|SYMPTOMS, HOW TO TAKE THE CASE|
Homeopathic Materia Medica by Dunham
SYMPTOMS, HOW TO TAKE THE CASE
( )SYMPTOMS, THEIR STUDY; OR, "HOW TO TAKE THE CASE"
In my last lecture I endeavored to define the scope, nature and limits of the science of therapeutics, and to show that homeopathy constitutes this science. I tried to explain to you how it is that, by analysis, every natural science may be reduced to two series of phenomena, connected by a law or formula which expresses the relation of these two series of phenomena to each other; and how the practical problem which the science enables us to solve is this: Given one series of phenomena and the law of relation, to find the other series of phenomena; and that, in this problem lies a test of the soundness of whatever claims to be a natural science, viz.: that it furnishes us a means of prevision or foreseeing and predicting that which is to be observed or discovered ; points which I illustrated by a reference to the history and structure of the simplest and most complete of the natural sciences, astronomy or celestial mechanics. Finally, I explained that the two series of phenomena which are the subject of a natural science, must be each capable of independent and indefinite expansion and development as a separate department of natural history; and that no expansion of either must destroy the applicability of the law of relation. I then showed you that in the science of therapeutics or homeopathy (as it is more familiarly called) the two series of phenomena are respectively the phenomena of the patient on the one hand, and the phenomena produced by the drug upon the healthy, living, human being, on the other hand; while the formula which expresses the relation between these series of phenomena is the well-known therapeutic law, "SIMILIA SIMILIBUS CURANTUR," " Likes are to be treated by likes."
I showed you that, in our practical application of the science of therapeutics, the constant problem before us is that which is the problem in every natural science, viz. : Given one series of phenomena and the law, to state the other series. Given the phenomena of the patient and the law, to find the phenomena of the drug which bear to the phenomena of the patient the relation expressed by the law. Or if we are studying a drug, and have the phenomena which it produces in the healthy, living, human being, then, having the law, to find the series of phenomena in the sick which, bearing a certain relation to the phenomena of the drug, will be canceled by the latter in the terms of the law. In other words, our constant problem is: Given the symptoms of a case, what drug known to us will cure according to the law, or what must be the effects of such a drug, not yet known to us, as will cure such a case. Or, conversely: Given the effects of a drug, what case, as yet seen or never yet met with, will that drug cure ?
Such prevision as this homeopathy has again and again in notable cases enabled us to exercise; and by this test she has justified her claim to be entitled the science of therapeutics.
After this general view and analysis of the subject, it remains for us to study in detail the elements of which the science is composed, viz. : the two series of phenomena respectively and the law.
I shall therefore ask your attention now to the first series of phenomena, those of the patient; or briefly to the subject of "symptoms," or how to take the case.
And, here, at the very beginning of the subject, let me say that much unnecessary confusion exists in the minds of our own school, and of our opponents, because we have not agreed upon the meaning we shall attach to the word symptom.
By the old school and by some homeopathists who have gone astray after the "strange gods" of the physiological school of medicine, a very restricted meaning is given to the word symptom; and this being done it is made a reproach to homeopathists that they take note only of symptoms, as though we disregarded some important phenomena presented by the patient. Assuming that homeopathists understand by symptoms only the subjective phenomena or sensations which the patient experiences and describes, " How, then," exclaims Prof. Bock, "can they prescribe for a typhoid patient who neither hears, sees, tastes, smells nor feels, and who could not express his sensations if he were conscious of them, but lies in a passive apathy, as indifferent as a log!" Well, the fact that he lies there and cannot express his sensations, if he have any, and that the avenues of communication between his brain and the world about him, his special senses and the general sense namely, are closed, constitutes a most important series of symptoms. For, gentlemen, in accordance with Hahnemann's instructions, no less than with the common sense of the matter, we include under the term "symptom " every phenomenon presented by the patient which is a deviation from, or an addition to, his condition when in average health.
Whatever we can ourselves observe by careful scrutiny of the patient, bringing to our aid every instrument of observation which the ingenuity of man has contrived; whatever the patient can tell us as the result of his observation of himself or of his sensations; whatever his friends and attendants have noticed concerning his appearance, actions, speech and condition, physical or mental, which differs from his condition and actions when in health,—all these phenomena together constitute what we call the symptoms of the patient.
