New approach to Casetaking

The Old Approach
In “The System of Homoeopathy” I explained that an ideal case had four steps, which could be likened to four spheres each within the other and with a common centre. Each successive sphere was therefore one step closer towards the central state of the patient. With each step one obtained finer and more specific data till one finally reached the central point where the deepest mental and physical sensations, the miasm and the kingdom all converge to a sharp focus. This is the patient’s delusion.
With this approach, one lets the patient describe his problem: physical or emotional, and while the patient was allowed to speak the physician’s focus would be on picking up peculiar symptoms and on getting to the bottom of the Mental State. The emphasis therefore was mainly on understanding emotional phenomena. Often this proved a difficult and confusing task, especially when one got lost in the story, rather than understanding the patient’s feelings.

The concept of Vital Sensation
As I made progress with my study of the plant families I realized that the concept of the common sensation (refer Introduction) was not just confined to the plant kingdom. In the case of disease and remedy states from all kingdoms one can perceive this common sensation both, as a physical sensation as well as on the emotional sphere. With the old approach there had been a lot of emphasis on the mind state and mental symptoms. Having discovered the concept of the common sensation however I realized that the central state was not merely an emotion or feeling, but was this common sensation that connected the mind and the body. I call this common sensation the Vital Sensation as it is something deeper to the mind and body.
What is the level is deeper to the mind and body? That is what I call the Vital Level. I used to think that the centre of the Mental State was the deepest point that we could reach, but I realized that the Vital Level is a step deeper than the Mental State. As for example when a person says that he feels jealous or suspicious or expresses something mental and emotional then we might ask him for the experience behind that. He may feel he is being attacked and is frightened. In this way an emotional situation is perceived behind the mental symptom, which is good enough, but if you want to take it one step further you ask him how he experiences the attack. At this point you come to the intersection or cross point where the mind and body meet. Here they may have the feeling that something is breaking or burning or twisting. This is the common point between body and mind (The Vital Sensation) and here he will describe his emotional symptoms and physical symptoms in the same terms. This is a very deep level and if you reach this point there is a much better chance of success.
With this new understanding I saw the patient’s delusion not only confined to the mind but also expressed on the physical sphere. In fact I could see that the Mental State is merely one expression of the Vital Sensation. And when I started looking for this common sensation or delusion or vital symptom in the physical sphere I realized that it was apparent right at the outset, with the chief complaint itself.

Importance of the Chief Complaint
I started concentrating on the various details of the chief compliant and I realized that here one always came across an element which had more than just a physical connotation and spontaneously connected to the mind state. Thus one could get directly into the center, to the Vital Sensation, from the chief complaint itself. In many cases when the patient expressed a physical sensation in relation to the chief complaint one could see the same sensation emerge in the emotional sphere. In other cases the effect of the chief complaint on the patient’s life was an expression of this Vital Sensation. In yet other cases it was the modality of the chief complaint. With more cases it became definite that the chief complaint itself gives direct access into the central state of the patient. So now I was starting with the core of the case right from the outset and then examining other, more superficial areas, which are more like expressions of this core state. This was completely opposite to the earlier approach where I would start with broad and seemingly disconnected data and then go step by step into the center.
With the old approach if we did reach the connecting symptom it was at the end of the case. The chief complaint itself was often neglected with the belief that we are not treating the pathology but the person having it. As a result one was impatient always to get over with the chief complaint and get to the nature or the mind state of the person. Further, many times we would simply get caught up in the mental phenomena without actually touching the sensation. In contrast, with the new approach one reached the common sensation by sticking to the chief complaint itself. And having unearthed this common sensation at the outset one could see that the whole case and expressions as branching out from this common core sensation.
As I used this approach more and more I began to understand that the chief complaint represents the crystallization of the Vital Sensation. Hence it is the best place to locate the Vital Sensation. It is the fountainhead where all the vital phenomena are expressed in their raw form. It certainly cannot be neglected; rather it is the main support around which the case revolves. It forms the foundation of the case. I learnt then to stick to the chief complaint and examine it in its depth and this has revolutionized my case taking and yielded far better results in my practice.

