The Development of Approaches to the Repetition of Dose
in Hahnemann's Homeopathy

The issue of repetition of dose is intimately tied up with the related issues of dose and potency. This essay is intended to be read alongside its sister-essay, The Development of Dose and Potency in the History of Homeopathy.

In the early years of homeopathy, we find little written about the issue of repetition of dose. Undoubtedly Hahnemann was experimenting widely, and he likely viewed the issue of repetition similarly to the manner in which he viewed dose at this time (see the accompanying essay re dose and potency) - as a variable to be determined individually for each of the various medicinal substances he employed, guided by an evolving recognition of the general significance of the minimum dose. It was not until 1825 (year 29*), with the recognition of the principle of dynamization, that Hahnemann broke from materialistic perspectives re dose, and began to see dose as an issue that transcended the physical properties of the particular medicinal substance in question.

From this early period we have only a few glimpses at Hahnemann's practices re repetition.

In his booklet Cure and Prevention of Scarlet Fever (1801; year 6*) (discussing the use of poppy in treating the active acute illness): "It is unnecessary to repeat these doses oftener than every four or eight hours, in some cases not more than every twenty-four hours, and that sometimes only a couple of times throughout the whole fever, for which the more frequent or more rare occurrence of these symptoms must be our guide". In the treatment of the desquamation following difficult cases, he dosed chamomilla daily.

In Treatment of the Typhus or Hospital Fever at Present Prevailing (Allgem. Anzeig. der Deutschen, 1814; year 19) (discussing the use of Bryonia in the active acute illness): "and as long as the improvement goes on, we give him no other medicine, nor even repeat the same one; for none of the medicines here recommended can be used oftener than once (in the dose of a drop) - seldom can they be given a second time with advantage."

The issue of repetition of dose began to receive understandably greater attention in the context of treating chronic disease.

It was in 1829 that Hahnemann proposed the standardized use of the 30th centesimal potency, and this was his preferred preparation when he wrote part 1 of Chronic Diseases in 1828 (year 32). His posology in treating chronic disease is detailed on pp. 119-129, & p. 137 (in the Jain edition). The carefully chosen dose & potency (most usually a single 30C pellet, dry or moistened) was allowed to act until the dose had exhausted its favorable action, with no other prescription to be considered so long as the improvement continued. Repetition or change of remedy was considered only when the old symptoms, which had been eradicated or very much diminished by the previous dose, commenced to rise again for a few days; discernment of the time to consider a second prescription required experience and careful observation.

Hahnemann suggested that the "third leading mistake" in treating chronic disease was in not waiting until the dose had exhausted its action; that this might require 30, 40, even 50 or more days, but could not be predicted ahead of clinical observation of the progress of the case. He suggested that practitioners "scrupulous on the wrong occasion" mitigate their own and their patients' impatience by giving milk sugar (sac lac) as a placebo during this period of observant waiting.

The only exception to patient waiting for such extended periods, was when the initial dose exhausted its action unexpectedly soon. He suggested it was then best to repeat, but if the same remedy was indicated, to repeat it at an altered potency. This could involve moving either up or down in the potency scale - e.g., from 30C to 24C, 18C to 24C, etc.

There is some heralding of his later use of split doses in medicinal solution, in his advice that to allow the dose to act more strongly, it could be given in water, divided over 2-3 days (not longer), stirred each time to modify the potency.

Hahnemann also introduced in this work the administration of remedies by olfaction, which he elaborated on later in 1832-1833; and he later introduced administration by application to the (healthy) external skin. As the issues of dose and repetition of dose are relatively independent of the method of administration, I will not go into greater detail on these topics now, but will rather cover them in a separate essay.

The 4th edition of the Organon, published the following year (1829), similarly advised that a "single dose of a well-selected homoeopathic medicine should always be allowed first fully to expend its action before a new medicine is given or the same one repeated".

Constantine Hering left Germany for Surinam in 1827, and was shipwrecked off Martha's Vineyard on his attempt to return home in 1833. He settled in Philadelphia well-practiced in the methods of the 4th edition of the Organon & the 1st edition of Chronic Diseases, and rooted the development of homeopathy in North America strongly this "wait & watch" methodology. Kent later provided perhaps the most eloquent and detailed description of this approach in his Lecture on the Second Prescription, read before the International Hahnemannian Association at Niagara Falls in 1888.

Between 1829 and 1833 (years 33-37), Hahnemann's focus was very much on the treatment of chronic disease, and overcoming the obstacles presented to its most rapid and gentle cure. He experienced difficulties using the "wait & watch" approach, which he described in the note to §246 of the 5th edition of the Organon: "...the vital force dose not quietly adapt itself to the transition from the natural disease to the similar medicinal disease, but is usually so violently excited and disturbed by a larger dose, or by smaller doses of even a homeopathically chosen remedy given rapidly one after the other, that in most cases its reaction will be anything but salutary and will do more harm than good". This difficulty led him into exploring the dosing alternatives described below, introduced to practice between 1833 and 1838 (years 37-42).

