Homoeopathic Posology- Controversy Confusion and Solution

Dr.Mohan Giri, Dr.Subhasish Ganguly and Dr.Neha Agarwal

Introduction
Basically the word Posology has originated from the Greek word Posos. The meaning of this word is how much [dose]. The word logos suggest study or discourse. So Posology means science of dosage.

The terminology of dose originates from the word dose that means the quantity of a drug or other therapeutic agent to be taken or applied. On the basis of this we may say that Posology is the branch of pharmacology and therapeutics concerned with a determination of the doses of remedies; the science of dosage. Or Posology is the scientific study of drug doses.

A homoeopathic concept of Posology necessarily means selection of potency, dispensing and repetition of the dose of the medicine. Homoeopathic Posology is based on the principles of the single remedy, minimum dose and minimum intervention.

Controversy and Confusion
Since after the death of our master Dr.Hahnemann, Posology remains a topic for controversy and confusion for beginners. After perceiving the concept of Hahnemannian Posology various stalwarts like Dr.Boenninghausen, Dr.Kent, and Dr.Boger etc have tried to express their own perception in a different manner. As a result of our misunderstanding profession has been divided in to different paths. Everyone is directly or indirectly walking on one or another path. Hahnemann had also at one stage proposed to treat all cases with the thirtieth potency.

After trying to understand the concept of stalwarts, as a beginner various confusing question should arise in our mind. They are like: whether to give single unit dose or repeated doses? If we give one dose then when to repeat it? What will be the frequency of repetition? How far we have to wait and watch? etc. As a result of all such controversial and unsolved questions Homoeopathy is still struggling for its existence in front of modern science in the country like India. If we perceive the actual evolutionary concept of Posology given by Dr.Hahnemann in different editions of Organon of medicine we can satisfy ourselves regarding the concept of Posology. This attempt has been made in this article.

Evolution of Homoeopathic Posology:

1) Before the Discovery of Homoeopathic System:-During his earlier period, Hahnemann was using massive doses, as was the practice in those days. But by his keen observation he was able to detect that large doses of medicine were causing undue aggravation. In aphorism 621 in Lesser writings (On the nature and treatment of venereal disease) 1786 (pg 133) he says …”in very sensitive persons I have sometimes not have the occasion to use more than 1 grain of soluble mercury to cure moderate idiopathic venereal symptoms and commencing syphilis yet I have met with cases in which 60 grains were necessary”. He says that he was forced to use large quantities of medicine, as some circumstances of the patient must have interrupted with the action of medicines. Hahnemann says that in moderately severe syphilis not more than 8 grains were required while for severe and deep-rooted cases about 12 grains were needed. After giving the first dose Hahnemann used to progressively increase the dose until the disease have disappeared. In Lesser Writings he narrates the way of increasing dose in a progressive scale from ¼ to 1/3, ½, ¾, 11/4 grains then after an interval of 14 days again dose is increased from 11/2 to 2 grains until syphilis disappeared.”

2) Here we can see that Hahnemann inferred that the large quantities of medicine was not the factor which helped in curing disease, but sufficient quantity just needed to excite an reaction was only needed. So Hahnemann reduced large quantities of mercury given for treatment of venereal disease to just sufficient quantity required to bring about mercurial fever. Thus Hahnemann reduced the quantity of mercury needed for the treatment of venereal diseases from 12 grains, 5 grains etc to 11/2 to 2 grains.

2) Period of Discovery of Homoeopathic System:-In 1790 Hahnemann on translating Cullen’s materia medica came upon the fact that the curative power of cinchona was due to its astringent property which he tested upon himself and established that medicines were able to cure owing to its property of producing similar symptoms. Thus in 1796 he laid down the foundation of a new system of medicine viz. Homoeopathy. In the period 1796-1801 we don’t find a marked reduction in the dosage for we find him giving 4 grains of Veratrum album for a case of colicodynia, Ipecac 5 grains, Nux-vom 4 grains etc.

