The Development of Dose and Potency

The Development of Dose and Potency
in the History of Homoeopathy

It is important to recognize that Hahnemann spent his life systematically exploring the ramifications of similia similibus. Homoeopathy did not spring fully-formed from the proving of Peruvian bark. If we are to understand our art, and particularly if we are to presume to further its development, we need to be familiar with the path of exploration followed by its founder.
It seems reasonable to date the birth of homoeopathy at the 1796 publication of Hahnemann's Essay on a New Principal for Ascertaining the Curative Powers of Drugs. If I may presume to anchor a chronology on the date of this Essay, we find ourselves today in year 202 "AE". The completion of the 6th edition of the Organon, and Hahnemann's death, occured in 1843, "year 47". I'd like to use this framework to examine the development of homoeopathy over those first 47 years, and in this essay to look specifically at the concepts of dose and dynamization as they developed over that time. In future essays I will address the related issues of repetition of dose and mode of administration, from this same perspective.
During the first 30-some years of the development of homoeopathy; from 1796 to somewhere around 1828-1832, Hahnemann's focus in the preparation of medicines was on finding an appropriately small material dose.
Prior to his recognition of cure by similars, Hahnemann practiced in the manner of his allopathic brethren. A largely botanical pharmocopoea were prescribed in doses intended to impose specific actions on the body. Kohler's Medizinal Pflanzen, published posthumously in 1887, detailed 300 medicinal plants employed in this period. Mineral remedies such as arsenic, mercurial compounds, antimony, etc. were similarly employed in quantity sufficient to produce an observable allopathic effect. Hahnemann was quite familiar with the prevailing use of these medicaments, and in fact was responsible for the translation of Monroe's Materia Medica, Haller's Materia Medica of German Plants, the London College of Physicians' Thesaurus Medicaminum, and of Cullen's A Treatise on Materia Medica, which lauched this wonderful journey we continue today. In his pre-homoeopathic medical career, Hahnemann's dosing of medicines corresponded to that of his colleagues; in Directions for the Cure of Old Sores and Ulcers (1784; 12 years "BE") we see him prescribing (allopathically) antimony in doses of 5-50 grains, and jalap root in doses of 20-70 grains. Writings from 1787 see him prescribing conium at 4 grains to several quarter onces daily; belladonna at 12-15 grains every other day; aconite at 1/2-several grains several times per day; digitalis at 1/2-1 spoonful of the juice of freshly crushed leaves twice daily; and hyoscyamus extract, 1 grain several times/d up to 30 grains in 24 hours. In 1790 (6 years "BE") we see him prescribing cinchona according to the allopathic standards of the day, at 1-1/2 to 2-1/2 ounces (45-75 grams) per 24 hours. If these substances sound familiar to the homoeopathist of today, it is only because Hahnemann's allopathic experience with them paved the way for his recognition of their potential to be used as similia in the homoeopathic treatment of disease.
Following the 1790 proving of Peruvian bark, with the pivotal audacious footnote to Cullen's Materia Medica alluding to cure by similars; and prior to the publication of Essay on a New Principal ... in 1796 (year 1 "AE"); Hahneman began experimenting with treating with similia. These early experiments revealed many of the fundamental correlaries of similia similibus that went on to shape later homoeopathic practice, one of which was that a well-chosen similimum can act in a rather small dose. In this 1796 essay he makes reference to the use of "small doses", but does not clarify this further.
By 1798, 2 years "AE", we see Hahnemann using small crude doses homoeopathically. In his Hufeland's Journal article Some Kinds of Continued and Remittent Fevers he notes using Ignatia in "large doses" of 1/2 to 3 grains, dependent on age; Opium in 1/5-1/2 grain doses; and Camphor at 15-30 grains/day. In Some Periodical and Hebdomadal diseases he notes using Ignatia at 8 grains and China at 1/2-1 grain doses. Although these are still "crude" doses, and rather large by later homoeopathic standards, they represent dramatic reductions from the allopathic doses of his contemporaries.
Hahnemann's experiments during this time led him to the use of even smaller (tho still crude) doses, particularly with those remedies he used commonly; we see his doses smallest with those remedies that we today recognize as our polychrests, perhaps because he was developing greater experience with these even-then frequently-used medicines. In his Apothecaries Lexicon (1798; year 2) he refers to using Sabina "in very small doses", Hyoscyamus at 1/60-1/30 grain (.001-.002 gram), Stramonium at 1/100th or 1/1000th part of a grain, and Veratrum album at "one thousand times smaller doses than those used by the ancients".
Serial dilution in the preparation of remedies appears to have been introduced in 1799 (year 3). In his booklet Cure and Prevention of Scarlet Fever (published in 1801, describing his treatment of an epidemic in 1799), he offers the first detailed statements regarding dilution. Opium tincture was used undiluted externally on the abdomen, but for internal use was prepared with two 1/500 dilutions (creating a solution of 1/5millionth part of a grain/drop), with a dose of one to 2 drops. Ipecacuanha was used variably in a dose of 1/10 to 1/2 grain, or 1 to 10 drops of a 1/100 dilution. A dose of Belladonna used early-on of 1/432,000th part of a grain was described as "too large a dose"; in preparing a dose he made a dilution from the tincture in two dilutional steps, of 1/300 and 1/200, resulting in a solution in containing 1/24 millionth grain of dry belladonna juice per drop, and used 2 or more drops/dose, depending on age (up to 40 drops for an adult). Chamomilla was prepared by dissolving 1 grain in 1000 drops, and then diluted 1/800; this final dilution contained 1/800,000th grain of inspissated juice/drop, and 1 or more drops constituted a dose, depending on age.
At this point, trituration and succussion were not recognized for the role in which they are now seen the process of preparation. He offers descriptions of mixing such as "shaking the whole well" and "intimately mixed ... by shaking it for a minute" that suggest an interest in dispersing the substance well throughout the dilution medium. And he describes these preparations in terms that clearly speak of his understanding of them as dilutions, attenuations or reduced doses, such as "weak solution of belladonna".
Reference to Hahnemann's casenotes at this point reveals that he continued to use some medications in small crude doses. These tend to be those that might be considered "smaller remedies" today, which suggests that he was moving to "infinitisimal" doses particularly with those medicines which he employed frequently, and had established enough hands-on experience with to begin to appreciate their ability to act well in such extreme dilution.
Hahnemann's assertions on the efficacy of such "infinitisimal" doses naturally brought out some critcism from his materialistically-oriented contemporaries. He responded with his 1801 (year 5) article On the Power of Small Doses of Medicine in General, and of Belladonna in Particular, in Hufeland's Journal. It is clear that he still understood these infinitisimal preparations to be dilutions or small doses. But there is also an inkling of an appreciation of the release of medicinal power by dispersal of a substance in a quantity of solute, which begins to shadow his 32-years-later appreciation of the dynamization of remedies.
Hahnemann's first homoeopathic materia medica, the 2-volume Fragmenta de veribus medicamentorum positivis, came and went in 1805 (year 9) with no mention of dose, as did part 1 of his Materia Medica Pura in 1811 (year 15). The 1st edition of the Organon was published in 1810, and refered only to "small doses", individually determined for each medicine. In 1819 (year 23), the 2nd edition of the Organon devoted §s300-308 to the issue of dose. §300 stated: "The suitability of a medicine for any given case of illness depends not only on a relevant homoeopathic selection, but just as much on the correct quantity necessary or rather the smallness of the dose." He went on to suggest that dose determination requires "clear experiments, careful observation and accurate experience."
Writings from this time reveal some of the results of Hahnemann's "clear experiments, careful observation and accurate experience" in this first half of the second decade of homoeopathic practice. In an 1812 (year 16) epidemic of intermittent fever, he employed Arnica in the 18th centisimal delution, and Nux-v in the 9th. In his 1814 (year 18) article Treatment of the Typhus or Hospital Fever at Present Prevailing, he used Bryonia & Rhus tox in dilutions prepared by serially diluting 1 drop to 6 drams twelve times, shaken for 3 minutes at each step, and used a dose of 1 drop of the 12th dilution.
In the subsequent volumes of his Materia Medica Pura, published between 1816 and 1819 (years 20-23), we see a good deal of variation in dose and dilution, suggesting experimentation to discover an optimal dose for each remedy and condition under treatment. In part 2 (1816), doses range from 1 drop of the original preparation for Causticum, to the 30th centisimal dilution for Arsenicum. Ferrum is given in doses described as 1/100, 1/1000th, or 1/50,000th of a grain. For Pulsatilla, Rhus-tox and Bryonia, he makes recommendations contingent on the condition of the patient: 1 drop of the pure tincture if the patient is strong & the illness protracted, and higher dilutions (Puls in the 12th centisimal dilution, Rhus-t in the 12th-15th, Bry in the 18th) in acute illness & delicate patients.
