Canad. M. A. J. OF THE 21 July 1954, vol. 71 WILLIAMSON: USE

USE OF THE VITAMINS This is not meant to imply that the subelinical deficiency does not exist. A moment's reflection PAUL WILLIAMSON, M.D., Walsh, Col. will convince anyone that, among the American people, there are all levels of intake and THIS IS A CRITIQUE of the most expensive utilization. An accurate and meticulous dietary placebo in current use, the vitamin tablet. While history will give one the basis for a shrewd guess I would in no way attempt to derogate the thera- but so many extraneous factors enter in that little peutic value of vitamins where definite indica- more than a guess is possible. tion exists for their use, I believe most firmly Such things as the interaction between the that an indication is present in less than one out vitamins and the essential amino acids, which has of a hundred cases in which vitamins are pre- been clearly demonstrated, and the effect of one scribed. vitamin upon the other as well as upon inorganic We need to evaluate most carefully the known materials, enter into the total picture. In the indications for the prescription of vitamins and present state of our knowledge only a few time- the contraindications for their use. Also, we need proven facts are available and we face a great to tell our patients quite frankly that the vita- mass of data which only serves to point out how mins have been oversold by tremendous adver- little we know about these compounds. The fol- tising campaigns. No known vitamin or combina- lowing summaries are designed as a working tion of vitamins is an accepted treatment for basis for clinical use of the vitamins: psychoneurosis and yet, each year, countless thousands of prescriptions are written ordering VITAMIN A expensive and extensive vitamin therapy for In private practice a true psychoneurotics. It is a known fact that an ade- is a medical rarity. Most healthy people with quate diet is the best source of these essential even a remotely satisfactory diet have an ade- compounds but few take time to quate intake. The vitamin is oil-soluble and discuss this aspect of the problem with their therefore somewhat dependent on adequate in- patients. testinal metabolism of fat for proper absorption. In many of the miraculous cures attributed to Diagnosis of deficiency.-If two points are kept therapy with these drugs no evaluation has been clearly in mind no difficulty will present. There made of possible psychic factors. Just because are only two proven effects of deficiency: (1) a vitamin-deficient rat is subject to infection, it Normal epithelial cells atrophy and are replaced does not follow that a man subject to recurrent by keratinizing cells. This is a slow process which infection must be deficient in vitamins. I have may begin anywhere. (2) There is an unknown been as guilty as the rest of us in using the drugs interference with the retinal visual mechanism for a "stop gap". Some preparations are ideally which results in night blindness. suited to give while waiting for the patient to It is important to recognize that night blind- recover by himself. This may be an "amiable ness is not a specific symptom of avitaminosis A. weakness" but it is bad when the him- The occurrence of this symptom should be an self begins to believe that the therapy and not indication for a careful dietary history and ex- nature did the trick. amination for other factors which contribute to Consider for a moment the subclinical . Remember well that the usual com- deficiency. Unquestionably it exists occasionally. plaint of temporary blindness after passing an We have no cheap and readily available test to oncoming car while driving at night is due a determine the amount of effective vitamin in thousand times more often to poor eye habits in human tissue and no accurate standard to go by driving than to deficiency. Show your patient if the test were available. By its very name one how to watch the right edge of the road, not the supposes that the "subclinical" deficiency cannot lights of the oncoming car. Don't give him be diagnosed by history and physical examina- vitamins. Bad driving habits will kill him just as tion. Then just exactly what is it and how does quickly whether or not he has a liver full of one diagnose it? In spite of the reams that have 'carotene. Remember, too, that as people get been written I have yet to hear or read an ac- older their eyes tend to be less efficient. Trying count of the subclinical deficiency that does not to treat the normal decline of age with vitamins get a bit hazy about exact diagnosis. is interesting, expensive, useless, and done too Canad. M. A. J. 22 WILLIAMSON: USE OF THE