SELECTION OF RUBRICS FOR REPERTORIZATION


SELECTION OF RUBRICS FOR REPERTORIZATION. I have compared two methods of approach to therapeutic problems, namely the empirical without a broad general concept that tends to bring order out of its findings, and the homoeopathic which uses experiments upon human beings in health, records its findings in lay terms, thus avoiding the need to throw away all its experimental evidence with the next change in the interpretation of symptom complexes, and is operating under a broad concept of what we consider a law of nature. The unavoidable size of our task is emphasized and a method that saves tie tote busy physician is suggested.


In therapeutics, as used generally by the great majority of physicians, we find even to-day that the very ancient empirical, trial and error approach is still the only method attempted. While this is so old that it goes back to the times of primitive medical men, it is constantly being refurbished in current technical language and offered as the newest thing in therapeutics. In emphasizing the great need for sound conceptual schemes, this led Dr. James B. Conant of Harvard University to comment as follows: +1.

I have suggested …..(the) need to enquire as to the degree of empiricism now present in any branch of science. The cases I quoted as examples were classical optics and chemo-therapy. In the former the conceptual scheme employed has wide validity, the degree of empiricism is very low. In the latter (chemo-therapy) the concepts are few and of limited application progress toward a new drug is still very much a “cut and try” after, the degree of empiricism is high, I would like to suggest that unless progress is made in reducing the degree of empiricism in any area, the rate of advance of the practical arts connected with that area will be relatively slow and highly capricious.

Another phase of the empirical, trial and error approach to therapeutic problems makes use of statistical findings. It is certain that no one therapeutic approach can honestly be rated as 100 percent effective. Always there is a varying per cent of cases in which even the most effective single measure fails us. This has always been so. Today, as 100 years ago, criticism of this statistical method by such a great mathematician and thinker as Comte +2 seems just as valid as ever. He is quoted:

I wish to speak of that assumed application of it (the numerical method) which is called the Statistics of Medicine, from which so many savants expect great things, and which from its very nature, can lead only to profound and direct degradation of the medical art (which would be reduced by it to a method of blind enumeration). Such a method…..it will tend to make al rational medication…..disappear from medicine, by (leading) the practitioner to make random trials of certain therapeutic measures with the object of noting down…..the numerical results of their application.

It is evident that the continual variations to which all organism is subject, are necessarily more pronounced n a pathological than a normal state, and as a consequence of this fact, the cases must be even less exactly similar, whence results the manifest impossibility of making a judicious comparison between two curative methods derived from data furnished by statistical tables alone independent of some sound medical theory.

As opposed to this, the oldest therapeutic method, we homoeopaths have been carrying on therapeutic experiments under a concept, the law of similars, Similia Similibus Curantur, for over a century. This concept remains so radically new that the dominant majority of physicians throughout the world have failed to be conscious of its real meaning.

These experiments begin with the administration of a drug to a group of reasonably healthy people of both sexes, in order that we may see what disturbances of health, if any, may be observed and recorded. Very wisely such disturbances are recorded in the language of the “prover.” During the past 150 years that these continuing experiments have been practised throughout the world, a great wealth of findings has accumulated about a great number of drugs. This experimental material has reached encyclopaedic proportions, so that he who would make the best use of it, must use a symptom index which we call a repertory.

As a result of decades of clinical experience with the above findings at the office and bedside, it has been found advisable to divide these symptoms into two great classes, which have come to be known as GENERALS: and PARTICULARS: those that apply to local areas and or organs and or parts of the sufferers body. It is only through these two groups that we can approach the study of our case by the use of the repertory (index).

The first question in the mind of the tyro is how do we determine which method of approach to use in the study of the case before us? The answer lies in the story (history) of all of the patients complaints and findings. When the patient has a few general symptoms, which are usually expressed by his use of the personal pronoun, as for instance, I am-feel-hate-love-crave- desire-am aggravated or ameliorated by, etc., begin the repertory differentiation with these rubrics, as experience has long shown them to be the very best for our purpose. This is not an arbitrary grading of such symptoms, but has been based on the practical therapeutic experience of generations of keen physician-observers. This approach in oftenest useful in treating patients who have a long and tedious medical history of a series of chronic complaints.

In acute cases, and in the young, we are often compelled to approach our differential diagnosis of the proper remedy by beginning with a particular symptom or rubric that describes a reaction of part of the body rather than the whole body. For instance, the head, chest, abdomen, extremity, throat, lung, stomach, joint, muscle, etc., because often in these cases the better method of the use of generals cannot be applied, as we are unable to observe such symptoms in these cases.

