case management

from The Genius of Homeopathy
Lectures and Essays on Homeopathic Philosophy
Stuart M. Close
Chapter X - Indispositions and the Second Best Remedy

Not every case which presents itself to the physician requires medicine. It may only require the searching out and correcting of some evil habit, some error in the mode of living, such as faulty diet, unsanitary, surroundings, non-observance of ordinary hygienic requirements in regard to breathing, exercise, sleeping, etc.

In Par. 4 of the Organon, Hahnemann says: "He (the physician) is likewise a preserver of health if he knows the things that derange health and cause disease, and how to remove them from persons in health."

In Par. 5 the physician is enjoined to search out "the most probable exciting cause of the acute disease, as also the most significant points in the whole history of the chronic disease to enable him to discover its fundamental cause, which is generally due to a chronic miasm."
In making these investigations he directs our attention to "the physical constitution of the patient, his moral and intellectual character, his occupation, mode of living and habits, his social and domestic relations, his age, sexual functions, etc."

But this line of investigation is equally fruitful and necessary in dealing with the indispositions of which I am particularly speaking.

In the note to Par. 7, Hahnemann says: "As a matter of course every sensible physician will remove such causes at first, after which the indisposition will generally cease spontaneously." By way of illustration he goes on to say: "He will remove from the room strong smelling flowers, which have a tendency to cause syncope and hysterical sufferings;" (and I may add that he will order hysterical and neurotic "lady patients" to abandon the use' of the strong perfumes and sachet bags with which they render the air of their rooms unfit to breathe, aggravate their complaints and make themselves a nuisance to everyone who comes near them); "extract from the cornea the foreign body that excites inflammation of the eye; loosen the over-tight bandage on a wounded limb, ligature the wounded artery, promote the expulsion of poisonous ingesta by vomiting extract foreign substances from the orifices of the body, crush or remove vesical calculi, open the imperforate anus of the new born infant, etc."

In short, Hahnemann has done his best to make it clear that the use of common sense is not incompatible with homœopathic practice, his enemies and some of his overzealous followers to the contrary notwithstanding.

The young homeopathic doctor, fresh from the halls of materia medica, with his brand new case of medicines, is apt to be like the small boy with his first jack-knife who wants to carve and whittle everything within reach-a simile, by the way, quite as applicable to the young surgeon! Both of them leave a trail which to follow does not require the sagacity of a Sherlock Holmes.

Consider for a few moments, then, that class of cases which require for their use only the correction of faulty habits and the removal of exciting causes. Consider also that it often requires the exhibition of as much wisdom, skill, good judgment and tact to perform this function as it does to prescribe medicine; indeed, it often requires more. It is much easier to deal out medicine and dismiss the patient, than it is to make a-careful investigation of the habits and circumstances of a patient who probably does not need medicine at all, but only wise and kindly advice on how to live.
Great is the power and value of homœopathic medicine, but, like all other good things, it can be abused. Even high potencies can be abused and cause mischief, as I saw illustrated very strikingly when I was sent for in haste to see a patient for whom I had prescribed a few days before. I relate the case because it not only illustrates the particular point I am discussing now, but also the subject (if posology which I shall take up subsequently.The patient was an old gentleman who was in a state of mild senile dementia, with enfeebled power of thought, loss of memory, tendency to involuntary urination and defæcation, rather persistent sleeplessness, and becoming careless in his personal habits. But lie had been perfectly tractable arid mild in his demeanor, and had made no trouble for his family.The symptoms led me to prescribe a remedy, which I gave in the two hundredth potency, with directions to take two doses daily.Three days later I was sent for in haste to see him. I found him in a highly excited state of mind, with flushed face, widely dilated pupils, staring expression and suspicious of being poisoned. He excitedly and harshly accused me of giving him "another man's medicine" which had "filled his bowels up;" he had removed all his clothes, refused to put them on again, and was going about the house nude before the women, without shame, and had tried to go out of doors in that state.

I recognized the symptoms immediately, as I hope you have done. Probably most of you will be able to name the remedy. It was Hyosciamus, of course.

On making inquiries I found that instead of taking the remedy twice a day as directed, owing to a misunderstanding, he had been taking it every two hours. Of course he was making 1 proving-of the two hundredth potency! A single dose of Belladonna, two hundredth, removed the whole trouble in a few hours, and he resumed his ordinary placid course of life.

An experience of that kind has a strong tendency to remove any scepticism one may have as to the power of high potencies. It also conveys an impressive warning against too frequent repetition of doses. Moreover, it upsets the theory that high potencies do not act upon the aged. Incidentally it shows the possibility, sometimes denied, of making provings with highly potentiated medicines and substantiates the claims of those who hold that no remedy can be considered as well proved until it has been proved in the potencies as well as in crude form.

It is well known that the most valuable, e part of a drug action, the finer shadings of symptomatology, are almost never brought out under the use of the tinctures and low potencies.These appear usually under the action of a medium or high potency, or toward the close of a proving of a low potency, long after the first effects of the drug have passed away; so that it has come to be a maxim among experienced provers that the last appearing Symptoms in a proving are the most valuable and characteristic. In the same way, the last appearing symptoms in a disease, especially chronic disease, are of the highest rank in selecting the remedy-a practical point it is well to remember.We should never neglect to inquire of a patient whether any new symptoms have appeared since the last visit or prescription and value any such highly.

Returning to the subject of indisposition: Having discovered such a case and determined that it does not require medication, the question arises, how is such a case to be managed? At first sight it would seem to be a very simple matter; merely to tell the patient bluntly that he does not need medicine, but only to mend his life and correct his habits according to the advice and instruction which you have given or will give.This view of the matter does not take into consideration the peculiarities of human nature as formed by ages and generations of habit and custom. Only occasionally do we meet a patient to whom we can give ideal advice and treatment. In spite of the rapid growth of the no-drug idea as promulgated by the various modern cults, the average patient who goes to the doctor, expects to get medicine. If he is so far advanced in his ideas as to believe in the no-drug theory he will probably not go to the doctor at all, but will seek out the osteopath or the Christian science healer.The patient who believes in drugs and goes to a doctor for treatment will be very likely to listen incredulously to your well-meant advice and will depart to tell his friends in anything but a respectful manner, that he thought you were a doctor, but he found that you were only a half-baked Christian scientist after all, or something to that effect.To direct his attention to his errors of living and order him to correct them is to apparently put the burden of cure upon him, and that is not what he wants at all. He expects us to bear that burden.That is what he comes to us for. Besides that, he often resents the assertion that his trouble is due to his own ignorance or willfulness.There is a large class of people today-selfish, pleasure-seeking, luxury-loving, dissipating creatures, male and female-who demand of the physician relief from the pains and penalties of their hygienic sins, but are not willing to do their necessary part toward bringing this about.They want to "eat their cake and have it too."

