THE DISEASES REFERABLE TO FAULTY DIET, OR THE SO-CALLED " DEFICIENCY DISEASES"

THE DISEASES REFERABLE TO FAULTY DIET, OR THE SO-CALLED " DEFICIENCY DISEASES"

It has been pointed out that in the year 1911 Funk
took up the study of the disease beri-beri. He made
use of the observation of Eijkman, that the symp-
toms could be produced experimentally in birds by
feeding them exclusively upon polished rice for two
to four weeks, whereas birds remain for much longer
periods in a state of health when fed exclusively upon
the unpolished grain. He also made use of the ob-
servation of Fraser and Stanton, that an alcoholic
extract of rice polishings would effect a "cure" of
polyneuritic birds. Funk made numerous elaborate
and painstaking attempts to separate the "curative"
substance, and wrote extensively on what he believed
to be "deficiency" diseases. Under this term he
included beri-beri, scurvy, pellagra and rickets.
Hopkins discovered that small additions of milk
to food mixtures composed of purified protein,
carbohydrate, fats and inorganic salts, rendered them
capable of inducing growth, whereas without such
additions no growth could be secured. The effects
were out of all proportion to the energy, or protein
value of the added milk, and he suggested the exist-

83

84 THE NEWER KNOWLEDGE OF NUTRITION

ence of "accessory" food-stuffs, which are required
in but small amounts, and which are absent from the
mixtures of purified food-stuffs, which fail to promote
growth. To the supposed " curative' ' substances,
the presence of which in the diet prevents the develop-
ment of several syndromes enumerated, Funk gave
the collective name "vitamines." Thus he distin-
guished an antineuritic "vitamine," an antiscorbutic
"vitamine," etc. These supposed substances have
since been variously designated as "growth sub-
stances/ ' "growth determinants/ ' "food hormones/'
"accessory" food substances, etc.

McCollum and Davis through their studies with
diets of purified food-stuffs, pointed out that it was
highly probable that there are essential in the diet
but two substances rather than groups of substances
of unknown chemical nature, and it was shown, as
has been pointed out, that one of them is associated
with certain fats, while the other is never found with
the isolated fats of either animal or vegetable origin.
McCollum and Kennedy * suggested that they be
provisionally called fat-soluble A and water-soluble
B, because of their characteristic solubility in fats
and in water respectively.

The above terms, except the last two, are mis-
nomers. The word accessory, carries the idea that
the substances in question are dispensable. Con-
diments may be desirable, but they can be dispensed
with and are properly designated as accessory food
substances. An indispensable* food complex cannot

"DEFICIENCY" DISEASES 85

properly be designated by this term. "Vitamine"
is objectionable, because the prefix vita connotes an
importance of these dietary essentials greater than
other equally indispensable constituents of the diet,
such as certain of the amino-acids which play a r61e
in protein metabolism. The ending amine has a
definite and specific meaning in organic chemistry,
being used to designate a compound derived from
ammonia by the substitution of one or more of its
hydrogen atoms by various organic radicals. Any
substance to be properly designated as amine must
contain the element nitrogen. There is no evidence
that either of these unidentified dietary essentials
is an amine, and indeed fat-soluble A probably con-
tains no nitrogen, for it is especially abundant in
butter fat, and the latter is practically free from this
element.

"Food hormones" is an objectionable term, be-
cause all the evidence available indicates that both
the fat-soluble A and water-soluble B are never-
failing constituents of the cells of both animal and
plant tissues. They have nothing in common with
the hormones. The latter are chemical substances
which are formed in the body by special tissues and
contributed to the blood stream where they cause
the stimulation of certain other tissues to physiolog-
ical activity. They are chemical messengers, while
the substances under discussion are food complexes,
apparently necessary for all the living cells of the
body. It has been pointed out that the content of

86 THE NEWER KNOWLEDGE OF NUTRITION

both of these two dietary essentials appears to run
parallel to the content of cellular elements in the
food-stuffs, regardless of their source.

"Growth substances' ' and "growth determinants''
are not good terms for the reason that the substances
in question are just as essential for the maintenance
of a full grown animal in a state of health as they are
for the support of growth in the young. Further-
more, in actual experience, rations are found in
which the content of one or more essential amino-
acids are present in such amounts that they form
the limiting factor which determines the value of the
ration . It is easy to prepare a food mixture in which
any one of the eight or nine essential inorganic
elements which the diet must furnish, will be so low
as to prevent the growth of an animal even though
the food is otherwise of satisfactory character. In
one case the addition of a suitable sodium compound
or in another a calcium or a potassium salt might
induce growth, and these elements might, with just
as much propriety, be called "growth determinants"
as to apply this term to one of the still unidentified
food essentials. The term might fittingly be applied
to any of the indispensable components of the diet,
such as certain of the amino-acids, which result from
the digestion of the proteins.

All natural food-stuffs, such as the seeds of plants,
the leafy vegetables, fruits, roots, tubers, meats,
eggs and milk, contain certain amounts of all the
substances which are indispensable components of

"DEFICIENCY" DISEASES 87

the diet. There is, however, great variation in the
quality of the different foods with respect to the sev-
eral factors. Some contain much protein, others
little, and a similar variation with respect to other
constituents is found. The special properties of the
several groups of food-stuffs have been described in
Chapters III and IV.

