Keratomalacia and Hunger-Osteomalacia



Rickets is
not the only disease of malnutrition asso­ciated with the quality of the fat in
the diet. Children on diets poor in " good " fats suffer sometimes
from a purulent inflammation of the eye, which if unchecked leads to
perforation of the cornea and blindness. This condition in infants and its
relationship to malnutrition was first noticed by W. Mackenzie in 1857. In 1892
cases were recorded by Holmes Spicer amongst artificially fed children in England, and he
also noted that the condition was not uncommon in countries where nursing
mothers practised long fasts. In 1904 Mori observed 1511 cases of a disease,
called Hikan, among Japanese children of two to five years, characterised by
diarrhoea, excessive appetite, swelled abdomen, loss of weight,
night-blindness, dryness of the skin and hair (cf. symptoms of Mackay's
kittens, p. 83); 116 of these children developed keratomalacia. Most of them
had been breast-fed for over a year, and afterwards their food consisted almost
entirely of cereals and some vegetables. Mori found that the disease was cured by cod-liver oil, fish oils
and chicken
liver. Czerny and Keller (1906) described a nutritional
disease in infants fed almost exclusively on carbohydrate; they called this
condition " Mehlnahrschaden," and keratomalacia was a common symptom.
Ronne (1915) observed 35 cases of keratomalacia in Copenhagen
in infants fed on buttermilk, During the two following years Bloch recorded 49
similar cases in Copenhagen.
The sick infants were at first treated in the Eye Depart-



of the hospital without success. The children were all poorly developed, weak
and anaemic, and some of the younger ones were greatly wasted. On inquiry,
Bloch found that they had been fed on pasteurised, skimmed milk which had been
re-heated in the home. Their food was therefore deficient in both the A- and
C-vitamins, and they showed some signs of scurvy. Bloch ordered as much whole
fresh milk and cod-liver oil as they could tolerate, thus supplying both the
missing vitamins. Rapid recovery followed this treatmen1;,»but in those cases
in which cod-liver oil was not given recovery was too slow to save the sight;
an indication that the eye symptoms were caused by the absence of A-factor and
relieved by its inclusion in the food. In the following year Bloch recorded
still another outbreak of eye disease in an institution at Copenhagen. The younger infants and sick children
were accommodated in one building and given whole milk; all these children did
well. Thirty older children were housed separately in two sections. Their food
consisted of gruels made of buttermilk, fruit syrups, barley, etc., fish,
minced meat, potato, cocoa, bread and margarine; they had no butter, eggs, or
cream. One of these sections had a little whole milk for breakfast, the chief
source of A-vitamin, and the other did not. The children who had this small
quantity of whole milk showed no symptoms and grew normally, but eight children
in the section without whole milk were stationary or losing in weight; they
showed signs of eye trouble which did not respond to local treatment and proved
to be keratomalacia. No change was made in the general diet, but the eye
trouble was cured in eight days by the addition of 10 grms. of cod-liver oil
twice daily; the children also began to grow and improved in health. Bloch
ascribed the effect of cod-liver oil to the presence in it of some unknown
accessory substance. He called special attention, to the frequent association
of diarrhoea, bronchitis, pneumonia, pyuria, discharges from the nose and ear,
and catarrhs of all sorts with the symptoms of


evidently all due to lowered resistance to bacterial infection. No mention was
made of rickets; but the children were stationary or losing weight, and rickets
is a disease associated with rapid growth and rare in atrophic (wasted) infants
or puppies.

A similar eye disease was observed during the War by Dr. Gideon Wells in
Roumania, so severe as to cause blindness. These children had no milk, as the
Austrians had taken away all the cows and their food was limited to corn-meal
and bran and vegetable soup. To improve their diet under war conditions seemed
impossible, but just at the most difficult time, Dr. Wells heard of a vessel
putting into Archangel with a cargo of
cod-liver oil. Through the agency of the Red Cross this cargo was sent to Roumania,
where the oil saved the life and sight of many children.

Dr. Dalyell in her work among the famine-stricken children of Vienna came across cases
of this eye disease in infants who had received little fat in their food; the
symptoms disappeared on treatment with cod-liver oil.

In the Madras Presidency, according to Col.
I.M.S., keratomalacia is common amongst
ill-fed Indians, and is treated successfully by improved diet and cod-liver

Budd in 1842, in his lectures on Diseases arising from Defective
referred to ulcerated cornea; he recorded several cases which
had arisen from a restricted diet following fever and were quickly healed under
the influence of animal food.

