- Email: [email protected]
Opening of the discussion
242
THE BRITISH HOMGEOPATHIC JOURNAL
proceed to Analysis, for we can only a n a l y s e something t h a t constitutes a whole, n o t s o m e t h i n g which is a collection of u n r e l a t e d facts or observations. W e are n o t dealing w i t h t h e h a p h a z a r d l y a r r a n g e d pieces in a kaleidoscope m a k i n g first one p a t t e r n , t h e n another. T h a t we are dealing w i t h p a t t e r n s is n o t to be denied, b u t w i t h a r c h e t y p a l p a t t e r n s , m a n i f e s t a t i o n s of u n i v e r s a l laws, of which t h e L a w o f Similars is b u t one. A n d now I should like to conclude b y quoting a s h o r t p a s s a g e from G o e t h e ' s scientific writings, in which he discusses t h e m e t h o d of i n v e s t i g a t i o n i n t r o d u c e d i n t o science b y Bacon. Goethe writes: " I n t h e r a n g e of p h e n o m e n a all h a d equal v a l u e in B a c o n ' s eyes. F o r a l t h o u g h he himself a l w a y s points o u t t h a t one should collect t h e p a r t i c u l a r s o n l y to select from t h e m a n d to arrange t h e m , in order finally to a t t a i n t o Universals, y e t t o o m u c h privilege is g r a n t e d to t h e single facts; a n d before i t becomes possible to a t t a i n to simplification a n d conclusion b y m e a n s of i n d u c t i o n (the v e r y w a y he r e c o m m e n d s ) , life vanishes a n d forces get e x h a u s t e d . He who cannot realize that one instance is often worth a thousand, bearing all within itself; he who proves unable to comprehend and esteem what we called Urphenomena, will never be in a position to advance anything either to his or to others' j o y and profit." (Italics are t h e a u t h o r ' s . ) REFERENCES
1 Controlled Clinical Trials. Papers delivered at the Conference convened by the Council
for International Organizations of Medical Sciences. Blackwell Scientific Publications, Oxford. Boyd, H. W., "The Importance and Difficulties of Research into the Effect of High Potencies and the Simile Principle". Brit. Horn. Journ., 45, 214. 1956. a Stephenson, g., "Review of Investigations into the Actions of Substances in Dilutions Greater than 1 • 10-24". J. Am. Inst. of Horn., 48, l l , 327-35. Nov., 1955. Kolisko, L., Physiologischer and physikalischer Nachweis der Wir~samkeit kleinster Entitgiten. Arbeitsgemeinschaft Anthroposophischer ~rzte, Stuttgart, 1959. Boyd, W. E., "An Investigation Regarding the Action on Diastase of Microdoses of Mercuric Chloride when Prepared with or without Mechanical Shock". Brit. Horn. Journ., 36, 11-23. 1946. Eodman, F., Brit. Horn. Journ., April, 1935, pp. 110-29. 7 Stephenson, J., "Homceopathie Provings in the Light of the Newly Formulated 'Human Pharmacology' ". J. Am. Inst. of Horn., March-April 1960. s Pirtkian, R., "Eine Arzneimittelpriifung mit Bryonia". Hippokrates. 32, 8, 288 and 32, 9, 329. 1961.
9 Asl.
10 Modell, W., "Problems in the Evaluation of Drugs in Man". Journ. Pharm. and Pharmacol., I1, 577. 1959.
OPENING OF THE DISCUSSION By W. Thomson Walker, M.B.E., M.A., M.D., F.F.Hom.