I conceive that it would be a waste of time to examine the alleged distinction between symptoms and " the disease." Since we have made the term symptom cover every phenomenon, whether it be felt by the patient, or observed, seen, handled or heard by the physician, it is manifest that we can know nothing of any disease except by the presence of symptoms; that its presence is announced by the manifestation of symptoms; that when the symptoms have all disappeared we cannot know that any disease exists, and that therefore by us, for all practical purposes, the totality of the symptoms must be regarded as equivalent to, and identical with, "the disease." Let, then, the bugbear of a disease as distinct from the totality of the symptoms never more haunt your path-way in practical medicine.
Hahnemann directs us to acquaint ourselves with every deviation from the patient's normal, healthy condition which we can observe; to gather from the patient's friends and attendants all of a similar character that they have observed; to listen to the patient's statement of everything of the kind which he has noticed, and of all unusual sensations and pains which he has experienced, and all unusual phenomena of which he has been conscious, whether of body or mind.
You will perceive that here are two classes of phenomena referred to, viz. : such as may be observed by the physician or attendants and friends, and such as are perceived and can be stated only by the patient himself. The former, which may be the objects of study and observation by the physician, are called OBJECTIVE symptoms. The latter are the subjects of the patient's own consciousness, and are styled SUBJECTIVE symptoms. We may notice and study the spasmodic twitching of the facial muscles, the alternate flushings and pallor in a case of facial neuralgia, but the patient alone can make us aware of the sensation which he experiences simultaneously with those twitchings and flushes. In a case of pleurisy we may detect a friction sound denoting dryness or roughness of the pleura, or the dullness denoting effusion; we may observe the deviation from the natural symmetry of the thorax; the labored and hurried breathing, the short, dry cough and the expression of suffering which accompanies it, but the patient alone can tell us that he suffers from a stitch in the side, where it is, what direction it takes, what provokes and aggravates and what relieves it.
The physician and attendants may notice and observe the accelerated yet unsustained pulse, the dulled perceptions and sluggish or perverted intellection, the red, or dry, or cracked and trembling, tongue, the elevated and uniformly fluctuating temperature of body, the tympanitic abdomen, the tenderness about the coecum caput coli and the enlarged spleen which characterize a typhoid fever; but only the patient could have made known to us the failing strength of body, mind and will, the peculiar headache and the desolate sense of illness which, perhaps many days preceding the commencement of the doctor's attendance, began to take possession of him.
We meet with few cases which do not present throughout their course, or at least in some portion of it, both subjective and objective symptoms. If there be an exception, it is that of some chronic affections, consisting exclusively, so far as our observations enable us to speak, of pains and abnormal sensations. I say so far as our observations enable us to speak, for I can hardly conceive of an abnormal sensation except as coincident with some structural change of tissue, although this be so fine as to elude our present means of research.
On the other hand, we meet cases presenting at first view only objective symptoms, as for example, chronic, cutaneous affections and heterologous formations. And yet I believe that in every such case, if we take a broad enough view of it, including the history of the case, we shall find a tradition of subjective symptoms. However this may be, and whatever may be their relative number, and what comparative importance we may be disposed to attach to them, these are the two varieties of symptoms which patients present to us.
Now we may study symptoms under two views, with two different objects: First, we may study the science of symptoms as a branch of medical science, as a department of the science of biology,—much as we study physiology, which is the other department of biology,—without any view to a practical application of the results of our study, without any reference to a proposed application of the therapeutic art, without considering how we shall remove the symptoms by interposing the action of a drug; and Second, we may study symptoms with reference to the practical application of our knowledge in bringing drug action to bear upon the patient's symptoms.
Let us first consider the study of symptoms as an independent department of science. It is one, let me say, which has not received the attention to which its great importance entitles it.
The patient is before us, the object of our observation and inquiry, just as the healthy human being is before us when we study his constituent tissues and organs and their respective functions in pursuing the sciences of anatomy and physiology. We observe his objective symptoms and learn from him his subjective symptoms.
A fact of prime importance for us to remember at the outset of our inquiry is this: that as in nature there are no accidents, so there can be no symptom which is not directly the result of some immediate cause operating in the organism of the patient; no abnormal appearance or condition of any tissue or organ which does not proceed from a modification of its cell structure, its nutrition, or of the normal proportion of the tissues which compose it; no abnormal sensation experienced by the patient which is not the result of some change, either appreciable in some tissue of the body, or assumed to exist therein, or referred to the indefinite realm of dynamics, the convenient habitat of functional derangement for which we have not as yet discovered any structural substratum.
