NEED FOR TRAINED PERSONNEL The advantages of theoretic knowle ology and paicogs af respirators transmitted to the patient unl fully administered? “Because of the complexity and diversity’ of modem apparatus, technicians must be properly trained and supervised, In New York City the Board of Elealth conducts examinations for licensure of technicians in inhalational therapy. Although at present licensure applies solely to those iy the business ‘of supplying inhalational therapy services end propric- tary hospitals. it provides an opportunity far extension to “hospital personnel. Hospitals have not generally considered it feasible to supply trained technicians for the administration of inhalational therapy: it is usually Felegated to a changing intern staff or to nurses and orderlies who as often as not have not hed proper instruction, ‘The fact that few medical schools and hospitals pro- vide instruction in inhalational therapy is another factor responsible for a lack of competent supervision of this type of treatment of conditions due to impaired respira- tory function. Frequently the trained technician is ‘more familiar with the procedures than is the physician, a situation which in all probability will continue until adequate teaching of inhalational therapy is undertaken by medical schools and hospitals Still another factor appears to be the unwillingness of physicians interested in respiratory physiology or in diseases of the chest to assume the directorship of, departments of inhalational therapy in the absence of full time trained technical assistants. Physicians who refuse such assignments would appear to be abundantly justified, since they themselves would be called en either to carry’ out in person time-consuming procedures of else to take responsibility for improper practice by poorly trained hospital personnel, In some hospitals the anesthesiologist has been placed in charge of the therapeutic use of gases and pressures because of his familiarity with the inhalation of anes- thetic agents. Unfortunately, clinical problems at times arise in disturbances of respiratory function in which he is not qualified as a consultant, To establish him in the role of glorified technician in charge of equipment and technic is of advantage neither to him nor to the hospital. If hospitals were required to provide trained thalational therapy technicians, the physician special- izing in respiratory disease might be interested in head ing ‘such a department, conducting studies on. those clinical entities characterized by impaired respiratory, function and providing the hospital elinie with consulta tive services, when desired; stich services might prove to be of value to those of his colleagues less’ well formed concerning the physiologic and technical prob- lems involved, of the physi are not tlie technics are skill SUMMARY “The purpose of inhalational therapy may be broadly described ak the attenupt to restore normal fenetion to the respiratory. system, Tmpairment of respiratory function ultimately manifests Hse n'a Tack of oxygen in the tsstes. At times this may be-conmteracted by simple inhalaion of ‘an oxyugen-enriched atmosphere es pathophysiologic changes fo the organs ef breathe fg tas sehmlated the development of yatious mess of controlling pressure oe well as the therapeutic use Alleviation of anoxia is frequently of crucial impor- Cerebral hromiaiee A peepee" umersndg of Te is event Hf the value of this tnpe of plysioloucsy directed therapy a actually 2 be ought othe ede Sn temps as been nade herein “to ferme. the iets now nen onder to promote more ete envplosment of inhalational therapy ‘Antetigh no emergency i mre eritical inclined the ilu to teach fntatatonal therapy in mead ‘The lack of sled technicians in many hospitals is responsible for inespert management of te methods of treatment, which are generals relegated to @ changing intern stay nurses or orderics, Physicians interested in respiratory physiology or ia diseases of the chest would seem toe the most qutable as heads of departments of inhalational therapy it hows Pils ecnase of the complexity of the problems needed. "However, without specially quatifed teshieal assistants the director wou find hinelf casying ut equal unfortunatly delegating serious fespons Bitiy Yo uneilled personel [Registration of tecnica and technician supervisors ssho have heen qunifed by written an orl examine tions, as aleady established in New ‘ork Cisy by the Hoard of Health, constttes the beginning of a progea whereby hospitals may acquire ait expert inaonal