Homeopathy Papers

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

Written by Elaine Lewis

How do you pick the right homeopathic remedy?

A Quiz respondant this month votes for Sulphur over Lycopodium because she says Lycopodium is a “chronic” remedy and the case is acute.

I have been pondering this premise: that there are two types of remedies: deep acting, “constitutional” remedies, and superficial “acute” remedies.  How many of you believe this?

If you’re lucky in an acute case, you will have the good fortune to see a “complete picture” in the patient.  You will see the remedy’s mental, emotional and physical indications in the patient, an example of which might be someone who has been in a car accident, he injures his head, there’s 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; I’m fine!”  Then the person nods off, and only responds again if he hears the word “hospital”, where he again protests that he’s “fine”.

This is a “constitutional” Arnica case!  Why do I say that?  Because we’ve got a complete remedy picture here!  We’ve got the mentals, the physicals…all matching Arnica!  And yet, this is an acute case, to be sure; shouldn’t we be looking for an “acute” remedy?  Now you see how pointless this discussion is!  Our only mission is to find the indicated remedy!  So how do we do that? 

Lesson One:

The remedy must always match the “mentals” in the case, regardless of whether the case is acute or chronic!

In an Arnica case, what are the “mentals”?  “Says he’s well when he isn’t.” That’s the Arnica mentals!  If you see that in an accident situation, give Arnica right away, it doesn’t matter what else is wrong with him!  The “mentals” are supreme and hold sway!

My way of looking at it is this:  When a person presents with an acute, the question always is, “What has changed about this person since the illness or event occurred?”  If a change has occurred on the mental plane, then the chosen remedy will have to match that!

However, if the patient is irritable–but is ALWAYS irritable–this is not part of the acute case and it doesn’t count!  If the patient desires to be alone, but ALWAYS desires to be alone even when he’s well, that is not a part of the acute case.  Similarly, if a person is thirsty, but is ALWAYS thirsty, even when well, that is not part of the case either!  You’re only interested in what’s different, what’s new, what’s recent, what’s changed from usual because that’s what you’ll be wanting to match a remedy to.

If the remedy is chosen based on it’s similarity to the physical symptoms alone, it will not work if there is a mental concomitant (component) that is a part of the case!  In other words, if you see a rash that looks like Sulphur (worse heat, worse hot bathing), but the patient is crying pathetically like Pulsatilla, then do not give Sulphur even though it matches the rash!  You have to give Pulsatilla because it matches the mentals!  

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 and apparently very afraid of bees!  Barb gave our famous fear remedy, Aconite, and it worked perfectly!  Why?  It matched the mentals!

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

Sometimes a case doesn’t have any mentals!  So just ignore the mental picture of the remedy, then, if it matches the physicals!

One of our famous homeopaths from South America, Dr. Francisco Eyziaga, had a dog who got into the trash one night and ate up all the fat from the left-over meat. The next morning the dog was nearly dead!  Dr. Eyziaga gave…do you know what? Think… “Ailments from Fat”…  Yes, he gave Pulsatilla!  Pulsatilla?  I know what you’re thinking: “Isn’t that the clingy, cry-baby remedy?”  Well, yes; but this case didn’t have any mentals or emotionals, so we just ignore the mentals of the remedy; as it happens, Pulsatilla is our “Ailments from Fat” remedy too, so the dog’s life was saved!

You can choose a remedy for a variety of reasons!  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.  Can we give Pulsatilla if the patient is not crying?  Yes, if the case had no mentals and Pulsatilla matched the physicals.

A final word on the subject by James Tyler Kent, MD, the guy who wrote The Repertory:

“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 inter-current.  [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.  (By constitutional, we mean your nature when you are not sick.)  Your constitutional remedy can change if you’ve been traumatized.  Maybe you were a lovable, sociable Phosphorus person until your parents got divorced.  You became sad, withdrawn, blamed yourself.  Now you’re a Nat-mur!  Whatever is most recent comes first.  The remedy will have to cover the most recent change to your case.

I read an article by Miranda Castro

in the American Homeopath 1995, 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.  In truth, should Miranda have been looking for her brother’s constitutional remedy if he had pneumonia?  No!  But when her brother said that the worst part about being sick was people noticing that you can’t cope, she thought she had an epiphany!  “Do you like eggs?”  Miranda blurted out, trying to confirm Calc-carb!  Yes, it turned out he did like eggs!  “He must be a Calc-carb!” she thought.  But the famous egg-loving Calc-carb., though helping him sleep that night, did not stop the pneumonia!!!!! 

