TOTALITY OF SYMPTOMS AND ITS VARIOUS CONCEPTS

INTRODUCTION :

Totality of symptoms is not a fortuitous jumble of symptoms thrown together, any more than a similar haphazard collection of pathogenetic symptoms in a proving that constitutes the Homoeopathic Materia Medica.

Totality of symptoms implies not merely a numerical aggravate of all the symptoms but is relates to the synthetic comprehension of a concrete individual picture of the patient through logical combination of general, i.e.,symptoms- mental and physical (referred to the patient as a whole), particular (referring to particular organ, tissues or parts of the body) and distinctive or individualizing peculiar symptoms (strange, rare and uncommon symptoms which can be fitted into the frame work of any concept and therefore based on perception) as manifested by the patient.

Totality of symptom According to :

Hahnemannn : Totality is the outwardly reflected picture of the internal essence of the disease, that is, of the affection of the vital force.

Kent :  “The totality of symptoms means a great deal . It is wonderfully a broad thing……

It is all that enables the physician to individualize between the disease and between the remedies; the entire representation of disease is the totality of symptoms and entire representation of drug is the totality of symptoms.

Boger : He re-emphasized the following seven points to appreciate the whole picture of the disease.

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

Boenninghausen : Totality of symptoms not only sum total of symptoms but one grand symptom, the symptom of the patient. In totality 3 factors must be present.
1.Locality
2.Sensation
3.Modality
In addition Boenninghausen emphasized the special value of concomitants in the selection of similar remedy.
The concomitant symptom is to the totality what the condition of aggravation or amelioration is to the single symptom. It is the differentiating factor.
“The totality” is not therefore, a mere haphazard, fortuitous jumble of symptoms thrown together without rhyme or reason. Totality should express the individuality of the case.

Stuart Close : The totality of the symptom means all the symptoms of the case which are capable of being logically combined into a harmonious and consistent whole, having form, coherency and individuality. Technically, the totality is more (and may be less) than the numerical totality of the symptoms. It includes the “concomitance” or form in which symptoms are grouped.

Dr. M.L. Dhawale : According to him the totality of a case is ( in order of importance )

1. Cause – Mental and physical
2. Aggravation
3. Amelioration
4. Unexpected deviation, Craving and Aversion
5. Characteristic particulars

Richard Hughes : “The totality of symptom is to the therapeutist the disease’’

THE TECHNIQUE OF ASCERTAINING THE “TOTALITY OF SYMPTOMS” :

The oxford school of medicine excels in diagnosis of diseases whereas Hahnemann’s system specializes in diagnosing the individual patient and treating him. While physicians have to face both concrete reality and scientific abstractions, Hahnemann discovered a technique to realize thereby this difficult feat building up a science of the particular- the individual. Before the advent of Hahnemann, all physicians where (and the allopaths even now) in the habit of using the expedient of indiscriminately apptying their scientific knowledge to each patient, as for instance, a salesman trying to fit the same ready-made coat to people of different sizes. But they did not really fulfil their duty unless they discovered the specific peculiarities of each patient. So Hahnemann had to discover a technique whereby the individual sick man would be caught up in the net of his mode of observation and examination of the patient.

This technique involves a novel method of observation of the patient whereby is noted the general aspects as well as the particular aspects in the setting of the generals, which characterize the uniqueness of the individual.

Disease is deviation from the state of health of the human organism. Health implies the state of complete physical mental and social well-being. A diseased individual manifests his state of ill-health by perceptions sensorial, functional and organic symptoms. We perceive the flux of this symptom- complex through our sense. Suited to the individualistic approach a special technique of observation is adopted. Symptoms are recorded in the language of the patient who only narrates his perceptual flux of sensations. Thus are avoided technical conceptual terms- the abstractions made named out of the perceptual flux. Other mental faculties are brought to play on the sense- data and sensations are generalized and at the same time particularized or individualized with references to:

1. Character of sensation
2. Its Locality
3. Its Modalities (i.e.,circumstances modifying the quality of symptoms in the direction of either aggravation or amelioration) and
4. Its Other Concomitant factors (i.e.,the simultaneously or co-existing symptoms).

An example will help to understand the technique: A patient comes to us and complaints of headache. He tells of his own perception, on doubt, but he has himself made an unconscious generalization of himself. There may be various kinds of actual unpleasant sensations in connection with one’s head, eg., burning sensation, throbbing sensation, pressing, bursting, tearing or stitching sensations. The patient himself generalize these different sensations and formulates a conception which he names a ‘headache’. But the physician wants the actual particular type of sensation complained of by the patient. Next he wants to further particularize the patient’s characteristic sensation with regard to the exact locality when he feels the said particular type of pain. Still the perception of the factual reality is not complete. A living man is always to be studied in relation to his environment.

There are continuous actions andreactions going on between the individual and the environment. In order to complete the patient’s perception Hahnemann wants us to extend our observation in all directions and he hit upon the technique of finding the modalities of a symptom through closesly questioning the patient. On the one hand these modalities serve to give us the fuller perception of factual reality; on the other they serve to particularize of individualise the symptom. Same thing can be spoken about the nothing of concomitant factors. Co-existance of several common or generalized symptoms serves to individualise a symptom complex, eg.,headache is a general symptom and diarrhea is another. But the association or alternation of these two general symptoms serve to make that symptom-complex peculiar, unique or individualistic. This is how a single symptom is studied to bring out its totality.

