B VITAMIN DEFICIENCY STATES 413 



Significantly, however, the original work upon which this test was based 

 was done upon a group of pellagrins most of whom suffered the disease 

 as a consequence of alcoholism, and pellagra secondary to alcoholism may 

 differ in some respects from other forms. As a result of the extreme nausea 

 and diarrhea, a hyperproteinemia may develop in advanced cases and a 

 disturbance of acid-base equilibrium may also occur. The decrease in 

 urinary levels (and blood and tissue levels in extreme cases) of niacin 

 and its metabolites has already been mentioned in earlier chapters; this 

 constitutes one of the most marked biochemical changes occurring during 

 early or mild deficiency. 104 It has also been reported that pellagrins are 

 extremely sensitive to insulin and are refractory to adrenalin, but these 

 factors have not as yet received adequate study. 105, 106 



Folic Acid and Vitamin B ]2 Deficiency. 107-111 A large number of different 

 clinical conditions result in the production of anemias, and in recent years 

 it has become readily apparent that many of these have a definite nutri- 

 tional deficiency involved in their etiology. Of these a rather significant 

 number of anemias have been found to respond to a greater or lesser 

 degree to the administration of the two most recently identified members 

 of the B group of vitamins, folic acid and vitamin Bi 2 . While it is by 

 no means certain that these anemias are caused by a nutritional deficiency, 

 it is apparent that for one reason or another the bodies of patients so 

 afflicted do not receive an adequate supply of these factors. It is undoubt- 

 edly true that a deficiency of any of the B vitamins would ultimately 

 result in anemia, 112 - 113 and anemias are associated with deficiencies of a 

 number of them; but the acute macrocytic anemias that respond to the 

 two vitamins here discussed are so marked and well recognized as to 

 leave little doubt that these factors have a particularly important func- 

 tion in normal erythrocyte physiology. The conditions that respond to 

 these factors are almost without exception marked by severe anemia, but 

 this is generally only one of a group of symptoms associated with each 

 clinical entity to be considered here. Thus there is no doubt that deficien- 

 cies of these vitamins are manifest throughout the body, and the weight 

 given the hematological aspect should not distract attention from the 

 other symptoms of these avitaminoses. 



A unique situation exists with regard to these avitaminoses: a number 

 of factors other than low dietary levels contribute to the majority of the 

 recognized cases, and these factors bring about a number of different, 

 prevalent, clinically identifiable forms of the deficiency. The situation is 

 even more unusual in that two different members of the B group of 

 vitamins are generally effective in curing most of the deficiency condi- 

 tions, and that a naturally occurring pterin and pyrimidine are also 

 known which are effective, though to a lesser degree. This multiplicity of 



