Layers in prescribing: The role of etiology and internal and external factors

The following essay is extracted from the book, Comparative Materia Medica: Integrating New and Old Remedies. The book is designed to revisit the art of homeopathic comparative materia medica and to explore the development of our knowledge of materia medica. One of the points of debate within homeopathy is whether there is ideally just one remedy only that will cure the whole person – if only it can be found – or whether a layered or phase like analysis needs to be incorporated in order to understand which homeopathic remedies may be suitable. The following is a discussion of this issue and then a remedy is used to example the process of homeopathic differentiation and knowledge of materia medica.

In the book, each remedy is classified according to 2 to 3 stages, identified as the intrinsic, compensated and decompensated stages, which are compared to the 3 main miasms of psora, sycosis and syphilis. Therefore the intrinsic/psoric state of a remedy relates to more constitutional factors, which often don’t change, the compensated/sycotic stage relates to the reactive, functional and exaggerated symptoms seen in a case and the decompensated/syphilitic stage relates to the broken down, structural and end stages of pathology in a remedy.

By describing each remedy within these stages, it allows for a more accurate comparison between remedies at different stages of the remedy picture. No one person expresses all the symptoms of a remedy. One has to identify a remedy based on a selective few symptoms and often people resonate predominantly in one stage or another, the homeopath having to identify and to know the stages of remedy expression.

One of the most important issues to address when deciding whether a prescription is constitutional or not is to look at the influence of external and internal factors. External factors can be influences such as ailments from shock, fright, and exposure to weather, grief, loss, physical injury and other trauma. Internal factors relate to intrinsic qualities of a person and their basic susceptibilities – physical characteristics, inherited physical and emotional qualities etc. One could make the argument that the susceptibility to external factors is predicated on intrinsic internal factors. One is a reflection of the other. Therefore, in analyzing a case, one considers both external and internal factors to help determine the remedy needed and a well indicated remedy often does exactly that. However, there are times when the influence of the external factor is so strong that it superimposes itself onto the constitution, overwhelming it with its dynamic influence and creating a layer or superimposed dynamic onto the constitution. In these situations, the nature of the etiology and the reactive mechanism of the individual will determine the remedy choice. This is where remedies such as Aconite, Gelsemium, Ignatia, Arnica, Staphysagria, Stramonium etc. can often be needed. These situations may not be acute but chronic states, the person laboring under the influences of whatever single or accumulated trauma has occurred and which has now become part of their basic state. However, it needs to be seen that it is still an imposed influence and the remedy needed will address both the etiology and the reaction to that state. However, the constitution has not necessarily been addressed. The most common example could be when a person who needs Natrum muriaticum goes into an Ignatia state when an acute grief is experienced. Homeopathic books are full of such examples of remedy relationships, when another remedy is needed to address a more intense or magnified state. In such situations, one must always distinguish whether the indicated remedy does seem to address the most basic qualities of the person or merely the layer most visibly expressed.

A basic equation can be stated as following: the more intense and strong the imposed state is (the etiology), the less important is the susceptibility of the basic constitution. We know that remedies such as Arnica, Aconite and Stramonium can be needed in a person, even an adult, when the trauma stems from the birth process. In these cases, this is still an imposed layer of trauma that has been carried ever since.

It is obviously the case that the dynamic interaction between the external condition and internal susceptibility is important in considering the totality of any case. Even with intense external circumstances, people react differently, conditioned by the inherent susceptibility in each individual. However, the same rule applies and a person has the potential to move into different energy states depending on the intensity of the external stimuli.

In identifying these distinctions, some homeopaths have defined these layers as follows (See A Treatise on Homeopathic Medicine by Francisco Eizayaga): The Constitution is the basic level, the Fundamental level represents symptoms and states that are a deviation from the constitutional and may require the same or a different remedy and the Lesional level which relates to specific pathologies and conditions which are superimposed onto the constitution. These mostly require a more specific remedy to address the condition, which should then be followed up by the constitutional remedy and perhaps a miasmatic remedy if indicated. There is also the Morbid Terrain level, which describes the miasmatic terrain in which the other levels are expressed. Ideally there is one remedy that would address all these situations and layers that arise, and this is the default position taken by most classical homeopaths. The idea is that as there is only one person, and as all things are connected, the remedy has to be given to address the whole person. Therefore the deepest remedy should be found that addresses both the presenting symptoms, even in more complex physical pathology, as well as the characteristics of the basic nature of the person. If this solution can be found, then most would agree that the confidence of the prescription is higher. However, in practice, there are many situations in which certain symptoms seem to demand more attention, especially in more advanced physical and mental pathologies and these symptoms will determine the prescription. In such circumstances, it can be a mistake to take into consideration other more background data such as food desires, weather preferences and personality characteristics. The question, as always with homeopathic prescribing, is which symptoms should be focused on and which should be ignored.