VITAMINS July 1954, vol. 71 often. In deficiency, night blindness does not to be at the root of the difficulty, a special water- seem to occur until liver stores of the vitamin are soluble form of the compound is available. exhausted. Other uses. - The vitamin has been recom- The process of keratinization of epithelium mended in urinary lithiasis, for prevention of most commonly shows itself in three places: (1) dental caries, in various arthropathies, for treat- Around the openings of the sweat and sebaceous ment of all types of hyperkeratosis, and as an glands, usually on exposed surfaces of the skin. anti-infective agent. There is no good evidence This follicular hyperkeratosis is by no means an that it has any worth except in the presence of infallible or an early sign but its occurrence deficiency. should make one suspicious. (2) The respiratory Other points to remnember.-There is universal mucous membranes are affected, the usual sign agreement that the use of vitamin A in con- being recurrent infections, frequently of increas- junction with vitamin D is of prophylactic value ing severity. Perhaps one out of each five to ten in children. Like all other good things, it can be thousand people who have recurrent respiratory grossly overdone. Administration of moderate infections has avitaminosis A. (3) Classical eye doses of a reliable preparation such as oleum signs. These are of very late occurrence and are percomorpheum from birth until two years of a part of the keratinization process. The first age has some advantage. Premature infants have sign is usually injection of the bulbar conjunctiva very low reserves of the vitamin and, in addition, with later development of Bitot's spots. These metabolize fats very poorly. Administration of a are yellowish, wrinkled areas of hyperkeratiniza- water-soluble vitamin A compound is valuable tion raniging from the size of a pinhead to the and should be routine. size of the cross-section of a cigarette. The process later extends to the cornea. Such far advanced disease is almost unbelievably rare in This is the most abused vitamin of all. In the private practice. past two decades some form of it has been Causes of deficiency.-Inadequate intake is recommended as good treatment for nearly half very rarely a cause of difficulty. In the presence the diseases known to man. If we are to believe of diseases affecting the liver and the intestinal the literature that appears on our desks each metabolism of fat (obstructive jaundice, cirrhosis, morning the practice of medicine is doomed. , pancreatitis), one should think of the Antibiotics and thiamine will cure everything. possibility of deficiency. It is not a likely possi- The vitamin is of major importance in nutri- bility but it can occur. One of the common- causes tion, playing an important role in the metabolism which we see is found in the inveterate taker of of carbohydrate. It is true that modern prepara- mineral oil. The vitamin dissolves in the oil and tion of foodstuff results in removal of much of is excreted. This is worth remembering. the vitamin B1 naturally present. Until a few Subclinical deficiency.-Minor degrees of night years ago there may have been an inadequate blindness have long beep attributed to sub- supply in the diets of many people. Now, with clinical avitaminosis A. In view of the statements most thiamine-deficient foods artificially en- made by some authorities that visual changes do riched, such inadequate supply must be nearly not occur until all supplies of the vitamin have non-existent except in the very lowest economic been exhausted, one might question this. I know groups. of no way to substantiate this diagnosis. Thera- True clinical deficiency of the vitamin is a peutic results are certainly unreliable, for too medical curiosity in the United States. Beri-beri many other factors enter in. I would suggest that is nearly non-existent except in the presence of we be chary about subclinical deficiency of vita- poor absorption. Some synthesis (by bacteria) min A until more realistic evidence is available. unquestionably occurs in the normal digestive Treatment.-In most suspected cases instruc- tract, and this may account for the rarity of fully- tion as to diet is entirely ample for treatment. developed cases. When the disease is clearcut and severe, a Signs of deficiency.