Chlorosis.

Synonym.—Green Sickness; Chloremia.

Definition.—A form of primary anemia affecting mostly girls at the period of puberty or early womanhood, and characterized by a marked deficiency of hemoglobin in the red corpuscles.

Etiology.—The disease is confined almost entirely to females. Noorden, Eichorst, Jurgensen, Hayem, Luzet, and Liebermeister hold that chlorosis never occurs in the male; but of one hundred and eighty cases of chlorosis reported in the Leipsic Medical Clinic, eight occurred in males, though some doubt exists as to the correctness of the diagnosis.

The disease nearly always appears during the second decade, or between the fourteenth and twentieth year.

Unhygienic surroundings undoubtedly figure as a causal factor, for it is quite common in those closely housed, and where the air is bad, and where there is little sunshine. Factory girls, clerks, sewing girls, and those. confined in badly lighted and poorly ventilated quarters, where the work is exacting and the hours long, and who eat hastily, improperly prepared food, are prone to chlorosis. While these conditions favor this lesion, it must also be recognized that girls reared in luxury are numbered among its victims.

Heredity is supposed to have some influence in predisposing to the disease, chlorotic children not infrequently having the history of anemia running back two generations.

There seems to be a close relationship between tuberculosis and chlorosis, since girls who have a strumous tendency are prone to become chlorotic. Some have claimed that it is due to mental emotion, and cite cases where chlorosis developed after sudden shock or violent emotion, homesickness, and disappointment in love.

Sir Andrew dark considered it due to the absorption of toxic products from constipation.

A change of climate has been considered a cause, and girls who have emigrated to this country and become chlorotic have been cited as examples. It is more probable, however, that a change in the manner of living has been more responsible for chlorosis than climate.

We may infer that any condition that lowers the vitality and impairs the blood-making function is a factor in producing chlorosis.

Pathology.—The pathological conditions are not very well understood, few cases dying of the disease, and where autopsies have been held the conditions were not constant.

According to Rokitansky, incurable cases of chlorosis are characterized by a defective formation of the blood-vessels and genitalia. Virchow also found a congenital hypoplasia of the vascular system in several autopsies on chlorotic patients. In some cases the uterus and appendages were imperfectly developed. Fatty degeneration of the intima of the arteries is sometimes noticed, and the heart has been softened, dilated, and the left ventricle hypertrophied.

There is a marked reduction in the hemoglobin, and though the red corpuscles are changed in size, there is but a slight reduction in numbers. The specific gravity of the blood is reduced.

Symptoms.—The disease usually comes on gradually, the patient losing color and taking on a greenish-yellow hue; hence the term "green sickness," characteristic of chlorosis. Sometimes the color of the cheeks and lips are retained, when the term chlorosis rubra is applied. The subcutaneous fat is retained, and in some cases increased. There is languor, weakness, with dyspnea, and palpitation of the heart on exertion. The patient complains much of headache and dizziness.

There is usually gastric derangement. The appetite is very poor or perverted, there being a craving for charcoal, chalk, slate-pencils, or even earth, pickles, and highly spiced articles of food. Following a meal, there are acid eructations, regurgitation of food or vomiting, the patient complaining of more or less pain. The tongue is usually pale, with a dirty coating, showing indentation of the teeth, or it is dry and brown.

Constipation is nearly always found, though a diarrhea frequently intervenes, owing to ingestion of some unwholesome food.

The pulse is small, frequent, and easily compressed, while the skin and extremities are cold. In some cases pulsation is visible in the carotids and superficial veins.

Examination of the heart reveals a soft systolic murmur, heard the most pronounced over the pulmonary area. Sometimes a systolic murmur is heard over the subclavian artery. A continuous murmur is often heard over the veins of the neck, and is called the venous hum or "bruit de diable."

In some cases there is an absence of horizontal folds in the forehead when the patient is suddenly asked to look up without raising the head. This is known as the "Jeffrey's sign." Edema of the ankles appears, and is often noticed where the disease is of long standing. The urine is pale and of low specific gravity. The conjunctivas become pale, while the sclerotic coat assumes a pearly or bluish-white color, and is considered by some as pathognomonic of chlorosis.

Neuralgic pains of the head, ringing in the ears, mental depression, and gastralgia and hysterical attacks are often present. Menstruation is generally arrested or scanty, though menorrhagia sometimes exists.

Diagnosis.—This is usually readily made. When a young girl appears with a yellowish-green hue, dyspeptic symptoms, capricious appetite, dyspnea and palpitation on slight exertion, bluish sclerotic coat, scanty menstruation, or amenorrhea, constipation, and with a well-nourished appearance, headache with dizziness, and more or less hysteria, we have a group of symptoms that can not be mistaken.

Prognosis.—This will be favorable in all cases except those where there are congenital anomalies of the vascular and genital system.

Treatment.—Dr. Scudder used to say: "In the treatment of chlorosis we have three prominent indications to fulfill: First, to remove any disease which may exist independently of the chlorotic condition, and which may, by its continuance, tend to keep it up. Second, to restore the blood to its normal condition, by the use of tonics and iron, nutritious diet, appropriate exercise, the use of baths, etc. Third, to stimulate the uterine organs to a performance of their natural functions." I am satisfied if we can correct the first two conditions the third will right itself.

To restore the blood to its normal condition requires, first, good food, capable of making good blood; and, secondly, a good digestive apparatus to prepare it for its final elaboration into healthy red corpuscles. Taking for granted that the patient has a good food-supply, our first object will be to restore the digestive organs. Wrongs of the stomach and constipation of the bowels will receive first attention. It is folly for us to expect to make good blood by the administration of iron, when our patient has a bad stomach, as shown by the coated tongue, bad breath, more or less nausea, and with the bowels constipated.

First clear the tongue, restore the appetite and overcome the constipation. Where the tongue is heavily coated, the quickest way to get relief is the old lobelia emetic, with copious draughts of warm water. By its action the stomach is thoroughly emptied of a viscid and offensive mucus and put into condition for the digestion of food and the absorption of medicines. It is, however, unpleasant treatment, and has largely gone out of use. The more modern method is, to wash out the stomach three or four times a week with the lavage tube. If the tongue has a dirty, pasty coating, sodium sulphite will accomplish the same results. Where the tongue is moist and yellow, with offensive breath, nothing quite equals potassium chlorate and phosphate of hydrastin. If the tongue be slick and dirty, sulphurous acid will correct the wrong. As soon as the tongue cleans, and the appetite improves, nux and hydrastin can be given with benefit, or drop doses of Howe's acid solution of iron. Cuprum is a good remedy where the skin is of a greenish-yellow color, and the tongue clean. Of the tincture add ten to twenty drops to half a glass of water, and give a teaspoonful every three hours.

For the constipation the small Podophyllin and hydrastin pill, with daily massage of the bowels, will prove curative. If very obstinate, an occasional fifteen or twenty grain dose of sodium phosphate will act as a persuader. As a tonic, the old compound tonic mixture (triple phosphate of quinine, strychnia, and iron) is one of the best.

As the patient improves, pulsatilla, viburnum, macrotys, and such remedies as act upon the reproductive organs may be used, though in most cases, as the general health improves, the menstrual function takes care of itself. The patient should live as much out of doors as possible, though exercise should never be carried to the extent of weariness. The diet should consist of broiled steak, lamb-chops, roast-beef, fresh eggs, farinaceous vegetables and ripe fruit.

The Eclectic Practice of Medicine, 1907, was written by Rolla L. Thomas, M. S., M. D.