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1948 3: 91-102

PERNICIOUS ANEMIA CAUSED BY DIPHYLLOBOTHRIUM LATUM, IN THE LIGHT OF RECENT INVESTIGATIONS

BERTEL VON BONSDORFF

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From bloodjournal.hematologylibrary.org by guest on August 12, 2011. For personal use only.

PERNICIOUS

ANEMIA

CAUSED

BY

DIPHYLLOBOTHRIUM

LATUM,

IN

THE
By

LIGHT
BERTEL

OF
VON

RECENT
BONSDORFF,

INVESTIGATIONS M.D.
broad fish tapeworm, Finland, (1894). Diphyllobostart-

T
ing inces total can
ages, For

HE thrium

MACROCYTIC latum, has

anemia been the

caused subject

by

the

of extensive

investigations in

with The fish more

the

pioneer tapeworm
90

work cent be

ofJ. of the

W.

Runeberg(1887) common

and in is infested

0. the

Schauman country. with one half the to

is extraordinarily per to population which carriers. of

the

In parasite. one in

certain Of million persons

parasite,

provthe of all
but

than

population be considered
even most
it

of the
children of these the

country, tapeworm
under
i

is about 4,000,000, The

is a

parasite
relatively

is found
innocent

in

year

age.
worm was

carriers, frequency of

in worm

some,

causes
192.6)

a macrocytic But, if of worm frequency

1944,

anemia.
anemia

According
estimated

to
i

earlier
to be in case

investigations
5,000-10,000

(R. a of

Ehrstrom,

carriers.

the

blood

of

worm be

carriers shown. in peace of

of

is examined

systematically,

far greater years of age of

1943,

number admitted in 659 the

tO

anemia cases can to a military hospital carriers.

noted,

Among the conscripts 2.0 time, (192.7) Seppa found i case in a community in136 383 carriers.
anemia carriers;

anemia he

G.
1942., in

T#{246}tterman (1944),
I

strongly
and in

infested

with

tapeworm,

case

anemia in
tapeworm

found
1941

to

ibe case

of

anemia in

In
in

a war
about

hosII,ooo

pital, medical
i8 to
40

from

I found

96

instances

cases. years above in blood that found can also or under with
2.0

The

number

of worm

carriers of the is a typical

this

group, of the

composed problem anemia agreeing in

of men of tapeworm with all

from

The anemia teristic with anemia terally, people

of age, is not known. figures give a good idea Finland. picture This and anemia

importance pernicious bone marrow,

a characrespects tapeworm os or paren-

a megaloblastic

in cryptogenetic be brought to stomach preparations

Addisonian remission with per most cases pernicious anemia, there

anemia. A pernicious liver preparations per removal tapeworm is an achiorhydria of the anemia

os without

worm. occurs after even the inin

In contrast

to cryptogenetic years of age. In

jection of histamine; though, especially in younger patients, the gastric juice often contains free hydrochloric acid and is secreted in the usual quantities. Signs of spinal cord involvement are less apparent than in cryptogenetic pernicious anemia. That the illness is really due to the worm infestation is proved by the fact that complete remission takes placeafter the worm is expelled without any further need for antianemic treatment. Since cryptogenetic pernicious is common, it is natural that simultaneously after
From

now the

anemia and In anemia

is not rare then both such often cases,

in Finland types of of course, more

and worm infestation anemia should occur there severe. is no remission

in worm
University

an In

individual. fact,

the
the

cure.

becomes

of Helsingfors,

Finland.
91

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92.

DIPHYLLOBOTHRIUM

LATUM

AND

ANEMIA

G. T#{246}tterman (1944) says that he has encountered mia in tapeworm carriers that did not respond to remission after a worm cure. He assumes that the form which On
chromic

cases of mild liver treatment pathogenetic pernicious in Finland

cured by

macrocytic anebut showed good mechanism for this tapeworm of cases

expelling

of

anemia

is different

from

that

for numerous
which

the

true reports

anemia, of hypothe worm.

does respond the other hand,

anemia in

to liver therapy. there have been

tapeworm carriers

were

not

On

this

point, question have

which

conflicting which pernicious

lead number to of

information is of special anemia?

the rise cases? of

is still Or
worm

found

in

the

literature.