We cannot afford to antagonize this class, either for their sakes or our own.We owe them a duty as well as ourselves, and few of us can afford to pick our patients.We must take them as they come and adjust ourselves to their individual needs and peculiarities.These in general are some of the cases which require tact in management. "You can catch more flies with molasses than with vinegar." We can gradually lead some of these people into better ways of life and thought and cure them of both their sickness and their sins, if we are patient and wise and tactful; while at the same time we are increasing the extent and influence of our practice.The physician who aims to be something more than a mere dispenser of palliatives, pills, and piffle, will never lack opportunities to magnify his profession and become a power for righteousness in his community, as well as 'a healer -of its diseases. It is in dealing with such cases-the indispositions and habit disorders-that the "second best remedy in the materia medica" so often comes into use. Of course you all know what the second best remedy is. No? I am surprised that your education. has been so neglected! But I am glad it is to be my privilege to teach you something you do not know.There are so few things that the average young doctor does not know!

In order to fully appreciate the value of the second best remedy, we must first clearly understand what is the best remedy in the materia medica.There cannot be any doubt in your minds as to that, I am sure. It is the indicated remedy.You also know that having once been found, the best remedy must be given time to act, and that its action must not be interfered with by other drugs or influences until it has accomplished all of which it is capable.You also know, or, if you do not, you will learn (if you keep your eyes open and your wits about you) that too many doses of the best remedy may spoil the case.

One of the distinguishing characteristics of a great painter is that he knows when to stop. Many a painting which would have been great, if the artist had known when to stop, has been weakened and spoiled by over-finishing. In his anxiety to perfect a few insignificant details he robs his work of, its vitality-kills it. It is the same in treating a case.The problem is to give just enough medicine and not too much.Too many doses may spoil the case. I have referred to the class of people who expect and demand medicine, and are not satisfied unless they get it, until they have been taught better.
Now just here comes in the second best remedy without which no good homœopathist could long practice medicine. Its technical name is saccharum lactis officinalis; abbreviated sac. lac. or s. I.; just plain sugar of milk! The young homœopath's best friend, the old doctor's reliance and a "very present help in time of trouble!"

The doctrine of placebo, from the Latin placere, to please-, future, placebo "I shall please," is as old as medicine itself. Its psychological value is commensurate with the frailties and peculiarities of human nature.The traditional "breadpill" of our medical ancestors has given place, in the march of scientific progress, to the more elegant powder of virginal white, pure sugar of milk; or to the seductive little vial of sugar pills or tablets, artistically labeled and bestowed with impressive directions as to the exact number of pills for a dose and the precise hours of taking, with confident assurances of the happy effects to be expected, if directions are faithfully followed!

Marvelous are the results witnessed from the resort to this remedy in cases where it is indicated. I have seen it bring sleep to the "insomniac," when even morphine had failed. I ha e heard patients declare that it was the most effective cathartic the had ever taken and beg for a generous supply for future use which supply I have usually refused on the ground that it was too powerful a remedy to be entrusted to the hands of the unskilled. It is indeed too powerful and too useful a remedy to be held 'lightly, or to be lightly used.The knowledge of its use is too dangerous to be disseminated among the laity. It should be as jealously guarded as a "trade- secret" worth millions. Never admit its use to any but the initiated, if you value your influence and reputation, but never fail to use it when your judgment dictates it.

Let us glance at a few of the practical uses of the placebo.You are called to a new case.You see the patient and make your examination.You decide that it is a case for medication.You have written down your symptom-findings and glanced over the record.The case is difficult and you are not able to decide offhand what remedy is indicated.You must have time and opportunity to study it up.The patient and friends want something done at once. Rapidly you run over the case in your mind.This patient is seriously ill.To make a mistake in the first prescription might be fatal, or it might prejudice the case by confusing it so that a quick and satisfactory cure would be impossible.Your reputation in the new family will depend upon your success.You must retain the confidence of the patient but you must have time and make no mistake.

This is where your knowledge of the second best remedy comes into use. Calmly and confidently you prepare and administer a generous "s. l." powder, leave explicit directions for the use of as many subsequent doses as you deem judicious, make an appointment to see the patient again in an hour or two, or three, and then hie you to the seclusion of your library, where you proceed to apply your knowledge of how to study the case and find the remedy according to the principles of the Organon.
When you have worked out your case and found the remedy, you return.Then you enter the patient's presence as master of the situation-unless the Master of Destiny has ordained otherwise.
Does anybody consider that lost time? It is a pity that more time is not lost in that way! Thousands of cases might have been saved and many a professional reputation, by following such a course, instead of yielding to the silly panic-impulse to "do something quick," which almost invariably results in doing the wrong thing.

Patients do not usually die in a minute.There is always plenty of time to do the right thing, always, at the right time. If you know what the right thing is without reflection and study, do it at once. Give your remedy at once if you are sure of it, but not otherwise. If you are not sure, give sac. lac.
If the case is really pressing and demands immediate medication, retire to another room with your repertory then and there.

The very greatest of our prescribers-men like Bœnninghausen, Hering, Lippe,Wells, Biegler, of those who are gone, and almost all our expert prescribers of today, do not fail to carry their repertory with them to all cases, nor hesitate to use it in the presence of the patient if necessary. Instead of arousing distrust on the part of the patients, as you might think, it awakens confidence.To see -a physician making a thorough examination, studying, "taking pains," showing a real interest in the case and a determination to do his best at the "psychological moment" (which is always the present moment with the man who is suffering), is calculated to inspire confidence at all times-except with fools, whom no physician wants for patients and who ought to be permitted to get off the earth as soon as possible for the benefit of posterity anyway.

Another use for the second best remedy is as a supplement to the indicated remedy. Experience shows that Hahnemann was right when he advised that the remedy should be stopped as soon as signs of improvement appear, and the curative reaction be allowed to go on without further repetition of doses as long as it will.This, of course, refers to the cases where repeated doses are given from the beginning.When improvement begins and you desire to cease medication, you will simply substitute sac. lac. for the remedy and watch your case.

The same course is pursued when treatment is begun with the single dose, by which method many of the most brilliant cures are made.

We may give enough sac. lac. powders to last during the interval between visits, or a vial of blank tablets or pellets; but be sure to moisten the tablets and pellets with alcohol, or put some unmedicated pellets in the sac. lac. powders. Patients have a way of investigating powders sometimes and counting the pellets. If they find no pellets they may become suspicious.

