THE EVALUATION OF SYMPTOMS.
In the lecture on case taking in the May issue we gave, in some detail, the hierarchy of the symptoms, and would suggest that in connection with this article the reader reperuse that one. The evaluation of symptoms is, perhaps, the most important part of the homoeopathic technique, and, to the beginner, one of the most difficult. Certain propositions in relation to it are axiomatic. Owing to the terminology of modern medicine and the training that patients have received from non-homoeopathic physicians, the emphasis which the patient himself places upon symptoms if often entirely misleading.
The doctor must separate diagnoses and common symptoms (that is, symptoms which are common to any patient suffering from a certain complaint, such as vomiting in a gastro-intestinal case). These common symptoms are valueless from the point of view of homoeopathic prescribing unless qualified by modalities. The physician must discriminate between the relatively worthless common symptom, which may often be the patients chief complaint, and the precious, minor, subjective symptoms which the patient, inadvertently, brings out. The patient may complain loud and long of some pain or inconvenience which is relatively irrelevant, and not even be aware of grave and helpful symptoms plain to the physician.
On the other hand, just because the physician knows that mental symptoms are most important he should not hunt in the haystack for a tiny mental, with which to open his case. The symptoms should have the same importance, the same weight or mass, in the patients case as it assigned to them in the symptom hierarchy. For example, a woman complains of indigestion and admits to overpowering fears, the fear, being a mental, outranks the stomach symptoms; but if this woman had violent pain in the stomach and an unimportant fear, the pain, being a much greater factor in the case, would outrank the fear.
A third axiom is that all rubrics used, or rather symptoms taken to be matched with rubrics, must be really true of the patient and reliable.
Another is that three or more similar particulars make a general, for instance, if the patient has burning in the head, the stomach, the feet, and the skin, the general rubric BURNING is applicable; whereas, if he has burning in the stomach only, it is a particular.
If a valuable general can not be found in the Repertory, as stated by the patient, it may be found under the opposite rubric, as, “cold weather ameliorated”. This is found in the Repertory under “warm air aggravates”. “Better in summer” is found under “winter aggravates”. This, again brings up the nice problem of the interpretation of the patients words and their translation into terms of the rubrics. Only a knowledge of the exact meaning of words and of psychology sufficient to divine what the patient means by what he says, and a through acquaintance with every rubric in the Repertory, will enable the physician to allocate the symptoms.
If care and ingenuity we taken it is not only justifiable, but sometimes, necessary, to combine rubrics in order to get the exact meaning. There are two ways of combining, by adding all the remedies in the two or more rubrics, especially when the rubrics are small; or taking only the remedies which appear in all the rubrics taken, which increases the grading of the remedies. An example of rubrics which may be combined by this latter method is, menses acrid, early, bright red and clotted.
There is divergence of opinion as to the proper place of pathology and also of objective symptoms (such as redness of the orifices). In the Kentian method, these are placed relatively low, whereas the Boger method, as given in his little General Analysis, stresses the pathological generals, as opposed to diagnostic pathology. Stearns favors stressing the objective symptoms as he feels that these can not mislead.
There are several kinds of pathology. Disease diagnoses appear here and there in the Repertory as, scarlet fever, septicaemia chorea, apoplexy, etc. Other conditions which are pathological and yet are symptoms rather than diseases are found, such as, convulsions, dropsy, cyanosis, haemorrhage, etc. There is a third class of pathology, the importance of which consists in the bodily tendency to produce such changes, such as, warts, polypi, fibroid tumors, etc. These are the most important of the pathological rubrics as they indicate the tendency of the whole constitution. Such a rubric as empyema, which is found under chest, is a pathological particular and less important although it may be of great interest in such a case to see when remedies have had the power to cause and to cure this condition.
The schema of the order of importance of symptoms according to Kent is:
Mentals-will, understanding, intellect.
Physical generals-time, temperature, weather, position, motion, external stimuli, eating, drinking, sleep, clothing and bathing.
Particulars-strange, rare and peculiar, and the modalities of the particulars. For details see May issue mentioned above.
In the Kent method after taking the complete case the physician selects any outstanding mentals, grading them in the order above given. He, of course, adds such mentals as he, himself, perceives in the patient or as a cause of the ailment. There may be from one, or indeed none, to six or seven marked mentals. The physician then takes the chief generals in the case, ranking them in the order above given. The mentals plus the generals will give him a working basis for the selection of a chronic remedy.
When the physician has repertorized these symptoms down to about five remedies he should then rank the particulars and see how the five remedies cover these. Then he must take these five remedies and study them in the materia medica, in order to select the one most similar to the case. It is obvious that this method proceeds from generals to particulars, and no special attention is paid to pathology.
In the Boger method fewer symptoms are used and special stress is put on pathological generals, for instance, if the case presents several excoriating discharges the rubric ACRIDITY, in Bogers General Analysis, would be taken; if the patient complains of marked dryness of mouth, rectum, skin, etc., the general DRYNESS would be used. In this method the mentals are prominent and take first place, as in the Kent method.
Stearns takes not more than five or six symptoms, of which one is mental, one pathological, one objective and two physical generals.
Boericke divides symptoms into basic and determinative classes, the basic being the common, diagnostic and pathologic, and the determinative the subjective, modalities and generals. Boericke, like Dr. Margaret Tyler, in England, advocates the use of certain large general rubrics, such as back of vital heat, as eliminative symptoms, which some kentians consider dangerous.
It is hoped that the student will not be confused by this variance of method among the masters and it is strongly recommended that each beginner master the Kentian technique first, the other variants being short cuts to suit different types of minds.
As soon as the case is taken and the physician sits down to study it, he will find it useful to run down the list of symptoms and mark with M opposite the mentals, G opposite the generals, PATH. opposite the pathology, P opposite the particulars, and O for objectives. This should be done in the left hand margin and should be in colored pencil. For further clarity he may underline any peculiar symptoms in red.
The symptoms to be actually used for repertorizing should be written off on a new sheet in the order of their importance. If the Kent method is being used he is then ready to transcribe the symptoms onto the special black repertory sheets which can be purchased from the American Foundation for Homoeopathy and which greatly simplify repertorizing.
After the beginner has listed his symptoms according to their importance he should reconsider, checking mentally his symptom list with his impression of the patient and see if any elements of the case are placed too high or too low, for on the correct evaluation of the symptoms depends the possibility of finding the most similar remedy which will lead to cure.