Chlorosis was one of the most common diseases affecting adolescent girls and young women in Europe and North America during the 17th to 19th centuries. Its main features were a pale or greenish appearance, fatigue and weakness, shortness of breath, palpitations, loss of appetite, and amenorrhea or irregular menstruation. Fanny Price in Mansfield Park, Madame Bovary, Juliet Capulet, Esther Summerson in Bleak House, and Milly Theale in The Wings of the Dove may all have suffered from chlorosis, as may have Alfred Tennyson’s Lady of Shalott.

Some descriptions of so-called diseases of virgins date back to Hippocrates. But credit for describing chlorosis as it is now understood is usually given to Johannes Lange, the German physician who lived in an elegant princely castle in Heidelberg.¹ It was the custom at his time for learned physicians to write letters describing their medical experiences to colleagues and even to non-medical friends.^1,2 In 1554 under the title de morbo virgineo Lange referred to pale, anorexic girls who complained of weakness and palpitations, whose “heart trembled with every movement of their body and whose arteries of the temples pulsated, who became short of breath when dancing or climbing the stairs, whose stomach loathed food and particularly meat, and whose legs, particularly the ankles, become edematous at night.” Lange maintained that “Venus” would cure the disease if they married and conceived. He therefore advised the friend to whom he addressed this letter to give away his daughter in marriage, adding that “I shall be present at the nuptials.” His advice was epitomized a century later in the following poem:

A handsome buxom lass
lay panting on her bed.
She look’t as green as grass
and mournfully she said
Unless I have some lusty lad to ease me of my pain
I cannot live
I sigh and grieve
My life I now disdain

In 1619, Jean Varandal of Montpellier also described the disease, in his De morbis et affectibus mulierum, and coined the term chlorosis. Shakespeare, in the second part of Henry IV (around 1587), refers to effeminate boys falling into a kind of “male green-sickness.” Sydenham (1661) and Willis (1681), the distinguished London physicians, achieved some success by empirically prescribing preparations containing iron. In the eighteenth-century, Jean Astruc, professor of medicine at Montpellier and Paris, described some women in early pregnancy who believed the green sickness to have caused their lack of periods.

The diagnosis of chlorosis was most popular between the years 1830 to 1900. Several physicians described cases of anemia in adolescent girls who mostly had irregular periods, insufficient diet, and often also gastro-intestinal or pulmonary affections. Most other accounts during the nineteenth century were in accord with this description.

Various physicians treating affected patients at the time postulated a constitutional weakness, limited exposure to the sun, or tight corsetry that supposedly compressed the internal organs and impeded circulation. They were struck by the peculiar appearance of their chlorotic patients, who unlike other anemics had a distinctly greenish or waxy complexion, now believed to have been due to severe anemia affecting skin tone. Psychological factors also received much attention, some physicians attributing chlorosis to emotional volatility, romantic longing, sexual frustration, or the excessive reading of romantic novels. Some physicians postulated the existence of a chlorosis subset that clearly suffered from anorexia nervosa.

By the end of the nineteenth century many physicians had written detailed accounts about this disease, notably Stockman in 1895.³ He concluded that although many factors predisposed to this disease, its two major causes were blood loss and insufficient intake of iron in the diet. By the mid-1930s, iron deficiency and hypochromic anemia had become accepted as the main cause of the disease, and chlorosis largely vanished from medical textbooks and clinical practice in Western countries.⁴ Advances in hematology enabled a more precise diagnosis of the different types of anemia, while improved nutrition, particularly increased dietary iron and better food preservation, reduced the prevalence of severe iron deficiency. Changes in women’s lifestyles, less restrictive clothing, more outdoor activity, and modified beauty standards that no longer prized extreme pallor contributed to reducing the incidence and eventual disappearance of the disease.

The chlorosis story also illustrates the difficulty of making a retrospective diagnosis in medical history. Some patients diagnosed as having chlorosis clearly had other or additional disorders. But the history of this disease also reminds us of the limitations of medical knowledge and of how we classify and treat the diseases that currently afflict mankind.

Further reading

1. Dunea, G. “Johannes Lange of Heidelberg.” Hektoen International History Essays, Winter 2026. https://hekint.org/2026/01/22/johannes-lange-of-heidelberg/
2. Major, RH. “Johannes Lange of Heidelberg.” Annals of Medical History 7, no. 2 (March 1935): 133-140.
3. Stockman, R. “Observations on the Causes and Treatment of Chlorosis.” BMJ 2, no. 1824 (Dec 14, 1895): 1473.
4. Patek, J and CW Heath. “Chlorosis.” JAMA 106, no. 17 (April 25, 1936): 1433-66.