MR. PRESIDENT, DR. BRIEGER, LADIES AND GENTLEMEN, I n t h e first place, p e r m i t me to c o n g r a t u l a t e Dr. Brieger on t h e excellence of her p a p e r , on its b r e a d t h of a p p r o a c h a n d a p p r e c i a t i o n of t h e t r u e p r o b l e m s of t h e situation, a n d if her conclusions seem a trifle gloomy, surely it is b e s t to look facts in t h e face a n d n o t waste v a l u a b l e t i m e in a n a p p r o a c h which is l i k e l y to be f o r e d o o m e d a n d b a r r e n of results. Dr. H. B o y d ' s w o r k was m e n t i o n e d a n d he has succeeded in doing more t h a n she suggests, b y d e m o n s t r a t i n g t h e effects of potencies u p to 30C (10 -60 g/ml) a n d t h e specific effects of succussion (a m e a s u r a b l e difference in the Loss F a c t o r in his di-electric c o n s t a n t experiments), b u t m e a n w h i l e p o i n t s o u t t h a t t h e d e m o n s t r a t i o n of t h e effects of high potencies in biological tissues would n o t
METHODOLOGICAL
OBSTACLES
IN
HOM(EOPATI~IC
RESEARCH
243
convince anyone, and give no understanding of the origin of such activity. But this work takes us a good deal further than Professor Burridge's work on high dilutions. Mine. Kolisko's work, though extremely interesting and enlightening, cannot be carried over directly from the vegetable to the animal kingdom, far less applied to man. The simplification afforded b y plant life does much to make these experiments possible, repeatable and reliable. Next, as to the Methodology of Provings, it seems to me t h a t controls are absolutely necessary, if only to demonstrate the fallacies which m a y be induced by expectation of symptoms. Dr. Brieger has quoted Koestler's recent article on this subject and J. R a m o n in 1938 said much the same; also, as she has said, a recent proving of Bryonia published in HippoIcrates underlined the same pitfall. Perhaps Dr. Raesidc would care to comment on this aspect of provings. We also have to remember that we do our provings on presumably healthy people, m a n y of whom are relatively insensitive to the drug in question, whereas sick people are often highly sensitized to the remedy. This is also true in orthodox drug trials (H. Beecher, World Med. Journ., 7, 80-82, March, 1960). General Considerations in our Approach to Research. I t is generally agreed t h a t some kind of research project is highly desirable for the more or less worthy objects of satisfying our State employers, furthering knowledge, promoting the well-being of our future patients, and extending our sphere of influence (there is no special significance to be attached to this order!). Moral considerations. As homceopaths we need not seriously fear harm to our patients unless it be through being neglected as members of the control group (cf. Bull, 1959), and the usual routine biological, chemical and biophysical tests are acceptable, provided t h a t no undue discomfort is inflicted upon the patient. The sanctity of h u m a n life must be remembered, and the supremacy of the claims of the individual (Darley, J.A.M.A.). Serving social medicine as we do, we are faced with the demand to co~fform to the statistical method and produce figures and results to prove that what we do is worth while. The social planners cannot work without figures, but we as clinicians must insist t h a t the claims of our patients of today must come before the claims of tomorrow or even the next generation, otherwise we are in danger of accepting the Marxian Communist thesis t h a t the end justifies the means and t h a t the community is of more importance t h a n the individual (Arnold Aldis). Christian and Humanist would unite to condemn this attitude, and the R o m a n Church, through Pope Pius X I I , in an address to an International Congress of Neurologists in ]952, said: "At no time must the interests of the individual be subordinate to those of the community, since the community exists for man." Ultimately, it must be left to the doctor to see that the best interests of the patient are the first consideration, because in the field of research the patient is in no position to judge, even when the nature of the experiment in question has been explained and consent obtained. I n no case m a y integrity be sacrificed on the altar of expediency (Arnold). Clinical research can be b y observation or planned experiment. The G.P. is in the best position to do the former, seeing 80 per cent. of cases, while the hospital physician should be better placed to do the latter. Although the method of observation is more widely applicable, it can at best only give clinical impressions with no controls, while planned experiment should, theoretically at least, offer a more precise tool for research. There is a sense in which every prescription we make is to some extent an experiment, the result leading to further knowledge and experience, and this method is open to us all.
