Installment 2 of a series on case analysis
© Will Taylor, MD 2001 (bio)
of the Totality of Symptoms
Part 1: Dimensions of a Physical Symptom
When the totality of the symptoms that specially mark and distinguish the case of disease or, in other words, when the picture of the disease, whatever be its kind, is once accurately sketched, the most difficult part of the task is accomplished.
- Samuel Hahnemann, Organon of the Medical Art, §104 (Dudgeon translation)
Last month's installment of this series focused on the homoeopathic interview. With the case taken, the symptoms written down and impressed on our minds, we're ready to match our collection of symptoms to a remedial agent - or are we?
Note that Hahnemann, in aphorism 104, did not state merely "When the symptoms that specially mark and distinguish the case of disease are identified ... " - rather, he specified the need to identify a "totality (Gesammtheit) of symptoms."
Hahnemann reminded us that the totality of the morbid symptoms of a case - as the "outwardly reflected picture of the internal essence of the disease" - is the only thing we can know about the internal essence of disease:
Now, as in a disease, from which no manifest exciting or maintaining cause (causa occasionalis) has to be removed, we can perceive nothing but the morbid symptoms, it must (regard being had to the possibility of a miasm, and attention paid to the accessory circumstances, § 5) be the symptoms alone by which the disease demands and points to the remedy suited to relieve it - and, moreover, the totality of these its symptoms, of this outwardly reflected picture of the internal essence of the disease, that is, of the affection of the vital force, must be the principal, or the sole means, whereby the disease can make known what remedy it requires - the only thing that can determine the choice of the most appropriate remedy - and thus, in a word, the totality of the symptoms must be the principal, indeed the only thing the physician has to take note of in every case of disease.
Samuel Hahnemann, Organon of the Medical Art, §7 (Dudgeon translation; this author's emphasis)
How does this totality, Hahnemann's Gesammtheit, differ from a mere collection - even a thorough collection - of the symptoms of the case?
Stuart Close, in The Genius of Homoeopathy, tackled this question:
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 ...
The totality must express an idea ...
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.
Close went on to describe the totality as a symptom picture of the disease - in fact borrowing that term from Hahnemann, "das Bild der Krankheit" (§104) - a composition created by the "harmonious combination of its elements into a whole."
This picture of the disease, painted by its collected symptoms, needs for our purposes not only the internal coherency of a composition, but also the individuality of a portrait. The totality needs to reflect the inner essence of the disease of the person, with the detail necessary to distinguish this individual case of disease from others of similar nature. Hahnemann pithily described what we require for individualizing detail, in the Organon:
In this search for a homoeopathic specific remedy, that is to say, in this comparison of the collective symptoms of the natural disease with the list of symptoms of known medicines, in order to find among these an artificial morbific agent corresponding by similarity to the disease to be cured, the more striking, singular, uncommon and peculiar (characteristic) signs and symptoms of the case of disease are chiefly and most solely to be kept in view; for it is more particularly these that very similar ones in the list of symptoms of the selected medicine must correspond to, in order to constitute it the most suitable for effecting the cure. The more general and undefined symptoms: loss of appetite, headache, debility, restless sleep, discomfort, and so forth, demand but little attention when of that vague and indefinite character, if they cannot be more accurately described, as symptoms of such a general nature are observed in almost every disease and from almost every drug.
- Samuel Hahnemann, Organon of the Medical Art, §153 (Dudgeon/Boericke translation of the 6th edition)
The application of this aphorism to individual symptoms - striking, singular, uncommon and peculiar (characteristic) signs and symptoms - will be taken up in a subsequent installment in this series. For now, I'd like to focus on the "if they cannot be more accurately described" portion of aphorism 153. What do we require in order to have an otherwise general and undefined symptom "more accurately described?"
Again, from Stuart Close in The Genius of Homoeopathy,
Dr. Hering, in his quaint fashion, ... said: "Every stool must have at least three legs, if it is to stand alone." He advised selecting at least three characteristic symptoms as the basis of prescribing.
A milking stool will stand upon one leg-if you sit on it and thus provide your own two legs as the other necessary props; but even then, as every farmer's boy knows by bitter experience, a vicious kick, or a "corkscrew swat" from the old cow's tail may upset the youthful milker and his pail of milk and bring him to grief.
So it is wise to always give the symptomatic milk-stool as broad a base and as many legs as possible. The youthful prescriber will get many a vicious kick from refractory cases. He may be knocked sprawling and lose his pail of milk a few times, but he will be able to avoid this when he has learned the peculiarities of his patient as well as I learned the peculiarities of my bovine kicker when I was a boy.
