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CONTENTS. 
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AUGUST, 1895 
REMARKS ON CHLOROSIS AND ITS TREATMENT. 
BY FREDERICK P. HENRY. M.D., 
PHILADELPHIA. REMARKS ON CHLOROSIS AND ITS TREATMENT.1 
By Frederick P. Henry, M.D., 
Philadelphia. 
The term chlorosis is derived from the Greek word which 
means greenish-yellow. By a slight stretch of the imagination the 
skin of a person of dark complexion suffering from chlorosis might be 
called greenish-yellow; but chlorosis is very common in Sweden, where 
the inhabitants are, as a rule, of very fair complexion, so that the 
name of the disease is, to a certain extent, a misnomer. It has, how- 
ever, the sanction of ancient usage, and it would be hard to find another 
to which even greater objections could not be raised. 
Etiology.-The chief predisposing causes of chlorosis are to be 
found in age, sex, and constitution. The forces emanating from these 
sources come to a focus, so to speak, in a case of chlorosis, and that 
which brings them to a focus is the advent of puberty. The principal 
of these predisposing causes is, I believe, a congenital tendency to 
anemia. Some years ago, while examining the blood of the new-born 
at the Maternity Hospital, I discovered an infant whose red blood- 
corpuscles numbered only 3,625,000 per cubic millimetre, the normal 
average being at least 5,000,000. Now, this child, which, by the way, 
was a female, might, under proper care, thrive until the age of puberty, 
when the demands made upon the blood and nervous system by the 
evolution of the sexual system would, in all probability, give rise to 
well-marked chlorosis. The chief predisposing causes of chlorosis 
then are : (1) Sex, the vast majority of cases occurring in females. 
(2) Age, the decade between 14 and 24 years furnishing all the cases. 
(3) Constitution either inherited or acquired. 
Exciting Causes.-The exciting causes of chlorosis are those of 
anemia in general, such as insufficient food, light, air, and exercise, 
overwork, either physical or mental, anxiety, grief, and nervous excite- 
ment in general. There is another exciting cause on which great stress 
was recently laid by a distinguished physician of London, the late Sir 
Andrew Clark, and which, therefore, deserves to be considered at some 
length. The cause to which I refer is constipation, and Clark con- 
sidered it of such paramount importance that he used the term fecal 
anemia as a synonyme of chlorosis. This theory of Clark was based 
1 Read at the meeting of the Kentucky State Medical Society at Harrodsburg, June 13, 1895. 2 
Frederick P. Henry. 
upon certain signs and symptoms that are more or less commonly 
encountered in chlorosis. Chief among them are digestive disturbances. 
The tongue is generally heavily coated at the base, large, flabby, and 
with its sides indented with the teeth. The breath is disagreeable, 
and sometimes, according to Clark, has a distinctly fecal odor. There 
is a sense of epigastric oppression after the ingestion of food. The 
bowels are either confined or inadequately relieved, and the feces 
generally consist of scybalous masses embedded in mucus swarming 
with bacteria. Pain in the side, generally most marked on the left, is 
a common symptom, and was believed by Clark to have its seat in 
either the hepatic or splenic flexure of the colon. This view of the 
nature of the pain in the side is corroborated by the fact that it is 
sometimes relieved by large enemata of warm water. According to the 
authority just named, it is a common thing for young girls to neglect 
the calls of nature so far as the bowels are concerned. The feces 
accumulate, and by their decomposition ptomaines and leucomaines are 
generated, absorbed, and by their poisonous action produce the multi- 
form symptoms of chlorosis. A treatment based upon the theory that 
chlorosis is due to fecal retention is sometimes eminently successful, 
and will be referred to later in detail. 
Another exciting cause of chlorosis is cold. Professor Augusto 
Murri, of Bologna, has recently published an elaborate paper on the 
influence of cold in the etiology of chlorosis. He gives the notes of 
three cases in which the symptoms of chlorosis were limited to the cold 
months of the year, disappearing in summer and recurring on the onset 
of the succeeding winter, and he states that others precisely similar 
have come under his observation. He, therefore, styles them "winter 
chlorosis," or chlorosis hiemalis. It is well known that chlorotic 
patients are affected unfavorably, as a rule, by such exposure to cold 
as is well borne by the healthy, and this Murri believes to be due to 
an instability of the vaso-motor system on the part of the former. In 
fact, he regards chlorosis as a vaso-motor neurosis, the blood changes 
in the disease being dependent upon disorders of the circulation induced 
by cold, nervous shock, or long-continued irritation as from the genital 
organs. This paper is certainly a most suggestive one, teeming with 
facts and giving evidence of a thorough knowledge of the circulation 
in its healthy and diseased states. It is impossible to discuss it at 
length. Suflice it to say that it deserves the careful study of all 
hematologists. 
