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This part of the discussion details the clinical perception of totality by various masters with subsequent plans of action. We examine the features of these totalities in terms of how they could be applied in emergencies.  The four perceptions discussed in detail are Boenninghausen’s totality and its application; Boger’s totality, its application and modern extensions; Clarke’s plan of action in The Prescriber; and Morgan’s Management of Diphtheria. These will form the philosophical and theoretical basis for suggesting a Therapeutic Strategy of Emergencies in the final conclusion.
 

1. BOENNINGHAUSEN’S TOTALITY

The structure of the Boenninghausen totality is one grand symptom - the complete symptom of the patient from whom four components must be accurately obtained for scientific classification:

• Location: the part, organ, tissues involved.

• Sensation: of pain or description of feeling in functional or organic change.

• Modality: which includes causative factors – emotional and physical

• Concomitant: the “attending circumstance” occurring at the same time with no rational explanation. It includes an analysis of the Mental State.

Plan of Action:

1. The Therapeutic Pocket Book (TPB) construction supports the 4 component Totality in remedy choice.
2. The grading of remedies (5,4,3,2,1)  in the TPB is based on the value of each symptom in a remedy proving, verified clinically. This grading is vital in remedy choice.
3. Improvement and relief in symptoms following the remedy is re-evaluated, and left over picture of symptoms including new symptoms are considered in a new totality.
4. Cure of left over symptoms, is completed by a remedy complementary to the previous one, covering the remaining characteristics.
3. The Concordance helps decide this sequence of remedies in acute or chronic cases.
4. Boenninghausen supported the use of an anti-miasmatic intercurrent remedy needed based on Hahnemann’s philosophy in the Chronic Diseases.

Boennighausen’s methodology is basic to homeopathy that every homeopath should master. It can be extremely useful in an emergency where symptom pictures are clear and the training involves being apt at finding the 4 components of a complete symptom quickly and accurately. A simillimum can be arrived at within 15 minutes (and even more quickly in experts) in acute diseases, epidemics, and even chronic diseases that have predominantly physical characteristics.  It is clinically useful in one sided chronic cases with a paucity of symptoms; those with a lack of mental symptoms; cases with PQRS symptoms; cases with characteristic modalities. Most emergencies could fall into any of these categories. (Ref case no: 11 )

 

2. BOGER’S TOTALITY

Supported by his clinical experience, Boger developed a pathogenetic totality format comprising of 5 components with sub-components:

1. Modalities: 1. Causation 2. time 3. temperature 4. weather/Open Air 5. posture 6. Motion 7. eating and drinking 8. Sleep 9. If alone 10. pressure/touch 11. Discharges
    

2. Mental State: especially: 1. Irritability 2. Sadness 3. Fear 4. Placidity
    

3. Sensations:
    Listen to the patients’ own description of sensations
    1. Burning 2. Cramping 3. Cutting 4. Bursting 5. Soreness 6. Throbbing 7. Thirst
    

4. Objective Observations:
   The distressed vital force uses the oldest and most universal language in the world, the Sign Language, which can be accurately interpreted by observation, when a homeopath knows what to look for. Training in observing these clinical signs will be essential for a homeopath working in emergencies.
   1. Demeanour: (behaviour, conduct); manner - a way of acting
   2. Restlessness/ Torpor: A state of mental or physical insensibility
   3. Nervous Excitability/ Sensibility: the mental or emotional responsiveness towards something; receptiveness to impressions
   4. Facial Expression eg: Terror or riscus sardonicus in Stramonium;
   5. Secretions: description/appearance
   6. Colour (of skin, discharges)
   7. Odour (from body, discharges)
    

5. Location: Part Affected: Organs, right side, left side
   Linking this picture with the diagnosis and investigations, further determines remedy choice and management.
    

Plan of Action:

Based on the pathogenetic totality obtained as above, appropriate rubrics are found in the same order to form a contour of the disease picture.  The differentiating factor for remedy choice may belong to any rubric that was sufficiently characteristic in a particular case. Cure could be hampered by laying too much stress on some particular factor at the expense of the disease picture as a whole, thus destroying its SYMMETRY and forming a distorted conception of the natural image of the sickness.

