Are the obstacles to certainty and simplicity in practical medicine insurmountable?

 

Are the obstacles to certainty and simplicity in practical medicine insurmountable?

1 Dr. Herz’s essay “On the Medicinal uses of the Phellandrium aquaticum,” andc., in the first part of the second volume of the Journal der practischen Arzneykunde, plunged me into a sort of melancholy, which only by dint of long continued reflection has given place to a remote but lively hope.
Here one of the most thoughtful physicians of our time, after twenty years of active practice, finds himself obliged repeatedly to make the open, but most melancholy acknowledgment: (p. 40.) “That we can lay no claim to the attainment of the ideal of simplicity in medical treatment.” “That the hope of ever arriving at perfect simplicity in medical practice, cannot be otherwise than very feeble” (p. 47).
The obstacles to pure observation of the effects of medicines in the various diseases, he enumerates with most overwhelming fullness of detail, and there he leaves us alone in the old well-worn path of uncertainty, almost without a cheering glance at a better futurity, a simpler, surer method of cure; unless we are to reckon his very complaints as foreshadowing coming improvements, just as the impassioned warmth of the sceptical casuist has always appeared to me a proof of that immortality he would deny.
I myself felt the external hindrances to our art more than I could have wished; they continually beset my sphere of action; and I, too, long considered them insurmountable, and had almost made up my mind to despair, and to esteem my profession as but the sport of inevitable accident and insuperable obstacles, when the thought arose within me, “are not we physicians partly to blame for the complexity and the uncertainty of our art?”

Obedience of patients

I have seen medical men take under their care patients who had only half confidence, and from whose demeanour any one might perceive that they put themselves under the physician whom they had chosen, not from any enthusiastic regard for him, nor from a strong desire to be relieved from their sufferings. How could implicit obedience be expected from such persons? And even when they spoke of, and commended in commonplace terms, strict attention to the physician’s orders, could he trust them, and with confidence ascribe the issue to his prescriptions, his medicines? By no means!

Diet and regimen

It is a constant complaint of physicians that patients will not observe the prescribed diet.

“Who shall give them assurance of such compliance? and how impossible, then, is it to determine the issue of a disease, or the effect of the remedies employed, since on this point in no case can any certainty be attained?”

Pardon me! We may be perfectly sure of such as with implicit confidence entrust themselves to the care of their almost worshipped physician. Of course, others are less to be relied upon. Methinks, however, that medical men when thus complaining, do not draw a sufficient distinction between, 1st, the errors of diet which produced and kept up the patient’s disease; 2d. their ordinary indifferent diet; and, 3d, the new dietetic regulations laid down by the physician.
If, with respect to the first of these (the correction of the errors of diet), the physician thinks that he does not possess sufficient authority with his patient, who will not pay strict attention to rules, rather let him dismiss such fickle-minded persons; better no patients at all than such! Who, for example, would undertake to cure a drunkard of induration of the liver, who merely consulted the physician en passant, because, perhaps, he met him in the street; or had some business-matters to arrange with him; or, because the physician has come to reside in the neighbourhood; or has become a connexion of his; or for some other trifling reason, but not from having implicit confidence in his skill? What immense influence the medical man must have with such a confirmed debauchee, to feel assured that he will pay attention to his orders, and daily diminish his allowance of the poisonous liquor!
A patient with such bad habits, must show by some considerable sacrifice, that he intends to submit himself entirely to the will of the physician. The physician would do well to try to dissuade him from submitting to treatment; to represent to him, in strong terms, the difficulties which his ruinous vice throws in the way, and the magnitude of the disease. If he return repeatedly, and express his willingness to make any sacrifices, then, what should prevent the physician trusting him, so long as he sees indubitable proofs of his resolution? If he cannot withstand temptation, then let him go his way; he will, at any rate, not bring discredit on the art, nor disappoint the hopes of the much-deceived physician. Are there not enough of patients, who, when solicitously advised by a universally esteemed physician, will, for example, scrupulously abstain from eating pork during a quartan fever, and for months afterwards; who will carefully avoid potatoes, if they are asthmatic or leucophlegmatic; sedentary occupations, if they are gouty; and sour wine, if suffering from the wasting diseases of youth brought on by venereal excesses?

In the case of a woman affected with a nervous disorder, should not a good physician be able to effect a gradual diminution in the quantity of coffee taken; or, if otherwise, will he not be able to perceive that she will not follow his advice?

From my own experience I can say, that it is no uncommon circumstance to meet with both these cases; and in each the physician may reckon with certainty on his observation. If we go to work in this manner, we shall attain to a high degree of empirical certainty. Is this not certainty? Or does the statesman, the teacher, the lawyer, the merchant, the general, possess any other than empirical certainties? Or is there any other positive rule to guide us, in any imaginable profession in which the free-will of man is involved?

But is the ordinary diet of those classes of the community who are not altogether corrupted, of such an objectionable nature, that we are compelled, in every disease, to prescribe a new one? This is one of the rocks on which so many physicians split.

In every acute or chronic disease that comes under their notice, they earnestly insist on a very complicated artificial system of diet, withholding many things, and ordering a host of others. Do we physicians, however, know with such extreme precision, the effects of all kinds of food, as to be able with certainty to say, in this case such and such an article of diet is to be taken, and this and that other to be avoided! How does experience refute our fancied omniscience! For what a length of time did our forefathers insist in their so-called acute (putrid) fevers with diminished vital power, on watery drinks, tea, andc.; and exclaimed against beer and wine as little better than poison-which, however, the patients long for so much, and which is now the main support of our practice! How long did we forbid fresh meat in cases of haemorrhage from passive plethora, in wasting pulmonary complaints, in scurvy, and in most other chronic non-gastric diseases, where it is now reckoned, if not a perfect panacea, at any rate indispensable!

A universal diet, like a universal medicine, is an idle dream; but speaking generally, nothing is more wholesome than fruit in abundance, and green vegetables ad libitum; and yet they frequently oppress the stomach of those who have poverty of the blood, of exhausted persons, and those suffering from the effects of a sedentary life, and increase in them the disposition to acidity, flatulence and diarrhoea! Roast beef and raw ham are considered more difficult of digestion for a relaxed stomach than veal boiled to rags. Coffee has the reputation of strengthening and assisting digestion, and yet it only hastens the expulsion of half-digested food from the bowels. I have seen children deprived of the breast-milk, crammed to death with wafer-biscuits, and perishing in numbers of jaundice. My expostulations on the indigestible nature of this unleavened and hard-baked mass of dough, were of no avail against the plausible folly of my colleagues-“it is impossible to imagine any thing lighter (in weight), or more delicate (to the touch)!”

I once knew an ignorant over-officious practitioner prescribe such a severe diet to a healthy young woman after a favourable first-labour, that she was on the eve of starvation. She held up for some days under this water-gruel diet-all meat, beer, wine, coffee, bread, butter, nourishing vegetables, andc., were denied her; but at last she grew excessively weak, complained of agonising after-pains, was sleepless, costive, and, in short, dangerously ill. The medical attendant attributed all this to some infraction of his dietetic rules. She begged to be allowed some coffee, or broth, or something similar. The practitioner, strong in his principles, was inflexible: Not a drop! Driven to desperation by his severity and her hunger, she gave way to her innocent longings, drank coffee, and ate in moderation whatever she fancied. The practitioner found her, on his next visit, much to his surprise, not only out of danger, but lively and refreshed; so he complacently noted down in his memorandum-book the excellent effects of slop-diet in the treatment of lying-in-women. The convalescent took good care not to hint to him her natural transgression. This is the history of many, even published observations! Thus the disobedience of the patient not unfrequently saves the credit of the physician. Is the error calculi, in such a case, the fault of the art or the patient, or is it not rather the fault of the physician? The artificial diet prescribed by the physician, is frequently much more objectionable than the accustomed diet of his patient; or, at least, he frequently does wrong in rejecting the latter all at once. As the physician would do well, in order to observe more distinctly and simply the course of the disease and the effects of his medicines, not to give any orders at all about the diet, except with regard to articles of which he possesses a positive knowledge, and these will be but few; he would also be consulting the good of his patient by not depriving him of anything which long habit had rendered innocuous, or perhaps indispensable.

A country midwife fell sick of a gastric fever. I purged her. I ordered her for drink, water and weak beer, and extreme moderation in eating. At first, things went on very well; but, after a few days, a new continued fever, with thirst, wakefulness, weariness, confusion of ideas, came on to such an extent as to render her state dangerous. I left none of the ordinary remedies untried. All in vain. I now left off every thing, from the sulphuric acid to the soup (at the time I was not sufficiently acquainted with the properties of opium), and promised to prescribe something on my return. I informed the relations of the danger I apprehended. The following day I was told that the patient was recovering, and that I need not give myself any further trouble. To my astonishment, I saw her pass my window, a few days afterwards, perfectly recovered, I subsequently learned, that when I had discontinued the medicine, a quack had been called in, who had given her a large bottle of essence of wood, his universal medicine, and told her to take so many drops of it. No sooner had she tasted the brandy in it than she gained, as it were, new life. She took the drops by table-spoonfuls, and, after a good sleep, she rose completely cured. This happened when I first began practice, else I should have ascertained at the commencement that, when in health, she could not live without her daily dram, consequently could not recover without it.

It is far less frequently necessary than most physicians think, to make a material alteration in the diet of patients suffering from chronic complaints, at least in ordinary cases; in acute diseases, the awakened instinct of the patient is often considerably wiser than the physician who does not consult nature in his prescriptions. I do not now allude to cures effected by dietetic rules alone, which, if simple, are not to be despised, and which are very serviceable in many cases. What I particularly call attention to is, the frequently useless change of diet, when treating a case with medicine, whereby the simplest method of treatment is rendered complex, and a composite result is produced, of which I would defy OEdipus himself to guess what part was owing to the new diet, and what to the medicine. We must certainly prohibit what we know to be hurtful in this or that complaint; but this can at the most be but two or three articles of diet in chronic diseases; the gradual disuse of which (for sudden suppression is always dangerous in such affections), cannot produce any great revolution in the system; cannot, therefore, have much effect in deranging the pure action of the medicine we are using.

If it be necessary to make considerable changes in the diet and regimen, the ingenious physician will do well to mark what effect such changes will have on the disease, before he prescribes the mildest medicine. A deeply rooted scurvy can often be cured by the united action of warm clothing, dry country air, moderate exercise, change of the old salted meat for that freshly killed, along with sour-crout, cresses, and such like vegetables, and brisk beer for drink. What would be the use of medicine in such a case? To mask the good effects produced by the change of diet! Scurvy is produced by a system of diet opposite to this, therefore it may be cured by a dietetic course-the reverse of that which produced it; at any rate, we may wait to see the result of this method, before we begin with our medicines. Why should we render the syphilitic patient, for example, worse than he is by a change of diet, generally of a debilitating nature? We cannot cure him by any system of diet, for his disease is not produced by any errors of the sort. Why then, should we, in this case, make any change? Since this occurred to my mind, I have cured all venereal diseases (excepting gonorrhoea), without any dietetic restrictions, merely with mercury (and, when necessary, opium); the metal has not a debilitated constitution to act upon, and my patients recovered more rapidly than those of my colleagues. I also knew for certain, that every change that took place, either for the better or the worse, was owing to the medicine.

