The only constant anatomical changes of chlorosis are those of the blood itself, and it is for this reason that the disease is classed among the primary ancemias. Even the blood-changes are not uniform. The researches of Duncan in 1567 first established the fact that, in well-marked cases of chlorosis, the number of red corpuscles might be normal, while their percentage of lnemoglobin might be greatly reduced, and this anomaly was, for a long time, regarded as the dis tinguishing mark of chlorosis. It has since been established that this view of the blood-change in chlorosis is alto gether too narrow, and at the present day it is generally admitted that the blood-ehanges in chlorosis may be at least threefold: 1. They may be of nor mal size and number, their only change being a deficiency of hmmoglobin. 2.
They may be diminished in number, with diminished percentage of hmoglo bin. 3. They may be diminshed in size and normal in number and in percent age of lli-emoglobin. Of these varieties, the second is the most severe, and in it there are often marked changes (poiki locytosis) in the shape of the red cor puscles, such as are so commonly ob served in pernicious anmmia.
From these facts it is evident that there is nothing unifor-rn in the be havior of the red corpuscles in the dis ease called chlorosis; so that an attempt to describe it as a distinct disease from an anatomical stand-point must result in failure. The essen.tial point is that the percentage of hwmoglobin is reduced, but this is common to many forms of amemia.
Chlorosis is due to oligochromeemia, the result of faulty heemopoicsis, in turn due to diminished hemoglobin produc tion. Heemoglobin is principally formed in the intestine; this is proved (a) by direct investigation upon lower animals,. and 0) by direct observation upon the human being. Hmmoglobin formation can be increased by the introduction into the intestine of agents not containing iron, but preventing putrefaction. Cblo rosis is due to a prevention of heemo globin formation by destructive agents. acting upon the precursor of luemoglobin in the intestine. Forchbeimer (Boston Med. and Sing. Jour., Aug. 24, '93).
The albumin is diminished, owing to the diminution of luemoglobin: the rela tion of albumin to globulin is normal and the amount of fibrin inerease.i. There is considerably more fat than nor mal in both the scrum and the erythro cytes; the lecithin is diminished in the total blood and the serum, but seems to be increased in the red cells. Choles terin is present in smaller amounts in.
both the serum and red cells. In tbe ash, phosphoric acid, potassium, and iron are. considerably reduced, caleium and mag nesium are increased. The increase of sodium chloride is only apparent, since^.
chlorotie blood contains a higher per centage of serum than normal blood: the amount of Isodium chloride in the serum is not, however, increased. Erhen (Zeitsch. f. klin. Med.. vol. xlvii, Nos. :3 and 4, 1003).
It has been contended by some writers, especially by Immermann, that chlorosis differs from all other forms of anmmia in that the albuminous bodies of the blood-serum are present in that fluid in normal or increased amount. This has certainly been proved to be true in a few eases by chemical examination, but it has not yet been proved that the same may not be true of other forms.
From the above it appears evident that the conditions of the blood and the other organs of the body are so various as to veto the present establishment of chlorosis as a disease with a distinct tomical basis. With advancing knowl edge, some etiological or pathological fact common to all cases of the affec tion may be discovered, but at present none such is known. With our present knowledge, the most sensible view of the nature of chlorosis appears to me the following, which I have already pressed elsewhere: At the time of pu berty there is an urgent physioloff.ical demand upon the blood, which is plied with by vigorous persons without detriment to the organism. The ordeal of puberty is safely passed. In less vig orous, but still sound, organisms a decided degree of amenaia, one calling for treatment, declares itself at this time. Finally, in those with any con genital tendency to anmmia, whether this be due to general malnutrition during intra-uterine life or to a special hypo plasia of the vascular system, the an mmia of puberty is intense; the case is a typical one of chlorosis.
Cases of ehlorosis may be divided into three cia,ses: (1) Chlorosis with vas cular hypoplasia without change in the sexual apparatus: (2) chlorosis with vaseular hypoplasia and excessive devel opment of the genital apparattrs; (3) eldorosis with vascular hypoplasia and defective development in the genital ap paratus. Even though later researches may show that the vascular hypoplasia is not constant. the lesions of the vessels and the heart -will occupy, nevertheless, a prominent place in the pathological anatomy of ehlorosis. flilbert, of Paris (Aletl. Record, Oct. 2, '97).