In terms of management, Boger suggested various interpretations:
When there is little or no reaction to a remedy either
a) Remedy Selection was faulty; the case must be reviewed for an appropriate pathogenetic remedy.
b) A miasmatic block existed requiring Psorinum, Sulph, Medorrhinum or Syphilinum 

In Inveterate Diseases,  following general beneficial response, avoid changing the remedy when new symptoms come up. Instead repeat it in a higher potency or change the potency scale.  Wait for a fairly definite new symptom picture or disease picture to choose the remedy successor. We must remember that the possibilities following the contact of the simillimum with the disordered vital force can never be foreknown. Utmost care should be taken in selecting the simillimum for an easier interpretation of remedy response and hence clearer subsequent management. An acute remedy is almost always followed by the constitutional remedy. Disease cure follows Hering’s Law of Cure and Miasmatic Cure.
 

Boger’s Methodology is a complete therapeutic strategy that has been further developed for both acute and chronic disease. It is reliable in both emergencies and in developing an accurate case history for infants.  The Synoptic Key helps in this process. It has 3 parts: Repertory -1, Synopsis of remedies – 2, Related Remedies, etc – 3; that supports the analysis and management of the pathogenetic totality.

Latter homeopaths, following Boger’s tradition further developed a methodology based on the pathogenetic totality, with clinico-pathological correlation to include modern developments in knowledge of disease:

1. Disease progress is assessed on 3 levels: (Kasad, 2003)
   1. State: Health à Diathesis à Disease
   This requires understanding the development of disease in an individual from a dynamic concept.
   2. Phase: Prodrome à Functional à Structural
   This suggests the development of the pathology of disease from the point of infection or psychosomatic imbalance, onwards towards tissue changes.
   3. Miasm: Psora à Sycosis à Syphilis
   This suggests the evaluation of disease progression in an individual patient based on the changes in symptoms over time, and correlating this with the miasmatic background of that individual.
    

2. Pathogenesis is observed in remedy and in disease, in FORM and STRUCTURE over TIME.
   
   
   Another way of understanding disease for remedy selection and case management based on Boger’s perception is explained by Dr. P. M. Barvalia (2006b) below:
    

“I like to use a clear concept of form-function-structure in every clinical situation I encounter as it helps us to get deeper insight to the clinical state that needs to be cured. Once the patient presents with complaints, it is important for the clinician to comprehend the degree/level of disturbance in function as well as nature of changes in the tissues and organs responsible for this symptom expression. I will explain how I use this concept.

What is perceptible to the homeopath are the external signs and symptoms. Based on this we recognize the disease and perceive it as a FORM (symptom expression) that evolves over a period of time. This expression keeps changing as the patient interacts with his environment. Ultimately changes in STRUCTURE take place. In other words, changing FORMS express themselves to us through disease complaints which result in structural changes over time. When we appreciate the interrelationships between these various expressions, we perceive a PATTERN in the expression of this form - which is the symptom picture that indicates a similimum remedy.

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Diseases arise due to a fault in the functioning of a system. Thus a FORM is an expression of disturbances in the organ function. These changes cause disturbances of FUNCTION (detected through appropriate laboratory investigations) which in time produce a disturbance in the STRUCTURE of the organ and then, the latter aggravates the former. Thus a vicious circle is set up in chronic diseases. Again both these disturbances are revealed to us through changing complaints --> changing FORMS (symptom pictures).  In other words, as the disease progresses, it is revealed to us in a continued change in FORM, FUNCTION AND STRUCTURE. It is important to have an integrated understanding of this phenomenon for management of serious diseases (and emergencies).

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Based on an understanding of this inter-related phenomenon, one can arrive at logical formulations about following homeopathic parameters:

i) Susceptibility of the patient: Is evaluated based on various factors
– Seat of disease
– Nature of changes
– Rate of changes taking place --> pace of disease.
ii) Miasmatic diagnosis: Identification of the dominant miasm as well as degree of miasmatic activity.
iii) Posology formulations: Based on susceptibility and clinico-pathological diagnosis.
iv) Phase diagnosis: Accurate identification of the current phase for a remedy choice :- constitutional , chronic, acute or purely antimiasmatic. We also get insight about possible pattern in which the case might unfold in order to make future projections of case management.

