There is comparatively little material available at present on the use of vitamins in clinical medicine. The whole subject is too new and too little understood to have had widespread application as yet. Nevertheless, certain extremely interesting and suggestive articles have appeared, in which those best fitted to speak with authority on the question have urged upon physicians in general the necessity for greater attention to these factors.1

It cannot be too strongly emphasised that the so-called " deficiency diseases " are not the only, or the most important, results of deficiency of vitamins. In the Harvey Society Lecture, 1921, Hess2 urges physicians to realise that a lack of these essential food factors generally does not bring about typical pathological states, but obscure alterations of nutrition; ill-defined functional disabilities, which cannot be characterized or even recognised as disease and that it is such incomplete, larval forms of the deficiency disorders to which physicians will have to address themselves. Further, Hess argues as to the probability that every organ or system in the body may be affected by faulty nutrition, so that the deficiency diseases must engage the attention of every physician, whatever his particular interest or specialty. For example, involvement of the eyes may lead to impaired vision or night blindness, or, on the other hand, neuritis, cardiac enlargement, disturbances of the circulatory system, atrophic disorders of the skin, nails or hair, caries of the teeth, or unaccountable lack of appetite and constipation may each in turn be the earliest symptom.

A more careful inquiry into the dietary of patients will result in bringing to light many cases in which vague and ill-defined symptoms can be remedied simply by rendering the diet adequate. The chief clinical importance of disorders of nutrition seems to be associated with the fact that they bring about an abnormal condition of the tissues which renders them more susceptible to the invasion of bacteria or their products. This relationship was exemplified in 1913, when, as the result of a dietary of pasteurized milk', latent scurvy developed among a group of infants under observation by Hess. This " scorbutic taint" was followed by a widespread grip infection with hemorrhagic skin manifestations, which disappeared on the administration of orange juice. For some years Hess was uncertain how to interpret this peculiar clinical picture, whether to regard it as due to scurvy or to infection. As the result of subsequent experience he realized that it was due to both causes, the result of a primary nutritional disturbance and a secondary bacterial invasion. Another illustration of the inter-relationship of disordered nutrition and infection was furnished by the frequent coincidence of nasal diphtheria and latent or subacute scurvy.

This concurrence is so suggestive that when a large number of cases of nasal diphtheria develops, suspicion should be aroused that the infection is implanted on tissues rendered susceptible by scorbutic or other nutritional disorders. This " nutritional-infectious " aspect has been convincingly illustrated on a large scale among the peoples of the Central Empires, who during the many years of the war suffered from various forms of malnutrition. The general impairment of health was most strikingly manifested both in adults and in children by the great spread of tuberculosis and its increased mortality. Davidsohn3 has reported that in Berlin there was a marked increase in infection with tubercle bacilli in children under the age of five years, and they had been infected earlier in life than formerly; whereas in 1913, 30 per cent gave positive reaction at four and one-half years, in 1919 this percentage was reached at two and one-half years.

1 Hopkins, Barr, et al. British Med. J. 1016, 2, 147; McCarrison, Ind. J. Med. Res. 6, 275,1010; Chick and Dalyell, British Med. J. 1020, 2, 546; Hess, J. Am. Med. Asm. 76,603,1021.

The growth of tumors may be stimulated by accessory factors. From their experiments on yeast, Suguira and Benedict suggest that the favorable effect of radium in such cases may be due to the partial destruction of accessory substances (see Zunx, Scalpel, June 10, 1020; Physiol. Abstracts 5, 556).

2 Hess, J. Am. Med. Assn. 76, 603,1021.

Reference has already been made to the observations of McCarri-son and others on the effect of vitamin deficiency on the various organs4 and are in themselves highly suggestive. McCarrison states that his clinical experience leads him to believe that there are many minor maladies associated with deficiency of the accessory food substances in the diet of children especially, or with incomplete assimilation of these factors, and remarks that the laboratory experience gained in animal experimentation with vitamins had been of no small measure of assistance in dealing with cases of bilious vomiting, acidosis, mucous disease, and other metabolic disorders of childhood which were referred to him.

The most common dietary faults among children of the well-to-do are considered by McCarrison 4a to be a deficiency of vitamins and an excessive amount of carbohydrates with low salt content, especially calcium, when milk is overheated and vegetables are scanty. The effects of such faulty foods as observed experimentally on monkeys have been: Congestion and hemorrhage in the wall of the stomach and intestine; atrophy of the my enter on; degenerative changes in Auerbach's plexus; dilations in various parts of the tract; increased tendency to intussusception; inflammations of the colon; bacterial infection; depressed functional activity of the intestinal glands. Continued subsistence on such diets may lead to intestinal stasis particularly in its effects on the neuromuscular control of the bowel. Secondarily there may arise disturbances in the endocrine organs, particularly the adrenal.

3 Davidiohn, Ztach. f. Kinderh. 21, 349, 1019. 4 Chap. DC.

4a Lancet 1921, L, 348.

In the early days of vitamin research Hucssy reported5 that orypan, a remedy prepared from rice husks,6 of which the principal constituent is probably vitamin B, was used with good results in the treatment of weakness and inanition of women.

Hawk, Knowles, Rehf uss, and Clarke7 have published the results of an investigation into the therapeutic value of baker's yeast (Fleisch-man's), another substance which most probably owes its potency almost entirely to its content of vitamin B. Their results are summed up as follows:

5 Huessy, Munch. Med. Wooh. 61, 081, 1014.

6 See p. 123.

7 Hawk, Knowles, Rehfuss, and Clarke, J. Am. Med. Asm. 60, Oct 13, 1017.

These investigators add that in many of the cases which came under their observation, the yeast treatment caused an improvement in the general physical condition of the patient quite unassociated with the improvement of the symptoms associated with the particular disease in question.8

8 Certain experiments on fermentation by Schweiier (Mitt. Lebensm. Hyg. ii, 200, 1920) according to his interpretation do not confirm the existence of vitamins in yeast.