The One Remedy

There is a tendency today in modern “classical” thinking to focus on finding just one remedy that will do it all, that will cover the complexity and depth of a case and anything less is seen as a meandering cure or even a suppressive affect. While the ideal of one remedy is good to strive for, the reality is that it is not always possible to find and mistakes are made in striving after this ideal. Some cases require more than one remedy to cure.

For example, if a nosode is given (for the morbid terrain), especially one of the big five, one should always look for a complementary remedy to follow on, to address the basic constitutional state. The same applies when a remedy is needed to address a true acute state or a strong physical lesional condition (Lesional level). Once completed, a deeper acting remedy should be given if there is a need and a picture is clear. Another common statement is that there is no such thing as an acute disease; all are expressions of a chronic condition. Treating such states as acutes will be suppressive, leading to further internalization of disease. It is a mistake to take this too literally. While Hahnemann states that most acute diseases are expressions of a chronic miasm, there are true acutes, and this is mostly found in bacterial or viral infections (not including external trauma), which can be part of an epidemic or sporadic infectious disease state. However, even in cases where the acute state is a direct expression of a chronic miasm, it can still require a specific remedy to address the immediate condition, if the picture is clear. If it is not, then the chronic, constitutional remedy should be given. The focus on suppression is more theory than reality and while no doubt there are examples of homeopathic suppression, it is often used more as a philosophical position than is found in reality. If the remedy given for an acute state (or acute expression of a chronic condition) cannot address the root of the condition, then generally it will only work superficially and the symptoms will return.

However, in the treatment of children, there can often be confusion between acute and chronic conditions, leading to superficial prescribing on presenting symptoms and not addressing the underlying state, especially in seeing the miasmatic influence in the case. While young, a child often attempts to throw off miasmatic influence, producing conditions such as repeated ear infections, sinusitis, asthma, eczema, behavioral states etc. While any appropriate chronic remedy can cure, a nosode is often needed to fully resolve the case. Elizabeth Wright-Hubbard’s writings are useful to study in this regard, as are Donald Foubister’s. Remedies may still be needed to address acute exacerbations but things will not change dramatically until a chronic remedy or nosode is given.

As a rule of thumb, it can be assumed that each person can potentially “vibrate” within the range of a certain number of remedies. The idea that they will only vibrate to one remedy or only need one remedy for life is not revealed in clinical practice. The energy of any remedy clearly overlaps with other remedies. Also, a person who may need a certain remedy for their “constitutional” susceptibility may move into the sphere of another remedy depending on circumstances. Within the temperamental dynamics of each person, the basic constitutional qualities predominate, yet as temperament is adaptable to circumstances, other remedies may be required at times. This is not indicative of a meandering route to cure with various partial similars but the fact that different remedies are needed to take the person all the way. It is too simplistic to assume that the complexity of a human being can be totally encompassed within the vibration of one remedy. Also, the stronger the external forces that influence a person, the further away from constitutional influences the situation develops, leading to the use of remedies that address the specific situation and not the constitutional dynamics in a case.

The 2nd Prescription

The challenge of finding the most exact remedy(ies) in a case leads to a situation where one remedy leads to another and maybe another based on a less than perfect simillimum found. There is nothing wrong with this and it needs to be understood that unless the remedy is repeated much too frequently, confusion or even damage to the patient will not occur. The remedy will work to the level of susceptibility it has in the case, eliminating some symptoms and leaving others untouched. The remaining symptoms and any new symptoms will generally become the new case to prescribe on, unless the other symptoms return when the whole case from the beginning is done. At times, if there is confusion in a case, going back to the original case is a good idea, even if the picture has changed.

Any strong new symptoms that appear after a remedy, if they stay and do not disappear as part of the remedy reaction often become the most important symptoms to consider for the second remedy. This information, plus an understanding of related remedies and miasmatic considerations can help one choose another remedy. Even one strong keynote can be enough. Do not look for a complete new image of a remedy. Often it is only a sliver of the remedy image that is seen.

