Homeopathy (2014) 103, 208e212

Ó 2014 The Faculty of Homeopathy

http://dx.doi.org/10.1016/j.homp.2014.03.003, available online at http://www.sciencedirect.com

HISTORICAL

Hahnemann and placebo

utte*
Robert J€

Leiter des Instituts f€

ur Geschichte der Medizin der Robert Bosch Stiftung, Straussweg 17, D-70184 Stuttgart, Germany

Samuel Hahnemann (1755e1843) known today as the founder of homoeopathy, was e

as far as we know e the first physician who administrated placebos to his patient on a
systematic and regular basis. This study is based upon unpublished documents (e.g. pa-
tients’ letters) in the Archives of the Institute for the History of Medicine of the Robert
Bosch Foundation in Stuttgart. It also profited from the critical edition of Hahnemann’s
case journals and the editorial comments which have also been published in this series.
Hahnemann differentiated clearly between homeopathic drugs and pharmaceutical sub-
stances which he considered as sham medicine (e.g. milk sugar). A close look at Hahne-
mann’s case journals reveals that the percentage of placebo prescriptions was very high
(between 54 and 85 percent). In most instances Hahnemann marked placebos with the
paragraph symbol (x).
The rationale behind this practice was that Hahnemann had encountered the well-
known problem that patients were used to taking medicine on a daily basis as it was
typical for the age of heroic medicine. The main reason for giving placebo was therefore
to please the impatient patient who was used to frequent medications in allopathic med-
icine, not only every day but sometimes also hourly. Homeopathy (2014) 103, 208e212.