An old colonel, with “fair round belly,” and apparently fond of the pleasures of the table, had suffered for the last forty years from ulcers almost all over the legs, and issues on the thighs. His food consisted of the strongest and most nutritive materials-he drank a good deal of spirits, and, for several years past, he had been in the habit of taking a monthly purge. Otherwise, he was vigorous. I allowed the issues to heal up, made him keep his legs rolled up in a narrow flannel bandage, and immerse them daily a few minutes in cold water, and afterwards dress them with a weak solution of corrosive sublimate. I made not the slightest alteration in his diet; I even did not forbid the monthly purge, as he was so constantly in the habit of taking it. In the course of a year his legs gradually healed, and his vigour rather increased than diminished in this his seventy-third year. I watched him for two years, during which he remained perfectly well, and I have since had good accounts of his health. The legs have always continued completely healed. Can I suppose that he would have recovered more rapidly or permanently had I deprived him of his eight or ten dishes, and his daily allowance of liquors? Had I changed his diet, and had he grown worse, would I have known whether this unfavourable turn proceeded from the food so much lauded in works on dietetics, but so different to what he had been accustomed to, or from my external applications, for I gave nothing internally? It would have been easy for me to conform to the schools, and sacrifice my patient methodically to the ordinary dietetic regulations; but how could I at the same time abide by my conviction, my conscience, and that prime guiding principle of the physician, simplicity!

I have no intention of exalting myself at the expense of my brethren, when I acknowledge that I have cured the most difficult chronic diseases, without any particular change of diet. I consider that I do quite enough if I advise moderation in all things, or diminish or forbid altogether particular articles of diet, which would be prejudicial to the object I wish to accomplish; as, for example, acids, when I am employing stramonium, belladonna, foxglove, monkshood, or henbane (the effects of these medicines being entirely counteracted by vegetable acids); or salted meats, when I prescribe oxyde of mercury; or coffee, when I am giving opium. Thus, if my treatment fail, I know that I have done no harm by an artificial system of diet (how much that is dangerous and hypothetical is there not in our dietetic regulations!), I know it is owing to the medicine used that the case grew worse, or, at least, did not improve. If amendment ensue, then I know that the medicine produced it, as it certainly was not owing to any change in the diet. Hippocrates, himself, if I recollect right, hints at something similar in his aphorisms, when he says, that medicine and the vis naturae produce much more considerable and profound changes in diseases than any small irregularity in diet. How near was this great man to the philosopher’s stone of physicians-simplicity! and to think that after more than two thousand years, we should not have advanced one single step nearer the mark! on the contrary, have rather receded from it! PAGE 315 Did he only write books? or did he write much less than he actually cured? Did he do this so circuitously as we? It was owing to the simplicity of his treatment of diseases alone, that he saw all that he did see, and whereat we marvel.

Climate, weather, state of the barometer, etc.

Should we abandon ourselves to despair, because we do not know, to a nicety, what is the exact influence which a slight change in geographical position, a small variation of the hygrometer, the barometer, the anemometer, the thermometer, andc., exercises upon the action of our medicines or our patients? According to many observations of the first medical men, it is not so very difficult to arrive at a pretty accurate general knowledge of the differences produced by a warmer or colder climate on the nature and treatment of ordinary diseases. They are, for the most part, merely differences in degree. The most opposite climates never produce a completely opposite code of medical laws. Is not bark as efficacious for the cure of pure intermittent fever in Mexico as in Norway; in Batavia and Bengal (the only difference, being in quantity), as in Scotland? The venereal disease is cured in China by mercury, just as it is in the Antilles. In our country, we have, inflammations and suppurations of the liver of the same nature as in the tropics; although, in the latter regions, they are twenty times as numerous as here, that makes not the slightest difference in the treatment, as in both situations mercury and opium (or something better still) are serviceable. Typhus, and similar fevers, are here as there fatal, if treated by bloodletting and nitre (not, indeed, so rapidly here as there)! They must also be treated in our country with bark and opium (not, indeed, in such large doses as there), in order to increase the strength. These varieties of climate do not change the treatment in nature, but only in degree, and such differences are determinable. But that the powers given by nature to man and habit will triumph over all variations of climate, to the preservation of life and health, is proved by there being inhabitants in the island of Terra del Fuego, as well as on the banks of the Ganges, in Lapland, as well as Ethiopia, in the seventieth as well as the third degree of latitude. And are we so ignorant of the other influences which the nature of the soil and country have upon diseases; so very ignorant that we cannot reckon the influence they would have on our practice? Do we know nothing of the different effects produced by a residence in a hilly country and on the sea-coast, on haemoptysis and phthisis; nothing of the action of the effluvia from marshes and seething intramural grave-yards in the production of intermittent fever, and diseases of the liver and lymphatic system; nothing of the power of pure air on those affected with rickets and those debilitated by sedentary occupations; nothing of the advantages of a level country over confined Alpine valleys, the cradle of cretinism, goitre, and idiocy; nothing of the peculiar power of certain winds and seasons in the production of inflammatory, or asthenic diseases, or of the effect of a low state of the barometer on the apoplectic; nothing of the influence of the air of hospitals in the production of gangrene and typhus? PAGE 316 And it is only these, and similar great and important differences, which exercise a marked influence on health and life itself, which it is necessary for us to know in our treatment of diseases. We do know them, and can calculate their influence. The influence of the finer shades of these differences is too insignificant to prevent us treating successfully the ordinary diseases. The vital power and the proper medicine generally obtain the victory over any influence which such very fine shades of differences could exert. What might be said of the Creator, who, having afflicted the inhabitants of this earth with a vast host of diseases, should at the same time have placed an inconceivable number of obstacles in the way of their cure; to discover the influence of each of which would defy the greatest efforts of the physician-a knowledge of which in their full extent (if they were of such great importance) could not be attained by the greatest genius? We cure diseases in pestilential dungeons, although we cannot, at the same time, impart to the patient the vigour of the mountaineer. Who would desire us to transform the delicate city lady into the buxom peasant girl? We remove, however, most of the ailments of the former. The sedentary man of business seeks at our hands only tolerable health, for the nature of things denies us the power of giving him the strength of the blacksmith, or the ravenous appetite of the porter. “But,” objects some one, “look what a perceptible influence a slight variation of the temperature, moisture, or relative proportion of oxygen and nitrogen in the atmosphere, a slight change in the wind, a higher or lower state of the barometer, a greater or less quantity of atmospherical electricity, and a thousand other physical powers, small though they may be, which are perhaps, as yet unknown to us, sometimes have upon diseases, at least upon the nervous, hysterical, hypochondriacal, and asthmatic!”

Shall I speak out what I think? It appears to me much less profitable to endeavour to ascertain (which is moreover impossible) all the degrees and varieties of the influence of those physical impressions, when they approach the minute, than to do our endeavour to fortify the sufferers against all these innumerable impressions, by implanting in them a certain degree of strength, whereby their system will be enabled to resist these, and many other still unknown physical impressions; just as I consider it much more practicable to dispel the morose ideas of the melancholic by medicine, than to abolish for him the countless evils of the physical and moral world, or to argue him out of his fancies. Or could all the physical and moral adverse circumstances of the atmosphere, and of human life, be more effectually prevented exercising their pernicious influence on the gossamer nervous system of yon nervous, spasmodic, chlorotic girl, did we, with angels’ understanding, completely investigate and maturely weigh, in quality and quantity, all these impulses in their full extent, than if we should restore her monthly periods? I do not believe that it is the smallness of our knowledge, but only the faulty application of it, that hinders us from approaching, in medical science, nearer to certainty and simplicity.

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The Medicine of Experience

 

HahnemannThe medicine of experience
– Samuel Hahnemann, 1805
Often considered to be the “precursor” to the first edition of the Organon

Man, regarded as an animal, has been created more helpless than all other animals. He has no congenital weapons for his defence like the bull, no speed to enable him to flee from his enemies like the deer, no wings, no webbed feet, no fins,- no armour impenetrable to violence like the tortoise, no place of refuge provided by nature as is possessed by thousands of insects and worms for their safety, no physical provision to keep the enemy at bay, such as render the hedgehog and torpedo formidable, no sting like the gadfly, nor poison-fang like the viper; – to all the attacks of hostile animals he is exposed defenceless. He has, moreover, nothing to oppose to the violence of the elements and meteors. He is not protected from the action of the water by the shining hair of the seal, nor by the close oily feathers of the duck, nor by the smooth shield of the water beetle; his body, but a slight degree lighter than the water, floats more helplessly in that medium than that of any quadruped, and is in danger of instant death. He is not protected like the polar-bear or elder-duck by a covering impenetrable to the northern blast. At its birth the lamb knows where to seek its mother’s udder, but the helpless babe would perish if its mother’s breast were not presented to it. Where he is born nature nowhere furnishes his food ready made, as she provides ants for the armadillo, caterpillars for the ichneumon fly, or the open petals of flowers for the bee. Man is subject to a far larger number of diseases than animals, who are born with a secret knowledge of the remedial means for these invisible enemies of life, instinct, which man possesses not. Man alone painfully escapes from his mother’s womb, soft, tender, naked, defenceless, helpless, and destitute of all that can render his existence supportable, destitute of all wherewith nature richly endows the worm of the dust, to render its life happy.

Where is the benevolence of the Creator, that could have disinherited man, and him alone of all the animals of the earth, of the bare necessities of life?

Behold, the Eternal Source of all love only disinherited man of the animal nature in order to endow him all the more richly with that spark of divinity-a mind-which enables man to elicit from himself the satisfaction of all his requirements, and a full measure of all conceivable benefits, and to develop from himself the innumerable advantages that exalt the children of this earth far above every other living thing-a mind that, indestructible itself, is capable of creating for its tenement, its frail animal nature, more powerful means for its sustenance, protection, defence and comfort, than any of the most favoured creatures can boast of having derived directly from nature.

The Father of mankind has chiefly reckoned on this faculty of the human mind to discover remedial agents, for his protection from the maladies and accidents to which the delicate organism of man is exposed.

The help that the body can afford itself for the removal of diseases is but small and very limited, so that the human mind is so much the more compelled to employ, for the care of the dïseases of the body, remedial powers of a more efficient kind than it has seemed good in the Creator to implant in the organic tissues alone.

What crude nature presents to us should not form the limit for the relief of our necessities; no, our mind should be able to enlarge her resources to an unlimited degree for our perfect well-being.

