|THE THERAPEUTIC LAW|
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Homeopathic Materia Medica by Dunham
THE THERAPEUTIC LAW
History—definition — empirical, requiring evidence — evidence furnished by physiological and therapeutic effects of drugs, and to be given, in extenso, in the course of the lectures on special drugs— practical application of the law— it involves a twofold study, each branch of which may be a distinct and independent study, viz. : 1. study of the phenomena of natural disease, and 2. study of the phenomena of the action of drugs on the healthy subject — these studies must be empirical and positive, recognizing only facts and disregarding hypotheses — symptoms in the broad sense the only object of study — similarity being the object of our search, cases are to be individualized, and nosologies to be disregarded—each case studied in and for itself—same with diseases and pathogeneses—what are symptoms ? — how are physiology and pathology to be employed?—varieties of symptoms—generic, specific, characteristic — the same of diseases as of drugs — what is a proving? — how to study a drug.
The last lecture concluded with a statement of what I regard as the universal therapeutic law; that commonly expressed by the words "SIMILIA SIMILIBUS CURANTUR" or, "Sick persons are to be cured by drugs which produce in the healthy symptoms similar to those of the sick persons."
Adherence to this law as the universal law of cure is distinctive of the homeopathic school of medicine. Nevertheless, the statement of the law did not by any means originate with Hahnemann, the founder of homeopathy ; nor is the acceptance of the law as a law of cure confined to homeopathicians. Many most distinguished physicians of the old school, as Pereira, Watson, Trousseau, Bouchut, and many others, accept it as a law of cure, of wide application, although they deny its universality. I believe their denial springs from a confusion in their minds between the procedures of hygiene and therapeutics. The law was clearly expressed in a very remarkable passage of a work ascribed to Hippocrates. Paracelsus had a glimpse of this truth, and expressed it in his quaint and mystical fashion; and in so far as the imperfect state of the materia medica allowed, it is believed that he practiced in accordance with it. "Stoerck was struck with the idea that if Stramonium disturbs the senses, and produces mental derangement in persons who are healthy, it might very easily be administered to maniacs for the purpose of restoring the senses by effecting a change of ideas." (Hahnemann's "Organon," 4th American Edition, p. 76.) This was a perception of a particular instance, but not of the general law.
Stahl expresses himself as follows: "The received method in medicine, of treating diseases by opposite remedies—that is to say, by medicines which are opposed to the effects they produce (CONTRARIA CONTRARIIS)—is completely false and absurd. I am convinced, on the contrary, that diseases are subdued by agents which produce a similar affection (SIMILIA SIMILIBUS); burns by the heat of a fire to which the parts are exposed; the frost-bite by snow or icy-cold water; and inflammations and contusions by spirituous applications. It is by these means I have succeeded in curing a disposition to acidity of the stomach by using very small doses of sulphuric acid in cases where a multitude of absorbing powders had been administered to no purpose."
This was written in Denmark in 1738, nearly fifty years before Hahnemann's first publication on the subject. It is a distinct statement of the law.
Hahnemann, who was a very learned man and a very highly educated physician, became, early in his practice, deeply and painfully convinced of the great uncertainty of medical science as it was then taught and practiced, and of the serious injuries that were often inflicted on the patients by the improper use of drugs. He fully indorsed the saying of his predecessor, Girtanner, that " the doctor with his drugs is like a blind man with a club. He aims to crush the disease, but is quite as likely to destroy the patient." Hahnemann was by no means singular in this view of actual medical science. Most of his contemporaries agreed with him. And from his day to the present, eminent physicians of the old school have expressed similar convictions. What fruits did this conviction bear ?
It is related of Sir Isaac Newton that when asked to account for his transcendent genius and its wonderful achievements, he modestly replied that it consisted in nothing but this: that he had a little more patience and perseverance than some other men.
So Hahnemann, when convinced of the uncertainty and unsafeness of the medical science of his day, rested not in his search for something more safe and sure. " He that seeketh shall find." To the receptive, eager mind, a trivial incident may serve as the clue to a brilliant discovery, just as the falling apple did in Newton's case and the swinging chandelier in Galileo's.
