Concepts of Health and Disease in Hahnemann
To the year 1 students (intake 2009) of the Centre for Homeopathic Education, London.
‘After I had discovered the weakness and errors of my teachers and books, I sank into a state of sorrowful indignation, which had nearly altogether disgusted me with the study of medicine.’ (S. Hahnemann, Aesculapius in the Balance, p.410)
Over the last 15 years it has been my experience that there is no better way to deepen one’s understanding of homeopathic philosophy than to read and reread the writings of Samuel Hahnemann. This article is concerned with concepts of health and disease as formulated by Hahnemann in his Organon, Chronic Diseases and some of his pre-Organon writings. A focus of this article is the productive tension which exists between Hahnemann’s theories (in particular the miasm theory and the concept of the Vital Force) and his phenomenological approach in practice. Having a good understanding of Hahnemann’s homeopathy establishes a standard by which all other, later developments in homeopathy, can be measured against. Such an approach can help to avoid confusion surrounding the different so-called ‘methodologies’.
Homeopathy as restorative art
It has become commonplace to speak of homeopathy as a science and an art. Hahnemann himself speaks of the healing art, by which he means more than just homeopathy. Some have taken this to mean that homeopathy is not just a rigorous, rational discipline (the ‘science’ part), but also a creative art where individual practitioners can freely add ideas to the already existing structure. The meaning of ‘art’ as it appears in the Organon is different. In ORG VI, 1 and 2 Hahnemann says of the ‘highest ideal of cure’ that it is to make the ‘sick healthy’ and a ‘rapid, gentle and permanent restoration of health’. Hahnemann stresses homeopathy as a restorative, not a creative art. The goal of homeopathy is to restore the patient to a previous state of health, which is at the same time the baseline for homeopathic treatment. On the one hand, that seems a fairly conservative undertaking, as it does not include any improvement of the person’s previous state of health, but simply a return to it. On the other hand, it introduces great clarity when it comes to the treatment goal, which is explicitly not to change or better the person to be treated, but simply to return that person, whatever their shortcomings, moral or otherwise, might be, to a state of capacity, which allows them to continue their life unhindered by disease. From the following passage one can see that Hahnemann does not think it is the role of the homeopath to change a person’s usual, healthy state of mind, whether that state of mind appeals to others or not:
For example, one often encounters patients with the most painful, protracted diseases, who have a mild, gentle emotional mind such that the medical art-practitioner feels impelled to bestow attention and sympathy upon them. If the physician conquers the disease and restores the patient again (which is not a rare possibility with the homeopathic mode of treatment) the physician is often astonished and startled at the dreadful alteration of the patient’s emotional mind. The physician often meets with ingratitude, hard-heartedness, deliberate malice and the most degrading, the most revolting tempers of humanity – qualities that were precisely those possessed by the patient in former, healthy days. (ORG VI, 210, footnote).
By calling the former days ‘healthy’ despite ingratitude, hard-heartedness, deliberate malice, degrading and revolting tempers, it is clear that Hahnemann was neither judging nor treating his patients according to their moral imperfections. A bad temper per se was not necessarily pathological; it only became so if that had changed with the onset or duration of the disease. For Hahnemann, health was the absence of disease, and disease the deviation from a previous state of health. No more, no less.
Knowledge of disease – what does that mean?
In ORG VI, 3 Hahnemann writes: ‘To be a genuine practitioner of the medical art, a physician must: Clearly realise what is to be cured in diseases, that is in each single case of disease’ (knowledge of disease). Disease, according to Hahnemann, can only be recognised in each individual case of disease. There is no abstract disease, but only individual cases of disease. Still, Hahnemann does not advocate ignoring conventional pathology. He just makes important distinctions as to its importance. Pathology consists of two aspects:
a) the disease label, e.g. arthritis, and b) of signs and symptoms, which in the case of pathology are called ‘pathognomic’ symptoms, e.g. pain, redness, heat, swelling, nodules, etc. The disease label is an abstraction, an interpretation; it belongs into the ‘meaning’ category. A series of individual signs and symptoms add up, in the pathology books, to the meaning ‘arthritis’. The pathognomic symptoms belong to the category of facts and data, including the felt experience of disease in an individual. Hahnemann was not at all concerned with disease names (ORG VI, 73 footnote). By themselves they have no value in homeopathic case assessment (including case analysis and prescription of remedies). However, he did think it was important to know what type or form of disease the patient suffers from, for the simple reason that individualisation of a case of disease is carried out within pre-defined parameters. These are mainly set by the existing materia medica and Hahnemann’s hypothesis that the many varied diseases can be traced back to three infections (psora, syphilis and sycosis). Already at the time of the 1st edition of the Organon (1810) (ORG I, 123; ORG II, 152) Hahnemann considered the number of well proven remedies sufficient for the ‘infinitely many disease states in nature’ ‘(thanks to the truth of the symptoms and the abundance of the disease elements that each one of the efficacious medicinal substances has shown in its impinging action on healthy bodies)’. (ORG VI, 145) If there would be no grouping of disease forms (according to miasms) or of the remedies there would indeed be the need for the strictest, self-standing individualisation, something which would make homeopathy an impossible undertaking. Hahnemann did not postulate treating every single case of disease as a free standing, peculiar disease, totally out of any context. Rather, he was looking for the peculiar form or variance of a familiar (known) and general disease species. G.H.G. Jahr compared the strictest, self-standing individualisation with declaring every single animal or plant as a peculiar animal or plant without having defined beforehand what species or family the animal or plant belongs to, e.g. whether the plant one talks about is an oak tree or a carnation, whether the animal is a donkey or a cat. Hahnemann’s miasm theory, which has an explanatory (nature of disease) and classifying function (type of disease), is an attempt to do this fact justice (see ORG VI, 103). We’ll return to the topic of miasms later.
Knowledge of disease, according to ORG VI, 3 further means to ‘recognise what is undoubtedly diseased in the patient’. Hahnemann did not want to rely on personal judgement and opinion about what has to be cured in patients. He aimed to introduce a clear standard of what ‘undoubtedly diseased’ is. It is obvious that there needs to be an agreement on what is deemed to be ‘diseased’ in order to conclude what is ‘undoubtedly diseased’. If there is no standard or agreement on this point, we will have no hope of ever agreeing what is to be cured in each individual case of disease. Has Hahnemann introduced such a standard, which we could follow? Yes, in my view, he has. In order to understand this fully, I would like to summarise some thoughts and findings by a German colleague, which will help to understand Hahnemann’s goal to be objective in what we do (‘unprejudiced observer’), despite the fact that we are mostly dealing in the medium language, which is notoriously subjective.
As C. Meinhard points out the basis of our art and science consists of two aspects: a) the pathogenetic trials (‘provings’) by which we ascertain what is curative in individual remedies and b) the relationship of similarity with an existing natural disease. Both are communicated via language, both rely on the subjective, albeit precise, expressions of patients and provers. The role of the homeopath is that of a translator who translates the language of the patient into that of the proving. What homeopaths are aiming to do is to compare the exclusively internal experiences of provers and patients, and prescribe a remedy on this thoroughly subjective foundation. All his life Hahnemann strove for more certainty in medicine. His project was to put medicine on a solid foundation. Was this his answer? Matching one subjective experience with another and arrive at a reliable remedy choice? Before we try to answer the question where we might find objectivity in this seemingly subjective set-up we need to understand Hahnemann’s views on pathology in more detail by answering the following questions: what helps us to cure, to restore health? (ORG VI, 5) and what do we perceive in diseases? (ORG VI, 6)
What is to be cured? What helps us to cure?