Thus the Creator presents to us ears of corn from the bosom of the earth, not to be chewed and swallowed in a crude and unwholesome state, but in order that we should render them useful as nutriment by freeing them from the husk, grinding and depriving them of everything of an injurious and medicinal nature, by fermentation and the heat of the oven, and partaking of them in the form of bread-a preparation of an innocuous and nutritious character, ennobled by the perfecting power of our mind. Since the creation of the world the lightning’s flash has destroyed animals and human beings; but the Author of the universe intended that the mind of man should invent something, as has actually been done in these latter days, whereby the fire of heaven should be prevented from touching his dwellings-that by means of metallic rods boldly reared aloft he should conduct it harmless to the ground. The waves of the angry ocean reared mountains high threaten to overwhelm his frail bark, and he calms them by pouring oil upon them.

So he permits the other powers of nature to act unhindered to our harm, until we can discover something that can secure us from their destructive force, and harmlessly avert from us their impressions.

So he allows the innumerable array of diseases to assail and seize upon the delicate corporeal frame, threatening it with death and destruction, well knowing that the animal part of our organism is incapable, in most cases, of victoriously routing the enemy, without itself suffering much loss or even succumbing in the struggle;-the remedial resources of the organism, abandoned to itself, are weak, limited and insufficient for the dispersion of diseases, in order that our mind may employ its ennobling faculty in this case also, where the question concerns the most inestimable of all earth’s goods, health and life.

The great Instructor of mankind did not intend that we should go to work in the same manner as nature; we should do more than organic nature, but not in the same manner, not with the same means as she. He did not permit us to create a horse; but we are allowed to construct machines, each of which possesses more power than a hundred horses, and is much more obedient to our will. He permitted us to build ships, in which, secure from the monsters of the deep and the fury of the tempest, and furnished with all the comforts of the mainland, we might circumnavigate the world, which no fish could do, and therefore he denied to our body the piscine fins, branchiae and float, that were inadequate to perform this feat. He denied to our body the rustling wings of the mighty condor, but on the other hand, he allows us to invent machines filled with light gas, that with silent power lifts us into far higher regions of the atmosphere than are accessible to the feathered tenants of the air.

So also he suffers us not to employ the process of sphacelus, as the human corporeal organism does for itself, in order to remove a shattered limb, but he placed in our hand the sharp, quickly-dividing knife, which Faust moistened with oil, that is capable of performing the operation with less pain, less fever, and much less danger to life. He permits us not to make use of the so-called crisis, like nature, for the cure of a number of fevers; we cannot imitate her critical sweat, her critical diuresis, her critical abscesses of the parotid and inguinal glands, her critical epistaxis, but he enables the investigator to discover remedies wherewith he may cure the fever more rapidly than the corporeal organism is capable of producing crises, and to cure them more certainly, more easily, and with less suffering, with less danger to life and fewer after-sufferings, than unassisted nature can do by means of crises.

I am therefore astonished that the art of medicine has so seldom raised itself above a servile imitation of these crude processes, and that it has at almost all periods been believed that hardly anything better could be done for the cure of diseases than to copy these crises, and to produce evacuations in the form of sweat, diarrhoea, vomiting, diuresis, venesections, blisters or artificial sores. (This was and remained the most favoured method of treatment from the earliest times till now: and it was always fallen back upon, when other modes of treatment founded on ingenious speculations disappointed the hopes they had raised.) Just as if these imperfect and forced imitations were the same thing as what nature effects in the hidden recesses of vitality, by her own spontaneous efforts, in the form of crises! Or as if such crises were the best possible method for overcoming the disease, and were not rather proofs of the (designed) imperfection and therapeutical powerlessness of our unaided nature! Never, never was it possible to compel these spontaneous endeavours of the organism by artificial means) the very notion implies a contradiction), never was it the Creator’s will that we should do so. His design was that we should bring to unlimited perfection our whole being, as also our corporeal frame and the cure of its diseases.

This design has hitherto been in part fulfilled by pure surgery alone. Instead of acting like unassisted nature, which can often only throw off a splinter of bone in the leg by inducing a fever attended by danger to life, and a suppuration that destroys almost all the limb, the surgeon is able by a judicious division of the irritable integuments to extract it in a few minutes by means of his fingers, without occasioning any great suffering, without any considerable bad consequences, and almost without any diminution of the strength. A debilitating slow fever, accompanied by intolerable pains and uninterrupted torturing to death, is almost the sole means the organism can oppose to a large stone in the bladder; whereas an incision made by a practised hand frees the sufferer from it often in a quarter of an hour, spares him many years of torment, and rescues him from a miserable death. Or ought we to attempt to relieve a strangulated hernia by an imitation of the mortification and suppuration, which are the only means, besides death that nature possesses against it? Would it suffice for the rescue and preservation of life, did we not know of any other mode of stopping the hemorrhage from a wound in a large artery than by causing a syncope of half-an-hour’s duration, as nature does? Could the tourniquet, bandage and compress be thereby dispensed with?

It has always been a matter worthy of the greatest admiration to see how nature, without having recourse to any surgical operation, without having access to any remedy from without, does often when left quite unassisted, develop from itself invisible operations whereby it is able,-often it is true in a very tedious, painful and dangerous manner-but still really to remove diseases and affections of many kinds. But she does not do these for our imitation! we cannot imitate them, we ought not to imitate them, for there are infinitely easier, quicker and surer remedial means which the inventive faculty implanted in our mind is destined to discover, in order to subserve the ends of medicine, that most essential and most honourable of all earthly sciences.

Medicine is a science of experience; its object is to eradicate diseases by means of remedies.

The knowledge of diseases, the knowledge of remedies, and the knowledge of their employment, constitute medicine.

As the wise and beneficent Creator has permitted those innumerable states of the human body differing from health, which we term diseases, he must at the same time have revealed to us a distinct mode whereby we may obtain a knowledge of diseases, that shall suffice to enable us to employ the remedies capable of subduing them; he must have shewn to us an equally distinct mode whereby we may discover in medicines those properties that render them suitable for the cure of diseases, – if he did not mean to leave his children helpless, or to require of them what was beyond their power.

This art, so indispensable to suffering humanity, cannot therefore remain concealed in the unfathomable depths of obscure speculation, or be diffused throughout the boundless void of conjecture; it must be accessible, readily accessible to us, within the sphere of vision of our external and internal perceptive faculties.
Two thousand years were wasted by physicians in endeavouring to discover the invisible internal changes that take place in the organism in diseases, and in searching for their proximate causes and a priori nature, because they imagined that they could not cure before they had attained to this impossible knowledge.
If the fruitlessness of these long-continued endeavours cannot be regarded as a proof of the impossibility of this undertaking, the maxim of experience that they were unnecessary for the cure, might suffice to shew its impossibility. For the great Spirit of the Universe, the most consistent of all beings, has made that only possible which is necessary.

Although we never can attain to a knowledge of the internal corporeal changes on which diseases depend, yet the observation of their external exciting causes has its uses.

No alteration occurs without a cause. Diseases must have their exciting causes, concealed though they may be from us in the greater number of cases.

We observe a few diseases that always arise from one and the same cause, e. g., the miasmatic maladies; hydrophobia, the venereal disease, the plague of the Levant, yellow fever, small-pox, cow-pox, the measles and some others, which bear upon them the distinctive mark of always remaining diseases of a peculiar character; and, because they arise from a contagious principle that always remains the same, they also always retain the same character and pursue the same course, excepting as regards some accidental concomitant circumstances, which however do not alter their essential character.

Probably some other diseases, which we cannot shew to depend on a peculiar miasm, as gout, marsh-ague, and several other diseases that occur here and there endemically, besides a few others, also arise either from a single unvarying cause, or from the confluence of several definite causes that are liable to be associated and that are always the same, otherwise they would not produce diseases of such a specific kind, and would not occur so frequently.

These few diseases, at all events those first mentioned (the miasmatic), we may therefore term specific, and when necessary bestow on them distinctive appellations.
If a remedy have been discovered for one of these, it will always be able to cure it, for such a disease always remains essentially identical, both in its manifestations (the representatives of its internal nature) and in its cause.

All the other innumerable diseases exhibit such a difference in their phenomena, that we may safely assert that they arise from a combination of several dissimilar causes (varying in number and differing in nature and intensity).

The number of words that may be constructed from an alphabet of twenty-four letters may be calculated, great though that number be; but who can calculate the number of those dissimilar diseases, since our bodies can be affected by innumerable and still for the most part unknown influences of external agencies, and by almost as many forces from within.

All things that are capable of exercising any action (and their number is incalculable), are able to act upon and to produce changes in our organism which is intimately connected with and in conflict with all parts of the universe-and all may produce different effects as they differ among themselves.
How various must be the effects of the action of these agencies, when several of them at once and in varied order and intensity exercise their influence on our bodies, seeing that the latter are also so variously organized and present such diversities in the various conditions of their life, that no one human being exactly resembles another in any conceivable respect!

Hence it happens that with the exception of those few diseases that are always the same, all others are dissimilar, and innumerable, and so different that each of them occurs scarcely more than once in the world, and each case of disease that presents itself must be regarded (and treated) as an individual malady that never before occurred in the same manner, and under the same circumstances as in the case before us, and will never again happen precisely in the same way.

The internal essential nature of every malady, of every individual case of disease, as far as it is necessary for us to know it, for the purpose of curing it, expresses itself by the symptoms, as they present themselves to the investigations of the true observer in their whole extent, connexion and succession.

When the physician has discovered all the observable symptoms of the disease that exist, he has discovered the disease itself, he has attained the complete conception of it requisite to enable him to effect a cure.
In order to be able to perform a cure, it is requisite to have a faithful picture of the disease with all its manifestations, and in addition, when this can be discovered, a knowledge of its predisposing and exciting causes, in order, after effecting the cure by means of medicines, to enable us to remove these also-by means of an improved regimen-and so prevent a relapse.

In order to trace the picture of the disease, the physician requires to proceed in a very simple manner.
All that he needs is carefulness in observing and fidelity in copying. He should entirely avoid all conjectures, leading questions and suggestions.

The patient relates the history of his ailments, those about him describe what they have observed in him, the physician sees, hears, feels, andc., all that there is of an altered or unusual character about him, and notes down each particular in its order, so that he may form an accurate picture of the disease.
The chief signs are those symptoms that are most constant, most striking, and most annoying to the patient. The physician marks them down as the strongest, the principal features of the picture. The most singular, most uncommon signs furnish the characteristic, the distinctive, the peculiar features.
He allows the patient and his attendants to relate all they have to say without interrupting them, and he notes down everything attentively-he then again inquires what were and still are the most constant, frequent, strongest and most troublesome of the symptoms-he requests the patient to describe again his exact sensations, the exact course of the symptoms, the exact seat of his sufferings, and bids the attendants once more detail, in as accurate terms as they are able, the changes they have observed in the patient, and which they had previously mentioned.

