The Examination of the Patient

The examination of the patient pertains to the homeopathic case taking, which Hahnemann discussed in aphorisms 83-103. Here Kent elaborates his approach to case taking along with clinical examples and common pitfalls….

$ 84. The patient details his sufferings; the persons who are bout him relate what he has complained of, how he has behaved himself, and all that they have remarked in him. The physician see, hears and observes with his other senses whatever there is changed or extraordinary in the patient. He writes all this down in the very words which the latter and the persons around him make use of. He permits them to continue speaking to the end without interruption, except where they wander into useless digressions, taking care to exhort them at the commencement to speak slowly that he may be enabled to follow them in taking down whatever he deems necessary.

One of the most important things in securing the image of a sickness is to preserve in simplicity what the patient tells us in his own way unless he digresses from the important things and talks about things that are foolish and not to the point; but as long as he confines his information and in the record use his own language, only correcting his grammatical errors for the purpose of procuring the record as perfect as possible. If you use synonyms be sure that they are synonyms and cannot be perverted.

Of course, when the woman speaks of her menstrual period as “monthlies” or as her “show,” the more suitable medical term is “menses,” which is a synonym for those expression, and is more expressive than her own way of calling it “a show”. So in general terms you can substitute terms of expression so long as you do not change the idea. Of course, the changing of “legs” into “limbs” if you feel like making such a change is not a change of thought, but be sure in making a change it is not a change of thought.

It is one the most important things in forming the record of a patient to be able to read it at a subsequent examination, without being disturbed by the repeated statements of the patient. If you write a record in consecutive sentences, you will be so confused when hunting out the symptoms of the patient that you will be unable to form an image of that sickness in the mind.

It is truly impossible when the mind is full with the effort at hunting out something to listen with proper and concentrated attention. You should divide your page in such a manner that when the patient is talking to you about this thing and that thing and the other thing of her symptoms, you can with one glance of the eye look down over the page of the record and see everything there is in that page. If you record is not so arranged, it is defective. Now, a record can be so arranged by dividing the page into three columns, the first of which contains the dates and prescriptions, the second the emphatic symptoms or headings and the third things predicated of the symptoms, thus:

Date } Symptom.

} Things predicated of the symptom

} (<) (aggravation).

Remedy (>) (amelioration).

After the patient has detailed his sufferings in his own way and you have gone through them and discovered all the things that you can predicate of his symptoms then you can proceed to make enquiry of some on who has been with this patient. In a study like this with most of our private patients there has been a nurse, sometimes only a sister or a mother or a wife, who has been observing all the sick individual has complained of. “The persons who are about him relate what he has complained of, how he has behaved himself, and all that they have remarked in him.” Now, this should be listened to with great care.

It is more important in this instance to decide whether the observe is overanxious, if a wife whether she is not frightened concerning her husband and so intermingles many of her notions and fears, which you must accept with discretion. Get the nurse, if possible, to repeat the exact words of the patient. If such a thing can be done in acute sufferings it is worth more than the words or expressions of the nurse, the wife for instance, because the more interested and anxious the person is the less likely she will be to present a truthful image, not that she wants to deceive, but she is dreadfully wrought up and the more she thinks of what he has said the greater his sufferings appear to her, and she exaggerates them. It is important to have the statement from one who is disinterested. Two or three of the observers who are intelligent having been consulted and their statements recorded, the physician then notes his own observation. He should describe the urine if there is anything peculiar about that, but if the urine and stool are normal he need not care about the description of these.

It has been the study for hundreds of years to find the best way to question witnesses in court, and as a result they have settled upon certain rules for obtaining evidence. Homoeopathy also has rules for examining the case that must be followed with exactitude through private practice. Among pupils who have been taught here, I know some who have merely memorized and some have not even memorized but have fallen away. These students are violating everything they have been taught; they have gone to low potencies, making greater and greater failures, to the shame of the tutor and the science they profess of follow.

