Understanding the application of Boger’s concepts while using Boger’s Synoptic Key: A case series
Objectives:Boger’s Synoptic Key is a less frequently used repertory. Homoeopaths can use it very effectively if they have the appropriate understanding of Boger’s philosophy and the background concepts. This paper explores the essential background concepts for using Boger’s Synoptic Key through a case series.
Materials and Methods:A retrospective study was done of the cases successfully treated by the author in his private practice using Boger’s Synoptic Key. Analysis of symptoms and prescribing totality was done to identify the background concepts applied when using Boger’s Synoptic Key.
Results:Concepts of tissue affinity, pathological generals, generalisation and consideration of modality and concomitant were identified as applied in case analysis and remedies arrived at through the use of Boger’s Synoptic Key.
Conclusion:Boger’s Synoptic Key is a tool well integrated with the concepts of generalisation, tissue affinity, time dimension and pathological generals and their importance in disease evolution. Hence, it needs to be used with consideration of these concepts in case processing.
The repertory section of Boger’s Synoptic Key is infrequently used. However, some homoeopaths use it very effectively due to their in-depth understanding of Boger’s philosophy. Boger’s Synoptic Key is a masterful piece of work for practical use, as its structure is closely linked with its background concepts. To use this book effectively, understanding these background concepts are essential. This paper explores the essential background concepts for using Boger’s Synoptic Key through case series.
Dr. Boger worked extensively on Boenninghausen’s philosophy and works. Boger’s Boenninghausen’s Characteristics and Repertory is a comprehensive compilation of Boenninghausen’s work based on Boenninghausen’s philosophy. Boger’s Synoptic Key was initially the extraction of the most marked rubrics and remedies from Boenninghausen’s repertory; subsequently, it was enriched with information Boger’s derived from clinical experience.
In the foreword of Boger’s Synoptic Key, he proposes to seek from the patient his understanding of evolution of clinical picture including the causation and modality followed by mind, general sensations, objective aspect and part affected.
However, in the last days of his life, he expressed his thoughts on case processing in a letter to Dr. L. D. Dhawale: “In my card system, I have taken middle ground by finding anatomical sphere wherein a symptom arises or occurs, modifying this by modalities first then reducing the number of remedies by noting the discrete symptoms as found in Kent. This soon reduces the drugs to a smaller number, when the mental outlook as given in a pathogenesis will decide.”
Dr. Winter wrote the following about Boger’s Synoptic Key, “Immediately after Boger’s death in 1935, the book became more and more misunderstood and slowly changed its place from the desk to the library and its use became rare.”
However, Dr. R. E. Hayes, Dr L. D. Dhawale, Dr S. R. Phatak, Dr M. L. Dhawale, Dr P. Sankaran and Dr. Kasad utilised the understanding of the structure and the background philosophy of the book and used it successfully in their clinical practice.
The successful application of this work relies on the grasp of the philosophy Boger used to build it. Without understanding, it one may not be able to solve the case.
Boger shares his philosophy related to pathogenesis and tissue affinity through a case requiring Strontium salts in his article. Moreover, his correspondences with Dr. L. D. Dhawale highlighted his emphasis on considering the affected location or tissue as most important, followed by the modality for further differentiation, characteristic particulars and the mental aspect at the final stage as his method of case processing.
Dr. L. D. Dhawale gave a formal structure to the repertorial approach if one has to apply Boger’s approach in managing a case. He highlighted the pathological generals with importance given to modality and concomitant with a focus on generalisation; this is detailed in the introduction to Boger’s card repertory, which is based on the same philosophy as Boger’s Synoptic Key.
Dr. S. R. Phatak used Boger’s Synoptic Key as his primary reference for Materia Medica and repertory, he was well-versed with every aspect of the book and every rubric from the repertory section; he used this information to the patient’s advantage, as seen in his clinical cases. Two of the most evocative examples that stress on the importance of generalisation, modalities and concomitant in case analysis are a case of cystitis treated with nitric acid and a case of peripheral neuritis treated with argentum nitricum. He at times applied the concept of generalisation/ analogous interpretation to the available symptoms and determined a more suitable modality or rubric from the book, as we can learn from the case of cystitis treated with nitric acid.
