Criteria for The Selection of Rubrics in a Chronic Case

[Dr K Saji]

Everyone knows that case taking, evaluation of symptoms and selection of rubrics are the main steps before repertorisation, which may lead to a successful prescription. The advent of Computer software in the field have changed repertorisation into a mere mechanical process. Ten doctors may prescribe 10 separate medicines for a single case if taken individually by each of them.

 

This is an attempt to present criteria for the selection of Rubrics for Repertorisation proper in a chronic case. I know you all will have different opinions on the subject and I am looking forward to reading what you have to say.

 

Let me explain what I mean by repertorisation proper

 

Charting out all the symptoms in a case (confirmed, doubtful, incomplete and the like) for repertorisation will result in nothing than more confusion. All the symptoms should be considered, but those which are recurrent, confirmed and more peculiar should be given more value. So Repertorisation can be subdivided in two processes.

• (a) Repertorisation proper, considering the most important symptoms and 
• (b) Analysis of all the remaining symptoms of the case.

 

 

Criteria for The Selection of Rubrics and Repertorisation Proper in a Chronic Case

 

1. The number of rubrics selected should be moderate ( Below 10 for best results ) 5-10 is the best choice. In cases with minimum number of symptoms, 2 or 3 confirmed symptoms are adequate.
   
   
2. Two or more rubrics from the same sphere or chapter should not be taken, unless unavoidable. If taken, those two should not be considered together for elimination process. Drugs usually have affinity for certain organs and parts. If more rubrics are selected from a single region, it may lead to prejudiced selection of a drug with specific action on such a region.
   
   
3. Common symptoms should not be considered as such. They may be used in a 'synthesized' form. Common symptom means, "Symptoms common to most of the drugs and most of the diseases."   For Eg. Appetite wanting, Thirst increased etc.  Here if you synthesize them to make a characteristic, " Appetite wanting, thirst with " it becomes valuable. Rubrics related to common symptoms presents with many medicines in repertory. Those related to characteristic symptoms presents with moderate number of medicines. Those rubrics with minimum medicines are reference rubrics. Common and reference rubrics should be avoided for repertorisation proper. 
   
   
4. Fixed and confirmed particulars should be given more value than assumed causatives and general symptoms - Mental or Physical. An assumed symptom, in terms of both symptom assumption and rubric assumption - can spoil the result. 
   
   
5. Symptoms represented in repertory in a scattered manner should not be considered for repertorisation. Eg. Renal Calculus In Kent's Repertory  - Urine, sediment Calculi, Phosphate , Oxalate, Sand, Gravel etc.. all leads to the main symtom 'Calculus.'  All these fractions should be combined to get a considerable rubric. 
   
   
6. Surgically treated diseases in the history of past illness should be considered as a part of the present totality. Only for those surgical diseases in which " If surgery was not done in the past, that symptom might have been present there for consideration"  Eg. Polyps, Fibroids, Deformities etc.
   
   
7. 'Hot and Chilly' fractions, 'Side' and 'Miasmatic'  symptoms should be grouped or synthesized to make a sensible combination. Hot means 'general aggravation by warmth' and Chilly means the contrary. We consider general modalities pertain to weather, bathing, clothing, air, fanning, intake etc to decide the patients thermal modality. The contradictory points are more valuable than the others. Logic of side selection and miasm also is the same. Affinity for the regionals are combined to make the general affinity, with a special note on the contradictory points. I think 'Considering Thermal modality, Side affinity, and miasm after repertorisation, for medicine selection' is an absurdity.

 

 

Analysis of the remaining symptoms.

After repertorisation proper, we will get a few medicines which covers all or almost all of the rubrics considered for repertorisation proper ( Repertorial Result ). In analysis of the remaining symptoms, we should list all the remaining symptoms of the case and should refer for the presence of these medicines in repertorial result under each of them to reach the similimum. I can show case examples if somebody is interested. There are certain methods for analysis of the repertorisation result, as well.

 

 

[Debby Bruck]

Dear Dr K Saji - this is an excellent presentation and I think could easily be categorized under Vera's recent inquiry "Towards Developing A Simple Case-Take Structure and Check-List"

Perhaps she will link this in her post.

I do encourage everyone to search the website before writing their discussion and then to Link to each other. Use the CHAINLINK icon on your menu bar to make the links. Thank you.

[Hans Weitbrecht]

Dear Dr K. Saji

There is an easy and fast way to get to the NOW needed remedy:

Materia medica Knowledge.

All it needs is to do the homework first before going out to do the job.

Doing it the other way around means: every time , at the final analysis of a case to study a few remedies entirely, which is fairly time consuming.

