A scientific understanding of ACUTES and their types with references to Hahnemannian Classification
Keywords: Acutes, Dr. Hahnemann, Types of acutes, internal altered pattern, External state, Formica Rufa, Case witnessing process in acutes
When I asked my collegues, teachers and fellow practitioners how they were treating acutes, and how they understood acutes, I was surprised to hear widely differing perspectives :
- A few of my colleagues thought of acutes as a different state altogether and treated them separately from the constitution. They saw the acute as a temporary condition that differed from the constitutional state, so the remedy to be given would be according to the present acute totality.
- Then there was an exactly opposite view, which said that the presenting acute situation was nothing but a part of the deeper underlying state, and rather was a window to the constitutional state. They thought there was no such thing as an acute and all these episodes were part of one single state. So the remedy was the same as the constitutional simillimum.
With these differing views I also wanted to look up what guidelines Dr. Hahnemann gave us and maybe that would clarify my confusion. Hence I began reading the aphorisms to seek Hahnemann’s view and found the following:
Dr. Hahnemann broadly categorized diseases into Acute and Chronic types, depending upon their period of onset, course, and progression of diseases. He treated acute illnesses successfully right from the beginning, but it was chronic illnesses that he would struggle with. On his journey to understand the chronic illnesses he found that although he would treat an acute episode successfully, there would be a) either a recurrence of similar acute episodes in certain patients or b) some patients would come with recurrent acutes but with a different presenting picture every time. Eventually this led to the discovery of the Miasms. He thus discovered that these recurring isolated attacks of particular syndromes are not many diseases but varied expressions of one continuous progressive morbid process which constitutes the “disease per se”. 
Dr. Hahnemann also distinctly defines acutes in the aphorism 72 of 6th edition of Organon, “The diseases to which man is liable are either rapid morbid processes of the abnormally deranged vital force, which have a tendency to finish their course more or less quickly, but always in a moderate time – these are termed acute diseases…”
Here we see two approaches to how we look at acutes; one, that there are acutes which are self limiting episodes per say, and the other one which states that the acute is a part of the chronic picture. But when a patient is sitting in front of us, how do we identify these in the patient? Does this imply that we generally should treat acute cases with the constitutional remedy?
Whenever a patient visited me with an acute complaint, I would think about what should be my approach while examining this patient in front of me. This question would keep hovering around in front of my eyes, making me wonder whether I was doing justice while treating acute cases. Therefore I began to study acutes in order to have a deeper understanding and this opened the window for me to a better understanding of acutes.
As I began exploring, more and more questions came up:
- Why in acutes do we need different remedies if we believe in one state, one remedy?
- Do I really know what an acute is? What is the real definition of acute?
- What are the possible types of acutes?
- Do we treat individual, sporadic and epidemics cases differently?
- What is acute-on-chronic and how should we treat them?
- Do we have a scientific, simple, reproducible method of case witnessing in acutes?
- How do we construct totality in acutes?
Furthermore I also found myself ending up using “favorites” so to say, favorite remedies in acutes (like Hepar Sulph, Gelsemium, Ars Alb), without actually trying to understand the whole state and going deep enough to understand the whole acute disease phenomenon.
In aphorism no. 123 of the 6th edition of Organon, Dr. Hahnemann himself mentions that “…therefore one will never cure according to nature-that is, homeopathically-unless one considers the mental and emotional changes along with the other symptoms in all cases of disease, even in acute ones, and unless for treatment one chooses from among the remedies a disease agent that can produce an emotional or mental state of its own similar to that of the disease as well as other symptoms similar to those of the disease…”
In fact, if we understand that during the acute illness, the sudden onset of the whole disease process shakes up the entire core of the patient, the intensity of the whole disease phenomenon is so much that the whole disturbed state comes on the surface, the disturbance of the vital force is right in front of us, without any covering. Even the World Health Organization defines acutes as: “The acute illnesses, falling into any category, are intense enough to have a significant and precarious effect on the patient, though temporary.” This intensity although temporary brings out the entire disease picture undraped in front of us, and hence we can get a clearer and deeper picture of the acute. We know that disease is “the crystallization of the whole inner state.”, so the acute illness is nothing but the “Crystallization of the patient’s state’, in the form of acute diseases of short duration”.
