SELECTION
Having gathered necessary information about the patient, the homeopath is faced with the task of synthesizing the information in such a way that the
correct homeopathic remedy may be selected. Case analysis is directed at developing an organized home-opathic picture of the patient that corresponds to a similarly organized picture of a homeopathic remedy.
Case Analysis
The patient’s story is organized into the homeo-pathic picture, which always includes and expands upon a conventional understanding of the patient.
The physician seeks to identify all distinctive quali-ties of illness and temperament that characterize the patient, to understand what is particular about the expression of illness in the patient. The physician considers all information gathered and must make a sensible analysis by answering a series of questions.
What Is the Central Feature of the Case?
The most important part of the analysis is to identify the central feature or disturbance, which may or may not be the same as the patient’s chief complaint. The central disturbance may be on one or more of three important levels—physical, emotional, or mental. The homeopath must identify and understand the central feature as the basis for selecting the appropriate remedy.
Samuel Hahnemann, in the Organon of Medicine, summarized this mandate as follows:
A physician must . . . clearly realize what is to be cured in diseases, that is, in each single case of disease. . . . It will help the physician to bring about a cure if he can find out the data of the most probable cause of an acute disease, and the most significant factors in the entire history of a protracted wasting sickness, enabling him to find out its fundamental cause.1
Hahnemann continues over many paragraphs to describe different aspects of what is referred to here as the central feature. The concept of a central feature is important, and is peculiar to homeopathic analy-sis. Although there are distinguishing characteristics among individual homeopaths at an advanced level of analysis, as a group homeopaths share an under-standing about health and disease that varies some-what from conventional medical understanding.
The totality of symptoms must be considered in every case. It is important to remember that, unlike conventional medicine, the pathologic diagnosis is only a possible starting point for the homeopathic diagnosis. The homeopath seeks the distinguishing
aspects of the complaint and the person who has the complaint, so that the Law of Similars may be applied and a homeopathic remedy chosen—one that has been shown to cause or cure the particular com-plaints of the patient. Totality does not necessarily imply a complete and exhaustive review of systems, but rather the importance of the whole picture. In an acutely ill patient, it may be the intensity of symp-toms and the level of the energy or malaise that rep-resents the totality of the illness picture. However, in a case of chronic rheumatoid arthritis, much more information (a complete review of systems, as well as an understanding of the patient’s nature or personal-ity) is needed, because the patient’s disease response is all encompassing.
In chronic cases, the overview is usually quite broad. Many aspects of the patient’s life will be con-sidered in search of emotional themes, limitations on any level, and distinguishing details that may not be pathologic but are nonetheless characteristic, such as food preferences and sleep habits.
The consideration of acute cases is more clearly focused for several reasons. First and foremost, it is usually the case that when an individual is suffi-ciently ill to merit attention, the defining aspects of the case are often quite clear. The physician is less interested in a global picture of the patient and more interested in a snapshot that answers the question,
“How are you different from your normal state?”
Answers to this question include acute physical symptoms and important general or emotional fea-tures. For example, a patient with an acute sore throat will usually be very clear about the nature of the pain and the accompanying modalities, as well as his or her general level of heat or chilliness, thirst, appetite, and mood. “I don’t have time for these ques-tions, just get me well . . . now!” provides sufficient information about the patient’s emotional state, as does, “I really don’t know. I don’t care. Leave me alone, I want to go home.”
The totality of symptoms is organized according to a functional hierarchy of symptoms, from most to least severe. In a general sense, any disturbance on a mental level (e.g., dementia, thought disorder) is usu-ally the most severe and disabling, followed by emo-tional disturbance (e.g., depression, anxiety) and finally by disease of the physical body. At each level, an appropriate internal hierarchy is structured based on the degree to which the problem compromises health, so that within the level of physical symptoms,
heart disease is more serious than skin disease. The hierarchy is flexible and based on logic, such that for every patient the totality of symptoms must be ana-lyzed, with due regard to severity of each symptom, in the context of the life of the patient. Where is the patient most restricted or disabled? What level of dys-function or suffering is most acute? What improve-ment would most benefit the patient?
Considering a totality of symptoms in each patient, the most crucial area or level of disturbance becomes the central feature of the case and the key to a successful prescription. Two examples illustrate this point.
First, although skin disease (physical) is almost always less disabling than mental or emotional symp-toms, a severe dermatitis, with intolerable itching, swelling, and even bleeding, is more disabling than a mild case of situational anxiety, even though anxiety resides on the deeper (emotional) level.