What we need to cure and to restore health is to ‘find out the data of the most probable occasion of an acute disease, and the most significant factors in the entire history of a protracted wasting sickness, enabling him to find out its most fundamental cause’ (a miasm). In addition to these two points the following have to be ‘taken into consideration’: The evident physical constitution; his emotional and intellectual character; his activities; his way of life and habits; his civic and domestic relationships; age; sexual function. (ORG VI, 5) The first category are data and facts, the second category provides context and ‘meaning’. Only the first category is relevant for the pharmacological part of our work: on the basis of these data and facts we prescribe the remedy. The second category is only to be ‘taken into consideration’ in order to see ‘what things in the patient’s life might tend to increase his malady, or to what extent they could favour or hinder his treatment.’ (ORG VI, 208). Unfortunately, confusion around these two categories leads in practice often to methodological confusion, where students are being taught that that which has only to be ‘taken into consideration’ is itself part of a characteristic totality of symptoms on which to base the prescription. Undue weight is then given, for example, to healthy constitutional traits, be they physical or mental, and some homeopaths even elevate the profession of a patient to an indication for a prescription. As can be clearly seen from ORG VI, 5 and ORG VI, 208, this was not the intention of Hahnemann.
ORG VI, 6 deals with what we ‘perceive in diseases’. The ‘unprejudiced observer’, he says, ‘perceives nothing in each single case of disease other than the alterations in the condition of the body and soul’. ‘Only […] the deviations from the former healthy state of the now sick patient’ are perceived. They are perceptible to the patient himself, by those around him and ‘observed by the physician’. Hahnemann contrasts this with futile ‘metaphysical speculations which are not borne out in experience.’ (ORG VI, 6) ORG VI, 7 specifies further how disease is defined in homeopathy: ‘In cases of disease where there is no obvious occasioning cause (causa occasionalis) to be removed, we can perceive nothing but the disease signs. Therefore, it must be the symptoms alone by which the disease demands and can point to the appropriate medicine for its relief, along with regard for any contingent miasm and with attention to the attendant circumstances.’ When Hahnemann speaks of ‘disease’ without qualifying it any further, e.g. indispositions or iatrogenic diseases (ORG VI, 74-77), he means the deviations from health (ultimately due to a miasm) which are expressed in a combination of signs and symptoms which are to be matched up with a combination of signs and symptoms in a remedy: ‘comparison of the complex of the natural disease’s signs with the symptom set of the available medicines.’ (ORG VI, 153) Both consist of data and facts, not opinions, interpretations or conjectures. What is to be cured ‘cannot therefore remain concealed in the unfathomable depths of obscure speculation, or be diffused throughout the boundless void of conjecture; it must be accessible, readily accessible to us, within the sphere of vision of our external and internal perception faculties.’ (The Medicine of Experience, p.439) That which ‘reveals itself to the senses in symptoms is the disease itself.’ (ORG VI, 6, footnote). Homeopathy, according to Hahnemann, only deals with concrete phenomena, ‘perceptible signs and symptoms’. What has to be elucidated in diseases are these concrete data, what is ‘undoubtedly sick’. Equally, our materia medica consists of concrete combinations of signs and symptoms. The more abstract, general, undefined the disease or proving symptoms are, the less useful they are, because of their lack of individualisation. (ORG VI, 153) In ORG VI, 21 Hahnemann writes:
Since the curative wesen in medicines is not, in itself, discernible (which no one can deny), and in pure experiments conducted with medicines [i.e. in provings] the most sharp-witted observer can perceive nothing about medicines that can constitute them as medicines, or curative means, except their power to bring forth distinct alterations in the condition of the human body, and especially their power to differently tune the healthy person in his condition and to arouse several peculiar disease symptoms in him, then it follows that when medicines act as curative means, they likewise can only bring their curative capacity into execution through this, their power to differently tune the human condition by means of engendering peculiar symptoms.
Hahnemann does not tire to stress that similarity is established on the level of concrete phenomena, never between abstract concepts, ideas or such like.
