Case-taking: acute, chronic and epidemic

case-taking medical history psychiatric epidemic acute chronic

The Strange Case of Doctor Rx

Taking a Medical Case History

Case histories are simple or complex and vary from individual to individual – regardless of a convenient name which may have been allocated to a group of symptoms. Diseases vary from acute, chronic, psychiatric, sporadic and epidemic or those induced by lifestyle and habits or environment. Hahnemann dealt with each of these situations and gave an explanation as to how case-taking should be done in each of these respective situations. In his detailed exposition on case-taking Hahnemann considers the patient, their lifestyle and environment, the physician, other observers and how to write notes in order to gather the exact details for the complete disease picture.

Hahnemann’s Instructions on Case-taking

Samuel Hahnemann gave a lengthy explanation on case-taking in his Organon of Medicine. The structure of the book is as follows: aphorisms (paragraphs) 1-70 explain the theory of homeopathy; aphorisms 71 to 291 is the treatise on the practice of medicine and aphorisms 72-100 specifically deal with what is essential for taking the details of a patient’s medical history. In aphorisms 210-230 he addresses “mental and emotional diseases” – although, he explains, one cannot separate them from bodily symptoms as the mental state should be considered when treating a physical ailment. He explains:

They do not, however, constitute a class of disease sharply separated from all others, since in all other so-called corporeal diseases the condition of the disposition and mind is always altered;121 and in all cases of disease we are called on to cure the state of the patient’s disposition is to be particularly noted, along with the totality of the symptoms, if we would trace an accurate picture of the disease, in order to be able therefrom to treat it homeopathically with success.

He qualifies this statement in footnote 121:

How often, for instance, do we not meet with a mild, soft disposition in patients who have for years been afflicted with the most painful diseases, so that the physician feels constrained to esteem and compassionate the sufferer! But if he subdue the disease and restore the patient to health—as is frequently done in homeopathic practice—he is often astonished and horrified at the frightful alteration in his disposition. He often witnesses the occurrence of ingratitude, cruelty, refined malice and propensities most disgraceful and degrading to humanity, which were precisely the qualities possessed by the patient before he grew ill.

Those who were patient when well often become obstinate, violent, hasty, or even intolerant and capricious, or impatient or desponding when ill; those formerly chaste and modest often become lascivious and shameless. A clear-headed person not infrequently becomes obtuse of intellect, while one ordinarily weak-minded becomes more prudent and thoughtful; and a man slow to make up his mind sometimes acquires great presence of mind and quickness of resolve, etc.

Case-taking Generally

§ 82 Individualising, acute and chronic symptoms

… for settling the indication in each case of chronic (psoric) disease he is called on to cure, the duty of a careful apprehension of its ascertainable symptoms and characteristics is as indispensable for the homoeopathic physician as it was before that discovery, as no real cure of this or of other diseases can take place without a strict particular treatment (individualisation) of each case of disease – only that in this investigation some difference is to be made when the affection is an acute and rapidly developed disease, and when it is a chronic one; seeing that, in acute disease, the chief symptoms strike us and become evident to the senses more quickly, and hence much less time is requisite for tracing the picture of the disease and much fewer questions are required to be asked¹, as almost everything is self-evident, than in a chronic disease which has been gradually progressing for several years, in which the symptoms are much more difficult to be ascertained.

§ 83 Physicians need to be objective
Physicians bring their own ideas, values, projections, assumptions about the patient, bias based on the latest publication or advertising etc. to the consulting room. Hahnemann warns:

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.

