C.P. BRYANT, M.D.
By way of introduction, I would like to state that this article is really a review of two books, one entitled Constitution and Disease by Julius Bauer, Professor of Physical Medicine, College of Medical Evangelists, Los Angeles, California, formerly Professor of Medicine, University of Vienna; and the book entitled Man, The Unknown by Alexis Carrel, M.D., who in 1939 concluded 33 years of brilliant biological research at the Rockefeller Institute. He perfected the surgical technique which made blood transfusion easy and he kept a section of chicken heart alive for a quarter-century. Dr. Carrel, also, won the Nordhoff-Jung medal for cancer research and the Nobel Prize for success in suturing blood vessels.
What is Individual Constitution?.
Many authorities define it as the total biological make-up of an individual. Constitution is not a physical entity but is a panel and plan of the total set-up of the individual personality. Constitution comprises physical and mental traits, visible and invisible characteristics, which may or may not be detectable by all or any of the various methods of physical examination and laboratory work. Constitution is therefore not a measurable entity.
What is Constitutional Pathology and its Significance to. Medical Practice?.
Constitutional pathology is concerned with all problems arising from the abnormal constitution. All structural or functional phenomena encountered in medicine which result from the presence of one or more abnormal genes belong to the realm of constitutional pathology.
The individual peculiarities of a person are often of greater importance than the number of pounds he may weigh. Hence strict adherence to pharmacological rules without allowance for individual peculiarities may have undesirable, and even disastrous, consequences.
Many years ago, a man of about 45 who had developed agranulocytosis with a septic sore throat was studied in the Polyclinic Hospital in Vienna. The arsenical “stovarsol” was administered to the patient and he recovered. Today, after about 15 years, I am inclined to believe that he recovered in spite of, rather than because of, this treatment. The man regained complete health and working capacity but his leucocyte count remained constantly at a level of about 4,000.
In the following years he was twice readmitted to the hospital with severe broncho- pneumonia, and on each occasion had a severe agranulocytopenia, of about 1,500 leucocytes. The actual cause of the condition in this case was not a specific germ, or a specific drug, but a specific constitutional pre-disposition to exhaustibility of the bone marrow in its function of supplying the organism with the necessary amount of granulocytes. Such a bone marrow may become exhausted either due to the strain imposed by a bacterial infection, or due to the slightly toxic action of certain drugs.
Intelligent study of diseases from the genetic standpoint is, therefore, the only method of detecting the constitutional biological inferiority. The results of such a study, however, are just as cogent as conclusions drawn from laboratory experiments.
Bones and Joints.
In 1914 an interesting family history was reported in the J.A.M.A. by Ransohoff. A 68-year-old woman dies from a sarcoma of the femur. Her younger son dies from the same disease at 48. The elder son develops a generalized severe Pagets disease (osteitis deformans) at 50, which eventually prevents him from walking. His daughter at the age of 6 months suffers a spontaneous fracture of the tibia that shows no tendency to heal. Later the fibula is found to be fractured as well. At the age of 13, the leg is more than 3 inches shorter than the other, and at 16 an amputation of the leg has to be performed on account of severe pain and trophic changes.
The author is inclined to assume imperfect osteogenesis as cause of the puzzling condition and concludes his report as follows: “I am safe in saying that in all these cases bone tissue was by heredity a locus minoris resistentiae, a phrase little used during the last decades in which the bacteriologists pushed aside our theories of the causes of disease. But for many things we are forced to fall back on heredity”.
The only thing we know about the etiology of psoriasis is its hereditary occurrence. That all kinds of polyarthritis are frequently found in several members of a family is well known to experienced physicians. An observation published by Marinesco and Allende illustrates this fact in a particularly instructive way. Two brothers and one sister all developed, in the first years of their childhood, a deformative type of infectious chronic poly- arthritis.
There is no doubt that the joints were a constitutionally weak point in this family and were therefore highly disposed to bacterial infectious. Thus the psoriatic arthritis should be interpreted as a manifestation of combined abnormality of two genes, one accounting for the psoriasis, the other for the constitutional predisposition of the joints to various types of diseases. Whether or not a linkage of these two genes must be assumed is open to discussion.
About 2,500 years ago, Hippocrates distinguished a long thin and a short thick type of human being.
The longitudinal type has been termed as follows: habitus longilineus, slender, linear, leptosome, sthenoplastic, hypotonic, microsplanchnic, hypo-vegetative, hyperontomorph, ectomorphic, asthenic, phthisis type.
The lateral type has also been called habitus brevilineus or quadrants, eurysome, euryplastic, hypertonic, megalosplanchnic, hypervegetative, hypo-ontomorph, endomorphic, hypersthenic, pyknic, plethoric, arthritic, apoplectic type.
There are, of course, no sharp borderlines between those two types and the intermediate average which may be termed normotype, and which has also been called mesoplastic, normosplanchnic, meso-ontomorph or mesomorphic.
It is strange, indeed, that there are leading physicians today who deny inheritability of cancer or, to be more precise, of cancer predisposition. Only ignorance of the principles of genetics accounts for the fact that inheritance, at best, is granted a role in a few exceptional cases of malignancy, whereas it is denied for cancer at large. Tremendous material has been accumulated, both from breeding experiments in laboratories and from clinical observations in man, that inheritable susceptibility to cancer is no longer a matter of belief, but a matter of fact.