3) Inception of Infinitesimal Posology:-But in 1801 in his essay ‘on the cure and prevention of Scarlet fever’, the first indication of infinitesimal Posology took its place and upto now it stands as essential and integral part of homoeopathic system. In cure and prevention of scarlet fever Hahnemann advises 1 part of opium to be taken in 20 parts of weak alcohol and keep it for one day, then one drop of it is taken and dissolved in 500 drops of alcohol and then one drop of this could be given for children and 2 drops for persons above 10 years of age.

Hahnemann says “The smallness of the dose in which the medicine acts upon the whole organism, when it is suitable to the case is incredible; at least it is incredible to my colleagues’’. In his essay ‘on the power of small doses of medicine in general and belladonna in particular’ (Lesser Writings) Hahnemann says a very hard dry pill of extract of belladonna produces no effect in a perfectly healthy man, but it may not be so if he is ill. One drop of belladonna taken in 2000 drops of water and is shaken vigorously and 1 teaspoon is given every two hours will produce violent symptoms in a strong man, if he is ill. Hahnemann says that except him no other physicians have noted this remarkable action and many physicians are ignorant of this dynamic action. Here Hahnemann was able to see that the medicines acted even in minute doses due to its dynamic action.

In Medicine of Experience (1805), which is the precursor to Organon of Medicine, he further elaborates upon his discovery, making it a doctrine and a foundation stone of homoeopathy. In this book Hahnemann says “…We have not only selected the right remedy but also hit upon the proper dose (for curative purpose incredible small doses suffice)…”

In the first edition of the Organon, which appeared in 1810, Hahnemann speaks much to the same effect. Here he says, “Scarcely any dose of the homeopathically selected remedy can be so small as not to be stronger than the natural disease and not capable of overcoming it”.

Thus in scarlet fever we find Hahnemann giving betwixt our 2^nd and 3^rd dilution. In 1814 we find him giving Bryonia and Rhus tox in a dilution equal to 15^th and 16^th of centesimal scale. Hyoscyamus was prescribed in 8^th dilution. In 1819 on the treatment of suicidal mania we find him giving gold in 6^th dilution.

In 1827 in his essay ‘How can small doses of such very attenuated medicine in homoeopathy employ still greater power’, Hahnemann says that there are various reasons why a sceptic ridicules these homoeopathic attenuations.

1) He is ignorant that by means of such triturations, the internal medicinal power is wonderfully developed and liberated from its material bonds.

2)Pure arithmetic mind believes that it sees here only an instance of enormous sub-division and does not observe in this spiritualization of internal medicinal power.

3) The sceptic has no experience relative to the action of preparations of such exalted medicinal power.

4) Concept of Posology in the Fourth Edition of Organon:-In the fourth edition of Organon Hahnemann introduced the single unit dose consisting of a few poppy seed sized pellets and taught that as long there was improvement, no repetition of the remedy was allowed. Only when a definite relapse of the symptoms occurred could a remedy be repeated. [Aphorism-240,242] The above aphorisms still are the basic principles for so many homoeopaths for their practice throughout the world. In this wait and watch method the homoeopath is totally committed to the first dose, delaying repetition in order to avoid unnecessary aggravation.

Dr.Kent was well aware of the Fifth Edition of Organon even though he kept the legacy of these aphorisms alive by practicing according to the fourth edition. He was a follower of the philosopher, Emanuel Swedenborg, one of the greatest scientists of that day. According to his theory energy is based on a fourth state of matter called the simple substance. Simple substance has no quantity but only quality in degrees of fineness. So the number of pills used in a dose makes no difference for Dr.Kent. Till today so many modern homoeopaths and followers of Dr. Kent are claiming that it never matters whether the remedy is given in water in spoonful doses or given in a few pellets dry on the tongue.