244
THE
BI%ITISH
I{OM(~OPATHIC
JOURNAL
Against hospital observation we m a y quote Pinsent who said (1953) t h a t a patient in a hospital ward is like a specimen in the z o o - - o u t of his natural e l e m e n t - - a n d so introducing a potential source of error. Some of the greatest advances in medicine have come from personal observations, e.g. Hahnemann, Harvey, Sir J. Mackenzie, to quote but a few. Cardiac surgery could not have come into being had not Werner Forssman, a young resident surgeon, catheterized his own heart first of all. The fallacies of the statistical method are continually being made the subject of fun and ridicule, yet the serpent continually rears its head in a menacing fashion and armies of unproductive clerks are kept for the sole purpose of nourishing the brute and feeding it with figures. I t is, however, a moral d u t y to test a treatment, old or new, critically, and not just to prescribe b y custom. Where a treatment has to be evaluated it is perfectly licit to employ controls, provided that an "escape clause" exists whereby any patient can be withdrawn from the trial should his clinical state make this desirable. We must remember t h a t knowledge can be bought at too high a price and what we need is wisdom to use our knowledge rightly. Most doctors agree that in medicine clinical judgement is paramount. Even inprognosis: it does not help Mrs. Brown to know t h a t in the operation which she is about to face statistically 75 per cent. of cases make an excellent recovery. What she wants to know is whether she will be numbered in the 75 per cent., or will be one of the unfortunate 25 per cent., and here statistics fail, whereas a good clinical opinion can assess her prospects with a much greater chance of success and give needed comfort and courage. Statistics do not help individual prognosis. Moreover, what is valid for t o d a y does not necessarily apply tomorrow, e.g. the results of penicillin treatment as published originally no longer apply (D. McG. Jackson). Another limitation of the experimental method resides in the actual therapeutic value of the inter-personal relationship between the physician and his patient. This cannot be assessed in any way and yet, as everyone knows, it is fundamental to good medicine. Again, there are the difficulties presented by specific sensitivities related to allergies, anaphylaxis, or previous sensitization by having had the same remedy before or an antidotal remedy immediately previously; any of these factors m a y bedevil the situation. Also, the body tends to react to all nocuous substances in a homeostatic fashion (Cannon), in accordance with Pflueger's law, restoring normality by various adjustments. I t is this very power which b y our remedies we are trying to stimulate. With all these difficulties in the human field, and others which I shall mention later, we might think of demonstrating our thesis by animal experiments: but just as m a n y difficulties exist there, quite apart from possible moral objections. When we look into the matter we find t h a t animals are affected very differently by the same drug and there is absolutely no correspondence on their effects in different species, and the pharmacological effects on man in m a n y cases show only a distant relationship. So this is of little value. How then in the face of all these incalculable factors should we approach the problem of clinical experiment? I n order to prove the validity of the homceopathic method it would be necessary to show t h a t homceopathically treated cases recovered in significantly less time and/or more completely than Untreated Cases--given placebo, and Cases treated b y allopathic or other methods. The problem has also to be faced that for statistical purposes it would be necessary to employ "disease labels", pathological diagnoses, which we deprecate, yet the value of remedies can only be assessed in relation to their effects
METHODOLOGICAL
OBSTACLES
IN
HOM(:EOPATHIC
RESEARCH
245
upon specific disease processes, and a measure of the speed rather than the completeness of restoration to a state of wholeness or health. No account could be taken of possible high potency aggravations or delay due to the "recapitulation of the diseases" on the way to full recovery. Nor could our cases be grouped constitutionally as we might wish to do for comparison of different remedies. Some cases might need several remedies in series, and several cases with a variety of pathological diagnoses might require the same or different remedies. Where can standardization come in under these circumstances? To add to the difficulties we might consider the question of uniformity of potency level, and even frequency of repetition of remedies, and having added these complications it becomes clear that standardization for the purpose of statistical analysis is completely impossible. A final difficulty was touched on already. The individual physician's personality and prestige are an inseparable part of the remedy and where, as occasionally happens, the junio r medical or nursing staff are unsympathetic, critical, or sceptical, this is readily communicated by their more intimate contact with the patient and can do much to destroy this element in cure. A good team can, of course, have the reverse effect. I t is regrettably patent that no statistician could take account of all these possible variables involved in homceopathic