Constitution and constitutional treatment ^{[*] [**]}

MR. PRESIDENT, LADIES AND GENTLEMEN, let me begin by telling you that I highly appreciate the opportunity to speak in this famous centre of British homoeopathy, and my thanks are due to the Council of the British Homoeopathic Society for their kind invitation.

The subject matter I have chosen, “Constitution and Constitutional Treatment,” certainly is a most important one for our medical art. For the constitutional treatment must be considered the highest aim of all internal medicine. One might well put the question, however: Is it not entirely superfluous to speak about constitutional therapeutics to homoeopathic physicians, seeing that all homoeopathic therapeutics are constitutional treatment? Indeed I should like to put this thesis at the head of my remarks. As a matter of principle and method homoeopathy means constitutional treatment. We are proud of the fact that the homoeopathic method enables us consciously to practise constitutional therapy with drugs; to realize this by other methods appears a scarcely attainable ideal, but in this circle, as it were intra muros, I need not point out the advantages of homoeopathic methods, rather do I wish to ventilate detailed problems of this kind which might determine our practice. A correct understanding of the relations between homoeopathy and constitutional therapy can, for instance, facilitate our decision in individual cases whether we might or should make the local and acute manifestations of disease the object of treatment, or whether the individual constitutional disposition has to take priority. Perhaps I may partially anticipate the answer to this question. Constitutional therapy is never a matter of something absolute, it is rather a matter of degree, of the extent to which the constitution can be diagnosed and treated. What I purpose to attempt to-day is mainly to elucidate the various degrees and stages into which medical treatment can delve.

I must first shortly establish homoeopathy as constitutional therapy and give it its proper place in the greater biological complex as I see it. Our conception of disease, natural and artificial healing, is that it forms part of the greater all-embracing nature principle of adaptation.

Like a river in its bed, the river flows but within its limits; the fluctuations of its level, dependent as they are on the weather, have a wide zone of adaptation. But the river can overflow its normal bounds owing to the abnormal weather conditions.

So also the individual is continually flowing, changing, altering. In the main it is adapted to the conditions of its environment, or it is easily able to adapt itself. It has a physiological margin of adaptation.

Looking at the surface we can observe adaptation as an active process in its details even in our humanly narrow field of vision. This becomes most distinct when and where the fluctuations exceed their normal limits. That is the case in disease, a process in the living being which particularly concerns us. We call an organism diseased when it fails to be adapted to unusual surrounding factors or even to its usual conditions of living. The pathological processes represent to our mind attempts at adaptation. But in disease these attempts are insufficient as they fail in time and in extent. Whether the organism will later on be successful in its attempts at adaptation, be it with or without artificial help, is another question.

During illness, these attempts are at least incomplete, if not entirely insufficient. What we want to show in this connection is how our conception of disease is governed by the great biological principle of adaptation. This conception corresponds to modern teaching of biology; it is dynamic, for it considers the forces of the living organism to be continually active with the aim of self-conservation.

With such a conception homoeopathy wholly agrees, since its aim is to further the efforts of the organism to adapt itself in those places and those stages where failure becomes manifest.

What is the meaning of our comparing the symptoms of the individual patient with the symptoms caused by medicines and then prescribing the most similar remedy? We bring the remedy into close accord with the diseased individual. The very object at which we direct our attack is the same human organism, the same psycho-physical unit against which the exterior or interior causes of disease are fighting. The intensity with which the organism reacts on the pathological or medicinal stimulus affords us our gauge. The reacting organism is what we always refer to; we judge the increase or decrease of the disease according to the symptoms the organism produces. Neither can the quantity of pathological causes be a measure of disease, nor the quantity of a remedy a measure of healing.

Homoeopathy seeks healing by furthering the reactions of the organism. Neglect or suppression of these reactions are in any case alien to homoeopathy. The fighting side, which is to be aided and supported by homoeopathic treatment, is really the reacting organism and that means nothing but the constitution. Thus homoeopathy is as a matter of principle constitutional therapy. The manner in which an organism reacts shows us the peculiarity of its constitution. In pathology and therapy we speak of constitution when we deduce the present state of the individual, his morphological and functional characteristics as having been caused by past influences; the same complex we should call predisposition when we refer to the future tendency with its accidental possibilities.