In 1821 (year 25), in volume 6 of his Materia Medica Pura , Hahnemann refers constantly to treating with "the smallest part of a drop". In the 1822 2nd edition of volume 1 of the Materia Medica Pura, dosing recommendations ranged from the crude tincture for Cannabis, to the 9th to 30th centisimal dilutions or triturations, with the dose consistently specified as the "smallest part of a drop". By "year 26", Hahnemann had evidently begun giving remedies in fraction-of-a-drop doses on medicinally-moistened globules, and had apparently settled on a centisimal standard for his serial dilutions.
Although Hahnemann briefly alluded to an accentuation of medicinal influence from dispersing a medicine in fluid solution in his 1801 (year 5) article On the Power of Small Doses of Medicine in General, and of Belladonna in Particular, there is as yet no real mention of the notion of potentization or dynamization of remedies. These preparations arrived at through serial dilution were still viewed as attentuated doses, and the process of shaking the dilutional solutions or triturating the solid dilutions was viewed as essential merely to disperse the medicine thoughout the diluting medium.
In 1825 (year 29) Hahnemann's "infinitisimal" dilutions were attacked in an article in Allg. Anz. d. Deutschen, with the assertion that the dilution of a medicine to a decillionth of a grain would require "a mass of water of about 52 quintillion globes, each of the size of our earth".
Around this time (1825, year 29), Hahnemann began viewing these preparations as "dynamizations" (dynamische, dynamisation) or "potentizations" (potenz, potenzirung) rather than as mere dilutions or attenuations of dose. In his article Information for the Truth Seeker (1825, in Allg. Ans. der Deutschen), he states "For hundreds of years nothing was known of the power of many crude medicinal substances. These, if made into a solution, can, by repeated shakings or by long-continued trituration with non-medicinal powder, be worked up to very intensive medicines with marvelous effects. ... By trituration (shaking) the latent medicinal power is wonderfully liberated and vitalised, as if, once freed from the fetters of matter, it could act upon the human organism more insistently and fully. In reality dilution is potentizing, not merely a material splitting up and lessening, in which every part must be smaller than the whole, but a spiritualising of the inner medicinal powers by removing the covering of nature's forces, and the palpable substance which can be weighed, no longer enters into consideration."
A detailed description of the process of trituration, principally for the first 3 centisimal dilutions of insoluble medicinal substances, was given in part 2 of the 1st edition of Chronic Diseases (1835, year 39).
Hahnemann used the terms verdünnung (dilution), verkleinern (diminish), gabe (a giving; dose), dosis (a giving; dose), dynamisation/dynamische/dynamisirt (dynamization/dynamic/dynamized), and potenzirung/potenz (potentizaton/potency) to describe these various concepts. The term "too-strong dose" refered to prescriptions making a too-strong impression on the life force (see the Organon, §s275-276) either by to being too large (in a material sense) or of too great a potency.
Some of Hahnemann's followers were at this point "leap-frogging" their mentor in preparing even greater potentizations of remedies by serial dilution and trituration/succussion. Notable among these were Dr. Gross in Jüterbogk; Dr. Schreter in Lemberg; General Korsakoff in Russia; and later, Jenichen in Wismar. In 1829 (year 33) Hahnemann wrote to Schreter & Korsakoff, urging them to adopt a limit at 30C, and even to adopt this as a "standard" potency. Seemingly undaunted, they went on to develop still higher potencies; Korsakoff to the 1,500th centisimal, Jenichen to the 2,500th, 8,000th, and 16,000th. Wahle, in Rome, worked with 6C preparations prepared with 1,000 succussions at each dilutional stage. In the 5th edition of the Organon, published in 1833 (year 37), Hahnemann falls only a little bit short of recommending the 30C potency (decillionth dilution) as a standard.
This suggestion of a 30C "standard" for potentization represented more than just an attempt to set a standard in practice. It represented a striking break from Hahnemann's previous search for the optimal attenuated dosages for each medicinal substance. The notion of a pharmacological dose - even a highly-attenutated pharmacological dose - went out the window with his recognition of the dynamic nature of the potentized remedy, so that "the palpable substance which can be weighed, no longer enters into consideration".
In the 5th edition of the Organon, Hahnemann clearly spells out the concept of dynamization/potentization in §269. He provides the first specific instructions on dynamization in §s270-271; 30 successive serial dilutions of 1/100 dilution, with 2 succussions at each dilutional step to produce the decillionth dilution, (reduced from prev. 10 succussions - note to §270). He also advocates that Provings be carried out with the 30C potency (§128).
In 1833 (year 37), Constantine Hering, returning to Germany from Surinam, was shipwrecked off Martha's Vineyard & induced to settle in Philadelphia. With his 4th & 5th editions of the Organon, his first edition of Chronic Diseases, his 30Cs & some high potencies from Jenichen, the seed of homoeopathy was planted on new soil and grew in its own directions. The homoeopathy of the American Institute of Homoeopathy (AIH) and later, the International Hahnemannian Association (IHA) was very much the child of the 4th & 5th editions of the Organon, developed along the lines of increasing centisimal potency.
In 1832 (year 36), Hahnemann began experimenting with olfaction of remedies, having the patient smell a moistened pellet as a dose. He described this in his preface to Boenninghausen's List of Symptoms of the Antipsoric Medicines , and again in detail in the 5th edition of the Organon (in the note to §288;). He evidently experimented extensively with olfaction in 1832-1833, but although he continued to use it as a dosing option into his later years, it did not catch on well among his colleagues.
Also about this time, Hahnemann began experimenting with giving the dose in solution, rather than as a dry pellet on the tongue. In the Organon, 5th edition, §s286-287 he describes an increase in the medicinal action of a dose when it is fully dispersed in medicinal solution.
In 1835 (year 39) Hahnemann wrote to Hering, describing the further diminution of dose by giving portions ("split doses") of a medicinal solution produced by dissolving a medicated centisimal pellet in a volume of water. This reduced dose allowed for more frequent repetition during the gradual amelioration of chronic disease, with gradual ascent of potency by stirring or succussion of the solution prior to each repeated dose. He wrote more detailed instructions on this approach in 1837 (year 41), which can be read in the preface to part 3 (2nd ed.) of Chronic Diseases.
When using remedies in the centisimal scale in split doses in medicinal solution, Hahnemann found it beneficial to increase the number of succussions at each dilutional step back to 10 (from the 2 succussions recommended in the 5th edition of the Organon). He apparently experimented with even greater numbers of succussions over the following year; see the preface to volume 5 of Chronic Diseases, published in 1838, where he makes reference to using "10, 20, 50 and more" succussions in the preparation of centisimals.
The LM (Q, fifty-millesimal) potency scale, which Hahnemann referred to only as his "medicaments au globule" as distinct from the centisimal "medicaments a la goutte", was developed in 1838 (year 42, 5 years before his death), with the intention of preparing remedies even better adapted for use in split dose in medicinal solution. These were prepared with even greater dilution at each step (~1/50,000, but using medicated pellets for the dilutions), and with far greater succussion at each dilutional step (100 succussions). Hahnemann shared this method during its experimental period only with Boenninghausen. He first described it in the 6th edition of the Organon (§270), which was prepared for the publisher in the year prior to his death (1842, year 46), but first saw light only in 1921 when William Boericke purchased the manuscript from the Boenninghausen family.
Intimately related to these new preparations (centisimals in medicinal solution, and shortly later the fifty-millessimals as described in the 6th edition of the Organon) were new approaches to the repitition of dose, a topic I'll cover in a subsequent essay.
Hahnemann's remedy chests at the time of his death (1843; year 47) contained 888 vials of centisimal remedies, in the 6th, 18th, 24th & 30th centisimal potencies (designated respectively II, VI, VII & X); a few vials of the 200th centisimal potency; and 1716 vials of LM potencies, most stocked in LM1 - LM10 range, with a few of the major polychrests stocked up to LM30 (designated 0/1, etc.). A letter from Melanie to Dr. Breyfogle of Louisville in 1876, shortly before her death, read: "Your enquiry as to whether Hahnemann altered his views about potencies in the last period of his life and whether he made us only of high potencies, I can answer in this way; Hahnemann used all degrees of dilution, low as well as high, as the individual case required. I saw him give the third trituration, but I also know that he used the 200th or even the 1,000th potency whenever he considered it necessary".