No symptom, then, is to be passed over as unimportant. We know not how important that which now seems most trivial may tomorrow be proved to be. This we know, that everything in the human organism, as in the universe, moves and occurs in obedience to LAW ; and when we observe the phenomena of nature, we fail of the reverent spirit of the true and faithful student, if we pass over any phenomenon assuming it to be of no account, just because our faculties are so little developed that we cannot see that it has any significance. If it be true, as the Lord of Glory tells us, that of two sparrows which are sold for a farthing not one falls to the ground without our Heavenly Father, that the very hairs of our head are numbered, how can it be that changes of tissue or of excretion or secretion should occur, that abnormal sensations should be experienced save in accordance with some law of the organism? The noble sentiment of the Latin poet, " I am a man: Nothing that is human can be alien to me," is true in a physical no less than in a moral sense.
It is our object to observe everything that is a deviation from the healthy condition. We must then keep up, during our observation, a constant recollection of the condition of organs and tissues, and the performance of function in the healthy subject; and our observation will be a sort of running comparison.
Our object is to note every deviation. We must necessarily follow some method in our investigation, otherwise among such a multitude of objects some would surely escape us. If it be necessary for a dog in hunting to scour a field according to a certain method of lines and angles, surely method must be needful when we are beating up this complicated field of the human organism, and that too in search of game which does not start up at our approach.
We may adopt the REGIONAL method and survey the whole body, passing from region to region in anatomical order. This is a valuable method and indispensable to a certain extent. It fails, however, to give us sufficient information respecting organs and tissues which, from their situation, are entirely removed from our physical examination or exploration, as, for example, the kidneys and the ovaries. The anatomical method of investigation must be supplemented by what I may call for a moment, somewhat incorrectly, the physiological method. By this we seek to arrive at the condition of an organ or its tissue, or of the parts of an apparatus by examining how it performs its functions. Thus, by examining the excretions of the kidney we form some conclusion respecting the condition of that organ. If we find albumen and certain microscopic objects in it, we may be certain that a portion of the kidney has become changed in a very definite way, which, however, we could not otherwise recognize during the life of the patient. The same is true of many other organs.
This knowledge has been obtained by accumulated observations of the symptoms of diseases, and of the results of diseases as noticed after death. But so difficult is the art of observation, and so hard is it to obtain from patients all of their subjective symptoms, for the reason that patients have not been trained to the observation of natural phenomena, and are not good observers even of themselves, that we should hardly succeed in getting all the symptoms of a case if we did not add to the regional and the physiological another mode of observation. The history of disease has taught us that when certain symptoms are present in some one organ or apparatus of the body, there are almost sure to be present certain other symptoms, objective or subjective, in other organs often anatomically quite remote, and of which the patient probably is hardly aware until his attention is called to them by the physician.
I may cite as examples the fact that certain pains in the head, persistently experienced by the patient, are found, by observation of a great many patients, to co-exist with certain uterine affections, of the existence of which the patient was hardly aware; and the immediate symptoms of which would probably have been overlooked in the recital. Another noteworthy instance, a recent discovery, is the coincidence of a certain morbid condition of the retina with a form of Bright's disease of the kidney, to which attention may thus be called at an earlier stage than that at which the kidney symptoms would have discovered it.
To recapitulate, then: we observe the changes in form and structure which are open to our senses, we use whatever methods we possess to discover others; we illuminate the interior of the eye, the rima of the glottis, the canal of the urethra, the meatus of the external ear. We sound the thorax and the abdomen by the methods of percussion and auscultation; we analyze the secretions and excretions, and reason from the results— through our knowledge of the history of disease —to a conclusion respecting the condition of organs and tissues hidden from our observation. Thus we obtain our complete series of objective phenomena.
We then address ourselves to the task of taking the subjective symptoms of the case. Availing ourselves of the regional method which investigates in topographical order one region of the body after another; the physiological method which traces sensations from one organ to another, and leads us to look for sensations or even objective symptoms in some part of the body because we know them to exist when certain others are present; and, finally, employing our knowledge of the history of disease to trace symptoms, both subjective and objective, from one organ and apparatus to another, we make up our series of subjective phenomena.
Now, it may occur to some of you that when I speak of the modifications of tissues and organs found in the patient, and of the necessity of exactly observing and studying them, I am advocating the study of pathological anatomy; and that in showing how a study of the connection of symptoms in the patients may greatly facilitate the discovery of symptoms by showing their mutual connection, dependence and succession, just as the study of physiology enables us to grasp the phenomena of the healthy organism, I am defending the study of pathology. And so I am. For just here we have the province of pathology and pathological anatomy, which are indispensable instruments in the study of symptoms. Let us not be frightened from their legitimate use for the reason that they have been put to a false use.