-The two classical forms regimen of 20,000 to 50,000 units of the vitamin of this disease simply seem to be thiamine de- daily should be instituted. This may be reduced ficiency without severe protein depletion (dry to 5,000 to 10,000 units daily after one week. beri-beri) and associated In cases where deficient fat absorption seems with insufficient intake of protein, and aedema Canad. M. A. J. July 1954, vol. 71 WILLIAMSON: USE OF THE VITAMINS 23 from the consequent lowering of plasma protein pronouncements in this field have been based on (wet ben-beri). Much confusion can be avoided studies of volunteers who were placed on thia- by keeping this fact in mind in considering an mine-deficient diets. In a very few weeks a actual case. statistically significant number of these men de- The principal in the dry veloped , fatigue, !irritability, and other form are those of severe degeneration of the signs and symptoms that have always been re- peripheral . Seldom are the cranial nerves garded as typical of psychoneurosis. Whether affected. There is, at first, severe peripheral this is significant or whether the diet was so bad with tenderness along the course of the nerves. that it gave the subjects a psychoneurosis has not This progresses steadily to complete loss of func- been determined. Actually, the studies were tion with . Wrist-drop and foot-drop significant but many physicians have fallen into frequently occur in far advanced cases and there the error of thinking that thiamine deficiency is is, of course, loss of reflexes and muscular the cause of all such symptoms. Probably only a atrophy. Instead of memorizing symptoms, simply very few of the similar cases we see are, in remember that the whole picture can be ex- reality, vitamin deficiencies. plained on the basis of progressive degeneration If the patient's dietary history indicates the of peripheral nerves. possibility of subclinical deficiency, thiamine is There are the usual signs of illness which are probably worth a therapeutic trial. Many times listed in all texts in describing nearly every dis- the effect is purely psychotherapeutic and the ease. The patient doesn't feel well, he doesn't long-term effect is to make the patient sure he want to eat, he is frequently restless and may has some terrible organic disease. If I had to become irritable. To simplify: he's sick. It does restrict this article to one sentence (not a bad not follow that all people who are sick have thought), this is the one I would pick: dont thiamine deficiency. treat psychoneuroses with thiamine-it won't The wet form, which is probably not a pure work. thiamine deficiency so much as a deficiency in There are two ways to get a reasonably ac- plasma protein seen often in conjunction with curate diagnosis of subclinical deficiency; the avitaminosis, is characterized by right meticulous dietary history, and the chemical test failure and generalized cedema. Since the cedema for the excretion of thiamine in urine. In the is due in large measure to protein depletion it presence of extremely low thiamine excretion we involves the face and arms. This is seldom seen are probably justified in administering three to in right alone. When it occurs in five mgm. daily for a short while. If any results acute form, this disease is a medical emergency. at all are to be obtained they will be sudden Look for the oedema of protein depletion super- and dramatic. The subelinical deficiency of thia- imposed upon right heart failure, each with en- mine, while it unquestionably exists, has been tirely typical signs. grossly oversold, like all other aspects of the vitamins. It is not a very tenable diagnosis with- Causes of deficiency.-To repeat, a thiamine out some deficiency of sufficient intensity to cause clinical positive evidence such as a carefully beri-beri is a medical rarity in general practice. taken dietary history. The average person has a sufficient intake of Just a few words about the use of thiamine tlhiamine. There are exceptions among the lower in the treatment of anorexia. It is a clinically income groups and the elderly, but these are not proven fact that the vitamin will stimulate ap- so common as we have been led to believe. petitp, albeit somewhat capriciously. It is not in- In certain diseases where intake is dicated for anorexia in children until the common limited or psychological factors usually at the root of this where the function of the gastro-intestinal tract trouble have been recognized and corrected. is inhibited, the threat of thiamine deficiency is very real. A moment's thought will serve to list Treatment of deficiency.-Administration of high dosage of the vitamin B complex is specific a number of such illnesses. for the dry form of beri-beri. In the wet form the Subclinical deficiency.-Here is the battle- addition of a high protein diet or one of the ground. Everything from calcaneal spurs to- hydrolysed protein preparations usually results allergy to groundhogs has been blamed on the in prompt recovery. In spite of millions of written subclinical thiamine deficiency. Many of the words, there is no proven and entirely acceptable 24 WILLIAMSON: USE OF TIE Canad. M. A. J. VITAMINS July 1954, vol. 71

