Modalities: the half of every symptom students forget to ask for

The half that gets lost

A complete symptom has four parts: location, sensation, modality and concomitant. Students record the first two reliably and the second two hardly at all.

The consequence shows up at the repertory. "Headache" is a rubric with several hundred remedies in it and it will not discriminate anything. "Headache, better from firm pressure" is a rubric with a few dozen. "Headache, better from firm pressure, worse from motion" is a case.

The modality is not decoration on the symptom. In most analyses it is doing more work than the symptom itself.

Why it does so much work

Two patients with the same pathology produce the same sensations. The pathology causes them. What the pathology does not cause is the pattern of relief and aggravation — and that pattern is therefore where individual reaction shows.

This is the same principle as strange, rare and peculiar symptoms, applied systematically: whatever the diagnosis does not explain is where the information is. A modality is almost always something the diagnosis does not explain.

The categories worth asking about

Ask across all of these, not just the one the patient volunteers.

The last row is the one most often skipped and among the most discriminating. Response to consolation alone separates several major remedies, and it takes a single question.

The questions that actually work

"What makes it better or worse?" produces a blank look surprisingly often, because patients have not thought of their symptom in those terms.

These work better:

"What do you find yourself doing when it is bad?" This gets the modality behaviourally. A patient who says "I sit very still" has told you worse from motion without ever being asked. A patient who says "I have to walk about" has told you the opposite.

"Is there anything that helps, even a little — even something that sounds silly?" The word "silly" gives explicit permission for exactly the observation you want, which patients otherwise suppress as too trivial to mention.

"When in the day is it worst?" Direct, and time modalities are strongly discriminating. Ask for the clock, not the period: "evening" is vague, "from about four" is a rubric.

"How do you sleep with it — which position?" Position modalities are almost never volunteered and often decisive.

"What is the first thing you notice when you wake?" Catches the on-waking modality, which patients rarely think to report.

Recording them properly

Three habits that make the difference between notes you can repertorise from and notes you cannot.

Attach the modality to the symptom, not to the case. "Worse in the evening" floating at the bottom of the page is unusable at the follow-up. "Headache — worse from 4 p.m." is a symptom.

Distinguish the general from the particular. The patient is worse in damp weather; the knee is worse in damp weather. These are different symptoms with different weight, and generals outrank particulars. If the patient's whole state changes in damp, that is a general and it carries the case.

Record the strength. "Slightly better for pressure" and "has to press hard on it with both hands" are not the same observation, and the second is worth a grade more. Marked modalities are the ones to build on.

The contradictory ones are the best

The highest-value modality is the one that runs against the pathology.

• Inflammation that is better for heat.
• A strain that is better for continued motion.
• Pain that is better for hard pressure.
• A chill that is better in the open air.

These are peculiars by definition — the diagnosis predicts the opposite — and they anchor an analysis. When you find one, confirm it carefully, and check it in more than one source. The Materia Medica library carries several authors side by side, and where they disagree about a modality the disagreement is itself worth reading.

What not to do with them

Do not repertorise on modalities alone. A modality is one dimension of a symptom, and a rubric list built entirely from modalities without the accompanying generals and mentals will be as unbalanced as one built without any modalities at all.

Do not accept a modality the patient inferred. "It is worse in damp because my mother's arthritis was" is a theory, not an observation. Ask what they have actually noticed.

Do not force one. Some symptoms genuinely have no modality. Recording an invented one is worse than recording none, because you will then repertorise on it.

One change to try

At your next ten consultations, do one thing: for every complaint the patient reports, write down at least one modality before you move on to the next complaint.

Not at the end. Immediately, while you are still on that symptom — because you will not come back to it, and at the follow-up "headache" will tell you nothing about whether the remedy worked.

It slows the consultation by a couple of minutes and it changes the quality of every analysis that follows.