Having a good MMP knowledge, there is no need for repertorisation anymore, no more insecurity if the symptoms expressed can be found in MMp, or if rubrics are found to match them,-- no more too much information, or too little.

you come to that point, where you are woken by the phone from your deepest sleep, you listen to the problem, you ask few questions, you tell the remedy and dosage and fall asleep again, not remembering a thing next morning, until the phone goes again , and someone is very thankful that the problem is resolved.

As the case emerges, the most suitable remedies appear before the inner eye, alongside the individual differences, -- which at the end of case taking can be asked.

In chronic cases a case history is helpful,-- not so much for the selection of the remedy to start out with, but in determining which remedies will follow and also how quick, and in assessing the overall progress of treatment.

Boenninghausen was a master in speeding up recovery by giving series of remedies in quick succession. this method still works amazingly fast, much faster than the kentian single dose high C-potency wait and see operation.

Sincerely
Hans Weitbrecht


I remember Kent teaching: you could have pages of symptoms and still no disease - picture .

[Dr K Saji]

Dear Dr Hans

With due respect to your suggestions, I strongly disagree with you.

Even Dr.Hahnemann who proved the initial drugs was thinking of the need of an index - a repertory and he himself created one at the time when the proved medicine number was a meagre 27 ! ( Fragmenta de viribus...... 1805 ) He is the man who did more 'homework' than all of us !

Now it has grown to thousands and how can one remember the symptomatology, or the characteristics of atleast the polychrests ?

" Doing it the other way around means: every time , at the final analysis of a case to study a few remedies entirely, which is fairly time consuming. "

For this i have to explain ' Analysis of Repertorial Result'

Methods Of Analysis Of Repertorial Result

First Method

By studying the symptomatology of each and every medicine under the repertorial result in the Materia medica and finding out the most similar one, based on the symptoms present in the case.

Demerits

1.Tedious and Time consuming.
2.Each case presents a fraction of symptoms of a medicine. Comparing the whole medicine as found in Comparative materia medica is very easy but comparing fractions seem difficult
3.Reading the drug pictures of similar medicines yields nothing but confusion.

Second Method

By preparing a potential differential field ( PDF ), by finding out all the symptoms of the case other than those taken for repertorization and analyzing the repertorial result by referring for these PDF symptoms in the repertory or materia medica

Merits

1.Takes less time
2.Yields a confident result


So reference of Materia Medica after Repertorisation do not mean - reading from mind to relationship section of the medicines in the Repertorial result. It is a search for those symptoms found in the case which are not found under the available repertory.


How can somebody say that memorising the whole Materia Medica is more easier than refering a few symptoms under a few drugs !

"Boenninghausen was a master in speeding up recovery by giving series of remedies in quick succession"

I think giving series of medicines in every case do not fit with the theories of Dr.Hahnemann.

Sincerely
Saji

[DR. ARINDAM DUTTA]

Dear Dr. K Saji,

So you want to routinize the process of repertorization through certain guiding rules.
Sorry Dr. Saji, I beg to differ from you, and that too pretty strongly.

Let me explain it to you where I differ.

Repertory itself is an instrument, and repertorization is the application of that instrument to get best out of it.

Screw-driver is an instrument and an efficient use of it in the hands of a carpenter can only produce the excellent results. The use of it depends on the nature of the surface you are handling with- whether it is wood or glass or aluminium panel or venyle surface,... and so on. The efficient carpenter knows it very well and act to fit with the situation accordingly. If we try to routinize the technique the whole thing will be in a mess.

Likewise, the technique of repertorization depends solely on the presentation of symptoms.... how the patient is presenting himself to us with his signs and symptoms. Here, if we try to routinize the process of analysing a case without giving much importance to each individual patient, surely we will be biased, we will be much more attentive to maintain the guiding schema by ignoring the essence of the case.

Homoeopathy is a science as well as an art. It becomes more evident when we are repertorizing. I think it wont be irrelevant here, if I try to make a schema below in this way-


# Case taking following Organon;

# Analysis of the case in hand;

# Repertorization proper (the tabulation and computation part);

# Selecting the similimum.


Among these four areas the first, second and the fourth should be performed in an artistic approach, whereas the third one - the computation part is entirely depends upon the science.

Art is always variable and it should be so.

As far as the case taking, case analysis and similimum selection are concerned, we should react according to the patient's representation of his symptoms, our understandings of the case and our skill to apply the drug knowledge to the disease knowledge, respectively.