I expect some in the sound of my voice will be doing this five years from now; thus is a warning, stop before you go too far, or you will not feel the fault is your own. You will think you hypnotized and led into false ways. If you neglect making a careful examination the patient will be the first sufferer, but in the end you yourself will suffer from it, and Homoeopathy also. The questions themselves that Hahnemann gives are not important, but they are suggestive and will lead you in a certain direction. Question the patient, then the friends, and observe for yourself; if you do not obtain enough to prescribe on, go back to particulars. After much experience you will become expert in questioning patients so as to bring out the truth. Store up Materia Medica so as to use it and it will flow out as your language flows. You must put yourself on a level with the form of speech your patients use.

Be sure you have not put any words into your patient’s mouth or biased his expression., You want to know all the particulars but without asking about it directly. If you ask a direct question, you must not put the symptom in the record, for ninety-nine times out of a hundred the patient will answer by `Yes’ or `No.” If the patient’s answer is `Yes’ or `No,’ you question was badly formed. If a question brings no answer let it alone, for he does not know or has not noticed. Questions giving a choice of answers are defective.

Ascertain the precise part of the body the pain was in and the character of the pain, etc. In investigating a case there are many things to learn, the length of the attack, appearance of the discharge it it be a case of vomiting, its character, the time of day, etc., etc. Every student should go over these questions collateral questions, and practising case-taking. Leave the patient in freedom always Do not put any words into his mouth. Never allow yourself to hurry a patient; get into a fixed habit of examination, then it will stay with you.

It is only when you sustain the sharpest kind of work that you can keep your reputation and fulfil your highest use. Say as little as you can, but keep the patient talking and keep him talking close to the line, If he will only talk, you can find out symptoms in general and particular. If he goes off, bring him back to the line quietly and without disturbing him. There is not much trouble in private practice. There you will do a better average of work.

All sleep symptoms are important, they are so closely related to the mind, the transfer from sleep to waking, from cerebrum to cerebellum, is important. Old pathologists were unable to account for difficult breathing during sleep. The cerebrum rules respiration during sleep. To know the functions of the white matter and gray matter is important. A rational knowledge of anatomy is important. No homoeopath ever discouraged the true study of anatomy and physiology. It is important not only to know the superficial but the real, profound character, to enable you to recognize one symptom-image from another.

Study this paragraph, carefully and meditate upon it. If you do not form habits now, you will not from practice hereafter. You have no regular course and will get into habits you cannot break up.

The examination must be continued with due respect to the nature of the sickness and with due respect to the nature of the Materia Medica. Some symptoms have references to pathology and diagnosis, while others have reference only to the Materia Medica, and symptoms must be constantly weighed in the mind in order to establish their grade whether common or peculiar. If all are found to be common symptoms, the Materia Medica is left out.

Either the examination has not been made with respect to the Materia Medica, or the symptoms are not there at all. It makes no difference as far as cure is concerned; it matters not whether they are not present in the case or whether the doctor has not found them, the key to the prescription is not present. But if the image is round and full and complete, there are symptoms with regard to pathology, diagnosis, prognosis and Materia Medica. It will be proper later to talk of incurable, diseases, pathognomonic symptoms obscure cases, Materia Medica symptoms, etc.

When the physician comes to look over the record after an examination to get the image to classify and arrange it, he will find what is peculiar, and those symptoms that are most general, and those that are but common. These three grades appear in every complete case, and in every complete proving of a remedy. Homoeopathic study and observation will enable one to pick out these grades at a glance.

Every case has common symptoms, but peculiar symptoms may be absent and you must not expect to cure when peculiar symptoms are absent. Homoeopathy is applicable in every curable case, but the great thing is to know how to apply it. The physician must sit in judgment upon the symptoms and determine whether they are peculiar or common. If the patient’s discourse is incoherent, the question arises is he intoxicated or delirious, or is there breaking down of the brain and insanity? The flash of the eye is important; it will tell things that cannot be told by the nurse.