When reliable modalities applying to a particular symptom can be found we are justified in giving it the value of a general rubric. Often, too, a combination of both methods may be used as even in infants acutely ill for the first time some mental quick may be apparent. Sometimes what would only be a particular, such as epistaxis, when associated with purpura, easy ecchymoses, etc., becomes a general symptom and any remedy found under hemorrhagic tendencies may be called for.

It is these particular symptoms as modified by some outstanding association, amelioration and or aggravation that have come to be known as “guiding” by Hering; “Keynote” by Guernsey; “leaders” by Nash and “characteristic” by others. These terms apply to the same kinds of symptoms. Their greatest value lies in their memorability; they stick in the students mind and severe to attract attention when met with in the patients history. Such common symptoms as diarrhoea, headache, vertigo pain, fever-which in themselves are of no help in the differentiation of a curative remedy-take on great value when association are considered with them.

For instance diarrhoea that drives patient out of bed early in the morning becomes a keynote of Sulphur; headache that begins or is much worse every morning from 9 to 11 A.M. and passes off in the late afternoon is a leader for Natrum mur.; vertigo that occurs only with the eyes closed is characteristic of Theridion, Lach., and Thuja; pain relieved by continued motion is characteristic of Rhus tox., Caps., Puls. and Sulph.; fever with desire to be covered brings Bell., Hep., Pyrog., Nux v., and Rhus tox. to mind.

However, experience has shown it to be unwise for the physician to place too much reliance upon such “leading,” “keynote” symptoms in making his selection of the best indicated remedy. It will give an occasional brilliant cure, but much oftener failure follows. For example, in the rubric given above, desire for covering during heat with its five “characteristic” remedies, namely, Bell., Hepar., Nux v., Pyrog., and Rhus tox., nevertheless, when this symptom is met with in a case of sickness, no matter what the diagnosis, any other one of the thirty-six remedies listed under the rubric”aversion to uncovering with fever” may be the better remedy to use, depending upon the concomitant symptomatology. To over-simplify our therapeutics by senseless elimination of known and recorded findings is to lead us into unnecessary failure and frustration.

Another hint as to the importance of a given symptom in any case is its prominence in the suffering of the patient. Does the patient list it as an outstanding cause of his distress? From a diagnostic standpoint it may be of little or no consequence, but therapeutically experience has shown that any particularly trouble-some symptom, whether it be nausea, sweating, thirst, weakness, or fear takes on added therapeutic value when it is unusually prominent.

The known fact that the attempt to repertorize by long hand, so to speak, is time consuming has led various men to try methods that may retain the advantages but that will reduce the time consumed. Field, Boger, Welch & Houston, W.W. Young, Weiss, and Jiminez have all used punched strips and or cards to make quicker eliminations. Some are too incomplete or too expensive. This led me in 1950 to compile and copyright a Punch Card Spindle Repertory of 190 General symptoms from our homoeopathic repertories. Enough experience has been had with each of these general symptoms to justify the inclusion of 15 or more remedies.

Those generals that either include too great or too few a number of drugs have been omitted, not because they have no value, but because the spindle method has physical limitations, which make the inclusion of more than 190 rubrics either too awkward or too expensive. Experience with the first experimental editions also demonstrated that greater accuracy in selecting a compound rubric containing remedies having all the patients general symptoms would not be enhanced by including the very large rubrics and might be inaccurate and misleading if those containing too few were included.

At times the inclusion of few drugs in a rubric may mean, not that no other drugs have the symptom but that observation has failed to note it. It has been shown that exclusion of a remedy from a rubric is a much more serious blunder than to include one inadvertently where it does not belong. Comparison will throw that one out, but will not restore the missing one that should be there.

Before giving a brief example of the time saving features of a punch card method let me explain that while these cards are on a spindle, which keeps them always in proper order, at the discretion of the user the spindle can be dispensed with and the cards then can be used as any loose card index.

This case is of a sixty-year-old man who comes because he has been told he has high blood pressure, 192/100. In taking his history the following general symptoms appeared:

Irritable, cranky.

Very restless.

Inclined to weep which embarrasses him very much.

Desire to be by himself.

Some pitting edema of legs to near knee.

Feels best when he keeps busy.

Has always felt worse when the weather is either too hot or too cold.

Working from these six rubrics we find that.

Weeping has 153 remedies listed.

Restlessness 200.

Averse to company 92.

Dropsy, external 89.

Better when busy or occupied 26.

