Scurvy VIII. Factors affecting the antiscorbutic value of foods

SCURVY VIII. FACTORS AFFECTING THE ANTISCORBUTIC VALUE OF FOODS1 ALFRED F. HESS, M.D., and LESTER J. UNGER, M.D. NEW YORK For many years following the classic exposition of Barlow and the studies to which it gave rise, scurvy aroused little interest and was represented in the literature merely by a succession of case reports. Of late, however, this subject has become one of the most active from the clinical as well as from the experimental standpoint. This striking change in the status of this disorder is due largely to the publications of Holst and his co-workers,2 who opened the field to experimental study by demonstrating that scurvy can be induced readily in the guinea-pig. It has received additional impetus through the war, which unavoidably led to the development of scurvy, not only among the troops, but among the civilian population. As there has been no account of this chapter of the medical history of the war, it seems of interest to review briefly, even at this early date, some of the reports which are accessible, and which show that, in spite of our knowledge of prophylaxis, scurvy still must be regarded as one of war's vicissi¬ tudes. In 1917 Harvier,3 a surgeon of the French army, was surprised to discover that 95 per cent, of the 800 troops of which he had charge suffered from scurvy; he tells us that other epidemic centers were 1. The previous articles of this series are: 1. Hess and Fish : Infantile Scurvy: The Blood, the Blood Vessels, and the Diet, Am. J. Dis. Child 8:386, 1914. 2. Scurvy: A New Aspect of the Symptomatology, Pathology and Diet, J. A. M. A. 65:1003, 1915. 3. Infantile Scurvy: Its Influence on Growth (Length and Weight), Am. J. Dis. Child. 12:152, 1916. 4. The Therapeutic Value of Yeast and of Wheat Embryo, Am. J. Dis. Child. 13:98, 1917. 5. Subacute and Latent Infantile Scurvy. The Cardiorespiratory Syndrome (A New Sign), J. A. M. A. 68:235, 1917. 6. Infantile Scurvy: A Study of Its Pathogenesis, Am. J. Dis. Child. 14:337, 1917. 7. The R\l=o^\le of Antiscorbutics in Our Dietary, J. A. M. A. 71:941, 1918. 2. Holst, A., and Froelich, T.: Ztschr. f. Hyg. u. Infektionskr. 72: 1912. 3. Harvier, P.: Paris m\l=e'\d. 7:394, 1917. Downloaded From: http://archpedi.jamanetwork.com/ by a University of Calgary User on 05/27/2015 recognized later outside this sector. Elsewhere we read4 of the occur¬ rence of scurvy in France, involving 40 per cent, of 1,700 men of the South African Labor Corps and that this disorder was still more serious in another company owing to the fact that it was not recognized.5 Another author reports scurvy among the Italian troops,6 giving an account of an epidemic of some 200 cases of infectious purpura with manifestations of hemorrhagic scurvy. Still another reports that in June, 1916, scurvy broke out among some Italian troops which were stationed at an altitude of 1,500 to 2,000 meters.7 Vallardi gives an account of 180 cases among Italian troops in Macedonia, accom¬ panied by slight jaundice and enlargement of the glands.8 It would seem that Germany likewise was not spared from this disorder, as is evidenced by a report of thirty cases noted by the French among prisoners of war captured in the beginning of 1917, which were once again diagnosed as purpuric rheumatism.9 Further¬ more, Morowitz10 writes of scurvy in Germany among the soldiers, stating that it was confined mainly to the Eastern front. Both of these papers remark on the difficulty of differentiating scurvy from purpura. In this connection the statement of another German author11 is interesting, namely, that during wars eruptions are apt to take on a hemorrhagic character ; for example, in association with typhoid fever, cerebrospinal fever and rheumatism, and that this has been true in this war, in the Franco-Russian War of 1812 and in the Crimean War. He believes that, although scurvy has been prevented in this World's war, the latent type of the disease has not been eradicated. Another significant term is used by Blatt,12 who writes of "a special depart¬ ment for scurvy containing about seventy patients." It is of course not surprising to read of scurvy occurring in Russia. In the beginning of 1916, cases were reported among Russian prisoners, 4. Dyke, H. W.: Lancet, London 2:513, 1918. 5. The writer adds that he believes that the health of the natives at home is protected by Kaffir beer which they consume even to the amount of 3 gallons a day, and which is made from germinated Kaffir corn. This cereal is germinated by steeping it in water for forty-eight hours and is then dried in the sun. Only enough is prepared for one brew. The French prepared a similar fermented beverage for these South African laborers, the sole difference in its mode of preparation being that the corn had not been germinated. 