Remember, Hahnemann had already cautioned in the footnote to the very first aphorism:

His mission is not, however, to construct so-called systems, by interweaving empty speculations and hypotheses concerning the internal essential nature of the vital processes and the mode in which diseases originate in the interior of the organism, (whereon so many physicians have hitherto ambitiously wasted their talents and their time); nor is it to attempt to give countless explanations regarding the phenomena in diseases and their proximate cause (which must ever remain concealed), wrapped in unintelligible words and an inflated abstract mode of expression, which should sound very learned in order to astonish the ignorant – whilst sick humanity sighs in vain for aid. Of such learned reveries (to which the name of theoretic medicine is given, and for which special professorships are instituted) we have had quite enough, and it is now high time that all who call themselves physicians should at length cease to deceive suffering mankind with mere talk, and begin now, instead, for once to act, that is, really to help and to cure.

§ 84 Acquiring the required information
While listening to the patient, keeping quiet and not interrupting is essential. We can return later to clarify the patient’s narrative. He says,

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 them81 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.

81 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.

§ 85 Taking the details
Hahnemann outlines a convenient way to write down the details in a manner which makes it easy to add information if more explicitly explained.

§ 86 Clarifying and confirming symptoms

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 No Leading questions

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 patient,82 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.

82 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 Questioning
Explaining further, Hahnemann says,

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 mind,83 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.

83 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 More precise questioning

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.84

Hahnemann then gives a masterful example of the possible questions he would ask to clarify a symptom. Too lengthy to cite here, it can be read here and here.

§ 90 The physician’s observations

When the physician has finished writing down these particulars, he then makes a note of what he himself observes in the patient,85 and ascertains how much of that was peculiar to the patient in his healthy state.

To explain further:

85 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 True symptoms
When a patient presents with a complex of symptoms, some symptoms may be produced as “side-effects” (direct effects) of some medication. Since these are not the symptoms of the patient’s disease, and therefore not to be treated, Hahnemann gives us some advice.

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.

Consequently, it may be useful to keep the patient off the medication some days and so allow a clear picture of the patient’s symptoms to evolve.

§ 92 Of course the physician cannot always be allowed the luxury of waiting.

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… 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 homoeopathic remedy, so that the patient shall not fall a sacrifice to the injurious drugs he was swallowed.

§ 93 Eliciting the truth

Some patients won’t want the truth to be known! At least not until they have established trust and confidence in their physician. Hahnemann gives some examples and how to deal with them:

If the disease has been brought on a short time or, in the case of a chronic affection, a considerable time previously, by some obvious cause, then the patient – or his friends when questioned privately – will mention it either spontaneously or when carefully interrogated.86

86 Any causes of a disgraceful character, which the patient or his friends do not like to confess, at least not voluntarily, the physician must endeavor to elicit by skilfully framing his questions, or by private information. To these belong poisoning or attempted suicide, onanism, indulgence in ordinary or unnatural debauchery, excess in wine, cordials, punch and other ardent beverages, or coffee, – over-indulgence in eating generally, or in some particular food of a hurtful character, – infection with venereal disease or itch, unfortunate love, jealousy, domestic infelicity, worry, grief on account of some family misfortune, ill-usage, balked revenge, injured pride, embarrassment of a pecuniary nature, superstitious fear, – hunger, – or an imperfection in the private parts, a rupture, a prolapse, and so forth.

§ 94 What to investigate

While inquiring into the state of chronic disease, the particular circumstances of the patient with regard to his ordinary occupations, his usual mode of living and diet, his domestic situation, and so forth, must be well considered and scrutinized, to ascertain what there is in them that may tend to produce or to maintain disease, in order that by their removal the recovery may by promoted.87

How often have you known a physician to ask questions about the state of one’s house; is it damp, does the child run around on cold tiles in bare feet? Does one drive with the car window open? Does he eat too much white bread, oranges, etc?

In regard to women, Hahnemann gives particular attention:

87 In chronic diseases of females it is specially necessary to pay attention to pregnancy, sterility, sexual desire, accouchements, miscarriages, suckling, and the state of the menstrual discharge. With respect to the last-named more particularly, we should not neglect to ascertain if it recurs at too short intervals, or is delayed beyond the proper time, how many days it lasts, whether its flow is continuous or interrupted, what is its general quality, how dark is its color, whether there is leucorrhoea before its appearance or after its termination, but especially by what bodily or mental ailments, what sensations and pains, it is preceded, accompanied or followed; if there is leucorrhoea, what is its nature, what sensations attend its flow, in what quantity it is, and what are the conditions and occasions under which it occurs?