© Will Taylor, MD 1998
May be freely distributed, with credit to the author
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The Development of Approaches to the Repetition of Dose
in Hahnemann's Homoeopathy
The issue of repetition of dose is intimitely tied up with the related issues of dose and potency. This essay is intended to be read alongside its sister-essay, The Development of Dose and Potency in the History of Homoeopathy.
In the early years of homoeopathy, we find little written about the issue of repetition of dose. Undoubtedly Hahnemann was experimenting widely, and he likely viewed the issue of repetition similarly to the manner in which he viewed dose at this time (see the accompanying essay re dose and potency) - as a variable to be determined individually for each of the various medicinal substances he employed, guided by an evolving recognition of the general significance of the minimum dose. It was not until 1825 (year 29*), with the recognition of the principle of dynamization, that Hahnemann broke from materialistic perspectives re dose, and began to see dose as an issue that transcended the physical properties of the particular medicinal substance in question.
From this early period we have only a few glimpses at Hahnemann's practices re repetition.
In his booklet Cure and Prevention of Scarlet Fever (1801; year 6*) (discussing the use of poppy in treating the active acute illness): "It is unnecessary to repeat these doses oftener than every four or eight hours, in some cases not more than every twenty-four hours, and that sometimes only a couple of times thoughout the whole fever, for which the more frequent or more rare ocurrence of these symptoms must be our guide". In the treatment of the desquamation following difficult cases, he dosed chamomilla daily.
In Treatment of the Typhus or Hospital Fever at Present Prevailing (Allgem. Anzeig. der Deutschen, 1814; year 19) (discussing the use of Bryonia in the active acute illness): "and as long as the improvement goes on, we give him no other medicine, nor even repeat the same one; for none of the medicines here recommended can be used oftener than once (in the dose of a drop) - seldom can they be given a second time with advantage."

