Examination of the Patient

The technique of an examination for the purpose of diagnosing the disease is quite different from that of the examination for making the homoeopathic prescription….

We take up, in a general manner, the subject of the examination of the patient for the special purpose of making a homoeopathic prescription.

At first thought it would seem as if this subject should have been presented before the general subject of symptomatology, treated in the preceding article, inasmuch as the purpose of any examination of the patient is to discover signs and symptoms. It is evident, however, that we cannot intelligently and logically take up the study of methods of examining patients for a homoeopathic prescription until we have learned what symptoms are, from the homoeopathic standpoint, and decided upon some adequate form of classification. We shall be more successful in our search for anything if we know what we are looking for.

The story is told of John Burroughs, the late venerable dean of American naturalists, that on one occasion he was visiting the home of an admirer, who lived in the suburbs of one of our large cities. His hostess, professing her great love of birds, bewailed their disappearance from her neighborhood. She had not seen a bird for such a long, long time. The wicked boys and the marauding cats had driven them all away! “Uncle John” looked sympathetic, but said nothing. Shortly afterward he put on his hat, tucked his note book and opera glasses in his pocket and went out for an hour’s walk. On his return he invited his hostess to sit down beside him, produced his note book and showed her a list of nearly twenty different species of birds which he had observed during his hour’s walk, within a half mile of her home! The difference between Mr. Burroughs and his hostess was simply that he not only knew *what to look for, but *where and *how to look for it; and so he easily found what was hidden from her eyes.

So it is in examining a patient. The student who knows the nature, constitution, forms and varieties of symptoms necessary for the homoeopathic prescription will find many things in a case which another, specially trained perhaps only in pathology and general diagnosis, will entirely overlook; because pathology and diagnosis do not seek for nor take into consideration the phenomena which are most significant from the standpoint of the homoeopathic prescriber. The “modalities” or “characteristic conditions,” for example, which we have seen to be of the highest importance in selecting the homoeopathic remedy, mean little or nothing to the pathologist or general diagnostician. The same might be said of mental and subjective symptoms. Thus we have to separate and classify the various kinds of symptoms revealed by a complete general examination, and vary our methods of examination according to the particular end in view.

The technique of an examination for the purpose of diagnosticating the disease is quite different from that of the examination for making the homoeopathic prescription.

The diagnosis of disease by modern methods is based largely upon physical signs, tests and reactions, involving the use of many instruments of precision, in which the patient takes no active part, and of which he has no knowledge. The selection of the homoeopathic remedy, on the other hand, is based very largely and sometimes almost entirely upon the phenomena, or deductions drawn from the phenomena, of subjective, conscious experience, perceived only by the patient and stated by him to the examiner. Nearly all of the objective phenomena possessing value from the standpoint of homoeopathic therapeutics are of such character that they require the exercise of only the physical senses and ordinary powers of observation by the patient, his friends, or the physician himself. This distinction should be kept clearly in mind. Examinations for the purpose of pathological study and for diagnosis are necessary and important in their several fields; but from the standpoint of homoeopathic pharmaco-therapeutics, their importance is relative, not absolute. Aside from the physical and organic localization of disease, they furnish comparatively little that is of value to the homoeopathic prescriber in his special work of selecting the symptomatically similar medicine.

Let not the pathologist, therefore, criticize the methods or findings of the prescriber, nor the diagnostician assume that his findings are sufficient for the materia-medicist; but let each regard these matters in the spirit and from the standpoint of the *physician. For the physician, as an ideal, is greater than any medical specialist. The specialties in medicine only exist in order that, by combining them, the ideal of the perfect physician may not die and disappear from among men. However doubtful we may be of the necessity of the real value of the results, it is true that in the vast extension of so-called medical science it has become impossible for any one man to grasp and master it all. Therefore medicine has been divided into so many specialties that we might paraphrase the old proverb, “it takes nine tailors to make a man” into a new medical proverb: “It takes nine specialists to make a physician.

The general practitioner, if one dare to follow that ancient and honorable calling, must act in several capacities – as hygiemist, sanitarian, pathologist, psychiatrist, diagnostician, therapeutist, and perhaps even surgeon and obstetrician; but in each of these departments he may be compelled to fill up the measure of his own technical shortcomings by recourse to the specialists. He is the wise physician who recognizes his own personal and technical limitations and judiciously uses the services of others who are specially qualified in some particular branch. And he is the wise specialist who recognize *his limitations – who realizes that, after all, no matter how expert he may be in his branch he is only, as it were, a part of a physician in the broad sense of the word. Modesty pays good dividends in the long run.

