|PATHOGNOMONIC AND CHARACTERISTIC SYMPTOMS|
Homeopathic Materia Medica by Dunham
PATHOGNOMONIC AND CHARACTERISTIC SYMPTOMS
( )Dr Veit Meyer, of Leipsic, in 1850, told me an anecdote of Hahnemann, which, so far as I know, has never appeared in print. It was related to him by Dr. Franz Hartmann, then recently deceased, who in his early days had been a pupil of Hahnemann, and was present at his consultations with patients.
Hartmann relates that one day a patient came to consult Hahnemann. The malady was condylomata (figwarts). Hahnemann examined them and then questioned the patient for a half-hour, noting symptoms in his record book. He then closed his book, consulted the "Materia Medica" for a few moments, went into the next room, brought out three powders, and said: "Take a powder every three days; come again the fourteenth day, and pay now four dollars." The man paid and retired.
"What then did you give, Herr Hofrath ?" "What!" replied Hahnemann, "have you listened to the examination and do you not know ? You must study the 'Materia Medica'! " So Hartmann said no more, for Hahnemann never told his pupils what remedy he gave, fearing to encourage routine practice. The fourteenth day the patient came again, the warts were but one-third their previous size. Hahnemann gave him two more powders, to be taken every fifth day. "Come again the fifteenth day; this time you pay nothing." Hartmann, surprised at the rapid diminution of the warts, said again, "But, Herr Hofrath, what did you give ?" " Do you not yet know ? study then 'Materia Medica.'"
The fifteenth day the man returned; no trace of the warts was to be found. Hartmann could not contain himself. He came to Hahnemann's study at an earlier hour than usual and opened his record book to learn the remedy given. It was Chamomilla 30; three powders. The two on the second day were sugar of milk alone.
More astounded than ever, Hartmann could not contain himself, and when Hahnemann came in; "Herr Hofrath," said he, "I have committed a great crime. The desire to know with what remedy you cured the figwarts so burned within me that I opened your book and ascertained it, and now I pray you, on what grounds did you give Chamomilla?" "Ah, have you done that?" said Hahnemann; "then take the book and read further, read the 'Symptomen-codex' and see if it were possible to give any other remedy than Chamomilla, when such symptoms were present." And so it was. Even Hartmann was satisfied that Chamomilla was the only suitable drug.
And yet the prescription was made without any regard being had to the chief objective symptom, to the very feature which, from a pathological point of view, was the central, pivotal fact of the case. To make such a prescription might seem "like playing 'Hamlet' with the part of Hamlet left out."
A great many most brilliant cures have been made by prescriptions precisely similar to this one of Hahnemann's. Nay, an entire class of cases, and, by no means a small one, must be cured in this way, if they are cured at all.
What are generally called organic diseases, well-defined and tolerably far advanced structural modifications of the nobler organs, we can never expect to see produced in any proving. Much less can we look for provings that shall exhibit analogues of the various forms of chronic organic disease, benign or malignant. Occasional accidental provings, in the way of cases of poisoning which come to our knowledge in a medico-legal way, may chance to throw light on these spheres of action of drugs; but these sources of information are infrequent, and always very imperfect and impure.
The science of therapeutics would be forever most imperfect, were we compelled to rely on the knowledge we can gather from such data.
For example, a proving can hardly be expected to be carried so far as to exhibit unequivocal signs of pneumonia. And although some cases of accidental provings in the shape of poisonings have shown us that certain drugs which we know to be curative agents in treating pneumonia do actually produce the organic phenomena of pneumonia, yet this knowledge, while it may confirm our faith in these drugs as proper remedies in cases of pneumonia, to which they correspond, would nevertheless lead us astray and ensnare us if we should allow them to withdraw our attention from other drugs which have not as yet been known to produce the organic signs of pneumonia. If, for example, because it is known that Tartar emetic, Phosphorus, Aconite and Bryonia have produced actual pneumonia, we should allow ourselves to look upon these as the sole remedies for this disease, we should be in danger of neglecting other remedies, such as Lycopodium, Sulphur, Chelidonium, Cepa, and a number of others which, though never known to produce the organic symptoms of pneumonia, have yet shown in practice a power to cure that disease speedily and completely when their general symptoms corresponded to those of the particular case in which they were given.
If this be true of a disease which is, pathologically considered, so simple as pneumonia, how much more likely is it to be the case with regard to affections which depend upon more complex and elaborate changes in the processes of assimilation and nutrition; such as tubercle, cancer, lupus, and many others; or (not to go so far) as the benign affections of the skin and glands, or even as the exanthematous fevers. It is manifest, that while symptoms resembling the general, constitutional symptoms that accompany all of these complaints, may be produced in provings of drugs, yet the organic phenomena which are pathognomonic of the malady, and in the absence of which the disease could not be diagnosticated, cannot be looked for in the pathogenesis of remedies.
But these organic phenomena, these pathognomonic symptoms, for such they are in most cases, are the very ones on which the diagnosis depends. If, therefore, the diagnosis and the prescription are to be worked out by the same method, and are to be made on the basis of the same symptoms or series of symptoms, then an accurate homeopathic prescription would be a rare thing, and in the majority of grave and serious affections, it would be an impossible thing; yet so many successful prescriptions have been made in such cases as to show that it is not impossible, nor indeed always very difficult.
But a prescription is always based upon a correspondence of the symptoms of the drugs with the characteristic symptoms of the case in hand. It follows, therefore, that those symptoms which the prescriber regards as characteristic symptoms, are not at all the same which the diagnostician regards as pathognomonic symptoms; they are not the phenomena from which the malady gets its name, those which depend upon, and indeed constitute, its pathological anatomy.
