Some Interesting Anecdotes about Case Taking and Case Analysis

On the first morning of a three-day seminar in Vienna in the mid-1990s, I mentioned that on average three hours are needed to take a complete case of a patient with a chronic disease of moderate complexity. At the back of the class was a group of doctors who disagreed and said they were doing very good work by taking chronic cases in about an hour. They were so dissatisfied with my approach to homeopathy that they left at the first break and didn’t come back for the rest of the seminar.

I regularly see patients who have been failed cases in the hands of well-known homeopaths. I remember in particular one such patient, who was suffering from depression, extreme fatigue and muscular weakness, and severe headaches associated with idiopathic intracranial hypertension, all of which were keeping her in bed for one to four days a week. She had consulted five other practitioners over a period of 13 years before I saw her in the late 1990s. It was a complex case with a history of rape and abusive relationships. I needed five hours to take her case before I was sure of the prescription. She responded wonderfully well to the remedy and during the following 15 years has continued to respond to the same remedy whenever she is unwell.

Once, I asked her how much time each of my predecessors had taken to examine her. She said they had all taken her case in between one and two hours. To this day, I am puzzled by how my predecessors in this case felt satisfied enough with such a short version of anamnesis to prescribe with certainty. But the facts are clear: here we have a patient who had spent a great deal of money and time over many years travelling many thousands of miles to visit five doctors in three different countries on two continents but without obtaining any benefit whatsoever. Fortunately, however, she had such faith in homeopathy that she never abandoned it and finally received the results she had always expected and that she should have received to begin with. Was my practice of spending three hours on average to take a chronic case such an anomaly? Let us see.

Within the first month of his arrival in France in 1835, Hahnemann addressed the members of the Society of Homeopaths of Paris.⁽¹⁾ In particular, he said that homeopathy is a very difficult art to practice and that in order to have the courage to study it and later to practice it conscientiously with the maturity that it requires, one must have a limitless dedication to the welfare of humanity. He added that a homeopath needs one or two hours to take a case and then as much time again to analyze the case.⁽²⁾ Therefore, late in his career, Hahnemann recommended a total of two to four hours for the combination of case taking and case analysis or an average of three hours;. that is exactly how much time I spend on average with a new adult patient since I am conducting the analysis of the case while I take it. Incidentally, that is the length of time I had arrived at over the years on my own for obtaining a complete picture of the disease and finding its simillimum in the materia medica.

Dr. Adolph Lippe was often referred to by his contemporaries as the best prescriber that homeopathy ever had. Moreover, it was not unusual to hear that he was a “flash” prescriber, a rumour that has persisted to the present day. In the early 1990s, I met Dr. Georg von Keller in the medical library of the University of Michigan. He was then a senior homeopathic physician from Tübingen in Germany. One of the first things he told me in the library and was proud of, was that he was seeing close to 125 patients a day, since he was prescribing like Lippe, “very quickly.” I told him it was true that Lippe was known as someone capable of taking an acute case very quickly⁽³⁾ particularly during epidemics, but that it wasn’t the case with chronic patients. Later that day, I showed him an article on exactly that subject by Dr. Edmund Lee, a former student and practice associate of Lippe’s.

Dr. Lee wrote, “As we have said, these opinions give a false impression, especially to those who did not know Dr. Lippe personally. This impression has already borne fruit, for at the meeting of the International Hahnemannian Association of 1888, a speaker alluded to Dr. Lippe as ‘a flash prescriber.’ We reiterate this view of Dr. Lippe’s success is misleading. No physician can succeed in the practice of homeopathic medicine unless he studies and studies hard at that; no one knew this better than the late Dr. Adolph Lippe. He was endowed with the gift for drug analysis and quickness of perception in discerning the symptoms of his patients which were the indicators for choosing his drug. The only other ‘genius’ Dr. Lippe possessed was a disposition to work hard and a profound admiration for the Organon. There are few men of even moderate ability who cannot achieve all of Dr. Lippe’s ‘genius’ if they work as hard as he did and in the right way. Bönninghausen was undoubtedly a grand prescriber, and it is an honour for anyone to be compared with him; but we doubt if he, or any other physician, ever studied out his cases with more unvaried care than did the late Dr. Lippe. No flashes of genius could have enabled one to cure the many chronic cases which he cured; diligent, careful work is required to gain such results. The necessity for this diligent study of the materia medica was impressed upon Dr. Lippe by his preceptor, the late Dr. Wesselhoeft; often have we heard him tell how his preceptor made him thumb his materia medica.