The medicine case should always contain a vial of blank pellets properly labeled for such use. One friend of mine always carries a duplicate case of vials containing blank pellets, but labeled as medicines to disarm suspicion.

These are some of the ways to use the second best remedy. If you follow the right course you will find more and more use teaching and thinking on therapeutic subjects.The use of placebo is simply one form, and a very powerful form of therapeutic suggestion; or, to use the still more recent term, psycho-therapy. In the habitual, systematic and judicious use of the harmless little powder of sac. lac. the homœopathist antedated all the modern cults of drugless healing, and even they have devised no more powerful nor efficient measure.

We are not under the necessity of sending our patients away, as Dr.Win. Gilman Thompson, of Cornell University Medical College, had to do. He was holding a medical clinic before the senior class,To this clinic came a woman whose case was diagnosed as neurasthenia.Among the multitude of complaints she poured forth, she laid most stress upon constipation; but declared that she could and would not take any more cathartics.

Dr.Thompson pondered over the problem a few moments and then turned to the class and said: "Gentlemen, there is but one thing to do for this patient.We will send her to Boston. There, they will give her a subconscious pill, and she will get an Immanuel Movement!"

Many who are not susceptible to the "subconscious pill" will respond to the somewhat more tangible but none the less efficient sac. lac. powder, even among those who live in Boston!

Objection has been made to this mode of dealing with cases, by certain individuals with very delicate consciences, on the ground that it was not strictly honest! To practice even such a mild deception upon patients would violate their fine sense of honor! Besides, it tended to engender in patients a habit of dependence upon sac. lac., and to demoralize the physician who followed the practice!
Recall the words of Him who said: "Woe unto you, Scribes and Pharisees, hypocrites! for ye pay tithes of mint and anise and cummin, and have omitted the weightier matters of the law, judgment, mercy and faith; these ought ye to have done, and not to leave the other undone.Ye blind guides which strain at gnat and swallow a camel!"

He who said that, anointed the eyes of a blind man with "clay mixed with spittle," bade him go and wash in the pool of Siloam, and he recovered his sight-healed by faith; awakened by the therapeutic suggestion of a clay placebo and an order to take a bath!

Any harmless measure which tends to arouse the curative reaction of the organism through the awakening of faith and confident expectation, is not only right but legitimate and sometimes indispensable.

But what shall we say of the men who have been so pained at the thought of using the placebo, when we find them violating every fundamental law and principle of the art whose name they profess before the world, by using powerful drugs in such a manner in their treatment of the sick, in both public and private practice, as to do irreparable injury?

Or what shall we say of men prominently before the public as official representatives of homœopathy in college and hospital, who herd patients in a Metropolitan Hospital ward, arbitrarily denominate them a "class," without regard to their individual symptoms, and give them all, indiscriminately, hypodermic injections of "a preparation of digitalis" for their hearts?

This is indeed neglecting "the weightier matters of the law." It is the irony of fate that makes it possible to say such a thing of men who conduct a great hospital which was specifically founded and financed for the purpose of dispensing the blessings of homœopathy to the poor of the great city.
And what about the young men who have come from far and wide to the colleges connected with such hospitals, and pay their money in good faith for such instruction in the methods and principles of homœopathy, who are called upon to witness such perversions of all true therapeutic principles, to say nothing of homœopathy? Should they not be considered?

President Cleveland immortalized himself by declaring that "Public Office Is a Public Trust."
President Roosevelt endeared himself to the people, and will go down in history as the great exponent of "The Square Deal."

These two great leaders, each in his own way, have thus voiced the principles of common honesty in the conduct of public and private affairs.The people have listened and responded.The world is waking up, for, as President Lincoln said: "You can fool some of the people all of the time; you can fool all of the people some of the time, but you cannot fool all the people all of the time."

When homœopathic colleges teach homœopathy in every appropriate chair; when homœopathic hospitals and homœopathic clinics are conducted on homœopathic principles; and when homœopathic physicians make at least a sincere attempt to prescribe homœopathic remedies for their patients; then, and not before, will the/principles of common honesty find their application in the homœopathic medical profession.

It is a breach of trust to do otherwise.The moral obligation is upon every man who is affiliated with a homœopathic institution, and upon every physician who professes the name of homœopathy, to be true to homœopathic principles.'

It is not many years since the late Judge Barrett, of the Supreme Court, in a decision which he handed down in a certain case, declared that the legal obligation rested upon every professedly homœopathic physician to practice according to homœopathic principles; and that he was liable at law if he did not do so.The people who give their money to found and sustain homœopathic institutions have some right in this matter which should be respected.

We have now a "pure food law" which requires that all goods shall be "true to label." The time may come, and perhaps is not far distant, when we shall have a "pure practice law," which will require that a man who represents himself as a graduate of a homœopathic school and a practitioner of homœopathy, shall be required to practice in accordance with the principles of that school or suffer the penalty of his misrepresentation-in other words, that he shall be "true to label." He will not be able in that day, as he is now, to advertise, "57 varieties!" There is but one variety of homœopathy, and that is the homœopathy of Hahnemann, the principles of which are plainly laid down in the Organon. All other varieties are fraudulent, concocted of impure materials and injurious to health, like the inferior canned goods of the manufacturers, which they try to preserve with antiseptics. If some of the fraudulent homœopaths were compelled, like the food manufacturers, to state on their labels the names and percentages of the foreign ingredients in their wares, it might be better for the people, but they would have to enlarge either their labels or their packages in order to make room for the list.

With all this there is no need to be pessimistic. The leaders of the homœopathic profession are awake to the true state of affairs. They are demanding of their colleges and teachers that homœopathic principles shall be taught, and the colleges are responding as rapidly as they can, hampered as they are by the presence of some men in their faculties who are antagonistic to everything homœopathic. They recognize that the future of homœopathy depends upon the young men who are coming up; upon the classes now within college halls; that the long neglected principles and methods of homœopathy must be restored to their true place in the college curriculum and taught by men who love the art of healing and are imbued with the spirit of homœopathy and the love of it! We may know the principles-the science of homœopathy-but unless we love the art, and practice it, we will fail in the highest department of our calling. Never was there such need as there is today for pure homœopathy, nor such opportunities for young men of enthusiasm and earnest purpose, who are thoroughly trained in homœopathic methods. The colleges need them as teachers.The hospitals need them as internes and visitors, and in other official positions.The people need them as practical healers. Prepared for that work, "The world is our oyster."

Margaret Lucy Tyler
How Not to Do It
The Homoeopathician, February 1912;
reprinted in the Homoeopathic Recorder, October 1929.

