I call by this name those, in which the exhalants pour out a fluid
different from that which is natural to them. The first which offers is
that of the blood.
_Sanguineous Exhalation._
The blood frequently passes off by the exhalants instead of their own
fluids; hence arise hemorrhages very different from those that take
place from rupture. I shall examine these hemorrhages in each kind of
exhalants.
_Hemorrhage of the Excrementitious Exhalants._
The vulgar expression which is sometimes used, to sweat blood and
water, &c. indicates that under certain circumstances, though they
are very rare, the cutaneous exhalants give passage to the blood.
Haller has collected a number of instances of it, that may be found in
his work. The first year that I came to Paris, I saw constantly with
Desault, a woman with a cancer of the womb, who had at certain periods
sweats that stained her clothes as much as is ordinarily done by the
catamenia. This woman had had frequent hemorrhages before the beginning
of her disease. After these sweats commenced, they had continued but
were more rare. I regret that I neglected to collect the particulars of
this singular fact.
No exhalants pour out blood more frequently than the mucous; so that
hemorrhages are an affection almost characteristic of the mucous
surfaces, in which they have different names, according to the portion
of them that are attacked. It is not my object to present here the
phenomena of these hemorrhages; I only wish to prove that they are an
exhalation.
1st. I have very often opened subjects that have died during a
hemorrhage; I have had occasion to examine with this view the
bronchial, gastric, intestinal and uterine surfaces; I have never
seen the least mark of erosion, notwithstanding the precaution of
carefully washing the surfaces, of letting them macerate and even
examining them with a glass. 2d. The following experiment uniformly
succeeds upon the wombs of women who have died during menstruation,
and often even at other times; by pressing them, there issues from the
mucous surface a greater or less number of little bloody drops, which
evidently correspond with vascular extremities, and being wiped off,
no erosion can be seen. 3d. The analogy of all the other open surfaces
that pour out blood, and which evidently do it by their exhalants,
is a proof that the same phenomenon has the same seat in the mucous
surfaces. 4th. The womb would be only a mass of cicatrices in females
of advanced age, if there had been a rupture in it in menstruation.
5th. In active hemorrhages, in which there is evidently a congestion of
blood previous to its escape, we can conceive, to a certain degree of
the rupture of the small vessels; but in passive hemorrhages, in those
in which the organic sensibility being annihilated, seems to allow of
a simple transudation through the exhalants, how can we conceive of
these ruptures? 6th. We understand with difficulty how an evacuation,
which is often produced with an extreme rapidity, which ceases in one
place and immediately appears in another, which is subjected to all
the sympathetic influences, we understand, I say, with difficulty how
it can happen from rupture. 7th. Observe menstruation, furnishing
sometimes for one moment blood, and not giving it the next, renewing
twenty or thirty times a day, in certain affections, these alterations
of flowing and ceasing to flow; it would be necessary then, that at
each time the wounds should open and be cicatrized. 8th. Besides,
compare hemorrhages evidently produced by rupture upon the mucous
surfaces, such as those, which in wounds of the head, take place from
the nostrils, the ears, &c.; those, which by a fall upon the rectum,
sometimes happen from the bladder; those which, in too great efforts in
coughing, arise upon the bronchial surface; those of which the stomach
is the seat from the action of different poisons, &c. &c.; compare, I
say, these hemorrhages, and many analogous ones that I could mention,
with those that take place spontaneously from the mucous surfaces; you
will see that they do not resemble them in their phenomena and their
duration; that by suppressing them, they do not give rise to others;
that they are independent of all kinds of sympathetic influence; that
the passions have no effect upon their cessation or their production,
whilst they have so powerful an influence upon the others.
