and averaged 91 and 69 percent of correspond- ing parameters for casein. White flour N was absorbed as well as that of casein, but retention of white flour N averaged 72 percent as high as casein and thus did not differ from retention of whole wheat N. Weight gains of the children during the wheat periods were less than half of those during the casein periods.

The inferior performance of the children while receiving wheat products was expected, since wheat protein is known to be of inferior quality, primarily because of its low level of lysine. Due to the wide variability in the data and the small sample numbers one cannot conclude with confidence that there were real differences in N utilization between wheat strains or prepara- tions.There was a trend towards better utiliza- tion of absorbed protein from the high protein whole wheats than from the corresponding

white flours, 79 versus 70 percent as well uti- lized as casein N, that was not seen in the commercial wheat data, 74 versus 77 percent. Data are not presented on the lysine content of these preparations. Since N utilization was equivalent among these dietary sources of wheat protein when fed, in equal and subop- timal amounts, it appears reasonable to con- clude as the authors do that if the wheats were fed in equal amounts the high protein wheats would yield results superior to those of the com- mercial wheats because of the 30 to 40 percent increase in N intake. 0

1. W. G. MacLean, Jr., G. L. De Romana and G. C. Graham: Protein Quality of High Protein Wheats in Infants and Children. J . Nutrition 106: 362-370, 1976

PERNICIOUS ANEMIA AND MENTAL DYSFUNCTION The EEG is a useful test to document cerebral dysfunction due to vitamin B I Z

deficiency in patients with pernicious anemia.

Key Words: electroencephalographic changes (EEG), hemoglobin, mentation, vitamin B I Z

Signs and symptoms of neurologic damage and mental changes are part of several syndromes of vitamin deficiency. When they occur as the presenting complaint of a patient in folic acid or vitamin BIZ deficiency, the illness is difficult to diagnose, especially if the degree of anemia is not severe. A folic acid deficient state, on rare occasions, may be the cause of a mental de- pression or psychotic state which leads the patient to first seek psychiatric help. Similar problems may also occur in BIZ deficiency. The electroencephalographic (EEG) changes which accompany changes in mentation in per- nicious anemia (PA) are of some help in these instances. The EEG can help resolve diagnos- tic difficulties for physicians, if they are alert enough to order the test.

Changes in the EEG were carefully review- ed in a series of 54 patients with PA.' The pa- tients had one or more of the criteria required to make the diagnosis of PA: macrocytosis with gastric achlorhydria after maximal histamine

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stimulation of gastric secretion; a positive Schil- ling test (less than 8 percent excretion in 24 hours); a low serum BIZ level (less than 150 pg per milliliter); or a positive reticulocyte response with BIZ replacement. The ages ranged from 24 to 93 years; 23 men and 31 women were in the study group. Hemoglobin levels of less than 12 mg per 100 ml in women and 14 mg per 100 ml in men were considered diagnostic of anemia. Four groups were defined on the basis of pre- senting signs and symptoms.

Group one: six patients with hematologic evi- dence of PA but no evidence of neurologic damage;

Group two: ten patients with peripheral neu- ropathy or spinal cord changes, but no cerebral involvement;

Group three: 19 patients with disturbance of cerebral functioning as shown by changes in mentation; and

Group four: 19 patients who had other neu- rologic diseases in addition to PA.

In group one, four men and two women had normal EEG's. Only three of these were anemic with hemoglobin levels between 10 to 12 mg

per 100 ml. Group two (four men and six wom- en) contained seven patients who were anemic (hemoglobin 7.5 to 12 g per 100 ml); four of these and two patients without anemia had normal EEG’s. In four patients, nonspecific changes were found in EEG consisting of a mild excess of theta activity (5 Hz) diffuse or local- ized over the temporal area. One patient, after treatment for one year, showed no change in EEG pattern. Three of the people with non- specific changes were anemic; one was not.

In group three (seven men and 12 women), the derangement of mentation was shown by memory disturbances, disorientation, irritabil- ity, lethargy, depression, paranoid delusions or hallucinations. Fourteen were anemic (hemoglobin 8 to 12 mg per 100 ml), five were not. Only two patients had normal EEG’s; their mentation disorders were only mild and hemo- globin was between 10 to 1 1 mg per 100 ml. In five, EEG changes were mild; theta activity (4 to 7 Hz) was found diffusely over temporal re- gions. Mentation disturbance was also mild to moderate. Fourwere anemic (hemoglobin 10 to 12 mg per 100 ml). In seven, EEG changes were moderate (diffuse 4 to 6 Hz) and so was their disturbance in mentation but anemia was not severe (four had hemoglobin levels of 10 to 12 mg per 100 ml). In five with moderate to severe mentation changes, EEG changes were classified as moderately severe showing dif- fuse 4 to 6 Hz slowing; in addition two of these patients had generalized and persistent 1 to 3 Hz delta slowing and intermittent 2 to 3 Hz slow wave activity was noted in the other three pa- tients of this same group. Of these five patients, three were anemic (hemoglobin 9 to 12 mg per 100 ml) and two had normal levels of hemo- globin. Significant improvement in EEG was found two and four weeks after B ~ z therapy in two patients.

In group four (eight men and 11 women), two patients were anemic (hemoglobin 9 to 12 mg per 100 ml) and seven were not. Six pa- tients had a cerebral infarct and showed delta wave slowing over the area of distribution of the cerebral artery which was occluded. Two pa- tients had ischemia of the posterior cerebral circulation and slowing was noted in these

areas. Two patients had focal tumors, and slowing and spiking was noted in the area of tumor. The other patients had seizures, head trauma, hypoglycemia, Parkinson’s disease and medication effects.

The study showed that the extent of EEG changes was correlated with the degree of disturbance of mentation in PA. The most con- sistent finding was diffuse theta slowing but in some patients generalized intermittent or persistent delta slowing was also present. If there were no disturbances in mentation or if nervous dysfunction was limited to spinal cord or peripheral nerve involvement, most EEG’s were normal or changes were nonspecific. If patients showed decrease in memory, disorien- tation, altered affect or psychotic symptoms, however, then their EEG was abnormal and diagnostic of PA. If other complicating features of nervous disease were present, the EEG was more variable and the diagnosis of PA was much more difficult to make by EEG analysis.

The change in EEG did not correlate with the degree of anemia shown by the patients. Thus the authors speculate that the changes were due more to a metabolic defect created by BIZ deficiency rather than being secondary to a state of anemia.

This paper emphasizes the importance of using all diagnostic procedures to rule out PA deficiency in patients hospitalized in a mental ward or institution. Suspicion of PA gained from other findings (history and/or physical findings, laboratory data) may not require an EEG but, on the other hand, if EEG facilities are available and B12 assays are not, it should be done in suspected cases. Mental distur- bances disappear with B12 therapy and thus, such patients should not be missed by practic- ing physicians and psychiatrists. On the other side of the coin, in proven PA patients, an EEG should be done to rule out other neurologic disorders not related to PA. It should not be as- sumed that mentation disturbances are only due to B12 deficiency. 0

1. P.W. Wallace and B.F. Westmoreland: The Elec- troencephalogram in Pernicious Anemia. Mayo Clin. Proc. 51: 281-285, 1976

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