Homeopathy Papers

Acute vs. Chronic Remedies, the Hierarchy of Symptoms, and the Kitchen Sink


Solving a Homeopathic Case

A quiz respondant this month votes for Sulphur over Lycopodium, which she prefers, because Lycopodium is a “chronic” remedy and the case is an acute.

I have been pondering this premise: that there are two types of remedies: deep acting/ “constitutional”–remedies, and superficial “acute” remedies, like Arnica.

Here’s where I am in need of an explanation: Are we looking for an acute remedy or a remedy for an “acute“?

This is where the confusion lies.

If you’re lucky, in an acute illness, you will have the good fortune of seeing a complete “remedy picture” in the patient, an example of which might be someone who has been in a car accident:  He injures his head. There is blunt trauma, shock, bruising, soreness and swelling and yet the person says, “I’m fine really, no, I don’t want to go to the hospital, there’s nothing wrong with me, really!” The person then nods off, and only responds again if he hears the word “hospital”.

This is a constitutional Arnica case! Why would I say that?  Because we’ve got a complete picture here!  The mentals, the physical particulars, the physical generals…all matching Arnica!  And yet, this is an acute case, to be sure; nonetheless, this person is now the “essence” of “Arnica”! He may have been “Sulphur” yesterday, but he is “Arnica” today. He is in an “Arnica state”. Arnica is his “constitutional remedy” (for now). If he doesn’t get Arnica, he may be “Arnica” for the rest of his life and therefore have a fear of being injured, a fear of being approached, aversion to being touched, forgetfulness, a tendency to have accidents, to be accident-prone, to dream of accidents, etc.

No one would say, “If he’s Arnica constitutionally, and this is an acute case, then we can’t possibly give Arnica, because we need an acute remedy!”  That would be the height of insanity!  This means, then, that we are asking the wrong question!  We need only be asking, “What is the indicated remedy in this case?”

The “too deep” remedy here is Sulphur–his former constitution! Sulphur is the layer underneath Arnica and it has nothing to do with this case; it might even aggravate if it were given.

The remedy must always cover the mental concomitant, regardless of whether the case is acute or chronic.

And what was the mental concomitant here?  “Says he’s well when he isn’t.” That’s Arnica for you!

My way of looking at it is this: When a person presents with an acute, the question always is, “What has changed in this person since this illness or event occurred?” If a change has occurred on the mental plane, then that is the mental concomitant and the chosen remedy will have to cover that (assuming that it is clear and intense). 

If the patient is irritable–but is ALWAYS irritable–this is not a part of the case!  If the patient desires to be alone, but he ALWAYS desires to be alone, that is not a part of the case.  Similarly, if a person is thirsty, but is ALWAYS thirsty, that is not a part of the case either!

If the remedy is chosen based on it’s similarity to the physical symptoms alone, it will not work if there’s a mental concomitant that is a part of the case!

My favorite example is a story told by our friend Barb about a family reunion of sorts in which one of her guests got stung by a bee!  Barb gave Apis, being very sure of herself, and it didn’t work.  What?  She was shocked–and embarrassed because everybody was watching!  (I’m shocked too!) 

Finally Barb had the presence of mind to notice that the victim was scared!  Barb gave Aconite and it worked!  Why?  It matched the mental concomitant!

Now, looking at this the other way–the opposite way– in cases with no mentals, can we reject a remedy that matches well except that it’s well-known mental concomitant isn’t in the case?  Can we withhold Pulsatilla because the patient isn’t crying?  Can we withhold Arnica because the patient is just bruised and not saying, “I’m fine, no really, I’m fine”?

Sometimes a case has no mental concomitants!  So just ignore the mental picture of the remedy, then, if it matches the physical case!

I’m reminded of the story of Dr. Eyziaga’s dog who got into the trash one night and ate up all the fat from the left-over meat from dinner. The next morning the dog was nearly dead!  The doctor gave…do you know what? Think, think… “Ailments from Fat”…  Yes, it’s Pulsatilla!  Pulsatilla?  I know what you’re thinking: “Isn’t that the clingy, cry-baby remedy?” Well, yes; but, it’s also our “Ailments from Fat” remedy! The dog’s life was saved!

Every remedy has a healthy presentation, an acute presentation, a chronic presentation, an “end stage” presentation, an early-stage presentation, an etiology it’s known for…in other words, a person can need Pulsatilla just because he’s eaten too much fat and for no other reason and that is just as much a Pulsatilla case as a clingy child with an earache; or a case of fever with thirstlessness, or even a prostatitis with a thick yellow bland discharge. Can we give Pulsatilla if the patient is not crying, nor jealous, nor feeling abandoned?  If there is no mental concomitant in the case stating otherwise, yes, we certainly can!

A final word on the subject by James Tyler Kent, MD:

“The Examination of the Patient” from Kent‘s Lectures on Homeopathic Philosophy

When an individual is suffering from a dangerous crisis, a serious accident or emotional trauma, or a virulent acute miasm [an infection like the flu], the treatment of choice is the acute remedy or acute intercurrent.  [Note: Kent doesn’t say to give the constitutional remedy to this patient, he’s implying that you have to stop the constitutional remedy and give a remedy that matches the acute.]