The carriers
factors only

interest for formulated

anemia

research is : why do so few worm in greater detail : what are the

and why are these factors active in

a small

Hitherto, of by them and Birkeland The present

the or worm with

these the
(1931).

questions tapeworm of
with

have anemia the

of

not

been

satisfactorily as a whole

answered. has anemia been

The reported that

discussion in detail

problem genesis

knowledge
interfered the production

of pernicious
or On sprue, the components
(1935).

suggests
of in of similar lesions, the its

in some
facThis re-

way tor the

the the

production

absorption involved basis ventricular

antianemic formation. reasoning intestinal

thought

was

first

expressed
in

by

Saltzman

pernicious

anemia

connection

with

sections, etc., can, An investigation explaining tapeworm

the

as is well known, is here reported

of cases

be explained. carried out

of pernicious

on on

these
anemia,
1937.

lines

with

the due

object to

of

pathogenesis

most them of

infestation.

The
1.

tests
THE

have
INTRINSIC

been

going
FACTOR

since

a) The course usual way (with restricted

blood picture reticulocytosis

of remission

after

removal

of the

worm. the If

3-4.5 a blood
has began become on

Gm. remission

Extraction begins a group

to the normal. In

filicis) shortly of
sixth

from

worm hospital

is and

expelled patients continues that

was

in the on an until the

expelled

unthe
in

diet,

afterwards 7 cases, it was

day after the

observed
worm

the

fourth

6 of the patients mum was reached

day mum amination after the of reticulocyte the

and in

in case, i not until the first 6 cases and

before and
i.i

the eleventh day. mentioned between case and

filicis per cu. mm.

The the

reticulocyte seventh and

maxithe tenth

worm cure, values blood

ii

in the
varied

seventh
between 7.4

on
2.3

the per

thirteenth day. The maxicent. In these cases, exgiven showed that the erythro-

Extractum million

was of

cytes
later values

were
than is on

between after
after the

blood.

Apparently,

the

worni
initial somewhat

cure,

the
liver lower

reticulocytosis
treatment. than in The cases

generally
maximum of pernicious

sets

in
for

a few
reticulocyte

days
treated

a strong average

anemia

with
of with the

liver,
adequate

but

on

the

other

hand,

the

reticulocyte per puncture day,

crisis which that

lasts is within

longer. just 48 as hours

The great

increase as after the

erythrocytes

is generally

about ioo,ooo

liver therapy.

It

has been

found

by

means

of a sternal

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BERTEL

VON

BONSDORFF

93
gives way to a normoblastic

worm type

cure,

the

megaloblastosis

in

the

bone

marrow

of regeneration. The most rational Only and cases,

was

therapy severe expel

it by

in anemia worm
difficult worm

pernicious
it is necessary

tapeworm
to start

anemia
treatment

is the
with

simple
liver

worm
in-

cure. jections such

anemia

in

very not

the
is the

until
to or not.

after
decide Only

the

blood
if the

picture
whether patient

has
the is very

improved.
pernicious young and/or

In

however,
caused

afterwards

has
that

free
the

hydrochloric
pernicious

acid
anemia

in the
was

gastric
caused

contents
by the

can
tapeworm.

one

be

to

some

extent after have the

certain worm access prinof

thereafter.

The all ciple.

worm,

fact

that can

the

pernicious in for required these

by the

tapeworm no the other are factor,

juice from

anemia way available

with which

is completely than that directly

the

cured the of after patients the

is expelled the

be explained

to the

substances Evidently,
as indicated

endogenous

formation

antianemic elimination
begins

substances
promptness

remission

If the factor b) Hernberg tapeworm Mixed

food contains the extrinsic becomes at once available.

Castles test with gastric
(1936-1941)

this

must

imply
with

above
pernicious

all

that
tapeworm

the

intrinsic
anemia.

patients

anemia, with meat,

has shown that the gastric juice in patients with as well as in persons who have it, had contains intrinsic such gastric juices produce a typical remission pernicious anemia. author has made at neutral reaction
has found (1940)

pernicious factor. when given proteogiven in It to

patients with cryptogenetic c) In vitro experiments. The lytic gastric enzyme active
Taylor et al. (1938), and

some investigations according to this enzyme pernicious

the

of the method

by the has

tapeworm latter been have has worm The cases

anemia the total

as

well amount this by results here

as enzyme Helander

in

that cryptogenetic gastric

occurs in anemia, much

pernicious though reduced.

of the is
(1945).

secretion

is very

suggested that been confirmed obtained similar anemia. investigations

identical with the intrinsic factor. My Hernberg (1939) with Laschs reaction gastric all juice support from the patients idea that with the pernicious gastric

results tapejuice of of an

in the reported, tapeworm fact that

patients with this, and in

pernicious spite of the

anemia contains intrinsic the amount of gastric juice

factor. is often

In spite normal,

anemia has arisen. caused by cessation the worm. However, tion free tients The a worm It seems occurrence well young, known have may occur hydrochloric who author cure showed has possible that later in patients