clinical experiment, so that the usual and accepted method, as Dr. Brieger has said, is unfortunately quite unsuited to our approach. So that for purely practical rather than philosophical reasons I have come to much the same conclusion as Dr. Brieger: that if ttomceopathy is to be demonstrated to be effective we have to find a new method. I shall be more than interested if someone here today can suggest a way out of the impasse. As Dr. Brieger says, we cannot accept defeat so easily. Only on the broadest possible basis could overall comparisons be made of the comparative value of homceopathic treatment, allopathic treatment, and no treatment. I t could be arranged that in one or more wards of the hospital one physician might treat all his cases suitable to be included in the series by strictly homceopathic treatment, say by high potencies, while in the same wards and with the same staff another physician for the sake of the trial might agree to use low potencies only, while a third might be persuaded to use only orthodox remedies. You can imagine for yourselves how difficult this would be to operate and I fail to see how sufficient standardization of cases or remedies could be made to tabulate any meaningful results. Many hundreds or even thousands of cases are necessary. One could probably get "clinical impressions", but little more. I t might be possible to conduct a limited investigation into the healing powers of individual remedies. For example, we might investigate the powers of Arnica in relation to the prevention or healing of bruises, the effect of the snake venoms on coagulation or lysing of blood in vitro, or clinically in thrombosis or hmmorrhagic states, and hope in these experiments to approach to the controls and criteria demanded by modern research. From such a limited objective the way might well open up to more ambitious schemes. As Dr. Brieger has rightly said, this problem which we face is one which can be solved only by patient observation and recording of facts, as has been done by all the great leaders of our profession. Although it is true, as she said, quoting Goethe, that "one instance is often worth a thousand, bearing all within itself"--and we have all seen examples of this in our experience which have made the deepest impression and changed our entire thinking--this revelation is not granted to all. They have never seen the dynamic of the potentized remedy, and so it remains our duty to attempt to demonstrate the principle of the Law of Similars to their complete satisfaction--and ours.
THE BRITISH HOMGEOPATHIC JOURNAL
proceed to Analysis, for we can only a n a l y s e something t h a t constitutes a whole, n o t s o m e t h i n g which is a collection of u n r e l a t e d facts or observations. W e are n o t dealing w i t h t h e h a p h a z a r d l y a r r a n g e d pieces in a kaleidoscope m a k i n g first one p a t t e r n , t h e n another. T h a t we are dealing w i t h p a t t e r n s is n o t to be denied, b u t w i t h a r c h e t y p a l p a t t e r n s , m a n i f e s t a t i o n s of u n i v e r s a l laws, of which t h e L a w o f Similars is b u t one. A n d now I should like to conclude b y quoting a s h o r t p a s s a g e from G o e t h e ' s scientific writings, in which he discusses t h e m e t h o d of i n v e s t i g a t i o n i n t r o d u c e d i n t o science b y Bacon. Goethe writes: " I n t h e r a n g e of p h e n o m e n a all h a d equal v a l u e in B a c o n ' s eyes. F o r a l t h o u g h he himself a l w a y s points o u t t h a t one should collect t h e p a r t i c u l a r s o n l y to select from t h e m a n d to arrange t h e m , in order finally to a t t a i n t o Universals, y e t t o o m u c h privilege is g r a n t e d to t h e single facts; a n d before i t becomes possible to a t t a i n to simplification a n d conclusion b y m e a n s of i n d u c t i o n (the v e r y w a y he r e c o m m e n d s ) , life vanishes a n d forces get e x h a u s t e d . He who cannot realize that one instance is often worth a thousand, bearing all within itself; he who proves unable to comprehend and esteem what we called Urphenomena, will never be in a position to advance anything either to his or to others' j o y and profit." (Italics are t h e a u t h o r ' s . ) REFERENCES
1 Controlled Clinical Trials. Papers delivered at the Conference convened by the Council
for International Organizations of Medical Sciences. Blackwell Scientific Publications, Oxford. Boyd, H. W., "The Importance and Difficulties of Research into the Effect of High Potencies and the Simile Principle". Brit. Horn. Journ., 45, 214. 1956. a Stephenson, g., "Review of Investigations into the Actions of Substances in Dilutions Greater than 1 • 10-24". J. Am. Inst. of Horn., 48, l l , 327-35. Nov., 1955. Kolisko, L., Physiologischer and physikalischer Nachweis der Wir~samkeit kleinster Entitgiten. Arbeitsgemeinschaft Anthroposophischer ~rzte, Stuttgart, 1959. Boyd, W. E., "An Investigation Regarding the Action on Diastase of Microdoses of Mercuric Chloride when Prepared with or without Mechanical Shock". Brit. Horn. Journ., 36, 11-23. 1946. Eodman, F., Brit. Horn. Journ., April, 1935, pp. 110-29. 7 Stephenson, J., "Homceopathie Provings in the Light of the Newly Formulated 'Human Pharmacology' ". J. Am. Inst. of Horn., March-April 1960. s Pirtkian, R., "Eine Arzneimittelpriifung mit Bryonia". Hippokrates. 32, 8, 288 and 32, 9, 329. 1961.