In this spirit we may all co-operate for the best interests of our profession and our patients, and agree with Hahnemann in the postulate of the first paragraph of the “Organon:” *”The highest and only mission of the physician is to heal the sick.” Every medical specialty is subordinate to that ideal. The work of the homoeopathic prescriber, dealing specifically (as it does) with the application of medicines to disease according to a definite principle for the purpose of curing such conditions as are amenable to medicines, must ever remain one of the most important of the functions fulfilled by the physician. Although the related branches of medicine – hygiene, prophylaxis, sanitation, surgery, physical therapeutics, etc., have made great strides, the time is yet far distant when pharmaco-therapeutics will become unnecessary.

It follows that the pharmaco-therapeutist must be a specialist in the sense of becoming an expert in his department and this, let it be said, is the crying need of the profession.

With diagnostic and pathological examinations and symptoms, as such, this article has nothing to do, except to show their general relation to homoeopathic prescribing. The purpose of this article is to teach the principles of “case-taking” and how to determine, from the record of an examination of a case, what symptoms are most useful as indications for the curative medicine under the homoeopathic principle. Some points on the method of conducting an examination in such a manner as to discover and develop these symptoms for use in prescribing will now be presented.

In the present state of the science of pharmaco-therapeutics and with our materia medica in its present form, the most important thing to be remembered in examining a patient for a homoeopathic prescription is that, with very few exceptions, the most valuable indications for the remedy are to be found:

1. In those subjective morbid sensations and phenomena which come within the sphere of the patient’s own experience and are perceptible to him alone.

2. In those objective signs of disease which are perceptible to the unaided or natural senses of ourselves, the patient or others.

For the first we must, of course, depend entirely upon the statements of the patient himself. The findings of the thermometer, the stethoscope, the microscope, and the various other diagnostic instruments give us very little, as yet, that is directly available for the selection of the remedy. Their principal value is in determinating the diagnosis and pathology of the case as bearing upon the prognosis and general auxiliary treatment. They also point out or more accurately define the anatomical basis of the prescription and aid us in correctly localizing symptoms.

It follows, therefore, in our special examination, that we should at once endeavor to put ourselves upon such a footing and in such personal relation to the patient as will best favor a full, frank revelation by him of all the circumstances and conditions that led up to his illness; and an equally full, simple and frank statement of his sufferings as they seem to him. The problem is here largely psychological. It is well in some cases to briefly explain to a new patient the special purpose of a homoeopathic examination and to point out how it differs from the ordinary examination, especially by including mental and subjective symptoms and certain conditions that are usually ignored.

We must first gain the patient’s confidence and relieve him, as far as possible, from the sense of restraint and embarrassment. This is favored in a general way by a calm, dignified, but at the same time quiet and sympathetic manner on the part of the examiner; a demeanor confident, but not pompous; simple and direct, but not aggressive; cheerful, but not flippant; serious, but not grave or funeral. We should try to put the patient at his ease by adapting ourselves to his personality and mood.

We should not confuse the patient by a too penetrating gaze at some objective feature which may attract our attention. We may learn to observe objective phenomena accurately without seeming to do so. If a patient sees us gazing fixedly at some part of his anatomy, he is likely to become anxious and forget other matters which are of more importance to us as prescribers.

The same is true of the use of instruments and the performance of the various acts of a physical examination. A nervous patient will often be seriously disconcerted by so simple a procedure as listening to his heart action with a stethoscope – sometimes even by taking his pulse. It is best, therefore, with nervous patients, to postpone such examinations until near the close of the examination, or until he has lost his nervousness.

The patient should be encouraged to tell his story freely and relieve his mind. We want the history and symptoms of the case from the patient’s standpoint first. If the physical examination is made afterward, when the patient is composed, there will be less danger of confusing or prejudicing his mind.

The first part of the examination should be conducted in an easy, semi-conversational manner. The best results, from the Homoeopathic standpoint, are obtained by making him forget that he is under examination. One can be painstaking and systematic without being over-formal. The mere thought of undergoing a formal examination is disconcerting to the ordinary patient.He dreads it as he dreads going to a dentist. he wants to feel, and it is best for him to feel, that he is relating his troubles to a sympathetic friend who has the resources at hand to help him. It is a good rule to keep the patient talking, but say little yourself during an examination; to let him tell his story in his own way, without interruption, except to bring him back to the subject if he digresses. We may start him in his narrative by asking when and how his trouble began, and we may instruct him to be as definite as possible in relating his history and in locating and describing his sensations *as they seem to him. We should not laugh at him nor pedantically correct his errors.

We should not ask “leading questions,” nor “put words in his mouth,” but let him express his feelings and observations in his own way. Afterward, we analyze, complete, correct and interpret his statements in accordance with the principles of homoeopathic symptomatology as set forth in a former article.

