I have purposely chosen this topic as an editorial, because I have learned through visiting homeopathic colleges and hospitals how very rarely indeed, did the practitioners know how to apply exactly the teachings recommended by Dr Samuel Hahnemann, our only Master.
The case taking should be such that after undergoing the proper homeopathic semiology we should be able to find the presumed pathological diagnosis and remedy suggested by the first recital of the patient.
This is true only if our approach towards the case is systemic and certain situations demand theory from the Organon which goes into the background and we have to approach the case by practical application as understood from the Organon.
Hahnemann, in his Organon, devotes more than sixty three paragraphs where he speaks about the art of case taking. Von Boenninghausen gives us excellent advice on how to take the case. Jahr furnishes a questionnaire, as well as others like Mure, Stuart Close and Kent. After the Organon, Kent gives us the best advice in his book dedicating almost 32 pages entitled ‘What the Doctor Needs to Know in order to make a Successful Prescription.’
Remember the famous lecture of Constantine Hering, published in 1833 in the ‘Bibliothéque Homoeopathique de Genève’ in which he sets forth the theme of how to trace the picture of the disease, his rules being summed up in four words – to listen, to write, to question, and to co-ordinate.
Unfortunately I see a lot of people, even senior homeopath that give seminars and present video or live cases making the worst mistakes. This invites a lot of shame and disgrace to the profession. The first mistake they make is they do not follow what was said by Hahnemann or Kent or other old masters. Following modern teachers will only bring confusion at the end of the tunnel, so be careful whom you follow. In the past 32 years I have witnessed many methods and many techniques but nothing works better than Hahnemann.
Is there any format that needs to be followed?
On one side, we have the counsel given by Hahnemann in his Organon, then the remarkable study of Kent in his 32-33 chapters concerning the value of symptoms, then the numerous classifications established by Grimmer, Gladwin, Julia Green, Margaret Tyler, Del Mas, and Stearns, to quote only a few. It is impossible to discuss here every one of the proposed classifications, the broad lines of which, nevertheless, converge in the same direction: First mental symptoms, then general symptoms, then cravings and aversions, then sexual symptoms, including menses, and finally sleep and dreams.
How now, to know if the questions are well asked and, consequently, well answered?
During the interrogation, the physician must carefully watch his patient and observe the way he answers. And in La Fontaine’s fable, the ‘ramage’ must accord with the ‘plumage’, i.e. the intonation of his voice, the play and expression of his physiognomy, especially in the mouth and eyes, must be carefully observed and grasped.
A patient who says, ‘Yes, I like rice, but I don’t drink milk with pleasure’ without change of expression indicates no symptom at all. But if he says, ‘Oh, I cannot do without rice, and I hate milk’ saying this with a happy face and an enlargement of the eyes regarding rice, but regarding milk with a wry face, and turning the head to the side, you then know you have good symptoms.
I always try to practice the advice of, Dr Austin of New York, who taught his students that a good physician should be able in the first consultation to make his patient laugh or cry, and so doing, he was assured that the contact was made, as he was able to put in vibration the living human being who was asking for help.
One mistake which is very common is asking leading questions. Avoid leading questions. In other words, you don’t ask a question that will be answered by ‘yes’ or ‘no’. I do sometimes the opposite only to get the intensity of the symptoms. There will be times during the case when you will specifically ask a leading question, just to see if the patient confirms the intensity by saying little loud or little intensely. But as a rule any answer that comes from a leading question, is misleading your mind, it is a trap. Every time you catch yourself asking a leading question, you are doing a wrong thing. Next time instead of saying: ‘Do you like cheese?’ you ask ‘What food do you like’. If you want to check how they like cheese if they didn’t mention, you don’t say: ‘Do you like cheese?’ you say ‘What about cheese?’ If you say ‘Do you like cheese?’ and the patient say ‘yes’, it is useless.
Never lose the objectivity of the case. This is the basis of good Hahnemannian homeopathy- to be totally objective. You stay with reality and you try to perceive reality as much as you can, without using your mind as interference. Methods like free association as described by Dr Freud the more you are able to perceive the better homeopath you will be. The more you are able to perceive accurately and meticulously (it is like being James Bond, you perceive things) the more you see through. It is their reality that is of the utmost importance, rather than your opinion of things. The more you bring your opinion into the case – in other words the more you are being subjective – the more you are going away from success in general. You have to be objective at all times.
