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The art of diagnosis
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T H E ART OF DIAGNOSIS By A. P. CAWAD'IAS,O.B.E., M.D., F.g.C.P. Professor Emeritus of Medicine of the University of Athens Endocrinologist to the Order of St. John Clinic TH~ Neohippoeratie principles, which under various names permeate contemporary Medicine, have enlarged the scope of diagnosis; the basis of medical handling. Diagnosis for Hippocrates, and, in general, for the Ancient Greek physicians was what it must be to-day, a bi-polar process. I t consists in Disease Diagnosis and in Constitutional Diagnosis ; in Diagnosis, or understanding, " of the disease that the patient has ", and in Diagnosis, or understanding, " of the patient.that has the disease ". " There are three things in Medicine," writes Hippocrates, in a famous aphorism. " The Disease, the patient and the physician." This conception of diagnosis is opposed to the one current in the official Medicine of the nineteenth century in which everything is Concentrated on disease diagnosis and the patient that is behind the disease is entirely forgotten. The school of Hahnemann was, from that point of view, on more accurate lines, because stress was laid on constitutional diagnosis. Unfortunately, as a sort of reaction there was a certain negleet--I speak, of course, of the more ancient Homceopathy--of disease diagnosis. Neohippocratism re-establishes the balance. What caused the neglect of constitutional diagnosis was the fact that whereas the science of disease had made enormous progress the science of constitution remained speculative, and little had been added, until twenty to thirty years ago, to the old temperaments and " psychophysieM constructions " of the Greeks. We are, however, in a better Position to-day. The researches on endocrinology and metabolism on the one hand, and on psychology on the other hand have helped us to unravel the secrets of constitution and have placed constitutional diagnosis on a more scientific basis. Disease Diagnosis. This is a double process and consists in disease determination and disease individualization. (a) Disease determination is the placing of our patient under one of the diseases or morbid categories of our nosography and is the first and indispensable stage in diagnosis. We have first of all to determine whether our patient has a pneumonia, a n osteoarthritis, a mitral insufficiency, a disseminated sclerosis, an anxiety neurosis and so on. Much has been written in these last years against this disease determination, and the platitude that there are no diseases but only patients has been repeated to satiety. I t is true that disease determination is the Alpha and not the Omega of Diagnosis, that it is o n l y a stage of diagnosis and not the whole diagnosis, but it is an indispensable stage, and without it no complete diagnosis is possible. I t is the thread of Ariadne that will guide us in the maze of morbid events. The placing of a nosographical label will help us to utilize in full our knowledge of clinical science, of the natural history of diseases, and it is through the fiction " diseases " that we shall bette r appreciate the reality, the individual patient. Clinicians who have disregarded disease diagnosis and grasped immediately at the " individual physiological diagnosis " have fallen into c~aos and error as is shown by the failure of the German " Physiological School " Of the Wunderlich-Trau]e-Virchow era. Ottomar Rosenbaeh, a representative of that school, could thunder, " We want to heal and not to classify." Experience has shown that those who cannot classify cannot heal because they are deprived of a safe basis of diagnosis and treatment. It is true that on the other hand the limitation of diagnosis to this disease determination,
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as advocated by Philippe Pinee, for example, and some Viennese and Parisian nosologists of the early nineteenth century is equally erroneous and leads to therapeutic sterility. Disease determination can be made-through the analytical process or through the intuitional process ; usually the two are combined. I t presupposes in both a great knowledge of clinical science acquired at the bedside and in books. In the rational process the patient is thoroughly and systematically examined a capite a d calcem. The critical Faculty allows separation of t h e essential from the non-essential symptoms. Every s y m p t o m detected is considered in the frame of all others, and its diagnostic significance assessed. Later, the diagnostic significance of the combination is assessed. Like an architect the clinician builds his diagnosis stone by stone into a harmonious whole. Here, also, a certain intuition intervenes, filling the gaps and vitalizing, accelerating the whole process, but the analytical process remains the safest method of diagnosis. In the intuitional process the impressions received from the patient are more rapid and more complete (intuition being bound up with impressionability) the critique and syllogism occur deeply in the subconscious more rapidly and more dynamically. Gaps are quickly filled. The result emerges into conscience as a sudden inspiration. I n other cases this process consists in comparison of the picture shown by the patient with other disease pictures that are in the subconscious but emerge rapidly. The basis in this process is a great memory of disease pictures and of combinations of symptoms. W h a t causes, however, that the clinician selects from all those memories, those few that shall be compared with the disease picture he has before him, is a mystery. It is probable that m a n y comparisons and rejections are made subconsciously, or that compartments in the Subconscious exist and the clinician knows subconsciously, immediately, which compartment he has to open. Such intuitiQnal diagnoses are given to clinicians of long study, rich experience and great artistic ability. However, in general, even such clinicians control their results by studying the patient more analytieMly. A fine example of such an intuitionM disease determination is told in the biography of Oppolzer. A young patient was brought to the clinic and for two days the assistants studied him without reaching a diagnosis. Oppolzer saw him and said that it was a ease of dysentery and that he would die in a few days. The patient had at that time no diarrhcea, but he developed, after twenty-four hours, a distinct picture of dysentery, confirmed by necropsy. On being asked by the assistants how he came to that wonderful diagnosis he said that he had seen similar cases of dysentery in the prodromie stage in a dysenteric epidemic in Prague, and he got from them the same impression he obtained from this patient. (b) Disease individualization consists in determining the individnal features t h a t the disease, pneumonia, gastric ulcer, anxiety neurosis show i n our particular patient, Smith or Brown. I t is built on the exploration of all organs and systems, of the general condition of nutrition, of the psychological reactions; Hippocrates does not speak of pneumonia or of dysentery or of any other disease in the singular. He writes the pneumonias, the dysenteries. He thus indicates that diseases have individuM features according to patients. Sir William Gull spoke in the s~me spirit of a typhoid man, of a pneumonic man. In every patient the " disease " as listed in our nosographies shows special features in the individual patient considered, and these should be determined. 9 The disease individualizations should not be confused with the diagnosis of the person. Disease individualization is the answer to the question, what particular features the disease pneumonia or neurasthenia shows in our individual patient ? The diagnosis of the person is the answer to the question, what kind of a man is our patient who has a pneumonia or a neurasthenia,