The issue of repetition of dose began to receive understandably greater attention in the context of treating chronic disease.
It was in 1829 that Hahnemann proposed the standardized use of the 30th centisimal potency, and this was his prefered preparation when he wrote part 1 of Chronic Diseases in 1828 (year 32). His posology in treating chronic disease is detailed on pp. 119-129, & p. 137 (in the Jain edition). The carefully chosen dose & potency (most usually a single 30C pellet, dry or moistened) was allowed to act until the dose had exhausted its favorable action, with no other prescription to be considered so long as the improvement continued. Repetition or change of remedy was considered only when the old symptoms, which had been eradicated or very much diminished by the previous dose, commenced to rise again for a few days; discernment of the time to consider a second prescription required experience and careful observation.
Hahnemann suggested that the "third leading mistake" in treating chronic disease was in not waiting until the dose had exhausted its action; that this might require 30, 40, even 50 or more days, but could not be predicted ahead of clinical observation of the progress of the case. He suggested that practicioners "scrupulous on the wrong occasion" mitigate their own and their patients' impatience by giving milk sugar (sac lac) as a placebo during this period of observant waiting.
The only exception to patient waiting for such extended periods, was when the initial dose exhausted its action unexpectedly soon. He suggested it was then best to repeat, but if the same remedy was indicated, to repeat it at an altered potency. This could involve moving either up or down in the potency scale - e.g., from 30C to 24C, 18C to 24C, etc.
There is some heralding of his later use of split doses in medicinal solution, in his advice that to allow the dose to act more strongly, it could be given in water, divided over 2-3 days (not longer), stirred each time to modify the potency.
Hahnemann also introduced in this work the administration of remedies by olfaction, which he elaborated on later in 1832-1833; and he later introduced administration by application to the (healthy) external skin. As the issues of dose and repetition of dose are relatively independent of the method of administration, I will not go into greater detail on these topics now, but will rather cover them in a separate essay.
The 4th edition of the Organon, published the following year (1829), similarly advised that a "single dose of a well-selected homoeopathic medicine should always be allowed first fully to expend its action before a new medicine is given or the same one repeated".
Constantine Hering left Germany for Surinam in 1827, and was shipwrecked off Martha's Vineyard on his attempt to return home in 1833. He settled in Philadelphia well-practiced in the methods of the 4th edition of the Organon & the 1st edition of Chronic Diseases, and rooted the development of homoeopathy in North America strongly this "wait & watch" methodology. Kent later provided perhaps the most eloquent and detailed description of this approach in his Lecture on the Second Prescription, read before the International Hahnemannian Association at Niagara Falls in 1888.

Between 1829 and 1833 (years 33-37), Hahnemann's focus was very much on the treatment of chronic disease, and overcoming the obstacles presented to its most rapid and gentle cure. He experienced difficulties using the "wait & watch" approach, which he described in the note to §246 of the 5th edition of the Organon: "...the vital force dose not quietly adapt itself to the transition from the natural disease to the similar medicinal disease, but is usually so violently excited and disturbed by a larger dose, or by smaller doses of even a homoeopathically chosen remedy given rapidly one after the other, that in most cases its reaction will be anything but salutary and will do more harm than good". This difficulty led him into exploring the dosing alternatives described below, introduced to practice between 1833 and 1838 (years 37-42).
When Hahnemann published the 5th edition of the Organon in 1833 (year 37), he introduced an option he felt preferable to this "wait & watch" approach, suggesting that a more rapid cure could be had by repeating a dose at "suitable intervals which experience has proved to be best adapted" , guided by the "nature of the medicinal substance, the corporeal constitution of the patient, and the magnitude of the disease". He suggested repeating dry or moistened 30C globules (in Hahnemann's notation, X, refering to the decillionth dilution) at an unaltered dose & potency. Dosing frequency might range from every 7 to 14 days in a chronic illness of slow pace, to every five minutes in an acute illness of rapid pace, guided by clinical experience and observation of the progress of the case. This approach often required that an "intercurrent" remedy be given after several doses; a precaution that was reversed with the later introduction of gradual ascending potencies. He modified the preparation of his centisimal potencies when intended to be used in this manner, reducing the number of succussions at each dilutional step from 10 to 2.

