symptoms

A contribution to the judgement concerning the characteristic value of symptoms
Clemens Maria Franz, baron von Boenninghausen
Allgemeine Homoeopathische Zeitung, Vol. 60, p. 73; translation by L.H. Tafel, 1908

It is now over there years since the great Homoeopathic Congress was held in Brussels, Gremany being, I am sorry to say, but little represented. In the last session of this meeting after several propositions has been read, my resolution was adopted and a prize-question was proposed, to answer which a period of two years was granted. This prize essay, as the Homoeopathic journals have also made known, was intended to call out a "Treatise concerning the greater or lesser (characteristic) value of the symptoms occurring in a disease, to aid as a norm or basis in the therapeutical selection of the remedy." The answer to this question was not limited to Belgium or to France, but it was handed over to the competition of the whole medical world, and it was thus unanimously acknowledged to be a subject of the greatest importance. Nevertheless, this question, in spite of the daily increase of the homoeopathic literature, has thus far remained unsolved. This silence extending far over the time set, which was computed liberally enough, seems to justify the assumption that the solution of the question has met with considerable difficulties, though every homoeopath must every moment find himself in the position to ask himself this question, and to have to answer it. It might not appear altogether proper for me, the author of the question, to also now enter among the competitors for this prize. But the old practitioner will be pardoned for furnishing at least some contribution to the solution, and thereby again calling attention to the question.

The teaching of the Organon in this matter really contains the proper, true kernel of the answer, and this, of course, deserves to be first premised. It is found in the great Paragraph No. 153 (5th Ed.) and is as follows:

"In seeking for the specific homoeopathic remedy, i. e., in this juxtaposition of the phenomena of the natural disease and the list of symptoms of the medicines, in order to discover a morbid potency corresponding in similitude to the evil to be cured, the more striking, particular, unusual and peculiar (characteristic) signs and symptoms of the case should especially and almost solely be kept in view; for there must especially be some symptoms in the list of the medicine sought for corresponding to this, if the remedy should be the one most suitable to effect the cure. The more general and indefinite symptoms, such as lack of appetite, headache, weariness, disturbed sleep, uncomfortableness, ete., in their generalness and undefinedness deserve but little attention, unless they are more expecially pronounced, as something of such a general nature is seen in almost every disease and in almost every medicine."

It is seen, however, that it is here left to the physician to judge what is understood by the "more striking, particular, unusual and peculiar" symptoms, and it might, indeed, be difficult to furnish a commentary to this definition, which would not be too diffuse and, therefore, easily understood, and on the other hand would be complete enough to be properly applied to all these cases. Whence is it that we are unable to show any such definition in our literature? Even what Hahnemann adduces in § 86, and those that follow, only contains some examples which are given without any systematic order, and are therefore but little suited to impress themselves on the memory, a requirement which in all such matters must appear to be of very great importance.

After looking about in the whole of the medical writings, allopathic as well as homoeopathic, for an aid, I remembered that in the middle ages they were accustomed to bring all such matters into the form of verses, in order that the memory might thus be assisted. The modern learned world knows, e. g., the diet of the Schola salernitana, dating from the beginning of the twelfth century, drawn up in leonine verses, as is supposed, by a certain John of Milan, from which some parts are quoted even to this day. But though I did not find here anything for the present purpose, I yet found something which, as it seemed, might prove useful with writers of quite a different doctrine. There is, namely, a hexameter dating from this same period but from the theologic scholastics; this is, indeed, of a somewhat jolting construction, nevertheless it contains briefly and completly the various momenta according to which a moral disease is to be judged as to its peculiarity and grievousness. The verse is the following: "Quis? quid? ubi? quibus auxiliis? cur? quomodo? quando?"

The seven rubrics designated in this maxim seem to contain all the essential momenta which are required in the list of the complete image of a disease. May I be allowed, therefore, to attach my remarks to this scheme with the desire that this hexameter, which was formerly used only by theologians, may now be also impressed on the memory of homoeopaths and be put to use by them.

1. Quis?-As a matter of course the personality, the individuality of the patient, must stand at the head of the image of the disease, for the natural disposition rests on it.

To this belongs first of all the sex and the age; then the bodily constitution and the temperament; both if possible, separated, according to his sick and his well days i. e., in so far as an apperciable difference has appeared in them. In all these peculiarities whatever differs little or not at all from the usual natural state needs little attention; but everything that differs in a striking or rare way therefrom deserves a proportionate notice. The greatest and most important variations are here found mostly in the states of the mind and spirit, which must be scanned all the more carefully, if they are not only sharply distinct, but also of rare occurrence and, therefore, correspond to only few remedies. In all such cases we have all the more cause to fathom these states with all possible exactness, as in them frequently the bodily ailments recede to the background, and for this very reason offer but few points for our grasp, so that we may be able to make a sure selection among the remedies which compete.

Paragraph 104 of the Organon makes it the duty of the homoeopath to make a written scheme of the image of the disease, and whoever has once acquired a certain facility in this will easily know how to satisfy this requirement and gradually acquire a certain specializing penetration, which will prove to him of ever increasing usefulness. For as every man presents an individual nature different from every other one, and as every medicine must be exactly adapted to this individuality, in agreement with the symptoms, which it is able to produce in the total man, so, at once, at this first investigation as to the Quis? A great number of medicines are thrust aside, just because they do not correspond to the personality of the patient.

The spiritual and dispositional individuality of the patient here gives the most important, often almost the only deciding points for the selection of the remedy, where the disease involved is one of the mind or spirit, and generally the two disturbances present themselves so conjoined into one that the signs of the one only receive their full and definite character from the other. Hahnemann, indeed, recognized the importance of this two momenta from the beginning, but the necessity of weighing the two in their connection with one another he only recognized later on in its full measure; and he then placed the symptoms proper to the two, which in the first provings had been separated, one making the biginning and the other the end, in the "Chronic Disease" immediately one after the other, an improved arrangement, which we also find in the best works on Materia Medica Pura of later times.

Many other things belonging to this rubric, but concerning the bodily individuality and presenting, as it were, the chief features in the portrait of the patient, are contained in those books under the heading of "general." It would be desirable and would greatly facilitate the use if everything not pertaining thereto should be excluded, and the former be brought under a particular rubric denominated either "Individual" or "Personal," in such a way that the corporeal would present a separate picture, as has been done with respect to the spiritual and mental.

2. Quid?-Of course this question refers to the disease, i. e., to its nature and peculiarity.

It may be unquestionably received as an axiom that we must first know an evil accurately before we are able to give any effectual aid against it. That occasionally relief may be given, without having first recognized the nature of the evil, as little refutes this axiom as the fact that an unexpected event occurs frequently which lies outside of our computation, and which either leads to good or evil, while neither the good will, nor the knowledge of the physician have the least to do with it.

But this axiom must be associated with another, which is no less true and no less important, namely this: That we must also know and possess the means which are able to relieve the evil when it is recognized. Where these are lacking, the former are of course of no avail.

Since the times of Hippocrates, thus since more than two thousand years, very much has been done with respect to the first point, and we have especially enjoyed a great progress and enlightenment within the last century and up to modern times. The path of pure observation and exprience, which for a time had been pretty much forsaken, and on which that ancient Father of the healing art had gathered his valuable material, has again been entered upon. At the same time our contemporaries possess and use the great advantage enuring to them from the fact that they stand on the shoulders of their predecessors, and can thus view a greater circle of vision and, more especially, that astonishing progress has been made in all the subsidiary sciences, especially in chemistry and anatomy; so also they have had the advantage offered them by many physical instruments, which it must be confessed they have used with industry and care. By these means the modern physiological school, and, at the same time, the diagnostics of diseases, have reached an excellence not attained in earlier times.

The only thing of which every Homoeopath has to complain in this matter, is that things are conducted in too general a manner for his doctrine, and that almost universally diseases are described and treated of under the same name, which differ essentially in their nature, and require for their cure very different medicines.

An immediate result of this failing is, that Homoeopaths can make only a very limited use of the great advance made by the dominant school in diagnostics, since their generality excludes every special direction as to the suitable remedy.

Now since the modern Materia Medica of allopathy, as well as the older one, moves in the same generality, the conclusion follows almost inevitably that even the most cultivated allopath often stands undecided when he is to make a choice of remedies, so that almost every one of them will order something different, and that he is usually compelled to mix many things together in order to cover the various indications.

