The examination of the patient and record-keeping

The examination of the patient

– BENERJEE.P
 One very important thing. While taking up a chronic case, you must begin with a written record of the history and symptoms. You must not begin the treatment of a chronic case, without first making a written record of it. I can hardly over-emphasise the importance of this advice. You should have a bound book; the left hand page should be used for recording the symptoms, the right hand page being kept blank. You should write out the symptoms separately one from another and leave sufficient space between the lines. More than one symptom should not be written in the same line. If you do the recording as advised by Hahnemann, much trouble and labour will be saved and the main work of treatment facilitated to a large extent. There are some, who do not realise the importance of record-keeping. They are inclined more to depend on their memory and intelligence. But you must ever remember, however sharp your memory may be, it can never be absolutely reliable. If once it has proved faithless to you in the course of the treatment of a given case and has led you to a blunder, there is nothing to help you out of it. Record-keeping is, therefore, indispensable, and you must not neglect it in any case. If however, you do it yet, you do it at the risk of your patient.

 While recording the history and symptoms of a case, you must have a free mind-free from all bias and prejudice, for or against any particular medicine; and most of all, you must not be thinking of any particular “disease.” Your aim throughout will be to examine the “patient” and not the “disease”. You will only try to understand the condition of the patient and to make out a picture of his case. Just as, while studying the materia medica of a particular drug, your endeavour is to have a picture of it in your mind’s eye, so while examining a patient and recording his case, your aim should be, to have a picture of him.
 First of all, note the patient’s name, sex, address, occupation, age etc. on the top of the left hand page. The date should be noted in the left hand corner of the page. As soon as you have made these preliminary notes, put the first question to your patient,-“What are your sufferings? Tell me how you feel now in your diseased state as compared with your healthy state. Please tell me all these slowly, so that I may write them out”. On this the patient will begin to give you a description of his condition, and you will go on writing it out, as far as possible, in the patient’s own language. You must write down the symptoms separately in different lines. Do not interrupt him at all, unless it is absolutely necessary for keeping him to his subject. Unless the patient is telling you a lot of irrelevant matter, such as have no connection or relation to his condition, no interruption should be offered to him. When, however, he has finished telling his case, you should make a note at the bottom of the record, as to the mental condition, movement and temper etc. of the patient, if there was anything unusual, while he was delivering his case to you. You will find, at times, that some patients will burst into tears while telling their symptoms, while others will heave heavy sighs at intervals, and while yet others will say at times in a tone of despair-“What is the use of telling all these to doctors? My case is incurable”. Some will even say-“Oh, I can’t bear all these, I must end myself and thus end all my sufferings”. Others will perhaps say-“Doctor, pray cure me at any cost, I can’t die, I must live”. These and various other things will be available to you, if you carefully watch the patient, while recording his case. And these facts when they have been watched out by yourself instead of being gathered by directly interrogating the patient will be of immense help to you in making out a correct picture of the case, which alone you are endeavouring to have out of him. But, in case of direct interrogation on such matters, the patient will seldom make a correct reply. For example, if you ask a patient straight-“Do you want to commit suicide?” He will perhaps say-“No”, but if you watch him out and can find that he seems to have a disgust for life on account of the magnitude of his sufferings, you may accept this as a genuine symptom un-exaggerated and un-magnified; and such genuine symptoms are very valuable for your purpose. And again, if you ask a patient straight-“Have you a silent sorrow eating within you?” He will possibly say-“No.” But if on the contrary, you find out that he was heaving deep sighs while telling out his case, you may take it that he is suffering from some internal sorrow. Thus you see that the condition, demeanour, movements and temper and attitude of the patient, if you can correctly grasp them by careful observation while recording the case, will help you to make out a correct picture of it for which only you are trying.

