Installment 5 of a series on case analysis
© Will Taylor, MD 2001 (bio)
Symptoms by Analogy
Sections: 1 | 2
The previous 3 installments in this series have discussed the characterizing dimensions of symptoms; Boenninghausen's dimensions of physical symptomatology in installment 2, and a contemporary model for describing the characterizing dimensions of mental/emotional symptoms in installments 3 and 4.
Breaking the complex symptoms of a proving or of a case into the component dimensions of Locality, Sensation, Modality/Causation and Concomitance allowed Boenninghausen to construct the first easy-to-use repertorial index of the Materia Medica. For example, complex symptoms such as:
"On lying down at night, feels an oppression of the chest, breathing became short, is obliged to sit up in bed; worse after midnight; drinking coffee or sugar with water relieves somewhat; symptoms worse on going up-stairs, gets out of breath." (example from Hering's Guiding Symptoms, for Arsenicum album)
Can be represented in, and reconstructed from, the Synthesis Repertory using:
CHEST - OPPRESSION (sensation)
GENERALS - LYING - agg. (modality)
GENERALS - NIGHT (modality)
RESPIRATION - DIFFICULT (sensation)
RESPIRATION - DIFFICULT - lying - impossible (modality)
GENERALS - NIGHT - midnight - after (modality)
GENERALS - FOOD and DRINKS - coffee - amel. (modality)
RESPIRATION - DIFFICULT - exertion - after / GENERALS - EXERTION; physical - agg. (modality)
So that, instead of searching through long lists of very specific symptoms for a precise match to the symptoms of a case, it is possible to reconstruct a complex symptom from these simpler components.
Now this offers an apparent problem, which is at the same time a marvelous solution to a difficulty that faced the early homeopaths, and still faces us today. Which is, that while the symptoms of the provings may be reconstructed from these component parts, it is also possible for us to create in this manner complex symptoms which have never been observed in provings or in cured cases. I like to refer to this as the "Mr. Potato Man Effect." Did you have one of those when you were a kid? (You don't have to admit it if you still play with one. Or if, like me, you remember when it didn't come with a plastic potato, and you had to find your own spud from the garden). With only a small number of different eyes, ears, mouths, eyebrows, etc., you could create a wide variety of characters. Some very credible, and some monstrosities that resembled nothing ever seen before.
With over 1700 pages of rubrics in the Synthesis Repertory, the number of complex symptoms that could be created from component parts is enormous. This raises for us both some concerns, and a solution to a problem inherent in our practice.
The problem this offers to help solve is that our provings are inherently incomplete. No matter how meticulously a proving is performed or observed - and even a quick perusal of TF Allen's Encyclopedia will demonstrate that many of our provings fall rather short in this regard - there will be gaps in the completeness of the recorded symptoms. Through inattentiveness of the subject, or of the observer, or through symptoms only brought out partially in an individual subject or small group of provers, we will have (e.g.) headaches described in the proving by their location and sensation, but without modalities.
Yet in this same proving, there may be clear modalities associated with other local symptoms. For example, we might find the symptom-fragments:
HEAD - PAIN - pressing
HEAD - PAIN - Temples - right
ABDOMEN - PAIN - pressure - amel.
- and feel tempted to grab the "pressure ameliorates" modality, to combine with the head pain locality and sensation, to complete the complex symptom of "pressive headache in the right temple relieved by firm pressure" - much as I might create a novel Mr. Potato Man by stealing a couple of ears from my sister's kit (I never really did that, of course!)
Boenninghausen described this as creating complex symptoms by analogy. After reviewing many provings and many clinical cases, he proposed that Sensations and Modalities might be best considered to belong to the case as a whole, rather than to merely the local symptom(s) to which they were attached in the proving. In his Repertory and Therapeutic Pocketbook, he Generalized the modalities and sensations, stripping them from their local symptoms and expressing them as symptoms of the whole.
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.