9 Asl.
10 Modell, W., "Problems in the Evaluation of Drugs in Man". Journ. Pharm. and Pharmacol., I1, 577. 1959.
OPENING OF THE DISCUSSION By W. Thomson Walker, M.B.E., M.A., M.D., F.F.Hom.
MR. PRESIDENT, DR. BRIEGER, LADIES AND GENTLEMEN, I n t h e first place, p e r m i t me to c o n g r a t u l a t e Dr. Brieger on t h e excellence of her p a p e r , on its b r e a d t h of a p p r o a c h a n d a p p r e c i a t i o n of t h e t r u e p r o b l e m s of t h e situation, a n d if her conclusions seem a trifle gloomy, surely it is b e s t to look facts in t h e face a n d n o t waste v a l u a b l e t i m e in a n a p p r o a c h which is l i k e l y to be f o r e d o o m e d a n d b a r r e n of results. Dr. H. B o y d ' s w o r k was m e n t i o n e d a n d he has succeeded in doing more t h a n she suggests, b y d e m o n s t r a t i n g t h e effects of potencies u p to 30C (10 -60 g/ml) a n d t h e specific effects of succussion (a m e a s u r a b l e difference in the Loss F a c t o r in his di-electric c o n s t a n t experiments), b u t m e a n w h i l e p o i n t s o u t t h a t t h e d e m o n s t r a t i o n of t h e effects of high potencies in biological tissues would n o t
METHODOLOGICAL
OBSTACLES
IN
HOM(EOPATI~IC
RESEARCH
243
convince anyone, and give no understanding of the origin of such activity. But this work takes us a good deal further than Professor Burridge's work on high dilutions. Mine. Kolisko's work, though extremely interesting and enlightening, cannot be carried over directly from the vegetable to the animal kingdom, far less applied to man. The simplification afforded b y plant life does much to make these experiments possible, repeatable and reliable. Next, as to the Methodology of Provings, it seems to me t h a t controls are absolutely necessary, if only to demonstrate the fallacies which m a y be induced by expectation of symptoms. Dr. Brieger has quoted Koestler's recent article on this subject and J. R a m o n in 1938 said much the same; also, as she has said, a recent proving of Bryonia published in HippoIcrates underlined the same pitfall. Perhaps Dr. Raesidc would care to comment on this aspect of provings. We also have to remember that we do our provings on presumably healthy people, m a n y of whom are relatively insensitive to the drug in question, whereas sick people are often highly sensitized to the remedy. This is also true in orthodox drug trials (H. Beecher, World Med. Journ., 7, 80-82, March, 1960). General Considerations in our Approach to Research. I t is generally agreed t h a t some kind of research project is highly desirable for the more or less worthy objects of satisfying our State employers, furthering knowledge, promoting the well-being of our future patients, and extending our sphere of influence (there is no special significance to be attached to this order!). Moral considerations. As homceopaths we need not seriously fear harm to our patients unless it be through being neglected as members of the control group (cf. Bull, 1959), and the usual routine biological, chemical and biophysical tests are acceptable, provided t h a t no undue discomfort is inflicted upon the patient. The sanctity of h u m a n life must be remembered, and the supremacy of the claims of the individual (Darley, J.A.M.A.). Serving social medicine as we do, we are faced with the demand to co~fform to the statistical method and produce figures and results to prove that what we do is worth while. The social planners cannot work without figures, but we as clinicians must insist t h a t the claims of our patients of today must come before the claims of tomorrow or even the next generation, otherwise we are in danger of accepting the Marxian Communist thesis t h a t the end justifies the means and t h a t the community is of more importance t h a n the individual (Arnold Aldis). Christian and Humanist would unite to condemn this attitude, and the R o m a n Church, through Pope Pius X I I , in an address to an International Congress of Neurologists in ]952, said: "At no time must the interests of the individual be subordinate to those of the community, since the community exists for man." Ultimately, it must be left to the doctor to see that the best interests of the patient are the first consideration, because in the field of research the patient is in no position to judge, even when the