After the acute state has subsided the underlying fundamental cause must be removed by complementary constitutional treatment to prevent reoccurrence and complete the cure.

No remedy is exclusively an ‘acute remedy’ by nature A remedy becomes acute or chronic depending on the strategy of the homeopath and how he applies the remedy. Deep acting remedies like Arsenicum, Mercury or Sulphur are often used in acute diseases if the symptoms of the acute layer call for them. 

The key in such situations is not to mix the acute and chronic symptoms together in one grand totality as this confuses the case. 

So listen, everybody, always take the case of the acute and only the acute.  Always remember this:

Acutes get treated first, the constitutional case comes after.

I read an article by Miranda Castro Acute vs. Chronic Remedies, the Hierarchy of Symptoms, and the Kitchen Sink 1 in the 1995 American Homeopath dealing with this very topic where she tells the story of her brother in the hospital with pneumonia.  She was distraught with not being able to figure out his constitutional remedy until she suddenly had a “light-bulb moment” after her brother said that the worst thing about being sick was people noticing that you can’t cope!  “Do you like eggs!”  Miranda blurted out!  Yes, it turned out he did!  But the famous egg-loving remedy, Calc-carb., though helping him sleep that night, did nothing to stop the pneumonia!!!!!  Miranda realized she’d have to treat this as an acute case, which led her to the remedy Crotalus horridus.  Upon checking the MM, she saw that even the mentals of Crot-h.– dwelling on thoughts of death and aversion to family members (he wouldn’t speak to his father)–were actually present in the case, making it a true “constitutional” remedy for his present state!  With repeated doses of Crot. horridus 30C, vast improvement occurred within 24 hours.

Any remedy that matches the acute case is suitable–we don’t have “acute” and “chronic” remedies (although I hasten to add that some of our remedies are under-researched and under-used and are therefore known to us only for just one or two things for which they have become famous, like the way Wyethia is known for tremendous allergic itching of the mouth, nose and throat.  If there are constitutional Wyethia’s out there, we would most likely never know it).

Don’t mix up constitutional symptoms with the acute complaint; the acute complaint is everything that has changed since the person became ill or injured.  It’s all the ways that the patient is different than his usual self!

Acutes don’t always have a mental/emotional component.  Don’t reject a remedy that’s a good match because its famous mental symptom, like crying or jealousy isn’t there.

But, if there is a clear mental component to the case, the remedy will have to cover that, even if it’s not known so much for the physical complaint that’s presentingas we saw in the example of Aconite being used for a bee sting.  Of course, if you can find a remedy that covers everything in the case, that would be ideal; but sometimes you won’t be able to.

This is the value in having a hierarchy of symptoms because…knowing that you will most likely NOT be able to match every symptom in the case, you will at least know to match what’s at the top of the hierarchy and be successful.

We’re more concerned that the remedy match what’s at the top–usually the mental and emotional symptoms–than what’s at the very bottom, which are usually the local physical symptoms.

In this context, the remedy that matches the Generals would be of more value than a remedy that matches only the Particulars.  The Generals are the symptoms that start with the word, “I” or “I’m”:  “I want air!”   “I want to go home!”  “I’m thirsty!” and so on.  The local symptoms start with “MY”:  “My nose is stopped up!”   “My eye itches.”

Even higher than the mental/emotionals in this hierarchy is the Etiology (the cause) as demonstrated in the dog’s illness:  “Ailments From Fat”–with Pulsatilla being the main remedy.  There was nothing else in this case to indicate Pulsatilla but it still worked!

Now, since I brought it up, here is the standard hierarchy:

1. Etiology (“Ailments From” or “Never Well Since” a certain trauma, event or illnesss)

2. Diagnosis (the name of the condition: Measles?  PMS?  Arthritis?  Gallstones?)  Some of you are going to say, “Isn’t this allopathy?”  If I don’t know what you have, if I don’t know the name of your illness, I won’t know what chapter of the Repertory to look in!  

You can have a rash, for example, but what’s it from?  Is it an allergy?  Is it the measles?  Is it poison ivy?  Is it a side effect of a drug you’re on?  Knowing the answer to this will tell me what the primary rubric is; so, having a diagnosis is basic.  Now, keep in mind, you don’t always need a doctor to acquire this information, sometimes what’s wrong with a person is quite obvious; but, you do have to ask your patient, and if he says, “I don’t know, I don’t know what’s wrong with me,” ask him, “When did it start?  What were you doing that day or around that time?  Re-trace your steps, give me the run-down.”

3. Onset (sudden or gradual?)

A sudden onset might trump everything  in the case and lead to an immediate consideration of Aconite or Belladonna and maybe even Baptisia in septic states.  Now, be careful with this.  “Sudden onset” doesn’t mean that you suddenly started coughing after someone blew smoke in your face!  It means you were fine, you went out for a brisk walk in the cold, windy weather, and half an hour later you had a fever, sore throat and runny nose!  That would be a perfect Aconite case (Ailments From cold, dry winds).

