The numerous complaints correspond comparatively little with the bodily manifestations. The color of the skin and mucous membranes is always pale. The state of nutrition may be good; but on the other hand there are frequent cases of badly nourished, chlorotic young women, especially in poor families if its beginning dates back to early childhood. In such cases a general enteroptosis is frequently met with, also in girls who do not wear stays, also in boys, although less frequently. The en largement of the spleen described in chlorotic eases (45 per cent. accord ing to von Noorden) is probably to be regarded as partly due to sinking.
As stated above, Virchow looked upon the cause of chlorosis as a hypoplasia of the vascular system. Pronounced cases of this kind always furnish a distinct pathological picture which is not difficult to diagnose (Frantzel). They generally occur in persons of tall and slen der build with but slightly developed muscles, little subcutaneous fat, and undeveloped sexual organs. The heart may be enlarged, the car diac impulse increased, the arteries strikingly narrow and tense; there is an absolute incapacity of undergoing even slight exertions, which defies treatment. The affection continues for years.
The heart frequently produces a split first sound, or even a systolic murmur. The increased strength toward the base of the heart, the ab sence of increase in strength of the second pulmonic sound, the venous murmur over the jugular veins when the head is in a forward position, are indicative of its functional nature. There arc many theories a-bout the origin of the abnormal cardiac sounds, but no positive explanation, whereas the venous murmur probably arises in connection with the decreased specific gravity. Cardiac dulness is seldom enlarged, presuma bly owing to the retraction of the lungs; this is also said to be shown by X-ray examination. (Edema is not frequent in children. As mentioned already, the gastric complaints are mostly of a nervous nature, the secre tion of acids is normal or more than normal, assimilation of food good (Lipman-Wulff). Menstruation is generally delayed and irregular, fre quently painful. There is often a mucous discharge which stains the underclothing barely yellow. Occurrence of acne and urticaria is con sidered by many to be connected with ehlorosis. The urine is normal or increased in quantity; when improvement takes place, there is said to be increased diuresis, according to von Noorden. The latter author,
Eichhorst and Hayein also consider fever to be connected with chlorosis.
Among the complications ulcer of the stomach may occur even in quite young girls; thrombosis, however, ought to be rare in children. Advanced anaemia may favor the development of scoliosis in growing individuals.
Course and Prognosis.—Some cases of chlorosis take an acute course in otherwise well nourished and apparently healthy persons and are gradually cured under proper treatment in three to six months. This may be the signal for a permanent cure, but there may still lurk a ten dency to relapses which are said to occur principally in the spring or late summer. Chlorosis which has commenced in early childhood may under favorable circumstances and proper care also be cured, hut here a prognosis of a complete return to health is uncertain. It is just in these cases that in later years hypoplasia of the vascular system sometimes becomes manifest, or else there is a tendency to relapses and develop ment of neurosis in more advanced age.
The diagnosis requires in the first place exclusion of all organic lesions especially on the part of the lungs, intestinal parasites or of ulcer of the stomach, which lead to secondary amemia through ha'uiorrhages, and finally of renal affections. The diagnosis of chlorosis is supported by the age and sex of the patient, the history of the case and by the decrease of haemoglobin, which is considerable in comparison to the decrease in red blood corpuscles. In pronounced changes of the blood (considerable poikiloeytosis, nor moblasts) the assumption of a secondary amemia always suggests itself. The only question is whether eases where the blood changes are only slightly pronounced, but their manifestations are present, should be classed with chlorosis. In practice this has formerly always been done, and perhaps it is superfluous even now to carry through a distinct separation. The pathological picture is the same and perhaps the assumption is correct that blood changes are more in the nature of a symptom Ivhich occurs in female persons and then only at a certain age. For purposes of therapy, however, the examination of the blood is very important.