In constitutional therapy, however, we always have in mind both the present situation resulting from the past and its future tendencies. For dynamic conception the improvement of the constitution is synonymous with elimination of the predisposition.

Whenever we improve the adaptation of the organism to the conditions surrounding it, whenever we further its reactions towards attacks and demands, we are practising constitutional therapy. That it is possible to be practised there can be no doubt; more important to us is the particular question how far into the organism, into the constitution can we trace the disease, with our perception on the one hand, with the stimulus of the remedy on the other. How far can we intensify constitutional diagnosis and constitutional treatment? Extent and depth, degree and grade, the more or less of the manner of penetrating the constitution, theoretically as well as practically—these are the real and internal problems of homoeopathy. Let us contemplate separately the continuity of space and time within which we also view the individual, first in the geometrical and then in the time dimension. We are well aware, that in reality we cannot separate the “now” and the “here,” but for the understanding we should do well to consider the steps and degrees leading us into the comprehension of the constitution separately according to space and time.

Consider the constitution, the organism, in its dimension of space, would that not lead us straight away to a localistic anatomical materialistic pathology? No that is not at all what we mean. Surely it is not only the material which has a relation to space, forces also can be localized. There exist between them super-ordination, co-ordination or sub-ordination, what we call peripheral, and more or less central localization. These dynamic localizations are what we principally mean. Let us take a cystitis; surely it can be limited locally. But what we have to comprehend and treat is not a conglomeration of inflamed mucous membranes. Rather are we bound, even here, in the mostly local peripheral case to suppose the existence of a centre for the disturbance as well as for its regulation. Let the ultimate cause be, say, wet and cold feet at a time when the coli bacilli are present. Here at least we have to super-ordinate the disturbance in the regulation of the blood-vessels to the alteration in the cells of the mucous membranes. Without such a central switchboard, a regulating centre, we cannot conceive a connection between morbific event and morbid manifestations. Neither can we conceive the medicinal regulation as a peripheral action on the mucous membranes of the bladder, when cantharis 6 presently induces an improvement. It would be impossible to suppose that the few drops can have a local mending action on the peripheral cells. We cannot be mistaken in assuming one and the same regulating centre for the genesis of the malady and for its abolition. This centre is super-ordinated with regard to the cells of the peripheral organ, but in such a rather peripheral process it would be an inferior centre. This centre too belongs to the constitutional part of the pathological and therapeutical process. But the constitution is engaged only partially or within certain limits in this case, in which the exogenous factors were preponderant. In giving cantharis we have used the partially constitutional method of a comparatively peripheral grade. A so-called “organotropie” because we have directed our efforts towards an organ; but it is still constitutional therapy.

Starting from such a low rung, the constitutional part of disease as well as the remedy, both of which meet at the same regulating centre, can proceed in two, as it were, directions of space, in the plane and in the depth, on the horizontal and in the vertical. First, in the plane. If the disease remains limited, let us say to the bladder, the external causes may diminish in case a stronger local disposition of the organ exists. Let us take the case of capsicum. There we frequently find an ectropion of the urethral orifice in women as an expression of the easily inflammable and irritable bladder. The nervous spasmodic accompanying manifestations are strongly apparent. One remembers that capsicum belongs to the family of Solanaceae, as Belladonna and Hyoscyamus. In such cases of easily inflammable bladder with ectropion urethrae in women I have seen good effects from capsicum. Here we may still speak of a peripheral affection and a comparatively organotropic therapy, but the exogenous causes are secondary to the stronger local disposition. Now let us take a Sepia woman patient with relaxed protruding abdominal organs. The down-drawn urethra causes a continual irritation of the neck of the bladder, again and again slight inflammation with slight incontinence. In such cases I have repeatedly been successful with sepia. It is obvious that here the constitutional part of the local affliction has become preponderant. The outer causes become secondary. We call them accidental. In such a case of cystitis in the Sepia woman, however, we see the constitutional part not only extended in the plane but also in the direction of depth. The affection of the bladder is subordinated to a more universal diseased state. The regulating centre, the existence of which we suppose we remove here, lies deeper in the constitution. The laxity of fibre is more general. The personality as a whole is affected, also its psychical reactions become more important. The entire psychophysical functional unit is modified in the sepia sense. The specific emotional symptoms, signs of psychic exhaustion, point in such cases even more definitely to sepia, for they lead us more directly to the centre of the personality. In the specificity of the person we see the most central point of the functional system. This central office of the individual receives the stimulus from outside already in its own specific manner, transforms it equally specifically, so that the outward effects also bear the stamp of its own specific personality. This refers to the normal as well as to the morbid attitude. The line from the periphery of an organ to this personal centre represents that dimension of depth in which we have to seek the points from which disease and cure are being regulated. This exploring into the depth of constitution when collecting and comparing symptoms is quite familiar to us. We know that the more characteristic symptoms, mental symptoms and modalities, that we can find and utilize in any single case, the more we shall penetrate into the depth towards the disturbed supreme centre of personality. What psycho-analysis tries to accomplish by its method is for homoeopathy a method long familiar. Later we shall see that also for the time dimension the same applies.

