Synonyms:—Green sickness; chloremia.

Definition:—A disease depending upon the reduction of the normal quantity of hemoglobin in the blood, most common among women before the age of twenty years.

Etiology:—This condition is directly due to faulty hemogenesis. It occurs in only very rare cases in males, but is of frequent occurrence in girls shortly after puberty and thence until about twenty years of age. It is rare that a case develops after that age, but it is not impossible that it should develop in middle life. The condition is frequently associated with menstrual irregularities. There is usually amenorrhea, exhibited either by deficient or infrequent periods, or by both, but it must be remembered that this condition is the result, not the cause of the deficiency of the hemoglobin.

A specific cause has not been determined. The conditions that lead to it are those which influence the blood making processes; unhygienic surroundings; monotonous, exacting employment in close, unpleasant, badly lighted quarters; improper food and bad habits of eating, and also of living, and of sleeping. These latter apply to girls well environed in the higher walks of life who are by no means exempt from the disease.

There are certain underlying conditions which conduce to chlorosis which are thought to be hereditary, and a strumous diathesis, or a tendency to tuberculosis will lay a good foundation for this disease. When these and other proper conditions exist the disease will often show itself after a sudden mental shock, or violent grief, or after an outburst of anger; homesickness or disappointment in love will cause it.

There is no doubt that chronic constipation or the persistent habit of retaining the urine for long periods results in an autointoxication which will act as a cause of this disorder, and it may be also induced by other toxemias. Menstrual irregularities, among them menorrhagia and amenorrhea, are common among young girl immigrants who cross the ocean. Other abrupt changes in climate, with correspondingly marked changes in the habits of living, precede the appearance of this disease, and are often classed as causes.

Symptomatology:—Girls who have previously been well nourished, and of plump and healthy appearance find themselves unable to perform active exercise or to engage in persistent employment without exhaustion. They become despondent, languid, irritable, and complain of being always tired. Early in the disease the skin assumes an unpleasant yellowish or pale hue which soon becomes actually greenish in tinge, or greenish yellow. Later all exercise results in weakness; the patient is troubled with vertigo, faintness, some nausea; irregularity of the heart's action, with palpitation after exertion, and some difficulty of breathing are common. Headache is a very frequent and troublesome symptom. The appetite is always poor, sometimes capricious or perverted, craving abnormal substances, or highly seasoned food; the digestion is seriously impaired and, as has been stated, there is constipation in a large per cent of the cases, and scanty urine, usually of a high specific gravity. In other cases there is a large quantity of pale urine of low specific gravity. There is also deficient menstruation, amenorrhea being very prominent. In occasional cases, without kidney complication, there is puffiness of the face and edema of the ankles.

In a few cases there is such freedom of the capillary circulation in the face or in the lips that, although the blood is deficient in hemoglobin, there is but little if any pallor, the patient being quite rosy or flushed in the countenance, but this is rare.

In some cases there is slight fever, but usually the temperature is normal or subnormal and the extremities are cold; the tongue is thick, pale and flabby, easily indented, and occasionally coated with a thick, greyish white coat. There are persistent eructations of gas and there may be simple regurgitation of food. Hysteria is a very common accompaniment. This may become the conspicuous condition, and all of its attendant symptoms may be present.

Diagnosis:—The diagnosis usually depends upon the observation of the color of the skin. An examination of the blood will usually confirm the suspicion, the hemoglobin is reduced at least one-half, and may be reduced to twenty or even fifteen per cent. This does not, however, prove that there is a great reduction in the number of red blood corpuscles. These may be normal in quantity or but slightly reduced. In this particular a differential diagnosis can readily be made between chlorosis and syphilis by the history and attendant symptoms. A well nourished patient suffering from headache and inclination to syncope and dizziness, with hysterical symptoms and with the characteristic color above specified can hardly be declared to be suffering from any other complaint.

Prognosis:—The disease is inclined to be transient in character and in mild cases spontaneous recoveries occur. In acquired cases the prognosis is seldom if ever unfavorable.

Treatment:—All bad habits of eating and living must be immediately overcome; the patient must be placed in excellent hygienic surroundings and all causes which influence the mind should be removed and hysterical symptoms should be carefully met; however, these may be relieved with the improvement of the condition of the blood, as they are closely related to the menstrual irregularities, and these seldom need any direct treatment for their correction when the faulty conditions of the blood are corrected. It is important that the condition of the blood be quickly restored. This is usually readily accomplished by the use of iron and other well known and accessible restorative agents. Occasionally these patients should be put to bed for a short time and quiet and restfulness should be enjoined. The condition of the stomach should receive immediate attention; it should be placed in a condition to receive and appropriate the food readily; the patient should be encouraged to eat normal, plain food with a minimum of condiments in their seasoning. Eggs, milk in abundance, fresh beef, and other nutritious foods of this class, with a well selected vegetable diet, should be partaken of. An excess of fats, fried foods, salted or preserved meat, canned foods, as well as an excess of the carbohydrates and tea, coffee and alcoholic beverages should be excluded.

Particular attention must be given to the persistent constipation which accompanies these cases, and because of the autointoxication which the constipation induces the patient should take echinacea, or some other specific alterative or antiseptic remedy which is known to antagonize the growth and development of toxins. The use of cascara sagrada in some palatable form, or a regular daily dose of the sodium phosphate of the magnesium sulphate, should be given for their laxative influence. Occasionally, by giving the sodium phosphate in from forty to sixty grain doses three times a day in hot water both a restorative influence upon the nervous system and a laxative effect upon the bowels is obtained. In the administration of iron to restore the blood it should be remembered that these patients appropriate a larger quantity of iron than those suffering from other forms of anemia. The oxid of iron in the form of a syrup, the carbonate or the sulphate of iron, are all accessible and beneficial forms. The pyrophosphate of iron is especially valuable, the citrate of iron and reduced iron have been used with good results. Where there is imperfect digestion, with a probable deficiency of hydrochloric acid, the tincture of the chlorid of iron will be of much service. I have used hydrastis in combination with the iron in nearly all of these cases and believe it to be a remedy of great efficacy. It not only stimulates the nervous system to normal functional activity but promotes to a high degree normal functional action of the stomach and of the organs of appropriation. It certainly facilitates the appropriation of the iron. If there are plainly marked heart faults the use of cactus or strophantus will not only overcome these but will greatly facilitate the appropriation of iron. The tincture of copper, in small doses, or the one-fiftieth of a grain of the arsenite of copper three times a day are said to exercise a direct restorative influence upon the blood, similar to that accomplished by iron. Where there is conspicuous impairment of the nervous system, with neurasthenic symptoms, free phosphorus should be also given. A phosphorized elixir of the calisaya bark and pyrophosphate of iron is a combination that has accomplished excellent results in my cases. In hysterical cases, indications will appear at times for gelsemium, hyoscyamus, pulsatilla, and perhaps the bromids. Where the menstrual derangement does not seem to be corrected by the improvement of the constitutional conditions this result may be brought about by the use of helonias, senecio, macrotys, or viburnum.

A happy condition of the mind, with pleasant surroundings, a condition of hopefulness, cheerfulness and restfulness, are all essential to a speedy cure. This disease often occurs when the patients are being crowded through a college course, or when they voluntarily take upon themselves a large amount of extra work in their college course. This should be anticipated and prevented, and if the condition is on the increase, all study must cease until a cure is accomplished.

The Eclectic Practice of Medicine with especial reference to the Treatment of Disease, 1910, was written by Finley Ellingwood, M.D.