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 launched this wonderful journey we continue today. In his prehomoeopathic 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 1/2several 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 nonmedicinal 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".