At this place in the aphorism 275 Dr.Hahnemann says: “A medicine given in too large dose, though completely homoeopathic to the case and in itself of a beneficial nature, will still harm the patient by its quantity and unnecessary strong action on the vital force, and through it, because the medicine is homoeopathic on precisely those parts of the organism which are the most sensitive and have already been afflicted most by the natural disease.”

5) Concept of Posology in the Fifth Edition of Organon:-The fifth edition of Organon was published in 1833. This edition had three major changes. Initially Hahnemann resisted the use of higher potency for longer period of time. Stapf, Gross, and especially Boenninghausen convinced Hahnemann to conduct his own experiment and to remove the 30ch limit. So the potency limit of 30ch was removed. This was the first change of Fifth Edition.

As a part of second change Dr.Hahnemann introduced to give medicines in watery solution instead of dry doses. He had concluded that the uses of watery solutions were far superior than to give dry doses. We may find such reference in aphorism 286 in Fifth editions: “For the same reason the effect of a homoeopathic dose of medicine increases, the greater the quantity of fluid in which it is dissolved when administered to the patient, although the actual amount of medicine it contains remains the same. For in this case, when the medicine is taken, it comes in contact with a much larger surface of sensitive nerves responsive to the medicinal action. Although theorists may image there should be a weakening of the action of a dose of medicine by its dilution with a large quantity of liquid, experience asserts exactly the opposite, at all events when the medicines are employed homeopathically.”

The third and very surprised suggestion given by Dr.Hahnemann in this edition was related to repetition of the dose even when improvement of the patient had set in. When we take the reference of aphorism 246, he says: “…If the disease is somewhat chronic, however a single dose of the approximately chosen homoeopathic medicine does sometimes complete the good that remedy can according to its nature accomplish in the case, but slowly over a period of 40, 50, 60, or 100 days. Now for one thing, this is very rarely the case and secondly it must be a matter of great importance to the physician and to the patient to reduce this period by half or three quarters or more, if possible, so as to obtain a far more rapid cure. As the most recent and frequently verified experiments have taught me, this can be accomplished very felicitously if the following conditions are fulfilled: firstly, if the medicine is very carefully selected so that it is accurately homoeopathic, secondly, if it is highly potentized, dissolved in water and given in suitably small doses at intervals that experience has shown to be the most appropriate for the speediest possible cure…” This statement was creating a great dissapointment for the followers of wait and watch method by giving dry doses in infrequent repetition. [According to Fourth Edition] Here the theme of this Para is: “suitably small doses at intervals”. At this point what was his perception regarding suitable intervals we may not say but one thing is clear that his suggestions were towards repetition for shortening the period of cure though improvement was going on. He called this path as a true middle path.

Later on in the same aphorism he says for this nature of the different madicinal substances, corporeal constitution of the patient and the magnitude of disease must guide us. This statement guides us to understand his perception regarding repetition. We may say that Dr. Hahnemann considered such factors for the basis of repetition at suitable interval.A

Here the question should arise in our mind that whether such repetition at suitable interval will produce aggravation or not? In the fourth edition Dr.Hahnemann had extensively mentioned regarding Aggravation by unnecessary repetition of similar medicine. Here in the Fifth edition he has mentioned his different view related to Aggravation than Fourth edition. In the aphorism 279 he says: “A dose of the homoeopathic selected remedy can never be prepared so small that it shall not be stronger than the natural disease, and shall not be able to overpower, extinguish and cure it, at least in part as long it is capable of causing some, though but a slight preponderance of its own symptoms over those of the disease resembling it, [slight homoeopathic aggravation] immediately after its ingestion. This makes our understanding clear that we must expect some aggravation after using this split method suggested by Dr.Hahnemann in Fifth Edition. This concept was totally changed after introducing LM potency in the Sixth Edition of Organon.