The physician thus hears a second time what he had formerly noted down. If the expressions correspond with what was already related, they may be considered as true, as the voice of internal conviction; if they do not correspond, the discrepancy must be pointed out to the patient or those about him, in order that they may explain which of the two descriptions was nearest the truth, and thus what required confirmation is confirmed, and what required alteration is altered.

If the picture be not yet complete, if there be parts or functions of the body regarding whose state neither the patient nor his attendants have said any thing, the physician then asks what they can remember respecting these parts or functions, but he should frame his questions in general terms, so as to cause his informant to give the special details in his own words.

When the patient (for, except in cases of feigned diseases, most reliance is to be placed on him as regards his sensations) has, by these spontaneous or almost unprompted details, put the physician in possession of a tolerably complete picture of the disease, it is allowable for the latter to institute more particular inquiries.

The answers to these last more special questions however, which have somewhat the character of suggestions, should not be accepted by the physician at the first response as perfectly true, but after making a note of them on the margin he should make fresh inquiries respecting them, in a different manner and in another order, and he should warn the patient and his attendants in their answers to make accurate replies, and to make no additions, but merely to tell the exact circumstances of the case.

But an intelligent patient will often spare the physician the trouble of making these particular inquiries, and in his account of the history of his disease, will usually have made voluntary mention of these circumstances.
When the physician has completed this examination he notes down what he has silently observed in the patient during his visit, and he corrects this by what the attendants tell him how much of this was or was not usual with the patient in his days of health.

He then inquires what medicines, domestic remedies, or other modes of treatment have been employed in former times, and what have recently been used,-and especially the state of the symptoms before the use or after the discontinuance of all medicine. The former form he regards as the original state; the latter is in fact an artificial form of the disease, which however he must sometimes accept and treat as it is, if there is any pressing emergency in the case that will not admit of any delay. But if the disease is of a chronic character, he lets the patient continue some days without taking any medicine, to allow it to resume its original form, until which time he defers his more particular examination of the morbid symptoms, in order that he may direct his treatment towards the persistent and unsophisticated symptoms of the chronic malady, but not towards the evanescent, ungenuine, accidental symptoms, produced by the medicines last used-as it will be necessary to do in acute diseases where the danger is urgent.

Finally, the physician makes general inquiries as to any exciting causes of the disease that may be known. In ten cases we shall not find one where the patient or his friends can assign a certain cause. If, however, there have happened one respecting which there can exist no dubiety, it generally occurs that has been voluntarily mentioned by them at the commencement of their account of the disease. If it is necessary to make inquiries respecting it, it usually happens that very uncertain information is elicited on this head.

I except those causes of a disgraceful character, which the patient or his friends are not likely to mention, at all events not of their own accord, and which, consequently, the doctor should endeavour to find out by dexterously framing his questions, or by private inquiries. With these exceptions it is a hurtful, or at all events, a useless task to endeavour to ferret out other exciting causes, by means of suggestions, especially as the medicinal art knows very few of these (I shall mention them in their proper places) on which we can base a trustworthy mode of treatment, regardless of the particular signs of the disease they have induced.

By exercising all this zealous care the physician will succeed in depicting the pure picture of the disease, he will have before him the disease itself, as it is revealed by signs, without which man, who knows nothing save through the medium of his senses, could never discover the hidden nature of any thing, and just as little could he discover a disease.

When we have found out the disease, our next step is to search for the remedy.

Every disease is owing to some abnormal irritation of a peculiar character, which deranges the functions and well-being of our organs.

But the unity of the life of our organs and their concurrence to one common end does not permit two effects produced by abnormal general irritation to exist side by side and simultaneously in the human body. Hence our
First maxim of experience.

When two abnormal general irritations act simultaneously on the body, if the two be dissimilar, then the action of the one (the weaker) irritation will be suppressed and suspended for some time by the other (the stronger);

and, on the other hand, our Second maxim of experience.

When the two irritations greatly resemble each other, then the one (the weaker) irritation, together with its effects, will be completely extinguished and annihilated by the analogous power of the other (the stronger).

(Illustration of the first maxim.) If a person be infected at the same time by, for instance, the miasmata of measles and small-pox (two dissimilar irritations), and if the measles have appeared first, it immediately disappears on the day of the eruption of the small-pox, and it is only after the latter is completely gone that the measles again returns and completes its natural course. The red rash that had already commenced to shew itself disappeared, as I have frequently observed, on the eruption of the small-pox, and only completed its course when the small-pox was dried up. According to Larrey, the plague of the Levant immediately remains stationary whenever the small-pox begins to prevail, but again returns when the latter ceases.
These two corporeal irritations are of a heterogeneous and dissimilar character, and the one is therefore suspended by the other-but only for a short time.

(Illustration of the second maxim.) If the two abnormal corporeal irritations be of a similar nature, then the weaker will be entirely removed by the stronger, so that only one (the stronger) completes its action, whilst the weaker was quite annihilated and extinguished. Thus the small-pox becomes an eradicator of the cow-pox; the latter is immediately interrupted in its course whenever the miasm of the small-pox that was previously latent in the system breaks out, and after the small-pox has run its course the cow-pox does not again appear.
The cow-pox miasm, which in addition to its well-known effect of developing the cow-pock with its course of two weeks’ duration, has also the property of giving rise to a secondary eruption of small red pimples with red borders, particularly in the face and forearms (and under certain unknown circumstances it produces this effect usually soon after the desiccation of the pocks), permanently cures other cutaneous eruptions wherewith the inoculated person was already, though ever so long before, affected, if this cutaneous disease was only tolerably similar to that cow-pox exanthema.

These two abnormal irritations cannot exist simultaneously in the same body, and thus the morbific irritation that appears last removes that which previously existed, not merely for a short time, but permanently, in consequence of being analogous to the latter; it extinguishes, annihilates and cures it completely.

It is the same thing in the treatment of diseases by means of medicines.

If the itch of workers in wool be treated by strong purgatives, such as jalap, it gradually yields almost completely, as long as the purgatives are continued, as the action of these two abnormal irritations cannot co-exist in the body; but as soon as the effect of the artificially excited irritation ceases, that is to say, whenever the purgatives are discontinued, the suspended itch returns to its former state, because a dissimilar irritation does not remove and destroy the other, but only suppresses and suspends it for a time.

But if we introduce into a body affected by this itch a new irritant-of a different nature, it is true, but still of a very similar mode of action-as for example the calcareous liver of sulphur, from which others besides myself have observed an eruption produced very similar in character to this itch, then, as two general abnormal irritations cannot co-exist in the body, the former yields to the latter, not for a short time merely, but permanently, as the last introduced was an irritation very analogous to the first; that is to say, the itch of the wool-workers is really cured by the employment of the calcareous liver of sulphur (and for the same reason by the use of sulphur powder and sulphureous baths).

Those diseases also which the casual observer considers as merely local are either suppressed for some time by a fresh irritation applied to this part, where the two irritations are of dissimilar or opposite tendency, as, for example, the pain of a burnt hand is instantly suppressed and suspended by dipping it in cold water, as long as the immersion is continued, but it immediately recurs with renewed violence on withdrawing the hand from the water-or the first is entirely and permanently destroyed, that is to say, completely cured, when the last irritation is very analogous to the first. Thus, when the action of the remedy, e. g., the artificial irritation applied to the burnt hand, is of a different nature, it is true, from the burning irritation of the fire, but of a very similar tendency, as is the case with highly concentrated alcohol, which when applied to the lips produces almost the same sensation as that caused by a flame approached to them, then the burnt skin, if it be constantly kept moistened with the spirit, is-in bad cases in the course of a few hours, in slighter ones much sooner-completely restored and permanently cured of the pain of the burn. So true is it that two irritations, even when they are local, cannot co-exist in the body without the one suspending the other, if they are dissimilar, or the one removing the other, if the added one have a very similar mode of action and tendency.

In order therefore to be able to cure, we shall only require to oppose to the existing abnormal irritation of the disease an appropriate medicine, that is to say, another morbific power whose effect is very similar to that the disease displays.

As food is requisite for the healthy body, so medicines have been found efficacious in diseases; medicines, however, are never in themselves and unconditionally wholesome, but only relatively so.
The pure aliments of food and drink taken until hunger and thirst abate, support our strength, by replacing the parts lost in the vital processes, without disturbing the functions of our organs or impairing the health.
Those substances however which we term medicines are of a completely opposite nature. They afford no nourishment. They are abnormal irritants, only fitted for altering our healthy body, disturbing the vitality and the functions of the organs, and exciting disagreeable sensations, in one word, making the healthy ill.
There is no medicinal substance whatsoever that does not possess this tendency, and no substance is medicinal which does not possess it.

It is only by this property of producing in the healthy body a series of specific morbid symptoms, that medicines can cure diseases, that is to say, remove and extinguish the morbid irritation by a suitable counter-irritation.

Every simple medicinal substance, like the specific morbific miasmata (small-pox, measles, the venom of vipers, the saliva of rabid animals, andc.), causes a peculiar specific disease-a series of determinate symptoms, which is not produced precisely in the same way by any other medicine in the world.

As every species of plant differs in its external form, in its peculiar mode of existence, in its taste, smell, andc., from every other species and genus of plant-as every mineral substance, every salt differs from all others both in its external and internal physical qualities, so do they all differ among themselves in their medicinal properties, that is to say, in their morbific powers; each of the substances effects an alteration in our state of health in a peculiar, determinate manner.

Most substances belonging to the animal and vegetable kingdoms, are medicinal in their raw state. Those belonging to the mineral kingdom are so both in their crude and prepared state.

Medicinal substances manifest the nature of their pathogenetic power, and their absolute true action on the healthy human body, in the purest manner, when each is given singly and uncombined.

Many of the most active medicines have already occasionally found their way into the human body, and the accidents they have given rise to have been recorded.

In order to follow still farther this natural guide and to penetrate more profoundly into this source of knowledge, we administer these medicines experimentally, the weaker as well as the stronger, each singly and uncombined, to healthy individuals, with caution, and carefully removing all accessory circumstances capable of exercising an influence, we note down the symptoms they occasion precisely in the order in which they occur, and thus we obtain the pure result of the form of disease that each of these medicinal substances is capable of producing, absolutely and by itself, in the human body.

In this way we must obtain a knowledge of a sufficient supply of artificial morbific agents (medicines) for curative implements, so that we may be able to make a selection from among them.

Now, after we have accurately examined the disease to be cured, that is to say, noted down all its appreciable phenomena historically, and in the order in which they occur, marking particularly the more severe and troublesome chief symptoms, we have only to oppose to this disease another disease as like it as possible, or, in other words, a medicinal irritation analogous to the existing irritation of the disease, by the employment of a medicine which possesses the power of exciting as nearly as possible all these symptoms, or at all events, the greater number and severest, or most peculiar of them, and in the same order,-in order to cure the disease we wish to remove, certainly, quickly and permanently.