The best sources of fat-soluble A are whole milk,
butter fat and egg yolk fats and the leaves of plants.
The seeds of plants contain less and those products
derived from the endosperm of the seed are very
poor in this substance. Such food-stuffs as bolted
flour, degerminated corn meal, polished rice, starch,
glucose and the sugars from milk, cane, and beet are
practically free from the fat-soluble A. The specific
result of a lack of a sufficient amount of this sub-
stance in the diet is the development of a condition
of the eyes which appears to be rightly classed as a
type of xerophthalmia. The eyes become swollen
so badly that they are opened with difficulty or not
at all. The cornea becomes inflamed, and unless
the missing dietary essential is supplied, blindness
speedily results. Osborne and Mendel 2 have also
noted this condition in experimental animals and
its relief by feeding butter fat. The introduction
into the diet of 5 or more per cent of butter fat
will cause prompt recovery in cases where the an-
imals are within a few days of death. Complete re-
covery takes place within two weeks if the sight has
not been destroyed. The normal condition of the

88 THE NEWER KNOWLEDGE OF NUTRITION

eyelids can be restored even after the sight is gone
and the cornea has faded.

When the diet consists principally of one of the
cereal grains such as the wheat, oat or corn kernel,
or even a mixture of these, and it is satisfactorily
supplemented with respect to the inorganic elements
in which they are deficient, viz., calcium, sodium
and chlorine, and their proteins are enhanced in
value by the addition of a protein of good quality,
animals restricted to such a food supply may long
escape the onset of this disease. The seeds are not
entirely lacking in the substance, fat-soluble A.
They contain, especially the wheat and corn kernels,
about half the amount required to maintain an
animal in a st^te of health. If the seeds or their
mixtures are supplemented with respect to but a
single dietary factor, e. g. inorganic salts, but the
protein content is left of relatively low biological
value, the debilitating effects of the low value of the
food mixture in the two dietary factors (protein and
fat-soluble A) simultaneously will hasten the onset
of xerophthalmia. 3 When judging the effects of the
diet on an animal, it is necessary to take into account
the fact that the diet is a complex thing, and that if
it is properly constituted with respect to all factors
hut one an animal may tolerate it without apparent
hether the fault lies in one or another of the
components. The value of one component
rell below that which will lead to serious mal-
when a second dietary factor is likewise poor.

"DEFICIENCY" DISEASES 89

The idea should not be entertained that butter
fat is the only food which supplies the fat-soluble A.
If the diet contains a liberal amount of milk, eggs,
glandular organs or the leaves of plants, it will, if
otherwise satisfactorily constituted, prevent the
onset of the eye disease. The seeds and seed prod-
ucts, such as wheat flour (bolted), degerminated
corn meal, polished rice, starch, the sugars, syrups,
tubers, roots, such as the radish, beet, carrot, turnip,
etc., and also the muscle tissue of animals, such as
bam, steak, chops, etc., do not contain enough of
the fat-soluble A to be classed as important sources
of this dietary essential. The tubers and roots
appear to be somewhat richer in it than are the
seeds. 4 In the form in which they are ordinarily
eaten, as mashed or baked potato, baked sweet
potato, fresh or creamed radish, cooked carrots,
beets or creamed turnips, the water content of the
dish as served is so high that the amount of solids
eaten is not a very high per cent of the total food
supply, and the protective action is correspondingly
limited. In America, however, potatoes are seldom
eaten without the addition of butter. The vegetable
fats and oils such as olive oil, cottonseed oil, peanut
and cocoanut oils, although good energy yielding
foods, do not furnish this dietary essential. The
body fats of animals such as lard, beef fat, etc., are
not important sources of the fat-soluble A.

McCollum and his co-workers have repeatedly
observed in experimental animals the type of xeroph-

90 THE NEWER KNOWLEDGE OF NUTRITION

thalmia of dietary origin which has been described
above. They have many times rescued animals
from the threshold of death by the addition of
butter fat to the diets of the animals which were
suffering from the disease which was brought about
by a lack of a sufficient amount of the fat-soluble A
in their food. It is important to inquire whether
or not this disease has ever occurred in man. It is
not easy to decide from the descriptions, in the clin-
ical literature, of the eye troubles of poorly nourished
peoples in various parts of the world, which are of
the peculiar type with which we are now dealing,
and which are due to other causes. Soreness of the
eyes is common among many primitive peoples.
Herdlika 5 describes severe eye troubles among the
American Indians of the southwest, and attributed
them to too great exposure to strong sunlight. In-
fection of the eyes is common among many peoples,
and the clinician, not being aware of the existence
of a pathological condition of the eyes due to faulty
diet, would, of course, be inclined to attribute such
conditions to other causes.

There are several instances of the occurrence of
conditions described in the literature as xerophthal-
mia, which seem to be beyond question, cases in
which the disease has occurred in man as the result
of specific starvation for the dietary essential, fat-
soluble A. Mori 6 in Japan described in 1904, four-
teen hundred cases of xerophthalmia among children
in a time of food shortage. He describes the condi-

