Clinical commentaries deduced from the morphology of the human body : part general

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Preface To The Second Edition

In this edition I have retained the dedication which I made of the first to the illustrious Charcot, for two reasons :

First, because the sentiments which induced me to dedicate to him the fruit of my long and fatiguing work have ever since remained active in me, and because the encouragement which I subsequently received from him also in academic form has almost imposed upon me the duty of honouring his memory.

Secondly, because the general conceptions which I expounded in the dedication transport us, I think, into that historical and philosophical atmosphere from which I started, and in which resound the pure and perfectly harmonious notes of classic empiricism and naturalism from which the scientific thoughts of modern medicine were gradually composed. Hippocrates, Malpighi, and Virchow indicate the most luminous epochs of the history of medical thought. Hippocrates, from the philosophy of Pythagoras, that can be called the germ of the positive philosophy of our day, drew the principle of harmony, of universal conspiration, of the equilibrium of the organic forces, to enable him to observe and reason about the facts of human Physio-pathology, and which forms the first code of our science. To this code Malpighi, by intuition of genius, was attracted, though against the tendency of his time, as he tells us himself. Malpighi, of whom Haeckel says that few biologists can equal him in his profound capacity for research, and in his wide philosophical comprehension— Malpighi interprets the Hippocratic mind, and from the contemplation of the organic actions sought in the Three Anatomies (vegetable, animal, and human) soars to the luminous visions of pathology, and dictates the following sentence, which adumbrates the theory of evolution : “ The things of Nature , though they seem very unlike, still , when considered with exactness vn

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PREFACE TO THE SECOND EDITION and maturity , are found to be not so disunited that one cannot observe a concatenation and uniformity of working, and therefore they reciprocally illustrate one another. Virchow, a splendid emanation of the times thus prepared, has the clearest vision of the origins of a great part of pathology and of the evolution of organic forces, when he affirms that the abnormal development of the organs is the object of necessary investigations for solving the difficult questions regarding morbid dispositions , and when he says that every ethnological form finds its equivalent in general pathology.

In reality, the modern morphological method is founded exclusively upon experience concerning the facts of the organization of Beings, and is directed by the doctrinaire conceptions which from them are legitimately derived.

Morphology has also suggested the quantitative study of Beings, and relatively to Man, with whom we must occupy ourselves, I maintain that Morphology has united to itself somatometry for the positive verification of the Individuality according to physiological and pathological requirements.

Thirteen years have elapsed since, following this scientific method, the first edition of this book was published. To-day it is satisfactory to me to know that similar conceptions have not only been confirmed, but also fully approved by able Italian biologists, such as Camerano, Andres, Ficalbi, Grassi, and others.

And I am equally pleased that these thirteen years have been as many years of control to the somatometrical method introduced by me for the verification of the human individuality, though the work especially of my pupils and of others.1

Therefore I think that every clinical investigation should be conducted on the basis of the individuality morphologically verified, for every other verification of the facts and phenomena in relation to doctrine and practice in their turn in every concrete case individualize themselves, or, to speak better, present themselves, not such as they may be according to the data of

1 I have much pleasure in recording here the names of the able doctors Massalongo, Pennato, Pugliesi, Remor, Romaro, Nalin, Chiaruttini, Messedaglia and Vainanidis, Rothschild, Lolide, Surgeon -Captain Ostino with Lieutenant Gilardoni, Galdi ; Viola, who is about to publish a book which will do him credit ; and Professor Castellino, of the University of Naples ; and Gregoracci — warm supporters of the morphological method.

PREFACE TO THE SECOND EDITION

IX general biological experience, but such as they must be in the morphological type of the individual under examination.

Medicus minister natural. In this expression are contained a precept and a programme : one remembers that the action of the physician must always correspond to the requirements of the nature of the patient, and that he must study the natural laws which govern the organization of individuals in order that he may be able to understand their association and mechanism, as well as the mode of reaching by their means the supreme aims of the science. It is not the histological or chemical or anatomico-pathological particular, but all this in the environment of the Individuality, morphologically understood, which must preoccupy us in our scientific and humanitarian work, because the law of Harmony, of Universal Conspiration, of Equilibrium of Organic Actions, presents in every human individual infinite varieties of actualization.