Let us conclude from all these considerations, that all mucous
hemorrhages, whether active or passive, are real exhalations. Hence
you see that there is not so great a difference as might be thought,
between the first and inflammation. In fact, in one there is an
accumulation of blood in the capillary system, then the passage of this
fluid by the exhalant vessels, that are continuous with this system. In
the other, there is only the first phenomenon. Undoubtedly the signs,
the circumstances, &c. are wholly different, because the modifications
the organic sensibility undergoes are not the same; but the state in
which the small vessels and the blood are respectively found, is not
less analogous. One proof that in active hemorrhages, it is the organic
sensibility which, differently modified, opens or closes the passage
to the blood by the exhalants, is this, that almost always there are
previous symptoms which continue for some time, and which evidently
declare the disturbance that the vital forces, the organic sensibility
in particular, experience in the part; we know the itching, the
forerunner of nasal hemorrhages, the tickling and sometimes sense
of heat which precede the pectoral. Sometimes, according to the
varieties of alteration it undergoes, the organic sensibility at first
permits serous fluids to pass, then bloody; this is what we see in
menstruation, in which the exhalants oftentimes pour out serum for some
minutes, then true blood.
In passive hemorrhages, the organic sensibility is without doubt
diminished, as well as the tone or insensible organic contractility.
We might say, that the small vessels were not able then to contract
sufficiently to retain the blood; it is as in our injections which
ooze from the mucous surfaces, because life no longer opposes their
passage. Observe that when these hemorrhages are produced by an organic
disease, it is almost always that portion of mucous surface nearest the
organ, that is influenced by it. Thus in the last stages of disease of
the heart or the lungs, the patients often spit blood; they pass it by
stool, towards the termination of those of the liver, or even throw it
up by vomiting, &c. The whole mucous system never loses its forces so
as to pour out blood everywhere; it is only in a determinate part that
it is weakened.
What disposes the mucous exhalants more than all the others to pour out
blood? It appears to be because the capillary system whence they arise
is constantly entered by blood, and the course is very short from this
fluid when present in the capillaries to the mucous surfaces. This is
so true, that those portions of the mucous system that have but little
of this fluid in a natural state, as those of the sinuses of the face,
of the ear, &c. are less subject to hemorrhages. I am confident, that
if there were exhalants upon the muscles to pour out constantly a fluid
upon the exterior of these organs, hemorrhages would be very frequent
in them.
Hence we see that the mucous hemorrhages have nothing in common,
but the extravasation of blood, with those which are the effect of
hemorrhoids, and always suppose a rupture of the veins, with those
that aneurisms or varices produce, with those that are the effect of a
cut, of a violent concussion, &c. They form a class by themselves, and
resemble those only that the exhalants furnish upon the other surfaces
where they open.
If I should class hemorrhages, I should distinguish them, 1st, into
those that come from exhalation; 2d, into those that are produced
by rupture. I should place among the first the bloody sweats, the
mucous, serous, cellular hemorrhages, &c.; among the second, those that
accompany wounds, aneurisms, &c. In order to embrace in one view all
the sanguineous evacuations that can happen in the animal economy, I
think it absolutely necessary to adopt this division which moreover
accords with the phenomena and treatment of hemorrhages. Would you
bleed to arrest a hemorrhage from rupture? undoubtedly not; but you
would bleed to check an active hemorrhage by exhalation, because by
diminishing the mass of blood, you diminish the excess of organic
sensibility which produces the hemorrhage; it is nearly the same as
when we bleed for inflammation. It is certainly necessary that the
hemorrhage should be stopped as it has been produced; it is necessary
that the sensibility of the exhalants should return to its natural type
before the blood ceases to flow. We do not bleed to draw the blood
to another place, as has been said; if it was so it should be done
in passive hemorrhages. Most of those who bleed much in hemorrhages,
believe that plethora is the sole cause that produces them, that the
vessels containing too much blood, require a part of it to be taken
away; but there are many more cases of active hemorrhage in which
there are no signs of plethora, than there are of those in which these
signs exist. There may be a real deficiency of this fluid in the
great vessels, but if the exhalants of a part are by their peculiar
sensibility in relation with it, they will pour it out in as great
abundance as if there was an excess of it. It is as in the increase
of natural secretions, exhalations, &c. Whether there was plethora
or not in the great vessels, when the local affection has raised the
peculiar sensibility of the secretories or the exhalants, they would
draw abundantly from the blood. The influence of plethora upon the
increase of the different fluids which are separated from the blood,
is evidently one of the remains of the opinions of Boerhaave. If the
heart agitated everywhere the fluids, if it propelled the blood, the
serum, &c. that go out by the exhalants, the, secreted fluids that go
out by their ducts, this influence would necessarily be real; but since
all the fluids going from the capillary system are necessarily beyond
every action of the heart, as in their circulation, they are wholly
under that of the organic sensibility and tone of the capillaries,
it is evident that these fluids are independent of the quantity of
blood contained in the great vessels and moved by the heart; that the
alterations of the vital forces of the part are the sole causes of the
different phenomena that their course exhibits.