A single symptom is more than a single fact; it is fact with its history, its origin, its location, its progress or direction and its condition. Such an integration of percepts and concepts is implied by the notion of the “totality of symptoms”. The same principle works with reference to the sum-total of symptoms complaint of by the patient. Out of the chaotic flux of symptoms, a sorting of symptoms is somewhat attempted- into generals and particular and then again setting  the particulars in the frame-work of generals. As an individual preserves its uniqueness in the setting of the universals so a Homoeopath proceeds to identify a diseased individual by sorting his symptoms into generals and particulars and then by attempting to realize the integration of particular symptoms with the common symptoms after placing them in the frame- mental integration whereby nearest approach to the concrete factual reality is affected.

The totality of symptoms is not, therefore,  a mera haphazard, fortuitous jumble of symptoms thrown together, any more than a similar haphazard collection of pathogenetic symptoms in a proving that constitutes the Homoeopathic Materia Medica.

Thus to bring out the totality of symptoms in a patient is a work of art, like picture, which express an idea- diagnostic idea and therapeutic idea.⁽¹⁾

CONCEPT OF HAHNEMANN :

Our master introduces this concept in his immortal Organon in the aphorism 7 and in many others. Let us review them.

§ 7
………… and, moreover, the TOTALITY of these its symptoms, of this outwardly reflected picture of the internal essence of the disease, that is, of the affection of the vital force, must be the principal, or the sole means, whereby the disease can make known what remedy it requires – the only thing that can determine the choice of the most appropriate remedy – and thus, in a word, the TOTALITY of the symptoms must be the principal, indeed the only thing the physician has to take note of in every case of disease and to remove by means of his art, in order that it shall be cured and transformed into health.

Fn: In all times, the old school physicians, no knowing how else to give relief, have sought to if possible to suppress by medicines, here and there, a single symptom from among a number in diseases- a one sided procedure, which , under the name of symptomatic treatment, has justly excited universal contempt because by it, not only was nothing gained, but much harm was inflicted. A single one of the symptoms present is no more the disease itself than a single foot is the man himself.⁽¹⁾

Explanation: Whilst paying attention to those circumstances (§ 5) the physician needs only to remove the totality of the symptoms in order to cure the disease.

Note 1: The cause that manifestly produces and maintains the disease should be removed.

Note 2: The symptomatic palliative mode of treatment directed towards a single symptom is to be rejected.⁽¹⁾

• 15
  The affection of the morbidly deranged, spirit-like dynamis (vital force) that animates our body in the invisible interior, and the TOTALITY of the outwardly cognizable symptoms produced by it in the organism and representing the existing malady, constitute a whole; they are one and the same.⁽¹⁾

Explanation: The affection of the diseased vital force and the disease symptoms thereby produced constitute an inseparable whole- they are one and the same.⁽¹⁾

• 16
  ……..after the changes in the health of the patient cognizable by our senses (the TOTALITY of the symptoms) have revealed the disease to the carefully observing and investigating physician as fully as was requisite in order to enable him to cure it.⁽¹⁾

Explanation: It is only by the spiritual influences of morbific noxae that our spirit-like vital force can become ill; and in like manner, only by the spirit-like (dymanic) operation of medicines that it can be again restored to health.⁽¹⁾

• 17
  ……..TOTALITY of the disease, the disease itself.⁽¹⁾

Explanation: The practitioner, therefore, only needs to take away the totality of the disease-signs, and he has removed the entire disease.

Note 1,2- Illustrative Examples.⁽¹⁾

• 18
  From this indubitable truth, that besides the TOTALITY of the symptoms nothing can by any means be discovered in diseases wherewith they could express their need of aid, it follows undeniably that the sum of all the symptoms in each individual case of disease must be the sole indication, the sole guide to direct us in the choice of a remedy.⁽¹⁾

Explanation: The totality of the symptoms is the only indication, the only guide to the selection of a remedy.⁽¹⁾

• 22
  But as nothing is to be observed in diseases that must be removed in order to change them into health besides the TOTALITY of their signs and symptoms, …………..for the TOTALITY of the symptoms of the disease to be cured, a medicine must be sought which has a tendency to produce similar or opposite symptoms.⁽¹⁾

Explanation: If experience should show that by medicines that possess similar symptoms to the disease the latter would be most certainly and permanently cured, we must select for the cure medicines with similar symptoms; but should it show that the disease is most certainly and permanently cured by opposite medicinal symptoms, we must choose for the cure medicines with opposite symptoms.

Note: The employment of medicines whose symptoms have no actual (pathological) relation to the symptoms of the disease, but which act on the body in a different manner, is the allopathic method, which is to be rejected.⁽¹⁾

• 24
  There remains, therefore, no other mode of employing medicines in diseases that promises to be of service besides the homoeopathic, by means of which we seek, for the TOTALITY of the symptoms.⁽¹⁾
• 25
  ………..the TOTALITY of the symptoms of this morbid state, that is to say, the whole disease present,⁽¹⁾

Explanation for § 24 & § 25 :  The other remaining method of treatment, the homoeopathic, by means of medicines with similar symptoms, is the only one that experience shows to be always salutary.⁽¹⁾

• 27
  The curative power of medicines, therefore, depends on their symptoms, similar to the disease but superior to it in strength, so that each individual case of disease is most surely, radically, rapidly and permanently annihilated and removed only by a medicine capable of producing in the most similar and complete manner the TOTALITY of its symptoms, which at the same time are stronger than the disease.⁽¹⁾

Explanation: The curative power of medicines, therefore, depends on the symptoms they have similar to the disease.

Note: Illustrations of it.