Apparently the pernicious anemia in tapeworm carriers is not of the secretion of the intrinsic factor because of the presence of it is evident that some inhibition of the gastric juice secrewith in to find pernicious the gastric the any secretion in who with a connection have had cryptogenetic tapeworm contents anemia difference and those of with a pernicious form was in intrinsic with the anemia, for in some cases after the remission in paapparent. speed normal factor tapeworm tapeworm of the of remission gastric may infestation. anemia disease. In facilitate It when some after secretion. the is

in connection acid reappears achlorhydria been that some fallen unable with

while achlorhydria

a decreased anemia people ill

of a pernicious

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94 families to tion ficient worm.

DIPHYLLOBOTHRIUM

LATUM

AND

ANEMIA

many The this production for

cases cause type of of

occur of this anemia. intrinsic

2..

of

both has It factor.

THE

cryptogenetic been may be

anemia that

and

pernicious consists

anemia disposiin a

due de-

considered

a special constitutional disposition this

ExTRINsIC

FACTOR

a) have tein such

Clinical pernicious of as, different of for

observations. anemia kinds. pernicious example,

Experience even though Apparently, tapeworm the nutritional

in

Finland their lack anemia tropical food ofextrinsic (in

shows contains

that factor

worm is not

carriers amount essential other However, of

can prothe cerfor conditions

a sufficient

occurrence

contrast pernicious

to

some anemia).

tam
can higher former special My mia, erythrocyte soldiers pernicious mental
sufficient

facts
contribute

do

support
to of food proteins. the

the
rise pernicious situation The

idea
of the

that
disease. tapeworm

relative
G. anemia
1942.

deficiency
T#{246}tterman in than found in

in
in
1943.

extrinsic
his In material the there considerably.

factor
a

frequency year lack the of seen count who peculiarity, diet. The logical patient, factor. tests. diet a worm observed became to and when yeast necessary. the meat, extract contain When course to of shortly came tapeworm

in next

our

country year and the even of from time and fed

was situation

particularly had

serious; improved

w.s

own
I

experience
have a

agrees
slight during for lived anemia

with
the

that

of T#{246}ttermans.
a meat. the in

In
certain This front. 3 sisters

some
was

cases
the by

of
of case

worm
the with of

ane-

reticulocytosis treatment at like directly the hermits

improvement Cramer (1911) who, with

administration same

observed reason an extremely some in-

themselves

b) It the twelve on given were

often

remission that before The

after there and patients extrinsic

removal will after of were factor the this

of be

the no worm

worm remission cure, to possible. of blood On

as

in

the after has has the

absence the taken been hospital

of worm food shown

extrinsic containing in they days, or

factor. if no of were at picture beis all, placed

is

assume

is expelled a series were they none blood or reticulocytosis

extrinsic a basic

correctness the from Very after

reasoning admitted as signs days.

soon As

as free cure. even

After regeneration, the diet, has brewers protein intrinsic for their contrary,

some

insignificant twelve more factor to fifteen abnormal. were improved casein, degree, a lesser Castles a means of

the known

progressively extrinsic blood milk, and, confirm furnishes picture to

substances

lieved began true trated These are factor. One must be 3. Castles worm The

added rapidly.

to pepton, soy that

the It

a marked been yeast were and content and added

that proved this

Hammarstens

concento the diet. factor

bean both

observations method

theory testing

extrinsic

substances

of extrinsic

practical given
THE

conclusion a diet rich in

is that, proteins

after

worm

cure, remission
AND

patients is to
EXTRINSIC

with be

worm expected.

anemia

if a rapid
THE INTRINSIC

INTERACTION

BETWEEN

FACTORS

test anemia,

has yet

not this

been

previously is

carried of great

out

on

patients

with It is

pernicious conceivable

tapethat

experiment

importance.