Sensation and reaction
As I started looking for emotional and physical expressions of the sensation in remedies and patients, I could see sometimes that the sensation would be expressed directly. At other times it was expressed as a reaction that was always equal and opposite to the sensation (and this I made the first law that has been explained above). In some other cases it could be seen as compensation.
I could also see that reactions were of two types, active and passive and they were both equal and opposite to the sensation (Refer Introduction). For example if the sensation is ‘caught up’ or ‘stuck’ the active reaction will be to want to move, the passive reaction will be being immobile or unable to move, while the compensation will be a person who is always on the move.
The modalities essentially speak the same language as the sensation. For example, if the sensation is of being caught the modality is better from movement. If the sensation is of being tightened the modality is better by loosening. In this way the modalities will also confirm the sensation.
While taking a case I would pay attention to the sensation expressed in the chief complaint and later in the dreams, interests and hobbies, fears etc. The sensations were of various types. In some cases throughout one sees nothing more than a particular sensation (for example, tied up); this means that the key issue for this patient is sensitivity (to being tied up) and such a person requires a plant remedy. If this sensation has to do with survival then the remedy required will be from the animal kingdom. If it is linked with structure a mineral remedy will be required. In this way the type of sensation gives an indication of the kingdom

The Miasm
Often I am asked the question:
In a given case if there is a feeling of ‘being suffocated’, is this the sensation described in the Rosaceae family or is it the suffocation of the tubercular miasm; how would one differentiate the two? Similarly the forced out sensation of the Liliflorae could be confused with the cast out theme of the leprous miasm; or the stuck feeling of Anacardiaceae with the similar theme of the malarial miasm.
To re-iterate what I have already said above the vital sensation is what the patient feels. Take, for example, pain which one can feel as cutting, stabbing, pinching etc. The intensity, pace and depth of this sensation or how he copes with it indicate the miasm. In practice, if the patient says he feels suffocated or something suffocates him the physician must endeavor to understand whether:
[1] The patient feels things to such a depth that it is suffocative. In this case the suffocation indicates the miasm and the area or issue connected with this suffocative degree will reveal his sensitivity.
For example: If he is vexed and excited so easily and frequently that he finds it oppressive, then his sensitivity is in the area of easy vexation and excitement, (family Ranunculaceae) while the oppressive degree is indicative of the tubercular miasm; the patient probably needs the remedy Cimicifuga.
[2] In every area of his life there is a sensation of being suffocated or pressed down. In this case he could perceive this sensation to any depth. He could feel acutely and dangerously suffocated (acute miasm, Rosaceae family), or he could feel suffocated to the point of being stuck (sycotic miasm, Rosaceae family) or he could feel so hopelessly suffocated that there is no way out (syphilitic miasm, Rosaceae family). In all these examples the suffocation is surely where his sensitivity lies and so indicates the family.
The type of sensation is only one of the components of the disease. For example if the main issue in a case is the sensation of being injured we can say that the patient will require a plant remedy from the Compositae family. But this is not enough to help us select one remedy from amongst the many, many remedies of the Compositae family. We know the type of sensation, viz. Injured sensation, but we can also perceive in the case the depth and intensity of the sensation and reaction as well as the manner in which the patient copes with these.
Sticking to the same example of injury there are different ways in which the patient may perceive the injury.
He may feel he will be suddenly injured in which case he may panic. The suddenness and the panic suggest an acute situation and response.
Another patient may perceive the injury as an acute crisis. He will respond by making a concentrated effort to overcome the crisis. The intensity of the injury (acute crisis) and the response suggest the typhoid miasm.
Or then he may feel that he is persecuted by injury from time to time while being stuck in a situation. The feeling of injury suggests the Compositae family while the depth is of the malarial miasm viz. stuck and persecuted intermittently.
So we can see from the above examples that the depth to which he perceives the sensation as well as the nature of his response determine the miasm. The miasm is the other component in the disease. So the disease has two components, viz. the type of the sensation and the depth of the sensation. The sensation and miasm together give the remedy. (Refer Introduction)
In the first example given above where the sensation is injury and the miasm is acute the remedy will be Arnica or Calendula, depending upon the symptoms. The remedy from the Compositae family of the typhoid miasm is Chamomilla, while Cina and Eupatorium perfoliatum are the remedies from the malarial miasm in the same family.