“Often has the writer heard Dr. Lippe say, in speaking of different physicians, ‘he does not study his cases thoroughly,’ or make some such remark, indicating the importance he attached to such study. The writer was one associated with Dr. Lippe in the care of a very difficult case, in which he has frequently known to spend hour after hour patiently conning the materia medica (this, too, after nearly forty years spend at such study). Many a time would he say, ‘Come over tonight and we will study the case over’; frequently have we asked his advice; before replying he would almost invariably take down a book or two to look up the remedy desired. Dr. Adolph Lippe was in no sense ‘a flash prescriber.’

“Genius has been defined as an unlimited capacity for hard work; this genius Dr. Lippe had and used it diligently (and in the right way) for forty [fifty] odd years. Was it then any wonder that he could occasionally prescribe quickly? He never prescribed until he felt sure of his remedy, and though he was quick in seeing the peculiar features of his patient’s history and rapid in selecting his remedy, he was never so quick as to be termed careless. There is a distinction to be noted here; one man may spend hours on a case and then make a careless prescription; another with a better-trained mind may prescribe in a few minutes and make a very careful, accurate prescription.

“We do not pretend to affirm that Dr. Lippe did not make mistakes; very probably he would have been the last man to deny legions of them; but we do believe that as a homeopathic prescriber neither Bönninghausen nor Hahnemann himself would suffer in comparing clinical results with their great admirer—Adolph Lippe.”⁽⁴⁾

When Dr. Arthur Eastman was a student at the Hahnemann Medical College of Philadelphia in the late 1870s, he lived in Dr. Constantine Hering’s house and was thus able to observe his mentor closely in the last year of his practice. He wrote, “Dr. Hering retained an old German custom to have a couple of students from the College reside in his family to keep in touch with the work and progress of the College. These places were much sought after, and happy he to whose lot fell the choice. I resided in his family during three courses of lectures, two winter terms and one spring term, from the fall of 1877 to the spring of 1879, and was also a frequent caller on him while I was a resident physician in the Homeopathic Hospital of Philadelphia until December 1879. …

“How did he [Hering] prescribe medicines? One might answer, very nearly as Hahnemann directed. He said: ‘There is an individuality in everything that the Lord has made. You cannot substitute one medicine for another. To mix medicines is a crime. Alternating is the halfway house to mixing. To make poor prescriptions when much driven is excusable, but the questions which must be kept freshly in mind are: What is your aim? What are you striving for? If a homeopathic physician once adopts the too-much-trouble creed, he is lost.’ It was certainly not his creed. His rules of practice, ‘golden rules,’ he called them, were ‘Learn to observe; learn to prove; learn to examine the sick; learn to select the remedy; learn how to repeat and how to change remedies; learn how to wait; learn how to profit by experience.’

“His method of examining a patient was an art. He took notes on his cases, full notes, and then would repair to his prescription room, where he could consult his repertories: his Jahr, his Bönninghausen, and then his materia medica. His remedy once selected, he would generally give in a high potency, way up in the thousandths sometimes. He had small envelopes with printed directions on the outside. Each contained six powders of Saccharum lactis, one of them containing some pellets of the indicated remedy and marked with a star. The directions were to dissolve the star powder in water and take a teaspoonful four times or more a day [for one day only] and go on each succeeding day with the other powders. You see, they took the medicine only one day, then placebos the succeeding days for a week, when they would report. If improvement, marked improvement resulted, they would get another envelope of blank powders for another week. If improvement stopped, they would get another powder of the same medicine of a higher potency, and, as he would say, ‘High and higher still, to heaven.’ If the patient was worse, a new remedy had to be selected, generally a remedy having some relationship to the first. Dr. Hering did not confine himself exclusively to high potencies or single doses. In certain cases, he repeated his remedies frequently. In chronic diseases the interval that elapsed between the doses might be two, four, seven, eleven, or sixteen days. In acute cases, he says, ‘The dose might be repeated as often as every hour, or even every five or ten minutes.’ He never alternated remedies, but if the symptoms suddenly changed he would often change his remedy. His success was phenomenal. Long-standing, chronic maladies yielded to his treatment. So-called incurable patients were cured by him. Patients came to him from the world over and were improved and cured.