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BERTEL

VON

BONSDORFF

95
interaction pernicious when that outside with juice hours by worm question. the the During these the results were tests mixture clearly source meat the of or first produced was negative at means gastric six that the this as occur between anemia. a patient the in worm the and of is unable Meat the yeast test If has same meat the extrinsic this is been way factor proves have enzyme to (iso extrinsic was period a splendid incubated in precases injure. Gm. facmixed a an acis given and true, able as it in to a mix-

the intrinsic
it

worm would of destroy the patients ineffective in day), The

150-175

in factors be meat the

the and and effect bodys ordinary while

intestinal in that gastric of own food. the the new was tests of test was cryptogenetic was the same conclusion these this no juice.

canal way gives This substances intrinsic If mixture remission

prevents rise would would supplied factor from mixture incubated might be to

the the indicate

expected

ture to the be tivity per tor. was In viously

from interacting of for

prevents

extrinsic 37#{176} does C.

a fresh

antianemic vitro,

effect, some
14

drawn which

substance carried yeast gastric period given. out

is formed to juice lasted pernicious clear was with eight extract,

A series

of
or daily

tests some amount Each mixture of effect On

up used which days. anemia

in ml.

nonincubated some or cases The not. remission.

equally other hand,

good the

whether test

of
used

pernicious
juice as in only

tapeworm
produced parallel after insulin which any observations canal is and anemia. that meat be extrinsic Perhaps and formed and this the remission give capable that incubation gastric in any tests the

anemia.
remission. with worm stimulation, mixture be strong of such an does juice vitro had

Neither
In cryptogenetic been and was produced. support preventing inhibition not confirms but only is not
THE LIVER

fresh
some pernicious expelled.

nor
cases

incubated
the identical anemia. of gastric with to the idea deemed improvement of that is in enzyme possible the

mixtures
gastric The juice io patient. that to the the that intestinal reaction. the the be the Gm. Not worm was of

of meat
juice remission brought meat even in and for for in

and
was

gastric

occurred

In
up hours, way These intestinal trinsic

one
daily could

case
after after

of pernicious

tapeworm

anemia,ioo
was administered to can involve the in

ml. incubated

six this the inthe

the be an

interaction

between

extrinsic reason

factors fact of cannot

pernicious The effect ciple between nex,

1940).

antianemia antianemic the wall interaction (Formijprin-

assumption vivo. place It

intrinsic interaction 4.

factors

takes a simple
FACTOR

If the antianemic already prived should dependently It where is it

worm factor stated, of its take of conceivable

in

pernicious is prevented is no of after supply that to be the

tapeworm by blood the of worm giving remission. factor, intrinsic may i.e.

anemia a diet This for and in

is expelled free shows were had factors. the intestine. from

and that present, been

the the

formation factor, liver blood removed, factor possibility at must

of then, be inthe is

new as de-

extrinsic

there stock place the

antianemic

if any worm extrinsic

regeneration

anemia-producing destroy the

antianemic Another

place that

is assumed

formed,

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96 the It partly tion tapeworm of worm is a priori because liver

it

DIPHYLLOBOTHR1UM

LATUM

AND

ANEMIA

toxins liver

absorbed factor somewhat is rather available

from improbable stable both and

the in the

intestine body, that partly the but because and

may this we per tapeworm

destroy is an can know os quickly

the improbable injure that

entire the the cures

quantity theory. liver administraa pernicious factor,

of

antianemic

preparations anemia.

parenterally

I have
at their

incubated
some

ordinary
days effect. and

injectable
could not,

liver
at

extracts
least in this

together
way,

with
prove

worm
any

in
decrease

vitro
of

37#{176} for C. antianemic

It
by

appears,
the tapeworm

then,

that
itself

the
nor

lack
by 5

of
toxins
. F0LIc

the

liver
from
ACID

factor
the worm.

is not

the

result

of destruction

I have
excellent days,

treated
remission

4 cases
was that folic

of pernicious
obtained acid 6. also
THE

tapeworm
in is all not cases with injured

anemia
doses by the

with
of worm.

folic
lo-30

acid
mg.

per
daily 7-10

os.
for

An

showing

ABSORPTION

The that
latum without conditions The anemia, cases cure; absorption.

clinical the
seldom anemia

picture in
suffer do tolerance before sugar not comparable

in
from not

pernicious this
severe differ from those has had to show been and cure

tapeworm is
each in sprue, carried

anemia
disturbances. Worm

gives Carriers

no of
carriers

reason
with In no etc.

to
and case

believe

absorption

disease
intestinal

impaired.
other out course there was in intestinal in blood

Diphyllobothrium
are the

this

respect. anastomoses, of before disturbance

with test the worm curve possible

glucose both the thus blood

it was

4 cases had both any

pernicious normal. and after in the

tapeworm In the all worm

after the

become

a normal that

glucose

7.

EXPERIMENTAL

FEEDING

WITH

TAPEWORM

PREPARATICN

The course,

effect been

on

the

blood in

of giving both animals

worm and

preparations humans.
8-1940)

per T. a certain W. has correctness answer

os

or

parenterally experia large effect of their

has,

of

studied

Tallqvist (1907) published anemising

mented
series preparations of

on

himself
tests. they stated has antianemic
(i)

in this
Both used. been have

way
I am attacked

and
thought not by of the

G.

