The fifth aphorism states:
Useful to the physician in assisting him to cure are the particulars of the most probable exciting cause of the acute disease, as also the most significant points in the whole history of the chronic disease, to enable him to discover its fundamental cause, which is generally due to a chronic miasm. In these investigations, the ascertainable physical constitution of the patient (especially when the disease is chronic), his moral and intellectual character, his occupation, mode of living and habits, his social and domestic relations, his age, sexual function, etc., are to be taken into consideration.
will help the physician to bring about a cure if he can find
out the data of the most probable occasion of an acute disease,
and the most significant history of a protracted wasting sickness,
enabling him to find out its fundamental cause. The fundamental
cause of a protracted wasting sickness mostly rests upon a chronic
miasm. In these investigations, the physician should take into
account the patient’s:
a) discernible body constitution (especially in case of a protracted disease),
b) mental and emotional character,
d) lifestyle and habits,
e) civic and domestic relationships,
g) sexual functions, etc.
When you are treating an acute case with homeopathy, one of the most important points to know is the ‘exciting cause’ – not the virus or bacteria – but that cause which made the body susceptible to an illness, the ’cause’ which ‘excited’ the susceptibility.
In conventional medicine, the occurrence of an acute disease is very simply understood – you come in contact with a pathogen and you catch that cold or fever or diarrhoea or any other acute disease. You ask them why some people are more prone to catching colds and the simple answer is ‘they have weak immunity’. But in homeopathy, we go beyond such simple and superficial explanations of acute diseases. We believe that there are innumerable factors which can disturb our homeostasis, derange or vitality and make us prone to an illness. These factors which ‘excite’ our susceptibility can vary from physical factors like exposure to heat, cold, rain, dampness, sun, or factors like overeating or overindulgence in anything – be it food, drinks or sex; mental factors like too much stress about studies or watching too much television, emotional factors like loss of a loved one or a heart-break etc. Many of these factors, if persist for a long time, can lead to chronic conditions. But often the first reaction to any such stress is an acute.
Let me give some examples of ‘exciting causes’ of acute diseases: If constipation sets in after a mental shock or nervous strain, Mag-carb could be the remedy; if you get a cold after getting a hair-cut (not a hair-do but a shave or a crew-cut), then Nux-vomica or Belladonna might be your remedy; if you get a cough after eating rich food, then Mag-mur or Pulsatilla might be you remedy, if you get a diarrhoea after drinking cold water on hot days, Vertrum-album might be your remedy. I can go on to give hundreds of other examples but the point to understand here is that the ‘nervous-strain, the ‘hair-cut’, the ‘rich food’ etc do not by themselves cause disease. They just disturb the fine equilibrium in our body; make it more prone to the action of pathogens, which ultimately leads to the development of ‘disease’ symptoms.
Another important thing to remember is that the correct remedy should not just cover the ‘exciting cause’ but also the presenting symptoms.
Treating an acute condition is not always easy, as the ‘exciting cause’ is not always very evident. Still the process of finding the remedy for an acute case is straight forward, when compared to the treatment of chronic cases. A person suffering from chronic gastric disturbance is very unlikely to tell you about the Typhoid that was mal-treated when he was three. A person suffering from Alzheimer’s’ might not even remember the name of his first crush – leave aside telling you the agony ‘her’ affair with someone else caused. A person suffering from congestive heart failure is unlikely to relate a theft in his house 20 years ago as the starting point of his sickness. So it’s not always easy to pin-point one ‘exciting’ cause that triggered a chronic illness.
So how do we treat a chronic disease systematically? If we just start treating the ‘current complaints’ in a chronic case, we will not be able to move beyond ‘palliation’ in the majority of cases. Just like in an acute case, in chronic cases we also have to chart the complete course of illness. But how? In acute cases, it’s easy to record changes by minutes and hours but how do you chart a chronic illness spanning many decades? Hahnemann gave the answer – take note of ‘the most significant points in the whole history of the chronic disease‘.
A chronic illness doesn’t develop overnight and often the patients come to us with case histories running into decades. During the whole life span of the patient, there are usually episodes of significant acute illness, some starting point where the chronic ‘disease’ is identified, followed by some treatment (usually conventional/allopathic), after which there is a gradual increase in the intensity and variety of complaints as well as medicines! When you start treating a chronic case, you have to gather all this information to treat judiciously. But how does all this information help in treatment? How does the past history help in selecting a remedy and managing a case? Hahnemann says that all this information – the backward tracking – enables him to discover its fundamental cause, which is generally due to a chronic miasm – that is, it allows you to identify the underlying miasm (susceptibility) of the patient, which is usually the ‘fundamental cause’ of a chronic disease.