Despite this, Hahnemann employed two speculative theories, which have become for some the cornerstones of homeopathy, for others, stumbling blocks: the concept of the Vital Force and the miasm theory. Both concepts have a peculiar relationship with the sense data, the facts, and the phenomena. This will be looked at now before we return to the topic of ‘certainty’.
The Vital Force – explanation or obfuscation?
Despite Hahnemann’s protestations that nothing can be perceived in disease than signs and symptoms expressing a deviation from a former healthy state, he hypothesises that the ‘essence’ of the disease is the disturbed vital force. (ORG VI, 7) And he speaks of disease as ‘a state of being of the organism dynamically untuned by a disturbed vital force, […] an alteration in the state of health.’ (ORG VI, 8.) Why do we need the concept of the vital force when he points out that the vital force itself cannot be seen, that as humans we are not equipped to perceive the inner working of the vital force directly, but that we can only see its effects: ‘we can perceive nothing but the disease signs. Therefore, it must be the symptoms alone by which the disease demands and can point to the appropriate remedy.’ (ORG VI, 7) Does the concept of the vital force add anything to our understanding of disease? Does the concept of the vital force help us to make our prescriptions more accurate (the one thing Hahnemann aimed for all his life)?
The theory of the vital force explains why potentised remedies are needed to cure diseases. Since the pathological disturbance is a dynamic one, it needs a dynamic intervention. ‘Vital Force’ signals the immaterial nature of diseases, and why it is necessary to use immaterial substances for their treatment: ‘The physician can remove these pathological untunements (diseases) only by acting on our spirit-like vital force with medicines having equally spirit-like, dynamic effects that are perceived by the nervous sensitivity everywhere present in the organism.’ (ORG VI, 16) In his essay Spirit of the Homeopathic Doctrine of Medicine he speaks of the ‘organs of the higher rank and of the vital force.’
Further, the concept of the vital force gives Hahnemann an opportunity to separate himself from those who engage in metaphysical speculations regarding the nature of disease, as doctors as well as the so-called nature philosophers of his age did. What Hahnemann aimed to do by postulating a vital force is to give a scientific explanation of what animates and organises the material body. In ORG VI, 9 he states: ‘In the state of health the spirit-like vital force (dynamis) animating the material human organism reigns in supreme sovereignty. It maintains the sensations and activities of all the parts of the living organism in a harmony that obliges wonderment.’ What Hahnemann describes here sounds very much like the modern concept of homeostasis, of which a definition reads: ‘Metabolic equilibrium actively maintained by several complex biological mechanisms that operate via the autonomic nervous system to offset disrupting changes.’ In ORG VI, 16 Hahnmemann writes: ‘The physician can remove these pathological untunements (diseases) only by acting on our spirit-like vital force with medicines having equally spirit-like, dynamic effects that are perceived by the nervous sensitivity everywhere present in the organism.’ Looking at the following quote from a standard textbook on anatomy and physiology it is clear that Hahnemann grappled with scientific rather than metaphysical concepts: ‘Nervous tissue detects changes in a variety of conditions inside and outside the body and responds by generating nerve impulses. The nervous tissue in the brain helps to maintain homeostasis.’ (Tortora, p.104)
As always, Hahnemann chooses his words carefully. He speaks of ‘spirit-like’, denoting an invisible and immaterial, but still substantial, force. That the vital force must be real can be seen from its effects, its manifestations. It is part of what Marilynne Robinson calls the ‘finer textures of the physical’. What is the force that holds atoms together, that forms molecules, which in turn form elements? etc. Can we name that force?