use other than to obtain specific cure of de- is that (a) dermatitis may not occur unless there ficiency. is exposure to sunlight, (b) diarrhoea is seldom Simple dietary advice, where the finances of present except in far advanced cases, and, (c) the the patient permit, will be all that is needed to patients we see in private practice now are correct suspected deficiency. The prophylactic seldom demented. May I interject an important use of thiamine is not warranted in the average thought? Deficiency diseases are not static things case. While mother's milk is not replete with the but change constantly as the nutrition of the gen- compound, an adequate diet fof the nursing eral populace changes. Many of the descriptions mother is a better solution than adding thiamine. of deficiencies available were written 30 years This is a valuable compound and an asset to the ago to picture the serious and deadly deficiencies physician's armamentarium. It is perhaps the common in low income groups. As nutrition has most abused drug in common usage. improved these major deficiencies have become increasingly rare. We now see very seldom and then usually in a minor form which In recent years deficiency of this vitamin has will be described here. Severe cases are some- become increasingly rare as a solitary occurrence. what rare and seen almost exclusively in the It occurs with relative frequency in the presence lower income groups. of general nutritional inadequacy and is easily Gastrointestinal symptoms usually appear first. diagnosed. The vitamin is plentiful in many food- The tongue gets sore and appears red and stuffs. swollen at the tip and along the lateral margins. Signs of deficiency.-Cheilosis (or the older A diffuse stomatitis may occur, usually with perleche) is the best known sign. This begins as secondary infection by Vincent organisms. Pa- an increasing paleness at the corners of the tients frequently complain of a burning sensation mouth. The skin and mucous membranes become of the tongue, and a similar sensation in the increasingly thin and ultimately fissure. These epigastrium is common. In most cases the bowels fissures extend irregularly from the corner of the move normally. mouth like spokes of a half wheel and may be The dermatitis of pellagra is easily diagnosed. crusted over with a dirty yellow crust. The It usually is seen on exposed surfaces, beginning tongue has a purplish colour and may be after the patient has been out in the sun. It starts fissured, with the expected burning and aberra- as an erythema, is bilaterally symmetrical and tions of taste. The eyes show injection of the looks identical with sunburn. It is sharply bulbar conjunctiva and ultimately of the cornea. demarcated from surrounding normal tissue and Photophobia and profuse lacrimation are usual. may be suspect because this demarcation does Causes of deficiency.-Inadequate intake is the not follow exact areas of exposure. As the disease only proven cause of deficiency. There has been, continues, the affected area turns a dirty reddish- fortunately, little speculation about subclinical brown and desquamation causes formation of deficiency of riboflavin. gray scales. In severe cases vesicles and bulle Treatment of deficiency.-Five to 10 mgm. of may form. riboflavin daily. Nervous symptoms usually seen in practice NIACIN are periodic depressions and "fear states" whioh This is the pellagra-preventive factor of older are more intense than those seen in the average writers. The vitamin is interesting because of the psychoneurosis. Mild confusion is common but fact that pellagra will respond on treatment or delirium and severe are quite rare. may be prevented by other compounds. For ex- Headaches, dizziness, and muscular weakness ample, milk and eggs contain little niacin, but are are common. There is absolutely nothing distinc- good preventives of the disease. There is a tive about the mental symptoms in niacin de- recognizable subelinical deficiency state, though ficiency. Diagnosis is made on the basis of dietary this diagnosis is not subject to absolute proof. history in the presence of the signs and symptoms Deficiency is very common in the southern states noted above. Today, pellagra is most often a but is gradually becoming less so as nutrition disease of poverty and is seldom seen except in improves. the presence of this factor. Signs of deficiency.