During the acute illness, the patient is so shaken up, that the central disturbance is right there, unaltered, and thus the acute disturbance becomes the best opportunity to understand the core of the patient in the shortest possible period of time.
But this whole disturbed state during an acute can be either: the patient’s own disturbed state, that has aggravated, or it can be an external state that has caused its impression on the patient.
Take for example a patient coming to us with an acute upper respiratory tract infection (URTI). Now when we look at this patient in front of us, we may see three possibilities. The exciting factors that have led to this acute episode can be either due to: a] the patient’s own susceptibility; if the internal environment is disturbed, his own susceptibility is down, due to which he is easily affected by the slightest internal or external exciting factors, and here these factors aggravate his own internal state; b] there is a strong external situation which has caused this acute episode, in this case the external state has caused its impression on the patient, for example, a sudden change in the weather, or outbreak of an epidemic, or a strong emotional situation which has shaken the patient’s core and lead to this whole temporary suspension of the patients health and caused an acute disturbance in the health. Or c] the patient suffers from recurrent acute episodes of this type (similar clinical condition every time), and hence it is a part of the ongoing chronic process…so here we see three possible types of acutes.
With this now, let us see how Dr. Hahnemann classified acutes in Aphorism 73 of the 6th edition of Organon, 
Hahnemann classified acute diseases as those that –
a) Attack human beings individually (exciting cause being injurious influences to which they were particularly exposed. Excess in food, or an insufficient supply of it, severe physical impressions, chills, overheating, dissipation, strains, and/ or physical irritations, mental emotions: are self limiting, transient explosion of latent psora)
b) Attack several persons at the same time, here and there – sporadically
c) Attack many persons with very similar sufferings from the same cause – epidemically; these diseases generally become infections (contagious) when they prevail among thickly congregated masses of human beings
The exciting cause and conditions of epidemic cases are –
- The calamities of war, inundations and famine, etc to which a mass of human beings fall a victim to
- Sometimes they are peculiar acute miasms which recur in the same manner (hence known by some traditional name) which
i. Either attack persons but once in a lifetime like small pox, whooping cough etc, or
ii. Such as recur frequently in pretty much the same manner, the yellow fever, Asiatic cholera etc.
So here in this classification Dr. Hahnemann classifies acutes as individual, sporadic and epidemic, and gives us the exciting factors for the epidemic diseases. He also gives us exciting factors for the acute episodes which are self limiting. The classification by Hahnemann explains the acutes which can result because of a strong external situation. But here we do not understand whether the patient’s own internal state would get aggravated or will the external strong state make its impression on the patient. So is the above classification of acutes only for those diseases in which the external state causes its impression on the patient, or does he mean to say that acutes are adynamic diseases? Then what about the acutes which disturb the patient’s own chronic constitutional state and the same remedy helps to cure acute diseases?
With my doubts and my own understanding and Dr. Hahnemann’s classification, I wondered, could there be a classification which is scientific and integrative, and which includes Dr. Hahnemann’s understanding and also gives us an idea of the further line of treatment in acutes once we have identified the type of acute in the patient?
Putting all the pieces together, I divided the acutes broadly into three types:
Type 1: Patients own internal altered pattern is aggravated.
In this type there is an imbalance in the patient’s own internal environment. The patient’s susceptibility is not up to the mark and hence internal or external exciting factors easily disturb his state. The acute illnesses where the patient’s own altered state and core is excited, owing to an external factor or internal imbalance, fall into this category. Therefore, on exploring the acute we will find that the remedy required will be the patient’s own constitutional remedy.
During such acutes when we explore the acute phenomenon from centre to periphery, all the PQRS symptoms at the physical particular, physical general, and mental general and subconscious areas in the acute episode will point towards the patient’s constitutional remedy itself.
In fact, during this acute episode we can find out the patient’s chronic constitutional state in the shortest possible time. It will be the best opportune moment to find out the constitutional remedy in those cases where we are not sure of the remedy in the first interview.
