Chapter 15

Digression: the importance and difficulty of writing a new treatise on
'experimentation in medicine'

2098. Let me conclude, and rest for a while, by expressing a hope that some wise doctor will bring out a new theory of the art of medical experimentation. If what I have said is true, the treatises published to date about such an important topic must seem insufficient. Real progress in medicine depends on experimentation, which is the foremost part of medical logic. Without this art, medicine can only be irrevocably ruined, as it turns from one cruel, gratuitous theory to an equally gratuitous and perhaps even more cruel theory. Any learned person undertaking this task should, it seems to me, keep in mind the following observations

2099. The first desirable improvement would be to eliminate any apparent disagreement of opinions by removing all obscurity from the argument. Learned people do great harm to the art in their controversies when, without seeking mutual understanding, they waste time and words on mutual opposition. For example, empiricists and rationalists, if they defined themselves in a reasonable way, would soon reach agreement.

2100. I propose the following definitions:
Empirical doctors are those who claim that remedies must be applied solely in accord with similar cases considered phenomenally. Rational doctors are those who claim that remedies must not be applied according to similar cases considered phenomenally but according to their internal, efficient causes which, although not experienced, are argued to from experienced data.

2101. The following consequences are drawn from these definitions:

1. Empiricists do not exclude reasoning (although they are falsely accused of doing so) but limit it to determine similar cases by means of phenomena obtained by experience.

2. Rationalists do not exclude experience (although they are falsely accused of doing so), but want experience to be used to indicate, by means of reasoning, the intimate constitution of the disease in question and hence its interior causes, which produce its symptoms externally.

When the two groups are defined in this way, and unjust, mutual recriminations are abandoned, the mistakes in each group, if there are any, are considerably reduced. This alone is sufficient to draw them together.

Empirical doctors will, quite rightly, no longer be confused with foolish doctors because an empirical doctor is not necessarily foolish. His proposal 'to heal according to similar cases considered phenomenally' demands immense knowledge and inexhaustible study. It is not easy to determine which cases are truly similar considered phenomenally, and to assemble and classify all disease phenomena according to their degree of similarity. Great wisdom is required to distinguish between phenomena which are similar in their specific essence and phenomena which are similar only in what is accessory and accidental. Again, it is not easy to determine the supreme importance of one relationship of similarity and the minimal importance of another, nor to recognise the various degrees of similarity and their importance in categorising an illness. Clearly, classification of illness demands infinite perspicacity and persevering observation. In the same way, we need to classify the different course and outcome of illnesses in various climates, temperaments and other circumstances. The method also requires continual argument a iuvantibus et a laedentibus [from what is helpful and from what is harmful] in order to discover the corresponding effects of remedies and doses, and the manner of their administration. If foolish doctors were set apart from true empiricists, doctors would soon understand each other more easily.

2102. But even granted such separation, the defect of the two groups cannot be reduced to lack of knowledge in one and superabundant knowledge in the other. The defect must be found perhaps in an arbitrary restriction imposed by each group on its own method. If so, everything can be reduced to showing how each gratuitously limits itself and makes the attainment of true medical knowledge, its avowed purpose, more difficult to achieve. We would then have reasonable, rather than empirical or rational doctors. They would 1. collect and reflect upon all phenomena (just as the empiricists propose) and classify them according to their characteristic similarities; 2. be ready to investigate the internal disease-condition through reasoning (as the rationalists propose), provided that inductions are rigidly logical. The question would no longer concern method, but the exact application of method. Instead of saying that similar cases have no value, people would simply say either that cases are not similar or have only an accidental similarity, not a characteristic, essential, specific similarity. Instead of saying that it is useless to investigate the internal cause of illness, people would say that induction which determines this internal cause is either illogical, or has only some degree of probability. In this case, care is needed in calculating the degree of probability which militates against the truth of such a cause. The questions are now clear; we are on strictly scientific ground, and progress of the art is assured.

2103. The new Treatise on Experimentation in Medicine ought therefore to determine:
1. the data given by sensible experience, the kinds of experimentation used to find this data, and ways of classifying it;
2. the rules for drawing logical inductions, and the conclusive force of each of these and their classification.

2104. These two parts of the treatise indicate the difficulties to be encountered in experimentation and in the deduction of conclusions from it. The illusions, errors and false reasoning into which practitioners and theorists may fall can now be kept in view.

This would also be achieved if the wise author I have in mind demonstrates the complexity of the human machine, the many active principles and sublime laws which modify it, the reciprocal activity of these changes and the comparative paucity of facts provided by experimentation. If the so-called 'three-body problem' in astronomy is so difficult to solve because it concerns the reciprocal yet uniform action of the sun, earth and moon, we shall be faced with a much more difficult problem when countless, continually changing bodies, possessing different forces, influence one another with their reciprocal, complicated movements. And this is exactly the case with the human body. Such a demonstration would prove that 'the claim 1. to know by direct experimentation or induction all the internal facts from which the healthy state of a living body results and 2. to provide some prognosis or apply a cure, is superior to human forces and certainly cannot be undertaken lightly.'

2105. The doctor who wants to achieve his aim can follow either of these two ways. He can persuade himself of success by studying illnesses in themselves, and the internal forces and changes which cause them. I call this 'analytical medicine', because its purpose is to study the internal elements of disease and catch them at their beginning through investigation of the nature and effects of composite forces and movements. In other words: first analysis, then synthesis in order to reach inductive conclusions.

