Case Analysis for the Beginner and Advanced Homeopaths

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Case Analysis for the Beginner

The next task in studying an initial case is to find the correct remedy, the simillimum. To the beginner with only a limited knowledge of materia medica, this decision can be very difficult, especially in chronic cases. Nevertheless, it must be emphasized that the choice of the initial remedy is the most crucial decision made in homeopathy. No shortcuts should be taken, and any judgments must be made with great circumspection. The first remedy is the one which opens up the case, which brings out the true healing potential of the defense mechanism, and which sets the case either in a direction toward greater order or toward confusion and disorder. Often, because the initial case has not yet been spoiled by previous incorrect prescribing, the choice of initial remedy is an easier decision than choosing later remedies; even so, it must be remembered that it is the most important prescription of all.

Occasionally (not often), the initial case is very obvious. The patient presents with a few simple complaints, the homeopathic image clearly fits a particular remedy, a few peculiar symptoms confirm that remedy, and no symptoms contraindicate it. Such a situation is obvious, and the prescriber can give the remedy with confidence. Even relatively inexperienced prescribers will see dramatic results when the initial image is clear and obvious. It is then very important to wait for a long time before either repeating the remedy or giving another one.

The more common circumstance, however, is a mixture of symptom pictures. A patient, for example, may present a highly characteristic mental symptom of Pulsatilla, and the prescriber naturally tends to believe that Pulsatilla will be the remedy. Upon further inquiry however, it turns out that virtually no other symptoms confirm Pulsatilla, and furthermore the patient is very chilly and desires fat (two symptoms which directly go against Pulsatilla). In such a circumstance, the homeopath must definitely not yield to the temptation to give Pulsatilla. More thought and study need be done to find a remedy that truly covers the totality of the symptoms. Every symptom may not be covered, but a remedy will hopefully be found which clearly covers the bulk of the most important symptoms.

In the beginning, it often happens that a seemingly confusing and unrelated collection of symptoms seems to fit no remedy at all simply because of the lack of knowledge of the prescriber. Someone with greater knowledge and experience may well see the correct remedy without difficulty. But what is the beginner to do in such a circumstance?

The best procedure is to "repertorize" the case. A careful list of the patient's symptoms is made according to procedures given in Chapter 13. Great thought should be applied to the choice of the symptoms to be used in repertorization, and then care should be taken to arrange them in their true order of importance.

To begin with, the very peculiar symptoms (those showing only a few remedies in the Repertory) should be excluded from the formal repertorization.

Then, beginning with the symptom at the top of the list, the homeopath writes on a sheet of paper every remedy listed in the corresponding rubric, including the correct grading of each remedy. This is done for each of the significant symptoms in the totality. Every remedy is included so as to reduce the chances of missing the true one (assuming that correct rubrics are chosen). Finally, notations are made of every remedy which "runs through" all of the rubrics.

In the ideal circumstance, such a repertorization will yield only one medicine running through all of the rubrics. This remedy is then carefully studied in the materia medica. If the "essence" of the remedy seems to fit the "essence" of the patient, and if the bulk of the symptoms are covered, then the remedy can be given with confidence.

This ideal is very rarely realized in actual practice, however. Usually, three or four drugs run through the rubrics, but only one must be chosen. Rubrics covering the peculiar symptoms are then consulted, and those remedies which have come through the full repertorization and are also seen in the peculiar rubrics are studied first. If the peculiar symptoms do not confirm any of the medicines from the repertorization, then all three or four drugs are carefully studied in the materia medicas to find the one most completely matching the totality of the patient.

Never should a remedy be given simply because it scores highest on repertorization. Even a remedy scoring much higher than the others should be rejected if its description in the materia medicas does not fit well with the patient. As mentioned before, repertorization is merely a clue; it is not a final answer.

Some homeopaths have developed "repertory sheets" which enable a numerical tabulation of remedies according to symptom. These sheets are handy to use, but they are not recommended for the beginner. Part of the purpose of studying a case in the early years is to gain a broader understanding of homeopathy and of medicines. The use of "repertory sheets" tends to prevent one from really thinking about each remedy in relation to the patient. The process of writing out each rubric with all drugs that can produce it, although tedious, can be a helpful way of learning the comparative value of remedies. As more and more medicines are learned, this method enables the prescriber to anticipate whether a particular symptom will be found in the proving of a particular drug. The process of actually writing out the rubric then provides feedback to the prescriber's "guess." This is a tedious process, but it nevertheless should not be given to assistants or secretaries, because a major part of its purpose is to add to the knowledge of the homeopath.