therapy service. This type of servite is of crucial importance in the management of the many elinial entities characteried by impairment. of weopratory function, Council on Foods and Nutrition DEFICIENCIES OF THE FAT-SOLUBLE VITAMINS. This paper sas prepared at the request of the Councit and is one of a sories appcoring in THE JOUHSAL. In the near future the entire series will oppcor in. book form as. the Cowneits Hondbook of Nutrition Janes RV so, M.D, Seerctery, In addition to the general limiting effect on growth common to all nutrients, vitamin A seems to” affect almost exclusively the mechanism of the adaptation of Vision to dim light (dark adaptation) and the health and integrity of the epithelium, ‘The functional and structural changes resulting from a deficieney of this vitamin constitute the manifestations of the deficiency disease. Dark Adaptotion—The adaptation of vision to dim bt, principally a function of the retinal rods, requires an adequate supply of vitamin A (vitamin A,), ‘The process depends on the presence of an adequate mosnt fof viswal purple (rhodopsin). Vitamin A’ with a pro- tein forms. purple. Visual purple, of rhodopsin, is reversibly broken down in bright Tight to setinene,DEFICIE. CIES OF which tum is reconverted to vitamin A, by a reaction siuaieig, feduced cozymase as a co-casvmer— Recent HMMHCS thaieate a compbieated process possibly invoke, in tw othasvicimins, nicotinic acid ant vitania fe 48 well as proteins." The continous process of break dlown “and regeneration, while obvieusly « everaive 5» requiting 4 supply Tor replace, tyenti” Without am adequate supply, Ae formu Fiswal purple fils and’ poor tk ‘adaptation orga, Blindness) results Poor dark xdaptation (night blindness, or nyetalopia) fas een known for centuries in crcimmege ee Known to be related to deficient inskes of sige It occurs also under ‘conditions interfering She gs absorption, storage and uilzation of Samein te 2g gfotene oF the conversion of the latter to ea tank ach, conditions include gastrointestinal diene s and disease of the liver, & 7 Slight night blindness i not recognizable except b instrumental means, even by the subject Mee Pins include dificulty Im reading. seaty of dated objects in dim light and stumbling in the dark, eee larly ‘on sudden changes from bright to dark fee, szay also be unde sensitivity to suten brag ight severe cases the subject is 50 blind a5 to be ear ehatda in dim igh Epithelium —Atthough vitamin A deficiency affects the epithelium in many sites, certain places ne fees Feason or another of greater clinical importance thes athers. They are the eves, the skin: the Spree nen the respiratory passages, the bronchi an perhoee We genitourinary tract. “These are nf tance either because ther focation mikes then rout observed or because the symptoms they vanes Particulary'importan Eyes: The changes in the epitheium of the eve involve particularly the scleras, tig corneas ag fhe oe glands and ducts, The other ands and te coer jumetivas age involved to a lewer‘estent Pettey doe garliest noticeable change is functional, decreneal ees ing. although it is possible shar this fs proceed fa brief stage of increased lacrimation, “The chen iste “conjunctivitis” of vitamin A defcienes: Pere, is a dry conjunctiva This ts accomennel ak itching and heting and, perhaps, some renee of ne Geniunetivas. “Follicular ‘conjunctivitis Sel arcane 1s have been reported as a rest of the deh, ths stage has been ealed prenerosic, nother ey change is comification of the epithalinm of tre ron, gee scleras,partinlary the latter, This can he and ed smears obtained from ccrveal oe okead scrapings, dhe epithelial cells showing the chavrete ee Sabtnng Feactons and suena changes of heer sclese there isa piling up of epithets to foructon Spots" arets ol thickening, with a leeroeed rarsluceney. When fully developed they sa eee iors spots, sivery cr pearly rsd, alle ee mented Backgrotnal. The slerss AAC on 3 greasy appearance and wrinkle en, aie eae tine Ueccming generally more opaiae art ee here is edema of the comea and inltration with Particular impor- PAT-SOLUBLE VITAMINS—YOUMANS 35 leukocytes, at first in localized ares diffuse and involving the entire cornes, the latter change giten appearing precipitously, At about this point, or fomewhat before, the stage known as xerophilislmis oF Keratomalacia is present, and progression af the drecace is often followed by secondary infection. (corynehaes jerium Xerose is a common invader), panophthalmitis, hspopvon and often loss of the eve, Vision is impaired