As homoeopathy is a holistic system of medicine, the parameter for treating the patient shifts from signs to symptoms. “Symptoms” are primarily the expression of the dis-ease of an individual, which also attributes to the homeopathic case taking being different from other medical/ clinical history and or case taking.
Case taking itself forms an integral part of homeopathic patient management. Standard case taking differs with the different human systems as the data required specializes to each one. But homoeopathy has one standard case taking format or method which has the provision to engulf the data or symptoms of all systems including mental symptoms. Ideally the Hahnemannian classification of disease should have formed the basis of homeopathic case taking.
KEY WORDS:
Case-Taking, Hahnemannian classification of diseases, Homoeopathy
DISCUSSION:
Case taking itself forms an integral part of homeopathic patient management, apart from playing the role of venting of emotions of the patient, while taking the life space and mental symptoms. The standard case taking differs with the different human systems as the data required specializes to each one. Homoeopathy has one standard case taking format where in the symptoms or data of all the systems, including the mental symptoms has evolved over the period and has been vastly followed and taught in medical programs.
While integrating all the systems of the human body and the format of the allopathic system the basic classification of disease done by Dr. Hahnemann has been grossly overlooked. One must remember that, as the homeopathic pathology (miasms) differs from the allopathic counterpart, so does the homeopathic classification and the management of disease. And the homeopathic case taking must be in accordance with the homeopathic classification of diseases, as the symptoms/ data required/ obtained differs with each category.
Having one standard method or format for all types of diseases creates chaos and ambiguity amongst the students and physicians, resulting in failure to prioritize the symptoms and hence, give results. Such practices in homeopathic medical education form the biggest lacunae as not only does it show to practice in difference with the homeopathic teachings but also create chaos leading to mismanagement of homeopathic patients.
Currently we have one standard format for acute/ acute Recurrent / acute exacerbation of chronic and chronic type of diseases. As Dr. Hahnemann has classified these into different categories owing to the difference in their management, the case taking will require different types of symptoms /data for the same reason.
In homoeopathy the mode of selection of the remedies as governed by the disease expression will be determined by whether the disease is acute or chronic. The acute disease throws up the acute symptomatology which guides to an acute prescription, the constitutional symptoms of the chronic being pushed into a background.
The acute cases lead either to recovery or death; while the chronic cases lead nowhere except lifelong suffering unless they are counteracted by homeopathic medicines. The difference between the acute and chronic disease is much more than the time – duration of the illness. In acute cases the life force or vital force is changed but the changes are more or less superficial as compared to what happens in chronic cases. An exclusive cross-sectional study of the case is required in acute cases, while a deep longitudinal study (at times along with cross- sectional study) is required in chronic cases.
The acute Diseases are of following types: –
- Classical acute disease or an episode of a sporadic disease (like a common cold or influenza)
- acute diseases as an acute exacerbation of an ACTIVE CHRONIC disease (like an zcute attack of asthma).
- acute disease recurring over a long period of time like recurrent cold persisting since many years.
- acute disease supervening in the course of an existing chronic disease, which is not related to the chronic disease (like an acute episode of loose motion in a hypertensive patient).
The second and third type are those acute diseases which though appear to be acute are but long-standing (chronic diseases) requiring both acute and chronic constitutional medicines to cure them in different phases.
As an acute disease never forms a COMPLEX with a chronic one, the latter being suppressed until the former one has run its course, care must be taken when ascertaining the symptoms of the acute disease not to take into account old symptoms which belong to chronic disease or prior state.
The case taking, the basis for the homeopathic prescription, in acute disease must confine itself to the acute state only and not to the constitutional state of the patient.
In acute diseases(cases) the chief symptoms are very prominent and impress on our senses quickly and hence much less time is required for tracing the full picture of the disease and much fewer questions are to be asked as almost everything is self-evident. In acute diseases the evolution of symptoms is also quick.
Whereas in chronic disease the symptoms take a slow evolutionary pace covering months and years and, so the investigation must be detailed and painstaking and as thorough and searching as possible, covering the past as well as the present conditions of the patient and even tracing the family history on both sides (paternal and maternal) of the individual concerned.
Hence the symptoms in chronic diseases are much more difficult to be ascertained. Acute diseases are morbid, rapid processes initiated by the abnormally deranged vital force. These are of self-limited nature, resulting in recovery in the course of time or in death, if the vital force is overwhelmed.
These may affect the individual or groups of persons in a sporadic manner. The presenting totality which consists of the chief complaint (s) and the concomitants, each under the four elements of Location, Sensation, Modality, Concomitants and accompaniment govern the choice of the remedy in acute disease.