4. Delusions and Strange/Rare and Peculiar symptoms

5. Mentals (symptoms like confusion, forgetfulness, poor concentration, stupor.)

6. Emotionals (fear, crying, yelling, whining, making demands, throwing things, etc.)

7. Physical Generals (“I’m thirsty”, “I’m cold”, “I want to sleep”, “I’m nauseous”, “I want ice”, “I want the lights out”, etc.)

8. Local symptoms (“My leg hurts”, “My eye itches”, “My throat is sore”, “My nose is stopped up.”)

So, using this hierarchy as a guide…let’s say you have a case of right-sided, throbbing headache with red face, that came on suddenly after being out in the heat of the sun.

Can we cover the top of the hierarchy?  The etiology?  Yes, Ailments From the sun.  It’s in “Headaches: Sun, from exposure to”.  What about the diagnosis?  The diagnosis is headache from exposure to the sun.  What about Onset?  Got it covered:  Sudden!  Any delusions?  No.  Mentals?  No.  Emotionals?   No.  Physical Generals?  Right-sided complaints  (“Generals: sides of the body, right”).  Local Symptoms?   “Face: red”.  “Headaches: throbbing”.

Sulphur has red face and throbbing headache, and Sulphurs hate the heat as everyone knows!   Can we give Sulphur?  No, because you’re starting from the bottom of the hierarchy, start at the top!  Will Sulphur cover the etiology?  “Headache from exposure to the sun”?  It’s only a “2” in that rubric and there are a lot of 3’s, I would say no, it doesn’t cover the etiology as well as other remedies do.  “Sudden onset?”  No!  What about right-sided headaches?  It’s only a 1 and there are many 3’s in that rubric.

Belladonna, on the other hand, has the etiology covered (ailments from the sun); the diagnosis, which is headache from the sun; sudden onset, right-sided headaches, red face during headache and throbbing headache, all in the highest degree; hence, Belladonna beats Sulphur.

Belladonna headache

I just need to make it clear that the top of the hierarchy over-rules the bottom half.  So let’s just say for example that you’ve got a case where the etiology is famous for one remedy, the way Arnica is famous for ailments from blunt trauma; the whole rest of the case becomes irrelevant because Arnica is at the top of the hierarchy!  You don’t have to go repertorizing to see if it also covers the bottom half: thirstlessness or headache or whatever else may be in the case; just give Arnica!  You will be surprised at how it will take care of everything in the case.  Let’s look at another example.  If you’ve got a peculiar symptom that famously goes for, let’s say, Rhus tox, like “all complaints disappear in a hot shower”; then give Rhus tox!  Nothing else matters, because “strange/rare and peculiar (characteristic) symptoms” is near the top of the hierarchy, and I’m assuming there’s nothing above it in the hierarchy to nullify it.  Am I being clear?  I hope so.  

Robin Murphy said in my interview with him that the mistake people are making is treating etiology as just one more symptom in the case, on equal footing with everything else; and no, the top of the hierarchy actually over-rules the bottom half; so you really do have to look for an etiology in your cases, a possible sudden-onset, characteristic symptoms….  When do we repertorize, when is everything on an equal footing?  When you’ve got a physical case, an injury perhaps, or a stomach upset, and there are no mentals, no clear etiology, no delusions or other peculiars… just a bunch of local symptoms. 

I have to do the dishes now…and then I have to fold laundry.  Can you manage by yourself now? 

Acute vs. Chronic Remedies, the Hierarchy of Symptoms, and the Kitchen Sink 2

See you next time!

About the author

Elaine Lewis

Elaine Lewis

Elaine Lewis, D.Hom., C.Hom.
Elaine is a passionate homeopath, helping people offline as well as online. Contact her at [email protected]
Elaine is a graduate of Robin Murphy's Hahnemann Academy of North America and author of many articles on homeopathy including her monthly feature in the Hpathy ezine, "The Quiz". Visit her website at:
https://elainelewis.hpathy.com/ and TheSilhouettes.org


  • This article is a gem! The author shows a deep knowledge about real homeopathic prescribing and helps homeopaths get away from the trap of constitutional prescribing when it is not appropriate to the case situation

    • I can’t believe I’m only just now seeing this! Dreams. It all depends. Sometimes dreams are the whole case! Like in night terrors where the patient is awake but still dreaming and saying things like, “Wild animals! Wild animals!” as if he’s being attacked, and of course, this is Stramonium. Sometimes you’re suspecting a remedy and the dreams confirm it, like you’re suspecting Pulsatilla and the patient says she has dreams about black dogs. If dreams are important, the patient will tell you. “I have disturbing dreams!” Then, of course, the dream is very important; but it doesn’t absolve you from pursuing the rest of the case. You may find out he’s “proving” some food or beverage he’s drinking to excess, like tea, for example. It’s part of the case, is all I can say; but you always have to find its place. It’s not important just because it’s a dream.

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