Notes of the patient’s statements should be made while he is talking, but quietly, without ostentation.

It is well to leave a space between the symptoms as they are written so that, when the patient has finished his voluntary statement, one can glance quickly back over the page, see what has been left out and write it in. Questions are then put in such a manner as to complete each symptoms as to location, sensation and modality and fill in the record.

As a matter of convenience in writing and keeping record it is well to divide the page into three vertical columns- the first for date and remedy, the second for the symptoms and the third for the modalities or conditions. This makes a page that the eye quickly takes in at a glance.

We should not hurry a patient in his narrative. We may quietly keep him to the point and prevent rambling and inconsequential statements, but that is best done, as a rule, by maintaining an attitude of business-like absorption in the medical features of the case.

It is well to keep in mind always, during the examination of a case, some working classification of symptoms – as *General, Particular and Common. In examining a case we are gathering data, facts, particulars, from which we are later to determine the characteristic features of the case by the logical process of generalizing. If we are to generalize correctly we must have all the facts and be sure of them.

One thing at a time and all things in order, with an eye to the outcome. First, the analysis- facts from the patient’s statements, then the nurse’s, relative’s or friend’s statements, and then our own observations. Then comes the synthesis – the review and study of the symptoms and construction of the case, classifying symptoms as we generalize. Comparison of the symptoms of the patient with the symptoms of the materia medica in repertory work follows, and finally the selection of the indicated remedy by the exclusion process.

It is well to practice on the simple cases first, in order to become familiar with the technic. The hard cases will come soon enough and they our skill and patience to the uttermost.

The suggested classification of symptoms into general, particular and common symptoms is applicable to difficult as well as simple cases; to chronic as well as acute disease. The general plan can be modified and adapted in various ways, but the principles underlying it are always the same.

The form of the examination and the direction it takes should conform to the classification of symptoms adopted, and one may well have blanks printed to use as a guide and reminder.

Hahnemann devotes twenty-two paragraphs in the “Organon” to the subject of the examination of the patient- Paragraphs 83 to 105.

In the footnotes to these paragraphs he gives many suggestions and special directions for conducting an examination. They teach among other things, *how properly to frame our questions a very important matter. It is not expected that one will ask every patient all the questions which Hahnemann gives in these important footnotes, but that we shall select and apply such as bear upon the particular case in hand. They are for general guidance in the art of questioning.

There is a point in Paragraph 83 that deserves special attention for a few moments.

Hahnemann says: “This individualizing examination of a case of disease… demands of the physician nothing but *freedom from prejudice and sound sense, attention in observing and fidelity in tracing the picture of the disease.”

“Without prejudice!” Said quickly it sounds simple, easy, almost trite. It is a “bitter dose” to swallow, nevertheless, when we stop to explore the depths of our own minds. In this respect it is like the old-fashioned bowl of “boneset tea” I had to swallow semi-annually in the spring and fall when I was a country boy in Wisconsin. Hot and well-sweetened it was to be sure; but bitter! Bitter was no name for it! I can still hear mother say: “Now shut your eyes, son and *swallow it quick; then you won’t taste it – much!” Sounds easy but – try it.

Who of us is without prejudice? The prejudice of a materialistic mind; of pathological theories which seem too often to be antagonistic to homoeopathic principles; of doubt as to the use of the single remedy or of use of any medicine at all; the prejudice of “a constitutional aversion to work!” Many of us are “born tired.” We don’t like to work. Laziness, selfishness and an “easy conscience” are responsible for more homoeopathic sins and shortcomings than anything else, for good homoeopathic prescribing means *work!

These are our worst enemies, and the worst enemies of homoeopathy. Against these, if we are to succeed in our work, there must be a constant warfare within ourselves, until they are conquered by the establishment of correct methods and practice and a genuine interest in the work is evolved. No man who is in the grip of settled doubt or prejudice can do good work. The commercial salesman of today, for example, is not regarded as competent, nor in the proper frame of mind to gain success until he is able to *”sell himself,” as the experts put it. That means that he must acquire and hold a thorough belief in and conviction of the usefulness, indispensability and value of the goods he has to sell. For him it means study, effort, personal self-discipline until he develops a genuine enthusiasm for his goods, his house and his work. It means *Confidence – in himself and in his goods.

Nowhere will prejudice show more clearly than in homoeopathic examination of a patient. If one approaches a case prejudiced in favor of some pathological theory his examination will insensibly, but inevitably, be limited by that theory. He will not get all the facts of the case, nor properly interpret those he does get; and without all the facts he cannot study or treat the case correctly.