T#{246}tterman (i
they saw of

from conclusions questions: nullified

the

convinced attempting mixture

the to

for reasons The

(i)

in another effect

publication. the juice following and meat of gastric if

problem the if way meat the as pernicious (or

Is

worm
tients The same genetic plus dried

is added?
mixtures

Is the

remission
juice and

after
is given meat The they the The

the
per

worm
os? (or yeast

cure
extract)

absent
were

in worm
prepared with days splendid.

anemia
in the

pa-

worm described

preparation of gastric earlier. anemia. First with latum. extract)

subjects were addition remission

were treated of was

patients for always eight a considerable

untreated with amount During gastric of

cryptojuice fresh the or

yeast

Diphyllobothrium

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BERTEL

VON

BONSDORFF

97 (or and yeast the the this kept days In was extract) blood worm the on extrinsic spite mixed effect. stomach to or the been and surroundings destroy of stomach after to factors at the place of this with In without regeneration cure, blood a diet was improved free factor addition hogs spite still the had from in the the stomach of the addia marked efeliminathat can be where the prothe given in the was worm the addi-

following tion no In powder usual In factor, yeast improved In order tion It feet tion inhibition duced only antianemic was of of to of way. some were extract connection of more one worm,

period no than of in rapid case per

Os

with new worm increasing the worm worm the with the worms shown of presence in the that gastric during

gastric reticulocytosis the anemia

juice was first the amounts. anemia

plus test patient, In patients then worm worm of such of and loss for

meat period. after spite were eight powder. powder of tests the

observed

of

tests given with rapidly.

extrinsic form blood in of

cure addition these in

and of tests, two

investigate powdered effect. thus mixtures the the worm of by the

possibility

antianemic hogs

addition juice of worm anemia. between worm in does

worm extrinsic not

is unable factor, prevent fact has intrinsic

antianemic preparations. the mean

Moreover,

remission interpreted extrinsic

worm living

This the its

interaction

natural

interaction

occurs.

8.

INHIBITIoN

IN

VITRO JUICE

OF AT

THE NEUTRAL

PROTEOLYTIC

ACTIVITY

OF

GASTRIC

REACTION

The in its

gastric hydrolytic of to nor but gastric factor, to not yet that is the per addition detailed nature os thus the

protease

which capacity in

is active vitro latum. minutes. ethyl alcohol. has of prove cannot as the follows: extrinsic does inhibits this of the

at after The It

a pH the is It been

range

from 9 is 5 greatly tO of substance and

50

inhibited relatively is destroyed is not soluble small by in

addition dialyzable be per vitro and vitro The intrinsic this be but living cent has

even

amounts heating ether, alcohol, The trinsic ponding has probable There hibit tion the more chemical

Diphyllobothrium 8o#{176} C. in 98 can for per twenty cent in the possible interaction between preparations in vitro that a descrepancy worm of worm Itseems knowledge of the

inhibitory not cannot

90 in

precipitated alcohol. to be been extrinsic As only worm factors, interaction, activity explained here and stated in

per cent with

with as in it seems administraagain juice we The have exact (c) at the corresvivo. seems canal. to inIt in-

be precipitated protease and question

quantitatively

assumed in

identical considered factors

hydrolysis between to

casein the this occur (a)

interaction such

intrinsic assumption. in and not the inhibit proteolytic cannot substances intrinsic

been

above the in (b) intestinal situ the while of gastric until

interaction of

neutral

reaction.

discrepancy different factor,

concerned. the tapeworm

extrinsic

factor

toxin

are as yet unknown.

From bloodjournal.hematologylibrary.org by guest on August 12, 2011. For personal use only.

98 9. Presumably factor the autopsy but there Diphyllobothrium be series quantities

TABLE i-Distance
(;roupl

DIPHYLLOBOTHRIUM

LATUM

AND

ANEMIA

THE

LOCALIZATION

OF

THE

TAPEWORM

IN

THE

INTESTINAL

CANAL

the the arises: information in general are no

worm worm Where on indicate systematic latum

cannot is present in this that is vomited,

inhibit at the point the the is

the

reaction place where canal

between the is the chiefly fact. that this at latum at

Diphyl/obothrium
3

extrinsic interaction worm from observed least to be

and occurs.

intrinsic Now Very and ileum,

unless question

intestinal available. has of which To the easy

Ova and/or

found? in that the

uncertain

Experience been this

operations

worm

observations

Sometimes happens it

shows

occasionally it can the produces distance

Latum Were

very of

high of

up

in

the was

intestine. As relatively
(cm.)
Cou

investigate Diphyllobothrium to determine

Proglottids of
Group Pernicious anemia,

question, what

author large from

Found

made the

intestinal eggs it
from

intubations.