• 70
  That everything of a really morbid character and which ought to be cured that the physician can discover in diseases consists solely of the sufferings of the patient, and the sensible alterations in his health, in a word, solely of the TOTALITY of the symptoms, by means of which the disease demands the medicine requisite for its relief;⁽¹⁾From all these aphorisms, totality is nothing but the essence of the disease and this has to be matched with the essence of the medicine to select the similar remedy and to facilitate a cure.

We accept unreservedly the following fundamentals as preached by Hahnemann :

1. Nothing can be known of disease except through symptoms.
2. It is the patient who is ill and not his parts or organs.
3. Symptoms furnish the only unfailing guide to the selection of the remedy.
4. Peculiar, characteristic, individualizing symptoms in the case, and not the common symptoms, denote the similimum.
5. The remedy is hardly ever indicated by a single symptom, howsoever peculiar.

The complete case record will be found to consist of :

1. A set of common group symptoms which enables us to diagnose the disease. These symptoms represent the troubles which bother the patient most and drive him to seek relief. They constitute the chief complaints.
2. A set of symptoms which is far removed from the sphere of the disease and which cannot be explained satisfactorily on the basis of the pathological changes that have occurred in the tissues. The only relationship this set bears to the first is its occurrence in the same patient at the same time. Many of the peculiar, queer, rare and strange symptoms which we consider as characteristic individualizing symptoms that distinguish one patient of the disease from another, belong to this set of symptoms which we term concomitants. We shall return later to their consideration in greater detail.

Both these sets of symptoms are necessary for us to have a complete picture of the disease and the similimum has to closely match this complete picture. In actual practice, however, we find that if we concentrate our attention on the second set (concomitants), we are able to determine the similimum. The phrase ‘totality of symptoms’, therefore, has come to mean the sum total of the characteristic symptoms of the case. We shall, therefore, turn our attention to the detailed consideration of the concomitants.⁽⁹⁾

CONCEPT OF BOENNINGHAUSEN:
He proceeded on the hypothesis that the totality was not only the sum total of the symptoms, but was in itself one grand symptom – the symptom of the patient; and that whether the individual parts of the symptom were considered or the grand symptom – the totality itself – three factors must be present
1. Locality – the part, organs or tissues involved in the disease process
2. Sensations – the kind of pain, sensation, functional or organic change characterizing the morbid process
3. Conditions of aggravation and amelioration – the circumstances causing, exciting, increasing, or otherwise affording modification or relief of the suffering.

Boenninghausen recognized that symptoms naturally occur in groups, some of which are marked & prominent & some of which are subsidiary. These appear in every chronic case, and often to a marked degree. These are always leading symptoms, and these may be defined as those symptoms for which there is clear pathological foundation; or the symptoms that are most prominent and clearly recognizable; or the symptoms which first attract the attention of the patient or physician; or which cause the most suffering; or which indicate definitely the seat and nature of the morbid process; which form the “warp of the fabric,” as it has been expressed. In the leading symptoms alone, however, there is nothing particularly characteristic from the standpoint of the prescriber.

For instance, we have 150 remedies which produce cerebral congestion; 36 which produce inflamed liver; 96 produce inflamed lungs; 54 produce inflamed ovaries; the same number produce inflammation of the uterus. Any one of these may become a leading symptom, yet the inflammation of any organ is not a fact of any great value in leading the prescriber to the similimum.

In any of these conditions we have a location, if we properly diagnose the case, but unless we can qualify the location by the sensations and conditions of aggravation and amelioration, we have no alternative except to proceed empirically in the selection of the remedy.

It was because of this that Hahnemann insisted on the necessity for considering the totality of the case. Boenninghausen, in the plan of his repertory, emphasized the value of the completed symptom ( by locality, sensations and conditions of aggravation and amelioration ) but added a fourth requirement, equally imperative to the first three, and yet in itself often divisible into those three divisions. This was the concomitant symptom, and has led to the statement that his repertory is founded on the doctrine of concomitants. We should say ; the doctrine of the totality of the case, which must include the concomitants.

The word concomitant means existing or occurring together; attendant; the noun means attendant circumstance.

We may go further and say that in nearly every case we may find one or more concomitant symptoms, and we often find that the concomitant symptoms are not only co-existing, but they are those symptoms that seemingly have no relation to the leading symptoms from the standpoint of theoretical pathology. They are often symptoms for which we can find no reason for their existence in the individual under consideration. We might almost term them unreasonable attendants of the case in hand; yet they have an actual relationship in that they exist at the same time, in the same patient. They must not be overlooked nor under-valued because they cannot be made to conform with the theories of traditional medicine nor with our own ideas of their peculiar unrelateeedness.

He says that the concomitant symptoms is to the totality what the condition of aggravation or amelioration is to the single symptom.

 BOGER’S CONCEPT OF TOTALITY :

“Probably there has never been a more thorough student of Boenninghausen than the late Dr.Cyrus M.Boger and perhaps one of the greatest pieces of homoeopathic literature left by Dr.Boger is the boenninghausen Characteristics and repertory. Boger’s Repertory is “ the combained observations and logic of Boenninghausen and the wide and wise observations garnered by Dr.Boger from long years of study and practice”. This is the High tribute that Dr.H.A.Roberts paid to Boger. Boger indeed helped the profession by pulling all his experiences in evolution of ‘Portrait of disease’ ( natural as well as artificial ). He re-emphasized the following seven points to appreciate the whole picture of the disease.