Can we explain only the processes or also the force driving these processes? An analogy from science might make it clearer what Hahnemann tried to articulate: This is what it says in a modern textbook on anatomy and physiology: ‘To synthesise proteins, the information encoded in a region of DNA is first transcribed (copied) to produce a specific molecule of RNA (ribonucleic acid). Then the information contained in RNA is translated into a corresponding sequence of amino acids that forms a protein molecule.’ (p. 86-87) What is the ‘information’? Where does it come from? Where is it ‘made’, ‘produced’? It seems our knowledge starts when the ‘information’ becomes manifest. However, the ‘information’ is obviously real. Science glosses over the fact that we do not actually know what this ‘information’ is. It ‘explains’ it by its material manifestations, although these are the products of this mysterious ‘information’. Hahnemann was more honest by stating the existence of the vital force (by logical deduction), but at the same time drawing a line by saying that we cannot qualify it any further. All we know is that it must exist because it clearly manifests in the physical. Another passage in the same book reads: ‘During transcription, which occurs inside the nucleus, the genetic information represented by the sequence of base triplets in DNA serves as a template for copying the information into a complementary sequence of codons in a strand of DNA.’
The base triplets are not the ‘information’ itself, they represent it. What, then is the ‘information’? By the same token, the physical manifestations (disease phenomena) represent the Vital Force, which itself remains invisible. ‘Being invisible, and recognisable solely by its effects on the organism, it can express itself and reveal its untunement only by pathological manifestations in feeling and function (the only aspects of the organism accessible to the senses of the observer and the physician), i.e. disease symptoms.’ (ORG VI, 11) Science is brilliant at describing and elucidating processes, classifying sense data, etc., but it cannot say what things really are. For that matter, no mode of knowledge can. Hahnemann is fully aware that we can only make statements with some certainty when it comes to sense data, appearances, and perceptible phenomena. However, he does not make the mistake to deny the existence of the ‘finer textures of the physical.’
Still, is it logical to say that the Vital Force is the originator of the disease manifestation just as the ‘information’ is the originator of a specific RNA molecule, which in turn becomes an amino acid, then a protein etc.? Why not?
From this one can see that Hahnemann was a thoroughly modern thinker, who anticipated current scientific concepts dealing with the dual nature of reality as energetic and material. However, Hahnemann did not separate one from the other, energy from matter, but understood them as one and the same, one (matter) the expression of the other (energy), just as the aforementioned base triplets are the expression of the ‘information’. Hahnemann had a non-dualistic view of reality. For him there was no hidden reality, no deeper layers of reality or some such things. ‘In the invisible interior of the body, the suffering of the pathologically untuned spirit-like dynamis (vital force) animating the organism and the totality of perceptible symptoms that result and that represent the disease are one and the same.’ (ORG VI, 15)
There is no dualism of spirit and matter or even mind and matter: ‘Almost all so-called mental and emotional diseases are nothing other than somatic diseases in which the symptoms of mental and emotional mistunement that is peculiar to each disease heightens itself as the somatic symptoms diminish […]’ (see ORG VI, 215). Vital Force and physical manifestations of vital force are one and the same.
The philosophical framework of Hahnemann informs homeopathic practice directly: The only indications for diseases are: Totality of symptoms (and the accompanying circumstances are to be taken into consideration for case management ORG VI, 5). (ORG VI, 15) Despite the fact that Hahnemann introduces theoretical concepts he always returns to the concrete, the facts, the data when it comes to the type of information we need in daily practice, which begs the question what the role of the miasms is.