nature of the experiment in question has been explained and consent obtained. I n no case m a y integrity be sacrificed on the altar of expediency (Arnold). Clinical research can be b y observation or planned experiment. The G.P. is in the best position to do the former, seeing 80 per cent. of cases, while the hospital physician should be better placed to do the latter. Although the method of observation is more widely applicable, it can at best only give clinical impressions with no controls, while planned experiment should, theoretically at least, offer a more precise tool for research. There is a sense in which every prescription we make is to some extent an experiment, the result leading to further knowledge and experience, and this method is open to us all.
244
THE
BI%ITISH
I{OM(~OPATHIC
JOURNAL
Against hospital observation we m a y quote Pinsent who said (1953) t h a t a patient in a hospital ward is like a specimen in the z o o - - o u t of his natural e l e m e n t - - a n d so introducing a potential source of error. Some of the greatest advances in medicine have come from personal observations, e.g. Hahnemann, Harvey, Sir J. Mackenzie, to quote but a few. Cardiac surgery could not have come into being had not Werner Forssman, a young resident surgeon, catheterized his own heart first of all. The fallacies of the statistical method are continually being made the subject of fun and ridicule, yet the serpent continually rears its head in a menacing fashion and armies of unproductive clerks are kept for the sole purpose of nourishing the brute and feeding it with figures. I t is, however, a moral d u t y to test a treatment, old or new, critically, and not just to prescribe b y custom. Where a treatment has to be evaluated it is perfectly licit to employ controls, provided that an "escape clause" exists whereby any patient can be withdrawn from the trial should his clinical state make this desirable. We must remember t h a t knowledge can be bought at too high a price and what we need is wisdom to use our knowledge rightly. Most doctors agree that in medicine clinical judgement is paramount. Even inprognosis: it does not help Mrs. Brown to know t h a t in the operation which she is about to face statistically 75 per cent. of cases make an excellent recovery. What she wants to know is whether she will be numbered in the 75 per cent., or will be one of the unfortunate 25 per cent., and here statistics fail, whereas a good clinical opinion can assess her prospects with a much greater chance of success and give needed comfort and courage. Statistics do not help individual prognosis. Moreover, what is valid for t o d a y does not necessarily apply tomorrow, e.g. the results of penicillin treatment as published originally no longer apply (D. McG. Jackson). Another limitation of the experimental method resides in the actual therapeutic value of the inter-personal relationship between the physician and his patient. This cannot be assessed in any way and yet, as everyone knows, it is fundamental to good medicine. Again, there are the difficulties presented by specific sensitivities related to allergies, anaphylaxis, or previous sensitization by having had the same remedy before or an antidotal remedy immediately previously; any of these factors m a y bedevil the situation. Also, the body tends to react to all nocuous substances in a homeostatic fashion (Cannon), in accordance with Pflueger's law, restoring normality by various adjustments. I t is this very power which b y our remedies we are trying to stimulate. With all these difficulties in the human field, and others which I shall mention later, we might think of demonstrating our thesis by animal experiments: but just as m a n y difficulties exist there, quite apart from possible moral objections. When we look into the matter we find t h a t animals are affected very differently by the same drug and there is absolutely no correspondence on their effects in different species, and the pharmacological effects on man in m a n y cases show only a distant relationship. So this is of little value. How then in the face of all these incalculable factors should we approach the problem of clinical experiment? I n order to prove the validity of the homceopathic method it would be necessary to show t h a t homceopathically treated cases recovered in significantly less time and/or more completely than Untreated Cases--given placebo, and Cases treated b y allopathic or other methods. The problem has also to be faced that for statistical purposes it would be necessary to employ "disease labels", pathological diagnoses, which we deprecate, yet the value of remedies can only be assessed in relation to their effects
