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By Will Taylor Francisco Eizayaga is a contemporary Argentinean homeopath, whose teachings in the 1980's in North America and Europe have contributed greatly to the current resurgence of interest in homeopathy. He stands out particularly in representing some ideas that appear, at least at the surface, to contrast significantly with the classical Kentian philosophy and practice advanced by George Vithoulkas and his students. Eizayaga's ideas are best expressed in his book, Treatise on Homoeopathic Medicine, first published in Spanish in 1972 and translated into English in its third edition in 1991. Quoted passages from Eizayaga below are taken from this text. One of the distinguishing features of Eizayaga's approach to case analysis is his concept of working with cases in "layers." In analyzing a case, Eizayaga suggests that we look at the disharmony of the patient as consisting of a series of concentric "layers", from the surface moving inward described as the:
He suggests that we need to address these consecutively from the outermost layer first, progressing "inwards" through these layers with successive prescriptions as necessary. Now we could look at this trivially as a suggestion that we prescribe mechanistically to "partialities" rather than to a "totality," but I do not believe that is what Eizayaga has in mind. Eizayaga distinguishes three possible types of cases, in which the patient may present with each of these layers "outermost". (1) A
localized lesion or clinical entity - Local/regional disease, "symptoms of the
disease" showing. From "inside out" (reversing the order of these "layers" from the above), he describes the "layers" of the individual's disharmony as: (1)
"Constitutional layer" - physical and characterological features of the person
which pre-exist in the individual before any pathogenesis, which are not be
considered abnormal. These are not treatable or curable, and Eizayaga states
"We only advise to prescribe the genotype's constitutional medicine to prevent
future ailments. In other words, to prevent the diseases from which human
beings will fatally suffer." ... "This constitutional remedy does not cure
anything; it just prevents disease." Eizayaga lists 5 fundamental "miasmatic diatheses," the Psoric, Tuberculinic, Syphilitic, Sycotic and Cancerinic terrains. He suggests that this "morbid terrain" be treated in its turn specifically with the corresponding nosode. (3) "Fundamental layer" - The symptoms "of the patient" that precede or are otherwise not seen to be "symptoms belonging to the disease." These are the mental/emotional symptoms of the patient and physical general disturbances with no particular organic location, "the typical symptoms of the patient who will suffer from future diseases and which therefore precede the symptoms of the disease itself." "They are revealing a pathological alteration of the phenotypical constitution which must be treated with the so-called 'fundamental remedy or simillimum' with which we shall not only cause the disturbed individual to recover but also we will prevent the future evolution and organic localization of the progressing disease." (4) "Lesional layer" - consisting of the "symptoms belonging to the disease." Eizayaga's writings are a bit confusing on this point. At one point, he defines this, saying (p. 257, para 5): "There is a very clear dividing line between the patient's symptoms and the symptoms of the disease. It consists in the localization of the pathological process in an organ or a system that provides us with the so-called local symptoms which Hahnemann called 'localized'." At another point (p. 260, para 5) he states "In order to select this 'local' medicine, we recommend not to reject any symptom of the disease or clinical entity, its modalities and concomitants, but on the contrary, to make use of them all. The psychic symptoms of an emotional, affective, or volitive type and the mental symptoms corresponding to the intellect and to judgement (psychiatric symptoms) will be immensely important and will constitute a fundamental aid in individualizing the acute medicine, on the condition that all these symptoms appeared or were exacerbated right from the beginning of the disease and that they are not chronic symptoms of the patient which preceded this disease." A reader could conclude two rather different definitions of this "lesional layer"; the first, a rather restrictive definition consisting only of the localized/regional physical symptoms; and the second, more of a Hahnemannian totality of those symptoms judged relevant to the current diseased state of the individual, spread across organ systems. The "lesional remedy" may be the same as the "fundamental" remedy, or may be complementary to the "fundamental" remedy, representing a pathological alteration dependent on the underlying "fundamental" susceptibility. Eizayaga's concept of "Constitution" as a rather rigid construct distinct from the type of disharmony that calls for earlier prescriptions; and his routine interposition of a nosode-requiring "Miasmatic layer" or morbid terrain; introduce a routinism based on a particular image of the structure of the individual that differs from Hahnemann's empirical pragmatism. In The Chronic Diseases, Hahnemann describes the eradication of Psora as a process that might require a succession of remedies, each prescribed in the same manner to the presenting totality of characteristic symptoms as this picture shifts in the course of treatment. The nosodes are not distinguished fundamentally from remedies from other sources, and the presenting symptoms of Psora e.g. in any individual would be addressed not necessarily with Psorinum but with