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Review Article
6 (
3
); 115-122
doi:
10.25259/JISH_66_2023

Homoeopathic materia medica in the pre-Boger era – A narrative review

Department of Homoeopathic Materia Medica, Dr. M. L. Dhawale Memorial Homoeopathic Institute, Palghar, Maharashtra, India
Corresponding author: Dr. Bipin Sohanraj Jain, Department of Homoeopathic Materia Medica, Dr. M. L. Dhawale Memorial Homoeopathic Institute, Palghar, Maharashtra, India. drjainbipin@gmail.com
Licence
This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, transform, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.

How to cite this article: Jain BS, Kadam VV, Nayak AD. Homoeopathic materia medica in the pre-boger era – A narrative review. J Intgr Stand Homoeopathy. 2023;6:115-22. doi: 10.25259/JISH_66_2023

Abstract

Homoeopathic Materia Medica (HMM) has evolved over the years with the advent of knowledge and new remedy provings. Different authors have tried to define symptomatology using their perspectives. However, as medical science evolved over time, so did the HMM. One needs to understand the changes and philosophy incorporated when writing the HMM. Dr. Cyrus Maxwell Boger, one of the stalwarts of homoeopathy, created Boger’s synoptic key (BSK) after integrating numerous concepts and his experiences. One needs to review the HMM before the first edition of the BSK to understand the concepts used by Dr. Boger to construct the BSK. This study was performed to understand the evolution of different concepts and philosophies of HMM and their influence on Boger.

Keywords

Evolution
Synoptic key
Schematic
Narrative
Keynote

INTRODUCTION

Homoeopathic Materia Medica (HMM) is a conglomeration of symptoms from different sources. Each HMM has the imprint of its author, who has structured it based on their concepts and integrated it per the homoeopathic philosophy. Another influence is the development of medical science and general philosophy in the author’s era. Authors are also influenced by their predecessors, in person or from their writings.

Dr. Cyrus Maxwell Boger, one of the pillars of homoeopathy, was primarily influenced by Dr. Boenninghausen. Boger, with his analytical approach and ability to synthesise and conceptualise, produced a synopsis of the key symptoms of the HMM, which he named Boger’s synoptic key (BSK). The structure and presentation of the remedies are unique and reflect the artistic and intellectual quality of Boger, who integrated his clinical experience after verification in his writings and formed the Genius of remedy.[1] To explore the evolution of the BSK, one needs to understand the influence of his predecessors, their writing, and the evolution of HMM until the first edition of BSK was prepared. This will help the homoeopathic fraternity to gain a deeper understanding of what influenced Boger, which, in turn, is a good lesson in utilising existing concepts and developing new methodologies. For this review of major concepts and their integration into HMM as done by various prominent authors earlier to Dr. C. M. Boger is taken up, for understanding the evolution of BSK.

HMM begins with the publication of materia medica (MM) Pura by Dr. Hahnemann[2] – the founder of homoeopathy, which is a compilation of proving symptoms arranged in an anatomical schema. He stated that matching the symptoms of the pathogenetic action of remedy (effect of remedy on healthy prover) with the symptoms of illness, arranged in an anatomical schema, will enable the physician to determine the patient’s symptoms. The same pattern has been followed by a majority of subsequent authors.

Even after good case-taking, many practitioners found it difficult to compare the case symptoms with those of HMM. To address this, Boenninghausen proposed Location, Sensation, and Modality as the three components of a complete symptom. Boenninghausen introduced the importance of understanding the ‘seat of disease, that is, Ubi.’[3] He emphasised determining which body part is affected in a case, as homoeopathic remedies have affinities for body parts. In addition, Boenninghausen introduced the concept of grand generalisation, which supported the concept of complete symptoms. To address the issue of incomplete symptoms, he proposed ‘what is true of the part is true of the whole,’ whereby he suggested generalising particular symptoms.[3] Another important concept introduced was the concordance of remedies – meaning the different relationships among remedies.[4]

These concepts had a significant influence on the way HMM was written afterward. The importance of general symptoms, which were mostly characteristic, and the generalisation of symptoms such as sensations, modalities, locations, and underlying pathology influenced the authors of that time, which can be seen in their writings.