6. Vannutelli, F.: Policlinico, Rome 24:873, 1917. 7. Gingui, F.: Riforma med. 34:22, 1918. 8. Vallardi, C.: Riforma med. 34:793, 1918. 9. Schreiber, G.: Paris m\l=e'\d. 26:508, 1918. 10. Morawitz, P.: M\l=u"\nchen. med. Wchnschr. 13:349, 1918. 11. Von Niedner: Med. Klin. 14:333, 1918. 12. Blatt, N.: Wien. klin. Wchnschr. 31:942, 1918. Downloaded From: http://archpedi.jamanetwork.com/ by a University of Calgary User on 05/27/2015 associated with the symptom of night-blindness.13 Elsewhere we read of 500 cases among prisoners captured in Turkestan.14 The data of the occurrence of scurvy among British troops is not yet available. There are many indications, however, which lead us to conclude that they also were affected. In one article 400 cases are referred to.15 This account likewise mentions night-blindness as a symptom, and notes the interesting fact that "scorbutic patients, when operated on, showed no particular tendency to hemorrhage." Most significant, however, are the preventive measures which were insti¬ tuted by the British government. A body of 256 men, designated as the Madras Gardeners' Corps, were dispatched to Mesopotamia to plant gardens all over the country and to supply packets of seeds to various units.16 At Bagdad alone their output of vegetables was over 400,000 pounds. This is certainly a remarkable innovation in the hygiene of armies. Another significant point referred to in this article is that a new dietary scale, increasing the amount of vegetables, has been ordered for the British troops in India. The activity during the latter period of the war of the Lister Institute in investigating scurvy must also be interpreted as the response to an urgent demand for knowledge on this subject. The civilian population was by no means spared. Indeed, it is probable that it suffered more widely in this regard. In Glasgow we learn of fifty cases developing in the Poor Law Hospital within a period of four months,17 and in Newcastle of sixteen cases appearing in the Poor Law Infirmary in the course of three months.18 A recent article from Vienna describes 200 cases occurring among older chil¬ dren, a situation quite unheard of in peace times.19 Morawitz10 also states that scurvy appeared mainly among civilians. In its fully developed form scurvy must be considered an excep¬ tional disorder in normal times. This applies to the United States and to most of Europe. In Russia and some other countries it is practically endemic. A recent communication from Aruba,20 a small island of Dutch Guiana lying north of Venezuela, illustrates the fact that in some parts of the world scurvy is still a plague. This note tells of 3,000 cases of this disease occurring in 1915 among a popula¬ tion of less than 10,000, and adds that the crops have failed almost entirely during the years 1912, 1913 and 1914. 13. Zak, E.: Wien. klin. Wchnschr. 30:592, 1917. 14. Disque: Med. Klin., No. 1, 1918. 15. O'Shea, H. V.: Practitioner, London (October) 1: 1918. 16 Trop. Dis. Bull. 12:257, 1918. 17. Pickens, R. M.: Lancet, London 2:21, 1917. 18. Harlan, G. P.: Brit. M. J. 2:46, 1917. 19. Tobler, W.: Ztschr. f. Kinderh. 87:459, 1918. 20. Hopkins, G. R.: J. A. M. A. 69:1641, 1917. Downloaded From: http://archpedi.jamanetwork.com/ by a University of Calgary User on 05/27/2015 It is difficult to estimate how common scurvy, and more especially infantile scurvy, is in the United States. A recent article by McLean21 gives an account of 50 cases admitted to the wards and outpatient department of the Babies' Hospital in New York City during a period of twenty months. Statistics, however, do not and cannot give an adequate idea of the incidence of nutritional disorders which require many months to develop fully. When we reflect that it usually requires about six months before a case of scurvy reaches the phase where it can be recognized clinically, it is clear that the great majority of cases must be latent or rudimentary, and inaccessible to diagnosis by clinical or laboratory methods. It would seem logical to believe that there is a considerable number of infants who for a period of one or more months are unwittingly deprived of the necessary quota of anti¬ scorbutic food, but who are saved from the manifest development of the disorder by a casual and fortunate change in their dietary. MILK The most important foodstuff in connection with scurvy in infants is the essential dietary of all babies, namely, milk. If milk were highly antiscorbutic, infantile scurvy would be a most exceptional disease. As brought out elsewhere, however, "raw milk must not be considered as having potent antiscorbutic properties."1 This was noted many years ago by Barlow22 in one of his later papers, and has been con¬ vincingly demonstrated by the recent experimental work of Chick and Hume23 carried out in the Lister Institute. In numerous communica¬ tions published during the past few years, we have laid emphasis on the fact that pasteurized milk possesses still less antiscorbutic power than raw milk ; that, indeed, it is not sufficiently rich in this "vitamin"24 to allow a positive balance to be maintained, so that infants fed for a considerable period on pasteurized milk develop a mild type of scurvy. 