• Changes of personality and temperament
• Peculiarities of disease
• The seat of disease
• Concomitants
• The cause
• Modalities
• Time

It is obvious that Boger has favoured the understanding of the whole phenomenon at the levels of constitution, Diagnosis and on going Pathology. Boger’s appreciation of time dimension, causative modalities, tissue affinities and pathological generals gave a new vista in understanding the case. In his article “ Some Thoughts on Prescribing” he instructs a physician to First try to elicit the evident cause and course of the sickness down to the latest symptoms and effect of such influences, time temperature, open air, posture, being alone, motion, sleep eating; drinking, touch, pressure, discharges, etc. Second comes the modalities and consideration of mental state in order of importance. Third entire objective aspect or expression of the sickness including the state of secretions ( sensations).

Lastly, the part affected must be determined which also bring sthe investigation in touch with diagnosis. He further states that by going over the above rubrics in the order named, the  contour of the disease picture would be pretty clearly outlined and would point fairly well towards similimum and the prescriber has only to keep in mind that the actual differentiating factor may belong to any rubric.

From the above, it is obvious that boger has given importance to Causation, Modalities, General sensations and Pathology. Location is given the last place in the order of hierarchy.

Mind is given adequate imporatance, and for selecting a drug it becomes imperative that the remedy selected is always in aggrement with the mind. He wrote in the article “ How Shall I find the remedy?” “The enter- dependence of mental and physical states is so great that we can never afford to overlook it entirely. They, moreover, always clarify every other symptoms, often in a decisive way.” ⁽³⁾

            The interpretation of what constitutes a striking or singular symptom is left to the physician, but is elucidated in the following seven considerations:

1. 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 few remedies. Taking written notes of every case gradually drills the mind into recognizing types (personalities) and their corresponding remedies.

The expression of the intellectual and moral proclivities are inter-dependent and their combined character affords the best and almost sole indication in the choice of remedies for mental affections.

2. It is self evident that the nature and peculiarities of disease, as well as the virtues of drugs, must be thoroughly known before we can hope to give practical aid in sickness. The homoeopath soon realizes that for him everything in medicine is generalized too much; the most diverse diseases needing quiet different remedies are designated by a common title which excludes every precise indication that might lead to the most suitable remedy hence he can make only a limited use of diagnosis. For the same reason every allopath orders a different medicine or mixes his drugs to cover the various indications.

The most accurate and indubitable diagnosis of a disease form as depicted in pathological (allopathic) treatises can seldom or never suffice for the sure selection of the similar (homoeopathic) remedy in a concrete case. It can, at most, but not invariably, serve to exclude from the comparison all medicines which do not correspond to the nature of the disease, but which on the contrary seem to expend themselves upon other parts of the living organism.

3. The seat of the disease frequently points to the decisive indications, for almost every drug acts more definitely upon certain parts of the organism, the whole body seldom being affected equally, even in kids differences occur in the so-called local disease, as well as in the affections designated as general; such as gout and rheumatism. At times the right, then again the left side suffers more; or the pains may appear diagonally, etc.

The amount of attention to be given to the affected part is necessarily proportioned to the magnitude of the general illness of which it is a portion. Such general terms, therefore, as headache, toothache, bellyache, etc., even when the nature of the pains is expressed, cannot contribute even the least towards a rational choice of the remedy.

It is essential to ascertain the seat of the local disease with accuracy; for every experienced homoeopath knows how, in toothache for instance, it is necessary to select the remedy which in its provings has repeatedly acted upon every tooth that suffers. The specific curative power of sepia in those stubborn and sometimes fatal joint abscesses of the fingers and toes is extraordinarily conclusive evidence upon this point, for they differ from similar gatherings in location only while the remedies so suitable for abscess elsewhere remain ineffectual here.

Had the niceties of physical diagnosis of our times been known during the age of Hahnemann he would doubtless have localized his remedies more accurately than merely giving such vague designations, as above, below, right or left, etc. it would become our contemporaries infinitely better to fill up these gaps than to keep on repeating well known symptoms or discovering others which are almost invariably of no importance.

In the treatment of disease the value of modern methods is far less therapeutic than prognostic. The internal physical signs and objective material changes never represent the dynamic disease but are its product, developing as it progresses. When, as is often possible, such disorganizations can be nipped in the bud by well selected remedies it is unpardonable to await their appreciable ravages. This is equally true of homoeopathic prophylaxis.

4. In finding the similimum for the whole case the concomitants, above all, demand the most thorough examination. 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. Commom place or well known accompaniments are unimportant unless they are present in an extraordinary degree or appear in a singular manner.

We must, therefore, examine carefully all those accessory symptoms which are :

1. Rarely found combined with the main affection, hence also infrequent under the same conditions in the proving.
2. All those belonging to another sphere of disease than that of the main one.
3. Finally those which bear the distinctive marks of some drug, even if they have never before been noted in the preceding relation.

A concomitant may so distinctly and decidedly depict the nature of a drug, and consequently indicate it, as to acquire an importance far outranking the symptoms of the main disease; it then points to the most suitable medicine. Such symptoms above all those 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. A number of efficient and partly specific remedies for various disorders are almost solely discoverable from among them because the disease symptoms proper, for lack of peculiarities, offer no possible assistance in the choice. The system of concomitants also makes Homoeopathy distinctly safer, rendering it less dependent upon a previously constructed diagnosis which is often deceptive.

5. The Cause. Pathological explanations and speculations are too far removed from our entirely practical method to have any great value in a therapy and cure. Disease are logically divided into internal and external. The formers arise from the natural disposition, which is sometimes highly susceptible (idiosyncrasy). That latter can excite disease principally by means of external impressions, when there is already a natural predisposition thereto.