Although often one can determine the depth to which the patient perceives the sensation, usually the response to this is very clearly seen. For example one may be able to understand that the patient perceives the injury as an acute crisis, but this becomes clearer when we see the patient’s response, viz. a concentrated effort to overcome it. This response therefore is the best indicator of the miasm. I also call this response the ‘coping mechanism ‘ and this is best seen in relation to the chief complaint as the patient’s attitude towards the illness. If his attitude is one of panic, the miasm in the case is likely to be acute. If it is hopeful, it is likely to be psora. If he adopts an attitude of resigned acceptance, avoidance or cover up it may be sycosis and if he feels hopeless and destructive it may be syphilis. This miasm can then be confirmed throughout the rest of the case as an action taken in response to the depth of the sensation perceived. Sometimes some expressions of the patient with regards to other parts of his case may point towards other miasms, but I usually only trust what the chief complaint as well as the areas of most stress indicate.
The coping mechanism applies to the depth of the sensation as well as the reaction. I have already explained that the reaction can be active or passive or in the form of compensation. So if we take once again the sensation of being injured as an example, if the depth of the injury is to the point of destruction his reaction will also have the same depth: he will want to injure to kill. But if he reacts passively he may become numb and hopeless. If he is well compensated he can respond by becoming the tough guy and facing the most severe and destructive type of injury.
If the sensation in the case is apparent then one can understand the miasm by asking the question, what does he do in response to the sensation? Or What is the action in response to the sensation? Does he panic, does he make a desperate, last ditch effort to overcome it, does he stretch himself far beyond his capacity etc. This will give the miasm in the case. In some cases one can see the action before one has actually understood the sensation. Here one can ask Where is the area of the action? or What is the issue related to the action? Is he panicking in response to sudden injury? In that case the injury will be the sensation. Does he stretch himself beyond his capacity to feel included? In this case the sensation will be that he is not included or left out. In this way in any case from the sensation we can find out the miasm and vice versa.
Disease therefore has two components: the sensation and the miasm. Also when we study well proved remedies the most characteristic symptoms of the remedy are a combination of the sensation as well as the miasm. The most characteristic symptoms therefore point directly to the core of the remedy

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The New Approach
Step one: Elicit the chief complaint exactly.
I have already emphasized the importance of the chief complaint. One should stick to it and examine all components thoroughly for the sensation and miasm. The sensation may be expressed directly, or one can see it through the modalities or the effect that it has on the patient’s life. The chief complaint is the best place to look for the sensation and the miasm.
One begins the case by asking for a detailed description of the main complaint and one keeps asking the patient to describe it further and further till one comes to a sensation that will have a greater connotation than just the presenting problem, or something that will lead into the Sensation. I usually stick to very simple questions at this stage, like “Tell me more about it…” or “Describe it further, I don’t understand . . .” or “What do you mean when you say . . . ?” or “What do you feel ?”
If the patient gives a sensation one can usually confirm it from the modalities. I also ask the patient to describe the opposite of the sensation in detail as sometimes the patient will spontaneously connect this with images, situations, fears, or other aspects of his totality.
As he is describing the chief complaint one also makes note of the pace and depth of the problem and the patient’s response or attitude or coping mechanism. These indicate the miasm in the case. The miasm becomes apparent once the sensation is known and vice versa (Refer above).
Some rules I follow:
1. I will never use a word that the patient does not use. I will always repeat the same word in exactly the same way and only tell him to describe further or tell more about it or ask about the sensation or feeling of it.
2. I will keep asking the same question in various ways till the patient leads me to the next question or step. This is reached when the patient gives another sensation that is more precise or more descriptive or deeper than the previous step.
One needs a lot of patience and faith that the patient will express something deeper.
Sometimes the patient can get frustrated from being asked the same thing repeatedly. One can therefore ask him the same question in different ways
Often patients revert to the chief complaint and furnish you with more details about when it happens etc rather than answer what you have asked. In such cases I tell the patient that I understand when it happens, but what is more important for me is what is happening rather than when and why.
With this sort of persistent and focused questioning there are two or three things that can happen.