21. McLean, S.: Arch. Pediat. 35:477, 1918. 22. Barlow, T.: Lancet, London 2:1075, 1894. 23. Chick, H., and Hume, E.: Biochem. J. 12:131, 1918. 24. There has been considerable discussion as to the proper generic term for the substances which are active in preventing scurvy, beriberi and other deficiency diseases. Some have preferred to use the indefinite term "accessory factor" rather than the word "vitamin," which connotes a definite chemical substance. "Accessory factor," however, leads one to infer that such a substance is not essential to well-being or to life in comparison to other food substances. In point of fact, just the opposite is true. We can prosper without fats or carbohydrates in our diet, but we cannot maintain health if the antiscorbutic factor, the antiberiberi factor, etc., are excluded from the dietary. From this point of view these substances are essentials for life, whereas the fats and the carbohydrates may be regarded individually as more truly "accessory." Downloaded From: http://archpedi.jamanetwork.com/ by a University of Calgary User on 05/27/2015 We wish to point out again that this deficiency of pasteurized milk is due only in part to its having been heated, that much of the anti¬ scorbutic factor is lost subsequent to the heating in the course of the handling and aging of the milk, so that pasteurized milk contains con¬ siderably less of the vitamin factor after forty-eight hours than it did immediately subsequent to heating. This is due in part to the fact that a large proportion of the acid-forming bacteria are killed, so that the milk gradually becomes less acid, developing a reaction which favors the loss of the antiscorbutic "vitamin." It is probably exceptional, however, for a well marked case of scurvy to develop on a diet of pasteurized milk, for enough of the protective substance remains to avert this disaster. In referring to scurvy occurring on this diet, we refer to the latent type of the disorder, characterized by stationary weight, fretfulness, a peculiar muddy complexion, rapidity of pulse and respiration (the cardiorespiratory syndrome) and slight edema over the tibiae ; in some cases this condition advances further, merging into what may be termed subacute scurvy — where tenderness of the bones, scattered petechiae, and perhaps a fine hemorrhagic rim along the gums of the incisor teeth are added to complete the picture. The more milk, whether raw or pasteurized, a baby receives, the less will be the chance of scurvy developing. This is likewise true in regard to experimental scurvy. It would seem that this fact con¬ stitutes conclusive evidence that this disorder is not brought about by an exogenous toxin existing in the milk, and also that it can be explained only on the supposition that a deficiency plays a rôle in the etiology of the disease. In considering whether a certain diet leads to scurvy, it is, therefore, of prime importance to know how much milk has been given. In most of communications, however, for example in the excellent report brought out some years ago by the American Pediatric Society, this item is not included in the data, so that it is impossible to appraise the rôle which the boiling or the pas¬ teurization of the milk, or the addition of various proprietary foods, played in bringing about the disorder. Frequently many factors must be taken into consideration when analyzing the relation of a particular food to scurvy. For example, when we regard malt soup from this point of view (a preparation consisting of 1 pint of milk, 1 pint of water, with the addition of flour, malt and a small amount of potassium carbonate), a diet which in our experience induces scurvy most readily, we find that there are the following determinants leading to this result: the amount of milk is insufficient to fully protect; the preparation is boiled and frequently prepared originally from pas¬ teurized milk; there is a period of aging between the pasteurization Downloaded From: http://archpedi.jamanetwork.com/ by a University of Calgary User on 05/27/2015 and the boiling of the milk and the flour;25 an alkali is added, thus hastening the decomposition of the "vitamin"; and finally, the addi¬ tions to the milk may exert a detrimental influence. Some time ago, in making up malt soup preparations, raw milk was used for a certain number of infants and pasteurized milk for others. A distinct superi¬ ority was found in favor of the former as regards the development of latent