Under ordinary conditions of life nutritional kerato­malacia is a
comparatively rare disease. Ross records only four cases among more than 28,000
infants admitted to the Johns Hopkins Hospital,

The connection between keratomalacia and a diet deficient in A-factor
has been strengthened during the last few years by the experiences of
scientific workers with rats fed upon artificial diets. Severe epidemics of eye
disease have invariably occurred among rats fed on


deficient in A-vitamin. Other rats on a normal diet in close contact with those
with the eye disease have remained healthy. McCollum and Davis (1917), who
first described this affection in rats and called it xerophthalmia, believed it
to be a deficiency disease. Eye disease in rats has been studied by Stephenson
and Clark; a cure was effected in every case by the addition of food containing
the A-vitamin to the diet. The actual inflammatory symptoms are produced by any
bacteria, normally present in the eye, invading the xorneal tissue. Guerrero
and Conception (1920) have observed eye disease followed by blindness in fowls
fed on polished rice and extract of rice polishing to supply B-factor; this
diet contained no A-factor.

Keratomalacia affords a remarkable example of lowered resistance to
bacterial infection directly attributable to a specific dietetic deficiency.
Two infantile diseases are thus associated with the absence or shortage of the
A-vitamin in the food, and both are cured by its administration. There is no
record of these two diseases appearing at the same time in the same individual.
The explanation is suggested that keratomalacia is the result of an almost
complete absence of A-vitamin over a short period, and that rickets is the
result of a less complete deficiency of the vitamin over a longer period. The
eye trouble is preceded by stoppage of growth and may be accompanied by
wasting, while rickets most commonly occurs in a rapidly growing child.


The bone disease osteomalacia in adults is now attri­buted to a diet
deficient in A-vitamin. Towards the end of 1918 many cases of this bone disease
were observed in Austria and
in adults suffering from food deprivation. The victims looked anaemic, old and
ill, and had a dry, harsh skin. The most remarkable sign was the stiff,
waddling gait with feet far apart; this


walk was adopted to avoid the acute pain caused by movement of the hip, knee, or
foot joints. Stairs could not be ascended unless there was some support, so
that the body could be hoisted by muscular effort of the arms. Pain was also
caused by stooping. The muscles were not tender, but certain areas, always over
bones, were very sensitive to pressure. In some cases there were spontaneous
fractures of the bones. X-ray photo­graphs showed osteoporosis. The symptoms
were at their worst in winter and spring and less severe in the summer.

Hayer (1920) recorded that the disease in Munich was associated with a diet poor in
energy value, and in fat, meat and fresh vegetables; it was cured by cod-liver
oil containing phosphorus. In Vienna,
Dalyell and Chick found that the diet in these cases consisted mainly of bread
and vegetables with small amounts of flour and sugar; milk, butter and eggs had
not been used on account of their prohibitive price; lard, the only kind of
fat, was not always obtainable. The patients were cured by rest in bed and good
food. The dietetic origin of the disease was thus confirmed. A careful
investiga­tion was made by Dalyell and Chick and by Hume and Nirenstein to
determine which were the active curative substances in the improved diet.
Recovery followed the addition of either cod-liver oil, butter, margarine con­taining
80 per cent, of animal fat, or olive oil. Cod-liver oil was the most effective
and olive oil the least; severe cases did not improve unless cod-liver oil were
given. No special virtue was found in oils containing phosphorus, other than
the value of the oil in which the phosphorus was dissolved. The curative value
of fats was thus found to depend on their content of A-factor.

The simultaneous increase in Central Europe
of rickets in infants, late rickets in older children and osteomalacia in
adults, suggested that these three diseases had a common cause; they were all
cured by the administration of cod-liver oil. Looser, from pathological,
anatomical and histological evidence, considers that late rickets is


condition intermediate between infantile rickets and osteomalacia. Adults are
less prone to bone disease than the growing child, but once the bone changes
have appeared in the adult they are much more difficult to heal. In addition to
the bone symptoms, tetany has been observed in all three diseases.

before the War was usually observed in pregnant women, or in women after a
succession of pregnancies. No increase of osteomalacia amongst child-bearing
women was described in Vienna,
and no clear connection has been traced between the osteomalacia of pregnancy
and hunger-osteomalaciaj

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