Dr. Kent, Dr. Gibson Miller, and others, can tell you, from long years of successful work and experience, how to do it. I feel that I am equally well qualified, from some years of poor prescribing and much failure, to tell you how not to do it. I used to get brilliant flashes of light and joy - when I hit the drug - and that was just often enough to keep up the enthusiasm of an optimist like myself; but, take it all around, it was failure; and, because it may help some of you, I will try to tell you why.

Homœopathy, as you and I know, would work, and did work. But I had not properly mastered it; my ideas were too crude, my methods too lawless and untrained, for it would work only fitfully for me. The power was there, right enough, for the illuminating flash testified to its presence; but I could not draw on it with confidence at all times, or make it work quietly and surely - as power will work for those who understand the forces they harness, and can recognize their laws and limitations, and the peculiarities of their manifestations.In short, I had not learned my philosophy .... to tell you the truth, I did not know that there was any philosophy to learn. And, without its philosophy, one may use homoeopathic medicines, even homoeopathically, but one is no homoeopath, and one will never get uniform nor satisfactory results. One will never even recognize the significance of the results one does get, nor know how to deal with them.

TO MASTER THE FIRST THING IS TO OBEY

Remember that the one thing that power exacts is obedience. Electricity is a great power; no man has doubted its existence; for the roar that has followed the flash since the dawn of time has proved too much for the stoutest skeptic. But, to utilize this power, man must court it in its own way, obediently, guiding it through its own channels, conforming to its idiosyncrasies one by one, as he makes its better acquaintance and discovers them. It is only by faithful obedience to the master-power that it may be bent to work for man, obediently, as his slave. So with homœopathy. There are no rough-and-ready methods. A child can stroke a cat's back and get sparks; but for a steady, useful current, to drive engines, or light a city, or girdle the earth, it requires rigid conformance to all the known laws. No great power works without definite laws and limitations; and with these we have to reckon, or fail. And in homceopathy, as in electricity, you have either something - or nothing! Both are giddily intangible - only to be recognized by results. And in both there are no half measures. All has to be in order with your method if the steady current of healing is to flow. A spark here and there - even evastating - is not business. It is convincing in its way, and may even hold a promise of better things if you can better your methods of dealing with it.

PRESCRIBING FOR THE DISEASE

For a homoeopath, I suppose the often fatal first step is to label diseases, and then to label drugs to match.

To ticket Rhus and Bryonia "rheumatic remedies", and practically make your choice between them, and to fling it in the teeth of homœopathy when they fail to cure a case that required Sulphur or Tuberculinum, or - the dentist;

To regard Sulphur and Graphites as "skin medicines", and utterly fail in the cases (and they are not few) that demand Pulsatilla;

To set Sepia aside as "a remedy for women's complaints", and scorn the person who dares to give it to babies.  Whereas, if you are to work your homceopathy for all it is worth, you will have to cure individual cases
Of tubercular dactylitis with Sepia, of all medicines!
Of goitre, even with a mass in the right lobe - not even the left - with Sepia (I showed such cases recently to the British Homoeopathic Society);
Constipation with Rhus, or Variolinum (as did Dr. Burnett);
Or (as did one of our men recently) a nocturnal gastralgia accompanied by wasting with a single dose of Syphillinum.

If you are to do it, and to do it often, you just have to let the disease alone and go for the patient. You have to say, not "this is a case of rheumatism, and I might try Rhus, because Rhus is a very good medicine for rheumatism", but "this is a Sepia patient, and, whatever ails her, it is Sepia she needs, and no other medicine". My goodness! if I had known that from the beginning.

And, for your own sake, don't be too ready to say, "I tried homoeopathy for such a case, and it failed". Remember, it was you who failed; and the very fact that you failed proves that, whatever it was, it was not homceopathy. The power was there all the time, only you failed to apply it. Say this to some one who knows, and he regards you pensively. You have merely betrayed your own limitations.

TOO FREQUENT REPETITION

Now, the second fatal stumbling-block is the cabalistic sign "t. d. s." - ter die sumendum (which the knowing ones reserve for Placebo). I suppose that that has blighted more brilliant homoeopaths in the bud than one can imagine. And next to that, in its self-stultifying mischief, comes the atrocious formula, of those who fondly imagine that they are doing high class homœopathy indeed, "once weekly". When I started on my career of failure and bad prescribing, I saw every one giving drugs "t. d. s." - for chronic cases anyway; think of it ! And, never having learned to prescribe, I fell headlong into the pit. In vain my mother protested - she had learned good homceopathy in the early days of better work.

"It is quite wrong", she said, "to give medicines like that, and for weeks at a time. It is not homœopathy at all. Directly there is improvement, you must stop; and only repeat later, if the symptoms return unchanged".

But "t. d. s." was everywhere the rule, on which I proceeded to improve. For, knowing that potencies worked, I gave 30s and 200s thrice daily - or once or three times a week, as the spirit moved me; not divining that, if one must play the "t. d. s." game, it is well to employ the drug in its highest state of im-potency - perhaps about the 3x, where you have not enough quantity for crude effects, or enough penetrating power for deep and lasting mischief. Men do get excellent results in some superficial cases, in this way.

Worse than all, I led others into the same error, inducing them to try the high potencies. I was always thrown back on myself to wonder why, when I had made a good prescription, the patient, after a few days' splendid betterment "Why, I thought I was cured for the first three days" - relapsed and came back worse than ever, or with new tales of woe, for which a new prescription went down - with like result. Always better - and then worse, perhaps in a new way; but never, never, never cured.

Gentlemen, you can go on in this way for years, curing your patients till they die. They will forgive you the relapse each time for the good hope of the first three days. In fact, that will go down to your credit, and the rest to the credit of the disease. You can ring the changes with a regular sequence of amelioration; drug effect; new prescription - symptoms wiped out; new drug symptom; new drug to meet them - fresh amelioration; fresh mischief; and again another remedy of like symptoms which, like all its predecessors, ameliorates promptly, and then proceeds (if persisted in in this idiotic way) to set up its own train of symptoms, for which you again drearily prescribe - while homœopathy sinks lower and lower in your estimation, and the younger men wonder that you have lost all enthusiasm for its cause. Even in those days of little knowledge, I could often have done brilliant work had I used my mother's words, and adjured the patient: "Directly you are better you have to leave off your medicine, and never touch it again, unless you are really worse".

I am afraid I spoiled several men's work by inducing them to try the higher and highest potencies. I know that I am giving myself away badly, but perhaps that is necessary. For, gentlemen, every evil that I have done in my ignorant flounderings after better things lives on in some corner of L.H.H., and I am always meeting my sins at odd moments and around unexpected corners - "hinc illce lachrymoe!"