The gradual penetration from the periphery to more and more central regulating seats, down to the most central point of the personality, will become quite apparent when I give you some examples. Take a series of cardiac affections represented by the effects of the similar remedies well familiar to you. You can then easily form a scale from the organotropic base up to the personotropic apex, for instance, if you hold before your mind the affinities of the following drugs in cardiac affections. At the lowest Digitalis and Stropanthus, a step higher Convallaria, Scilla, Adonis then Crataegus, Laurocerasus, Cactus then Kalmia, Spigelia. Lachesis then Arsenicum, Phosphorus and finally Kali carbonicum. In this scale you see the personal part crescendo (increasing) and the local organotropic one decrescendo (decreasing). What remedy from this scale the therapeutist chooses depends objectively on the individual case, that is to say how far individualization is possible on the one hand and on the other hand subjectively from the ability of the physician to find the adequate consonance.

But also within the sphere of a single drug you can follow this scale from the periphery to the centre from the end-organs to more and more central seats of regulation. Take for instance arsenicum album, there you know on the lowest rung of the ladder the destructive effects on cells, gangrene and necrosis, carcinoma, septic embolic processes with foetid and acrid secretions. The next rung is taken by the inflammatory alterations leading finally to fatty degeneration of the cells of organs and of vascular endothelium. From these toxic effects we derive clinical indications as enteritis, nephritis, myocarditis, cardiovascular syndromes with tendency to oedema and so on. On the next higher rung we find the effects on the nervous system as caused by minute but often repeated doses. The neuralgias and neurites, the various trophoneurotic troubles, ulcers, herpes zoster are of this kind. Here the heavy burning pains, the aggravation from cold, the midnight aggravation are keynotes. And again the constitutional part increases proceeding to the allergic conditions which indicate arsenic, as asthma, hay-fever, urticaria, and the vasomotor megrims and headaches. Here the organic part recedes more and more to the background and the functional part becomes preponderant. We penetrate more and more to the top point of personality when anxiety, restlessness, pedantry, are guiding symptoms. However arsenicum album is not at all a remedy especially appropriate for penetrating to the very personal centre of a patient. We should not call arsenic a constitutional remedy in a stricter sense. Take, for instance, calcarea carbonica as a constitutional remedy of the first rank. Here the stress lies on those symptoms which characterize the person, the focus lies in the supreme centre of the psychophysical functional unit, the depth of personality. The local effects on the organs are of comparatively little importance in a calcarea patient, and at the same time the exogenous causes become less important in such calcarea cases. These conditions are mainly of an endogenous nature. The individual shows itself already insufficiently adapted to common conditions of life. Such conditions arise also from the normal stages of development, as is, for instance, puberty. Further on this constitutional inferiority is of a universal kind, not limited to a single organ. Let me briefly quote a case of my own experience. A boy, aged about 12, formerly very vivacious and irritable, changed more and more into a distinct habitus femininus. He became bodily and mentally indolent and slow; certainly the diagnosis dystrophia adiposo-genitalis under which this case has to be classified is not to be found in our register of calcarea symptoms. However, we find there great obesity and increasing corpulence of the young. In this patient the mental symptoms and modalities also pointed exactly to calcarea. About eighteen months later the patient, treated only with calcarea carbonica 30 in varying intervals, was normally developed and the restriction of his mental activity had disappeared. Let the sceptic of such a change of the constitution in its morphological aspect ascribe all success to the influence of time and nothing to the highly potentized calcarea. Those who have experiences of their own will continue to prefer the homoeopathic remedy to the hormone preparations, which latter can perhaps be supported by theoretical arguments but only very slightly by practical success.