Hahnemann, having taken a dose of tincture cinchonae, observed the symptoms which resulted from it. He was struck with their similarity to the symptoms of an attack of intermittent fever, from which he had suffered years before. He knew that cinchona was the great specific for intermittent fever. The question at once occurred to him, Can it be that this similarity is a mere coincidence in the case of this particular drug and the disease which it cures, or is it an example of a general law of nature? If it be indeed a general law of nature, may it not be the great therapeutic law of which we are in so great need ? Up to this point of perceiving or suspecting the law, SIRNILIA SIMILIBUS CURANTUR, Hahnemann had been preceded, as he very well knew and openly stated, by Hippocrates, Stoerck and Stahl, and others. They, however, contented themselves with throwing out the intimation or conjecture and abandoning it. Not so Hahnemann. He argued: if this be a general law, it is capable of demonstration in two ways :
1. A POSTERIORI,—by searching and analyzing the records of medicine,—a task which he forthwith undertook with great success, and,
2. A PRIORI,—by the direct experiment,—by ascertaining the effects of some drugs on the healthy subject, and then giving them to sick people whose symptoms happened to be similar to those which the drugs had produced.
By experiments and observations of these kinds, carried on for twenty years, Hahnemann satisfied himself of the truth of the law. The points of evidence will be laid before you when we study the different drugs of the materia medica.
But now, please take notice that this law requires that the sick person shall receive a drug which is capable of producing in the healthy subject symptoms similar to those of the patient. This law can never be applied in practice unless we possess a materia medica which contains a record of the symptoms which drugs produce in the healthy. No such materia medica existed in Hahnemann's day. All that there was, was a mere record of the effects upon the sick, and of hypotheses and guesses. Now came into operation that infinite patience and that perseverance which mark transcendent genius. Hahnemann undertook the Titanic labor of creating this indispensable materia medica. Proving more than a hundred drugs upon himself and his friends, subjecting himself thereby to toil and suffering indescribable, he compiled for us the " Materia Medica Pura," in six volumes, and the " Chronic Diseases," in five volumes,—an imperishable monument to his genius and self-devotion.
This materia medica, founded by Hahnemann, and enlarged and enriched by the labors of his successors and by the addition of all that is trustworthy in ancient or contemporary literature, is our treasury of knowledge of the action of drugs upon the human organism.
You will observe that the therapeutic law we have laid down speaks of two classes of symptoms:
1. Those of the patient; and,
2. Those produced in the healthy subject by a drug. If the latter be similar to the former, then the drug which produced the latter will remove the former.
This statement points to two subjects for our study,—the symptoms respectively of sick persons and of drug-provings.
The law, it will be noticed, is empirical. It is based on no theory of the action of drugs, and it involves no theory whatever. It merely states that a coincidence has been observed to exist between the symptoms which a drug will cause in the healthy and those which it will remove in the sick. In this respect it is analogous to the laws of gravitation and of chemical affinity, and in definite proportions indeed to the great central laws of all the natural sciences.
In like manner the studies of the two classes of symptoms to which the law points us, are to be made in a positive and empirical manner; and we are to take care that no hypothesis respecting the nature and ultimate cause of the symptoms which we observe in the sick, be allowed to come in and modify or pervert our pure observation.
In order to apply the therapeutic law in the treatment of disease, we have then to study,
1. The symptoms of patients ; and,
2. The symptoms of healthy persons who have taken drugs for the purpose of ascertaining their effects.
These studies are similar in their character, but they are wholly independent of each other, and may be pursued separately ; indeed, are only conjoined when the object of the study is to be qualified to practice the art of curing. This being one object, we cannot do better than devote some time to an investigation of the modes of studying symptoms.