2106. These two great aims characterise and distinguish two medical schools: analytical medicine and synthetical medicine. By these expressions I mean the following:

2107. Medical art, the art of curing illnesses, is one; medical knowledge is the theory of this art.
But the doctor who wants to achieve his aim can follow one of these two ways. He can be convinced of success in curing illnesses by studying them in themselves and in the internal forces and changes which cause them. I call this 'analytical medicine', because its purpose is to study diseases in their internal elements and find their origin by investigating the complex of forces, the movements and the effects of movements, from which the illnesses may come. This means proceeding first by analysis in order to produce a synthesis in the consequent inductions.

But he can also be convinced of success by studying the clues which indicate improvement or further deterioration, without being concerned about positive knowledge of how this happens. I call this 'synthetical medicine', that is, medicine whose aim is to know the overall effect of remedies. However, having started from this knowledge, the doctor can analyse this overall effect and use it to know the internal elements from which it results. Either of these methods can certainly lead to the end, but they need to be united if they are to work together towards their one common purpose. An indispensable condition however is that the observed facts must be certain and precise, and the conclusions rigorous. Both are difficult to obtain.

2108. For the rest, it is clear that analytical medicine takes the longer way, a way which is more difficult to follow to its end through logical induction. This should be fully obvious from the treatise on experimentation which I favour.

2109. This extreme difficulty could be demonstrated from many points of view, and principally from the two following:

By commenting on both these sources of difficulty, I hope to clarify my concept.
The great difficulty of the task becomes clear when we note that:

A single link of the course results from numerous causes, each of which is difficult to identify. Every link is composed of two elements: a sensible and a movable element: the sensible element is a composite of numerous feelings, only a few of which fall distinctly within our awareness; many are grounded in a single feeling which constitutes precisely the sensible state of the animal. The movable element is similarly the result of numerous intestine movements and of their mutual action and fusion.

We would also need to note the order of contemporary movements in the movable and sensible elements of a given link. The different systems of the human body operate reciprocally and successively on each other. Consequently some of the contemporary movements within the body are part of a longer series of preceding movements, others of a shorter series. For example, muscular movements are not the effect of contemporary nervous movements but of nervous movements belonging to the previous link.

We can therefore conclude with certainty that it is impossible to determine the art of medicine solely on the basis of the internal causes of diseases whether these are directly known or indirectly argued from the factual data provided by observation of the human body.

2110. This difficulty of fully knowing the internal state of the animal is further confirmed when we consider that all the inductive rules laid down until now for this purpose are false:

1. Symptoms. We need to recall what was said against symptomatic medicine. Nearly all modern doctors have certainly started from Brown's principle that the healthy state of the human body depends solely on excess or absence, or balance, of stimulus. They allow however that symptoms are totally false if the sthenic or asthenic state of the body is induced from them.(114) Indeed they attribute illnesses and all their characteristic symptoms sometimes to excess and sometimes to absence of stimulus. For example, according to them, both excess and lack of stimulus can cause hydropsy, and the same is true of many other illnesses. Hence not even the kind of illness indicates with certainty its cause and internal nature.(115)

2. The rule 'a iuvantibus et laedentibus' is certainly valuable when used for ascertaining the efficacy of remedies, but false if we claim it can be used for indicating the internal causes of disease, that is, the intimate disease-condition. I am convinced that, due to internal complexities, two opposite remedies, one a stimulant, the other a counter-stimulant, can in certain cases produce the same effect. I have myself observed that the stimulus, when excessive, debilitates the fibre and diminishes its quantity of action, with the result that the movements and internal stimuli produced by the action are also diminished. The effect depends on the proportion between increase of the external, therapeutic (as I would call it) stimulus on the one hand and diminution of the internal, physiological or pathological stimulus on the other. If the diminution is greater than the increase, the total effect will be a diminution of the stimulus. The applied remedy, although a stimulant, will seem a counter-stimulant. The complexity of the human machine is such that these two contrary effects of growth and partial diminution of stimulus are verified in it much more frequently than we believe. The resultant total effect is excessive growth or diminution.

2111. Whenever retardation of venal blood initiates yawning, the succeeding diminution of stimulus is spontaneously followed by an effort on the part of the animal to breathe in more air, which in turn increases the stimulus. The same can be said about all those causes which, through lack of stimulus, make breathing more frequent and respiration more deep: either the quantity of air or blood diminishes, or excessive heat and rapidity in the circulation consumes more red blood, or the human being feels, as death draws near, that life is failing. In all these cases the diminution of stimulus is soon followed by or associated with an increase, caused by the diminution itself because the sensuous instinct increases its action in an attempt to reproduce the stimuli it has lost. Here we have clear proof that the sensuous instinct does not act simply in the power of or in proportion to external and internal material stimuli, but according to laws of its own; it is both passive and active.

2112. In no illness, even when cured with stimulants, is weakness such that the patient lacks some increase of partial stimulus. This occasionally deceives doctors, who judge the illness as inflammatory or sthenic. To grasp this, it is sufficient to read the two series of case-histories added by Rasori at the end of his Teoria della Flogosi. The first concerns illnesses considered inflammatory which are first brought to an extreme condition by use of an antiphlogistic application and then cured by a stimulating application.(116) The second case concerns other illnesses considered inflammatory which end in death, although the corpse shows no sign of inflammation. These two cases convince me that a partial increase of stimuli occurs in every illness without our being able to infer with certainty that the illness is sthenic.

