VIII. VITAMIN A DEFICIENCY IN HUMAN BEINGS 151 



metrical, but occasionally the lesions were few and widely scattered, or more rarely, 

 restricted to a single area. 



All ''acne-like" eruption on the face, differing from acne vulgaris with 

 respect to dryness of the skin and rarity of pustulation, was also described. 

 Microscopic study of the follicular lesions indicated that "the primary proc- 

 ess was an extensive epithelial keratinization, resulting in mechanical oc- 

 clusion of the hair follicles and sweat ducts, and in secondary degeneration 

 of the sebaceous and sweat glands." With improved diet and cod liver oil 

 therapy (up to 30 ml. daily), the skin lesions improved, but more slowly 

 than the ocular symptoms; even after 2 months the skin had not regained 

 its normal texture and appearance. 



In a later report Frazier and Hu^^ review and extend their previous 

 findings, commenting on cutaneous lesions observed in 180 patients with, 

 and 27 patients without, evidence of xerophthalmia. Of 91 patients, 1 

 month to 15 years of age, about equally divided as to sex, only 6 showed 

 follicular hyperkeratosis and 26 simple xerosis of the skin. In 103 patients 

 16 to 30 years of age, almost all males, 47 showed follicular lesions and 12 

 xeroderma. They emphasized that the papular eruption was not seen in 

 infants and rarely occurred before puberty, and that simple xerosis of the 

 skin, which frequently preceded the onset of follicular lesions in adults, 

 may represent a common manifestation of vitamin A deficiency in infants 

 and children. 



It is of interest to note that follicular hyperkeratosis, responding to cod 

 li\'er oil therapy, was described as frequently appearing before the onset 

 of keratomalacia,'^^ and often before, or sometimes in the absence of, signs 

 of xerophthalmia.^^ Reiss,''^ reporting from Shanghai, described similar 

 follicular lesions of at least 8 months' duration in 7 rug-factory workers 

 showing only night blindness; only 4 showed complete recovery with cod 

 liver oil therapy. With increased tendency to accept follicular hyperkerato- 

 sis as pathognomonic of avitaminosis A in the absence of other well-es- 

 tablished evidence of the deficiency state, it is natural to question whether 

 investigators in various countries (through laxity in diagnostic criteria and 

 lack of facilities for adequate evaluation of the vitamin A status in patients) 

 may have unwittingly included among their cases instances of follicular 

 eruptions unrelated to lack of vitamin A, especially when dealing with 

 children. 



b. Studies in Other Countries 



The findings of Frazier and Hu^' were independently confirmed by the 

 studies of Xicholls^^ on laborers in Africa and convicts in Ceylon, and those 



" F. Reiss, Chinese Med. ./. 50, 945 (1936). 

 " L. Nicholls, Indian Med. Gaz. 68, 681 (1933). 



