Grading of Symptoms

-- C. M. Boger, 1925

Most repertory making is the compiling of a working index of the Materia Medica, and because of its magnitude has long ago passed beyond the powers of a single mind. Even major works of this kind soon fall behind developments, so we now use a form of analysis which assembles the most salient and useful points into rubrics, which are then arranged in a flexible and easily grasped schema.

Illness may present any possible combination from among many thousands of symptoms, although as a matter of fact such extreme variability of disease expression is the exception; were it otherwise the problem must remain, practically unsolvable. Most of its symptom groups are referable to particular diseases, organs and individuals. The two former remain fairly constant, at times, how-ever, exhibiting very pronounced disease phases, thereby beclouding the diagnosis and leading to organopathic, pathological or diagnostic prescribing of a makeshift nature; ultimately a most pernicious thing.

Of far greater importance are the individualistic symptom groupings, for they generally show forth the real man, his moods, his ways and his particular reactions. Occurring singly, in small groups or at indefinite intervals, they often seem to lack distinctive support, hence are more difficult to link together and interpret. This encourages palliative medication as well as makes real curing much harder. On the other hand cases presenting very numerous symptoms are hard to unravel, especially when brooded over by an active imagination.

The final analysis of every case resolves itself into the assembling of the individualistic symptoms into one group and collecting the disease manifestations into another, then finding the remedy which runs through both, while placing the greater emphasis on the former. This method applies to repertory making just as fully as it does to case taking and prescribing. Therefore the over large rubrics of our repertories are likely to be more useful for occasional confirmatory reference, than for the running down of the final remedy. By eliminating all but the two highest grades of remedies in the large, general and including all the confirmed ones in the smaller rubrics we bring to the fore the largest possible number of characteristics. Each case, of even the same disease, presents a slightly different alignment of symptoms, particularly in its latest and most significant development, which is usually but an outcropping of another link in the chain of individualistic symptoms belonging to the life history of the patient. This way of looking at the matter presupposes the taking of a pretty thorough case history, but furnishes a therapeutic key to almost every sickness for long periods of time.

While the grading of symptoms largely depends upon their discovery and the extent of subsequent confirmation obtained for every one of them, their spheres of action are also of vast importance, and may not be safely left out of the calculation, because they go far toward certifying the choice of the remedy. To depend wholly upon a numerical concurrence is indeed, fallacious, and yet, every use of the repertory implies the presence of this factor, to some extent; but it is greatly over-shadowed by the relative standing of the individual symptoms.

In the abstract the same symptom may have the highest standing in one case and the lowest in the next, all depending upon the general outline of the case, as delimited by the associated symptoms. Viewed from this standpoint symptom grading, as found in the repertories, is unsatisfactory as well as of lesser importance, and yet has great value. The relative value of a given symptom. depends almost wholly upon its setting, therefore changes from case to case and is only finally determined as to its repertorial standing by numerous clinical trials. If I apprehend the matter rightly the original pathogenetic symptom is really only a hint of what it may possibly develop in the future, as determined by successive testings.

A case in point: Intolerance of clothes about the neck is found in the provings of, quite a number of remedies, but it remained for Hering's Lachesis to show that it very decidedly outranks them all, and has really only a few straggling followers. This is a particular which accentuates the value of Lachesis over Glonoinum if the patient is intolerant of heat, but if sensitive to cold Sepia takes the lead.

Experience leads to the conclusion that the patient's actions and what he says of himself, are of the highest import and may not be lightly set aside. Just so, do drugs, in their general action, exhibit this or that predominant phase, and when one finds its counterpart in the other, the similimum has been discovered, provided the remedy contains the characteristic of the case in hand, also. For example, we do not think of Phosphoric Acid for excitable, or Coffea for lethargic patients, unless the individualistic symptoms call for these remedies in the most positive way, an unlikely contingency. The quality of the general reaction greatly influences symptom values, be they pathogenetic or clinical.

In a new proving each prover reacts to only a part of the prospective picture and we properly sense the whole only by seeing all the parts as a compound unit, exactly as we see it in disease, the arrangement never being precisely the same, in either case.

The interrelation of effects always brings out a certain demeanour or general reaction. It is nature picturing forth her demands in the oldest and most flexible of languages, that can be thoroughly understood only by also taking fully into account the context.

The whole trend of education leaned more and more toward fixity, until first Madame Curie and then Einstein demonstrated the essential fallacy of such a position. In this connection I would call your attention to Hahnemann, his philosophy and his Materia Medica, in the practical application of which fixedness is reduced to the observation of certain natural working rules which underlie successful medical practice and that these are essentially of a flexible nature.

DISCUSSION

Dr. Field: We all know the versatility of Dr. Boger regarding his subject, but relative to the subject in hand, leads me, to think back to the correspondence and a good deal of it, between a good many physicians through the States, and myself, regarding the repertory of why I did not include thirty-three rubrics in the symptoms in Deek's repertory. At the time I answered the questions as well as I could, telling them that perhaps some of them were not authentic, and some often were, but during the interim, having a sort of inter-chronological leaning myself, I think I have explained the reason for it.

I discussed this thing with Dr. Stearns in two or three words yesterday, as simply this: a good many of the particulars are absolutely non-authentic. I make this statement. The statement is made with these points in view, of course: modem science teaches us, or as a matter of fact every one knew years ago, that every individual is a different individual. In other words, if I were to give a certain individual some strawberries, and it were to produce a rash, if I were to put that down as a proving of strawberries, for that reason, that would be nonsense. One person may be sensitised to strawberries and another person might not be helped by strawberries.

In other words, if we were to take any of our well-known polychrests, at the present time, and give it to about twelve types of individuals, we see some are similar and some are absolutely different. We get a certain definite Mix Vomica proving which would stand out as a Nux vomica proving, and I should judge that would be about four or five rubrics. Then we would get particular symptoms among the types of individuals which would only hold good among certain individuals of that type. We couldn't put that peculiar type down as a type to be asked for someone affected of the same similimum unless- he was the same type of individual. By type, we will briefly state there are some individuals who are prone to be bald-headed, and some individuals who cannot lose their hair, regardless of tonics. Now that isn't just because it is so, there is a reason for that. Those individuals who cannot lose their hair if they did all the thinking and studying in the world, and the other individuals, no matter how often they would use hair restorers would never have their hair grow back again. There is some other reason. The same thing runs with the mentality of the individual, the same thing goes with the gastric intestina1 symptoms of the individual, and if we were just to use as Dr. Boger said, the particulars to sort of check up, as we say, ok, the actual symptoms of the case at hand which are practically the mentals, the generals, and some of the major things, I think we would come closer to it.

Dr. Waffensmith: I merely want to thank Dr. Boger for this most masterful address on the philosophy of the study of the repertory. I am very much impressed with the way in which he presented the fact that there exists in the last analysis a fundamental individualistic relationship between the prescriber and the patient which is different than any other preceding relationship could or had been seen before.

In other words, if you don't get in the correct relationship with our patient dynamically, as it were, we cannot use these tools that we have at our discretion, satisfactorily. And this was presented, it seems to me, in a most masterful fashion by Dr. Boger in this remarkable paper.

Dr. Boger: Let me emphasize one point not in the paper; it is the greatest art which the physician can attain: the art of quick adjustment. If you can grasp what I mean. To see Nux vomica in this case and Nux vomica in the next, even if the pictures are different. The flash comes before you, one after another, just like the motion pictures, and you adjust yourself as the flash comes and goes.