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thus independently of his actual disease. There is, unfortunately,' much confusion between these two things. I have diagnosed pneumonia, Bright's disease, duodenal ulcer or anxiety neurosis. I shall proceed, and on_ the basis of m y complete examination I shall determine that m y patient, Smith, has a pneumonia of such and such an extension with heart involvement of such a degree, With such and such nervous or psychological reactions. I n other words,-I shall determine what is really wrong with the physiology and psychology of m y patient. Here intervenes the famous physiological thinking. I shall, also, determine what special etiological conditions have caused this disease . . . And I shall say, pneumonia or Bright's disease with such and such individual features. This art of individu.alization of the disease is the mainstay of all great clinicians. When, later, I shall have proceeded to m y diagnosis of the person, when I shall have determined what kind of a man m y patient, Smith, is, independently of his disease, m a n y of those individual peculiarities t h a t Smith shows in h i s pneumonia, Bright's disease, duodenal ulcer and anxiety neurosis will be explained: The two processes, however, should not be confused.. Constitutional Diagnosis, or Diagnosis of the Person. I have developed the technique of this constitutional diagnosis in m y Modern Therapeutics of ]nternal D,seases. To u n d e r s t a n d the constitution, the " person ", of m y patient, Smith or Brown, independently of his disease I have to investigate three things: (a) his actual psychophysical construction, (b) his development, that is the phases through which Smith or Brown has passed to reach his actual psychophysical constitution or personality--this investigation includes the hereditary investigation, and (c) his environment, because e v e r y " person " is bound up with his environment, and we cannot understand him without his environment. An individual constitution, a " person ", is three dimensional, the three dimensions being the actual Constitution (Johansen's Phaenotype), the development (from the union of the Gametes up to the moment of our investigation), and the environment. I cannot go into the details of the constitutional diagnostical procedure except to insist again t h a t thanks to endocrinology, metabolism and psychology we can place this constitutional : diagnosis on a basis as safe as that of disease diagnosis. General Course of Diagnosis. Diagnosis has been described analytically, but, in fact, all processes of diagnosis, disease diagnosis--disease determination and disease individualization--and constitutional diagnosis--actual constitutional diagnosis, developmental constitutional diagnosis, environmental constitutional diagnosis--occur more or less simultaneously. The whole process of diagnosis of the patient dccurs in three phases : a phase of initial synthesis, a second of basic analysis, a t h i r d ' o f terminal synthesis. The initial synthesis is intuitional. When a patient enters a consulting room the physician tries to penetrate into his innermost, so that he m a y contemplate him from the inside. He obtains a first impression of the whole from his patient's appearance, some fleeting signs, the way he walks, speaks, looks and from simple questions. This first initial synthesis is of the greatest importance, because we must have a view of the whole before we examine the parts and because the parts can only be considered in the light of the whole. This first "impressionistic " synthesis, however, Should not bihd us, and should be a support and not a chain. I t shall be corrected and completed with the rest of our examination but it must be there at onset. The next phase, th.at of basic analysis, is essentially rational, although the intuition intervenes to make it more rapid and to vivify it. I t is at that phase that we proceed analytically in disease determination, disease individualization, " person " determination, using the Various methods of clinical explorations and, principally at onset, the historical and the physical exploration.
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The third phase, that of the terminal synthesis, is rational and intuitional. On the basis of our analytical exploration we proceed to understand the patient as a whole, as a total reaction. Intuition completes our rational procedure. The Practice of the Internist in the Light of this New Conception of Diagnosis. Prognosis as well as treatment is based on this double diagnostical process. On account of the shortness of space I shall limit myself in the question of treatment. Disease determination may indicate to us certain so-called specific remedies, as, for example, quinine for malaria, but to apply this only on the strength of the label " malaria " is to court disaster. We have to take into consideration the individual features the disease malaria shows in our patient, Smith or Brown, and, particularly, the constitution of Smith or Brown. Smith may have the same malaria as Brown but if he is of a. different constitutional type: quinine will act differently in him as in Brown, and may even be noxious to him, whereas it m a y be curative for Brown, who, as I have said before, has the same disease, Here I must do honour to the Itahnemannian School. Notwithstanding the somewhat difftlse arrangement of the Homceopathic ~ateria 3/Iedica, the leading lines conform to the Hippocratic doctrine. Homceopathic drugs are administered on the basis of (a) the disease, (b) the individual features of the disease, (c) the constitution and, of course, the individual features of the disease, and, principally, the constitutional features of the patient are the most important leaders. A clearer rearrangement of the )/[ateria Medica so as to render these lines more evident would be welcomed. I am sensible, Mr. Chairman, of the great honour you have made me in asking me to address the Faculty of Homceopathy. -My attitude towards Homceopathy has been questioned and the term, eclecticism, has been applied to m y doctrine. I am not an eclectic, and I consider eclecticism as a cowardice of thought. Neohippocratism is a synthetic and not an eclectic process. Let me remind you of the great philosophical principle of Heraclitus, that great Greek philogopher of the fifth century B.C., translated in modern language by Hegel. Two doctrines m a y appear to be opposite, but this does not mean that the one or the other is wrong, because there are arguments for and against regarding each of these ~wo opposing doctrines. Truth lies in a third doctrine which unites on a higher plane these two opposite doctrines. We cannot stop at a one-sided doctrine. The mind is driven forward to even wider and more comprehensions of truth. The combination of two partial doctrines and a third is the dialectic " Triad " of Hegel. Allopathy and Homceopathy are terms that signified something in the beginning of the nineteenth century but are meaningless to-day. The principles included in these terms are united on a higher plane in the doctrine of Neohippocratism. Hippocrates wrote two thousand and four hundred years ago, " There are diseases that have to be treated by contraries and others by similars. Everything depends on the nature of the disease and of the patient." This principle is elaborated to-day through the high synthesis of Neohippocratism. I have described the art of diagnosis according to the Neohippoeratic doctrine. Now regarding treatment, everything for us depends on clinical observation. If clinical observation shows us that a remedy A is superior to all others for patients who show such and such a disease, with such and such individual disease features, with such and such constitutional features we prescribe this remedy whether it comes from th~ Homceopathic )/Iateria Medica, from the Physiological laboratory or even from popular tradition. This does not mean eclecticism but the plemaey of clinical observation and I consider that Neohippoeratism--as this has been already accepted by some French homceopaths--can give Homceopathy a new life.