“I will relate one case of his marvellous prescribing: One evening, in the summer of 1879, while a resident physician in the hospital, I called on Dr. Hering. ‘Come in, come in and sit down. Well, what is new at the hospital?’ I replied, ‘Nothing startling, Doctor. A poor fellow came in, a charity patient, who had been at the University Hospital and at the Pennsylvania Hospital, and both Da Costa⁽⁵⁾ and Pepper⁽⁶⁾ have diagnosed his disease locomotor ataxia and beyond help.’ ‘So Da Costa and Pepper can no nothing? Bring him over to me.’ I replied, ‘He is beyond relief and only a poor weaver and has no money to pay a doctor.’ He replied, ‘Oh, damn the money! Bring him over here tomorrow at five. I must see him,’ he said with the fire of youth in his dark eyes, and the stroke of his fist on his desk. And so I did. With notebook in hand, he began asking symptoms and modalities, beginning with the patient’s ancestors—and such a history as he took! He examined him thoroughly from top to toe in every possible manner. In the meantime, Dr. Hering’s reception room was filling with patients and Dr. Knerr motioned me to step into the hall, where he said, ‘Try and get that patient out, as Dr. Hering still has much important work to do.’ After an hour’s examination, Dr. Hering said, closing his book, ‘Bring him over again tomorrow.’ The next day Dr. Hering spent another hour with the poor weaver, and then said, ‘Bring him over again tomorrow.’ After continuing the examination for another hour, closing his book, Dr. Hering said to me, ‘You come alone tomorrow.’ I said, ‘What remedy shall I give him?’ He answered, ‘I cannot tell until I have studied it more.’ The next day I returned and he had a sort of condensed summing up of the case written in German, and after more conversation, he went to his prescription room and brought me an envelope, with the remark, ‘This is Rhus tox, 65 M. Give it to him and report in a week.’ The poor fellow had to be taken to Hering in a wheelchair and could only take a few steps with the assistance of two canes. His condition was very distressing. To make a long story short, Dr. Hering treated him for about four months, when the poor weaver walked out of the hospital without canes, seemingly on the road to complete recovery.”⁽⁷⁾

In other words, Hering, who had by then been practicing homeopathy for close to 55 years and had been writing his magnum opus, The Guiding Symptoms, for almost 30 years, needed three hours to take the case and had to spend an indefinite amount of time studying the case afterwards to find the exact correspondence in the books.

Students of Dr. Pierre Schmidt have told me that their teacher would examine each new patient for three hours during the morning session and have him or her return for another two hours in the afternoon for a detailed physical examination.

The practice of genuine homeopathy is based on the totality of symptoms, which includes all the symptoms that the patient has manifested since infancy. Therefore, we never work with a truly complete case, since a great number of old symptoms have long been forgotten and many other current ones escape a patient’s notice. However, as physicians, we have the duty to investigate all pertinent aspects of a patient, as Hahnemann explained so well in paragraphs 82-104 of the Organon. The application of the law of similars requires great precision, and there seems to be no easy way of obtaining consistent and predictable success in homeopathy other than to leave no stone unturned in taking a case and by conducting the process of differential materia medica until one is reasonably certain of having found the simillimum corresponding to the genius of the patient’s disease.

References

(1) This address should not be confused with the formal one Hahnemann made before the Gallican Homoeopathic Society on September 15, 1835, which I mentioned in my article in the June 2014 newsletter.
(2) Correspondance (Anonymous). Extrait d’une lettre de Paris, 13 juillet. Bilbliothèque Homoeopathique 1835; 5: 320-322. To my knowledge this extract from Hahnemann’s address was never quoted, translated or referred to, even in Josef Schmidt and Daniel Kaiser’s Gesammelte kleine Schriften von Samuel Hahnemann (Heidelberg: Karl F. Haug Verlag, 2001).
(3) E. B. Nash. Comments. Transactions of the International Hahnemannian Association 1886: 32.
(4) Edmund J. Lee. Bönninghausen and Lippe. Homoeopathic Physician 1890; 10: 35-36.
(5) Dr. Jacob Mendes Da Costa was professor of the theory and practice of medicine at the Jefferson Medical College in Philadelphia and author of the textbook Medical Diagnosis, which went through nine editions during his lifetime and served as the first complete guide of its kind.
(6) Dr. William Pepper was professor of clinical medicine at the University of Pennsylvania and author of the System of Medicine, which was one of America’s standard medical textbooks.
(7) Arthur M. Eastman. Life and Reminiscences of Dr. Constantine Hering. Hahnemannian Monthly 1917; 52: 472-496.