More about this will be found in the course of this short treatise in a more suitable place, where the other questions are also discussed. Here I can only say so much about it.

a. That the most penetrating and most indubitable diagnostic as offered by the best allopathic manuals is rarely if ever sufficient for the Homoeopath, so as to enable him to make a sure selection of the remedy, and that

b. Such a diagnostic at most, and even then not always, may serve to exclude all those remedies from the competition which do not correspond with the common genius of the disease, but seem to act chiefly on other parts of the organism.

3. Ubi? - The seat of the disease really makes a part of the former question, but it nevertheless deserves to be more particularly emphasized, as it frequently furnishes a characteristic symptom, since almost every medicine acts more and also more decidedly on certain particular parts of the living organism.

These differences not only enter into consideration in certain so-called local diseases, but also in those diseases which are called by more general names, as affecting the whole body, e. g., gout and rheumatism. For it is probably never or very rarely the case that all parts of the body are affected in the same degree; even if it should be merely the case that the right side is more affected than the left or the reverse. But the examination of the parts affected is most necessary and most required when the whole to which they belong is larger, and is described merely in that general way which allopath seem to delight in. Such names as headache, eyeache, toothache, colic and the like can in no way contribute to a rational choice of a remedy, not even when also the kind of pain is indicated.

Of course, the exact individualization of the ubi is most necessary in local ailments. Every Homoeopath knows from experience how necessary it is, e. g., in treating toothache, to select a remedy which in accordance with its provings on healthy persons has shown its action on the especial tooth to be treated. Among the most striking and decisive phenomena in this respect we should especially number the sores on the upper side of the joints of fingers and toes, which under allopathic treatment frequently prove very obstinate, and not unfrequently become malignant, and necessitate an amputation, and, as I had an opportunity of witnessing here in two cases, may even have a fatal result. Every Homoeopath knows the efficacy of Sepia in these ulcers of the joints, which have no otherwise distinguishable features when this remedy is taken internally; without any external medication it will have a sure effect. Medicines which correspond to similar ulcers on other parts of the body in such cases are utterly useless.

If the practice of auscultation and percussion, as well as the use of the stethoscope, the plessimeter, etc., had been as well known to Hahnemann and his pupils as to our young physicians, they would no doubt have made the most extended use of the same for gaining a more exact knowledge and delimitation of interior ailments. They would have found out in lung troubles, e. g., definite local signs pointing to the use of certain remedies, and would have indicated them more accurately, and would not have limited themselves to defining them as being on the left or on the right side or at the top or below. To bring up to date and to specify more closely might be one of the chief duties for those who make additional provings at the present time, and might serve to an important and essential enrichment and completion of our Materia Medica more than a whole mass of confirmations of older symptoms or the finding out of new ones, which mostly have a lack of individuality.

At the same time it will be conceded from the allopathic side that the closer delimitation of the part affected, even though it may be of moment in the completion of the diagnosis, will be of no use to allopathic therapy, because this school is unacquainted with the peculiarities of the various medicines. No allopathic Materia Medica gives any information that the one remedy, e. g., corresponds more to the anterior or the posterior lobe of the liver, more to the upper or the lower part of the lungs, on the right or the left side, according to which the choice of the remedy may be made. Even if we Homoeopaths do not as yet know this as to all remedies, we do know it with respect to many of them, and for what is lacking we find a substitute in other signs, since, as is well known, all of these correspond to the remedy to be selected, at least they must not be opposed to it. Thence it may be seen that these new inventions, the value of which I am not in any way inclined to undervalue, have far less value in a therapeutic direction than in prognosis, where they show the extent and the dangerous nature of the malady.

Finally, we must yet consider in this question that neither the internal changes, which can be determined by these instruments, nor the material external changes, which manifest themselves openly to our notice, ever present the dynamic disease itself, but are only its products, and are only developed in the course of the disease. When, therefore, these first beginnings are checked by the suitable remedy before those disorganizations take place, then these latter would not come to be developed, and it would be an inexcusable procedure to allow these sufferings to advance to a point where these material changes can be recognized in an artificial manner. It was necessary to mention this, in passing, in order that it may be shown how Homoeopathy proceeds, and to deny most decidedly the objection sometimes made that Homoeopathy is merely an expectative method, which allows the disease to develop without hindrance until it is too late to help. On the contrary, Homoeopathy knows and uses in infectious diseases sure prophylactic remedies, which are always and exclusively such as have the power to heal the disease itself, and they never omit their use for the protection of those around the patient.

4. Quibus Auxiliis?-If the hexameter which we are following had been originally written for our doctrine, probably a more suitable expression would have been used in this instance, e. g., quibus sociis or quibus comitibus? Still the name does not matter, and it is manifest that it must refer to the accompanying symptoms.

Now since in Homoeopathy the chief aim consists in ascertaining the remedy which most completely corresponds to the totality of the symptoms, it is evident that this point is of the greatest importance and deserves the most careful consideration.

For every disease presents in its recognizable phenomena a more or less numerous group of symptoms, and it is only their totality which presents its complete image. This image may be compared to a portrait, which can only then claim to be a striking likeness when all the features of the original are faithfully presented in it. It is not sufficient that mouth, nose, eyes, ears, etc., should be presented in such a manner as characterizes man, and distinguishes him from the monkey and other animals but as every human physiognomy possesses its peculiarities and is distinguished from every other, so also here the more or less strongly pronounced abnormalities must most carefully and with the greatest faithfulness and truthfulness be presented and given their prominence. If, therefore, retaining our former comparison, the nose should have a most peculiar form, color or size, it would not be sufficient to present this alone, though it should be most lifelike, and to add all the rest according to fancy, but also the secondary parts, which, as it were, form the back-ground, must present a whole, such as it exists in reality, in order to give a perfect likeness.

It is from this point of view that the concomitant ailments are to be regarded when we select a remedy according to the motto: Similia similibus. Thence it is evident that the rare, striking and peculiar symptoms which present themselves demand a more prominent place than the common ones, because on them chiefly though not exclusively the similitude depends.

From this it naturally follows that the value of such concomitant symptoms for the purpose intended varies widely. But it would too far transcend the purpose of this contribution if I should adduce and explain all the many categories of value. I shall therefore limit myself to the presentation of a few of the most important points here involved:

First of all, those symptoms which are found in almost all diseases may be left out of our count, unless they manifest themselves in a striking manner.

The same obtains as to those ailments which are wont to appear as constant concomitants or at least as usual in the disease under consideration, unless they should be distinguished by some rare peculiarity and in this respect offer something characteristic.

On the other hand, all those attendant symptoms should be carefully noted which (a) rarely appear in connection with the leading disease, and are, therefore, also found rarely among the provings; (b) those which belong to another sphere of disease than the chief ailment, and (c) lastly, those which have more or less of the characteristic signs of one of the medicines, even in case they have not before been noticed in the present juxtaposition.

Now if besides this among the last mentioned concomitant symptoms there should be one or another in which the genius of one of the remedies should be plainly and definitely portrayed, so that it would be plainly pointed out, this one symptom thereby would acquire such an importance that it would even outweigh those of the chief ailment, and may then be at once considered as the most suitable. Such a symptom would be included among those which Hahnemann calls "striking, strange, unusual and peculiar (characteristic) signs," and which are then "almost alone to be considered" because they preëminently give to the whole disease its individual character.

One circumstance deserves to be particularly mentioned here which particularly shows the importance and value of concomitant symptoms, namely, that several very efficient and in part specific remedies in certain diseases were discovered almost exclusively through them, the other symptoms indicating the main disease not having pointed in that direction, nor indeed could they have given such an indication, because the noticeable proximate signs could not sufficiently indicate the real peculiarity of the disease. This same system of concomitant symptoms also gives to Homoeopathy a much greater sureness in the treatment of diseases as compared with Allopathy, which first constructs for itself a frequently deceptive diagnosis of the disease, which at most only points out the genus of this disease, and where there are important attendant symptoms it endeavors to help itself by adding to the leading remedy given for the genus of the disease one or another additional remedy to cover the concomitant ailments.

5. Cur?-Why? The causes of the disease play a prominent part in pathological books, and justly. But a large part of this amounts only to guesses and attempts at explanation, which mostly have only a very subordinate value or none at all in the proper therapy of the disease, and which are too remote for our doctrine which is directed merely to the practical.