The modality (ies) may be causative/ precipitating, aggravating, and ameliorating. The causal factors may be at the emotional, intellectual and the physical levels of the functioning of the vital force. The differential modalities which are particular modalities running counter to the general modalities, assume the highest importance.
Generally, in acute diseases the constitutional symptoms of the patient are thrown into the background, and the vital force under the impact of the environmental force brings the acute symptomatology to the forefront. The value of the concomitants (or the associated symptoms) in acute prescribing has to be borne in the mind, especially the mental concomitants in the physical disease and the physical concomitants in the mental disorders.
In acute cases the particular symptoms (pertaining to a specific part /organ/tissue) dominate the expression when the acute disease localizes. There may be some characteristic individualizing general symptoms (pertaining to the person as a whole, like thirst, sweat etc.) in the very initial prodromal phase of the disease, apart from malaise and sick feeling.
It must be noted here that on the basis of this General totality present in prodromal phase when treated with the presenting constitutional symptoms, one can abort the progress of the acute disease. But this stage of prodrome is short and eventually the disease localizes at rapid pace. Hence particular symptoms dominate the totalities in acute cases.
But if the vital force is severely deranged and affected the general symptoms start appearing in the acute cases. The appearance of general symptoms in acute diseases is an alarming situation as these are those fulminating acute cases which if not treated properly may end in death.
As the acute cases result in either recovery (many a times unaided) or in death, it is obvious that the clinical presentation will be different for both the resulting situations. This demarcation if missed by the physician will result in grave negligence.
Only the RECENT deviations are to be considered while taking the acute case and enquired upon, meaning thereby, only those expressions, symptoms and changes in the body and mind that have been initiated after the onset of acute disease are the part of the acute picture.
This is commonly mistaken and confused with the Constitutional expressions by the homeopathic student and many a times by the new homeopathic physicians as only one case format is used. For example, a person may be generally thirstless and after the onset of the acute complaints, drinks more water but in sips, then this alteration or change IF present is ONLY considered, the otherwise prevalent expression even if persistent is of No value. IT IS THE DEVIATIONS FROM THE “PERSON’S NORMAL”, after the onset of acute disease these are to be considered to form the acute totality of symptoms. Though this is a known fact, it fails to reflect while practically taking a case.
Acute fulminating diseases are the acute fulminant infections with extreme susceptibility to overwhelming /massive environmental onslaught inimical to life. The susceptibility is annihilated and there is total failure of the mechanism of homeostasis. This represents the critical state threatening dissolution/ death, as the vital force is so overwhelmed by the morbific agent inimical to life, that, it is not able to throw up the acute response but has to call upon the “Generals” in self-defense.
In such acute a fulminating case the constitutional symptoms, instead of receding into the background become prominent and are read by the discerning eye of the alert physician. This calls for the deep acting constitutional remedy indicated for the case like in uremia diabetic acidosis, pneumonia etc.
In this situation, if the right remedy is not given in time, the case is likely to turn fatal. We need to recognize these situations as EMERGENCIES and a remedy based on ONLY the PRESENT General Symptoms has to be given. The generals considered in acute cases are different from the generals in the chronic cases.
In acutes, only the deviations felt after the onset of symptoms are considered, and these may be different from the person’s basic constitutional expression. In chronic cases the constitutional physical general expressions are considered for prescription and in acute cases only the physical general deviations from the constitution are considered for prescription.
But, as physical generals are to be taken in both acute and chronic cases the demarcation if not proper, leads to incorrect recording of the symptoms leading to gross mistakes and incorrect prescriptions. So, when the young homoeopath is unable to get results in practice he blames the method and is easily discouraged from practice of homoeopathy.
Successful homeopathic prescribing demands detailed case taking in depth to bring out i) the characteristics in the present complaints ii) the evolution of the complaints over a period of time, iii) the true significance of the complaints in relation to the life situation, and iv) a full account of the personal as well as the family, past, history which often guides the prescriber.
The physician also requires separating the acute totality from that of the chronic totality. Failure to separate these totalities not only results in confusion in prescribing but is often responsible for needless aggravations. Also, if constitutional symptoms are considered in acute disease it results in premature induction of the constitutional remedy, which vitiates the picture or produces an aggravation. It can also be treated as negligence of the physician. An ideal case record format should follow and illustrate these various points in an effective manner.
The symptoms expressed and that which are required, are different in each type of disease as per its unique clinical presentation, for the formation of the totality of symptoms. In short, the method of forming a totality of symptoms in a classical acute case (a single sporadic event of acute condition) requires a cross- sectional study of the case, while the acute exacerbation of a chronic case (like an acute attack of bronchial asthma) and acute recurring disease like renal calculi or recurring common cold, require longitudinal study (along with cross- sectional study) of the case.