Mouth

where

s anemia

Xo

anemia

Nonperniciou

tapeworm manifest

Group 4 Pern,icius taPeworm anemia in p?ntaneous remission

2.35
2.35 2.30

334 i8o
140

35
12.0 12.0 12.0 115

32.0 2.40 2.05

i8o
i8o

i8o i6
ISO 145 530

ii

iio
105 105

95

mouth self way eggs vinced cases. The groups The up better How cult cm. and to from the
JO.

the were the are

first aspirated highest produced

eggs at point

could the in the be can were in table i, that than

be same the

aspirated. time. intestine highest obtained out which manifest on the Perhaps interaction Of

In where segments which

many the of allow

cases possible worm the

small to is worm, comparison

pieces calculate attached. yet

of

theitin

worm this no condifferent into higher 4 been

course, is not it

Although I have between

from

that intubations as results the able high

results

carried in in

2.6 worm results are one can

carriers also anemia imagine extrinsic

who summarized. the

were worm that and in is

divided found

appears show intestine to up

pernicious

in

otherwise. with the favor ought

that it is region intrinsic factors. lies 50 the jejunum

interfere My mouth,

between must opinion be about that the

in the intestine results which

the worm the to

be it to inhibit for borderline

this a critical

reaction limit 140-I between

difliis

determine. the ileum.

AN
ATTEMPT

TO

EXPLAIN TAPEWORM

THE

PATHOGENESIS

OF

THE

PERNICIOUS

ANEMIA

As causes

described pernicious

above,

it appears

to inhibiting

be

possible the

that interaction

the

Diphyllobothrium between extrinsic

latum and intrin-

anemia

by

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BERTEL

VON

BONSDORFF

99 if the there is worm reason factor occurs : the high or in or is sufficiently to the not low formation time that of pernicious diet Most therefore, to aborin anemia If the worm circumwhich he falls for one possibly well At the worm. of the and my up passage and the the occurrence high in of it can be towards values up the in lower is lower enzymes of the theory, in the also part are anemia.small A intestine, part that the are not jejunum. rare in worm of the the worm, while through affected of less the small active. after the have ill with reason as or a reinis prinif is only exfrom is that or that the the anemia tapeworm a hereditapeworm amount presume would of position of liver will is gastrointestinal depend extrinsic in the high that in the

sic the

factors, intestine. of is also a definite the a

but extrinsic of amount time factor deprived itself.

that However,

this factor

reaction as in among stated the

can food Thus these factor, also been then in the be is

occur and three and taken there of

only

previously, whether the

amount canal on factor, intestine. Finally antianemic wholly manifest It anemia, tary anemia not classify tive ciple the pelled The stances hitherto a) another, festation. b) expelled c) times tion testine more intestine d) amount small are e) because The a longer
it

intrinsic anemia determinants worms into for reason

some of factor must of

importance. intrinsic must have Only that basis to for be ill it.

correlation

consideration. The such to of either a long expect cases

inhibited

must

be there

emphasized is no are the

great with

majority that as

the reckoned later of with

assumption

a defective causes. I can, suffering tapeworm intestine. following and before worm, sometimes
it seems that

disposition patients confirm forms any worm-ceteris a complete theory which been A person anemia. has have of worm surviving

co-operating anemia.

donot fall correctness patients genuine carrier paribus-is restitution I have difficult can The invaded who has that from all the to to digestive only of can Yet had worm cause cases by volume, go undergo is fact at to carry

with Birkelands

a cryptogenetic conclusion anemia view get up my in of the

appropriate

Diphyllobothrium anemia. My can enough follow. explains-in put

as the

pernicious whosoever high can specially to explanation the had the an seen that upper pernicious get anemia worm anemia in interpret. Diphyllobothrium

problem

a pernicious

formulated been

opinion-the by Saltzman (1914) years the

forward latum for can the be

many that intestine, and

pernicious

of parts

this of worm

A person
does A can worm no worm be has the and amount of worm intestine. often of due distance not

anemia in is the often being During it the had colon, with is collected According

becomes with parts to

worm

necessarily

if he is again is only patient the the feces. worm, expelled. autolytic if than

infested lowest

reinfestaintestine. discolored. Somethis intestine the disintegrahas inhad

tion it may

happen expelled

disintegrating higher its decomposition been where the in

before it was a strong pass is not anemia with anemia. has very through in enzymes to

had

by

correlation if it so ifit large In such forced to normal

is sufficiently amounts cases upwards blood

a large amount

does not necessarily do

worm, 8o-ioo

M. and

more,

accompanied its great remission

imagined

been

Spontaneous

with

a return

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100

DIPHYLLOBOTHRIUM

LATUM

AND

ANEMIA

anemia. of type
(cf.

