Taking the case

By | August 19, 2015

By C. M. Boger

The proficiency of the physician’s daily work, rather than the flash of genius which makes an occasional brilliant cure, is the final measure of the successful practitioner. His abilities will very largely depend upon the powers of observation and proficiency in details. No branch of medical research will enhance this more than the exhaustive study of physical diagnosis, for it bears a close and many-sided relationship to our symptomatology. In a sense therapeutics and physical diagnosis are mutually interdependent, the one helping to interpret diagnosis should be as accurate as the fitting of the remedy. We must not only diagnose sickness in its larger sense but the comprehension of its picture will most certainly limit our grasp of the remedies from which a choice may be made. This is especially true of localized affections.

The location
Different drugs affect different parts, tissues and functions of the organism, but the final reason why one depresses and another excites, or one either heightens or lowers activity according to dose and circumstances, remains substantially unknown in spite of researches into drug affinity which seemingly push it further and further into obscurity.

The study of regions implies a discovery of the seat of the disease and of the remedies related thereto. A large number of drugs are known principally by their regional effects; many of them are imperfectly proven and crudely applied because their drug image is not well rounded out. They are often prescribed for specific, antipathic, palliative or suppressive effects. This is especially, although not exclusively, true of the use of low potencies or crude drugs. In a general way drugs which affect the same or similar tissues bear a certain relation to each other and are differentiated through the mental sphere and the modalities. Each holds some other as its acute or chronic counterpart; the mental state of the one being generally the opposite to that of the other.

Baryta carb in common with Apis affects the the lymphatic system, but their respective mental states are almost diametrically opposite. While the former stamps its dyscrasic character upon the mind and countenance, the latter is its acute complement. The Baryta carb. Constitution takes on Apis symptoms when the lymphatics show the presence of a blood infection. Similarly the chronic Sepia patient displays Lachesis symptoms in the presence of alcoholism.

The origin
In ordinary parlance we speak of the etiology of disease, but for us these old school ideas are far too narrow because the radius from which we draw our information is wide and may include any influence whatsoever. Things, in themselves apparently very trivial may become of the greatest import when related to the beginnings of disease. Sickness arises from extrinsic as well as autogenetic causes. The former are in a general way more accessible and therefore more accurately defined. They embrace the susceptibility to certain external influences which pervert the vital force, injuries, the state of the weather, heat, cold, dampness, physical exertion, etc.

Taking the case
Autogenetic causes often have mental states as their starting point; the effects of grief; worry or fright are good examples. Emotional states may be the beginning of a long train of untoward manifestations for which the simillimum cannot be perceived until they are given a proper place in the pedigree of the disease and as the mind does not always readily disclose such things they may be difficult to discover. Whether the causes come from without or arise from within, the homoeopathic simillimum cannot be chosen with safety without taking them fully into account. The great miasms belong to this class.

The modality
Closely related to the cause, are the circumstances under which disease, and the conditions which modify it, makes its appearance. These are commonly known as the modalities; they individualize the most suitable medicine cannot be chosen while they remain unknown. They include such modifying agents as the effect of posture, the different kinds of motion, the various forms of heat and cold, the effects of the weather, or bathing, washing, getting wet or any modifying agent whatsoever. Many odd or strange modifying influences also occur; they belong to but few remedies and are not often seen in practice, but possess the highest value. A striking instance of this kind is found under Clematis which has an eczema which is moist during the increasing moon but dries up during the waning moon. We now know that this modality belongs almost exclusively to Clematis and that any symptoms having it will almost certainly belong to this great antisycotic, whether it be a skin eruption or a goitre. Conditions which modify or excite mental symptoms are not exceeded in importance by any others. To these belong the influence of the emotions, of fright, grief, solitude or company, thinking of the disease, consolation, vexation, etc., on the mind. “Pain which excites to anger” is an excellent example.

The mind
The mind is a subjective as well as an objective index which reveals the bias which rules the whole case. Rarely do we see a mental exaltation or depression coupled with an opposite physical state, but when we do its remarkableness points the indication. The relative activity of the intellect combined with its moral trend is an invaluable aid and should always if possible be ascertained. A study of the mental symptoms should include the gross objective changes noted by the attendants as well as a close scrutiny and interpretation of the speech, action and countenance by the physician, for the mind mirrors itself with great accuracy in the different modes and manners of physical expression. An intonation of the voice may sometimes explain the source and meaning of a particular symptom, so intricate are the mental processes. It is to be remembered that changes in the ordinary moods are points of departure whose value depends upon their variation from the normal or everyday condition.
The concomitants As a group the concomitants contain many anomalous and peculiar symptoms. They are often so distinctive of a remedy as to render the name of the disease under which a peculiar symptom may occur of little moment. Nevertheless the modalities, mental accompaniments and duration of an unusual symptom govern its position. When these go to make up a harmonious picture it becomes a true characteristic, otherwise it has only a negative value.

Sometimes the affected organ seems overwhelmed by the impact of the disease and the vital powers can find expression through the concomitants only; then they become of supreme importance as the almost sole guide for the selection of the remedy.