The causes of diseases are most generally and, indeed, very properly divided into external and internal.

The internal causes properly refer only to the general natural disposition, which in some cases amounts to a peculiar supersensitiveness (idiosyncrasy). The external causes or occasional causes embrace everything which, where there is such an internal disposition to disease, may produce disease.

The general natural disposition which is also called the proximate cause, really belongs to the first question (Quis?) which respects the individuality of the patient. It only belongs here in so far as the consequences of a former disease may have modified the original natural disposition, and thus it deserves mention.

The occasional cause, however, is the matter with which the present question occupies itself and which deserves to be more closely considered. As to the natural disposition notified through previous diseases, this either depends on the miasmatic-chronic nature of those diseases as yet unexterminated, among which in agreement with the teachings of Hahnemann many homoeopaths even at this day count psora, syphilis and sycosis, or it is derived from the remains and after-effects of acute diseases, which when, they do not belong to the former, as is frequently the case, constitute the numerous class of medicinal diseases or poisonings. Not unfrequently, however, we meet with cases where both these momenta have coöperated to undermine the natural health, thus producing a monster of a disease which is even more deeply inrooted and more difficult to combat.

As to the recognition and treatment of the first mentioned miasmatic diseases and their complications, Hahnemann himself in his masterly work on the Chronic Diseases left us the most complete directions, founded on many years' experience. The much disputed division of medicines into antipsorics and non-antipsorics need not be considered here. It is enough to know that the former far excel the latter in their effectiveness in chronic diseases, and that their originator has nowhere excluded them from use in acute diseases. Later experience has also taught us that additional medicines from our medical treasury should be numbered in this category which have not been thus treated of in that excellent work. I am only sorry that Hahnemann has not been able to fulfill the promise which he give me in writing, that he would treat as thoroughly and completely the images of syphilis and sycosis with his accustomed mastership as he had done in the above mentioned work (Vol. I, p. 58 ff. of the Second Ed.) with respect to latent and re-awakened psora. Whether we may believe in what many somewhat derisively call Hahnemann's Psora-theory, or reject the same, the attentive practitioner must frequently have found cases where even the remedy chosen with perfect correctness, in some acute disease, did not unfold its proper and decided effect before one of the so much criticised antipsorics-frequently Sulphur-had first been used, when psora had been involved, or an antisyphilitic or antisycotic when syphilis or sycosis had been present before and had remained uncured. It must, however, be confessed to be one of the most difficult tasks of the physician to always make the most suitable choice among the antipsoric remedies, as most of them have almost the same symptoms and very few truly characteristic symptoms are found with the different remedies. The more necessary is it for the homoeopath to study with continuous industry these lists of symptoms and to compare them with each other in order that he may pick up the scattered grains of gold for his use.

Poisonings and medicinal diseases are in one line and it makes no difference by whose hand any one has been deprived of his health by means of a substance injurious to his organism; among these substances medicines as will as poisons find their place. Of course, it is always of the greatest importance to know in every case the medicines or poisons, in order that they may be met by the proper well-known antidotes. The simple poisons may be pretty easily and surely recognized by their effects! It would have required but one case of poisoning occurring before the eyes of a Homoeopath for him to have recognized the effects of Arsenic, which yet remained unknown to all the allopathic physicians, in the case of the thirty murders of Gessina Timme in Bremen, until the facts were obtained. In the medicinal diseases this is much more difficult, because seldom or never is one medicine given by itself, but always mixed with others; it can not, therefore, yield a clear and definite image. With these, therefore, it is necessary, as in the other case it is desirable, and it facilitates the treatment, if we can have a reliable account of what has preceded, and to be able to look over the prescriptions. Since this may be of use even later on, as the treatment proceeds, the journals of many Homoeopaths have a special rubric reserved for this subject. We must consider these symptoms, called anamnestic, as being of special importance in this question. Although the ordinary consequences of such morbiferous circumstances and events are mostly already contained in the lists of symptoms of the medicines proved on healthy people, yet homoeopathic practice has long ago shortened and made sure the tedious and troublesome path of such investigations, and indicated for most of these cases the remedies which are foremost in their usefulness in such cases. This is e. g., very much simplified in cases of contusions, sprains, burns and the like. In other cases, e. g., in colds, the matter is already somewhat more complicated, since the kind of a cold and the part of the body affected offer differences which again point to different remedies. Thus there is a great difference in this respect as to whether the person has been simply exposed to the cold, or whether this took place while the body was in a perspiration, or if he at the same time got wet through. So also it is well known that different remedies are indicated when internal parts (stomach, abdomen, chest) have been exposed, or merely external parts (head, feet, back), and this must be carefully weighed in every case. All this, as before said, is found among the symptoms in the Materia Medica; but when once it is known that a cold in the head from exposure to cold air, after previously being in a heated room, or after having the hair cut, points to Belladonna or Sepia; after taking cold in the feet, to Baryta or Silicea, and when at the same time there has been a wetting, to certain other remedies, then the attention will first of all be directed to these, and only comparison be made with others which are also occasionally indicated when the first are not sufficiently suitable.

Finally we must yet add a word under this question about infectious diseases, about which in pathological manuals we read so much that is contradictory and unreliable; the influence of which teachings is, however, much more far reaching than is generally supposed. To meet these diseases, which often spread until they become a real calamity, Homoeopathy has the most sure and approved prophylactics, and these, indeed, are the very same which have the power of healing those diseases when they have developed. Therefore, when we find in a family a case of infectious typhoid fever, there the same remedy, which has been given the patient in accordance with his symptoms, will also be sure to, protect those in the house from infection, as it destroys the natural disposition thereto, and it will even in the shortest time restore those with whom there may have already been apparent the beginning of the disease. This last fact is the more important, as these first beginnings are usually so poor in symptoms that no certain choice can be founded on them; but the known occasional cause fully makes up for what is lacking. Of course, such a cure is not so brilliant as when the patient has been at the verge of the grave, but the gain for him and the consciousness of the physician is his sufficient reward.

6. Quomodo?-From its etymology, this preposition excellently describes the essence and the scope of the question before us. For the word Modus in the old classics not only refers to the manner and mode in general, but also to all the modifications which can take place in anything, thus the measure, the rule, the aim, the relations, changes, etc.; thus whatever, with the exception of time, which is included in our last question (Quando), possesses the ability to produce a modification, aggravation or improvement with the patient, naturally belongs, according to the usage of the language, to this rubric. This question has a double importance to Homoeopathy, first, because it was first discovered and developed by Homoeopaths, and is, therefore, their indisputable and exclusive property, and secondly, because all the results of provings and of experience, without exception, belong to the more or less characteristic signs, of which no one is a matter of indifference, not even those of a negative kind.

Allopathy has never given any general attention, which might have been of use to therapy, to this moments. At least its manuals on Pathology, Therapy and Materia Medica contain nothing of importance on this subject. Homoeopathy, on the other hand, soon after its discovery, recognized its great therapeutic value, and we find the first but already clear traces of it in Hahnemann's "Fragmenta de viribus medicamentorum positivis," which appeared in the year 1805. But during the progressive development of our science its importance appeared more manifest, and it was soon declared to be indispensable, so that in the later provings the attention was more and more directed upon it. On this account the latter provings are the more complete, with the exception of those made by Hahnemann in the Materia Medica Pura, which were elaborated with especial industry and on account of their constant use accompanied with copious notes.

If we compare the lists of symptoms of the medicines which have been proved somewhat fully, even a superficial survey will show that we find in almost every one of them the general indications of almost every disease; headache, colic, pain in the chest, diarrhoea, constipation, as well as dyspnoea, pains in the limbs, fever and cutaneous ailments, etc., are in no case quite absent. But if we study these indications somewhat more closely, with respect to the special parts of the body and the different sensations, then, indeed, differences will appear, and we frequently discover symptoms which appear more or less frequently in one remedy and are totally lacking in another. But the number continues too large to bring the decision to a sure and indubitable point, and we soon feel the need of securing additional points in order that we may find the true and suitable simile among the competing medicines. But the Quomodo with the Quando generally solves the riddle in the most satisfactory manner, and not only removes every doubt, but also furnishes the proof for the solution which we may have before supposed to be the right one. That in such investigations and comparisons we must also, as in what precedes, occupy the especial standpoint, is a matter of course. It is not sufficient, e. g., to merely consider motion in general in contrast with rest in the body, or in the part affected, we must also consider incipient and continuous motion, as well as the different kinds and degrees of motion. The same applies to lying down, we must not only consider the kind of position (on the back, on the side, doubled up, horizontal, etc.), but also aggravation or improvement in the parts affected by lying on the painful part, or the part not painful; all this is to be found out accurately and adapted to the remedy.