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Dr. TEMPLETON recollected t h a t he h a d been indirectly responsible for Dr. Cawadias's first appearance before this Society m a n y years ago. Dr. Cawadias had been a good friend to Homceopathy in circles where it was anything but popular. The f a c t t h a t he thought there was something in Homceopathy had cpnsiderable influence in orthodox medical societies coming as it did from a physician with a European reputation. Dr. Cawadias would know t h a t he meant nothing derogatory when he suggested t h a t most of the ground he had covered in attempting a diagnosis was indeed covered b y a full Homoeopathic consultation. Where perhaps they differed was in the ultimate end, viz., treatment. Dr. Cawadias, perhaps spread his net wider than the average homceopath (that might indeed, be an advantage) and one knew t h a t he did use potencies where he thought them indicated but one would like to know why and when he chose to treat b y the law of similars and when b y other means. Dr. CAWADIAS, in thanking Dr. Templeton for his kind appreciation, said there had been misconception in regard to his lecture at the Wellcome Institute. He had merely said at t h a t time that the empiricists who were disciples of Hippocrates were those who preceded H a h n e m a n n in their evaluation of symptoms, and in t h a t connection he spoke from the historical standpoint. He regarded H a h n e m a n n as a great m a n in the history of medicine. I t was necessary to ask what led to H a h n e m a n n and what followed after Hahnemann. The principles he had put forward in his address were those which m a n y members of the Faculty already accepted regarding constitutional diagnosis ; they dated even from the time of Hippocrates which was, again, a matter of history. One of the great merits of H a h n e m a n n was t h a t he took medicine and developed only one part of Hippocratic medicine, and in so doing he was absolutely right. In fact, in the days when H a h n e m a n n lived, all diagnosis was centred on disease determination: the physicians made a diagnosis of disease and that was all. Hahenmann had had to fight hard for his tenets: It was said in his time that Vienna was the great medical centre of the world ; that there everything possible was done for the patient. People were told that if they were fll they should go to Vienna for treatment because there they would find everything necessary for their recovery: they would be diagnosed by Skoda, and autopsied by Kokitansky. That was why one had to examine the matter historically. Admittedly, by going too much against the practice of the time Hahnemann overstepped the mark on the other side. Me rather over-emphasized the necessity for constitutional diagnosis though that was really all to the good because as a result he developed constitutional diagnosis and therefore, again, one had to regard the matter from the historical point of view. Dr. Cawadias did not subscribe to ~the dogma that every new discovery in science was a new name for a discovery of the Hellenic thinker; all the same the principles which he had enunciated had been laid down at that time and developed later on. That was why he agreed so much with what the homceopaths taught; he believed in the old conception-the diagnosis of Hippocrates, the disease determination, disease individualization and person determination, Hippocrates never spoke of " the pneumonia " but of " the pneumonias ", showing that he believed every type had different features. As to his personal determination, one had only to read his observations on epidemics, to consider his descriptions of the persons to whom he spoke. For instance, a black-haired woman with jet-black eyes who was living near the market, and so on. I)r. Cawadias thought that in regard to actual treatment he had been sufficiently clear though he had not had time to discuss the whole treatment. Nevertheless, he had insisted on the fact that the personal determination, the constitutional diagnosis, provided an indication of the method of treatment of any patient. He recalled that when assistant physician in Paris he was
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studying chronic rheumatism. He had a patient who was so terribly deformed as to be incapable of doing anything, and that condition had prevailed for a number, of years. One day a queer looking but distinguished Paris physician had called on him and had said : " I hear that you are interested in the disturbance of metabolism~. Do you realize that in the endocrine glands we have a method of changing the metabolism of the individual ? W h y not t r y this on your patient--apply endocrine therapy and thus correct the metabolic disturbance." That was m a n y years ago. He had given the patient thyroid on the basis of the constitutional diagnosis of hypothyroidism and the man got on brilliantly. Actually that was what members of the Faculty were now doing with their constitutional remedies. The complete method of diagnosis had given indication of the complete method of t r e a t m e n t . If he h a d an indication from the disease, he used that indication because it was the outcome clinical experience. Dr. FRASER KERR, in adding his appreciation of the extremely interesting and helpful address, said he had been particularly impressed b y Dr. Cawadias's suggestion that 95 per cent. of determination of constitution occurred during the p~riod of pregnancy. This is a wonderful commentary on the Homceopath's contention that treatment during pregnancy is the most important work we do. He had been :fortunate in looking after pregnant women not merely in saving the patients trouble, but also in seeing the h a p p y results in their children. He was reminded of one case that dated before he was a homceopath. The patient had repeated h~emorrhages ; a consultant advised removal to hospital if this could not be stopped. Rest was not sufficient, but he noticed that the patient's elder child was a poor little monkey, definitely sub-thyroidic. Thyroid extract given to the mother stopped the bleeding and all went well. He had found thyroid, by the way, a dangerous drug to give during the menstrual periods as he had twice been forced to the conclusion that it had caused flooding. Another and recent case had been fairly simple and short in tha~ it took only about ten days from beginning to end. The patient came with a red swelling round the corner of her mouth. The doctor she had seen had been unable t o do anything because there was not sufficient diagnosis. But t o the homceopath there was a very red, hot swelling of the right cheek and half of the lip with throbbing, worse at night (or lying down) and worse warmth ; he could say red swelling very like belladonna " and that cured in two days. (The doses were 200 at once and 1 m. twelve hours later.) Dr. LEDERlV[ANNconsidered that when Dr. Cawadias spoke of the hormone gland he had in mind certain individual glands. When speaking of hormones was it not true to say that every cell in the body produced some form of what one might call a hormone ? One could surely think of e v e r y cell in the body as a hormone-producing unit ? The speaker added that he had been reading a~book by Asehner who had practised in Austria and was now in the United States of America. He had written about constitutional medicine and used the methods which were known as pre-scientific, purging, blood-letting, vomiting, increasing the menstrual flow, etc., not using endocrinology or other modern drug treatment. He is guided by the principles of humoral pathology. Was there any evidence in the history of medicine to show whether the results thus obtained were definitely as good as those obtained by modern endocrinology ? Dr. CAWADIAS,in reply to the first question, said it was true that all cells of the body secreted enzymes ; there were various degrees of secretion. There were enzymes that were intracellular ; others which were extracellular and also hormones which went much further, and there was union between all. Borden, who was one of the pioneers of endocrinology and was a physician at Montpelier at the end of the eighteenth century, had followed the Hippocratic: tradition. He said that the cells of the body secreted certain substances which "
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went into the blood and regulated the whole body. All cells secreted certain chemical substances; certain cells secreted more than others. There were some cells that secreted hormones, but they were isolated cells. Other cells accumulated together and made, as it were, diffuse endocrine organs. There were also the interstitial gland cells which were also rather diffused. At some other time other cells coalesced and made more complete glands. That was why he did not accept the endocrinology of the five or six glands of destiny. He considered that the endocrine function was something more than a chain of five glands. He knew Aschner and had not only been in correspondence with him but had often met and discussed the subject with him, the last occasion being at the Congress on Constitutional Medicine and Endocrinology held in Italy. Aschner had very fine ideas but he seemed to have stopped short somewhere ; he had done excellent work in endocrinology; in fact he ought to be more widely known in that connection. He had, however, stopped short in that regard and had gone on with his old constitutional methods by means of which he had obtained some very good results. He had once asked Aschner if he wanted to go on to constitutional medicine, why did he not go in for the Homceopathie Materia Medics, and Aschner had replied that h e could deal by his methods with his patients and that if there was nothing he could do then he could send them i o a Homceopath. Mr. POWER felt that Dr. Cawadias had been concerned during the course of his address rather more with functional or very early disease than with late disease. Would Dr. Cawadias agree that the later the disease the more stereotyped the treatment became ? In fact, with late organic disease it seemed that it was the disease which mattered and not the individual. Dr. TEMPLETON : And the surgeon and not the ]ohysieian ! Dr. CAWADIASthought this applied to all diseases, even the most serious. I n every disease it was 9 by acting on the constitutional factor to do something very big. If a lesion was very advanced it was not possible to do that although it was possible to help by acting on the constitutional phasel I t was interesting from that point of view to bear in mind the differences between organic diseases. In the case of gastric9 ulcers it might be said that 9 mortality was 5 per cent. or 10 per cent. but he was not interested in that ; he was interested to know what were the features of disease individualization and what was the constitution of the patient which would cause the one with the gastric ulcer either to die or to survive. That was the important factor. 