The value of a concomitant is often fixed by its age. The acute or more recent ones are of course the most guiding, for within their genesis lies bound up the type of the simillimum. Remedies suitable for acute vital disturbances stand in an accessory relation to the constitutional or antipsoric drugs. They are capable of correcting the irregular expenditure of energy which may temporarily be imperilling the life of the patient but are mostly impotent to remove the great fundamental dyscrasias which they nevertheless have the power to uncover or arouse into activity. To combat the latter we have the great antipsorics of Hahnemann and unless we have at least some comprehension of the correlative relation of the two classes we may find ourselves opening a Pandora’s box. The alternator and mixer, owing to the spurious teaching so long prevalent, often has the embarrassment of finding himself in this predicament, that is, if he is capable of seeing it.

The presence of an old constitutional symptom belonging to the miasms, although it may be peculiar, should not mislead us into following it during an acute illness, unless because of its malign presence the drug, pictured by the recent sickness fails to act.

The peculiarities In making an examination it is generally best to allow a free statement of the case in the patient’s own way while we take pencil memoranda of the salient points, gradually filling in the deficiencies by such questions as the notes suggest.

As every sickness, whether natural or induced, is the child of a combination of events which never again produces its exact self, it follows that the best indicated remedy is the one holding the closest similitude thereto in location, origin, modality, mental condition, concomitants, peculiarities and time. Objective phenomena, being exempt from self-interpretation and allowing the largest scope to the acumen of the examiner are withal the least deceptive and should receive our first and best attention. They teach lessons not to be learned elsewhere, and by their great utility have contributed much to the brilliant success of Homoeopathy, particularly in the diseases of children. The facial expression, the involuntary posture, the temperature both localized and general, alterations of colour or consistence, the state of the reflexes including sensibility, the odour of the patient, etc., are but a few of the points to be noted. Nothing should escape the observer, for faulty examinations are the main cause of failure. Most subjective symptoms have an indefinite character or are common to many disorders, therefore deserving of little attention. It is only when an ordinary symptom appears in an extraordinary place or way that it becomes of much value.

Sensations are expressed according to the mentality of the subject and vary from the simple indefiniteness of those of childhood to the hysterical loquacity which takes on every symptom thought of: it therefore follows that the attributes of the symptoms are of far greater importance than the sensations themselves. In certain cases by paying more attention to the time, manner and circumstances under which a given symptom occurs we succeed in not only diverting the mind of the patient, but in gaining a great deal of very valuable information.

Every sickness possesses a more or less definite individuality which is reflected by those symptoms which in their nature epitomize the various attributes of the whole case, the characteristics. They may not belong to the pathogenesis of any known remedy, and even if they do, their setting may only accentuate their unsuitableness to the concrete case under consideration. Such a case must then be worked out by means of the modalities, mental symptoms, etc., then if the peculiar symptom disappears along with the others it may be kept under observation for future confirmation. The available key-notes are inadequate to answer all purposes. It is far better to be able to see the general picture and use the key-note as a differentiating point, just as we would use a modality. The key-note characterizes the case much more than it does the remedy, because its position in the picture is always modified by the accessory symptoms. The self-same symptom may be the guiding one in certain instances and of little or no consequence in others, according to its surroundings, its modalities and origin. The diagnostic and common symptoms as shaded by the general modalities from the ground colour of the picture, from which its special features portraying the individuality emerge with more or less distinctness. The focal point of the scene reveals its inherent genius with which the outlying parts must harmonize, if we wish to fully grasp its meaning. Running after key-notes while paying scant attention to the general harmony of the picture has spoiled many a case and leads to polypharmacy.

The time
Symptoms which return at stated times become important in proportion as the sickness of which they form a part diverges from the malarial type or is not connected with naturally periodical functions. A few remedies have such a remarkably exact periodicity as to distinguish them from among all the ordinary anti-periodics, but in spite of this, they have not been found to be even as frequently useful in intermittants as many others having a much less marked periodicity. They are more suited to erratic forms of malaria, such as malarial neuralgias, etc. Aranea, Cedron and Sabadilla seem to hold the chief rank among them.

There are certain other remedies which exhibit their action during a more or less definite time of the day; among the most prominent are Natrum mur., 10-11 p.m. ; Apis, 3 to 5 p.m. and the well known Lycopodium from 4 to 8 p.m.

The different divisions of the day have a large number of medicines each, from among which a few stand out prominently. We have Pulsatilla in the evening; Rhus tox. and Arsenicum right after midnight and many more. The action of some medicines coincides with the time periods of the sun, moon or the seasons, and thus affords peculiar differentiations by which we may pick them from among others. That drugs may also exhibit cycles of action corresponding to other planetary influences seems very reasonable but has as yet not received much attention. Many plants are known to show certain manifestations at particular hours of the day. According to the doctrine of signatures they have a meaning for us if we are only wise enough to see and use them. When we bear in mind that the universe moves forward in obedience to laws which work harmoniously and that every part thereof bears a definite relation to every other part, no fact however insignificant remains without value. Such things are the little hints thrown out to attract our attention, the rest we must do for ourselves.

In conclusion As the preservation of health depends largely upon an harmonious mental as well as physical adjustment to our surroundings we as healers of the sick must perforce remember that our dealings are with vital processes indissolubly connected with the expenditure of force gathered and stored by the human economy from food and from the media in which it moves. That the intake of energy cannot be shown equal to the outgo need only trouble the materialist, for we do not live by bread and meat alone and the inflow from the infinite is measured by the capacity to receive. The common parent to our ills is ignorance, and when the future once reveals a just apprehension of our natural position and we live to fill it, the simillimum will be less frequently called into requisition.