In chronic diseases, things happen slowly and may easily be forgotten or symptoms may not be strong enough for the patient to be cognizant of them.

§ 95

In chronic disease the investigation of the signs of disease above mentioned, and of all others, must be pursued as carefully and circumstantially as possible, and the most minute peculiarities must be attended to, partly because in these diseases they are the most characteristic and least resemble those of acute diseases, and if a cure is to be affected they cannot be too accurately noted; partly because the patients become so used to their long sufferings that they pay little or no heed to the lesser accessory symptoms, which are often very pregnant with meaning (characteristic) – often very useful in determining the choice of the remedy – and regard them almost as a necessary part of their condition, almost as health, the real feeling of which they have well-nigh forgotten in the sometimes fifteen or twenty years of suffering, and they can scarcely bring themselves to believe that these accessory symptoms, these greater or less deviations from the healthy state, can have any connection with their principal malady.

§ 96 Exaggerating and understating symptoms
Hahnemann singles out hypochondriacs for special attention here. They and others of a sensitive or impatient disposition, in order to obtain relief, describe their symptoms in exaggerated expressions. This in itself is an important symptom.

§ 97 Physicians often meet people of the opposite character. From indolence, false modesty, mildness of disposition, he says, may refrain from mentioning some of their symptoms, describe them in vague terms or consider them to be of little consequence.

§ 98 Erroneous statements
A physician will often be glad a patient, by accident or design, brought a companion – even if only their young child. They will often reveal what the patient doesn’t reveal, see in the patient what they themselves are blind to. Hahnemann says:

Now, as certainly as we should listen particularly to the patient’s description of his sufferings and sensations, and attach credence especially to his own expressions wherewith he endeavors to make us understand his ailments – because in the mouths of his friends and attendants they are usually altered and erroneously stated, – so certainly, on the other hand, in all diseases, but especially in the chronic ones, the investigation of the true, complete picture and its peculiarities demands especial circumspection, tact, knowledge of human nature, caution in conducting the inquiry and patience in an eminent degree.

§ 99 Acute symptoms clearer
As stated above, acute symptoms are more recent and usually more intense and therefore “… All deviations from health are fresh in the memory of the patient and their friends. He has much less to inquire into; they are for the most part spontaneously detailed to him.”

Case-taking in Epidemics and Sporadics

“But how does homeopathy treat the masses?”, I was once asked. This confusion is understandable since treating epidemics and sporadic diseases homeopathically is not individualized as is the norm when treating acutes and chronics. Hahnemann has teased out the rational and scientific method for treating epidemics and sporadics.

Most people suffering from an epidemic or sporadic infection will receive the same remedy, depending on the phase of the symptoms, known as the genus epidemicus. Hahnemann explains this in aphorism 101:

It may easily happen that in the first case of an epidemic disease that presents itself to the physician’s notice he does not at once obtain a knowledge of its complete picture, as it is only by a close observation of several cases of every such collective disease that he can become conversant with the totality of its signs and symptoms. The carefully observing physician can, however, from the examination of even the first and second patients, often arrive so nearly at a knowledge of the true state as to have in his mind a characteristic portrait of it, and even to succeed in finding a suitable, homeopathically adapted remedy for it (emphasis mine).