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Contents

PAG E

Dedication --------- v

Preface --------- vii

Introduction -------- 1

Part I

The Anatomical and Etiological Diagnoses are Insufficient for the Supreme Scopes of the Clinic, if they are not, assisted by Morphology -------- 17

The Morphological Doctrines contribute to the Reform of the

Medical Art - - - - - - - - 24

PART IL

Morphology contributes to the Doctrine of Pathogenesis - 42

I. A Glance at Teratology - - - - - - 43

II. A Glance at Comparative Anatomy and Physiology - - 48

1. Bony System - - - - - -51

2. Vascular System - - - - - - 55

3. Nervous System - - - - - - 66

4. Muscular System - - - - - - 77

5. Digestive and Nutritive Processes - - - - 79

PART III Method proposed for Determining the Individual Morphological

Value or Type - - - - - 98

I. Measurement - - - - - 98

Generalities on the Morphology of the Vertebral Column - 152

Notes on the Morphology of the Extremities - - - 160

II. Inspection -------- 162

1. Lymphatic Glands - - - - - - 162

2. Fat and Panniculus Adiposus - - - - 166

3. Subcutaneous Veins - - - - - 170

4. Arteries and Capillaries - - - - - 174

111. Anamnestic Examination - - - - - - 199

1. Notes on the Criterion of Inheritance - - - 200

2. Functional Attitudes of the Nervous System - - 208

3. Notes on Instinct, Habits, and Idiosyncrasy - - 211

xi

CONTENTS

XI 1

PAGE

IV. Morphological Examination of the Heart - - - 216

1. Insufficiency of the Plexic Examination and of the Averages 216

2. Method for the Morphological Examination of the Heart - ' H

V. Examination of the Abdomen - - - - - ^

1. How to establish the Development of the Liver - - 240

2. How to recognize the Development of the Intestine - 244

3. Rules, founded upon Clinical and Anatomical Observations,

for judging the Development of the Liver, Kidneys, Vena Portae, and Vena Cava Inferior .... 240

PART IV Application op the Method, and Explanation of the Fundamental

and more Frequent Morphological Types - - 256

I. Epilogue of the General Principles of Morphology and Physio-

pathology, constituting the Key of the Method - - 256

II. First Morphological Combination - .... 258

(a) Modifications regarding the Heart - - - 272

( b ) Changes regarding the Thorax - - - 282

(c) Changes regarding the Abdomen - - - 285

III. Second Morphological Combination .... 296

(a) Changes regarding the Heart - - - 309

(b) Changes regarding the Thorax - - - 313

(c) Changes regarding the Abdomen - - - 313

3. Plethora according to the Conceptions of Morphology - 319

IV. Third Morphological Combination ----- 353

Morbidity of the Third Combination considered in its Relations with the preceding Combinations - - - 360

Abdominal Lymphatism ..... 363

The Third Combination presents Different Morbidities, according to whether, owing to its Thoracic Development, it shares in the Morphological Characters of the First or of the Second Combination - - - 381

Diseases of the Locomotor Apparatus - 386

Diseases of the Abdominal Apparatus (Intestine, p. 390 ;

Liver, p. 394 ; Kidneys, p. 401 ; Female Internal Genital Apparatus, p. 402) ..... 389

Diseases due to Anomalies of Metabolism - - - 406

The Function of the General Medical Clinic in Biological

Investigations - - - - - - -418

THE

MORPHOLOGY OF THE HUMAN BODY

Even in the first years of my medical education I recognized that medicine had entered into the fellowship of the natural sciences, and one demonstrated it adducing the very valuable conquests of the microscope, chemistry, physics, and the experimental method.

During these first years I watched enthusiastically the rising of the new sun : the cellular 'pathology was the necessary foundation, the vital environment of medical science.

Dwelling upon the hypotheses derived from the new truths, I became convinced that medicine must be considered as a branch of zoology, or — to use an expression of Topinard — of zoological anthropology, which is the study of the human group considered in its relations with the rest of organized nature ( Elements d' Anthropologie generate , p. 185, Paris, 1885). Further, passing from the professional teachings to the field of practice, I became aware that this was not conformable in every respect to the modern naturalistic method.