from the beginning of corneal keratinization and clotdy ing. | Microscopically, there is metaplasia followed by atrophy and desquamation of the epithelium of the test glands and ducts, as well as the comnification of the scleral and corneal epithelium, In addition to these changes, Kruse? has described hat he considers still earlier or milder changes, mainly in the subepithelium, detectable only with magnification and proper illumination (slit lamp and suitable micro, Scope). Others, however, believe these to. be sewie and presenile changes or the effect of physical or other irritants, such as wind and dust, rather than the result of vitamin A deficiency. An important criticism of Kruse's theory is the failure of the lesions to clear, despite administration of large doses of vitamin A over Jong periods. In animals * the response is rapid ‘and complete, It is true that the lesions may be more chronic in man, but it is-difficult to accept failure of cure in so slight a Iesion as consistent seth Kruse's hypothesis. “Elsewhere the repair, microscopically ae Well as grossly, is relatively ‘rapid. In rabbits. the corneal epithelium, comeal nerve fibers and retina are Hot affected, nor does corneal vaseularization of infiltexs fon occur. In subjects with true xerosis or xeroph. qhalinia, the level of vitamin A in the blood is usually ow, as is true experimentally Recovery following treatment may be incomplete, and sears are leit if the damage has passed beyond the Feversible stage. This occurs fairly early in the Care gf the cornea, and comeal scars are not uncommon Otherwise, the eye returns to normal. Upper Part of the Respiratory Trac similar to those in the conjunctiva glands occur in the mucosa of the Fespiratory tract, notably in the sinuses and da exstachian tubes and salivary glands and ducts ave larly involved. The nares are of particular impor. tance because they provide a handy source of epithelial scrapings, which may be of some hielp in. digenosis at least in infants. Such changes may favor the cceur, Fence or at Teast the persistence of localized infecr In the mouth and throat these same change the normal degree of comnification at these sites wakes them of title practical interest. Despite some. cen lation on the Felation of these changes and vitae A deficiency to buccal leukoplakia, no deiinite rman has heen established. However, the pres acteristic alterations in the salivary glide and ‘ly shown, bis ‘The stratification, comnifcation and desqa mation of the mucosal epitheliuun of the bronchi, besa Ghioles and bronchial glands is of purticatar elieieal importance because of their relation to atclectasie aad neusnonia in infants, ‘The d to be the . later becoming Changes and the lacrimal upper part of the eG stots at“ srninil taboo souenicnlaela or Imot canon sans of death in inns dving of vitamin’ A deiciney.® With the epithelial metaplasia aud atrophy there is, of course, loss of ein and decrease or cessation of bronchial secretions, What part these changes may. play in. chronie disease, partielaey in chronte infections of the Uronchi, s ot well established Genitourinary Tract: Metaplasa of the epithelium, followed by comnifcation, desquanation and repla ment with stratified epithelium, nndoubtedlyocetes fa the genitourinary tract. I is questionable whether or not the leukoplakia inthis ata is the result of vitamin A deficiency” Tn the renal pelvis and in the bladder such changes have been alleged to provide a nidus of desquamated epithelium abost which the desposition of mineral salts {orm calcul A ‘noninfectious vaginitis, especially in eldertywonven, has been attributed to the came case Neither has heen elealy established elinicalle. Similar changes in the epithet of other organs, such as te pancreas, have been suspected, but attempts to link Vitamin A deficiency with such conditions a8 Abrocystic disease ofthe pancreas have failed. Absence and defec- tive formation of dentin and enamel of the teeth occur, with resulting deformities of the teeth ‘Skin: Much has been written ‘and considerable uncertainty and difference of opinion has asen over the question of changes in the ski in vitamin A def ciencies, In past this isa reflection of the generat lack of knowledge concerning ewtanenus lesions in any of the Seficiency states. As Wolbach points out.’ no one has as yet been able to correlate such lesions with knovn functions of the skin oF “the normal. morphologic sequences of the epidermis and its appendages.” ‘There can be ile doubt that a characteristic derma- titis occurs as a