Let me give you an example. Suppose you have got four Asthma patients. All of them will show the common signs and symptoms of asthma like breathlessness, wheezing respiration, aggravation by cold and exertion and often night too, dry cough etc. This is the presenting picture of the chief complaint. So do we give the same remedy to all of them? Let’s delve a bit deeper into their histories: One of them was declared asthmatic in infancy and both of his parents were asthmatic. The second one had eczema on both legs ten years ago. It was suppressed with corticosteriods for years and gradually he developed occasional episodes of breathlessness. The third one, used to suffer from frequent colds, which were usually treated with antibiotics. Later he developed allergic rhinitis with sensitivity to dust, mites, pollens, strong odors and many other things. He kept taking anti-allergic drugs for years and gradually symptoms of dry cough and dyspnoea started manifesting. The fourth one is a miner and has worked in coal mines for 20 years. His breathlessness has increased gradually over the years. The first case with strong family history is clearly Sycotic and the medicines that might work for him are Natrum-sulph and Medorrhinum, the second case with history of suppression of skin disease is clearly Psoric and the medicine for him is most likely Sulphur, and the third one with marked hypersensitivity, is very much Syphilitic and the medicine that might work for him is Merc-sol. The last one suffers from a pseudo-chronic or an occupational disease. Hahnemann has said - “fundamental cause, which is generally (NOT ALWAYS) due to a chronic miasm”. The last case falls into this category, where the fundamental cause is NOT a chronic miasm. The medicine that might help this case is Stannum.
This is just a gross example of how the origin and the course of disease affects our remedy selection. There might be finer variations depending upon the complete case details and modalities.
But our work of finding the simillimum is not easy and although the causative factors play a decisive role in finding the simillimum, we still have to take into consideration a variety of other factors to make a correct remedy choice and to lead the patient to cure. In addition to the causative factor, we can use many other variables, like the appearance of a person, his mental constitution, his work or profession, lifestyle, habits, relationships, gender, sexual functions, age etc.
Let us explore some of these factors in more detail. This will help us appreciate their importance in finding the similimum.
1. Physical Constitution
You must have read about the constitutions associated with many of our remedies – Sulphur is tall, thin and stooped shouldered; Calcarea is fat, fair and flabby; Sepia is thin, scrawny and flat-chested; Phosphorus is tall, lean with sharp features; Graphites is stout in appearance; Baryta is short and so on.
Ever wondered where these physical constitutions come from? There are two primary sources- first, during a proving, a medicine is seen to affect a particular constitution more than the others. Secondly, after prescribing a particular remedy to dozens (probably hundreds) of people it is seen that the people who are benefited by this remedy often have some common physical traits. Such traits, when confirmed repeatedly, find their way in our materia medicas as ‘physical constitution’.
Physical constitutions are not definite. That means, not every Calcarea case is going to be fat, fair and flabby. I have prescribed it to too many thin and dark people with success to take it as a definite. Similarly not every Phosphorus is going to be tall and not every Baryta is going to be dwarfish. BUT the constitutional picture is still very handy. Why? Because the physical structure is usually inherited …inherited along with many other mental traits and susceptibilities. So when a person with a particular constitution comes in front of you, you are often able judge what to expect from this case. It may not prove correct every time but it does help us narrow down our choice of remedies. It is also a very useful tool in situations where a homeopath needs to prescribe a remedy but is unable to communicate effectively due to language or religion barriers.
A note of caution: the physical constitution is never to be used in isolation to prescribe a remedy. DO NOT use it blindly. It can help in remedy selection when used judiciously and along with the ‘complete’ case, but if used in isolation, the results will be few and far in between.
Another note of caution: in some books of materia medica, you will find constitutions classified as hydrogenoid, nitrogenoid, carbo-oxygenoid, phlegmatic, leuco-phlegmatic etc. In my personal opinion, you should not use this data in relation to our remedy pictures. This classification is very hypothetical and is actually derived from a nearly 2000 year old classification given by hippocrates. Von Grouvgol promoted these constitutional types in homeopathy with a broad remedy classification, which in my opinion, is very synthetic.