-The classic triad is derma- Causes of deficiency. - Inadequate intake. titis, diarrhoea, and dementia. The only trouble While inadequate absorption of niacin or allied Canad. M. A. J. July 1954, vol. 71 WILLIAMSON: USE OF THE VITAMINS 25 products has been postulated, it has never been reason, this discussion will be confined to the proved. infantile form of the disease. Subclinical deficiency.-While it is not subject Signs of deficiency.-The disease is seldom to scientific proof at present, clinical practice seen before the age of eight months and equally. confirms the fact that some indefinite pre- seldom after four or five years. Children who are pellagra symptoms do exist. Loss of strength, breast-fed and whose mothers take an adequate particularly in the legs, aberrations in appetite, diet practically never have . It is usually and paraesthesias probably constitute the seen in the child w'ho has been fed cow's milk, principal symptoms. It is possible but not proven which is a very poor source of the vitamin. that minor mental deviations may be premoni- A frequent complaint is that the child seems tory of the full-blown clinical deficiency. When irritable and cries whenever he is handled. This these symptoms occur, a careful dietary history is simply a matter of soreness in the extremities is very much in order. It is certainly not wise to and the child is objecting vociferously to move- make such a diagnosis unless there is a clearcut ment. When you suspect scurvy, wait until the history of inadequate intake. baby is resting and then grasp his legs firmly Treatment of deficiency.-There is much evi- just above the knees. The normal infant may dence that clinical pellagra is usually seen when object but the scorbutic child will cry out with a general deficiency exists along with the specific pain. By being very gentle you may be able to deficiency of niacin. One of the standard multi- feel the subperiosteal haemorrhages which are vitamin preparations should be given until most common on the femur just above the knee. cessation of symptoms. An adequate diet is As the disease continues the child will tend to certainly a necessity and should receive major immobilize himself and will ultimately assuTme attention. In minor or subclinical deficiencies, the "frog" position. When on his back, he will adequate diet is all that is necessary. spread his legs and flex them at the knee so that Nicotinic acid in fairly high dosage will pro- no part of the leg and foot is not supported by duce a vasodilatation which lasts several hours. the bed. It is occasionally used for this purpose in cases Changes in the gums are seldom pronounced of cerebral vascular spasm. Relative lack of until several teeth have erupted. They are usually toxicity is the only advantage it offers. of a deep purple colour and feel boggy and Points to remember.-Pellagra is found usually oedematous to the touch. Foul-smelling fluid in the presence of multiple deficiencies. It should faintly tinged with blood will be exuded upon be treated with multiple vitamins. As with the pressure. The swelling may be sufficient to cover other vitamins, many symptoms thought to be the teeth. quite typical of subclinical deficiency are, in H.emorrhage is the most dramatic symptom of actuality, symptoms of psychoneurosis. Multi- scurvy. Since the vascular system is involved vitamins are an expensive placebo. in toto, the haemorrhage may appear anywhere- largely conditioned by trauma. Gastro-intestinal AscoRBIC ACID bleeding is not rare; neither is hematuria or purpuric spots. By far the most serious is intra- In the absence of this vitamin, tissues from the cranial hlimorrhage which may pose an immedi- mesenchyme are unable to produce intercellular ate threat to life. Subdural hlematomas occur substance. In simple language, the glue that with moderate frequency and scurvy should be holds these cells together isn't made without considered when the diagnosis is made in a two ascorbic acid. Literally this is a disease where to four year old without history of trauma. you fall apart. Formation of dentine (which helps Typical x-ray changes are seen frequently. The hold the teeth in place) is impaired, the matrix most common and easily seen of the early of thebone is inadequate, there is little produc- changes is the white line at the junction of the tion of collagen by the fibrous tissues, and the shaft and epiphysis of the long bones near the vascular endothelium tends to come apart with knee. This is simply a deposition of calcium resultant small-vessel haemorrhage. The defi- which has not been utilized at this growing area ciency is clear cut and has been known for years. of the bone. The epiphyseal ossification centres In the United States it is rare in adults but is still also show a surrounding ring of heavy calcium seen with some frequency in babies. For that deposition, giving them a typical appearance. 26 WILLIAMSON: USE OF THE VITAMINS Canad. M. A. J. July 1954, vol. 71