scurvy, so that we would recommend that raw milk should be employed in preparing malt soup and similar formulas which involve heating. Another milk formula which frequently leads to mild scurvy is Schloss milk, which contains 280 c.c. of milk and cream to the quart, in addition to sugar, flour, casein and potassium chlorate. Here again the small amount of milk is largely accountable for the pro¬ duction of scurvy, although there is probably the additional factor of low acidity, as it is only half as acid as raw milk, when measured by its power to neutralize a solution of sodium hydroxid. Reduc¬ ing the acidity of a food does not entail an immediate loss of anti¬ scorbutic vitamin, although it initiates a gradual and continuous loss of this substance. Just as we must consider exactly the nature of the diet, and more particularly the amount and quality of the milk in judging of the relation of a diet to scurvy, so in drawing con¬ clusions as to the value of an antiscorbutic substance, the complete dietary must likewise be taken into account. It is evident, for example, that it will require less orange juice to cure a case of scurvy which has developed on a formula containing 24 ounces of pasteurized milk than one which has developed on a diet of malt soup. This point is rarely borne in mind. It is important to main¬ tain the same viewpoint in judging those cases scattered through the literature where scurvy is reported to have developed in nursing babies. Probably one of the causative factors in these cases has been a deficiency in the amount of milk; in others, the hemorrhages associated with infection have been mistaken for scurvy.26 There 25. Heating destroys to a greater or less degree the antiscorbutic "vitamin," so that if milk is pasteurized and also boiled, there is a double loss of this substance. However, this loss is greater if an interval is allowed to elapse following the pasteurization, for then the milk is also subjected to the deteriorating influence of age, which is considerable after prolonged heating at a low temperature. 26. There seems to be some misconception as to the pathogenesis of the subperiosteal hemorrhage in scurvy. In most reports this lesion is described as if it resulted from a hemorrhage burrowing its way beneath the periosteum and raising it from the subjacent bone. In point of fact, such an event is impossible, as will be fully realized when one experiences the great difficulty in separating periosteum from normal bone. Scurvy involves the periosteum which is not normal; it is insecurely attached to the shaft of the bone, so that it is readily stripped off by hemorrhage. Downloaded From: http://archpedi.jamanetwork.com/ by a University of Calgary User on 05/27/2015 are a few reported cases, a very few, however, which are difficult to explain in these ways. DRIED MILK In view of the increasing use which is being made of dried milk, it seemed distinctly worth while to determine whether milk necessarily loses its antiscorbutic power in the course of drying. In their work on animal scurvy, Chick and Hume27 employed dried milk as a part of their routine diet, as providing a well balanced ration which was devoid of the antiscorbutic factor. The milk which they used had been heated to 120 C. for an hour. It would be a mistake to infer from these experiments that all dried milk must he regarded as inert in this particular, for milk may be desiccated at a lower temperature, and one sustained for a much shorter period. We have tested a brand of dried milk which has been heated to about 116 C. for about one minute, and found that when it was given to the guinea-pig to the equivalent of 80 c.c. of fresh milk, it was able to cure scurvy. These experiments will be reported in detail elsewhere in connection with guinea-pig scurvy. We have had an opportunity, however, of testing this milk in two cases of human scurvy. The babies showed the typical signs of scurvy— peridental hemorrhage, tenderness of the femora, and the milder symptoms which we have heretofore enumerated. When the diet of the one child was changed from malt soup to 4 ounces of dried milk diluted with a quart of water, there occurred distinct improve¬ ment in all the scorbutic signs and in the general condition. In the other case the malt soup was replaced by the same quantity of dried milk solution (1 quart), to which, however, malt, flour and potassium chlorate were added according to the previous formula. In this instance likewise a decided improvement in the scorbutic signs occurred—the hemorrhages of the gums disappeared, the child soon began to stand, and her temperament became happier. It may seem that this result runs contrary to all that we know of the antiscorbutic "vitamin" and its sensitiveness to destruction by heat. We must remember, however, that there are many factors which determine whether or not heat shall bring about destruction of "vit¬ amin." For example, it was found that orange juice can be boiled for a period of at least ten minutes and lose vary little of its anti¬ scorbutic value.1 Recently Harden, Zilva and Still28 have shown that lemon juice may be reduced almost to the dry state and still retain its power. This resistance has been attributed to its acid reac¬ tion. We know, however, that cabbage may be dried and still retain 27. Chick, H., and Hume, E.: Tr. Soc. Trop. Med. and Hyg. 10:141, 1917. 