Part 2

3d. What I have said of the serous exhalations, must be said of the cellular; some of them are active, such as those of pus and the serum that sometimes accompanies it; others are passive, as the leucophlegmasia after organic diseases. The same observation is to be made as before; there is an accumulation of blood in the capillary system in the first kind, a diminution of this fluid in the second. Observe the fatty exhalation; a man in health who is very fat, has a rosy colour upon the integuments distended with fat, which indicates the abundance of blood in the capillary system. On the contrary, in certain cases of sudden corpulency after diseases, in that which is called false fat, and accompanies weakness, a general paleness corresponding with the fatty bloating, indicates the absence of the sanguineous fluid.

4th. Mucous exhalations present also an analogous phenomenon. I shall prove soon that the hemorrhages from the mucous surfaces are real exhalations; now some of them are active, a name which Pinel has given them in his Nosography; these are the nasal, pulmonary, gastric, uterine hemorrhages, &c. of young people and even of adults. All these hemorrhages are accompanied by a local increase of action, by greater heat, by a deeper colour of the mucous membrane, by the greater abundance of blood in the capillary system. Who does not know, that Galen predicted a hemorrhage from the redness which he saw upon the nose and the eye of the patient? On the other hand, observe the hemorrhages of the mucous surfaces, which take place after long diseases, hemoptysis, which terminates the diseases of the heart, hematemesis, the effect of organic derangement of the liver, hemorrhages from the intestinal canal, so frequent at the end of all the long organic diseases of the abdomen, &c. nasal hemorrhages in certain low fevers, those which take place in scurvy from the different mucous surfaces, the gums especially, &c. all these hemorrhages, which are truly passive are not accompanied by this preliminary sanguineous congestion in the capillaries, by this increased activity of vital action; it might be said that it is the blood, which transudes, as in the dead body, through the pores, that have not power to retain it. This distinction is so true, that without making a theory of it, physicians conform to it in their practice. We bleed to arrest an active hemoptysis, but would you bleed to stop that which comes on in the chronic diseases of the thorax? The same observation applies to all the hemorrhages; they require means wholly opposite, according as they are active or passive; a remark moreover that is applicable to all diseases that have increased exhalations or secretions, whatever may be their seat. It is not the phenomenon that we are to resist, but the cause that has produced it. We diminish the forces, when serum is accumulated in the thorax, from a pleurisy; we increase them, when it accumulates from a disease of the heart, the lungs, &c.

What I have just said of exhalations applies to secretions. The mucous glands pour out a greater quantity of fluids in two ways, sometimes from irritation, sometimes from the want of force. When this happens in the intestines, there results from it in the first case a diarrhœa from irritation, in the second a colliquative one. Now it appears that the blood enters the gland in greater abundance in the one than the other case. Its increase takes place undoubtedly in most acute catarrhs, in which there is active secretion of mucus; its diminution or at least its want of increase is not less sensible in many chronic catarrhs, in which we may consider the secretion as passive. We know that the abundance of urine, of bile, sometimes supposes an increased, sometimes a diminished action of the kidney and the liver. Is there not a superabundance of semen from excess of vitality, and an unnatural flow from weakness? All the secreted fluids have the same arrangement; now according to these two opposite causes of the superabundance of the secreted fluids, the capillary system of the glands is certainly penetrated with a different quantity of blood. Though the phenomenon be the same, the treatment in the diseases in which it is manifest, is as in the preceding cases, wholly opposite, according as the local increase or diminution of life concurs to produce it.

_Consequences of the preceding Remarks._

From all that I have said, it is evident that in the organs whose capillary system contains in part blood, and in part different fluids, the proportion of the first to the others is infinitely variable; that a thousand causes in a state of health, as in that of disease, by bringing to the organ more or less blood, can fill more or less its capillary system.

The trunks and branches that go to an organ, are they more or less dilated, according as the capillary system of this organ is more or less filled with blood? For example, when the mucous glands pour out fluid in the greatest quantity, are the neighbouring branches more full? Some experiments that I shall mention hereafter do not seem to prove it.

IV. _Of the Anastomoses of the General Capillary System._

All that has been said evidently supposes a free communication established between all the parts of the capillary system; this communication is in fact clearly demonstrated by observation. When we examine a serous injected surface, of which the capillary system is full, we see that this system is a real net-work with fine meshes, and in which no vessel runs a distance of more than two lines, without communicating with others. The passage then, is constantly open between the portion that receives blood, and that which admits fluids differing from it. The same arrangement exists in the dermoid system, in the origins of the mucous, &c. and in general in all those in which the capillary system contains blood and white fluids.