1. The patient can give you a visual picture or an example. For example if he says he feels stuck to one point and you persist with asking him to explain what he means he can say that he is stuck to one point as if he is in the middle of a street and there is a car coming at him at full speed… “How one feels stuck in such a case”, this is how he feels.
2. Or he can associate this with something else in his life or in his story. For example he can spontaneously describe an incident when was going in the street and he felt stuck in the same way.
In either case what one has to get to is the sensation or what he experiences emotionally and physically when he is in that situation.
3. Or he may describe the sensation as a fear. Then the next question would be, “Where do you experience that fear?” or “How do you experience that fear?”
Where the patient can express no more than an emotional feeling one can ask him how he experiences the feeling in the body or what are the physical symptoms he experiences at the time. This could lead to the sensation.
In this manner by chasing the chief complaint one can come to the main feeling or sensation. Thus the presenting problem can be seen as an expression of the Vital sensation.

Observation of hand gestures:
With the emphasis on sensations I realized that in many cases these were best expressed by hand gestures, even better than words sometimes. The ‘forced out’ feeling of Liliaceae, the ‘obstructed feeling’ of Cruciferae or the ‘pinched feeling’ of Rosaceae can be well observed even when the words may actually be saying something else. These hand gestures are subconscious, involuntary and often not even noticed by the patient. Sometimes I stop the patient while he is gesturing and ask him what the gesture denotes.
In one case the patient described her asthmatic attacks to have a sensation of being tightly twisted in her upper chest, like choked or strangled. She gave a picture of the sensation like a python strangling its prey. Later on in the case she spoke of being hurt when her husband admonished her. When I asked her to describe the feeling of hurt, she used the word sad, while at the same time her hands went towards her chest and were clenched, the same gesture she had used while describing the strangled, twisted feeling in the chest. What she could not express in words, her hands were speaking to us, even without her being conscious of this.
So when thereís no hand gesture, no image, no connection then itís used casually and need not be followed.

Step Two: Go to the areas of least compensation.
Usually if we go in depth into the description of the sensation and persist in this area, the patient himself will lead us into all the significant areas of this life like vocation, relation and recreation. If he does not do this despite our best efforts and the case staking process is stuck at a point, then we may need to inquire into some areas, especially those which are likely to show the least amount of compensation. These include hobbies, interests, dreams, fears and childhood. Here the delusion is best expressed.
Once one has derived the sensation and response or action in the chief complaint the next step is to confirm these in the areas of least compensation. The same sensation or its opposite will be found here, as also the action and one will come back to the same core undisputed.
Step Three: Other areas
Now one has the freedom to go into other areas, especially those that are seemingly disconnected and see how they connect to the common sensation.
Step Four:
Go back to the sensation that the patient has repeatedly confirmed and take the patient deeper till he gives a situation (actual or visual) where the sensation, miasm and kingdom concur.
Or
Go back to the areas of most stress and go deeper with the patient till a point is reached where the sensation, miasm and kingdom concur.
It is important to note at which point in the case the local phenomenon becomes general or emotional, or at which point emotional phenomena become physical. This is the Vital Level, something that connects the mind and the body.
Illustrative Case:
The method will be better understood if illustrated with a summarized case. The method is explained in italics while the case is in normal type.
P: Cough four to six times in the day.
Q: Describe the cough some more.
P: Blank out with the cough. Want of breath. Pulling sensation in abdomen, throat. It is worse when going out, from a draft of air. It comes on suddenly, especially when talking suddenly.
So one can see that he has a cough which gets severe from time to time, and at such times he gets a black out. The cough gets worse when he is outdoors and so he cannot go outside the house.
So there are two aspects to the cough:
• blank out (sensation)
• It comes from time to time and he can’t go out of the house anymore (pace/miasm).
Q: Tell me about ‘blank out’, describe it.
P: It becomes black before my eyes, as if I am stuck to one point.
Q: Stuck to one point meaning . . .? What is the feeling when stuck to one point?
I have used only the words of the patient and keep up this questioning till he leads me to the next question. This could be a more precise feeling or a visual picture or something that comes up by association.
P: It is as if I cannot move.
