REP^RINIBD^rROM 
UNIVERSITY 
Medical Magazine. 
EDITED UNDER THE AUSPICES OP THE ALUMNI AND FACULTY Of MCClONI 
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MARCH, 1893 
A CLINICAL LECTURE ON CHLOROSIS. 
By James Tyson, M.D., 
Professor of Clinical Medicine in the University of Pennsylvania. A CLINICAL LECTURE ON CHLOROSIS.1 
By James Tyson, M.D., 
Professor of Clinical Medicine in the University of Pennsylvania, 
The patient is a young woman 18 years old, who works in a book- 
binding establishment. Her father and mother are both living and in 
good health, as are also her brothers and sisters. She herself was well 
up to the time of her present illness. Her special duty in the bindery 
has been to bronze the backs of books, and at this she has worked from 
ten to fifteen hours per day for the past two years. Last summer, 
however, she took a vacation, and it was during it, on the Fourth of 
July, that while running she was taken with vertigo. Then, apparently 
for the first time, her paleness attracted attention. She returned to her 
home in the city, and soon afterward, in the late summer or early autumn, 
applied to the hospital dispensary for treatment. Dr. Fussell, who was 
on duty in the dispensary, prescribed for her, and directed her to 
return. Feeling improved after taking the medicine she failed to report 
as directed, but soon realized that she was growing worse. Then she 
returned to the hospital, and was admitted to the wards about No- 
vember i. 
Note now the peculiar faint greenish pallor of her face character- 
istic of her disease. More vivid is the paleness of the lips, contrasting 
strongly with the bright red of good health. Her other symptoms are 
not numerous, being mainly shortness of breath on exertion, a feeling 
of weakness and an indisposition to exertion. This girl has been over- 
worked. Her nutrition is at fault. This defect manifests itself in an 
imperfection of the blood, which we will study more closely, since the 
superficial examination gives no clue to its real alteration. Fortunately 
1 Delivered at the Hospital of the University of Pennsylvania. 2 
James Tyson. 
we are now enabled to do this with a precision formerly impossible. 
With appropriate apparatus we can not only count the corpuscles, but 
we can also measure the hemoglobin, their most important constituent. 
More than one instrument has been devised for this purpose. I like 
best the Thoma-Zeiss cytometer for counting corpuscles and Fleischl’s 
hemometer for measuring the hemoglobin, for the description of both 
of which I must refer you to the books on clinical diagnosis. I may 
mention, however, in passing, that cytometers bearing the name of 
Quinke, Mallassez, Hayem and Gowers have been devised by these 
observers, while Henocque has also constructed a hemoglobinometer 
and Bizzozero an instrument for Both uses, corpuscle counting and color 
measuring. 
The following are the directions published by Zeiss himself for the 
use of the Thoma instrument made by him. 
This apparatus consists of three parts : 
(1) A graduated pipette (melangeur) with india-rubber tubing and 
mouthpiece. 
(2) A divided cell upon an oblong slip. 
(3) A cover-glass with plane ground surfaces. 
In order to count the red corpuscles of human blood the tip 
•of any finger is cleaned with water and alcohol and then rubbed 
between the fingers of the other hand. A slight arterial hyper- 
emia of the tip of the finger will arise, so that a fairly deep punc- 
ture with a lancet-like needle is sufficient to cause a drop of blood 
to appear. The point of the pipette is quickly placed into it and 
the blood sucked in up to division 1. Then the point of the pipette is 
-cleaned from the blood sticking to it by a cloth kept ready for the 
purpose, and it is placed into a 3 per cent, filtered solution of common 
salt. This also is immedietely sucked up, so that the fluid enters into 
the spherical enlargement of the pipette. As soon as the sphere is filled 
up to Division 101 the sucking is interrupted and the mouthpiece of 
the india-rubber tube closed by putting the finger upon it. The con- 
tents of the spherical enlargement are now to be mixed by careful 
shaking. Thus in this sphere ninety-nine parts by volume of salt 
solution are mixed with one part by volume of blood, or 100 parts by 
volume of the mixture contain one part by volume of blood, for the 
fluid in the capillary tube does not enter into the mixture. 
If the blood is sucked in up to another division, say 0.5, instead of 
division 1, then with the same mode of proceeding another dilution is 
obtained, viz., 1 : 200. 
Afterward, by blowing air into the india-rubber tubing, the salt 
solution may be removed from the capillary tube, and by constant 
shaking about one-half of the sphere is emptied. The next drop of 
the mixture is emptied upon the middle of the bottom of the divided A Clinical Lecture on Chlorosis. 
cell, after the latter has been carefully cleansed. The cover-glass is 
immediately placed over it, and the apparatus is transferred to the 
horizontal stage of the microscope and left standing quietly for some 
minutes, so that the blood corpuscles may settle down. 