9 In dealing with serious organic disease it was necessary to have regard to disease determination, the disease individualization and the personal determination. He had had a ease of Graves' disease and was against operation though a surgeon friend had assured him that the disease would more quickly be dealt with by surgical means ; that it was an operation with only 1 per cent. mortality. Personally, it was a matter of indifference to him whether the mortality from the operation was 99 per cent. or 1 per cent. ; his patient might be that 1 per cent. He preferred in such cases to know which were the disease individual features and the special features that would make clear whether a particular patient needed a certain medicine or an operation, or whether the patient would survive or die. That applied also to the organic disease, and even more so. Sir JOH~ WEII~ was glad that Mr. Power had raised that point because it was at the root of the whole problem. W h y did one find so many remedies in cases of gastric ulcer ? Firstly, there was the disease, then individualization, then the personality. To whom would one give Phosphorus ? Therein lay the dependence on the personality of the individual. He had seen a patient with a very large duodenal ulcer which showed by X-rays and so on, but in that case it had not been possible for him to decide on the remedy until he had arrived at the man's personality, which was Phosphorus, and as soon as
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that treatment commenced the patient had had no pain for months past. In conclusion, Sir John thanked Dr. Cawadias for coming to give his address. He had been a good friend to homceopathy and a great help to the speaker in 1932 when the Centenary of the British Medical Association took place and Dr. Cawadias gave a paper. He had also lectured to the Royal Society of Medicine. Personally, he would never forget the night when Dr. Cawadias had befriended him and backed him up. In spite of the fact that Dr. Cawadias went in for so m a n y deep things he always came back with a good word for homceopathy. That encourage d the members of the Faculty to carry on in a simple way and by so doing to get results which were just as good as those obtained by anybody else. Dr. MCCaA~ also wished to- thank Dr. Cawadias for his excellent address. He had stated that once he had made his diagnosis he knew what world to send his patient out into. There was good reason for that statement. When travelling in any part of the world one seemed to come across Dr. Cawadias. The speaker had moved about the Continent before the war and whether it was on a boat crossing the Channel or in Paris or Budapest or elsewhere he met Dr. Cawadias. Therefore, he knew where best to send his patients in order that they might be completely restored to health ! Also in his great travels Dr. Cawadias had learned m a n y interesting facts. Although he had not stressed his leanings it was evident that he was a skilled homceopathic practitioner. The main interest of all was his condemnation of the five glands of destiny. At the commencement of treatment one could often see quite plainly the different endocrinological tendencies. When the remedy was provided those things dissolved or disappeared entirely and then one saw one's patient and not the endocrinologieal peculiarity. Therefore, through homceopathy one eliminated the first two of Dr. Cawadias's trio and came to the third--the person. That was the aim of Dr. Cawadias's work and it corresponded to the result achieved by a good homceopathic physician. I t was interesting to follow the thoughts of such-an independent worker and learn that his deductions corresponded to our own work. The PRESDSNT felt sure that members would agree that they had listened to a most interesting address, followed by an equally interesting discussion. As Dr. Templeton had named him in association with Dr. Cawadias, the President felt he must reply to the criticism in connection with t h e alleged modern tendency to isolate a germ and base all treatment on its identification. Dr. Templeton knew very well that as a bacteriologist he personally did n o t believe in the so-called germ theory ; the theory put forward by Pasteur. He believed that the pathogenic germ was the result of-something which was known as constitutional action; in other words, the constitution determined the germ to a great extent. ~That could be qualified but on general terms he would say that the constitution determined the germ. Dr. Cawadias had drawn attention to a tendency for laboratory technique to displace the old clinical instinct. There was no doubt that the older physicians " knew the constitution ". He personally could remember as a child his grandmother using the phrase, when a new doctor came into a certain district, Oh, old Dr. - knew our constitutions." It seemed that the modern doctor did not make much attempt to know constitutions ; he wanted to know the latest drug from the drug houses. When Dr. Cawadias had cited the example of quinine in malaria the President felt it a pity that he had not come to the more modern sulpha drugs in pneumonia ' because that would have given rise to an even more interesting discussion. There was no doubt that Dr. Cawadias in his particular work had built, as it were, upon the same foundation as had.homoeopaths. I t was obvious that he conceived a vital function and his diagram had shown that if there was a break across in any one particular line there was dysfunction. "
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Dr. MeCr~e had pointed out that under homceopathic remedies it was possible to see the functional of glandular disturbance disappear. That suggested that the. glandular treatment as carried o u t by Dr. Cawadias must be very much on the same plane of bio-chemical action as that by which homceopaths presumed their remedies to act. -He personally conceived, and had put forward that view, that Hahnemann discovered and made apparent the full action not only of remedy but of the cell, and it was necessary to consider the relationship of the one to the other, and in these modern days the biochemist was considering what he called the biochemical, something which had an effect on life. Dr. Cawadias had given his point of view on endocrinology, but Hahnemaun had recognized a constitutional state and unless one could recognize the constitutional phase which Hahnemann called miasm in the patient, one was not likely to cure disease. I t was necessary to bear in mind what Dr. Cawadias had said as to the old Greek medicine in the time of Hippocrates, namely, that it was centred on health, not disease ; on health and the maintenance of health. There was now before the nation the National Health Service Act which, originally, was to be a comprehensive service for the treatment of disease, but so far little had been done to conserve health, which was really the important factor. Dr. Templeton did not seem to think that birth injuries could have much -effect. In modern days probably not, but the President said he could look back to forty years ago when he started in general practice, and could recall the treatment which was given then to women during confinement. Judging from the damage then done to the mothers he could not but come to the conclusion that there must have been some damage also done to the infants by the use of forceps. I t was gratifying to feel that that phase had passed as a result of modern teaching ; and the action taken by the public health authorities with regard to maternity work was another reason for improvement. General practitioners in certain cities had taken exception to the fact that the authorities were taking over maternity work. There was, however, a reason for that. As a result of thinking back into his own experience Dr. Paterson felt that birth injuries were possible. Coming to his own experience of homceopathic medicine with children he could also think of a number of cases in which Arnica was a routine prescription. Children came with mental defectiveness and m a n y colleagues took the attitude that there might have been a birth injury. Taking the clinical results he had seen in the Children's Hospital, it was surprising to think of the number of children who responded to that treatment. Accepting the argument that Arnica had some effect on injuries, which would be the homceopathie attitude, one might ~reasonably conclude that those children had suffered from injuries at birth. The President added that he had not at the outset of the meeting said an)~hing about the Neohippocratic attitude to medicine or Dr. Cawadias's previous papers to the Society on the subject because h e had suspected and hoped that Dr. Cawa~lias' would speak on that same subject. Members were greatly indebted to him because he had taken up- a more modern attitude to constitution and disease and the application of medicine to the treatment of disease. I n doing so Dr. Cawadias had included Hahnemann's conception of the homceopathic method of treatment. I n the name of all present Dr. Paterson heartily thanked Dr. Cawadias for his most interesting address and for the trouble he had so obviously taken to answer the questions raised during the course of the discussion. (Applause.) Dr. CAWADIASexpressed his appreciation of the thanks accorded him, and the meeting terminated.