Acceleration of pulse and increase of heat always manifest a partial increase of stimulus; even if there were nothing else, movement alone, or simply increased heat, would be a stimulus and produce internal stimuli. An increased, partial stimulus always accompanies pain which is itself a stimulus and producer of stimuli through the excited action of the animal. A partial stimulus also always accompanies an increase in secretions and excretions, because an increase of secretions manifests greater activity on the part of the excretory and secretory organs themselves, and the activity presupposes greater excitation and stimulus. Again, there can be increased stimulus wherever secretions and excretions are below the required flow, for example, when excessive stimulus obstructs the action of the organs and as it were stupifies them. Indeed, every abnormal, disordered secretion and excretion can manifest some increase of partial stimulus, even if there is a simultaneous diminution of partial stimulus. Convulsion of muscles, drowsiness, lethargy and delirium also manifest a partial increase of stimuli which excite the nerves and brain. In a word, there are very few morbid symptoms which do not reveal a partial increase of stimulus and excitation.

Moreover, symptoms which would more naturally indicate weakness can be an indirect effect (if we wish to call it that) of partial or total stimulus and excitation, or can be accompanied by symptoms which indicate partial or total weakness and diminution of stimulus.

Doctors still do not agree whether the labyrinth of choked vessels in inflammation indicates a state of weakness or of excessive energy. Rasori admits the presence of a kind of weakness in the venal capillary complex, the seat of inflammation, although he says that this kind of weakness must not determine the curative method.(117) Let me note in passing that this distinction is in itself an indication of the need to distinguish more accurately than in the past the precise kind of weakness indicated by those doctors who wish to reduce the whole of medicine to excessive stimuli or the absence of stimuli. They grant that not every observable weakness in the human body is adapted to their system, but must admit that some kind of weakness is present in an inflamed capillary network. They clearly grant therefore that in one and the same part of the human body an element of weakness and an element of force can be found together, or better, a debilitating cause and an excitatory cause. The flow of blood to an inflamed part, although undoubtedly an increase of stimulus applied to the part, certainly cannot be the first cause of the disease.

If however one preferred not to acknowledge any other cause of weakness in the blocked blood vessels than the mechanical action of the blood itself which forcibly introduced has excessively distended the vessels, it nevertheless remains true that the agent, the blood, acts in two ways in the same part which it either tires, weakens and wears out, or excites, stimulates and strengthens. Hence the state of the part must not be determined solely by either the element which weakens it or the element which strengthens it, but by calculating the two opposite, simultaneous and intermingled effects.

2113. However, has it ever been shown that the weakness of the choked vessels depends solely on the mechanical action of fluid impelled into them? I know of no conclusive proof. These days it seems certain that circulation does not depend only on the force of the heart,(118) but that the vessels have a contradistension of their own. Although the venal system appears relatively passive and the arterial system relatively active, the walls of the veins cannot in fact be stripped of all their elastic and contradistensive quality.(119) If so, their response to stimuli would be no better than that of some inanimate substance. Granted therefore greater vital activity in the arteries and lesser activity in the veins, surely it is not impossible that the morbid cause which increases the action of the heart and arteries is the same as the cause which produces the contrary effect in the capillary veins by making them less resistant, more pliant and expandable relative to the flow of blood? If this is so, the real cause of the greater activity of the heart and arteries and of the relative weakness of the venal capillaries should be attributed to the modified action of the animal instinct as its real efficient cause, an action which has increased in the arteries and diminished in the veins.

2114. Nor does it seem improbable that the venal and arterial systems are mutually antagonistic. The arterial system is ordered to impelling the blood from the centre to the periphery; the venous system does the opposite. This explains why doctors looked for antagonism between the white and red capillary vessels, although I do not see how Festler could attribute greater attractive force to the white capillaries than to the red capillaries, and greater expansive force to the red rather than the white, when the contrary would seem to be the case.(120) On the one hand, contraction supposes a greater vital action, which certainly dominates in the red vessels; on the other, expansion is not always an effect of vitality alone but also of weakness and passivity. It is clear, for example, that veins react less to the fluid they receive than the arteries which, helped by their contradistensive force, impel the blood. Is it entirely impossible that the increased weakness from whatever source in the venal system, that is, the greater pliancy of the parts of the venal vessels, should result in greater activity in the arterial system? If so, the weakness in the vital force of the veins would be a cause of the morbid state in question, and be prior to the cause of arterial excitation which, as a consequence, would be relatively an effect rather than a cause.

I am persuaded that this could be the case by the following argument. If we suppose greater dilation of the veins, that is, smaller resistance to the flow of the blood, the veins would bring a greater quantity of blood to the heart, thus increasing stimulus and activity in the heart. As a result of this activity, the heart impels the blood through the arteries to the whole body which would otherwise be without it. If we also suppose that the calibre of the arteries is not increased in proportion to that of the veins (the arteries, endowed with greater life and more resistant to the material impulse and to the blood considered as a stimulus, contract), the speed of circulation in the arteries would necessarily increase, sending through them a quantity of blood equal to that passing through the veins, which is a necessary condition of circulation. Moreover, because the venal network is much more capacious than the arterial network, the flow of blood in the arteries would have to accelerate (even when the vessels of both networks are equally dilated) in order to cope with all the blood brought to the heart by the veins. If not, the heart would stop. What is the cause, therefore, that maintains the flow of blood? The real and first cause, as I have mentioned, is animal instinct. This instinct, feeling some disturbance, strives to rid itself of the nuisance. In order to impel the blood more strongly, it will cause yawning which produces deeper breathing and asthma.