 When however, the patient has finished his history and you have made your own notes at the bottom, as to how you found him while telling his case, you should obtain from the patient by interrogating him further details, that is to say, the “particulars” of the symptoms already noted, and record these details on the right hand page, against the symptoms to which they relate. Suppose for example, he stated, while relating his condition that he has a “headache.” Now, greater details about this “headache” should be obtained from the patient. He should now be asked to state-(1) when the headache comes up, (2) when it begins, (3) when it ends, (4) how it is relieved-by sitting, by lying down, or by tight bandaging, or by walking etc. In this way, you have to elaborate each symptom that has been recorded by you on the left hand page. You have only noted there the general symptoms-“the generals”-on the left hand page, as given to you by the patient, and “the particulars” in respect of each of the generals should be obtained from him and the picture made out more vivid, sharp and well defined. After finishing this elaborating of the “generals” by collecting and recording the “particulars” in respect of them, you should proceed to ascertain from the patient’s friends, guardians, and nurses, his temper and nature etc. These informations cannot be had correctly from the patient, as being a patient himself, he hardly understands that there is anything unusual in his nature and temper. You have, therefore, to obtain these from the guardians and friends and from a direct observation of the patient, as far as possible, when he is before you for giving his case. Next, you should proceed to ascertain the cravings and desires of the patient-his aversions, likes, dislikes, etc., what he prefers, what he does not prefer and so forth; whether he likes cold or heat, whether there is any difference in his desires for cold and heat in the different parts of the body, (e. g. one patient wants cold in the head and warmth in the chest). All these should be correctly ascertained and recorded. At times, you will have patients who will say,-“Not to speak of drinking milk, the very sight of it causes nausea”. Another will perhaps say,-“Oh, I can’t tolerate meat at all”, etc., etc. These peculiar likes and dislikes should be carefully noted. Then again, the patient may prefer heat or cold, but these may unfortunately aggravate his troubles. Such peculiarities should also be noted. On which side the patient lies whether on the right or on the left or on the back; the position in which he generally lies; whether he prefers cold or heat; whether he prefers open air or closed room; whether these different conditions affect him differently in the different parts of the body;-all these things should be carefully noted and the picture of the case made as complete as possible. The more vivid and well defined you will make the picture, the easier will be the task of prescribing.

 The next thing is to note if there is any periodicity in the patient’s sufferings, and that with all details of amelioration and aggravation.
 After this, you will have to record whatever changes there may have been in the functions as also in the structures of the various physical organs. For this purpose, a physical examination of the patient-of his liver, spleen, heart and lungs etc. is necessary. It should also be ascertained, if there is any pain or any kind of unusual sensations etc. in those organs or parts of the body, and necessary note of these should be made. Functional deviations of the organs, the condition of the bowels and urine, the number and character of the stools passed, the number and character of the urine voided-all these should be recorded in all their details.
 The above method of examination of the patient is applicable also to the cases of those suffering from acute diseases, the only difference being that in acute cases such minute details as required for the treatment of chronic cases, are not generally necessary. But besides this small difference, there is a further difference between the manners of studying up chronic and acute cases. And that difference is based on the fundamental difference between the two classes of diseases. Acute diseases have an inherent tendency to come to an end of themselves after running their courses, while chronic diseases have quite the opposite character of never ending of themselves i.e. , without the aid of curative medicines, but of continuing and continuing. And we have studied before, that this tenacity which characterises chronic diseases and differentiates them from the acute, is due to the chronic miasms-Psora, Sycosis and Syphilis. In every case of chronic disease, it is either any one or any two or all the three of these miasms that are in the back ground and are making the disease chronic i.e. , giving it the characteristic tenacity. And in examining your case, you have to complete the record you have made, by ascertaining which of these miasms is or are in your patient and which of them has the preponderance. Unless you ascertain this, it will not be possible for you to make a prescription sufficient for curing the chronic disease, and your prescription would in that case only cope with the acute condition of the case; because, it is these miasms that have made your cage chronic, and unless your prescription is based on these miasms, that is to say, unless your prescription is miasmatic, there cannot possibly be a cure. Therefore, for ascertaining which of the miasms are there in your patient and which of these miasms again has the preponderance, you have to record the history of the patient from his childhood or from as far back as possible. The ills and ailments the patient had in his past life and the treatment he had; whether the parents or their parents, on any side (father’s or mother’s), had any miasmatic disease, and if they had, how they were treated; of what the family members on hoth sides have died so far, and whether they too had any miasmatic disease; whether the patient himself had acquired any miasms in his own life time, and if he had acquired any, how they were treated;-all these must be ascertained from the history of the patient, and in doing so, the testimony of parents and friends should also be had, if necessary, and then necessary notes made in the record prepared.

 It is however, very very difficult to ascertain the above details, as parents are almost always unable to furnish such history, while the patient himself is ever vigilant for suppressing the history of direct acquirement of Sycosis and Syphilis, out of delicacy. If however, in any case, such detailed miasmatic history is not at all available in spite of the best of endeavours, you have to make the best of the situation, that is to say, you have to exercise your discretion and find out for yourself the miasmatic character of the patient from what symptoms you have already recorded. All the three miasms have their characteristic ways of expression. The Psora patient has a particular character of his diseases and symptoms, the Sycotic patient has his, and the Syphilitic too has his. Then again, the mixed miasms-such as, Syco-Psora, Syphilo-Psora, Pseudo-Psora and Psora-Syco-Syphilis-have also their definite characters of manifestation as diseases. And if you have learnt up the distinctions between the one and the other, it will not be altogether impossible for you to find out the miasmatic basis of your patient, with success. And this you have to do and add to the record you have prepared, as without knowing the miasmatic basis of the case-that is to say, without knowing that which is giving your patient a chronic disease of a particular kind, you can not make a miasmatic prescription, and unless a miasmatic prescription is made, the cure of the chronic disease is far from hand.

