§ 83

This individualizing examination of a case of disease, for which I shall only give in this place general directions, of which the practitioner will bear in mind only what is applicable for each individual case, demands of the physician nothing but freedom from prejudice and sound senses, attention in observing and fidelity in tracing the picture of the disease.

Commentary:

Three basic necessity for individualization of a case of disease are

Freedom for prejudice

sound sense

attentive


                                                       § 84

The patient details the history of his sufferings; those about him tell what they heard him complain of, how he has behaved and what they have noticed in him; the physician sees, hears, and remarks by his other senses what there is of an altered or unusual character about him. He writes down accurately all that the patient and his friends have told him in the very expressions used by them. Keeping silence himself he allows them to say all they have to say, and refrains from interrupting them1 unless they wander off to other matters. The physician advises them at the beginning of the examination to speak slowly, in order that he may take down in writing the important parts of what the speakers say.

1 Every interruption breaks the train of thought of the narrators, and all they would have said at first does not again occur to them in precisely the same manner after that.
Commentary:

Recording of symptoms in case taking involve three sources

patient himself (subjective symptoms)

close attender such as wife, children, father, mother etc

physicians observation (objective symptoms)                              

Taking the case- maintenance of case record

Taking the case involves 

The physician must be attentive: The physician sees, hears, and remarks by his other senses what there is of an altered or unusual character about his patient.

The physician should use the very language of the patient:      He writes down accurately all that the patient and his friends have told him in the very expressions used by the patient. Diagnostic terms should be avoided. eg. instead of the term gastric ulcer we can use the very expression of patient cutting, gripping colic usually one hour after food.

Maintenance of silence by the physician  until patient has told completely regarding his illness: Keeping silence himself he allows the patient  to say all they have to say, and refrains from interrupting them  unless they wander off to other matters not involving patients illness.

Physician should take note of everything in a case: The physician advises them at the beginning of the examination to speak slowly, in order that he may take down in writing the important parts of what the speakers say.

One of the most significant things in procuring the image of a sickness is to conserve in simplicity what the patient tells us in his own way unless he sidetracks from the important things and talks about things that are unnecessary  and not to the point ; but as long as he bounds his information to his own excruciations, let him tell it in his own way without disruption and in the record use his own language, only correcting his grammatical errors for the purpose of securing the record as perfect as possible.

If you use synonyms be sure that they are equivalent word and cannot be distorted. Example: when the woman speaks of her menstrual period  as her "show" the more suitable medical term is "menses" which is a synonym for those expressions, and is more expressive than her own way of calling it "a show".

So in general terms you can replace terms of expression so long as you do not change the idea. Example; the changing of "legs" into "limbs" if you feel like making such a change is not a change of thought.

It is one of the most significant things in forming the record of a patient to be able to read it at a future examination, without being interrupted by the repeated statements of the patient.

If you write a record in serial sentences, you will be so confused when tracing out the symptoms of the patient that you will be unable to form an image of that sickness in the mind.

CASE RECORD KEEPING

 You should divide your page in such a manner that when the patient is talking to you about this thing and the other thing , of her symptoms, you can with one glance of the eye look down over the page of the record and see everything there is in that page.

If your record is not so arranged, it is defective. Kent has proposed 

"Now, a record can be so arranged by dividing the page into three columns, the first of which contains the dates and prescriptions, the second the emphatic symptoms or headings and the third things predicated of the symptoms, thus :

Date

 

Remedy

   Symptom.

      Things predicated of the symptom

        < (aggravation)

        > (amelioration)

Patients narration:

After the patient has elaborated his sufferings in his own way and you have gone through them and ascertained all the things that you can predicate of his symptoms then you can continue to make ,enquiry of some one who has been with this patient.

Bystanders observation:

In a study like this with most of our private patients there has been a nurse, sometimes only a sister or a mother or a wife or a relative, who has been observing all the sick individual has complained of.

"The persons who are ,about him relate what he has complained of, how he has behaved himself, and all that they have remarked in him."

Now, this should be listened to with great care. It is more important in this instance to decide whether the observer is overanxious, if a wife whether she is not frightened concerning her husband and so blends many of her notions and fears, which you must accept with your own judgement.

Get the nurse, if possible, to repeat the exact words of the patient.

If such a thing can be done in acute conditions  it is worth more than the words or expressions of the nurse, the wife for instance, because the more interested and anxious the person is the less likely she will be to present a truthful image, not that she wants to delude, but she is awfully shaped up and the more she thinks of what he has said the greater his sufferings appear to her, and she exaggerates them, It is important to have the statement from one who is disinterested person.