Second, a patient’s primary complaint is chronic eczema, but further questioning reveals that he or she struggles chronically with depression. A thorough exploration and analysis of the depression reveals an unresolved grief in the patient’s childhood. The homeopath understands that the depression reveals a disturbance on a level more central than the skin, and so selects the remedy based primarily upon the under-standing of the depression. A remedy selected with this understanding is most likely to address both the depression and the eczema and lead to a successful outcome.
What Are the Strange, Rare, and Peculiar Aspects to the Case?
It is essential that the physician have an understand-ing of both medical pathology and human nature upon which to base his or her evaluation. Crucial to a correct homeopathic prescription is the identifica-tion of aspects of the case that are unexpected, dis-tinguishing symptoms that are thus considered strange, rare, and peculiar.
Symptoms may be considered strange, rare, and peculiar by several different criteria. A symptom may be quite unusual and striking by its very nature, or by its intensity or frequency, or it may be unusual only in the context of the particular patient and his or her illness or personality.
For example, a patient with a severe sore throat states that the pain is eased only by eating solid food and is made worse by swallowing liquids. This
unusual modality becomes a central feature in under-standing the patient and making the correct pre-scription.
In another case, a patient with migraines since a business failure is presumed to be suffering financial worries. The patient reports that he or she worries constantly about money and making ends meet.
Further inquiry reveals that because of a generous inheritance the patient has no real basis for financial concern.
Finally, a patient with allergic rhinitis sneezes for several hours each morning on waking, or hiccups after each sneeze. Patients with allergic rhinitis are expected to sneeze most when they are most exposed to allergens. However, patients whose sneezing becomes strongest according to the time of day, or who follow an allergic sneeze with a hiccup, are revealing individual symptoms uncommon in this condition.
Is There Clear Causation?
The homeopathic physician will inquire carefully into the circumstances surrounding the beginning of an illness, looking for an event or a condition that may have precipitated the lapse in health. An essen-tial assumption in homeopathic perspective is that a healthy body operates to preserve homeostasis; con-fronted with stress of any sort, the organism will seek to maintain a healthy state. When the homeostatic mechanism fails, illness ensues as a result of a partic-ular stressor affecting a particpartic-ular weakness of the organism.
To evaluate stress or causation, the homeopath examines factors that are usually considered, such as habits, lifestyle, and infectious disease, but expands the analysis to identify specific stressors. Selection of the appropriate homeopathic remedy will vary, depending on whether the stress is the grief of an emotional loss, the shock of a near-accident, or over-work associated with final examinations for a college student. The specific nature of the stress and the patient’s reaction to it are important factors to understand.
Is the Case Acute or Chronic?
In most cases the answer to this question is not diffi-cult, yet it must still be carefully considered. The important point is to question when the patient was last in good health, which necessitates understanding what good health is for that patient. The patient’s
sense of well being is one possible guideline, the report of family members is another.
In the case of recurring acute illness, such as repeated otitis media in children, the homeopath will consider whether the tendency to such problems is chronic, or whether the child is generally healthy but has been unable to successfully heal an acute illness.
If the condition is the result of a chronic weakness, consideration of the complete history may lead to a treatment that eradicates the tendency to ear infec-tions. In the second circumstance, treating it with a homeopathic remedy as opposed to using the sup-pressive antibiotic may enable the child’s immune system to eradicate the infection, which then does not reappear.
What Other Features Are Important to the Case?
While evaluating the totality of symptoms and the patient as a whole, a great deal of information may be acquired that does not seem central to the case at hand. Considering a wide variety of information offers the homeopath the opportunity to develop a greater sense of patience, to resist the urge to discard what seems irrelevant. At times what seems most irrelevant will in fact be important to understanding the patient or may provide an essential clue in the search for the correct remedy.
As the physician gains clinical experience and increased familiarity with homeopathic medications, the process of sorting valuable information from the merely extraneous becomes more efficient. The skill of effective analysis at this level is best acquired in a clinical situation, working with the guidance of an experienced homeopath.
What Features of the Patient’s Life or Lifestyle Contribute to the Disease Process?
In general, the answers to this question overlap broadly with conventional understanding of how lifestyle affects health. Lifestyle choices clearly have an influence on certain states of health or illness, and each physician develops a personal style for advising patients regarding those choices. Homeopaths are usually very successful at helping patients change unhealthy lifestyle habits.
Consider the example of a heavy coffee drinker who has problems with insomnia. Obviously, any physician would consider counseling the patient about the relationship between coffee and sleeplessness.
However, the homeopath will also consider the patient’s craving for coffee as a symptom, and if the remedy selected has been observed to decrease a cof-fee craving, the homeopath may choose to sit in silence while waiting to see whether the patient’s craving changes without counseling.
Many other choices are not so clear cut—many are controversial—and the decisions made by home-opaths regarding the importance and effectiveness of lifestyle counseling are as personal as the choices made by conventional physicians.