 Intelligent patients are very rare. Such as will come up to you and give out all their symptoms and history straight, you will hardly find in course of your practice. This is, because they regard the disease for which they have come to you, as the only thing to let you know, and as such no importance is attached to the other things they may have besides. For example, if a patient has come to you for a tumour in the tongue, and if he has got a periodic headache or diarrhœa, besides, he will hardly volunteer these symptoms to you, as he is unable to see that the headache or the diarrhœa can have any connection with the tumour. In such cases, i. e., where patients are unable to give out their condition and history in all their completeness of themselves, you have to put questions to them and cross-examine them in all possible ways for collecting their symptoms etc. Samuel Hahnemann has advised that in doing this, no leading questions should be put-that is to say, questions that would lead the patient to the answer. For example, if you enquire-“Is the urine high-coloured?” The patient will most probably say-“No” or “Yes.” If you enquire-“Do you feel any mental restlessness?” He will possibly say-“Yes” or “No”. These answers are not in most cases correct, and they will often spoil the whole picture of the case that you have been preparing. You must not, therefore, put such questions to your patient. You may only ask-“What is the colour of the urine”, “What is the condition of your mind”, and so forth. The risk of putting leading question is very great.

 While examining your patient, you will often find peculiar symptoms, such as you do not find generally. These peculiar, unusual symptoms are very valuable, and they should always be studied with attention and recorded with care. They will simplify the work of prescribing to a very great extent.
 When you have finished the recording of the case as detailed above, you have once to read it through, carefully, and judge out if the picture obtained is complete. If the picture is not complete yet, find out the points wanting, and make it complete by ascertaining further facts from the patient. After this, you will advise your patient to stop the use of any medicine that he may have been taking. Tell your patient to be without any medicine for about a week and to report after that any change that he may feel in his condition. If he reports any such change, you have to re-adjust your record, as it will be understood that this new condition is the correct picture of the case, while the previous one was the case plus the medicine that he was taking. You have to take account of this picture now in making your prescription. If however the patient was not taking any medicine, the question of stopping it and of delay of a week for watching the change does not come in, and in that case, you can go straight for the prescription.
 For making the prescription, you have now to study up the record again and see if sufficient particular symptoms in respect of the general symptoms have been recorded, as without the particular symptoms, no prescription is possible. If you have in the record, only “dysentery”, it cannot lead you to any “one” medicine. “Dysentery” would suggest some forty medicines, and you cannot fix upon one out of these forty unless the particular symptoms about that “dysentery” are there. If there is only “fever” in your record, it suggests all the medicines in your Materia Medica-from Aconite to Zincum. Unless the particular character of the “fever” is available from your record, no selection of medicine is possible. If however against the general symptom “fever” in your record, you have-“Coming on at 9 or 10 a. m, headache, thirst, constipated bowels and then remission with perspiration”, you at once think of Natrum Mur. Thus you see that, the particular symptoms are very important. It is they and they alone that enable you to picture the particular case in your mind’s eye and to find but the similimum. Unless there are particular symptoms, no prescription is possible from the general symptoms, which are in fact only so many disease-names. Perhaps the patient will come to you and say-“What else can I say? The only thing is that I get a headache at times. Do something for me.” Now, this “headache” is a general symptom-it is only the name of a so called disease, and unless you can get the particular symptoms of this “headache” so as to frame a picture, so that, that particular headache patient may stand out distinctly separate from all other headache patients, you cannot do anything. And it is better for you to tell him so. There arc headaches and headaches and unless you know this particular headache you cannot cure it.

 It therefore, comes to this that you must ever prepare your record in such a way as there may be sufficient particular symptoms in respect of each of the general symptoms, so that not only you alone will be able to prescribe on it, but also any other able Homœopath. Remember, while making the record your aim should always be to make out a well defined picture, and unless you can do this, the record is incomplete, as it cannot lead you to any “one” particular medicine in the Materia Medica. It has been stated before, that a thorough knowledge of the Materia Medica is essential. And if you have a thorough knowledge of the medicines in the Materia Medica-such a knowledge as can conjure up their definite pictures, as in a mirror, before your mind’s eye, you can at once see from your record as to which of these medicines it resembles most. You may not come to “one” such medicine at once, (though this is certainly due to incompleteness in the record), yet it should land you at the most, on two or three medicines, and not more If however this is the case, you have to re-examine the patient and collect such further particular symptoms as would clear up the picture of the case and make it resemble only one and one medicine and not more.