"DEFICIENCY" DISEASES 91

tion in a manner which agrees closely with that which
McCollum and Simmon ds have observed in animals
whose diets were lacking in a sufficient amount of
fat-soluble A. The evidence that he was dealing
with this disease is made almost conclusive by the
fact that he states that feeding chicken livers effected
a cure. It has been already mentioned that the
glandular organs contain the fat-soluble A in fairly
liberal amounts. The Japanese have, as a rule, no
dairy products. Their diet consists of seeds and
seed products, roots, tubers, leaves and meats, prin-
cipally fish. Their principal sources of the dietary
factor in question are the leafy vegetable and eggs, the
former of which in normal times they consume much
larger amounts than do the peoples of most parts
of Europe and America. Shortage of food will occur
usually owing to drought, and the first products
which fail are the green vegetables, and accordingly
the dietary essential which would be least abundant
would be the fat-soluble A. Mori attributed the
xerophthalmia to fat starvation. It seems highly
probable, however, that a lack of fat was not in it-
self the cause of the disease, but rather the lack of
the unidentified dietary essential which is associated
with certain fats, but is not furnished by any of the
isolated fats of vegetable origin, although it is present
in plant tissues where these contain cellular struc-
tures. Mori states that the disease does not occur
among fisher folk.
Bloch 7 has recently described forty cases of severe

92 THE NEWER KNOWLEDGE OF NUTRITION

necrosis of the cornea with ulceration, in the vicinity
of Copenhagen. The children had been fed nearly
fat-free separator skim milk, and were atrophic or
dystrophic and anemic. He attributed the disorder
to fat starvation, since the children responded with
recovery when fed breast milk, or in the case of older
ones, with whole milk mixtures and to codliver oil
administration. The recovery, it will be noted,
followed the feeding of those substances which are
good sources of the fat-soluble A.

Czerny and Keller 8 describe a similar condition of
the eyes in children suffering from malnutrition as
the result of being restricted to a cereal diet.

It seems certain that these cases of xerophthalmia
should be looked upon as a " deficiency disease"
not hitherto recognized in its proper relation to diet.
It is not a fat starvation, but, if it be the same condi-
tion which McCollum and Simmonds have definitely
shown to be readily relieved in its early stages by
the administration of such foods as contain liberal
amounts of fat-soluble A, it would not be relieved
by feeding with vegetable fats in any amounts. Milk,
eggs, leafy vegetables and the glandular organs,
are the foods which serve to protect against a short-
age of this indispensable dietary component. This
type of xerophthalmia is analogous to beri-beri, in
that it is due to the lack of a specific substance in
the diet. Beri-beri and xerophthalmia are according
to McCollum and Simmonds, the only diseases refera-
ble to faulty diet, which are to be explained inthis way.

"DEFICIENCY" DISEASES 93

Beri-beri is a disease common in the Orient among
peoples who limit their diet largely to polished rice
and fish. It has, in recent years, been described in
Laborador owing to excessive consumption of bolted
flour, 9 and in Brazil among laborers whose diets were
of varied character, but not judiciously chosen. 10
Its most striking characteristic is a general paralysis,
and it is frequently referred to, especially when pro-
duced experimentally in animals, as polyneuritis.

The disease was first produced in animals by
Eijkman n in 1897. He discovered that when
pigeons and chickens were restricted to a diet of
polished rice, they steadily lost weight and in time
came to manifest all the essential symptoms char-
acteristic of beri-beri in man. In pigeons the disease
usually appears in two or three weeks. He found
that feeding rice polishings would produce a relief
of the symptoms. This result suggested that there
was lacking from polished rice, something which was
necessary for the maintenance of health in the bird,
and that that something was present in the rice
polishings:. This was the first experimental evidence
that there is necessary in the diet substances other
than proteins, carbohydrates, fats and inorganic salts.

The observations of Eijkman attracted but little
attention until Funk 12 took up the study of beri-
beri in 1910. Fraser and Stanton had, as early as
1907, employed alcoholic extracts of rice polishings
for the cure of experimental polyneuritis. Funk
made numerous studies directed toward the isolation

94 THE NEWER KNOWLEDGE OF NUTRITION

and study of the substance which exerts the curative
effect, and developed in his writings the well-known
*"vitamine" hypothesis. This hypothesis postulated
the existence of a similar protective substance for
each of the diseases scurvy, pellagra and rickets,
in addition to that which in the normal diets pro-
tects against beri-beri.

Funk had experimental evidence in support of his
theory only in the case of beri-beri. The evidence
that the other diseases which he included in the
category of " deficiency' ' diseases are due to the lack
of specific complexes, was of the nature of clinical
observations, rather than well controlled experiments.
The peculiar value of butter fat was unknown to
him, and he classed it among the food substances
which contain no "vitamine" because its administra-
tion to polyneuritic pigeons produced no beneficial
effects. 13 Funk deserves great credit for the evidence
which he secured that the amount of the substance
which can be extracted from rice polishings, which is
necessary to cause the relief of polyneuritis in a
pigeon, is exceedingly small. A few milligrams of
material which is still contaminated with impurities
suffices to bring about relief in a bird which is in a
helpless condition and within a few hours of death,
and to make it appear like a normal pigeon. The
effects seem to be out of all proportion to the amount
of substance administered. Funk's studies were con-
firmed and extended by the important work of
Williams. 14

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"DEFICIENCY" DISEASES 95

There can be no doubt that there are two " de-
ficiency' ' diseases in the sense in which Funk and
his school employed this term. One of these is
beri-beri and the other the type of xerophthalmia
which McCollum and Simmonds have pointed out
as occurring occasionally in man as the result of
faulty diet, and have demonstrated to be the
same condition which results in animals as the re-
sult of specific starvation for the unidentified di-
etary essential fat-soluble A. It is of the greatest
importance to determine whether scurvy, pellagra
and possibly rickets are likewise to be attributed to
the lack of similar substances of a specific nature in
the diet. It has already been mentioned in Chapter
II that from a knowledge of the dietary properties
of the oat kernel, McCollum and Pitz concluded
from a study of experimental scurvy in the guinea
pig, that this disease, while referable to faulty diet,
does not result from the absence of any special sub-
stance from the diet. The evidence upon which this
conclusion rests has been touched upon (page 36)
and will be next briefly considered.