Quite a prominent part in this rubric is occupied by the partaking of food and drink, and this not only in diseases of the digestive organs, but also in fevers and other internal and external affections. Here it is not so much the amount of appetite, or thirst, to which also allopathy in some cases gives a proper importance, but especially the dislike or the desire for particular kinds of food and drink, and more especially also the change of condition after partaking of one or another article of food that often gives the most important hints as to the medicine to be selected. All experienced Homoeopaths have therefore always given the greatest attention to this subject, and it is very much to be desired that whatever different persons have discovered in this direction should be collected and published.

It was mentioned above, in passing, that even negative signs, so far as they belong to this rubric, should not be neglected. An example will show best what is meant by this: when a patient, for whose condition Pulsatilla seems suitable according to the five preceding questions, feels best while at rest in a warm room, while he feels uncomfortable in the open cool air, and also is fond of fat foods and bears them well, or offers other peculiarities which are in conflict with the characteristics of Pulsatilla, this would give an urgent cause to doubt the applicability of it to his case and to look for another remedy which also in these points corresponds with the symptoms.

I am sorry that the space for these contributions, which anyways may seem to have been already greatly exceeded, does not permit me to enter more in detail on one and another matter belonging to this division, as I may openly confess that I consider the indications obtained from this and the following question as the most important, indubitable, and therefore the decisive ones for therapeutical purposes. Even the numerous class of reflex actions, almost all of which fall into these two rubrics, do not by their internal contradictions diminish this importance, as soon as we know their mutual value, and are, therefore, enabled to estimate properly the worth of each.

7. Quando?-This last question concerns the time of the appearance, of the aggravation or the improvement of the ailments, and follows in natural order after the preceding, and is hardly of less importance in therapy than the last one.

From the time of Hippocrates and his commentators up to our times great attention has been bestowed on the periods of time in the various phases and stadia of the disease. The endeavor has been made to fix the period and continuance of the beginning, of the increase, the acme, the decrease and of the end of the disease. This would, indeed, make a useful contribution to the recognition and the characterization of the disease. But only in case it should be left altogether to itself and not be modified by medical interference. But on the other hand it can not be denied that this cannot give the least aid in the selection of the remedy, if only owing to the fact that the medicines cause disturbances in the natural course of the disease, which frequently lie altogether outside of all computation. Least of all can they be of any advantage to allopathic therapy, because it lacks all criteria from which to indicate the one or the other. I hope that I may not here hear the objection that, e. g., the periodical return of a fever points to an actual or a disguised intermittent fever and therefore indicates Quinine in its various preparations; for we are not likely to find a homoeopath who has not in his practice had to treat numerous victims of this error.

Homoeopathy intends something quite different in this question, having nothing in common with what precedes. But it is concerned with two momenta which have an immediate effect on the choice of the remedies, namely: (a), the periodical return of morbid symptoms after a longer or shorter cessation, and (b), the aggravations and alleviations depending on the time of the day. These two will require but a few words.

The periodical return of morbid phenomena often coincides with periods of time which carry with them particular occasional causes. Among these are to be numbered the menstrual ailments, as well as those which ate conditioned by the seasons, the weather, etc. Where such definite secondary causes cannot be discovered, and where as is mostly the case, the attacks are not closely bound to any sharply defined periods, they have no therapeutic value for homoeopaths as they lack the quality of a useful indication.

But of the greater importance are the aggravations and alleviations at particular times of the day, and this with respect to those which refer to single symptoms as well as those that refer to the general health. In this respect Homoeopathy possesses a great and valuable treasury of well prove experiences which are being more and more enlarged by careful observations. For there is hardly any disease, from the malignant internal fevers down to local ailments, in which during the different times of the day there does not manifest itself a more or less decided and distinct aggravation or alleviation. Now since homoeopaths have learned these peculiarities also in the various medicines during their provings on healthy persons, they are enable to make extensive and blessed use of this peculiarity in their therapeutics, and they are obliged to do this in order that they may satisfy the rule Similia similibus also in this respect.

To demonstrate the preceding with some special facts, I will only adduce here the importance which the time of the day has on coughs with respect to the expectoration, as well with respect to the greater ease with which it is discharged, as also the consistence and the taste. Something similar we know about the stools, and although most of the remedies have diarrhoea among their indications, we so far know only of two (Conium and Kali carb.) where this takes place only by day and not by night.

With respect to the ailments which have a typical return, independent of other causes, we have a considerable series of remedies corresponding to this, without on that account excluding others, when they are indubitably indicated by their symptoms. Only in cases where this return is sharply and definitely pronounced, as for example in the evening from 4 to 8 o'clock (Helleborus and Lycopodium), or exactly at the same hour (Antimon. crud, Ignatia and Sabadilla), we should give it a special importance and only be careful that there may be no contra-indications.

I conclude these contributions, which I have only hastily sketched down, with the hope that I may have succeeded in putting into the true light the difference between Allopathy and Homoeopathy and to incite my colleagues on their part to treat these important themes more at length, even if this be done only with respect to some one of the questions indicated at a time.

On the Comparative Value of Symptoms in the Selection of the Remedy
R Gibson Miller
paper read before the Section of Medicine and Pathology of the British Homeopathic Society, December 1, 1910; and published in the British Homeopathic Journal 1911, vol.1, nos.2 & 3.

By Robert Gibson Miller, M.B.

Mr. President And Gentleman, - I have chosen as the subject of my remarks to-night the comparative value of different classes of symptoms in the selection of the remedy, for it is, I fear, a subject that has far too little attention paid to it. It is a common experience to find cases reported in our journals, presenting large and complex masses of symptoms, to which, as a whole, no remedy in the materia medica corresponds, and no reason being given why the remedy that proved curative was selected in preference to many other competing ones. We can learn little or nothing from these cases. Even when we study some of the model cases reported by masters in homoeopathic prescribing, we are often utterly at a loss to understand why the curative remedy was selected, unless we understand the rules that led them to give a preference to certain symptoms and to relegate others to a very secondary place.

Hahnemann advises us to base the selection of the remedy upon the totality of the symptoms presented by the patient, as they are the outwardly reflected image of the internal and invisible disease, and the only means by which we can truly apprehend this internal distunement of the bodily forees.

I do not at this point propose to go into the observations and arguments that led Hahnemann to advise that the choice of the remedy should depend almost entirely upon the symptoms, to the practical exclusion of pathology. If these symptoms are to be our guides, what do we include in this terms? Every deviation from perfect health experienced by the patient, or observed by others, including all disturbances of functions and sensations, all alterations in the external appearance of the patient, and also all probable causative conditions. As a rule, in acute disease there is little difficulty in determining the totality of the symptoms, for the deviation form health is usually sharp and well defined. As an acute, supervening disease never forms a complex with a chronic one - the latter being suppressed until the former has run its course - care must be taken when ascertaining the symptoms of the acute disease to exclude from consideration the symptoms of the now latent chronic disease. According to Kent, at times some symptoms of the chronic disease may persist, and be active during the acute disease. Such symptoms are peculiar, because they have not disappeared, and are often guiding in the choice of the remedy for the acute disease. But when we come to deal with chronic diseases the matter is more complicated, for we have to take into account not only the now present symptoms, which often show only a very partial picture of the disease, but must also include many former symptoms that are now active; for even in those patients that have suffered for very long periods, and from many apparently diverse troubles, there always is method and order running through all their illnesses if only we can find the clue. While, theoretically, we should consider all the symptoms experienced by the patient since his birth, excluding those due to acute disease, yet the task is a very difficult one both for patient and physician, and we can only make very cautious use of these bygone symptoms. Even if we could trust to the accuracy of the memory of our patient, or his friends, these old symptoms can only be used with the greatest care, for so many of them may have arisen from faulty environment, the abuse of drugs, or the acquisition of some other miasm, that they would not truly indicate the course and progress of the disease. This is also very often the case when no such question of old bygone symptoms is involved, and those who are guided in the selection of their remedies mainly by the symptoms are in special danger of overlooking such causes, and have to be perpetually on guard lest they fall into the error of ascribing to disease what is really due to other causes.