 After the examination of the patient has been finished and a complete record made out, your business will be to select the remedy. But this has to be done with caution. If in your case, there are any symptoms of medicines previously used, and if there are any new symptoms of an acute character, on account of the patient having had an acute disease in the meantime, these should be carefully eliminated from the picture. The prescription will always be based on those symptoms only that are permanent-permanent in the sense that it is they alone that have made the case as it is i. e. “chronic”. The acute symptoms and the drug symptoms that may have intervenned in the meantime are only so many “reflexes”, and they do not belong to the individuality of the patient. As such, they have no bearing on the prescription. If the medicine selected fits the picture of the “individuality” of the patient, that is to say, fits that which has made that patient as he is and not otherwise, cure is certain, and in that case the acute symptoms and the drug symptoms, mentioned above as so many “reflexes”, will automatically disappear, having nothing to be fastened to.

 There is another thing, however, namely the various combinations of the miasms of Psora, Sycosis and Syphilis, in the same patient. How these combinations or knots will have to be untied and how the treatment will have to be conducted in cases of such knotty miasmatic combinations, will be dealt with later.

All systems of medicine including Allopathy speak of “Diagnosis of the disease”, but in Homœopathy, it is the “Diagnosis of the patient” that is necessary, because Homœopathy has to treat the patient and not the disease-the external manifestations of the patient’s condition. The Homœopath has, therefore, to understand correctly the internal essence of the patient that is to say, the personality of the patient. For a Homœopath, the external manifestations of the disease, that is to say, the disease-symptoms, apart from the personality of the patient have no meaning, and as such, a mere diagnosis of the disease, a mere cataloguing of disease-symptoms, as it were, is of no use to him. It is the patient, therefore, that he must examine, study up and understand, and if he is to do this successfully, he must have a thorough-very thorough knowlege of all the anti-Psoric, anti-Sycotic and anti-Syphilitic drugs of the Materia Medica. His knowledge regarding the materia medica of these drugs must be so thorough and clear, as their very names may conjure up before his mind’s eye, living pictures of these drugs. Unless one can master the Materia Medica in this fashion, it is an idle endeavour to attempt treatment of chronic cases. The examination of the patient again, is a far more difficult business than one might seem to think. It is a business that has to be done with care, patience and close attention. It is no hasty, off-hand process. You can not expect to examine and prescribe for a dozen or more chronic cases in a day. The maximum number of such cases that you can possibly do in a single day is hardly two or three, and this should give you an idea of the magnitude of labour that a chronic case demands. You may, therefore, charge high fees, but never do cheap hasty work. Treatment of acute cases is far easier and far less laborious than the treatment of chronic cases. In the former, the symptoms stand out prominently, and they at once call for the right remedy, which is however never the case in chronic patients. In the former, the patient feels his sufferings acutely, and as such, he can describe his condition with accuracy and precision, but in the latter, the patient is unable to do this, as having been long used to his sufferings, he gradually seems to think that the condition is his normal condition. It therefore, happens at times, that the most important symptoms for a correct prescription, are ignored, overlooked and left out by the chronic patient, while giving his history. A chronic Arsenic patient will seldom tell you that he has a decided aversion to water or that there is no thirst. Similarly, the Graphites or Mercurius patient will never state before you that he has an obstinate constipation or an offensive perspiration. He seems to think that, these are all his normal, natural conditions, and as such, they are of no importance to the physician for his prescription, and he will, therefore, never give them out to the physician. Then, again, certain symptoms in chronic patients appear at intervals, and the patient himself does not know if these will be considered as belonging to the same or different groups of symptoms. He attaches no importance to this type of appearance of symptoms at intervals. Then again, there are other symptoms which have a periodicity in their appearance, e. g. dysentery in the rainy season and rheumatism and cold in the winter, or headache in the rainy season and constipation in summer, and so forth. The patient never knows that there is anything of importance in this periodicity of symptoms, and he, therefore, leaves it out of account, thinking these symptoms as so many separate diseases, and thus makes his case doubly difficult for his physician to cure. Then again, long course of suffering makes a chronic patient callous to himself and sceptic of cure; he begins gradually to think that no physician can cure him, and as such, he neglects making a thorough statement of his case to all the physicians he goes to. Added to the difficulties described above, a chronic case is made doubly difficult by injudicious unhomœopathic medications, as these drive the disease inward, and instead of curing the patient, intimately mix up the disease and drug symptoms, producing a complexity. In fact the disease and drug symptoms so mix up in such cases in course of time, that it becomes very very difficult for the physician to discriminate between them. These are some of the difficulties that you have to encounter in treating chronic cases, and you must therefore understand, that it is a business that has to be done with care, patience and attention. Charge heavy fees, if you will, but do not render cheap, hasty work.