Chapter 12

The universal cause of illness

1963. Let us look now at medical practice, from which I have learnt so much. All systems of medical practice which have appeared so far have perhaps contained some luminous idea; their shortcomings have basically been due to some forgotten part of truth. Some doctors seem to have considered only that class of disease processes by which nature restores the animal to health; they greatly extolled the (*) [autocracy] of nature. The idea was excellent. No one can deny that certain phenomena of sickness tend to the restoration of health: certain haemorrhages, diarrhoeas, fevers are sick nature's effort to restore itself by means of actions which, although apparently leading to disease, restore health. The school of Montpellier became famous for this. Pinel calls such ideas, held by Van Helmont and Stahl, 'healthy and fruitful'.(72)

1964. But we must not forget the existence of another series of movements and sense-experiences which follow a cyclic path and cause the deterioration and even the destruction of the animal. There are certainly disease processes which lead the animal from one state to another and finally cause its death. However, those doctors who had been deeply struck by this fact did not pay equal attention to the first. Consequently one group was ready to leave everything to nature, the other thought skill alone was necessary. In Stahl's system nature tends to a state of health, while nature's errors remain without any satisfactory explanation. In the opposing system, the errors of nature are at least acknowledged if not explained; on the other hand the reparative and health-restoring tendency of nature remains unrecognised and therefore unexplained. I have said that there is only one natural law which explains both the health-giving process and the fateful process of animal nature: both processes are the work of the life and sensuous instincts. These instincts, with their ceaseless alternating action and mutual modification, would of their nature always tend towards good if they were independent of material, foreign stimuli, which alter them, disturb them and upset their natural harmony.

1965. Consequently the causes of all illnesses can be reduced to one, IRRITATION, understood in its widest sense.

1966. By irritation, I mean the effect of a force, foreign to feeling and animal instinct, which acts on them, changes the normal state of the instinct and causes an alternating action in its two modes of operation (the life mode and sensuous mode). This alternating action, in itself diseased, is conducive in its outcome either to health - granted that the instinct frees itself from the irritation - or to death.

1967. The first effect of the foreign stimulus and of its consequent irritation takes place in the life instinct which tends to produce a normal feeling, in itself pleasant, but when opposed produces a painful or troublesome, abnormal feeling.

1968. The second effect takes place in the sensuous instinct which when aroused by an abnormal feeling, increases and changes the quantity of the body's motion. These increased, changed and abnormal movements provide matter for new, abnormal sense-experiences, which themselves produce new movements.

1969. This course of alternating action, once begun, can take on two qualities:
1. It can cease when the stimulus ceases. This happens whenever the stimulus does not alter the matter of the life instinct but simply gives the instinct greater activity and excitation, or when it alters the matter but in such a way that the sense-experiences produced by the stimulus induce the sensuous instinct to cause movements whose effect is to restore the thing to its pristine state. Here the movements restore to the life instinct the matter suitable to it which had been altered by the stimulus.

1970. 2. It can continue even when the stimulus ceases. This undoubtedly happens if the movements of the sensuous instinct following the painful sense-experiences of the life instinct cause greater change by arousing new stimuli without restoring and reforming the changed matter of the life instinct. The parts and molecules of the living body, displaced or shifted by a certain impetus, become a new stimulus, a truly foreign stimulus, because they are matter opposing the life instinct. The course of alterations and internal sequences in the animal now continues independently of the primal stimulus; all the actions resulting from the modifications of the life and sensuous instincts reproduce a new range of irritant stimuli. The result is the diseased state which modern doctors have called diathesis.

1971. These two qualities of the alternating course of sense-experiences and movements, the first of which has short duration as one of its principal characteristics, and the second longer duration, were very carefully observed by modern doctors. But their observation was almost exclusively limited to the fact of inflammation. I will take a passage from Tommasini, to whom Italian medicine owes so much, which will allow me to add a helpful observation:

When excessive stimulus did not produce inflammation, the effects in the dynamic state of the stimulated fibres were, as we saw, proportionate to the degree of the stimulus itself. The resultant diseased excitation and increased movement were also seen to be proportionate to the stimulus. Consequently, as the stimulus diminished, the excitation and movement diminished; and when the stimulus ceased or was corrected by the appropriate action of contrary agents, the excitation and movement quickly faded away. Excessive heat, dryness of skin, feverish movement of the heart and arteries, intense absorption by the lymphatic vessels, thirst, ruddiness of face, swelling of the cerebral veins and headache produced by too much sun or too much haste, are all easily dissipated by rest, withdrawal of the source of heat and the application of antiphlogistic and counter-stimulant drinks. Similarly, drunkenness caused by the abuse of wine and liquor ceases when the action of the transitory stimuli ceases or is dispersed; the condition is also corrected by prompt administration of iced drinks, tartar emetic or cherry laurel. Up to this point, the excess, moderation or lack of excitation correspond exactly to the abuse of sobriety and to the privations, calculated relative to the subject's individual susceptibility and habits. At this level therefore the entire code and therapeutic apparatus of medicine would consist in the universal norms of moderation and appropriateness.(73)