Now this does not yield a finer description of being stuck at one point, nor has he given a picture of what it is like to be stuck at one point. You cannot go any further with this. So I will again ask about his feeling when he is stuck to one point.
Q: What is the feeling when stuck to one point?
He reverts back to the chief complaint. Now it is our job to keep him to track so repeat the same question till he goes one step deeper.
P: It is like you are in the middle of the street and car is coming at full speed. That is how I feel.
Now this is a visual picture. It could have been an actual experience from his life. It is a window into the Mental State, one level deeper than the physical. Question him further and ask about his experience in this situation and one may be able to see a connection with the cough.
Q: How does one feel when one is in the middle of the street and a car comes at you at full speed?
P: It happened to me as a child. I felt the same way.
We have to get to the sensation in that situation. Ask him now to describe the experience in emotional and physical terms.
We started with the cough and then came to blank out and then to black before the eyes and then to stuck to one point then to the childhood situation. All this by sticking to the chief complaint and chasing it.
P: The fear is I will be suddenly killed and so I cannot move.
So in this manner by chasing the chief complaint one can come to the main feeling or fear which is that suddenly he is going to be killed and he is stupefied from this fright.
Now you can see the connection with the cough. The cough comes suddenly from time to time and he cannot go out of the house. It gets black before the eyes and he is stuck to one point as if he is going to be killed. He is frightened and stuck to one point. Fright stupefies. The cough stupefies. He avoids going out of the house because he will get a cough. He avoids the situation that stupefies him but he still gets the cough from time to time.
So this is the malarial miasm, Solanaceae family and the remedy is Capsicum. So the remedy became apparent from the chief complaint itself and could be confirmed in other areas in the case.
Once you get the sensation you have to get the opposite. To get the opposite go to the area of least compensation or no compensation: hobbies and interests, dreams, childhood.
For example in the case of a patient for whom I prescribed Mangifera needed to be in company. When I asked about her feeling when in company she replied that she feels things are moving and are not static. What does that have to do with company?! So it is this that she says which ties with the rest of the case. Mangifera is a sycotic remedy from the Anacardiaceae family. The main sensation in this family is of being caught or stiff or stuck. One can see the opposite in her hobby, i.e. not static and always moving.
The beauty of this whole exercise is that you never know what comes up; as the case goes on the sensations and feelings unravel as a surprise.
So, nowadays I concentrate on the chief complaint and in this way reach the center in all my cases. The old way was from outside inwards whereas the new approach is from within outwards starting with the chief complaint. The concentration should be on the chief complaint, whether the problem is emotional or physical. The chief complaint is the main support around which the case revolves. And instead of letting isolated emotional phenomena or physical symptoms mislead us the emphasis should be on the vital symptoms, or the symptoms that connect the mind and body.
All this time instead of catching hold of the chief complaint and not letting it go till we have understood it clearly, we used to go all around to other areas in the patient’s life. All that is clothed in the expressions of the emotional state becomes naked in the chief compliant. If we go to the other areas first we will only feel the tremors; if we concentrate on the chief complaint right at the outset we discover the volcano from where the tremors originate; we discover the wound that is most tender. If we focus our complete attention onto the chief complaint, its sensation and modalities, we understand the very core of the case right away.
The body and the mind both express the same phenomena, same disturbance, and the same vital problem. If we understand the physical aspect first it may be more helpful and save us from getting ourselves lost in the mental phenomena.
This new approach to case-taking was the beginning of an understanding of the various levels of perception and led to the discovery of the seven levels viz. Name, Fact, Feeling, Delusion, Sensation, Energy and The Seventh.
In the medical terms, the first level has to do with diagnosis, the second level with the complaints, third with the feelings and emotions, fourth with the delusions and dreams, fifth with the sensation, sixth with the energy pattern and the seventh with what lies beyond.
So far in Homoeopathy we could treat the patient with symptoms, pathology etc. ‘The Spirit of Homoeopathy’, introduced the level of delusion. This book introduces the idea of sensation. The idea of levels has been a big step for me and clarified not only case taking and analysis but also the vexed problem of potency.
An extensive understanding of the levels and its practical utility will be dealt with in my forthcoming book entitled, ‘The Sensation in Homoeopathy’.