According to the different atmospheric conditions, it will move the lungs by accelerating or retarding respiration. This in turn depends on what the instinct feels is better for it. Sometimes it causes fuller and deeper breathing, sometimes longer or shorter or more frequent breaths, sometimes more vigorous or less vigorous breathing, sometimes gentler or heavier breathing. We should have recourse therefore to vital activity as the first cause of the acceleration of the blood and of the greatest flow in the veins. This activity is aroused by the weakness and flacidity growing in the veins. Thus the whole problem should be reduced to identifying the first cause of this morbid relaxation of the veins. This first cause must undoubtedly be sought in the painful irritation of the life instinct which forces it, as I have described, to undertake the struggle against the irritating cause. I do not intend, nor is it necessary, to investigate this no doubt manifold cause. Instead, I will return to the phenomenon of inflammation which, I think, receives greater clarity from what has been said. The increased flow of blood in the venal capillaries and the additional movement in the arteries are causes (together with many others) capable of developing a great quantity of heat and giving the blood a tendency to dissolve into its three principles of serum, coagulation and fibrin. This flow and movement seem sufficient to explain how the venous capillary complex, choked and as it were stagnant with blood, becomes swollen, warm and susceptible to suppuration. This is particularly true where capillaries, whose calibre is very irregular, are accidentally larger in size - a circumstance which according to Rasori can explain the locality of inflammation,(121) - and where, for reasons I will explain later, they become more pliable and loose when unnaturally swollen through their morbid dilation.

2115. Everything I have said is simply intended to show that excessive weakness can accompany excessive stimulus. In other words, increased and diminished vital action can be found together; one occasions the other. This is, I believe, a universal law of illness, as I will explain later. But I can go still further with my description of the phenomenon of weakness in a state of inflammation. Granted the weakness I have indicated in the inflamed area, and granted, as I have said, the prostration of force in the veins, caused or occasioned by increased stimulus, it will be much easier to observe weakness co-existent with the inflammation by considering the whole complex of phenomena in a body suffering from some local inflammation.

2116. I am fully convinced by the arguments of the many famous doctors who censured Brown for favouring stimulants as a cure for many 'asthenic' (as he called them) inflammations. However, even granted this error in the curative method, I do not think I am obliged to conclude that excessive stimulus is the only thing to be noticed in inflammations. Brown's critics have been obliged to distinguish two kinds of weakness, which they call pathological and physiological; they agree that the latter is present together with excessive pathological robustness. This is precisely what I have been saying: that is, force and weakness exist simultaneously in the human body and in the same illness. However, I am not at all sure that the terms 'physiological' and 'pathological' are sufficiently precise and clearly defined. I see how our doctors formed the concept of what they call 'pathological weakness' from curative action, and this immediately causes me to reflect:

1. We must determine whether a remedy is a stimulant or a counter-stimulant, either according to its effect on a healthy body (in which case our conclusions about a sick body are subject to serious reservations), or according to its effect on a sick body (which supposes prior knowledge that the morbid state is, as they say, sthenic or asthenic). Thus we could easily find ourselves in a vicious circle: on the one hand, morbid sthenia or asthenia is defined according to the stimulating or counter- stimulating property of the remedies; on the other, this property of the remedies is defined according to the sthenic or asthenic state which they are intended to heal. This, I think, explains the still extant difference of opinion about the efficacy of remedies. However, because I simply want to indicate the kind of sound logic that should be applied to experimentation in medicine, I believe it more important to note the following:

2. The effects of remedies can indeed serve as a secure guide in synthetical medicine which is content to indicate (by means of all the symptoms, apparent phenomena and definite characteristics) the good or harm done by various remedies in determined illnesses. But I do not see how these effects can, at least through reliable induction, determine the internal causes of illness and the modifications, few or many, of the vital action in its multiple different, complex and sometimes opposing, antagonistic activity. On the contrary, it seems to me that direct deduction from the effects of remedies to morbid aetiology, and the formation of rules for remedies solely on this aetiology, involves a method which only too easily brings medical science within the constraints of a system.

2117. These thoughts are not as opposed as they seem to the curative method of the famous founders of what is (correctly?) called new Italian medical teaching, which is indeed to the glory of Italy because of the many truths it contains. For example, I think that Tommasini and others did indeed teach a truth contributing to knowledge when they maintained that the inflammatory process is one and that 'phlogosis, natural or morbid, and wherever present, is a process independent of the degree of vigour in the system. Its presence causes an increase of vegetation in the parts where it is found, whatever the deterioration in other parts.'(122)

Blood congestion alone demonstrates this. Blood which slows down at the point of congestion is as it were cut off from the general circulation; it no longer follows the flow but possesses its own movement. Nor does it lose its life as a result, except through suppuration; before breaking up and dying, it vegetates independently of and disharmoniously with the body's general vegetation.(123)

2118. Two questions present themselves:
1. Must a doctor's efforts always be directed to curing an inflammation wherever visible or suspected, without regard for the general state of the body?

We note first that the question pertains to synthetical, not analytical medicine. Per se, it does not tend to explain and analyse the dynamic, organic disturbance of the inflammatory process and its causes. Whatever this disturbance, whatever the complexity of the internal elements and the material and formal causes of the inflammation, the question asks whether health is better restored by combating local inflammation and neglecting the rest, or whether some account has to be taken of the general state of the body.
Although I am dealing with analytical medicine, I will offer some thoughts on the question.

