If the venous murmur be heard, there can be no doubt that the blood is in a condition in which bruits are readily produe,ed. The same conclusion may be safely arrived at if slight pressure on an artery develop a short whiff,' which seems close to the ear, is synchronous with the pulse, and ceases to be heard when the pressure is removed. Similarly, but not so certainly, may a blood-sound be diagnosticated if it oe,cupy the whole of the re. gion of the base of the heart, being especially audible in the pul monary artery, where the blood is generally most superficial, but evidently not confined t,o that locality. The consideration of this subject will be resumed in the examination of the heart. (See chap. XXT, Div. § 3.) § 5. Cachremia, or alchexia.—Mal-nutrition may exist without the remarkably exsanguine hue of anEemia, under the form simply of general derangement of health; there is perhaps emaciation, with a tendency to ill-defined cutaneous eruptions; wheals on the fingers, resembling chilblains, and afterwards forming watery blebs or blains secreting purulent fluid; unhealthy pustules on the lower limbs, &c., and yet no organ gives any distinct evidence of disease. This condition is apt to be generated by improper or insufficient food, ill-ventilated apartments, and all those condi tions to which the poorer artisans in large towns are exposed. On the other hand, cachtemia may assume a more definite cha racter from the previous accident of a poisoned wound ; and while, as a general rule, inflammation of the absorbents is the more common consequence, yet we do occasionally meet with cases in which the whole circulating fluid appears to be deterio rated in its qualities.
The general class is an unimportant one, because in a great many instances, some definite malady may be detected as the basis of the depraved state of the blood—scrofula, disease of the , kidney, congenital syphilis, &c. Of such states nothing more need now be said ; but there is one form of cacluemia which is well marked, and of grave import: it is characterized by con tamination of the blood from an admixture of pus—pyiemia, or, pyoluemia. Not unfrequently arising in unhealthy subjects after operation, it has been argued that the pus secreted in the wound actually finds its way into the blood : but it is by no means limited to such cases, and is constantly met with under circumstances in which there is no channel by which the pus globules could find their way into the circulating system. Its probable source in all cases is the lining membrane of the veins, which puts on a form of suppurative inflammation, and secretes pus ; this is washed into the general current of the circulation, and so produces puru lent contamination of the blood; its existence must therefore be secondary to a form of phlebitis. We find it as a sequence of almost any extensive suppuration, but more especially after dif fuse cellular inflammation. It very rarely appears at the termi nation of phlegmasia dolens, the "white leg" of parturient females, a form of phlebitis unattended with suppuration. This circum stance seems to negative the idea of its existence being ever due to the absorption of pus ; because the direct admixture of pus with the blood has been shown to produce its coagulation, and the phlebitis of childbirth probably arises in this very way, from the entrance of unhealthy fluid, purulent or sanious, into the open mouths of the uterine veins. The condition which we call pya3 mia must therefore have some different cause, and none appears more rational than that the pus is secreted from the lining mem brane of the veins.
The history of the case is therefore important; but most com monly the disease commences under the practitioner's own eye, because it supervenes on one which has already required medical treatment. Sometimes, however, the cause of the sup
puration has been so insidious and obscure, that the first evidence of the presence of pus is derived from its general diffusion through the blood. It is marked by fever of an adynamic type, quick, feeble pulse, dry brown tongue, shivering, often intense, followed by copious perspiration& These are only the general signs of extensive suppurative action, and it is to be presumed that they indicate a further formation of pus, not improbably in the blood itself, but still more certainly in the various organs in which what are called secondary deposits are found. These, in their turn, become the direct evidence of ppemia; the pus is believed to be obstructed in its passage through the capillary vessels, and at each point where it rests to become a focus of inflammation which rapidly terminates in a small abscess.
When seated in internal organs, the existence of secondary deposits can only be inferred from the previous knowledge of suppuration elsewhere, taken in conjunction with the general evidence of its extension, and the local symptoms of pain or altered function in the particular organ. Those most liable to be so affected are the lungs and liver, and secondary deposits are rarely found elsewhere without their being also found in them. Very often, however, the suppuration takes place near the surface; it commences with a patch of intense redness on the skin, accom panied by but little tension or tenderness, and thus proving that the inflammatory action is of a very low type; it passes in a few hours, perhaps, into suppuration and abscess, becoming soft and fluctuating. Erythema nodosum occasionally presents characters which might be readily mistaken for the early stage of these small abscesses; the previous history ought to preserve us from such a mistake, and the course of the disease will soon clear up any doubts that may have remained. In cases of erythema the probably acquires a bluish tint, or remains unchanged; and though the swelling feel soft, there is no fluctuation and no formation of pus.
In other instances the presence of pus in the blood leads to the formation of small pustules on the skin itself; not very numerous, they are prominent, fill rapidly, do not pass through any prelimi nary stage of serous exudation, but evidently from the first con tain purulent fluid; they can only be confounded by a very superficial observer with a varioloid eruption. These two forms' of deposit are each very characteristic, and are generally associated with larger collections of pus around the joints, or spread abroad it), the cellular tissue and burrowing among the muscles. In the absence of the pustules and small abscesses just mentioned, the inflammation around the joints may be mistaken for acute rheu matism, which it simulates in attacking several in succession ; but it will be observed that the swelling is very much more extensive, and the redness more erysipelatous-looking than ever happens in rheumatism. This is caused by the tendency to diffuse cellular inflammation, which generally also shows itself in other parts, at a distance from any joint, over the thorax, about the eyes and face, ate.
Cases of pya3mia bear a close analogy in many respects to glanders, and when the primary suppuration cannot be discovered, they are somewhat perplexing. A sallow aspect, and a peculiar odor of the breath have been both urged as characteristic of the disease; bat while they may aid the diagnosis, they cannot be made the principal grounds of discrimination.