This is a description of the short-duration course. The professor now passes to what I call the long-duration course of sense-experiences and alternate movements. But as soon as an acute or chronic, serious or mild inflammation appears, there is no proportion between abuse and disease-excitation; all dependence between effect and cause ceases. Correction or amendment cannot remove the harm done by the excess of wine or heat or exercise. Antiphlogistics or counter-stimulants used as remedies do not stop the excessive movement aroused in the inflamed part and in the parts contiguous or allied with it. A drunkard who has developed an acute gastritis or hepatitis does not correct his abuse by drinking (if it were possible) as much water in a single day as he had gulped down wine in a month. The dangerous inflammation aroused by excessive stimuli does not clear. Appropriate treatment may indeed slow the progress of the gastric-hepatic phlogosis, but the condition endures for a definite time, passing through certain stages. Sometimes lightning, sunstroke or the shock of a sudden rush can bring on pneumonia, ophthalmitis or angina. Even if the sick person rests, lies down in cool surroundings, avoids light, takes nitrogenous and saline drinks or submits to repeated, careful bleedings, the inflammation of the lungs, throat and eyes will not stop immediately. On the contrary, it increases and goes on increasing unless medical skill keeps it to levels below dangerous disorganisation. Thus it continues on a given course independently of its causes which have already ceased.(74)

1972. In these extracts, which truly describe facts, the only thing I consider incorrect is the expression 'excessive stimulus'. It contains the limitations of the Brownian system from which medicine must completely dissociate itself before embarking on its noble course. The expression should not be 'excessive stimulus' but 'inappropriate stimulus' because, as Tommasini himself admits, illnesses resulting from stimulus are not proportionate to the size and intensity of the stimulus; the cause of disease is not excessive but inappropriate stimulus. If a stimulus, no matter how small, is inappropriate in certain states of animality, that is, if it irritates and disorders the functions of the life and sensuous instincts, it is excessive, and that which is bad is already too much. Inappropriateness depends on innumerable causes (the atmosphere, temperament, the particular state of the animal, the ceaseless, alternating course of sense-experiences and movements, etc.), which offer a wide field to medical investigation. This observation did not entirely escape the acumen of Tommasini who, being tied to a system which made all illnesses depend on excessive or insufficient stimulus, was perhaps unable to draw all possible profit from his own observations. Indeed he admits that the necessary course of inflammation is not a phenomenon dependent on the greater degree or gravity of illness.

Take, for instance, some tiny outbreak of erysipelas. It is totally disproportionate to heavy drunkenness in which the whole system of vessels and circulation is roused to disease-excitation, together with possible serious delirium and consequent paralysis, fainting, vomiting and the subversion of every natural function. The same comparison can be made between erysipelas and any violent, ephemeral fever produced by the sudden action of IMMODERATE STIMULI; a fever of this kind is sometimes severe enough to induce fear of encephalitis. Nevertheless, provided the vessels are not inflamed or ruptured, and dangerous loss of blood is avoided, the alarming display of drunkenness and passing fever would cease as soon as the stimuli were withdrawn. The case is not the same with erysipelas. The tiniest inflammation of the eyelids or minor erysipelas will follow their course, quietly passing through their various stages despite the action of any suppressive or counter-stimulant remedies. I challenge anyone not convinced about the inevitable or necessary course of inflammation to use any antiphlogistic or means he may choose to control a truly phlogistic condition of the mildest kind in any part of the body. This certainly shows that inflammation, whether extensive or limited, serious or mild, contains something proper to itself: the illness begins when the external causes producing it have ceased to act. This is a marked difference from many other diseased conditions which terminate or endure simply because the external causes have either ceased or continue to act. Clearly, inflammation creates through its own action an independent pathological condition (extension, force, duration and influences) which would be very difficult to determine relative to the force and duration of no longer existing external causes. This independence of a diseaseaffection from its original external causes is the principal, exclusive characteristic which in my opinion must be attributed to diathesis.(75)

1973. These very accurate observations prove what I have said: the necessary course of inflammation, which does not begin even granted a greater stimulus, is caused not by excessive stimulus but by its inappropriateness. When therefore is a stimulus inappropriate? We are not dealing simply with measuring the quantity of a stimulus; we need to note the numerous circumstances whose measure, so to speak, makes the stimulus appropriate or inappropriate. This takes us back to the ancient method and wisdom of Hippocrates.