Four years later, in the Preface to part 3 of Chronic Diseases (1837, year 41), Hahnemann described a major refinement of this repeated-dose approach, noting: "Experience has shown me, as it has no doubt also shown to most of my followers, that it is most useful in diseases of any magnitude (not excepting even the most acute, and still more so in the half-acute, in the tedious and most tedious) to give to the patient the powerful homoeopathic pellet or pellets only in solution, and this solution in divided doses." Repeated doses of the medicine were considered "indispensible to secure the cure of a serious, chronic disease". He provides directions to dissolve one or more pellets (centisimal pellets, usually 30C [X in Hahnemann's notation, for the decillionth dilution]) in 7-20 tablespoons of water, and to give portions of this solution (1 tablespoon, or a small part of a tablespoon in more sensitive patients) in acute illness "every 6, 4 or 2 hours; when very urgent, even every hour or 1/2 hour", and in chronic diseases, "a dose (e.g., a spoonful) every two days, more usually every day". Each subsequent dose was to be modified "only a little in its degree of dynamizaton so the vital force will calmly receive the same medicine", by shaking the solution 5-6 times. After the solution was used up in this manner, if a subsequent bottle of the same remedy was required, he suggested either (1)preparing the 2nd bottle with one or two pellets of the same medicine in a lower potency (e.g., 30C -> 24C); or, (2)if the same potency were desired, to make it up in the manner the first bottle, but prior to the first dose, to give it as many shakes plus a few more as the previous bottle had received during the entire time of its use.
He described an alternative "small bottle" method of making up the medicinal solution, using 200, 300 or 400 drops of water & brandy to half-fill a small vial, into which one or more pellets were dissolved, and briskly shaken 5-6 times before each dose. According to the vitality & sensitivity of the patient, 1, 2, 3 or several drops were removed to a cup containing a spoonful of water, to be stirred, and the contents (or a portion of the contents) to be taken for a dose.

In 1838 (year 42), Hahnemann developed his new potencies, his "medicaments au globule" (the LM or Q or 50-millesimal potencies), which were intended to optimize the medicinal solution dosing approach described above. He shared his experience with these only with Boenninghausen, and first wrote about them in the 6th edition of the Organon, the year prior to his death (1842), but which was only made available to the homoeopathic community 80 years later, in 1921. Directions for the preparation of LMs are provided in the 6th edition of the Organon, in §270; and for their use in §s245-248 and 280-282. Choudhury's book Fifty Millesimal Potency - Theory and Practice is an excellent resource for this method; the best writings I've seen on this approach are the series of articles titled Hahnemann's Advanced Methods available on David Little's website. I'll outline the basics of this approach below, but refer practitioners to the resources above (& particularly to David Little's writings) as guides to actual application of this approach.
In the 6th edition of the Organon, Hahnemann states (§246):
"Every perceptibly progressive and strikingly increasing amelioration in a transient (acute) or persistent (chronic) disease, is a condition which, as long as it lasts, completely precludes every repetition of the administration of any medicine whatsoever, because all the good the medicine taken continues to effect is new hastening towards its completion. Every new dose of any medicine whatsoever, even of the one last administered, that has hitherto shown itself to be salutary, would in this case disturb the work of amelioration".
However, in gradual amelioration, he suggests that one can ensure and hasten cure if one repeats the dose in medicinal solution with modification of potency each time by succussion. He provided much more explicit instructions for this approach than for the methods that led up to its development. Most importantly, it is important that the degree of potency deviate somewhat from the previous and subsequent ones, in order to avoid the development of accessory symptoms (symptoms of the similar medicinal disease that are not part of, & therefore are not homoeopathic to, the original natural disease of the patient). In order to hasten cure, one may also gradually increase the size of the dose, but not so aggressively as to result in a homoeopathic aggravation. Repetition of the dose in this manner was to be carried on until eradication of the disease, or until the picture of the disease-gestalt changed to one demanding a different remedy (§248)
The actual potency selected to begin treatment, the size of the dose(s) given, and the frequency of repetition of the dose were variables to be determined individually for each case. Hahnemann does provide some general guidelines for consideration, outlined below.
He suggested 2 options for making up the medicinal solution (§ 248, note). The first involves using one or (rarely) more pellets in 40, 30, 20, 15 or 8 tblsp water (4 - 20 oz), adding alcohol or a piece of charcoal to keep the solution from spoiling. This would be succussed about 8, 10 or 12 times before each dose, and a dose would consist of one or several teaspoons.
The second option uses one or (rarely) more pellets in 7-8 tblsp (~4oz) water, preserved with alcohol or charcoal. After succussing as above, one tablespoon of this solution would be stirred vigorously into a dilution glass containing 8-10 tblsp (4-5oz) water, and a portion of this would be given for a dose. In sensitive patients, a tsp of this dilution would be stirred into a second dilution glass, and this might be carried through a third or even a fourth dilution glass to create an appropriately small dose.
Repetition was recommended (§246 & §248) "at intervals that experience has shown to be the most distinctly appropriate for the best possible acceleration of treatment"; in chronic diseases of slow pace, this might be daily or every second day; in acute diseases, it might be every 6, 4, 3, or 2 hrs; in urgent cases, it could be hourly or even more frequently.
If a second or subsequent bottle of the same remedy is required, this should be made up with a pellet of higher potency. Over the course of treatment, it is likely that the size of the dose would need to be increased to ensure progress in the case, but this should be done only gradually to avoid creating aggravation, and particularly to avoid the production of accessory symptoms by the repeated doses.
Any "perceptibly progressive and strikingly increasing amelioration" would preclude continued repetition (§246), as would any aggravation (§282). As the natural disease of the patient lessens in intensity towards the end of treatment, symptoms of the medicinal disease resembling those of the original natural disease of the patient might appear; this would occasion a reduction in the size of the dose and/or the dosing frequency, or a brief suspension of dosing to assess the status of the remnants of the natural disease prior to proceeding (§248 &§s280-281).

Although Hahnemann did share some of his early experiences with giving centisimal remedies in split dose in medicinal solution in an 1835 letter to Hering; and although Hahnemann was certainly familiar with the experiences of Hering (and others) in using high potencies according to the 4th-edition "wait and watch" methodology (and in fact, as the note to §246 in the 5th edition of the Organon reveals, had made his own observations on this method); these two approaches to dosing continued to develop rather independently in the Hahnemannian and Hering-Kentian lineages of 19th century homoeopathy. It is important to recognize that they each have their own set of safeguards, principally from the risk of producing non-homoeopathic aggravation or accessory symptoms of medicinal disease that could be obstructive of cure. These are outlined in the careful methodologies of use, perhaps described best, respectively, (1)in the 6th edition of the Organon, §s245-248 and 280-282, in Choudhury's book Fifty Millesimal Potency - Theory and Practice, and in David Little's series of articles on Hahnemann's Advanced Methods; and (2)in Kent's Lecture on the Second Prescription.
Perhaps it is a gift that difficulties in trans-Atlantic communication, and the delayed publication of the 6th edtion of the Organon, permitted these posologies to each develop to their current fruition. Today we can learn from both approaches, and select that which appears to be optimal for each case that sits before us.