Dunham, in "The Science of Therapeutics," gives many instances where such mistakes have been made, and only a wide knowledge of drugs, of the habits of the people, and the special conditions under which many occupations are carried on, will enable us to avoid these errors. Such, for example, was the case of a young lady who, for a very considerable time, presented a perfect picture of the classical symptoms of sulphur, and upon whom that remedy, in all potencies, to say nothing of other remedies, failed to produce the slightest effect. It was finally discovered that she was in the habit of suing sulphur to cleanse her teeth, and upon this being stopped the symptoms at once ceased. Or, the case of a maker of crucibles for casting steel ingots, who had suffered for seven years with all the symptoms of graphites gastralgia, and for whom that remedy did no good, until it dawned upon me that I had somewhere read that plumbago was now being used for making these moulds.

When we have excluded all symptoms due to such causes, there is the vast number remaining which can only be ascribed to disease proper, and it is with these in particular I wish to deal to-night.

Theretically, we endeavour to find a remedy whose symptoms correspond exactly - both as regards character and intensity - to those experienced by the patient. This can rarely, if ever, be done, and in chronic cases, at any rate, we have, as a rule, to make a selection from amongst the mass of symptoms, and to base the selection of the remedy mainly upon these. If it were necessary always to select a remedy that corresponded perfectly to every one of the symptoms, our already vast materia medica would be utterly inadequate, and we should require at least 10.000 more fully proven drugs. Who would care to undertake the task of searching for a similimum in such a labyrinth?It is quite bad enough as matters are at present, but we must think of our remedies as complex tools, capable of doing many very different pieces of work, which to the uninitiated would seem to require many diversely shaped ones. Who have made finer cures than the old masters in homoeopathy, with their very limited number of fully proven remedies?But they knew each one through and through, in a way that few of us do nowadays, and in their hands a comparatively few medicines were in the majority of cases sufficient for all their work. It was because they were able to comprehend not only the spirit of each remedy, but also those symptoms that characterized the patient. Following in their footsteps, we must also endeavour to learn to grade the symptoms according to their respective values, and not to act as mere symptom-coverers - an opprobrious name that has at times been only too well deserved.

In every case of disease there are always two classes of symptoms: first, those that pertain to the disease, that is, the common or pathognomonic ones; and, second, those that pertain to the patient; and in all advanced cases a third class that pertains to the ultimates or results of disease. To attempt to select the remedy in accordance with the first and last of these alone is simply to court failure in the majority of cases, for so many remedies will be found to correspond more or less closely to the first, at any rate, that, unless we have some other means of individualizing, we shall be quite unable - except by good luck - to select the correct remedy. Still less can we hope to find a sure basis if we depend upon the pathological condition, for very few drugs have had their provings pushed forward enough to elicit such effects, and consequently we would have to depend mainly upon such cases of accidental poisonings as happened to be available.

Dunham, writing upon this subject, points out that the drugs varying according to the size of the dose may produce three sets of symptoms, viz.: (1) The chemical; (2) the mechanical or revolutionary, consisting chiefly in violent efforts on the part of the organism to eject from its cavities the offending substance; and (3) the dynamic, contingent on the vitality, or resulting from the relation of the peculiar properties of the drug to the susceptibility of the living healthy organism.

He still further subdivides the dynamic ones into the generic - or those common to all members of a certain class of drugs. As an example of this, arsenic in certain doses produces vomiting, diarrhoea, cold perspiration, cramps in the limbs; but cuprum, veratrum, antimonium tartaricum, which belong to the same group, produce identical symptoms.
The second section of the dynamic symptoms are the specific ones, or those that are peculiar to one remedy and severe to distinguish it from its relatives.

In the vast majority of poisonings little else is produced than the first two classes - viz., the chemical and mechanical - and the symptoms obtained therefrom are of little value in the great majority of cases we are called upon to treat; but our main reliance must ever be placed upon the symptoms that signify the patient, and Hahnemann directs that we should be particularly and almost exclusively attentive to those symptoms that are peculiar or characteristic of the patient, and not to those that are common to the disease. Kent, after many years' experience, states that he regards this advice of Hahnemann's to be the strongest thing that the master ever wrote.

In acute disease there is not much difficulty, as a rule, in recognizing the symptoms that are peculiar to the patient, for the symptoms usually appear in an ordinary manner, and the common or pathognomonic ones are well known; but when we come to deal with chronic diseases our difficulties are greatly increased, for they are often so complex in nature that it is not always easy to separate the symptoms that are peculiar to the patient from those that are common to the disease. In many old-standing chronic cases, especially those that have been long under allopathic treatment, these peculiar and characteristic symptoms have at times so completely disappeared - or have been so utterly forgotten - that our difficulties are greatly increased; nay, it is even the case at times that the characteristic symptoms may never have existed, except in the patient's ancestors, and under these circumstances cure is practically impossible. It is as if, during the exploration of some old city, a coin was discovered which, if we could determine the year of the king during whose reign it was issued, we would be in a position to fix an important date. If the coin were well preserved, any skilled numismatist would promptly furnish us with all the information we desired; but if it were greatly worn or eroded, while he might from the shape or composition of the metal be able to determine the dynasty under which it had been issued, it would be utterly out of his power to state the individual king, to say nothing of the year of his reign.

In this connection let us take a few examples of the symptoms that are peculiar to the patient as distinguished from those that are common to the disease.

The common or pathognomonic symptoms of dysentery are bloody, mucous stools, pain, and tenesmus. From these alone we can determine the group of remedies that corresponds in general to this disease, and in J.B. Bell's classical monograph on this subject over fifty remedies are mentioned; yet from these alone it would be impossible to discover the individual remedy for the case under treatment. If, however, the patient has much thirst, and every time he drinks he shivers, and each drink is followed by a loose stool, then these symptoms, being unusual in the disease, would consequently be peculiar to the patient and guiding to capsicum as the remedy.

Dyspnoea, oedema, and palpitation of the heart, albuminuria, are the common symptoms of many kidney troubles, and from them alone we cannot determine the curative remedy; but if we find in addition there is a strong craving for fat, intensely strong-smelling urine, and a sensation as if the urine were cold when passed, then these would be peculiar to the patient, and point to nitric acid as the remedy.

Or let us turn to characteristic modalities. In a case of spasmodic asthma an aggravation from lying down is so common as to be valueless in the individualizing of the remedy; but if we find there is great relief from lying down, as in psorinum, or from assuming the knee-elbow position, as in medorrhinum, then -these being peculiar and characteristic - will be invaluable.

In hysteria we have an illustration of the danger of prescribing for the symptoms that are common to the disease, and hence not peculiar to the patient. It seems the most natural thing to gather up all the incongruous and peculiar symptoms that characterize this disease, and to prescribe for them; but when we realize that this incongruity is the very essence of the disease - in other words, is pathognomonic of it - we then perceive that we have been prescribing for the symptoms that represent the disease and not for those that characterize the patient. In such cases the true guides to cure, if discoverable, are to be found in the changes of desire, the aversions, the loves and the hates, and these are particularly difficult to find, for the hysterical patient conceals her real hates and loves and relates what is not true.

In the foregoing, stress has been laid on the supreme importance of paying the greatest attention to the symptoms that are peculiar to the patient, but it would be foolish to ignore the symptoms that signify the disease. They must indeed be taken into consideration, but subsequent to, and of much less value than, those that are predicated of the patient. In a very large number of cases no one remedy corresponds to all the peculiar symptoms, but three or four seem to have equal numbers of them, and of approximately the same value. In such a state of affairs the remedy that has also the common symptoms best marked must prevail. It must ever be kept in mind that there must be a general correspondence between all the symptoms of the patient and those of the remedy, and that however helpful the peculiar symptoms may be in calling attention to certain remedies, yet they are not the sole guides; for, after all, it is the totality of the symptoms that determines the choice.

