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Installment 3 of a series on case analysis

© Will Taylor, MD 2001

Characterizing Dimensions of the Totality of Symptoms

Part 2: On the Characterizing Dimensions of a Mental/Emotional Symptom

Presented at the March 2001 meeting of the Homeopathic Medical Society of the State of Pennsylvania; and published in the Summer 2001 issue of the journal Simillimum.

Sections: 1 | 2 | 3

In 1858 Boenninghausen drafted his essay, "A Contribution to the Judgment Concerning the Characteristic Value of Symptoms"1. In this he relied on the 12th century hexameter, "Quis? Quid? Ubi? Quibus Auxiliis? Cur? Quomodo? Quando?" (Who? What? Where? With Whom? Why? How? When?), to define the characterizing features of the symptom-totality on which we select the similar remedy.

These 7 characterizing symptom features have found expression in the construction of our repertories, and in the dimensionality of Boenninghausen's case-analysis method. In this method physical symptoms are represented as localities, sensations,modalities, and concomitant symptoms - the classic 4 dimensions of symptom-totality in Hering's blackboard:2

Hering's dimensions

Why Symptom Dimensions?

This system of dissecting symptoms into component dimensions has been significant to the organization of our knowledge materia medica in two important ways:

First, it allowed the construction of manageable reportorial indices. Boenninghausen's Repertory, and those that followed, allowed us to reconstruct a complex symptom by locating its component "parts" as separately listed and easily indexed symptom-fragments consisting of and organized by these dimensions of locality, sensation, modality, and concomitance.

Second, in doing this, Boenninghausen recognized a creative way of overcoming the shortcomings and limitations of our knowledge of the materia medica. It was apparent to him that sensations, modalities, and concomitants often had more to do with the symptom totality than with merely the local symptom to which they were attached in a proving or a case. He suggested that we could generalize these symptom-fragments, and use them by analogy to describe symptoms to which they were not directly attached in the proving or in the case at hand.

For example, the provings of Colocynthis reveal pressive pains in many localities; but indicate amelioration by hard pressure only for colicky pains of the gut. Boenninghausen lists Colocynthis in the General amelioration rubric Ameliorations; Pressure, external in his Therapeutic Pocketbook, which allows us to consider this remedy in a case with pressive headache better with hard pressure, even though this modality is not reported for this locality in the provings.

Obviously - as pointed out historically by Hering and others - this practice risks errors of inclusion, a fact that undoubtedly did not escape Boenninghausen. He did not suggest that we revise the primary materia medica with generalized sensations and modalities; rather that we use this to reduce potential errors of exclusion in reportorial analysis.

What's Unique about Mental/Emotional Symptoms?

The mental/emotional symptoms occupied an exceptional position in Boenninghausen's scheme, to be referred to only after the initial stages of case analysis, when the results of repertorization were taken for comparison with the primary materia medica. This was clearly not because of any neglect or assumed lesser importance of the mental/emotional realm, but rather because the mental/emotional symptoms were not readily dissectible according to Boenninghausen's scheme of symptom-dimensionality.

Yet, Hahnemann and his colleagues had very early on recognized the central importance of the mental/emotional state of the patient in determining the curative remedy.

From the Organon,3

"... in all the so-called somatic diseases as well, the mental and emotional frame of mind is always altered. In all cases of disease to be cured, the patient's emotional state should be noted as one of the most preeminent symptoms, along with the symptoms complex, if one wants to record a true image of the disease in order to be able to cure it homeopathically."
(aph. 210)

"This preeminent importance of the emotional state holds good to such an extent that the patient's emotional state often tips the scales in the selection of the homeopathic remedy. This is a decidedly peculiar sign which, among all the signs of disease, can least remain hidden from the exactly observing physician."
(aph. 211)

"The Creator of curative potencies has also preeminently taken into consideration this chief ingredient of all diseases, the altered mental and emotional state, in that every efficacious medicinal substance in the world very noticeably alters the mental and emotional state of the healthy individual who proves it and, to be sure, each medicine does so in a different way."
(aph. 212)

"For this reason, one will never cure in accordance with nature, that is, one will never cure homeopathically unless:

  1. one attends to the symptom of the mental and emotional alterations, together with the other symptoms, in every case of disease, even acute ones, and
  2. for aid, one selects, from among the remedies, a disease potency that, along with the similarity of its other symptoms with those of the disease, is of itself capable of engendering a mental or emotional state similar to that of the disease."

(aph. 213)

It is the purpose of this essay to explore the dimensionality of mental/emotional symptoms, in order to be able to more fully integrate these symptoms into Boenninghausen's scheme and aid their use in case analysis.