If we disregard these auxiliary sciences, our collections of symptoms must be for us incomplete lists of unmethodized and unarranged observations. How can we imagine that any department of medical science can exist and be pursued which would not be a useful auxiliary to the physician ?
Let us turn now from this glance at the independent study of symptoms as a science, to their study as the means to a practical end. As practitioners of medicine, what is our object in collecting and studying symptoms?
If we regard our duties to our patient in the order in which they were stated in my last lecture, that we are to ascertain for him where and what he ails, whether and how soon he can recover, and finally what will cure or help him, we study symptoms, first of all, to form our diagnosis. Viewed with this object, the symptoms we have obtained from the patient at once classify themselves in our minds. Certain symptoms take front rank as indicating the organ which is chiefly affected, and the kind of deviation from a healthy state which exists in it. Such a symptom is called pathognomonic ; and is entitled to that epithet if it be found only when a certain diseased condition exists, and always when that condition exists. We cannot pronounce a symptom to be pathognomonic, nor recognize it as such, unless we are acquainted with the history of disease. Then we require to form our prognosis. Here again we must have a knowledge of the history and course of disease, that we may recognize any symptoms which indicate a lesion so extensive that recovery is unusual or impossible. We must know, likewise, the history of disease, as its course is capable of being modified by medical treatment, and by different varieties of medical treatment.
THIRD: Our object in the study of symptoms is to get into position to ascertain what drug shall be applied to cancel the symptoms and effect a cure. This is the practical end.
The homeopathist obtains his series of symptoms, and then, in accordance with the law, SIMILIA SIMILIBUS, he administers to the patient the drug which has produced in the healthy the most similar series of symptoms.
Now, in speaking of the independent study of symptoms as a science by itself, I have urged the necessity of eliciting all of the symptoms, both objective and subjective, bringing every auxiliary science to aid in the search for symptoms. But when we come to the practical application of the law, SIMILIA SIMILIBUS CURANTUR, when we come to place side by side the two series of symptoms, those of the patient and those of the drug respectively, it is manifest that those of the patient to which we find nothing corresponding in the symptomatology of the drug, are of no use to us in the way of comparison. Practically, then, unless the observation of symptoms as produced by drugs in our provings is developed PARI PASSU with that of symptoms as observed in sickness, there will be much of which practically we can make no use. And you will find this view to explain much that is said in disparagement of the study of pathology and pathological anatomy, and of any aid which they may afford to the practitioner.
The difficulty resides in the present imperfection, respectively, of the sciences of pathology, symptomatology and pathogenesy.
Of the symptoms which we have obtained from our patients, the question of their relative value must occur to you. I have mentioned pathognomonic symptoms and their supreme value as determining the diagnosis. Are they as valuable when we are in search of the right remedy ? To answer, let us see what we are doing. We are seeking that drug of which the symptoms are most similar to those of the patient. We may have seen in our lives a hundred cases of pneumonia. Every one of these presented the symptom which is pathognomonic of pneumonia. And yet the totality of the symptoms of each patient was different, in some respects, from that of every other pneumonia patient. And this must necessarily be so, because the diseased condition of each patient is the resultant of two factors, the morbific cause, assumed to be the same for all, and the susceptibility or irritability to that cause, which susceptibility may be assumed to be different for each; the resultant must be different for each. We must look, then, for the symptom which shall determine our prescription in some other symptom than the pathognomonic, in some symptom which from the diagnostic point of view is far less important, in some subjective symptoms, or in a condition which individualizes.
Is it essential that the pathognomonic symptom of the case should be present among the symptoms of the drug ? Theoretically, it certainly is. Practically, in the present rudimentary condition of our provings, it is not. We attain a brilliant success if not a certain one, where it has never been observed; although I think we are bound to assume, and are justified in assuming, that were our provings pushed far enough it would be produced. This subject will come up again hereafter.
Recalling now the practical division made of symptoms into objective and subjective, the question presents itself: Do we, in the practical use of our symptom series, make use of objective symptoms as in the independent study of symptoms? Unquestionably, wherever the character of our provings has made this possible, and indeed wherever clinical observation has supplemented the provings.
