It does not seem probable that _exudative diathesis_, a term which implies a predisposition to develop exudations or denudations of the skin and mucous membranes, is the result of a lack of vitamine. This condition does, however, predispose to scurvy. The a.s.sociation was very evident in the group of cases reported by Hess and Fish in 1914. It is not without significance that the blood-vessels in exudative diathesis also show a decided weakness, an increased permeability, as judged by the "capillary resistance test." In both scurvy and in exudative diathesis eczema and petechial hemorrhages are encountered.

There may be _nutritional diseases due to an excess of food_ rather than to a deficiency. A superfluity may be harmful by hindering the proper utilization of the food, or may possibly lead to the formation of deleterious products. Disturbances of this kind do occur. For example, it is by no means uncommon for an infant which has been overfed with milk to show the typical signs of rickets. Young guinea-pigs which are fed liberal amounts of cow's milk develop a disease characterized by fragility of the bones. The experience of Lubarsch, who produced osteogenesis imperfecta in rabbits by means of a diet consisting mainly of liver, or adrenal gland, is of interest, especially as this condition did not come about when they were fed muscle tissue.

From what has been stated, it must be evident that this subject not only is in a state of flux but that it is in a state of great confusion. This applies not only to the relationship of vitamines to these disorders, but to their identification and demarcation pathologically as well as clinically. During the past few years we have begun to regard these diseases from a new viewpoint, which no doubt will be helpful, but it is probable that they will not be sharply defined and their relationships determined until it is possible to bring about each disease definitely and regularly in an experimental animal. Until this time we should proceed slowly, and not bring about "confusion worse confounded" by yielding to the vogue, and grouping together heterogeneous and little-understood clinical conditions under the caption of deficiency diseases. There is a growing danger of attributing every unexplained nutritional disorder to the new, overworked, but ill-defined vitamines--of their sharing with the secretions of the endocrine glands the fate of becoming the dumping-ground for every unidentified disorder.

APPENDIX

Extract from "Treatise on Scurvy," by James Lind, London, 1772.

(a) _Recipe for preparing a stable orange or lemon juice._ Let the squeezed juice of these fruits be well cleared from the pulp and purified by standing for some time; then poured off from the gross sediment; or, to have it still purer, it may be filtrated. Let it then be put into any clean open vessel of china or stone-ware, which should be wider at the top than bottom, so that there may be the largest surface above to favor the evaporation. For this purpose a china basin or punch-bowl is proper, and generally made in the form required; all earthen glazed vessels are unfit, as their glazing will be dissolved by the acid. Into this pour the purified juice, and put it into a pan of water, upon a clear fire. Let the water come almost to a boil, and continue nearly in that state (with the basin containing the juice in the middle of it) until the juice is found to be of the consistence of a thick syrup when cold. The slower the evaporation of the juice the better; and it will require at least twelve or fourteen hours continuance in the bath heat before it is reduced to a proper consistence.

It is then, when cold, to be corked up in a bottle for use. Two dozen good oranges, weighing five pounds four ounces, will yield one pound nine ounces and a half of pure juice; and when evaporated, there will remain about five ounces of rob, or extract; which in bulk will be equal to less than three ounces of water. So that thus the acid, and the virtues of twelve dozen lemons or oranges, may be put into a quart bottle, and preserved for several years.

I have now some extract of lemons which was made four years ago.

Those who intend this extract for making punch may infuse some of the fresh peel of the oranges or lemons into the spirit before it is used.

But for this purpose I find it is sufficient to add a very small quant.i.ty of the outer peel to the extract a little before it is taken off the fire, and there will be all that is requisite to make it entirely equal to the freshest fruit.

(b) _How to preserve berries and other fruits for long periods._ And it may be proper to acquaint them that most berries, and several fruits, when gathered two-thirds ripe on a dry day, while the sun shines, if put into earthen pots, or rather in dry bottles, well corked, and sealed up, so that no air or moisture can enter, will keep a long time, and at the end of a year, be as fresh as when new pulled.

(c) _Method of preparing an antis...o...b..tic decoction from fir-tops, leaves, bark, etc._ When the Swedes carried on a war against the Muscovites, almost all the soldiers of their army were destroyed by the scurvy, having putrid gums, rigid tendons, etc. But a stop was put to the progress of this disease by the advice of Erbenius, the King's physician, with a simple decoction of fir-tops, by which the most deplorable cases were perfectly recovered, and the rest of the soldiers prevented from falling into it.

I am inclined to believe by the description given by Cartier of the ameda tree, with a decoction of the bark and leaves of which his men were so speedily recovered, that it was the large swampy American spruce tree.