Dr. Von Lippe (the ‘elderly Lippe’) focused on the characteristic symptoms that are repeatedly observed during sickness, also produced in healthy subjects during proving; these help differentiate among remedies. He wrote ‘Key to the MM or Comparative Pharmacodynamics’ in 1854.[5] Dr. Von Lippe mentioned such characteristic symptoms along with their analogous drugs for comparison. He also stated the increased value of cured symptoms, which is available in proving. He directed physicians to refer to the pathogenesis to understand the relative value of symptoms in diseases to be treated; this implies understanding the evolution of disease with time and then understanding the relative value of symptoms with respect to the progressing pathology. If the symptom corresponds to the pathology, it is a common symptom; otherwise, it is characteristic. Also need to compare the symptoms in different remedies and their peculiarity.

Dr. Von Lippe primarily included Polychrest remedies – which are important and most frequently prescribed – and suggested that his HMM can also be used as a repertory. The arrangement for each remedy is a generality, pains, affinity to organ, accompanying symptoms, ‘the conditions as to time and circumstances under which the symptoms are aggravated or relieved,’ which highlights the importance of time – focusing on the time of day (morning, night, afternoon and evening), periodicity and circumstances of aggravation and amelioration – which included talking, warmth of bed, waking, rising after, cold/hot food and specific food like that; then prominent effects on different body parts. For example, Sulphur, beginning with the generalities –has the first symptom of ‘Tearing’, which is divided into

  1. Of the limbs, outer parts (analogous remedies: Acon, Ars, Bry, Chin, Kali, Lyc, Sil and Zinc)

  2. In the muscles (analogous remedies: Calc, Carbo-veg, Caust, Kali, Lyc, Merc, Nitric-ac, Rhod, Staph, Stront, and Zinc)

  3. In the joints (analogous remedies: Arg, Caust, Kali, Lyc, Merc, Rhus, Stront, and Zinc)

  4. From above downwards (analogous remedies: Caps, Fer, Kali, Lyc {marked italic}, Nux-v, Pul, and Rhus).

Another example of Sulphur is inflammation of the mucous membrane (analogous remedies: Acon, Ars, Bell, Merc, and Nux-v).

Methodology used for Review, to understand the evolution of HMM
Step 1 All homoeopathic materia medica's written earlier than BSK were identified.
Step 2 The prefaces of those books were read to understand the original author's concepts.
Step 3 Description of the remedies was referred to understand the reflection of the author's concepts regarding the representation of remedy.
Step 4 Each author's concepts were placed in a timeline. Prominent concepts which influenced the writing and future materia medica were represented in the review.
Step 5 Discussion to understand the evolution of concepts before BSK
Step 6 An attempt was made to represent the evolution of concepts used by various authors of materia medica before the BSK.

HMM: Homoeopathic materia medica, BSK: Boger's synoptic key

Thus, this work helps to understand the characteristic symptoms of the remedy, which is the generality that also includes the pathological symptoms to enable comparisons. The author has tried to introduce the value of symptoms with respect to the progress of pathology regarding time and location to decide its value and the pathological symptoms. Through his writing on analogous remedies, he introduced the concept of the group. Here, he also introduced the idea of clinicopathological correlation.

In the same year as Lippe’s Key, Teste wrote, ‘The HMM arranged systematically and practically.’ Dr. Teste elaborates on the need of systematically arrange the elementary facts of therapeutics.[6] He followed the analogous remedies to form the groups; he used the empirical knowledge available from the allopathic therapeutics which helped him to understand the physiological and pathological alterations due to medicinal action. He also referred to the work of Antoine Laurent de Jussieu, a botanist who created the foundation of the natural system of plant classification.[7] Using both references, Dr. Teste used the natural history of drugs, their known effects on animals of different species, and, most importantly, the history of their empirical application; supplemented with the diligent study of symptomatology of the remedies, he created groups based on the analogous drugs.