Prejudice and doubt may be overcome by reflection, study, self- discipline and auto-suggestion; by cultivating the scientific spirit; by returning often to a consideration of and reflection upon the broad general principles underlying our art with the purpose of reforming methods, strengthening morale and correcting faulty mental attitude, or point of view; all looking toward the development of a more practical, more accurate and more comprehensive technic.

Beliefs and convictions may be strengthened and energy stimulated by reflecting upon the fact that our therapeutic method is efficient and successful because it is based upon immutable law. We may mentally recall and restate the law and its corollaries and review the facts upon which it is based, or, better yet, write a little essay on the subject; recall to mind or seek out illustrations and examples of its truth and adequacy; study the cases and cures reported in our literature by the masters; think of duty, loyalty to principle and consistency of practice; think of success, gained by right methods and without compromise. To *think success goes a long way toward realizing success.

Our work as physicians involves the performance of a number of related functions, all of which are subordinate to the main function of healing the sick.

As specialists in therapeutic medication we examine for the symptoms upon which the choice of the remedy depends; but as physicians we also examine for the symptoms upon which the diagnosis and prognosis depends. Our aim is to make a complete examination, including all necessary pathological investigations. Having all the facts in hand we determine what features of the case are medical, what are surgical, what are psychological, what are hygienic, what are sanitary, etc. We keep all these departments distinct in our minds as bearing upon *the case as a whole, realizing that each has its particular relations to and bearings upon all the others; and especially do we seek to realize this of the department of homoeopathic therapeutics, which for us is the most important of all, because we know it is useless to attempt to base the homoeopathic prescription upon anything except the symptoms which belong to its legitimate sphere. The generalizations of the diagnostician or the pathologist, be they ever so correct, cannot serve as the basis for the homoeopathic prescription.

*The purpose of the homoeopathic examination is to bring out the symptoms of the patient in such a way as to permit of their comparison with the symptoms of the materia medica for the purpose of selecting the similar or homeopathic remedy. Every disease has its symptomatic likeness in the materia medica. The homoeopathic materia medica is like a “rogues gallery” in which are hung up the portraits of all the pathological rogues in the world. When you catch a rogue compare his features with the portraits. Then make him “take his medicine!”

Like all rogue – catchers, when on duty our senses must all be on the alert, our minds clear, our logical faculties acute, our sympathies and prejudices held in abeyance. When all the facts are before us we may sympathize, correct, reassure and encourage as far as seems judicious and wise.

Artifice must sometimes be resorted to in the examination of a case, in order to get a the facts. Many obstacles have to be overcome. Among them is modesty, often on the part of the patient, *sometimes (rarely, nowadays!) on the part of the physician if he is young and inexperienced. I often recall with amusement my feelings as I witnessed for the first time an examination of a case of phthisis pulmonalis by my old preceptor, Dr. Wells. The part of the examination which excited my risibilities was that which referred to the character of the sputum. He inquired particularly as to its color, *odor, form and taste! It was the first time I had ever heard such questions and the first time that it had ever been brought home to me that such facts could have any bearing upon the selection of the remedy. I believed that I was not over modest, but such refinement of analysis rather disgusted me. After the patient had been prescribed for and dismissed, I frankly stated my difficulty to the old master. He laughed a little sympathetically at my ignorance and rallied me on my squeamishness. Then he soberly pointed out that the patient’s reply that the sputum “tasted sweetish” had enabled him to differentiate between two very similar remedies and make an accurate choice. He made that the text for some sadly needed instruction *in the necessity for close analysis of all the elements of the case – instruction which no one ever gave me during my college course.

Stuart Close
Stuart M. Close (1860-1929)
Dr. Close was born November 24, 1860 and came to study homeopathy after the death of his father in 1879. His mother remarried a homoeopathic physician who turned Close's interests from law to medicine.

His stepfather helped him study the Organon and he attended medical school in California for two years. Finishing his studies at New York Homeopathic College he graduated in 1885. Completing his homeopathic education. Close preceptored with B. Fincke and P. P. Wells.

Setting up practice in Brooklyn, Dr. Close went on to found the Brooklyn Homoeopathic Union in 1897. This group devoted itself to the study of pure Hahnemannian homeopathy.

In 1905 Dr. Close was elected president of the International Hahnemannian Association. He was also the editor of the Department of Homeopathic Philosophy for the Homeopathic Recorder. Dr. Close taught homeopathic philosophy at New York Homeopathic Medical College from 1909-1913.

Dr. Close's lectures at New York Homeopathic were first published in the Homeopathic Recorder and later formed the basis for his masterpiece on homeopathic philosophy, The Genius of Homeopathy.

Dr. Close passed away on June 26, 1929 after a full and productive career in homeopathy.