result of vitamin A deficiency, a3 described in the classic papers of Frazier and Hu and Loewenthal'* ‘The differences of opinion and the tuncertainty have occurred in part because of the desig= nation by some writers of minor abnormalities of the Skin as characteristic of vitamin A. deficiency. - Such changes, dryness, for example, which, occurring. in vitamin’ A deficiency, is nonspecific, oceur from many bother causes, Their presence, labeled asa sign of vita min A deficiency, in’ circumstances clearly eliminating ich asa case, Has been contasing, Tn part such eon Fision has rested {rom a lack of proper knowledge and understanding of various diseases and abnormalities of the skin on the part of some observers, AS an example, ichthyosis, & congenital disorder of the skin tunrelated to vitamin A, fs confused by some with the ermatesis resting from vitamin A deficiency “The typical, characteristic lesion of the skin in vitae ain A efiy he dy, horns, peri, hyper Keratotic pape. Microscopically the pape f seen to arise from and’ about the pilosebaccous folie. The tamen and moth of the flict ate eared and ied wth a. plug of dense, horny, comifed. desquamate epithelium arranged in concentric lamelas, often sur= founding the remnant-of a hair, ‘There are varying degrees ef metaplasia and Keraisization of the flliceat 1 Sod Paleg al St, Beda ESS, New Coneest of Selle ‘in Relative to Nutritional Reseatehy 6. s Cunnemts Te Tey ena New Cangas’ tmestan inthe aqelcmggt Comin 'a Bos, anc att Se PAT-SOLU. VITAMINS—YOUMANS- Lo oh epithelium, with hyperplasia of adjazent epidermal cll and hyperirophy and byperkeratinization of the super ficial epideratis” These iy a mild, ivitative, infanana tore Heaction of the ells vera around the folie With itl cellular infiltration, ‘There are varying grade of metaplasia ant atrophy’ of the sebaceous ands, an ‘mau may disappear. Sweat glands and duets: show about the follicles. Tn the type described as aenefor the changes are similar and resemble the ebanges acne without the cellar infration ‘The papiiles range in size from pinhead to § em in dianteer and ate distributed principally on_ th extensor surfaces of the arms and thighs, shoulders aldomen, back and buttocks, n frequency ta the orde named.” ‘The papules are conical ot hemispherical an Contain the eental plugs” When the latter 1 expressed a gaping hole is let. Hairs are short, broker ff 0 absent. There maybe increased pigmentation abou the papule. Infection is absent in uncomplicated case but pustules and furuncles may be present as a compl cation, In addition to these moze characteristic lesions the skin i commonty dry and ragh, with a fine, bran desquamation. So-called erackling, a change resembling ichthyosis somewhat, is not, in my opinion, a significant Gbservation. It is inost often observed on the lowe feg, an area infrequently involved ‘by “the papula eruption Tn this country papules of large size or extensiv distribution are snommon, ‘The tsual lesion iy abou the size of the papule of “ordinary “goosellesh” wit which it may be confused unless one takes eare to not the chillinss and strokes the are, causing the papules to disappear. Washing may lessen the eruption, a nate ral result, since the effect is to remove the heaped ead epithelium, It should not be allowed to be mis leading. In certain patients a somewhat. different_tesfor appears to be the result of vitamin A deficiency." "Thi is an acne-like eruption with dill red, flat or slight conical, discrete papules of abouit the usual size of th acne papule.. ‘The individual lesions often simulate pustule, but the whitish top, when pierced oF removed proves to be a thin seale with a rast surface but no Pi Endemeath, ‘Significant features ate the eccurrence the lesion after the patient is beyond the ordinary age 9 Which acne occurs and a distribution of the lesions ove the anterolateral surface of the arms and back, ith fey iany on the face or abdomen. They may be found the thighs and buttocks, The skin i not dry or Toul and the lesions seem more common in those who bath frequently. An assocation of vitamin A dehcieney will true acne has been suspected but ae. not been estab iahed'™ ‘There is evidence to indicate that comedos ma have a similar relationship, atleast in part* "The dermatosis of vitamin A defcieney is uncomny in children before puberty, which has been related Frazier and his associates to changes in the sebaceod glands and hair which occur at thal tine. The var shis, Beet Bedieny ‘ot Vier Bay, Be slattcles Dae te Viti Sot, NUS ie ht Me eta