It is necessary for a successful operation that the divided cell and 
cover-glass should be thoroughly cleaned. If this is done properly the 
Newtonian rings will be perceived along the edge of the cover glass as far 
as it rests upon the wall of the cell, and this indicates that the cover- 
glass lies well upon it. At the same time it must be seen that no fluid 
enters between the cover-glass and the wall of the cell. On the con- 
trary, the drop of blood should be placed in the center of the cell, and 
spread thence to fill up the space between the cover-glass and the 
bottom of the cell for some square millimeters. 
Special care should be taken to keep the pipette in clean condition. 
Every time after having been used, it should be rinsed with (i) the 
diluting fluid, (2) distilled water, (3) absolute alcohol, and (4) ether. 
If dust or coagulated blood should still stick to the pipette, it should 
be removed with strong acids or alkalies by repeated rinsings, assisted, 
if necessary, by a bristle. 
The corpuscles may be counted by any object glass magnifying 
about 300 diameters. 
Every fifth square of each horizontal and vertical row of squares is 
crossed by an additional line to facilitate the counting. Each square 
occupies an area of y-jyy sq. mm., and above each square there 
is a space of c. mm., since the distance of the bottom of the 
cell from the lower surface of the cover-glass amounts exactly to 
Ty mm. The corpuscles which first were suspended in this space have 
now settled and are lying on the bottom of the cell, where they may 
be counted. The corpuscles lying upon the lines should be counted, 
but, of course, only once. Thus, all corpuscles lying on the hori- 
zontal lines should be counted in the squares above them, and all 
corpuscles lying on the vertical lines should be counted in the squares 
to the right of them. 
The calculation is as follows : If by a dilution of the blood in the 
proportion of 1 : a in n squares z corpuscles have been counted, then 
1 c. mm. of undiluted blood will contain : 
3- X Z 
4000 x —— blood corpuscles. 
n 
If, for example, by a dilution of the blood in the proportion 1 : 100, 
as we supposed above, in 200 squares altogether 2570 red blood 
corpuscles were found, then the calculation will give for 1 c. mm. of 
blood— 
4000 x 100 x , , , . 
— - ——JJ— — 5,140,000 blood corpuscles. 
200 4 
James Tyson. 
For counting the white blood corpuscles a pipette should be used 
which allows a dilution in the proportion of 1 : 10, and instead of the 
salt solution an aqueous x/i per cent, solution of acetic acid should be 
chosen for diluting. The red corpuscles will disappear in this fluid, 
but the white ones will remain and are easily counted. The method 
of calculation is the same as that given above for the red blood 
corpuscles. 
Studies by Thoma and others, with a view to determining possible 
errors with the instrument whose use has just been described, go to 
show the constant errors to be insignificant, less than 1 per cent., while 
the accidental and variable errors, which are unavoidable, diminish 
with the number of corpuscles counted. Thus, by counting 200 cor- 
puscles they amount to 5 per cent, of the total result. 
1,250 corpuscles amount to 2 per cent, of the total. 
5,000 “ “ 1 “ “ “ “ 
20,000 “ “ y2 “ “ “ “ 
Recently, in 1885, Professor Blix, of Upsala, Sweden, suggested the 
use of centrifugal force in estimating the volume of red blood corpus- 
cles, and Dr. S. G. Heden has devised an instrument called the hemat- 
okrit, for this purpose. Dr. Judson Daland has further improved this 
instrument so that after the blood, diluted with an equal bulk of a 2.5 
per cent, solution of bichromate of potash,1 has received the requisite 
amount of rotation, the percentage volume of red corpuscles may be 
read off from the cylindrical tubes in which the blood is placed, and 
from this deduced the nuviber in each cubic millimeter by simply add- 
ing six ciphers to the reading. 
Dr. Daland2 regards thehematokrit as both more speedy and more 
accurate than the cytometer, basing his conclusions on a very large 
number of comparative observations. He used also a great variety of 
fluids for dilution, and concluded that the above solution of bichromate 
of potash is, for many reasons, the best. The hematokrit also enables 
one to measure the volume of colorless blood corpuscles, but no 
method has as yet been devised for calculating their number. 
In the patient before you the blood count was made with the 
Thoma-Zeiss apparatus, and there were found upward of three millionsof 
red discs, with no disproportionately large number of white corpuscles. 
Now, the number of red discs per cubic millimeter in health is put down 
at five millions for men and four and a half millions for women. But 
a very considerable range must be admitted, and while three and a half 
' This solution is also an excellent one for diluting the corpuscles when counting them 
■with the Thoma-Zeiss counter, and is the one commonly in use at the Hospital of the University 
of Pennsylvania. 
1 A Volumetric Study of the Red and White Corpuscles of Human Blood in Health and Dis- 
ease.—University Medical Magazine, November, 1891. A Clinical Lecture on Chlorosis. 
5 
millions of corpuscles is less than normal it cannot be asserted that 
this number is not compatible with perfect health, and the amount of 
hemoglobin may still be sufficient. 
We must go further, therefore, in our study of the blood and 
measure the quantity of hemoglobin. This has been done by Fleischl’s 
hemoglobinometer with the astounding result of 15 per cent, as com- 
pared with a normal 100 per cent., although this maximum is rarely 
reached, 90 per cent, being the more usual. 