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This philosophical understanding can be observed with training in any expression of disease including emergencies. The above is a development of Boger’s clinico-pathological correlation”.

The significance of this analysis in an emergency, is that it supports the choice of a simillimum correlated on clinico-pathological grounds which increase the accuracy of selection and also relies on investigations for confirmation.

 

 

3. CLARKE'S PLAN OF ACTION

 

Dr. Clarke (2006) wrote the first edition of The Prescriber in 1885 which underwent a second updated edition by him in 1925. I would like to give an idea of his intentions behind this work, as I consider his thoughts in this book to be foundational to emergency management. He gives clear and necessary characteristic homeopathic indications of homeopathic remedies in various clinical conditions, based on the reliable experience of his colleagues and of himself. He states on page 3 of the Introduction, that there are many ways in which the practice of homeopathy can be approached. His intention in writing The Prescriber was primarily to enable an approach to therapeutics from the clinical standpoint and to allow for quick reference when one was not able to do a thorough research for remedies. My personal understanding is that the approach to managing emergencies in general should begin from the clinico-pathological perspective, before chronic homeopathic evaluation comes into play.

 Clarke explains, “I suppose that my reader is one who has become convinced of the truth of Hahnemann’s law and the efficacy of this method, and who wishes to avail himself of the power it puts in the hands of those who can use it.” He then recommends the use of The Prescriber as a ready instrument by which one can put these precepts to the test. His intention is that a homeopath may find in most cases (especially in emergency - Leela), “a remedy which fits with tolerable closeness of similarity the case in question and will thus be enabled to prescribe”. When it happens that The Prescriber is not sufficient to enable a choice of remedy, reference can be made to his Dictionary of the Materia Medica (1925) where the actual symptoms of different remedies can be studied. In addition, one can refer to the Clinical Repertory to the Dictionary of the Materia Medica (1904) to for a greatly extended list of remedies that were not included in The Prescriber.  Thus Clarke suggests, “The Prescriber and the Clinical repertory together provide as complete an approach as is possible, to homeopathic practice from the clinical aspect.”
 
 He goes on to caution though, “But after all, this is only a limited approach, that is it an approach limited to a limited area of the field”, which I suggest here that the field may be limited to Homeopathic Emergencies. Again he states, “For a clinical or nosological repertory is perfectly justifiable from a homeopathic point of view, provided its limits are clearly understood.

Based on his experience he also gives us an encouragement for emergency management when on page 18 he says, “In most cases there are more remedies than one that will benefit; and if the exact simillimum is not found, the next or the next to that, will give a measure of help; so the beginner need not abandon the ideal as too difficult an attainment.” Then he goes on to suggest that there are “many different kinds of similarity, as well as of degrees, and every kind is available for the homeopaths’ use.” Similarity in organ affinity; in tissue affinity; in diathesis; in sensations and conditions (of modalities) there are indications that allow the homeopath to find a likeness with a remedy and a practitioner need not tie himself to only one single of these perspectives for a similarity.

With regards diagnosis or the nosological names of diseases, Clarke says that fixing of the correct nosological label (diagnosis) on each case is both important and useful. This is especially in acute cases, where the physician must take the characteristic points and digest them rapidly. The correct name of the disorder goes a long way towards pointing out the remedy. It reduces the selection to a group of remedies from among which the simile or the simillimum is most likely to be found.

 

Dr. J. H. Clark presented an updated version of The Prescriber (2006) in 1925. He describes a clear ‘Plan of Action’ to make optimum use of this handbook. His approach is not very much different from Boger or Boenninghausen, where in fact, he subscribes to a similar methodology for obtaining a totality of symptoms. The Prescriber serves as the final aid to remedy selection through the diagnosis of the pathological condition.