eaning, 6. W Se Aeneas Saba ig Aina A Deceney feow Infancy to Poop id at Gas) 1DEFICIENCIES OF Fad: tility of vitamin needs at difteent periods of growth and development under the influence of endocrine hee fions and the greater demands at certain periods ve important in this regard. iiimust be emphasized that the specificity of the skin Kesions has not heen established, and doubt hee het espressed of their relationship to vitamin A, The obecc, grisunderstanding ofthe nature of the lesions seas soee interpretation of “experimental observations. Hes srorkers question the relation of vitamin Ato the dere tosis just described on the. following: bases th Pathogenesis of the epitheal lesions of sitmoms A ae ciency is assumed to be atrophy fllowed by petctiests fuithelial hyperkeratiniztion. “The skier aha Keratinized; therefore, how can such ‘clonges wee Sullivan and Evans support their conclashone ty Sack, dermal lesions failed to develop in tats eas diet deficient in vitamin A, but, when & dehceng B vitamins was added, a thin, atrophic shin Initeec, later by some keratinization of the hair tolcen: et develop. "Such an argument misses the eset set 25 it 8 often missed clinically, that the leson at ot is primarily a lesion of the follicles and sehucerar sr glands. ‘The papule is a. perifeliculas sete set epithelium of ‘the hair ‘oliles, sweat Gertis ee sebaceous glands isnot norinally Neratinsed neon so, ‘The changes in the horny layer, while proses not great ot especialy characeritie The question of the relation of vitamin C to the dermatosis commonly atrbuted to vitamin A deftgenns is more dificult. Lesions ofthe skin, apparendg sheng, I. except for hemorrhage, with these steed es Hittin A deficiency, have frequently heey dene be in cases of scurvy.i!” This has gencralp ese Hicled as indicating the presence of 4 detente Htamin A and C, though some writers have one a manifestation of vitamin C deiefency alone cried lew has been sirengehened andthe saeco of te relation of vitamin A to the: dermatos’ considera clouded by the development of cath an enngee nanan subjects with experimentally duce re Cspovitaminosis C).+" fy the lator cose owner, 35.3, the naturally cccurring eases, the Tapes Wace been hemotrhagic except in the earls stages in Nae has been thought to hate been Site These ani- scurvy which were’relieved with Bssive doses of ascorbic acid. Previous workers hed shown lowered levels of ascorbic acid in’ bleed tissue, in experimental animals rendered deficient ia Gtamnin A.* “If the possibility be accepted thet sd ciency of one vitamin may cause at least a ches vine ea ne eh : “SOLUBLE VITAMINS—yoUMANS leficiency of another, as in this instance, then a det Gicucy of vitamin C might lead to a deficiency of vite, rnin A, with the development of the characteristic dermatosis, which, in such circumstances, might here the added picture of hemorthage. In any event, 4 is ny opinion that in tiany instances the dermatosis described is the result, ditectly or indirectly of whee nin A deficiency and should be so treated. ft cant, however, be considered specific or pathognomonic at resent. As in all but pathognomonic lesions, all factors faken into consideration in any given case The presence of one or two papuiles does not warrant Sydiagnosisy neither docs dryness and desquamation Fen ysis Ate falsely exaggerated by cold (goose, sesh). , Naturally, the ash can ‘be improved ‘by a Haan, a fact sometimes cited as evidence against its being the result of vitamin A deficiency. ‘The excess come fied epithelium is removed mechanically. Finally and Bnfortunately, confusion has arisen because of the tana lg in both the appearance and disappearance of the eruption in relation to blood levels of vitamin AC dark Adaptation tests and treatment with vitamin At It must be remembered that considerable time is Required for the stcuctural changes in the skin to occur, both in the development of the lesion and in its vector, tion to normal, while changes in the concentration of pitamin in the blood- (particularly an inerease) and Treattk adaptation can occur many times more rapidly Hence, direct correlation with changes in the sla 3 any one time may fail A few other lesions, notably coms and calluses, have been attributed to vitamin A” deficiency" ‘Though Sxch @ relationship has not been established, a faily Rood case, theoretically, could be made for it Such In relating any such posstiity (0 teeet ‘ment, fall consideration must be given to the oo fats needed to produce sguifcant chase, Diagnosis—Recognition or detection