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.
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
These cli'nical and experimental observations sug-
gested the use of cod liver oil and tomato juice to prevent the occur-
rence 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 herepresentedl.
'Until the roentgenologyical studies of Brown and Sampson in
1919,3 autopsy studies revealed that intestinal tuberculosisfrequently
logically the intestinal tracts of 141 patients, of whom I111 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, or28%o.
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
(letermined by the roentgenological procedure of Brown andSampson.
During the past eleven years, the nuimber of patients comingr to
Ray Brook with intestinal uilceration has gradually declined from
16% in 1928 to 3~/c in 1938 (Table 1). It is of interest that the inci-
dence for the year 1938 is approximately the same for Trudeau* and
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 Agri-
culture (Table 2). The sale of tomato juice alone has increased 77-
*Personal communication from Dr. HomerL. Sampson.
TH-E INCIDENCE, OF INTERTINAL ULCERATION FROMI 1928 TO 1938 INCLUSIVE AMIONG
PATIENTS IN THE MODERATELY AND FAR ADVANCED STAGES OF PULMTONARY
TUBERCULOSIS AT TH-E TIME OF ADMNISSION To RAY BROOK.
Total Patients Examined
1928 ............ 196
1936 ............ 182
32, or 16.3%
29, or 14.2%
20, or 9.9%
21, or 10.0%
25, or 10.7%
10, or 5.1%
THE SALE OF TOMAI.TO, FRUL.IT JUICES AND COD LIV-ER OIL FROMI 1929 TO 1937
INCLUSIVE. FIGURES. KINDLY FURISIIED) BY U. S. DEPARTMENT
the past nine
The figures for cod liver
striking, explained in part at least by
the substitution of concentrates
and other fish liver oils.
In recenit years, foods which possess a thera-
peutic and prophylactic value in intestinal tuberculosis have been used
generally and in increasing
amountsby the patients before enter-
and the decline in the incidence of the complica-
tion may be attributed to this factor.
is revealed more clearly
of patients who showed
Cod Liver Oil
V'ALUE OF COD LIVEIR OIL AND TO-MATO JUICE IN TUBERCULOSIs
Do evidence of intestinal tuiberculosis by X-ray examination at the
time of their adlmission to Ray Brook, but who developed symptoms
of intestinal ulceration while undler ouir observation. For example, the
remedy was not given as a prophylactic measure in 1927. In this year
there wiere 214 patients, 193 in the mnoderately advanced and 21 in
the far advanced stagyes 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 uinder our observation. The
diagnosis was later confirmed by X-ray examination.
11312 patients were observed from 1928 to 1938 inclusive, 1002 in the
mioderately advanced and 310 in the far advanced stagyes of pul-
monarv tuibercuilosis, who likewise showed no evidence on admission
of intestinal ulceration by X-rav examination. All the patients in this
g,roup received half an ouince of cod liver oil and three ounces of either
orangre or tomato juice after each meal during their entire period of
treatment, ax'erag,ing, eight months. Of the 1312 l)atients, 11, or ap-
proximately 1% first developed definite symptoms of intestinal ulcer-
patients, received some form of collapse therapy.
In other words, in 1927, 10%/ of our patients in the moderately
andI far adv'anced stages of the disease first developedI symptoms of
intestinal tuiberculosis while under our observation, but in the follow-
ing yea, 1928, it dropped to1/4 and has remained at this level up
to the present time.
In considlering the reasons for this decline during the past eleven
years,it is to be noted that at RZay Brook there has been no apprecia-
ble chang,e in the rouitine sanatorium treatment, includingy the diet,
of thelpatientsduring the past twenty years, aside from the introduc-
tion of heliotherapv, collapse therapy and the administration of codl
liv~er oil and tomiato juice. Heliotherapy may be dismissed, as it was not
employ'ed as a preventive measuire in intestinal tuberculosis. It is pre-
sumne(l that collapse therapy prevents intesti-nal tuberculosis by free-
ing, the sputum of tuibercle bacilli.
approximately~40%/( received some form of collapse therapy and in
somewhat less than 5%of instances the sputum was renderedl free of
tuibercle bacilli by this method of treatment. Collapse therapy, there-
In this series of 11312 patients,
fore, cannot reasonably he regarded as an important factor in the
marked decline of intestinal symptoms in this group. Finally, if col-
lapse therapy were the important factor, the decline should have been
restricted to the group receiving collapse therapy, but in reality the
(lecline occurred to the same extent among the patients who did and
those who did not receive collapse therapy.
At Ray B3rook, 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
developingy among our patients, irrespective of whether they had or
had not receivedl collapse therapy.