So all these steps will vary with their own merit for each and every individual case. If we try to manage all these three sectors in a schematic format, we can not be unprejudiced enough to make a successful homoeopathic prescription.

But as far as the tabulation and computation part is concerned, it is purely mathematics i.e. science, completely a mechanical job. If I can rely upon my memory-.... there was an old journal writing of Dr. M. Tyler, where she told us this computation part is the most boring as well as an essential part for repertorization.

........................................ARINDAM

[Dr K Saji]

Dear Dr Arindam

Very Happy to read your idea on the subject.
Can you please give me a better explanation of the last three steps. I mean Analysis, Repertorisation and Selection of Similimum. What i want to know is how do you manage those steps exactly. It is better if you explain it with an example.

Learning different ideas can correct my prejudices no ?

Saji

[DR. ARINDAM DUTTA]

Dear Dr. Saji,

My intention is not to continue this discussion only on theoretical base. As physicians we must contribute here from our little or vast experiences to enrich each other in particular and to make our Homoeopathy wealthier in general.

In my last post I had mentioned about the four areas for repertorization-

# Case taking following Organon :

On this subject so much learned discussions are going on at this moment here in HWC. So we don't require any repetition of them here. The only thing to mention here is- We should follow the rules & regulations laid down in Organon regarding CT. This is the primary and the basic criteria. Even by following this criteria we see in practice, there are different approaches from different practitioners toward this case taking event. I think it is obvious, because the whole thing depends on the skill and experiences from the physician's part. e.g.- to get the portrait of a case a novice practitioner has to wait till the end but an experienced practitioner can get many clues by studying patient's attitude, body language, dress code, etc. through his expert clinical eye.
Its like the difference between the amature detective and Sharlock Holmes....LOL.

# Analysis of the case in hand :

On a practical basis we may subdivide this event.

Picking up of characteristics-
We have already taken the full case. Now to initiate the analysis, we have to identify the symptoms. What the patient has told us, all of them may not be the symptom.
e.g.- patient may complain about nausea in the morning whenever he tries to clean his tongue base by touching it with his fingers. Is it a symptom? No, obviously not. This is physiology.
Again our patient may give us plenty of symptoms. We have to chose only those symptoms which characterize or individualize the patient from others. That is to say making the portrait of the case.

Evaluation-
We have to categorize the characteristics of the patient according to the intensity of them in the case. There are different philosophical concepts to do it. Which one we have to adopt depends upon the presentation and the merit of the case in hand.
Here also I think a bit elaboration is needed. Suppose we have adopted Kentian way, because the case in hand is full of strong generals and peculiar particulars. The case has mentals .... but they are not so strong enough in comparison with physicals. Should we give priority to these vague mentals only because they are mentals? No. Here we have to evaluate the symptoms according to their strength of presentation in the case.

Repertory selection-
As soon as the evaluation is done, the selection of the philosophy of repertory is over. Now it is our turn to select our favorite repertory backed by that chosen philosophy.

Conversion into rubrics-
Here our skill and acquaintance with the selected repertory are needed. Proper understanding of the rubrics' meaning is essential.

# Repertorization :

Repertory searching-
We should have a through knowledge about the plan of construction of the selected repertory.

Repertorization proper (Tabulation & computation)-
This step is truly mechanical. Only plain calculation is needed. In different notebooks authors tried to present various techniques of achieving it, but they are only theoretical. The essence of this step is to calculate mechanically which drugs cover all or most of the rubrics of the case along with how much ranks they have scored. Here lies the scope of softwares which can calculate the whole mathematics flawlessly in fractions of a second.

Repertorial result-
Accurate calculations will give us the result which consists of a small group of drugs similar to the case in hand.

So from the discussions above in the area of Repertorization it is quite clear that the whole process is purely a mechanical job and has no scope of applying Homoeopathic skill or art.


# Selecting the similimum :

Similimum selection by consulting Materia Medica-
We have to match the portrait of the patient with the portrait of the drug. The most closer similar medicine to the case may be selected as similimum. Dr. Dhawale of I.C.R., Bombay, India coined the term PDF ( Potential Differential Field) to describe all the symptoms of the case other than the evaluated ones and taught us that this pdf plays a vital role for the similimum selection after consulting Materia Medicas.

Cross repertorization-
Sometimes to gain the firm conviction over our prescription we may re-repertorize the same case with different repertories, provided the case in hand has a wide dimension to be fit in for any type of analysis.

Prescription.-
Now the selected similimum is to be prescribed. The potency, dose, repetition schedule are to be finalized on the basis of susceptibility, level of similarity, functional and structural changes, underlying miasms, etc.