Miranda realized she’d have to treat this as an acute case, which, of course, it was! Upon taking the case of his acute symptoms, Crotalus horridus came up.  Upon checking the Materia Medica, she saw that even the mentals of Crotalus (dwelling on thoughts of death and aversion to family members) were present in the case!  With repeated doses of Crotalus horridus 30C, vast improvement in the pneumonia occurred within 24 hours.

Don’t mix up constitutional symptoms with the acute complaint; the acute complaint is everything that has changed since the person became sick 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 presenting along with itas we saw in the example of Aconite being used for a bee sting.  Even though Aconite only covered the mentals, it STILL cured the whole case!

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 a case, you will at least know that if you can match what’s at the top of the hierarchy, you will be successful.  The mentals are almost always at the top.

Also, 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”:  “I want air!”   “I want to go home!”  “I’m thirsty!” and so on.  The local symptoms start with the word “MY”:  “My nose is stopped up!”   “My eye itches.”  If a remedy matches the Generals in the case, but doesn’t match the Particulars, give it anyway!

Even higher than the mental/emotionals in this hierarchy is the Etiology (the cause) as demonstrated in the dog’s case:  “Ailments From Fat”–with Pulsatilla being the main remedy.  The etiology is always expressed as “Ailments From”.  There was nothing else in this case to indicate Pulsatilla but it still worked because our Ailments From Fat remedy is Pulsatilla and “Ailments From” is always at the top of the hierarchy and always holds sway!

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

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?”  No.  We frequently have to know what’s wrong with you so we know what chapter of the Repertory to look in!  Otherwise all we’ve got are symptoms, and the same symptoms seem to come up every time!  Think about it, about how ubiquitous symptoms are: diarrhea, cough, runny nose… so common, found in so many diagnoses.  We have to know more than that.  We have to know what’s wrong with you!

You might have a rash, 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 or vaccine?  Knowing the answer to this will tell me what the primary rubric is in the Repertory (our Index of Symptoms); so, knowing what’s wrong is so basic.  Now, keep in mind, you don’t always need a doctor to acquire this information, sometimes what’s wrong with a person is so 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?” and “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, our two main sudden-onset remedies.

4. Delusions and Strange, Rare and Peculiar symptoms

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

6. Emotionals (fear, crying, yelling, whining, 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 Onset!  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 a red face and throbbing headaches, and Sulphurs hate the heat as everyone knows!   Can we give Sulphur?  No, because you’re starting from the bottom, start at the top of the hierarchy!  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, Sulphur’s not under “sudden onset”!  What about right-sided headaches?  It’s only a 1 and there are many 3’s in that rubric; so, no, it doesn’t really cover right-sided headaches.

But 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.

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 covers the top of the hierarchy!!!!!  OK?  You don’t have to go “repertorizing” to see if the whole case goes for Arnica, Arnica will cure the whole case.  Why?  It covers the Etiology: “Ailments From Blunt Trauma”!

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 bath or shower”; then give Rhus tox!  Nothing else matters, because “strange/rare and peculiar (characteristic) symptoms” are near the top of the hierarchy and therefore hold sway, and I’m assuming there’s nothing above it in the hierarchy to supersede it; in other words, there’s no etiology to knock it out of the running.  Am I making myself clear?  God, 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 an equal footing with everything else; no, it actually over-rules everything else!  And by extension, whatever is nearest the top of the hierarchy over-rules all the symptoms that come below it!  Very often it’s the mentals.  That’s why it appears as though all we care about is the mentals.  Well now you know why!  Because if there are mentals in the case, the remedy has to cover them, and if it does, it will not necessarily have to cover whatever is below it in the hierarchy!   

When do we repertorize a case?  Usually when everything is on an equal footing.  When you’ve got a physical case with no mentals, no etiology, like a toothache case, for example….

So look, I have to do the dishes now, OK?…and then I have to fold laundry.  Can you manage this by yourself now?

Bye!  See you again next time!


Elaine Lewis, DHom, CHom

Elaine takes online cases.  Write to her at [email protected]

Visit her website: https://ElaineLewis.hpathy.com

About the author

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.

  • You explain so well, Elaine! Is “Ailments From Wireless Technology” an etiology that’s in modern repertories?

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