accompanied in the commencement by one or the other of two groups of characteristic symptoms. Accordingly as one or the other of these groups is present, Bryonia of Rhus is to be given. When the consequent amelioration ceases, then the case is to be examined anew, and according to the characteristics then found to present themselves, a new remedy is to be selected and thus the practitioner is to go on until the case is cured. But alternation is nowhere advised or allowed.

Hahnemann's brief and very general hints relating to the treatment of croup are of the same general character. In the introduction to Spongia (Materia Medica Pura, Vol. VI, second edition, Dresden, p. 199), he says, “Homoeopathy has found, in symptom 145 and in other symptoms, the most remarkable applicability of Spongia to that terrible acute disease — membranous croup — provided however the local inflammation has first been diminished or subdued by a very small dose of Aconite. The additional use of a small dose of Hepar sulph. will rarely be found necessary.” Nothing is here said or in any way intimated, concerning alternation.

In giving general directions beforehand for the treatment of this disease which usually presents a very uniform group of symptoms, he shows that the symptoms while the local inflammation is still raging call for a very small dose of Aconite; that when this has acted, it will generally be found that the local inflammation is subdued, leaving a group of symptoms which correspond best to the symptoms of Spong.; that sometimes there may be such a modification as to call instead or subsequently for Hepar sulph.

When a physician has it in his power to visit his cases frequently and to watch their course, he has no excuse for deviating from the methods of a true homoeopathic prescription. If it prove necessary to give a succession of remedies, he is bound to make each successive prescription the subject of a special study, both of the symptoms of the patient and of the provings in the Materia Medica and to select on each occasion the remedy which corresponds best to the symptoms of the case.

But, where, as sometimes happens, the physician is unable to. see the case at all, or where he is giving general directions for the treatment of a case which it is supposed may, at some future time, occur, this accuracy is impossible. His duty is then to describe to his client the symptoms which will probably be present in each stage of the disease, if it appear in the ordinary form and follow the ordinary course; to point out the indications for the appropriate remedy in each stage; and to instruct his client to give only one medicine at a time at each stage and never to repeat the dose, or to give any other remedy so long as amelioration is manifest. This is the best the physician can do when treating disease under the disadvantage of never seeing the patient. This is the method adopted by Hahnemann with reference to the hospital typhus. It is the method of Dr. Boenninghausen in treating croup.

It is well known that Dr. Boenninghausen does not visit his cases but prescribes chiefly in his offices. He knows that the first symptoms of croup are almost uniformly combined with a local inflammation which, along with all the other symptoms, forms a group to which Aconite corresponds better than any other remedy. His first powder therefore is Acon. And his instructions are explicit. The second powder is never to be given until the amelioration, consequent on the first, shall have ceased and so with the remaining powders. The recipients of “croup powders” are especially and carefully instructed under what circumstances alone it is proper to give any or all of the subsequent powders. This is as near an approach to a new study for each change of remedy as is possible when the physician does not see the patient.

It does not really amount in most cases even to a succession, much less an alternation of remedies, for in a large majority of cases the Aconite alone cures the patient.

That Dr. Boenninghausen does not regard this method as an “alternation of remedies” is Shown in Vol. ll, p. 561, of the American Homoeopathic Review.

Indeed in theory and in practice Dr. Boenninghausen is as decidedly opposed to alternation, as we have shown that Hahnemann was.

We believe we could say, that Dr, Hering's views are similar to those we have expressed, but we prefer to await a statement from his own vigorous pen of those arguments, both theoretical and practical, which none could give so well as he.

In conclusion, we hope it is hardly necessary to add, that inasmuch as offensive language and odious epithets lend no strength to argument nor sweetness to persuasion, we entirely agree with our colleague in his closing paragraph. Nay! for that very reason, he will allow us to say, we could almost wish his own expressions had been a very little less emphatic.