28. Harden, A.; Zilva, S., and Still, G. F.: Lancet London 1:17, 1919. Downloaded From: http://archpedi.jamanetwork.com/ by a University of Calgary User on 05/27/2015 a large amount of its antiscorbutic quality ; this has been demon¬ strated by Hoist29 and recently proved by Givens and Cohen.30 In this instance the acid reaction cannot be regarded as the pro¬ tective influence. In the case of this dried milk we must bear in mind that it possessed a comparatively high degree of antiscorbutic power at the time of drying, which was carried out within six hours of the milking. Shortness of subjection to heat and rapidity of des¬ iccation occasion a minimum degree of destruction. In connection with the effect of aging, of alkalinization, of heating and probably of other agencies deleterious to this "vitamin," the length of time to which it is subjected to the injurious environment is in general more important than the intensity of the process. The recent pronouncement of the Food (War) Committee of the Royal Society31 that the scurvy "vitamin is deficient in all dried and preserved foods" is evidently too sweeping. We shall see later that this criticism applies also in regard to a preserved food. The fact that dried milk may largely retain its antiscorbutic value is of interest as indicating how little the milk has been changed from a biologic point of view, and therefore is important from a dietetic standpoint. It should be remembered, however, that milk heated for a long period in the course of drying loses much or all of its protective value, and furthermore, that our experience has not embraced the question of whether dried milk undergoes gradual changes in the course of a period of -many months. Babies fed on pasteurized milk must have additional antiscorbutic food in their dietary. This does not mean that human milk con¬ tains more of the antiscorbutic "vitamin" than does cow's milk, but merely that the attending circumstances render the latter less valuable in this regard. The fact that cow's milk is pasteurized or boiled, that it is not perfectly fresh and has undergone considerable handling, that it is diluted and cannot be given in full strength, all contribute to decrease its antiscorbutic potency.32 29. Holst, A., and Froelich, T.: Norsk. Mag. f. Laegevidensk. 8:989, 1916. 30. Givens, M. H., and Cohen, B.: J. Biol. Chem. 36:127, 1918. 31. Food Committee, Royal Society: Lancet, London 2:756, 1918. 32. It is not possible to say exactly how much raw milk a baby needs to protect it against the development of scurvy. We may, however, reach an approximate estimation of this figure. We know that it takes about 2 c.c. of orange juice to protect a guinea-pig against manifest scurvy, and about 10 c.c. to protect a baby. The ratio, therefore, between the guinea-pig and the infant in this regard would seem to be about 5 to 1. We also know that it takes about 80 to 100 c.c. daily of fresh cow's milk to protect a guinea-pig for long periods. If we assume the ratio of 5 to 1, it would therefore seem that it would require about 500 c.c., or a pint, of fresh raw milk daily as a minimum to protect the baby. (It is quite possible that a slight negative balance of the vitamin may exist unless a still greater amount is given.) Downloaded From: http://archpedi.jamanetwork.com/ by a University of Calgary User on 05/27/2015 This raises the question as to just when the antiscorbutic diet should be introduced; at what age it should be added to the dietary of the bottle-fed infants. In point of fact this question is asking merely in an indirect way how long it is wise to allow a negative balance of scurvy "vitamin" to persist. Stated in this form it would seem that the answer must be that this deficiency should be allowed for as short a time as possible. In our experience there is no contra¬ indication whatever to giving a baby orange juice (or canned tomato) when it is a few weeks of age. FRUITS Orange juice must be regarded as the prototype of antiscorbutics. As far as we know, it shares with lemon juice the distinction of being the most potent food in this respect. It would be of no avail, in the present state of our knowledge, to consider in detail the nature and basis of this potency. There are some results, how¬ ever, brought out by recent investigations which should