While menstruation is, as a rule, either scanty or suppressed, cases are now and then encountered in which the flow is so profuse as to have given rise to the term "chlorotic menorrhagia." Chlorosis is sometimes attended by febrile symptoms.
Fever may occur in the course of chlo rosis. It may be stibilivided into three classes: eases with (1) continuous, (2) intermittent, and (3) inverted fever. The continuous form is, perhaps, commonest ; the intermittent—of which a remarkable case, with wasting, cough, and other sus picious symptoms, occurred the prac tice of Jaccoud—is least so. Paul Chi5ron (T:LInion Mkt., Dec. 9, '90).
C'ases of pure "febrile chlorosis" very rare, the eases usually so regarded being due to fatigue or other complications. Hayem (L'Union AIM.. Dec. 9, '90).
But one ease met with; most of them are due to constipation and absorption of poisons from the bowels. Potain (L'Union MM., Dec. 23, 30, '90).
A febrile type of chlorosis does not exist, but a certain degree of apyrexia accompanies true chlorosis. Hence, when fever is present, it must be attributed to some concomitant morbid state, as con stipation or tuberculosis. E. Griam (11 -Iiirgagni. Dee., '94).
None of the symptoms can be consid ered pathognomonie. As to the color of the skin. supposed to be due to deficiency of lermoglobin, the general view is in correct., as in profound aturmia there is often only the slightest chemical change 111 the blood, while with no apparent anagnia the change may be profound. There are other coloring matters in the blood of Nvhieli little is known, and it is t o t hose that tilP C0101' Of the (Ille chlorosis. Dyspncea and headache have also been attributed to deficiency of oxy gen, consequent on the deficiency of hceinoglobin; but deficiency of hcemo globin does not necessarily diminish the amount of oxygen present; it has been shown that there may be even more oxygen than normal in such blood. Great stress should be laid on the clear appear ance of chlorotic blood; it is to this clearness, due to some anomaly in the blood-pigments, in which hcemoglobin plays little or no part, that the color of the skin is due. Biernacki (Wien. med. AN'och., No. 8, '97).
Complications.—There are certain dis eases to which chlorosis stands in the relation of a predisposing cause, and which, therefore, may be considered as complications or sequehe. The chief of these are phthisis, gastric ulcer, chorea, and exophthalmic goitre. There can be no doubt that one of the best prophy lactic measures against phthisis is the maintenance of a good condition of the blood, and that, conversely, a poor state of the blood may be regarded as a pretubercular or prebacillary stage of phthisis.
Gastric ulcer is by no means uncom mon in chlorotic women, and its occur rence is favored by degenerative changes in the blood-vessels of the stomach, lead ing to thrombosis and 1-tmorrhage and subsequent sloughing in the mucous membrane of that organ. Chorea, it is well known, is decidedly more common in females than in males, and, although more frequently observed under than over fifteen years of age, is yet far from being rare between the ages of fifteen and twenty. Its occurrence is undoubt
edly favored by chlorosis. The same is true with regard to that peculiar neu rosis known as exophthalmic goitre.
.'"•!even eases of chlorosis eomplicated with the signs and syinptoms of exoph thalmic goitre, the latter disappearing as the condit ion of the blood improved and, therefore, presumably symptomatic. F. Chvostek (Centralb. f. 3.1ed., Apr. 14, '94).
"When the aortic valves are affected, chlorosis, though a troublesome compli cation, does not aggravate the malady. Mitral regurgitation, on the other hand, tends to be exaggerated by a chlorotic condition. In these eases iron not only augments the number of red corpuscles, but will lead to a greater capillary re sistance, and, consequently, to an im proved circulation. Potain (Jour. de Med., Aug. 14, '95).
Diagnosis.—The diagnosis of ehlorosis is made by an examination of the blood and a careful exclusion of organic dis ease. As stated under the anatomical characters of the disease, the blood changes are not uniform. There is, how ever, usually a decided, sometimes a very g-,reat, decrease in the percentage of hmmoglobin. In the majority of cases, also, if the disease has lasted sev eral weeks, the blood-corpuscles are di minished in number. For example, in the well-marked case of a young girl, aged 17, whose blood I recently exam ined, I found the following condition:— r. c. per cubic mm., 2,690,000 IImmoglobin 32 per cent.
The percentage of red corpuscles as compared with the healthy standard (5,000,000) was, therefore, 54, so that the -value of each corpuscle (the "hmmic unit") was only 32/„ of the normal, mak ing the real value of the 2,690,000 cor puscles only equal to 1,594,080. Hayem gives 3,520,000 corpuscles per cubic millimetre as the mean of 18 counts, and Conpland about 3,000,000 as the mean of 7 counts. There are conflict ing statements with reference to the size and shape of the red corpuscles, and there can be no doubt, as already stated, that they may be normal or subnormal in size.
Bright's disease, which is often very insidious in young people and attendant with great anmmia, is excluded by a careful examination of the urine.
Chlorosis is, as a rule, with few excep tions, a non-febrile disease, and, there fore, if the temperature be elevated, latent tuberculosis should be suspected.
A cardiac murmur should not be hastily set down as inorganic, for long-contin ued ancemia is one of the recognized causes of chronic endocarditis.
Cardiac murmurs appearing in the course of chlorosis are indicative of gastro-intestinal disorders that influence the volume of the heart. Nicolas (Gaz. Hebdom. de MCA. et de Chir., Jan. Il, 1900).
The blood diseases from which chlo rosis should be differentiated are the following:—