Nature of the Central Significance of the Mental/Emotional State

The mental/emotional state might be considered to gain its central significance for our appreciation of the true image of disease in either one, or both, of two ways:

(1) These symptoms may merely be "decidedly peculiar signs which ... can least remain hidden from the meticulously observing physician". Regardless of their role in the disease process, they most often stand out within the symptom totality as strongly characterizing and differentiating.

(2) As suggested by the Swedenborgian-inspired cosmology of James Tyler Kent and some schools of contemporary alternative healing philosophy, the mental/emotional state of the organism may lie in a more proximate position in the generation of disharmony of the organism - which then ultimates in the physical realm.

I want to sidestep this second possibility - as the insufferable pragmatist that I am - and choose here to "let the mystery be "regarding whether the mental/emotional state is closer to the generation of disease than is the physical state. I am open to long evening discussions on this point; but it is not essential to the practical points to be made in this essay. It is my personal impression that both mental/emotional and physical symptomatology co-arise from a disharmony more profound than our imposed mind/body dichotomy can appreciate. Perhaps the assumed primacy of the mind and emotions in health and disease in some of our contemporary alternative medical philosophies arises out of reaction to the near-total disregard of these factors in the prevailing medical philosophies of the past several centuries, and our need to regain balance and find a rightful place in medical thought for the psyche.

This latter point is in fact the major point I glean from Hahnemann's aphorisms 210-214. Hahnemann lived in a period when, much as today, a dichotomy of mind and body was believed to exist by conventional medical philosophy. I see in aphorisms 210-214 an outright rejection of this mind/body duality, recognition that there can be no inherent distinction made between the symptoms and diseases we describe as somatic and those we describe as mental/emotional.

Kent on the Dimensions of Mental/Emotional Symptoms

James Tyler Kent offered an alternate approach to the organization of symptoms in a case, bringing in the mental/emotional symptoms in the earliest stages of case analysis. This hinged largely on Kent's Swedenborgian cosmology, in which Mind was seen to occupy a higher position than the physical body in the hierarchy extending from the dynamic plane to its ultimation in physical disease.

In offering us this approach however, Kent did not follow up with a great deal of guidance regarding the characterizing values of the varieties of mental/emotional symptoms we might obtain in a case, or find in the pathogeneses of remedies. In his essay "Use of the Repertory"4, he does describe the following hierarchy of mental/emotional symptoms:

"First - are those relating to the loves and hates, or desires and aversions.

"Next - are those belonging to the rational mind, so-called intellectual mind.

"Thirdly - those belonging to the memory."

In "How to Use the Repertory"5 he adds, "I next [after aggravations and ameliorations of the general state] consider carefully all his longings, mental and physical, all the desires and aversions, antipathies, fears, dreads, etc. Next I look for all the intellectual perversions, methods of reasoning, memory, causes of mental disturbances, etc."

I find in these descriptions some seeds for a deeper understanding of the dimensionality of symptoms of the mind, but not that needed to organize the mental/emotional symptoms within Boenninghausen's scheme.

Mental/Emotional State v/s Mental/Emotional Symptoms

An examination of Hahnemann's aphorisms 210-213 tells us that we are not merely looking for a collection of mental/emotional symptoms in our patient, but rather for a mental/emotional state. I have seen arguments regarding Hahnemann's use of the term state (-zustand) here - based on the brief examples he gives in the footnote to aphorism 214 - to the extent that what Hahnemann had in mind here was a simple elimination based on some very general similitude of condition, such as eliminating Aconite "if the patient's emotional state is quiet and uniformly calm," eliminating Pulsatilla "if the patient's emotional state is glad, cheerful and stubborn,"6 etc. Yet Hahnemann's sense of meticulous detail would seem to rule out something so simplistic, as would the rich detail in which he records the symptoms of the mind in his provings.

Aphorism 153 of the Organon offers us the clarity we need on this subject. We are asking a particular task of the symptoms brought to case analysis - which is to characterize the totality of the disease of the organism, to paint a definitively recognizable picture of the state of the disharmony of the patient.

This is the difference between producing on one hand a mere collection of mental/emotional symptoms, and on the other, describing the mental/emotional state of our patient. The latter - our goal - is intended to provide a characterizing picture of the totality. To this end, we need to have - as we do for physical symptomatology - some framework on which to hang our collected symptoms, to have some understanding of how these are integrated in the construction of the whole organism.

Outward Behavior

The most immediate thing we can describe about things mental and emotional is the outward behavior of the patient. Much of the Mind section of our Repertories is taken up by such objective descriptions of outward behavior, with entries from A to Z: Abrupt; Absorbed; Abusive; Adulterous; Yielding disposition.

Although these are often the easiest kinds of mental/emotional symptoms to gather in a case, they rarely offer in themselves the characterizing detail we require.