In cases of this kind we are accustomed to seek the disturbed regulating centre in the system of endocrine glands. But it is not possible to hold responsible either the genital glands or the hypophysis alone. The functional harmony has been disturbed and the entire dynamic of the personality has been altered. We know of the intimate interchange of cause and effect between psychic functions and endocrine metabolism. One can no longer speak of a materia peccans, these interchanges are only accessible to a dynamic conception of disease, thus co-ordinating the immaterial psychic forces as causes and the psychic symptoms as effects with the material causes and manifestations.

Just as the natural diseases vary strongly in the depths to which they reach into the personal constitution, so also the artificial images of disease represented by the effects of medicines. For this reason I spoke in my textbook of constitutional remedies of the first, second and third order according to their degree of depth. I have pointed out that the constitutional remedies of the first order are almost entirely taken from minerals which are necessary ingredients of the organism. I have argued why the elements compounding the organism are particularly qualified to supply constitutional remedies of the first rank. It was very interesting to classify these mineral constitutional remedies according to the place of their elements in the periodic system of chemistry. That means according to the sense of their electric charge, positive, negative or amphoteric, and then to recognize parallel correspondences to the three types of constitution as classic in homoeopathy. How this division into three types of constitution is elaborated by Grauvogl who interpreted Hahnemann and Rademacher in his own way, and the relation in which these types of constitution stand to the classifications of the official school, has also been sufficiently discussed in my text-book, and as this part already exists in an English translation in the Journal of the American Institute of Homoeopathy, I need not go further into these details here and now.

When we see the present symptoms of the patient as reflected in the image of the similar effects of a remedy our tracing the constitution is limited to the present situation. That is what I called comprehension of the constitution in its dimension of space, and I explained the two directions in the plane and into the depth, This way of proceeding and applying constitutional remedies may be sufficient in many cases. Hahnemann, in his first homoeopathic epoch, lasting from 1796 to about 1818, worked out this method based on the present situation of the patient. The difficulty which he saw before him about 1818 was the following: the present picture of symptoms recorded and utilized even in a perfect manner sometimes gave unsatisfactory results. The improvement was transient only, the same or another syndrome returned after some time. Hahnemann with his ingenious intuition acknowledged that there must exist a deeper reaching evil. The essence of his teaching about the chronic diseases might not be his aetiological reduction of all chronic diseases to the three great miasms well known to you as psora, sycosis and syphilis. Rather would I see the principle progress in the accomplishment of his method. Hahnemann thus made the chronic diseases (the chronic patients’ constitution), accessible to our exploration and to our medicinal treatment with regard also to the dimension of time.

It is obvious that the more chronic a disease is the greater will be the part played by the constitution. Therefore, constitutional treatment must justify its highest claims in chronic diseases. Here it must be proved how far it will reach into the individual constitution in the dimension of time; in correcting the influence of past events and preventing long enduring future consequences. The further constitutional treatment can go back into the past the more we may call it a profound one, but we speak of profound treatment, too, with regard to the permanence of recovery. This is not always synonymous, as the one does not necessarily correspond with the other. But often the profound restitution can be obtained only by extending our measures far into the past, and that can best be accomplished by the homoeopathic method, as I shall later explain.