Meinert, of Dresden, claims to have demonstrated a displacement 
of the stomach (gastroptosis) in sixty consecutive cases of chlorosis. 
Fifteen per cent, of the cases were complicated with right movable 
kidney, and in one both kidneys were movable. The gastroptosis Chlorosis and its Treatment. 
3 
is secondary to enteroptosis, and this in turn to the pressure of the 
corset, so that, according to Meinert, it is to this article of female 
apparel that chlorosis is indirectly due. After the cure of a case of 
chlorosis, its anatomical substratum, the visceral displacement re- 
mains, and hence the notorious tendency of the affection to relapse. 
No one doubts the evil effect of tight lacing, and all will admit that in 
an individual predisposed by inheritance or otherwise to chlorosis, the 
development of the disease may be accelerated by constriction of the 
thoracic base and consequent displacement of viscera. 
It is scarcely necessary to add that there are those who regard 
chlorosis as an infectious disease. Among these are Clement, of the 
Hotel Dieu, Paris, who bases his opinion of its infectious nature on 
the enlargement of the spleen which he has found in thirteen cases, on 
the frequency of febrile movement, the occasional complication of 
phlegmasia dolens, and the epidemic occurrence of the affection. 
The hypothesis is well argued, but the facts on which it is based are 
questionable. 
Anatomical Characters.-From the fact that there is such diversity 
of opinion concerning the etiology of chlorosis it may almost be in- 
ferred that the anatomical characters of the disease are by no means 
uniform. Virchow endeavored to place the affection upon a distinct 
anatomical basis by the demonstration that, in fatal cases, there is often 
found an imperfect development of the aorta and arterial system gener- 
ally. He has found the aorta of a full-grown woman so small as 
barely to admit the little finger, whereas normally it should admit the 
thumb, and with this contraction of the lumen of the vessel its coats 
were found to be much thinner than normal. He regards this condi- 
tion of the vessels as congenital, and the importance of the observa- 
tion depends upon the fact that the blood-vessels and the blood-corpus- 
cles are both derived from the same embryonic layer,-the mesoblast, 
-an imperfect development of the one necessarily entailing the same 
condition in the other. I have little doubt that Virchow's theory is 
true with reference to some of the cases, especially those that run a 
fatal course. A condition of imperfect development of the vascular 
system might doubtless give rise to grave disturbances of nutrition 
which would eventually end in death, but chlorosis is not, as a rule, a 
fatal disease, the great majority of cases under appropriate treatment 
ending in recovery, and with reference to them there is no proof that 
such a stunted condition of the blood-vessels is present. 
The only constant anatomical characters of chlorosis are those of 
the blood itself, and it is for this reason that I classify the disease 
among the primary anemias. Bven the blood-changes are not uni- 
form. The researches of Duncan, in 1867, first established the fact 4 
Frederick P. Henry. 
that in well-marked cases of chlorosis the number of red blood-cor- 
puscles might be normal while their percentage of hemoglobin might 
be greatly reduced, and this anomaly was for a long time regarded as 
the distinguishing mark of chlorosis. It has since been established 
that this view of the blood-change in chlorosis is altogether too narrow, 
and at the present day it is generally admitted that the changes in the 
red corpuscles may be at least threefold, (i) They may be of normal 
size and number, their only change being a deficiency of coloring 
matter. (2) They may be diminished in number with diminished per- 
centage of coloring matter. (3) They may be diminished in size and 
normal in number and in percentage of coloring matter. 
Of the above-mentioned varieties the second is the most severe, 
and in it there are often marked changes in the shape of the red 
corpuscles (poikilocytosis) such as are so commonly observed in per- 
nicious anemia. 
From these facts you will perceive that there is nothing uniform 
in the behavior of the red corpuscles in the disease called chlorosis, so 
that an attempt to describe it as a distinct disease from an anatomical 
stand-point must result in failure. The essential point is that the per- 
centage of hemoglobin is reduced in this affection, and this is common 
to many forms of anemia. 
It has been contended by some writers, especially by Immermann, 
that chlorosis differs from all other forms of anemia in that the albu- 
minous bodies of the blood-serum are present in that fluid in normal 
or increased amount. This has certainly been proved to be true in a 
few cases by chemical examination, but it has not yet been proved that 
the same may not be true of other forms of anemia. 