He explains further in § 102 that epidemics are one disease coming from the same cause, regardless how many have symptoms, and it is the collective symptoms of these patients which help build a picture of this single disease:

In the course of writing down the symptoms of several cases of this kind the sketch of the disease picture becomes ever more and more complete, not more spun out and verbose, but more significant (more characteristic), and including more of the peculiarities of this collective disease; on the one hand, the general symptoms (e.g., loss of appetite, sleeplessness, etc.) become precisely defined as to their peculiarities; and on the other, the more marked and special symptoms which are peculiar to but few diseases and of rarer occurrence, at least in the same combination, become prominent and constitute what is characteristic of this malady. All those affected with the disease prevailing at a given time have certainly contracted it from one and the same source and hence are suffering from the same disease; but the whole extent of such an epidemic disease and the totality of its symptoms (the knowledge whereof, which is essential for enabling us to choose the most suitable homoeopathic remedy for this array of symptoms, is obtained by a complete survey of the morbid picture) cannot be learned from one single patient, but is only to be perfectly deduced (abstracted) and ascertained from the sufferings of several patients of different constitutions.

The same is true with intermittent epidemic fevers – where it is not due to the influence of a marshy area preventing cure, a certain disposition he terms psora, where it is not endemic or of a single acute paroxysm, but rather:

… each single epidemic is of a peculiar, uniform character common to all the individuals attacked, and when this character is found in the totality of the symptoms common to all, it guides us to the discovery of the homoeopathic (specific) remedy suitable for all the cases… (§ 241)

The approach to taking the case is important. He tells us in § 100:

In investigating the totality of the symptoms of epidemic and sporadic diseases it is quite immaterial whether or not something similar has ever appeared in the world before under the same or any other name. The novelty or peculiarity of a disease of that kind makes no difference either in the mode of examining or of treating it, as the physician must any way regard to pure picture of every prevailing disease as if it were something new and unknown, and investigate it thoroughly for itself, if he desire to practice medicine in a real and radical manner, never substituting conjecture for actual observation, never taking for granted that the case of disease before him is already wholly or partially known, but always carefully examining it in all its phases; and this mode of procedure is all the more requisite in such cases, as a careful examination will show that every prevailing disease is in many respects a phenomenon of a unique character, differing vastly from all previous epidemics, to which certain names have been falsely applied – with the exception of those epidemics resulting from a contagious principle that always remains the same, such as smallpox, measles, etc.

Case-taking in Psychiatry

Hahnemann devotes twenty aphorisms to the care and treatment of patients with “mental and emotional diseases” and is too detailed to present here, deserving its own space which is now available, titled Psychiatry and Homeopathy.

References
Vithoulkas.com and HomeoInt.org have both published the Organon online. HomeoInt has, slightly confusingly, made the 5th and 6th editions available together. Google has digitised the book on Hathi Trust here

Further Reading
For an example of modern research with a genus epidemicus, see: “Homoeopathic Genus Epidemicus ‘Bryonia alba’ as a prophylactic during an outbreak of Chikungunya in India: A cluster-randomised, double-blind, placebo-controlled trial.” The findings were published in Indian Journal of Research in Homeopathy

If you’d like some ideas from psychology and psychotherapy, Dr Brian Kaplan has published The Homeopathic Conversation: the Art of Taking the Case. It might not help in epidemics or serious acutes but has its uses. Available from Minerva (UK), Emryss (EU) and Narayana-Verlag (Int.) and Nature-Reveals (USA), among others.

Dr John Henry Clarke makes the comment in his book The Prescriber:

The doctrine of genius epidemicus is another practical aid in prescribing. Just as one proving gives only a partial idea of a drug, so one case of an epidemic disease gives only a partial idea of the disease. It is perfectly legitimate homœopathy to take a number of cases and having found the drug disease which corresponds most closely to the disease in all its developments, to give that drug in a routine fashion to all cases which do not manifestly call for some other drug. The use of Baptisia in this way in the influenza epidemics has saved me a great deal of brain-work and has cut short, often in a few hours, many an attack of the, disease. That does not mean that I have given no other remedy, on the contrary, I have had to use in some case or other almost every remedy in the materia medica; but the knowledge of the doctrine of the genius epidemicus has saved a vast amount of trouble, nevertheless. (Book can be read here)

Image: Wiki Commons: The Strange Case of Doctor Rx, 1942, movie still

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