*As in previous essays, I've adopted a chronology dating from Hahnemann's publication of Essay on a New Principal for Ascertaining the Curative Power of Drugs, establishing 1796 as the "birth" of homoeopathy. This is done purely to simplify the picture of the developmental chronology of our art. To those who might quibble and ask that the translation of Cullen's Materia Medica be used as a landmark (1790), I might suggest that we call this the date of conception, followed by a 6-year gestation.

© 1998, Will Taylor, MD
may be freely distributed with credit to the author
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HOMOEOPATHY: HOW DOES IT WORK?
By Paul Callinan M.Sc. N.D. D.Hom. Ph D.
Recently homoeopathic medicine has risen to new heights of controversy in the world of medical science. Nature, a prestigious journal in the field of Bioscience, has taken the unprecedented step of issuing a warning to readers to suspend judgement on one of its printed research papers. The author and principal experimenter, Professor Jacques Benveniste of the French Medical Research Council, has been subjected to scorn, ridicule, and critical investigation of his experimental procedures because the results he printed supported homoeopathic medicine. Paul Callinan, one of Australia's few homoeopathic researchers, looks at the past and present of this contentious medicine.
The rising profile of homoeopathy has produced something of a dilemma in the world of medicine: does it work or doesn't it? The decision bites deep: if homoeopathic medicine is nothing but fraud, quackery, and placebo, as many of its opponents would maintain, then a large number of competently trained homoeopaths and doctors, together with countless thousands of dedicated lay practitioners have been led up the medical garden path. Their millions of patients, including many heads of state and prominent members of several of Europe's royal families, have fallen victim to the most successful medical hoax ever perpetrated. On the other hand, if homoeopathic medicine is effective, then for the first time in more than a hundred years the Western world is on the verge of developing an entirely new system of medicine. The medicines are non-toxic and easily manufactured; they are also very cheap.

During the 170 years of its existence, homoeopathy has been the centre of continual and often bitter medical controversy. It has been particularly opposed by orthodox medicine, otherwise known as allopathy. But recently, both research and patient support has grown at a rapid pace. Yet rather than being hailed as a possible new medical breakthrough to give better health for all, it has been ridiculed, ignored and systematically suppressed.
Clearly, something is wrong. The problem is that homoeopathic medicines can be diluted to such extremes that it can be shown physically, chemically, and mathematically that there is nothing in the final dose but water. Obviously then, the objection goes, any medicinal effect is nothing but placebo, and the homoeopaths are both frauds and charlatans.
Yet the origins of homoeopathic medicine are both honourable and orthodox. It was developed in Germany by the research of Dr. Samuel Hahnemann (1755-1834), who as well as being an experienced orthodox physician was also a competent chemist, a good mineralogist and botanist, and an able translator of eight different languages. His research stemmed from a dissatisfaction with the standard medical practices of his time: routine bleedings, heroic purgings with cathartics, and administration of large doses of crude drugs. While translating Cullen's Materia Medica into German, he was struck by a hitherto unexplored medical observation, first mentioned by Hippocrates. Cullen had proposed that the notable success of cinchona (an extract of quinine bark) in the treatment of swamp fever was due to its value as a stomach tonic. Hahnemann disagreed, and in his research on the question decided to take a course of the cinchona extract himself. To his surprise, he developed a set of symptoms remarkably similar to those of the swamp fever it was used to treat. All the symptoms disappeared when he stopped taking it. Further administration to himself and his family always produced the same symptoms, varying only in degree.
This was a strange phenomenon, uncited in the medical literature of the day. A remedy which was effective in a particular disease would produce a similar set of symptoms in a healthy person, when given in sufficient doses. In searching for precedents for this effect, he established that the first mention made of it was in the writings of Hippocrates (460-377 B.C.), regarded by the orthodoxy as the father of modern medicine. Hippocrates had said that likes can be cured by likes: that vomiting may be stopped by being made to vomit, and any illness caused by one means can be treated successfully by a similar means.
The Law of Similars
From this Hahnemann produced the first axiom of homoeopathy: Similia Similibus Curentur - Let Likes be Cured by Likes, otherwise known as the Law of Similars - and so began his life's work. By 1821 he had produced two major works: The Organon of Rational Medicine, embodying the principles of the homoeopathic approach to medicine, and his Materia Medica Pura, covering the effects of sixty four medicines.
This approach to medicine represents a dramatic move away from the established method. The allopathic approach was of establishing the existence of a particular disease, clarifying its symptoms, and then testing the effectiveness of various medicines on it, by the use of opposites. An illness accompanied by fever and diarrhoea, for example, would call for the combined use of medicines which would be anti-febrile and others which would normally constipate, and so in a crude way, a total balance would be found by using a number of appropriate medicines together. The homoeopaths tried the opposite approach: first test a substance for medicinal use, they said, by giving it to healthy volunteers, and carefully noting the symptoms it produces. This is known as a proving. Once the symptom picture has been fully developed over a number of human trials, then it can be assessed for usefulness against diseases with a similar set of symptoms. A substance which produces a bizarre set of symptoms such as bright red orifices and blue-green discharges, for example, will have little use in homoeopathic clinical practice because symptoms of this type are rarely met. However a substance which produces a runny nose, watery red eyes and repeated sneezing would be of great value in the treatment of hay fever. The common onion produces just those symptoms (as countless cooks can guarantee), and by use of the above trial system the onion has now achieved an established place in homoeopathic therapeutics. In essence, allopathic medicine embodies the law of opposites, homoeopathic medicine the law of similars.
Potentisation
At first the homoeopathic approach to medicine seems contradictory. Surely experience would tell us that exposing hay fever sufferers to large doses of onion would just add insult to injury, and make them worse rather than better. The homoeopaths would agree, but with two provisos.
First the symptoms must match closely before onion will have a therapeutic effect; this is embodied in their Law of the Single Remedy, which states that the most effective result will come from the most similar remedy given in single doses. Then after the initial aggravation of symptoms dies down, the hay fever will be noticeably better.
Second, if the initial doses of onion are sufficiently diluted, there will be very little aggravation at all before improvement sets in. In fact, the homoeopaths see dilution to infinitesimal degrees as a necessary part of the preparation of their medicines. It is embodied in the other important axiom for treatment; the Law of the Minimum Dose. This states that the most effective dose for a disorder is the minimum amount necessary to produce a response. Give one dose only of the diluted substance, the homoeopaths say, and then wait for a favourable reaction. Having produced the desired improvement, give a second dose only when improvement stops.
It is this dilution of homoeopathic medicines which has been the greatest obstacle to their more universal acceptance. The process is known as potentisation, and involves a sequence of progressive dilution and a rhythmic shaking, termed succussion. In the normal case, 1 part of the source substance is added to 9 parts of water and shaken rhythmically. This is known as a 1x (decimal) dilution, or 1 part in 10. One part of this is then taken and added to another 9 parts of water, and again succussed, to give a 2x dilution, or 1 part in 100. Similarly, a 3x dilution is 1 part in 1000. These dilutions, also known as potencies, can be repeated an large number of times.
Dilutions are also made on a centesimal scale, or 1 part in 100, yielding 1c, 2c, and so on. It needs only a little mental arithmetic to appreciate that a dilution procedure of this type (either decimal or centesimal) rapidly disperses the original substance. Figure 1 gives a summary of the potencies, and their corresponding dilutions.