the remedy that emerges as the simillimum to the characteristic totality of the disharmony of the patient. I will take up these points a little further down the line. I would first like to address this distinction that Eizayaga makes between the "lesional layer/lesional remedy" and the "fundamental layer/fundamental remedy" before moving on to looking further at his constructs of "morbid terrain" and "constitution." Eizayaga and Hahnemann would be in agreement that, in cases presenting with physical pathology, there is often need to progress through more than a single remedy to bring the person into health. In practice, they would likely come up with the same remedies, in much the same manner. However, they would likely disagree with their justification for this observation. There are several trivializations of Eizayaga's approach that I see homeopathic students falling into. Two of these are the (incorrect) notions - (1) That we have a choice, based on our philosophy, to prescribe to the characteristic totality of "the person" or to the characteristic totality of "the disease"; or for that matter, that the "characteristic totality of the person" and the "characteristic totality of the disease" at any point in time are or could possibly be different; (2) That we can recognize the "lesional remedy" and the "fundamental remedy" (and even "miasmatic" and "constitutional" layers of the patient) simultaneously, as multiple aspects of the totality of the person in the present - that is, that we can "see through the layers" to the remedy(-ies) that will be needed in the future. In practice, it is the role of the "carefully observant physician" to be open to the characterizing aspects of the case initially and at each stage as it unfolds. The chapter in which Eizayaga introduces the preceding concepts of "layered" treatment is titled "What Must be Cured in Diseases." This is an obvious reference to Hahnemann's aphorism 3, "To be a genuine practitioner of the medical art, a physician must: 1. clearly realize what is to be cured in diseases, that is, in each single case of disease..." Hahnemann puts this statement up front, because he spends a good deal of the following 300 pages, as well as his companion text The Chronic Diseases, talking about what it is that is to be cured in diseases. Eizayaga refers to Hahnemann supporting the idea of treating cases as "layered" in the Organon, suggesting (in Treatise, p. 259) that "in Par. 163 he (Hahnemann) recommends a fragmentary remedy to be applied, i.e., a medicine partially covering similitude ... " It is my impression that Eizayaga meant to refer to aphorism 177. In aphorism 163, Hahnemann discusses the difficulties of treating with an inadequate stock of medicines, and the need to sometimes use a "close-enough-icum" when no known remedy fits the picture of the patient's disharmony. The aphorism (162) preceding this section reads: "Because there are still only a moderate number of medicines which are exactly known ... it sometimes happens that only a portion of the symptoms of the disease to be cured are met within the set of symptoms of the still best-fitting medicine. Consequently, this imperfect medicinal disease potency must be employed for lack of a more perfect one." O'Reilly annotates this section with the note "Making the first prescription with an imperfect medicine." The only other reference by Hahnemann to prescribing to less than a characteristic totality of the patient is the following section of aphorisms from 172-203, where he discusses defective or one-sided disease, diseases with "all-too-few symptoms." This is the section of the Organon on which Eizayaga could best support his approaches to treating local or "lesional" disease. In this section of the Organon, Hahnemann offers two main caveats to prescribing on apparently one-sided diseases. First, in aphorism 175, "Diseases with an internal main symptom that appear to be one-sided are, in fact, often not one-sided. Rather, the medical observer, due to inattentiveness, has not completely tracked down the befallments that are at hand for the completion of the outline of the disease-gestalt." And in aphorism 189, "Little cogitation is needed for it to dawn on us that no external malady (except for those that arise from particular external damages) can arise without internal causes, can persist in its place or even grow worse, without the cooperation of the entire (consequently, sick) organism. Such external maladies could not come to light at all without the concurrence of the entire rest of the condition and without the participation of the living whole ... the emergence of such an external malady will not even allow itself to be thought of apart from its being occasioned by the whole of the misattuned life, so intimately do all the parts of the organism cohere and form an indivisible whole in feelings and functions." It is useful to give careful consideration to this section of the Organon, (aphorisms 173-185) because it is this type of disease that Eizayaga speaks of when he refers to situations where his "Local/lesional" remedy is distinct from the "Fundamental" remedy. Hahnemann is telling us in these aphorisms that, in treating these "local diseases": (1) if
it looks to us as if we have only a local syndrome or a disease-state defined by
pathological characteristics to prescribe to, it is *most* likely that we are