On the other hand, the organs in which we find only white fluids, evidently communicate with those that are near them, and in which there is blood; those in which blood alone flows, have the same arrangement.

The capillary system must then be considered as a general net-work, spread throughout the body, which communicates on one side in every organ, and on the other from one organ to another. In this respect there is from the head to the feet a general anastomosis, a free communication for the fluids. It is in this way that we can conceive of the permeability of the body, and not from the cellular texture, in which the serous and fatty fluids alone stagnate.

As the arteries enter the capillary system, and as the veins, the exhalants, the secretories, go from it, it is evident from this manner of considering the capillary system, that all these vessels ought to communicate with each other; that by pushing a fine fluid into the arteries, it should go out by the excretories, the exhalants, and return by the veins, after having gone through the capillary system; this is in fact what takes place. In this respect, a thousand ways are constantly open for the blood to escape from its vessels, which communicate thus everywhere without, and do not present any mechanical obstacle to the blood in their cavity, which life alone retains within the limits of its circulation. The oozings after death through the exhalants, the excretories and the veins, are so well known, so many anatomists have related examples of them, that I think it unnecessary to give them in detail here. We have seen, then, fine injections pour out upon the serous membranes, upon the pericardium, the pleura, the peritoneum, &c. transude upon the mucous surfaces, even upon the skin. We have seen them flow through the ureters, the pancreatic, biliary, salivary ducts, &c. Haller, in the article upon each organ, has not failed to relate examples of this sort, which prove the communication of the arteries with all the other vessels, by means of the capillary net-work. What anatomist has not sometimes made even coarse injections return by the veins? The communication of these vessels with the arteries, through the capillary system, is now an anatomical axiom. At one time, it arrested much attention. It has been asked, if there was any thing intermediate between the arteries and the veins; inspection proves that the capillary system alone is there.

Hence it is necessary to represent the capillary system as a kind of general reservoir, in which the arteries enter on one side, and from which go out on the other side, in all the organs, the nutritive exhalants, in some, certain particular exhalants, as those of the sweat, the lymph, the fat, &c. in others the secretory vessels, &c. It is a common reservoir, if I may so express myself, in which the red blood enters, and from which the black blood, the exhaled, the secreted fluids, &c. go out.

This idea is not hypothetical; the injections of which I have spoken are the most evident proof of it. Let it not be said that it is a transudation after death, analogous to that of the bile through the gall-bladder: if it were so, not only the fine fluids injected would go out by the excretories and the exhalants, and return by the veins; but in oozing through the pores, they would fill the whole cellular texture. On the contrary, nothing escapes into the cellular texture, around the vessels by which the injection passes; there is then a continuity of tubes from the artery which has received the fluid, to the excretory, the exhalant, or the vein which transmits it.

These are the communications of the capillary system that explain how the skin becomes livid on the place on which a dead body has for a long time lain, as on the back, for example; how by turning a dead body, so that the head may hang down, it becomes full of fluid; how, on the contrary, by placing upright the body of one dead from apoplexy, asphyxia, &c. the capillary system of the face is freed in a great measure from the blood it contained; how an erysipelas disappears on a dead body, when the blood, arrested during life on a part of the skin, by the vital action, is spread after death to all the surrounding parts; how every kind of analogous redness of the skin, and even of the serous surfaces, disappears because the blood goes by the communications of the capillary system to the neighbouring organs. During life the tonic action retains the fluid in a determinate part; abandoned to its gravity, and other physical causes, after death, it soon disappears from the part in which it was accumulated, on account of the innumerable communications of the general capillary system.

I would observe to those who examine dead bodies, that these considerations are very important. Thus we must not judge of the quantity of blood which penetrated the inflamed peritoneum or pleura, by what is seen twenty-four hours after death; local irritation was a permanent cause that fixed the blood in the part; this cause having ceased, it escapes from it. A serous membrane may have been very much inflamed during life, and yet exhibit almost its natural appearance after death; as it is in erysipelas. I should have been often tempted from opening dead bodies, to deny the existence of an affection which had been real. The same remark applies to the inflamed cellular texture, the mucous surfaces, &c. Examine a subject that has died of angina, which during life gave the deepest red colour to the pillars of the velum pendulum pelati, to the velum itself and the whole pharynx; after death, the parts assume nearly their natural colour.