Type 2: An External State causes its impression on the patient
In this type of acute, we find that patient’s susceptibility is fine, but a sudden strong external situation caused its impression on the patient, and hence during the acute this strong state manifests itself. For example; take the 9/11 situation which blew both the towers of the world trade centre. The sudden terror attack had shaken the entire nation into anger, fear and mourning upon the lost lives and to date many people are deeply affected when they remember 9/11. Or, the Tsunami which destroyed and caused mayhem in Japan, or the SARS epidemic which had sent the world into paranoia. These extremely strong situations shake us to the core and the external pattern superimposes itself on our own innate pattern.
In Aphorism 38, 6th edition of Organon: “ if the new dissimilar disease is stronger, in this case the disease under which the patient originally labored, being weaker, will be kept back and suspended by the accession of the stronger one, until the latter shall have run its course or been cured, and then the old one reappears uncured”
These highly potent external factors cause an impact on the patient, temporarily suspending their chronic altered pattern and giving rise to a temporary state which differs from their constitutional simillimum; hence the remedy to be given here will be different from the constitutional remedy.
When we explore this acute, all the PQRS symptoms at the physical, and mental level will bring out an acute picture related to this external state and not the patients chronic constitutional picture.
This external state can affect masses of people, or few individuals, or only one individual, so this type is further divided into
a) Individual: This is the type where the external situation will affect the individual alone; situations such as death of a near one in the family, or other strong emotional situation are the example for this.
b) Sporadic: in this type few people get affected, as described by Dr. Hahnemann.
c) Epidemic: in this type many individuals are affected at the same time because of the external strong situation, like an epidemic breakout or natural calamity or a terror attack like 9/11 etc… Here we see that the same situation affects many individuals at a time, and therefore the remedy required for all those affected by them will be mostly the same (Genus Epidemics). (Here the same external situation is causing its impression on many individuals hence mostly the state expressed by everyone will be the same.)
3. The third type of acute is an Acute-on-chronic type: In this type the acute episodes come up recurrently or periodically and are a part of the chronic disease process, there is an acute exacerbation of the chronic disease and hence this cannot be ideally classified as an acute disease. Here the remedy required will be the constitutional remedy itself. (Bronchial Asthma, Renal Colic-ureteric colic, Rheumatoid Arthritis, or any other disease which shows acute exacerbations, fall into this category) On exploring these acute exacerbations we can come to a constitutional simillimum in a short period of time.
With this let me summarize the types of acute diseases 
The next question then comes to my mind is “Would this viewpoint improve my case witnessing technique in acutes?” Let me illustrate this with the example of a case:
(NOTE: The case has been edited for brevity. Peculiar sentences are highlighted in italics. My explanations, observations and notes are in plain brackets ( ) or are mentioned in points. D, P, stands for Doctor and Patient respectively. Follow ups have been summarized at the end of the case.)
Following is a case of a middle aged lady who was coming to me for her chronic complaint of Eczema, which she had all over her face, palms, ears and a few lesions all over her body. After her case interview I had given her Lithium Mur. The remedy would help her temporarily but she would come back with her complaints every now and then. When she came down with an acute flare up, this time her face was badly covered with red eczema patches extending to her ear and with lots of oozing. I decided to explore the acute episode completely. This time I understood her in depth and the remedy helped her, after which she completely recovered.
Passive Case Witnessing Process in Acute
D: Now tell me what’s happening? What is bothering you right now, everything, with this?
P: Extreme irritation, extreme burning, I am not able to normally function. I have just lost it, mad irritation. It is itching, it is so bad... It’s really oozing, itching is so bad. It’s so unhygienic, it presents a bad picture. Because it’s more unhygienic, more than that ah, looks …. More than the …. I am always bothered about looking presentable and feeling miserable, unbearable itching. Till last week there was unbearable pain, also couldn’t sleep on sides. I am not able to function, not like… I feel I should have done allopathy right in the beginning and then to the side effects with homoeopathy.
D: Just be with this experience of yours. Just be with it. Just keep talking about what you feel?
P: House is in a mess, every bit is in a mess. I am not able to do anything, as it is. I just feel that need to get back to into perfect health.
