The Doctor–Patient Relationship as Reflected in the Case Books of Samuel Hahnemann

What were the things that set Hahnemann apart from other doctors of his day – other, that is, than the system of medicine he had discovered? A key difference, undoubtedly, is that Hahnemann expected his patients to consult him at his practice; with few exceptions, he refused to make house calls. ‘[…] In order that we do not waste our valuable time, and compromise our dignity, we must not make house calls to any chronically sick person –though he be a Prince – if that person is able to come to our practice. It is only the acutely ill, bed-ridden patients whom we should visit. Those who are able to get out and about and yet refuse to come to us for their consultation – well let them stay away. That’s all there is to say on the matter. All this running about after patients as the allopaths do is demeaning. You arrive to see the patient and are turned away by the housemaid: the master is at the theatre, has gone out, etc. Pah! You must go on to a second then a third patient, just like an allopath, or a beggar. Pah! […]’ [1] Thus wrote Hahnemann in 1829 in a letter to the homeopath Dr Johann Heinrich Wilhelm Ehrhardt (1794-1848) in Merseburg. Hahnemann kept to this rule even after he moved to Paris, despite the fact that his high-ranking Parisian clientèle were used to having their doctor visit them at their residence. Two years before he died, Hahnemann wrote to his friend and favourite pupil Clemens von Bönninghausen, that patients ‘must come to [my] practice, if they are able to get out and about, however noble they may be’. He justifies this as follows: ‘[…] for I consider it to be beneath the dignity of a true doctor to have to run about after patients who are able to come to me. I will only take my carriage to visit those patients who are confined to bed.’ [2] During the years he practised in Leipzig (1811-1821), it seems Hahnemann handed over all house calls to his son Friedrich. [3]

How did Hahnemann treat his higher ranking patients, above all the Duke, to whom he was personal physician? Did he make an exception in his case? As far as we can tell from the case books, treatment of the Duke took place mostly via intermediaries. In other words, for the most part Hahnemann did not visit the Duke in his castle, and the Duke did not come to Hahnemann’s practice – something that would have been viewed as being beneath him. Here therefore we find that remains of the traditional  patronage system ­– which characterised the doctor–patient relationship to the end of the 18^th century, and to an extent into the 19^th – are still intact.

What was unusual in those days, is now the norm. Homeopaths have their consulting hours at their practice just like any other doctors, and where necessary, they make house calls. But in contrast to Hahnemann’s practice, nowadays it is very rare for a consultation to take place by letter. The telephone has replaced the post, and many homeopaths now have call-in times for their patients to speak with them over the phone. However, a telephonic consultation generally lasts a shorter length of time than a face-to-face consultation. Markus Mortsch has shown that the ratio of personal to postal consultations in the early years of Hahnemann’s Köthen practice was 3:1.

But it is not only methods of communication that have changed over the last hundred years. Hahnemann treated a not inconsiderable number of his patients long distance, i.e. without having the patient in front of him. But only a very small number of these were people whose case-taking and treatment took place exclusively by correspondence. And this despite the fact that many of his patients did not live in the vicinity, indeed, they often lived far away, sometimes beyond the borders of the German Empire. Nowadays, because of the extraordinary developments in transport (car, rail and plane), patients are more mobile. There are also more homeopaths than in Hahnemann’s time. Indeed, Hahnemann complained that after the death of his patron, Duke Friedrich von Anhalt-Köthen, no more homeopaths were permitted to practise in the State. This explains his bemoaning, in a letter to Clemens von Bönninghausen in 1832, ‘and so I have no-one to whom I can send my great excess of patients.’ [4]

Compliance – or: the willingness of the patient to participate in the healing process