missing the bigger picture due to inattentiveness in case-taking; Eizayaga's advice on how to prescribe for local diseases does not differ, in practice, from Hahnemann's. His rationale for this approach, however, is quite different. Eizayaga asserts that we are to find the simillimum for a disharmony that is well-described by the local disease symptoms, and then follow later with a series of remedies for underlying pre-morbid conditions and predisposing states that allowed the body to come to these ends. Hahnemann asserts that we must do our best to approximate a similimum for the whole person to open the case, based on the incomplete guidance offered us by the paucity of local disease symptoms, and refine our prescription as the case opens to the action of that probably imperfect attempt. Eizayaga and Hahnemann are in agreement that the progression of remedies given in a case cannot be perceived at the outset - the case needs to be re-taken following a response to each prescription. A Sample Case 7
month-old boy The Approach We have a defective/one-sided illness here - the only symptomatic expression of the disharmony of the individual we can obtain is in the skin symptoms. This may be in part because the patient can't talk to us (aph. 175 - "it is often only a matter of the medical observer's inattentiveness if he does not fully detect the symptoms that are there and that would allow him to complete the outline of the disease image") and in part because that's all there really is (aph. 176 - "Nevertheless, there certainly are a few troubles of this kind which present after all initial investigation only a few strong, intense symptoms, while the rest are indistinct"). So we do what we can do. Eizayaga would encourage us to address the "local disease" of eczema at this point, and come back later to address the "fundamental layer", "morbid/miasmatic terrain" and "constitution", in that order. Choosing rubrics inclusively for the skin disease (overlooking for now the smaller and more specific rubrics we could use): HEAD;
ERUPTIONS; milk crust This list of remedies should be broadly inclusive of the remedies that could address the disease manifesting on the skin. If we
focus on the smaller and more characterizing symptoms: We get
(I used van Zandvoort's Complete Repertory): So Graphites is the remedy most similar to the paucity of symptoms arising from the disharmony of the individual (Hahnemann), or to the symptoms of the local lesional illness (Eizayaga). I gave Graphites 30C, one dose of a single pellet (old case - I probably would use an aqueous dose today - but this worked just fine, as we will see) What happened? Child returns after 6 weeks; now 8-1/2 months old. Eczema persists behind ears, in elbow and knee folds, on fingers. No longer any cracking or scabbing, although still gets moist behind ears, but not the sticky stuff he used to get. Looks different on fingers and behind ears -gets clusters of little tiny pinpoint-sized "water blisters" before it breaks out, these are really itchy, scratches until raw. Think these are new – never noticed them before. Cut a couple of teeth. No other changes. The case has shifted after the first prescription. Hahnemann would tell us that the "disease" or the underlying disharmony is the same - that the first prescription, of Graphites, has served to "call forth" this altered expression of the original disharmony, and we need to use these new aspects of the case along with the old to guide us toward the simillimum: Aphorism 181 One should not object that these side effects and new disease symptoms now apparent are to be attributed to the remedy. They come as a result of using it, but they are only the symptoms that this disease was apt to produce by itself and in this organism, and the medicine merely calls them forth and brings them out by its power of producing similar ones. In a word, one has to regard the whole group of symptoms now visible as belonging to the disease itself, as its true present state, and conduct further treatment accordingly. Aphorism 182 Thus the imperfect choice of a remedy, here almost inevitable because there are too few symptoms present, serves to complete the symptom content of the disease and facilitates the choice of a second, more homeopathic medicine. Using
the rubrics: We get: We could also let Boenninghausen help us here, with his concordances. We have seen a change in the case after Graphites, with persistence of the features of Locality, Sensation, and symptoms of the Skin; so to help with the "remedy to follow," we could look up the appropriate concordance rubrics in Boenninghausen (in the back of his repertory):
RELATIONSHIPS; Graphites naturalis; Localities Rx: Calcarea carbonica 30C, one pellet once And then? 3rd visit after another 6 weeks (child now 10 months old, 3 months after the initial visit at 7 months age). The eczema cleared up completely within 2 weeks of the Calc-c 30C; some minor roughness of skin behind knees, and a little bit of diaper irritation now and then, but nothing at all like before. All of a sudden 5 new teeth (now has all upper and lower central and lateral incisors - that's on schedule for 10 months). Is pulling up on furniture, cruising the length of couch holding on. Head still a bit damp when fusses, but not moistening pillow during naps anymore. No other complaints - he's doing great. Eizayaga would suggest that this second prescription (of Calc-c) both finished off the "lesional" layer - which was started by the first prescription of Graphites - and addressed the "fundamental" layer (symptoms of the person - the general symptoms of delayed dentition, sweaty scalp). Hahnemann would say (Aphorism 182): Thus the imperfect choice of a remedy (Graphites), here almost inevitable because there are too few symptoms present, serves to complete the symptom content of the disease and facilitates the choice of a second [Calc-c], more homeopathic medicine. If Psorinum is for Psora, why did Hahnemann describe so many antipsorics? Eizayaga's writings offer support to two notions regarding the chronic miasms: (1) that