In skin diseases, wherever we meet the well-defined, smooth erysipelas of Belladonna, or the vesicular erysipelas of Rhus, or the bullae of Euphorbium, or the cracks of Graphites, or the lichen of Clematis, or the intertrigo of Lycopodium, or the hard scabbed ulcers of Mezereum, from the edges of which thick pus exudes on pressure,—do not these symptoms almost determine our selection of these remedies ? Or the white tongue of Pulsatilla, the red-tipped, dry tongue of Rhus, the moist trembling tongue of Phosphoric acid, the broad, pale, puffed and tooth-indented tongue of Mercurius solubilis, the yellow coat at the base of the tongue of Mercurius proto iodatus, or the patchy tongue of Taraxacum,—do we not recognize these symptoms as most important indications for these remedies respectively ? Shall I further mention the objective symptoms,—sandy grains deposited in the urine, or a red deposit which adheres to the vessel, or the various peculiarities of feculent excretion and of sputa, which are well-known and universally admitted indications of certain remedies, or the radial pulse, or the heart rhythm ?
It appears, then, that objective symptoms are valuable indications for the remedy, just in proportion as they have been observed in proving drugs, so as to afford a ground of comparison ; and just in proportion as the observation has been precise and definite, enabling us to distinguish one case from another, or, as we term it, to individualize the case.
Such is the value of objective symptoms. But, our object being to individualize the case, it frequently, indeed generally, happens that the distinctive symptoms are subjective.
How now shall we examine the patient to get his symptoms ? Do you say that this is an easy matter ? Gentlemen, it is the most difficult part of your duty. To select the remedy after a masterly examination and record of the case is comparatively easy. But to TAKE the case requires great knowledge of human nature, of the history of disease, and, as we shall see, of the materia medica.
We see the patient for the first time. If the case be an acute one, it may be that at a glance and a touch we shall observe certain objective symptoms which, at least, help us to form our diagnosis, and constitute the basis of the picture which leads us to the choice of our remedy.
Further examination reveals other objective symptoms. For others, as well as for subjective symptoms, we must depend on the testimony of the patient and his attendants. We have then to listen to testimony, to elicit more testimony by questioning and cross-questioning the patient and his friends, and to form conclusions from their evidence. We have to weigh evidence, and here we encounter a task which is similar to that of the lawyer in examining a witness, and success in which requires of us obedience to the rules for the collection and estimate of evidence. We must study our witness, the patient; is he of sound understanding? may we depend on his answers being true and rational ? He may be naturally stupid or idiotic, he may be insane, he may be delirious under the effect of the present illness. Or, putting out of view these extreme suppositions, is the patient disposed to aid us by communicating freely his observations of himself, or is he inclined to be reticent? You will be surprised at the differences in patients in this regard. Some meet you frankly, conscious that by replying fully, and by stating their case carefully, they are aiding you to help them. Others act as if they felt that in meeting the doctor they have come to an encounter of wits, in which they are determined that their cunning shall baffle his shrewdness. Others again are morbidly desirous of making themselves out very sick, and will unconsciously warp their statement of their symptoms so as to justify their preconceived notion of their case ; and if you question them, however you may frame your question, they will reply as they think will make out the case you seem to apprehend. Others, on the contrary, so dread to give testimony which, they fear, may make it certain that they have some apprehended disease, that they cannot bring themselves to state facts as they are, but twist and misstate them as they fain would have them.
I might pass without mention the case of those who deliberately conceal or deny the existence of symptoms which would betray the presence of diseases of which, with abundant reason, they are ashamed, because, I take it, you will be minded to have no dealings with those who refuse to their physician their unlimited confidence.
There is another class whose statements are plus or minus what exactness would require. Almost all of our descriptive language is figurative. We describe sensations certainly according to our idea of what effect would be produced by certain operations upon our sensory nerves, E. G., burning, boring, piercing. This involves an act of the imagination. We are differently endowed with the imaginative faculty. Some persons cannot clothe a sensation in figurative language, and are therefore almost unable to describe their subjective symptoms, and are very difficult patients. Others, again, naturally express themselves in this wise, and, where imagination is controlled by good judgment, are excellent patients, because they describe their symptoms well. This is a matter dependent upon natural endowment, and not upon education or culture. Some persons who cannot construct a sentence grammatically will give us most graphic statements of symptoms; while others who have borne off the honors of a university are utterly at a loss for the means to express what they feel.