By a symptom of disease, whether it be a natural disease or a diseased state produced upon himself intentionally by a prover of drugs, we mean any deviation from a normal condition in any organ or function of the body, which deviation is capable of being observed by the physician or by the attendants, or by the patient himself. The senses of the observers may be assisted by any implements or processes, such as the stethoscope, the microscope, the ophthalmoscope, chemical analysis, etc., etc. If every function of the body be performed in a proper, healthy manner, there can of course be no symptoms of disease. If any function be not performed in a proper, healthy manner, the facts by which we perceive and which enable us to know that this is so, are the symptoms of the case. We sometimes hear of the existence of latent disease of which no symptom exists. This may be, but its existence is only hypothesis, and is afterward inferred from the subsequent occurrence of symptoms. To detect its existence when thus latent would be impossible, for if it gave in any way the least token of its existence, that token would be a symptom.
Symptoms may be objective or subjective. Objective symptoms are those which are observed and taken note of by the physician or by the attendants of the patient. They could be observed whether the patient were conscious or not. The aid of his intelligence is not invoked in gaining a knowledge of them. They are the color, texture, temperature of the skin and membranes, the expression of the eyes and features generally, position, motions and attitudes of the body, secretions and excretions of glands and surfaces; in short, objective symptoms comprise everything which the physician can take cognizance of in the sick man, by the aid of his five senses assisted or unassisted. Physical and chemical and microscopic analyses are included. Subjective symptoms are those of which we get a knowledge through the medium of the patient's own intelligence and testimony. They comprise the various sensations, pains and abnormal feelings, the infinite variety of unwonted thoughts, emotions, sentiments, dreams and visions which diversify the existence of the sick man. If the patient be ill of a disease which makes him stupid or unconscious, we cannot get any subjective symptoms,—as in typhoid fever sometimes. If he be delirious we have to receive his expressions with due caution.
To these varieties of symptoms must be added a third, which modifies the former, viz., the symptoms comprised in the previous history of the case. These will show us any constitutional taint or miasm in the patient; and by teaching us his habits and idiosyncrasies may often enable us to decide how much weight to attach to one or another subjective or objective symptom.
We have thus briefly described the classes of symptoms. The law requires us to compare the aggregate of symptoms presented by the patient with the symptoms produced by drugs that are known to us; and to select for the case the drug of which the symptoms are most similar to those of the patient. It is objected to this very empirical and almost mechanical method, that it takes no account of the causes of symptoms, does not undertake to trace them to their causes; that it entirely ignores physiology and pathology, sciences which have thrown so much light on the nature and causes of disease ; that ft exposes the prescriber to the hazard of making great errors, inasmuch as the same external symptoms may be due to very different internal causes; and finally, that it virtually makes out disease as consisting of an aggregate of external symptoms, whereas it is universally conceded that disease exists by virtue of an internal dynamic cause, no less a cause than a deranged condition of some of the vital forces or susceptibilities.
Now, I hold strictly to the therapeutic law. I maintain that, viewed from the stand-point of the prescriber, the aggregate of the symptoms does constitute the disease. That in no other way than by selecting his drugs in strict accordance with the similarity of the symptoms, can he so surely prescribe accurately, and cure his patient quickly. Nevertheless, I shall endeavor to show you that this adherence to the law is by no means equivalent to a declaration that the symptoms are really the disease; I shall show you that we are in no danger of confounding different diseases—misled by a similarity of their symptoms—if we strictly follow the law. And then, if I do not show you as we proceed in our course, that for the proper study of symptoms before we get ready to prescribe for our patient, we have need of and must employ our knowledge of physiology and pathology to the utmost extent of our resources, bringing every auxiliary medical science to bear on our study of symptoms, I shall submit to be offered a sacrifice to the offended divinities of these respectable sciences—auxiliary merely and subsidiary as they are to the great practical end and aim of medicine, the application of drugs to the cure of the sick.
