TAKING THE CASE by H.A. Roberts
Dr. Robert’s comments on case taking. …
(***SEE *Organon, Paragraphs 83-104.) In taking the case, the homoeopathic physician has two objects in view. First, there is the object of diagnosis. This is to place your difficulty in a group class. The homoeopathic physician can have no other object in making a diagnosis than to classify the symptoms under a group head, since the homoeopathic physician never uses his diagnosis for therapeutic purposes. In this he differs from the ordinary school of medicine, which uses the diagnosis as a guide to the desired therapy, certain group conditions determined by the diagnosis determining the therapy to be applied.
With the homoeopathic physician, the group is never treated as a unit; the individual patient, into whatever diagnostic group he may fall, is treated as an individual, and the therapeutic measures are directed according to the individual symptoms.
Therefore, the second and greater object in the taking the case is to select the true symptoms of the patient, and to clarify them so that we can make a definite picture of the ills of the patient.
Many of the things of which we speak, when it comes to taking the case, may seem very commonplace, but there is nothing in the practice of homoeopathy upon which so much depends as the thorough comprehension of the background that we must have in taking the case, and getting the case properly before us for analysis. The presentation of the case should include the whole picture. We cannot depend upon our memory in taking the case. The picture must be preserved in indelible form, in a form which we may go over in review without the danger of leaving out any important symptom; we must be able to turn back to any individual symptom or group of symptoms at any time. So as the first requisite in taking the case, you must have your record cards with you to note down the case as it is taken. So much depends upon this record that you cannot afford not to take the time for properly recording the case.
In making the first prescription, this record is all-important; and in the making of subsequent prescriptions and in reviewing the case so that we may know the sequence of symptoms and the order of disappearance of the symptoms, we cannot move with any degree of assurance unless we have the record in accessible form.
The attitude of the physician should be one of absolute rest and poise, with no preconceived ideas nor prejudices. He should be in a quiet, listening attitude, and as the case is presented to him he should have no previous impressions as to what remedy the patient will require, because this of itself would bias his judgment.
The first thing to note is the patient’s name, age, sex, vocation and, if possible, avocation. Then we are often greatly helped by getting a record of the family; that is, the age of the parents, their general health, and cause of death if they are deceased. This applies to brothers and sisters also; and we must not neglect to get a picture of the types of ailments from which they have suffered. We often get a good picture of hereditary tendencies in this way. Find out, if possible, if there is or has been blood relationships between ancestors. Consanguinity plays an important part in hereditary tendencies as well as in making your prescription (*Phosphorus).
Now we are ready to proceed with the record of the patient himself. Let us begin to record his past illnesses. What illnesses has he had? How about his recovery from each illness? Particularly note whether he reports himself as fully recovering from illnesses, or whether he says he “has not been well since” any particular illness.
Now ask the patient to tell you in his own words how he became ill and exactly how he feels. Do not offer any interruption, lest you break his thread of thought. As you record the symptoms, leave space between them so that you can fill in later answers to questions as it may be necessary. If he comes to a point where he seems to hesitate, simply ask, “What else?” Continue this system of interested listening until he (seemingly) has exhausted his story.
Then you are ready to review the case as it has been given to you. Perhaps before we go into the next step, the questioning by the doctor, it will be well to state the things we must ***NEVER do. We cannot place too much emphasis upon the absolute necessity of leaving these things undone.
I. Avoid all leading questions. By leading questions, I mean questions that suggest answers to the patient, or suggest that you want to bring out certain answers. Some patients are desperately anxious to have answers suggested to them and the physician must be constantly on his guard to avoid doing so.
2. Never ask direct questions, that may be answered with a direct affirmative or negative.
3. Never ask alternating questions.
4. Avoid questioning along the line of a remedy. Sometimes we may get a clue from the statement of a symptom that may suggest a certain remedy, and we must be very cautious not to allow this to prejudice us in favour of the remedy suggested by questioning the patient along this line, and thus perhaps bias the patient in his replies.
5. While you are dealing with one symptom, confine yourself to that symptom. Never skip from one symptom to another at random, as it confuses the patient and scatters the physician’s ideas.