The small the worm

i).

explanation intestine was after only eggs worm and found an can cure-after is often

of

this

can

be down in cure the in the

that

the towards

worm the

had ileum.

deserted In my

the

upper of

parts this

the table f)

wandered just as low worm of seen the removed. blood In driven be

3 cases worm

the can

intestine also

as in

nonanemic cure at all can is the idea-the of the its of fail

carriers such and improves. after

Remission that worm of first

incomplete amount still

occur. filicin A or In has none spite become to to one

in

a way the At at amount the remained ducing This worm tube the sis glide is, far dinary
2.

a small

worm, feces. picture

expelled, blood worm intestine anemia-pro-

cure a later

of this, my part exercise case Through

normal-a

considerable but

worm in the was the fihicin to and in, in depth contain

(ii

such from no

cases-according the upper able test. In mouth. worm not filicin tillcm. longer

unsuccessful lower confirmed eggs emulsion

cure part by were

was

whereit was the foundi were egg, A few picture eggs Following latum
i

effect. idea anemia Gm. following cm. but days were from The they after not another were could the found rapidly.
LCO

manifest the

pernicious intestinal and as the present allowed that of orfeces at to

the

instilled.

was be cure The

not

expelled

continued former began farther down

worm cm.). blood

demonstrated a marked tube from with the was

31 filicin, M.

reticulocytothen mouth,

the and the

improved

worm ileum.

treatment expelled.

looking

Diphyllobothrium

COMMENT

According change worm gration. anemia other sumed individual ness; G. granulocytopenia experimental the that with basis unless (a-f) There one places of handles a small burning. worm tells liver of them, extrinsic above is no macrocytic or in in the the The patients theories, a varying

to

one character

earlier of but segments been cause of has to of the these its

theory, the I have which very of the use the of the of

the parasite, been motile anemia the

occurrence possibly unable and lay intestinal organs tapeworm Apart none appears as an theories expulsion no of in to

of an

worm abnormal any at

anemia signs intubation

may of such

be the

due

to

disintegrationf o

intestine, worm have the susceptibility

find

a disintefrom worm to pre-

I sometimes

aspirated ordinary the wall to host. to it, from of artificial allergic is that of them the or

appearance. These worm an the seem to reaction. the the occurs under a powerful skin is greatly tongue, to proved allergic with fact to conceive Another anemia worm. after the that theories

According have a special, preparedmalignant I find to of can Again, the Section worm
JO

permeability classed

toxin,

hemopoietic perncious amidopyrine. defective, It

T#{246}tterman due basis anemia anemia against the stomach it are fresh The

anemia

the explain

theories satisfactorily.

me

problem with toxic and

the fact be cured on the cure

megaloblastosis allergo-toxic without explain to explain. why The

preparations to is not that easy with of dried of available. Diphyllobothrium unprotected and worm

is difficult factor also

remission

circumstances listed latum hands, worm has contains the on been the

doubt worm amount

poison. irritated. there produce

If If one is a feeling nausea,

pulverized powder

inhalation

From bloodjournal.hematologylibrary.org by guest on August 12, 2011. For personal use only.

BERTEL

VON

BONSDORFF

101

fever, often philia changes. these resembling my only Tests icity Yet
it

rhinitis, suffers (which Like phenomena those the on of has the not to confusion to details in to these light August. in its idea, from

asthmatic giddiness, may the can which inhibition of the Among possible Addisonian in produce in the the animals worm. been the with or may macrocytic, be

cough various not be

and

eosinophilia nervous absent in anemia expression ofpernicious between injections it tests in could, man. I believe, was appears to produce manifestations anemia

in and

the cases)

blood. nausea, and by G. has

A shows

worm eosino-

carrier

serological

nonpernicious as the interaction toxicity. preparation other with discussions things, these anemia anemia anemia the curves the rise

described of the

T#{246}tterman, of toxic activity, to is toxtoxin. directly ability from Like definite from agrees to decide himself: acid (as of could the factors. anemia of to has the liver whole suggested with perbe deterpoison to are what to of its the factors to which if the the according

considered condition of the worms worm

effects and bear

anemia. extrinsic also to an be

Thus, intrinsic witness

one expression

contain anemia avoided kept await anemia during own the

a hemolytic

corresponds Much the other Certain cryptogenetic variations March be extent on by pigment nicious The mined, interferes I have not great treatment only question and
it

worm toxic

pernicious tapeworm anemia, distribution.