Dr. Kasad developed a systematic understanding of Boger’s concept and technique. He highlighted the time dimension, tissue affinity and pathological generals as key aspects of Boger’s approach that is to be used when dealing with his repertory. The time dimension is appreciated in the time modality chapter in the repertory; at a broader level, the evolution of disease with time is studied considering causation, concomitant and pace. Further, the time dimension can be appreciated at different level; time of day, periodic expression of disease, stage/epoch of life and evolution pattern of disease expressed on time axis. He also incorporated modern clinical knowledge into the explanations of some potent rubrics of Boger’s Synoptic Key. These knowledges are essential while working with Boger’s Synoptic Key.
In recent times, Dr. Winter has shared his understanding about Boger’s way of thinking and Boger’s Repertories and Repertorisation Methods in his interview. He also shared his understanding about case processing using terms such as spatial pervasion, temporal pervasion and qualitative pervasion while working with Boger’s Synoptic Key.
Dr. P. M. Barvalia emphasised in an interview the understanding of pathogenesis, which is the consideration of evolution of disease process as well as the characteristic aspect of disease process. This is more important than pathology while applying Boger’s Concept and Boger’s Synoptic Key; the concept is amply illustrated with several examples.
This study tries to understand the application of Boger’s philosophy applied in cases worked with Boger’s Synoptic Key.
MATERIALS AND METHODS
This was a retrospective study – case series method.
A retrospective analysis of cases was conducted to show the application of Boger’s Synoptic Key, its section of repertory and Materia Medica, while incorporating the underlying philosophy.
Successfully treated cases from private practice were selected where Boger’s Synoptic Key was used. As most of these cases typically presented with limited data, in light of Boger’s philosophy and interpretation, generalised rubrics were useful to work on them. Direct references from a larger repertory without philosophy might not be helpful, as all symptoms are not important but states and patterns were elicited from data, which is more suitable to application of Boger’s Synoptic Key.
Cases were studied from Boger’s philosophy perspective, analysed and repertorised with Boger’s Synoptic Key’s repertory section.
A 28-year-old woman, a teacher by profession, complained of hypopigmented spots all over the body for 3 months. The spots started during the 8th month of pregnancy. They started on the face and spread to the upper limbs, back and rest of the body. The case was defined 1 month after delivery. Unfortunately, her baby was crying constantly, so the detailed case taking was postponed.
She also had agalactorrhoea since delivery. There was no milk production whatsoever. She tried some Allopathic and Ayurvedic medicines without benefit.
O/H: G2P2A0L2; 2 full-term lower segment caesarean section (LSCS)
The case was defined in detail in the next follow-up.
Pityriasis alba, post-LSCS agalactorrhoea.
Symptom classification [Table 1]
|Hypopigmented spots on face then spread arms, forearms and back and all over body||Location/pattern of complaints/characteristic|
|Pregnancy aggravation||Modality (epoch)|
|Milk absent in lactation||Characteristic/concomitant|
Rubrics from Boger’s Synoptic Key – Repertory and its philosophical implication [Table 2].
|Generalities: Pregnancy, childbed, etc.||Both complaints are related to pregnancy, it is, therefore, a time dimension – epoch, modality.|
|Mammae: Milk, scanty, absent, etc.||Characteristic concomitant, expression during physiological stress.|
|Generalities: Direction, downwards||Pathogenesis pattern of appearance of symptoms|
Boger’s Synoptic Key Repertory section [Table 3].
|Generalities: Pregnancy, childbed, etc.||3||2||2||1|
|Mammae: Milk, scanty, absent, etc.||2||2||0||0|
|Generalities: Direction, downwards||1||1||1||1|
The repertorial totality is well covered by Pulsatilla and Bryonia. Based on the Materia Medica reference from Boger’s Synoptic Key, Pulsatilla was selected for having chief and marked action on pregnancy and the lactation state, both of which are prominent in the case, and the important concomitant of suppression of lactation.
Pulsatilla 200 one dose weekly for 1 month.
Total improvement in skin hypopigmented spots observed. Patient also reported improved milk production within the 1 month of treatment.
State of pregnancy and childbirth in one rubric reflects the affection related to it. Here, both complaints are related to an epoch, an important stage in patient’s life where expressions are available making it a modality as well. Thus, the rubric pregnancy, childbed, etc., are considered as an expression of time dimension as well as modality in this case, which was then considered with generalisation. Concomitant and the pattern and progression of complaints, which are parts of the pathogenesis, were highlighted in the totality as an important aspect in this case with rubrics milk, scanty, absent, etc., and direction downwards, respectively. Here, direction downward represents the characteristic aspect of pathogenesis and was referred from the generalities section using the concept of generalisation.