Aggr. either extreme of temperature 27.

Looking through the perforations in the cards show that only three drugs are common to all, giving us a compound rubric consisting of Lyc., Nat.c., and Sepia.

Repeated urine analysis show a consistent low specific gravity, albuminuria: 140 remedies, some red blood cells: 120 remedies, sediment reddish: 84 remedies. His blood counts were within normal limits.

Of the three remedies in the compound rubric above, blood in the urine rules out Nat.c., leaving Lyc. and Sep. Albuminuria rules out Sepia. The reddish sediment contains both Sep. and Lyc. in the highest rank among the 84 drugs known to have such a symptom.

Lycopodium was given and followed by prompt improvement of his mental state and a lowering of his blood pressure, perhaps due to his greater degree of relaxation. How reversible the urinary condition is, remains to be seen as the case progresses.

Summary. I have compared two methods of approach to therapeutic problems, namely the empirical without a broad general concept that tends to bring order out of its findings, and the homoeopathic which uses experiments upon human beings in health, records its findings in lay terms, thus avoiding the need to throw away all its experimental evidence with the next change in the interpretation of symptom complexes, and is operating under a broad concept of what we consider a law of nature. The unavoidable size of our task is emphasized and a method that saves tie tote busy physician is suggested.

BIBLIOGRAPHY.

1. James B. Conant: Science, Vol. 107; Jan. 1948.

2. Carroll Dunham: Science of Therapeutics.

DISCUSSION.

DR. GARTH BOERICKE [Philadelphia, .]: I have been intrigued by Margaret Tylers method. I pressure you are familiar with it, But her method is to seek an eliminative symptom. If I were repertorizing Dr. Farleys case, I would only consider that aggravation from extremes of temperature, 27 remedies. I would have listed the 27 remedies and run against that as many rubrics as you please, arguing this way: that in a case that has an outstanding symptom of that sort, that symptom has to be n the remedy you select.

This is what I use when repertorizing. I have Dr. Farleys spindle Repertory, and I think I have every known Repertory. I always believe what Dr. Cameron said, never overlook buying a Repertory. I have dozens of them. There is always something in every Repertory that is valuable, but that is my method.

DR. ALLAN D. SUTHERLAND [Brattleboro, Vt.]: Dr. Boerickes remarks are very interesting because that same method of seeking an eliminative symptom can be used with Boenninghausens, and if shortens the work considerably.

I have compared cases, using Dr. Farleys spindle Repertory and using Boenninghausen, with the eliminative symptom system Dr. Boericke described, and it was very interesting to me to see the remedies that came through, I mean to compare them, because Boenninghausen will reach the same group, perhaps not the same value for each remedy as the spindle Repertory. Actually, there is less work involved in using the spindle Repertory and hence, it is a time-saver and is quite accurate.

In the last analysis, one has to go to the Materia Medica. You cant expect the Repertory to choose the remedy for you. That would be really making life too easy for a homoeopath, and, of course, we dont want an easy life; otherwise we wouldnt be homoeopaths, So, I will recommended Dr. Farley;s Repertory very highly as it is simple and a distinct contribution to the mechanics of remedy selection.

DR. RAY W. SPALDING [Dedham, Mass.]: I sat with Dr. Margaret Tyler over in London some years ago and watched her work. The important thing isnt just to have the eliminative symptom but if it is outstanding if it is marked, then she will use it as a check and throw everything against it. You couldnt tell, the way Dr. Farley read that paper, whether that was a marked symptom or not, at least I didnt get it that way, So I myself would be a little hesitant in using that as an elimination. But in taking the symptoms as given, I think he has shown a short cut to a consideration of several remedies.

DR. FARLEY [closing]: Thank you, Dr. Boericke. I agree with you that the eliminative symptom is one of the outstanding ways of reaching your remedy. I use it quite a good deal.

The comment that I got from Dr. Sutherland is that it came out the same as Boenninghausens method. said, “Thank God for that because if it didnt there would be something wrong with it.” [Laughter] I am still more afraid of leaving something out than I am of making the wrong punch. In the beginning I inserted go errors.

On very fifth card I punched in three to five errors deliberately, where they could be shown up very plainly on black spaces that I left. Then, for the first year or so, not one of them ever could possibly come out. It would be a ten million to one chance, because it would mean your patients complains had to be only the ones that had the errors in them. One symptom that didnt have the error would eliminate all the errors right like that.

Then I began to worry about leaving something out that ought to be in there, and that is a real worry. I still cant get around that one.

Robert Farley