The result of a treatment so conformable to nature may be confidently depended on, it is so perfectly, without exception, certain, so rapid beyond all expectation, that no method of treating diseases can shew anything at all like it.

But here it is necessary to take into consideration the immense difference, that can never be sufficiently estimated, betwixt the positive and negative, or as they are sometimes termed, the radical (curative) and the palliative modes of treatment.

In the action of simple medicines on the healthy human body there occur in the first place phenomena and symptoms, which may be termed the positive disease, to be expected from the specific action of the medicinal substance, or its positive primary (first and principal) effect.

When this is past, there ensues, in hardly appreciable transitions, the exact opposite of the first process (especially in the case of vegetable medicines), there occur the exact opposite (negative) symptoms constituting the secondary action.

Now, if in the treatment of a disease we administer those medicines whose primary symptoms, or those of its positive action, present the greatest similarity to the phenomena of the disease, this is a positive or curative mode of treatment, that is to say, there occurs what must take place according to my second maxim of experience, rapid, permanent amelioration, for the completion of which the remedy must be given in smaller and smaller doses, repeated at longer intervals, to prevent the occurrence of a relapse; if the first, or first few doses have not already sufficed to effect a cure.

Thus, to the abnormal irritation present in the body, another morbid irritation as similar to it as possible (by means of the medicine that acts in this case positively with its primary symptoms) is opposed in such a degree that the latter preponderates over the former, and (as two abnormal irritations cannot exist beside each other in the human body, and these are two irritations of the same kind) the complete extinction and annihilation of the former is effected by the latter.

Here a new disease is certainly introduced (by the medicine) into the system, but with this difference in the result, that the original one is extinguished by the artificially excited one; but the course of the artificially excited one (the course of the medicinal symptoms), that has thus overcome the other, expires in a shorter time than any natural disease, be it ever so short.

It is astonishing that, when the positive (curative) medicine employed corresponds very exactly in its primary symptoms with those of the disease to be cured, not a trace of the secondary symptoms of the medicine is observable, but its whole action ceases just at the time when we might expect the commencement of the negative medicinal symptoms. The disease disappears if it belong to acute diseases in the first few hours, which are the duration allotted by nature to the primary medicinal symptoms, and the only visible result is-recovery-a real dynamic mutual extinction.

In the best cases the strength returns immediately, and the lingering period of convalescence usual under other modes of treatment is not met with.

Equally astonishing is the truth that there is no medicinal substance which, when employed in a curative manner, is weaker than the disease for which it is adapted-no morbid irritation for which the medicinal irritation of a positive and extremely analogous nature is not more than a match.

If we have not only selected the right (positive) remedy, but have also hit upon the proper dose (and for a curative purpose incredibly small doses suffice), the remedy produces within the first few hours after the dose has been taken a kind of slight aggravation (this seldom lasts so long as three hours), which the patient imagines to be an increase of his disease, but which is nothing more than the primary symptoms of the medicine, which are somewhat superior in intensity to the disease, and which ought to resemble the original malady so closely as to deceive the patient himself in the first hour, until the recovery that ensues after a few hours teaches him his mistake.

In this case the cure of an acute disease is generally accomplished by the first dose.
If, however, the first dose of the perfectly adapted curative medicine was not somewhat superior to the disease, and if that peculiar aggravation did not occur in the first hour, the disease is, notwithstanding, in a great measure extinguished, and it only requires a few and always smaller doses to annihilate it completely.

If, under these circumstances, in place of smaller doses, as large or larger ones are administered, there arise (after the disappearance of the original disease) pure medicinal symptoms, a kind of unnecessary artificial disease.

But the case is quite different with palliative treatment, where a medicine is employed whose positive, primary action is the opposite of the disease.

Almost immediately after the administration of such a medicine there occurs a kind of alleviation, an almost instantaneous suppression of the morbid irritation for a short time, as in the case cited above of the cold water applied to the burnt skin. These are called palliative remedies.

They prevent the impression of the morbid irritation on the organism only as long as their primary symptoms last, because they present to the body an irritation that is the reverse of the irritation of the disease; thereafter their secondary action commences, and as it is the opposite of their primary action, it coincides with the original morbid irritation and aggravates it.

During the secondary action of the palliative, and when it has been left off, the disease becomes aggravated. The pain of the burn becomes worse when the hand is withdrawn from the cold water than before it was immersed.
As in the (positive) curative mode of treatment in the first hour a slight aggravation usually ensues, followed by an amelioration and recovery all the more durable, so in the palliative method there occurs in the first hour, indeed almost instantaneously, a (deceptive) amelioration, which, however, diminishes from hour to hour, until the period of the primary, and in this case palliative, action expires, and not only allows the disease to reappear as it was before the use of the remedy, but somewhat of the secondary action of the medicine is added, which, because the primary action of the remedy was the opposite of the disease, now becomes the very reverse, that is to say, a state analogous to the disease. This state is an increase, an aggravation of the disease.

If it is wished to repeat the palliative aid, the former dose will now no longer suffice; it must be increased, and always still further increased, until the medicine no longer produces relief, or until the accessory effects, whatever these may be, of the medicine continued in ever increased doses, are productive of bad consequences, that forbid its further employment, bad consequences which, when they have attained a considerable height, suppress the original malady that has hitherto been treated (in conformity with the first maxim of experience), and, in place thereof, another new and at least as troublesome disease appears.

Thus, for instance, a chronic sleeplessness may be frequently suppressed for a considerable time by means of daily doses of opium given at night, because its (in this case palliative) primary action is soporific, but (in consequence of its secondary action being sleeplessness, accordingly an addition to the original disease) that only by means of ever increasing doses, until an intolerable constipation, an anasarca, an asthma, or other malady from the secondary action of opium, prohibits its further employment.

If however, but a few doses of the palliative medicine be employed for a habitual malady, and then discontinued before it can excite an important accessory affection, it is then speedily and clearly apparent, that it is not only impotent against the original malady, but that it moreover aggravated the latter by its secondary effects. This is truly but negative relief. If for instance, in the case of chronic agrypnia sought to be cured, the patient only obtained too little sleep, in that case the evening dose of opium will certainly immediately cause a kind of sleep, but when this remedy, which here acts only in a palliative manner, is discontinued after a few days, the patient will then not be able to sleep at all.

The palliative employment of medicines is only useful and necessary in but few cases-chiefly in such as have arisen suddenly and threaten almost immediate danger!

Thus, for example, in apparent death from freezing (after friction to the skin and the gradual elevation of the temperature) nothing removes more quickly the want of irritability in the muscular fibre, and the insensibility of the nerves, than a strong infusion of coffee, which in its primary action increases the mobility of the fibre and the sensibility of all the sensitive parts of the system; and is consequently palliative as regards the case before us. But in this case there is danger in delay, and yet there is no persistent morbid state to be overcome, but whenever sensation and irritability are again excited and brought into action even by a palliative, the uninjured organism resumes its functions, and the free play of the vital processes maintains itself again, without the aid of any further medication.

In like manner, cases of chronic diseases may occur, for example, hysterical convulsions or asphyxias, where the temporary assistance of palliatives (as eau de luce, burnt feathers, andc.,) may be urgently demanded, in order to restore the patient to his usual undangerous morbid state, for the cure of which, the totally different durable aid of curative medicines is required.

But where all that is capable of being affected by a palliative is not accomplished in a few hours, the bad consequences spoken of above commence to make their appearance.

In acute diseases, even such as run their course in the shortest time, we would better consult the dignity of medicine and the welfare of our patients, by treating them with curative (positive) medicines. They will thereby be overcome more certainly, and on the whole more rapidly, and without after-complaints.
However, the bad consequences of the palliative in slight cases of acute diseases are not very striking, not very considerable. The chief symptoms disappear in a great measure after each dose of the palliative, until the natural course of the disease comes to an end, and then the organism, which has not been very seriously deranged during the short time by the secondary effects of the palliative, again resumes its sway, and gradually overcomes the consequences of the disease itself, together with the after-sufferings caused by the medicine.

If, however, the patient recover under the use of the palliative, he would also have recovered equally well and in the same space of time, without any medicine (for palliatives never shorten the natural courses of acute diseases), and would thereafter more readily regain his strength for the reasons just given. The only circumstance that can in some measure recommend the physician who practises in this way, namely, that the troublesome symptoms are occasionally subdued by his palliatives, offers to the eyes of the patient and his friends some apparent, but no real advantage over the spontaneous recovery without the use of medicine.
Hence the curative and positive treatment possesses even in diseases of a rapid course, a decided advantage over all palliative alleviations, because it abridges even the natural periods of acute diseases, really heals them before the time for completing their course has expired, and leaves behind no after-sufferings, provided the perfectly suitable curative agent has been selected.

It might be objected to this mode of treatment, “that physicians from the earliest periods of the existence of the medical art, have (to their knowledge) never employed it, and yet have cured patients.”
This objection is only apparent; for ever since the existence of the art of medicine, there have been patients who have really been cured quickly, permanently, and manifestly by medicines, not by the spontaneous termination of the course of acute diseases, not in the course of time, not by the gradual preponderance of the energy of the system, but have been restored in the same manner as I have here described, by the curative action of a medicinal agent, although this was unknown to the physician.

In order to determine this, we must select the cases detailed by some perfectly truthful and accurate observer, where some disease not of an acute character, limited by nature to a certain short course, but some long-lasting disease, was cured permanently and without any sequelae, not by a mixture of all sorts of different drugs, but by a single medicinal substance. This we should certainly find to have been a (curative) medicine very analogous in its primary effects to the disease. Had it been a palliative, given in ever increasing doses, the apparent cure would not have been permanent, or at least, not without some after-disease. Unless by the instrumentality of a positive (curative) medicine, no rapid, gentle, permanent cure ever took place, nor in the nature of things, could it ever occur.

Occasionally, however, physicians suspected that it was that property of medicines (now confirmed by innumerable observations)-of exciting (positive) symptoms analogous to the disease, by virtue of a tendency inherent in them-which enabled them to effect real cures. But this ray of truth, I confess, seldom penetrated the spirit of our schools, enshrouded as they were in a cloud of systems.

When the remedy has been discovered by this mode of procedure, so conformable to nature, there still remains an important point, namely, the determination of the dose.

A medicine of a positive and curative character, may, without any fault on its part, do just the opposite to what it ought, if given in too large a dose; in that case it produces a greater disease than that already present.

If we keep a healthy hand in cold water for some minutes, we experience in it a diminution of temperature, cold; the veins become invisible, the fleshy parts become shrunken, their size is diminished, the skin is paler, duller, motion is more difficult. These are some of the primary effects of cold water on the healthy body. If we now withdraw the hand from the cold water and dry it, no long time will elapse before the opposite state ensues. The hand becomes warmer than the other (that had not been immersed), we notice considerable turgescence of the soft parts, the veins swell, the skin becomes redder, the movements more free and powerful than in the other-a kind of exalted vitality. This is the secondary or consecutive action of the cold water on the healthy body.