Although I treasured up every new cognition of anatomy, physiology, and semeiology, at each step I found myself confronted by the same unknown ; the most subtle analyses, though they were suitable for enabling me to conceive the concrete idea of morbid states, were not sufficient to enable me to understand precisely diseased man. Very frequently, after having pondered over my work, and having made use of every means known to the science and art, I had to content myself with concentrating my thoughts in words which expressed the unknown much more than the known — in the words constitution , temperament, individuality, predisposition.

And my mind after long meditations became more and more convinced that medicine, as part of zoology applied to man, required a method for arriving at the scientific knowledge of the Individuality, without which constitution, temperament, predisposition, would always remain vain expressions, very obscure problems.

To us, introduced to the science in the early days of the revival of medicine in Italy, the theories of natural history were not explained. This was nothing but a dry emanation of names and of external characters; when, on the contrary, with the demonstration of the main facts of Nature the fundamental principles of the organization— the biological law — should have been explained to us.

Being ignorant of this, I awaited from the progress of the science the explanation of the problems which daily confronted me. In 1806 — that is, four years after I had obtained my degree — there fell into my hands a book whose title, as well as the name of the author, recommended themselves to me. This was food to my curiosity in my leisure hours, and thus I became acquainted with the Philosophic zoologique of Lamarck.

The study of this book, though I was incapable of criticizing its particular doctrines, including the fundamental conception in its entirety and importance, produced a revolution in my scientific ideas which equalled that already brought about by Cabanis in the order of psychological ideas.1

The theory of descent enabled me to understand the transformation of species, the law of adaptation, that of atavism, and the natural history of creation — conceptions which were nourished and enlarged by later studies.

And in the meantime I meditated on, and interpreted in every sense, by means of physiological and clinical observations, the passage of Lamarck which says : “ Every individual after birth

1 When reading Lamarck, there recurred to me some facts concerning comparative anatomy which I gathered from that incomparable teacher, the celebrated anatomist Panizza, whose memory, if it be recorded in imperishable scientific monuments for his classical anatomical researches on man and animals, I would wish also to be recorded for the trouble which he took, on every occasion that the subject of his lecture gave him, to demonstrate the facts which are the foundation of the scientific conception of phylogeny. Therefore one can say that he was the able precursor of the reform in the teaching of anatomy expounded to physicians as the basis of the naturalistic culture necessary for them.

finds himself in the midst of special circumstances which contribute to render him what he is in the different epochs of life .”

The very obscure problem referred to above — namely, that regarding the study of individuality — acquired in my opinion more and more importance, and medical practice demonstrated to me how urgent its solution was.

While admitting the weak side of the doctrine of constitutions and of temperaments, nevertheless I maintain the justice of the practical views which have led so many able minds to conceive and to reform many times that doctrine.

Whenever and under whatsoever form one meditates on it, one will feel the necessity of trying to study the individuality .

I was very soon convinced that the polemics between the new times and the old must be given up ; that as regards these doctrines it was necessary to separate the facts from the words, to discover in the spirit of the positive observations, dimmed by strange scholastic delusions, the clear allusion to the laws of individual organization.

Further, although one knows exactly the histology and physiology of the nerve, muscle, lung, connective tissue, glands, etc., and makes use of such knowledge for describing the organs and functions of every individual, one does not yet know how it is that from the fusion of these elements originate individuals who, when compared with one another, present infinite physiological variations — originate those individualities possessing a particular constitution and temperament.

If the classification of constitutions and of temperaments be based on fictitious scholastic conceptions, the classification is cancelled, every aprioristic or even premature classification is excluded. But in the natural morphological characters one studies those complex individual conditions through which every individual is what he is — a variety of the species.

Dominated by such thoughts, I passed my years of clinical study independently of the school and of the teachers, observing and registering everything which tended to prove the practical interest of my thesis, or offered itself to me as an argument favourable to its development.