I have seen Calc. carb. CM prescribed thrice daily for a month by a man who was, as he expressed it, "giving the high dilutions a trial". And my evil suggestions as to giving Tuberculinum weekly, while one gave, say, Silica 30 t. d. s. (Silica, that deep-acting drug of 40-60 days' action ! ), are still haunting the place like evil spirits, to lay which it will take more of the holy waters of repentance and confession than I can manage this afternoon.

USE OF REPERTORY

But it was not all imagination and daring experiment. I did try to work out my cases, believing that when I failed it was because I had the wrong drug - which by no means follows. I did try to work out cases, with hours and hours of labor - generally in vain ! For I had never been trained.

Till our first scholars came back from America, no one had ever taught me how to recognize the few symptoms of inestimable value in the equation. NO one had ever shown me how to eliminate drugs and minimize labor by starting with certain general symptoms well marked in the patient. I had no faintest idea how to work economically as regards labor.

I would start by writing down that terrific list of drugs producing constipation - if the patient complained of that trouble; and so on through all his symptoms, important or unimportant, even mechanical, and probably altogether misleading, giving to each drug its value according to type, and never once considering (what is most important) whether the type coincided in patient and drug; then rounding up with an arithmetical calculation. Sometimes the drug came out: but the labor was hideous, monotonous, and not even remunerative in results.

I was not easily beaten; if there was anything in repertorizing, I was determined to master it, and more, to make it practical with a minimum of labor; for I went so far as to devise a card-trick system, every card a symptom, and all drugs that produced that symptom punched out. I deafened myself punching one thousand such cards. I have them still, a great cabinet full. But even this could not help, because the system was wrong.

When one knows how to repertorize, a choice from some 80 cards of "general" symptoms in a small portfolio is all that is needed to start a case - often to work it out in five minutes with a glance at the materia medica - had I known ! But I have learned one thing from all this, and that I am competent to teach any one, viz., how not to do it.

Another way to insure failure, in some cases, is to start your repertorizing (by way of weeding out useless drugs and lightening labor) not with generals, but with some list of drugs that has the patient's ailment. Say it was my case of goitre, where Sepia cured - one dose of Sepia.

In my days of fruitless repertorizing, I should have begun work on a case like that by writing down all the drugs that have been found useful in goitre; then, as there was a mass in the right lobe, I should have eliminated all the drugs, by the help of another list, that did not affect the right side of the body, or neck. And I should have failed - absolutely and inevitably have failed; because Sepia is in no list of drugs known to affect the thyroid gland. And again, though Sepia is among the drugs that pick out one side of the body, it happens to choose the left side for its operations, in the general way; so, again, I should have inevitably missed it. She received Sepia because she looked, and was, a typical Sepia patient, with Sepia symptoms, and because I simply could not give her anything else - then; my absurd intention being to cure her first and then to tackle her goitre.

But if (and it is a large if) you cure your patient, the odds are that there will not be anything left to cure. Your business is to cure her; the rest is her affair. Make her normal, and she will have no further use for acquired abnormalities. Healthy nature makes short work with superfluous details; for she can waste, as well as develop. Given the irritant, and she will sprout "ultimates", and in vain you prune them away. Put her right, and she starts clearing them off and setting her house in order. Be well assured that 8nothing continues to exist without cause! And learn a lesson from the tadpole's tail; it has taught me much. I used to think it dropped off ! We have a great deal to learn about absorption !

HASTY PRESCRIBING

Another way not to do it is to be too ready with your prescription. If you take a lot of trouble with a case (when you know how), it will give you very little trouble afterwards. Conversely, if you take a very little trouble to begin with, it will give you endless trouble, many times repeated. You have fouled the clear waters with a wrong prescription, and how are you going to peer into the depths? You no longer have a true disease picture to match. One bad prescription leads to several, perhaps to a hopeless mixing-up of the case. "Curses and chickens (and bad prescriptions) come home to roost". If you are not sure give a Placebo and wait. Hahnemann says, "A week's Placebo to start with, anyway" !

PRESCRIBING DURING AMELIORATION

And when you have worked it out, and actually found your drug, there are still several ways of how not to do it. One of the most catastrophous and heart-breaking is to repeat while amelioration holds. Two cases have bitten into my memory, though hardly understood at first; and yet I go on doing the same thing again and again, for it is the hardest lesson in the world to learn, to hold your hand and do nothing. One catches at the excuse of any little recurrence of symptoms to repeat, and often spoils the case - pro tem., anyway.

A glaring instance, which in those early days I did not even understand, was a chronic typical Aloes-diarrhea. (I have hunted in vain for the notes so speak from vivid memory only). He got Aloes CM (either one dose or two at a week's interval). He came back so much better, practically cured, that I hugged myself, and hugged homceopathy as a very wonderful thing. I had found his remedy right enough, and I would keep him on it for a bit, lest he should relapse! Of course, he came back less well. Then I gave it more often (it was the right remedy, for the first dose had been magic). I piled it on - homceopathy was a less wonderful thing (my homoeopathy, that is, which ought to have been written in inverted commas); and presently he came no more.

That case has rankled ever since. I came to the conclusion, at that time, that the first prescription was a comparatively easy matter; but what to do with patients when they came back better was beyond me! The very obvious "do nothing" was also beyond me for ages.

That is where the philosophy comes in. That is where, in homceopathy, we perish for lack of knowledge. That is where the young men, who have been trained score. They will never know so much about "how not to do it"; but they have been taught when not to do it ! For there is one rule, and one only, that meets the case:So long as amelioration holds, let it be;.and only repeat, or reconsider the case, when you are sure that it is quite at an end.

Why, Wright has proved that recently, under the microscope, for Tuberculinum; though Hahnemann laid down the law more than a hundred years ago. And we who call ourselves his followers sneer at "the eternal Hahnemann'', and do not even take the trouble to master his teachings.

Never repeat while amelioration holds. It will be from minutes to hours (Hahnemann says so) in acute cases, and from days to weeks or months, according to drug and case, in chronic diseases. But, unless you want to see your work always going back on you, unless you want to be one of those who have "tried homceopathy and failed", let your ameliorations severely alone, and keep your enthusiasm for scientific medicine.

The other sharp lesson was a case of heart failure in a woman of 29, mitral incompetence, etc., that I got permission to treat after admission to the L. H. H. Here I have the house physician's notes and measurements. She worked out Arsenicum, and I gave a dose of Ars. CM two days running (as she had been given a dose of Spig. low in the intervening night, and it might have interrupted). The effect was magical. Three days later (only four days after admission):

The heart had contracted, and was now only one inch, instead of two, to right of the sternal margin. The liver had also contracted, and now, in the nipple line, measured 6 1/4 inches instead of 8 3/4 inches.One hundred heart beats out of one hundred and forty-four now reached the wrist, instead of sixty-two out of one hundred and sixty.