Dr. Teste made 20 ‘types,’ which is nothing but a group of remedies based on their sphere of action, pathophysiology, and analogous relationship. The groups are created primarily on the basis of general relations among them (groups) and secondarily those having more or less similar course and symptoms when developed under physiological conditions. For example, if we look at the types such as Mercurius or Pulsatilla, the description begins with type and analogous remedies falling under these types, like under Pulsatilla,[6] analogous remedies are Silicea, Graphites, Calcarea carbonicum, Phosphorus and Hepar sulphuricum calcareum. The common characteristics are described with respect to their common physiological sphere of action; that is, these remedies indicate the condition of the vascular apparatus, followed by the characteristic symptoms which are covered by all these remedies, followed by each remedy with their natural history, known effects on animals, then empirical applications and then homoeopathic applications where characteristic symptoms of the remedies pertaining to the chief sphere of action along with comparison within the group remedies are done; ending with remedy relationship. The author has introduced an understanding of the pathophysiology of the remedy, leading to an understanding of the evolving symptomatology of remedies and the concept of ‘Group analysis.’

In 1865, Hempel and Arndt wrote, ‘A new and comprehensive system of materia medica and therapeutics arranged on a physiologicopathological basis.’[8] Hempel tried to present the logical unit of drugs in a coherent group of physiologicopathological facts. The remedies are being explained not as per the anatomical schema but with source, preparation methods, toxicological data, and physiological action of the remedy, followed by therapeutics; these are coupled with the clinical experience of cases. For example, in Aconite,[8] the author has given the description of the natural habitat, its empirical uses along with empirical information about the same, how the tincture is prepared, some information about the Ranunculaceae family is given, as it belongs to the plant kingdom. Hempel, then shared 12 cases of poisoning; through each case, the author has evolved the physiological action and pathological action. After 12 cases, the author has summarised the action of remedies based on the diseases/therapeutics or pathology where physiological action along with characteristic symptoms of Aconite is explained. The author has extended Teste’s method, with supportive clinical experience and empirical data, to evolve the symptomatology on a physiological and pathological basis.

Thus, we can state that the concept of physiology, pathogenesis, and clinic-pathological correlation in the evolution of HMM dates back to 1853; here, the importance of physiological locations is also highlighted in the understanding of HMM.

Dr. Von Lippe wrote another book in 1866 – ‘Textbook of MM’[9]– which included mainly characteristic and most prominent special symptoms of the best proved and most frequently used remedies in practice. In this work, Dr. Von Lippe excluded the pathogenetic and curative symptoms (clinical observation of sickness); this was because these details are usually part of a textbook, and this work was more of an ‘introduction and guide.’ The arrangement is mainly Mind – head to foot anatomical schema – Generalities (including nervous system and circulation) – sleep – fever – skin – modalities (<,>), time, places, and circumstances. This work does not provide any different perspective in understanding remedies.

In 1867, Dr. Gross wrote the comparative MM,[10] the idea of which was suggested by Dr. Hering. He compared the hundred most used remedies, partly using Dr. Hahnemann’s schema. He termed the similimum a diagnosis that every homoeopathic physician should be able to find. Dr. Gross suggested that this comparison of remedies is a first step towards – as advised by Hering – ‘a mathematical method of elaborating materia medica’. Moreover, each remedy can be studied through different perspectives, and one remedy also offers a glimpse of another remedy; this is why comparing them gives a different perspective. The author has also given many examples where one symptom can be seen associated with a physiological action in the human body, for example, ‘in anger and sexual passion the secretion of saliva is increased; in a paroxysm of fear diminished’ and shared a few examples where multiple remedies have the same symptom. Dr. Gross has also tried to provide the analogy between symptoms and the circumstances and their representation in the remedies;[10] this helps to understand how a symptom actually is represented in the MM and how to understand its utility. For example:

  1. Those drugs that cause appetite for beer, as well as those which generally cause scentless flatus, are at the same time remedies for the liver. Here, the author has shown the analogy of liver affection with the characteristic symptoms that it is associated with.

  2. The condition ‘compression of teeth’ is identical to that of pressure in general, as well as with lying on the painful side. – Here, the author has shown how a symptom is generalised based on modalities.

  3. The remedies which have a specific direction to the hard palate act at the same time on the inner nose and inner ear (second branch of the trigeminal nerve); on the other hand, those remedies which act principally on the soft palate generally affect at the same time the external ear and the external nose (connection of the facial with the lingual nerve) – here, the author has clearly established the action of remedies based on their physiological understanding, that is nerve supply.[10] This approach includes the anatomical region and physiological functioning and their simultaneous logical application to the study of HMM.