Keywords: Hahnemann; History of homeopathy; Placebo

How the term placebo entered the sors at the Edinburgh Medical School, who disseminated
this term in British medical circles. In 1772/3 he used for
medicalsphere the first time the word ‘placebo’ in his popular clinical lec-
The term ‘placebo’ has not been part of medical usage tures. He referred to a patient to whom he gave an external
for very long, but the phenomenon we refer to as the ‘pla- application of mustard powder although he was not
cebo effect’ has been known in medical as well as lay cir- convinced of its specific effect: “I own that I did not trust
cles for a long time.1,2 It was not until the second third of much to it, but I gave it because it is necessary to give a
the 18th century that the phenomenon, or at least a medicine, and as what I call a placebo. If I had thought
partial aspect of it, was first referred to as ‘placebo’. In of any internal medicine it would have been a dose of the
this period the term ‘placebo’ became part of medical Dover’s powders.”4 In another case which he also consid-
jargon. In contrast to the prevailing opinion that it was ered to be hopeless he prescribed a kind of palliative med-
the Scottish physician William Cullen (1710e1790) who icine that was ineffective in his view. He justified his
introduced this expression into medical language in 1772, ethically doubtful decision as follows: “I prescribed there-
the credit must be given to another English-speaking physi- fore in pure placebo, but I make it a rule even in employing
cian, Alexander Sutherland (born before 1730-died after placebos to give what would have a tendency to be of use to
1773) of whom we hardly have any biographical informa- the patient.”5 (Cullen, 1772).
tion.3 But it was Cullen, one of the most influential profes- Cullen’s ‘placebo’ was, however, not an inert substance.
He tended to use low doses of drugs (a kind of pseudo-
placebo) which he thought to be ineffective given the
*Correspondence: Robert Ju € tte, Leiter des Instituts fu
€r
severity of the disease. His main concern was not what to
Geschichte der Medizin der Robert Bosch Stiftung, Straussweg prescribe but how to fulfil the patient’s desire for a remedy
17, D-70184 Stuttgart, Germany. even though he did not personally believe in its pharmaco-
E-mail: [email protected]
Received 13 April 2012; revised 3 February 2014; accepted 4
logical effectiveness (according to the state of knowledge
March 2014 at the time).
 Hahnemann and placebo
R J€utte
209
Hahnemann and placebo of the drugs administered to this patient were non-medici-
nal.8
Thirty years later, a German doctor by the name of
Samuel Hahnemann (1755e1843) known today as the
founder of homoeopathy, was e as far as we know e the Hahnemann’s forms of placebo
first physician who administrated placebos to his patient In his case journals covering the period from 1801 to
on a systematic and regular basis. Although his rather idio- 1843 Hahnemann usually marked placebos with the para-
syncratic translation of Cullen’s Materia Medica into graph symbol (x) (for example: D 38, 172, line 19). This
German triggered the famous experiment with Peruvian sign might have been imbued by the abbreviation for sugar
bark (which actually started his work on a new art of heal- in pharmaceutical literature which is ‘ff’. A single placebo
ing, later labelled homoeopathy), Hahnemann was obvi- powder weighed 0.12e0.18 g. These powders were admin-
ously not familiar with the Clinical Lectures by the same istered by handing out to the patient small wrappers or en-
author. For this reason he did not come across the term ‘pla- velopes which had no labels and were merely numbered.
cebo’ used by the famous Scottish professor. But there can “If the patient should wish to take medicine every day the
be no doubt e as we shall see later on e that Hahnemann homoeopathic physician may give him every day a dose
knew the underlying principle, i.e. giving ‘something non- of sugar of milk of about three grains, all these powders be-
medicinal’ to an anxious patient expecting at least some ing marked with successive numbers”.9 The patient there-
kind of treatment. fore did not know which of these contained homeopathic
drugs and which just lactose. Hahnemann even thought
Methods about a system in which concealment could be achieved
by sending a patient to a local pharmacy where the apoth-
Hahnemann’s medical case journals starting in 1801 and ecary dispensed homeopathic drugs and placebos without
ending in 1843 are a unique source for studying Hahne- being able to differentiate between the two in order not
mann’s medical practice. Parts of this unique treasure to influence the patient.6
have been published in recent years. Some volumes of Another sign for placebo is a small zero (o) below the
this edition have been studied in depth by homoeopaths line (for example: D 38, 41, line 32), indicating that Hah-
and medical historians, revealing an ‘unknown’ Hahne- nemann gave the patient a non-medicinal globulus. In
mann, always willing to experiment for the benefit of his some cases he dispensed with a special sign for placebo.
patients. The following analysis is based upon unpublished Instead he used an apothecaries’ weight (ounces) preceded
documents (e.g. patients’ letters) in the Archives of the by numerals. This combination also indicates that the pa-
Institute for the History of Medicine of the Robert Bosch tient received a placebo.
Foundation in Stuttgart. It also profited from the critical After first experimenting with ground oyster shells
edition of Hahnemann’s case journals and the editorial (conchae) as placebo at the beginning of his homoeopathic
comments which have also been published in this series. practice, Hahnemann later on almost exclusively gave
lactose in these cases to which the homoeopathic Materia
Theimportant role of placeboin Medica (and modern pharmacology too!) does not attribute
a medicinal effect. However, till the mid-1820s, Hahne-
Hahnemann’s practice mann continued to give conchae which later (1828)
Many people still believe that homoeopathy is a placebo. became part of the Materia Medica (calcarea carbonica)
For them it must come as a surprise that Hahnemann unlike as placebo, especially to children.6 The 4-year-old
most of his contemporaries was already familiar with a daughter of a coachman, for example, received 1822 eight
phenomenon which we call today placebo effect. First, conchae as placebo (Case journal D 22, 412, line 29).
he differentiated clearly between homeopathic drugs In a footnote to the first edition of his work on Chronic
administrated in line with the law of similars and such Diseases which appeared in 1828 (first English translation
pharmaceutical substances he considered quite rightly as in 1845), Hahnemann explained why he had finally chosen
sham medicine (e.g. milk sugar). Second, as far as we milk sugar as his favourite placebo:
know, he was the first physician who systematically used “There are hypercritical homoeopathic physicians who
a single blinded approach in therapy. This means that the were afraid that even the sugar of milk might obtain medic-
patients were kept in the dark about the identity of the inal qualities from being long kept in a bottle, or from long
drugs. trituration. Long-continued experiments have convinced
A close look at Hahnemann’s case journals reveals that me that this apprehension is unfounded. Both the raw
the percentage for placebo prescriptions is very high. In and the prepared sugar of milk may be taken as nourish-
his case journal no. 22 from 1821 85% of the medications ment in considerable quantity without the least disagree-
are placebo.6 This is also true in regard to his later years. In able symptoms being experienced from it. Fears have
the period between 1833 and 1835 more than half (54%) of also been entertained that, in triturating the medicinal sub-
Hahnemann’s prescriptions are placebo.7 The few medico- stance in a porcelain mortar, particles might become de-
historical studies on individual patients treated by Hahne- tached from this latter, and that the triturating process
mann, e.g. the father of the famous German musician Clara might change them to powerfully active silicea. To ascer-
Schumann, Friedrich Wieck, also reveal that up to a quarter tain whether such fears were founded, I caused one