The symptoms which a patient presents do not constitute the essence of the disease; they are not the disease itself, they are only a result of the disease. This we freely admit. We have already stated that the essential nature of the disease is to be sought in a modification of that mysterious property of the organic cell-walls, by virtue of which the respective organs of the body perform their functions. In the healthy body we know nothing of the nature of this property or vital force. We should not know of its existence were it not for the functions which, by virtue of its exercise, the organs of the body perform. But in like manner, we should not know that the action of this mysterious force was perverted in disease, were it not that in consequence of its perversion the functions of the organs of the body are performed in an abnormal manner. But the abnormal performance of its function by any organ of the body constitutes a symptom of disease. It is, therefore, from the existence of symptoms of disease that we argue the existence of disease. PER CONTRA, if no symptoms of disease present themselves to our scrutiny, we cannot know that disease exists. It is, therefore, strictly correct to say that we recognize the existence of disease only through the existence of its symptoms. It is manifest, then, that if we can cause the permanent cessation and disappearance of symptoms we shall have effected an annihilation of the disease, in so far as it is possible to judge of this matter. And it follows that the declaration that the aggregate of the symptoms is, from the practical stand-point, equivalent to the disease, is correct, because, the aggregate of the symptoms being permanently removed, we are justified in assuming that their cause has been removed.
It has been objected to the mode of prescribing which the law, SIMILIA SIMILIBUS CURANTUR, enjoins, that it is a prescribing for the symptoms and not for the disease. This is not a fair criticism. The symptoms are our guide in selecting the remedy. It does not follow that they are the object of our prescription. This no more follows than it follows that because a traveler in a strange road goes from guide-post to guide-post, from mile-stone to milestone, therefore the guide-posts and mile-stones are the object of his journey, that his sole purpose is to find and come up with one after another of these useful indicators, these symptoms that he is on the right road.
The objection of which we are speaking, viz., to the treatment of symptoms, is well grounded only in cases where one or a very few symptoms are taken as the basis of the prescription, while the remaining symptoms are ignored. Where this is done, we often see deplorable mistakes committed. A remarkable instance of this is furnished by a celebrated surgical case. When Mr. Perceval was shot, as he came out from the House of Commons, being mistaken for Sir Robert Peel, he came under the care of the celebrated surgeon, Mr. Guthrie. The wound was of the thoracic walls. The public interest in the case was very great. Daily bulletins were required, and were issued. Mr. Guthrie reported that his patient's wound was doing well and that his prospects of recovery were excellent. One day, after such a report, the patient died; and it was discovered at the autopsy that he died of empyema (or pus in the cavity of the pleura). How came Mr. Guthrie to blunder so terribly? Why, it was explained. in this way. His specialty being surgery, he had confined his attention to the wound and had overlooked the symptoms of pleuritis which had no doubt been present for a number of days, obvious to whomsoever had eyes to see. To give this case as an instance of the impropriety of judging and prescribing according to the symptoms of a case, is to lose sight of the fact that our law requires that the aggregrate or totality of the symptoms be made the basis of the prescription. This is the all-important point.
Not only will care in this respect prevent our overlooking and failing to meet the real nature of the case; but it will obviate another objection which is raised against a prescription based on the symptoms, to wit: that the same symptom may depend upon any one of several morbid states, and that therefore we may be led to adopt a mode of treatment very suitable for one form of disease that often presents the symptoms before us, while in reality a very different disease is at the foundation of the symptoms of the case in hand. We admit this to be true of isolated symptoms or groups of symptoms, but we deny that it is true of aggregates of symptoms. The same aggregate or totality of symptoms can be produced only by the same morbific cause, acting in the same manner and direction. Were it otherwise, it would be impossible to distinguish between the two causes, since these imponderable causes are recognized only by their effects, the disease only by the totality of its symptoms.
This position should be illustrated by examples. The disease known as acute hydrocephalus has well-marked symptoms, indicating first, inflammation of the meninges of the brain, and then effusion with its resultant symptoms of oppression.
Now there is an affection, which is pathologically of a precisely opposite character, and which is not infrequently met with, the hydrocephaloid affection described by Marshall Hall. The signs of irritation in the first stage and of oppression in the second stage, are so very similar to those of hydrocephalus acutus, as to deceive all but the most wary practitioners. Yet the symptoms of hydrocephalus acutus result from a true inflammation of the meninges of the brain, while those of the hydrocephaloid affection depend altogether upon a depressed state of the vegetative system, in fact upon a starved condition of the organism, caused by either a too severe antiphlogistic course of treatment, or a too abstemious regimen during some general disease (not cerebral). The pathological difference is world-wide. The difference in the symptoms, so far as the brain symptoms are concerned, is hardly perceptible. Yet it is of the utmost importance, so far as the treatment is concerned, that these affections should be clearly distinguished. How shall it be done? Why, if we confine our attention to the brain symptoms alone (and a careless writer calls these the important symptoms), to the symptoms of that organ which seems to be chiefly affected, I hazard nothing in saying that the distinction cannot be made and the treatment cannot be judiciously selected.