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T H E ART OF DIAGNOSIS By A. P. CAWAD'IAS,O.B.E., M.D., F.g.C.P. Professor Emeritus of Medicine of the University of Athens Endocrinologist to the Order of St. John Clinic TH~ Neohippoeratie principles, which under various names permeate contemporary Medicine, have enlarged the scope of diagnosis; the basis of medical handling. Diagnosis for Hippocrates, and, in general, for the Ancient Greek physicians was what it must be to-day, a bi-polar process. I t consists in Disease Diagnosis and in Constitutional Diagnosis ; in Diagnosis, or understanding, " of the disease that the patient has ", and in Diagnosis, or understanding, " of the patient.that has the disease ". " There are three things in Medicine," writes Hippocrates, in a famous aphorism. " The Disease, the patient and the physician." This conception of diagnosis is opposed to the one current in the official Medicine of the nineteenth century in which everything is Concentrated on disease diagnosis and the patient that is behind the disease is entirely forgotten. The school of Hahnemann was, from that point of view, on more accurate lines, because stress was laid on constitutional diagnosis. Unfortunately, as a sort of reaction there was a certain negleet--I speak, of course, of the more ancient Homceopathy--of disease diagnosis. Neohippocratism re-establishes the balance. What caused the neglect of constitutional diagnosis was the fact that whereas the science of disease had made enormous progress the science of constitution remained speculative, and little had been added, until twenty to thirty years ago, to the old temperaments and " psychophysieM constructions " of the Greeks. We are, however, in a better Position to-day. The researches on endocrinology and metabolism on the one hand, and on psychology on the other hand have helped us to unravel the secrets of constitution and have placed constitutional diagnosis on a more scientific basis. Disease Diagnosis. This is a double process and consists in disease determination and disease individualization. (a) Disease determination is the placing of our patient under one of the diseases or morbid categories of our nosography and is the first and indispensable stage in diagnosis. We have first of all to determine whether our patient has a pneumonia, a n osteoarthritis, a mitral insufficiency, a disseminated sclerosis, an anxiety neurosis and so on. Much has been written in these last years against this disease determination, and the platitude that there are no diseases but only patients has been repeated to satiety. I t is true that disease determination is the Alpha and not the Omega of Diagnosis, that it is o n l y a stage of diagnosis and not the whole diagnosis, but it is an indispensable stage, and without it no complete diagnosis is possible. I t is the thread of Ariadne that will guide us in the maze of morbid events. The placing of a nosographical label will help us to utilize in full our knowledge of clinical science, of the natural history of diseases, and it is through the fiction " diseases " that we shall bette r appreciate the reality, the individual patient. Clinicians who have disregarded disease diagnosis and grasped immediately at the " individual physiological diagnosis " have fallen into c~aos and error as is shown by the failure of the German " Physiological School " Of the Wunderlich-Trau]e-Virchow era. Ottomar Rosenbaeh, a representative of that school, could thunder, " We want to heal and not to classify." Experience has shown that those who cannot classify cannot heal because they are deprived of a safe basis of diagnosis and treatment. It is true that on the other hand the limitation of diagnosis to this disease determination,
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as advocated by Philippe Pinee, for example, and some Viennese and Parisian nosologists of the early nineteenth century is equally erroneous and leads to therapeutic sterility. Disease determination can be made-through the analytical process or through the intuitional process ; usually the two are combined. I t presupposes in both a great knowledge of clinical science acquired at the bedside and in books. In the rational process the patient is thoroughly and systematically examined a capite a d calcem. The critical Faculty allows separation of t h e essential from the non-essential symptoms. Every s y m p t o m detected is considered in the frame of all others, and its diagnostic significance assessed. Later, the diagnostic significance of the combination is assessed. Like an architect the clinician builds his diagnosis stone by stone into a harmonious whole. Here, also, a certain intuition intervenes, filling the gaps and vitalizing, accelerating the whole process, but the analytical process remains the safest method of diagnosis. In the intuitional process the impressions received from the patient are more rapid and more complete (intuition being bound up with impressionability) the critique and syllogism occur deeply in the subconscious more rapidly and more dynamically. Gaps are quickly filled. The result emerges into conscience as a sudden inspiration. I n other cases this process consists in comparison of the picture shown by the patient with other disease pictures that are in the subconscious but emerge rapidly. The basis in this process is a great memory of disease pictures and of combinations of symptoms. W h a t causes, however, that the clinician selects from all those memories, those few that shall be compared with the disease picture he has before him, is a mystery. It is probable that m a n y comparisons and rejections are made subconsciously, or that compartments in the Subconscious exist and the clinician knows subconsciously, immediately, which compartment he has to open. Such intuitiQnal diagnoses are given to clinicians of long study, rich experience and great artistic ability. However, in general, even such clinicians control their results by studying the patient more analytieMly. A fine example of such an intuitionM disease determination is told in the biography of Oppolzer. A young patient was brought to the clinic and for two days the assistants studied him without reaching a diagnosis. Oppolzer saw him and said that it was a ease of dysentery and that he would die in a few days. The patient had at that time no diarrhcea, but he developed, after twenty-four hours, a distinct picture of dysentery, confirmed by necropsy. On being asked by the assistants how he came to that wonderful diagnosis he said that he had seen similar cases of dysentery in the prodromie stage in a dysenteric epidemic in Prague, and he got from them the same impression he obtained from this patient. (b) Disease individualization consists in determining the individnal features t h a t the disease, pneumonia, gastric ulcer, anxiety neurosis show i n our particular patient, Smith or Brown. I t is built on the exploration of all organs and systems, of the general condition of nutrition, of the psychological reactions; Hippocrates does not speak of pneumonia or of dysentery or of any other disease in the singular. He writes the pneumonias, the dysenteries. He thus indicates that diseases have individuM features according to patients. Sir William Gull spoke in the s~me spirit of a typhoid man, of a pneumonic man. In every patient the " disease " as listed in our nosographies shows special features in the individual patient considered, and these should be determined. 9 The disease individualizations should not be confused with the diagnosis of the person. Disease individualization is the answer to the question, what particular features the disease pneumonia or neurasthenia shows in our individual patient ? The diagnosis of the person is the answer to the question, what kind of a man is our patient who has a pneumonia or a neurasthenia,
