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Correspondence 756 Correspondence. " Audi alteram partem." DISPENSARY SUPERVISION IN PULMONARY IN view of the fact that outbreaks of scurvy have occurred at various times, both in this country, and abroad in His TUBERCULOSIS. Majesty’s Forces, and in order to guard against a recurrence To the Editor of THE LANCIET. of such outbreaks, especially at places far removed from SIR,-I can cordially endorse everything written in the sources of supply, the Royal Society Food (War) Committee article under this heading by Dr. G. Jessel published in have issued the following Memorandum, based chiefly upon your columns on Oct. 26th. This may possibly be the more investigations carried out at the Lister Institute :- valuable as the experience which endorses it is obtained in the of with a of THE CAUSE AND PREVENTION OF SCURVY. county borough Middlesbrough population 126,000 in an area of 6 square miles against Wigan’s 40 square 1. like is a and is due to the Scurvy, beri-beri, "deficiency disease," miles. The same method of home treatment with long-continued consumption of food lacking in an accessory food dispensary substance or vitamine. The view that scurvy is due to tainted food attendance and constant nursing supervision has been in must be abandoned. operation here for the last four years, and the nursing 2. This vitamine is contained in a number of fresh foods in largest element is continually growing and still insufficient, although amount in oranges, lemons, and fresh green vegetables ; in considerable we have three dispensary nurses employed. Recently we amount in roots and tubers, such as swedes, and in potatoes, &c. ; on all small quantities in fresh meat and milk. It is deficient in all dried have instituted monthly nursing reports insured cases, and preserved foods. however well they are, with most valuable results. This has demonstrated in to 3. It is destroyed by prolonged heating. such as takes place during been specially controlling the tendency stewing. Thus, potatoes in stews would be devoid of vitamine, but if deteriorating health in the two influenza epidemics. We will still some boiled rapidly contain quantity. Alkalies rapidly have also added three weeks’ in a suitable antiscorbutic Soda should therefore not be added recently holiday destroy properties. when for to the water in which vegetables are soaked or boiled. locality, needed, paid by after-care scheme, which is an essential in those if home treatment is 4. Before the onset of definite symptoms of scurvy there is a period really stabilised, of debility and weakened resistance to disease. The occurrence of to be efficiently carried out. The result of this experiment was cases of debility in any body of troops without sufficient cause .should very interesting; at first it seemed rather a failure, but a at once direct the medical officer’s attention to the sufficiency of the diet. review of the cases two months after demonstrated its Prevention of Scurvy. unexpected value. The disappointment was due to the fact that 50 cent. of the cases sent were imme- 5. West Indian lime juice, as ordinarily prepared, is useless for the only per away prevention of scurvy. Fresh limes have an antiscorbutic action, diately benefited ; the unexpected and gratifying result was but their efficiency is only one-fourth that of lemons. The so-called that in the two months’ revision subsequent to their return "lime juice," by the regular administration of which scurvy was from the the first half of the nineteenth 75 per cent. were benefited, and this in spite of the fact that eliminated Navy during " century, was really lemon juice obtained from the Mediterranean. The we went through the first I I flu epidemic during the holiday history of Arctic exploration affords numerous examples in which period. As this result is rather opposed to sanatorium scurvy was prevented for long periods of time by the agency of lemon juice regularly taken. Nares’s expedition of 1875, notorious for the results the suggestions are very interesting. serious outbreaks of scurvy encountered, was the first to be provisioned There is one other matter suggested by Dr. Jessel’s article. with " lime juice " prepared from West Indian limes. Orange juice is During the reconstruction period after the war, with its large as effective as lemon juiee. housebuilding schemes, it would be worth while considering 6. Potatoes and root vegetables have a distinct value in the prevention whether it would not be advisable, when so of the of scurvy, much less, however, than green vegetables or fresh fruit many juices. A daily ration of 14 oz. of potatoes, boiled rapidly but not houses in which the tuberculous live are so unsuitable for stewed, will suffice to prevent scurvy. their residence, for the local authorities who are rebuilding 7. Pulses, beans, peas, and lentils in the dried condition have no anti- to