case management

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

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

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

TO MASTER THE FIRST THING IS TO OBEY

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

PRESCRIBING FOR THE DISEASE

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

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

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

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

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

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

TOO FREQUENT REPETITION

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

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

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

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

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

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

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

USE OF REPERTORY

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

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

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

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

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

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

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

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

HASTY PRESCRIBING

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

PRESCRIBING DURING AMELIORATION

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

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

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

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

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

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

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

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

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

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

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

HIGH POTENCIES IN ADVANCED CASES

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

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

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

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

INTERFERENCE

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Proper time to change

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

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

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

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

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

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

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

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

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

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

Avoid haste

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

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

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

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

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

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

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

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

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

Wait and observe

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

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

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

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

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

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

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

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

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

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

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

Improper action

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

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

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

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

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

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

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

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

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

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

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

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

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

Remedies suitable to follow

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

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

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

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

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

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

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

Careful records

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

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

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

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

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