Section 4—Vitamin Requirements and Avitaminoses

Summary A study based on 500 cases, with several deficiencies, seen at the Hospital del Niño of Mexico City is presented. The main cause was a diarrhea that lasted for months because of lack adequate treatment because of the ignorance of the parents. Protein deficiencies were present in 100 % of the cases; of these, 31 % corresponded to the first degree malnutrition; 50 %. to the second degree; and 20 %, to the third degree. Nutritional edemas were present in 78 % of the cases; 11 % were of the first degree, 29 % of the second, and 5.1 % of the third degree. The total blood albumins were low in 90 %, of the cases. In 75 % of them, the values were between 4 and 7 grams; and in 25 %, they were a little above 7 grams. The serum albumin, in 60 %, of the cases, was below 3 grams; and in 30 %, it was between 3 and 4 grams. The serum globulin was below 3 grams in 60 % of the cases; and between 3 and 4 grams, in 30 % of them. The deficiency phenomena by lack of vitamin A were found in 90 % of the cases from which, 78 % had a beginning of xerosis; 7 % had xerophthalmia with corneal ulcer; 12 % had keratitis; Bitot's patches were seen in 1.3 %; follicular hyperkeratosis was found in 8 % of the cases. The study by means of the biomicro‐scope revealed diminished humidity of the conjunctiva in 90 % of the cases; diminished brilliancy in 70 %; epithelial thickning in 90 %; and wrinkles in 58 %. The blood titres of vitamin A and carotene were as low as 10 to 20 units per 100 grams. A thiamine deficiency was found in 100 % of the cases; anorexia and diarrhea, also in 100 %; vomiting in 50 %: generalized hyperesthesias in 70 %; lack of patellar and Achilles tendon reflexes in 50 %; polyneuritis in 50 % depression in 100 %; irritability in 100 %; diminished physical and intellectual powers in 100 %; edemas in 75 %, but these were rather related to the hypo‐proteinemia; cardiomegalia in 1.3 %; heart murmurs in 1 %. The data of the electrodiagnosis and chronaxia are the following: a) A reaction of incomplete degeneration in the upper limbs, of bilateral distribution, and symmetrical, of distal predominance. – b) The reaction of degeneration was seen especially in the lower limbs where the most affected muscles are the flexors. – c) In the little advanced deficiency states, the only finding was a hypoexcitability to the electrical stimulus (1st. and 2nd. degrees), without reaction of degeneration. — d) In none of the cases seen with reaction of degeneration was there any paralysis. – e) In the advanced cases of avitaminosis, the chronaxia was greatly increased. – f) Besides, there was hyposensibility to the electrical stimulus, both galvanic and faradic. The avitaminosis by riboflavine deficiency was found in 90 % of the cases. Cheilosis at the angles of the mouth was present in 88 %; fissures at the sides of the mid‐line, were seen only in advanced cases; intense glossitis with smooth and red tongue; in 60 %; slight lesions of the tongue, in 30 %; nasal dryness, in 18 %; maceration of the perineum in 10 %; keratitis in 12 %, but assooiated to lack of vitamin A; engorgement of the circumcorneal veins in 62 %; and alterations of the nails in 6 %. Nicotinic acid deficiency, with pellagrous manifestations were seen in 100 % of the cases. The symptoms found were, scaly skin in 100 %; dry skin in 99 %; brittle hair, easy to pull off, with alterations in its pigmentation, in 90 % where 90 % had dry hair, 60 % had hair easy to pull off, change in color 70 %, gray hair in 2 %. Pellagroid erythema in 67 %; pigmentary hyperkeratosis in 70 %; flushed lips in 80 %; erythematous lesions of the perineum in 10 %; chronic pneumonitis with permanent infiltrations in 15 %; abdominal distention in. 35 %. The hematologic alterations found were, nutritional anemia in 80 %; hypoplastic anemias with leukopenia in 7 %; hypoplastic anemia with a diminution of all the elements including platelets in 5 %; thrombocytopenic purpuras in 5 %; cachectic purpuras in 1.6 %. – Discrete ascorbic acid deficiencies were seen in 100 % of the patients. In their dietetic history, all of them had a lack of intake of vitamin 0 for months. The titre of ascorbic acid in the blood gave values under 0.6 milligrams per 100 grams. The typical scurvy was rare; it was seen only in 1 %. Epistaxis were seen in 5 %; gingivitis Avith hemorrhages in 35 %; petechiae and ecchymoses in 15 %; urine with red cells in 7 %; rheumatoid pains, that yielded with ascorbic acid in 1 %; frank radiologic lesions of scurvy in 1 %. A vitamin D deficiency was rare, and the symptoms of rickets were moderate. Only 4 % showed sufficient signs to support the diagnosis of active rickets. Sweating of the head was present in 2.7 %; muscular weakness and anemia, in 100 %, but related to other avitaminosis; rachitic rosary in 7.6 %; keeled chest, in 1.5 %; craniotabes, in 0.4 %; delayed closure of fbntanelles, 3 %; alterations of the bones revealed at the X‐rays, 4 %; increase in phosphatase, in 3.5 %; diminution of calcium in 3 %; diminution of phosphorous, 2 %. Calcium deficiency was also rare. Only 1 % of the patients had tetany. The association of avitaminosis with other diseases was found with the following incidence: parasitization, 21 %, where 8.4 % was by asoaris; trichuris, 5 %; lamblia intestinalis, 4.9 %; necator. 3.2 %. – Bloody mucous colitis, 14 %; suppurative otitis, 21 %; congestive otitis, 9.2 %; bronchopneumonia, 22 %; toxic diarrhea, 10 %; glomerulonephritis, 6.5 %; malaria, 2.7 %; pneumonia. 1.3 %; scabies 1.3 %; mastoiditis, 1.6 %; typhoid fever, 1.6 %: thrush, 1.6 %; prurigo, 1.6 %: whooping cough, 1.5 %; encephalitis, 1.5 %; lung abscess, 1.1 %; intestinal occlusion, 1.7 %; umbilical hernia 1.6 %; intussusception 1.5 %; eczema, 1.6 %; hydrocele, 1.7 %; amebic colitis, 1.5 %; suppurative appendicitis 1.3 %; hypochromic anemia, 19 %: hypoplastic anemia, 7.2 %; thrombocytopenic purpura, 5 %; primitive cicatricial lung infection, 10 %; tuberculous meningitis, 2.6 %; tuberculous bronchopneumonia, 2 %; blepharitis, 1.2 %; impetigo, 1.3 %: pneumothorax, 1 %; cachectic purpura, 1.6 %; liepatomegalia, 2.7 %; splenome‐galia, 2.7 %. The mortality was close to 50 % in spite of the intensive therapeutics employed. Theurapeuticas was begun with a milk diet of high proteins using calcium casemate, powdered half skimmed milks, amino acids orally and parenterally. As soon as the diarrhea gave way, the diet was changed for a balanced cow's milk formula, eggs, meat, particularly viscera, vegetables, fruits, whole wheat bread, butter, etc. Blood transfusions were routinely made at the dosis of 10 to 20 grams per kilo of body weight and per day. Vitamin A was given at the dosis of 100 000 units per day. Thiamine, 10 to 30 milligrams. Eiboflavine, 10 to 25 mlgms. Nicotinic acid, 100 to 200 mlgms. Ascorbic acid 100 to 500 mlgms. Vitamin D, 5 000 to 10 000 units per day. Brewer's yeast, 15 to 30 grams daily. Total liver extract 5 to 10 c. c. daily. Folic acid, 5 to 10 mlgms. Ferrous sulphate 0.5 to 1 gins. Ammonium iron citrate, 1.5 to 3 grams.