Repertorization methods by CM Boger

Dr Sapna.M BHMS MD(Hom)

INTRODUCTION

• The homeopath forms a conceptual image of the disease by collecting data from the patient, patient’s relatives and from his own observations.
• The totality of a case is the basis for repertorization and serves the purpose to find out the most similar medicine of the Materia Medica.
• Based on a different conception of the Totality of Symptoms there are different repertorization method.
• The four major influences in the art of repertorization are Hahnemann, Kent, Boenninghausen and Boger.
• Each of them emphasizes different aspects to form the totality of a case, yet they all have their origin in the Organon.
• It is important for a homeopath to be familiar with these subtle differences so that he may apply them depending upon the prescribing data elicited from the patient.
• Each case is to evaluate as a whole in order to see which of these repertorization methods is best suited to the case in hand.
• A thorough understanding of the plan and construction of the different repertories is indispensable for the application of the appropriate repertorization method.

BOGER-BOENNINGHA– USEN’S CHARACTERISTICS AND REPERTORY

• Cyrus Maxwell Boger’s edition of Boenninghausen’s Characteristics and Repertory is the amplified version of Boenninghausen’s Therapeutic Pocket Book.
• He accepted Boenninghausen’s approach to the totality of the patient with emphasis on Physical Generals, Modalities and Concomitants.
• Boger was of the opinion that it was better to include main rubrics with subrubrics that carry further particularization.
• Thus his repertory includes all the generalizations and particularization’s.
• Unlike the BTPB where General and particular modalities are not differentiated, the BBCR has the modalities for each part assembled at the end of each section and at the end of the book devoted to general modalities.
• Concomitants are also mentioned at the end of each chapter and there are some new chapters not found in other repertories.
• That is, each chapter has a separate section for aggravations and ameliorations as well as concomitant symptoms and a cross reference.
• Boger rewrote Boenninghausen’s Therapeutic Pocket Book in order to minimize the error of Grand Generalization and his work is seen as an attempt to bridge Boenninghausen and Kent.
• His appreciation of time-dimension, causative modalities, tissue affinities and pathological generals give a new vista in understanding the case.

ADAPTABILITY OF BOGER’S REPERTORY :

• Cases rich in particulars with marked modalities and concomitants , pathological generals , clinical symptoms,
• one-sided diseases (if the totality of the state can be filled out),
• objective symptoms and pathological symptoms (with absence of characteristic symptoms),
• cases without many mental symptoms,
• fever cases,
• useful to get related remedies by working on the chapter on Concordances

Boger’s concept of Totality :

• Boger has favored the understanding of the whole case on the levels of constitution, diagnosis and ongoing pathology.
• He emphasized on the complete study of the case and also advised against giving more importance to a single symptom, even if it might be a key-note one.
• He expressed the importance and hierarchy of the various types and parts of the symptoms and that every symptom should be valued as per the condition.
• Boger too subscribed to the principle of totality of symptoms and was fully in agreement with the idea of what constitutes a complete symptom, which is studied in relation to four factors, viz., location, sensation, modalities and concomitants.
• He also stressed the importance of uncommon symptoms for the choice of the indicated remedy and Boger advised against the great error of regarding a numerically large mass of symptoms that are general (common) in their character, but do not individualize the case, as a sufficient guide in choosing the remedy.
• The keen perception and appreciation of those symptoms, which at the same time, correspond to the nature of the disease and also designate the remedy which is exclusively or at least most decidedly indicated – this alone betokens the master mind. (C.M.Boger, Boenninghausen’s Characteristics, Materia Medica & Repertory, p.viii)

Boger’s concept of totality is based on the following concepts:

• Doctrine of Complete Symptoms
• Prime importance of Modalities
• Doctrine of Concomitants
• Doctrine of Generalization
• Doctrine of Pathological Generals
• Doctrine of Causation and Time
• Clinical Rubrics
• Placing the Mental symptoms at the end
• Fever totality
• Evaluation of Remedies
• Concordances

Forming a complete image

1. Changes of personality and temperament
2. Peculiarities of disease
3. The seat of disease
4. Concomitants
5. The cause
6. Modalities
7. Time

These factors are elucidated similar to Boenninghausen’s seven factors which mirror all the essential aspects required to get a complete image of the disease.