The oat kernel, when submitted to the biological
method of analysis described in the first chapter, was
found to contain all the chemical elements and com-
plexes necessary for the promotion of growth and
health in a mammal, but not in suitable proportions.
Like other seeds it requires certain inorganic addi-
tions, and its content of the unidentified fat-soluble
A is entirely too small to permit of growth, or to

96 THE NEWER KNOWLEDGE OF NUTRITION

protect an animal against the eye disease, xeroph-
thalmia. In addition, its proteins are not com-
parable in value with those of such foods as milk,
eggs and meats. The important fact was demon-
strated by McCollum, Simmonds and Pitz, that
if the extracts of natural foods which we have long em-
ployed in our experimental work and which we desig-
nate water-soluble B, contain any physiologically in-
dispensable substance other than that which prevents
beri-beri, the oat kernel contains all of these. This
follows from the fact that they were able to induce
normal growth and prolonged well-being in animals
fed the oat kernel supplemented only with purified
food substances, — viz: protein and inorganic salts,
and a growth-promoting fat. The latter term
is used to designate a fat containing the fat-
soluble A.

McCollum and Pitz observed that the guinea pig
suffers from scurvy, not only when restricted to a
diet of oats, as stated by Hoist, but likewise when fed
oats and all the fresh milk it will consume. Jackson
and Moore 15 made this observation independently
and described it several months previous, in their
excellent studies of the bacteriology of the digestive
tract and tissues of the guinea pig, after the animals
have developed the disease as the result of an ex-
clusive oat and milk diet. Milk alone is a complete
food, and suffices for the maintenance of growth and
a good state of nutitrion in several species of animals,
such as the rat and swine. It cannot, therefore, be

"DEFICIENCY" DISEASES 97

lacking in any unidentified food substance. Why,
then, should the guinea pig suffer scurvy when re-
stricted to a diet of oats and milk?

McCollum and Pitz found in the guinea pigs which
had died of scurvy, that the cecum which is a very
large and very delicate pouch through which the
food must pass in going from the small to the large
intestine, was always packed with putrefying feces. 16
They decided that the mechanical difficulty which
the animals have in the removal of feces of an un-
favorable character from this part of the digestive
tract was in some way related with the development
of the disease. That this assumption was correct,
was shown by the fact that the administration of
liquid petrolatum, a "mineral" product to which no
food value can possibly be attributed, served to re-
lieve a certain number of animals after they were
near death from the disease, while confined strictly
to the diet of oats and milk which caused them to
develop scurvy. The explanation which they offered
was that the liquid petrolatum served to improve
the physical properties of the contents of the packed
cecum, and thus enable the animals to rid themselves
of this mass which was undergoing putrefactive de-
composition.

Further experiments showed that when the ani-
mals were fed an oat and milk diet, to which was
added suitable doses of phenolphthalein, a ca-
thartic, they could withstand the diet for long
periods without developing scurvy. This, accord-

98 THE NEWER KNOWLEDGE OF NUTRITION

ing to McCoJlum and Pitz, was due to the addi-
tional secretion of water into the digestive tract,
brought about by the cathartic, and resulted in
softening the feces so that they were more easily
eliminated from the cecum.

It has long been known that orange juice is a very
efficient protective agent against scurvy, both in man
and the guinea pig. In fact it was because of the
spectacular relief of the disease by the administration
of orange juice or of fresh vegetables, that Funk
was led to the belief that scurvy is, like beri-beri,
due to the lack of some specific chemical substance
from the food supply. McCollum and Pitz further
tested their theory by preparing an artificial orange
juice, in which every constituent was known, and
the administration of this to guinea pigs which were
confined to a diet of oats and milk, on which food
supply they almost invariably develop the disease.
The "artificial orange juice ,, consisted only of cit-
ric acid, cane sugar and inorganic salts, in about the
proportions in which these occur in the edible portion
of the orange. It was demonstrated that this mix-
ture exerted a decidedly protective action when added
to the oat and milk diet, and prevented the develop-
ment of scurvy over a long period.

Jackson and Moore suggested that scurvy is a
bacterial disease, and they have secured experimental
evidence which strongly supports that view. They
found in the hemorrhagic joints a diploccocus, which
may have a causal relationship to the disease. They

u

oniposition as shown by
protein which they con-
tains from the corn kernel
?oteins and gelatin. The
is solely the result of the
3orn proteins and gelatin
(See legend to Chart 8.

1

he rations of these two rats had the same
ilysis. They differed only in the source of th
rat on the right grew up on a mixture of pro
luten; that on the left on a mixture of com p
size, and remarkubli- ililTi-iviHw in appearance
the quality of the proteins in the two diets,
ement each other's amino-acid deficiencies.