I would observe that in this respect it is necessary to distinguish acute from chronic affections. In the chronic inflammations, for example, of the pleura, of the peritoneum, &c. the redness continues after death, because the blood is combined, as it were, with the organ; it makes a part of it, as it makes a part of the muscles in a natural state. So the chronic affections of the skin, of the mucous surfaces, retain after death nearly the same blood, that they had during life; whereas in acute affections, the blood retained for a time by irritation, escapes when life has ceased, upon which this irritation depended. These principles can be applied to many diseases; I repeat it, they are of great importance in examining bodies. The neglect of them has often led me into an error, upon the degree and even the existence of acute inflammations, of which the organs that I examined had been the seat.

V. _How, notwithstanding the general communication of the Capillary System, the Blood and the Fluids differing from it, remain separate._

Since in the dead body, and consequently during life, there is in the capillary system no organic obstacle to the communication of the fluids through its small branches; since the general net-work that these vessels form is everywhere free, how does it happen that the blood does not pass into the part destined to the white fluids? how is it that these do not enter where the blood is to circulate? Why does not this fluid go out by the exhalants and the excretories, since these tubes communicate with the arteries by the anastomoses of the capillary system? This depends wholly upon the relation which exists between the organic sensibility of each part of the capillary system, and the fluid that it contains. That which carries the blood, finds in all the other fluids irritants that make it contract at their approach; and reciprocally, where the other fluids belong, the blood would be a foreign fluid. Why does the trachea admit air, and reject every other fluid? Why do the lacteals choose only chyle from the contents of the intestines? Why does the skin absorb certain substances, and repel others, &c.? It all depends upon this, that each part, each portion of an organ, every organic particle, has its own sensibility, which is in relation only with one substance, and repels others.

But as this kind of sensibility is remarkably subject to vary, its relation to substances foreign to the organ changes also; thus the part of the capillary system which rejected blood, admits it at the moment when its sensibility has been increased. Irritate a part of the skin, it reddens in an instant; the blood flows there; while the irritation continues, it remains; when it ceases, it disappears. Whatever be the external means which raise the cutaneous or mucous sensibility, we observe the same phenomenon. We can in this way bring more or less blood into some parts of the capillary system. Bring the hand to the fire, the heat exalts the sensibility of its system, more blood enters it; take it away, this property resumes its natural type, and the blood is brought back to its ordinary quantity. The internal organs which are subjected less to the causes of excitement, have less varieties in their capillary system; yet, however, there are many, and all arise from the same principle.

A series of organized tubes are unlike an assemblage of inert ones. These last require mechanical obstacles to prevent the communication of fluids with each other; where there is a communication between the tubes, there is a communication in the fluids. On the contrary, in the living economy, it is the peculiar vitality with which each tube is animated, which serves for an obstacle and a limit to the different fluids; this vitality performs the part of different machines that we place in the communicating tubes, to separate them from each other. Every organized vessel is then truly active; it admits or rejects fluids which enter there, according as it is able or not to support their presence. Disproportion of capacity has nothing to do with this phenomenon; a vessel may have mere than four times the capacity of the particles of a fluid, and yet refuse to admit them, if this fluid is repugnant to its sensibility. It is in this point of view that the theory of Boerhaave has a great defect.

At the period in which this physician wrote, the vital forces had not been analyzed. It was necessary to employ physical forces to explain vital phenomena; hence it is not astonishing that all his theories are so incoherent. In fact, theories in the vital phenomena borrowed from physical forces, exhibit the same inadequacy, as those would in the physical phenomena borrowed from vital laws. What would you say, if in explaining the motion of the planets, rivers, &c. they should talk of irritability and sensibility? you would think it absurd; it is equally absurd, in explaining the animal functions, to talk of gravity, impulse, inequality of the capacity of the tubes, &c.

Observe, that the physical sciences made no progress until they analyzed the simple laws that preside over their innumerable phenomena. Observe also, that medical and physiological science was not accurately explained, until the vital laws were analyzed, and it was shown that they were everywhere the principles of the phenomena. See with what ease all those of the secretions, exhalations, absorptions, inflammation, capillary circulation, &c. are referred to the same principles, flow from the same data, by deriving them all from their real cause, the different modifications of the sensibility of the organs which execute them. On the contrary, see how each presented a new difficulty, when the mechanical causes were employed to explain them.