In the case related by Hartmann, the symptom pathognomonic of the case was the tumor. This was the "pathological anatomy" of the case. By this symptom the case was classified. From this, it takes its name, and this was the symptom of chief importance to the diagnostician.
But the proving of Chamomilla did not contain this symptom. Consequently, had Hahnemann regarded this symptom as a characteristic symptom from the point of view of the prescriber, he would not have been able to select Chamomilla as the remedy. He did not so regard it.
The symptoms which he regarded as characteristic of the case, and for which he sought and found in Chamomilla corresponding symptoms, were the general constitutional, for the most part subjective, symptoms,—the symptoms of mind and disposition, and the conditions of time and circumstance, such as aggravation, amelioration, etc.
Cases still further illustrating these facts are to be found in the clinical records. It happens sometimes that cases of disease are cured by drugs that had not, at the time they were so used, been known to produce the pathognomonic symptom of the malady they seem to have cured, whereas subsequent more extensive provings, or accidental observations in cases of poisoning, have shown that these drugs are capable of producing and do produce these organic changes, these pathognomonic objective symptoms.
A considerable number of cases of albuminuria, some of them, no doubt, cases of Bright's disease, have been recorded as cured by various remedies.
Some of these remedies are not yet known to have produced albuminuria in the healthy subject. Others are known to have done so.
One of them, Arsenic, has cured a number of cases. It has almost always been selected because of the correspondence of its general constitutional symptoms with those of the cases in hand. And indeed the correspondence, in this respect, with the general symptoms of Bright's disease, is very striking. I myself once cured with four doses of Arsenic 200, a most severe case of post-scarlatinal dropsy, which had already lasted ten days before I was called to it, growing steadily worse until death seemed imminent, and in which the urine in the test-tube became nearly solid on applying heat, the entire quantity of urine passed in twenty-four hours being less than two gills. In this case, of course, the pathognomonic symptom for the diagnostician would have been the albumen, the blood discs, and the casts in the urine (they were all there).
The symptoms which guided my choice in the selection of the remedy were the general symptoms, the character of the pains, their aggravations and ameliorations, the prostration, thirst, temperature, posture, etc., etc., all of which were so characteristic of Arsenic that I could not hesitate a moment.
I did not know at that time that although Hahnemann's proving does not contain this pathognomonic symptom, albuminuria, yet this symptom has been produced by Arsenic, together with all other objective signs of Bright's disease, in healthy cats in numerous instances, by Dr. Quazlio of Munich; and again it was observed, with equal minuteness, in two remarkable cases of arsenical poisoning recorded by Dr. Maclayan in 1852. (Editor " Medical and Surgical Journal.")
Phosphorus has been found to produce Bright's disease ; Mercury has produced albuminuria. Cantharides have produced objective symptoms corresponding to, at least, the first stage of one form of Bright's disease.
Now if we had a case of Bright's disease to treat, how should we select a remedy ? The fact of the drug having produced albuminuria in the healthy subject is common to these four drugs, and is perhaps true of several others. How should we choose among these drugs ? Why, by the general subjective symptoms. But these symptoms alone, without the objective symptom, albuminuria, have already, in a great number of cases, been sufficiently good guides, to enable us to select not merely this group, but the exactly appropriate drug in the group.
Thus it appears that these general constitutional symptoms are not only a sufficient, but they are a more accurate guide, than the objective pathognomonic symptom.
They are also a more comprehensive guide. They enable us to employ, and direct our attention to, remedies that we should not be led to employ if we confined our attention to the pathological anatomy of the disease under treatment.
For example: Apis has cured many cases of albuminuria. The general symptoms of Apis correspond well to some cases of this disease. Yet we find no record of albuminuria in the proving of Apis. Nor is it likely that we shall ever have toxicological data to complete our proving in this respect, because Apis is not a substance likely to be employed as a poison.
It is possible that as Arsenic and Phosphorus and Mercury have accidentally been found to be capable of producing pathologico-anatomical conditions corresponding to those which they have cured, so Chamomilla may have been, or may some day be, found capable of producing haemorrhoidal tumors. If so, the fact will be interesting; but it will not make it one iota easier to prescribe Chamomilla for haemorrhoids. For the prescription, if we would have it an exact one, must be based on the correspondence of the general and subjective symptoms, and on the times and conditions of their occurrence and aggravations.
Upon these slightly desultory remarks three propositions might be based.
I. The point of view from which the pathologist and diagnostician regard a case of disease, and that from which the therapeutist or prescriber regards it, are radically different. And inasmuch as therapeutics, as a science, have hardly received any systematic cultivation, while great and successful attention has been paid to pathology and diagnosis, it has happened that the manner in which disease has been studied, discussed and described by medical authors,—contemplating it rather as a natural phenomenon to be studied and classified, than as a condition of the individual patient, for which an individual specific is to be found,—has been unfavorable to the purposes of the prescriber, obscuring rather than elucidating those points which are to be his chief guides, and exalting into a position of prominence features which are to him only of subordinate value.
2. The arrangement of materia medica on the basis of a pathologico-anatomical schema, as is desired by some, would be, first, impossible, second, useless, third sure to mislead.
3. It is probable that while to the diagnostician, the pathological anatomy of a case is the fact of prime value ; to the prescriber the diathesis, general and special, is that to which he is chiefly to look for his indications.