A 65-year-old man presented with severe pain in the left foot and ankle, especially while walking and in the morning, for 20 days. The left foot showed oedema3 [Figure 1] and the affected joint was tender on examination. None of his lymph glands were swollen and he had no fever. The complaint started after the patient had a bout of fever that subsided with Allopathic medication. The patient took a nonsteroidal anti-inflammatory drug, which did not help. He also presented with anxiety (ghabarahat) in the chest and epigastric region.
Post-viral synovitis of the left ankle.
Symptom classification [Table 4]
|Pain in left foot and ankle joint||Location with sensation/characteristic|
|Oedema, pitting in the left foot||Objective/particular/characteristic|
|Pain in left foot and ankle in morning||Characteristic particular time modality|
|Subacute complaints||Phase of pathology|
|Anxiety in chest and epigastrium||Mental concomitant/characteristic|
Rubrics from Boger’s synoptic key and its philosophical implication [Table 5].
|Generalities: Dropsy, oedema, etc.||The process of inflammation of the tissue gave rise to the swelling – oedema. When the concept of what is true to part is true to whole – the concept of grand generalisation is applied, this is further extended to generalisation of pathology of swelling – dropsy – oedema (due to intensity) when it comes to creation of a pathological general.|
|Generalities: Membranes, serous||Affections of synovial membrane in joints are considered Tissue affected|
|Time: Morning aggravation||Time modality|
|Potential differential field (PDF)||To be considered from Materia Medica or larger repertories|
|Anxiety in chest and epigastric region||Mental concomitant|
|Oedema of the left foot||Characteristic particular|
|Subacute condition||Stage/phase of disease (part of pathogenesis)|
Boger’s synoptic key repertory section [Table 6].
|Generalities: Dropsy, oedema, etc.||2||1||1||1|
|Generalities: Membranes serous||1||2||1||1|
|Time morning aggravation||2||1||2||1|
Sulphur, Bryonia and Kali Carb, all act on the joints. Kali Carb was selected on the basis of the subacute nature of the complaints, anxiety in the chest and stomach for mental concomitants for the final differential point and left foot oedema as the characteristic particular mentioned in Boger’s Synoptic Key Materia Medica section.
Kali Carb 200 diluted doses twice a day for 3 days.
Oedema was considered as a characteristic aspect of pathogenesis, as Boger placed importance on objective signs as part of the pathogenesis. The importance of time dimension in terms of time modality (morning aggravation) and tissue affinity in terms of rubric (serous membrane) was appreciated. As Boger followed Boenninghausen’s concept of grand generalisation, it was applied; oedema was generalised as dropsy, oedema, etc. Regarding evolution of disease, the process of inflammation progressed to the state of swelling and oedema and remained in that state for 20 days. This suggests the illness moved from acute to subacute. Thus, understanding of disease process and pathogenesis helped in totality formation and to consider selected symptoms to be taken as general rubrics in Boger’s totality. The mental concomitant was used for final differentiation with reference to Materia Medica.
A relative of an 85-year-old man came with investigation reports suggesting advanced stage of squamous cell carcinoma of the mouth in the poorly differentiated stage. The patient had complaints of ulcers in the mouth near the gums with moderate pain, bleeding ++ and excess salivation, < especially in the morning (“mouthful in morning”).
A few months prior, the patient had some ulcerative pathology on the ear lobe. A surgeon treated it by removing that part of the ear lobule.
The other symptoms were memory poor – dementia, vision poor, no other data available, just sitting all day, demanding and complaining nothing.
Squamous cell carcinoma of mouth
Symptom classification [Table 7]
|Squamous cell carcinoma||Diagnosis/pathology|
|Ulcer in mouth||Pathology with location|
|Ulcer painful||Sensation with pathology/characteristic|
|Vision poor||Associated complaint|
|Memory poor||Mental general/characteristic|
|Ulcerative pathology in ear||Location with pathology|
|Sitting all day, doing and asking nothing||Concomitant mental state characteristic|
Rubrics from Boger’s Synoptic Key – Repertory and its philosophical implication [Table 8]
|Generalities: Old age, senility||Time dimension and pathological general raised from degenerative nature of chief and associated complaints|
|Generalities: Orifices||Tissue affinity: Generalised tendency for location raised from mouth and ear affection with similar pathology|
|Mouth and throat: Ulceration, apthae, etc.||Pathology with location|
|Saliva: Bloody||Suggestive of the phase of pathology; bleeding ulcer|
Boger’s synoptic key repertory section [Table 9]
|Generalities: Old age, senility||1||3||0||1|
|Mouth and throat: Ulcer, apthae, etc.||2||1||1||0|
Nitric acid, Lachesis and Mercurius were considered for the final differentiation. All of them have end-stage degenerative pathology; however, the chief action on orifices supported nitric acid over Mercurius and Lachesis. Lachesis is more loquacious and Mercurius is impulsive. Further, bleeding ulcer with advanced degenerative pathology affecting orifices in late old age was considered to select nitric acid.