of vitamin A deficiency rests on te diagnostic tind of Nt nad gal examination and laboratory testa The ieee includes inquiry not only into the symptom bee ioe, the dietary (oF other) intake of vitamin Ae ey toms are usually conjunctivitis, athenapla, drone oe the eyes, dfclty in vision (even night flfndeocy ay the eruption. “In more advanced ate thee ed ours, severe ocular symptoms. ‘Chideen fal erase Neigh, which for them ' probably the fest yea and, if palmonaey complications develop: the ae the “usual “symptoms of such disease.” Beene branes and ‘shin previewly: described, Tn ataease night bindhes 3 detected by gross teh There are three hboratory or speck tei ete thea surfaces for comnfctin of ti een determination of the concentration of are an earatene fn the blood Tests of darks adaptation with or photometer wll uratottedly ee Eudes, but tat need not destroy the wilue oe nef the test af ty empluped peoperiye tke © dish’ comes with entronely seh gre table adaptometer a mild or severer it A deficiency, se of night38 DEFICIENCIES OF PAT-SOLUBLE ¥ITAMINS—YOUMANS kek Mh af night blindness, or beter still, extremely slight vari Stiong in dark aaprarion detected by means of an trthin the Timits of error rest ‘uch factors slight errors fn techie, is not surprising THe fllore to correlate. variations in photometric reach ef situ A fn the blood and history and physical Sore Should hase occurred. Ago, regardless of dit Se aeveding stores of vitamin Ay children sho have Sante and certain other tinor allaients show poor Staptation promptly. Adaptation rexurns to. normal Siihrecovéry: from the illness, In selecting. subjects Nh oor sdapeation, some iavestgators may have Ticcedl those who were temporarily airected with minor fiises With recovery from. the illness, adaptation Ipcoved irrespective of vitamin A additions. AM ep factor i not involved in such circumstanc etd not be taken, as an excuse for the tse of Strate or ieproper instruments, but it docs mean that Standards should be adopted, based On care experi; Mental evidence, which wil clearly differentiate reat Tings Gn dare adaptation, ven with tis Timitation, reecpsuile that night biindess can be. detected bs instradmental: means earier than otherwise, and the roper instruments should be used for this purpose Bake causes of night blindness mest, of conse. be eliminated before the condition ean be attributed to vta- thin X dekeieney, but ordinarily this is cacy. Tt should Ta cemsembered,howeves, that sitamin A. deicenes ten probably ‘occur and manifest itself before night Gihdheas develops, althoagh an man might binde: creer and be demonstrated before corneal and con Sanctieal changes become grossly apparent. In experi- niet animals the concentration of vitamin A in the Mua may erin. normal while that of the blood is Fedluced geealy and, under treatment, retorns to normal Felore tet of the blood* Fiually, other ocular deieets, fading those due to other nutritional deficienck rroscopie examination of scrapings from the nose to detesmine the presence of cormiBeation of the epithe- Peart a nechemended in the diagnests 1 the con tion in infants Similar examination of scrapings {fou de seleras and_ corneas as been suggested for fom Ah “sas. In my experience, the latter is eSequr suitable nor reliable, at east for the diagnosis neigh deficiency” In the same category 13 the Genstration of excessive epithelium in urinary sedic wenee or vaginal smear although this should arouse Mepiion of & possible vitamin A deficiency Bfation of the concentration of sitanin A and carotene inthe blood ie use. diagnosis and i saree the best laboratory aid, ‘The concentrations Brea? doo substances donot necessarily parallel el Sines, however, “Carotene values are easily infivenced Ty tietary intake, hepatic disease. or disorders of UBeorpians without, of necessity, dye concentration of crea X being aifeced. For this reason, the 0 Wicrminations are usefal ia diferential diagnosis of see her iveases as sprue and hepatitis. For the dee aa is much yore helpfal and reliable. | Low serteatye found ina fully developed deficiency. How= ie Besant AM As, GBH ESTES Ba rma J. Yo; Core ML 284 Caete, MG and Rea ad a Ri ihe bigeye Sekt Nii A SSR RR Ee Meas Teese ever, the storage of vitamin adults, and a considerable time is neccled to deplete these Stores, The exact levels at which vitamin A deficiency actually exists have not heen established. Tn‘part, this is due to dissimilarity of method and the failure of the varios investigators to follow similar procedures. In Caperimental