Chapter XII. Anaemia - The Interdependace Of Diseases

A careful examination of the subject teaches us that Anaemia is one of the most frequent vestiges of all severe diseases when they do not terminate in death; - the patient remains anaemic during convalescence, and in a large number of cases continues so long after returning to the duties of life. Again, we observe that anaemia is continually occurring in connection with the periods of puberty and the cessation of the catamenia, and that during the intervening years, it is one of the most frequent forms of impaired health connected with derangements of menstruation, with lactation, with convalescence from the puerperal state, and during pregnancy.

Innumerable other causes may be found for this condition which is, in fact, the type of most of those miserable states of health referred to by the Times in the memorable article already quoted - " There is a certainty worse than any occasional and precarious plague. We may anticipate it from our own experience - we may see the great fact with our own eyes. It is not disease, but it is not health. It is a low state of vitality, of physical power, of mental energy, of enjoyment, and even of moral strength. Shocking as it may seem, a plague once in twenty years seems but a light evil to so low a condition of humanity."

From a concatenation of circumstances, it so happens that the female portion of the population have to support the principal weight of this dire affliction. Anaemiated girls, anaemiated brides, anaemiated spinsters, anaemiated mothers, abound in the consulting room, the out-patient room, the hospital ward, the home; wherever, in fact, the physician's duties call him there they are to be found. Yet from the long list of diseases named in the mortality tables, this name, anaemia, is absent. Is it, then, a thing to be endured, but not to be feared? Is it a name for sickness only, and not a cause of death? Quite the reverse; the fact is, that, like some individuals of great influence and importance, anaemia travels incognito. When we discover its various "noms de guerre," we are startled to find ourselves face to face with the impersonation of long-dreaded enemies.

These are some of the names under which anaemia travels among the sick, and takes its place in the bills of mortality. The way in which it does so is as stealthy as it is deadly. I will tell you something of how it happens.

"Among the children of the poor of London, the most widely-spread of these diseases (tuberculosis, scrofulosis, rickets,) is rickets. It is, however, by no means limited to the poor, or to London, or even to large towns." I quote from one of the most correct medical philosophers of modern times. - (Sir W. Jenner, "Lectures on Rickets," Medical Times and Gazette, March 17, 1860.)

Rickets is essentially and purely a disease of nutrition, not of one part only, but of the whole body.

Rickets causes, primarily or secondarily, more deaths than any other disease of childhood.

The great causes of death in rickets are: - 1. Intensity of the general cachexia. 2. Catarrh and bronchitis.

3. Albuminoid infiltration of organs, especially of the lymphatic glands and spleen (but also of the liver).

4. Laryngismus stridulus. 5. Chronic Hydrocephalus. 6. Convulsions. 7. Diarrhoea.

You see how closely this list of the causes of death in rickets corresponds with the list I have just given of what I have called the - noms de guerre "of anaemia; and the correspondence is really closer than it appears at first sight.

"The connection between rickets and laryngismus stridulus" continues Sir William," is very close,

I believe the reason of laryngismus stridulus being so constantly referred to teething is that the rickety condition retards the development of the teeth, and the medical practitioner refers the laryngismus to that which, like itself, is the consequence of constitutional disease.

"If a child pass over the ninth month without teeth, you should carefully inquire into its cause. It may be, and this is infinitely the most common cause of late dentition, that the child is rickety."

Many deaths, therefore, registered under the head of dentition, may be referred to rickets.

"Catarrh and Bronchitis," says Sir William, "are unquestionably the most common causes of death in rickets. The softening of the ribs rendering the mechanical power by which inspiration is performed so defective, that the impediment offered to the entrance of the air by the mucus in the bronchial tubes cannot be overcome: and collapse of large portions of the lung follows.

"This want of inspiratory power, and the consequent accumulation of mucus in the bronchial tubes, affords an explanation of the extraordinary mortality of measles, whooping cough, and bronchitis in rickety subjects."

Thus may we refer two more of the headings of the Registrar - measles and whooping cough - to rickets.

For similar reasons, and still more from the intensity of the general cachexia and the corresponding defect in the vital force, rickets will be found to be the true cause of fatality in many of the deaths registered under the name of pneumonia.

Then we have the deaths from childbirth 4.3 per week, and it is very interesting to trace out the influence of rickets in causing these miserable deaths. The mode of its operation is twofold. First, there is the large size of the head in the rickety foetus; and secondly, deformities of the pelvis in women who have been rickety in their childhood. On examining into the causes of death in childbirth, as carefully collated by Dr. R. Collins, of the Dublin Lying-in Hospital, I find that of eighty-one cases of death during parturition, thirty-two were due to rupture of the uterus, eleven to tedious or difficult labour. If we, then, inquire into the causes of rupture of the uterus and tedious or difficult labour, to which forty-three out of eighty-one deaths were due, we find that narrowing and deformity of the pelvis, and abnormal size of the child's head, stand prominently forward in their importance; and thus we are brought back to rickets as the chief cause of these deaths.

But you will perhaps ask, how anaemia is proved to be the cause of the deaths under these different headings, by proving that they are due to rickets? That is, in fact, the important question. The answer is this, that anaemia in the mother produces rickets in the child, and anaemia in the child may lead to rickets also. This may be as familiar to you all as it is to me; but I will give you the authority of Sir William Jenner again, who has devoted great attention to this subject: -

The health of the mother has a decided influence in the development of rickets in the offspring. Of this much, I am sure - that when the mother is in delicate health, in a state of which anaemia and general want of power form the prominent features, without being the subject of disease usually so-called, there the children are often in a very decided degree rickety, although the father is in robust health, and the hygienic conditions in which the children are placed are most favourable. It is very common for the first two or three children to be free from any signs of rickets, and yet for every subsequent child to be rickety.

Whatever external conditions are favourable to the formation of hydraemic blood in a child, seem to be favourable to the development of rickets.

Albuminoid infiltration of the lymphatic glands spleen, and other organs is by no means an uncommon cause of death in rickets. The two great features, during life, of albuminoid infiltration of these organs in a young child are emaciation and pallor: the anaemia is often most remarkable."

You will not fail, then, to see at once the intimate connection between rickets and anaemia, and between anaemia and that list of terrible names in the Registrar's Reports.

I do not wish you to suppose that I attribute all the deaths under those headings to anaemia; that would be a great mistake. But from an elaborate and careful analysis of such deaths, I have found, and you may find, that a very large, a very remarkably large, proportion of them are due to anaemia in the individual, or to anaemia in a parent and rickets in the offspring. It is important to bear in mind, that, with the exception of hydrocephalus, the diseases I have enumerated from the mortality-tables are extremely common every-day complaints - that they occur and terminate favourably thousands of times every year; that it is only the fatal cases that come into our list, and with which we are now concerned. And what I have endeavoured to show, and what I wish to impress upon you is, that we must look to anaemia as the chief cause of this fatality; that it is anaemia in the individual or anaemia in a parent that brings these remediable, every-day complaints into the bills of mortality.

When, therefore, we see anaemia establishing itself, as a vestige of the diseases from which our convalescents have lately suffered, or in any other way, we must regard it as the grim harbinger of death in a vast family of diseases.

The next example I shall give is Fatty degeneration, which, like the last, does not appear in the Registrar's Reports.