reserve certain houses in each area, to be let at a lower scorbutic properties. If, however, the dried seeds are soaked in water rental if necessary to those tuberculous families in need of and are allowed to germinate for a short period, one or two days, they as one in develop the antiscorbutic vitamine. At the same time these pulses other quarters, of the most economic expenditures are also rich in the vitamine which prevents beri-beri, and are, more- the control of tuberculosis. It is not suggested that these over, valuable foods. houses should be segregated, unless the local bodies were The method adopted for germination is as follows. The beans, peas, to an sum on of the or lentils are soaked in water at room temperature (60° F.) for 24 hours. prepared spend extra the beautifying The water is then drained away and, to permit germination, the soaked area to overcome the natural tendency there would be to seeds are spread out in layers, not exceeding 2 to 3 inches in depth, considerI it a leper area, and so defeat its own ends. May I and kept moist for a period of about 48 hours at ordinary room temperature (60? F.). They should not be allowed to dry after this say that home treatment, to be properly carried out, needs operation, but should be cooked as rapidly as possible (lentils, a home, not a hovel, and tuberculosis does not require this 20 minutes; peas, 40 to 60 minutes). more than other diseases. 8. The antiscorbutic value of fresh meat is very low in comparison For home treatment to be successful there must be constant with that of fresh and fruit. If fresh meat is consumed in vegetables to the of the case, reason- large quantities, 2 to 4 Ib. a day, scurvy will be prevented. Tinned supervision according requirements and preserved meat possess no antiscorbutic value. Frozen meat. able freedom from anxiety, and a possibility of removal to while more valuable than preserved meat, must be considered inferior a sanatorium, when the extra rest there obtained is an to killed meat in this freshly respect. essential consideration. In Middlesbrough the results are Methods of Cooking. fully justifying the idea that the only real way in which 9. The destruction of the antiscorbutic properties depends rather tuberculosis can be controlled is by making home treatment upon the time than the temperature employed. All foods, especially and supervision the foundation-stone of the whole structure. vegetable, should be cooked for as short a time as possible at boiling- Sanatoria, and farm colonies should be point. Slow methods of cooking, such as stewing with meat or hospitals, only simmering below boiling-point, should be avoided. Potatoes should be separate rooms in the structure for special use ; home treat- plunged into boiling water and the boiling continued for 20 to 30 ment and supervision must be the foundation of the whole. minutes after the has been Frozen meat boiling-point again reached. I am. Sir, vours faithfullv. should be roasted when practicable, H. A. ELLIS, The Memorandum closes with a summary of measures Middlesbrough, Nov. 16the, 1918. Tuberculosis Medical Officer. recommended for the prevention of scurvy when fresh PS.-Since writing the above I have read Dr. F. E. are unobtainable: The ration vegetables (a) lime-juice Wynne’s letter in your issue of Nov. 16th. Surely he should be lemon the ration should be replaced by juice ; hardly makes out a case. While admitting the failure in 1 oz. served with Cooked daily sugar. (b) germinated peas, present methods of dealing with tuberculosis, as "vital or lentils form of the beans, should part regular daily ration. statistics show no decline whatever, either in the incidence Attention should be to the methods of (0) paid cooking of tuberculosis or the mortality from this cause," he as set forth under 9. employed, depreciates a method which has at least demonstrated that it has attained the supervision of 1615 cases where before . 1164 were or that a third of the cases were THE PARLIAMENTARY REPRESENTATION OF THE only supervised, SCOTTISH UNIVERSITIES.—Professor William R. Smith previously not supervised. At least home supervision requests us to intimate that he will address the graduates does away with many present extravagant and irksome of the Scottish Universities at the Royal Institute of Public methods, which apparently, in Dr. Wynne’s belief, are Health, London, to-day (Saturday) at 4 P.M. entirely useless. Whether home supervision and treatment 757 is the right path remains to be proved, and will in the very with a word of encouragement pass on to his next patient.- nature of things require about ten years to show results. Although district nurses have been here and there available- My own, in spite of war food difficulties and influenza, show and they have done splendid work under trying conditions- this year so far a reduction of 20 per cent.
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