The characterizing features of a symptom need to stand to the symptom like the legs stand to a milking stool - widely-spread and solidly supporting. The "5 W's" of journalism come to my mind: "Who, What, Where, When, Why" serve to broadly characterize the events of the news. What came to Boenninghausen's mind, was a 12th-century verse used by theologic scholastics to determine the severity of a sin, on which he based his 1860 essay, A Contribution to the Judgement Concerning the Characteristic Value of Symptoms.
In this essay, Boenninghausen investigated the characterizing dimensions of the totality in terms of the descriptives "Quis? quid? ubi? quibus auxiliis? cur? quomodo? quando?" ( "Who? What? Where? Associated with what? Why? In what manner? When?"). An otherwise too-general symptom - e.g., "head pain" - assumes characterizing value within the totality of symptoms when it is fully described across these several dimensions as:
- Quis? - a generally irritable and impatient man
- Quid? - dull pain, becoming throbbing, and at its most intense like a nail (3) boring into the brain
- Ubi? - right eye (3), temple and forehead
- Quibus auxiliis? - with bitter vomiting (2)
- Cur? - after commuting on the train
- Quomodo? - worse jar or motion (2), worse light (2); better vomiting (3)
- Quando? - worse evening (2)
Hering used a simplified diagram to graphically illustrate the dimensions of the totality of symptoms:
These four principal dimensions of a fully-characterized totality - Locality, Sensation, Modalities, and Concomitants - serve as the 4 potential legs of Stuart Close's stable metaphorical milking-stool. [Note that these characterizing dimensions do not appear to apply as well to symptoms of the mental/emotional realm. This was a sticking point in Boenninghausen's scheme, which I will address in the next installment of this series].
Not every symptom in a case is characterized by all four of these dimensions. Due to inattentiveness on the part of the patient, and/or on the part of the interviewer, or due to true one-sidedness of disease, some collected symptoms may be missing potentially characterizing dimensions. Awareness of our reliance on the full dimensionality of the totality during casetaking (see "keep your eyes on the prize" in the prior installment of this series) may help us in part to avoid such a deficiency. However, it is important to recognize that we do not require each of our symptoms to be fully characterized along these lines - it is the totality of symptoms that needs to be fully characterized in as many of these dimensions as possible.
Boenninghausen recognized that our cases, as well as our provings, are necessarily incomplete. Anticipated modalities are often missing in both cases and in provings; sensations are often inadequately described. On pondering how to adapt to these deficiencies, it occurred to him that modalities and sensations often belong more to the case as a whole - i.e., to the totality of symptoms - than just to a local symptom. [We might reflect that Burnett similarly suggested the same of locality, in his concept of specificity of seat]. Boenninghausen suggested that modalities and sensations might be used in case analysis as descriptors of the whole, rather than merely of the parts, and he elevated them from local descriptors to general symptoms.
A strategy I often use in case analysis, is to organize symptoms for repertorial analysis according to Boenninghausen's dimensions. Using the RADAR repertory software, for the headache caselet above, I would place the "Quis" (who) rubrics into the first rubric clipboard; the "Quid" (what) rubrics into the second clipboard; etc. This helps me to see that I have a balance of symptoms across the characterizing dimensions of the case.
It also allows me to use the Herscu analysis module in an unorthodox way. By selecting this analysis method,
the remedies having at least one symptom in each dimension are emphasized. The multiple clipboards can be viewed simultaneously within the Herscu module analysis, and from the analysis window itself, the various remedies that run thru the dimensions represented can be directly compared.
In the two installments to follow, I will extend Boenninghausen's concept of the characterizing dimensions of a symptom to symptoms of the mental/emotional realm, discuss Boenninghausen's concept of the construction of symptoms by analogy, and examine the pros and cons of the practice of generalization of modalities and sensations.
Organon of the Medical Art
Samuel Hahnemann (Dudgeon/Boericke translation of the 5th/6th editions)
German exercepts are taken from Organon der Heilkunst, Textkritische Ausgabe der 6.Auflage; Josef M.
Schmidt, ed.; Haug Verlag, Heidelberg (1992)
The Genius of Homoeopathy; Lectures and Essays on Homoeopathic Philosophy
Stuart Close (Professor of Homoeopathic Philosophy, New York Homoeopathic Medical College, 1909-1913)
Bonninghausen's Therapeutic Pocketbook
The challenges met in producing a new translation of the Boenninghausen Repertory for RADAR Software, taken from the original German version.