Immediately toward the shaft of the bone (or 'light. The disease is seldom seen in areas where toward the middle of the ossification centre) children have sufficient exposure to the sun on there is usually an area of rarefaction. a year 'round basis. The history of the disease Causes of deficiency.-Inadequate intake is the is interesting, for it appears to have been ex- only common cause. The diagnosis should be ceedingly rare until the refinement of our civili- suspected in any child that has been artificially zation to its present state nearly stopped the fed and who has not been given fruit juice or exposure of infants to sunlight and out-of-doors vitamin supplements. living. Since the human organism, in the absence Subclinical deficiency.-There are many cases of sufficient sunlight, has no other source of the of incipient scurvy. Unfortunately, there is no vitamin, artificial feeding is necessary. Most readily available way to check for this condition. children of the middle and upper economic The symptoms listed by textbooks are simply groups are given a sufficient supply, but it is symptoms of the ill child. A strong suspicion frequently discontinued too soon. During the should be aroused by history of an inadequate entire period of bony growth there is need for diet and there is one sign which is reasonably the vitamin. At about age four the diet of the reliable. Inflate a blood pressure cuff around child usually widens sufficiently in scope and his the child's arm (or leg) to a pressure of 40 mm. exposure increases so that no further supple- Hg and leave it for four to five minutes. Remove mentation is necessary. Before that time a part of it and examine the extremity for petechial hae- the requirements may be met by the artificially morrhages. If many are present, you may infer enriched foods but seldom is the entire need damage to the vascular system. The diagnosis fulfilled. is incorrect in the absence of a clear-cut history The disease is essentially an interruption of of deficient intake. the proper deposition of bone. Osteoid tissue, Treatment of deficiency.-Fruit juice is cheaper which normally becomes calcified to form bone, than vitamin pills and nourishing to boot. Irn does not so calcify in the presence of an inade- severe cases several tablets of 100 mgm. ascorbic quate amount of vitamin D. It is important to acid may be given daily. The deficiency is ap- remember that the formation of osteoid tissue is parently specific and an adequate diet and/or not interfered with. Mild cases, such as those the vitamin is all that is needed. Like most such we commonly see, seldom progress to the stage diseases, scurvy is more easily prevented than of deformity. cured. A few moments spent in instructing Signs of deficiency.-Early offers diag- mothers should result in nearly complete elimina- nostic difficulty. The best indication is a carefully tion of the disease. taken history which indicates deficient intake. Ascorbic acid has no use except to prevent This history is one of the essential features of or cure specific deficiency. It has been used as the diagnosis and is too frequently neglected. a treatment for Vincent's angina and pyorrhcea Craniotabes is one of the first signs commonly entirely without effect. Think of the possibility encountered and is most frequently seen be- of scurvy in any artificially fed infant and inquire tween the ages of four and eight months. It con- about dietary supplementation. Remember that sists of soft spots (from the size of a quarter most subclinical scurvy ain't. Occasionally to the size of a silver dollar) in the posterior mothers unintentionally cause scurvy by heating half of the skull. The bone may be indented and fruit juice or by adding a pinch of soda to it. gives the sensation on pressure of indenting a Both of these destroy the ascorbic acid. punctured ping pong ball. Remember that this sign usually disappears by the end of the first VITAMIN D year. Concurrent with it there may be softening Rickets, the childhood form of vitamin D de- of the borders of the anterior fontanelle, but this ficiency, is very common in mild form. Far- alone is by no means diagnostic. advanced cases are seen with increasing rarity. In older children asymmetry of the skull may For that reason this brief discussion will cover be striking and there may be early cranial only the mild form of rickets seen so frequently bossing. This bossing is simply the presence of in private practice. four rounded protuberances, one in each quad- Vitamin D is