Fig. 9.—1
chemical an
tained, Th
and wheat |
difference in
difference in
do not supp
Lots 651 an

"DEFICIENCY" DISEASES 99

were able to induce mild symptoms of scurvy by the
injection of bacterial cultures into animals which
were fed upon a diet which regularly maintains the
guinea pig in a state of health. McCollum and Pitz
hold the view that there may be an invasion of the
tissues by organisms as the result of injury to the
cecal wall, when the animals are debilitated. The
cecum is injuied by long contact with the irritating
products formed by putrefactive bacteria acting on
the protein substances contained in the cecum when
it becomes packed with feces of such a character
that they cannot be eliminated. They suggested the
alternative hypothesis that there may be formed
through bacterial activity, substances which are
toxic, and have such pharmacological proportion as
cause injury to the walls of the capillaries of those
areas in which hemorrhage is observed in scurvy.
There are several problems still to be solved in con-
nection with the cause of scurvy, but it seems to be
satisfactorily demonstrated that it is not a "de-
ficiency" disease in the sense in which are bori-bori
and the type of xerophthalmia of dietary orgin . There
is, according to McCollum and bis co-workers, no
protective substance against this disease. Diets of
faulty character, and especially bacfajriologieally un-
satisfactory, are responsible for its etiology, and it
is relieved by a satisfactory diet. The peculiar an/ir
tomical structure of the alimentary tract, of the
guinea pig makes it difficult for it to thrive unles*
its diet contains a succulent vegetable, which give*

100 THE NEWER KNOWLEDGE OF NUTRITION

the feces favorable physical characters and which
makes them easy of elimination.

Hess 17 has recently described the results of his
observations on infants which wer§ fed milk treated
in various ways, and these are of great significance
in throwing light on the cause of scurvy- He points
out that for a period of two years milk which had
been pasteurized commercially at 165° for thirty
minutes was employed in feeding the infan fcs in his
charge. For two subsequent years the dealers raised
it to only 145° for thirty minutes. In his experience
the former milk was more likely to induce scurvy
than the latter. Hess thereafter secured raw cer-
tified milk and pasteurized it at the institution for
thirty minutes at 145.° Infants fed this milk did not
develop scurvy in any instance, and one which
showed symptoms of subacute scurvy improved on
the home pasteurized milk. How did this milk differ
from the commercially pasteurized milk which did
show definite tendency to induce the disease? He
points out that it differed mainly in the interval
which elapsed between the time of the heating process
and the time of consumption of the milk. In New
York City, the greater portion of the bottled milk
sold is of Grade B, most of which is brought to the
city for pasteurization, which is done soon after mid-
night. Much of this is delivered to the consumer
the following morning, but a part is allowed to stand
until the following day before delivery. The city
milk of Grade A was largely pasteurized in the coun-

t(

DEFICIENCY" DISEASES 101

try, and since they stored the milk for twenty-four
hours after the heat treatment so as to insure a con-
stant supply in case of delay in the delivery from the
country, there was an interval of forty-eight hours
between the pasteurization and the delivery of the
milk to the consumer. Hess reproduced these con-
ditions in his institution by keeping milk pasteurized
at 145° for forty-eight hours on ice. Of eight in-
fants which were fed the milk so treated, two showed
scorbutic symptoms, which were relieved by giving
them orange juice. Two out of another eight which
were fed milk which was kept on ice forty-eight
hours after the heat treatment showed signs of
scurvy. In other cases scurvy was observed in
infants fed certified milk which had not been pas-
teurized, when the latter had been kept on the ice
forty-eight hours before feeding. Ageing is, therefore,
effective in causing changes in both raw and pasteur-
ized milk, so that the danger of the development
of scurvy in infants to which it is fed is increased.

Boiled milk has been extensively fed to infants in
various parts of the world and in the experience of
some observers does not induce scurvy. The expe-
rience of Hess further supports the view that boiled
milk Ls less liable to induce scurvy than is milk which
has been pasteurized at 165° or at a lower temper-
ature. Milk which has been pasteurized at 165° is
more liable to induce scurvy than either boiled milk,
or milk which has been pasteurized at lower temper-
atures, as 140-145° for thirty minutes. The most

102 THE NEWER KNOWLEDGE OF NUTRITION

satisfactory explanation for these results seems to be
found in the bacteriological condition of the milks
treated in the various ways described. Heating milk
at 165° kills nearly all the lactic acid forming bacteria
which normally cause the souring of milk. Heating
for thirty minutes at 140° to 145° leaves some of the
organisms capable of development, and milk so pas-
teurized will sour. In the absence of the acid formers
there develop during the interval between heating
and consumption the spore-forming organisms which
are not killed by pasteurization. These will, in time,
cause the putrefactive decomposition of the milk.
Any heat treatment which kills all the acid formers
leaves the milk in a suitable condition for the devel-
opment of the pernicious forms, and old milk so
treated may be a menace to the health of infants,
and unfit for consumption by adults. Boiling tends
to destroy all the organisms in milk and will do so
if sufficiently prolonged. Such milk may be more
suitable for food than that which has been so treated
as to prevent souring and yet be in a condition to
permit the growth of putrefactive forms of bacteria.
These results strongly support the view that there
is a bacteriological factor involved in the causation
of scurvy, and emphasizes the importance of securing
clean milk, and of having it so handled as to insure
its delivery in a good bacteriological condition.
Milk should not be kept in the home without efficient
refrigeration, and should be consumed before it
becomes stale. Pasteurization seems, in itself, to

"DEFICIENCY" DISEASES 103

have little influence in lowering the food value of
milk. The staleness is the great element of danger.
Pasteurization is desirable as a safeguard against
such diseases as typhoid fever, tuberculosis, scarlet
fever and such organisms as cause epidemics of sore
throat. It does not render milk permanently harm-
less. The public should insist upon having its milk
supply produced under hygienic conditions. Milk
should then be cooled promptly so as to depress as
far as possible the growth of the organisms which
always find entrance through the air and from the
cow and the milker. It should be carefully refrigeiv
ated, and promptly delivered and properly cared for
in the home, and should not be allowed to age un-
necessarily before use. If pasteurized, it should pref-
erably receive the lowest heat treatment which will
effectively destroy the pathogenic organisms, and
should be delivered as promptly as possible there-
after in a suitably cooled state. Stale milk is danger-
ous, especially for use in infant feeding.