In 1876, in an article on chronic diseases ( Cenni suite malattie

1—2 croniche e dei vecchi : Gazz. med. ital. lomb ., serie vii., tom. iii.), 1 referred to those special dispositions oft he organism whose study includes whatever remains to be known regarding constitutions. And I declared that to reach the knowledge of these we had to grope with the mind loaded with new facts into the series of problems which concern the history of organizations .

In 1876 also I published my studies on a part of the nervous system (Patologia del simpatico , Milano, Tipografia Fr. Rechiedei), in which I showed that this was one of the morphological elements which co-operate in the manifestation of human constitutions besides their normal and pathological variations.

At p. 49 of the above-mentioned book I say : The phenomena which each individual presents may offer peculiarities in number, extension, etc. And this fact, recognized by all physicians in every epoch, depends not upon the conditions inherent in the chemistry of the organism, but upon the organization and anatomical distribution of the nervous system through which healthy individuals are differentiated from one another , and the factors that give rise to the symptoms vary.

Further, at p. 195 and following pages I give clinical facts as well as others scattered throughout the work for the purpose of proving the truth of my proposition.

On the basis of my observations and analyses in those pages I proposed the name by which I wished to indicate that special condition of the nervous system owing to which it occurs that individuals feel and react differently to the causes and stimuli which affect them : and I proposed that this special condition should be called nervous idiosyncrasy , which I divided into permanent and transitory. I connected the former with the primary organization, or with irremovable morbid conditions in the centre of innervation; the latter with temporary causes, which may influence directly or indirectly that centre or a part of it. Therefore in every concrete case idiosyncrasy may also be the manifestation of a very circumscribed part of the nervous system.

In 1878, discussing the pathogenesis of gout and of chronic rheumatoid arthritis ( Annal . univers. di med. e di chir.,v ol. ccxliii.),

I made new applications of the physiological conception of nervous idiosyncrasy', and explained the pathogenesis of the gouty diathesis, connecting it with the morphological conditions of the individual and with their changes depending on the mode of life.

In February, 1879, in a preliminary communication on the symptoms of pulmonary phthisis ( Rendiconti del R. Istituto lombardo di scienze e letter e), I made ample application of these principles demonstrated by irrefutable facts, which later on I more fully expounded in another publication ( Pulmonary Phthisis , Tip. Detken, 1882, Napoli) to show that not only the symptoms of the disease, but also the predisposition to it, were connected with the special morphology of the individual.

In 1879 also, in my introductory lecture to the course of clinical medicine at the University of Padua, I spoke of the Aspirations in the Method of Clinical Investigation (see Bollettino scientifico, anno I., Pavia), which will reach final perfection when the knowledge of the laws of organization will suitably co-operate in the study of healthy and of diseased man.

And in the following year, describing the results of the investigations which I had carried out for some time, I explained the method of clinical anthropometry directed to collect the anatomical data that, together with the physiological criteria, must lead to the knowledge of the morphological type in the concrete case, and I showed the perfect agreement between many facts of clinical tradition and the results of actual researches. Therefore I maintained —

1. That the cause of the special morbidity of organisms resides in their special morphology .

2. That the same principle which explains the formation of the organs , of the organisms and their function , explains the anomalies of form and of function that the organisms present during the periods of life ( La morfologia e la clinica : Gazzetta medica ital. della prov. ven., No. 50, 1880).

In 1880, in an article entitled Some Clinical Facts concerning the Pathology of the Heart and the Stomach ( Giornale inter - nazionale of Naples), I brought forward facts and considerations which induced Dr. Patella to write a judicious memoir on A New Element regarding the Pathogenesis of Heart Affectioris.

In the same year and successively I published Notes on Morpho logical Studies of the Human Body as a Contribution to the Clinic {Bollettino scientifico above mentioned), aiming to prove if and how the special morphology of organisms constitute the basis of their special morbidity ; how it happens that the same diseases present so many nosological varieties ; how by means of clinical anthropometry one can recognize some fundamental morphological causes which govern the morbidity of the individuals.