Hahnemann acknowledged diagnosis as of comparatively little value, first regarding the present state of disease. He put in its place the totality of symptoms of the individual patient. This totality of symptoms is, according to him, all that can be observed of the dynamic disturbance or disharmony. Going back to the forces, he could view the psychic and physical causes and effects appearing as immaterial or as material on the same plane. We also must accept this dynamism of Hahnemann, otherwise it would be impossible to bridge the gap formed by the theoretical separation of psychic and physical causes and effects as in no way comparable, but such a separation does not exist in reality, as proved by daily experience. Hahnemann, in his second homoeopathic epoch, applied the same statements to the genesis of the chronic diseases, or we should rather say to the history of the chronically diseased person. First he acknowledged this—the chain of the morbid manifestations may not every time consist of links of equal kind. A present manifestation can connect with a former one of a quite different symptomatology. One disease seems to be substituted by another, but there is only a change of manifestations in a chronic morbid condition. This matter is quite familiar to the popular experience, but official medicine agrees with it only hesitatingly and only concerning few examples which are undeniable, such as the alternation of eczema and asthma, of poly-arthritis, urticaria, erythema nodosum and chorea. The old school fears to risk or to lose the independence of their diagnostic types as being the base of their treatment. But the change of manifestations appearing as alternation and vicariation of diseases occurs quite frequently and is well founded in nature. If the diseases of a patient at his various epochs of life cannot be considered as independent from each other, they have quite a natural connection, namely, as a functional unit and totality of the person, the constitution. This unit remains super-ordinate also in the course of time to the single disturbances and is comparatively independent. Surely the connection over a longer time of life exists only for the constitutional part of the disturbances, but even this part is the most important one in chronic diseases. After all, a failure of constitution has in every case to be held responsible for the chronicity of a disease. The question to be answered before we can treat rationally is in what kind of an affection has the constitution failed, what morbid process could not be completely overcome? Thus exploring the chronic patient, we often find a decisive event in his history. Apparently this was the beginning of the chain of chronic ailments or of unfavourable modifications of a formerly harmless affection. Of course, not in all cases is such a distinct event to be found, but if it can be ascertained it affords us the point where we can apply the lever. Getting into a more chronic or less favourable state means that the reactions of the organism have become retarded and diminished. If the kind of retarded or even suppressed reactions is indicated by a distinct past event, we have the means of comparison needed to choose the adequate reactive remedy. It matters not that the decisive event has passed, the organism which formerly failed in its reactions has remained the same. Thus we can make up for the efforts the organism failed to make in a past but decisive period or state, even though it were years ago.

Without insight in these connections the successful cures of chronic patients would sometimes appear incredible or miraculous, but we know by experience how deeply into the past of a patient we can delve with medicinal energies. A clear understanding of constitutional treatment of chronic diseases is apt materially to increase its sphere. In applying the principle of simile to past manifestations we are by no means attempting to blot out or undo some past event, but we merely want to cause the organism to make up for a former deficiency, to improve on a previous want of adaptation.

You will, no doubt, have known cases in which the formerly suppressed perspiration of feet or an old eczema reappeared for instance in an asthma patient under silica or sulphur respectively, and the asthma attacks ceased definitely. After a formerly suppressed secretion has reappeared, the change of the whole patient is often so evident that it is usually to be spoken of as a change of the total constitution. That was the case of a girl aged 11, of my experience. She was troubled by a cough, swollen glands, want of appetite, and mainly by very painful warty callosities on the soles of the feet. The feet were noticeably cold and blue. After silica 30 was given, a foetid perspiration of feet appeared, the callosities and the other troubles vanished and at the first glance improvement could be perceived.

If the original morbid event during which the reactions were incomplete or missed, happened a long time ago, the provoked outbreak of an old evil may not be finished at once. I treated in 1923 a patient aged 54, for an obstinate polyneuritis and found occasionally a residual annular eczema on one leg. The patient did not attend to it because it had existed there since his earliest youth. But his attention was claimed soon after Sepia 30, and later on Sulphur 30, when a moist eczema spread over the whole body and worried him for about four months. Then the eruption ceased gradually, and since this time the patient is in perfect health. In explaining more thoroughly the biological connection within which such cures are to be seen, let us start from considering the opposite kind of diseases, the acute infections. They also have constitutional effects, favourable as well as unfavourable. Measles or whooping- cough without complications in the one child, even they leave an immunity for this infection as a favourable constitutional effect. Sometimes also we see a chronic eczema disappear during measles, but in other children when the unfavourable modification of constitution becomes evident the child appears sensitized for other infections. Quite correctly we think it dangerous if an acute exanthema is suppressed, be it with or without artificial intervention. Thus also in acute diseases retardation or even suppression of reactions is responsible for developing a chronic state of sickness. With the sudden suppression of secretion, be it physiological, as menstruation or perspiration, or pathological, as leucorrhoea, bleeding haemorrhoids and so on, it is all the same. Further on the psychic shock, too, may become the cause of chronic affections manifested often as strongly somatic. Here once more the main condition is that the reactions are incomplete, the psychic shock is pushed away, supplanted. You see we use the same expressions to explain the mechanism of growing into chronicity as the individual exploration of psycho-analysis does. The conception of our curing chronic diseases also corresponds with this psychological method which attempts to awaken old disturbances in order to bring suppressed reactions to an end. Only the means are different, there psychological, here medicinal. It is not my purpose to weigh the one method against the other, only I wish to explain what it means when emotions are given as aetiological indications in our materia medica. Then tacitly it is supposed that the emotions were not released, but were suppressed, and so psychic aetiological indications are meant in the same sense as, for instance, suppressed eruption.