Now we will return to the necessity of rounding out the symptom picture in our record. Some symptoms may have been given with a fair degree of completeness; others are very incomplete. We must complete, as far as possible, every symptom that has been presented, and for this careful questioning is necessary. Each symptom must be rounded out as to time and place; the sensations; the kind of distress; the type of pain; all of the modalities connected with it; the probable causation, that is, what the patient thinks was the start of the trouble. Under the modalities, we must secure the aggravations and ameliorations of each individual symptom, so far as possible. Not the least important is the emotional reaction of the patient.
When we work out the recording of the case in this way, we cover all the parts of the man, and can see the picture as a whole. We must leave nothing uncovered. In order to do this, we may have to bring into play the testimony of the family or nurse on symptoms or conditions that may have a bearing of considerable value. However, this source of information must always be scanned with a great deal of circumspection and we must weigh the integrity of the source as being worthy of consideration.
With the most careful recording and the most cautious questioning we may be unable to find complete symptoms and may be unable to build up more than a sketch of the patient himself. We will deal with this in a later chapter.
In acute illnesses, take the acute symptoms, carefully record each one, and find out all there is to know about them. Likewise in the chronic picture, record all the symptoms as far back as you can dig out the symptoms, and the sequence of the symptom pictures, and prescribe for that state. However, if you are dealing with an acute condition, limit yourself to dealing with the acute state alone and do not at the same time attempt to dip into what has been a chronic state. Acute manifestations show themselves with surprising clearness, and to include chronic symptoms that have been manifest at other periods will but confuse the picture.
Remember, we must prescribe for the totality of the symptom picture and not for any one symptom alone, but for the complete picture as it is presented in the individual. In an acute explosion the chronic picture will retreat completely; therefore, in treating the complete picture that is present there will be no need to take the chronic picture into consideration. At the close of the acute attack we again see the chronic picture. Then will be the time to deal with it. In fact, there is no time in the history of the case when we can see the picture of the chronic underlying condition so plainly as at the end of an acute attack, after the acute conditions have subsided. Therefore, after dealing properly with the acute attack, and waiting until it subsides, we will be in a position to see clearly the picture of the chronic case. This condition following acute illness is much more apt to be the manifestation of the chronic condition than it is to be the aftermath of acute conditions, as is popularly supposed.
In considering the totality we cannot over-emphasize the necessity of getting the complete description of each symptom, as to its location, character, and modalities. The modalities, the aggravations and ameliorations, are the most important. Next in order come the character of the sensations.
The most important symptoms, of course, are the general symptoms that pertain to the patient as a whole. Then come the aggravations and ameliorations. The mental symptoms rank very highly for the reason that they point to the man himself, and they may be classed under the generals to a marked degree.
The thorough examination of the patient from every possible angle should be carried through, not for the gross diagnostic symptoms, important as these may be from diagnostic and hygienic points of view. From the curative point of view we should not fail to elicit all the possible clues that may lead us to the remedy. Subjective and objective symptoms are to be elicited and recorded. Sometimes this will require the utmost ingenuity to elicit the necessary intelligent replies without leading questions. The physician’s degree of success in obtaining the proper symptom picture lies in his skill and patience. We cannot rush these patients through. We must be good listeners. Get the patient to talking, and tactfully keep him talking about the symptoms rather than wandering far afield. Then cultivate your powers of listening and give your powers of observation full sway, to form the complete picture of the little details and habits of your patient. It has been said that criminal lawyers should be medical men; it is eminently necessary, however, that homoeopathic physicians be past masters of the art of cross- examination; and the observance of the patient’s every movement and expression should be a matter of record.
Before leaving the case, go over again the family history, the personal history, the mental and physical symptoms. Consider the temperament, the habits, the occupation, the personality of the patient. Ask yourself if you have skipped anything. See that you have questioned every item, every function; question the modalities in particular. Go over the previous drug treatment and consider that. Remember that the nature and sensation of the symptoms, the time of day, the positions and circumstances under which symptoms appear, are the most important modifiers of any given case.
To clarify these general instructions, let us take up the matter in greater detail, and go over together the following requirements.