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 Hahnemann and placebo
R J€utte
210
hundred grains of sugar of milk to be triturated with a new from each. Of course, he ought not to know whether any
porcelain pestle in a porcelain mortar, the bottom of which or all of the powders contain medicine.”10
had been recently polished; thirty-three grains were taken The main reason for giving placebo in homoeopathy was
at a time. They underwent the process of trituration eigh- therefore to please the impatient patient who was used to
teen times, each trituration lasting six minutes. Every frequent medications in allopathic medicine, not only
four minutes the mass was stirred up with a spatula. The every day but sometimes also hourly.
object of this frequently repeated trituration, which lasted Studies on Hahnemann’s case journals found out that the
in all three hours, was to impart medicinal qualities, either founder of homoeopathy gave placebo to his patients also
to the sugar of milk, or, at any rate, to the particles of sili- for other reasons:
cea which might have been separated from the mortar; but,
 Hahnemann himself was not sure whether he had found
from experiments which I have made upon highly suscepti-
the right homeopathic drug.
ble subjects, I have been obliged to infer that the prepared
 The patient looked in his eyes so sensitive that he wanted
sugar of milk is no more medicinal than the sugar in its raw
to find out first how this patient would react to placebo.
state; its only quality is that of being nutritious”.10
 If a female patient began to menstruate during the treat-
In the early days of his homoeopathic practice Hahne-
ment, Hahnemann stopped the verum treatment and
mann even used coloured placebos: “6 [ounces] 3 [scru-
gave placebo.
ples] jjj red” (Case journal D 16, 534, line 35). We can
 If a patient was used to drinking tangy beer e which Hah-
assume that he used raspberry juice for this which he
nemann thought might have medicinal ingredients e this
considered pharmacologically as non-specific.11
person was temporarily treated with placebos.
Some examples from the case journals help to illustrate
Hahnemann’s pragmatic approach:
Reasons for giving placebo
 A patient named Barthols: “Bell[adona] did not yet take
Early on in his homoeopathic practice Hahnemann
its full effect. Therefore only 14 o x and soon Calc R.”
encountered the problem that his patients were used to tak-
(Case journal D 38, 28, line 44)
ing medicine on a daily basis as it was customary in ortho-
 Treating a child Hahnemann noted: “today once again 6 x
dox medicine at the time. In homoeopathy, however, it was
[scruples] j in order not to rush, as the child feels other-
important, in his view, to allow the remedies to fully unfold
wise well.” (Case journal D 16, 312, line 17/18)
their action. In an essay that was printed in the Allgemeine
 A patient named Werther got only placebo because he
Anzeiger der Deutschen in 1814, Hahnemann offered the
had taken allopathic medicine (herbal tea) just before
following recommendation to his colleagues: “In the mean-
he came to Hahnemann: “drank this morning pansied
time, until the second medicament is given, one can soothe
tea, therefore only 6 x [scruples] j.” (Case journal D
the patient’s mind and desire for medicine with something
16, 415, line 45)
inconspicuous such as a few teaspoons a day of raspberry
 About a female patient: “As menstruation has just
juice or sugar of milk.”12 In his work on chronic diseases
started, 6 [ounces] in the future to be mesmerized again.”
treated with homoeopathic drugs he advised: “No popular
(Case journal D 16, 473, line 14)
habit, were it ever so injurious, can be abolished all at
once. This is the reason why the homoeopathic physician
cannot avoid giving to his patients a powder every day;
though this appears considerable, nevertheless, there is a
Deception
good deal of difference between this daily administration What did Hahnemann think of deceiving the patient? He
of a powder and the alloeopathic practice. It is a great was fully aware of the fact that his patients were not sup-
blessing for the patient, in taking these powders, marked posed to know that they received placebo. He even used
with successive numbers, especially when he has been pre- the word ‘deception’ for his action. What mattered to
disposed against the more rational method of cure by the him was the goal: “Patients who have firm confidence in
artful insinuations of calumniators, not to be able to distin- the honesty and skill of their physician, will have no hesi-
guish the powders containing the medicine from those con- tation to be satisfied with a dose of sugar of milk, which
taining the pore sugar of milk. If he knew that the medicine, may be exhibited every two, four, or seven days, agreeably
of which he expects such brilliant results, is contained in to the wishes of the patient; such a course will never lessen
any particular powder, he would often be imposed upon their confidence.”10
by his fancy; he would imagine to experience effects which In Hahnemann’s world view shared by many, also allo-
he would set down as real, and he would be in a constant pathic doctors until modern times, there was no place for
state of excitement. By the system which I propose, all these ethical consideration of the kind we have to day when phy-
disagreeable consequences are avoided. The patient, who sicians ask themselves whether they allowed to give a pa-
knows from experience that he need not expect any painful tient a placebo without telling him on legal or moral
effects from the medicine he takes, calmly observes the grounds. Hahnemann was already aware e as we have heard
changes which are really going on in his system, and re- from his own mouth e that the effective use of placebo re-
ports to his physician facts, and not illusions. By taking a quires a stable doctorepatient relationship e a fact which is
powder every day, the patient will expect same effects corroborated by recent studies on the placebo effect.13,14