This is, moreover, almost the greatest dose in which cold water can be employed with a permanent good result, as a positive (curative) medicinal agent in a state of (pure) debility analogous to its above described primary effects on the healthy body. I repeat, the “greatest dose”; for if the whole body should be exposed to the action of this agent, and if the cold of the water be very considerable, the duration of its application must at least be very much shortened, to a few seconds only, in order to reduce the dose sufficiently.

But if the dose of this remedy be in all respects much increased above the normal amount, the morbid symptoms peculiar to the primary action of the cold water increase to a state of actual disease, which the weak part it was intended to cure by its means cannot or can scarcely remove again. If the dose be increased still more, if the water be very cold, if the surface exposed to the water be larger and the duration of its application much longer than it ought to be for an ordinary curative dose of this agent, there then ensue numbness of the whole limb, cramp of the muscles, often even paralysis; and if the whole body have been immersed in this cold water for an hour or longer, death ensues, or at least the apparent death from freezing in healthy individuals, but much more speedily when it is applied to feeble individuals.

The same is the case with all medicines, even with internal ones.

The reaper (unaccustomed to the use of spirits) exhausted by heat, exertion and thirst, who, as I have said above, is restored in the course of an hour by a small dose, a single mouthful of brandy (whose primary action shews a state very similar to that sought to be combatted in the present instance), would fall into a state of (probably fatal) synochus, if under these circumstances he were to drink, in place of a single mouthful, a couple of pints at once;-the same positive remedial agent, only in an excessive, injurious dose.
Let it not be supposed that this injurious effect of excessively large doses appertains only to medicinal agents applied in a positive (curative) manner. Equally bad results ensue from excessive doses of palliatives,-for medicines are substances in themselves hurtful, that only become remedial agents by the adaptation of their natural pathogenetic power to the disease (positively or negatively) analogous to them, in the appropriate dose.

Thus, to give an example of negative (palliative) medicines, a hand very much benumbed by cold, will soon be restored in the atmosphere of a warm room. This moderate degree of warmth is efficacious in this case as an agent of antagonistic tendency to the numbness from the cold, that is to say, as a palliative; but its employment is not attended with any particular bad effects, because the dose is not too strong and the remedy need only be used for a short time, in order to remove the moderate and rapidly produced morbid state it is wished to cure.

But let the hand which has become completely benumbed and quite insensible from the cold (frost-bitten), be quickly immersed for an hour in water of 120° Fahr., which is not too great for a healthy hand, and the part will inevitably die; the hand mortifies and falls off.

A robust man, much over-heated, will soon recover in a moderately cool atmosphere (about 65° Fahr.) without experiencing any appreciable disadvantage from this palliative; but if immediately after being so over-heated he has to stand for an hour in a cold river (wherein he might probably have remained without any bad result when not in a state of heat), he will either fall down dead, or be effected by the most dangerous typhus.
A burnt part will be alleviated in a palliative manner by cool water, but will become sphacelated if ice be applied to it. And the same is the case with internal remedies also. If a girl, excessively over-heated by dancing, swallow a quantity of ice, every one knows what usually ensues,-and yet a small tablespoonful of cold water or a minute quantity of ice would not do her any harm, although it is the same palliative, only in a smaller dose. But she would be certainly and permanently cured, even though excessively over-heated, if she were to chose a small, appropriate dose of a remedy whose primary effect is analogous (curative) to the state she is in; for instance, if she should drink a little very warm tea mixed with a small portion of heating spirituous liquor, (rum, arrack or the like), in a moderately heated room, walking quickly about;-but a large glass of alcoholic liquor would, on the other hand, throw her into a high fever.

None but the careful observer can have any idea of the height to which the sensitiveness of the body to medicinal irritations is increased in a state of disease. It exceeds all belief, when the disease has attained a great intensity. An insensible, prostrated, comatose typhus patient, unroused by any shaking, deaf to all calling, will be rapidly restored to consciousness by the smallest dose of opium, were it a million times smaller than any mortal ever yet prescribed.

The sensitiveness of the highly diseased body to medicinal irritations increases in many cases to such a degree, that powers commence to act on and excite him, whose very existence has been denied, because they manifest no action on healthy robust bodies, nor in many diseases for which they are not suited. As an example of this, I may mention the heroic power of animalism (animal magnetism), or that immaterial influence of one living body upon another produced by certain kinds of touching or approximation, which displays such an energetic action on very sensitive, delicately formed persons of both sexes, who are disposed either to violent mental emotions or to great irritability of the muscular fibres. This animal power does not manifest itself at all between two robust healthy persons,-not because it does not exist, but because, according to the wise purposes of God, it is much too weak to shew itself betwixt healthy persons, whereas the same influence (quite imperceptible when applied by one healthy person to another) often acts with more than excessive violence in those states of morbid sensibility and irritability,-just as very small doses of other curative medicines also do in very diseased bodies.

It is analogous to the medicinal powers of the application of the magnet in disease and the contact of a morbid part with the other metals, to which the healthy body is quite insensible.

On the other hand, it is as true as it is wonderful, that even the most robust individuals, when affected by the chronic disease, notwithstanding their corporeal strength, and notwithstanding that they can bear with impunity even noxious irritants in great quantity (excesses in food and alcoholic liquors, purgatives, andc.)-yet as soon as the medicinal substance positively appropriate to their chronic disease is administered to them, they experience from the smallest possible dose as great an impression as if they were infants at the breast.
There are some few substances employed in medicine which act almost solely in a chemical manner-some which condense the dead fibres as well as the living (as the tannin of plants), or loosen them and diminish their cohesion or their tension (as the fatty substances)-some which form a chemical combination with hurtful substances in the body, at least in the primae viae (as chalk or the alkalies which combine with some deleterious metallic oxydes or some acrid acid in the stomach-sulphuretted hydrogen water with the most dangerous metals and their oxydes); others which decompose them (as alkalies or liver of sulphur do the noxious metallic salts); others which chemically destroy parts of the body (as the actual cautery). With the exception of these few things and the almost purely mechanical operations of surgery on the body, amputation which merely shortens the limb, and blood-letting which merely diminishes the amount of that fluid, together with some mechanically injurious and insoluble substances that may be introduced into the body – all other medicinal substances act in a purely dynamic manner, and cure without causing evacuations, without producing any violent or even perceptible revolutions.

This dynamic action of medicines, like the vitality itself, by means of which it is reflected upon the organism, is almost purely spiritual in its nature; that of medicines used in a positive (curative) manner is so most strikingly with this singular peculiarity, that while too strong doses do harm and produce considerable disturbance in the system, a small dose, and even the smallest possible dose, cannot be inefficacious, if the remedy be only otherwise indicated.

Almost the sole condition necessary for the full and helpful action is that the appropriate remedy should come in contact with the susceptible living fibre; but it is of little, almost of no importance how small the dose is which, for this purpose, is brought to act on the sensitive parts of the living body.

If a certain small dose of a diluted tincture of opium is capable of removing a certain degree of unnatural sleepiness, the hundredth or even the thousandth part of the same dose of such a solution of opium suffices almost equally well for the same end, and in this way the diminution of the dose may be carried much farther without the excessively minute dose ceasing to produce the same curative result as the first; of which more will be said in the special part.

I have said that the contact of the medicinal substance with the living, sensitive fibre is almost the only condition for its action. This dynamic property is so pervading, that it is quite immaterial what sensitive part of the body is touched by the medicine in order to developed its whole action, provided the part be but destitute of the coarser epidermis-immaterial whether the dissolved medicine enter the stomach or merely remain in the mouth, or be applied to a wound or other part deprived of skin.

If there be no fear of its causing any evacuation (a peculiar vital process of the living organism, which possesses a peculiar power of nullifying and destroying the dynamic efficacy of the medicines), its introduction into the rectum or application to the lining membrane of the nose, fulfils every purpose, e. g., in the case of a medicine which has the power of curing a certain pain in the stomach, a particular kind of headache, or a kind of stitch in the side, or a cramp in the calves, or any other affection occurring in some part that stands in no anatomical connexion with the place to which the medicine is applied.

It is only the thicker epidermis covering the external surface of the body that presents some, but not an insurmountable obstacle to the action of medicines on the sensitive fibres underneath it. They still act through it, though somewhat less powerfully. Dry preparations of the medicine in powder act less powerfully through it; its solution acts more powerfully, and still more so if it be applied to a large surface.
The epidermis is however thinner on some parts, and consequently the action is easier in those situations. Among these the abdominal region, especially the pit of the stomach, the inguinal regions and the inner surface of the axilla, the bend of the arm, the inner surface of the wrist, the popliteal space, andc., are the parts most sensitive to the medicine.

Rubbing-in the medicines facilitates their action chiefly on this account, that the friction of itself renders the skin more sensitive, and the fibres, rendered thereby more active and susceptible, more apt to receive the impression of the specific medicinal power, which radiates thence over the whole organism.
If the groins be rubbed with a dry cloth until their sensibility is exalted, and the ointment of the black oxyde of mercury then laid upon them, the effect is the same as though we had rubbed the same place with the mercurial ointment itself, or as though the ointment had been rubbed in, as it is usually incorrectly expressed.

The peculiar medicinal power of the remedy, however, remains the same, whether it be employed outwardly or inwardly, so as to be brought into contact with the sensitive fibers.

The black oxyde of mercury taken by the mouth cures venereal buboes at least as rapidly and certainly as the rubbing-in of Naples ointment upon the groins. A foot-bath of a weak solution of muriate of mercury cures ulcers in the mouth as rapidly and certainly as its internal administration, especially if the part that is to be bathed be previously rubbed. Finely levigated cinchona powder applied to the abdomen cures the intermittent fever which it can cure by internal use.

But as the diseased organism is altogether much more sensitive for the dynamic power of all medicines, so also is the skin of diseased persons. A moderate quantity of tincture of ipecacuanha applied to the bend of the arm effectually removes the tendency to vomit in very sick individuals (by means of its primary power to excite vomiting).

The medicinal power of heat and cold alone seems not to be so exclusively dynamic as that of other medicinal substances. Where these two agents are employed in a positive manner, the smallest possible dose of them does not suffice to produce the desired effect. When it is requisite to obtain relief rapidly they both have to be employed in greater intensity, in a larger dose (up to a certain amount). But this appearance is deceptive; their power is just as dynamically medicinal as that of other medicines, and the difference in given cases depends on the already existing habituation of our body to certain doses of these stimuli, to certain degrees of heat and cold. The heat and cold to be employed in a medicinal manner must surpass this accustomed degree by a little, in order that it may be employed in a positive manner with success (by a great deal, if it is to be used in a negative or palliative manner).