While performing the above mentioned steps at the time of repertorization we have to be versatile with each and every case separately according to their merit. If we try to fix any strict rule as you have mentioned under the heading “Criteria for The Selection of Rubrics  - for Repertorisation Proper - in a Chronic Case” I think the whole thing will be spoiled for the sake of maintaining the routine and ignoring the patient as a separate individual.

..................................ARINDAM

[Dr K Saji]

Dear Dr Arindam

Now i can point out where exactly my subject fits into.

We too had been taught in the same manner, the same steps and every one know that these are the essential points; but

After Case taking, Analysis of Symptoms, Evaluation of symptoms, Selection of Repertory and Conversion of symptoms into rubrics we should decide what rubrics are to be considered for Repertorisation proper -And that is the subject i am trying to discuss.

We all know that repertorisation of all the rubrics in a case will not yield a good result. After evaluation of the totality, the physician have to decide which are the rubrics to be cosidered for Repertorisation proper.

In my opinion, there are 10 points in Homoeopathic case study.

1. CASE IDENTIFICATION :

An immediate identification, an overall assessment, whether the case is acute, sub-acute, chronic, intermittent etc., because, the next steps depend on the nature of the case.

2. CASE TAKING
3. ANALYSIS AND EVALUATION OF SYMPTOMS

4. RUBRIC SELECTION

5. REPERTORISATION PROPER
6. ANALYSIS OF REPERTORIAL RESULT
7. ANALYSIS OF REMAINING SYMPTOMS ( PDF )
8. MEDICINE SELECTION
9. POTENCY & DOSE SELECTION
10. FOLLOW UP

RUBRIC SELECTION is the part i was trying to explain.

"Repertorial result-
Accurate calculations will give us the result which consists of a small group of drugs similar to the case in hand."

For this let me give my idea on

REPERTORIAL RESULT : Evaluation & Interpretation

Criteria Of A Good Repertorial Result

1. A Minimum Number Of Competing Medicines

Less Than Five Is The Best :Many Medicines With Almost Similar Coverage-Results From Repertorisation Of Common Symptoms

2. Related Medicines

Repertorial Result Containing Inimical Medicines Is The Best
Repertorial Result Containing Complimentaries Is Next
Repertorial Result With Antidotes Is Last
Repertorial Result With Unrelated Remedies- Least



For this it is good if we have a look into the symptomatic relationship of the related medicines.

Inimicals : Those with maximum Similarity becomes inimical.

Eg.

Rhus-t, Apis
Phos, Caust
Calc-c, Bar-c
Psor, Sep
Bell, Dulc
Merc sol, Sil.

Antidotes : Those with moderate Similarity

Eg.

Bell, Hep
Borax, Cham
Canth, Apis
Graph, Nux
Ipecac, Ars
Nat mur, Phos

Complimentaries : Those which are similar with cotradictory modality

Eg.

Rhus-t, Bry
Ars, Phos
Lach, Lyc


I had mentioned about the Methods of Analysis of Repertorial Result in my previous post


Verifying Repertorial Result :

One Among The Medicines In the Repertorial Result Will Cover All Or Almost All Of The Rubrics Under PDF. If Not, It Reveals That There Occurred Some Error In Our Repertorisation. ( Case taking error, Evaluation Error, Symptom to rubric conversion error, Selection Error , Repertory Error Or Mechanical Error )

NB : That Sherlock Holms comparison is a Classic one !! LOL

Sincerely
Saji

[dipesh k vyas]

thank you sir I would like to learn more about rubrics

[Vicky Zora]

Dr K. Saji. I do like and I agree with this method of repertorization and analysis. In addition I would be appreciated if you could give us some more case examples.

[Dr K Saji]

CASE 1.

 

R - Female 36yrs, Housewife.

 

PC :

1. Knee pain – Right :  4-5 months duration

            Intense pain

            < 3-4 days.

            < walking, rising from sitting, ascending stairs

2. Pain in finger joints – vague pain, with mild stiffness.

            < Morning

3. Pain in wrists - occasional

 

HPC : Had temporary relief with pain killers at the beginning. The case was diagnosed as RA by an Post Graduate (GM)  doctor. He referred the case to Homoeopathy.

 

HPI : Skin eruption 10 yrs back – On dorsum of feet – for about 3-4 yrs. Had AGN in the course of

treatment. Both relieved with allopathic medication.

 

FH :

            Twin sister – Eczema - RA

            Mother  - DM

            Father* - HTN

PH :

            Husband – Auto driver

            two children ( 5,1)

 

 

Generals :

 

            Heat sensation of

            Appetite : diminished.

