Day: March 1, 2010

Learning From the Past. What is Chlorosis?

Patient Presentation
A pediatrician was reading for pleasure and came across this passage describing Mary Queen of Scots, just before her ascension as Queen of France when she was 17 years old in 1559: “{England’s ambassdor to France} Throckmorton also noticed that Mary was unwell and she soon had to retire from court in a state of nervous collapse. He found Mary and Henri’s daughter, Marguerite, ‘somewhat sickly’ and on 24 May, visitors said she was ‘very ill, pale and green and withal short-breathed and it is whispered amont them [in the French court] that she cannot live long’. By 18 June, one of Mary’s attendants felt that she ‘was very evil at ease and to keep her from fainting were fain to bring her wine from the altar…I never saw her look {so} ill…she cannot long continue’. ”

The diagnosis of Queen Mary’s illness was chlorosis, which the pediatrician had never heard of. She decided to use a literature and Internet search to try to learn more about this adolescent malady.

Discussion
In practicing medicine, clinicians try to provide the best care for the patients and families they serve. They usually try to use the most current information available and apply it to the specific patient situation, yet medicine is an ever-changing science and art. Disease theories change. For example, mental illness was once thought to be caused by the lunar cycles thus the name “lunacy” or “lunatic.” Overtime it became known that neurochemical and genetic factors play a role. Scientific information is re-analyzed or classified. For example, the organism that causes cat-scratch disease has had 3 names since 1991 – Afipis felis, Rochlimacae henselae, and currently Bartonella henselae. Disease treatments are often changing as new information becomes available. For example, up until the early 1990s, intravenous theophylline was widely used for asthma treatment as it was thought to be better than aerosolized albuterol, and oral steroids were not used at all. Likewise “new” diseases are described. Some continue to be a distinct entity because the causative agent is accepted as distinct, such as HIV. Other diseases also continue to be viewed as distinct entities but a causative agent has not been defined or may be multifactorial, i.e. Kawasaki disease. It is only the test of time that allows clinicians to know with more or less certainty if their present information is correct.

Learning Point
Chlorosis was considered a blood dyscrasia that was ill-understood, but feared by people. Clinical descriptions were of teenage and young women with menstrual irregularities who were generally well-nourished but would have a pale coloring of their skin. The skin color was described as greenish and hence the name, but this actually occurred very rarely. The young ladies were always described as having extreme fatigue, to the point that many were felt to be dying. Other descriptions include being a brunette, blond or redhead (depending on the source), and having a bluish cast to the eyes. Possible causes included overwork or underwork, poor hygiene, tight corsets or clothing, spurned love, or sudden shocks or frights. Other names for the disease were norbus virgineus (virgin disease) or greensickness. Many different treatments were promulgated, but the most common one was to marry and begin sexual intercourse. If a woman continued to have episodes after marriage, then increased frequency of intercourse was recommended.

Contemporary accounts of chlorosis go back to ancient history. William Shakespeare described greensickness in 4 plays including 1 where he describes a “male greensickness.” Even in the early 20th century, Henry James’s novel The Wings of the Dove describes a woman who is mortally ill with an ill-defined disease which is often taken for tuberculosis, but which describes chlorosis. Many young girls and women were felt to be dying when they would have these episodes including Mary Queen of Scots, presented above. With newer science, the true cause of chlorosis was determined to be iron deficency anemia and thus over time, chlorosis has had its demise including its own obituary written in 1936.

It is intriguing to think about how history might have changed if the then “modern” understanding of chlorosis was true. In real history, Mary Queen of Scots was truly felt to be dying while she was married to King Francois II. He later died before producing an heir with her. Queen Mary remarried and later had one child, James VI of Scotland who eventually became James I of England and Ireland, effectively unifying the current Great Britain. How would the histories of France, Scotland, England and Europe itself have changed if the prevailing understanding of chlorosis was actually true and Mary had died? How will our understanding of disease today, change the future of the world?

Questions for Further Discussion
1. What changes in medicine have you experienced over your professional lifetime?
2. What other extinct diseases can you name?
3. What is the effect of disease on war?
4. List other histories that were or may have been changed because of disease?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Anemia and at Pediatric Common Questions, Quick Answers for this topic: Iron Defiency Anemia

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

Shakespeare W. Romeo and Julie Act 3 Scene 5.

Shakespeare W. Antony and Cleopatra Act 3 Scene II.

Shakespeare W. King Henry IV Part 2 Act 4. Scene III.

Shakespeare W. Pericles, Prince of Tyre Act 4, Scene VI.

Fowler WM. Chlorosis – An Obituary. Annals of Medical History. 1936:8,168-177.

Time Magazine. Medicine: Chlorosis. April 6, 1936.

Mercer CG, Wangensteen SD. Chlorosis, A Heroine’s Illness in The Wings of the Dove. Journal of the History of Medicine and Allied Sciences. 1985;259-285.

Graham, R. The Life of Mary Queen of Scots, An Accidental Tragedy. Pegasus Books, NY. 2009 page 83.

ACGME Competencies Highlighted by Case

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    12. Evidence from scientific studies related to the patients’ health problems is located, appraised and assimilated.
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
    15. Information technology to manage information, access on-line medical information and support the healthcare professional’s own education is used.

  • Systems Based Practice
    23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.
    26. Partnering with health care managers and health care providers to assess, coordinate, and improve health care and how these activities can affect system performance are known.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital