The Pathogenesis of Deficiency Disease. III. The Influence of Dietaries Deficient in Accessory Food Factors on the Intestine

THE. PATHOGENESIS OF DEFICIENCY DISEASE. No. III. THE INFLUENCE OF DIETARIES DEFICIENT IN ACCESSORY FOOD FACTORS ON THE INTESTINE. BY ROBERT AloCARRISON, az.n., D.Sc., F.R.c.P., Brevet-Lieutenant-Colonel, Indian Medical Service. (Pasteur Institute of S. India, Coonoor.) EReeeived for publication, June I, 1919.1' Tim patbological changes in the intestine which result from dietaries deficient in accessory food factors have been studied in: (I) pigeons fed exclusively on autoclaved milled rice: that is to say, on food lacking in all three classes of accessory food factors; (2) pigeons fed on autoclaved rice together with fresh butter and onions : that is to say, on food deficient in accessory food, factors of the ` B ' class ; (3) pigeons fed on autoclaved rice together with fresh butter that is to say, on food deficient in accessory food factors of the ` C' class (anti-scorbutic substances), as well as in factors of the '13 ' class (the so-called 'anti-neuritic vitamines ') ; (4) guinea-pigs fed on a diet of crushed oats and autoclaved milk: that is to say, on food deficient in anti-scorbutic substances; and ; ( 167 ) subito e.V. licensed customer copy supplied and printed for Helsinki University Main Library (SL103X00759E) 168  The Pathogenesis of Deficiency Disease. (5) guinea-pigs fed on an exclusive diet of autoclaved rice : that is to say, on food deficient in all three classes of accessory food factors. While the morbid changes resulting from these dietaries are attributable in the main to deficiency of accessory food factors, their genesis is no doubt contributed to, or their effects enhanced, by deficiency of other essential attributes of a satisfactorily balanced ration. All experiments were carried out under conditions and precautions previously detailed(1) : they were continued to a point at which death of the animals occurred or was about to occur. I. THE EFFECTS OF AN AUTOCLAVED RICE DIETARY ON THE INTESTINE OF PIGEONS. The pathological changes were studied macroscopically in 152 pigeons fed exclusively on milled or on autoclaved milled rice, and microscopically in 24. All these birds developed polyneuritis gallinarurrz , in consequence of the deficient dietary. A.---Macroscopical Appearances. The chief macroscopical features observed at autopsy in the intestine were atrophy and congestion, both of which might be extreme. All cases presented atrophy in greater or lesser degree, while a proportion, estimated at about 30 per cent, shoved no congestions appreciable by the naked eye. The upper portion of the intestine of healthy pigeons, especially that part embracing the pancreas, is thick and muscular (Fig. 6). It is this,'portion which suffers most in consequence of the deficient dietary. The atrophy is of all grades of severity '; it may be comparatively slight, or progress to a point at which the intestinal walls are so thin as to be transparent. As a rule the atrophy is more marked; the longer the bird, is under the influence of the defective diet. The congestion is commonly confined to the upper part of the alimentary tract ; less often it involves its whole extent. The branches of the mesenteric vessels surrounding the bowel may be greatly engorged, and extravasations of blood are occasionally to be seen under its scrolls coat. subito e.V. licensed customer copy supplied and printed for Helsinki University Main Library (SL103X00759E) Robert McCarrison.  175 The atrophy of the bowel, although often considerable, was usually less marked than in cases dying in consequence of complete ` vitaminie' starvation. Histologically one did not, as a rule, encounter the same degree of congestion : actuaI heemorrhages were more rarely met with, while the degree of atrophy of the myenteron and of the elements of the mucous membrane, although usually considerable, were often comparatively slight. Two cases were encountered amongst twelve examined where bacterial infection of the bowel walls had assisted in bringing about changes as pronounced as those so commonly seen in the case of birds wholly deprived of accessory food factors. Fresh butter and onions when added to a dietary of autoclaved rice thus provide some at Ieast of those factors on which the functional perfection of the alimentary tract is dependent. III. THE EFFECTS OF .A. DIETARY OF AUTOCLAVED RICE AND BUTTER ON THE INTESTINE OF PIGEONS. The effects of this dietary, which is deficient in ` vitamin,es' of the ` B' anal ` C' classes and gives rise to typical polyneuritis, were studied macroscopically in eighteen cases and microscopically in six. The description given of the effects of complete ` vitaminic' starvation applies to these cases. The butter used afforded the birds no protection in so