In my clinical lectures I introduced methodically the criteria of anthropometry as a contribution to the study of pathogenesis, and in all my scientific writings I refer more or less clearly to the data of morphology and its applications to clinical medicine. I mention among others those on the alterations of the ascending vena cava and of its physio- pathology , that on the treatment of abdominal scrofulosis (see De-Giovanni, Commentari di clinica medica, Draghi, Padua, 1889).

I hope the courteous reader will pardon this recapitulation. It has a threefold scope :

1. Having to deal with a difficult subject, it was necessary to give the proofs of the long study to indicate the point of departure and the many pathological facts on which I dwelt to obtain arguments useful to my theme.

2. To justify the citations which in the course of this book I am obliged to give of my writings. They having been almost all completed under the inspiration of the general principles of morphology, I shall draw from them facts and judgments which must concur in defining the general principles of its application to the clinic.

3. To insure me the advantage of priority. Very frequently in the farrago of the press some were lost which subsequently had to be re-presented by way of vindication. Then at times, owing to the idea of the author not having been sufficiently developed, the facts were neither accepted nor appreciated. Thus, what is called the right of priority fell into oblivion.

I have also had to claim this right for other works of mine. I cite by way of example that on the Pathogenesis of Arteritis ; that on the Contractile Red Corpuscles , described by me in 1870 ; and for others briefly mentioned, however slight and controvertible may be their value, I have special tenderness.

Therefore, for the little or no account in which most of my writings have been held up till now I would wish to compensate myself, showing that they are flashes — pale, it is true, but repeated — of the light which the new naturalistic views have shed upon the clinic.

I would wish this all the more because, at the very time in which I desired to expound my studies to workers in clinical pathology, I have seen others bringing forward identical scientific conceptions, and substituting for other disciplines those aspirations which for many years I have followed indefat igably in the investigation of diseases.

I allude not to the researches of Virchow ( Ueb . die Chlorose, etc., Berlin, 1872), nor to those of Tuczek (of which I do not know the original, and which combine with the preceding), but to the accurate, patient, and interesting anatomical researches of Beneke ; to those of Thoma ( Untersuch . iib. cl. Grosse u. d. Gewicht d. anatomisch. Bestandtheile d. menschlich. Korpers, Leipzig, 1882), in which is maintained the same principle which I have introduced— namely, that of the variation of the individual, and the importance derived from it in the scientific study and practice of medicine;1 2 and to those of Schile-Viegand (Virchow's Arch., B. lxxxii., p. 27) and of Hermann v. Hosslin (Arbeiten aus dem pathologischen zu Miinchen, herausgegeben v. Bollinger, p. 359 et seq., Stuttgart, 1886), although contradictory to the former.

I have said that the cause of the special morbidity of the organism resides in its special morphology .

If the reader will reflect on this sentence, and apply it to clinical pathology, he will perceive in the fact of organization the doctrine of constitutions and of temperaments, or, according to Thoma, the theory of individual differences r

I consent to follow the path taken by the great masters, and with the facts of the new science I will illustrate the indestructible axioms of physiology and pathology, by which has been transmitted to us, and after us will be transmitted, the best part of their work.

1 Thoma proposed to found upon anatomical and other data a theory according to which it would be possible to determine mathematically the normal and the variant of the individual organization. Although I see the grave difficulties of these studies, and the little utility which at present the clinic can derive from them, still, I must applaud the initiative of my Heidelberg colleague, hoping that meanwhile his studies will enable it to be understood that medicine can assimilate the conceptions of natural history.

2 Anthropology recognizes the necessity of studying the extent and nature of individual variations before deciding on the variations of races. This study is very difficult, says Topinard, and requires a delicate method, which, however, does not lessen its importance. The growth of the organs and the evolution of forms constitute its fundamental part, and it is also that which highly interests the physiologist and the pathologist.

If we interpret our sentence with the necessary broadness of view, the conception of medicine as a branch of zoology will appear in its true expression, and the factor of heredity, of adaptation, and that of anatomical and physiological correlations which co-operate in the genesis of infirmities, will declare themselves more clearly.