1974. A healthy state is undoubtedly conditioned by the continuous action of stimuli. The stimuli can be air, light, food, or stimuli aroused by exercise or reproduced by continuous intestine movements perpetuated in the living composite. There is no doubt that all these are appropriate stimuli.

1975. They can even increase and diminish, without exceeding the sphere of appropriateness. A healthy man can abstain from wine, drink little or even generous amounts, without any harm to his health. He can eat much or little, exercise his physical, intellectual or moral strength in varying degree, without damage to his health. The course of animal functions certainly changes, but is not altered. The alternating sequence of sense-experiences and intestine movements can vary in rapidity and vigour without any disease-affection. Indeed, creative wisdom had to grant this aptitude by which animality adapts in varying degree to a great variety of natural stimuli, and without which it could not preserve itself. The slightest atmospheric change, every variation in food, every increase or decrease of exercise, can initiate a course of disease-phenomena. But how far does this sphere of appropriate stimuli extend, and where do we find the principle determining the characteristics of inappropriate stimuli?

1976. The sphere of appropriate stimuli undoubtedly extends according to the health and robustness of the body, and to the special state which the body acquires, principally from habit. This explains why the human body resists the different climates of the world and adapts to different temperatures, and also how much individuals differ in their docility to and tolerance of stimuli. While one person is apparently not adversely affected by a change of atmosphere, by heavy work or change of diet, another is affected by even the slightest cause.

1977. Our search for the characteristic of irritation or diseased alteration must therefore be directed to the state of the animal body, to the alternation of sense-experiences and intestine movements, whose laws I have described. These laws explain why the alternation, in its normal state and excited by certain external stimuli, is on the one hand not disturbed and on the other is irritated and altered. They also explain why an irritation gives rise to a disease-course of sense-experiences, which is either so short in duration that the irritation disappears immediately after the withdrawal of the stimuli, or so long that even after the withdrawal of the stimuli, it continues for some time while passing through many stages, manifesting various phenomena and terminating either with the restoration of health or with death. Note carefully that this second course, once begun, does not cease immediately after the withdrawal of the initiating stimuli; the two courses differ, not because one is immediate and the other drawn out, but because one takes a short time and the other a long time.

1978. A disease-course therefore does not depend upon excessive stimuli, but upon stimuli inappropriate to the state of the internal sequence of sense-experiences and intestine movements. I think this is the real reason why doctors, committed to the excess/deficiency system of stimulus, can never determine the degree and measure at which the excess or deficiency begins. When they do determine it, they continually cite facts which contradict their system. Tommasini admits his inability to determine the limit where excitation becomes phlogistic:

It is difficult to determine the line of demarcation, the real limits. On the one hand we have excessive excitation which is not phlogistic but simply induces increased movement and turgid vessels without altering the fibres. On the other, we have excitation where the size and constitution of the fibres and membranes are far removed from their natural state - it is difficult, I say, to determine the limits between these two kinds of excitation. It is also difficult to determine not only the degree of stimuli which can increase the oscillation of the vessels in an unhealthy way, but also the act necessary for inducing a change of organic conditions in the fibres and tissue of the parts.(76)

1979. Because he finds it impossible to determine these limits, Tommasini asserts that the level of degree must be considered relative to individual tolerance. But drunkenness that has brought on delirium and threatened paralysis clearly demonstrates, phenomenally, that the stimulus has overcome individual tolerance. Nevertheless, the course of this illness may come to an end in a short time (when the wine has been rejected or digested), while a very slight phlogosis continues its course for some time, a course which Tommasini correctly says is necessary. The stimuli therefore can be excessive, even relative to individual tolerance, and yet not produce phlogosis, while a lesser stimulus on the same individual produces it. At this point the great man, forced by the evidence of the facts, touches upon the truth when he adds:

The difference of effect may perhaps depend not only on the DEGREE but on the QUALITY OF THE STIMULI APPLIED. These are either endowed with stimulant activity and thus indicate simply an increase of movement, or instead, exert some chemical or other more penetrative influence by imparting to the stimulated fibres a process which involves the tissue and induces a change of mode, form and extension in the fibres. We see therefore that the continuation of the excessive excitation within the first limits and the passage to a deeper state do not always depend ON A KNOWN VARIABLE DEGREE OF STIMULI. In certain atmospheric conditions, where the air is perhaps the conductor of unknown elements (powerfully expressed by Hippocrates' quid divinum), we see various degrees of inflammation in all sick people, even though the temperature is mild and excitation of the systems does not appear greatly increased. On the other hand, we sometimes see in the most scorching heat and under a DEGREE OF STIMULUS OBVIOUSLY MUCH GREATER THAN THE FIRST, increased excitation and circulation in almost all bodies, without inflammation in any of them, or only in very few.