From the foregoing remarks it appears to me evident that the 
conditions of the blood and the other organs of the body are so various, 
not to say contradictory, as to veto the present establishment of chlor- 
osis as a distinct disease. With advancing knowledge some etiological 
or pathological fact, common to all cases of the affection, may be dis- 
covered, but at present none such is known. 
With our present knowledge, the most sensible view of the nature 
of chlorosis appears to me the following, which I have already ex- 
pressed elsewhere :1 At the time of puberty there is an urgent physio- 
logical demand upon the blood which is complied with by vigorous 
individuals without detriment to the organism. The ordeal of puberty 
is safely passed. In less vigorous, but still sound, healthy organisms, 
a decided degree of anemia, one calling for treatment declares itself 
at this time. Finally, in those with any congenital tendency to 
anemia, whether this may have been due to general malnutrition 
1 Anemia, by F. P. Henry, Philadelphia, 1887. Chlorosis and its Treatment. 
5 
during intrauterine life, or to a special hypoplasia of the vascular 
system, the anemia of puberty is intense. The case is a typical one 
of chlorosis. 
Complications.-There are certain diseases to which chlorosis 
stands in the relation of a predisposing cause, and which, therefore, 
may be regarded either as complications or sequelae. The chief of 
these are phthisis, gastric ulcer, chorea, and exophthalmic goitre. 
There can be no doubt that one of the best prophylactic means of 
averting phthisis pulmonalis is the maintenance of a good condition of 
the blood, and, conversely, that a poor state of the blood is often a pre- 
tubercular or pre-bacillary stage of phthisis. Gastric ulcer is by no 
means uncommon in chlorotic women, and its occurrence is favored by 
degenerative changes in the blood-vessels of the stomach leading to 
thrombosis and hemorrhage as well as by the hyperacidity of the gas- 
tric juice, which recent researches of Lava, of Turin, Cantu, of 
Pavia, and Osswald, of Germany, have shown to be the rule in chlor- 
osis. 
Chorea, it is well known, is decidedly more common in females 
than in males, and although more frequently observed under than over 
15 years of age, is yet far from rare between the ages of 15 and 20. 
Its occurrence is undoubtedly favored by chlorosis, and the same is 
true of that peculiar neurosis known as exophthalmic goitre or Graves's 
disease. 
Omitting, for the sake of brevity, any further remarks on diagnosis 
and prognosis, I will conclude with some observations upon the treat- 
ment of chlorosis. 
Treatment.-As Immermann remarks, " there is scarcely any point 
in therapeutics so fully established as the remarkable efficacy of iron, 
in removing all the symptoms of chlorosis," but it does not follow that 
iron should initiate the treatment in every case. Nearly all chlorotics 
are dyspeptic, and until the digestive disorder is relieved, the full ben- 
efit of iron cannot be obtained. In cases of atonic dyspepsia the sim- 
ple bitters, such as quassia or gentian, or exciters of the smooth muscular 
fibres, such as strychnia or brucia, may be administered before meals, 
or if there is gastric dilatation, naphthol, salicylate of bismuth or chlo- 
roform-water may be given three or four hours after meals, as recom- 
mended by Le Gendre, in order to limit or stop the abnormal fermenta- 
tions generally present in that condition. Hyperacidity of the gastric 
juice should be treated with full doses of alkalies-soda, chalk, or 
magnesia-from one to two hours after meals, and an acidity, with 
dilute hydrochloric acid immediately after eating. 
According to Dr. Haig, of London, who has done so much to ad- 
vance our knowledge of lithemic conditions, "iron cures anemia by 6 
Frederick P. Henry. 
clearing the blood of uric acid." When iron fails to cure chlorosis, he 
recommends its suspension and the administration of mercurials and 
salicylates until the blood is cleared of uric acid, after which improve- 
ment may occur even without the resumption of the iron. 
There has been much discussion concerning the modus operandi of 
iron in chlorosis. A study of a few cases of chlorosis, perhaps even of 
one, will lead any reflecting physician to the conclusion that the cause 
of chlorosis is not a deficient supply of iron, but something that inter- 
feres with its assimilation. To begin at the beginning, we find that in 
mothers' milk there is more iron than is necessary to supply the wants of 
the new-born child, for distinct traces of the metal are found in its excre- 
ment. This also proves that the amount of iron necessary to maintain 
the normal composition of the blood is very small, for there is but a 
minute quantity of the metal in human milk. Nearly all our food 
substances contain iron, and there is probably no drinking water in 
which traces of it cannot be found. It is evident, therefore, that 
there is something which interferes with the digestion and assimilation 
of the iron, which is abundantly present in the food of chlorotic indi- 
viduals. 
