PREDISPOSING INFLUENCES 331 



majority of eases oceur. Immediately after the establishment of menstruation 

 chlorosis is rare. An interval of five, or even ten, years often follows. — Ed.] 

 The disease does appear, however, in young children, or, on the other hand, 

 and this is not infrequent, may occur in the twenties; after the thirtieth year 

 chlorosis is exceedingly rare, either as a primary or recurrent attack. 



Concerning the constitution it may be said that young, delicately built 

 girls, weak in muscle, but comparatively fat, are most likely to be affected 

 with chlorosis; on the other hand, the robust constitution of a girl raised in 

 the country, for instance, a servant, ofEers no protection against the appear- 

 ance of this disease. It must be confessed, however, that when chlorosis 

 appears in girls of the latter type, as a rule it is milder, and can be remedied 

 sooner and more surely than in those with a delicate constitution. 



Whether chlorosis occurs more often in certain localities than in others 

 is difficult to determine, for it is almost impossible to obtain positive statistics 

 of this disease, and especially because many physicians include under the 

 name of chlorosis all varieties of anemia in young girls. It is certain at any 

 rate that the disease is more frequent in large cities than in the country. 



PREDISPOSING INFLUENCES 



Many factors may be looked upon as predisposing causes of chlorosis, and 

 a knowledge of these is of the utmost importance for the thorough compre- 

 hension of the entire "picfure of the disease on the one hand, as well as for 

 the treatment on the other hand. 



These deleterious predisposing influences are to be found, first, in the 

 domain of general hygiene, and, secondly, among certain organic diseases. 



In the first group, i. e., the hygienic influences, we must include errors 

 in physical and mental training, which, especially among the higher classes, 

 are of great social importance. 



Here, to cite a very frequent error, we observe a neglect of the physical 

 development of growing girls as compared with that of boys. Out of regard 

 for their dress, they are not permitted to romp freely, but are taken out to 

 walk by the side of a governess ; they are not sufficiently in the fresh air, and 

 have no opportunity of enjoying a rapid, powerful and invigorating exercise 

 of the muscles. 



When we consider the view of Virchow, previously referred to, that hypo- 

 plasia of the heart and of the vascular system is partially acquired in intra- 

 uterine life but is specially developed in extra-uterine existence, the thought 

 involuntarily arises that, in many cases, this lack of development of the heart 

 and vessels may be due to the fact that the normal stimulus for such a develop- 

 ment of the vascular system as is unquestionably necessary for free movement 

 of the muscle masses in the limbs and trunk is in these children not sufficientty 

 active, and that this faulty development of the circulatory apparatus may, 

 perhaps, be considered a form of inactivity hypoplasia. [If this be true, the 

 apparent diminution in the number of cases of chlorosis presentmg themselves 

 at our clinics might be explained by the more active habits of life which are 

 certainly prevalent in America in the present decade.— Ed.] 