The modified natural tendency to disease depends, according to Hahnemann, upon the uneradicated miasms of psora, syphilis and sycosis. When it does not originate in these it is mostly composed of remains and sequels of the acute affections which so largely go to make up drug diseases and poisoning; but we not infrequently see both factors combine to undermine the health thus presenting a proportionately deeper rooted disease just that much harder to combat. In such cases antipsoric remedies very much excel all others in efficacy. (The scrofulous diathesis-psora-is constantly being extended by the practice of vaccination: our view of the matter receives confirmation from the fact that in very many cases of such diseases which are essentially acute in character it is only by the administration of our so-called antipsoric remedies that rapid and durable cures can be effected. Preface to Whooping cough.

Whether or not we believe the psoric theory the fact remains that the best selected remedy is often ineffectual unless preceded by the proper antipsoric, antisycotic or antisyphilitic, as the case may be, but because of their almost identical symptom lists it is generally chosen with difficulty by differentiating and searching out the few true characteristics.

Drug diseases and poisonings do not differ in their health destroying power. The drug given should be ascertained and properly antidote. Simple poisons are easily detected by their effects but a drug disease is generally a compound result which fails to show a clear and accurate picture, hence a knowledge of the contents of former prescriptions taken is a necessity and lightens the labor.

Practice has extracted and rendered the anamnesic symptoms easy to access, thus greatly restricting the list from which the selection is to be made so that attention to but a few characteristics quickly determines an accurate choice. This is especially true of sprains, burns, etc. clods are more complicated because of the divers manner in which they are contracted and the different parts which they affect point to different remedies; for instance, it makes a great difference whether they are contracted while sweating, by exposure of a part being drenched all over or party, etc. Various remedies must be considered according to whether the symptoms localize themselves internally (stomavh, chest, abdomen, etc.) or externally (head, feet, back, etc.). Such remedies are not to be to readily thrown aside unless certainly found dissimilar in other respects, so much depends upon a knowledge of the cause (Anamnesis) of disease, that without it the choice of a homoeopathic remedy cannot be made with safety: Aphorisms of Hippocrates, VII., 12.

Homoeopathic prophylactics are tested and sure. The very remedies which cure the fully developed disease will protect exposed persons. This is very important for the reason that incipient diseases are generally very lacking in the characteristics which determine the choice.

6. The Modalities are the proper and most decisive modifiers of the characteristics, not one of which is utterly worthless, not even the negative ones. They have developed in importance with the growth of Homoeopathy.

A superficial examination of any completely proven drug will reveal the common symptoms of all diseases, such as headache, bellyache, diarrhea, eruptions etc, a little closer inspection of their sensation and relation to the different parts of the body establishes undoubted difference in the manner of their appearance, the modality. All experienced homoeopaths pay great attention to this point. It is self evident that the modality must be, specialized; it is not sufficient, for instance, to note the general effect of motion in a given case, but the various kinds of motion and whether they arise during continued or at the start of movement must be known. Likewise, the general effect of position, such as lying on the side, back, crosswise, horizontally, etc. as well as the special discomfort or ease caused from lying on the painful or painless side; must be elicited in order to apply the most suitable remedy.

The craving and aversion to various foods furnish some of the most important points in deciding upon the 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 has the most urgent reason to doubt its fitness: he should therefore, seek for another having the same symptoms.

7. The Time is hardly less important than the aggravation and amelioration itself and could be of great use where the different stages of disease left undisfigured by drug influences, for they constantly produce the most devious effects upon the natural course of disease. I hope no one will say that periodicity necessarily indicates Cinchona (Quinine), for there is hardly a single homoeopath who has not treated numerous victims of this error. This homoeopathic objective concerns two points which have a direct bearing upon the choice of the remedy.
8. The periodical return of the symptoms after a shorter or longer period of quiescence.
9. The hour of the day when they are better or worse.

The former coincides with epochs having special accidental causes such as menstrual disturbances, all seasonal or temperatural influences, etc. Where it is impossible to discover such secondary causes or where as is usually the case their time of recurrence is not more accurately designated they have no value for homoeopaths because they are lacking in precise indications.

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 proving supply the same peculiarity, qualifying them for the best and most comprehensive uses. To illustrate this we need only refer to influences which the time of day exerts upon coughs, diarrhoeas, etc. A considerable list of remedies exhibit typically recurrent effect, unless these are clear and decided (like Hell, and Lycopod, at 4-8 P.M.) or return at exactly the same hour (Ant.c., Ign., Saba.) they are unimportant.⁽³⁾

TOTALIT  OF SYMPTOMS ACCORDING TO KENT :

Totality of symptom is all that is visible and represents the disease in the natural world to the eye., the touch and external understanding of man.

The characteristic image must be there to individualized the case as well as the drug Kent emphasized of detailed study of the expression of the whole person who is sick. A holistic approach to study both disease phenomenon and drug. Kent give importance to the general symptoms of the patient as it express the man himself. Pathological symptoms are only the end results.

A man consists of body mind and spirit and he is known to us by his total behavior .

Kent classified symptoms into general, particular and common to understand person ,part and disease respectively. Kent gave more emphasis on the general and uncommon peculiar symptom which characterize a person and his disease. The mental symptoms are most important as it the expression of the inner man. The loves and hates or desires and aversions are the deepest mental symptoms.

KENT’S CONCEPT OF TOTALITY
MIND
a) Will.
b) Perversion of understanding/Intellect.
c) Perversion of memory/memory.