2. Mental and Emotional Constitution
Now let us move on to the mental and emotional constitution of a person. Hahnemann was a visionary in that he was probably among the first few people who thought of using our mental and emotional framework as an aid to treatment. But before we move further, it is necessary to differentiate between mental symptoms and mental characteristics.
Mental and Emotional Symptoms: These are changes in our mental and emotional functions as a result of sickness, the disease process. For e.g., ‘Anxiety after witnessing an accident’. Here ‘the shock’ of witnessing an accident is an ‘exciting cause’ and the anxiety is the symptom. Similarly, ‘depression due to grief’. Here the ‘grief’ is the exciting cause and the ‘depression’ is a symptom.
Mental and Emotional Characteristics: These are the mental and emotional ‘traits’ that people are born with or sometimes acquire due to life experiences. In most case the traits are inherited. For e.g. ‘optimism’ and ‘pessimism’ are often mental attitudes that people are born with. Similarly some people are ‘anxious’ right from birth. They worry about everything. The anxiety is then not a mental symptom (unless associated with some disease), it is a mental characteristic. Some people are emotionally expressive, some are not; some people think before they act and there are others who act before they think. ‘Fear’ if associated with some cause is a symptom but there is no dearth of people who are ‘fearful’ in general. Here the ‘fearfulness’ becomes a ‘trait’ – something that characterizes that person, not just his/her disease process.
The first homeopathic idiom that we were taught in our college was – ‘treat the person, not the disease’. That we were never taught, HOW to treat the ‘person’, is an entirely different matter! Anyway, what this basically means is that we have to study the person along with his disease process. Many people misunderstand this idiom and start believing that we do not need to bother about the ‘disease’. But that is entirely wrong. Ultimately it is the ‘disease-process’ that you are trying to cure. Homeopathy was never meant to treat the fundamental human traits in isolation.
Mental symptoms and mental characteristics are both useful in selecting the remedy. But the symptoms come first. A remedy that covers the ‘traits’ but not the ‘symptoms’ is not the ideal simillimum. Just like physical constitutions, the knowledge about traits is not as objective as proving data and you should always study the mental ‘constitution’ with a pinch of salt. because not every Arsenic is ‘anxious’, not every Tarentula ‘loves music’, not every Carcinosin is ‘artistic’, not every Sulphur is a ‘philosopher’. The mental constitutions fit in a large number of cases but NOT ALWAYS. So always be open-minded and flexible at the time of remedy selection. DO NOT make these mental and emotional constitutions a hard and fast rule for remedy selection. Just like physical constitution, mental and emotional characteristics should also be used to select the best remedy from among the group of remedies that cover the ‘symptoms’ of the case well. They should not be used in isolation to prescribe, because if you do so, you will not be doing ‘homeopathy’.
I have another thing to say here. In the last few decades, there has been an increasing ‘trend’ to prescribe on the basis of mental and emotional constitution. This movement to understand the ‘essence’ of a remedy started with the work of Vithoulkas and Masi and was carried forward by the likes of Sankaran, Mangialavori and Scholten. There is nothing wrong in understanding the ‘person’ BUT the problem started when people in some schools started to ignore the physical generals, the disease symptoms and the pathology and started prescribing only on the constitutional essence of the patient. This trend still continues and is actually on the rise. Such one sided prescriptions and the schools that teach such methods, should be condemned in the strongest possible words.
Now let us move to occupation, another important factor that needs to be considered while evaluating a person for chronic diseases. In my last lecture, I had discussed the diseases, whose ‘fundamental cause’ is not a chronic miasm. These diseases are called occupational diseases. These days an increasing number of chronic conditions arise due to the occupation or from stress associated with the work. Whenever you get a patient, do ask about his occupation, whether he likes his work or not, what is the environment in his office or if there are any issues associated with the work-place etc.
There are some diseases that you can directly relate to the occupation. For e.g., Asthma in people working in mines, Sinusitis in people working in damp environments like dairies, skin infections and dermatitis in people working in chemical and dyeing industries, cervical spondylitis in people working on computers for long hours, indigestion in people with sedentary work. In such cases your remedy will not be able to cure the patient unless and until the causative and maintaining factor is removed.
In other cases the ‘work’ by itself does not cause any disease but the work-environment may be causing problems. There may be issues related to abuse, injustice, frustration, jealousy etc that arise from issues related to the work place. Such issues need to be brought into the open during the case taking and addressed with counseling and suitable homeopathic remedy.
