Observations placeholder

THE VALUE OF COD LIV'ER OIL AND TOMATO JUICE IN THE PROPHYLAXIS OF INTESTINAL TUBERCULOSIS. By M1ACK McCONKEY, M.D.,  New York State Hospital for Incipient Pulmonary Tuberculosis, RAY BROOK, N. Y.  

PMID:  21407584

The administration of cod liver oil and either tomato juice or orange juice alleviates the symptoms of intestinal tuberculosis,' and experimentally tomato juice prevents ulcerative intestinal tuberculosis in guinea pigs These clinical and experimental observations suggested the use of cod liver oil and tomato juice to prevent the occurrence of intestinal tuberculosis complicating, pulmonary tuberculosis.

At Ray Brook the remedy has been used for this purpose during the past eleven years, and the results are here presented.

Until the roentgenological studies of Brown and Sampson in 1919, autopsy studies revealed that intestinal tuberculosis frequently went unrecognized clinically. These authors studied roentgenologically the intestinal tracts of 141 patients, of whom 111 were in the moderately advanced and 30 in the far advanced stages of pulmonary tuberculosis at the time of their admission to Trudeau Sanatorium.  They found evidence of intestinal ulceration in 40 instances, or 28%.

In 1928 at Ray Brook, 32, or 16% of 196 patients, of whom 167 were in the moderately advanced and 29 in the far advanced stages of the disease presented evidence of intestinal ulceration on admission as determined by the roentgenological procedure of Brown and Sampson.

During the past eleven years, the number of patients coming to Ray Brook with intestinal ulceration has gradually declined from 16% in 1928 to 3% in 1938 (Table 1). It is of interest that the incidence for the year 1938 is approximately the same for Trudeau* and Ray Brook.

Attendant with this decline, there has been a notable rise in the sale of cod liver oil, tomato and citrus fruit juices as shown by the figures kindly furnished us by the United States Department of Agriculture. The sale of tomato juice alone has increased 77-fold during the past nine years.

In recent years, foods which possess a therapeutic and prophylactic value in intestinal tuberculosis have been used more generally and in increasing amounts by the patients before entering the sanatorium, and the decline in the incidence of the complication may be attributed to this factor.

The value of cod liver oil and tomato juice as a prophylactic measure is revealed more clearly by a study of patients who showed evidence of intestinal tuberculosis by X-ray examination at the time of their admission to Ray Brook, but who developed symptoms of intestinal ulceration while under our observation.

For example, the remedy was not given as a prophylactic measure in 1927. In this year there were 214 patients, 193 in the moderately advanced and 21 in the far advanced stages of pulmonary tuberculosis, who were treated at the sanatorium for a period averaging nine months. In this group of 214 patients, 23, or approximately 10%, first developed definite symptoms of intestinal ulceration while under our observation. The diagnosis was later confirmed by X-ray examination.

In contrast, 1312 patients were observed from 1928 to 1938 inclusive, 1002 in the moderately advanced and 310 in the far advanced stages of pulmonary tuberculosis, who likewise showed no evidence on admission of intestinal ulceration by X-ray examination. All the patients in this group received half an ounce of cod liver oil and three ounces of either orange or tomato juice after each meal during their entire period of treatment, averaging eight months.

Of the 1312 patients, 11, or approximately 1% first developed definite symptoms of intestinal ulceration while under our observation. Incidentally, 3 of these 11 patients, received some form of collapse therapy.

In other words, in 1927, 10% of our patients in the moderately and far advanced stages of the disease first developed symptoms of intestinal tuberculosis while under our observation, but in the following year, 1928, it dropped to 1% and has remained at this level up to the present time.

In considering the reasons for this decline during the past eleven years, it is to be noted that at Ray Brook there has been no appreciable change in the routine sanatorium treatment, including the diet, of the patients during the past twenty years, aside from the introduction of heliotherapy, collapse therapy and the administration of cod liver oil and tomato juice.

Heliotherapy may be dismissed, as it was not employed as a preventive measure in intestinal tuberculosis.

 It is presumed that collapse therapy prevents intestinal tuberculosis by freeing, the sputum of tubercle bacilli. In this series of 1312 patients, approximately 40% received some form of collapse therapy and in somewhat less than 5% of instances the sputum was rendered free of tubercle bacilli by this method of treatment. Collapse therapy, therefore, cannot reasonably he regarded as an important factor in the marked decline of intestinal symptoms in this group. Finally, if collapse therapy were the important factor, the decline should have been restricted to the group receiving collapse therapy, but in reality the decline occurred to the same extent among the patients who did and those who did not receive collapse therapy.