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thus independently of his actual disease. There is, unfortunately,' much confusion between these two things. I have diagnosed pneumonia, Bright's disease, duodenal ulcer or anxiety neurosis. I shall proceed, and on_ the basis of m y complete examination I shall determine that m y patient, Smith, has a pneumonia of such and such an extension with heart involvement of such a degree, With such and such nervous or psychological reactions. I n other words,-I shall determine what is really wrong with the physiology and psychology of m y patient. Here intervenes the famous physiological thinking. I shall, also, determine what special etiological conditions have caused this disease . . . And I shall say, pneumonia or Bright's disease with such and such individual features. This art of individu.alization of the disease is the mainstay of all great clinicians. When, later, I shall have proceeded to m y diagnosis of the person, when I shall have determined what kind of a man m y patient, Smith, is, independently of his disease, m a n y of those individual peculiarities t h a t Smith shows in h i s pneumonia, Bright's disease, duodenal ulcer and anxiety neurosis will be explained: The two processes, however, should not be confused.. Constitutional Diagnosis, or Diagnosis of the Person. I have developed the technique of this constitutional diagnosis in m y Modern Therapeutics of ]nternal D,seases. To u n d e r s t a n d the constitution, the " person ", of m y patient, Smith or Brown, independently of his disease I have to investigate three things: (a) his actual psychophysical construction, (b) his development, that is the phases through which Smith or Brown has passed to reach his actual psychophysical constitution or personality--this investigation includes the hereditary investigation, and (c) his environment, because e v e r y " person " is bound up with his environment, and we cannot understand him without his environment. An individual constitution, a " person ", is three dimensional, the three dimensions being the actual Constitution (Johansen's Phaenotype), the development (from the union of the Gametes up to the moment of our investigation), and the environment. I cannot go into the details of the constitutional diagnostical procedure except to insist again t h a t thanks to endocrinology, metabolism and psychology we can place this constitutional : diagnosis on a basis as safe as that of disease diagnosis. General Course of Diagnosis. Diagnosis has been described analytically, but, in fact, all processes of diagnosis, disease diagnosis--disease determination and disease individualization--and constitutional diagnosis--actual constitutional diagnosis, developmental constitutional diagnosis, environmental constitutional diagnosis--occur more or less simultaneously. The whole process of diagnosis of the patient dccurs in three phases : a phase of initial synthesis, a second of basic analysis, a t h i r d ' o f terminal synthesis. The initial synthesis is intuitional. When a patient enters a consulting room the physician tries to penetrate into his innermost, so that he m a y contemplate him from the inside. He obtains a first impression of the whole from his patient's appearance, some fleeting signs, the way he walks, speaks, looks and from simple questions. This first initial synthesis is of the greatest importance, because we must have a view of the whole before we examine the parts and because the parts can only be considered in the light of the whole. This first "impressionistic " synthesis, however, Should not bihd us, and should be a support and not a chain. I t shall be corrected and completed with the rest of our examination but it must be there at onset. The next phase, th.at of basic analysis, is essentially rational, although the intuition intervenes to make it more rapid and to vivify it. I t is at that phase that we proceed analytically in disease determination, disease individualization, " person " determination, using the Various methods of clinical explorations and, principally at onset, the historical and the physical exploration.
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The third phase, that of the terminal synthesis, is rational and intuitional. On the basis of our analytical exploration we proceed to understand the patient as a whole, as a total reaction. Intuition completes our rational procedure. The Practice of the Internist in the Light of this New Conception of Diagnosis. Prognosis as well as treatment is based on this double diagnostical process. On account of the shortness of space I shall limit myself in the question of treatment. Disease determination may indicate to us certain so-called specific remedies, as, for example, quinine for malaria, but to apply this only on the strength of the label " malaria " is to court disaster. We have to take into consideration the individual features the disease malaria shows in our patient, Smith or Brown, and, particularly, the constitution of Smith or Brown. Smith may have the same malaria as Brown but if he is of a. different constitutional type: quinine will act differently in him as in Brown, and may even be noxious to him, whereas it m a y be curative for Brown, who, as I have said before, has the same disease, Here I must do honour to the Itahnemannian School. Notwithstanding the somewhat difftlse arrangement of the Homceopathic ~ateria 3/Iedica, the leading lines conform to the Hippocratic doctrine. Homceopathic drugs are administered on the basis of (a) the disease, (b) the individual features of the disease, (c) the constitution and, of course, the individual features of the disease, and, principally, the constitutional features of the patient are the most important leaders. A clearer rearrangement of the )/[ateria Medica so as to render these lines more evident would be welcomed. I am sensible, Mr. Chairman, of the great honour you have made me in asking me to address the Faculty of Homceopathy. -My attitude towards Homceopathy has been questioned and the term, eclecticism, has been applied to m y doctrine. I am not an eclectic, and I consider eclecticism as a cowardice of thought. Neohippocratism is a synthetic and not an eclectic process. Let me remind you of the great philosophical principle of Heraclitus, that great Greek philogopher of the fifth century B.C., translated in modern language by Hegel. Two doctrines m a y appear to be opposite, but this does not mean that the one or the other is wrong, because there are arguments for and against regarding each of these ~wo opposing doctrines. Truth lies in a third doctrine which unites on a higher plane these two opposite doctrines. We cannot stop at a one-sided doctrine. The mind is driven forward to even wider and more comprehensions of truth. The combination of two partial doctrines and a third is the dialectic " Triad " of Hegel. Allopathy and Homceopathy are terms that signified something in the beginning of the nineteenth century but are meaningless to-day. The principles included in these terms are united on a higher plane in the doctrine of Neohippocratism. Hippocrates wrote two thousand and four hundred years ago, " There are diseases that have to be treated by contraries and others by similars. Everything depends on the nature of the disease and of the patient." This principle is elaborated to-day through the high synthesis of Neohippocratism. I have described the art of diagnosis according to the Neohippoeratic doctrine. Now regarding treatment, everything for us depends on clinical observation. If clinical observation shows us that a remedy A is superior to all others for patients who show such and such a disease, with such and such individual disease features, with such and such constitutional features we prescribe this remedy whether it comes from th~ Homceopathic )/Iateria Medica, from the Physiological laboratory or even from popular tradition. This does not mean eclecticism but the plemaey of clinical observation and I consider that Neohippoeratism--as this has been already accepted by some French homceopaths--can give Homceopathy a new life.