2119. An inflammatory process leads per se to suppuration. The process, which seems to be 'the only dynamic procedure that harms, damages and de-natures the organic organisation of parts',(124) leads to death if it is extensive or indirectly affects an organ necessary for life. The supreme importance of preventing such a tragic end means that in many cases every other consideration must be forgotten - first treat what is more serious, then what is less.

2120. 2. But is there another way for the doctor to prevent the fatal outcome of an extensive or serious inflammation, besides removing the forces from the inflammatory process?
I have no adequate reply to this question. I simply want to point out that even this question in itself pertains to synthetical, not analytical medicine. We are seeking what must be done for health; we are not trying to discover internal, dynamic, organic and mechanical mainsprings by which in this case health may be restored.

However, even if the progress of inflammation cannot be stemmed, as has been said, by any anti-phlogistic means or in any other way, it is still not totally logical to conclude that inflammation is rendered less harmful by removing the forces which cause it. Nevertheless this withdrawal of forces would be an excellent expedient for weakening the enemy and rendering him less destructive. Synthetical medicine stops here. Analytical medicine on the other hand does not stop here. It seeks to draw conclusions about the intimate nature of disease. This is a wonderful aim provided it is guided by the dictates of irrefutable logic. When the forces are withdrawn from an inflammatory process, the process is certainly rendered more benign, and is no longer life-threatening. It would seem therefore that inflammation is an illness consisting in excessive stimulus and robustness. But this conclusion either adds nothing to the previous conclusion of synthetical medicine 'that inflammation is successfully cured by removing the forces which enable it to pursue its course', or is illogical and mistaken.

It adds nothing if the characteristic of excessive robustness predicated of the illness simply means that the illness is cured by debilitating elements; it is illogical and mistaken if the characteristic of excessive robustness is an accurate description of the nature of the illness. The animal body can be very weak and excessively extenuated, but nevertheless inflamed. Hence, if we understand robustness in the normal sense, it is no longer true that the sick person suffering from inflammation is robust and of a high vitality. This absurdity cannot be intended by analytical practitioners; the sick under their observation prove exactly the opposite. But it is inevitable unless we give their definition a non-literal meaning.

Let us recall what has been said about the distinction between pathological and physiological robustness which seems, at first sight, one of the many distinctions whose sole purpose is to complicate and uselessly burden science. It could easily be avoided, we imagine, by the use of proper language, that is, of language understood by the people in general, who rule language and legislate for it. Nevertheless, the distinction is real and founded in nature, if we pay careful attention to its description and definition. What then is the definition of this pathological robustness or weakness, which appears quite different from what is commonly understood by 'robustness' and 'weakness'?

Rasori describes robustness and weakness as 'relative to the curative method. We can conclude therefore that the method must either stimulate (strengthen, if preferred) or serve as a depressant'.(125) So far, so good. But the definition belongs to synthetical medicine. It does not indicate a real state of weakness or robustness in the body - as analytical medicine would rashly conclude - but the presence of an enemy whose forces can profitably be diminished. Everyone knows, however, that enemy forces are always excessive, and that an active enemy who cannot always be eliminated immediately must be gradually weakened. This is evident logic. But it is done because of the presence of enemy forces, not of excessive forces, in the body. We can conclude therefore that the fault lies not in excess but abnormality of robustness and force which, I repeat, even if slight, would be excessive because abnormal.

As I said, we have no proof that inflammation originates from absolute excessive activity of the heart and arteries, rather than from excessive activity relative to the relaxation of the capillary veins. In other words, it has not been shown that the increased weakness of the latter has determined the excessive activity of the former. Hence, it is still possible to conceive another way of overcoming inflammation, namely, by allowing the venous, capillary network sufficient force to permit the congested blood to return to general circulation rather than produce its own process of vegetation.

I am not speaking here about the effects of cold applied to an inflamed part, and other particular cases. I simply want to affirm in general that it is one thing to say a way is not present, another to say that it cannot be discovered. This impossibility, if maintained, must be proved by arguments totally different from those put forward to support the state of excessive stimulus. Excessive, partial stimulus would cease as soon as deceleration of the congested blood in the capillaries were naturally overcome by an increase of strength in the relatively relaxed vessels.

2121. It may be objected that the expression, 'pathological weakness or robustness', is correct because it does at least indicate the element to be cured which, as such, forms the base of the illness as far as the curative method is concerned. Let us grant that there is an element to which the doctor must restrict his attention and which determines the relevant medication. Let us also grant that this medication is divided into two classes called 'reinforcing' and 'debilitating'. In this case, the expression 'pathological weakness or robustness' would certainly be precise, but not adequate; it would not tell us the meaning of 'weakness' or 'robustness'.

2122. But is it true that the doctor's attention must be so restricted? For example, must he totally neglect what I call physiological weakness or robustness? If 'pathological' means morbid, or at least relates to illness, why do we not call 'pathological' the weakness and prostration accompanying inflammatory ills, especially when the phlogistic process afflicts and lays low the nervous system? Surely this is an effect of the illness itself? In fact, there are very many cases, admitted by everybody, where the whole body, although utterly weakened, thin, pallid and near collapse, possesses some infected part where inflammation develops and flourishes more vigorously than ever. Cut off, as it were, from the unity of the animal, it has begun to perform by itself certain functions of life.(126) But if pathological weakness indicates morbid weakness, then surely there is no weakness more morbid than that which weakens and softens the body even fatally?