When Hahnemann published the 5th edition of the Organon in 1833 (year 37), he introduced an option he felt preferable to this "wait & watch" approach, suggesting that a more rapid cure could be had by repeating a dose at "suitable intervals which experience has proved to be best adapted" , guided by the "nature of the medicinal substance, the corporeal constitution of the patient, and the magnitude of the disease". He suggested repeating dry or moistened 30C globules (in Hahnemann's notation, X, referring to the decillionth dilution) at an unaltered dose & potency. Dosing frequency might range from every 7 to 14 days in a chronic illness of slow pace, to every five minutes in an acute illness of rapid pace, guided by clinical experience and observation of the progress of the case. This approach often required that an "intercurrent" remedy be given after several doses; a precaution that was reversed with the later introduction of gradual ascending potencies. He modified the preparation of his centesimal potencies when intended to be used in this manner, reducing the number of successions at each dilution step from 10 to 2.

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

He described an alternative "small bottle" method of making up the medicinal solution, using 200, 300 or 400 drops of water & brandy to half-fill a small vial, into which one or more pellets were dissolved, and briskly shaken 5-6 times before each dose. According to the vitality & sensitivity of the patient, 1, 2, 3 or several drops were removed to a cup containing a spoonful of water, to be stirred, and the contents (or a portion of the contents) to be taken for a dose.

In 1838 (year 42), Hahnemann developed his new potencies, his "medicaments au globule" (the LM or Q or 50-millesimal potencies), which were intended to optimize the medicinal solution dosing approach described above. He shared his experience with these only with Boenninghausen, and first wrote about them in the 6th edition of the Organon, the year prior to his death (1842), but which was only made available to the homoeopathic community 80 years later, in 1921. Directions for the preparation of LMs are provided in the 6th edition of the Organon, in §270; and for their use in §s245-248 and 280-282. Choudhury's book Fifty Millesimal Potency - Theory and Practice is an excellent resource for this method; the best writings I've seen on this approach are the series of articles titled Hahnemann's Advanced Methods available on David Little's website. I'll outline the basics of this approach below, but refer practitioners to the resources above (& particularly to David Little's writings) as guides to actual application of this approach.

In the 6th edition of the Organon, Hahnemann states (§246):
"Every perceptibly progressive and strikingly increasing amelioration in a transient (acute) or persistent (chronic) disease, is a condition which, as long as it lasts, completely precludes every repetition of the administration of any medicine whatsoever, because all the good the medicine taken continues to effect is new hastening towards its completion. Every new dose of any medicine whatsoever, even of the one last administered, that has hitherto shown itself to be salutary, would in this case disturb the work of amelioration".

However, in gradual amelioration, he suggests that one can ensure and hasten cure if one repeats the dose in medicinal solution with modification of potency each time by succession. He provided much more explicit instructions for this approach than for the methods that led up to its development. Most importantly, it is important that the degree of potency deviate somewhat from the previous and subsequent ones, in order to avoid the development of accessory symptoms (symptoms of the similar medicinal disease that are not part of, & therefore are not homoeopathic to, the original natural disease of the patient). In order to hasten cure, one may also gradually increase the size of the dose, but not so aggressively as to result in a homoeopathic aggravation. Repetition of the dose in this manner was to be carried on until eradication of the disease, or until the picture of the disease-gestalt changed to one demanding a different remedy (§248)

The actual potency selected to begin treatment, the size of the dose(s) given, and the frequency of repetition of the dose were variables to be determined individually for each case. Hahnemann does provide some general guidelines for consideration, outlined below.

He suggested 2 options for making up the medicinal solution (§ 248, note). The first involves using one or (rarely) more pellets in 40, 30, 20, 15 or 8 tblsp water (4 - 20 oz), adding alcohol or a piece of charcoal to keep the solution from spoiling. This would be succussed about 8, 10 or 12 times before each dose, and a dose would consist of one or several teaspoons.

The second option uses one or (rarely) more pellets in 7-8 tblsp (~4oz) water, preserved with alcohol or charcoal. After succussing as above, one tablespoon of this solution would be stirred vigorously into a dilution glass containing 8-10 tblsp (4-5oz) water, and a portion of this would be given for a dose. In sensitive patients, a tsp of this dilution would be stirred into a second dilution glass, and this might be carried through a third or even a fourth dilution glass to create an appropriately small dose.

Repetition was recommended (§246 & §248) "at intervals that experience has shown to be the most distinctly appropriate for the best possible acceleration of treatment"; in chronic diseases of slow pace, this might be daily or every second day; in acute diseases, it might be every 6, 4, 3, or 2 hrs; in urgent cases, it could be hourly or even more frequently.

If a second or subsequent bottle of the same remedy is required, this should be made up with a pellet of higher potency. Over the course of treatment, it is likely that the size of the dose would need to be increased to ensure progress in the case, but this should be done only gradually to avoid creating aggravation, and particularly to avoid the production of accessory symptoms by the repeated doses.

Any "perceptibly progressive and strikingly increasing amelioration" would preclude continued repetition (§246), as would any aggravation (§282). As the natural disease of the patient lessens in intensity towards the end of treatment, symptoms of the medicinal disease resembling those of the original natural disease of the patient might appear; this would occasion a reduction in the size of the dose and/or the dosing frequency, or a brief suspension of dosing to assess the status of the remnants of the natural disease prior to proceeding (§248 &§s280-281).

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

Perhaps it is a gift that difficulties in trans-Atlantic communication, and the delayed publication of the 6th edtion of the Organon, permitted these posologies to each develop to their current fruition. Today we can learn from both approaches, and select that which appears to be optimal for each case that sits before us.

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