COURSE OF THE DISEASE 337 



The local examination of the genital organs in the one ease, or of the 

 stomach, the vomit, the feces, etc., in the other, will guard us from error. 

 But even before these points are decided, chlorosis may usually be distin- 

 guished from simple anemias by the great number of pre-eminently nervous 

 and circulatory disturbances which distinctly separate the one clinical picture 

 from the other. 



There are other organic diseases which often occur insidiously in young 

 girls and lead to anemia, so that difficulty in diagnosis may arise, especially in 

 family practice where the aids to diagnosis are not so easily obtained as in the 

 hospital, and where errors may more readily be made. 



In the first place I shall name pulmonary tuberculosis, which, at the onset, 

 often causes but slight local disturbances, perhaps only a trifling cough of 

 which but little notice is taken. Nevertheless, the affection in these early 

 stages gives rise to a distinct anemia. [It is important, however, also 

 to recognize that intense pallor without any demonstrable anemia is very 

 prone to occur in tuberculosis. — Ed.J And it becomes an imperative duty 

 most carefully to examine the lungs, especially at the apices, in any doubt- 

 ful case. 



Another organic affection, which in practice frequently resembles chloro- 

 sis, is chronic nephritis; this is prone to appear at puberty in those who, as 

 children, have passed through an infectious disease and recovered, especially 

 scarlatina which was later followed by a sequel — renal inflammation — the lat- 

 ter, however, not having been entirely cured but, on the contrary, continuing 

 to affect the patient in later life, although not infrequently the distinct signs, 

 particularly edema, appear first during puberty. It is therefore absolutely 

 necessary in doubtful cases to make a careful examination of the urine, both 

 chemically and microscopically. 



COURSE OF THE DISEASE 



The course of the disease in individual cases shows great variation, and 

 from the earliest periods cases of chlorosis have been observed in which there 

 was prompt improvement, whereas others manifested a tendency to relapses, 

 and others again were so stubborn as to appear incurable in spite of any form 

 of therapy. 



Therefore, various forms of chlorosis have been differentiated, such as 

 " transitory," " relapsing," and " habitual." These variations in the form of 

 the disease can rarely be recognized at the onset. The course is also dependent 

 on a variety of- factors so that these forms can only be differentiated from one 

 another after prolonged observation. The most common form is unquestion- 

 ably the benign and transitory, in which all of the symptoms and the blood 

 condition are relieved in the course of a few weeks. 



The main contingent of this group is of course made up of girls and women 

 of strong constitution, who, before the development of chlorosis, were com- 

 paratively well and active. The favorable progress of the disease, as will be 

 more minutely demonstrated in the therapy, is due partly to the fact that the 

 patient is removed from her usual surroundings, and is treated under condi- 

 33 