Now the problem that this raises, is that not all of the complex symptoms that we can create by analogy really belong to the remedy. Not all of our "Mr. Potato Men" can exist in real life. For example: we know that Arsenicum is cold, and is generally aggravated by cold; yet, we have for it the unique local symptom: "head pain relieved by applying cold water" (from Hahnemann's proving). Here, the General modality of "aggravation by cold" is contradicted, and the Local modality of "ameliorated by application of cold water" cannot be generalized from its local applicability in headache to other Arsenicum symptoms.
Classical authors have criticized Boenninghausen's generalization of modalities and sensations, and his use of symptoms by analogy. Most vocal among his critics on this point, were Constantine Hering and Hering's protege, Ernest Farrington. Their criticisms can be summed up by two points:
- Information is lost when a locally-specific, non-generalizable modality or sensation is stripped from its local symptom and treated as a general symptom;
- Information is distorted when a non-transferable local modality or sensation is applied to another symptom inappropriately.
We could get carried away with this apparent conflict as one more place where homeopaths just can't seem to agree, or we could apply Taylor's First Law of Apparent Contradiction - which states that, when 2 intelligent and discerning individuals appear to contradict each other, there is a very important thread of truth that runs through both opinions. Let's see if this could be true in this situation.
First, let's look at where Boenninghausen suggested generalizing modalities and sensations. Actually, let's look at where he did not suggest generalizing - i.e., in the Materia Medica. Boenninghausen's Characteristics remains free of generalized modalities and sensations, and free of symptoms created by analogy. It remains a careful record of symptoms harvested from the provings, and confirmed by clinical observation. It would satisfy Hering and Farrington in this regard.
Where he did suggest the generalization of modalities and sensations was in the Repertory. This is where Colocynthis' "Griping (drawing hither and thither) in the umbilical region ... constant severe constriction of the viscera for ten or twenty minutes, relieved by violent pressure with the hand" becomes:
Internal Abdomen, Umbilical Region
Sensations, Cramps, Internal
Ameliorations, Pressure, External
And it is in the repertory where "Ameliorations, Pressure, External" becomes a "free agent," for us to apply experimentally, Mr. Potato-Man fashion, to other local symptoms in our analyses.
This highlights one of the very important differences between the character of the information contained in our Materia Medica, and that borne by the Repertory. We should expect our Materia Medica to be a careful compilation of the pure and clinical symptomatology of our remedies. Various texts offer a range of emphasis from principally clinical offerings, to purely pathogenetic (proving) symptomatology, to mixes of these; and range from comprehensive treatises to concise keynote/confirmatory symptom listings. At the completion of case analysis, we should expect to find our case cleanly represented, and thus confirmed, in the Materia Medica.
The Repertory, on the other hand, does not contain a definitive description of individual remedies, but is expected to serve as a guide to recognizing the simillimum for a case. As such, its greatest potential for error is in exclusion - missing the simillimum for the case at hand in our analysis. With reference to the Materia Medica and seasoned wisdom remaining the final gold-standards in remedy selection, we can tolerate the Repertory suggesting a few extra remedies in our analyses - particularly when these errors of inclusion serve to avoid missing a good remedy suggestion due to an error of exclusion.
Due to the flexibility of the Repertory, we can create symptoms by analogy to be used in our analyses. Yet, there will be a point in case analysis - prior to choosing the remedy for the case - when we will need to critically evaluate these created symptoms, to determine whether the remedy in question really could be a serviceable simillimum in our case.
What criteria can we use to evaluate the validity of these complex symptoms assembled by analogy? How will we decide if "headache ameliorated by firm pressure" is a reasonable symptom for Colocynthis, or if "asthma better with continued motion" is a reasonable symptom for Rhus toxicodendron?
Ernest Farrington tells us that "To clearly discriminate in such cases, requires not only a general knowledge of drug effects but a particular knowledge1". What kind of "particular knowledge" is he speaking of?
Sections: 1 | 2
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.