Changes of personality and temperament are particularly to be noted, especially when striking alterations, even if rare, occur; the latter often supplant or by their prominence may obscure the physical manifestations and consequently correspond to but a few medicines. The expressions of the intellectual and moral dispositions are interdependent and their combined character affords the best and almost sole indication in the selection of medicines for mental affections.

The nature and peculiarities of disease, as well as of medicines, must be known thoroughly. Allopathic diagnosis can seldom or never suffice for the sure selection of the indicated homeopathic remedy.

The seat of the disease often points to the decisive indications, for almost every medicine acts more definitely upon certain parts of the body. It is important to ascertain the seat of the local disease accuracy. The amount of attention to be given to the affected part is necessarily proportioned to the magnitude of the general disease of which it is a portion.

In finding the simillimum for the whole case the concomitants, above all, demand the most thorough examination. These are a sound doctrine of procedure for the more strange, rare and peculiar the symptom grouping is, the better guide we have for the choice of the indicated remedy. While carefully elucidated characteristics strikingly portray the leading features of a case they are always modified by the peculiarities of the relief before the picture can be said to be accurate. Well known or common-place concomitants are unimportant unless they are present in an extraordinary degree or appear in a singular manner. Therefore, those accessory symptoms are to be examined carefully which are rarely found combined with the main affection, those belonging to another sphere of disease than that of the main one and those which bear the distinctive marks of some drug. A concomitant may so distinctly and decidedly depict the nature of a remedy, and consequently indicate it. Such symptoms evidently belong to those which Hahnemann called striking, extraordinary, and peculiar (characteristic) and are to receive our almost exclusive attention because they lend their individuality to the totality.

So much depends upon the knowledge of the cause of disease, that without it the choice of the simillimum cannot be made with safety. The modified natural tendency to disease depends upon the uneradicated miasms of psora, sycosis and syphilis. The best selected remedy is often ineffectual unless preceded by the proper antipsoric, antisycotic or antisyphilitic, as the case may be.

The modalities are the proper and most decisive modifiers of the characteristics, not one of which is utterly worthless, not even the negative ones. A closer inspection of the symptoms will reveal their sensations and relations to the different parts of the body and establishes undoubted difference in the manner of their appearance, the modality. Modalities must be specialized in order to apply the most suitable remedy. When the symptoms seem to point out a particular remedy with which the modalities however do not agree, it is only negatively indicated and the physician should seek for another remedy having the same symptoms. Cravings and aversions to different foods furnish some of the most important points in deciding upon the remedy.

The time is hardly less important than the aggravation and amelioration itself, and could be of great use were the different stages of disease left undisfigured by drug influences, for they constantly produce the most devious effects upon the natural course of disease. This homeopathic objective concerns the hour of the day when symptoms are better or worse, as well as the periodical return of the symptoms, both having a direct bearing upon the choice of the remedy. The latter coincides with epochs having special accidental causes. The general or special modalities referable to the time of day are of much greater importance, for hardly any disease lacks this feature and the provings supply the same peculiarity, qualifying them for the best and most comprehensive uses.

Regarding case taking Boger advised us to first elicit the evident cause and course of sickness down to the latest symptom, and that especially the natural modifiers of sickness, the modalities, should be very definitely ascertained. A consideration of the mental state comes next in order of importance, to be followed by the patient’s own prescription of his sensations, then the entire objective aspect or expression of the sickness (facial expression, demeanor, nervous excitability, sensibility, restlessness etc.), and lastly the affected parts. These will clearly outline the disease picture and point toward the simillimum. The actual differentiating factor may belong to any rubric.

How to work out a case

A SYNPOTIC KEY OF THE MATERIA MEDICA : Boger has given a clear cut view on how to work out cases with his repertory in his synoptic key :

MODALITIES	CAUSATION ,TIME, TEMPERATURE, WAETHER, OPEN AIR, POSTURE, MOTION, EATING AND DRINKING, SLEEP, IF ALONE, PRESSURE, TOUCH, DISCHARGES
MIND	IRRITABILITY, SADNESS, FEAR, PLACIDITY
SESATIONS	BURNING, CRAMPING, CITTING, BURSTING, SORENESS, THROBBING, THIRST
OBJECTIVEASPECT	DEMEANOR, RESTLESSNESS, NERVOUS EXCITABILITY, FACIAL EXPRESSIONS, TORPOR, SECRETIONS, COLOR, ODOR
PART AFFECTED	Organs, Right, Left.