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Dr. TEMPLETON recollected t h a t he h a d been indirectly responsible for Dr. Cawadias's first appearance before this Society m a n y years ago. Dr. Cawadias had been a good friend to Homceopathy in circles where it was anything but popular. The f a c t t h a t he thought there was something in Homceopathy had cpnsiderable influence in orthodox medical societies coming as it did from a physician with a European reputation. Dr. Cawadias would know t h a t he meant nothing derogatory when he suggested t h a t most of the ground he had covered in attempting a diagnosis was indeed covered b y a full Homoeopathic consultation. Where perhaps they differed was in the ultimate end, viz., treatment. Dr. Cawadias, perhaps spread his net wider than the average homceopath (that might indeed, be an advantage) and one knew t h a t he did use potencies where he thought them indicated but one would like to know why and when he chose to treat b y the law of similars and when b y other means. Dr. CAWADIAS, in thanking Dr. Templeton for his kind appreciation, said there had been misconception in regard to his lecture at the Wellcome Institute. He had merely said at t h a t time that the empiricists who were disciples of Hippocrates were those who preceded H a h n e m a n n in their evaluation of symptoms, and in t h a t connection he spoke from the historical standpoint. He regarded H a h n e m a n n as a great m a n in the history of medicine. I t was necessary to ask what led to H a h n e m a n n and what followed after Hahnemann. The principles he had put forward in his address were those which m a n y members of the Faculty already accepted regarding constitutional diagnosis ; they dated even from the time of Hippocrates which was, again, a matter of history. One of the great merits of H a h n e m a n n was t h a t he took medicine and developed only one part of Hippocratic medicine, and in so doing he was absolutely right. In fact, in the days when H a h n e m a n n lived, all diagnosis was centred on disease determination: the physicians made a diagnosis of disease and that was all. Hahenmann had had to fight hard for his tenets: It was said in his time that Vienna was the great medical centre of the world ; that there everything possible was done for the patient. People were told that if they were fll they should go to Vienna for treatment because there they would find everything necessary for their recovery: they would be diagnosed by Skoda, and autopsied by Kokitansky. That was why one had to examine the matter historically. Admittedly, by going too much against the practice of the time Hahnemann overstepped the mark on the other side. Me rather over-emphasized the necessity for constitutional diagnosis though that was really all to the good because as a result he developed constitutional diagnosis and therefore, again, one had to regard the matter from the historical point of view. Dr. Cawadias did not subscribe to ~the dogma that every new discovery in science was a new name for a discovery of the Hellenic thinker; all the same the principles which he had enunciated had been laid down at that time and developed later on. That was why he agreed so much with what the homceopaths taught; he believed in the old conception-the diagnosis of Hippocrates, the disease determination, disease individualization and person determination, Hippocrates never spoke of " the pneumonia " but of " the pneumonias ", showing that he believed every type had different features. As to his personal determination, one had only to read his observations on epidemics, to consider his descriptions of the persons to whom he spoke. For instance, a black-haired woman with jet-black eyes who was living near the market, and so on. I)r. Cawadias thought that in regard to actual treatment he had been sufficiently clear though he had not had time to discuss the whole treatment. Nevertheless, he had insisted on the fact that the personal determination, the constitutional diagnosis, provided an indication of the method of treatment of any patient. He recalled that when assistant physician in Paris he was
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studying chronic rheumatism. He had a patient who was so terribly deformed as to be incapable of doing anything, and that condition had prevailed for a number, of years. One day a queer looking but distinguished Paris physician had called on him and had said : " I hear that you are interested in the disturbance of metabolism~. Do you realize that in the endocrine glands we have a method of changing the metabolism of the individual ? W h y not t r y this on your patient--apply endocrine therapy and thus correct the metabolic disturbance." That was m a n y years ago. He had given the patient thyroid on the basis of the constitutional diagnosis of hypothyroidism and the man got on brilliantly. Actually that was what members of the Faculty were now doing with their constitutional remedies. The complete method of diagnosis had given indication of the complete method of t r e a t m e n t . If he h a d an indication from the disease, he used that indication because it was the outcome clinical experience. Dr. FRASER KERR, in adding his appreciation of the extremely interesting and helpful address, said he had been particularly impressed b y Dr. Cawadias's suggestion that 95 per cent. of determination of constitution occurred during the p~riod of pregnancy. This is a wonderful commentary on the Homceopath's contention that treatment during pregnancy is the most important work we do. He had been :fortunate in looking after pregnant women not merely in saving the patients trouble, but also in seeing the h a p p y results in their children. He was reminded of one case that dated before he was a homceopath. The patient had repeated h~emorrhages ; a consultant advised removal to hospital if this could not be stopped. Rest was not sufficient, but he noticed that the patient's elder child was a poor little monkey, definitely sub-thyroidic. Thyroid extract given to the mother stopped the bleeding and all went well. He had found thyroid, by the way, a dangerous drug to give during the menstrual periods as he had twice been forced to the conclusion that it had caused flooding. Another and recent case had been fairly simple and short in tha~ it took only about ten days from beginning to end. The patient came with a red swelling round the corner of her mouth. The doctor she had seen had been unable t o do anything because there was not sufficient diagnosis. But t o the homceopath there was a very red, hot swelling of the right cheek and half of the lip with throbbing, worse at night (or lying down) and worse warmth ; he could say red swelling very like belladonna " and that cured in two days. (The doses were 200 at once and 1 m. twelve hours later.) Dr. LEDERlV[ANNconsidered that when Dr. Cawadias spoke of the hormone gland he had in mind certain individual glands. When speaking of hormones was it not true to say that every cell in the body produced some form of what one might call a hormone ? One could surely think of e v e r y cell in the body as a hormone-producing unit ? The speaker added that he had been reading a~book by Asehner who had practised in Austria and was now in the United States of America. He had written about constitutional medicine and used the methods which were known as pre-scientific, purging, blood-letting, vomiting, increasing the menstrual flow, etc., not using endocrinology or other modern drug treatment. He is guided by the principles of humoral pathology. Was there any evidence in the history of medicine to show whether the results thus obtained were definitely as good as those obtained by modern endocrinology ? Dr. CAWADIAS,in reply to the first question, said it was true that all cells of the body secreted enzymes ; there were various degrees of secretion. There were enzymes that were intracellular ; others which were extracellular and also hormones which went much further, and there was union between all. Borden, who was one of the pioneers of endocrinology and was a physician at Montpelier at the end of the eighteenth century, had followed the Hippocratic: tradition. He said that the cells of the body secreted certain substances which "
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went into the blood and regulated the whole body. All cells secreted certain chemical substances; certain cells secreted more than others. There were some cells that secreted hormones, but they were isolated cells. Other cells accumulated together and made, as it were, diffuse endocrine organs. There were also the interstitial gland cells which were also rather diffused. At some other time other cells coalesced and made more complete glands. That was why he did not accept the endocrinology of the five or six glands of destiny. He considered that the endocrine function was something more than a chain of five glands. He knew Aschner and had not only been in correspondence with him but had often met and discussed the subject with him, the last occasion being at the Congress on Constitutional Medicine and Endocrinology held in Italy. Aschner had very fine ideas but he seemed to have stopped short somewhere ; he had done excellent work in endocrinology; in fact he ought to be more widely known in that connection. He had, however, stopped short in that regard and had gone on with his old constitutional methods by means of which he had obtained some very good results. He had once asked Aschner if he wanted to go on to constitutional medicine, why did he not go in for the Homceopathie Materia Medics, and Aschner had replied that h e could deal by his methods with his patients and that if there was nothing he could do then he could send them i o a Homceopath. Mr. POWER felt that Dr. Cawadias had been concerned during the course of his address rather more with functional or very early disease than with late disease. Would Dr. Cawadias agree that the later the disease the more stereotyped the treatment became ? In fact, with late organic disease it seemed that it was the disease which mattered and not the individual. Dr. TEMPLETON : And the surgeon and not the ]ohysieian ! Dr. CAWADIASthought this applied to all diseases, even the most serious. I n every disease it was 9 by acting on the constitutional factor to do something very big. If a lesion was very advanced it was not possible to do that although it was possible to help by acting on the constitutional phasel I t was interesting from that point of view to bear in mind the differences between organic diseases. In the case of gastric9 ulcers it might be said that 9 mortality was 5 per cent. or 10 per cent. but he was not interested in that ; he was interested to know what were the features of disease individualization and what was the constitution of the patient which would cause the one with the gastric ulcer either to die or to survive. That was the important factor. 