But we have repeatedly stated that the aggregate of the symptoms, the totality of the symptoms, is to be regarded. Now, in this aggregate or totality are included not merely the brain symptoms, but likewise all other symptoms, and not merely the present state but also the past history or anamnesis of the patient. If we turn from the cerebral symptoms to the history and to the other symptoms of the patient, we shall find that whereas in the case of true hydrocephalus there is a hard, full, and rather frequent pulse with evident inflammatory fever, and the disease has come out from a state of tolerable, sometimes of what is called "ruddy," health; in the other affection the pulse is small, or, if full, is very soft, infrequent and irregular, the skin is cool, and the history of the patient discloses that the affection is always a sequel of some acute and exhausting malady, quite frequently of some one of the exanthematous fevers. Thus, a study of the totality of the symptoms rescues us from the danger into which we might fall from a study of a few prominent symptoms only,—the danger, namely, of confounding one disease with another, and of thus forming and adopting an erroneous plan of treatment.
Now, while these remarks are fresh in your minds, let me ask you to notice these facts. The example just cited shows you that while observations of symptoms may be correct, yet the conclusions drawn from them when we reason upon them may be altogether erroneous; and a treatment based upon this reasoning would of course be injudicious. Now, if we can base our plan of treatment directly upon the aggregate of the symptoms, without the interposition of a course of reasoning which may or may not be erroneous, but which is always liable to be false, shall we not be much more sure of success?
Another instance of an error in treatment from the exclusive observation of a few symptoms and the neglect of the aggregate, is so common among old-school practitioners that I may do you a service in mentioning it.
Young girls who have just become young women, and have grown rapidly, and have been perhaps assiduous at school, often complain of dyspnoea, of stitch in the side, of a slight cough, of lassitude. Their complexion may be very fair and a high color may give brilliancy to their cheeks, particularly in the afternoon. The doctor is called. The chest is the part complained of, and so he addresses his power of observation to the chest. He observes dyspnoea; ah ! that shows infiltration in the air-cells; cough, irritation of the mucous surface; stitch in the side, circumscribed pleurisy of course; heightened color in the afternoon, what can this be but hectic? No more is needed to be looked for or asked about. He diagnosticates at once tuberculous deposit, inflammation around it, and incipient phthisis. Now is the very time for antiphlogistic measures, that we may nip it in the bud. Accordingly, if the doctor be of the very old school, he bleeds; if not so very old, he depletes in some less obvious, less sanguinary manner. But the patient does not improve. She grows steadily worse. If I had not very frequently seen such cases, were not indeed in the habit of seeing them, I should not venture to give such gross instances of error from forming a judgment on the basis of a few symptoms only. In truth, there is no tuberculosis, no inflammation about these cases. If the doctor had studied the totality of the symptoms, he would have found in the history of the case a fine state of health, gradually impaired by too close application at school; menstruation free and frequent, gradually diminished in quantity and frequency, and deteriorated in quality; the stitch in the side not, like that of pleurisy, aggravated by motion and pressure, but actually relieved by exertion in the open air; the supposed hectic no such thing, the pulse being actually at that time small, and though frequent, yet very soft and compressible, and the lungs, on percussion and auscultation, normal, showing that there can be no deposit in them. In addition to all this there will be a change in temperament and disposition, a timid, despondent, sighing and longing disposition, which makes the patient melancholy, prone to tears and easily discouraged, the very reverse of that which characterizes incipient phthisis. These symptoms all taken together clearly indicate the remedies required, if indeed any be needed. I express this doubt, because often a mere change of diet, regimen and associations will work the desired cure ; while the antiphlogistic treatment, by rendering still more serious the existing debility, may induce the very state of things which, under an erroneous diagnosis, it supposes to exist and seeks to remove.