far as the intestines were concerned. Figs. 6-9 typify the appearances seen. With the reservation that the number of birds in this category is small in comparison with those in the, two previous categories, one is led to suspect that, since butter did not protect, it was the addition of fresh onions to the basal diet of autoclaved rice that afforded the birds in the second, category the measure of protection against congestive and hemorrhagic processes which they undoubtedly enjoyed. In order to provide further evidence on this point, the appearances presented by the intestines of guinea-pigs fed, on dietaries (a) of crushed oats and autoclaved milk, and (b) of autoclaved rice,. were studied. IV, TITS EFFECTS OF A SCORBUTIC DIET ON THE INTESTINE OF GUINEA-PIGS. Twelve guinea-pigs, with an equal number of controls, were employed in this experiment. The animals were isolated in separate cages. They subito e.V. licensed customer copy supplied and printed for Helsinki University Main Library (SL103X00759E) 1.76  The Pathogenesis of Deficiency Disease. were fed on crush ecl oats and autoclaved milk. The oats were locally grown and were of poor quality. The mill-, was autoclaved at a temperature of 130°C. for one hour. The experiment was continued to the death of the pigs, which occurred within periods ranging from twenty to thi - rty clays. Autopsies were performed immediately after death wi111 11e , detail and precautions previously described(1). Three of twOve guinea-pigs were excluded owing to the presence of complicating patUlogical processes, such as peritonitis. The macroscopical appearances found - in the gastro-intestinal tract were studied in nine cases ; the microscopical , in five. A.---Maeroscopical Appearances. The most notable feature present was intense congestion, of the duodenum. This part of the bowel, for a variable distance from the pylorus, was in four out of nine cases so congested as almost to present the appearances seen in strangulated bowel. The congested area was sharply demarcated by the pylorus and extended down the bowel for a distance of from one to two inches. In two other cases the congestion of the duodenum was of a patchy character. In the three remaining cases moderate congestion of the whole bowel was present in two, while no appreciable congestion was present in the third. In contradistinction to the appearances presented by the upper intestine of pigeons, where the bowel is often greatly thinned, the duodenum of guinea-pigs was usually swollen and turgid, the tumefaction being due largely to haamorrbagic infiltration of all coats of the bowel. On opening the duodenum and examining the mucous surface with the hand-lens, ecchymoses were frequently to be seen, while areas resembling punched-out ulcers, whose base extended almost to the peritoneal coat, were occasionally encountered. At these areas the bowel walls were almost transparent. _  The intestinal tract is thin in healthy guinea-pigs. Apart from the duodenum, the bowel walls in pigs dying in consequence of the deficient dietary were, generally speaking, thinner than in health. In three cases of the nine referred, to, punched-out necrotic ulcers were found in the stomach. In one case as many as fifteen were counted, the base of the ulcer extending down to the peritoneal coat, the mucous membrane of the stomach being studded with the brownish debris of hmmorrhages into the interior of the organ.. s Thus localized, destructive changes in the subito e.V. licensed customer copy supplied and printed for Helsinki University Main Library (SL103X00759E) G - PLA.TE IX, Fig. 13. Fig. 15. Fig. 14, Fig. 16. RoS&RT i1NIOCARRISON. —The Pathogenesis of Deficiency Dis ease. No. III. subito e.V. licensed customer copy supplied and printed for Helsinki University Main Library (SL103X00759E) VjG. 13. Section. of (Juo4"um of guinea-pig dying in consequence of a scorbutic diet of crushed oats and, autoclaved milk, X 105. Nate : large degenerated and swollen ganglion (G) of myenteric plexus with a, number of blood corpuscles scattered tbrougb it and through the disorganized eircular layer (H) of the muscular: coat. Compare with Fig. 12. FIG. 11. Section of upper bowel of guinea-pig, X 50 ; shorting the normal Appearances in liealtb. FIG. 15. Sestion of upper bowel of guinea-pig (No. 1) ivbicb died as a result of a crushed oats and autoclaved milk dietary, X 50. Note : turgidity of bowel walls duo to diffuse bwmorrbagic infiltration Of all coats; loss of villas-structure. Compare witb Fig. 20, which is a bigher mmaragnification o; a portion of this specimen. FIG. 1.6. Section of upper bowel of guinea-pig (No. 5) ,vbicb (lied as a result of a crushed oats and aaitm.laved milk dietary, h 50. Note : generalized atrophic and necrotic changes in the mucous, tnerabrane. The muaeular coat shows some bwInoxrh:agic infiltratioaa. Compare with Fig. 18, wbicic is a l,Ibhex njtc;mif'icatiou of a portiou of this speoimez) @ subito e.V. licensed customer copy supplied and printed for Helsinki University Main Library (SL103X00759E) Robert NeCarrison.  