Who does not know that feeble and delicate temperaments are often
subject in women to a much more copious menstruation than those that
are stronger, more vigorous, more sanguineous, as it is called? You
will find many results in authors, upon the quantity of blood evacuated
by the catamenia, and you will observe at the same time that these
results do not resemble each other; why? because each womb has, if you
may so say, its own temperament, which oftentimes does not correspond
with the general temperament, because each is disposed consequently to
a different kind of vitality. There is more or less blood then given
at each menstruation, as it is given for a greater or less time, for
some women have at first only a serous fluid, while others have blood
immediately. I cannot repeat it too much, that every vital phenomenon
is necessarily subjected to many irregularities, which arise from those
to which the vital forces are themselves exposed. On the contrary,
every physical phenomenon is almost immutable, because it is the nature
of physical laws to remain always the same.
Hence we see how hemorrhages of the great arteries, which are under
the immediate influence of the heart, should differ essentially from
those of the capillary system and of the exhalants, whose phenomena
are under the influence of the forces of the part where they happen,
whether they arise from rupture or exhalation. Though in fact these two
classes may be essentially different in their principal phenomena, as I
have already said, yet they approximate, because the modifications of
the vital forces of the part have a necessary influence upon them when
they are in the capillary system. Thus astringents, tonics, styptics
and other medicines which evidently act upon the organic sensibility
and the insensible contractility, frequently stop hemorrhages of the
capillary system. The contact of the air, by modifying these properties
in wounds is even sufficient to produce this effect. On the contrary,
ligatures alone can, in the great vessels, resist the powerful
influence of the heart. All styptics imaginable may be heaped upon an
open artery, and they would not check the effect of this influence.
This then is the essential difference between the hemorrhages of the
capillaries and exhalants, and those of the arteries, that every
medicine which acts upon the organic sensibility and tone, can be
advantageously employed for the first, whereas they have no effect upon
the second. I go now to the sanguineous exhalations which are made by
the recrementitious exhalants.
_Hemorrhages of the Recrementitious Exhalants._
The serous membranes are the frequent seat of hemorrhages. The
examination of dead bodies incontestably proves it. Nothing is more
common than to find in the peritoneum, the pleura, the pericardium, &c.
a serum, reddish if a little blood is effused, very red if more, and
even pure blood is found under certain circumstances.
I have made these observations in two different cases, 1st. After
inflammations whether acute or chronic, especially the last. The serous
sac then contains a greater or less quantity of blood, sometimes alone,
more frequently mixed with serum, and now and then even with whitish
and albuminous flakes. The previous inflammation seems to rank these
hemorrhages among the active. 2d. Often at the end of organic diseases,
in which the exhalations of serum increase almost uniformly in the
serous sacs so as to produce dropsies evidently passive, a greater or
less quantity of blood is mixed with this serum. What anatomist has not
observed these bloody effusions in the pericardium, the pleura, &c.? I
have observed that the tunica vaginalis and arachnoides are infinitely
less subject to them than other similar sacs; I have never seen them in
the last, and twice only in the first. I of course do not speak of the
hemorrhages that are the effects of wounds of the head and in which the
blood is effused between the two folds of the arachnoides.