The temperature of blood-heat is for most people in our climate higher than the usual degree for the skin, and consequently a footbath of 98° to 99° Fahr. is sufficiently temperate and warm enough to remove positively heat in the head (if no other morbid symptoms are present); but in order to alleviate in a palliative manner the inflammation of a burnt hand, we require to use water considerably colder than we are accustomed to bear comfortably in healthy parts of the body, and the water should be, within certain limits, so much the colder the more severe the inflammation is.

What I have here stated respecting the somewhat greater dose of heat and cold for curative purposes applies also to all other medicinal agents to which the patient has already been accustomed. Thus for medicinal purposes we require to administer to persons hitherto accustomed to their use doses of wine, spirits, opium, coffee, andc., large in proportion to the amount they were previously accustomed to.

Heat and cold, together with electricity, belong to the most diffusible of all dynamic medicinal stimuli, their power is not diminished nor arrested by the epidermis, probably because its physical property serves as a conductor and vehicle for their medicinal power, and thus helps to distribute them. The same may be the case with regard to animalism (animal magnetism) the medicinal action of the magnet, and in general with regard to the power of the external contact of metals. The galvanic power is somewhat less capable of penetrating through the epidermis.

If we observe attentively we shall perceive that wise nature produces the greatest effects with simple, often with small means. To imitate her in this should be the highest aim of the reflecting mind. But the greater the number of means and appliances we heap together in order to attain a single object, the farther do we stray from the precepts of our great instructress, and the more miserable will be our work.

With a few simple means, used singly one after the other, more frequently however with one alone, we may restore to normal harmony the greatest derangements of the diseased body, we may change the most chronic, apparently incurable diseases (not unfrequently in the shortest space of time) into health-whereas we may, by the employment of a heap of ill-selected and composite remedies, see the most insignificant maladies degenerate into the greatest, most formidable, and most incurable diseases.

Which of these two methods will the professor of the healing art who strives after perfection, choose?
A single simple remedy is always calculated to produce the most beneficial effects, without any additional means; provided it be the best selected, the most appropriate, and in the proper dose. It is never requisite to mix two of them together. We administer a medicine in order if possible to remove the whole disease by this single substance, or if this be not completely practicable, to observe from the effect of the medicine what still remains to be cured. One, two, or at most three simple medicines are sufficient for the removal of the greatest disease, and if this result does not follow, the fault lies with us; it is not nature, nor the disease, that is to blame.

If we wish to perceive clearly what the remedy effects in a disease, and what still remains to be done, we must only give one single simple substance at a time. Every addition of a second or a third only deranges the object we have in view, and when we wish to separate the effects of the remedy from the symptoms of the morbid process (seeing that at the most we may indeed be able to know the symptoms of the action of a simple medicine, but not the powers of a mixture of drugs, that either form combinations among, or are decomposed by, one another, and these it will never be possible for us to know), we now no longer see what portion of the changes that have taken place is to be ascribed to the disease,-we are unable to distinguish which of the changes and symptoms that have occurred are derived from one, which from another ingredient of the compound remedy, and consequently we are unable to determine which of the ingredients should be retained and which discarded during the subsequent treatment,-nor what other one we should substitute for one or other or for all of them. In such a treatment none of the phenomena can be referred to its true cause. Wherever we turn, nought but uncertainty and obscurity surrounds us.

Most simple medicinal substances produce in the healthy human body not few, but on the contrary, a considerable array of absolute symptoms. The appropriate remedy can consequently frequently contain among its primary effects an antitype of most of the visible symptoms in the disease to be cured (besides many others which render it suitable for the cure of other diseases).

Now the only desirable property that we can expect a medicine to possess, is this, that it should agree with the disease-in other words, that it should be capable of exciting per se the most of the symptoms observable in the disease, consequently, when employed antagonistically as a medicine, should also be able to destroy and extinguish the same symptoms in the diseased body.

We see that a single simple medicinal substance possesses in itself this property in its full extent, if it have been carefully selected for this purpose.

It is therefore never necessary to administer more than one single simple medicinal substance at once, if it have been chosen appropriately to the case of disease.

It is also very probable, indeed certain, that of the several medicines in a mixture, each no longer acts upon the disease in its own peculiar way, nor can it, undisturbed by the other ingredients, exert its specific effect,-but one acts in opposition to the other in the body, alters and in part destroys the action of the other, so that from this combination of several powers that dynamically decompose each other during their action in the body, an intermediate action is the result, which we cannot desire, as we cannot foresee, nor even form a conjecture respecting it.

In the action of mixtures of medicines in the body, there occurs what, indeed, must occur according to the maxim of experience given above (viz.:-that a general irritation in the body removes another, or else suppresses it, according as the one irritation is analogous or antagonistic to the other, or provided the one be much more intense than the other)-the actions of several of the medicines in the compound partially destroy one another, and only the remainder of the action, which is not covered by any antagonistic irritation in the mixture, remains to oppose the disease; whether this be suitable or no, we cannot tell, as we are unable to calculate what actually will remain.

Now, as in every case, only a single simple medicinal substance is necessary; no true physician would ever think of degrading himself and his art, and defeating his own object, by giving a mixture of medicines. It will rather be a sign that he is certain of his subject if we find him prescribing only a single medicinal substance, which, if suitably chosen, cannot fail to remove the disease rapidly, gently and permanently.
If the symptoms be but slight and few in number, it is an unimportant ailment that scarcely requires any medicine, and may be removed by a mere alteration of diet or regimen.

But if – as rarely happens-only one or a couple of severe symptoms be observable, then the cure is more difficult than if many symptoms were present. In that case the medicine first prescribed may not be exactly suitable, either because the patient is incapable of describing the extent of his ailments, or because the symptoms themselves are somewhat obscure and not very observable.

In this more uncommon case we may prescribe one, or at most, two doses of the medicine that appears to be the most appropriate.

It will sometimes happen that this is the right remedy. In the event of its not being exactly suitable, which is most commonly the case, symptoms not hitherto experienced will reveal themselves, or symptoms will develop themselves more fully, that the patient has not previously noticed, or only in an indistinct manner.

From these symptoms which, though slight, now shew themselves more frequently and are more distinctly perceptible, we may now obtain a more accurate picture of the disease, whereby we may be enabled to discover with greater and even the greatest certainty the most appropriate remedy for the original disease.
The repetition of the doses of a medicine is regulated by the duration of the action of each medicine. If the remedy acts in a positive (curative) manner, the amendment is still perceptible after the duration of its action has expired, and then another dose of the suitable remedy destroys the remainder of the disease. The good work will not be interrupted if the second dose be not given before the lapse of some hours after the cessation of the action of the remedy. The portion of the disease already annihilated cannot in the mean time be renewed; and even should we leave the patient several days without medicine, the amelioration resulting from the first dose of the curative medicine will always remain manifest.

So far from the good effect being delayed by not repeating the dose until after the medicine has exhausted its action, the cure may on the contrary be frustrated by its too rapid repetition, for this reason, because a dose prescribed before the cessation of the term of action of the positive medicine is to be regarded as an augmentation of the first dose, which from ignorance of this circumstance may thereby be increased to an enormous degree, and then prove hurtful by reason of its excess.

I have already stated that the smallest possible dose of a positively acting medicine will suffice to produce its full effect. If, in the case of a medicine whose action lasts a long time, as for instance digitalis where it continues to the seventh day, the dose be repeated frequently, that is to say, three or four times in the course of a day, the actual quantity of medicine will, before the seven days have expired, have increased twenty or thirty-fold, and thereby become extremely violent and injurious; whereas the first dose (a twentieth or thirtieth part) would have amply sufficed to effect a cure without any bad consequences.
After the expiry of the term of action of the first dose of the medicine employed in a curative manner, we judge whether it will be useful to give a second dose of the same remedy. If the disease have diminished in almost its whole extent, not merely in the first half-hour after taking the medicine, but later, and during the whole duration of the action of the first dose; and if this diminution have increased all the more, the nearer the period of the action of the remedy approached its termination-or even if, as happens in very chronic diseases, or in maladies the return of whose paroxysm could not have been expected during this time, no perceptible amelioration of the disease have indeed occurred, but yet no new symptom of importance, no hitherto unfelt suffering deserving of attention have appeared, then it is in the former case almost invariably certain, and in the latter highly probable, that the medicine was the curatively helpful, the positively appropriate one, and, if requisite, ought to be followed up by a second-and finally even, after the favourable termination of the action of the second, by a third dose if it be necessary and the disease be not in the mean time completely cured,-as it often is, in the case of acute diseases, by the very first dose.

If the medicine we have chosen for the positive (curative) treatment excites almost no sufferings previously unfelt by the patient, produces no new symptom, it is the appropriate medicament and will certainly cure the original malady, even though the patient and his friends should not admit that any amendment has resulted from the commencing doses,-and so also conversely, if the amelioration of the original disease take place in its whole extent from the action of the curative medicine, the medicine cannot have excited any serious new symptoms.

Every aggravation, as it is called, of a disease that occurs during the use of a medicine (in doses repeated before or immediately after the expiry of its term of action), in the form of new symptoms not hitherto proper to the disease, is owing solely to the medicine employed (if it do not occur just a few hours before inevitable death, if there have taken place no important error of regimen, no outbreak of violent passions, no irresistible evolution of the course of nature by the occurrence or cessation of the menstrual function, by puberty, conception, or parturition); these symptoms are always the effect of the medicine, which, as an unsuitably chosen positive remedy, or as a negative (palliative) remedy, either ill-selected or given for too long a time, and in too large doses, develops them by its peculiar mode of action to the torment and destruction of the patient.

An aggravation of the disease by new, violent symptoms during the first few doses of a curative medicine is never indicative of feebleness of the dose (never requires the dose to be increased), but it proves the total unfitness and worthlessness of the medicine in this case of disease.

The aggravation just alluded to by violent, new symptoms not proper to the disease, bears no resemblance to the increase of the apparently original symptoms of the disease during the first few hours after the administration of a medicine selected in a positive (curative) manner, which I formerly spoke of. This phenomenon of the increase of what seem to be the pure symptoms of the disease, but which are actually predominant medicinal symptoms resembling those of the disease, indicates merely that the dose of the appropriately selected curative medicine has been too large-it disappears, if the dose has not been enormously large, after the lapse of two, three, or at most, four hours after its administration, and makes way for a removal of the disease that will be all the more durable, generally after the expiry of the term of the action of the first dose; so that, in the case of acute affections, a second dose is usually unnecessary.

However, there is no positive remedy, be it ever so well selected, which shall not produce one, at least one slight, unusual suffering, a slight new symptom, during its employment, in very irritable, sensitive patients,-for it is almost impossible that medicine and disease should correspond as accurately in their symptoms as two triangles of equal angles and sides resemble each other. But this unimportant difference is (in favourable cases) more than sufficiently compensated by the inherent energy of the vitality, and is not even perceived except by patients of excessive delicacy.