177 mucus and underlying coats of the stomach and duodenum are amongst the more occasional results in guinea-pigs of a dietary of crushed oats and autoclaved milk. These changes were present in the g a stro -intestinal tract of guinea-pigs, dying in consequence of this dietary, which exhibited none of the characteristic naked, eye appearances of scurvy. In a clinical sense then they may be regarded as pre-scorbutic. B.---Ilisto-Pathology. The microscopical appearances seen in sections of the duodenum in these cases comprised, (1) turgidity, with diffuse heemorrhagic infiltration of all coats of the bowel; (2) degenerative changes in the myenteron (3) degenerative changes in the myenteric plexus; and (4) atrophic and necrotic changes in the cellular elements of the mucous membrane. These lesions resemble closely those described in the case of pigeons fed, on an exclusive dietary of autoclaved. rice. In general the same description applies to both. In the case of guinea-pigs the more diffuse haemorrhagic infiltration of the mucous membrane may impart to it a degree of turgidity which is not seen in pigeons (Figs. 14 and 15). The degenerative process involves the ganglia of the myenteric plexus in a manner similar to that described in pigeons. In some cases, more especially in the vicinity of extensive haemorrbagic infiltration of the myenteron, the normal bistological structure of the ganglia may be mucb altered. In these circumstances, ganglia may be encountered whicb are infiltrated with blood, and in, which no single cell contains a normal nucleus. As in the case of diseased pigeons so also in guinea-pigs, the myenteric plexus is much more prominent than in health. In hcematoxylin-stained sections the ganglia appear swollen, the nerve cells ill-defined, the nuclei degenerated, and the nucleolus fragmented. Not all cells, however, are so affected in either species, some exhibiting nuclei o f apparently normal structure. Widout definitely asserting that the degenerative changes in the myenteric plexus are more pronounced in guinea-pigs th a n in pigeons, they certainly appear to be no less. There can be little doubt _that neural lesions (Fig. 13), which may impair the nervous control of the boNvel, result in consequence of J MR  12 subito e.V. licensed customer copy supplied and printed for Helsinki University Main Library (SL103X00759E) 178  The Pathogenesis of .Defccienq Disease. this dietary ; faxther bistological study by special methods is necessary to determine their character. The nLve.nteron also is often, although not always, greatly clisotganized in consequence of diffuse b~ . emorrhagic infiltration of its ; in such circumstances separation of muscular fibres with t etr segmentation and fragmentation, are common appearances (F+igs. 19 and 24). The degenerative and necrotic changes in the mucous membrax,e are as pronounced in guinea-pigs as in pigeons, and are of similar character, (compare Figs. 3, 18, 19, and 20). The same comments as to the facilities which these pathological processes afford for infection of the bowel walls and for systemic infection, therefrom, apply with equal force to both species. The histological changes in the lower bowel are of like character to those found in the upper bowel, but more moderate in degree. The histo-pathological eb anges found in, guinea-pigs axe illustrated in the series of photo-micrographs numbered 13 to 20. If these are contrasted with Figs. 1 to 12, wbieb illustrate the bistopathologi.cal changes found in Aves, their similarity will become very apparent. V. THE E FFECTS OF AN AUTOCLAVED RICE D IETARY ON THE I NTESTINE OF GUINEA-PIGS. For the purpose of this study, four guinea-pigs were employed. They were fed on an, exclusive diet of autoclaved rice until death occurred, which event took place within 46 days of the initiation of the experiment. My post-mortem notes with regard to the intestinal tract in these animals read as follows :-- No. 1. The duodenum shows intense congestion,, the first ineb-and.- a-half looks almost gangrenous, so intense is the congestive process there is a well-marked ulcer at one, point, its base extending to the peritoneal coat, . so that only the serous covering appears to intervene between the bowel lumen and the abdominal cavity. Both small and large bowel are Icongested, while they appear thinner than in health. No. 2. Perhaps the most interesting pathological appearance is that presented by the duodenum. This part of the bowel is mach congested, its vessels. being_greatly engorged ; two b wmorrbagic areas of subito e.V. licensed customer copy supplied and printed for Helsinki University Main Library (SL103XO0759E) Fim. 17, Section of iutzootts membrane of upper hovel of heAltby guineapig showing the normal appeaa:ance of the -lands ~xid villi, X 105. FTr,. 