Attention should be paid to "small" remedies which run through a few rubrics in a repertorization, even though their grade was "1" all the way through. "Small" remedies are those whose provings are as yet incomplete, and therefore the number of symptoms listed for them is small. If such a medicine runs all the way through the repertorization, this can be an important sign. It should be carefully studied in as many materia medicas as possible. It may not cover the entire case, simply because the provings are incomplete, but enough of the image may be present to enable the prescriber to give it. Such a judgment is, of course, quite delicate and requires some experience, but it should be considered.

Very often, it will be found that a particular remedy runs through all rubrics except, say, the third and the fifth (as listed in order of importance); the first and most important symptoms are covered, as well as some lesser symptoms, but a few in the middle are not. If the rest of the repertorization has not produced an obvious solution, such a remedy should also be considered. It should be compared with any peculiar symptoms, and then carefully studied in the materia medicas. Since there are many uncertainties involved in case-taking, in the listing and grading of symptoms, and also in the recording of provings into the Repertory, it is frequently found that the simillimum will not cover all the important symptoms in a case. In such a circumstance, careful questioning about the missing symptoms should be made on follow-up visits to ascertain whether they are cured as part of a cure of the whole patient; if so, and if confirmed in other patients, that remedy may be added to the rubric as having produced a "cured symptom."

Using this tedious and painstaking procedure, the homeopath will steadily add to his or her knowledge of materia medica. After 10 years or so of practice, the homeopath will evolve to the point where the label "beginner" is no longer appropriate. As more and more experience is gained, the process of repertorization may be streamlined a bit by doing an "elimination" procedure. This modification should be undertaken only after the homeopath has gained an extensive knowledge of materia medica, because it distinctly reduces the opportunity to consider all possible remedies.

"Elimination" repertorization is done by first constructing a very carefully considered list of major symptoms. The most characteristic symptoms are pulled out and arranged according to their importance. This must be done with extreme care, taking into account a variety of factors: the severity of the symptom, its hierarchical level, how strongly it represents the essential pathology of the patient, its timing in relation to the evolution of the current pathology, etc.

The first symptom in such a list is then written down, and all remedies shown in that rubric are written on a sheet of paper, including the grading of each remedy. The second symptom is then written down, but this time only those medicines contained in the second rubric as well as in the first are written down. Drugs which are not present in the first rubric, but which are in the second, are eliminated. Next, the third symptom is noted down, and only those remedies included in it as well as in the previous rubrics are recorded. Finally, at the end of this process, only a small number of remedies should remain after the full elimination has been completed. These remedies are then thoughtfully studied in the materia medicas.

This method will appeal to everyone right from the beginning because it saves a lot of tedious labor. However, it is a risky procedure because the original listing of symptoms is very critical. For example, if a symptom is listed first but should be listed in third place, the chances are very good that the true simillimum will be eliminated from the analysis. The patient would consequently receive an incorrect remedy at the very outset of the case. Only a homeopath with a quite good knowledge of materia medica could spot such a mistake in time to prevent it.

Case Analysis for Advanced Prescribers

As experience is acquired, gradually less reliance is placed upon a formal repertorization. Possessing an extensive knowledge of remedies, the homeopath may have a very strong impression of the correct remedy by the end of the case-taking. Only a quick glance to certain rubrics in the Repertory will then suffice to confirm or deny this impression. In this instance, the homeopath may use a mere "finger" repertorization, which is my term for the process of inserting fingers into appropriate places in the Repertory, and then looking back and forth to perform the elimination procedure.

To a beginner observing an advanced prescriber, this process would seem easy indeed. Nevertheless, what seems so simple is in reality highly sophisticated. The same painstaking procedure occurs in the mind of the advanced prescriber as has been described for the beginner, but an advanced homeopath's grasp of the rubrics is so complete that remedies do not have to be physically written down. In the mind of the advanced prescriber, the pertinent rubrics are virtually memorized from long experience of writing them out time and again, so that repertorization is mostly done in the homeopath's head. Such prescribers can accurately quote, remedy for remedy, the contents of all of the most important rubrics.