be borne in mind. It has been shown that orange juice preserves its pecu¬ liar efficacy after it has been subjected to boiling for a period of ten minutes; that the active factor may be extracted by means of alcohol;33 that it is not destroyed even though the juice be evapo¬ rated almost to dryness, and finally, that the orange juice seems to have lost none or little of its efficacy after it has been deprived of the free citric acid and other acids.34 Recently it has been stated by McCollum and Pitz35 that the antiscorbutic power of orange juice resides in its salt constituents ; that a solution containing these salts in a proportion similar to that in the natural juice will possess the same therapeutic quality. In a previous article we have shown this not to have been our experience in the scurvy of guinea-pigs,33 and have referred elsewhere to the fact that a preparation of this kind failed to cure the scurvy of infants. In one case (baby Margolis) 1 ounce of this "artificial orange juice" was given for a period of eighteen days. This baby had a pulse ranging from 164 to 196. The addition of this solution to the dietary did not increase the appetite or alleviate the symptoms in any way, nor did it act as a laxative. The sole effect which was observed was a diuretic action. In another case, which will be referred to later in connection with intravenous therapy, this treatment in the same dosage was con¬ tinued for ten days and was then discontinued, as there was no beneficial result. We feel, therefore, that the value of orange juice 33. Hess, A. F., and Unger L.: J. Biol. Chem. 35:487, 1918. 34. Harden, A., and Zilva, S.: Biochem. J. 12:259, 1918. 35. McCollum, E. V., and Pitz, W.: J. Biol. Chem. 31:229, 1917. Downloaded From: http://archpedi.jamanetwork.com/ by a University of Calgary User on 05/27/2015 Some have encouraged the wide use of dehydrated vegetables, claiming that they have all the properties of fresh food. Recently Murlin44 has urged an extended use of this product, stating that "by simply soaking in water and boiling in the same water these vegetables are brought back to the condition of fresh vegetables." In a general review of this subject, published not long ago,1 we said that such had not been our experience and cited reports taken from the medical histories of our Civil War and other wars, where the dependence of troops on dehydrated vegetables led to the develop¬ ment of scurvy. In view of the increasing importance of this sub¬ ject, it may be well to give our experience in two cases: In one instance increasing amounts of dehydrated vegetables were given daily, equivalent to 1, 2, 3 and 6 ounces of fresh carrots for a period of six weeks, without alleviating the scorbutic signs. When the amount of fresh carrots was substituted, all signs disappeared in the course of twelve days. In another case the same lot of dehydrated carrots was given to the equivalent of 8 ounces a day, but here also there was no therapeutic effect, and when an equal amount of fresh carrots was substituted, the signs disap¬ peared within two weeks. An attempt to prevent the loss of the "vitamin" by immersing the carrots in a weak solution of citric acid previous to their dehydra¬ tion was unsuccessful. Our experience with animals coincides with these clinical tests. We do not wish to draw the inference from these results that the dehydrating process, as such, destroys the "vitamin" but merely that in the vegetables employed, which were of excellent appearance and flavor,45 the "vitamin" had been almost entirely lost. It is quite possible, indeed probable, that the method of preparing dehydrated vegetables will be perfected so that a product can be furnished which will be comparable in nutritional value to the fresh vegetable. Some unpublished animal experiments have shown that when carrots are dehydrated only a few hours after they are plucked, they retain considerable of their pristine antiscorbutic "vitamin." The problem seems to be one, therefore, that is open to solution. The question of the degree of heating, which is generally regarded as of prime importance, appears to be merely one of several factors. Ideal conditions for furnishing dehydrated vegetables include the use of young vegetables, dehydrating these shortly after they are plucked, keeping them well sealed until they are ready to be eaten, and probably numerous other details which must be carefully observed if dete¬ rioration is to be prevented.46 44. Murlin, J. R.: Boston M. & S. J. 179:395, 1918. 