THE OJCPCD PRESENTS: A MEDICAL HUMANITIES CHALLENGE QUIZ #1: DERMATOLOGY IN SHAKESPEARE

 

by Leonard Hoenig, M.D., Section Editor

 

Beginning with this issue, the OJCPCD presents a new feature called “A Medical
Humanities Challenge” that will appear several times a year, to test your knowledge of medical humanities.

Quiz #1 examines your ability to identify the medical condition in the following quote from Shakespeare’s play Romeo and Juliet:
“ Out, you green-sickness carrion! Out, you baggage!
You tallow face!”
(Lord Capulet to Juliet:  Act 3, Scene 5)

Image from: https://archzine.com/

Scroll down for answer:

 

ANSWER:  Chlorosis (green sickness) caused by iron deficiency anemia.

COMMENT:  Green sickness, or chlorosis, was a common disorder during the 16th thru 19th Centuries that typically affected young, unmarried girls causing a distinct green tinge to their skin.  It was one of the clinical manifestations of iron deficiency.  The English physician, Thomas Sydenham (1624-1689) is credited with the introduction of iron therapy to treat chlorosis, although the medicinal use of iron dates back to antiquity.

In the aforementioned quote, Lord Capulet, Juliet’s father, becomes enraged and
verbally abusive to his daughter because she refuses to marry Paris.  He calls her a
green-sick piece of meat and pale faced (“tallow face”). During the early 20th century, chlorosis disappeared as a clinical feature of iron deficiency, probably because iron deficiency was more readily diagnosed and treated than in earlier times.

The other cutaneous features of iron deficiency likewise have become clinically less frequent, including:

  • Koilonychia (spoon nails)
  • Angular stomatitis (cracked epithelium at the lips edges)
  • Glossitis (smooth, red tongue).

Recently, the first case of chlorosis in 70 years was reported in a 9 year old girl with
a green complexion and iron deficiency.  A striking photograph of the patient with her greenskin tone can be seen in the article (see reference 1 and accompanying link).  Her skin condition resolved with iron therapy

The story of chlorosis, and its clinical decline, illustrates the phenomenon of “disease evolution” which means that a disease, for various reasons, can change its clinical presentation over time.  Thus chlorosis, once so common, is rarely seen anymore.  A remembrance of this greenish skin condition is found in Shakespeare’s masterful portrayal of the beloved Juliet.

REFERENCE

Perdahl-Wallace E, Schwartz RH. A girl with green complexion and iron deficiency: chlorosis revisited.  Clin Pediatr 2006; 45:  187-189.
Apreviously healthy, 9-year- old girl of Mediter- ranean/Filipino descent was referred for a 2-month history of her face, hands, and fingers. “becoming green
http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.891.8610&rep=rep1&type=pdf (Accessed 12/9/18

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4 comments on “THE OJCPCD PRESENTS: A MEDICAL HUMANITIES CHALLENGE QUIZ #1: DERMATOLOGY IN SHAKESPEARE

  1. Leonard Hoenig on said:

    Thank you for the nice comments. This is in answer to Marla’s question. It was long suspected that there was iron in blood because both rust and blood are reddish in color. Two French physicians, Louis Lemery and Etienne Francois Geoffroy, are credited with having demonstrated for the first time, in 1713, that iron was present in the ash of blood. Impressive studies along this line were then carried out by the Italian physician, Vincenzo Menghini, in 1746. He conclusively showed that iron was present in red cells more than other tissues. He dried blood in an earthenware vessel. The residual particles were attracted by a loadstone. Menghini further demonstrated that giving iron to chlorotic patients caused increases in the iron content of their blood. Again, thank you all for your comments and I look forward to sharing with you future Medical Humanities Challenges.
    Leonard J. Hoenig, MD

  2. humanemedicine on said:

    From Rich Ratzan: i knew it!
    i once thought i had a patient with it – an anemic and green looking 25 year old woman, but … she was a health food nut who ate tons of blended vegetables daily!

  3. humanemedicine on said:

    From Marla Lukofsky: I loved this piece from Len Hoening. It was well written and oh so interesting to read up on medical concerns and issues from centuries ago particularly iron deficiency.
    I think one of the reasons why iron deficiency is less extreme in these times is partially because of the availability to foods that contain iron, on a regular basis that is also preserved under safe conditions. We have fridges now for instance. Dairy products and meat can last longer and we know to eat them to obtain a good amount of iron. In addition, iron is added to foods, most prominently, cereals. We now know that it is an essential mineral the body needs to function, therefore its added. What I find most interesting is how advanced medicine was as barbaric as it was back in the 1600’s. How did the drs. test the blood to know that it was lacking in iron that created the green face? And if it wasn’t by testing the blood, then how did they solidify the answer to their query?
    Marla
    Tks for this great essay!

  4. humanemedicine on said:

    From Stephen Danziger, M.D.: Chlorosis also occurs in plants and can be due to reduced nutrients, especialy iron. This may be considered ironic. Leaves lose green color when this develops, vs getting green.

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