animals the concentration of vitamin A in the blood has heen observed to have fallen to 10 per cent of less of normal before microscopic lesions were detected in the eves. Several methorls, nearly all of which tse the Carr- Price reaction and involve the use of a photoelectric colorimeter, are available." ‘Those are probably. the most practical ior ordinary clinical use. A micro: method, using the measurement of ultraviolet ray absorption with a spectrophorometer, has been devel- oped © and is useful when one is dealing with small Amounts of blood or making mass determinations Recently ether technics have been introduced which may offer certain advantages.” ‘0 final agreement hasbeen reached on normal standards for vitamin A. There is a wide acceptance of a lower normal value for adults of 70 international nits (approximately 20 micrograms) per hundred nnillliters of serum or plasma. Values for infants may be lower, but an esact level cannot be, stated with certainty. Some evidence suggests 20 micrograms as the lower normal value for infants, ‘Studies of experimental deprivation in_humans** showed clearly that no. symptoms or signs appeared until the concentration in the serum dropped below 40 International units (approximately 12 micrograms) per hundred milliiters, ‘The earliest manifestation was night blindness detected by instrumental methods. ‘Accordingly, it would appear that values below 40 international units per hundred milliliters of serum fof plasma may be associated with clinical evidence Of deficiency but must be interpreted in the light Of other evidence. ‘The lowest value found by Lewis fand his associates ® in what they considered nornvat Gnfants was 43 international units per hundred milli- Hers, and this value has been suggested as a low orinal level." Values below this were associated with Uekcient diets and disorders of fat absorption. Chil- Gren 6 to. 12 years old had concentrations similar to those, of aduits. Conservatism would require that the concentration be extremely low before it ts consid- fred strong evidence of an actual deficiency, especially in the absence of other evidence. |As indicated, carotene values are so much affected by intake and other factors not necessarily related to A is ordinarily great in 2 deficiency of vitamin A that they are of much less ise in the diagnosis of this condition. The usual fig- tures in normal, healthy adults appear to be between 60 and 200 micr ‘ams per hundged milliliters. Low tata Nett UESehs ihe! Tate The MEG Beate et Maia cise SoM Bg Chaba ie aoa ad Been fel Exihtats Nitta ETRE Te WR pi Ho Be Saami chn rine Sart On eset oh Witte ha Stee i's Goats a potest Satie me uae oe Agathe hees heed iit, FM ae TSE, REL. TUl aan wo tn, Gz ew. Wes A iqstieeee Wh “dav nS Bacon Tere Sot ie Cotesalues (below 30 micrograms in adults) are usually fated with either a low imake or defective intes, tinal absorption. In ‘infants, the serum. of plasma carotene level is usually. zero or approxinatehy thet until quentities of green and. yellow, vegetables sed fruits or other carotene-containing foods nee eaten Temporary fluctuations in the concentration of vita: tin A occur as an effect of the ingestion of akcohal or fever, but ordinary meals do not affect the concentaa, tion,’and it is not necessary that the blood be tested With the patient in the fasting state. Arise occurs aiter the administration of large doses of the vitanie, and a tolerance test may be used suc as that proposed by Ruch, Bransting and Osterberg.2” Such & test i also used in the diagnosis of other diseases, especially those aifecting the absorption of ft For the reasons stated, correlation between blood levels and other aspects of vitamin A nuttition sod deficiency need not occur and may not be observed wher they are present unless die allowance is made for the time-lag factor. Incidence—The incidence of actual vitamin A deficieney is unknown. Nerophthalmia and. kerato- malacia are certainly rare in adults. in this countty, They are not common in children. The same may be said of frank night blindness, | What the incidence of mild deficieney—~as represented by slight (detectable only with instruments) grades of might blindness, slight dermatosis or debatable changes in the scleray mar be—depends on one’s interpretation and evaluation of sich signs. “The strikingly high incidenee, based on adaptometer readings, which was reported’so fre- quently a few years ago’ seems. scarcely, credible. Ta & survey of a general population,” only Il. of 450 subjects tested ad values for serum vitamin A’ below 30 international units per hundred milliliters: (O to 2).”