314 THE ANEMIAS 



appear. In a number of cases, failure of the memory and lasting impairment 

 of intelligence have been noticed. 



In the reports of the last decade, numerous disturbances of the spinal 

 CORD — in fact, a symptom-complex — have been observed corresponding exactly 

 to the picture of a genuine tabes dorsalis; namely, pupillary rigidity, loss of 

 knee-jerks, ataxia of the limbs, incontinence of the bladder and rectum, 

 lancinating pains, disturbances of sensation, anesthesia, and paresthesia. In 

 some cases one or another classical symptom of tabes is missing and those 

 of the clinical counter-picture, spastic spinal paralysis, are found. [Occa- 

 sionally intense neuralgic pains in the extremities occur when locomotion 

 is attempted. These cases are doubtless akin to those of intermittent claudi- 

 cation. — Ed.] 



It has already been remarked that these affections of the nervous system 

 are not regular accompaniments of progressive pernicious anemia; and it 

 must be added that in all probability they are usually independent of the 

 severity of the anemia, but due, as we suppose, to some special etiology. In 

 any case, we are not justified in regarding these symptoms as consequences 

 of the anemia, but they are presumably co-ordinated consequences of the 

 same cause — the effect of toxins. [Three groups of cases should be here dis- 

 tinguished : 



(ft) Those in which the nerve symptoms appear late in the course of a case 

 of obvious pernicious anemia. 



(&) Those in which there are no nerve symptoms (except peripheral pares- 

 thesiffi) during life, but obvious sclerotic changes in the cord post mortem. 



(c) Those in which the cord symptoms precede and overshadow the mani- 

 festations of anemia. This most interesting group of cases has been studied 

 especially by James J. Putnam of Boston. — Ed.] 



More exact clinical knowledge of progressive pernicious anemia has led 

 us to give special consideration to the changes in the eye, particularly to the 

 RETINAL HEMORRHAGES and their consequences. It cannot be denied that 

 these changes are usually found in progressive pernicious anemia, but isolated 

 cases have been met with in which the eyes were quite normal ; and besides, in 

 undoubted cases of simple anemia as already mentioned, profuse retinal hemor- 

 rhages may occur. Consequently this symptom may be considered as a sign 

 of the degree, and not of the variety, of the anemia. 



Disorders of the sense of hearing and of smell are of slight importance and 

 exceedmgly uncommon ; but these may, under some circumstances, proceed to 

 complete suppression of these functions. 



The POST MORTEM FINDINGS in progressive pernicious anemia are of espe- 

 cial interest because in some respects they give important information regard- 

 ing the nature of the disease. 



Besides the extreme anemia of all the organs and the hemorrhages that 

 are always present, though these vary in amount and localization, siderosis 

 IS always found, that is, an abnormally increased amount of iron in the inter- 

 nal organs, especially in the liver, in the spleen, in the bone-marrow, and in 

 the lymph-glands. [Neither the hemorrhage nor the siderosis is invariable, 

 though in the majority of cases they are found.— Ed.] This increase of iron 