Finally, some persons have a natural fervor and tropical luxuriance of expression, which leads them to intensify their statements and exaggerate their sensations. And some, like the Pharisee who believed he should be heard for his much speaking, think to attract our attention, and excite us to greater effort in their behalf, if they magnify their sufferings and tell us a pitiful tale. Others, on the contrary, of a more frigid temperament, give us a statement unduly meagre in its Arctic barrenness; or else, fearing to seem unmanly if they complain with emphasis of suffering which is perhaps the lot of all men, understate their case and belittle their symptoms.
In estimating your patients in these regards, judging while the tale is being told what manner of man you have to deal with, what allowances you must make, what additions, what corrections, you will have full scope for your utmost sagacity and SAVOIR FAIRE; and of the value of this estimate of your patient I cannot speak too highly. I have often seen the thoroughly scientific man led astray and bamboozled, where one far inferior to him in scientific knowledge detected the peculiarities of the patient, made the necessary corrections, got an accurate view of the case, and then the prescription was easy. Why, sometimes the patient will, in good faith, state a symptom so incompatible with others that we know and must declare it impossible, and so it is finally admitted to be by the patient.
If it be necessary to make this estimate of the patient, so must we likewise of his friends, who, besides having the peculiarities already spoken of, may be unfriendly to us or to our mode of treatment, and may thus be reticent or reluctant witnesses, or may even mislead us willfully.
We make this estimate of our patient and his friends while he and they are stating the case to us; and this statement we should as far as possible allow them to make in their own way, and in their own order and language, carefully avoiding interruption, unless they wander too far from the point.
We must avoid interrupting them by questions, by doubts, or even by signs of too ready comprehension of what they are telling us. It will of course happen that they skip over important details, that they incompletely describe points that we need to understand fully. But we should note these as subjects for future questions, and forbear breaking in upon the train of our patient's thoughts, lest once broken he may not be able to reconstruct it. When he has finished, we may, by careful questioning, lead him to supply the deficiencies. We must avoid leading questions, and at the same time must not be so abstract and bald that for lack of an inkling of our meaning, the patient becomes discouraged, and despairs of satisfying us. It is never our object, as it may be that of the lawyer, to show our own cleverness at the patient's expense, and to bamboozle him. We must, on the other hand, make him feel, as soon and as completely as possible, that we are his best friend, standing there to aid him in so reviewing his case that we may apply the cure. And so we must encourage his diffidence, turn the flank of his reticence, lend imagination to his matter-of-fact mind, or curb the flights of his fancy, as may be required.
We want a statement of the case in graphic, figurative language, not in the abstract terms of science. It does not help us to hear that the patient has a congestive or an inflammatory pain (however correct these conceptions may be); but a burning or a bursting pain is available. Nor does it specially enlighten us to know that the patient feels now just as he did in last year's attack, unless indeed we attended him then.
Having received the patient's statement and made our own observations, we have a picture of the case, more or less complete. What are we to do with it ? What is the next step ? We have now one series of phenomena. The law tells us that the drug which will cure that patient must be capable of producing in the healthy a similar series of phenomena.
Seeking the means to cure the patient then, we look among drug provings for a similar series of phenomena. Let us suppose that we find one which corresponds pretty well. Not exactly, however, for here are certain symptoms characteristic of that drug, of which the patient has not complained. We examine the patient as regards those symptoms. No! his symptoms in that line are quite different. We try another similar drug, comparing its symptoms with the patient's, and questioning the patient still further; and thus the comparing and trying proceed until we find a fit. This is a mental process, so expeditious sometimes that we are hardly aware how extensively we engage in it. But it shows how difficult it is to take a case unless we have some knowledge of the materia medica, and how much an extensive knowledge of materia medica aids us in taking the case; and this explains why the masters in our art have given us such model cases. (In consultations, a doctor will send his taking of the case. We cannot prescribe from it. We must take the case ourselves.) In thus fitting the case and the remedy be honest with yourselves, just as in getting shoes for your children. Do not warp or squeeze to make a fit.
And now, before we go further, let us ask what are the symptoms generally which give the case its individual character, and determine our choice of the remedy. Are they the pathognomonic ones ? They cannot be unless we are to treat every case of disease named by a common name with one and the same remedy. Are they those which are nosologically characteristic? No, for the same reason. They are the TRIFLING symptoms, arising probably from the peculiarity of the individual patient, which make the case different from that of the patient's neighbor. They may be a sensation or a condition. If it be metrorrhagia, the mere fact that the flow is worse at night may determine the choice between two such remedies as Calcarea and Magnesia.