It seems justifiable, therefore, to concluide that the administra-
tion of this remedy is a valuable measure in the prevention of intes-
tinal tuberculosis. WNith this point in mind during, the past five years,
our pa-tients, 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 intes-
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,
recent figyures of Burke and Aronovitch.* Their patients did not re-
ceive 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
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 concern-
ing the incidence of intestinal tuberculosis at Sea View Hospital:
'During the year 1938, there were 143 cases of straight chronic pul-
as shown by the
VALUE OF COD LIVER OIL AND TOMATO JUICE IN TUBERCULOSIS
monary tuberculosis which we autopsied. Of these, 34, or 22.8%0,
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 sub-
jects who had died of advanced pulmonary tuberculosis, found ulcera-
tion 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 re-
ceive cod liver oil and tomato juice are comparable to those of Louis,4
who in 1825 found ulcerative intestinal tuberculosis in 82%0 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%s, presented tuberculous ulceration
of the intestines at necropsy. In 80 consecutive autopsies on tuber-
culous 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 pre-
scribed for all patients with pulmonary tuberculosis.
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 Defi-
ciency 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,
4. Louis, P. C. A., quoted by Brown & Sampson on page 106 of their book on
Intestinal Tuberculosis, Diagnosis and Treatment.
Lea & Febiger, 1926.
DR. DAN-ID T. SMITH (Durham, N. C.) : It
colleag,ue of Dr. McConkey's at the beg,inning, of this work of his on intestinal
tuberculosis, xx hich beg-an hack about 1926.
tiful environment back down south to North Carolina and I carried with me
some of McConkev's cod liver oil and tomato juice doctrines. We followed from
the beg,innin- of the hospital there the policy of 'giving cod liver oil and tomato
juice to every tuberculous patient who had positive sputum on the basis that
prevention was easier than treatment, ancl if thev had positive sputum, they,wNere
were not inp)o,_~tionto follow our cases the way Dr. McConkey has ov-er these
DR. THoxrxs T. MIACKIE (Newv York, N. Y.)
tions are extremcly interesting to me because of the studies that wNe have been
making, in a considerable group of patients suffering from other conditions in
wvhom wxe hav-e been following the blood levels of vitamin A and vitamin C and
carotene as xx-ell. The tomato juice cocktail essentiallyrep)resentsa supplement to
the diet of vitamins A, C and D.
There wxere twxo facts in these presentations thatp)erhapsare relevant to this.
For example, the difference in the incidence ot laryngeal tuberculosis, or rather
the failure of difference of incidence. The experimental pathology of vitamin A
consists of alteration of mucous membranes and this is most easilv dlemonstrable
in the upper respiratory tract and the bronchial tree in which the normal ciliated
columnar epithelium becomes translated gradually
epithelial structure. Under those circumstances, it miay perhaps be more easy to
account for the hig,her incidence of laryngeal tuberculosis.
Another thing, it was very interesting to see the high incidence of intestinal
tuberculosis in the last group that were cited from a different institution and
where those people are drawn from a low economic level of the population.
the studies wNhichi we have been carrying on in Newx York City, we have found
almost without exception that the lower economic group show a level of bloocl
vitamin A andi a level of blood vitamin C wvhich is definitely beloxv, that wvhich
wxe would find, for example, in the (group in this room.
may be some significance in that, the bad dliet and consequently the increased
susceptibility to certain specific localizations.
Dr. ALXAHi H, GORDON (Montreal, Canacla)
man, one might throw some light upon the differences in the statistics shoxv-n by
those from Rav Brook and those from the Grace Dart Hospital, which are men-
tioned. Those wxho liv-e near the Grace Dart Hospital remember it is the inheritor
of an institution known as the Grace Dart Home for the Incurable, and it is the,
xvhat shall Isay, court of last resort for a case otherwvise unplaceable or placedi.
People wvith v-erv advancedi tuberculosis only, as a ruile, are sent to that institu-
lion, Nxxhich points out, of course, the other sicde of th-e story, thiat inte-m-tinal
wxas mx1 good fortune to be a
I move(l from this pleasant and beau-
case-; of intestinal tuberculosis.
I can offer you no figures because xv-e
All I can offer you is my clinical impression that it works and it is
Mr. Chairman, these observa-
a keratinizing type of
I think perhaps there
I think perhaps, Mr. Chair-
iS, much more likely to occur in in lances of tubOerculosis wNhich are
verv far advanced. No doubt it has been noted that these people probably are
people in a lower income level because they are people who have no other place
for care except so-called incurable hospitals, which the Grace Dart Hospital is nlot
now but of which it is the inheritor.
DR. JABEz H. ELLIOTT (Montreal, Canada)
this paper I would just like to make one suggestion, accepting the whole of the
inferences fromi those tables. We know we are in the home of Lawrason Brown
and others who have told us to study statistics, but we always should have proper
NoNx, Dr. Gordon has spoken of the far advanced type of case in the
Grace Dart Home, which would readily account for the hig,h incidence of in-
testinal tuberculosis amongst those suffering frompulmonary,tuberculosis.
Dr. McConkey's own tables for Ray Brook, the fir-st three
1928, 192Q and 1930, show approximately
clinically, to have intestinal tuberculosis. The last year it is doxx-n to 4'/ per cent.