If both parents are afflicted with carcinoma of the same organ, from 50 to 100 per cent of their children are victims of the same disease.
If both parents suffer from cancer of different organs, the chances for the offspring are infinitely more favorable, in fact they are not much worse than if only one parent had been afflicted with cancer.
Identical (uni-ovular) twins tend to suffer from the same type of tumor. There is a large body of material available in the literature pertaining to this problem.
It has just been mentioned that both extrinsic and intrinsic etiologic factors other than the two abnormal genes may cooperate in the etiology of tumors.
Principles of Treatment.
If constitution comprises all traits and characteristics of an individual that are potentially determined at the moment of fertilization, if constitutional pathology is no more than the pathology of genes, what then is the practical value of studying constitution, since there are no means to influence chromosomes and genes by therapeutics measure? The ultimate aim of medicine is successful treatment of ailments. If ailments are caused, entirely or partially, by abnormal genes, and if there is no hope of mastering those genes, of what use is constitutional pathology to physicians? Does it not hamper rather than enhance our therapeutic attempts, does it not create fruitless pessimism and therapeutic nihilism? Such criticism is frequently heard from those who practice medicine as a craft, and not as a science and art.
Whatever the consequences may be, medical science must discover the facts. We have to face the truth and nothing but the truth, whatever the therapeutic prospects resulting from it may be. Furthermore, the medical student must be familiar with all facts pertinent to the understanding of human nature and human disease, whether or not these facts have any direct bearing on treatment. Many facts taught and included in the preclinical curriculum have no such relationship.
Various branches of physiotherapy, intelligent and sympathetic psychotherapy, are available to relieve the complaints of constitutional neuropaths.
Body and Physiological Activities.
“Man cannot be separated into parts. He would cease to exist if his organs were isolated from one another. His aspects are the heterogeneous manifestations of his unity to our sense organs.” [Alexis Carrel, M.D., in Man, The Unknown].
Let us suppose that our subject receives bad news. The psychological event may express itself simultaneously by moral suffering, nervous agitation, circulatory disturbances, lesions of the skin, physico-chemical modifications of the blood, etc.
It is impossible for a specialist, actively engaged in the pursuit of his own task, to understand the human being as a whole.
The vast cellular associations called viscera are placed, as we know, under the command of a single nervous center. This center sends its silent orders to every region of the organic world. In this way, heart, blood vessels, lungs, digestive apparatus, and endocrine glands become a functional whole in which all organic individualities blend.
In short the body is an anatomical heterogeneity and a physiological homogeneity. It acts as if it were simple. But it shows us a complex structure. Such an antithesis is created by our mind. We always delight in picturing man as being constructed like one of our machines.
Disease consists of a functional and structural disorder. No disturbance remains strictly confined to a single organ. Only those who know man both in his parts and in his entirety, simultaneously under his anatomical, physiological, and mental aspects, are capable of understanding him when he is sick.
Infectious, or microbian, diseases, are caused by viruses or bacteria. They produce infantile paralysis, grippe, encephalitis lethargica, and perhaps cancer.
The years of life which we have gained by the suppression of diphtheria, smallpox, typhoid fever, etc., are paid for by the long sufferings, and the lingering deaths caused by chronic affections, and especially by cancer, diabetes, and heart disease. In addition, man is liable, as he was in former times, to chronic nephritis, brain tumors, arterial sclerosis, syphilis, cerebral haemorrhages, hypertension, and also to the intellectual, moral, and physiological decay determined by these maladies. Although modern hygiene has made human existence far safer, longer, and more pleasant, diseases have not been mastered. They have simply changed in nature.
A man of forty-five has no more chance of dying at the age of eighty years now than in the last century.
This failure of hygiene and medicine is a strange fact. Inspite of the progress achieved in the heating, ventilation and lighting of houses, of dietary hygiene, bathrooms, and sports, of periodical medical examinations, and increasing numbers of medical specialists, not even one day has been added to the span of human life.
We have already mentioned that physiological time is a flux of irreversible changes of the tissues and humors.
The leucocytes multiply, secrete new substances. They form abscesses in the infected regions, and the ferments contained in the pus of the abscesses digest the microbes. These ferments also possess the power of dissolving living tissues. They thus open a way for the abscess, either toward the skin or some hollow organ. In this manner, pus is eliminated from the body. The symptoms of bacterial diseases express the effort made by tissues and humors to adapt themselves to the new conditions, to resist them, and to return to a normal state.
The Remaking of Man.
Medicine cannot give to man the kind of health he needs without taking into consideration his true nature. We have learned that organs, humors, and mind are one, that they are the result of hereditary tendencies, of the conditions of development, of the chemical, physical, physiological and mental factors of the environment. We must help this whole perform its functions efficiently rather than intervene ourselves in the work of each organ. Some individuals are immune to infections and degenerative disease, and to the decay of senescence. We have to learn their secret. It is the knowledge of the inner mechanisms responsible for such endurance that we must acquire.
The marvelous success of hygiene in the fight against infectious diseases and great epidemics allows biological research to turn its attention partly from bacteria and viruses to physiological and mental processes.
It is evident that the trend of medicine today is toward the teachings of Samuel Hahnemann, which demonstrates conclusively that all therapy must follow the law of similia. The human body is a unit, and cannot be divided into single parts for therapy. This, also, has been demonstrated by J.E.R. Mac Donagh in the book entitled The Universe Through Medicine.