It is important for the physician to know the value of expressions. When the patient stares with glassy eye, is he injured about the head, is he suffering from shock, intoxication or typhoid fever or some disease in which the mind is stunned? The physician immediately proceeds to ask, “How long has the patient been in bed?” If the character is above reproach, he will not suspect intoxication; if the patient has been sick for many days with fever, tongue coated, abdomen sensitive, etc., he is fully entered upon the course of typhoid fever.

The physician must know immediately upon entering the room what the state of the patient resembles: apoplexy, coma, opium poisoning, etc. A physician is supposed to set his mind to work instantly, to ascertain the condition of the patient and what relation the symptoms maintain to the Materia Medica. If an opium poisoning there must be selected an antidote; if apoplexy, a careful taking of the symptoms in relation to the cerebral clot to prevent inflammation and symptoms relative to that state, and relative to the remedy. The patient may be intoxicated and have apoplexy at the same time.

There is no symptom in the sick room without its value, especially in acute and serious cases. Children are sometimes found in a sound sleep and cannot be aroused; the mother says the child has worms and gives Cina, for Cina has all these symptoms of stupor, difficulty in arousing, falling back to sleep. But the child fails, going into coma, the nose flaps, the chest heaves, the brow is wrinkled, there is rattling in the chest, showing the child is going into cerebral congestion. The physician now must examine on every side of the case to find the nature, to know what to expect. He who neglects this is not a true homoeopathic physician; a mere superficial application of Homoeopathy is not sufficient. After all the symptoms are written out, the physician must study the character of the fever, whether it is intermittent, continued or has come on in one sudden attack; he must know sufficient of the symptoms to judge of all these.

You will learn so much about the purport and the aspect of every motion of the human being that you will place less and less reliance on diagnostic symptoms as diagnostic symptoms, and learn more the value of symptoms as symptoms. You will be astonished to find how expert you will become about diagnosis and prognosis by studying the symptoms. You can learn something from every case you have mind; but by a process of rapid exclusion, you say it is not cholera, not haemorrhage, etc., and latterly you come to the cause of this aspect.

You can tell when it is to me for cardiac compensation to be broken in Bright’s disease; a peculiar tremulous wave that belongs to the muscles of the face and neck, a tremulous jerk of the tongue, putting about half way; the pale, cold, semi-transparent skin with cold sweat. It is important to know instantly what the cause is, for the treatment will be different, but remember that it is nothing that you need to name that makes it important.

All these symptoms have respect to remedy and to diagnostic conditions. So far as there is a morbid anatomy which can account for symptoms, so much less are those symptoms worth, as indicating a remedy; if you had no other than such symptoms, you could find no remedy.

Among the many things that interfere with the examination of the patient the most important is the taking of medicines or having done something, no matter what it is, that has been capable of changing the symptoms. Very commonly, the patient will present himself in the doctor’s office, and after giving a long array of symptoms will relate a dose of Quinine, and he thinks he is no better, and now he applies to you for relief. In acute diseases this is very bad and may interfere with finding the homoeopathic remedy.

Very often the general state collectively both drug and disease symptoms, in a very acute condition must be prescribed for, but in chronic disease the plan is different. The symptoms that arise after the taking of a dose of powerful medicine are not indicative of a remedy, they are confusing, they present no true image of the disease and hence the physician has nothing to do but wait, or at most administer a well-known antidote to the drug taken. Sometimes he must wait a considerable time until the symptoms reveal themselves and express the nature of the sickness. It is just as bad where the physician himself is a bungler as it is where the patient has taken the drugs.

The confusion arising from bad prescribing is just the same as that produced by the patient’s drugging. There are physicians going about will mix up their cases and continue to prescribe for their own drug symptoms, and who never have any idea of waiting for the true image of the disease to develop itself. Drugging is only a matter of changing symptoms and masking the case. Anything that will effect a change in the symptoms, the taking of drugs, or drinking too much wine or drinking today, or great exposure, will mask case, and this mask must wear away before the intelligent physician can make a cure.