45. These carrots were prepared and kindly furnished by the Mrs. Oliver Harriman Food Research Laboratory of this city. 46. It is worth considering in this connection whether the date of the dehydration should not be stated on the package of these foods. Downloaded From: http://archpedi.jamanetwork.com/ by a University of Calgary User on 05/27/2015 CANNED TOMATOES For some time we have been looking about for an antiscorbutic which is less expensive than orange juice. In a previous publication it has been shown that a decoction of grated orange peel serves this purpose. This, however, also was not economical, so that for almost a year canned tomatoes have been employed as a substitute in the infant asylum with which we are connected. Tomatoes are not in good repute among food experts in view of the small amount of calories which they contain—only about 100 to the pound—and are regarded with suspicion amounting almost to superstition by mothers and nurses as a food for children. Although poor in calories they Chart 2.—Cure of scurvy by the addition of canned tomato. In this case, as frequently, the alleviation of symptoms preceded the gain in weight. are rich in organic acid, stated by some to be mainly citric acid, by others malic acid, and contain also some salicylic acid and traces of benzoic acid.47 It may be added, they are rich in "vitamin." Tomatoes undergo a two-fold heating in the course of canning, the second constituting the so-called "processing," during which the temperature is raised to about 230 F. The canned tomatoes were strained through a colander, warmed, and fed through a nursing bottle, one ounce daily being given to an infant a few months of age.48 This has been the routine for all infants, and in no instance has there been the least intestinal or nutritional disturbance. From the administrative point of view, this substitute has been valuable in 47. There is no relation whatever between the acidity of canned vegetables and their possible contamination with tin. Experiments carried out to determine this question demonstrated, for example, that a "sample of red kidney beans showing the highest acidity contained the least tin," and that those samples containing the most tin were all relatively low in acidity. (Report of Conn. Agric. Exper. Station Bull. 200, 1917. J. P. Street.) 48. These tests have been controlled by a long series of experiments on animals. Groups of guinea-pigs have been fed on a diet of hay, oats and water, with the addition of various amounts of canned tomato. It was found that 5 c.c. were sufficient invariably to protect a pig from the signs of scurvy. (Proc. Soc. Exp. Biol. & Med. 15:96, 1918.) Downloaded From: http://archpedi.jamanetwork.com/ by a University of Calgary User on 05/27/2015 saving some hundreds of dollars to the institution. Babies tolerate these tomatoes exceedingly well; in some cases, indeed, the daily amount was increased to 4, 6 and 8 ounces without causing the least untoward symptom. There need be no hesitation in giving a teaspoonful of tomatoes to an infant a few weeks of age, as its acidity is only about one half that of orange juice. They may be boiled, if this is preferred, although it is quite unnecessary; cooking reduces their potency only slightly. All the infants thrived satisfac¬ torily, many of them showing a gain greater than before tomato was substituted for orange juice. This may have been due to the fact that the former contains a considerable amount of water soluble "vitamin," which was demonstrated by means of curative tests on pigeons affected with polyneuritis. During the summer season toma¬ toes had to be used which had been canned almost a year previously. This aging, however, was noted not to have diminished appreciably their antiscorbutic value, probably on account of the acid reaction and method of preservation. We believe, therefore, that canned tomatoes can safely be recommended as an inexpensive and practical addition to the dietary of the bottle-fed infant. In this connection it should be added that canned tomatoes form part of the ration of the U. S. Army, in which they can be given "in lieu of an equal quantity of potatoes, not exceeding 20 per cent, of the total issue." We have been unable to ascertain through inquiries from the Surgeon-General's Office the nature of the expe¬ rience which led to their incorporation in the ration, and whether they were added specifically as an antiscorbutic. They appear for the first time in the revision of the Army Regulations of 1895. The only reference to the antiscorbutic property of canned tomatoes which we have been able to find in the literature is in the excellent treatise by Munson.49 That the necessity of including an antiscorbutic in the ration has been recognized only in recent years may be judged by the fact that during our Civil War, and for thirty years there¬ after, there was no such provision. It was stated at that time that "a general scorbutic taint pervaded the troops"—a mere euphemism for the widespread existence of subacute or latent scurvy. Even today the ration of the French and of the Italian armies makes no absolute provision in this regard, and the