Symptoms by Analogy (By Will Taylor, MD 2001)

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
and
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?

One form of "particular knowledge" is clinical verification. Following up on the "amelioration by pressure" modality for Colocynthis, generalized from the proving symptom of "abdominal colic ameliorated by firm pressure" and applied by analogy to headache, Samuel Lillienthal described the following for Colocynthis in his Clinical Therapeutics:

Bilious headaches; gouty or nervous headaches, of excruciating severity; violent tearing pain, digging through the whole brain, increased particularly when moving the upper eyelid; frontal and coeliac neuralgia alternating; intermittent headaches; severe boring burning pain in one or both temples; compressive sensation in forehead; worse when stooping or lying on back; aggravation afternoon and evening, with great restlessness and anguish, especially when the sweat smells urinous; little urine is passed, or very foul-smelling during the interval, and copiously and clear during the pain, amel. by firm pressure and lying on affected side; great restlessness and anxiety.

Here we have two separate pieces of information, each standing on somewhat shaky ground (on one hand, a complex symptom created by analogy; on the other hand, a clinically-derived symptom). Each gains strength, however, by its association with the other. Our ability to create the symptom of "headache ameliorated by firm pressure" by analogy supports our accepting it as a clinically-derived symptom; and the clinical verification of this symptom conversely supports the validity of our creation of it by analogy. I believe it was Sherlock Holmes who said "an improbable piece of evidence gains in strength by its association with known facts".

Another form of "particular knowledge" is based on a deeper appreciation of the pathogenesis of our remedies. Farrington gives some excellent examples of this in his essay Modalities as Arranged by Boenninghausen1. One example he gives, is the well-known "amelioration from violent exertion of the body" for Sepia. Is this equally applicable to Sepia's lumbosacral pains and to its pelvic congestive symptoms? A thorough knowledge of Sepia tells us that it is not. Sepia's amelioration by vigorous motion appears to apply to those physical symptoms that have to do with vasomotor relaxation and impaired venous and lymphatic return, and to those mental/emotional symptoms that have to do with emotional stasis. Its lumbosacral pains are markedly aggravated by motion. Therefore, we can really apply the modality "ameliorated by vigorous exertion" only to symptoms of Sepia that originate with venous, lymphatic or emotional stasis.

The Use of Symptoms by Analogy in Case Analysis

Use of General Sensations and Modalities

Here's a fragment of a case, successfully cured with Argentum nitricum, a prescription that was nicely confirmed in the characterizing totality of the entire case. I'd like to focus now, though, on just the local presenting complaint, in a case-fragment.

This was a carpenter, who presented with multiple small pimple-like skin lesions widely distributed on his trunk and limbs, which would occasionally head up and express a tiny amount of discharge. He was not too concerned otherwise, but they were very painful - "like splinters, very sharp". He obtained some relief from applying cool compresses.

Here is a repertorization of this case-fragment, using the "pain-stitching" and "cold applications-ameliorate" rubrics from the Generals section of the Repertory. Argentum nitricum comes through nicely. (The rubrics "Skin-eruptions-pustules" and "Skin-eruptions-pimples" were combined for the purposes of this analysis). I would have missed this remedy using local modalities and sensations, because Argentum nitricum is not listed in the Skin section under any "stitching" or similar rubrics, or any "cold ameliorates" rubrics. These are strong symptoms observed in other localities in Arg-n's provings, which have been generalized and applied by analogy to the skin lesions of this case.

Stitching pimples

(Note - final selection of the remedy for this case required attention to more than just this local complaint - clearly, with just the information given here, Bryonia and Cantharis remain in consideration).

Combining Local and General Modalities or Sensations

Where Local and General modalities or sensations exist, the local rubric can be combined with the general rubric, to assure inclusion. This may be important, in cases where there is a "paradoxical" local modality or sensation in the remedy needed for the case. I've already mentioned the "paradoxical" modality of Arsenicum album, of head pain ameliorated by cold applications (paradoxical, because Arsenicum is generally worse cold). Were we working up an Arsenicum case, and used only the general modality:

GENERALS - COLD APPLICATIONS - amel.

We would risk missing Arsenicum in the case, as it is not present in this general rubric; while it is prominent in the special local modality:

HEAD - PAIN - cold - applications - amel.

Combining Rubrics

It is simple to combine rubrics in RADAR. The rubrics will appear separately in the analysis clipboard and analysis graph, but will be calculated as one combined rubric in the analysis. Rubrics may be combined when selected, or after they have been collected in the analysis clipboard. To combine them when selected, type "+(grade)(group_letter)" - e.g., "+1a" when the pointing hand is on the desired rubric:

Adding

You can then go on to add any number of additional rubrics to this rubric group, by including the group letter (here, "a") after the grade in the addition command.

For rubrics already selected in the analysis clipboard, control-click on the rubrics you wish to combine, so that they're both (or all) highlighted. Press to open the Edit Take Options dialog box, and enter a letter in the "Add this symptom to group" box:

Adding
Searching for Rubrics

Often it is not clear which rubric(s) apply best to the case at hand. In the case of the stitching pimples above, there is no obvious rubric for the local sensation of "stitching pimples" or "stitching pustules". A convenient way to find local (skin) sensations rubrics that might be of use is to use RADAR's search command. Typing a question mark automatically brings up the dialog box, and the terms "skin" and "stitch*" (using the asterisk as a wildcard to find "stitch," "stitching," etc.) are entered:

Searching

Pressing <RETURN> gives us a list of "skin stitching" rubrics. Note that none of these really refer directly to the complex symptom of our case; we will be using them only for the local (skin) sensation of "stitching," which they include as one of their dimensions; and will be applying this by analogy to the pimples/pustules:

Searching

These can then be combined as a group, along with the General "pain-stitching" rubric, so that they will collectively be considered as a single combined rubric in the analysis. Here the letter "b" is chosen for the group, as "a" has already been used to combine the pimple and pustule rubrics:

The Thread of Truth that Runs Through

Boenninghausen has offered us a creative method of making up for the inadequacies of our provings and clinical observations of cure, by the generalization of sensations and modalities, and their recombination into complex symptoms by analogy.

Hering and Farrington remind us that this liberty demands of us some attention to detail, requiring a deep knowledge of the particulars of drug effects, and an awareness of the frequent importance of truly local or locally paradoxical modalities and sensations.

If we are cautious in these ways, and remember always that the final selection of the remedy requires careful discernment while placing the case next to the primary Materia Medica, then Boenninghausen's approach will offer us a tool simultaneously creative and safe from excesses.

Related Article:

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.