9 In dealing with serious organic disease it was necessary to have regard to disease determination, the disease individualization and the personal determination. He had had a ease of Graves' disease and was against operation though a surgeon friend had assured him that the disease would more quickly be dealt with by surgical means ; that it was an operation with only 1 per cent. mortality. Personally, it was a matter of indifference to him whether the mortality from the operation was 99 per cent. or 1 per cent. ; his patient might be that 1 per cent. He preferred in such cases to know which were the disease individual features and the special features that would make clear whether a particular patient needed a certain medicine or an operation, or whether the patient would survive or die. That applied also to the organic disease, and even more so. Sir JOH~ WEII~ was glad that Mr. Power had raised that point because it was at the root of the whole problem. W h y did one find so many remedies in cases of gastric ulcer ? Firstly, there was the disease, then individualization, then the personality. To whom would one give Phosphorus ? Therein lay the dependence on the personality of the individual. He had seen a patient with a very large duodenal ulcer which showed by X-rays and so on, but in that case it had not been possible for him to decide on the remedy until he had arrived at the man's personality, which was Phosphorus, and as soon as
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that treatment commenced the patient had had no pain for months past. In conclusion, Sir John thanked Dr. Cawadias for coming to give his address. He had been a good friend to homceopathy and a great help to the speaker in 1932 when the Centenary of the British Medical Association took place and Dr. Cawadias gave a paper. He had also lectured to the Royal Society of Medicine. Personally, he would never forget the night when Dr. Cawadias had befriended him and backed him up. In spite of the fact that Dr. Cawadias went in for so m a n y deep things he always came back with a good word for homceopathy. That encourage d the members of the Faculty to carry on in a simple way and by so doing to get results which were just as good as those obtained by anybody else. Dr. MCCaA~ also wished to- thank Dr. Cawadias for his excellent address. He had stated that once he had made his diagnosis he knew what world to send his patient out into. There was good reason for that statement. When travelling in any part of the world one seemed to come across Dr. Cawadias. The speaker had moved about the Continent before the war and whether it was on a boat crossing the Channel or in Paris or Budapest or elsewhere he met Dr. Cawadias. Therefore, he knew where best to send his patients in order that they might be completely restored to health ! Also in his great travels Dr. Cawadias had learned m a n y interesting facts. Although he had not stressed his leanings it was evident that he was a skilled homceopathic practitioner. The main interest of all was his condemnation of the five glands of destiny. At the commencement of treatment one could often see quite plainly the different endocrinological tendencies. When the remedy was provided those things dissolved or disappeared entirely and then one saw one's patient and not the endocrinologieal peculiarity. Therefore, through homceopathy one eliminated the first two of Dr. Cawadias's trio and came to the third--the person. That was the aim of Dr. Cawadias's work and it corresponded to the result achieved by a good homceopathic physician. I t was interesting to follow the thoughts of such-an independent worker and learn that his deductions corresponded to our own work. The PRESDSNT felt sure that members would agree that they had listened to a most interesting address, followed by an equally interesting discussion. As Dr. Templeton had named him in association with Dr. Cawadias, the President felt he must reply to the criticism in connection with t h e alleged modern tendency to isolate a germ and base all treatment on its identification. Dr. Templeton knew very well that as a bacteriologist he personally did n o t believe in the so-called germ theory ; the theory put forward by Pasteur. He believed that the pathogenic germ was the result of-something which was known as constitutional action; in other words, the constitution determined the germ to a great extent. ~That could be qualified but on general terms he would say that the constitution determined the germ. Dr. Cawadias had drawn attention to a tendency for laboratory technique to displace the old clinical instinct. There was no doubt that the older physicians " knew the constitution ". He personally could remember as a child his grandmother using the phrase, when a new doctor came into a certain district, Oh, old Dr. - knew our constitutions." It seemed that the modern doctor did not make much attempt to know constitutions ; he wanted to know the latest drug from the drug houses. When Dr. Cawadias had cited the example of quinine in malaria the President felt it a pity that he had not come to the more modern sulpha drugs in pneumonia ' because that would have given rise to an even more interesting discussion. There was no doubt that Dr. Cawadias in his particular work had built, as it were, upon the same foundation as had.homoeopaths. I t was obvious that he conceived a vital function and his diagram had shown that if there was a break across in any one particular line there was dysfunction. "
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Dr. MeCr~e had pointed out that under homceopathic remedies it was possible to see the functional of glandular disturbance disappear. That suggested that the. glandular treatment as carried o u t by Dr. Cawadias must be very much on the same plane of bio-chemical action as that by which homceopaths presumed their remedies to act. -He personally conceived, and had put forward that view, that Hahnemann discovered and made apparent the full action not only of remedy but of the cell, and it was necessary to consider the relationship of the one to the other, and in these modern days the biochemist was considering what he called the biochemical, something which had an effect on life. Dr. Cawadias had given his point of view on endocrinology, but Hahnemaun had recognized a constitutional state and unless one could recognize the constitutional phase which Hahnemann called miasm in the patient, one was not likely to cure disease. I t was necessary to bear in mind what Dr. Cawadias had said as to the old Greek medicine in the time of Hippocrates, namely, that it was centred on health, not disease ; on health and the maintenance of health. There was now before the nation the National Health Service Act which, originally, was to be a comprehensive service for the treatment of disease, but so far little had been done to conserve health, which was really the important factor. Dr. Templeton did not seem to think that birth injuries could have much -effect. In modern days probably not, but the President said he could look back to forty years ago when he started in general practice, and could recall the treatment which was given then to women during confinement. Judging from the damage then done to the mothers he could not but come to the conclusion that there must have been some damage also done to the infants by the use of forceps. I t was gratifying to feel that that phase had passed as a result of modern teaching ; and the action taken by the public health authorities with regard to maternity work was another reason for improvement. General practitioners in certain cities had taken exception to the fact that the authorities were taking over maternity work. There was, however, a reason for that. As a result of thinking back into his own experience Dr. Paterson felt that birth injuries were possible. Coming to his own experience of homceopathic medicine with children he could also think of a number of cases in which Arnica was a routine prescription. Children came with mental defectiveness and m a n y colleagues took the attitude that there might have been a birth injury. Taking the clinical results he had seen in the Children's Hospital, it was surprising to think of the number of children who responded to that treatment. Accepting the argument that Arnica had some effect on injuries, which would be the homceopathie attitude, one might ~reasonably conclude that those children had suffered from injuries at birth. The President added that he had not at the outset of the meeting said an)~hing about the Neohippocratic attitude to medicine or Dr. Cawadias's previous papers to the Society on the subject because h e had suspected and hoped that Dr. Cawa~lias' would speak on that same subject. Members were greatly indebted to him because he had taken up- a more modern attitude to constitution and disease and the application of medicine to the treatment of disease. I n doing so Dr. Cawadias had included Hahnemann's conception of the homceopathic method of treatment. I n the name of all present Dr. Paterson heartily thanked Dr. Cawadias for his most interesting address and for the trouble he had so obviously taken to answer the questions raised during the course of the discussion. (Applause.) Dr. CAWADIASexpressed his appreciation of the thanks accorded him, and the meeting terminated.