The following model is a suggestion of how to analyze the relationship of remedies and when one needs to consider more than one remedy to fit a particular case.

Strong emotional picture: A top layer where the emotional/mental picture of a remedy is strong with or without physical symptoms. An underlying constitutional remedy may be needed to follow if there are symptoms indicating this. Often the top remedy may be a plant or animal remedy and there may be a clear etiology in the case. In these cases, much of the energy is given to the response to a particular situation.

A nosode is needed: A top layer where a nosode is needed based on the predominant symptom picture and/or a clear family history. This often would need to be complemented with a constitutional remedy, often related to the nosode given. In other cases, the constitutional remedy may be given first, followed by the nosode at a later date if indicated and/or if the first remedy does not complete the case. In these cases, an understanding of broad miasmatic qualities needs to be identified, along with confirmatory keynotes of a particular nosode.

Incomplete cure: If a constitutional remedy has been given, and works well, it can occur that it doesn’t address all the symptoms in a case, leaving one or more chronic conditions untouched. However, the remedy has worked very well; it is not just a partial simillimum. In these cases, a complementary remedy may be needed, which can come from a similar or different family or may also be a nosode. In these cases, one needs to understand when the limits of one remedy have been reached and another one is needed. This is very delicate. In some cases, one needs to wait many months before thinking to change the remedy. It can even extend to years. In other cases, after three months, if a certain chronic, often long-term symptom has not changed, then another remedy should be considered. The key consideration is really the clarity of the case for the prescriber and whether he/she can perceive another indicated remedy. In these cases, a recognition of key “constitutional” characteristics can be helpful in knowing which other remedy may be indicated. It can also be that what one has considered to be a constitutional remedy is in fact a more superficial remedy for the person and another deeper remedy is needed.

A specific etiology: A remedy can be needed to begin the case based on a clear etiology that has to be addressed first. This could include shock, fright, grief, and other emotional dynamics, or it could be due to toxic effects e.g. drugs, vaccines, environmental exposure, diseases such as malaria, STDs, tropical diseases in general, other inflammatory diseases such as meningitis etc. In these cases, a remedy may be needed based on the symptom picture of the original condition, plus what is remaining as part of the current picture. Once this remedy is given, a complementary constitutional remedy can be followed. In these cases, the underlying constitutional remedy may or may not be seen right away. If all one sees is the Stramonium picture, for example, then perhaps that is all that is needed. However, an awareness of underlying constitutional factors should be kept in mind when looking at the symptom totality. This level of causation can often be missed in case taking, at times because the patient has forgotten, but it can be vital in opening up cases. Trauma of all sorts (emotional or physical) frequently leaves a powerful and often unconscious imprint on the body/mind and can affect both long-term physical well-being and psychological outlook. This always needs careful analysis by the homeopath.

A new picture emerges: Another remedy can be needed when the first remedy brings up a clearer remedy picture. New symptoms may appear or old symptoms reappear which do not disappear naturally, revealing a new image. In this case, the first remedy may or may not be the simillimum and/or the deepest possible remedy but functioned to reveal a clearer picture of the disease. In the somewhat messy world of clinical practice this happens and we need to see when we have to change the remedy. Hanging onto the same remedy from the beginning based on the idea of the “one” remedy is a mistake here. The skill of the homeopath in identifying the new remedy image is key in determining the next remedy and when to give it.

Idea: I have to be able to escape the horror, pain and terror to survive or I will suffer terribly and be condemned to a fate worse than hell.

Fear, terror – the dark, alone, animals, demons, graveyards, water, shining surfaces.
Pain, torture, violence, threat, danger.
Alone, forsaken.
Shock, fright. Ailments from violent shock.
Rage, violence, destructiveness, kicking, biting, spitting, wildness.
Mania, violent, wild, religious, praying, zombie.
Delirium and delusions.
Light, seeks the.
Body is split, cut in two, half buried.
Speech, prattling, manic, stammering.
Laughter, sardonic.
Strength, sensation of great.
Spasms, convulsions, unconsciousness.
Aggravated by glistening objects.
Aggravated by water.

Intrinsic/Compensated state:
Intensity of emotions.
History of fear, shock, fright. Near death experiences. Feeling of being suffocated.
Attacked, feels he could be; sense of danger. On guard.
Feelings of intense fear and terror. Trapped in fear. Fear of the dark, dogs, being alone, night.
Dilated pupils.
Unconscious fears. Split between the conscious and unconscious. Suppression of fear.

