B VITAMIN DEFICIENCY STATES 419 



triglutamic acids are also both effective in the treatment of sprue. 139, 140 

 Some cases of sprue, like those of pernicious anemia, are apparently 

 refractory to folic acid however. 141 



Nutritional macrocytic anemia is an ill-defined condition that resembles 

 both sprue and pernicious anemia, and in many cases may actually repre- 

 sent stages of one or the other of these diseases. It frequently differs 

 from sprue in that there is a normal oral glucose curve, and from perni- 

 cious anemia in the frequent presence of gastric acid and intrinsic factor. 

 It is most generally a compound deficiency and is often associated with 

 more marked manifestations of other avitaminoses, such as pellagra. 

 Spies et aL 124 have presented evidence to show a similar efficacy in this 

 case of thymine, folic acid, and vitamin Bi 2 to that in sprue and pernici- 

 ous anemia, as shown in Figure 20. 



The macrocytic anemia of pregnancy is also an ill-defined condition 

 similar to those already discussed, but characterized by its temporary 

 nature. It is generally thought to be a manifestation of the heavy demands 

 upon the mother made by the foetus, since recovery generally follows 

 delivery, and continuous therapy is seldom necessary. This condition 

 responds to folic acid, 142 thymine, 127 or liver therapy, vitamin B 12 being 

 as yet unreported upon. It has recently been reported, however, that this 

 condition, which is cured by crude liver preparations, does not respond 

 to some highly purified preparations that are very active against per- 

 nicious anemia, and there is therefore considerable reason to suspect a 

 basic difference between the two types of anemia. 143, 144 



The megaloblastic macrocytic anemias of infancy and childhood con- 

 stitute a number of clinical entities: celiac disease or steatorrhea, gen- 

 erally characterized as infantile sprue; true pernicious anemia of childhood 

 which is extremely rare; a condition characterized as "temporary 

 pernicious anemia"; and "goat's milk" anemia. The first three of these 

 conditions are known to respond to folic acid therapy, the last being as 

 yet unreported upon. The effects of thymine and vitamin B i2 in these 

 conditions are also unknown. 145 



Finally, a variety of miscellaneous conditions, such as diarrhea, gastric 

 cancer, gastrectomy, and alcoholism, have resulted in conditions of 

 macrocytic anemia which resemble more or less the syndrome noted above, 

 and have as their basis the absence of extrinsic factor or an inadequate 

 supply of folic acid or vitamin B x2 . Some of these, such as gastrectomy 

 and the so-called "chronic diarrheas," have already been shown to respond 

 well to folic acid, but further studies are as yet lacking. A macrocytic 

 anemia caused by infestation with the fish tapeworm, Diphyllobothrium 

 latum, resembles pernicious anemia in many respects and is noteworthy 

 because of the extreme nature of the causative agent in this case. This 