Pellagra.— This disease has been common in parts
of Europe for centuries. It is especially common in
northern Italy, and has been sometimes referred to
as Alpine scurvy. It is likewise known in Spain and
and the south of France. The disease was first ob-
served in America in 1907, and has been steadily
on the increase, especially in certain of the Southern
States. In 1917 it was estimated that there were
165,000 pellagrins in the United States.

Pellagra is essentially a disease of poverty, al-

104 THE NEWER KNOWLEDGE OF NUTRITION

though there are many cases recorded among the
well-to-do. It has been especially prevalent in the
country, in villages, and in the poorer sections of
cities, and is observed to occur most frequently
following periods of scarcity of food. In Europe
the disease was long associated with the consumption
of spoiled maize as the chief article of diet, but it is
now known that the eating of this grain has nothing
whatever to do with its causation. All observers
are agreed that the diet is of primary import in the
etiology of the disease, but differences of opinion
still exist as to whether there is likewise a bacteri-
ological factor involved.

The trouble begins with digestive disturbances of
an indefinite character, followed by soreness of the
mouth, which renders eating difficult, and a per-
sistent diarrhea which saps the strength of the pa-
tient. Skin eruptions appear, and there are formed
on parts of the body dark crusts which sometimes
suppurate. In severe cases there are pronounced
nervous disturbances preceding death.

In its early stages pellagra yields fairly readily
to dietetic treatment. Indeed it has been emphasized
by clinicians that without dietary measures, there is
no effective treatment, and numerous cases are re-
corded in which the disease has disappeared promptly
when milk, eggs and meats, string beans, together
with a liberal amount of the leafy vegetables, such
as cabbage, collards, and lettuce, were included in
the diet. 18

"DEFICIENCY" DISEASES 105

In the United States, especially, pellagra tends to
seasonal occurrence, most new cases occurring in the
spring, or better, as Goldberger has emphasized,
at the end of winter. Jobling, in his excellent survey
of pellagra in Nashville, found that nearly all cases
had their onset in the spring and early summer. 19
It frequently happens that sufferers recover from
their attacks of the disease during the later summer
and fall, and suffer a relaspe during the following
spring. Indeed the diet of many of the poorer people
of the South, during the winter, consists principally
of corn bread, pork and molasses. From what has
been said in earlier chapters, it will be easily ap-
preciated that such a combination of food-stuffs does
not constitute an adequate diet, and it is significant
that nearly all new cases develop after a hundred
days or more of confinement to such a food supply.

It should be pointed out that Jobling and Peter-
son emphasize that from their observations the
pellagrins, and the class from which the new cases
develop, consume relatively much carbohydrate and
relatively little protein, since they make liberal use
of corn bread, corn grits, and potatoes and biscuits
made from bolted flour, together with molasses,
There were some who declared that they had regu-
larly eaten eggs, butter milk, milk and meat. They
further point out that in the spring, summer and
autumn months a great deal of green stuff in the
form of turnip tops, wild mustard, green peas (seed)
and green onions are eaten. The green onions are

106 THE NEWER KNOWLEDGE OF NUTRITION

eaten raw, the others cooked. In addition, during
the summer months much fruit, especially peaches
and apples, are eaten since these are usually cheap.

In commenting upon the studies of Goldberger,
Jobling and Peterson point out that the poorly nour-
ished individual is prone to contract many diseases
and their observation that there is a close relation-
ship between the sanitary condition of the different
parts of Nashville and the incidence of pellagra,
tends to strongly support the view that the disease
is associated with poor sewage disposal. The sani-
taiy conditions in those districts where pellagra is
common are of the worst sort, in many instances
there being little pretense made of doing anything
with the excreta, which during the summer is usually
covered with flies. Screening was usually absent
from those houses where the disease was found.
Jobling and Peterson are essentially in accord with
the conclusions of the Thompson-McFadden Com-
mission * which made a thorough investigation of
conditions in Spartanburg County, S. C, where
pellagra is a scourge, and arrived at the conclusion
that the disease is in some way related to a bacte-
riological factor, and is probably distributed by an
insect.

Golderger has accomplished a great work in demon-
strating that the diet, when properly constituted,
causes the disappearance of pellagra, and prevents
its recurrence. His dietary studies have demon-
strated beyond a reasonable doubt that a faulty

"DEFICIENCY" DISEASES 107

diet is the most important factor in causing the de-
velopment of the condition. . He has shown that
when liberal amounts of milk and eggs and of meat,
are introduced into the diet of institutions, such
as insane asylums and orphanages, in which the dis-
ease was previously common, they become free from
it even though new cases are admitted freely and
the sick are mingled with the well. He and his co-
workers have likewise made heroic attempts to
transmit the disease to themselves by means of the
administration of the excreta and material from the
lesions of pellagrins, but without success, when the
experimenters were taking a satisfactory diet. 21