She was sleeping quietly at night, instead of the suffocating spells when she dozed, and the frequent vomitings all night that had been a feature of the case.

She felt very much better. Every one was amazed at the improvement, and, in my joy and desire to hasten matters yet more, I gave her, a week later, another dose of Ars. CM. And that ended the case - in all senses! She grew worse. Lyc. was given, and failed to relieve. All her fearful restlessness returned; she could stay nowhere. She demanded to go home, where she died very soon after.

You who know realize that it was risky even to give a CM to such a case, but that it was madness to repeat it while the patient was doing so well. You see that it is not enough to spot your drug; it is not enough to make a successful prescription, even. You need all the philosophy if you are to carry your work through every time, if you are to get nearly all there is to be got out of homoeopathy. I was like an electrician who, having proper wires and a lamp of just sufficient resistance to glow its brightest, wantonly doubles the current, fuses the filament, and earns darkness. The greater the power, the more carefully must it be handled, to avoid disaster.

HIGH POTENCIES IN ADVANCED CASES

Another way not to do it., a case that emphasized the fearful risk of giving a high potency of the indicated remedy to advanced disease, was a case of malignant tumor of the breast. The woman had been doing well on unit doses of Scrof. nod., had lost pain and swelling of the arm, and inconveniences of the disease, though it was steadily progressing. She was a healthy looking, robust old woman of masculine appearance.

I worked her out and gave Lach. 200, and then a dose of Lach CM. This was promptly followed by alarming collapse, hemorrhage, rapid greenish fungations, and intolerable odor (all relieved, by the way, by a dose of Ornithogalum a few weeks before she died). This Lach. CM aggravation pleased me, rather than otherwise - showed that I had hit the drug. A second dose, later was followed in half an hour by collapse; and, again, a horrible aggravation of all symptoms. But I still fondly hoped that the reaction might carry her a long way toward clearing up the case. It never came. And I have learned my lesson now.

In advanced disease, malignant or tuberculous, with much tissue change or lowered vitality, philosophy teaches that the most terrible that you can give your patient is the indicated remedy in high potency. Give her anything but that!

Some of you are fidgeting with impatience, not believing this, or vowing that if you did believe it you would quit homceopathy. But others in the discussion, by and by, will more than confirm it from their own experience. You will find that it is the men who know their work, and can handle their power, and get results, who are not only the most keen and enthusiastic, but who develop at times a positive terror of their drugs - in the potencies; for they know how potent they may be for evil as well as for good; that when the disease mass is large, or the reaction poor, the most harmful drug you can give to a patient is the simillimum unless very cautiously and low.

INTERFERENCE

Another brilliant way not to do it (you see that I have tried them all) is to have your cases in common, and to work with some one who knows little, and cares less, for the philosophy of prescribing. It is late; there are a heap of patients to be got away in a short time. He sees a case on which you have expended much labor and thought; hears a tale of woe - a medicinal aggravation perhaps (your poor prescriber does not believe in aggravations, for in the nature of things he gets few, and never spots one when he does get it ! ); or old symptoms returned; or a diarrhea or rash or excessive sweating that may be critical, mean a sharp leap towards the cure of some serious condition, if left alone; or even symptoms worse and patient better (if he inquired), which should call a halt. But, at the first word, down goes a new drug; and the case is off at a tangent - perhaps beyond recovery.This is how not to do it, with a vengeance! For this is to throw your very life, your energy, and your success, to the moles and the bats - and without compensation. You and your patient have both suffered for the victory that has been snatched from you, and suffered in vain! We all have plenty of chances, unless we walk warily, of spoiling another's work.

But enough of how not to do it! There has been plenty of that in the past; but the past is beyond our reach. Old things are passing way, rapidly! Our concern is with the present; and the future, living or dying, is ours! Let us only diligently train the younger men, and the great cause is safe in their hands Those who can wield power can be trusted never to betray it. And to you who have learned your homceopathy under a master; who know its philosophy by heart; who have been trained to work out your cases, to respect and fear your potentized drugs and to use them only safely; who have learned to recognize and understand and deal with results - to you I would say:Be patient, be gentle and courteous, be tolerant and forbearing. You have no idea how those who have not had your advantages have struggled and do struggle, in a heart sickening way, and without your results to buoy them up and reward their labors. They can look back, many of them, to the time when their enthusiasm was as great as yours; when they knew their drugs, from diligent study, as well as you do, and with far more labor than you have bestowed, who have had them presented to you in an attractive way - who have been taught.

And, above all, be good stewards of the gift that was given to you, and be ready to impart. Each one of us, working by himself and for himself, has only a limited life work, a limited fund of hours and energy, and then comes the "whisper out of the darkness" that says "the end is forbidden"; that says, "thy use is fulfilled'' - and then, silence. But think how enormously we can multiply our life work, our influence, the sphere of our energy and usefulness, by helping and inspiring others. What an enormous mass of work may at last be laid to our account. Think of the work that Dr. Kent is doing in the world today, through his scholars, through the men he has kindled and inspired, and taught, and the men that they, in their turn, have taught and are teaching. Believe it, there is no greatness in the world but through service.

He that would be great among you, let him serve. Teach! Help! Strengthen! Hearten! Inspire! Freely we have received freely give - and of the best that is in you.

James Tyler Kent
The second prescription
Lecture read before the International Hahnemannian Association at Niagara Falls, 1888.

Editorial Note: What perplexing problems we often meet in practice! How we crave, at times, the advice of a master mind!   We are so often the victims of prejudice, over-confidence or ignorance, and our patients suffer in consequence of this.  Could we but understand the intricate laws governing the inner man, disease, and remedies, how much more wisely might we adjust ourselves to the far-reaching problems which endanger the life of a father, a mother, a noble son or an affectionate daughter. We would not then, as is so often done, impede or pervert the action of a carefully selected remedy by our impatience to get results, or by our impetuosity in hastening certain conditions which will not be hastened, or by our ignorance in so quickly changing remedies before one of them has had time for definite action. To help us in this noble work we reproduce below a masterly paper by Dr. J. T. Kent, read before the International Hahnemannian Association at Niagara Falls in 1888. -G. E. D.

What is more beautiful to look upon than the bud during its hourly changes to the rose in its bloom. This evolution has so often come to my mind when patiently awaiting the return of symptoms after the first prescription has exhausted its curative power. The return symptom-image unfolds the knowledge by which we know whether the first prescription was the specific or the palliative, i. e., we may know whether the remedy was deep enough to cure all the deranged vital wrong or simply a superficially acting remedy, capable of only a temporary effect. The many things learned by the action of the first remedy determine the kind of demand made upon the physician for the second prescription.