            Desires sour

            Unsatisfactory stools.

 

Regionals :

 

            Perspiration of face (Observed Symptom)

 

            Itching between thighs, with discolouration and desquamation–7-8 yrs duration-recurrent

 

            Brittle finger nails, Shapeless. – 2-3 yrs duration

 

            Ingrowing nails – toes – 4-5 yrs duration

 

            Back pain – lumbar – menses during.

 

Mind :

            Husband was a bit handicapped. He corrected his complaint recently with a surgery. Now       

            she is living in her house with her mother for the last 5-6 months. She never mentioned

            anything about her family problem.

 

Investigation : Before : 20/08/11.

 

            RA Factor - Positive : 86 IU/ml.

Rubrics :

1.Extremities; ingrowing toenails

2.Extremities; eruptions; feet; back
3.Extremities; inflammation; chronic; joints

Repertorial Result :

Caust
Sil
Thuj
Hep

( Sil and Thuja - Complementary; Sil and Hep - Antidote )

Remaining symptoms :

1. Extremities; pain; knees; ascending stairs agg. : Thuj.
2. Extremities; pain; knees; right : Caust., Thuj.
3. Extremities; pain; fingers; joints : Caust., Sil., Thuj., Hep.
4. Extremities, pain, rheumatic, knees : Caust., Thuj.
5. Skin; eruptions; suppressed : Caust., Sil., Thuj., Hep.
6. Generals, Heat, sensation in body : Caust., Thuj.
7. Generalities; food and drinks; sour, acid; desires : Thuj., Hep.
8. Rectum; constipation; insufficient, incomplete, unsatisfactory stools : Sil., Thuj., Hep.
9. Face; perspiration : Sil., Thuj., Hep.
10.Extremities; excoriation; thighs, between : Caust., Thuj.,Hep.
11.Extremities; brittle; nails : Caust., Thuj., Hep.
12.Back; pain; lumbar region, lumbago; menses; during : Caust., Thuj.

Prescription : Thuja CM/1d + Placebo.

 

Investigation : After : 27/10/11.

 

            RA Factor - Negative

CASE 2 :

J-Female, 25 yrs.

 Date : 11/03/06

 

PC : Infertility, primary, 3 yrs duration.

 

HPC : Consulted a Gynaecologist for late menses and he diagnosed the case as PCO. Advised some anti-diabetic tablets, hormone supplements and regular exercise. Patient tried this for about 4 months. Menses was regular during the treatment period but, became irregular again when she discontinued the hormone supplements.

 

HPI : Hypotension

         Recurrent painful oral ulcers.

 

FH : Father is diabetic.

 

Generals :

 

Appetite increased.

Profuse sweating

 

 

MH : Late (2-3 months) protracted, profuse menses.

         Irritable before menses, Constipation during menses, Pain in lower limbs during menses.

 

BP : 100/70 mm of Hg

Investigation before : Follicular study : 16/12/05.

 

            Multiple small follicles in both ovaries ( PCO )

            A developing follicle in left ovary

            Re-scan on 21/12/05 : No significant increase in size of follicle.

 

Rubrics :

1. Mind; irritability; menses; before (70)
2. Abdomen; degeneration; fatty; liver (62)
3. Clinical; hypotension (76)
4. Mouth; ulcers; painful(67)

Repertorial result :

Nat-m
Phos

Remaining rubrics :

1. Extremities; pain; lower limbs; menses; during -Phos
2. Female, Infertility - Nat-m, Phos
3. Rectum; constipation; menses; during - Nat-m, Phos
4. Female; menses; late, too; profuse, and - Phos
5. Female; sterility; menses; early, and too; late, or too - Phos

Prescription (11/03/06) : Phos CM/1d.

 

 

Investigation after : Follicular study : 17/06/06.

 

            A developing follicle in left ovary

            Re-scan on 21-06-06 : Follicle left 1.5 x 1.3 cm

            Re-scan in  26-06-06 : US features suggestive of follicular rupture.

[faridul islam]

Repertorizing with all available data of the pt will lead to failure and we will find that only a number of polycrest are coming in the result.  Now from my 7 yrs experience  I fully  agree with u. I have some question/observation about  importance  of symptoms of some particular origin which i would like to share u in future.  I have some confusion about - The contradictory points are more valuable than the others. Logic of side selection and miasm also is the same. Affinity for the regionals are combined to make the general affinity, with a special note on the contradictory points. I think 'Considering Thermal modality, Side affinity, and miasm after repertorisation, for medicine selection' is an absurdity. would u pl explain a little more

regards

farid