18, 8eetian of niocous nienibra-ne of upper boN el of guinea-pig (No. 5) which died as a resiilt of a cruslied oats and autoclaved drill: dietary, X 105. N oto : atrophy and degeneration Of secrettoryi eloments. Compaic with Fig. 1.7. ection of upper bowel of guinea-pig (No. 3) which died as a result of a crushed oats and autoclaved mmilldietary, x 105. Note : degenerative ebanges in mucous membrane (N) ; extensive I)mmorrha;ic infiltration (H) ; diffuse htemorrbagic infiltration witli segmei tation and fragmentation of muscle fibres of ni,yentero-n (A).. Compare with Fig. 3. FiG. 20. Section of upper bowel of guinea -pia (No. 4) which died as a result of a die.tary of crushed oats and autoclaved milk, X 10 5 5, Note: degenerative changes iii mucous - membrane (1VT) and diffuse Iitomorrhagic infiltration of rausett)ar coat (A). Se g . mentation and, fragme - VtAtiwi of musele fibres. Corapaare Wit;it F 0, 3. 17 subito e.V. licensed customer copy supplied and printed for Helsinki University Main Library (SL103X00759E) 184  The Pathogenesis of Deficiency Disease. by Professor Keith, are strikingly similar to those I have enumerated as occurring in pigeons fed on a ` vitamine'-free food. He describes the morbid changes as affecting two systems—the glandular and the neuron usci lar : ` The chief change in the muscular coats of the diseased great bowels removed from cases of enterostasis is a fibrosis---one which mainly affects the tissue between the outer and inner coats of the bowel, the intermediate stratum which insheathes the myenteric plexus. Degeneration in areas of the musculature, particularly of the outer longitudinal coat, also occurs. In, every case there are inflammatory changes varying in degree. There are many marked changes in tb e lining glandular epithelium and in the submucous coat. One notes also that there is engorgement of the subperitoneal vessels, and that the subperitoneal tissue is much thicker and denser than is normal.' Having regard to the fact that the pathological processes I have described are acute in nature, and induced by intensive `vit.aminic' deprivation, whereastbose recorded by Professor Keith are chronic, the similarity between them suggests that sub-minimal ` vitaminic ' supply protracted from an early age has a fundamental influence in causing the lesions found in stasis. However this may be, we must regard with suspicion an influence which is capable of providing at once the anatomical conditions necessary for the development of stasis and the facilities for systemic infections which are known to result from it. OBSERVATIONS ON THE EFFECTS OF ' VITAMINIC ' SUBSTANCES AS CURATIVE .AGENTS IN ' POLYNEURITIS G &LLINARUM.' In the course of the present research, many observations have been made with regard to the curative action of `vitaminic' extracts, and also of such whole grains as many dal in the morbid state induced in pigeons by an exclusive dietary of autoclaved rice. Since these therapeutic trials bring into prominence certain points of interest, the following illustration may be given ; Two young pigeons developed polyneuritis gallinarum in typical .form and in severe degree as a result of an exclusive diet of autoclaved rice and butter. Both birds presented pronounced cerebellar symptoms ;and astasia ; both had severe convulsive ,seizures turning ` cart-wheels' backwards at frequent intervals(I). At this stage, the birds were artificially fed with, the dry whole grains of mung dal (a species of pea). Within twenty-four hours the convulsions had ceased, the cerebellar subito e.V. licensed customer copy supplied and printed for Helsinki University Main Library (SL103)(00759E) Robert McCarrison.  185 symptoms had disappeared, and both birds were able to walk, although with a high-stepping and uncertain gait. They improved hourly on this dietary, both eating greedily of it. After. the lapse of seventy-two hours one died suddenly. An autopsy was performed immediately ; the whole gastro -intestinal tract was greatly engorged, the bowel walls were very thin and the upper four or five inches of the bowel distended with partly digested grain, the lower bowel being practically empty. It was noted that the contents of the upper bowel were not of that creamy consistency which is usual in health, but resembled rather a coarselyground collection of the ingested grain. The transport of the intestinal contents along the bowel lumen was delayed. Histological examination revealed pronounced changes in the bowel walls. The heart's blood yielded no growth by aerobic methods of culture. The other bird survived. It was placed subsequently on mixed grains, and