^ I * /kJ^ ^(u cAx^ ^-^CiM^ Q^ujUl a^nt^/tc^^ u^ / Rejoinder to Dr. Hughes, BY PROSPER BENDER, M.D., BOSTON, MASS. s • •• r 1 • * : - .1 I ,' !*' • J '' > «« 1 1 • I ■ ' . " ' ' ' • '.' » '1 > * » * • » < , « 3 1 • I ^ A REJOINDER TO DR. HUGHES. BY PROSPER RENDER, M.D., BOSTON, MASS. Dear Dr. Hughes, — The courteous letter which you did me the honor of addressing me through the September number of " The New-England Medical Gazette," I have read with much interest. At the opening, you remark, with reference to my " Address " delivered before the Hahnemannsis Societas, B. U.S. M., Feb. 9, 1888: " I was naturally somewhat troubled at seeing students warned against a mode of homceopathizing which you associate with my name, and I read on with some curiosity to see the grounds of your admonition ; " and you add you were not "a little astonished" to ascertain that in reality you had fulfilled every requirement of the law I had advocated of practising according to the totality of the symptoms. In support of this statement you cite the introduction to your work on " Therapeutics." I am happy to admit that in the chapter mentioned you have fairly and ably vindicated " the scientific accuracy and practical adaptability " of the law of siniillimum ; but, as regards the therapeutical hints interspersed through the body of the work, I regret to have to say, they seem of a nature to induce the investigator to adopt an " easy made," simple system of homceopathy, which cannot be successfully practised, leading in many cases to discouragement and doubt. But more of this anon. To return to your letter. You state that " you and I mean something very different by the phrase ' totality of symptoms,' " your view being similar to Hahnemann's ; i.e., " that the pa- tient's condition shall find as close a reflection as possible in the pathogenetic effects of the drug." Now, I cannot imagine on what grounds you hold this opinion. In the " Address " under discussion, I particularly and emphatically assert my belief in that law, repeating it more than once. I acknowledge I alluded to the diflficulties occasionally experienced in selecting the simillimum from an array of symptoms, but I do not think I said, nor did I mean, that such was " illusory," or any thing of that nature. I tried, however, to point out to the students ex- pedients or " short cuts," with a view to facilitating the selection of the right remedy, naming several, with the careful reminder 51499 at the same time, to " select a medicine which will not only cover single symptoms but the totality of them," and to " prescribe according to the totality of the symptoms, whatever the name of the disease" {vide "Address"). But, while I believe in the law of similars as enunciated above, I, too, must assert that " you and I mean something very different by the phrase ' total- ity of symptoms,' " as I shall try to show in this letter. You have correctly apprehended the law in the introductory chapter you refer to, but you give little evidence of its recognition or influence in the rest of your work. In relation to the therapeutical rules which I suggested to the members of the society, styled by you " empirical expedi- ents," you observe : " These indications, I say, are mostly empirical. There is nothing about mechanical injury in the pathogenesis of hypericum, or of a wetting in that of rhus. The ' keynotes ' of Guernsey and his followers are only ex- ceptionally to be found among the effects of the drug on the healthy body. The mental symptoms of certain well-known remedies doubtless appear under their headings in the pure materia medica, but so they do under those of a hundred others with which they have never been associated. The same may be said of the conditions ; and both are so mixed up with others of opposite character as to be practically neutralized." In a species of happy second thought you state in the next para- graph, " Please do not understand me to be denying the value of such indications. I have dwelt on them all in various places in my books, and use them all in my daily practice. The point I am making is, that they are outside of homoeopathy proper." I am aware "there is nothing about mechanical injury in the pathogenesis of hypericum, or of a wetting in that of rhus," but I am sure that you will not challenge the fact that the train of symptoms in both remedies closely correspond with those following such factors. In the pathogenesis of hypericum we have most of the symptoms witnessed in injuries of the nervous tissues, and in rhus an almost identical reproduction of the picture of the case of a person who has been exposed to a drenching rain. The provers of hypericum, while suffering from severe pains in the spine and back, with numbness and crawling in the limbs, felt exacerbations from motion or pressure ; the provers of rhus experienced, in addition to aching in the muscles, stiffness of the joints, aggravation during rest, and relief from motion, and a marked susceptibility to atmospheric changes such as an approaching storm