“By going over the above rubrics in the order named the contour of the disease picture will be pretty clearly outlined and will point fairly well toward the similimum, and the presciber has only to keep in mind the fact that the actual differentiating factor may belong to any rubric whatsoever and also that the scope of these rubrics reaches far beyond the appended synoptic text ”.

COMMENTARY TO BBCR BY S.K.TIWARI :

• Boger has given greater importance to causation, time dimension, modalities and generals (pathological, physical and mental).
• The repertory can be used in different methods which allow us to use it in different cases of different dimensions with individual pictures.
• It is the case which decides the method to be applied to select the similimum, not the physician.
• This highly qualitative approch gives less chances of manipulation of data.
• Mental section should be used for final selection of the drug in all the methods.
• Selection of method is entirely based on the availability of data in a case.

Methods of Repertorization

1. Using causative modalities in the first place
2. Using modalities in the first place
3. Using concomitants in the first place
4. Using pathological generals
5. Using diagnostic rubrics
6. Following Robert’s method (BTPB)
7. Fever totality
8. Use of concordance chapter

Using causative modalities in the first place

If the case has definite causative modalities and other expressions :

• Causative modalities (A.F) : mental & physical. i.e. fear, excitement, getting wet etc.
• Other modalities

Agg.   –  mental, physical

Amel  –  mental, physical

• Physical generals
• Concomitants
• Locations & Sensations

Using modalities in the first place

When case has no causative modalities, but it has other general as well as particular modalities :

• Modalities –  Mental, Physical
• Concomitants
• Physical generals
• Locations & sensations

Using concomitants in the first place

When clear concomitants are available even without any modalities :

• Sensations and complaints
• Concomitants
• Physical generals
• Locations

Using pathological generals

• Pathological generals
• Physical generals
• Concomitants ( weak concomitant)
• Modalities

Using diagnostic rubrics

If the case is lacking in characteristic expressions. Helps mainly in finding a palliative drug.

• Clinical rubric
• Aggravations
• Ameliorations
• Concomitants (weak concomitant)
• Physical generals

Following Robert’s (B.T.P.B) method

• Locastions
• Sensations
• Modalities
• Concomitants
• Physical generals

Here, sensations and modalities are first refferred to the parts concerned. In case the paticular sensation and modalities are absent they can be refferred to in the General chapter.

Fever totality

• In a fever case, if the stages (Chill, Heat, Sweat) are distinct.. If some stage is not available in a case, only the next stage should be used for repertorization.

CHILLType/partial chill/coldness-partial/shivering Time Aggravation Amelioration Concomitant

HEATType/partial Time Aggravation Amelioration Concomitant

SWEATType/partial Time Aggravation Amelioration Concomitant

• Pathological types of fever mentioned in the repertory can be used for reference and finel selection of the drug.
• Sometimes these rubrics (pathological types) can be used by following 5^th
• Section on blood (circulation, congestion, palpitation, heartbeat and pulse) should be used if symptoms are prominent during any of the stages of fever.

Use of concordance chapter

• This chapter deals with the relationship of remedies.
• The chapter can be used by following the same method, which is used in working out of “Relationship of Medicines” in Boenninghausen Therapeutic Pocket Book.

1. It can be used for studying the relationship of remedies at various levels – mind, parts, sensations, modalities.
2. It helps to find out a close running medicine, which can be thought of in future follow-ups if picture changes.
3. To find out a second medicine, if the first one (though-indicated), does not meet the expectation on given time.
4. To find out an anlogue to deep acting medicine so as to avoid unwanted precipitation of adverse symptoms.
5. Helps us to study various relationships of remedies.- by a close study   ( eg: Acon. And Sulph , Puls with Sil. and Kali sulph.)