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 Hahnemann and placebo
R J€utte
211
Hahnemann knew too well that concealment was not al- followed certain rules: The medicinal powders were
ways successful. One of his patients, also an eager reader of administered by handing out to the patient small wrappers
his writings, had seen through the deception, but still re- or envelopes which had no labels and were merely
mained loyal to Hahnemann: “The powder I took regularly numbered. The patient therefore did not know which of
although I am well aware that only number (figure illeg- these packages contained homeopathic drugs and which
ible, RJ) is a medicine as instructed in your worship’s just lactose. Hahnemann even thought about a system in
books which I looked into.”15 which concealment could be achieved by sending a patient
to a local pharmacy where the apothecary dispensed ho-
meopathic drugs and placebos without being able to differ-
Discussion entiate between the two in order not to influence the
What catches one’s eye is the large extent of the delib- patient.
erate use of placebos in Hahnemann’s homoeopathic prac- After first experimenting with ground oyster shells as
tice. The main reason was to satisfy unduly demands by placebo at the beginning of his homoeopathic practice,
patients. But Hahnemann never thought of placebo as a Hahnemann later on almost exclusively gave lactose.
means to itself. In a letter to his pupil Ernst Stapf Long-continued experiments had convinced him that
(1788e1860) he stated: “The homoeopathic physician milk sugar was pharmacologically inert as this easily avail-
must come to a point when he refused to give placebos able substance may be taken as nourishment in consider-
[the German original has Schein-Arznei, sham medicine, able quantity without any side-effects.
RJ] and will only give the helpful remedy when and where Early on in his homoeopathic practice Hahnemann
required.”16 This dictum is still true for everybody who encountered the problem that his patients were used to tak-
practices homoeopathy in our days. ing medicine on a daily basis as it was customary in ortho-
Today we make the distinction between pure placebos dox medicine at the time. The main reason for giving
(substances with no pharmacological effect, e.g. sugar placebo was therefore to please the impatient patient who
pills) and impure placebos (substances with pharmaco- was used to frequent medications in allopathic medicine,
logical effect but not on the condition being treated). not only every day but sometimes also hourly.
In the late 18th century those physicians who already Hahnemann was fully aware of the fact that his patients
prescribed placebo one upon a while usually thought were not supposed to know that they were receiving pla-
of drugs which were considered not very effective in cebo. He even used the word ‘deception’ for his course
the particular case, e.g. a mild ointment. At the same of action. In Hahnemann’s world view shared by many,
time, only very few brilliant minds such as Samuel Hah- also allopathic doctors until modern times, there was no
nemann came up with the ingenious idea of using inert place for ethical consideration of the kind we have today
substances as placebo. An alternative to milk sugar when physicians ask themselves whether they are allowed
used as placebo in homoeopathy was bread pills. The on legal or moral grounds to give a patient a placebo
earliest references I could find date from the 1780s. without telling him so.
An article which appeared in 1787 in the German jour-
nal Allgemeine Deutsche Bibliothek reports of an exper-
iment in which a doctor gave his female patient rather Conflictsof interests
expensive looking pills made from breadcrumbs covered
The author declares there is no conflict of interests.
with silver instead of a strong purgative. The sham med-
icine showed the same results. After the physician had
told the patient about the true nature of the presumed References
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