PHYSICAL
1- Perversion of sexual sphere including menstrual symptoms; general agg, before, during, after menses; effects of coition.
2- Symptoms pertaining to appetite, food desires and aversions and thirst.
3- Things affecting the entire body- Weather and temprature,food,positions, motions, etc.
4- Symptoms of special senses

PARTICULARS
Symptoms related to the parts (characteristics)l
1- Symptom that cannot be explained
2- Symptom with clear modalities

CONCEPT OF STUART CLOSE :

“ Totality of the symptom” is an expression peculiar to homoeopathy  which requires special attention. It is highly important to understand exactly what it means and involves, because the totality of the symptoms is the true and only basis for every homoeopathic prescription.

Hahnemann § 6 – “The ensemble or totality of these available signs or symptoms, represents in its full extend the disease itself; that is, they constitute the true and only form of which the mind is capable of conceiving.” The expression has a two-fold meaning. It represents the disease and it also represents the remedy, as language represents thought.

1. The totality of the symptoms means, first, the totality of each individual symptom.

A single symptom is more than a single fact, with its history, its origin, its location, its progress or direction, and its conditions.

Every complete symptom has three essential elements- ocation, Sensation and Modality.

By location is meant the part, organ, tissue or function of body or mind in which the symptoms appears.

By sensation is meant the impression, or consciousness of an impression upon the central system through the medium of the sensory or afferent nerves, or through one of the organs of senses: a feeling, or state of consciousness produced by an external stimulus, or by some change in the internal state of the body. A sensation may also be a purely mental or physical reaction, such as fright, fear, anger, grief or jealousy.

By modality we refer to the circumstances and conditions that affect or modify a symptom, of which the conditions of aggravation and amelioration are the most important. Dr.William Boericke well said: “ The modalities of a drug are the pathognomonic symptoms of the material medica.”

By aggravation is meant an increase or intensification of already existing symptoms by some appreciable circumstance or condition.

“Aggravation” is also used in homoeopathic parlance to describe those conditions in which, under the action of the deeply acting homoeopathic medicine (or from other causes), latent disesase becomes active and expresses itself in the return of the old symptoms or the appearance of new symptoms. In such cases it represents the reaction of the organism to the stimulus of a well selected medicine, and is generally curative in its nature.

“Amelioration” is technically used to express the modification of relief, or diminution of intensity in any of the symptoms, or in the state of the patient as a whole, by medication, or by the influence of any agency, circumstance or condition.

2. The totality of the symptom means all the symptoms of the case which are capable of being logically combined into a harmonious and consistent whole, having form, coherency and individuality. Technically, the totality is more (and may be less) than the numerical totality of the symptoms. It includes the “concomitance” or form in which symptoms are grouped.

Hahnemann § 7 calls the totality, “this image (or picture) reflecting outwardly the internal essence of the disease, i.e., of the suffering life force.”

The word used is significant and suggestive. A picture is a work of art, which appeals to our esthetic sense as well as to our intellect. Its elements are form, colour, light, shade, tone, harmony, and perspective. As a composition it expresses an idea, it may be of sentiment of fact; but it does this by the harmonious combination of its elements into a whole- a totality. In a well balanced picture each element is given its full value and its right relation to all the other elements.

So it is in the symptom picture which is technically called the totality. The totality must express an idea. When studying a case from the diagnostic standpoint, for example, certain symptoms are selected as having a known pathological relation to each other, and upon these is based the diagnosis. The classification of symptoms thus made represents the diagnostic idea. Just so the “totality of the symptoms,” considered as the basis of a homoeopathic prescription, represents the therapeutic idea. These two groups may be and often are different. The elements which go to make up the therapeutic totality must be as definitely and logically related and consistent as are the elements which go to make up the diagnoatic totality.

The totality means the sum of the aggregate of the symptoms: Not merely the numerical aggregate- the entire number of the symptoms as particulars or single symptoms- but their sum total, their organic whole as an individuality. As a machine set up complete and in perfect working order is more than a numerical aggregate of its single dissociated parts, so the totality is more than the mere aggregate of its constituent symptoms. It is the numerical aggregate plus the idea or plan which unites them in a special manner to give them its characteristic form. The symptoms of a case must be assembled in such a manner that they constitute an identity, an individuality, which may be seen and recognized as we recognize the personality of a friend.

The same idea underlies the phrase, “Genius of the Remedy.” Genius, in this sense, being the dominant influence, or the essential principle of the remedy which gives it its individuality.

The idea of the totality as an abstract form, or figure, has been applied to the material medica as a whole. The material medica as a whole is the sum total of the symptoms of all proved medicines- a grand, all inclusive figure which may be imagined or personified in the form of a human being or “super-man,” this conception being based upon the anatomical, physiologicaland psychological plan or framework of the material medica.

The idea is applicable in exactly the same way in pathology. Disease in general, considered as a whole, is composed of the totality of all the symptoms which represent it to our senses. The pathological totality, also, can be personified or pictured by the imagination in the form of a human being.

Starting with this conception some of our ingenious writers have amused themselves and added to the gaiety of the profession by personifying medicines, microbes and maladies and casting them in all sorts of roles- a dramatic whimsy which has its value as an educational expedient for a certain type of mind.

The  material medica from this point of view becomes a portrait gallery of diseases, a sort of medical “Rogues Gallery” by means of which we may identify the thieves who steal away our health and comfort and bring them to justice. In homoeopathic practice, to carry out the simile, we merely “set a thief to catch a thief.”