6) After the Invention of Psoric Theory:-After his invention of Psora theory Hahnemann fixes an uniform standard for the dose of all remedies at a globule of the 30^th dilution. In his essay ‘On the extreme attenuation of homoeopathic medicine’ he is found to recommend 30^th dilution as standard.

Korsakoff’s statement about high Potencies;-Graf Von Korsakoff’s says that he has diluted medicines up to 150^th, 1000^th, 1500^th attenuation and he has found them to be still efficacious. Korsakoff’s says that the material division of medicinal substance attains its limit at 3^rd and 6^th dilution and subsequent attenuation obtain their medicinal properties by a kind of infection or communication of medicinal power after the manner of contagious disease to the non-medical vehicle. He says he communicated medicinal properties to large quantities of unmedicated globules by shaking them up with one dry medicated globule. By diluting medicines highly the primary action of the medicine or its tendency to produce homoeopathic aggravation declines, whilst the curative action of medicine continuously increases.

To this Hahnemann says that we are indebted to Korsakoff’s, who has brought the idea of contagion in communicating the power of medicine to another globule, but the supposition that dry globules, that has been impregnated with a certain degree of development of power can be further dynamized and their medicinal power increased in their bottles by shaking or carrying about in pocket is incredible.

Hahnemann says even though triturations can be carried out to any limit it is advisable in preparing all kinds of medicines not to go higher than the decillionth attenuation and dynamization (x) in order homoeopathic physicians may be able to assume themselves of uniform results in practice.

7) Directions given during the last years of his life:-At Paris, on Dec 1838, Hahnemann states that “Thus we obtain, even in the fiftieth potency (the new wiseacres have hitherto ridiculed the thirtieth potency, and made use of the lower, little developed, more massive medicinal preparations in large doses, whereby, however, they were not able to effect what our system can do), each lower one of which has been dynamized with an equal number of successions, medicines of the most penetrating efficiency, so that each of the minutest globules impregnated with it, dissolved in much water , can be taken in small portions and must be so taken in order not to produce too violent effects in sensitive patients, not to mention that such as mode of preparation develops almost all the properties that lie hid in the essential nature of the medicinal substance, which thereby done can attain any activity.

In the preface to 3^rd volume of Chronic Disease (edition 1837) he says that when we repeat the medicine we should descend from 30^th to the 24^th dilution and below. In the history of 2 cases collected in lesser writings he gave medicines especially Sulphur and Mercurius in doses greatly below 30^th dilution.

In the last years of life he again allowed himself a greater range of dose, chiefly by extending the scale of dilutions upwards as high as 60^th, 180^th and even and even 300^th dilutions, but also downwards to the 24^th and occasionally also much lower. Hahnemann however used almost all potencies from lower to 30^th, 60^th, 150^th and 300^th dilution.

8) Concept of Posology in the Sixth Edition of Organon:-History related to Sixth Edition is very interesting. Dr.Hahnemann had completed the Sixth Edition in 1842 but his dream to make aware the world with such new way of selection of dose and potency was not fulfilled because of his death on second July 1843. As a result of this his work was remained unpublished for years and later on with the financial help of Dr.William Boericke the first German edition was published in 1920. During this period there were numbers of followers of Dr.Kent in the world but Sixth Edition was published after the four years of the death of Dr.Kent. So it was very clear that Dr.Kent remained deprived of the hidden treasures of the Sixth Edition. As a result of this so many followers of Dr.Kent had raised their questions regarding the purity of this Edition by saying that Melanie made such changes after the death of Dr.Hahnemann and they were not the original work of Dr.Hahnemann. But truly speaking it was the original work of Dr.Hahnemann and we may confirm it by referring the Dr.Boericke’s translation of Sixth Edition. Overall view of aphorisms makes our concept clear regarding thinking of Dr.Hahnemann.