I have carefully examined the internal surface of the peritoneum, the
pleura, and the pericardium, after this kind of hemorrhages, produced
either in consequence of the inflammation of the membrane itself, or of
an organic disease; their surface has appeared to me to be perfectly
sound, so that it is very evident that the exhalants have furnished
blood, instead of the serum they threw out there before.
I compare a serous surface preternaturally pouring out blood after
inflammation, with the active hemorrhages of the mucous surfaces. On
the other hand, when the serous exhalants throw out blood at the end of
organic diseases of the heart, the womb, the lungs, &c. it is certainly
the same phenomenon, as when blood brought by the mucous exhalants,
under like circumstances, is thrown off by spitting, vomiting, or stool.
Are there cases during life, in which the blood, poured out by
exhalation upon the serous surfaces, is afterwards taken up by
absorption? I believe that it may happen after inflammation, though
we are possessed of no positive facts upon the subject. Cruikshank
and Mascagni have seen the blood absorbed by lymphatic vessels, after
wounds of the chest; why might not that happen after hemorrhages by
exhalation, which takes place after those from rupture?
The cellular exhalants frequently pour out blood in the cells. 1st.
This phenomenon is often very evident in phlegmon or in other similar
tumours. By cutting into them, in the dead body, we find blood
extravasated in the cells; this is so true, that some authors have made
the nature of inflammation consist in this extravasation. But in slight
phlegmonous inflammation, the blood undoubtedly remains in the cellular
capillary system; it is only in those cases where the inflammation
is very great, that this passage takes place. 2d. As to the passive
hemorrhages of the cellular texture, who does not know that oftentimes
the water in dropsies is reddish? who does not know, that in scurvy,
considerable portions of the cellular texture are infiltrated with
blood, which has certainly not been poured out by erosion? I injected
not long since two subjects, with very evident scorbutic spots on the
legs, and there was no kind of extravasation in them; there would have
been if the rupture of the vessels produced these spots. As these
things did not arrest my attention particularly in former years, I did
not pay much attention to many subjects that I have injected with these
scorbutic spots. I do not think that they would ever have presented
cellular effusions, which would undoubtedly have struck me if they were
there, when I dissected bodies for the students.
As to the hemorrhages of the medullary exhalants, we are ignorant of
them. I have never seen in examinations of dead bodies, blood effused
in the articulations, except from wounds, &c.
As to the nutritive exhalants, it is evident that every sanguineous
exhalation is foreign to them.
_Preternatural Exhalations, not Sanguineous._
The blood is not the only fluid that sometimes passes by the exhalants
instead of the fluids that these small vessels naturally pour out. Who
does not know how much the sweat differs? Sometimes water is almost
alone transmitted by the skin; at other times the sweat is filled
with many substances more or less heterogeneous; it is more or less
salt; we know how very different at times is the odour of it. Observe
the many substances that are thrown out upon the external surface by
the exhalants, in the small pox, measles, scarlatina, &c. in herpetic
affections, in different eruptions; compare the critical sweats with
those that are natural, and you will see that the exhalants are, if
I may so express myself, a common passage, which all the substances
contained in the body can pass through, and which in fact they do pass
through in certain cases, when, among the numerous modifications of
which the cutaneous organic sensibility is susceptible, they find those
that are in relation with them. Shall I speak of the serous exhalants?
observe that the surfaces of the same name, according as they are
affected, pour out many different fluids, a milky serum, and a thick
substance that attaches itself to their surface in the form of a
compact membrane, &c. If you have opened but little the bodies of those
who have died of chronic peritonitis, you must have been astonished
at the diversity of fluids then contained in the peritoneum. Grey,
yellowish, fetid, without odour, thick, viscid, thin, &c. &c. these
fluids are hardly twice the same. The serum appears to be always the
general vehicle; but the substances that it contains, by the effect
of the change that disease has produced in the vital forces of the
membrane, are infinitely variable.
Thus we shall see that the glands are a common way, through which pass,
according to the manner in which they are affected, many substances
which differ essentially from those that compose the secreted fluids in
the natural state.