Compare: Aconite, Adrenalinum, Belladonna, Bufo, Camphora, Cannabis indica, Gallic acid, Gelsemium, Hyoscyamus, Mandragora, Opium, Proteus, Tuberculinum.

Decompensated state:
Wildness of feelings, desire to run, to escape.
Violence, rage, desire to strike, to tear, to kick, bite, spit.
Mania, out of control. Insanity.
Great strength.
Everything is dark. Sees demons, devils.
Sardonic laughter.
Loquacity, prattling speech.
Sensation of being split, divided in half.
Convulsions, spasms.

Compare: Belladonna, Bufo, Cannabis indica, Carcinosin, Hyoscyamus, Lyssin, Mandragora, Medorrhinum, Opium, Tabacum, Tarentula, Veratrum album.

A particularly traumatic and violent experience, or repeated shocks and frights will eventually lead to a state of terrible fear and intense compulsions – to run, escape, hide and to do intense violent things. Initially if the fear can be contained or limited to a few things, e.g., the dark, or dogs or being alone, the rest of life can continue but if the fears are too strong or are exposed from early days, when they were sublimated to the unconscious, then the wilder and more crazy conditions arise and these violent impulses and emotions can no longer be controlled. Physically there can be violent convulsions and inflammatory states.

Idea: I have to maintain my sense of nobility to preserve my dignity, or I feel I will lose control and suffer the slings and arrows of indignation.

Mildness, timidity, reserve.
Dignity, honor.
Suppression of feelings.
Anger, suppressed.
Guilt, self-reproach. Lack of confidence.
Chagrin, mortification, indignation.
Abuse, violation.
Injured feelings –physical injuries, lacerations, sensitive wounds – mental injuries, violation, the least emotional “touch” aggravates.
Sexually minded, platonic relationships. Suppression of sexuality.
Losing control, breaking down.
Rage, breaking things, violent feelings, anger.
Margins of orifices, eyes, styes, rectum.
Glands, hardness, warts.
Urinary conditions, cystitis.
Ovarian and prostate conditions.
Teeth problems, blackness of roots.
Lacerated wounds.
Aggravated by touch (sensitivity, violation, intrusion), genitalia.
Aggravated by sexual excess.

Intrinsic/Compensated stage:
Mild, timid, yielding, pleasant.
Sensitive emotionally.
Dignified, proud.
Holding things in. Suppression of feelings behind a sweet façade.
Suppressing sexuality. Sexual thoughts.
Living in difficult circumstances, abdicating self for others.
Irritability, anger but afraid to express.
Wounds, ailments from. Lacerations, feeling violated.
Aggravated by touch.
Recurrent styes, or cystitis.

Compare: Calendula, Carcinosin, Causticum, Colibacillinum, Folliculinum, Medorrhinum, Morgan gaertner, Pituitary, Platina, Pulsatilla, Silicea, Thuja, Xanthia spinosum.

Decompensated stage:
Sadness, weeping, despair.
Feeling broken down, fears losing control, falling apart, feels could go insane.
Rage, anger, desire to break things.
Indignation, great mortification.
Effects of masturbation – impotence, depletion, exhaustion.
Ailments from abuse.
Ovarian and prostate problems.

Compare: Carcinosin, Colocynthis, Conium, Kali phosphoricum, Lyssin, Selenium, Sepia. Thuja.

Intrinsically there is great sensitivity but lacking emotional strength. There is an idealistic but over-sensitive nature and if emotionally hurt a tendency to retreat and become more introverted. There is a difficulty to confront things and when hurt a feeling of being wounded. There is a desire to keep the peace, to be nice but also a quality of being reserved and somewhat proud, sensitive to how one is perceived by others. There is a struggle to acknowledge one’s own feelings and as things become more compensated, feelings are held in more, while simultaneously being more easily offended and upset, suffering from grief, loss, mortification and easily feeling indignant. As feelings are held in, there can be hard styes in the eyes, skin eruptions and warts, as well as urinary and ovarian conditions. When things are getting more decompensated, there is a breaking down of emotions, leading to extreme bouts of anger, rage, out of control emotions, weepiness, depression, even to suicidal ideation. There is a fragmented and broken down state of being.


Please add your experience or remedy comparisons.