manufactured in the skin by the rant of the head giving a "squarehead" appear- action of certain wave-lengths of ultraviolet ance. It is not marked in early cases. In con- Canad. M. A. J. OF THE July 1954, vol. 71 WILLIAMSON:, USE VITAMINS 27 sidering skull asymmetry remember that there pneumonia only in such a stage that diagnosis are tremendous normal variations in the cranium by clinical means is unlikely. I have little belief of infants. Some stupid-looking, lopsided babies in the fact that a subclinical deficiency is an are normal and a few have even become presi- entirely different entity somewhat like a psycho- dent. Slight thickening of the wrists and ankles neurosis and related to the true deficiency by no may be perceptible at this stage, but not very symptoms at all except the symptoms of illness. often. Delay in dentition occurs but is more Treatment of deficiency.-This depends en- frequently an hereditary thing than a sign of tirely on the severity of the disease. From 1,500 disease. Actually, a good history and realization I.U. daily for the mildest- cases to 5,000 that minor rickets is common are the two most I.U. for the most advanced is sufficient. When important factors in diagnosis. healing is well progressed the mother can usually The x-ray performs signal service in this condi- take over all responsibility after a few minutes' tion. While I hesitate to recommend the frequent instruction. use of radiography, knowing such recommenda- Points to remember.-Prevention of rickets is tions are frequently carried to the point of utter easy. There is to disagreement about the fact foolishness, this is one case where the procedure that vitamin D -shouild be given in some form to is frequently valuable. It should be done in sus- all infants and young children. Remember to pected cases after a good dietary history and a inquire carefully about the intake of this vitamin confirmatory sign or two have been elicited. The and to be sure that they continue to take it until x-rays should never be used for screening be- at least the age of three. cause of the cost to the patient. The distal end of the ulna is the best place to demonstrate early rickets. There is a cupped or concave appearance MULTIVITAMINS with a frayed, "rotten fence post" look to the Without a doubt most deficiencies are defici- end of the bone.' The distance between the ulna encies of general nutrition and not of a specific and the carpals or metacarpals appears much in- substance. The possible exceptions are infantile creased. (Osteoid tissue is not visible in radio- lack of vitamins C and D. This fact of multiple graphs.) The shafts are less dense than normal nutritional deficiencies has been twisted in sup- and trabecule appear prominent. In healing port of one of the greatest sources of waste of rickets a white line appears just distal to the money in our country. The best treatment of frayed ends of the bone. This represents the zone nutritional deficiency is nutrition, not pills. ITere of preparatory calcification and is gradually fused is no cogent reason to supplement the diet of a with the shaft as healing continues. By following this process, the x-ray can be a good evaluator of healthy adult with vitamin preparations. Millions treatment. of people have been convinced that they just can- not feel well without their daily pill and this, Causes of deficiency.-Rapid growth increases to me, appears silly. If a person does have an the demand for vitamin D. This should be kept inadequate diet he can in mind particularly in premature infants. be helped a great deal The more by adequate instruction than he can be most frequent cause of deficiency is insufficient helped by a pill. supplemental intake in a baby who is seldom exposed to sunlight. Negro children seem particu- larly susceptible. Subclinical deficiency.-Here, I believe, is an excellent example of the mixup about subclinical deficiency. Rickets is rickets, whether in its earliest stage and detectable only by microscopic ERRATUM examination of the bone or whether advanced The paper by Drs. Fyles and Rose on "Corticotrophinr to in Allergic Disease" (May 1954, p. 551) contains a table- the point of permanent deformity. When we (Fig. 1) in which the creatinine values should be shown try to make a definite disease out of the sub- with a decimal point, 1.2; 2.2, etc. clinical deficiency we soon get in hot water. The same correction applies to the first values for- Speak, if you will, of subclinical pneumonia. Un- ketosteroids and creatinine shown in Fig. 1 in a second paper by these authors on p. 644 of the June issue, on questionably it exists 'but it is identical with "The Use of Oral Compound F. in Asthma."