Dr. Gross has acknowledged the work of Boenninghausen on Calcarea and Causticum in which contrasting features of both were described, which helped the author complete this work. He has explained how to interpret the different modalities’ side affinity – with similar examples as described above – and generalise them.[10] The author has also included the importance of moon phases and the effect of the sun in certain remedies.[10] He excluded common symptoms pertaining to the remedies that he has compared and those based on single observation. In the same work, Dr. Hering mentions that the author has not used the typological groups as published by Teste.[10] It begins with generalities, then skin, fever, mind, head to foot, modalities and finally contrasting features of compared remedies.

In 1869, Burt wrote the Characteristic MM.[11] Here, the author has mainly focused on the ‘characteristics or Keynote’ symptoms of the remedies. To make them easier to understand, the author has adopted a grouping of remedies that have similar ‘physiopathological and pathogenetic symptoms’. The author adopted this different method as he was dissatisfied with Teste’s grouping method. He felt that by understanding the pathological correlations and pathogenetic symptoms, one can apply those remedies successfully. Therefore, while describing the remedies, it begins with the special affinity of the remedy with the tissue and organ involved, at those level physiological changes and influence of pathology is mentioned followed by the characteristic symptoms of the remedy. The author has shared the source of characteristic symptoms of the other authors along with their abbreviations, wherever applicable. A total of 15 groups are mentioned; the number of remedies covered by each group varies.[11] For example, group 1 has 17 remedies, such as Aconitum napellus, Veratrum viride, Cactus grandiflorus, Gelsemium sempervirens, Bryonia alba and Rhus toxicodendron. While describing the group, author begins with the characteristics of those remedies as mentioned earlier with a physiopathological basis. These group remedies are antiphlogistics; all of them reduce activity of circulation, quiet nervous excitement and excessive action of the heart and arteries and prevent congestion and inflammation. After explaining the group characteristics, the individual remedies of the same group are explained – where initially special affinity of that remedy with respect to system/organ/tissue is taken up and physiological and pathological changes explained with the symptoms belonging to remedy, followed by characteristic symptoms of the remedy.[11]

Between 1873 and 1875, Dr. Farrington wrote the supplement to Gross’s Comparative MM part 1. As new provings had occurred, the author highlighted the organs and regions that appeared repeatedly and compared with the existing proving. Dr. Farrington suggested studying the individual remedies from any given family to find the family characteristics. He also suggested comparing the symptoms produced with the cured symptoms so that the remedy’s sphere of action can be enlarged. Finally, he recommended studying the concordance of remedies to have a new perspective towards new physiology, pathology and scientific pharmacology.[12]

Between 1874 and 1880, Dr. TF Allen published the Encyclopaedia of our MM, in which proving symptoms are arranged per the anatomical schema.[13] Here, the author has compiled symptoms from the authentic provings, and they are mentioned in the beginning of each remedy with their abbreviations, which are followed in the whole text at the relevant places, along with time of appearance of symptom and dose/potency. Special emphasis is given to general symptoms which are divided into Objective – which are given first and followed by Subjective – which are sensations. Under the same heading, symptoms pertaining to increased action, function or activity are given first, followed by symptoms pertaining to depression, loss of action or function.

In 1878, Dunham published the Lectures.[14] This work is of a narrative type, beginning with the information about the source, proving and source of information; then, the anatomical schema is followed in which symptoms of each region are discussed along with their modalities. In this same section, comparison with other remedies is also done. Then is the section of General Analysis – where mostly functional physiological actions and pathology in the remedy in terms of affinity at the tissue, organ and system level are described. This is followed by characteristic symptoms and then therapeutics application. Finally, the analogous remedies with respect to symptoms are given.

In 1897, Cowperthwaite wrote A Text book of MM: Characteristic, analytical and comparative.[15] The author felt the need to present the MM in a concise and clear manner with prominent features of remedies, which would provide a systemic knowledge base. This would help the student to comprehend the wider application of these remedies. To serve this purpose, the author included mainly two groups of symptoms. The first was those termed grand characteristics, marked with italics, found in provings and frequently verified in clinical practice. The second was those symptoms found more in practice than provings; these were marked in normal font. Remedy description begins with physiological action, which helps learn the remedy’s general action, followed by the above mentioned two groups. For comparison, remedies having similar action are mentioned. The remedy therapeutics follow, where diseases covering the remedy symptoms and those found in clinical practice are mentioned. These depict the Totality of Symptoms, which is termed homoeopathic. For example, Argentum nitricum,[15] it begins with its common name and chemical formula, then General Analysis which covers the physiological action of the remedy, followed by Characteristic symptoms in anatomical schema from mind to extremities, generality, skin, sleep, modalities (aggravation and amelioration), then therapeutic range and remedy relationships such as comparisons and antidotes.