or wet weather. The provers of aconite exhibited, beside mental and physical rest- lessness and uneasiness, decided susceptibility to dry, cold winds; the provers of ignatia were particularly affected by KX worry or grief, and so forth. These are well-known conditions following equally well-known causes. But here is a stronger case in point. When we are called to patients affected with infectious diseases, remedies are suggested by the phenomena present only ; we do not seek for drugs which can produce the inateries morbi of those affections, since none are known to us. As in the clinical cases quoted in the " Address," we prescribe for the results which we associate with certain causes. To repeat : we know from clinical observation that a person who took a wetting is likely to be affected in the same manner as the one who is proving rhus ; that the party who meets with an injury of the spine suffers pretty much in the same way as the prover of hypericum. Symptoms and conditions identical are present in both instances. Hahnemann himself trusted to clinical verifications when repeatedly noted useful by compe- tent observers in usus morbis ; and in the hands of reliable and observant practitioners hypericum, rhus, and arnica have been proved clinically effective in the removal of the symptoms de- scribed. This is surely more than what the lawyers would style /^m^ / justification. In fact, as you are aware, some of the most reliable symptoms in our materia medica are of clinical origin. On the subject of " characteristics," or " keynotes," Hahne- mann expresses himself thus (section 153): "This search for a homoeopathic specific remedy consists in the comparison of the totality of the symptoms of the natural disease with the lists of symptoms of our tested drugs, among which a morbific potency is to be found, corresponding in similitude with the disease to be cured. In making this comparison, the more prominent, tmcommoH, and peculiar (characteristic) features of the case (102) are especially, and almost exclusively, considered and noted ; for these in particular should bear the closest similitude to the symptoms of the desired medicine, if that is to accomplish the cure. The more general and indefinite symptoms, such as want of appetite, headache, weakness, restless sleep, distress, etc., unless more clearly defined, deserve but little notice on ac- count of their vagueness, and also because generalities of this kind are common to every disease and to almost every drug." On this point, I have taught the students in the clinics, there may be marked similarity in the general effects of several rem- edies, but each has a distinctive characteristic by which it may be individualized and set aside from any other. In disease, I counselled, endeavor to single out the characteristic symptom, and then find a remedy which has a similar symptom in its pathogenesis, when generally it will be seen that the other symptoms correspond with it. The law of relationship of cura- tives to disease is based on these characteristics ; around them the minor symptoms cluster or harmonize, and thus make a tout ensemble. No Hahnemannian contends he can prescribe exclusively upon any " keynote." All the symptoms taken col- lectively are necessary, giving, however, especial prominence to some. The experience of many brother practitioners also corresponds with my own as to the great value of the mental symptoms, often directing us to the right remedy. A physician who is not acute may not readily distinguish between the mental condi- tions of aeon., ars., chamo., coffea, nux, puis., etc. ; but to the observant they are as distinct as day is from night, and they prove the rational guide to the proper remedy. You remark towards the end of your letter, that what "the patient desires to be rid of is his malady : ... it is not the peculiar way in which this may affect his nerves." But, my dear doctor, you will hardly dispute the fact that it is the state of his nerves, as expressed by his symptoms, which best indicates the remedy to be given. I believe the neglect of the conditions you so little value, often results in failure to cure. I think them only less im- portant than the mental state. Hahnemann gave both great consideration and prominence. The aggravation by motion or rest is one of the leadmg factors in the pursuit for the simi- lar in rheumatism ; and the effects of the weather in certain mental states will often help us to secure the fitting remedy. With rgard to symptoms in their relation to time, is not the hour when the chill in intermittent fever appears, one of the main indications .^ Is not the hour of the return of pain in neuralgia, or the paroxysm of cough in phthisis, or the spasm in asthma, a valuable guide in the selection of the remedy .