As a constructive principle, therefore, the idea of the totality enters into the formation not only of the material medica as a whole, but of every remedy and every symptom.

Each disease, each individual case of disease and each symptom of disease has its totality or individual form.

The true totality, therefore, is a work of art, formed by the mind of the artist from the crude materials at his command, which are derived from a proving or from a clinical examination of the patient.

Points that obscure totality :

1. Error may arise in placing too much emphasis upon a single symptom, or perhaps actually prescribing on a single symptom as many thoughtlessly do.
2. Error may arise in attempting to fit a remedy to a mass of indefinite, unrelated or fragmentary symptoms by a mechanical comparison of symptom with symptom, by which the prescriber becomes a mere superficial “symptom coverer.”
3. Failing in both these way the prescriber may fall in the level of the so called “pathological prescribers,” who empirically base their treatment upon a theoretical pathological diagnosis and end in prescribing unnecessary and injurious sedatives, stimulants, combination tablets, and other crude mixtures of common practice.

The physician who know what a symptom is from the homoeopathic standpoint & how to elicit it; who knows what the totality of the symptoms means and how to construct it, and who has the intelligence, the patience and the honesty to study his case until he finds it will not be guilty of such practice.

TOTALITY ACCORDING TO DR.H.A.ROBERT’S :

A few observations of Dr.Roberts from the “Pricncipal and Art of cure by Homoeopathy” will be in order. The personality, the individuality of the patient, must stand out pre-eminently in the picture. The embraces not only his physical characteristics, but the expression of his mental and emotional characteristics as well.

The generals rank the highest in evaluating the case; without generals we cannot expect to find the simlimum. At this same time the mental and emotional characteristics have a high value since these are the true reflections of his personality, the man himself.

Infact, the similimnum is practically never found among the diagnostic symptoms.

If we allow ourselves to be  guided by the symptoms of the patient, ( not the diagnosis ) which are and infalliable guid, we shall probably save the patient, even though THE REMEDY SELECTED ON THE BASICS OF THE SYMPTOM TOTALITY MAY NEVER HAVE BEEN USED UNDER LIKE DIAGNOSTIC CONDITION BEFORE.

The symptoms of LOCATION frequently furnish quit characteristic symptoms. Certain types of diseases localize in certain parts, like gout in great toe, and yet are of systemic origin. Localisation in the left or right side of the body or in the base or apices or middle lobe of the lung; on which side the trouble starts and in which direction the symptoms move and where they localize, as for instances throat trouble going from the left side to the right, or from the right side to the left, or continuous alternation of sides. These are all peculiar, characteristic symptoms.

Besides the CONCOMITANT symptoms, there may be one in which the genius of the remedy is plainly and definitely portraryed so that it would be immediately noticeable. This symptoms would immediately attain such imporatance that would outwaeigh the chief ailments in choosing the simlimum. Such a symptoms correspond to Hahnemann’s dictum about striking, strange, peculiar and unusual symptoms. It may be considered alone in choosing the remedy because it gives pre’eminently the character of the whole design.

No medicine can cure any disease unless its acts upon the diseased parts, either directly or indirectly. One organ cannot suffer alone anymore than one cell can suffer by itself.

Very often the concomitance of circumstance is of greater importance to the whole case than the expressed sensation.

The character of the drug is represented not by a single effect, but by a group of effects, this groups is the only representation we have or can  have of the medicinal character of a drug. This effects are the only relationship that can established between the medicinal effects of a drug and the disease.

We must not fail to recognize the value of the TOTALITY of the symptoms; and this must take into consideration the chief complaint, those of which the patient most often complaints, plus the peculiar characteristic of the patient… If we can find a remedy that has the “more striking, particular, unusal & peculiar signs & symptoms” of the case and if INADDITION it covers the chief complaint as well, we may consider ourselves as having a sound basis for the prescription of the similimum.

After taking the case, the physician categorises the important and relevant data under 4 heads, i.e.,location, sensation, modalities and concomitants. The analysis and classification of symptoms under these four heads would help the physician to utilize BTPB. Rubrics can be arranged in the following order-

• Location.
• Sensation.
• Condition of aggravation and amelioration.
• Concomitants.

MODERN METHOD :

From Robert’s arrangement of symptoms, we may soon realize that the list becomes longer and the physician has to refer to a large number of large rubrics. Thus it becomes time consuming and complex for a practisioner. Dr.M.L.Dhawale has modified the method, without compromising with the principle and result, by rearranging the order of symptoms. According to this modified method, the symptoms should be arranged in the following hierarchy.

1. Causative modalities- Emotional, intellectual and physical.
2. General aggravations- Emotional, intellectual and physical.
3. General amelioration- Emotional, intellectual and physical.
4. Physical generals- Sensation and complaints.
5. Mentals- For reference and differentiation.

 ESSENTIAL  EVOLUTIONARY TOTALITY :

This term has been introduced by Dr.M.L.Dhawale to help the physician in constructing the evolutionary picture of a person. It consists of a longitudinal section study and a cross sectional study of the person.

Longitudinal section study means the study of an event in the life of the person from birth till the present state. This includes all the relevant events with characteristic expressions in relation to his reactions in family, work and social environment. It helps to understand the constitution including miasmatic background.

Cross-sectional study means the study of an event in the life of the person with all the details of its expressions. This helps to understand the totality of different expressions of the constitution at different times. The study of a few cross sectional totalities helps to understand the dominant miasm at different stages so that the evolution of a constitutional miasmatic state can be understand properly.