The whole aim of the physician is to secure the language of nature. If it has been masked by medicines, it cannot be secured. Any meddling will so affect the aspect of the case that the physician cannot prescribe, and the physician who does this meddling must inevitable be driven into bad methods or into allopathy. I have looked over the work of bad prescribers and have wondered what on earth they could see in Homoeopathy to attract them; they do not cure folks. They have no cures to present.

The patients cannot well be satisfied by these things. It is true that once in a while a strong vigorous, robust patient, when he gets a homoeopathic remedy, will go on getting well through a mess of symptom changing and drugging, so that in spite of this meddlesome practice he will recover. The physician in that case, knows not what remedy to attribute to it, for he has given a great many. But only the most vigorous constitution will stand such homoeopathic villainy, go on and get well in spite of their indulgence in wine, in eating, etc.; it is wonderful what their own powers will do in throwing off disease.

In ordinary cases, however, we see no such things, confusion is brought about at once if the physician administer another medicine in place of administering placebo. At times a patient will present himself, and you will be able to get a true image of the sickness by ascertaining all the things that occured up to a given date. “Upon that date,” he says. “I took some medicine, and most of my symptoms, subsided.” They lead to another image from which you can gather nothing; a scattering has taken place.

The symptoms may cover page upon page, and yet what remedy do you see? None at all; it looks as if a number of provings of drugs had been mixed up all together, intermingling symptoms here and there without any distinctness. No individualization is possible. Now up to that date the symptoms you gathered may be just all that is necessary. Up to that date the symptoms present the image of a remedy which, it administered, may yet though sometimes it will fail at first because of the confusion, but after waiting a little it will act. After the the administration of a remedy prescribed upon symptoms in the past I have known the remedy many times to go on acting.

Again I have known that remedy to fail entirely. In such a case, wait awhile and then order will begin to come and that remedy which was indicated previous to the drugging will act. Suppose a physician comes to you and says, “Up to a certain date I was able to hold this patient’s symptoms in order with Thuja; but when the symptoms seemed to change and I gave such and such medicines, and have never seen such good results in prescribing as I did up to that period.” You must give him Thuja again, and in this way take up the thread where it was lost. Examine the image of the case where the order was lost; because that is where the image must be found. “On the contrary, the symptoms and the inconvenience which exhibited themselves previous to the use of the medicine, or several days after their discontinuance, give the true fundamental notion of the original form of the malady.”

This is the idea, get the original from of the malady. To do this, at times we have to trace through a mass of difficulties and conditions to get back to the original form of the trouble, but you must get there because you will see that in the beginning this malady, in accordance with all laws of Divine Providence, must have conformed to some remedy that had been created for its cure. The symptoms at that time stood out indicating this medicine, but since then there has been nothing but confusion, nothing that can be tied to, nothing that can be examined; it appears to have no relation to anything.

Very often we can take up the thread and get back to the remedy that was clearly indicated, even twenty years before. If that remedy was indicated then, and was not given the cure that was possible by that remedy or a similar one is the only thing to be considered; that is the only remedy in the case. Since that time the patient has been in continued turmoil from the action of drugs. Because it was twenty years ago there is no reason that you should not think of that drug. The patient’s disease has not been cured, it has only been changed and modified; but it is the same patient, and the same sickness and requires the same medicine. If the disease has been complicated by drugs, however, you cannot always get the action of that medicine which the patient needs for the disease per se, but after the drugs have been antidoted you will have to give that very medicine that you figured out and he will be cured.

James Tyler Kent
James Tyler Kent (1849–1916) was an American physician. Prior to his involvement with homeopathy, Kent had practiced conventional medicine in St. Louis, Missouri. He discovered and "converted" to homeopathy as a result of his wife's recovery from a serious ailment using homeopathic methods.
In 1881, Kent accepted a position as professor of anatomy at the Homeopathic College of Missouri, an institution with which he remained affiliated until 1888. In 1890, Kent moved to Pennsylvania to take a position as Dean of Professors at the Post-Graduate Homeopathic Medical School of Philadelphia. In 1897 Kent published his magnum opus, Repertory of the Homœopathic Materia Medica. Kent moved to Chicago in 1903, where he taught at Hahnemann Medical College.