the miasms represent a "layer" of the disharmony of a person, that creates a
"diathesis" or predisposing susceptibility to particular ways of being ill, this
"diathesis" being somehow distinct from the more direct expressions of disease
treated in the "lesional" and "fundamental" levels of treatment; I would like to address these two notions in turn, and suggest that they represent significant departures from the understandings of chronic illness and its treatment proposed by Hahnemann. Hahnemann suggested that a chronic miasm *is* the chronic disease - not merely a "diathesis" or predisposition to become diseased in a particular manner. The chronic miasm giving rise to a particular set of chronic symptoms is like the root of a plant bearing many leaves, or, in Hahnemann's own words, like the Hydra bearing many heads. From this perspective, treatment of a chronic illness involves addressing the chronic miasm at every stage in prescribing, from the very first prescription. Each prescription is addressed to the current disharmony (disattunement) of the organism in addressing this chronic miasm. Hahnemann does not speak of Psora "predisposing" us to chronic illness - rather, he describes (aphorism 81) "how psora could now unfold itself in so many countless disease forms ..." [my emphasis]. Now it's easy to get sloppy around our use of terms, but I see a rather major difference between calling, e.g., psora, a "diathesis" or state of predisposing susceptibility to chronic disease, vs. a condition that may "unfold itself in so many countless disease forms." If psora were a diathesis, our aim could be to first address the disease(s) dependent on this state of susceptibility, then turn our efforts to the state of susceptibility itself - as in Eizayaga's scheme. However if the chronic disease is an "unfoldment" of psora itself, then we are addressing Psora very directly from the very first prescription, and there is no point where our approach changes in any fundamental way. Each prescription is addressed to the current disharmony (disattunement) of the organism in addressing this chronic miasm. We sometimes speak of certain remedies being "central" to a miasm. The nosodes are said to be "central" to their respective miasms, as are certain non-nosode remedies - e.g., Sulphur to Psora, Thuja to Sycosis, Nitric acid to the Cancer miasm. This does not mean that they will be of any greater significance in the treatment of individuals bearing the miasm than many other remedies might be, or any more likely to be needed to "open" or "finish off" the case of a patient bearing that miasm. What it does mean is that these remedies reflect the "issues of the miasm" in a rather undifferentiated manner, while other remedies reflect the issues of the miasm in particular individually differentiated ways. Here is a very brief and incomplete example. The Psoric miasm represents a disturbance of the will and understanding such that the person feels that the world is big, difficult, and requiring of continuous struggle to maintain oneself. In Psorinum, this issue is rather undifferentiated - it is felt and expressed broadly, in all the various areas of one's life: in maintaining one's health, in finances, in work, in relationship to others, and so on. In other antipsoric remedies, this struggle may be felt disproportionately in some particular areas of life, or may be expressed in particular ways. For example in Sulphur, it is expressed somewhat disproportionately in the issue of superficial appearance and attractiveness (either in increased attention or in disregard); in Rhus toxicodendron it is manifest disproportionately in restlessness (physically and mentally/emotionally); and so forth. So when we describe Medorrhinum or Thuja as being central remedies for Sycosis, it is this relatively undifferentiated relationship to the "issues of the miasm" that is implied. It is not implied that they will be needed to "clear", "open", or otherwise treat the sycotic miasm in any routinist way to the exclusion of other antisycotic remedies. Hahnemann suggests (aphorism 209) that we treat a chronic miasm "by selecting the (antipsoric etc.) medication that has the utmost possible similarity of signs to those of the disease". In one of his softer rants, he suggests in somewhat different context (aphorism 258) that the medical-art practitioner "will bear in mind that the only medicine that deserves his attention and preference is always the one that, in each case of disease, most aptly corresponds in similarity to the totality of characteristic symptoms, and he will not allow petty passions to interfere with this serious choice." Now in going back to the eczema case I've been using as an example, I do not see any reason that Calc-c might not be the remedy that eventually frees this child from psora. If Psorinum comes up in the case at some point as the remedy that "most aptly corresponds in similarity to the totality of characteristic symptoms," I will not "allow petty passions to interfere with this serious choice" - but I can say that of Calc-c too, or of any remedy in our materia medica for that matter. I do not understand the rationale, or the basis in clinical experience, for suggesting that the psoric miasm in this child will require a routinist prescription of Psorinum to set it on its heels. So, in summary, while the Eizayaga approach provides a model to help us deal with a case which unfolds itself in successive layers, Hahnemann's original recommendations in the Organon will enable us to prescribe for the same type of case even more successfully, but does not necessitate dividing the living, breathing case up into abstractions of dubious validity.
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