Until quite recently no satisfactory explanation could be given of 
the efficiency of iron in chlorosis, and especially of the necessity of ad- 
ministering it in large doses, for it was known that very little of the 
drug was absorbed? Nearly all the iron given by the mouth can be 
recovered in the feces, and therefore it would appear that a large por- 
tion of the drug is wasted, and that equally good results might be 
obtained by its use in small doses. This, however, is not the case, and 
thanks to the investigations of a German chemist, named Bunge, we 
have, at the present time, at least, an idea of the mode in which iron is 
so efficacious in chlorosis. 
In the first place, our food, which contains all the iron we need, 
does not contain that metal in inorganic form, but in an exceedingly 
complex organic union. Now, in chlorosis, as is so emphatically in- 
sisted upon by Sir Andrew Clark, digestive disturbances are exceedingly 
common. Abnormal fermentations and decompositions take place in 
the gastro-intestinal tract, which give rise to the formation of quanti- 
ties of sulphides. These decompose the iron contained in the food and 
completely unfit it for the purposes of nutrition. By administering an 
inorganic preparation of iron we protect the organic combinations of 
that metal in the food, for the sulphur in the intestine combines with 
the iron administered, and allows that normally contained in the food 
to be absorbed. This theory of Bunge also explains why it is some- 
times necessary to administer colossal doses of iron, for, in such cases, 
the decompositions in the intestine are unusually active; sulphur is Chlorosis and its Treatment. 
7 
formed in large quantity and requires a proportionally large amount of 
iron to take it up. 
It is only proper to add that Bunge's theory has lately been con- 
tested by Ralph Stockman, of Edinburgh, who claims to have cured 
cases of chlorosis by giving them sulphide of iron, and who contends 
that bismuth, manganese, and other drugs which are just as capable of 
absorbing sulphuretted hydrogen as is iron, are inert in chlorosis. 
Stockman, however, acknowledges that the promptest curative effects 
are obtained with inorganic preparations of iron. On the other hand, 
Forchheimer, of Cincinnati, believes in the therapeutic virtues of intes- 
tinal antiseptics in cases of chlorosis, and my own opinion is in favor 
of their efficacy. 
There has been a good deal of discussion as to the relative merits 
of organic and inorganic preparations of iron, and there can be no doubt 
that both are effective. The protoxalate is a favorite salt of certain 
eminent French practitioners, while others claim that the best results 
are obtained with the sulphate. For my own part, I am accustomed 
to place the most reliance on the inorganic salts of iron, although I 
have obtained good results from both the malate and the lactate. 
In conclusion, I will describe the method of treatment so strongly 
advocated by the late Sir Andrew Clark. 
With careful attention to the diet and a tepid sponge, followed by 
brisk towelling both night and morning, he prescribes the following 
mixture, to be taken twice a day : 
B Ferri sulphat gr. xxiv. 
Magnes. sulphat 3vi. 
Acid, sulph. aromat gi. 
Tinct. zingib gii. 
Infus. gentian comp, vel quassise . , . M. 
SiG.-One-sixth part twice daily, about eleven and six o'clock. 
" Occasionally this acid mixture produces sickness, dries the skin, 
and is otherwise ill borne." In such cases he prescribes the following 
alkaline mixture : 
B Ferri sulphat gr. xxiv. 
Sodii. bicarb gii. 
Sodii. sulphat 3 vi. 
Tinct. zingib gii. 
Spt. chloroformi 3 i. 
Infus. quassiae 3 viii. M. 
SiG.-One-sixth part twice daily, at eleven and six. 
Sometimes neither mixture agrees, and then he prescribes sulphate 
of iron in pill with meals, and a saline aperient on first waking in 8 
Frederick P. Henry. 
the morning. By this plan Clark claims that nine out of ten cases 
of chlorosis recover in from one to three months, and by careful atten- 
tion to the bowels, taking twice a week a pill composed of aloes, myrrh, 
and iron, the recovery will probably be permanent. 
There is one important fact concerning the treatment of chlorosis 
upon which stress has been recently laid by Stephen Mackenzie, and 
which I have had repeated opportunities of verifying. It is that while 
it is easy to improve the condition of a chlorotic girl up to a certain 
point, it requires great perseverance on the part of both physician and 
patient to effect a complete cure. The hemoglobin percentage may 
rise from 25 or 30 to 70 or 75, and may there remain for many weeks. 
The patient's general condition is vastly improved ; she considers her- 
self well and refuses to continue the treatment that has apparently cured 
her. Relapse, under such circumstances, is certain and speedy. Fer- 
ruginous preparations should be continued for two or three months 
after apparent cure.