At Ray Brook, the use of cod liver oil and tomato juice as a prophylactic measure in intestinal tuberculosis was started in 1928, the year in which an abrupt decline occurred in the development of intestinal symptoms among, our patients from 10% in 1927 to 1%, in 1928. The remedy has been used for this purpose to the present time and there has been no change in the incidence of intestinal symptoms developing among our patients, irrespective of whether they had or had not received collapse therapy.

It seems justifiable, therefore, to conclude that the administration of this remedy is a valuable measure in the prevention of intestinal tuberculosis. With this point in mind, during the past five years, our patients, for psychological reasons, have not been warned of the danger of swallowing their sputum; yet during this period there was no increase in the number of patients developing, symptoms of intestinal tuberculosis.

Conversely, the lack of cod liver oil and tomato juice, or their equivalents in the diet, is associated with a high incidence of intestinal ulceration complicating, pulmonary tuberculosis, as shown by the recent figures of Burke and Aronovitch.* Their patients did not receive cod liver oil and tomato juice or their equivalents in adequate amounts, and in a series of 226 patients examined by them in 1938 they found intestinal ulceration as determined by X-ray present in 71, or 31%, figures comparable to those of Brown and Sampson in 1919.

Thirty-three patients died at Ray Brook of advanced pulmonary tuberculosis who had not received cod liver oil and tomato juice. Of this number, 29, or 88%, presented ulcers of the intestines. Dr. Oscar Auerbach has kindly furnished us with the following figures concerning the incidence of intestinal tuberculosis at Sea View Hospital:

“During the year 1938, there were 143 cases of straight chronic pulmonary tuberculosis which we autopsied. Of these, 34, or 22.8%, had no intestinal tuberculosis, while 109 (77.2%) had intestinal tuberculosis. A number of patients received cod liver oil, but there was no regularity in this treatment."

Burke and Aronovitch at the Grace Dart Hospital in Montreal, in a series of 109 autopsies on subjects who had died of advanced pulmonary tuberculosis, found ulceration of the intestines in 76, or 70%.

It is interesting to note that these necropsy figures concerning the incidence of intestinal tuberculosis among patients who did not receive cod liver oil and tomato juice are comparable to those of Louis, who in 1825 found ulcerative intestinal tuberculosis in 82% of 125 autopsies on tuberculous subjects.

However, in a small series of 20 patients who died at Ray Brook of advanced pulmonary tuberculosis and who had received cod liver oil and tomato juice, only 6, or 30%, presented tuberculous ulceration of the intestines at necropsy. In 80 consecutive autopsies on tuberculous subjects by Dr. Gardner and Dr. Vorwald* of the Saranac Lake Laboratory between the years 1930 and 1934 inclusive, ulceration of the intestines occurred in 61 %, while in 80 consecutive autopsies between 1935 and 1939 inclusive, the incidence dropped to 41%.

The decline in the incidence of intestinal tuberculosis in this last five-year period may be ascribed to the more frequent administration of cod liver oil and tomato juice, or their equivalents.

The conclusion seems justified from clinical and necropsy studies, that the administration of cod liver oil and tomato juice is a valuable prophylactic measure in intestinal tuberculosis and should be prescribed for all patients with pulmonary tuberculosis.

BIBLIOGRAPHY.

1. MCCONKEY, MACK: The Treatment of Intestinal Tuberculosis with Cod Liver Oil and Tomato Juice. American Rev. Tb., 1930, 21, 627.

2. MCCONKEY, MACK, AND SMITH, DAVID T.: The Relation of Vitamin C Deficiency to Intestinal Tuberculosis in the Guinea Pig. Jour. Experimental Medicine, 1933, 58, 503.

3. BROWN, LAWRASON, AND SAMPSON, HOMER L.: The Early Roentgen Diagnosis of Ulcerative Tuberculous Colitis. American Jour. Roentgenology, 19,19, 6, 625.

4. Louis, P. C. A., quoted by Brown & Sampson on page 106 of their book on Intestinal Tuberculosis, Diagnosis and Treatment. Lea & Febiger, 1926.