In the aphorism 246 in the Fifth Edition he had used the sentence “be repeated at suitable intervals”. Here in the same aphorism he says: “The degree of every dose deviate somewhat from the preceding and following in order that the vital principle which is to be altered to a similar medicinal disease be not aroused to untoward reactions and revolt as is always the case with unmodified and especially rapidly repeated dose.” In the foot note of this aphorism he further says: “During the last four or five years however all these difficulties are wholly solved by my new altered but perfect method. The same carefully selected medicine may now be given daily and for months, if necessary in this way, namely after the lower degree of potency has been used for one or two weeks in the treatment of chronic disease, advance is made in the same way to higher degrees.”

In the next aphorism [247] he says: “it is impractical to repeat the same unchanged dose of a remedy once, not to mention its frequent repetition. The vital principle does not accept such unchanged doses without resistance, that is, without symptoms of the medicine to manifest themselves than those similar to the disease to be cured, because the former dose has already accomplished the expected change in the vital principle and a second dynamically wholly similar, unchanged dose of the same medicine no longer finds, therefore the same conditions of the vital force. The patient may indeed be made sick in another way by receiving other such unchanged doses. But if the succeeding dose is changed slightly every time, namely potentized somewhat higher than the vital principle may be altered without difficulty by the same medicine.”

In the aphorism 248 he says: “For this purpose we potentize a new medicinal solution from which we give the patient one or increasingly several teaspoonful doses, in long lasting diseases daily or every second day, in acute diseases every two to six hours and in very urgent cases every hour or oftener. Thus in chronic diseases, every correctly chosen homoeopathic medicine, even that whose action is long duration, may be repeated daily for months with ever increasing success. If the solution is used up it is necessary to add to the next solution of the same medicine if still indicated one or several pellets of a higher potency with which we continue so long as the patient experiences continued improvement without encountering one or another complaint that he never had before in his life. For if this happens, if the balance of the disease appears in a group of altered symptoms then another, one more homoeopathically related medicine must be chosen in place of the last and administered in the same repeated doses, mindful, however, of modifying the solution of every dose with thorough vigorous successions, thus changing its degree of potency and increasing it somewhat.”

In the same aphorism regarding homoeopathic Aggravation he says: “On the other hand should there appear during almost daily repetition of the well indicated homoeopathic remedy, towards the end of the treatment of a chronic disease, so-called [aphorism 161] homoeopathic aggravation by which the balance of the morbid symptoms seem to again increase somewhat [the medicinal disease, similar to the original, now alone persistently manifest itself]. This statement is totally creating contradiction of his own statement given in the Fifth Edition where the question of aggravation had been mentioned immediately after administration of homoeopathic medicine. While here homoeopathic aggravation is seen at the end while patient is on the path of cure and it is only due to presence of medicinal symptoms. In Further aphorisms he has also represented the method of preparation of the medicine according to the LM potency and he has expressed his great trust in his LM potencies. [Aphorism-279]

In the aphorism 284 he has also mentioned the route of administration of medicine, which is also a part of Posology. He says: “Besides tongue, mouth and stomach, which are the most commonly affected by the administration of medicine, the nose and respiratory organs are receptive of the action of medicines in fluid form by means of olfaction and inhalation through the mouth.

In the footnote of the aphorism 285 he has given the proper guideline to give mild Antipsorics treatment especially with Sulphur to the pregnant women in order to protect the posterity [hereditary] in foetus. Such women have given birth to children usually healthier and stronger. [Here the time, where she has to take medicine and its dose is not mentioned.]

Factors that led Hahnemann to arrive at the concept of minimum dose:

Dr.Dudgeon in his Lectures and Practice of Homoeopathy says that following factors led Hahnemann to arrive at the concept of minimum doseas….

a) Hahnemann observed that medicines exhibited greater strength when given in dilution than in dry state.

b) He observed the greater power of medicine when given in divided dose than given at once.

c) He observed the greater susceptibility of disease organism for the medicine having a specific homoeopathic relation to the affected parts.

d) Hahnemann observed an increasing power of medicine by a thorough admixture of vehicle by means of succession.

e) Desire to evade precession of apothecaries who tried legal proceedings against Hahnemann for invading upon their privileges for dispensing medicines.

f) To avoid aggravation of disease when given in large doses.