Many problems come up to be solved that must be solved, or failure may follow.
How long shall I watch and wait? Is a question frequently asked but seldom answered.

Is the remedy still acting? Is the vital reaction still affected by the impulse of the remedy?
If the symptoms are returning, how long shall they be watched before it is necessary to act or give medicine.?
Is the disease acute or chronic?
Why is the second prescription so much more difficult than the first?
Why is it that so many patients are benefited when first going to the physician and thereafter derive no benefit?
I presume that most good prescribers will say: "We have often acted too soon, but never waited too long." Many physicians fail because of not waiting, and yet the waiting must be governed by knowledge. Knowledge must be had, but where can it be obtained? To know that this waiting is right is quite different from waiting without a fixed purpose. This knowledge cannot be found where its existence is denied; it is not found with unbelievers and agnostics.

When the first prescription has been made and the remedy has been similar enough to change the existing image, we have but to wait for results. The manner of change taking place in the totality of symptoms signifies everything, yet the manner of the return of the image, provided it has disappeared, signifies more.

First. If aggravation of symptoms follow;
Second. If amelioration of symptoms follow;

1. Aggravation of existing symptoms may come on with general improvement of the patient, which means well; but-
If aggravation of the symptoms is attended with decline of the patient the cure is doubtful, and the case must be handled with extreme care, as it is seldom that such patients recover perfectly.

2. If amelioration follow the prescription, to what does the amelioration apply?
It may apply to the general state or but to the few symptoms. If the patient does not feel the elasticity of life returning, the improved symptoms are the facts upon which to doubt recovery.
The knowledge that the disease is incurable often is obtained only in this way. In such cases every remedy may palliate his sufferings, but cure does not come. The symptoms that are the expressions of the debility are there, and hence the totality of the symptoms is not removed.

After the curative impulse has entirely subsided, the symptoms will appear one by one, falling into place to arrange an image of the disease before the intelligent physician for the purpose of cure.

If the first prescription has been continuously given, there has been but little if any chance of a pure returning image of the disease, therefore this image must be very unreliable. When the remedy has been fully exhausted, then, and only then, can we trust the symptoms constituting the picture.  If the first prescription was the similimum, the symptoms will return-and when they return-asking for the same remedy.

Too often the remedy has been only similar enough to the superficial symptoms to change the totality and the image comes back altered, therefore resembling another remedy, which must always be regarded as a misfortune, by which the case is sometimes spoiled, and the hand of the master may fail to correct the wrong done.

Whenever the symptoms return the same image, calling for the same remedy, then it is that we have demonstrated, that-for a time, if the disease be chronic - we can but recommend the range of dynamics to cure this case. This rule is almost free from exceptions if the remedy is an antipsoric.

What must the physician do who has not the knowledge of dynamic medicines? He must sometimes see sick images come back without change of symptoms, though I believe it is seldom.

The symptoms may call for Phosphorus as strongly as when he began, and Phosphorus 6x has served and no longer cures. What can he do but change his remedy?

Can it be possible that man can be so ignorant of how to cure as to give a drug that is not indicated because the one that is indicated does not cure?

These ignorant mortals condemn the system of Homoeopathy and feel that they have performed their duty to the sick, forgetting that ignorance was the culprit.

I have observed in cases where a low potency had been administered in frequently repeated doses, that some time must elapse before a perfect action will follow the higher potency; but where the dose had not been repeated after its action was first observed, the new and higher potency will act promptly.

When the symptoms come back-after prudent waiting-unchanged, the selection was correct, and if the same potency fail to act a higher one will generally do so quite promptly, as did the lower one first. When the picture comes back unaltered except by the absence of some one or more symptoms, the remedy should never be changed until a still higher potency has been fully tested, as no harm can come to the case from giving a single dose of a medicine that has exhausted its curative powers. It is even negligence not to do such a thing.

Proper time to change

When the demonstration is clear that the present remedy has done all it is capable of doing-and this demonstration can not be made until much higher potencies than usually made have been tried-then the time is present for the next prescription.

To change to the next remedy becomes a ponderous problem, and what shall it be?

The last appearing symptom shall be the guide to the next remedy. This is so whenever the image has been permitted to settle by watching and waiting for the shaping of the returning symptom-picture. Long have I waited after exhausting the power of a remedy, while observing a few of the old symptoms returning; finally a new symptom appears. This latest symptom will appear in the anamnesis as best related to some medicine having it as a characteristic which most likely have all the rest of the symptoms.

It is not supposed that this later appearing symptom is an old symptom on its way to final departure, for so long as old symptoms re-appear and disappear it is granted that no medicine is to be thought of.

It is an error to think of a medicine when a symptom-image is changing. The physician must wait for permanency or firmness in the relations of the image before making a prescription.

Some say, "I must give the patient medicine or he will go and see someone else." I have only to say that it were better had all sick folks gone somewhere else, for these doctors seldom cure but often complicate the sickness.

The acute expressions of a chronic disease have a different management from the acute disease, e. g., a child suffers from bronchitis in every change of weather. It may grow worse if treated with the remedy for the acute symptoms.

The miasm that predisposes the child to recurrent attacks must be considered.

One recently under my care had received Antimonium tart., Calcarea, Sulphur, Lycopodium, etc., in such indiscriminate confusion that the child was not cured. The waiting on Sac.-lac. through several attacks permitted the drug-effects to pass off, and the true image of the sickness was permitted to express itself through several of the exacerbations taken as a whole.

When western ague is complicated with a miasm, a single paroxysm does not fully express the totality, but several must be grouped and the true image will be discovered. If the acute disease be complicated with a miasm the indicated remedy will wipe it out "cito, tuto et jucunde."

Avoid haste

All things oppose haste in prescribing. In very grave diseases haste is a common error, more frequently with the second prescription than the first. Many doctors suppose that a diphtheria demands a medicine immediately because "something must be done." This is an error; many a life has been saved by waiting and waiting.

A little girl was suffering from a severe attack of diphtheria and the mother had treated it four days with Mercurius 3x, and Kali bich. 3x, in alternation. She was poor, and therefore I did not refuse to take the case which was then in a very bad state: nose, mouth and larynx full of exudate.

After a long study the child received Lycopodium cm., one dose, dry, which cleared out the exudate from nose and fauces, but did not touch the larynx.

I dare not tell you how long I watched that child before I saw an indication for the second remedy which it would have needed had the Lycopodium been given when the child first took sick. I waited until the poor child was threatening dissolution when I saw a little tough yellow mucus in the mouth. Kali bich., cm., one dose, cleared the larynx in one day and there was no further medication necessary.