Method of Working

• When the indicated medicine helped a little and when there is no further improvement without much change in the presentation the section can be referred to for finding out a close medicine which would help the patient.
• Under the medicine (first prescription) refer the subheading which could be the main complain of the patient and use it as the first rubric.
• Next, take mind and all other sub-headings one after another.
• The first rubric can be used as an eliminating rubric (only those medicines would be taken further which cover the first rubric).
• If it is a case of Tonsillitis – ‘Glands’ could be first rubric. For headache, it could be ‘sensations’ etc.
• Example of finding out a second prescription from BBCR
• A viral fever case presented with the picture of Bryonia. Bryonia  was prescribed which relieved bodyache, constipation and headache, but the temperature used to vary between 101⁰ to 103.After three days, when there was no further improvement, the case was worked out for a second medicine with the help of this section.

First prescription – Bryonia

CASE WORKED OUT WITH BBCR

• Name of the patient : Balan.P.P
• Age : 72 yrs
• Sex : Male
• Address : Padinchattinkara payil (H),   Palath (P.O), Kakkodi, Calicut.

• Occupation : Catering service
• Religion : Hindu
• OP No : 8933
• IP No : 172
• O.A : 23-5-2011
• O.D : continuing treatment
• Admitted by : Dr.Abdul Hameed
• Department : Dept. of Practice of Medicine

PRESENTING COMPLAINT :

• Cough with difficulty in breathing with sore pain in right side of chest worse since 2 weeks.
• < exertion, ascending steps, talking, lying on right side., cold climate.
• Wants to sit up.
• >Warm drinks
• Expectoration profuse yellowish mucoid.

HISTORY OF PRESENTING COMPLAINT :

• The complaint appeared around 20 yrs back as haemoptysis. He consulted an allopathic physician and it was relieved. Later difficulty in breathing developed. He had cough with expectoration. Then after 5yrs he had similar attack of haemoptysis, and the case was diagnosed as Right lower lobe bronchiectasis.
• Now for the last 2weeks he has sore pain in right side of chest, with occassionally pricking sensation. with difficulty in breathing.There is cough with profuse yellowish mucoid expectoration.

HISTORY OF PAST ILLNESS :

1. H/o typhoid in childhood.
2. Known hypertensive for the last 16yrs. taking allopathic medicine.
3. H/o Right inguinal hernia 16yrs back. Done surgery.
4. H/o diminution of vision of right eye. Done surgery.

TREATMENT HISTORY :

• Took Allopathic treatment with temporary relief.

FAMILY HISTORY :

PERSONAL HISTORY :

• Place of birth : Palath
• Occupation: catering service
• Marital status : married , has 2 children
• Habits/Addictions/Dependence : drinks tea frequently, especially in morning
• Appetite : good
• Thirst : normal
• Desire : pungent food
• Aversion : nothing particular
• Stool : Regular but unsatisfactory.
• Urine : No complaint, passes 3 times at night.
• Sweat : increased, generalised.
• Sleep : disturbed due to cough.
• Thermal Relation : Hot patient ( prefer fanning, aversion covering )

PSYCHIC FEATURES :

• Prefers company, Talkative,
• Fastidius, easily becomes tensed. Anxious about financial problems.
• Mental anxiety increases the breathing difficulty.

REGIONALS :

• Head : Headache with sensation of heaviness in the head. pricking , throbbing pain.
• Eye : Dimness of vision especially left eye.
• Stomach : occasionally indigestion.
• Abdomen : flatulent complaint
• Chest : pain over right costal margin.
• Extremities : Numbness of both lower limbs with sensation of weakness. Trembling of both hands and legs.

PHYSICAL EXAMINATION :

GENERAL SUEVEY :

• Built – moderate
• Complexion – dark
• Obesity/wasting- nil
• Anaemia – no pallor
• Cyanosis – nil
• Clubbing – absent
• Oedema – absent
• Gait – normal
• Jaundice – nil
• Rashes – nil
• Facial characteristics – anxious.
• Dehydration – nil
• Respiratory rate – 26/minute
• B P -150/86 mm of Hg
• Lymphadenopathy – absent

SYSTEMIC EXAMINATION :

RESPIRATORY SYSTEM :

• Inspection : chest – bilaterally symmetrical No visible swellings. No dialated veins. Shape of chest : barrel shape
• Palpation : Tenderness over right costal margin.especially right supramammary & inframammary regions.
• Percussion : Resonance over pulmonary areas.
• Auscultation : Expiratory crepitations over Rt and Lt infra clavicular areas close to sternal margin.