Another big mistake which I see often is not writing down everything that the patient says. The whole case taking I see from some senior homeopaths in just five to ten lines or five lines.
Always quote the language of the patient. Along with that put your own quote marks; the patient told me that………., because after few weeks from the date of the case taking you don’t remember exactly what the patient told you. If you write textual what they told you, you can check your notes after twenty years and see what the patient said and later you can easily share this information in case reporting.
Let me explain this in detail- suppose a patient says ‘I have stress in my head’, and you say ‘Where is the stress?’ and the patients points to the mandible area, he does not point to the head, should you write down ‘I have a stress in the head?’, No, you write the correct anatomical part, you say pain in wherever the patient is pointing. If the patient is making a little mistake like this, you may correct it. Or sometimes you may want to put it in the language of the repertory, but as a rule, write it in the patient’s language and that is all. I see this every day where the patient says one-thing, but means totally opposite of it.
When I was looking at Hahnemann’s case in the Robert Bosch foundation, I saw that he wrote exactly what the patient told him. I looked at the follow-ups, he wrote every day what the patient had felt. Let’s say a patient comes for follow up after one month. He writes ‘the patient felt that’ and he writes exactly what the patient said in the language of the patient. And the next day he said, I felt this, I woke up in the night and I felt nausea on rising from the bed. He wrote ‘got up this night and felt nauseous’ instead of writing ‘nausea worse night’. He wrote the whole case in the patient’s own words.
Vital information is often missing in many case histories I see, presented to me by other doctors. Always write down all the important information for the diagnosis of the remedy, all the symptoms with intensity, all the information that will be important for prognosis. Any information that is important for prognosis, even if it is not important for the diagnosis of the remedy, you write it down. Any symptom that has importance for just general pathological diagnosis, you write it down. Detail family and past history with treatment taken – you write down everything. Later try to find out the diathesis or the fundamental miasm of the patient from the given data.
When you do your cases, you should underline or give intensity to your symptoms. Remember the underlining is only for the intensity, it is not to say if the symptom is characteristic or not. Intensity means that, how intense is the symptom for the patient? The intensity that we find in the repertory is the intensity of the symptom for the remedy. When you underline it doesn’t say if the symptom is characteristic or not, it just says this symptom is intense for this patient. We use four or five grades of underlining- zero for something that is very common, one for something that is slightly intense, two for something that is a bit more intense, three for something that is very intense and four for something that is extraordinary intense.
Always start the case with the chief complaint. This is a very safe method. Write chief complaint along with proper onset, duration and the progress of the complaints.
Never ignore the investigations. Write down all the investigations, the patient has undergone in detail and if possible scan the reports.
The physical general symptoms are very important especially the sleep, appetite, thirst, menses, cravings, aversion, his reaction to warm and cold weather etc. They are very important and the patient will start feeling that you are really interested in his/her case. By now the patient feels comfortable to open up and this is the best time to explore his/her conscious and unconscious mind.
The patient will never open up if they don’t develop the confidence in you- for that you have to talk very maturely, show genuine concern and indicate to them that you are very learned.
The most intimate symptoms of the patient will never be disclosed to the homeopath if they do not provide proper atmosphere and privacy to the patient. I many times ask my patient to send me an e mail describing their intimate symptoms.
Here is a nice passage from Herbert Roberts (1930) about getting the mental symptoms. He says:
‘The problem of eliciting mental symptoms when they have not been expressed requires all the ingenuity and resourcefulness of the physician, because almost more than any other group of symptoms, it is the mentals that will be wrecked if direct questions are asked.’
In some patients it may take several visits before the mental symptoms are obtained. Some mental symptoms need to be observed rather than to be told e.g. tendency to contradict, loquacity, laughing involuntary, sighing, hysteria etc. Fear and grief are more apt to be observed than expressed. It is generally recognised that mental symptoms are frequently associated with sexual conditions – the patient’s verdict sometimes in this matter can be least trusted. Sometimes a close friend or a family member, associated to the patient may be able to throw light on the case. Remember the truthfulness of the patients expressions must be carefully balanced with the physicians ‘power of analysis.’
