SYMPTOMS 321 



the first glance, vividly recalls that of persons affected with acute nephritis, 

 yet this, of course, is not due to the yellowish discoloration. 



The circulatory apparatus presents numerous and striking symptoms. In 

 the heart there is almost always an increase of the area of dulness, to the right 

 and to the left. The hand may feel a distinct systolic thrill, especially over 

 the pulmonary artery, and on auscultation systolic murmurs, which commonly 

 have a peculiar blowing character, are very distinctly heard. 



These cardiac murmurs have been recognized for a long time, and, in spite 

 of careful study, are still subjects of dispute. The murmurs are usually loud- 

 est over the pulmonary artery, and an attempt has been made to explain them 

 by the fact that there is a relaxation of the heart muscle owing to insufficiency 

 of the blood-supply, that the papillary muscles do not contract with sufficient 

 power, that, therefore, during systole there is a relative insufficiency of the 

 auriculoventricular valves which causes a regurgitation of the blood to the 

 auricles during systole in the same manner as in cases of organic mitral insuf- 

 ficiency. 



This much is certain; that these systolic murmurs are intimately related 

 with the anemic condition of the blood, that they appear when the disease 

 develops, and disappear when the general clinical picture shows improvement. 



Therefore, they have been properly called " aneinic murmurs," in contra- 

 distinction to heart murmurs produced by valvular lesions which are desig- 

 nated " organic murmurs," and an exact knowledge of these conditions is the 

 more important as it is frequently the duty of the physician to decide whether 

 changes and murmurs in the heart, especially in young persons, are to be 

 attributed to a valvular lesion or whether they are only accompanying symp- 

 toms of anemia. [The term, " anemic " or " hemic " murmurs, is not well 

 chosen, for the majority of such murmurs occur not in anemic cases but in 

 fevers, in neurotic or excited conditions, in growing children and after any 

 violent exertion (boat-races, etc.). On the other hand, cases of marked 

 anemia without any murmurs are not very uncommon. I prefer the term 

 " functional murmur." — Ed.] As an instance of the importance of this dif- 

 ferential-diagnostic distinction, we may mention the requirements for enlist- 

 ment in military service, in which this question is of momentous importance. 



As a criterion in practice the following important points favor anemic 

 murmurs : 



1. The existence of distinct anemia. 



2. The simultaneous presence of the systolic murmur over all the valves. 



3. Especial loudness in the pulmonary area. 



4. Absence of that accentuation of the pulmonic second sound which con- 

 stantly accompanies insufficiency of the mitral valve. 



It" must, however, be stated with emphasis that simple as this appears in 

 theory it is often difficult in practice to arrive at a decision ; for, in the first 

 place, training is necessary to make these examinations correctly, and, further, 

 prolonged observation of the patient is the only decisive criterion, for, as has 

 been stated, anemic murmurs are transitory while organic heart murmurs are 



permanent. 



JSTeither does the character of the pulse give reliable information in regard 

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