Be never content, then, to prescribe without carefully collecting and studying the totality of the symptoms.
We know nothing about life, except through its manifestations in the functions of the living organism. Disease has been defined as modified life. Whatever life may be, disease is the same thing modified so as to have become abnormal. As life is known only through its manifestations, so can disease be known only through its manifestations, which are the perverted functions of organs or the modified and altered tissues of the body. But we cannot have any knowledge of, or ability to recognize, a perverted function unless we be familiar with the healthy or normal function. We cannot recognize a changed or diseased tissue unless we be familiar with the healthy tissue. But we derive a knowledge of healthy tissue through the science of anatomy, and of healthy and normal functions through the science of physiology. It is, therefore, I think, a logical necessity to admit that we cannot recognize and study symptoms which are the manifestations of disease unless we be familiar with anatomy and physiology.
It is clear, then, that no matter in what way we may propose to use our symptoms in making a prescription, whether we compare them directly with those of drugs in order to find a simile, or whether we use them as the basis of theory, in correspondence with which we are to prescribe "on general principles,"—it is clear, I say, that we cannot recognize nor obtain our symptoms without the aid of physiology.
Furthermore, we are to get the totality of the symptoms. So numerous are the organs of the body, so complex their functions, so intimate their relations to each other, so various their mutual reactions, that unless we follow some guiding method in the examination of the patient, we shall be in great danger of letting some symptom, or group of symptoms, obscure perhaps but all important, elude our vigilance.
Now, the relations of different organs of the body are so intimate, that when the functions of certain organs are altered it invariably happens that certain other organs likewise are affected. A knowledge of such facts as these affords us incalculable aid in getting at the true state of our patient, and it is indispensable. Knowledge of this kind belongs to the science of pathology which treats of the perverted functions and relations of the diseased organism.
Again, the function of an organ may be so modified as that, under certain conditions and circumstances, this modification must be regarded as a symptom of disease, while under other conditions it should not be so regarded. An enormous appetite which, under ordinary circumstances, would be a symptom of disease, might, during convalescence from a typhoid fever, be looked upon as not abnormal in any degree. So, too, of the cough in hypostatic pneumonia. So, likewise, of many alterations of taste and appetite, E. G., for fruit at the close of rheumatic fever. But with the significance of the functions of the organism under various circumstances it is the special province of pathology to deal.
We perceive, then, that without the aid of physiology and pathology, we are utterly unable to recognize and to discriminate and estimate symptoms.
Now, I think, with these points settled, we may pass with quiet confidence to the practical question: How shall we study and arrange this totality of the symptoms, so as to make a prescription in accordance with it?
The therapeutic law requires us to select a drug of which the symptoms produced on the healthy are most similar to those of the patient. It appears, then, that we are to make a comparison between the aggregate of the patient's symptoms and the symptoms of the drugs in the materia medica, in order that we may find among these drugs that one drug of which the symptoms are the most similar. It is probable—indeed we well know—that the symptoms of a large number of drugs may present some similarity to each other and to the case in hand. A few will be very similar, and it may be very difficult to select from these that one which is most similar. The spirit of the whole process is evidently one of individualization. We take groups of drugs and analyze the symptoms they present, and select the one or the few that seem similar, and if there are several we analyze again, and select from among these that one which is the most similar. The process is the reverse of generalizing.
It is evident that for the convenience of this process, through which the prescriber must go at each prescription, drugs will naturally divide themselves into groups, the members of which resemble each other pretty closely, but which, nevertheless, may be distinguished from each other, and from all others by a few symptoms. Now, the symptoms which the members of these groups have in common are generic symptoms. These symptoms could never enable us to select the remedy, but they would point out to us a group of drugs, all of which possess these symptoms, and all of which are therefore tolerably similar; but which of these is most similar, we can only ascertain by finding some symptom or collocation of symptoms possessed by that drug alone, and which serves to distinguish it from all other drugs. Such symptoms are what are called characteristic symptoms, and are of the greatest importance to the prescriber.
They are different from those symptoms which the diagnostician would call characteristic, and which are pathognomonic symptoms.
Our next lecture will be on ACONITUM NAPELLUS.