4. Lifestyle and Habits
These days our lifestyle and habits are increasingly becoming a source of increased susceptibility to diseases. Unhealthy diet, junk and processed food, pollution, watching TV for long hours, lack of physical exercise, late nights, irregular sleep, too much exposure to pornography – all tend to make us more susceptible to disease processes by decreasing our vitality. These factors may not be easily related with the current condition of a patient but in a large percentage of cases you will find that the person himself is responsible for his own undoing.
In the fourth aphorism, we discussed that a physician is not just supposed to treat the sick. His work also includes prevention of disease and maintenance of health. You need to work with your patients to ensure that they develop a healthy life-style. Otherwise it is often difficult to cure – you can’t clap with one hand! The patient needs to work on his own wellbeing too. And as a physician, it is your duty to guide him in the right direction.
5. Social and Domestic Relations
The social and personal relations of a person can also give us a cue to his predispositions, changes in his mental and emotional health and his/her mental characteristics. The way people behave with their wifes/husbands, children, parents, friends, colleagues, neighbors and strangers walking on the road, can give you sufficient information about a persons likes, dislikes, preferences and overall mental traits. When the patient is known to you, you will be able to observe the behavior yourself, in other cases you may need to ask the patient as well as the attendants about the person’s behavior and relationship with others. Let me give you some examples: the Flouric-acid patient is known to be a gentleman outside the home but a ‘baddy’ inside; the Lachesis patient may feel envious of others easily; the Natrum-sulph and Pulsatilla patients may be easily dominated in their relations, whereas Platina may try to be the center of every thing in a relationship; the Causticum patient may try to help an injured person or an old man whereas the Staphysagria patient may have an ‘who cares’ attitude in such situations. The study of relationships helps us decipher the mental traits that we have discussed above and is hence an important part of case taking.
Age is again an important factor and can help us narrow down our choice of remedies. During our provings, it was found that some remedies work better in some age groups. For instance Barytas’ seem to work well at the two ends of the age-spectrum – very young and old; Chamomilla, Cina, Podophyllum, Antim-crud are known to cover the problems of children well; Calcareas are often indicated in adolescence; Lachesis often finds indications at menopausal age and so on. These indications of age are not definite. Ultimately, the remedy selection is governed by symptom similarity. But we have to value the experience that homeopaths have gathered in these last 200 years and if a remedy is known to work well in a particular age group, there is no harm in keeping it in mind when selecting the remedy for the patient.
7. Sexual Functions
Another very important aspect of human life is – sex. ‘Sex’ is one of the most searched words on the internet. Our biological drive to reproduce is so strong that we don’t need to read someone else’s opinion to understand the importance or our sexual functions. In modern society, as the hold of religion has weekend and the desire for ‘freedom’ has increased, there has been a marked change in human sexual-social behavior. Living-in, one-night stands, casual sex, promiscuity etc have become so common that we do not even raise an eyebrow when we hear about them. Sex has come out of the sanctity of married relations.
But all this has led to ever increasing sexually transmitted diseases like AIDS, Syphilis, Gonorrhea, Chlamydia, Hepatitis etc. The ‘sexual freedom’ has also led to relationship problems for many. With increasing sexual desires, sexual frustrations have also increased manifold – resulting in a variety of problems varying from impotence to psychological disorders. Unplanned pregnancies, abortions and side-effects of oral contraceptive drugs is also part of the ‘trade-off’ for sexual freedom.
So whenever you take a chronic case, do take the sexual history of the patient wherever it appears relevant. In both males and females the age of attainment of puberty and history masturbation should be enquired into. In adults enquiry should be made about promiscuity, sexual diseases, menses and any issues associated with sexual functions. But do remember that you need a lot of tact to gather such information and the information should not be sought bluntly or when not relevant. The patient should be made to understand the importance of these details, if he/she is hesitant in answering your queries. It is still not very easy to gather this information in the eastern world but efforts should be made to find as much relevant information as is possible.
There is no mathematical formula for good case-taking. You
have to individualize your case-taking according to the patient
in front of you. Hahnemann was way ahead of his times in ascertaining
the totality of the case. There is probably no literature parallel
to The Organon that lists the need for such detailed evaluation
of a patient. Chronic diseases arise from a variety of causes
and you have to do a detailed assessment to find out what it
was that deranged the vitality of the person to such extent
as to cause such chronic disease. The work is not easy but the
rewards compensate amply for the hard-work.
Audio lectured was transcribed by Dr.K. Savitha