The doctor–patient relationship is put under the greatest strain when the patient does not follow the treatment prescribed by the doctor. We know that Hahnemann generally reacted in a surly manner to such patients. His patients were clearly aware of his sensitivity on this matter, and so attempted to justify – to a greater or lesser extent – any omissions or straying from the treatment plan. Here, for example, is Antonie Volkmann, wife of the Lord Justice of Leipzig, writing to Hahnemann: ‘[…] Esteemed Sir, You appear to believe that I have been taking other medication, or not keeping to my diet. But neither of the above have yet come to pass. Right up to the last time I was unwell I have taken no other medication, even by olfaction, and as to my diet, I keep to it if anything excessively strictly rather than too laxly.’ [5] And in a later letter this patient asks explicitly if it is really advisable to take ‘the camphor tincture as prescribed’ [6] for cholera prevention, as she had once before had serious side-effects from this. In this case Hahnemann bows to the patient’s wishes. And on other occasions he also shows himself willing to compromise, but only in matters concerning the method of administration of homeopathic remedies.

This applied particularly to the olfaction of homeopathic remedies, a practice Hahnemann found to be extremely effective, but which he did not feel he could prescribe for all his patients. We learn this in a letter he wrote to Bönninghausen in 1833: ‘But I am not doing this [i.e. prescribing olfaction – RJ] yet, as the public is accustomed to taking powders – even if there is nothing in them. My foreign patients, those from Denmark, Russia and several from France, who have become more acquainted with this practice, are given – and indeed demand to be given – their medication by olfaction.’ [7] Only recently a classical homeopath recounted similar acceptance problems to me. She told me that she successfully prescribed the olfaction of remedies for her family and friends, but that the idea was met with great scepticism by her other patients, to whom she generally prescribed, therefore, globules, powders or tinctures.

And what about those patients who broke off their treatment, who for various reasons decided not to continue with homeopathy? Hahnemann of course had such patients. But for the most part we know nothing about their motives, for they are never mentioned again in the case books – though we cannot exclude the possibility that this is because they had died or perhaps were completely cured. It is only by chance, therefore, that we occasionally learn of the reasons that led particular patients not to continue to seek Hahnemann’s advice. One such case is that of a young patient by the name of Jenny von Pappenheim, whom Hahnemann treated in 1829-30 for depression caused by an unhappy love affair. We find the following entry in his case book for 17 February 1830: ‘[…] she feels she is no longer in need of my assistance. If she were to experience a relapse, however, she may call on my beneficial services once more, which have freed her so happily from her burdensome ills, and restored to her her youth and health.’ [8] But this is less a case of her and Hahnemann agreeing to break off the treatment, than of the treatment’s having been successful; in the event of a relapse, it would be continued with no difficulty. There were other reasons too for people recommencing treatment they had previously broken off. For example, there is the case of the Captain from Erfurt whose professional responsibilities meant he was forced to interrupt his treatment, but he re-established contact with Hahnemann some time later. [9]

And on the subject of patients who broke off their treatment, we are finally in a position to be able to solve the mystery surrounding the case-history of one of the most famous of Hahnemann’s patients. It has long been a matter for speculation why the famous violinist Nicolò Paganini only consulted Hahnemann twice. It had been assumed that Hahnemann’s treatment of this severely ill musician, with doses of Pulsatilla, had been unsuccessful. Paganini, after all, already had a long history of illness. However, as I discovered thanks to a serendipitous find in the Library of Congress in Washington D.C., the truth is actually much more banal. The doctor–patient relationship was put under severe strain due to Paganini falling madly in love with Hahnemann’s young wife, Mélanie d’Hervilly, at his very first consultation. Mélanie was working at that time as her husband’s assistant, and she also treated some patients herself – though only those without means. A strongly worded letter from Mélanie to the enamoured patient, in which she gave him to understand that he could not hope for any reciprocation of his love, led to both sides preferring not to continue with the treatment. [10]

Alongside the few dissatisfied patients, given their marching orders by Hahnemann, there were a remarkably large number who stayed faithful to their doctor, even when their treatment was only moderately successful. Many of these patients followed Hahnemann’s instructions to the letter – some even went beyond that. Karl Höde from Ziebigk, for example, admits to Hahnemann in a letter that he had been taking the medication sent to him more frequently than prescribed. [11] And then last but not least, there were the patients who couldn’t get enough instructions from Hahnemann. Of Frau Kranske from Leipzig, for example, Hahnemann wrote in his case book on 13 April 1830 that she was ‘very sensitive to my refusal to write more often’. [12] Hahnemann was clearly not prepared to write to his patient more often than he felt her case warranted.