An advanced prescriber has such a deep grasp of remedy "essences" that it is possible to match directly and immediately the essence of the patient to the essence of the remedy. If the essence is clearly and unequivocally seen, then only a few confirmatory symptoms are needed to select the remedy. Of course, the full case must be taken anyway, in order to be sure that no contra-indicating symptoms are present. Nevertheless, in a case which matches the "essence" of the remedy so closely, the process of case analysis will appear to be extremely rapid in the hands of an advanced prescriber.

If the essence of a remedy is perceived in the patient and a few other symptoms confirm it, then no further thought need be given to the prescription. The situation becomes more complex when there are one or two symptoms which strongly go against the remedy. Then the homeopath must go all the way back to the beginning and reconsider the entire case. In this circumstance, even the advanced homeopath will spend as much time and care selecting the remedy as the beginner. As a matter of fact, the procedure for selecting a remedy in such a case is essentially the same as would be true for the beginner. The entire totality is considered carefully, all uncertainties are taken into account, the appropriate rubrics in the Repertory are reviewed, and finally particular attention is paid to the peculiar symptoms. Great thought is put into the case; perhaps a somewhat compromise judgment is 211 made. Nevertheless, the final prescription will match as closely as possible the totality of symptoms of the patient with the totality of manifestations of the remedy.

In such complex cases, it may be necessary to "throw out" even important mental or general symptoms and to rely on seemingly less significant but more peculiar symptoms. Precisely how this is done cannot be described adequately in a book. Every case is so unique that it would be impossible to generalize about such judgments. They come from experience, and to a great extent they can only be learned in a supervised setting. Such judgments belong to the realm of art rather than science, even though there are always very cogent reasons for them.

Frequently, cases are encountered in which there are many common symptoms but only two peculiar symptoms. Acquiring a distinctive totality of symptoms is impossible. Repertorization is done, but because the symptoms are common, a large number of remedies come up which inevitably are those most widely proven — remedies which we call "polychrests." Such analysis and repertorization have little chance of producing the correct remedy. In this situation, it is permissible to focus solely on the peculiar symptoms — even disregarding the repertorization altogether. The remedy is selected from the rubrics describing the peculiar symp toms, and often the prescription will tend to be a rather unusual remedy. As always, careful study of the materia medicas must be made before deciding upon such a selection.

Occasionally, a case is encountered in which the chronic state arose very dramatically out of a powerful exciting cause. For example, a patient might be seen whose miasmatic background is quite insignificant but whose entire spectrum of, say, neurological complaints, dates from a severe head injury received in an auto accident. If, upon taking the case, one or two peculiar symptoms fitting Arnica or Natrum sulphuricum (noted for effects from head injuries) are found, then the prescription can be based solely upon the causative factor (confirmed by one or two peculiar symptoms). In this unusual circumstance, symptoms elicited during the rest of the case-taking are ignored for the moment, although they may become significant for later prescriptions.

As one can readily see, the selection of a remedy is a complex process. Many factors must be taken into account, balanced against each other, accepted in some instances, and rejected in others. The uncertainties involved underscore strongly the necessity for having a well-taken case in the first place. The principles described, and particularly the exceptions to the "rules," are valid only if information derived from the original case is reliable. If the original case is sketchy, or misleading, or incorrect, then all of the delicate judgments later made while studying it are likely to be wrong. A correct homeopathic prescription depends upon a correctly taken case, correct information from provings, correct preparation of the Repertory, and finally correct analysis of the case.

It can also be readily understood that "keynote" prescribing can occasionally produce successful results. Sometimes the most careful and detailed study of a case by an experienced prescriber will arrive at the same remedy which a "keynote" prescriber would have chosen in a matter of minutes. In such an instance, the careful prescriber may seem foolish or even ignorant. However, "keynote" prescribing does not produce reliable and consistent results. Correct remedies may be selected here and there, but not in virtually every case — which is possible by strict application of deeply understood homeopathic principles.

Index
1. Homeopathic Case Analysis and First Prescription
2. Case Analysis for the Beginner and Advanced Homeopaths
3. Selection of the Single Homeopathic Remedy and Potency