Nitric acid 30 BD.
For 2–3 months till the patient lived.
Total relief in pain and bleeding observed within 2 weeks. Considering the advanced nature of pathology, medicine was continued till the patient lived. The patient died peacefully without pain.
In this case, age, which represents the dimension of time in evolution of the human being, was considered. Particular to this case, old age was considered, as it was the time in which he presented for treatment and when he developed the disease. At the same time, all presenting complaints are suggestive of degenerative process related to old age, which is reflected in the rubric Senility. There were two locations – ear and mouth, which are orifices of a human being. Therefore, the concept of generalisation for tissue/location was applied and orifices were considered. These two rubrics were generalised as first pathological general and second as generalised tissue affinity from Boger’s philosophy. The other rubrics, ulcer and saliva bloody, were considered to define the state of current pathology with the location for better narrowing down.
Concepts of tissue affinity, pathological generals, generalization and consideration of modality and concomitant were identified as applied in case analysis and remedies arrived at through the use of Boger’s Synoptic Key.
All the above cases have brought out important concepts of Boger and highlight his genius at arriving to the similimum in cases with limited data. The concepts of tissue affinity, pathological generals and time dimension can be very well understood through these cases. At the same time, it is not only important to understand the pathology but also the pathogenesis of the whole disease process, which is the key to individualisation. Additional considerations of modalities and concomitants help in completing the totality to come closer to the similimum. The cases also bring out the important concept of grand generalisation “what is true to the part is true to the whole” of Boenninghausen, which Boger has also applied in his synoptic key.
The cases show different phases of pathology range from functional to irreversible structural pathology. This suggests that application of Boger’s philosophy can work for any phase of pathology rather than just structural pathology, provided that the data from case is suitably worked with Boger’s Synoptic Key and Boger’s philosophy. The time dimensions, tissue affinity and pathological general are important elements to be considered while applying Boger’s concept and to work with Boger’s Synoptic Key as demonstrated with choice of rubrics in the cases discussed. As Boger followed Boenninghausen’s concept and worked on it further, the consideration of generalisation, concomitants and modality in case processing and totality formation remain important.
The repertory part of the Synoptic Key reflects this philosophy in quality of rubrics and the whole structure. We can perceive the arrangement of chapters from time, modalities, generalities and regional part, this reflects the importance of time dimension, modality and generalities in totality. In the generalities chapter, he incorporated different general sensations, pathological generals as well as generalised tissue affinity, all of which need to be appreciated while using it.
The rubrics of this repertory mean more than the words they represent; they demand that the reader apply their mind from specific to general, from observation to tissue affected, from cause to concept of time in all its various implications. One
who can train their mind to master this journey will enjoy the benefits of this classic. If the physician who uses this tool restricts their thinking to the literal meaning of the words, they are not going to fully obtain the benefits of this tool.
A major limitation of this tool, it has very few remedies represented in the repertory section as compared to the Materia Medica section. This gap can be utilised by scholars to enhance the repertory section with ever-increasing clinical knowledge of application of Materia Medica.
Boger’s Synoptic Key is an ultimate integration of philosophy to a tool that can be used at the bedside. The utility of this tool can be best exploited when we are well versed with the philosophy of generalisation, tissue affinity, concept of time and its implication in evolution of disease phenomenon and drug disease. This is the repertory Boger developed for his personal use at the bedside, it has a limited number of rubrics and remedies. However, when used with the diligence sought by the philosophy, this limitation too can produce miraculous clinical results.
AcknowledgmentsThis paper evolved due to an opportunity given Dr. Bipin Jain, Principal, Dr. M. L. Dhawale Memorial Homeopathic Institute (MLDMHI), who initiated the webinar series for alumni. Dr. Nikunj Jani, Associate Professor, Department of Repertory, MLDMHI, who has been guiding me for making my work more and more authentic. Dr. Kumar Dhawale, Chairman MLD Trust, who always finds time, I do not know how, to guide us to turn good work into perfect work.
Declaration of patient consentPatient’s consent not required as patients identity is not disclosed or compromised.
Financial support and sponsorshipNil
Conflicts of interestThere are no conflicts of interest.
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