Historical Interpretations

Clinical Manifestations and Diagnosis

The green skin color of chlorosis, from which it may have derived its name, remains, like the origin of syphilis, one of the more fascinating problems in the history of disease. The conundrum appeared when chlorosis was equated with iron deficiency; yet greenish skin in Caucasians was rarely observed in the many cases of hypochromic anemia then being diagnosed. Some of these cases undoubtedly related to the conditions just mentioned in which a hypochromic anemia appeared secondarily. Another possibility is that chlorosis was a misnomer, that the word "green" was used metaphorically. In this sense the word can be traced back to the Oxford English Dictionary to mean "of tender age, youthful. . . immature, raw, inexperienced."

Significantly, the green skin was included only sporadically in clinical descriptions of chlorosis over the years. Lange made no mention of it in his original description. In one study, of 27 authors who listed the usual signs of chlorosis, only 16 mentioned greenish skin as characteristic of the disease (Hudson 1977b). In another analysis, of 19 descriptions only 3 were considered definitely green, 3 possibly so, and 2 yellowish green (Loudon 1980). In 1915 Richard Cabot, author of a popular textbook of physical diagnosis, concluded that "it takes the eye of faith to see any justification for the title of the disease." On the other hand, the 1975 edition of a prominent textbook of dermatology averred that "the skin may have a green or brown tint in the iron deficiency syndrome" (Siddall 1982). Yet recent work on the nature of chlorosis has done nothing to alter this author's conclusion of a decade ago: "In the question of the green skin of chlorosis, the available historical evidence permits us to go no further than a suspension of judgment" (Hudson 1977b). At the very least, it is now reasonable to remove green skin as the outstanding characteristic that the designation chlorosis implied.

Distribution and Incidence

The incidence of chlorosis in earlier times is impossible to determine. From the attention it received in medical and other literature as well as in art, one may infer that the condition was not rare. By the end of the nineteenth century, it was viewed as extremely common. Clifford Allbutt (1909) observed, for example, that "the chlorotic girl is well-known in every consulting room, public or private." This conclusion is all the more striking in light of the rapid exit of chlorosis from center stage. By 1915 medical observers were commenting on the disappearance of the green disease (Osier and McCrae 1915; Campbell 1923). Between 1924 and 1930 only seven cases of chlorosis were diagnosed in Guy's Hospital (Witts 1930). By 1936 W. M. Fowler was asking "What disease . . . can compare with chlorosis in having occupied such a prominent place in medical practice only to disappear spontaneously while we are speculating as to its etiology?"

He was premature, in his use of the words "disappear" and "spontaneously," but he was not alone. Others concluded that chlorosis had never been anything but a simple iron deficiency anemia brought on by an inadequate diet and a loss of menstrual blood (Patek and Heath 1936). With this understanding another physician wrote that "this disease about which so much has been written and disputed has finally ended its stormy career" (Bloomfield 1960). Again the optimism was premature. Physicians continued to find chlorosis very much alive. In 1969 it was listed as one of the five major categories of hypochromic anemia that were considered diseases sui generis (Witts 1969). In 1980 Irvine Loudon concluded that chlorosis was a functional disease intimately related to anorexia nervosa; that although chlorosis, like the Cheshire cat, "faded from sight, it is, in this story, still there under another name." Current medical dictionaries still carry the term and define it as an iron deficiency anemia of young women.

Owing perhaps to its ephemeral nature, chlorosis has been particularly alluring to revisionist historians. Recent work has emphasized the importance of the general perception of women and their role in what physicians thought and did about disease, although there is surprisingly little about chlorosis as such in this literature (Hartman and Banner 1974).

Marxist and social historians have also become interested in chlorosis. These revisionist approaches, to varying degrees, tend generally to diminish the importance of pathological physiology in explaining the rise and decline of chlorosis. The more committed the revisionists are to their historical biases, the more difficulty they have squaring their interpretations with those of others as well as with more purely medical explanations. The Marxist, for example, must construct social and political conditions that produced chlorosis in young women of the capitalist class as well as the oppressed poor, because the evidence is incontrovertible that the condition affected both, as one of them readily acknowledges (Figlio 1978).

The feminists who would argue that nineteenth-century physicians mistreated women consciously on the basis of gender must account for the fact that many of the treatments accorded women by male physicians at the time derived from an inadequate understanding of reproductive physiology, and that masculine sexual conditions were also mistreated. The historian who argues that chlorosis was nothing more than a cultural construction of Victorian family life, that physicians diagnosed the condition simply because they expected to encounter it, and that young women simply learned to manifest the clinical picture of chlorosis (Brumberg 1982) must explain the well-documented existence of the disease in young men as well (Fox 1839; Evans 1845; Witts 1930).

Enthusiasm for new historical approaches to disease should not obscure the importance of the final common pathway of social, political, and cultural forces. And that common denominator for chlorosis in the nineteenth and early twentieth centuries was an iron deficiency anemia. Social and cultural factors certainly predisposed individuals to chlorosis, but persons became patients ultimately because they had red blood cells that were too small and lacked the normal amount of hemoglobin. Poor nutrition -whether due to poverty or cultural preferences-certainly contributed. Physicians, with their heavy reliance on blood-letting, even prophylactically in pregnant women, undoubtedly played a part as well (Siddall 1980). Chlorotic women gave birth to iron-deficient children - "larval chlorotics" they were called. Chlorosis, at bottom, was a deficiency disease. Explaining it historically demands an eclectic historiography. The biopsychosocial model emerging as the proper paradigm for health professionals dealing with disease in our time has always operated historically. Ockham's razor may be useful in logic, but it may slice too narrowly in history. Plethora rather than parsimony more often illuminates the complexities of humanity's interaction with society at any given time and place. Chlorosis is a case in point. There remains ample reason to recall L. J. Witt's remark (1969) that "however one looks at it, one is left with the uneasy feeling that the mystery of chlorosis, like that of Edwin Drood, remains unsolved."

Robert P. Hudson

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