Should a patient of ordinary sensibility observe during the duration of the action of the first dose, an unusual sensation, and should the original disease appear at the same time to decline, we are unable to determine with precision (at least not in a chronic disease) from this first dose, whether or no the medicine selected was the most appropriate curative one. The effects of a second dose of equal strength, given after the first has exhausted its action, can alone decide this point. From the action of this, if the medicine was not perfectly or exceedingly appropriate, there will again appear a new symptom (but not often the same that was observed from the first dose, usually another one) of greater intensity (or even several symptoms of a like character), without any perceptible progress occurring in the cure of the disease in its whole extent;-if, however, it was the appropriate positive medicine, this second dose removes almost every trace of a new symptom, and health is restored with still greater rapidity, and without the supervention of any new ailment.
Should there occur from the second dose also some new symptom of considerable severity, and should it not be possible to find a more appropriate medicine (the fault of which may however lie either in a want of diligence on the part of the physician, or in the smallness of the supply of medicines, whose absolute effects are known) in the case of chronic diseases, or acute diseases that do not run a very rapid course, a diminution of the dose will cause this to disappear, and the cure will still go on, though somewhat more slowly. (In this case also the energy of the vitality aids the cure).

The choice of the medicine is not inappropriate if the chief and most severe symptoms of the disease are covered in a positive manner by the symptoms of the primary action of the medicine, while some of the more moderate and slighter morbid symptoms are so only in a negative (palliative) manner. The true curative power of the predominant positive action of the remedy takes place notwithstanding, and the organism regains full possession of health without accessory sufferings during the treatment, and without secondary ailments thereafter. It is not yet decided whether it is advantageous in such a case to increase the doses of the medicine during the continuance of its employment.

If, during the continued employment of a curative medicine without increasing the doses (in a chronic disease,) fresh symptoms not proper to the disease should, in the course of time, present themselves, whereas the first two or three doses acted almost without any disturbance, we must not seek for the cause of this impediment in the inappropriateness of the medicine, but in the regimen, or in some other powerful agency from without.
If, on the other hand, as is not unfrequently the case when there is a sufficient supply of well known medicines, a positive medicine perfectly appropriate to the accurately investigated case of disease, be selected and administered in a suitably small dose, and repeated after the expiry of its special duration of action, should none of the above alluded to great obstacles come in the way, such as unavoidable evolutions of nature, violent passions, or enormous violations of regiminal rules, and should there be no serious disorganization of important viscera, the cure of acute and chronic diseases, be they ever so threatening, ever so serious, and of ever so long continuance, takes place so rapidly, so perfectly, and so imperceptibly, that the patient seems to be transformed almost immediately into the state of true health, as if by a new creation.
The influence of regimen and diet on the cure is not to be overlooked; but the physician needs to exercise a supervision over them only in chronic diseases, according to principles which I shall develop in the special part of my work. In acute diseases, however (except in the state of complete delirium), the delicate and infallible tact of the awakened internal sense that presides over the maintenance of life, speaks so clearly, so precisely, so much in conformity with nature, that the physician needs only to impress on the friends and attendants of the patient, not to oppose in any way this voice of nature, by refusing or exceeding its demands, or by an injurious officiousness and importunity.

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James Tyler Kent – Lecture on The second prescription

 

James_Tyler_KentThe second prescription – James Tyler Kent
lecture read before the International Hahnemannian Association at Niagara Falls in 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 jocund.”

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.

For example:

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.


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The Medical Observer

 

HahnemannThe Medical Observer
Samuel Hahnemann

from the introduction to Materia Medica Pura

In order to be able to observe well, the medicinal practitioner requires to possess, what is not to be met with among ordinary physicians even in a moderate degree, the capacity and habit of noticing carefully and correctly the phenomena that take place in natural diseases, as well as those that occur in the morbid states artificially excited by medicines when they are tested upon the healthy body, and the ability to describe them in the most appropriate and natural expressions.

In order accurately to perceive what is to be observed in patients, we should direct all our thoughts upon the matter we have in hand, come out of ourselves, as it were, and fasten ourselves, so to speak, with all our powers of concentration upon it, in order that nothing that is actually present, that has to do with the subject, and that can be ascertained by all the senses, may escape us.

Poetic fancy, fantastic wit and speculation, must for the time be suspended, and all over- strained reasoning, forced interpretation and tendency to explain away things must be suppressed. The duty of the observer is only to take notice of the phenomena and their course; his attention should be on the watch, not only that nothing actually present escape his observation, but that also what he observes be understood exactly as it is.

This capability of observing accurately is never quite an innate faculty; it must be chiefly acquired by practice, by refining and regulating the perceptions of the senses, that is to say, by exercising a severe criticism in regard to the rapid impressions we obtain of external objects, and at the same time the necessary coolness, calmness, and firmness of judgment must be preserved, together with a constant distrust of our own powers of apprehension.

The vast importance of our subject should make us bestow the energies of our body and mind upon the observation; and great patience, supported by the power of the will, must sustain us in this direction until the completion of the observation.

To educate us for the acquirement of this faculty, an acquaintance with the best writings of the Greeks and Romans is useful, in order to enable us to attain directness in thinking and in feeling, as also appropriateness and simplicity in expressing our sensations; the art of drawing from nature is also useful, as it sharpens and practices our eye, and thereby also our other senses, teaching us to form a true conception of objects, and to represent what we observe, truly and purely, without any addition from the fancy. A knowledge of mathematics also gives us the requisite severity in forming a judgment.

Thus equipped, the medical observer cannot fail to accomplish his object, especially if he has at the same time constantly before his eyes the exalted dignity of his calling — as the representative of the all-bountiful Father and Preserver, to minister to His beloved human creatures by renovating their systems when ravaged by disease.

He knows that observations of medical subjects must be made in a sincere and holy spirit, as if under the eye of the all-seeing God, the Judge of our secret thoughts, and must be recorded so as to satisfy an upright conscience, in order that they may be communicated to the world, in the consciousness that no earthly good is more worthy of our zealous exertions than the preservation of the life and health of our fellow-creatures.

The best opportunity for exercising and perfecting our observing faculty is afforded by instituting experiments with medicines upon ourselves. Whilst avoiding all foreign medicinal influences and disturbing mental impressions in this important operation, the experimenter, after he has taken the medicine, has all his attention strained towards all the alterations of health that take place on and within him, in order to observe and correctly to record them, with ever-wakeful feelings, and his senses ever on the watch.

By persevering in this careful investigation of all the changes that occur within and upon himself, the experimenter attains the capability of observing all the sensations, be they ever so complex, that he experiences from the medicine he is testing, and all, even the finest shades of alteration of his health, and of recording in suitable and adequate expressions his distinct conception of them.

Thus only is it possible for the beginner to make pure, correct, and undisturbed observations, for he knows that he will not deceive himself, there is no one to tell him aught that is untrue, and he himself feels, sees, and notices what takes place in and upon him. He will thus acquire practice to enable him to make equally accurate observations on others also.

By means of these pure and accurate investigations we shall be made aware that all the symptomatology hitherto existing in the ordinary system of medicine was only a very superficial affair, and that nature is wont to disorder man in his health and in all his sensations and functions by disease or medicine in such infinitely various and dissimilar manners, that a single word or a general expression is totally inadequate to describe the morbid sensations and symptoms which are often of such a complex character, if we wish to portray really, truly, and perfectly the alterations in the health we meet with.

No portrait painter was ever so careless as to pay no attention to the marked peculiarities in the features of the person he wished to make a likeness of, or to consider it sufficient to make any sort of a pair of round holes below the forehead by way of eyes, between them to draw a long-shaped thing directed downwards, always of the same shape, by way of a nose, and beneath this to put a slit going across the face, that should stand for the mouth of this or of any other person; no painter, I say, ever went about delineating human faces in such a rude and slovenly manner; no naturalist ever went to work in this fashion in describing any natural production; such was never the way in which any zoologist, botanist, or mineralogist acted.

It was only the semeiology of ordinary medicine that went to work in such a manner,

when describing morbid phenomena. The sensations that differ so vastly among each other, and the innumerable varieties of the sufferings of the many different kinds of patients, were so far from being described by word or writing according to their divergences and varieties, according to their peculiarities; the complexity of the pains composed of various kinds of sensations, their degrees and shades, was so far from being accurately or completely described, that we find all these infinite varieties of sufferings huddled together under a few bare, unmeaning, general terms, such as perspiration, heat, fever, headache, sore throat, croup, asthma, cough, chest complaints, stitch in the side, bellyache, want of appetite, indigestion, dyspepsia, backache, coxalgia, haemorrhoidal sufferings, urinary disorders, pains in the limbs (called according to fancy gouty or rheumatic), skin diseases, spasms, convulsions, and c.

With such superficial expressions, the innumerable varieties of sufferings of patients were disposed of in the so-called observations, so that — with the exception of some one or other severe, striking symptom in this or that case of disease — almost every disease pretended to be described is as like another as the spots on a die, or as the various pictures of the dauber resemble one another in flatness and want of character.

The most important of all human vocations, I mean the observation of the sick, and of the infinite varieties of their disordered state of health, can only be pursued in such a superficial and careless manner by those, who despise mankind, for in this way there is no question either of distinguishing the peculiarities of the morbid states, or of selecting the only appropriate remedy for the special circumstances of the case.

The conscientious physician who earnestly endeavours to apprehend in its peculiarity the disease to be cured, in order to be able to oppose to it the appropriate remedy, will go much more carefully to work in his endeavour to distinguish what there is to be observed; language will scarcely suffice to enable him to express by appropriate words the innumerable varieties of the symptoms in the morbid state; no sensation, be it ever so peculiar, will escape him, which was occasioned in his feelings by the medicine he tested on himself; he will endeavour to convey an idea of it in language by the most appropriate expression, in order to be able in his practice to match the accurate delineation of the morbid picture with the similarly acting medicine, whereby alone, as he knows, can a cure be effected.

So true it is that the careful alone can become a true healer of diseases.


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aphorism 1

 

HahnemannThe physician’s high and only mission is to restore the sick to health, to cure, as it is termed.1


1 His mission is not, however, to construct so-called systems, by interweaving empty speculations and hypotheses concerning the internal essential nature of the vital processes and the mode in which diseases originate in the interior of the organism, (whereon so many physicians have hitherto ambitiously wasted their talents and their time); nor is it to attempt to give countless explanations regarding the phenomena in diseases and their proximate cause (which must ever remain concealed), wrapped in unintelligible words and an inflated abstract mode of expression, which should sound very learned in order to astonish the ignorant – whilst sick humanity sighs in vain for aid. Of such learned reveries (to which the name of theoretic medicine is given, and for which special professorships are instituted) we have had quite enough, and it is now high time that all who call themselves physicians should at length cease to deceive suffering mankind with mere talk, and begin now, instead, for once to act, that is, really to help and to cure.


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