consistently still tapeworm usual my

separate solution. shows period

properties. problem is with It depend contents substances. also the to here but macrocytic are termed be taken toxin a better between that can and the also pernicious.
REFERENCES

pernicious seasonal

pernicious It most which is on the at diet A into

Illustrative monograph. variations on or the other must nature be the to of which possible interaction show interest the of

experience patient folic (in both If by the worm forms that which

found

Birkelands seasonal

present of racial

impossible the protein, factor

circumstances in

conditions, metabolism) anemia. chemical might with tried a local

in

Waldenstr#{246}m),

connection

consideration in unknown. the process and pernicious to anemias the which

worms get

is still idea the of of extrinsic

intrinsic

investigation contribute megaloblastic

elucidation respond

RIR1CELAND, voN
BONSDORIF,

I. Acta especially

W.:
B.:

Bothriocephalus
Liver extract

anemia.
exposed

Medicine the action

ii:

I,

1932..

to

of intestinal activity
reaction.

worms in vitro

does

not

its anti-anemic lose

effect. The and The ized

On

med. of gastric
reticulocyte

scand. human effect

100,

436, gastric Acta

5939.

influence of intestinal worms on the inhibitory human

the

proteolytic latum scand. los, anemia. at neutral pernicious

502.,

of trypsin, ioo, activity of the orm w io, juice

1940. i6,

papain 459, 1939. in

and

pepsin

juice neutral at med.

and

Acta med.

scand.

of Diphyllobothrium
response

on

the after

proteolytic removal med. due scand. of gastric to

vitro depcpsinof
patients

juice. latum anemia

1940.

1940. in

course remission of

with

Diphyllobothrium
-:

and activity

pernicious in and vitro with

Acta reaction anemia

On

the

proteolytic pernicious
105, 540,

from

patients Acta

with mcd.

crvpto-

genetic
scand.

Diphyllobothrium latum.

From bloodjournal.hematologylibrary.org by guest on August 12, 2011. For personal use only.

102.

DIPHYLLOBOTHRIUM

LATUM

AND

ANEMIA

: On

the

remission

after

removal

of

the

worm

in

pernicious

tapeworm

anemia

in

presence

and

ab-

sence ofextrinsic
:

factor in the food.

Acta latum

med. anemia. influence

scand. Acta the

In press.

ii6, 1943. 77, med. interaction

found?

Castles

test

in of
of of

pernicious Diphyllobothrium
Castle? the intestinal Acta

tapeworm
med. canal

scand.

Suppl. between

196, the

456, intrinsic
med.

5947. and
scand.

Does
extrinsic
-:

feeding
factors which part

the

scand. is the fish

In In

tapeworm

A questionnaire. Acta

press. :The

site
acid

of
in

infestation
the treatment

with
of

fish

tapeworm

determined
tapeworm,

by
anemia.

means
Acta

of

intestinal
scand.

intubation.
In press.

Acta

med.
-:

scand. In press.
pernicious med.

Folic

CRAMER,

A.:

Trois Med
ROBERT:

cas
Zur

simultan#{233}s dan#{233}mie pernicieuse de Paris 46. 5475,92.2.. 1

der Darmparasiten in Kenntnis

botrioc#{233}phalique
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chez
scand.

trois
2.9, 64.

soeurs.
192.6.

Bull.

et

m#{233}m.Soc. EHRSTR#{246}M, FORMIJNE,

d. hop.

P.:
Med.

Experiments
66: 1191,
1940.

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the

properties

of the bei

extrinsic

factor

and

on Acta

the

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Supp.

of Castle.
1945.

Arch

mt.
HELANDER, HERNBERG,

E. V.: C. A.: Acta

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Magensekretion the scand. anti-anaeniic Supp.78:

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scand. med.

Concerning
of the
123.

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juice in

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pernicious

in pernicious

Botriocephalus

anaemia.
On
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582.,

1936. in the Botriocephalus anaemia.

occurrence
scand.

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Supp. Deutsch. Bedeutung

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0.:

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Supp. 7. 2.68,
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L#{228}k.s#{228}llsk. Hdl. 77?

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-:

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