Physicians observation:

Two or three of the observers who are intelligent having been consulted and their statements recorded, the physician then notes his own observations. He should describe the urine if there is anything peculiar about that, but if the urine and stool are normal he need not care about the description of these. KENT SAYS  "It has been the study for hundreds of years to find the best way to question witnesses in court, and as a result they have settled upon certain rules for obtaining evidence. Homoeopathy also has rules for examining the case that must be followed with exactitude through private practice".

If you neglect making a careful examination the patient will be the first sufferer, but in the end you yourself will suffer from it, and Homoeopathy also. The questions themselves that Hahnemann gives are not important, but they are suggestive and will lead you in a certain direction. 

Question the patient, then the friends, and observe for yourself ; if you do not obtain enough to prescribe on, go back to particulars. After much experience you will become expert in questioning patients so as to bring out the truth.

Store up Materia Medica so as to  use it and it will flow out as your language flows. You must put yourself on a level with the form of speech your patients use. Be sure you have not put any words into your patient's mouth or predetermined his expression.

Must not ask direct question:

You want to know all the particulars but without asking about it directly. If you ask a direct question, you must not put the symptom in the record, for ninety-nine times out of a hundred the patient will answer by "Yes or 'No". If the patient's answer is "Yes or No," your question was badly formed.

If a question brings no answer let it alone, for he does not know or has not noticed.  Questions giving a choice of answers are defective.  Ascertain the precise part of the body the pain was in and the character of the pain, etc. In investigating a case there are many things to learn, 

the length of the attack, 
appearance of the discharge (if it is a case of vomiting, discharge from a wound, diarrhea, nasal discharge etc ) 
its character, 
the time of day, etc., etc.

Every student should go over these questions framing collateral questions, and practicing case-taking.

FOLLOWING THINGS MUST BE CONSIDERED IN CASE TAKING

Leave the patient in freedom to say always.
Do not put any words into his mouth.
Never allow yourself to hurry a patient ; get into a fixed habit of examination, then it will stay with you.
Say as little as you can, but keep the patient talking and keep him talking close to the line. If he will only talk, you can find out symptoms in general and particular.
If he goes off, bring him back to the line quietly and without disturbing him.

I have given you that no homoeopath should ever discouraged the true study of anatomy and physiology.

 

§ 85

He begins a fresh line with every new circumstance mentioned by the patient or his friends, so that the symptoms shall be all ranged separately one below the other. He can thus add to any one, that may at first have been related in too vague a manner, but subsequently more explicitly explained.

§ 86

When the narrators have finished what they would say of their own accord, the physician then reverts to each particular symptom and elicits more precise information respecting it in the following manner; he reads over the symptoms as they were related to him one by one, and about each of them he inquires for further particulars, e.g., at what period did this symptom occur? Was it previous to taking the medicine he had hitherto been using? While taking the medicine? Or only some days after leaving off the medicine? What kind of pain, what sensation exactly, was it that occurred on this spot? Where was the precise spot? Did the pain occur in fits and by itself, at various times? Or was it continued, without intermission? How long did it last? At what time of the day or night, and in what position of the body was it worst, or ceased entirely? What was the exact nature of this or that event or circumstance mentioned - described in plain words?

§ 87

And thus the physician obtains more precise information respecting each particular detail, but without ever framing his questions so as to suggest the answer to the patient1, so that he shall only have to answer yes or no; else he will be misled to answer in the affirmative or negative something untrue, half true, or not strictly correct, either from indolence or in order to please his interrogator, from which a false picture of the disease and an unsuitable mode of treatment must result.

1 For instance the physician should not ask, Was not this or that circumstance present? He should never be guilty of making such suggestions, which tend to seduce the patient into giving a false answer and a false account of his symptoms.

§ 88

If in these voluntary details nothing has been mentioned respecting several parts or functions of the body or his metal state, the physician asks what more can be told in regard to these parts and these functions, or the state of his disposition or mind1, but in doing this he only makes use of general expressions, in order that his informants may be obliged to enter into special details concerning them.

1 For example what was the character of his stools? How does he pass his water? How is it with his day and night sleep? What is the state of his disposition, his humor, his memory? How about the thirst? What sort of taste has he in his mouth? What kinds of food and drink are most relished? What are most repugnant to him? Has each its full natural taste, or some other unusual taste? How does he feel after eating or drinking? Has he anything to tell about the head, the limbs or the abdomen?