Role of the miasms
The miasms are Hahnemann’s second great speculative theory. Whereas the Vital Force may well be vindicated as a theoretical concept with explanatory power, the miasms have less of a chance of surviving new medical insights. With the psora theory Hahnemann tried to explain the multi-faceted nature of so many disease forms which have ultimately one origin, and he introduced with it the concept of ‘diathesis’, the predisposition of individuals to certain diseases. He strictly adhered to a model of infectious diseases (primary infection not properly treated leads to latent or secondary psora with all its problematic sequelae. They develop chronic character and undermine the health gradually). His best available example (and analogy for psora) was syphilis. He modelled psora on this disease process. (A good modern example is borreliosis, Lyme disease). We now know that we cannot say that all chronic diseases are due to an original infection (some are, of course, e.g. a whole host of viral and bacterial diseases). Apart from explaining the origin of diseases Hahnemann intended to use the miasms as a classification tool (the latter is the much more common use of the miasms these days). He did not go as far as his successors by trying to classify symptoms according to miasms (e.g. Allen, Ortega, etc.), since 7/8th of all disease forms and symptoms were due to psora anyway, according to Hahnemann. Nor did he mean to characterise the nature of the disease processes, as is customary these days, e.g. psora represents an underfunctioning, sycosis overproduction, syphilis destruction, etc. However, the classification was clinically important to him, because once a miasm was identified it indicated a chronic disease process. This was relevant in practice with reference to case taking (the case had to be taken very comprehensively, going into the smallest details – ORG VI, 86, 89 and 90) and remedy prescription (Hahnemann would choose remedies from the stock of anti-psoric remedies as presented in Chronic Diseases). But beyond that the task of the homeopath was exactly the same as if the discovery of the miasms had never taken place: each case of disease had still to be rigorously individualised. The identification of the miasm did not add a dimension to the symptomatology as such. Not, at least, according to Hahnemann:
With the discovery of psora, that great source of chronic diseases, and with the finding of more specific homeopathic remedies for psora, the medical art has come some steps closer to the nature of the majority of diseases to be cured. Even so, the homeopathic physician’s duty to carefully apprehend the investigable symptoms and peculiarities of diseases remains just as indispensable as before, for the formation of the indicator for each chronic (psoric) disease to be cured. No genuine cure of the psoric diseases, or any of the remaining diseases, can take place without the strict individualised treatment of each case of disease. (ORG VI, 82)
The need for strict individualisation includes the demand of finding the remedies through the study of the sources, not by taking short-cuts via repertories.
With the great conscientiousness which should be shown in the restoration of a human life endangered by sickness more than in anything else, the Homoeopath, if he would act in a manner worthy of his calling, should investigate first the whole state of the patient, the internal cause as far as it is remembered, and the cause of the continuance of the ailment, his mode of life, his quality as to mind, soul and body, together with all his symptoms (see directions in Organon), and then he should carefully find out in the work on Chronic Diseases as well as in the work on Materia Medica Pura a remedy covering in similarity, as far as possible, all the moments, or at least the most striking and peculiar ones, with its own peculiar symptoms; and for this purpose he should not be satisfied with any of the existing repertories, -a carelessness only too frequent, for these books are only intended to give light hints as to one or another remedy that might be selected, but they can never dispense him from making the research at the first fountain heads. (CD, 121)
Although Hahnemann speaks of ‘specific remedies’ for the treatment of chronic diseases, this does not imply a dispensation from strict individualisation, which for Hahnemann always involves the study of the provings: ‘The search for the remedy that is homeopathically the most suitable, in all regards, for a given disease state is a laborious, occasionally a very laborious, pursuit. While there are praiseworthy books for facilitating this process [i.e. repertories and materia medica] it is still necessary to study the sources themselves [i.e. reports of provings].’ (ORG VI, 148, footnote)
Certainty and the logic of homeopathy
This brings us back to the topic of how we can achieve any certainty in prescribing homeopathic remedies. It was mentioned above that the undertaking of finding a remedy rests on two subjective factors: the report of the patient and the reports of the provers, which are to be matched in order to find the most similar remedy. As C.Meinhard pointed out the report of the patient remains inevitably subjective, we have no way of assessing its veracity. The patient simply has to be believed. On the other hand, the process of provings allows us to introduce objective standards to tone down the potential subjectivity. In provings it is the frequency with which a sign/symptoms or a combination of signs and symptoms appears. The more often these appear in different provers the less likely it has its origin in the imagination of the prover. Hahnemann’s footnotes to Ignatia in Materia Medica Pura point to that fact. That this process is precarious there is no doubt, since provings are often based on just a few provers. On the other hand, clinical confirmation of these few symptoms strengthens the degree of objectivity. And it should not be forgotten that Hahnemann undertook repeated provings for individual remedies, which over time, revealed the full extent of the objective combinations of signs and symptoms.