To summarize, we can establish that, whereas disease is caused by failure in adaptation of the constitution, cure can be furthered by reactivating the means of adaptation in constitution, and this is possible too even if the failure is of long standing and if the original consequences are substituted by others. Substitution of one manifestation by another is unfavourable, if the latter consequence is caused by retardation, restriction, suppression of the activity of the organism; then the tendency is from acuteness to chronicity.

On the other hand, the substitution of a chronic state by an acute one sometimes is seen favourable, curative. Such a cure may happen spontaneously, or Nature may be imitated by medical art. The old humoralists and their modern followers intend to produce fever inflammation or suppuration; the cure of progressive paralysis by malaria is a well-known example to-day. In provoking reactions of the organism our intention agrees with this unspecific stimulative method, but homoeopathy differs from it by the higher grade of specificity in the direction of individual constitution; our great advantage by applying the principle of similars. We try to promote the processes which fail in the individual patient or have failed in a previous period of his life and thus turned into chronicity with or without change of its manifestations. It must be clearly understood that our constitutional treatment is based on the principle of similars when it is adjusted for the past as well as for the present state. Indeed, we have before us an enlargement of our constitutional treatment according to the principle of similars, an enlargement in the dimension of time.

Why, for instance, do we choose Thuja, if in a patient it has become apparent that a scrofulous or neuropathic disposition has been sensitized by vaccination, and since that time chronic ailments will not end. Because in proving thuja, similar feverish states with burning pustules are observed as in vaccinosis, so the similarity of symptoms with the original affection which could not be overcome by the constitution governs our treatment.

And we look firstly at sulphur or nux vomica if chronic ailments date since bleeding haemorrhoids were suppressed, be it with or without artificial intervention; that is to say we look for remedies which are known as apt to produce the haemorrhoidal syndrome from provings, and thus also to reproduce it in this chronically affected patient. And with ignatia for the consequences of disappointment it is the same. By no means do I wish to plead for a schematic aetiological treatment. When we refer to such a principal cause, we attain a decisive past state of the patient as a further object of comparison, an additional indication but a very important one. However, the system we always refer to really is the individually reacting constitution.

So again and again we meet constitution as the great mediator, receiving, transforming and answering each stimulus in an individual manner, the morbific stimulus as well as the remedial one, and so constitution mediates also our curing, based on comparison even of its individual reactions.

By acknowledging this connection, the seeming contradiction dissolves between the first and the second epoch of Hahnemann’s teaching, the first based on symptomatic comparison only, the supplementary teaching of the chronic diseases seemingly based on aetiological indications ; seemingly, I said, because I think it has become evident that the cure of chronic diseases implies only a larger application of the principle of similars.

Furthermore, we may correct according to the explained conception an easily mistaken interpretation of Hahnemann. When Hahnemann speaks of the substitution of one disease by another, he seems to omit his dynamic conception and to admit diseases as independent entities. If he says that the natural disease must be substituted by a stronger artificial medicinal disease, it would be difficult to conceive why artificial disease might be stronger than a natural one. But if the reactive organism, the constitution, is interposed, it becomes quite evident what is meant. The afflicted organism is stronger in its attempts to adapt itself when stimulated by the adequate remedy than it was before.

In closing my lecture, I fear to have been too abstract, but a certain abstractness is inevitable in discussing such methodical problems. However, the clearness of our method and its compatibility with the best available knowledge of biological science is so important a matter that it must be shown again and again and from different aspects. Modern science is ripe for homoeopathy. Let us be well prepared to receive a medical art which will join modern biological conceptions and then will meet Hahnemann’s teaching. Time works for homoeopathy.

*Read to the Annual Assembly of The British Homoeopathic Society, June 28, 1934.

**This article is a reprint of a previously published article. For citation purposes, please use the original publication details; Br Hom J, 1934; 24: 230–244.