The first prescription is made with the entire image of the sickness formed. (People usually send for the doctor after there can be no doubt of the sickness to be treated.)

The doctor watches the improvement of the patient and the corresponding disappearance of the symptoms under the first prescription, and when the case comes to a standstill he is uneasy, and with increasing fidgetiness he awaits the coming indication for the next dose of medicine.

This fidgetiness which comes from a lack of knowledge unfits the physician as an observer and judge of symptoms; hence we see the doctor usually failing to cure his own children. He cannot wait and reason clearly over the returning symptoms.

While watching the prescriptions of beginners, I have observed very often the proper results of the first prescription. The patient has improved for a time, then ceased to respond to any remedy.

Close investigation generally reveals that this patient improved after the first dose of medicine, that the symptoms changed slightly without new symptoms, and the new "photo" seemed to call for some other remedy, when, of course, the remedy was changed and trouble began. Constant changing of remedies followed until all the antipsorics in the Chronic Diseases had been given on flitting symptom-images, and the patient is yet sick. This is the common experience of young Hahnemannians trying to find the right way. Some of experience make lesser blunders and some make few, but how many have made none? All of these blunders I have made, as I had no teacher, until I blundered upon the works of the great Master.

Wait and observe

The first prescription may not have been well chosen medicine, and then it becomes necessary to make a second effort.

As time brings about the re-examination of the patient, new facts are brought out in relation to the image of the sickness, indicating that the first medicine had not been suitable; perhaps several weeks have passed and the re-examination finds no change in the symptoms.

Shall I compare all the facts in the case to reassure myself of the correctness of the first prescription, or shall I wait longer?

Yes, to the former, of course, and if the remedy is still the most similar to all the symptoms, wait, and watch, and study the patient for a new light on his feelings to which he has become so accustomed he has not observed.

Commonly the new study of the case will reveal the reason why the first prescription has not cured: it was not appropriate.

If it still appears to be the most similar remedy the question arises: "How long shall I wait?"

At this point it should be duly appreciated that the length of time is not so important as being on the safe side, and "wait" is the only safe thing to do. It may have been many days, but that matters not, wait longer.

The finest curative action I ever observed was begun sixty days after the administration of the single dose.

The curative action may begin a slate as a long-acting drug can produce symptoms on a healthy body.  This guide has never been thought of by our writers, but it is well to be considered. Why not?

It is the practice for some to go lower if a high potency has failed.
This method has but few recorded successes but should not be ignored.

The question next to be considered is the giving of a dose of medicine in water and divided doses. This has at times seemed to have favor over the single dry dose. This is open for discussion, requiring testimony of the many, not of few, to give weight. The best reports are made from both methods, and both are in harmony with correct practice.

Improper action

The next important step to be considered is when the first prescription has acted improperly, or without curative results.

Then it becomes necessary to consider a second prescription. The first prescription sometimes changes the symptoms that are harmless and painless into symptoms that are dangerous and painful.

If a rheumatism of the knee goes to the heart under a remedy prescribed for the one symptom, the remedy has done harm. It is an unfortunate prescription and must be antidoted. In incurable diseases when a remedy has set up destructive symptoms, an antidote must be considered.

If the remedy changes the general symptom-image, and the general state of the patient is growing worse, the question then comes up, was the prescription only similar to a part of the image, or is the disease incurable? Knowledge of disease may settle this question. If the disease is incurable, the action of the remedy was not expected to do more than to change the sufferings into peaceful symptoms, and the second prescription is to be considered only when new sufferings demand a
remedy.

But suppose such a change of suffering comes after the first prescription and the disease is undoubtedly curable, then the conclusion must be that the first prescription was not the true specific, and that the true image has not been seen.

Wait until the old image has fully returned is all there is to do.

It is hazardous practice to follow up rapidly all the changing symptoms in any sickness, with remedies that simply for the moment seem similar to the symptoms present. The observing physician will know by the symptoms and their directions, whether the patient is growing better or worse, even though he appear to the contrary to himself and his friends.

The complaints of patient or friends constitute no ground for a second prescription.

The greatest sufferings may intervene in the change of symptoms during progress of permanent recovery, and if such symptoms are disturbed by a new prescription or palliated by inappropriate medicine, the patient may never be cured.

The object of the first prescription is to arrange the vital current or motion in a direction favorable to equilibrium, and when this is attained it must not be disturbed by a new interference. Ignorance in this sphere has cost millions of lives.

When will the medical world be willing to learn these principles so well that they can cure speedily, gently and permanently?

There can be no fixed time for making the second prescription; it may be many months.

The second prescription must be one that has a friendly relation to the last one or the preceding. No intelligent prescription can be made without knowing the last remedy. Concordances in Boenninghausen must not be ignored. The new remedy should sustain a complementary to the former.

Remedies suitable to follow

In managing a chronic sickness the remedy that conforms to an acute experience of the illness is worth knowing, as very often its chronic may be just the one that conforms to its symptoms.

Calcarea is the natural chronic of Belladonna and Rhus;
Natrum mur. sustains the same relation to Apis and Ignatia;
Silicea to Pulsatilla;
Sulphur to Aconite.

When Pulsatilla has been of great service in a given case and finally cures no more, while the symptoms now point to Silicea, the latter will be given with confidence as its complementary relation has long been established.

On the other hand Causticum and Phosphorus do not like to work after each other, nor will Apis do well after Rhus.

How physicians can make the second prescription without regard to the experience of nearly a century, is more than man can know.

These things are not written to instruct men of experience in the right way, but for the young men who have asked so often for the above notes of our present practice.

I am told almost daily that this kind of practice is splitting hairs, but I am convinced of the necessity of obeying every injunction.

Careful records

You should have no confidence in the experience of men who do not write out faithfully all the symptoms of the patient treated, and note carefully the remedy, and how given. Especially is this necessary in patients likely to need a second prescription.

The physician who has in his case-book the notes of every illness of his patients has wonderful hold of any community. He has the old symptoms and the remedies noted that cured, and he can make indirect inquiry after after all the old symptoms long ago removed.

The pleasure is not small found in consulting such a note-book.

Experience soon leads the close prescriber to note all the peculiar symptoms and to omit the nondescript wanderings indulged in by sick people; however. it is important to be correct in judgment.

Many physicians make a correct first prescription and the patient does well and cheers up for a while, but finally the test is made for the second and then all is lost. Homoeopathy is nothing if not true and, if true, the greatest accuracy of detail and method should be followed. It is fortunate that the physicians who repeat while the remedy is acting are such poor prescribers or their death-list would be enormous.