In the severer grades of anemia the complexion appears yellow or a greenish-yellow ; and the skin, owing to the more watery character of the blood, loses its elasticity and pliability and becomes puffy. Aided by a weakened heart, this also brings about a swelling around the ankles and over the shins, especially in persons who have to stand a great deal. An im provement in the condition of the blood rapidly causes the disappearance of these symptoms. As a rule, the urine is pale and watery in proportion to the paleness of the skin, and the bile likewise is not so deeply stained, so that the stools have a very light colour. As the food is not properly assimilated by the body, a great deal of it remains undigested as a waste product, and various digestive disturbances result. Hunger, which serves as an indica tion of the necessity for taking food, and appetite, which is the expression of a desire for some particular kind of food, both become lessened ; or there may he alternating periods of extreme greed for food, followed by a complete loss of appetite and an aversion against food, especially against a stimulating or albuminous diet. The intestinal movements become steadily lessened, and constipation results, with much flatulence and colicky attacks, because the gut may become very irritable and the accumulated masses of hard fecal matter can only be evacuated with difficulty.
Various disturbances of the appetite may appear before or after the condi tion just described is developed, although hunger, properly speaking, may be entirely absent. The patients manifest an uncontrollable desire for certain substances which either serve as substitutes for those which are neces sary for proper digestion, or as chemical or mechanical counter-irritants against abnormal sensations. Some of these increase the secretion of the gastric juice, and the act may be compared to the ingestion of sand by birds. which acts on the stomach-juices or aids in the mechanical disintegration of its contents. An interesting example is afforded by the dirt eaters of South America, who almost invariably are anaemic by reason of intestinal parasites, Uncinaria AmPricana. A definite indication for medical treatment is afforded by the well-marked desire of these patients for salty or acid dishes, which make good to a certain extent the deficiency of hydrochloric acid in the gastric secretions. This desire may be gratified without fear, but absolute denial should he extended to the longing for various indigestible articles such as chalk, coffee-beans, etc., which not only irritate a stomach poorly supplied with blood, but do not afford any nourishment to the body. The apparent advantage gained by the increased secretion of saliva and gastric juice which is brought about by the ingestion of these substances is more than offset by the introduction into the stomach of indigestible materials, and the physician may well direct his attention to more suitable remedies. Neither is it wise to give way to the repeated desire for strong spices ; in such cases the digestive secretions are sufficiently stimulated by eating a little dry bread with salt, dried fruit, simple bitters (herb teas), or by the administration of medicines prescribed by the physician. Meat and
albuminous foods require a considerable amount of digestive fluid for their complete and proper digestion, and for this reason their use in patients should be restricted as much as possible ; if given, acids should at the same time be administered. When the feeling of hunger is absent, the diet had better consist principally of rice, mashed potatoes, toasted bread, fruit, buttermilk, white (cream) cheese, and farinaceous soups with milk.
The more advanced disturbances of nutrition become manifest in various organs in the course of the disease. Gastric ulcers and hemorrhage may result, also nosebleeding. The monthly periods may be diminished or extended, and such irregularities are among the earliest and most important evidences of abnormalities in the blood. It must not be forgotten that an apparently free bleeding does not necessarily signify the loss of any con siderable amount of blood, as this fluid possesses marked staining powers ; on the other hand, a comparatively small showing may consist entirely of pure blood. Any considerable loss of pure blood from this source may in itself be a contributing factor in producing anemia. Also, other disturb ances may result, among which may be mentioned mucus or purulent dis charges from the female genitals, which are apt to bring on a great deal of discomfort and soreness of the surrounding parts if neglected. That bad hemorrhages may be the direct result of an impoverished condition of the blood is readily explained by the fact that the poorly nourished blood vessels are unable to retain the contained blood ; and in the severest grade, the pernicious anemia, hemorrhage of an extreme and dangerous degree may take place.
Insufficient nutrition of the heart reduces its propulsive powers, and as a result the extremities—the tip of the nose, the ears, the fingers, and the toes—do not receive their full amount of blood, and become blanched and cold. Under these conditions the lungs are likewise incompletely nourished, and in consequence readily become diseased ; it is known that pulmonary tuberculosis is frequently associated in its early stages with the symptoms of anemia. Respiration in anemic individuals must therefore be carefully watched. They should not be permitted to \ yea r corsets, and the danger of catching cold should be guarded against by the wearing of suitable underclothes. Appropriate respiratory exercises under medical direction are to be recommended. The lungs must be carefully watched when obstinate, chronic digestive disturbances are present, as these are frequently the forerunners of consumption, or else favour its development, because the entire body is insufficiently nourished.