Summary of the homoeopathic potencies
showing concentrations of the source drug.
The Avogadro Limit
In practice, a convenient classification of the dilutions is usually used:
Low potencies: 1x to 30x, or 1c to 15c.
Medium potencies: 30c to 200c.
High potencies: Above 200c.
Hence the low potencies have been diluted least, and may still contain significant amounts of the source drug. But at 12c or 24x what is known as the Avogadro limit is reached, and at this concentration it is unlikely for even a single molecule of the original drug to be still present in one litre of the preparation. Yet the Avogadro limit occurs in the low potency range, and the homoeopaths maintain that, contrary to expectations, the power of the medicine increases as the potency increases. So there is very little doubt that many patients treated with high potencies receive nothing but water.
The Homoeopathic Dilutions.
While the toxicity of such medicines is obviously very low, their efficacy has been seriously questioned, as dilutions above 12c can be dismissed on pharmacological grounds as completely inert. Yet potencies in the medium to high dilution range are the normal working area of homoeopathy, and many striking cures have been claimed. The first and obvious response is to claim that the action in successful cases is purely placebo, and the medicine is useful only in the suggestible and the gullible. Not so, maintain the homoeopaths, who claim cures on infants, animals, unconscious patients, those with infectious diseases, and those with deep seated chronic disorders. In addition, the clinical trials are impressive. So the medical plot thickens.