But the most important difference of such effects must depend above all on the particular constitution of the individual and on what I would call a certain variation in alterability of organic, modal conditions, whether the intermingling or state of the fluids which enter into the complex of the organic constitution is involved or not. This dependence must also apply to any change which takes place more easily in some individuals than in others, that is, when the excessive stimulus and excitation become a real phlogistic, inflammatory condition of parts which transcends the limits of the simple, increased movement. Thus, in some people, the same contusions, the same wounds and the same thorn produce (apart from the first, direct and mechanical disunion of parts) only a transitory increase of stimulus. In others, however, the same lacerations, even with less force, cause a deep and rapidly expanding phlogistic and an alteration that is difficult to heal.(77)

1980. Recourse therefore to the presence or absence of excessive stimulus cannot explain the process of inflammation and of every diseased process. We must turn to the laws of the alternating action of the life and sensuous instincts, of senseexperiences and of organic movements, which (to use Tommasini's expression) constitute a necessary, fixed course that, in a sick or healthy person, always follows the same laws. This reduces pathology to a continuation of physiology: the same laws govern the operation of the living machine in both a diseased and a healthy state, while the phenomena vary as a result of variation in the state and reciprocal relationship of the two instincts producing the phenomena, and of variation in the relative quality of the external stimuli drawing the instincts into movement. Tommasini acknowledges that the generation, development and reproduction of parts are internal actions of the animal.

Granted the appropriate impetus of external agents, these actions proceed independently of the agents in the power, in my opinion, of the animal's spontaneity manifested in the two instincts, each serving the other as lever. Tommasini refers to Harvey's observations about a pregnant womb and hundreds of eggs. These observations indicate that the stages followed by the living body within a living body, from the first moments of conception to greatest development, resemble those of inflammation. He mentions the opinion of Onofrio Schassi, according to whom the membrane of the uterus which Hunter called decidua, is only the product of a species of natural inflammation. He points out that the reproductive activity is due to inflammation, that cavities left by wounds and cuts are filled by means of inflammation, which also generates new fibres and reproduces entire pieces of flesh which sometimes acquire an extraordinary disease-bulk. He mentions that Mascagni, Hunter, Testa, Potolongo and Moore noted that blood vessels, lymphatic and cellular vessels, cartilages and bones, develop, extend and increase in size under the influence of inflammation; indeed, in pneumonia, cell tissues form as organic productions which Maincourt distinguished from false membrane, and in which small red vessels branch out. Finally he points out that according to Cruickshank even nerve filaments increase. Tommasini is correct when he says that in disease processes nature 'wanders from the laws overseeing health' or calls the products of these processes 'growths of unknown type'; but he falls back on the established, very limited system when he attributes all this to excessive stimulus, to excessive excitation.

I can understand that increased excitation is noted in generation, in the normal reproduction of severed parts, in the process by which soft parts become hard between infancy and adulthood, but this is not due to excess. Strictly speaking, irregularity and abnormality of animal action is present when the foetus OUT OF PROPORTION with the rest, sometimes develops to a size dangerous to the mother. This is so true that sometimes the mother is greatly exhausted in her other parts due to lack of physiological forces, and sometimes even becomes emaciated.

If through slow phlogosis a mesentery, omentum or a vessel grow to such a size that they become serious and fatal as a result of mechanical compression, this, strictly speaking, must not be ascribed to excessive excitation but to animal activity which directs and accumulates its products in one place (I will discuss this law of locality later). One and the same greater quantity of excitation given to an animal in other circumstances, far from being harmful, could be helpful to it. Excessive stimulus therefore differs from inappropriateness of stimulus, just as increase of vital action differs from vital action that has strayed from the laws of health. The latter, I repeat, can be called excessive excitation only in the sense that what goes wrong and does harm is always excessive. 'Excess', used in this sense, would incorrectly mean that every cause of illness is an excess. The word must therefore be avoided.

Notes

(72) Nosographie philosophique etc., 2nd edition, Introduct., 32.

(73) Dell'Infiammazione etc., c. 2.

(74) Ibid.

(75) Ibid.

(76) Ibid., c. 1.

(77) Ibid., c. 2.