-' I would like to enlarge on this subject, but out of regard for the Gazette's space I refrain. I must, however, repeat, unless we closely individualize the symptoms of the case, the curative specific will elude our grasp, when the patient may either slip through our hands to join the " majority," or long elude our skill. Now, with your permission, I will give my reasons for the statement in the " Address," that your "recommendations often proved disappointing," although I admitted that through their aid I not seldom made " a brilliant cure, but oftener, when mov- ing solely by these lights, failure occurred." I shall here illus- trate some of the perplexities which may arise from a sole dependence upon your Manual. Let us suppose that I have a case (I take a subject at hap-hazard) of vicarious menstruation. Under that heading, I find in your volume on " Therapeutics," p. 408 : " Dr. Leadam recommends ferrum, and Dr. Carroll Dun- ham bryonia, as the most .suitable ; hamamelis also has occasion- ally effected this purpose." Both these gentlemen take high rank as able physicians and authors in their respective countries. If I were an Englishman, I would likely give ferrum ; if an American, bryonia. I may or may not hit off the case with either, depending upon, if I have accidentally struck an appro- priate case, where one or the other remedy is called for. If I fail with both, I naturally resort to hamamelis ; but here again I may be disappointed, for that particular case may demand a totally different remedy. What follows such a groping about in prescribing } Is one not likely to become disgusted, and throw homoeopathy aside, as having been tried and found wanting .-" The Hahnemannian proceeds very differently. He consults all the symptoms of the case, the conditions, concomitants, and so forth ; and when he has finally decided upon a remedy, pre- vious experience justifies him in expecting that it will act satisfactorily. If the pulse be irritable, blood flowing from the nose, dark and clotty, in a patient with cold hands and feet, who is easily fatigued and flushes from the least excitement, he gives ferrum ; if, on the other hand, she belongs to the bilio-lymphatic temperament, inclined to be irritable, the blood brown, the dis- charge starting or increasing by motion, he administers bryonia ; if, again, the blood be dark, venous-looking, flowing passively, varicose veins of legs, with relief of the pain in the forehead from the flow, he orders hamamelis. But the subject may call for puis, instead ; blood alternately pale and dark, chilliness in- doors, with sense of suffocation, relieved in the open air, the emotional faculties so affected that the least thing will cause weeping ; or perhaps bell., with its hot red blood, congested face, drowsiness but inability to sleep, etc. ; in point of fact, any remedy in the materia medica may be the simillhnmn. You may say, however, "the investigator should consult at the same time my work on Pharmacodynamics." But here also he may find himself stranded, for under the above remedies there is hardly any better " precisionizing " in the manner of a Hahnemannian. The same objections might be urged against many other equally vague prescriptions of yours, but enough on this subject for the present. In truth, dear Dr. Hughes, you have sought to give your readers an easy system of homoeopathy ; a dependence upon which will frequently lead to professional failure. Your system is, in a measure, the old-school generalization, exempting one from the laborious method of the differentiating of the elements of the case and of drug-action. You overlook the subjective symptoms, the modalities, conditions, etc., which generally enable the Hahnemannian to prescribe successfully. You seem to consider all the symptoms of a given case as a whole, to be treated as such. Now, the simple name of a disease does not help the healer in the solution of the problem of the best remedy ; it is the phenomena presenting themselves.' Nor does the fact of a certain remedy having once proved useful, afford any particular aid in the bulk of the cases bearing a generic resemblance to that disease ; a correct decision being obstructed, not seldom, by the varying decisions of perhaps a dozen author- ities on the subject. I have found it "illusory" in practice to base my selection of a remedy upon pathological conditions, or, in other words, to select a drug because known to affect one particular organ, which I suspect to be affected, unless I have positive evidence of a disturbed balance in its functions, as manifested by pain, etc. We must choose a remedy capable of modifying the healthy functions in the same manner as the malady does ; including characteristics, conditions, concomitants, and so forth. When the pathological conditions and symptomatic indications are in clear relation to each other, the case is easy and simple ; but often you cannot recognize any distinct pathological state, and then your location of the seat of disease must be a simple surmise. Under such circumstances, the prescription of the adherent of the pathological school must be problematical in its effect. Daily experience teaches me that the strict inductive method of Hahnemann is the only safe and rehable one.