We can look at a rubric e.g. such as {Mind: Jealousy}, with its 37 listed remedies, and see such disparate remedies as Apis, Hyoscyamus, Nux vomica and Pulsatilla. It can be a good exercise for us to compare the respective jealousies of these remedies.

One way of differentiating these "jealous" remedies would be to look at concomitant symptoms - both in the mental/emotional and physical realms. Concomitance clearly maintains its role as a characterizing dimension for mental emotional symptoms.

Another way of differentiating these remedies would be to investigate what kind of jealousy each manifests. This requires the dissection of this symptom into component dimensions. Is there a consistent way in which we can dissect such symptoms, to provide us with an ordered approach to differentiating mental/emotional symptoms?

A First Division

An obvious first division of the mental/emotional state into appreciable dimensions would borrow from Behavioral biology the distinction:

Stimulus -> Response

We can look to our repertories and immediately begin to appreciate how we might use this dimensionality to differentiate between remedies with similar symptoms of observable outward behavior.

In this way, we can e.g. distinguish between the jealousies of Hyoscyamus and Lachesis. In Hyoscyamus, jealousy is a Response to the Stimulus of immediately impending loss of relationship - we have, e.g., "Delusions, as if would be sold" and "Delusions, affection of friends, has lost" on the Stimulus side of this equation.

Delusions, as if would be sold
Delusions, affection of friends, has lost -> Jealousy

The jealously of Lachesis is more competitive in character. On the Stimulus side of the equation, we have e.g. "Delusions, that there were conspiracies against him" and "Delusions, jealousy, lovers concealed behind stove; wife has".

Delusions, that there were conspiracies against him
Delusions, jealousy, lovers concealed behind stove; wife has -> Jealousy

Already, we can appreciate that a simple classification of mental/emotional symptoms into the complementary dimensions of Stimulus and Response can offer some robustness into our appreciation of the mental/emotional state of a patient or of the materia medica. Stuart Close compared the use of Boenninghausen's dimensions to adding one's own legs to a traditional one-legged milking stool - by spreading these widely, we gain support in our selection of a matching remedy. As we add dimensions, our ability to fully characterize a mental/emotional state - by spreading the supporting legs of our milking-stool broadly among the dimensions that describe the state -becomes more robust and useful in case analysis.

Refinement of the Behaviorist Model

Victor Frankl 7 has revised the Behaviorist model by suggesting that our personal freedom lays in a moment of choice interposed between stimulus and response:

Stimulus -> Moment of choice -> Response

Our health resides in the flexibility of this "moment of choice", our freedom to perceive and respond creatively and in harmony with the demands of our environment. Disharmony or disease resides in the frustrations of our ability to freely and creatively choose in any given circumstance. Recall George Vithoulkas' definition of health as freedom and creativity, and of disease as limitations in the exercise of creativity8. When disease affects this "moment of choice" interposed between stimulus and response, it results in restrictions or distortions of choice, and consequently in restrictions or distortions of our behavior.

Joseph (the one with the coat) did not need Hyoscyamus as he was being taken away by slave-traders before his brothers' eyes. His response to the reality of being sold was genuine, not constrained by distortions or restrictions of his moment of choice.

An inner experience distorted by disease may result in restrictions and/or distortions of choice, in which one might feel like Joseph at that moment, in contradiction to actual circumstances. What will come of this inner feeling or belief, "as if one were being sold, as if one were losing the affection of his friends"?

This may affect the processes at both of the arrows in the equation:

Stimulus -> Moment of choice -> Response

The inner distortions and restrictions affect, on one hand, our sensitivities to stimuli. An individual in the Hyoscyamus state will be more likely to be vigilant to things that feel like being sold or injured, to things that feel like loss of others' affection. So we can understand the Stimulus-dimension symptoms of Hyoscyamus in our repertory9, such as:

AILMENTS FROM - rudeness of others
AILMENTS FROM - scorned; being
DELUSIONS - poisoned - he - about to be poisoned; he is
AILMENTS FROM - love; disappointed

Similarly, the inner distortions and restrictions affect the outward behaviors we exhibit; and so we can understand the outwardly exhibited behaviors of Hyoscyamus that have to do with avoiding 'being sold': e.g.,

ESCAPE, attempts to - surrounded and captured from men, as if
ESCAPE, attempts to - run away, to
ATTACK others, desire to
HIDING - himself
HOME - desires to go

and with 'losing the affection of others': e.g.,

KISSING - everyone
CHEERFUL - dancing, laughing, singing; with

I believe this distortion of Victor Frankl's "moment of choice" is what James Tyler Kent was referring to when he described "perversions of the will and understanding". In addition, it is clearly what Rajan Sankaran is referring to in his description of the "Core Delusion". With several terms to describe it, is it possible to define its dimensions more clearly?

Sections: 1 | 2 | 3

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