2123. But this weakness must not bear on the choice of cure. - I repeat, the importance of fighting the inflammatory process threatening dissolution and destruction is undeniable, and is certainly helped by diminishing the enemy's forces. We must however acknowledge simultaneous weakness and robustness (which are relative, not absolute) in the inflammatory process. Consequently, we cannot decide entirely a priori that there is no other way for re-establishing the balance between, for example, the relatively excessive weakness of the veins and the relatively excessive robustness of the arteries. In any case, it is totally false, even in the modern system under discussion, that we need not keep an eye on the state of general weakness of the body when using an anti-phlogistic method.

Neither Rasori nor Tommasini push matters to this extent. Although they promote the anti-phlogistic method, they acknowledge that it is not always 'sufficiently in tune with general weakness'.(127) Hence, even though they classify continuous nervous fever among inflammatory illnesses, they admit the need for great moderation in the use of counter-stimulants. - Relative to this point Tommasini says:

2124. The following is therefore sufficiently demonstrated:

1. In no case must the doctor lose complete sight of general bodily weakness, which must be called pathological, if by pathological we mean 'that which must direct the doctor in the application of remedies'.

2. If we wish to follow the new medicine, we will find that its guiding, intimate concept does not posit a single enemy in the sick body, that is, either weakness alone or robustness alone (although it sometimes seems to teach this expressly). It affirms that the strongest or most threatening of the two is to be conquered. Normally, this is inflammation, which therefore calls for prior attention. However, general debilitation must also be our concern if it becomes equally or more threatening.

3. Finally, the words 'weakness', 'robustness' etc., which pertain to analytical medicine, can be very easily abused, or used without any profit at all to medicine, although 'inflammation', 'phlogosis', 'anti-phlogistic remedies' etc., which pertain to synthetical medicine, are certain and necessary. They are not intended to describe the internal causes of disease nor are they used to reduce disease to one, simple cause; they are simply content to name the disease from knowledge of its phenomena, and to indicate remedies according to their apparent effects on illnesses known and described phenomenally.

2125. From all this we must conclude that even the rule a iuvantibus et laedentibus is excellent when used to draw inductions proper to synthetical medicine, but extremely difficult, if not impossible, when used to draw inductions required by analytical medicine.

2126. The same thing could be said about other well-known medical rules. We could show how difficult it is to use them as a constituent factor in analytical medicine. But I consider it is better to illustrate from another point of view how the same difficulty is present in drawing the logically certain inductions required by analytical medicine. I do so, not to discourage in any way the followers of analytical medicine but to caution them against deviating from logical rigour in their arguments and thus ending with only error and equivocation.

2127. There is a syllogism proper to synthetical medicine and a syllogism proper to analytical medicine.
The syllogism proper to synthetical medicine states:
The known phenomena (subjective and extrasubjective) of a disease are such and such.
But in a state of equal phenomena, one curative method helped, another harmed.
We must therefore follow the former, not the latter.

2128. The syllogism proper to analytical medicine states:
The internal, formal causes constituting the present disease are such and such.
A particular curative method diminishes or destroys these causes.
Therefore this method is suitable for curing the disease.

2129. The propositions of the syllogism proper to analytical medicine are more difficult to verify than the corresponding propositions of the syllogism proper to synthetical medicine.
The first proposition of the syllogism proper to synthetical medicine is pure observation of phenomena; the first proposition of the syllogism proper to analytical medicine is a logical inference from phenomena which are presumed to have been identified and accepted. The internal, formal causes of illness can be induced solely by reasoning from phenomena, the only thing we know directly by perception.

The deduction, by reasoning, of the internal, formal causes of a disease from the phenomena offered to observation by the disease is a task of immense difficulty and uncertainty, which synthetical medicine avoids. This difficulty, which I have discussed, arises principally from the complexity of the zoic course. The theory of this course must first be fully known; we must then deduce its abnormal deviations with their characteristics, and finally be able to identify its realisation in the concrete fact of the sick person being cured.

2130. The second proposition of the syllogism proper to synthetical medicine again results from accurate observations; the second proposition of the syllogism proper to analytical medicine is an inference obtained again by reasoning from observations previously supposed. Although both forms of medicine have in common the same effort to collect, certify and classify observations, an infinitely heavier burden is added to analytical medicine, which must determine the action of the remedies not in direct relationship to the disease, but in relationship to its internal, formal causes. A curative method should be determined not by noting whether it draws a sick person closer to or further from health, but whether the internal action of the method restores the supposed causes of health and removes the morbid causes, or vice versa.

This is an immense difficulty which should be discussed fully, positively and in detail in a Treatise on Experimentation in Medicine. I can consider it only from a partial part of view, as a little example of what I would like others to do.
I said that no effect obtained in the human body must be considered as a product of one single agent; there are always two causes, the agent and the re-agent, that concur in its production. Action is continuously accompanied by re-action, and the state of the body is simply the result of this concomitant action and re-action. If action is co-relative to the activity of an agent, re-action is co-relative to the activity(129) of a patient.