In 1880, Dr. Hering worked on Guiding symptoms of MM;[16] he also published a condensed MM. Guiding symptoms mainly included the symptoms verified at the bedside through repeated observation; these were termed ‘principally collection of CURED SYMPTOMS’. Arrangement is anatomical schema along with introduction of grades to symptoms. In this, symptoms are also identified with the corresponding clinical disease, pathological condition or physiological general states. Tissues affected are given as a separate sub-section under applicable remedies, along with stages of life and constitution. Stages of life and constitution help to understand the affections of various systems and organs at different ages and the pathology observed. These last two sections are new compared to those in preceding HMMs.

In 1881, Dr. Burt wrote the Physiological MM to compile a book wherein remedies were explained combining pharmacology, pathology and therapeutics.[17] The author has mainly given importance to understanding the physiological action (system – organ – tissue) and pathological action of remedies on healthy organism; followed by therapeutic individuality of remedy and characteristic individuality. Characteristic symptoms found repeatedly in practice are also included in the work.

Dr. Hughes wrote the Cyclopaedia of Drug Pathogenesy in 1886.[18] It is a narrative description of remedies from toxicological/poisoning data followed by the proving symptoms obtained with potencies below 12C in the order of their circumstances and appearance.

In 1887, we have Keynotes by Guernsey and Henry; these were actually compiled after the author’s demise. These were based on lectures given by Guernsey and Henry between 1871 and 1873.[19] During these lectures, the author, through constant illustrations, called the students’ attention to special characteristics and differences between remedies with finer shades so that the students would be able to prescribe at the bedside.

In the same year, Dr. Farrington’s Clinical MM was released; this was also a compilation of lectures brought out after the author’s demise.[20] Dr. Farrington described the remedies based on the kingdom: Plant, animal and mineral. He has emphasised on clinical symptoms along with differentiation from other remedies; the intention was to prepare a firm knowledge foundation for the students. Moreover, each remedy has numerous symptoms which are difficult to memorise, so a study plan is required. Therefore, the author has tried to focus mainly on the effect of the remedy with respect to functioning – increased, decreased or altered; along with this, the pathology observed gives a collective image of remedy coupled with the understanding of the ‘relative value’ of these symptoms. Similarly, the knowledge of pathology also helps to understand the symptom’s relative. The author wished to show the students the Genius of the drug and its relations with other drugs. Therefore, he has emphasised the studying the physiological effects of remedies at different locations found predominantly in the drug for better understanding and application. The author has suggested to study the points of differences, that is, comparison of drugs. Then, the author recommends studying the relationships among drugs, the similarities and differences. There are five types of correlations – family relation, concordant, complement, antidote and enmity. Based on family relation, the author has highlighted the Plant, Animal, Mineral and Nosodes as groups where they have certain similarity and then dissimilarity in general and individual remedies are compared with related remedies; overall, the explanation is focused from general to particulars.

In 1895, Burt wrote the ‘Characteristic Materia Medica Memoriser’. This book provides a complete framework or skeleton of each drug with the most practical characteristics or keynotes with respect to drug pathology and therapeutics to build up an organic form of each remedy in the mind which can be completed with help of particular details afterwards. According to the author, this work should help students to memorise remedies; as this work provides leading characteristics of the remedies which are useful to be fixed fast in the memory and can be recalled for application, it will make a physician a good clinician.[21]

This book can be considered a gist and complement to the author’s earlier publications: Physiological MM and Characteristic MM. Each remedy is described in the following manner: Remedy name, common name followed by the special centres of action which includes system/organ and physiological-pathological changes at those centres, followed by Grand characteristics.[21]

In 1898, Nash wrote Leaders in Therapeutics: [22] ‘To fasten on the mind of the reader the strongest points in each remedy, that is, characteristics’ focus was on what we terms as keynote symptoms. The author explains the importance of pathology in understanding the symptoms. He has followed an untraditional pattern to describe the remedies (not using the alphabetical way). Author has mainly written, to share his ‘observations in practice and principles’ which he has experienced.