Clinical Trials
The early homoeopaths were all trained allopaths, and once having been convinced of the effectiveness of homoeopathic medicines, felt no need to prove anything to anybody. After all, they had the training to use whatever medicine they considered appropriate for their patients. It was also expedient to make as little noise as possible about their use of a medicine which was already regarded as suspect within their own ranks. In any case, most of their research time was spent on provings, in order to expand the number of known and useful medicines, and very little on clinical trials.
As a result, it took an event of considerable magnitude to bring the medicine out into the open, and the European cholera epidemic of 1832, two years before Hahnemann's death, was just such an occasion. By the accounts of all observers, the homoeopaths had a far higher recovery rate than the allopaths, and it is recounted that in Paris, the price of the homoeopathic medicine for cholera increased 100-fold. In Russia (where it is said the epidemic originated), the report from the Consul General showed that of the 1,270 cases treated homeopathically, 1,162 recovered, and only 108 died, giving a mortality rate of less than 10 percent. By contrast, the mortality rate from allopathic treatment was 60 to 70 percent.1
Following the homoeopathic success in the epidemic, medical interest in homoeopathy increased at a rapid rate, and by the time of the next European cholera epidemic in 1854, the London Homoeopathic Hospital was already established. Its facilities were turned over entirely to the treatment of cholera victims, and the results were impressive. The homoeopathic death rate was 16.4 percent, compared to the allopathic death rate of 51.8 percent. Similar successful figures were reluctantly reported by a number of other countries2. Detailed returns for Britain had to be made by all hospitals and practitioners as to treatment and results in cholera, and the totals submitted by the British Medical Council in their Blue Book of Statistics. However, the figures from the Homoeopathic Hospital were deliberately omitted, and were only produced after considerable protest. The official reason for the omission was that inclusion of the homoeopathic figures "would give an unjustifiable sanction to an empirical practice, alike opposed to the maintenance of truth and the progress of science."
This prejudiced and bigoted reaction to the success of homoeopathic medicine is typical of the problem which has plagued the advance of science for many centuries. Orthodox medicine, in particular, is well known for its poor track record in meeting innovative change and research breakthroughs with the proper degree of scientific detachment and quiet encouragement. Even within their own ranks, some of the greatest of innovators, such as Lister, Jenner, and Harvey, suffered ridicule and professional ostracism over discoveries which later became mainstays of medical practice. In reaction to homoeopathic successes, the modern orthodox call has been for more clinical trials. Give us controlled trials, many allopaths have said, and if successful, we will accept the medicine.
Since that time, a number of clinical trials have been run, but many of them with poor controls. Some of the better run trials are summarised here briefly. Those looking for a more complete list could do no better than the excellent review of Scofield3.
Mustard Gas
The best controlled of the early clinical trials was conducted jointly in London and Glasgow during the second world war, to find a method of prevention and treatment of mustard gas burns. Mustard gas in the 30c potency, given as a preventative, reduced the incidence of deep and medium burns significantly. THe remedies Rhus tox and Kali bich also gave statistically significant results in treatment3.
Rheumatoid arthritis
More recent trials were conducted in 1978 at the Glasgow Homoeopathic Hospital, now emerging as a stronghold of homoeopathic research. Gibson and co-workers conducted a double-blind comparison of a range of homoeopathic remedies (matched against the individual symptom pictures), and compared the responses to those of salicylates and placebo in the treatment of rheumatoid arthritis. They showed that the patients who received homoeopathic remedies responded statistically better than those who received salicylates; moreover 42 percent of the homoeopathic group were able to discontinue all other treatment during the year3.
Objections to the method of trial led to a more rigidly designed trial in 1980, where patients were given either a homoeopathic medicine or placebo, but were allowed to continue with their orthodox anti-inflammatory drugs. The homoeopathic group showed significant improvement as judged by a number of tests, as compared to the patients who received placebo. It was noted that homoeopathy was a safer and no less effective alternative to present day second line drugs in the treatment of rheumatoid arthritis3.
Hay Fever - The Crack Widens
One of the most recent clinical trials, and certainly the most tightly controlled to date, was conducted in 1986 at the Glasgow Homoeopathic Hospital by Dr David Taylor Reilly, an allopath by training. The claim that homoeopathic medicines are placebo was tested in a randomised, double-blind, placebo-controlled trial. The effects of a homoeopathic preparation of mixed grass pollens (30c potency, no molecules of the original pollen remaining) was compared with those of placebo in a total of 144 patients with active hay fever. The homoeopathically treated patients showed a statistically significant reduction in symptoms as assessed by both patient and physician. No evidence emerged to support the idea that placebo action explains the clinical response to homoeopathic remedies.4
The publishing of this latter paper in the Lancet, arguably the most prestigious medical journal in the world, indicated the depth of penetration of homoeopathic medicine into the allopathic world. The controversy it produced indicated the degree of crystallisation of the collective allopathic brain. Here at last was proof positive in the much upheld double-blind trial, yet the collective reaction was less than positive. Although some of the more far-sighted of the correspondents suggested the possibility that a new chemistry and a new physics had been born, the reliance on pharmacology in the allopathic way of thinking showed its dominance. Reactions to drugs are caused by molecules of drug substance interacting with various body components, the thinking goes, and if there are no drug molecules in a medicine then there is no reaction aside from placebo effects. The experiment was simply testing one placebo against another. The fact that statistical significance was obtained for one of the `placebos' was apparently deemed of no consequence, and indicates that the issue may not be a scientific issue at all, but more an economic and emotional one.
Pharmacological Support
Logically, one of the first areas to investigate for support (or the lack of it) in homoeopathy is the area of pharmacology, or drug action. And contrary to expectations, some surprising support is appearing.
Ask a pharmacologist about the biological effect of very low concentrations of common substances on living organisms and the answer will be that there is typically very little or zero response. Ask for some theoretical backup, and in short order you will find yourself confronted by one of the pharmacological tools of trade, the Dose - Response Curve. In brief, the curve illustrates one of the rules of thumb in drug use: that an increased dose of a drug will give an increased effect, while a lowered dose of a drug will give a reduced effect, and a very low dose will give no effect at all.
A glance at the curve in Figure 3 will show that the pharmacologically recommended dose of a drug lies in the area of the ED50, the dose which produces 50% of the total or maximal effect. The homoeopathic area of interest, on the other hand, lies at the very start of the curve, in the area of the so-called threshold dose.

The area of the threshold dose is usually avoided in standard pharmacological drug testing, for two reasons. The first is that the threshold dose lies some distance from the area of the ED50, so investigating this area for drug reaction is basically a waste of time. But the other reason is far more interesting. The threshold dose is an area where paradoxical and contradictory results are obtained, not easily explained in conventional terms. Again, the easy answer is to simply avoid it in experimentation. But the bottom line is that for many years the pharmacologists have known of the strange results obtained in the threshold dose area, but have simply chosen to ignore them. In doing so, they had unwittingly withdrawn orthodox support for an entirely different field of medicine.

It is interesting that one of the very earliest laws of pharmacology, known as the Arndt - Schulz Law, had already expressed the homoeopathic effect. Formulated by Arndt in 1888, and restated by Hueppe a few years later, the law set the groundwork for what should have been a side-by-side development of allopathic and homoeopathic medicine in the following century. It states:
For every substance, small doses stimulate, moderate doses inhibit, large doses kill.
Allopathic medicine, with its emphasis on moderate drug doses, works in the inhibitory part of the scale. The result is seen in the typically inhibitory medicines produced: antihistamines, antibiotics, antacids, cough suppressants and so on, laying the basis for the so-called `suppressant' effect of drugs.
Homoeopathic medicine, on the other hand, begins at the stimulatory end of the curve, and moves to the left, into the smaller and smaller dose range. Its emphasis is on the stimulation of the body's natural balancing mechanisms, as seen in its philosophy of the natural regeneration of the body through rebuilding of vitality, a concept also in close agreement with naturopathic thought.
The pioneering work of Boyd12 bound the worlds of homoeopathy and Arndt-Schulz together in the early 1940s with a series of tightly controlled experiments, and set the stage for work much later on as to how homoeopathic medicine may work. Boyd worked with the enzyme malt diastase, which was already known to be inhibited by crude doses of the salt mercuric chloride, and measured its speed in the hydrolysis of starch. He also used a number of homoeopathically prepared dilutions of mercuric chloride, including a batch at 61x, where there was no likelihood of any of the original salt remaining - it was pure water. He also worked with distilled water as a control. He showed that crude doses of mercuric chloride inhibited diastase activity, as was already well known, and that distilled water had no effect. But he also showed, with statistically significant results, that mercuric chloride 61x accelerated diastase activity.

Now this experiment had a number of ramifications, besides supporting the Arndt-Schulz Law. If there was no mercuric chloride in the 61x potency, the it should have reacted the same as distilled water. If, on the other hand, there was a contamination of mercuric chloride somehow in the test doses, then the activity of the enzyme should have decreased. Instead it did neither, but increased, From the laboratory
point of view, homoeopathic medicines not only had b