From what has been said, it is then evident, that in the innumerable variations of which the fluids of the capillary system are susceptible, in the different portions of the system which they fill, there is always antecedent variations in the sensibility of the vascular parietes; these varieties produce the first.

It is especially in the capillary system and its circulation, that the variations of the organic sensibility of the vessels produce varieties in the course of the fluids; for as I have observed, in the great arterial and venous trunks, in the heart, &c. the fluids are in too large masses, and they are agitated by too strong a motion, to be thus immediately subjected to the influence of the vascular parietes. Thus when nature wishes to prevent the fluids from communicating in the trunks, it places among them valves, or other analogous obstacles, which become useless in the capillary system.

Though the anatomical arrangement be the same in the living and the dead body, there is then a very great difference in the course through the capillary system, in one and the other. Push, into the aorta of an animal in whom you destroy life by opening this artery to fix in it a syringe, different fine fluids; you will never see them fill the capillary system, pour out by the exhalants, the excretories, &c. as when the subject has been some hours deprived of life. The organic sensibility inherent in the parts repels the injection; it can only circulate in the great trunks, in which there is a large space. I have injected, with other views, a great number of times, fluids by the arteries and the veins; now, the capillary system is never filled with these fluids; they circulate only in the great vessels, when the animal can bear them. Mr. Buniva has also made comparative experiments with injections upon living animals and those deprived of life; he has experienced in the first a resistance which he has not found in the other; now this resistance is in the capillary system, whose vessels refuse to admit a fluid to which their organic sensibility is not accommodated.

VI. _Consequences of the preceding principles, in relation to Inflammation._

From what has been said thus far, it is easy, I think, to understand what takes place in the inflammatory phenomena, considered in general.

If a part be irritated in any manner, immediately its organic sensibility is altered, and increased. Without previous connexion with the blood, the capillary system is then placed in relation with it; it as it were calls it there; it flows there and remains accumulated until the organic sensibility returns to its natural type.

The entrance of the blood into the capillary system is then a secondary effect of inflammation. The principal phenomenon, that which is the cause of all the others, is the local irritation which has changed the organic sensibility; now this local irritation may be produced in different ways; 1st, by an irritant immediately applied, as a straw upon the conjunctiva, cantharides upon the skin, acrid vapours upon the mucous surface of the bronchia or the nasal cavities, atmospheric air upon any internal organ laid bare, as we see in wounds, &c.; 2d, by continuity of organs, as when a part of the skin, of the pleura, &c. being inflamed, those that are near it are also affected, and the blood flows there, as when one organ is diseased, that which is near it becomes so by the cellular communications; 3d, by sympathies; thus the skin being seized with cold, the pleura is sympathetically affected; its organic sensibility is increased, the blood immediately enters it from every part. When this property is raised in one of these three ways in the capillary system, the phenomena that result from it are the same. For example, when in the pleura it is raised because the air is in contact with this membrane, because the lungs that it covers have been first affected, or because coin has seized upon the skin in sweat, the effect is nearly analogous, as it respects the entrance of the blood in the capillary system.

It is then the change that takes place in the organic sensibility, that constitutes the essence and the principle of the disease; it is this change which makes a pain more or less severe soon felt in the part; then the sensibility that was organic, becomes animal. The part was before sensible to the impression of the blood, but did not transmit this impression to the brain; then it transmits it, and this impression becomes painful. Irritate the healthy pleura in a living animal; it does not suffer; irritate it on the contrary during inflammation, and it gives signs of the most acute pain. Who does not know that most often and almost always, a pain more or less acute is perceived in the part, some time before it becomes red? Now this pain is the indication of the alteration that the organic sensibility undergoes; this alteration exists some time, often without producing an effect; this effect, which is especially the afflux of blood, is subsequent.

It is the same of heat. I shall say hereafter how it is produced. It is sufficient now to show that it is, like the passage of the blood in the capillary system, only an effect of the change that has taken place in the organic sensibility of the part; now this is evident, since it is always consequent upon this change.

There happens then in inflammation exactly the reverse of what Boerhaave thought. The blood accumulated according to him, in the capillary vessels, and pushed _à tergo_ by the heart, as he termed it, was truly the immediate cause of the affection, whereas, from what I have said, it is only the effect.