It is true that at times a brilliant cure has been made by a remedy that corresponded only to those symptoms that were peculiar to the patient and was not known to possess any strong resemblance to the common symptoms of the disease; but even in such a case it is almost absolutely certain that further provings will show that the remedy has the common symptoms also. But when using these peculiar and characteristic symptoms as the main guides in the selection of the remedy, it is important to bear in mind that they must be equally well marked both in patient and in remedy; in other words, no matter how peculiar and outstanding a symptom may be, either in the patient or in the remedy, unless it be of equal grade in both we must pay little heed to it. For example, if a patient experiences occasional and slight heat in the soles of the feet at night in bed, this symptom would not be of much importance in selecting sulphur as the remedy, because in that drug this symptom appears in such a vigorous and outstanding way that the provers declare that their feet burn at night as if they had been on fire. Or, take a case of rheumatism, markedly aggravated in dry weather and better in damp; in such a case the selection of phosphorus as the remedy could not be based upon this modality, for, while phosphorus has it, it is only in the lowest degree. Even in a case with, let us say, ten peculiar and characteristic symptoms, of which one remedy has eight, but of a very low rank, while another has only five, but of high rank and corresponding to the rank of the symptoms as experienced by the patient, in such a case it is very improbable that the first medicine will prove to be the curative one, and the second is much more likely to be so.

It is this question of the rank of symptoms that is the great objection to the numerical method of selecting the remedy. It seems to have fascinated some minds, for, while it is laborious in the highest degree, it seems to promise certain and exact results; but medicine - even homoeopathic - is not yet an exact science, and even when we have perfect our armamentarium it is extremely improbable it ever will be. Consequently all such mechanical methods are to end in failure, for quality will ever be of infinitely more importance than mere quantity.

In opposition to this numerical method, some physicians have gone to the other extreme, and have been content to be guided in the selection of the remedy by one or two peculiar and outstanding symptoms, practically ignoring all the others, because they have overlooked the fact that - unless there be a general correspondence between the symptoms of the patient and those of the remedy - it is not reasonable to expect a cure. This so-called "keynote" system of prescribing is very attractive, as it seems so easy, and saves all the laborious comparison of competing drugs that is involved in the numerical method, and also because by means of it many brilliant cures have been made; but it is from its very nature a wrong method, and in the great majority of cases is doomed to failure, because it ranks one or two symptoms very high and practically ignores the others.

Having discussed the difference in value, so far as the selection of the remedy is concerned, between the symptoms that signify the patient, and those that signify the disease, we would turn to the other great division of symptoms - viz., the generals and the particulars.

The general symptoms are those that affect the patient as a whole and, because of this very fact, are naturally of higher value than the particulars, which only affect a given organ. What the patient predicates of himself is usually general, as when he says: "I am thirsty," "I am sleepy" - thereby indicating that his whole being is so affected, and not merely one or two particular organs. So much higher may a general symptom rank that if it be a strong and well-marked one it can overrule any number of even strong particulars. Let us take a case of gastric catarrh, with semi-lateral headache, roaring in the ears, greasy taste, aversion to fat and butter which aggravate greatly, fulness and pressure of the stomach after eating, flatulence, chilliness, vomiting of the food. So far pulsatilla and cyclamen compete equally; but if we have in addition diarrhoea only at night, nausea from hot but not from cold drink, palpitation when lying on the left side, then the balance would turn towards puls. But, if we find that the patient has the greatest aversion to the cold open air, and is always aggravated by the least cold, then this one strong, general symptom would overrule the marked particulars that puls. alone has, and declare plainly that puls. could not be the remedy, not withstanding the fact that it alone had the three strong particulars. But, on the other hand, a number of strong particulars must not be neglected on account of one or even more weak generals. Let us take another case of gastric catarrh, with severe pain over the right eye, bitter eructations, pain in the stomach - worse from cold and better from hot drinks, one cold and one hot foot. So far lycopodium and chelidonium correspond about equally to the case; but if there is in addition a constant pain under the inferior angle of the right scapula, a yellow-coated tongue with indented margins, and clay-coloured stools, no one would hesitate to give the preference to chel. But if, on still farther examining the case, we find that the patient always feels worse all over - though not in a very marked degree - after eating, also that he feels better moving about than when sitting, these generals would be against chel. and in favour of lyc., but they are only weak and not strongly-marked generals, and consequently should not be allowed to overrule the strong particulars that indicate chel.

Amongst general symptoms are to be included the mental state, which, reflecting the condition of the inmost part of man, is bound to be of the utmost importance, and - as Hahnemman so strongly insists - must always, if well marked, take the highest rank in the selection of the remedy. These symptoms are naturally the most difficult to elicit, for people, as a rule, shrink from revealing their inmost thoughts and motives, their hatreds and yearnings, their evil tendencies, and their delusions, and c., and it requires the greatest tact and a full knowledge of human nature before we can hope to win the confidence of our patient and so understand his deepest thoughts.

Of course, we are all aware of the value of the more common mental states, and these influence us, consciously or unconsciously, in the choice of our remedies. We all recognize, for example, the fastidiousness of arsenic, "the gentleman with the gold-headed cane", the irritability of bryonia, chamomilla, and nux-vomica, the gentle, yielding lachrymose puls., the ever-varying moods of ignatia, the hauteur of platina, the lack of self-confidence of silicea; but there are many less apparent conditions, which have to be deeply probed for, though when found are invaluable. Such is the presentiment of death of apis., the lack of natural affection of sepia and phosphorus, the strange impulses to kill those dearest to them of mercurius and nux., the suicidal promptings of china. - not open and obvious like those of natrum.- sulph, but hidden, shamefaced, and mixed with fear. These latter, in the early stages, few patients care to allude to, yet their value to us is inexpressible. Even amongst the mental symptoms there are various ranks, and consequently they vary greatly in their value. All symptoms of the will and affections, including desires and aversions, are the most important, as they relate to the inmost in man. Of less value are those relating to the intellect, while those of memory are to be ranked lowest of this group.

Amongst our other generals are the effects of sleep and dreams, such as the aggravation after sleep of lachesis and sulphur, the aggravation from loss of sleep of cocculus, and the great relief from sleep of phos. and sepia.

Again, how often has the study of the dreams revealed the hidden key to the remedy!For in sleep man is off his guard and his subconscious self can assert itself, and under such circumstances the veil is often lifted a little, so that we are able to apprehend in some degree the deep and hidden mysteries of that disordered life we call disease. Of course, such dreams must be regular and persistent to make them of value, and great care must be taken to eliminate the effect of all external influence.

I recall a case of aortic aneurysm, giving rise to much pain and many other pressure symptoms. The patient had not the slightest idea what his disease was, yet he dreamed night after night of pools and seas of blood, and so distressing was this that sleep was one wild nightmare. The other symptoms were valueless so far as the selection of the remedy was concerned; but, taking the dreams as my guide, I gave solanum tuberosum aegrotans, which completely removed the dreams, and so releived the pains that he went down to his grave in peace.

But one grand general - viz., the effect of different temperatures upon the patient as a whole - is often of the greatest service in calling our attention to special groups of remedies and excluding other groups, so that the labour of selection is thereby greatly lessened. It is by no means always an easy general to use - in fact, I am more careful in questioning patients with regard to this than with regard to anything else. How often, in response to our question as to how they are affected by heat and cold, they will reply: "Oh! I can't stand heat!"But on inquiry you discover that they hate cold, but cannot stand a close, stuffy place - or perhaps they may say so because they are worse in summer - which is not necessarily the same as aggravation from heat, for summer, in this climate at any rate, means more than heat.

Another frequent source of error is the tendency to mistake any undue readiness to perspire as an indication that heat aggravates. On the other hand, many confuse an undue tendency to catch cold with aggravation from cold; but when we have eliminated these errors and find the patient markedly aggravated as a whole by heat or cold, we are greatly aided in our choice of remedy.

This question of temperature is often very valuable when the body as a whole is markedly affected by one temperature, and some special organ by the opposite; for example, we find a general shrinking from cold under ammonium carb. and carbo vegetabilis, yet their respiration is releived by cold air. Cycl. has the same aggravation, except with regard to its headache and catarrh; magnesia phos., except for its cough and some headaches; china., except for its stomach symptoms; or phosphorus, except for its headache and stomach symptoms. Or, as a patient suffering from headache and general rheumatism of the body remarked, if he could only have his body in a bath and his head in an ice-tub, he would be supremely happy. Conversely, the general aggravation of heat of lycop., except for its stomach and some rheumatic symptoms; or secale, except for some headaches and neuralgias, illustrates the value of this general. The exquisite sensitiveness of the mercurial condition to both extremes of temperature, only finding comfort at a medium temperature, is doubtless known to all of us, and must often have served us in good stead when the other mercurial symptoms were absent.

