Pregnant women represent the largest proportion of cases. Repeated parturi tion is probably the most prolific cause of the disease, for it is seldom met with in primiparae. Excessive and prolonged lactation and puerperal haemorrhages and other exhausting conditions frequently appear as the primary element in the causation Of the disease.
Certain atrophic conditions of the gastric mucous membrane, ulcers of the stomach, malaria, syphilis, cancer, and alcoholism have also been considered as etiological factors.
Infection through solutions of con tinuity or purulent foci may possibly act as a primary cause.
Intestinal parasites—the anchylostoma duodenale and the bothriocephalus latus —are also considered as possible etiolog ical factors.
In twenty-six fatal cases in Fiji eighteen found to have anehylostoma in duodenum. Hirsch (London Lancet, Dec. I, '94).
Of twenty-three native African ne groes, representing various parts of East and West Africa, the following parasites were found: Anchylostoma duodenale, twenty-one times; trichocephalus dispar, eight times; asearis, eight times; an guillula stercoralis, four times; tmnice, four times; amoebre, twice. The negroes showed no sign, of ancrinia,—so striking a symptom in Europeans with anchy lostomiasis. Zinn and Jacoby (Berliner klin. Woch., No. 36, '96).
A severe form of anxmia due to anchylostomiasis is found among native Egyptians, in the East and West Indies, South America, and Europe. The promi nent symptoms of this condition are colicky pains, irregular bowels with oc casional attacks of diarrhtua, nausea, and more rarely vomiting. There is great weakness in some cases, with ema ciation, and the circulatory symptoms found in the extreme anwmias, dizziness, palpitation, and haamic murmurs are noted. Eight cases of the same kind re ported in the United States, in which the parasite has been identified. It may be more frequent than is believed, because the intestinal discharges are not exam ined for the parasite, the anmmic con dition being thus regarded as primary. H. B. Allyn and M. Behrend (Amer. Med., July 13, 1901).
Alterations in the size of the heart in anemic subjects. Dilatation is com monly met with, and sometimes, espe cially in chlorosis, elevation of the dia phragm displaces the heart upward and an apparent dilatation is found. Ancemic
dilatation is to be considered true idio pathic dilatation resulting from over strain. None of the usual symptoms are present; gastralgia alone is complained of. Wybauw (Jour. Mid. de Brux., Mar. 15, 1900).
dyspncea is mainly due to vasomotor failure; the disease is preva lent in the female sex, whose vasomotor system is more unstable than that of the male, it usually occurs at puberty when this system is unusually active. J. Hen ton White (Birmingham Med. Rev., Oct., 1900).
The cord and nerve changes sometimes met with probably result from the same irritant. These, with the irregular course, fever, and gastrointestinal dis turbance, indicate a toxic cause. The general condition does not seem to bear any definite relation to the blood-state. at least as far as the number of erythro cytes is concerned, for one individual with only 1,000,000 per cubic millimetre may be capable of prolonged efforts, while another with 4,000,0o0 may be weak and easily exhausted. Weakness, then, is not proportionate to the aim mia, is often the earliest symptom com plained of, and may precede the pallor. MePhedran (Lancet, Jan. 19, 1902).
Deficiency of red corpuscles (oligo cythTmia) is always very great; the blood is, therefore, pale and thin, resem bling sherry-wine. The oligocythxmia is sometimes so marked that the normal proportion of 5,000,000 red corpuscles to the cubic millimetre is reduced to twenty-fifth of that number. Quincke reported a case in which there were only 143,000 to the cubic millimetre imme diately before death.
The hmoglobin is also greatly re duced (oligochromTmia), but not in proportion with the cell-reduction. The hmoglobin percentage was greater by 10 per cent. in a case seen by Osier.
Emphasis upon the reduction in the number of the red blood-corpuscles. There is no disease. except pernicious antemia, in which the number of red corpuscles is at any time reduced below 20 per cent. This affords a distinction between pernicious aufemia and latent gastric cancer: a disease with which the former is most likely to be confounded.