Herein, then, we have the solution to our problem and the appear- 
ance of the patient. With a moderate reduction of the number of corpus- 
cles is associated an enormous falling off in the amount of hemoglobin. 
From this it appears, therefore, that the individual hemoglobin value 
of each corpuscle is greatly diminished. Beyond this there is nothing 
abnormal to note. The proportion of white corpuscles to red discs is 
normal. There is no undue smallness or the opposite in the size of 
the discs, no undue irregularity of shape. But in this reduction in the 
amount of coloring matter we have one of the essential conditions of 
an anemia which may be defined as any condition of the blood charac- 
terized by an undue diminution in the total bulk, its albumen, its hemo- 
globin, or of the latter two. 
We have, therefore, before us, a case of anemia. What variety is 
it ? The symptoms of pallor, vertigo, weakness, and shortness of 
breath on exertion are common to all varieties. So are palpitation and 
irregular heart action, and even anemic murmurs. There are, how- 
ever, some special features in this case which have already been pointed 
out. There is a peculiarity in the pallor of our patient. It is a yel- 
lowish-green, and the patient is a young girl, overworked, not ema- 
ciated, but fairly nourished. Above all, there is a marked reduction in 
the hemoglobin without a corresponding reduction in the corpuscles. 
Now, these are the essential features of chlorosis, or green sickness, one 
of the varieties of essential anemia. 
There is no enlargement of the spleen, or of the lymphatic glands. 
There are no essential anatomical changes in this disease. Many years 
ago Professor Virchow p unted out an imperfect development of the 
circulatory system as more or less characteristic; that the heart was 
small; the large blood vessels small and thin walled. Such a state of 
Uiffairs, must, however, be accidental, and there is no definite morbid 
anatomy to the disease. Rarely there is compensatory hypertrophy of 
the left ventricle. We must, therefore, look upon the condition as 
consisting in a physiological failure on the part of the cytogenetic 
apparatus to supply the proper proportion of hemoglobin to the blood 
corpuscles. A further study of the blood discovers a marked diminu- 
tion in the iron, a constituent of the hemoglobin, resulting in a lighter 
hue of the blood when seen en masse. 6 
James Tyson. 
The corpuscles may be somewhat altered and even fantastically 
irregular in shape, constituting what is known as poikilocytosis, or they 
may be larger than in health, when they are known as megalocytes. But 
these alterations are not common, even in slight degree. More frequent 
is an undue reduction in size of the corpuscles, a microcytosis. They 
may also be appreciably paler in hue than is typical, and the blood 
en masse may appear paler. The proportion of leucocytes may be 
slightly lowered. 
Gruber found increased alkalescence of the blood, but von Jaksch 
found it diminished in three cases. Whence it may be concluded that 
none of these features are essential or diagnostic. 
To sum up then, chlorosis is a disease characterized by a defective 
formation of red blood cells, resulting in a deficient amount of hemo- 
globin, without, as a rule, any marked reduction in the number of the 
red discs. 
The course of a case of chlorosis is limited by the treatment, for by 
judicious management a few months to a year will generally establish 
a cure, for the prognosis is the most favorable of that of all the anemias. 
The diagnosis is based chiefly upon the age and sex of the patient, 
the peculiar greenish, pale color of the mucous membranes and the 
diminished hemoglobin. Ulcer of the stomach is sometimes simulated 
by chlorosis because of epigastric pain which occasionally accompanies 
it, and some little study is sometimes necessary to complete a diagnosis. 
The anemia which is sometimes very marked in gastric ulcer is not 
accompanied with such a disproportionate reduction of hemoglobin as 
compared with the corpuscular reduction, and they are more apt to go 
pari passu. The history of the case will also aid in the separation. 
There are few things more satisfactory in therapeutics than the 
treatment of a properly managed case of chlorosis. Time, however, is 
required, and too rapid a cure must not be promised. The remedy 
par excellence is iron, and it does not matter what preparation of 
iron is used. At the present day Blaud’s pill of carbonate of iron, 
made by double decomposition between carbonate of potassium 
and sulphate of iron, is very popular. Half an ounce of each are 
combined and made into ninety-six pills so that each pill contains five 
grains. Of these from one to two are given at a dose. Reduced iron 
is also a valuable preparation in doses of one to three grains. Arsenic 
is a valuable adjunct. It should be given in ascending doses. Fowler’s 
solution is the most convenient preparation, but arsenious acid is also 
a good form. The latter is now made up in combination with Blaud’s 
pill, one-fortieth of a grain in each pill. This is a small dose. If 
Fowler’s solution is used the dose may be commenced at a single 
minim and gradually increased until the physiological effect results, 
when the dose is again reduced. A Clinical Lecture on Chlorosis. 
7 
Rest in bed for a time, associated with massage and an abundance 
of easily assimilable food, in a word, the “ rest cure,” is an important 
auxiliary, if it can be availed of, to hasten a cure, which at best is not 
rapid, while a sojourn at the seaside when convalescence is fully 
established, is a fitting close and crowning measure of treatment.