‘Of these, 8 were children (under 18 years of e),_ although” these values are probably significant exer for thems Forty-five or 18 pee et Bh reas of age ot over) tad Tess than 70 units Of this later group, 33 per cent had greater or lester Jimpairment- of dark’ adaptation a aneasared sett oe adaptometer (Hecht). Inthe total. poptlation of approximately 1,200 persons, onfy some’ 35, or about 3 per cont, ad a detmatosis, “This dermatosis, hows ever, was found in about one fith of the 40 white male subjects of the age group 16 to 20 Ina survey of the blood levels of vitamin A in school children in New York State, Besser and Lowry ® found 0 to 1 per cent of those tested in. cight different schools with values. below 70 international: units per hundred millers. "From 1 to 10 per cent had valkee row 105 international units, which the authors classed as “iain.” The incidence of the dermatocs in a sroup of soldiers during the war ranged from 4 to 26 per cent “The actual incklence % probable somewhat less than indicated by" these observations tnt it must be remembered that a greater frequency te be expected among such a selecied group at persone i with other diseases, Sig Mowe A aml autores of DEFICIENCIES OF PAT-SOLUBLE "—YOUMANS 39 Treatment-—Escept for scarring of such tissues as the eyes, the lesions of vitamin “defensy shoud respond to adequate Geatment with the viesige Ae accordance with genera principles fetid! changes represented ‘bythe night blindness. should respond Prompt, and strctural changes sch ae the “eeoe tesa, more slowly the latter olin onl over a period af several weeks,’ Except in onnstal creators small t0-moderate doses-10(000 to 40.00) units das spat tare neta There f'n exene tt structural lesions will respond mere rapidly to exces sively lage doses unless tere fs diel of sonption Tio exceptions to this general prineple preatly Gees inpatients, especially infants or elulron, with sate Keratomlacia and infants with involvement of the Uronchi, atelectasis and pneumonia. "In such sane much larger doses, $0,000 to, 100,000 uns, may be ‘sel enpirically with the hope of more quickly stopping the process before irreparable damage de death teers ‘There may bea paradoxie exacerbation of sympons at the oneet of treatment (de to a swdlen sloughing of Tange masses of comifed epithelim).." corona inassve doses, 00,000 nits or more, may be reared to overcome diffesities “of absorption or audited peculiarities, The preparations of choice are the fh fiver oils or concentrates. ‘There ae many forms, containing op to 60,000 international units per hundred lies? Care shouldbe taken, when massive doses ave teed to guard against overdosage with vitamin By whch ie present in relatively high concentration yn ‘sose Preparations. Large dates may eause nausea and ono, fesia, “Recents, parenteral preparations: have become available, but they are rarely needed, "Aside from the specific treatment, itl is needed but ordinary cleane es, viTasiN Rickets is the result of a deficiency of vitamin D, and it is interesting to note that all stages of the deficiency, from mild to severe, are thought of and written of as Fickets and not, as has been the case with some other vitamins, called rickets only when clearly manifest and given some other name when less severe. Rickets is a disease of growing bone and hence does not occur in adults. Vitamin D deficiency in adults is perhaps best called osteomalacia, Confusion has sometimes arisen because other factors may aifect the occurrence of rickets, particularly experi= ‘mentally and in animals. For example, grossly alors mal diets favor the development of rickets (actually. cause it in some animals) ; other deficiencies, notably that of calcium, may complicate rickets, with a resulting tetany, and a clinical picture resembling rickets but unrelated toa deficiency of vitamin D can occur. Rickets may also occur in premature infants as a result 9 caleium and phosphorus deficieney when hi ik and not supplemented, A deficiency of ‘vitamin D is, however, the common and primary cause of rickets, The nature of the group of substances included under the name vitamin D, together with rekuionships. and action, has been described elsewhere.” Whether other effects are attributable to a deficiency of these substances and whether they: are concerned with some of the nonosseous mamifestatfons of rickets is unknown, The clinical manifestations of rickets are 100 well Known to warrant extensive description here. They