Hence whenever the state of a re-agent changes and takes an opposite aptitude, the real effect of the agent also varies, and is sometimes the opposite. Consequently, if the state of the human body to which a remedy is applied is not fully known, the real effect of the remedy, deduced from the causes, cannot be predicted. It is in fact the human body itself (in our case the ens) which must re-act. Although this undeniable principle is known and granted, doctors who acknowledged its supreme importance sometimes lacked the logic necessary to proceed with sufficient deliberation in the deductions they wanted to draw from the principle. No one knew this better than Rasori, who used the fact of disease capability almost to the point of making it the supreme rule in medicine. But it is one thing to know the truth in its vague generality; another to see it in act, in the concrete.

It seems to me that Rasori was overconfident about knowing, without too much difficulty, the complete state and etiology of diseases; he was satisfied with two simple words, which in the last analysis mean excessive stimulus and lack of stimulus. No one attributed more importance to Hahnemann's principle that the effects of remedies on a healthy body should be known before anything else, but he was far too precipitate in drawing the general consequence that an agent acting in a sick body would always produce a contrary effect. Hence, the foundation on which he based the whole of medicine was an uncertain conclusion, impossible to prove because of its vastness and ambiguity. What these doctors did not know was the extreme difficulty of drawing logical inferences from that principle.

2131. A doctor may indeed claim to evaluate the effect of a remedy by calculating the state of the re-acting body and the efficacy of the acting remedy. But before doing this he is faced with the difficulty of knowing precisely the state of the body that must re-act. We return once again to the complexity and hidden laws of the zoic course and of the frequently changing sources and forces which produce it. There is also the difficulty of knowing the agent and its efficacy. The efficacy in itself is certainly constant but no less difficult to determine in relationship to the effect. The following are some points among the many which ought to be discussed in the treatise on experimentation:

1. When both the agent and re-agent are complex, that is, the agent results from many elements and different forces, and the re-agent from many elements susceptible of different passions and re-actions, it becomes very difficult indeed to forecast the true effect; often the forecasts are very mistaken. The effect may even be the very opposite of what is forecast or of what the agent, considered in itself, would indicate.

Examples:
1. Relative to the complexity of the re-agent. Cold makes the fluid in a thermometer contract. Nevertheless, the fluid rises for an instant when a thermometer is dipped in cold water, and drops when the thermometer is dipped in boiling water. This contrary effect is difficult to foresee unless demonstrated by experiment. How does it arise? Because the patient/re-agent, that is, the thermometer containing the liquid, is composed of two parts, 1. the tube and 2. the liquid; it is not a single thing. When the tube expands, therefore, the liquid must drop and vice versa. But the action of the cold and of the heat is communicated first to the tube, and only an instant or two later to the liquid.

Note the kind of opposition here. There is apparent antagonism between the tube and the liquid. When both are warmed, the tube expands and makes the liquid drop; at the same time, the liquid expands and tries to rise. But the prevailing effect, although usually taken as the effect of the agent, is in fact the difference between two contrary effects produced by the same agent.
Fire expands things, but makes a ball of soft clay contract. Why? Because the ball of clay is composed of argil and water; the water expands as steam and allows the argilaceous parts, which no longer encounter an impediment to their mutual attraction, to pack more closely.

2. Relative to the complexity of the agent. The agent is complex when it results from substances having different properties; it can therefore give an unexpected effect.
Although the agent can be simple relative to the nature of the substance, the substance can act with different forces.

Air, acting on fire with chemical forces, clearly produces effects contrary to its action with mechanical forces. With chemical forces, it feeds fire by supplying hydrogen and oxygen; with mechanical forces, for instance, in the case of a sudden blast, it extinguishes fire. To imagine that only one of these forces was present in the air and conclude that air always acts on fire in the same way, would be mistaken.

Cold contracts bodies by removing from them the heat which keeps their molecules at a certain distance from one another. But water, which slowly contracts in proportion to increased cold, suddenly expands as it freezes. The same happens with sulphur, iron and other metals: they expand when passing from a liquid to a solid state during cooling.

Thus, 1. nearly everything used by a doctor to effect the human body is complex, because of its many component substances and the diversity of the chemical and mechanical forces with which it acts; and 2. the living human body, which is what must re-act, is even more complex. This depends on its various component substances, its properties, and the chemical, physical, mechanical and vital forces which act in it simultaneously, and often in contrary ways. Such different effects are often accompanied by real antagonism.

2132. The Treatise on Experimentation that I would like to see should descend to particulars and explain all the different classes of illusions which can result from the many substances and forces of the agents (remedies, curative method) and of the re-agent (human body).
This is still not sufficient however. Even if the substance and force of both agent and re-agent were simple, effects could vary and even be opposed to one another. Only the circumstances, that is, the accidents surrounding agent and re-agent, would change. The following observation is relevant here.

1. Vital forces. Their effect varies i) according to the condition of the matter on which they act, of the organisation, etc.; ii) if their action is considered as modifying mechanical rather than chemical forces, or vice versa; and iii) in so far as their spontaneity is aroused, or disposed to act.

2. Chemical forces. Every chemical substance acts in a different way i) in so far as it must act in another substance with which it has a given affinity or repugnance; ii) according to the proportion in which two or more substances are mixed together; iii) according to the way they are mixed, that is, according to their time, proximity, shape and all the accidents carefully observed by chemists; iv) in so far as it is an elementary substance or composed of several elements whose substantial union gives them new properties.

3. Mechanical forces. Time, speed, the laws of the communication of motion, the form, the opposition between forces, etc., are circumstances which produce opposite, contrary effects. A gentle gust of air can open a door; a bullet passes through it without opening it. The force in the bullet is more powerful than that of the air, but does not produce the same effect because of its extreme velocity. It leaves no time for movement to be communicated to the door. The tiny piece is torn from the door before the communication takes place.