Russians provide merely for a variable quantity of vegetables. When we read that "during the Crimean War the temperature was never very low, and a report of the times suggests that the large number of congelations observed among the soldiers might well be regarded as gangrene owing to a scorbutic tendency exaggerated by the cold,"49 it seems quite possible 49. Munson, E. L.: Military Hygiene, New York, 1901. Downloaded From: http://archpedi.jamanetwork.com/ by a University of Calgary User on 05/27/2015 that this factor may have played a rôle in the congelations which occurred in such great numbers among the soldiers in the trenches during the great World War. In civil life, in framing dietaries for children and for adults, our minds are still focused on insuring a sufficient supply of calories in the food, and we have not yet reacted in practice to the newer knowledge that ample carbohydrates, fats and proteins may consti¬ tute a dangerously deficient diet. This same criticism holds true for experimental work on nutrition and on infection, much of which will have to be revised to conform to our broader conceptions of nutrition. SUMMARY Numerous reports show that during the late war there was con¬ siderable scurvy among the troops of the various armies ; least of all along the Western front. The scurvy was mainly of the latent or subacute variety and influenced the character of some of the infec¬ tious diseases, and may well have been a factor in the congelations occurring among the soldiers in the trenches. It is evident also that scurvy prevailed among the civilian population to a degree far greater than in peace times. In infants the question of scurvy centers about the milk supply. An infant requires fully 1 pint of fresh raw milk daily to protect it from this disorder. If the milk is pasteurized, or stale, or heated for a second time, or rendered more sensitive to deterioration by means of an alkali—and particularly if more than one of these influ¬ ences are operative—more than a pint is needed. The fact that there is an inverse relationship between the amount of milk consumed and the tendency to scurvy shows that we are not dealing with an exogenous toxin and argues in favor of the disorder being primarily a deficiency disease. Milk does not necessarily lose its antiscorbutic value in the course of drying. If it is dried rapidly even at a temperature of about 240 F. it retains sufficient of the protective factor to have curative value, provided, naturally, that it was fresh at the time of drying. In considering the question of destruction of this "vitamin" by heat or by alkali, the duration of exposure to the detrimental influence is of the greatest importance. Babies fed on pasteurized milk should receive an antiscorbutic from the time they are a few weeks of age, as there is no reason for allowing the negative balance of "vitamin" to continue for a longer period. A small amount of orange juice will answer the purpose, and is potent for a period after alkalinization. Its value does not reside in its laxative properties, nor in its salt content, as "artificial orange juice" has practically no therapeutic effect. Downloaded From: http://archpedi.jamanetwork.com/ by a University of Calgary User on 05/27/2015 If orange juice is filtered, boiled, and rendered faintly alkaline it may be given intravenously without causing any slightly untoward reaction. In this way a very prompt cure can be accomplished. From a pathogenetic viewpoint a result obtained by this route is of interest as demonstrating that scurvy can be counteracted by a therapy acting quite apart from the alimentary tract. Diuresis and catharsis do not play an important rôle in the cure of scurvy, as they may be stimulated to a high degree without alleviating the symptoms. This fact argues against regarding this disorder as essentially toxic in nature. It was found also that giving an antiseptic (sodium benzoate) was without effect. Dehydrated vegetables were ineffective in two instances in which an equivalent amount of fresh vegetable brought about a cure. It is not to be inferred from this result that dehydration necessarily destroys this "vitamin." In this connection too much attention has been paid to the degree of the heating process, and too little to the more impor¬ tant factors—the age of the vegetables, their freshness previous to dehydration, their manner of preservation, etc. For almost a year strained canned tomatoes have been given, in place of orange juice, to a large number of infants. This sub¬ stitute has been found a very effective antiscorbutic, and is well borne by babies a few weeks of age. It has the advantage of low cost and availability, and therefore is of particular value for the infants of the poor. Downloaded From: http://archpedi.jamanetwork.com/ by a University of Calgary User on 05/27/2015