There is little need to call attention to the general effect of the various weathers, but many a valuable hint is obtainable from them, not only in a positive but also in a negative way. In many conditions such as rheumatism, where we expect as a rule to have an aggravation from weather changes, the absence of such an aggravation becomes peculiar and characteristic, and enables us to throw out of consideration whole groups of remedies. For example, where change of weather does not influence a rheumatism, we can safely exclude dulcamra, nux. Moschata, phos., ranunculus bulbosus, rhododendron, rhus, sil., tuberc.; or, if wet weather does not affect, we can eliminate calc., merc., natrum carb., natr. Sulph. and ruta. Such negative conditions are not sufficiently made use of -for, while the mere absence of particular symptoms that strongly characterize a remedy cannot be relied on as excluding that medicine, yet when strong generals that characterize the remedy are absent we can, with a fair degree of confidence, exclude that remedy, simply because each drug is a unity, and such characteristic generals are their very web and woof.

Amongst the generals must be included the influence of the various positions, such as the great aggravation of most symptoms by standing of sulphur and valerian, the aggravation of lying on the right side of merc., the peculiar aggravation of phos. when lying on the left, yet with aggravation of the head symptoms when lying on the right. To be of any value as a general symptom, the patient as a whole must be markedly influenced by these, and if only one organ is so affected they can only take low rank, being particulars. The tendency of disease to affect particular parts of the body is often well marked and may be a general of considerable value. Such, for example, is the semi-lateral nature of many illnesses that require alumina, kali carb, phos. acid; or, if the right side is mainly affected, apis, bell. And lyc.; or, if it be left-sided, argentum nit., lach. And phos. Again, how often has the oblique appearance of symptoms led to the choice of agaricus or asclepias tuberosa as the remedy, and even more frequently the appearance of symptoms on alternate sides has led to a cure by lac. caninum.

But let us consider how profoundly time influences our diseases, and how common it is to find the symptoms aggravated regularly at particular hours. Here, indeed, is a valuable and great general whose proper use will enable us many a time to decide which is the true remedy. It may be the morning aggravation of chel., natr. mur. or nux, or the evening one of bry., bell., or puls. - perhaps coupled in the latter remedy with the exceptional aggravation of the stomach symptoms in the morning. Or if we find the cases characterized by periodic return of the symptoms - whether it be daily, as in aranea, or on alternate days, as in chininum sulph. or lyc., or every two weeks, as in ars. or lach. - we here, again, have a general of the greatest value. But it is worthy of note that the less the disease that happens to be under consideration is itself normally characterized by periodicity, the more does this periodic return of symptoms indicate special remedies which have this characteristic in a marked degree. This is well exemplified in the case of ague, which is normally characterized by the periodic return of the paroxysm at fixed intervals, due as we are all now aware to the segmentation of each variety of the parasite at definite times; but the mere fact that this periodicity is common to the disease, and hence not peculiar to the individual patient, has led the most successful prescribers for this disease to base their prescription on other factors that are present rather than on the periodicity, though of course by no means excluding it from consideration.

The various cravings for, and aversions to, various substances are as a rule general symptoms, for they depend upon some deep need in the body as a whole, and, if outstanding and definite, must always take high rank. It is easy to understand many of these, such as the aversion to fat of puls., for it also disagrees, or perhaps also the craving for salt of natr. m.; but the reason for many others is utterly beyond our ken at present. For example, an intense craving for pork in a case of rheumatoid arthritis, which presented no symptoms beyond those common to this disease, put me upon the track of crotalus and led to the cure of the case, though the patient had been bedridden for over six months.

One more of these general symptoms I would allude to - viz., the influence of eating. Of course, so far as it affects the stomach directly, it is only a particular, and we do not as a rule find it to be of much help in the selection of the remedy; but when the man as a whole is thereby influenced, and states that he feels better, or worse, all over, by eating, then it becomes a general of high rank. Especially is this the case when symptoms in parts far distant from the stomach are so influenced, such as the aggravation of the pains in the limbs of indigo, or the amelioration of natrum carb., or kali. bichromicum. The effect of special foods is at times general, affecting the man as a whole; but as a rule they only affect the digestive organs, and in that case are merely particulars, it is through forgetting this distinction that all of us at times rank their influence too high, and are disappointed when remedies selected more or less in accordance with them fail to cure the case.

The special senses are often so closely related to the whole man that many of their symptoms are general. For example, when the patient states that the smell of food sickens him, this is a general; but if he only experiences a subjective, offensive smell in the nose, this would merely relate to the one organ and consequently would be only a particular, and of comparatively low rank.

General symptoms are not always recognized at once to be so, but on examining a series of particular organs we find that a symptom or modality runs so strongly through them all that it may be predicated of the patient himself. Here we have a general made up of a series of particulars. For example, if we take a case in which, wherever the pain happens to be felt, whether in head, or chest, or limbs, there is relief from lying on the pain-ful side, this becomes so common as to characterize the patient as a whole, or if we find that in all organs and tissues affected the pains are boring from within out-wards, as is found under asafoetida, then this symptom can be raised from being an ordinary particular to a general of low rank; or, if the pains, wherever they may chance to be located, are always associated with numbness, as in cases requiring plat. or cham., then this may also be regarded as a general, though, of course, of a comparatively low rank. But there is a real danger of overdoing this dependence on generals in the selection of the remedy, and a glaring example of this is seen in Boenninghausen's "Pocket Book."In this he overdid the generals, for he generalized many rubrics that were only particulars. For example, writing is a rubric of particulars, and in no instance is the patient himself worse from writing; but in some cases it is the eyes, from looking; in others the hand, from exertion; or in others the back from sitting bent. If we are searching for the remedy for a headache aggravated by writing, a rubric composed after this manner would be useless. But the rubric aggravation from motion is on quite a different footing, for, if we have a case requiring, say, bryonia, we find so many particulars aggravated by motion that it appears that the very patient himself is worse from motion, and consequently in this case motion is a general.

But there is one other general - the greatest of them all - which I must not omit, for it is created by the blending of all the generals and particulars into one harmonious whole. For lack of a better word we speak of, let us say, the "sepia" constitution, meaning thereby that special diseased condition of mind and body for which that remedy has so often proved itself curative, that we come to look upon it almost as an entity. At times it is plainly discernible by all, and capable of being described in words, such as the leuco-phlegmatic constitution of calc., the tall, thin, narrow-chested one of phosphorus, or "the lean, stooping, regged philosopher," as Hering called the sulphur patient; but far oftener it is something much more subtle, such as that of arg. nit., with its fears and anxieties and hidden, irrational motives for all it does. To very few of us is it given to penetrate into these secrets and to understand that almost indefinite something which often lies behind the mere symptoms, modifying and characterizing them all, and so becoming the governing element in the whole case. he masters in our art are those who have had the power to understand this great general, and we stand amazed at their skill in penetrating right into the heart of the most complex cases and evolving order and consequent cure out of seeming chaos.
But while the general symptoms are of the highest rank as a rule, simply because they relate to the man as a whole, yet we must on no account undervalue the particulars, and, in fact, many cases seem to be composed only of particulars, and have few or no generals of any importance. In such a case, where no one remedy corresponds to the case as a whole, we must base our selection upon those particulars that are most characteristic and peculiar, for it must be borne in mind that both generals and particulars may either be characteristic and peculiar, such as, say, a vague aggravation from cold and damp, an indefinite depression of spirits, or an irritability without any qualifying conditions, or not of much intensity, then the characteristic particulars must lead.

There is one matter in connection with prescribing the particulars that may give rise to a difficulty in selecting the remedy. In alternating complaints, such as of eye and stomach, we may find that, say, euphrasia is more sharply related to the eye symptoms than the deep-acting remedy that best fits the whole case, and that puls. corresponds to the stomach ones better than the deep-acting one does; yet we must ever remember that there is one deep-acting remedy that is more similar to the whole patient than these special remedies, because it corresponds better to the general symptoms. I have previously quoted Hahnemann and Kent with regard to the importance of paying heed mainly to the symptoms that are peculiar, but this is only one aspect of the truth, for the highest rank of all belongs to those symptoms that not only are peculiar but are also general. A very good example of this is a case with very high fever, let us say, of 105°, yet without the least thirst. Here we have without doubt a very peculiar symptom, for the absence of thirst with such a temperature is a most unusual thing, and this thirstlessness is a general, for it is the whole man that is thirstless. Of course, if we had only temperature of, say, 101° this symptom would not be specially characteristic, and consequently of comparatively low rank.