The whole study can be represented in the following scheme, which helps to  the individual in terms of predisposition, disposition, diathesis and disease. It also includes evolutionary miasms in the person.

Essential evolutionary totality, if worked out properly, gives the glimpses of all the events in totality. It helps the physician to work out the constitutional, sector, acute, and intercurrent remedies.

E.E.T has four main lines as  represented in schematic represention; line causation, line of concomitant, line of evolution and line of phase.

Line of causation : The middle longitudinal line is called the line of causation. It contains predisposition, disposition, diathesis and disease. It is held that the cause of disease is the person’s predisposition and disposition, which leads to a particular diathesis in a unfavourable condition. The resultant diathesis gives rise to disease in due course.

Line of concomitant: The middle transverse line is called the line of concomitant. The expression at mental and physical plans are noted above and below line respectively. The expression are recorded in relation to the environment.

Line of evolution : The cross line from left upper corner to right lower corner is called line of time. It represent various events from birth to the present state. The events should be correlated to concomitants and modalities to understand the events in totality.

Line of phase : The cross line from left lower corner to right upper corner is called line of phase. It represent the various phases of disease – psora, sycosis, tubercular and syphilis.⁽⁸⁾

ACUTE TOTALITY :

            It is the totality of the characteristic symptoms manifested during an acute disease. It is the total of sector totality and fixed general totality.

Since sector totality is fast changing in an acute case one should rely more on general symptoms, which are comparatively fixed or slow in changing. Hence the totality based on general symptoms is known as fixed general totality in an acute case.

SECTOR TOTALITY :

Symptoms with location, sensation and characteristic modalities form the sector totality.

FIXED GENERAL TOTALITY :

Changes at physical, general and mental level form the fixed general totality.

FEVER TOTALITY :

This is a unique contribution of Boger. The arrangement of the chapter on Fever is self-explanatory. Each stage of the fever is followed by Time, Aggravation, Amelioration and Concomitant. Thus they help to repertorize any simple as well as complicated cases of fever.

They should be arranged properly in order to get similimum with the help of Bogers repertory.

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

CHILL

• Type / partial chill / coldness- partial / shivering
• Time
• Aggravation
• Amelioration
• Concomitant

HEAT

• Type / partial
• Time
• Aggravation
• Amelioration
• Concomitant

SWEAT

• Type / partial
• Time
• Aggravation
• Amelioration
• Concomitant

Pathological types of fever mentioned in the repertory can be used for reference and final selection of the drug, but more importance should be given to the reportorial result which is obtained by following the above order.

Section on blood circulation (congestion, palpitation, heartbeat, and pulse) should be used if symptoms are prominent during any stage of fever.

TOTALITY OF SYMPTOMS ACCORDING TO RAJAN SHANKARAN :

The essential idea behind the term “totality of symptoms” is that all the signs and symptoms present in an individual at a time arise from one basic disturbance which is the disease of the individual. Signs and symptoms that exist together without being the cause of one another is called concomitant symptoms. The totality of symptom is thus totality of concomitants. When put together, concomitants become meaningful and form a picture which is the picture of the disease.

We can describe the totality of symptoms under different aspects :

• Pace
• Sensitivity and excitability
• State of mind and dreams
• Nature of pathology and its meaning to the patient
• Causation
• Characteristic symptoms
• Miasmatic consideration
• Past history

The coordinated picture of all these is the totality of symptoms.

CONCLUSION :

A symptom as an expression of sickness in the human being, is a complex entity (as complex and differentiated as the man himself), hence, with all our ingenuity in classification and evaluation, we are constantly reminded of our shortcomings. One thing is certain, that basic traits of the symptom remain the same; the sensation, location, modality and concomitant differentiate a symptom; less of these elements, less of its value, and more of its commonness. As the disease advances, these elements tend to disappear and gross pathology appears. The diagnostic and common symptoms, shaded by the general modalities, form the ground colour of the picture, from which its special features portraying the individuality emerge with more or less distinctness.

If the Homoeopathic doctor succeeds in extracting from the whole symptom-picture, those outstanding characteristics which refers to the patient’s reaction as a whole, and not merely to the local pain or inflammation, he will soon recognize four or five determinative or determining symptoms, mental, general or modified particulars, according to the patient under study; which will lead him to the exact diagnosis of the remedy.

We often talk of totality of symptoms as the basis of selection of symptoms. The students of Homoeopathy are reminded here again and again that numerical total of what the patient talks about or what the physician may interpret, is not the true totality. The ‘gross’ or so called total totality will often land us in trouble and indicate only remedies like Sulphur, Bryonia, Bell etc. No Repertory or computer can help us in such a situation. It is only the totality of discriminating, individualizing symptoms, which alone are the pathognomic of the sickness in a particular individual at that particular point of time.

The construction of the ‘Totality’ implies knowledge by the homoeopathic physician of the following disciplines :

1. Logic & Philosophy in general
2. Homoeopathic Philosophy

• Clinical Medicine & Pathology

1. Paramedical Sciences
2. Psychology – Normal & Abnormal, and Psychodynamics.
3. Hahnemannian Pathology – Theory of Chronic Diseases or Miasms.

The Data/ Symptoms/ Facts form the common denominator of both Natural and Drug disease. These should be most carefully gathered and marshaled through accurate, complete, and unprejudiced observation of the whole ‘Field’ in a most meticulous manner. These are then analysed through classification and evaluation in a most critical manner. This constitutes the Method of Analysis. This is followed by reassembling of the analysed data through the Method of Synthesis towards the evolution of a composite homogenous Conceptual Image or ‘Portrait’.