Active case witnessing process
D: How does it feel deep within you?
P: Soul feels like highly, feel totally…can’t express it …. I mean, Soul is being eaten by thousands millions I don’t know… of ants. It seems so bad, it’s unbearable, intolerable there is no other word to describe. Totally unbearable, you can’t do anything at that moment of time.
D: That feeling as if soul is being eaten by thousands of ants. Just be with it. Forget your illness, let this come out, and let this be as imaginative as possible. Just be with this more.
P: It’s like inner… like it’s just being eaten away, it’s just being totally wiped away slowly, slowly torture. Its total torture absolute torture (PAUSE) unbearable, can’t express it. It’s just … get in total control of it, and that looks so unhygienic, so bad I mean it’s so unfair to having someone around you. I feel I owe to everybody for being around me. That too be presentable than just to be not a model or a beauty, just to be presentable, to be hygienic to be presentable and from I have been anything not like that.
Totally away from peace (HG hands move apart from each other) in an ageless for just want total solitude… it’s very irritating, it’s highly irritating. Just by inflicting pain on myself which is very good way of controlling…Feels like totally like I am totally in a different space around… it’s totally different … nothing, nobody around me. (PAUSE WITH CLOSED EYES)
Active-Active Case Witnessing Process
D: Let it be as abstract as possible. Just talk about that how those ants are? What is happening?
P: Corroding slowly… corroding slowly, slowly, slowly causing massive irritation … causing my whole being to just (HG CLAWED) literally slowly torturously just being, you are troubled extremely troubled. It’s extreme, extreme. Feel I can see a heart, for me the soul and the heart are the same, the heart being slowly), slowly, slowly corners of it , thousands ants on it, eating it slowly, slowly and I am totally helpless to do anything because it’s inside me and I can’t do anything (CLOSES EYES)
It’s happening very slowly, slowly. They are at their work (HG CLAWED, CLOSES EYES) and just getting totally helpless (HG CLAWED) to stop that whole thing happening and thousands of … ants at that time just … starting with one corner concentrating in it. Thousands of holes tiny, tiny holes, it’s not a smooth surface. It’s just been eaten away, eaten away and it’s just being, it’s not one part eaten away, it’s tiny, tiny thing of holes all over. Just being attacked, it’s being attacked even more like, could be like could be acid thrown on (OPENS EYES) it’s like something like that the rough surface … just being (CLOSES EYES) thousands of them unable to stop just stocked just stocked in one place.
It’s totally being out of control, totally out of control sending out (CLOSES EYES) signals to my brain that some ah …. Totally in a daze really on a high crazy… crazy irritability level
Active-Active Case Witnessing Process: finding out the chronic picture
D: Keep this feeling in front of you and see what else is coming up right now…
P: Totally being out of control, totally out of control sending out (CLOSES EYES) signals to my brain that some ah …. Totally in a daze really on a high crazy… crazy irritability level, I felt like this when my Husband also came back after a binge. Like it just felt like this, it’s gone down to my soul absolutely… it’s so irritating. (CLOSES EYES THROUGHOUT, HG CLAWED) Extreme anger, extreme helplessness and sadness and totally helpless to do anything, tired at that time, also very tired at that time.
D: Again I just ask you to repeat that whole feeling of what you experienced inside, of the whole feeling of the soul being eaten by the ants …. Just be with it.
P: Something inside me which my soul has been totally corroded (HG CLAWED) It’s thousands of tiny, tiny holes and … feels unhealthy and doesn’t feel nice … plain nice surface… feels like it’s when the itching starts it’s at that point of time ah (CLOSES EYES THROUGHOUT) tiny ants are attacking and I am totally helpless to stop it and I feel pain can only take away from that, relieve that kind of intolerable feeling at that point of time.
Nerves that nerves these burning of the nerves .You can irritate, highly irritated highly conscious of conscious of every …Same feeling in my heart when my husband is drinking alcohol or I am not able to do my duty at house.
D: Where else have you got this feeling?
P: When I feel alone and have that guilt feeling of not doing enough same experience I get in my heart.