 It is essential first, that one obtains an accurate totality with the required characteristics. He explains that this totality includes objective signs, pains and sensations which for all practical purposes are indications of the concrete problem before us, of the dynamic, invisible disease. He reminds us to be on the look out for the most absurd symptoms which often contain the entire solution to the mystery we are trying to solve. When we do this, the diagnosis reduces the selection of simillimum to a group of remedies that have an established scope in the pathology in question either through provings, or clinical experience or recorded toxicological effects. He reaffirms Boenninghausen’s single symptom totality with its focus on obtaining valuable modalities and concomitants, as vital to remedy choice. Based on these suggestions from Clarke, we will develop later in the dissertation a concept of ‘Emergency Totality’ that combined with suggestions from Boger’s pathogentic totality, will emphasize those aspects required to be focused on in an emergency situation. This emphasis would be two fold: the pathology in question; and the objective ‘Sign Language’ as listed by Boger.

In The Prescriber, Clarke names the various disease diagnoses in alphabetical order. Each disease heading lists remedies most commonly indicated for their cure, along with the most important characteristics. These are present in the form of a complete symptom. Thus, Boenninghausen’s single symptom totality forms the basic building block of this concept, which was modified from the clinical standpoint by Dr. Clarke’s brilliance and clinical acumen. The indicated remedies can hence easily be differentiated from one another other using this book at the bedside. In situations where remedy characteristics and differentiating symptoms are not given, the plan and format allows that the remedies are named in order of their general applicability, with numbering. His intention was that the homeopath would make use of the remedies in that order when there were no other differentiating points in the case pointing to one remedy more than another.

 

From this listing, Clarke gives us a glimpse of a possibility of developing in the future an Homeopathic Emergency Manual, that lists all of the emergency conditions along with indicated remedies in complete, clinically validated, one symptom totalities like Boenninghausen suggested. This would necessarily be a dynamically evolving manual as the clinical application of homeopathic emergency therapeutics gains momentum.

 

Thus, The Prescriber could be modified and evolved into this idea of an Homeopathic Emergency Manual which also includes referencing to an updated Clinical Repertory to the Dictionary of the Materia Medica. Further, I visualize this to be incorporated and created into Emergency Homeopathic Software Programme, making a search for a remedy quicker and easier in an emergency situation, while allowing for multiple Materia Medica references to differentiate between two remedies in those situations.

For ongoing management, Clarke’s advise continues clearly based on homeopathic principles in the Organon. He emphasizes the importance of perceiving whether the diagnosis of a case under treatment is an active manifestation of chronic miasm. If so the management involves not only the acute remedy, but should also be followed by the constitutional remedy after the acute manifestation is over. Clarke understood well Hahnemann’s perception of miasmatic management; he advises that a remedy must be chosen that can also deal with the active miasmatic totality if it is to truly cure. Following the direction of cure from within outward is also an important clinical manifestation of cure both of disease in general and of the chronic miasms in particular. The constitutional remedy choice always follows the totality of symptoms as a whole.

Beyond all this, he also saw some clinical situations where a single remedy was not easily found, either due to lack of remedies available or else an inability of the homeopath to find a single remedy at that point of time. On page 48 of The Prescriber (2006), he advocates a pragmatic approach where it may be necessary to use two different remedies in alternation. But though he says one may need to resort to using two remedies in alternation, one should not adopt this as a routine method. If a totality seems to point to two different remedies, one could prescribe the first and wait for its response, to make an accurate analysis before prescribing the next one. Giving both at the same time would destroy the value of accurate observation, and would weaken the homeopath’s powers of diagnosing the remedy.

There is an interesting historical debate on the subject of alternation of remedies. In some complex emergency situations, some homeopaths have used the alternation of remedies approach. Though the basis for choice of two remedies remains uncertain, Dr. Morgan who wrote on the management of Diphtheria in epidemic used two remedies in alternation in him management as described below and in the case section. The debate was in two journals, the American Homeopathic Review and Annals of British Homeopathic Society between 1863 and 1865, about the use of alternation of remedies, which was mainly responded to by Dr. Carol Dunham (1877) in favour of a single remedy, and against alternation which was not based on the highest principles homeopathy was capable of for curing. Nevertheless, alternation could be regarded as an of inferior/secondary method of prescribing, especially in emergencies, when a good single simillimum was not easily available or detectable.

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