The inquiry on the part of the physician embraces the following points: a. The existence of hemorrhage. b. Want of proper nu triment. c. Causes which prevent the nutriment from being con verted into healthy blood. d. Conditions of system which directly tend to deteriorate the blood.
a. Hemorrhage diminishes the quantity of the circulating fluid; and when the loss is made up by the absorption of liquid, its quality is impoverished. The hemorrhages most commonly producing this effect are from the uterus in females, and from the bowels in both sexes; anaemia frequently follows on litematemesis, and more rarely on prolonged epistaxis; it is also to be seen in patients who have been frequently bled. When associated with hxmoptysis or hsematuria, the anaemic state is rather the result of disease of the lungs or lddney than of the loss of blood. It must not be forgotten that the hemor rhag.e may be the consequence and not the cause of t,he changed qualities of the -blood.
b. Simple anemia is generally the effect of insufficient nutriment; when the food is improper in quality, special forms of disease are more liable to be engendered— cachexia, purpura, scurvy, &c. Starvation implies absolute want of blood, and the disproportion of the constituents iB only referable to excess of water.
c. The causes which prevent the formation of blood include especially dis orders of the digestive apparatus, the stomach, the liver, and the intestines; as well as obstruction to the absorbents, as seen in mesenteric disease. We must bear in mind, however, that derangements of all possible kinds may result from the anemia in place of causing it. We may be somewhat guided in forming our judgment by the history of the ease, pointing out priority of occurrence either m the dyspeptic symptoms, or in the general feeling of weakness, and by the relative intensity of each class of indications ; the ane mia is much more intense when it produces the dyspepsia than when caused by it. There can be but little difference between the want of blood arising from imperfect assimilation, and that from insufficient food.
d. Special forms of anemia are directly traceable to conditions which, without int,erfering with digestion and absorption, seem to act by deteriorat ing the quality of the blood, inducing especially disproportion among ita con stituent elements. Of this kind are the effects of cancer and of disease of the kidney; to the same class we must refer chlorosis and leucocythemia. All these subjects must again occupy our attention in considering varions regions of the body ; meanwhile it is only needful to remark, that the anemia is ra ther an accidental symptom in the case of cancer and albuminuria, but is an essential one in chlorons and white-cell blood ; in the latter, too, it serves to draw our attention to the spleen, and we have no other direct evidence of splenic disease.
In cancer the pallid appearance is combined with a sallow hue, which has been called the ' malignant aspect :" in disease of the kidney there is usually some puffiness of the face, and the cheeks are occasionally mottled ; in chlorons, as its name implies, there is a slight tinge of green, with a transparency of skin which makes the face look like a wax model: in leucocythEemm the as pect is muddy, earthy, and a similar appearance may be seen in the tubercu lous cachexia of early life. These differences, well-marked in advanced cases,
and frequently sufficient to an experienced eye for the discrimination of the disease, must not be much relied on by the student. They are to be regarded simply as aids to diagnosis, not as the grounds on which it.is based.
In rare cases none of the conditions just mentioned Can be made out as having had any share in the production of anemia ; even when fatal, no organic disease has been detected. This amemia is of slow development ; it seems to exist alone, and is marked by no symptoms except such as are referable to a deterioration of the circulating fluid. For the present we must rest satiefled with determining its presence, and ascertaining that it is unc,om plicated ; we cannot get beyond the fact which the name amemia, or spamemia, as used by some pathologists, implies.
The general state, from whatever cause derived, is followed, in most cases, by the symptoms already enumerated—dyspncea and palpitation, headache and ieneral weakness, and frequently by emaciation, the latter being least observed in those associated with hemorrhage and chlorosis. Having got the clue from the objective phenomenon of aspect, we have only to observe what are primary and what secondary affections among the symp toms present. The pulse is pretty full when the change is rather in quality than quantity; if weak and small, there is certainly deficient amount of blood ; with a soft pulse—both conditions are probably present. The tongue is very generally clean, always remarkably pale, and sometimes slightly furred and inclined to be oedematous, bearing marks of the teeth on its edge. The co incidence of depraved appetite and irregular bowels with anemia is rather the rule than the exception. Local congestions of vari ous organs are very frequently met with, and the full recognition of the general condition of anemia is essential to their rational treatment. The association. of oedema is also not uncommon: probably every case of anemia, at an advanced stage, would be come more or less dropsical in circumstances favorable for its development; but we must be particularly careful in investigating the origin of this symptom, and must not rest satisfied with the ready explanation that the condition of anemia offers, till all the other causes of its existence are fully examined. (See Chap. VII., Div. I., § 1. Anasarca.) § 8. Chlorosis.—Although essentially a form of anemia, this condition demands separate notice, from its peculiar association with perverted function of the uterus. It seems to exist under two primary forms; (a) previous anemia, followed by schinty mem struation, terminating m complete suppression of the menses ; (b) sudden suppression of the menses, terminating in general alter ation of the blood; the aspect betraying something more than mere anemia.