Chlorosis is recognizable by the greenish pallor which develops in the face of those who are affected by it, and by the bloodless appearance of the ears, lips, and mucous membranes. Usually emaciation is not observable, although there is often some loss of flesh. Breathlessness on exertion and palpitation of the heart are complained of commonly. Patients generally lack both energy and endurance. Neuralgias are not uncommon. Digestion is almost invariably impaired. Indeed, derangement of digestion often precedes the anemia. Dilatation of the stomach exists in more than one-half of all cases. The secretory activity of the stomach varies, but in the largest number of cases there is increased secretion of hydrochloric acid. The proportion of cases of hyperpepsia to those of hypo-pepsia is approximately as 3 to 2. In a smaller number of cases the gastric juice is normal. Round ulcer of the stomach is a common complication. Constipation is the rule in this ailment. Menstruation is irregular, deficient, or wanting. In severe cases a little edema is often observable about the eyelids and ankles.

Blood examinations show that a moderate reduction of red blood-corpuscles occur, with a great reduction of hemoglobin. In cases of average severity, the red corpuscles will vary from three to four millions, but the hemoglobin will range from thirty to thirty-five per cent.

Cause

The essential cause of chlorosis is unknown. That it is something which interferes with the production of hemoglobin or hastens its destruction seems evident. By many clinicians chlorosis is believed to be due to an intoxicant generated in the intestinal canal. However, positive proof of this is wanting. It is generally admitted that the disease frequently recurs in the same family, and an inherited tendency to it is thought to exist. A sedentary life, hard work, emotional disturbances, and deficiency and unsuitability of food are predisposing conditions. In most cases, gastro-intestinal derangements of more or less chronicity will be found to have preceded the onset of characteristic symptoms.

Treatment

Rest is an essential element of treatment. In some cases patients should be kept in bed for some days, or, if the climate will permit, recumbent in the open air. In mild cases long hours of rest and gentle, measured exercise must be prescribed. Rest prevents wasting of stength and tissues, while the blood is too deficient in power to carry oxygen to maintain good nutrition. Rest is also essential because the heart is weak and because the anemia produces breathlessness if more than a little exertion is made. When improvement has been effected, a little exercise may be permitted, and it may gradually be increased. A dry rub with a coarse towel is desirable in most cases both night and morning. Often the stimulating effect of this rub can be increased if it is preceded by a sponge bath of tepid or cool salt water.

When active exercise is taken, it should not be enough to produce palpitation or shortness of breath or a degree of weariness which cannot be readily recovered from by a rest of a few minutes.

A change of climate often does good, especially a sojourn at some quiet hamlet, at the seashore, or at a sheltered spa with chalybeate waters. When season and climate permit, the patient should be kept as much as possible out-of-doors. If treatment must be carried on indoors, the living and sleeping rooms should be large, perfectly ventilated, bright, and cheerful. Depressing and exciting conditions are so often harmful that treatment at home frequently becomes tedious and unsatisfactory.

Dietetic management is most important, both in order to restore to the blood the iron in which it is deficient and to correct the disturbed functional activity of the digestive organs. From the commonly disturbed state of digestion and enlargement of the stomach it becomes necessary to give food which is easy to digest, which is not bulky, and which is nutritious and contains a good percentage of iron. When the stomach is much dilated, it should be cleansed; if necessary, by lavage. Abstinence from food except a minimum amount of milk, and water enough to flush the stomach, will prevent its distention and help to keep it clean. A dose of Carlsbad salts in a glass of water taken before breakfast is of value in all cases. So soon as stomach and bowel have been well emptied meat and eggs should be given freely, liquids sparingly, and fats and carbohydrates not at all. The diet will then consist of chopped or scraped beef, mutton, chicken, squab, lean cold boiled ham, eggs, a little lettuce, raw tomatoes, or spinach, whole wheat bread, or Zwieback, raisins, prunes, oranges or apples. This strongly albuminous diet will agree especially well with those cases in which there is hyperchlorhydria. If the gastric juice is deficient, hydrochloric acid should be given with each meal, and food should be eaten often and in small amounts at a time. When the stomach has regained its normal dimensions and peristalsis is sufficiently active to prevent the accumulation of food in the stomach, the diet can be made more generous, and larger quantities can be given at longer intervals.

Pastries and sweets are often eaten with especial relish by those who are chlorotic. Such foods, however, are actually harmful in most instances, for they are indigestible. The appetite of those who are chlorotic is frequently capricious, and craves acids as well as sweets and many other useless or harmful articles.

When the stomach is not enlarged and there is hyperchlor-hydria, an exclusive milk diet will give the greatest comfort. As soon, however, as digestion becomes comfortable, lean meat and eggs should be added to the diet. When the gastric juice becomes normal, the green vegetables and bread can be eaten in small amounts, and later, when convalescence is established, a greater variety may be introduced into the dietary.

Although the iron needed to restore what the blood has lost can be obtained from food, it can be advantageously given as a medicine. It is doubtful if the latter restores to the blood the needed iron, and Bunge's suggestion that it unites with and makes inert the sulphids in the intestines, and therefore permits the better absorption of the organic iron of foods, has not been established. Unquestionably, however, ferruginous preparations do good, in all probability by stimulating blood production. It is equally necessary to administer laxatives to most patients. Among the best are Carlsbad salts and spring-waters of similar composition.

The following list of foods with their iron contents, prepared chiefly by Bunge, is of use in selecting a diet for the chlorotic, and will supplement the list given on page 323.

Diet In Diseases Of The Blood

It is of great importance also, to select food that is easily digested and that is least likely to ferment or putrefy in the stomach or intestine.

It is generally admitted that stimulating beverages, not only alcoholics, but tea and coffee, should not be used. In mild cases they may be permitted in small amounts. Their use is conditioned rather by the state of digestion and of the nervous system than by any effect which they have upon the blood. It must be remembered, however, that alcohol interferes with the oxygen-carrying power of the blood. It tends, therefore, to aggravate the essential pathologic feature of the disease.

An error often committed in treatment is the discharge of a patient as cured as soon as color is restored to her lips and cheeks, menstruation reestablished, and discomfort during digestion relieved. In almost every instance in which this is done a relapse soon occurs. Although in most cases great improvement is rapidly effected, a permanent cure can rarely be accomplished in less than from three to six months. During this time care should be taken as regards mode of life and diet and especial pains taken to maintain regular and copious bowel movements.