In chronic work it is necessary to take into consideration the general symptoms. By general symptoms we mean those symptoms which pertain to the patient as a whole, or to the complaint which he brings to us. In order to get a complete picture of the case as a whole let us consider these elements:
The aggravations, the periodicity, the seasons aggravations, weather aggravations as to sun, wind, cold, dry, wet, fog, etc.; changes of weather, as cold to warm or warm to cold; changes of weather as before, during or after storms, such as thunderstorms, rain, snow, etc.; the tendency to develop certain conditions, such as the tendency to take cold, sore throats, headaches, etc.; the reactions of fresh air, such as craving for or aggravation from; reactions to positions in rest or in action, such as worse walking, or better lying with arms raised; these reactions in relation to position include also riding in trains, in cars, in vessels; conditions of appetite and the cravings or aversions of aggravations from certain foods; the effects of vaccination or serum treatment; reactions to bathing; effect of altitude, seashore, or mountain; the amount of clothing required, during the day and at night; the rapidity with which wounds heal if the patient is subject to haemorrhages; the reaction of the patient to the presence of others, whether he prefers to be alone or in company, or whether worse being alone or in assembly; the sides affected.
How about the thermic reactions of the patients? Is he hot or cold, in general or under varying circumstances? If there are variations of temperature do they involve the whole or part of the body? Is his skin moist or dry? If he perspires, under what conditions? Freely or scantily? All over or only in certain parts? Is the perspiration offensive, exhausting, greasy, hot or cold? Is he better or worse during or after? How is the sweat related in time to the chill and heat? Is the chill (or heat) partial or general? Is there shivering of a apart or in general, and does this occur with or without chill? Is there thirst? In what relation of time to the heat, chill and or sweat?
Note should be made of the aversions and cravings; the type of sleep and dreams; the positions of the body in sleep; how the patient wakens from sleep and his condition after waking. With either a man or woman patient, the abnormalities of the sexual functions should be noted. Then the strange, rare, and peculiar symptoms should be sought out.
I have left until the last mention of the essential part of the case-taking, the comprehension of the mental symptoms. To a great extent these are symptoms that must be observed from the attitude of the patient. Another reason for leaving these until the last is that during the examination you have probably been able to get the confidence of your patients to a greater degree and they will give you more fully their confidence. Find if they are subject to hallucinations or fixed ideas, especially any fears that are persistent. Take into consideration irritability, or a change in disposition; if you can unearth traits of jealousy, or absent- mindedness, these must be seriously considered. Sadness, ailments arising from grief, vexation, sudden joy, are important. Is the patient over-insistent upon the patient over-insistent upon the minor details of life as to scrupulous cleanliness, etc.? Or is the contrary true?
Your patient should readily reveal many of these most important things to you if you have been tactful and have secured his confidence.
I refer you a wonderful questionnaire compiled by Dr. Pierre Schmidt. This will assist you in securing the information you desire, and if you will study this carefully it will prove a valuable guide in directing your questioning, *after the patient has finished telling you all he thought was necessary to your treatment of the case.
It is well to reiterate the instruction: Do not interrupt you patient while he is telling all he knows of his case, except is so far as he may require guidance to keep him to the subject in hand. The physician’s questioning comes afterward, and it is here that we must complete the picture of the case.
What are the essentials to record in taking the case? (*Answer: The general symptoms; the modalities; the sensations; the concomitants)
Why should we have a written record of each case? (*Answer: So that we may view the case as a complete whole, (I) for our first prescription; (2) for future reference, so that we may note progress.)
Why do we need to pay little attention to the chronic symptoms in taking an acute case? (*Answer: We take each case as completely as possible, for when an acute seizure is present the chronic symptoms usually retire in to the background, so that we need only prescribe for the totality as presented.) When do we find the chronic symptoms portrayed most clearly? (*Answer: At the end of an acute attack the chronic symptoms usually show themselves clearly, even more clearly than at other times; the conditions following an acute attack are not the result of a cute attack, but because Nature has cleared the patient to a great or less degree by the acute explosion and his leaves a clear picture of the chronic condition.).