The question of payment

Lastly, we come to the matter of paying for the medical services rendered, another factor that plays a role in the doctor–patient relationship. It played an even bigger role in Hahnemann’s day than in ours, given that for the most part now state or private health insurers and doctors’ professional associations take care of the financial side of things between themselves, without the direct involvement of the patient.

Hahnemann required his patients to pay for their treatment in advance, and in cash – something that was most unusual for the time. We can see how his pricing and billing system worked from descriptions such as the following, which is by his pupil Dr Franz Hartmann: ‘The cheapest price for 6 numbered powders, only one of which was medicated, and either 3 or 2 of which were to be taken daily, was 16 gute Groschen. The rich were charged between 1 Thaler 8 gute Groschen and 2 Thaler – or else he had them pay the sum of 10–12 Louisd’or in advance, which after some time he demanded of them ad libitum again.’ [13] It was this last practice in particular, that of payment in advance, that some of his contemporaries felt went against the grain, despite the fact that it was common at the time for well-to-do patients to engage a personal physician on an ongoing basis, whom they paid a flat fee. This fee, however, was only payable at the end of the year, which meant the debtor could delay, reduce or even refuse payment.

Hahnemann seems to have been more aware of the morals of many patients when it came to settling bills than most of his opponents who – afraid of the competition he posed – accused him of avarice. Hahnemann can be seen to have been a realist and pragmatist in this regard, a man with his finger firmly on the pulse of the business side of running a medical practice. One of the most vivid accounts we have of his views on this matter is contained in a letter he wrote to his pupil Friedrich Rummel (1793-1854), from Köthen on 19 May: ‘[…] and so the purely homeopathic doctor is also advised to value his infinitely better form of treatment highly enough, and thus to get a better price for it; the chronically sick, at least, should pay a monthly fee (preferably in advance), and the little man should pay an amount at each consultation and prescription – even if it is only a few Groschen each time – accipe dum dolet. In this way the doctor shall never leave empty handed, and he remains of good cheer seeing cash in return for his efforts. These small sums, if paid without fail on each and every occasion, grow imperceptibly into a larger amount, and the patient who pays each time barely notices a dent in his pocket, as he is paying only little by little, so that when he is well again, or breaks off his treatment prematurely, we are finished with him: he has nothing to demand of us, and we nothing of him. He parts from us, if not with satisfaction and thanks, then at least never with ill-will – he has forgotten all about that which he has paid out over time, and the doctor has what is reasonably due to him, and it accumulates, without any vexation on the part of the patient, in his doctor’s purse.’ [14]

We can see from the case books and the patient letters we have that most patients were willing to pay Hahnemann’s charges, which were by no means cheap. This goes for the less well-off amongst them too, who often had to plunder their meagre savings to find the money necessary for a course of homeopathic treatment, which was not necessarily cheaper than allopathic treatment, and which might continue for a considerable length of time. Friederike Lutze, one of Hahnemann’s many female patients makes it plain in another of her letters to Hahnemann that such financial worries often added to the woes experienced by patients: ‘[…] my protracted illness has already cost me dearly, and the worry of how I am to meet these costs is not the least of the anxieties that weigh me down and fill me with fear.’ [15] Against this background we can see what an achievement it is that in some countries state medical insurance now covers, to a certain extent, the cost of homeopathic treatment, thus lifting from patients’ shoulders the burden of this financial worry.