§ 89

When the patient (for it is on him we have chiefly to rely for a description of his sensations, except in the case of feigned diseases) has by these details, given of his own accord and in answer to inquiries, furnished the requisite information and traced a tolerably perfect picture of the disease, the physician is at liberty and obliged (if he feels he has not yet gained all the information he needs) to ask more precise, more special questions.1

1 For example, how often are his bowels moved? What is the exact character of the stools? Did the whitish evacuation consist of mucus or faeces? Had he or had he not pains during the evacuation? What was their exact character, and where were they seated? What did the patient vomit? Is the bad taste in the mouth putrid, or bitter, or sour, or what? before or after eating, or during the repast? At what period of the day was it worst? What is the taste of what is eructated? Does the urine only become turbid on standing, or is it turbid when first discharged? What is its color when first emitted? Of what color is the sediment? How does he behave during sleep? Does he whine, moan, talk or cry out in his sleep? Does he start during sleep? Does he snore during inspiration, or during expiration? Does he lie only on his back, or on which side? Does he cover himself well up, or can he not bear the clothes on him? Does he easily awake, or does he sleep too soundly? How often does this or that symptom occur? What is the cause that produces it each time it occurs? does it come on whilst sitting, lying, standing, or when in motion? only when fasting, or in the morning, or only in the evening, or only after a meal, or when does it usually appear? When did the rigor come on? was it merely a chilly sensation, or was he actually cold at the same time? if so, in what parts? or while feeling chilly, was he actually warm to the touch? was it merely a sensation of cold, without shivering? was he hot without redness of the face? what parts of him were hot to the touch? or did he complain of heat without being hot to the touch? How long did the chilliness last? how long the hot stage? When did the thirst come on - during the cold stage? during the heat? or previous to it? or subsequent to it? How great was the thirst, and what was the beverage desired? When did the sweat come on - at the beginning or the end of the heat? or how many hours after the heat? when asleep or when awake? How great was the sweat? was it warm or cold? on what parts? how did it smell? What does he complain of before or during the cold stage? what during the hot stage? what after it? what during or after the sweating stage?

(Added to the Sixth Edition)

In women, note the character of menstruation and other discharges, etc.

§ 90

When the physician has finished writing down these particulars, he then makes a note of what he himself observes in the patient1, and ascertains how much of that was peculiar to the patient in his healthy state.

1 For example, how the patient behaved during the visit - whether he was morose, quarrelsome, hasty, lachrymose, anxious, despairing or sad, or hopeful, calm etc. Whether he was in a drowsy state or in any way dull of comprehension; whether he spoke hoarsely, or in a low tone, or incoherently, or how other wise did he talk? what was the color of his face and eyes, and of his skin generally? what degree of liveliness and power was there in his expression and eyes? what was the state of his tongue, his breathing, the smell from his mouth, and his hearing? were his pupils dilated or contracted? how rapidly and to what extent did they alter in the dark and in the light? what was the character of the pulse? what was the condition of the abdomen? how moist or hot, how cold or dry to the touch, was the skin of this or that part or generally? whether he lay with head thrown back, with mouth half or wholly open, with the arms placed above the head, on his back, or in what other position? what effort did he make to raise himself? and anything else in him that may strike the physician as being remarkable.

§ 91

The symptoms and feelings of the patient during a previous course of medicine do not furnish the pure picture of the disease; but on the other hand, those symptoms and ailments which he suffered from before the use of the medicines, or after they had been discontinued for several days, give the true fundamental idea of the original form of the disease, and these especially the physician must take note of. When the disease is of a chronic character, and the patient has been taking medicine up to the time he is seen, the physician may with advantage leave him some days quite without medicine, or in the meantime administer something of an unmedicinal nature and defer to a subsequent period the more precise scrutiny of the morbid symptoms, in order to be able to grasp in their purity the permanent uncontaminated symptoms of the old affection and to form a faithful picture of the disease.

§ 92

But if it be a disease of a rapid course, and if its serious character admit of no delay, the physician must content himself with observing the morbid condition, altered though it may be by medicines, if he cannot ascertain what symptoms were present before the employment of the medicines, - in order that he may at least form a just apprehension of the complete picture of the disease in its actual condition, that is to say, of the conjoint malady formed by the medicinal and original diseases, which from the use of inappropriate drugs is generally more serious and dangerous than was the original disease, and hence demands prompt and efficient aid; and by thus tracing out the complete picture of the disease he will be enabled to combat it with a suitable homœopathic remedy, so that the patient shall not fall a sacrifice to the injurious drugs he was swallowed.

Commentary: § 85 TO § 92 NEXT PAGE