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Secondary Anemia.

Synonym.—Symptomatic Anemia.

Etiology.—All cases of anemia occurring in the course of other affections; or due to hemorrhage, are classed as secondary anemias, the various causes being included in the following classification:

Hemorrhage.—The loss of blood may be rapid and in large quantity, giving rise to an acute anemia, as where the hemorrhage is due to injury of the blood-vessel, either from serious wounds or from the rupture of an aneurism, or from flooding during parturition. In these cases, there is loss of all the constituents of the blood. When sudden and in large quantities there is danger of fatal syncope. Severe hemorrhage may arise from gastric or duodenal ulcers.

The patient may lose considerable blood in hemophilia, scurvy, and purpura, though in these cases the loss is not so rapid.

The loss of blood may be small in quantity each day, but when continued for several days or weeks, gives rise to severe anemia; thus in epistaxis, bleeding piles, uterine hemorrhage, or cirrhosis of the liver, we have examples of a large loss of blood, extending over a period of days or weeks, and which may be considered as chronic anemia.

Inanition.—This may be due to insufficient food, or the quantity may be sufficient, but lack the constituents necessary for the elaboration of a normal blood supply, or, having a sufficient quantity and quality of food, there may be wrongs of the digestive apparatus whereby digestion and assimilation are impaired, thus cancer of the esophagus or stomach, or atrophy of the gastric mucous follicles, or cirrhosis of the liver, would result in a failure to manufacture good material into blood.

Wrongs of the sympathetic nerve, as seen in lesions of the rectum, uterus, and urethra, may so impair the blood-making organs as to give rise to anemia.

Albuminous Waste.—A long, continuous drain upon the albuminous material of the blood, as in chronic nephritis, long-continued suppuration, chronic diarrheas, profuse leucorrhea, and prolonged lactation gives rise to anemia.

Toxic anemia results from certain organic and inorganic agents; thus, arsenic, lead, phosphorus, and mercury are well-known blood destroyers, and the poison from venomous snakes acts in the same way. Of the chronic infections, syphilis, tuberculosis, and malaria are marked examples, and, not infrequently, typhoid fever, pyemia, septicemia, diphtheria, and kindred diseases give rise to anemia. Various intestinal parasites also play some part in producing anemia.

Pathology.—The condition of the blood varies from the slightest impairment to the gravest form of anemia, depending upon the severity and duration of the producing cause, and upon the power of blood renewal. The number of red corpuscles and the percentage of hemoglobin are proportionately diminished, while the red corpuscles remaining, vary in size and shape, some being unnaturally small (microcytes) and others unduly large (macrocytes), while still others are of irregular sizes (poikilocytes). Nucleated red cells are also found, and usually there is an increase in the leukocytes, the exceptions being in tuberculosis, enteric fever, measles, influenza, and malaria. The alkalinity of the blood is generally slightly diminished, the specific gravity reduced, and the watery elements increased, rendering the blood more fluid, and the color of the entire fluid being more pale than normal blood.

The fluid and albuminous principles of the blood are quickly restored, the corpuscular elements following next in order, and the hemoglobin last, in some cases the last constituent requiring months before it reaches the normal standard.

Females can lose a much larger quantity of blood and recover quicker than males, though infants of both sexes do not bear the loss of much blood.

Symptoms.—Pallor of the skin, colorless appearance of the ears, and particularly of the mucous membranes. are among the early symptoms of anemia, though we must remember that not all pale people are anemic, nor that all anemic people are pale.

Cardiac Symptoms.—The pulse is usually small and rapid, of low tension, though a high-tension pulse is sometimes encountered. Palpitation and attacks of syncope are not uncommon. The heart, being poorly nourished, is apt to lose its muscular tone, attended by slight dilatations; as a result, a systolic hemic murmur may be heard over the pulmonary area, and transmitted to the axilla. The murmurs arise from dilatation of the left ventricle, which gives rise to relative mitral insufficiency.

Dyspeptic symptoms are nearly always present; the tongue is pale, broad, and flabby, the appetite poor, some headache, and generally there is constipation.

Pulmonary symptoms are present when the anemia is well developed. A slight hacking cough is common, and dyspnea, on slight exertion, usually attends, and occasional sighing may be noticed.

Cerebral Symptoms.—Cerebral anemia is indicated by spots appearing before the eyes, ringing in the ears, and vertigo. Mental apathy and inability to concentrate the mind is not an uncommon symptom. The patient complains of a pain in the top of the head.

Nervous symptoms are not infrequently present, the patient being irritable and restless at night, though drowsy and passive during the day. The patient may complain of hot or cold flashes, crawling or creeping sensation of the skin, and vague pains in different portions of the body. Menstruation is disturbed; at first there may be menorrhagia, but later, the flow becomes pale, scanty, and finally ceases. Generally debility is noticed, and in extreme cases a low temperature is noted.

Edema of the ankles and legs are common, and where tuberculosis or cancer are present, emaciation is a marked feature.

Diagnosis.—A grouping of the above symptoms are so characteristic that the diagnosis is rendered comparatively easy, but a positive diagnosis is only made by examination of the blood.

Prognosis.—This depends upon the primary lesion that gives rise to the disease, and our ability to overcome it.

Treatment.—The treatment depends upon the cause. If due to traumatic hemorrhages, and they have been arrested, rest, good nutritious food, and plenty of fresh air and sunshine, will be all that is required. If due to hemorrhoids, they should be removed; or from menorrhagia, suitable treatment should be instituted to overcome it.

The patient should be examined very carefully as to the cause or causes giving rise to it, and the treatment directed to removing it. The idea that iron and arsenic are to be given whenever anemia is present, is a fallacious one.

Wrongs of digestion are to be corrected, constipation must be overcome, and the nervous system built up. Bach case will need a special study, and special remedies required for individual cases. Copper, iron, and arsenic will be useful agents in connection with the specially indicated remedy; but, above all, do not forget to give the patient fresh air, plenty of sunshine, nourishing food, sponge-baths, and moderate exercise.

The Eclectic Practice of Medicine, 1907, was written by Rolla L. Thomas, M. S., M. D.

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