The best way to start the case is from the chief complain. Lead the interview for the chief complaints and the physical generals and ask the questions e.g. if the patient is suffering from dysentery then start the interview by asking, ‘Tell me about your dysentery?’, ‘Anything else about the dysentery?’, ‘Anything else?’ And then review all the symptoms and the possible modalities – anything that makes the complaint worse or better. You now have all the symptoms of dysentery and you go to the next ‘chief complaint’. They say obesity. These are the two chief complaints.
Now you consider the physical general. ‘Tell me about your energy levels?’ ‘When are you the most tired?’ ‘When do you have the highest levels of energy?’ etc. When you have finished all the questions regarding physical generals, you may explore the symptoms of mind.
For the mentals symptoms always allow the patient to lead. You can start the interview with an open question like – ‘You know there are different types of people in this world, and people all over the world have different types of behaviour and emotional states, they feel different emotions and mentally they are different, they have a personality, and what is your personality? What characterises you the most as a person? – your personality, your temperament, your behaviour, your relationship with people, as a whole – what is your nature, what characterises your nature?’ And then you sit back and you let the patient talk, let them think and let them take a long time, because that is when they are going to reveal about themselves and come right from their heart.
Always pay attention to first few sentences of the patient; the first thing they reveal, is usually the most important and the most intense. They may say, ‘Well, I’m a nervous person’ ‘I like the company of rich and classy people’ ‘I like to watch movies’ and then you ask, ‘What else?’ You let them talk; at this moment you really don’t want to interfere. The first symptom that they reveal, at that very moment describe their personality and characterises them as a person – this is the way they perceive themselves.
Always ask the question ‘Anything else?’
Every time you ask the question ‘Anything else?’ – It is like, you had a towel and you are trying to squeeze water out of this towel. You ask again, ‘Anything else?’ (You squeeze it a bit) and little water more comes out, and you say it again (squeeze it more) and some more water comes out. When you have asked this many times during this process, the patient may say, ‘I’m not sure if it is interesting doctor, but …..’ YES!!, that is what we are looking for.
If the person accompanying the patient is sitting in the same room, ask them to add any details to the case e.g. ‘Can you substantiate what the person said?’ or ‘What could you add?’ or ‘Is there anything you would like to say that you don’t agree with?’ or ‘Could you confirm what the patient said?’
Never interrupt the patient in the beginning of the case especially during the first five or ten minutes. Sometimes the patient may skip or may get confused, still do not interrupt them because now they are starting a process of revealing, they are going to reveal in a certain way, if you interrupt them and you say, what do you mean by this or that, then they may not be able to tell or further get confused.
If the patient does not know how to answer about them self and is too succinct and they will say, ‘I’m just an ordinary person, there is nothing special about me’ or ‘I don’t know’, then you can try asking, ‘What do people say about you?’ ‘What do they tell you that what kind of person you are?’ And if they still fail then you may ask, ‘What did your mother told you when you were a child?’ This should work and they may tell you ‘Oh, my mother said I was very quiet.’ And when you ask, ‘What did your father tell you?’ ‘What did your brother tell you?’ ‘Did they make any criticism?’ ‘Did they say you were always an angel?’ Then you might start getting some symptoms. Sometimes I use the analogy and I ask, ‘If I had to pick you out of a crowd of thousand people, how would I recognise you?’
Are direct questions allowed?
Yes, sometimes you can ask direct questions in the interview in the sense of ‘What is your strength?’ or ‘What are your weaknesses?’ Never ask two questions at the same time like, ‘What are your strengths and weaknesses?’ or ‘What are your desires and your aversions?’, instead you may ask, ‘What are your desires?’ first and then, ‘What are your aversions?’
Once the patient has described all that he has said spontaneously and you may now return to all the complaints and ask them to explain each of it and can now complete the psychological part.
Confirm some situations and condition, in which the person feels bad or worse e.g. ‘When are you emotional?’ ‘When are you sad?’ ‘When do you get angry?’ ‘When do you get violent?’ ‘How do you feel when somebody tries to console you?’ If they say, ‘it depends’ I ask them, ‘Explain it to me.’ You are always trying to free the information in a spontaneous way; if it is not free, it has no value.