with the exception of a high-stepping and somewhat unsteady gait it exhibited after four days no symptoms referable to the .nervous system. It appeared to be perfectly restored to health within ten days. In connexion with this illustration I. would direct attention to the following facts ; (1) The nervous symptoms present in polyneuritis gallinarum may be rapidly ameliorated, or even recovered from., and yet the bird die in consequence of gastro-intestinal lesions or (as I have found in other cases) of haemic infections. This observation, has, I think, a significant bearing on work designed to determine the ` vitaminic ' value of foodstuffs by means of curative experiments in pigeons suffering from polyneuritis gallinarum. (2) The rapid recovery from nervous symptoms indicates that the nervous system is, of all others, the least affected as regards organic lesions. In this system the symptoms are mainly the result of functional disorder. In the intestine, on the other hand, a greater destruction, of tissue cells takes place. The intestinal lesions will consequently be recovered from more slowly. (3) The remarkably rapid disappearance of convulsive seizures, of astasia and of cerebellar symptoms indicates that accessory food factors, if they do not actually activate or energize the nerve cells, at least they complete the  o circuit of nervous current. In their absence the large mass of nerve cells is incapable of normal activity; their provision establishes relatively normal cellular activity with dramatic suddenness, subito e.V. licensed customer copy supplied and printed for Helsinki University Main Library (SL103X00759E) 186  The .Pathogenes 's of Defi.c-lency Disease. Their action bas been compared by Bayliss to that of catalytic substances; my own experimental experiences lead me to a like view. (zt) Solutions of `vitaminic' substances (such for example as a solution in water of the dried alcoholic extract of the yolks of eggs) will, when administered to birds suffering from avian be:Gi -beri, often cause recovery to take place with extraordinary rapidity. In cases, such as are recorded in the above illustration, recovery from nervous symptoms was quickly brought about by artificial feeding with the small Indian pea known as mung dal. The question, then arises as to whether the liberation of accessory food factors from the dry hard seeds of mung dal, in quantity sufficient to bring about so rapid an amelioration of nervous symptoms, is wholly due to the ordered processes of digestion. It is hardly credible that a gastro-intestinal tract, in wbicb are present tb e grave. pathological ebangesl have described, could complete the processes of digestion witb sufficient despatch to secure so rapidly beneficial a result. Indeed, in the bird which died digestion was far from complete, the bowel contents were abnormally delayed in transit and histological examination revealed an extreme degree of patbological change in the bowel walls. One is led to surmise, therefore, that some process more rapid than that of digestion maybe concerned in the liberation, of these substances—a process comparable, it may be, to the generation, of growth ferments in seeds planted in warm moist earth, CONCLUSIONS. l..  Dietaries deficient in accessory food factors give rise in pigeons and in guinea-pigs to congestive and atrophic ebanges i n all coats of the bowel, to lesions of its neuro-muscular mechanism., to impairment of its digestive and assimilative functions, and to failure of its protective resources against infection. 2. The functional perfection of the gastro-intestinal tract is dependent in considerable measure on the adequate provision of accessory food factors derived from fresh fruit and vegetables. 3. Certain gastro-intestinal disorders in the human subject—of wbieb three examples are referred to—may owe their origin to the long-continued sub-minimal supply of accessory food factors. subito e.V. licensed customer copy supplied and printed for Helsinki University Main Library (SL103X00759E) Pobert McOarrison.  187 REFERENCES. 1. 2. MCCARRI$ON, R. MCCARRISON, R. Pathogenesis of Deficiency Disease, Ind. Jour. Xed. Research, 1919, VI, 3, pp. 275 -355. The Genesis of (Edema in Beri=beri, communicated to Roy. Soo., London, 27th March, 1919. 3. HAmmToN WRIGHT Quoted from Vedder's Beri-beri, London, 1913. 4. MCCARRISON, R. Pathogenesis of Deficiency Disease, II.  Ind.  Jour. Ned. Research., 1919, VI, 4. 5. PARK, F. S.  .. War (Edema.  Jour. Am..h2ed. Assoc., 1918, LXX, 24, pp.  1826-1827. 6. STILL, G. F.  .. Cceliac Disease. Lumleian Lectures.  Lancet, August 14, 17 and 24, 1918. 7. LANE, SIR W. ARBUTIINOT 'The  Operative Treatment  of. Chronic Intestinal Stasis,' London, 1918 (4th Edition). subito e.V. licensed customer copy supplied and printed for Helsinki University Main Library (SL103X00759E)