After all, when in presence of a patient we consider the problem of the diagnosis, when we endeavour to discover the reason of his special manifestation, and to trace this back to his intimate morphological condition, we shall feel the necessity of a new means for clinical investigation, of a means which will reveal how the organs and apparatus are mutually associated, how they influence one another, how finally that morphological value, that physiological and pathological variation, constitutes itself in the individual.

No one would wish to maintain that the method of clinical investigation commonly followed is in every way excellent or is truly naturalistic in every respect.

With the increase and improvement in our knowledge our aspirations become greater and more concrete — our intentions must have higher aims.

The application of general conceptions alone to the origin of the morbid processes which are being revealed to us by pathological anatomy and experimental pathology do not fully satisfy the requirements of the clinic, nor are the results of the objective examination and. of the anamnesis rigorously instituted sufficient for it.

Even when we have worked wisely searching for and interpreting the history and symptoms, we desire to know another thing — namely, that owing to which the actual case is always new and problematic to us.

Therefore I maintain that the clinical method must be improved by the results of modern morphology.

While not presuming that the results of my modest observations are sufficient to perfect it, I trust that in what I shall expound pathologists will find at least some just views, some facts not destitute of value — an initiative, perhaps, superior to my capacity, but thought out and founded upon undeniable scientific conceptions, for they are corollaries of infallible biological laws.

My timidity, it is hardly necessary to confess, comes from my being alone in the new and difficult contest. However, I am comforted and stimulated by a thought which Lamarck, understanding the difficulty and the novelty of the matter of which he had to treat, wrote in the preface to his book already mentioned. It is as follows : “ Les autorites en fait de connaissances doivent s'apprecier et non se compter ; quoique, a la verite, cette appreciation soit tres difficile

Although my work may be considered imperfect, still, I have the profound conviction that it is placed on a scientific path to which future studies will converge ; and, however humble may be the judgment of it, I shall be contented to have raised questions which stronger and more fortunate minds than mine will solve to the advantage of the science and humanity.

Part I

The point of departure of my studies, as I have said in the introduction, was a fact of very common observation known to all physicians — namely, that the same disease in different patients may present different clinical appearances .

In every morbid case it would be necessary to have present, besides the theoretico-practical knowledge of the malady, the knowledge of the circumstance by virtue of which it acquires special form and colour ; the knowledge of those special individual attributes or characters that justify the inadequately interpreted axiom which says not diseases, but individual patients, must be treated.1

The above-mentioned fact corresponds to another of physiology

1 The illustrious French clinician, Jaccoud, in one of his later publications ( Lecons cliniques faites a VHopitol de la Pitie 1886-87, Paris, 1888), says almost that he would wish to adopt the above axiom as the motto of his school : “ . . . ma constants preoccupation a etc la comparaison des types cliniques individuels avec les types pathologiques abstraits, cette etude comparative etant V essence meme de la clinique medicate.'' Doubtless the preoccupation of the illustrious Jaccoud is that of all the physicians, who, though endowed with some culture, are not in the least observers. Besides, that which has been the preoccupation of Jaccoud is, as I have already mentioned, a fact of very common observation. Nevertheless, it will not be useless to have recorded what Jaccoud has recently written, especially as, according to his own testimony, new knowledge can be derived from knowing how to individualize the clinical fact. And now I ask the illustrious Jaccoud, Must we be always content with the verification of the individual clinical types ? or cannot something else be derived from the notion of the variety of clinical types ? For example, the scientific task of at least initiating investigations for the interpretation of the individual clinical types. I shall be delighted to discuss this point with the illustrious Jaccoud, who, after having for so many years illuminated the obscure career of the clinic with his splendid clinical teachings, certainly will have understood that the nosological varieties are infinite, and that to the clinician are necessary scientific principles and rules of practice capable not only of enabling him to recognize the clinical individuality, but also of indicating its scientific reason and physiological mechanism.

— namely, that in the variety of the human species, besides the races, the individuality is distinguished.

And all this corresponds to the principle proclaimed by biology, — namely, variety is the law of the being .

Wherefore, in the presence of the sick man — that is to say, in the presence of the nosological variety — one feels the necessity of possessing first of all exact knowledge of the individual on whom one has to investigate the genesis of the morbid state and the mechanism of the symptoms.