But before we pass from the consideration of particulars, I would call attention to the fact that common particulars may in certain circumstances assume a comparatively high rank. When two common symptoms which, if they appeared alone, would be of little importance, yet when associated at once become of considerable value - the coryza with polyuria of calc. is a good example of this. In this connection it is worth noting that a remedy can cure groups of symptoms, even where they did not appear as concomitants in the proving; and this is even the case when the components of the group were observed by quite separate provers. Kent, in his great repertory, has left out the majority of concomitants, and has only retained those few that abundant clinical experience has demonstrated to be frequently associated.

Other examples of this raising of the rank of common symptoms are where the common symptom is associated with a peculiar modality, such as the chilliness of puls., worse near the fire, or a special localization may emphasize a quite common symptom, such as the aching pain at the inferior angle of the right scapula of chel., or finally, the mere intensity of a common symptom such as the overwhelming sleepiness of nux. m. gives it a value that otherwise it would not possess.

Ranking close behind, or even at times taking precedence of the peculiar and general symptoms of a case. These symptoms to be of any real importance, must of course be outstanding and definite, and if so they are always of the first important in the choice of the remedy. So much is this the case that where no remedy can be discovered that corresponds to the case as a whole, it is at times necessary to be guided almost exclusively by them. When so prescribing it is not to be expected that the remedy will influence the case very deeply, or cause any markedly curative results; but it will modify the symptoms and open up the way for other remedies.

The foregoing refers to the symptoms that have been the last to appear, before homoeopathic treatment was instituted; but even when the appropriate homoeopathic remedy has been given and modified the case, and new symptoms have appeared, the same law holds good. Hering, however, cautions us to note that these new symptoms will generally be found amongst the symptoms of the last given remedy, but only of low rank and not guiding in the choice of the second remedy. These new or last-appearing symptoms may be old ones which had disappeared many years ago and have now returned through the action of the first remedy. Accordingly, before using them as guides in the selection of the second remedy, we must have patience and make sure that their return is permanent, and not merely a temporary reappearance while on the way to final extinction.

Another very important rule of Hering's, the observance of which will often prevent many mistakes and save much study, is - that the second remedy must bear a complementary relation to the first, and hence the last remedy that has ACTED, either homoeopathic or allopathic, forms one of the most important guides in the selection of the second. The knowledge of this rule is a great time and trouble saver, for in the majority of cases a reference to the tables of related medicine would enable us to select with ease the remedy that is to follow.

Towards the beginning of this lecture, I made passing mention of the value of old symptoms which had long ago disappeared, pointing out that for many reasons they were often of very uncertain value; but while it is seldom advisable to give them any very high rank in the selection of the remedy, yet they are of the utmost value in confirming the choice of remedy, or in differentiating between competing remedies selected in accordance with the now active symptoms. As an example of this, Kent mentions the case of a man who had long suffered from neuritis of the limbs, and whose present symptoms did not point decisively to any one of five or six competing remedies. It was discovered that in infancy he had been affected by eczema capitis, very similar to that caused by mezereum, one of the competing remedies, and on examination of the pains in the limbs produced by that remedy it was found that they closely resembled those now experienced by the patient. This remedy proved curative and reproduced the original eruption.

Dunham's well-known cure of deafness by the same remedy is another example of this use of old symptoms.

In the cases just mentioned, the diseases cured were not characterized by any marked pathological changes, but even in cases where these changes have become quite definite it is useless in the majority of cases to prescribe upon the symptoms that now present themselves. We must here also seek to discover the primitive symptoms that the patient experienced long before any definite pathological change took place, and though the task, as I stated, is difficult, yet we can often obtain enough data upon which to base our prescription.

I need hardly say that no one, even when he has been able to obtain the fullest and most accurate description of these old symptoms, expects to be able to cure diseases that have advanced so far as to lead to practical destruction of organs and tissues. It is only the beginnings of such processes that are amenable to medicines, so far as positive cure is concerned. Even in comparatively recent and uncomplicated cases of chronic disease

from Stuart Close, The Genius of Homeopathy, chapter XI, Symptomatology:

Totality of the Symptoms.-"Totality of the Symptoms" is an expression peculiar to homoeopathy which requires special attention. It is highly important to understand exactly what it means and involves, because the totality of the symptoms is the true and only basis for every homoeopathic prescription.

Hahnemann (Org., Par. 6) says:-"The ensemble or totality of these available signs or symptoms, represents in its full extent the disease itself; that is, they constitute the true and only form of which the mind is capable of conceiving." The expression has a two-fold meaning. It represents the disease and it also represents the remedy, as language represents thought.

1. The Totality of the Symptoms means, first, the totality of each individual symptom.
A single symptom is more than a single fact; it is a fact, with its history, its origin, its location, its progress or direction, and its conditions.
...
2. The Totality of the Symptoms means all the symptoms of the case which are capable of being logically combined into a harmonious and consistent whole, having form, coherency and individuality. Technically, the totality is more (and may be less) than the mere numerical totality of the symptoms. It includes the "concomitance" or form in which symptoms are grouped.
Hahnemann (Org., Par. 7) calls the totality, "this image (or picture) reflecting outwardly the internal essence of the disease, i. e., of the suffering life force."

The word used is significant and suggestive. A picture is a work of art, which appeals to our esthetic sense as well as to our intellect. Its elements are form, color, light, shade, tone, harmony, and perspective. As a composition it expresses an idea, it may be of sentiment or fact; but it does this by the harmonious combination of its elements into a whole-a totality. In a well balanced picture each element is given its full value and its right relation to all the other elements.

So it is in the symptom picture which is technically called the Totality. The totality must express an idea. When studying a case from the diagnostic standpoint, for example, certain symptoms are selected as having a known pathological relation to each other, and upon these is based the diagnosis. The classification of symptoms thus made represents the diagnostic idea. Just so the "totality of the symptoms," considered as the basis of a homoeopathic prescription, represents the therapeutic idea. These two groups may be and often are different. The elements which go to make up the therapeutic totality must be as definitely and logically related and consistent as are the elements which go to make up the diagnostic totality.

The "totality" is not, therefore, a mere haphazard, fortuitous jumble of symptoms thrown together without rhyme or reason, any more than a similar haphazard collection of pathogenetic symptoms in a proving constitutes Materia Medica.

The Totality means the sum of the aggregate of the symptoms: Not merely the numerical aggregate-the entire number of the symptoms as particulars or single symptoms-but their sum total, their organic whole as an individuality. As a machine set up complete and in perfect working order is more than a numerical aggregate of its single dissociated parts, so the Totality is more than the mere aggregate of its constituent symptoms. It is the numerical aggregate plus the idea or plan which unites them in a special manner to give them its characteristic form. As the parts of a machine cannot be thrown together in any haphazard manner, but each part must be fitted to each other part in a certain definite relation according to the preconceived plan or design-"assembled," as the mechanics say-so the symptoms of a case must be "assembled" in such a manner that they constitute an identity, an individuality, which may be seen and recognized as we recognize the personality of a friend.

...

The true Totality, therefore, is a Work of Art, formed by the mind of the artist from the crude materials at his command, which are derived from a proving or from a clinical examination of the patient.

It is important that these points should be understood, because, otherwise, there is liability to err in several directions.

1. Error may arise in placing too much emphasis upon a single symptom, or perhaps actually prescribing on a single symptom as many thoughtlessly do.

2. Error may arise in attempting to fit a remedy to a mass of indefinite, unrelated or fragmentary symptoms by a mechanical comparison of symptom with symptom, by which the prescriber becomes a mere superficial "symptom coverer."

3. Failing in both these ways the prescriber may fall to the level of the so-called "pathological prescribers," who empirically base their treatment upon a theoretical pathological diagnosis and end in prescribing unnecessary and injurious sedatives, stimulants, combination tablets, and other crude mixtures of common practice.

The physician who knows what a symptom is from the homoeopathic standpoint and how to elicit it; who knows what the totality of the symptoms means and how to construct it, and who has the intelligence, the patience and the honesty to study his case until he finds it will not be guilty of such practice.