In the end, check for anxiety, fears and phobias. Common questions that I ask are ‘What type of person are you in terms of fears and anxiety?’ then you let them talk. When you ask, ‘Anything else?’ and if they don’t answer well, you may ask, ‘What do you worry the most about?’ ‘On what occasion are you anxious?’ ‘Any phobias?’ ‘Any panic attacks?’
Then you can ask about shyness, confidence level and guilt. The question I ask are, ‘What about guilt?’, ‘Is there anything for which you feel guilty?’
In children, especially ask for violence and destructive behaviour- ‘How violent are you?’ ‘How violent are you to animals?’ When you ask the question ‘How violent are you to animals?’ the Hyoscyamus niger patients will smile. They will smile, because they find joy in cruelty. Every time you talk about something violent and hurting, especially towards the animals they will smile again and you will know it by their smile.
When you ask, ‘How destructive are you?’ usually the destructive person wouldn’t tell you this instead you will get such information from the third person. Sometimes one might get really angry and say, ‘I will kill you!’ How often have you said that? Because the symptom of saying I’m going to kill you, or wishing to kill the person, is the symptom. All those remedies that we have under the rubric Kill, desire to have that feeling and it comes out when they are angry. If it gets more pathological, they really go and do it, but it starts with this desire to kill someone.
Similarly when you ask about jealousy, ‘Do you know what jealousy is?’ and they will say ‘yes’ then you can ask, ‘When do you feel jealous?’ ‘How often do you feel jealous?’ People, who are competitive, usually have tendency to be jealous. ‘If you are in a contest or you are performing and somebody is better than you or you are second and somebody else is first, how do you feel about the person who is in first position?’ If they feel bad, that is jealousy.
Regarding ego, I usually ask this question – ‘How do you deal with your employees?’ A person will not say he is dictatorial, but when you ask, how they deal with their employees, peers, brother or sister; they will then tell you, ‘Well, my employees, I want them to be like this….’. And I say, ‘Okay what about if they don’t do it?’ – they will express their personality, but they will not say they are dictatorial.
For trying to find impulsive behaviour, I usually ask, ‘Any tendency to be impulsive?’ ‘Any tendency to do something unusual, something dangerous, or perhaps something foolish’
For memory I ask, ‘How is your memory?’ ‘What about for places and names of people?’ Like for instance Chlorum typically does not remember the names. Usually all self-centered people will have trouble remembering the names. They can see their face, but they cannot remember their name, because they are self-centered.
Aversion and cravings are very important mental symptoms. This remark comes from Dr Margaret Tyler. For instance aversion to food, or if craving for food – not desire, but craving for food, is considered as a mental symptom. When patient says a craving, it is almost a symptom of love or expression of what s/he need.
Discussion of sexual symptom is a delicate issue, especially in Indian society. This is what I do, I tell them, ‘People have various forms of sexual desires and expressions; sexual life is different for each person; How is your sexual desire? How is your sexual life? How are you during sexual intercourse? How do you experience it?’ and you will be surprised by the number of people who only perform, but do not enjoy. ‘How easy is it for you to get an orgasm?’ It is not unusual for patients to say they never felt an orgasm in their life. ‘How are you in regards to reading, movies, pornography and so on?’ Remedies like Thuja occidentalis, Medorrhinum, Staphisagria, or Hyoscyamus niger thrive on pornography.
Concomitant symptoms – physical symptoms which are associated with mental symptoms are important part of the case taking. ‘Hering’s Analytical Repertory of the Mind’ enlists complaints associated with symptoms like anger and jealousy.
Finally we try to find out the aetiology or causation – how the disease started and why it started?
Remember, if the interrogation is not based on the essential principles of homeopathic doctrine (by Hahnemann) and is led by the caprices – it leads to the formation of incomplete picture of the patient and results in failure of prescription. This failure demonstrates the ignorance.
Even after providing so much information, I feel that case taking, is vast ocean of information and interrogation. I would like to mention in the end that, ‘All I know is, that I know nothing!’