Active-Active Case Witnessing Process: Towards Complete Pattern and Source
D: Can you describe this thing, those ants- just to understand?
P: Ants (CLOSES EYES) feels like thousands of them are at work peeping, crawling and causing that ah that irritation… just can’t stop them, thousands of them at work causing that irritation, causing that itching, unbearable itching. They are at work as very busy at work, like black ants hung at work…that thousands of black ants at work running busily and stopping and just very busy at their work, just very busy at their work
I observe ants…they go to the source of food and they meet at a point meet each other and pass by they are going very busy … they are running to and fro. They are…eating away my soul my inside my innermost (PAUSE) corroded it. They corroded it so badly … with tiny holes all over. (CLOSES EYES)
CHANGES at PHYSICAL GENERAL LEVEL…
Perspiration has increased since illness has started.
Itching agg with cold bath, with draft of air.
Agg at night.
Moving in open air gives me relief
(We see that in the active-active process of case witnessing when I try to find out the chronic picture, after taking a pause, she connects the experience with episodes of varied different life situations, like moments with her husband or when she fails to do her duty properly, or when she feels guilty. Therefore this whole experience is holistic… Hence here we see that this presenting acute experience is not only a temporary acute phenomenon but is also the chronic picture. With this acute, if the patient would have come to us for the first time, we would have understood that her internal altered pattern is aggravated during the acute episode, and hence we would have opted for the remedy which would be her constitutional remedy. But since she has been coming to me for her chronic complaint which again is eczema, this episode we will refer as an acute-on-chronic type, as it is a part of the ongoing disease process. Also make note that when we are dealing with acutes, only after the complete experience is in front of us, during the active-active case witnessing technique, will we be able to understand which type of acute we are dealing with.)
Centre of the case
- Massive irritation inside, being eaten away, being totally wiped away slowly, slowly; torture, absolute torture
- Eroding corroding slowly, slowly, slowly.
- The heart being (sic) slowly, thousands ants on it, eating it slowly, slowly, tiny holes all over.
- Attacking just and attacking. I am totally helpless to do anything.
- That thousands of black ants are at work running busily and stopping, just very busy at their work, peeping, crawling, and causing that irritation
SUB KINGDOM: Insect
Since she connected the mess and irritation, she feels because of the complaint the whole feeling of being eaten by thousands of ants and connects the whole process with her being.
REMEDY: FORMICA RUFA 1M every 2 hourly (Since Level of Experience DELUSION)
ABOUT FORMICA RUFA:
Ants are social insects of the family Formicidae and along with related wasps and bees belong to the order Hymenoptera. Ants communicate with each other using pheromones. These are chemical signals. Ants perceive smell with their antennas. Ants attack and defend themselves by biting and, in many species, by stinging, often injecting or spraying chemicals like formic acid. Many animals can learn behaviors by imitation but ants may be the only group apart from mammals where interactive teaching has been observed. Complex nests are built by ants.
Materia Medica picture of Formica Rufa:
“Sudden and unexpected return of sense of mortification and grief, with vivid recollection of circumstances long since passed, which had caused great mortification and pain, and which had rendered several years of his life unhappy; this was caused by the transactions of a near relative; this grief returns and manifests itself whenever he is not occupied [after several weeks].” [Allen]
Within 10 days eruption from face started going and within 15 days they were 80% better.
Along with this her old eczema started improving.
Her relation with her husband and children improved.
Feeling of guilt and loneliness reduced.
Whole sensation only came once in last two years.
Hence with this case we see that how a holistic approach in acutes would not only help us to increase our surety about treating acutes but also gives us a three dimensional approach where holistically we would understand the type of acute we are dealing with: the acute simillimum and also the constitutional simillimum in a very short period of time and further line of treatment in such cases.
Bibliography Sarkar B. K, Organon of Medicine with an introduction and commentary on the text by B.K. Sarkar, Birla Publications 2003-04  Hahnemann Samuel, 6th edition of The Organon of medicine, B. Jain Publications  For more details on the Acutes, and case witnessing in acutes, refer to the upcoming book of Chauhan Dinesh, Case Witnessing Process in Acutes [temporary title]