A simple decoction of the tops, cones, leaves or even green bark and wood of these trees is an excellent antis...o...b..tic medicine; but it will, I am apt to think, become much more so when fermented, as in making spruce beer. By carrying a few bags of spruce or its extract to sea, this wholesome drink may be prepared at any time. But where it cannot be had the common fir-tops used for fuel in the ship should be first boiled in water, and the decoction afterwards fermented with mola.s.ses in the common method of making spruce beer; to which a small quant.i.ty of wormwood and horse-radish root (which it is easy to preserve fresh at sea) may be added. The juice of the cocoanut tree was experienced to be of very great benefit to several persons afflicted with the scurvy.

BIBLIOGRAPHY

ALBERT, J.: A Case of Infantile Beriberi with Autopsy Report, Phillip.

Jour. of Sci., Sec. B, 1908, III, 345.

AMERICAN PEDIATRIC SOCIETY: Collective Investigation on Infantile Scurvy in North America, Arch. of Ped., 1898, XV, 481.

ANDREWS, V. L.: Infantile Beriberi, Phillip. Jour. of Sci., 1912, VII, 67.

ANSON, Lord: Walter and Robins, Voyage Round the World, London, 1848.

ARNETH: Ueber s...o...b..t im Felde, Deutsch med. Woch., 1918, XLIV, 509.

ARON, H.: Biochemie des Wachstums des Menschen and die hoeheren Tiere, Jena, 1913, Gustav Fischer, 58.

ASCHOFF, L., and KOCH, W.: Der s...o...b..t, Jena, 1919, Gustav Fischer.

AUSSET, E.: (1) La Maladie de Barlow, Annal. de med. et chir. Inf., 1904, VIII, 289.

AUSSET, E.: (2) Un cas de maladie de Barlow chez un enfant nourri exclusivement avec du babeurre frais, Bull. Med., 1910, XXIV, 675.

BACHSTROM: Observationes circa s...o...b..tum, 1734.

BAGINSKY, A.: Demonstration von anatomischen Praeparaten eines Falles von Barlowscher Krankheit, Berl. klin. Woch., 1897, x.x.xIV, 324.

BAHRDT, H., and EDELSTEIN, F.: Organa.n.a.lysen bei Barlowscher Krankheit, Zeitschr. f. Kinderheilk., 1913, IX, 415.

BARLOW, T.: (1) On Cases described as Acute Rickets, Med. Chir. Trans., 1883, LXVI, 159.

BARLOW, T.: (2) Infantile Scurvy and Its Relation to Rickets, Lancet, London, 1894, II, 1075.

BARNES, K. E., and HUME, E. M.: Relative Antis...o...b..tic Value of Fresh, Dried and Heated Cow's Milk, Biochem. Jour., 1919, XIII, 306.

BARROW, SIR JAY: Supplement to Encyclopedia Britannica, article "Navy,"

cited by Budd.

BARTENSTEIN, L.: Beitraege z. Frage des kuenstlichen Morbus Barlow bei Tieren, Jahrb. f. Kinderheilk., 1905, LXI, 6.

BATEMAN: Scurvy in a Child, Birmingham Med. Review, 1886, Abstr. Arch.

Ped., 1886, III, 304.

BAUMANN, L., and HOWARD, C. P.: (1) Metabolism of Scurvy in an Adult, Arch. Int. Med., 1912, IX, 665.

BAUMANN, L. and HOWARD, C. P.: (2) Mineral Metabolism of Experimental Scurvy of the Guinea-pig, Am. Jour. Med. Sci., 1917, CLIII, 650.

BENOIT, A.: Une epidemie de s...o...b..t, Paris Med., 1919, IX, 469.

BERNHEIM-KARRER: Saeuglings...o...b..t bei Ernaehrung mit h.o.m.ogenisierter Berner Alpenmilch, Korrespondenzbl. f. Schweizer Aerzte, 1907, x.x.xVII, 593.

BLANE, SIR GILBERT: Observations on the Diseases Incident to Seamen, 1789, London, J. Murray.

BOERHAAVE: Cited by Lind.

BOERICH, R.: Ueber s...o...b..t, Archiv. f. Klin. Med., 1919, Cx.x.x, 151.

BOHN: Acute Rachitis, Jahrb. f. Kinderheilk., 1868, II, 201.

BOLDYREFF, W. N.: Quelques Considerations sur les Causes etiologiques du s...o...b..t, Comp. rend. soc. de biol., 1917, Lx.x.x, 911.

BOLLE, C.: Zur Therapie der Barlowschen Krankheit, Ztschr. f. diaetet.

u. physik. Therap., 1902-03, VI, 354.

BRADDEN, W. L., and COOPER, E. A.: The Influence of the Total Fuel Value of a Dietary upon the Quant.i.ty of Vitamine Required to Prevent Beriberi, Brit. Med. Jour., 1914, I, 1348.