An experiment on man, which was carried out by
Goldberger, is of special interest. A diet consisting
of dishes prepared from degerminated corn meal,
bolted wheat flour, rice, starch, sugar, pork fat, to-
gether with sweet potatoes, cabbage, collards, turnip
greens and coffee, induced the appearance of what
were regarded as the incipient signs of the disease by
the end of five and a half months in five of eleven
men, who volunteered to submit themselves to this
dietary regime. 22

Chittenden and Underhill 23 have described ex-
periments in which dogs were restricted to a diet of
crackers (wheat flour), cooked (dried) peas and^
cottonseed oil. After intervals varying from two to
eight months, the animals developed the typical sore
mouth, severe diarrhea and skin changes strikingly
suggestive of pellagra in man. They were of the

108 THE NEWER KNOWLEDGE OF NUTRITION

opinion that this diet caused these symptoms be-
cause of the lack of some substance or substances of
the class designated as "vitamines" by Funk.

McCollum, Simmonds and Parsons 24 demon-
strated that the diet of Chittenden and Underhill,
which consisted of bolted wheat flour, peas and
cottonseed oil, cannot be deficient in any other uni-
dentified dietary essential than the fat-soluble A, a
lack of which is associated with the development of
the eye disease, xerophthalmia. This conclusion is
necessary since rats were shown to fail to grow or
remain in a state of health, on this mixture, and that
it is rendered dietetically sufficiently complete by
the addition of three types of purified food sub-
stances, viz., mineral salts, protein, and fat-soluble
A, to induce growth at the normal rate. The animals
failed, however, to successfully rear young. The
first limiting factor is the inorganic content. Every-
thing of an unknown chemical nature which the diet
must contain is present in a mixture of wheat flour,
peas and cottonseed oil, but there is a relative short-
age of the fat-soluble A, which is abundant in cer-
tain fats, and is associated with cellular structures
generally in both animal and vegetable food-stuffs.
McCollum, Simmonds and Parsons pointed out that
although their rats failed to maintain satisfactory
nutrition on this food mixture, unless the three
kinds of supplements were added, there was no
soreness of the mouth or diarrhea, such as was ob-
served by Chittenden and Underhill in dogs, and are

"DEFICIENCY" DISEASES 109

usually present in pellagra in man. The eyes became
swollen when the diet was supplemented only by
salts.

An inspection of the diets described by Goldberger
as common in those institutions where pellagra is
prevalent, and the winter diets of people in those
districts where there is a high incidence of the dis-
ease in the spring and summer months, shows that
these are composed largely of seeds and seed prod-
ucts, and the amounts of leafy vegetables, milk,
eggs and meat, are very small, or are entirely absent,
for varying periods. McCollum and Simmonds 25
have pointed out that in the experimental diet with
which Goldberger reported having produced incipi-
ent pellagra in man, about ninety-six per cent of the
total solids of the food supply was derived from seed
products: corn meal, wheat flour, rice, starch, sugar,
molasses and from pork fat, and only about four per
cent from sweet potatoes and the leafy vegetables
together. Such a small amount of the leaf does not
suffice to make good the dietary deficiencies of the
seed products in such a diet. These deficiencies are
now well understood, and it is further known that
the tubers, such as the potato and sweet potato, are
not so constituted as to serve as "protective" foods
when taken together with seed products. The diets
of those people who suffer from pellagra are, there-
fore, deficient in three respects. They are relatively
low in protein and their proteins are of relatively
poor biological value, because they do not yield on

110 THE NEWER KNOWLEDGE OF NUTRITION

digestion, a favorable mixture of amino-acids for the
transformation into body tissues. They lack a
sufficient amount of the unidentified dietary essential
fat-soluble A, and also of certain mineral elements.
The latter fault is iq most instances limited to a
shortage of calcium, sodium and chlorine. Since it
is the regular practice of man to make additions of
sodium chloride in the form of table salt, to his diet,
the mineral deficiency in these diets may be said to
be limited to the element calcium. Any one of these
faults alone is sufficient to induce malnutrition when
either the young or the adult animal is restricted to
such diets as are common in pellagra stricken districts.
Since, however, there seems to be good evidence
that there sometimes occur cases of pellagra in in-
dividuals whose diets have included a certain amount
of such articles as McCollum and his co-workers
have designated as PROTECTIVE FOODS, viz.,
milk, eggs and the leafy vegetables, the theory of
an infection is supported. The prevalence of the
disease in badly sewered districts supports this view.
That there is a bacteriological factor involved in
pellagra is further supported in some degree by the
fact that McCollum, Simmonds and Parsons 25 ob-
served only malnutrition without diarrhea or sore
mouth in rats fed diets which in the experience of
Chittenden and Underhill produce in dogs the gastro-
intestinal symptoms seen in pellagra in man. The
sloughing of the mucous membranes of the mouth,
and the presence of ulcers in the intestine affords

"DEFICIENCY" DISEASES 111

conclusive evidence of an infection in their dogs.
McCollum and co-workers found no unhealthy ap-
pearance in the mucosa of the digestive tract, even
when their rats were moribund as the result of being
fed only wheat flour, peas and cottonseed oil. It
seems probable that the difference in this respect in
the two species may well be attributed to a chance
infection in the one case which did not occur in the
other. These observations are in harmony with the
fact that not everyone who takes the poor diets de-
scribed develops the disease. It seems logical in the
light of all the data available, to conclude that poor
nutrition predisposes to infection, and that there is
an infectious agent involved in the production of
pellagra. There can be no reasonable doubt that
the possibility that pellagra is a " deficiency' ' dis-
ease, in the sense in which Funk employed this term,
is definitely answered in the negative by the ex-
perimental work of McCollum and his co-workers.