Exception to infinitesimal dose:

Hahnemann states an exception to infinitesimal dose in aphorism 282 fn of Organon of Medicine, “….there is an exception in the treatment of three great miasm while they still efflorescence on the skin i.e.recently erupted itch, the untouched chancre and the fig warts. These not only tolerate but indeed require from the very beginning large doses at their specific remedies of ever higher and higher dynamization daily.

The reasons why we should employ only minimum or infinitesimal dose are:

1) When the disease attacks the body, it overcomes the body resistance. Now the body becomes vulnerable to the action of a similarly acting disease producing agent. So this disease-producing agent via the drug need only be applied in a minimum dose just sufficient to produce a cure.

2) Disease has already rendered the parts abnormally sensitive, so if the stimuli applied are large it will produce an aggravation.

3) According to Arnold-Schutz law minimum dose stimulates medium inhibits and maximum destroys.

Conclusion

1) On the basis of this study of Posology we may conclude that it is necessary that each and every homoeopath must thoroughly do the comparative study of 4^th, 5^th, 6^th Edition of Organon of Medicine and Chronic disease written by Dr.Hahnemann. It is also desirable that we have to compare the concept of stalwarts with Hahnemannian concept of Posology.

2) After doing an attempt to perceive the understanding of Dr.Hahnemann we may also conclude that he has shown the superiority of LM potency. But he has also warned us regarding its action related to aggravation.

3) It is a wrong concept that LM potency never aggravates the case. As such the high number of dilutions makes the power of the remedy very high and the remedy quickly penetrates very deeply, to the mental-emotional level. So mechanical repetition of LM without considering the instructions given by Dr.Hahnemann will cause similar aggravations and the production of accessory symptoms.

4) Principles upon which the selection of potencies depends vary according to individuals clinical experiences.

BIBLIOGRAPHY:

1. Cambridge – International Dictionary of English, Cambridge University Press.
2. Hahnemann S. 2002 Organon of Medicine. Sixth Edition. Translated by W.Boericke. B.Jain Pub.Ltd.
3. Schmidt P. The Hidden Treasures of the last Organon.
4. De Luc Schepper. Achieving and Maintaining the Simillimum, B.Jain Pub.Pvt Ltd.
5. Hahnemann Samuel, Organon of Medicine.
6. Hahnemann Samuel, Lesser Writing.
7. Dudgeon R.E. Lectures on the theory and Practice of Homoeopathy.
8. Hughes R. A manual of Pharmacodynamics
9. David Little, www.simillimum.com

Regarding Authors;-

3. Dr.Mohan Giri took B.Sc(HONS) in bio-sciences from Varanasi and then  BHMS (HONS) and M.D.(HOM) both from NIH,Kolkata.After that worked as Research Fellow at NIH and published several articles in different journal like CCRH Bulletin and Ind.J.Physiology and allied Science, New Delhi and then NIH Bulletin and in National Homoeo Recorder . After that I worked as Lecturer in NSHMCH Bhopal. At present working as Lecturer in the Department of Practice of Medicine at Mahesh Bhattacharyya Homoeopathic Medical College & Hospital Howrah (Govt of West Bengal).
4. Dr. Subhasish Ganguly. M.D.( HOM), MSc.( Dietetics), B.H.M.S.( Cal) ,HOD,Department of  Organon of Medicine at Mahesh Bhattacharyya Homoeopathic Medical College &  Hospital, Howrah (Govt. of West. Bengal).Stood 1st in Public Service Commission examination 2000, Govt of West Bengal in Teaching Cadre.
5. Dr.Neha Agarwal passed BHMS examination from PCM Homoeopathic Medical College and Hospital, Kolkata and practising classical homoeopathy.