CENTRAL NERVOUS SYSTEM : With in normal limits

CARDIO VASCULAR SYSTEM : With in normal limits

PROVISIONAL DIAGNOSIS :

Bronchiectasis

INVESTIGATIONS :

• Blood :R/e:

TC : 9x 10 ³ /ml

DC:  Lym : 46%, Mxd : 12%     , Neut : 42%

ESR : 12mm/hr

• ( 25-5-2011) F B S : 102 mg/dl
• Sputum : culture ( 11-6 –’84 ) : A F B : negative.
• T F T : (21-2-’11) :
• T3 : 2.0 ng/ml
• T4 : 95 ng/ml
• TSH : 0.27 u IU /ml

DIFFERENTIAL DIAGNOSIS :

• Tuberculosis
• Chronic Bronchitis
• Emphysema
• Lung Cancer

CLINICAL DIAGNOSIS :

• Bronchiectasis
• ANALYSIS OF THE CASE

PATIENT SYMPTOM        Prefers company, talkative,fastidious,tensed easily, anxious about financial problems, Appetite-good, Thirst-normal, Desire-pungent, bowels-unsatisfactory. Urine-3 times at night, Sweat – increased Sleep-disturbed due to cough Hot patient

DISEASE SYMPTOM         Difficulty in breathing,pain in right side of chest <exertion,ascending steps,talking,lying on right side. Wants to sit up >warm drinks

TOTALITY OF THE CASE

• Prefers company, Talkative,
• Fastidius, easily becomes tensed. Anxious about financial problems.
• Appetite : good
• Thirst : normal
• Desire : pungent food
• Aversion : nothing particular
• Stool : Regular but unsatisfactory.
• Urine : No complaint, passes 3 times at night.
• Sweat : increased, generalised.
• Sleep : disturbed due to cough
• Thermal Relation : Hot patient
• Head : Headache with sensation of heaviness in the head.pricking , throbbing pain.
• Eye : Dimness of vision especially left eye.
• Stomach : occasionally indigestion.
• Abdomen : flatulent complaint
• Chest : pain over right costal margin.
• Extremities : Numbness of both lower limbs with sensation of weakness. Trembling of both hands and legs.
• Cough with profuse yellowish mucoid expectoration.
• Difficulty in breathing with pain in right side of chest worse since 2 weeks.
• < exertion, ascending steps, talking, lying on right side, cold climate.
• Wants to sit up.
• >Warm drinks

EVALUATION OF SYMPTOMS

MODALITIES :

• Weather – cold
• Posture – lying down<, lyng on Rt side <
• > sitting up
• Eating & drinking –  warm drinks >

MIND :

• Prefers company, Talkative,
• Fastidius, easily becomes tensed. Anxious about financial problems.
• Mental anxiety increases the breathing difficulty.

SENSATIONS :

• Sore & pricking pain in right side of chest.
• Pricking, throbbing pain in head.
• Numbness of both lower lombs with sensation of weakness.

OBJECTIVE ASPECT :

• Profuse yellowish mucoid expectoration. Anxious expression .
• Expiratory crepitations over Rt and Lt infra clavicular areas close to sternal margin.

PART AFFECTED :

• Chest : pain over right costal margin.
• Head : Headache
• Extremities : Numbness of legs, trembling of hands & legs.

REPERTORIZATION

MANAGEMENT

Medicinal :25-5-’11 Cough with froathy scanty expectoration Pain in right side of chest Numbness of legs Weakness, vertigo. Burning sensation 27- 5 ’11: cough , scanty froathy expectoration persists Headache with heaviness of head. 30-5-’11 : cough with scanty expectoration Pain in Rt side of chest > Hoarseness of voice Headache >

Rx Kali carb 200/1 dose BT – 4 dose Grindelia Q (S.O.S )   Rx SL – 2 dose BT – 4 dose   Rx SL – 2 dose BT – 4 dose Grindelia Q ( S.O.S )

REFERENCE

• Synoptic key of the Materia medica
• Boger- Boenninghausen’s Characteristics and Repertory
• similima.com
• hpathy.com