Rickets. — There can be no doubt that rickets is a
nutritional disease, but its relation to the diet is not
clear. It is characterized especially by an alteration
in the growth of the bones. These become enlarged
at the extremities and so soft that they bend under
the stress of muscular contraction and under the
weight of the body. It is a disease of the first two
years of life, and is especially prevalent in children
in whose diet milk is replaced too largely by cereals
and other vegetable foods, not suited to the delicate
digestive tract of the young child. Predisposing

112 THE NEWER KNOWLEDGE OF NUTRITION

factors in many cases are undoubtedly tuberculosis
and syphilis. The symptoms develop gradually.
Restlessness and perspiration at night, great sen-
sitiveness of the limbs, that even a light touch is
extremely painful, are characteristic signs of the
disease. There are gastro-intestinal disturbances,
especially colic and distension of the intestine with
gas, so that the abdomen protrudes. The bones
become thickened, and nodules develop at the junc-
tures of the ribs with the costal cartilages, forming
the characteristic " beaded' ' ribs. There is defective
ossification of the skull; the teeth appear later than
normal and in unusual order. Various deformities
of the head, spine, chest and limbs result as the child
develops. Recovery with deformity is of frequent
occurrence.

There must, at the present time, be an element of
speculation in any discussion of the relation of diet
to rickets. The well-known deficiencies from the
dietary standpoint of the cereal grains and the other
storage organs, together with the injury to the in-
testine, which is nearly always present, as shown by
the distended abdomen, and the occurrence of
rickets only in early life, and so frequently in associa-
tion with infectious disease, all make it unnecessary
to invoke the aid of any hypothetical "vitamine,"
to a lack of which the disease may be attributed.

Hess 26 has recently described the results of bis
dietary studies among the negro women of the
Columbus Hill district in New York, whose children

"DEFICIENCY" DISEASES 113

almost all suffer from rickets. It is significant that
these women are attempting, like the very poor in
many cities, to live on a diet derived from the en-
dosperm of wheat, maize and rice, bolted flour,
degerminated cornmeal, polished rice, together with
tubers and meats. It will be evident from the data
furnished by the application of the biological method
for the analysis of food -stuffs, which McCollum and
his co-workers have perfected, and which was de-
scribed in Chapters I to III, that there are no com-
binations of those food-stuffs whose functions are
those of storage organs, which will constitute a satis-
factory diet for growth. Muscle tissue does not tend,
except in respect to the protein factor, to correct the
dietary faults of such mixtures. The regular con-
sumption of such diets will in the course of a few
months cause a distinct lowering of the vitality of
an adult and will cause even greater injury to the
young child. In a later chapter it will be shown that
the milk of mothers taking such diets does not
satisfactorily nourish the young.

What has said been above regarding the special
dietary properties of the different food-stuffs which
go to make up the diet of civilized man, and the
dietary habits of those classes of people who suffer
from the diseases which have come to be recognized
as being due to faulty diet, make it easy to see that
there has become fixed in the minds of students of
nutrition and of the reading public, an altogether
extravagant idea regarding the importance of the

114 THE NEWER KNOWLEDGE OF NUTRITION

substances to which Funk gave the name "vita-
mines." Of the diseases which Funk considered due
to lack of unidentified substances of this nature,
viz., beri-beri, scurvy, pellagra and rickets, but one,
beri-beri, has been shown to be due to this cause.
In the course of the analysis by McCollum and Davis,
of the problem of what chemical complexes are nec-
essary to constitute the simplest diet which will
serve to support growth in the young, and maintain
physiological well-being in the adult, a second dietary
"deficiency" disease in the same sense as beri-beri,
was discovered, and shown to have occurred sporad-
ically in man. This is the type of xerophthalmia
which results from a deficiency of the dietary essen-
tial of unknown chemical nature, fat-soluble A.
Beri-beri is due to the lack of the second unknown
dietary essential water-soluble B. Pellagra, scurvy
and rickets do not belong in the same category with
beri-beri, and there do not exist "curative" sub-
stances of unknown nature for these diseases. The
individual is predisposed to the development of these
syndromes by faulty diet, but the faults have been
shown by the biological method for the analysis of
the individual food-stuffs or their mixtures, to reside
in maladjustments, and unsatisfactory quantitative
relationships among the now well-recognized con-
stituents of the normal diet. They are to be sought
in the quality and quantity of the protein, the char-
acter and amount of the inorganic constituents, the
physical properties of the residues which are left

"DEFICIENCY" DISEASES 115

after digestion, and form the feces from which the
intestine must rid itself. It seems probable that
the only unidentified substance which is physiolog-
ically indispensable, which is not sufficiently abun-
dant in the diets employed by the people of the
United States and Europe where there are used in-
sufficient amounts of milk, butter, cream, eggs and
the leafy vegetables, is the fat-soluble A, but occa-
sionally diets may be met with which contain too
little of the water-soluble B. Sufficient knowledge is
now available to make it possible to select such foods
as will mutually make good each other's deficiencies,
and to combine them in such proportions as will
insure the disappearance of all the diseases of man
which are brought on by faulty diets. The same
knowledge will, in the future, make possible an
efficient utilization of feeding-stuffs for animal pro-
duction, which will be of inestimable economic
value to mankind.

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