In a word, all the elements capable of changing the effects of experimentation, or even producing opposite effects, should be listed. Finally, as a corollary, a clear solution to the following problems should emerge:
'What logical inferences can be drawn, or not drawn, with rigorous certainty from an effect obtained by experimentation?'
'What degree of probability is present in a conclusion drawn from the effect of experimentation when certainty cannot be obtained?'

2133. Synthetical medicine is helped therefore by those complex, mediate rules which, as we saw, constitute the wonderful sagacity of prudent people (cf. Development of the Human Soul, 1686-1697). These rules, which shorten the way to the solution of the most difficult and complex problems, have been followed by the most famous doctors of all times, who fought disease with wisdom and sureness of touch.

2134. Abandonment of these rules in favour of analysis of the primitive elements constituting the causes of diseases and their cure often resulted in the collapse of medicine and in cruel pain and death to suffering humanity. If however the rules are adhered to, research will gradually reach more specialised states, and progress will be assured and commendable. Thus synthetical medicine, which must never be relinquished, will gradually arrive at analytical conclusions; this is the only way possible of reconciling the two kinds of medicine. As far as I can see, analytical medicine can never hope to stand alone; it must originate from synthetical medicine; it will always be the difficult, hard and never completed coming to birth of synthetical medicine. This is the destiny of medicine.

Notes

(113) In addition to these two two points of view, the author of the Treatise on Experimentation should apply himself to unravelling the difficulties which arise from 1. the fact that the doctor can deal with only a few agents acting on or in the human body, and 2. the fact that there are only a few places of the body, that is, the internal and external surfaces of the body, where agents can be directly applied.

(114) The falsity is not properly speaking in the symptoms but in people who argue from them and draw unnecessary and illogical conclusions.

(115) The discussion concerns what characterises the illness up to this point, that is, the disease-effects which fall under observation. But if illnesses are to be classified according to their internal cause and nature, we would first have to know the cause with certainty, which is precisely what we are seeking. We should be aware of this difficulty if we are to avoid illusion.

(116) We must also keep in mind that these sick people, before being treated with a stimulant cure, were all treated for some time with a counter-stimulant cure. - Cf. Rasori's Teoria della Flogosi, bk, 2, cc. 4-5, for the difficulty of ascertaining the existence of internal inflammation.

(117) 'Although these vessels are clearly in a state of weakness, the weakness must be understood in the sense of a truly mechanical action, as in the case of a membrane which, even if lifeless, would lose some of its elasticity or aptitude to return to its first state by contraction, when excessively stretched or extended. From this we deduce that this kind of weakness must not be understood relative to the curative method and therefore conclude that the cure must be stimulating or, as they say, reinforcing' (Teoria della Flogosi, bk. 3, c. 1). - Note here that restricting the weakness of the inflamed capillary complex solely to mechanical action of blood seems to be a purely gratuitous affirmation, as I shall show later.

(118) Hastings, Philip Wilson, Treviranus and others removed a frog's heart and tied all the large vessels. After this, the blood circulated for a fairly long time in the natatory membranes. - Salandier, in 1820, suggested that circulation in the capillary vessels acts independently of the heart (Archives de dcouvertes et inventions nouvelles, 1821, p. 211 -Analyse des travaux de l'Acadmie des sciences pour l'an 1820).

(119) Note that the veins gradually diminish in volume as the circulatory movement ceases.

(120) Saggio di nuovi principii fondamentali per la Fisiologia, Patologia e Terapia, dedotti dall'Economia de'vasi capillari di Franc. Sav. Festler , etc., pt. 1, §4 (Padua, 1834).

(121) Teoria della Flogosi, bk. 2, c. 15.

(122) Dell'infiammazione e della febbre continua, pt. 2, c. 5.

(123) I think that the relatively greater flow of blood in the capillary network, although slowed in its course partly through the greater inertia of the vessels, partly through the alteration of the blood, partly by the pressure of the great quantity which obstructs the blood's ready passage, and partly by its adherence to the walls, certainly continues to produce continuous vegetation. Nor can we suppose that the capillary vessels re-act against this stimulus by subtracting sufficiently to repel it; the veins, particularly when weakened through reduced vital action, lack sufficient irritability for the purpose. Relative to John Thomson's opinion (that the action of the vessels of an inflamed part is much superior to the action of the heart and of vessels in other parts of the body, Lez. sull'infiammazione, bk. 3), I think I have to say: 1. that the increased action must be understood relative only to the effect of greater vegetation, an effect which must be attributed more to the congestion of the blood than to the activity of the vessels which, even if it existed, would not stop the blood but impel it on its way; 2. that a greater action must be acknowledged in the arteries which impel the blood in the veins even to the point of emptying them, as we see in corpses (this may be a primal, not a subsequent action), and finally 3. that the cause of the increased action is the severance of the active process in the inflamed part from the process of the body in general; the process, once cut off and left to itself, is by that fact a morbid condition and therefore excessive, even if only slightly so.

(124) Tommasini, ibid., c. 1.

(125) Teoria della Flogosi, bk. 3, c. 1.

(126) Tommasini describes different cases of this in Dell'infiammazione ecc., c. 4.

(127) Dell'infiammazione ecc., §29-30.

(128) Ibid., §32.

(129) As I have noted elsewhere, the word 'activity' has, for me, a very wide meaning: it is also found in an ens which suffers.