METHODOLOGICAL
OBSTACLES
IN
HOM(:EOPATHIC
RESEARCH
245
upon specific disease processes, and a measure of the speed rather than the completeness of restoration to a state of wholeness or health. No account could be taken of possible high potency aggravations or delay due to the "recapitulation of the diseases" on the way to full recovery. Nor could our cases be grouped constitutionally as we might wish to do for comparison of different remedies. Some cases might need several remedies in series, and several cases with a variety of pathological diagnoses might require the same or different remedies. Where can standardization come in under these circumstances? To add to the difficulties we might consider the question of uniformity of potency level, and even frequency of repetition of remedies, and having added these complications it becomes clear that standardization for the purpose of statistical analysis is completely impossible. A final difficulty was touched on already. The individual physician's personality and prestige are an inseparable part of the remedy and where, as occasionally happens, the junio r medical or nursing staff are unsympathetic, critical, or sceptical, this is readily communicated by their more intimate contact with the patient and can do much to destroy this element in cure. A good team can, of course, have the reverse effect. I t is regrettably patent that no statistician could take account of all these possible variables involved in homceopathic clinical experiment, so that the usual and accepted method, as Dr. Brieger has said, is unfortunately quite unsuited to our approach. So that for purely practical rather than philosophical reasons I have come to much the same conclusion as Dr. Brieger: that if ttomceopathy is to be demonstrated to be effective we have to find a new method. I shall be more than interested if someone here today can suggest a way out of the impasse. As Dr. Brieger says, we cannot accept defeat so easily. Only on the broadest possible basis could overall comparisons be made of the comparative value of homceopathic treatment, allopathic treatment, and no treatment. I t could be arranged that in one or more wards of the hospital one physician might treat all his cases suitable to be included in the series by strictly homceopathic treatment, say by high potencies, while in the same wards and with the same staff another physician for the sake of the trial might agree to use low potencies only, while a third might be persuaded to use only orthodox remedies. You can imagine for yourselves how difficult this would be to operate and I fail to see how sufficient standardization of cases or remedies could be made to tabulate any meaningful results. Many hundreds or even thousands of cases are necessary. One could probably get "clinical impressions", but little more. I t might be possible to conduct a limited investigation into the healing powers of individual remedies. For example, we might investigate the powers of Arnica in relation to the prevention or healing of bruises, the effect of the snake venoms on coagulation or lysing of blood in vitro, or clinically in thrombosis or hmmorrhagic states, and hope in these experiments to approach to the controls and criteria demanded by modern research. From such a limited objective the way might well open up to more ambitious schemes. As Dr. Brieger has rightly said, this problem which we face is one which can be solved only by patient observation and recording of facts, as has been done by all the great leaders of our profession. Although it is true, as she said, quoting Goethe, that "one instance is often worth a thousand, bearing all within itself"--and we have all seen examples of this in our experience which have made the deepest impression and changed our entire thinking--this revelation is not granted to all. They have never seen the dynamic of the potentized remedy, and so it remains our duty to attempt to demonstrate the principle of the Law of Similars to their complete satisfaction--and ours.