It is cut one-thirdi in those cases using tomato juice and cod liver oil. But surely
all those cases have been taught, had it drilled into them, that intestinal tuber-
culosis is the result of swallowing sputum.
The Grace Dart Home cases are patients who have been living in their homes
and swallowing their sputum (id lib.
In the sanatorium all patients are taught
not to swallow their sputum.
cod liver oil and tom-ato jutice is having impressed upon himself once, twice or
thrice a day, as often as he takes the close, this is to combat the dangers of swal-
low,,ing the sputum, and if this regimen of cod liver oil and tomato juice has cut the
incidence of intetAinal tuberculosis in the Ray Brook cases from 13'1/
cent, one-third, surely part of that is due to the regimen introduced of teachingr
the patients not to swallow sputum.
I can't see that those statistics are at all convincing as to the value of tomato
juice and cod liver oil. But when one comes to the autopsy cases, I think Dr.
McConke', has given us something that so far I can't find fault with or pick any
hole in. It does look as if it is responsible for decided lessening of it, but I would
like to make that criticism of the fall in the clinical cases.
DR. CHES~TER M. JONES (Boston, Mass.) :I would like to ask how many of
the-se patients had pneumothorax during the last few years, whether that might
not have something to do in cutting down the incidence of tuberculosis com-
municatedl to the gastro-intestinal tract?
CHAIRM AN HEISE: Any further discussion?
Before calling on Dr. McConkey to close, I should like Dr. Mackie, if he
w~ill, tu luok at the chart un the wall in cunnectiun with vitaminis A, C, D anid E,
in connection wNith tuberculosis.
I shall ask Dr. McConkey if he will further note some of Dr. Smith's work
on subvitaminosis C as regards the dlevelopment of intestinal tuberculosis.
Will you close, Dr. McConkey?
DR. MIACK MICCONKEY: I think Dr. Elliott made a verv interestin- and im-
portant comment and I wvould like to say, Dr. Elliott, in connection with swallow-
Mr. Chairman, in discussin-
-ears of the study
per cent of their
I can't conceive but that the patient who is taking
to 4' 2 per
I think that has some bearing on the subject you
ing the sputum, that in the first years of this stu(dy, when we were all so afraid of
intestinal tuberculosis, we used to tell our patients just that, "If you swallow the
sputum, you are going to get intestinal tuberculosis.' As a consequence we used
to go around and find the sputum cup full of saliva and probably a half tea-
spoonful of mucopurulent sputum in the cup.
After the studies went along a few years, w~e began to pay less attention to
that and now we don't tell the patient anything about swallowing his sputum. A
Pood many of those patients you saw in both groups swallowed a good deal of
sputum. That perhaps in some ways is justifiable criticism, but I would like to
make that comment. We no longer advise our patients not to swallow their
In regard to the very far advanced stage of the disease in the Grace Dart
patients, I think from the clinical studies in our patients it is perfectly justifiable
to say that we will expect less tuberculosis of the intestine here than wve would in
the Grace Dart Home. However, those autopsies y-ou must remember are all on
patients who succumbed to their disease and they were no longer moderately
advanced cases, thev were far advanced cases of tuberculosis.
dence of intestinal tuberculosis in those far advanced groups is striking, consider-
ing that they swallow their sputum, and many of them couldn't take the cod liver
oil and tomato juice the last month or two of life.
I would like to comment also that in the 20 patients who took cod liver oil
andI tomato juice, only two had clinical intestinal tuberculosis. The other four
had from one to six pin head size ulcers in the intestinal tract, and they are not
in any sense to be called clinical intestinal tuberculosis; anatomically they were,
and were reported as such.
In answering Dr. Jones, I michtsaythat among our patients as they came
into the sanatorium less than 2 per cent of our moderately advanced cases have
even today any form of collapse therapy. Those fig.,ures on ~incidence are when
the patients come to uis.
form of collapse therapy wouldmateriallyaltcr our figures.
true that collapsing a lunLg and stopping a positive sputum will prevent intestinal
tuberculosis and also tubercular laryngitis.
Dr. Heise has asked that I say a word about Dr. Smith's and mv work on
intestinal tuberculosis experimentally.
Dr. Smith and
vitamin studies and found that if you deprive the guinea pig of vitamin C, par-
tiallv deprive him of it over a number of months and feed him tubercle bacilli, or
tubercular sputum, he will develop ulcerative intestinal tuberculosis that resembles
in everv way that seen in man in approximately, 20 per cent of some 70o pigrs,
whereas in the control animals who had adequate vitamin C, there w,ere only
3 or 4 who developed intestinal tuberculosis. Thismig,htlead one to believe that
vitamin C is the only important factor in preventing intestinal tuberculosis, but
I do think we have to remember that the guinea pig can in a measure, at least,
synthesize vitamin D from dry hay, which is includedi in his diet.
I think the inci-
I hardly think that an inicidence of 3 per cent of any
It is undoubtedly
a'll of our