^ No physician can be successful who is not familiar with the laws of life in disease and in health, and the means of maintain- ing the latter and correctihg the former. Disease is many- sided, and should be studied in all its phases, as well as the manner in which remedies are capable of modifying the healthy functions of the human body. I yield to none in recognizing the importance and utility of pathology and diagnosis in their clinical bearing : a complete knowledge of disease, its causes, course, duration, morbid anatomy, and ultimate issue, being essential to success in the practice of medicine. But in sum- ming up a case with the view of prescribing, we must include all the symptoms, subjective and objective, with their conditions. ■ p. p. Wells truly says, "The modern resort to generalization in pretended homcEo- pathic practice and teaching, is ever an exclusion of all which is essential to the philosophy of the natural law of therapeutics." ' Dr. Carroll Dunham, in speaking of pathology as a basis of treatment, says, " The endeavor can never be successful, inasmuch as the mnction of pathology is to furnish not an indication for medical treatment, but simply a means of elucidating and collating the symp- toms. The result has been a sad falling-off from the standard of success in practice, which was established by Hahnemann and his pupils." He also states elsewhere, " Success in treat- ment, based upon a pathological consideration of the case, must depend on the correction .of the pathological hypothesis, a matter in which certainty can never be attained." etc. If these be excluded from the picture, an imperfect selec tion is most likely made. The symptoms by which we diagno.sc a disease are often of little or no assistance : it is the symptoms which are peculiar or unusual, and not those belonging ordi- narily to thf* diseased organ, which should take precedence. These characteristics point to one remedy or a group of them, and then the incidental manifestations come in as "clinchers." I began this reply by a tribute to the courteous tone you adopted in addressing me, and this, as far as I know, has been characteristic of all your utterances in discussion. There is one allusion, however, in the first part of your letter to me, which marks something approaching an exception to your usual deli- cacy ; but I suppose that haste or heedlessness will be the explanation. You say, in referring to my selection of ipecac in the case of broncho-pneumonia, which I reported, that you too would have prescribed the same, and that " without consulting Jahr." There is here the suspicion of a reflection which, for the sake of yourself as well as my claims, I would have pre- ferred unwritten. The casual reader might infer that I was not conversant, at the time I wrote, with the symptomatology of ipecac, whereas in the "Address" I stated the related incident occurred " when I began the study of homoeopathy," some few years after I graduated (in 1865). At a similar stage of your own homoeopathic professional experience, it is quite possible that you yourself might have been obliged to refer to some authority on the subject. I cordially recognize that you have presented to our English confreres a method of practising homoeopathy, which, by its simplicity, enforced by a felicitous aiction and unusual lucidity, immediately commanded their respectful attention and approba- tion ; but candor compels me to add that those who will adhere to your method will not prove the best exponents or most suc- cessful practitioners of our school. When I prescribed by such aids as you present, I felt less confidence in my prescriptions than after I had adopted the Hahnemannian system. Now, when I have found a remedy whose record corresponds closely with that of the sick phenomena, I am satisfied that my services will prove profitable to the patient. I admit the study of whole columns of symptoms is a laborious task, but the reward and satisfaction it generally yields constitute a sufficient recom- pense to the conscientious physician. In conclusion let me say, I have thought it my duty to notice every point you made, and refute it, if able, for the sake of the cause we both have at heart, even if di^ering in some respects in its practice. I hbpJ&JI'hayjB*\s^bJYii:jiiy*apptr&ciation of your spirit of candor and: e&r6i^tnds*s.4nlrftv36wiiigray humble article ; • • • • • • • •<•••* ' ••• •• ; 8 but I have too high an opinion of your character and qualifica- tions as an able, learned author, as well as an experienced, zealous physician, to imagine that you would shrink from a full, sincere expression of my mind on subjects and courses not only highly interesting to our profession, but deeply concerning that vast and rapidly increasing multitude, in all civilized nations, whose confidence and highest temporal interests are so closely bound up with the great and beneficent system of homoeopathy. I am, dear Dr. Hughes, Faithfully yours. Prosper Bender. 134 BoYLSTON St., Boston, Mass., Sept. 30, 1888. • ► r' % WiliinvL-rHWIJ.*, ■ *-\: * /,. * s^ 1WNP AVERY Opi«K»ANY,l*ltli