As the homeopathic management of these conditions are different in these two types which appear to be acute bouts but of long standing and need both acute medicines in acute phase and constitutional homeopathic medicine when the patient is not in an acute attack of disease.
The data of the patient is an admixture of the acute and the chronic symptomatology. Special care has been taken to separate the acute from chronic symptomatology.
Dr. Samuel Hahnemann found that homoeopathy failed to bring a real cure in some diseases in the sense that, though the disease appeared to subside for a time under properly selected homeopathic drugs, they always had a tendency to relapse at some time in future.
This fact led him to conclude that the homeopathic physician in such a situation has not only to combat the disease presented before him but must view and treat it as if it were a well- defined chronic disease and then as required for chronic diseases it needed a remedy considering the deep-seated original disease rather than considering some superficial fragments of it.
In other words, Hahnemann was led to conclude that though certain cases were temporarily benefited by remedies which seem to correspond accurately with the symptoms actually present, there were points of importance in these cases to which they failed to correspond.
In fact, these were only one event in a series, and it was necessary to find medicines corresponding to the series if a cure was to be effected. All these isolated attacks of particular syndromes (acute recurrent and acute on chronic disease types) are not many diseases but varied expressions of one continuous progressive morbid process which constitutes the ‘disease per se’.
The law of cure or Homoeopathy was not at fault but the defect was in ascertaining the Totality of Symptoms on a wider basis comprising not only the present but the past and whole picture of the individual was required.
This discovery made by Hahnemann ultimately led him to the theory of chronic diseases.
Acute exacerbations of active chronic diseases and acutes of recurring disease must be treated in a different way from that of an acute sporadic disease. Here the acute attacks have to be treated on the basis of acute totality of Symptoms done by the cross-sectional study of the case and ONLY after the acute attack subsides, a deep acting chronic constitutional remedy needs to be given after considering the chronic totality, done on the basis of longitudinal study of the case.
These acute recurrent or acute on chronic type of diseases are the chronic diseases of a relapsing nature or periodicity (regular or irregular), interspersed with acute attacks/episodes. They are totally or partially asymptomatic during the intervals, e.g. epilepsy, bronchial asthma, menstrual colics, migraines, allergies etc.
Such acute paroxysms/episodes require acute prescribing based on presenting totality. The chronic state (in between asymptomatic period) requires constitutional prescribing of the chronic deep acting remedy, selected on the basis of the constitutional symptoms present only in the free interval/phase, and it has to be administered only after the acute phase of the disease is over.
It then becomes pertinent to have one case record format having both the acute phase symptoms and the chronic phase symptoms depicting separate, required data.
In an acute phase or stage the patient may not be able to give the chronic symptoms and so one should ideally record only the acute symptoms. After the recession of the acute attack one can enquire into the chronic case. Having a single case format will keep all the relevant data in one place and the student / physician will be able to segregate both the acute and chronic totalities as they will be separately available. The data of the patient is an admixture of the acute and the chronic symptomatology. Special care has been taken to separate the acute from chronic symptomatology.
At present, there is no separate case record format having provision for obtaining and enquiring into data required for both acute and chronic expression of the disease. Thus the students either end up having only the acute or chronic, or worse, a mix of both the expressions of disease, leading to ambiguity and confusion amongst the students and the physicians.
Until now only one format is used for homeopathic case taking for all types of diseases, in homeopathy colleges and U.G, P.G teaching institutes, clinics, etc. One universal case record format in a homeopathic training and practice is not justifiable to record the varieties of clinical expressions in different types of acute diseases, let alone having one format for acute and chronic diseases in Homoeopathy.
Though there are innumerable books available on homeopathic case taking, the students are often at a loss as to what exactly needs to be asked and how to take mental symptoms or ask the correct questions. Formation of the Totality of Symptoms (TOS) by the students and the physicians often leads to gross mistakes ending up in giving incorrect medicines.
This is usually due to either incorrect or incomplete case taking. Taking a chronic case is a cumbersome process and is also time consuming, hence the chance of missing the required details is very high, unless it is reminded or has become a habit.
When taking personal history, generally emphasis is given on desires and aversions by the student as they fail to ask the proper questions which will help get the individualizing details of the patient, which will also be more reliable when forming the totality of Symptoms.
A longitudinal study of a case requires one to enquire and note all the important aspects of both the patient and the disease evolution. As the chronic cases can be complex due to mixed miasm, the approach needs to be more detailed and reliable for the homeopathic management of the chronic diseases.
An ideal case record format should follow and illustrate these various points in effective manner. Though homoeopathy teaches prescribing on the basis of pathology and also using clinical repertories, examining patients clinically, diagnosing the patients, and segregating the disease (common) symptoms from the individual (characteristic) symptoms, identifying the pathological general symptoms of the case is overlooked.
REFERENCES:
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