In 1898, Allen’s Keynotes were published; ‘mainly to help the master the guiding and characteristic’s individuality of each remedy’ which is to ease the student’s task and to help the practitioners for ‘revision’; focus is on the characteristic symptoms or keynote symptoms.[23]

In 1900, Clarke’s ‘Dictionary’[24] was published. The author’s purpose was to write ‘Materia Medica Companion to the Prescriber’ and to gather all the information pertaining to the remedy accessible at one place without being mixed/or explained with other remedies in the form of comparisons. The author has provided the information systematically, beginning with the remedy name, common name, its source, clinical – disease conditions where that remedy can be used or is being used, characteristics – which includes mainly keynotes in a narrative way, along with modalities, remedy relationships, causations, then symptoms according to the anatomical schema. This is a good compilation in narrative as well as schematic form.

In 1901, Boericke brought out the ‘Pocket Manual.’[25] The author felt the need to have a pocket companion in which characteristic and cardinal symptoms of the known remedies are contained, and the book is arranged as per the Hahnemannian Schema. The remedy begins with the description of the characteristics, which are the general action of the remedy followed by the symptoms as per the schema.

In 1901, Kent’s ‘Lectures’ were published.[26] These were actually lectures delivered by the author at the Post Graduate School of Homoeopathics, which were then compiled and extensively revised due to student demands. Dr. Kent has explained remedies in simple language as if a layman is presenting his sickness to the physician, devoid of technicalities, and in a descriptive or narrative style. The emphasis is mainly on characteristic symptoms, which are often repeated to ensure students retain them. The lecture begins with generals and progresses to the particulars, along with comparisons wherever required.

DISCUSSION

In this study, we have tried to understand the major HMM books by different authors before Boger to understand the authors’ perspectives. The pre-Boger era saw the development of medical science and philosophy, which is reflected in the writing of the HMMs as seen in the plain narration and schematic presentation of symptoms from proving data (Hahnemann, TF Allen, Hering) to the concept of taxonomy and generalisation applicable to the study of HMM (Boenninghausen). Advances in physiology, pathology, pathogenesis, and toxicology influenced subsequent writers (Von Lippe, Teste, Hempel, Hughes, Cowperthwaite, Farrington, Boericke, Clarke). These authors tried to organise the presentation of HMM from a monogram of remedies to a group approach. This approach was from the analogous remedies (Teste) to classification based on physiopathology to being based on the sphere of action (Hempel, Burt). The approach also extended to botanical/chemical/kingdom classification (Farrington E. A.). All of them focused on the value of symptoms and their derivation based on comparison with clinical diagnosis and pathological evolution. They focused on the characteristics of each drug and comparison based on similarity and dissimilarity (Gross, Farrington E. A.).

The concept of keynotes (Guernsey, Allen H. C.) originated and focused on the characteristics of the maze to help in the study and application of HMM from the maze of data, simultaneously narrative HMM (Dunham, Kent) also developed to connect with the experience of the author along with the experience of the reader which helped in recalling and application. The concept of remedy relationship also evolved based on sphere action, depth of action, pathogenesis, and similarity and dissimilarity (Boenninghausen, Gross, EA Farrington). One needs to explore now how all of this influenced Boger in his endeavour as a homoeopathic physician and author of BSK.

CONCLUSION

The era before Boger after Hahnemann’s schema saw Generalisation by Boenninghausen, Gross, Von Lippe, Dunham, Kent; Locations/regions highlighting the pathophysiological process from Boenninghausen, Teste, Hempel, Burt, Cowperthwaite, Farrington; Concept of time from Boenninghausen, Von Lippe, Gross, Farrington; Modalities and Generalising them from Boenninghausen, Gross and Farrington and the use of Characteristic symptoms and clinical symptoms by most of the above authors. HMM has evolved with the evolution of concept and time and has always progressed with the changes in the worlds of medicine and philosophy. There is a need to study how all these have influenced Boger as a homoeopathic physician and author.

Ethical approval

The Institutional Review Board approval is not required.

Declaration of patient consent

Patient’s consent was not required as there are no patients in this study.

Conflicts of interest

There are no conflicts of interest.

Use of artificial intelligence (AI)-assisted technology for manuscript preparation

The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript, and no images were manipulated using AI.

Financial support and sponsorship

Nil.

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