322 CHLOROSIS 



to this question. The pulse of anemics is for the most part simply accelerated, 

 of varying strength, and often slightly dicrotic; in some cases a crural mur- 

 mur has been noted. Obviously, then, the pulse of chlorotics presents no char- 

 acteristic changes. 



The acceleration of the heart heat and of the pulse is explained by a diminu- 

 tion of hemoglobin, as the blood, in order to accomplish the required oxida- 

 tion of the whole organism, must circulate more rapidly than when it contains 

 a normal amount of hemoglobin. As a result of this, acceleration of the heart's 

 action is one of the common symptoms of chlorosis as well as of other forms 

 of anemia. 



Subjectively, the patients are often vividly conscious of this acceleration, 

 so that a troublesome sensation of cardiac palpitation develops, a point which 

 has been noted in the earliest literature as a prominent symptom of chlorosis. 

 This sensation becomes aggravated upon exertion as when they attend to their 

 housework, ascend stairs, etc. As a result they readily become short of breath, 

 and the rapid beating of the heart which appears after these slight exertions 

 often persists afterward as a subjective but very disagreeable symptom.. 



In these cases it is surprising to note that some chlorotics, who during the 

 day become dyspneic on the slightest exertion, are able in the evening to 

 attend a hall and indulge most immoderately in dancing, and even to con- 

 tinue this exercise for hours without any difficulty in breathing approaching 

 that ivhich occurs during the day, when, for instance, they ascend only one 

 flight of stairs. Of course, upon the following morning, a particularly great 

 prostration is discernible. 



Similar to the murmurs in the heart, in such patients " venous murmurs " 

 have for a long time been recognized which are designated " nun's murmurs " 

 or also " bruit de diahle." These are best auscultated over the sterno-clavicu- 

 lar articulation; care must, however, be exercised that the neck of the person 

 is not turned too much to one side, for, in this case, the murmur may also be 

 noted in normal subjects. This murmur is due to the circumstance that the 

 jugular vein is held by tense bands situated behind the articulation just men- 

 tioned, so that in this region it cannot expand and contract with facility, as 

 it does, for instance, higher up in the neck. Now, since in anemics the lumen 

 of the vein is lessened — being less full — when the blood enters from the nar- 

 rowed portions into the easily dilatable parts previously mentioned, differences 

 in the blood current arise which give rise to these murmurs. This is the usual 

 explanation of these conspicuous venous murmurs, but it is unsatisfactory, 

 inasmuch as in other anemic conditions in which the blood reveals much 

 greater deterioration than in chlorosis — therefore a more favorable condition 

 for the production of the murmurs — no adventitious bruits are discernible. 

 [It should be mentioned at this point that violent pulsations of the peripheral 

 arteries, especially the carotids, are noticeable and sometimes troublesome in 

 cases of severe anemia of any type. The arteries flap and jump so violently 

 as to remind one of the conditions seen in aortic regurgitation. 



Dilatation of the heart is not uncommon and may be demonstrated by 

 radioscopy or by percussion. A beautiful picture of a heart dilated in the 

 course of a case of chlorosis is included in the v. Ziemssen-Eieder Atlas.— Ed.] 



