Arthur F. Abt

Determination of reduced ascorbic acid in small amounts of blood.

We previously presented data as to the quantity of reduced ascorbic acid in blood plasma and showed its dependence upon the dietary supply of vitamin C, or of ascorbic acid administered as a medicament. 1 The data were obtained by deproteinizing plasma by means of tungstic acid and titrating immediately the reduced ascorbic acid present with 2:6 dichlorobenzenoneindophenol. In working with infants, and when making repeated observations on the same individual, it is desirable to have a method which requires a minimum of blood. We have, therefore, developed a micro-method requiring but 0.3 ml. blood, which may readily be secured from the finger of an adult, or the heel of an infant. In the guinea pig, blood is obtained by cardiac puncture, or sometimes by incision of the marginal vein of the ear. In the latter case, a special blood pipette is required. Collection of Blood. Collect approximately 0.3 ml. blood from a lancet wound, into a small phial (Fig. 1, B) containing sufficient powdered potassium oxalate to prevent coagulation. Stir immediately with a toothpick or small glass rod. The phial is made by sealing the end of a piece of glass tubing of approximately 10 mm. outside diameter, and, while hot, pressing it against a piece of iron to form a flat base. The tubing is cut off at about 15 mm. from the closed end. The cut end is then ground flat on a fine stone wheel and the outer wall ground to a taper for a distance of 5 mm. from the top. The grinding produces a thin edge which greatly facilitates the collection of blood from the heel of an infant. It is unnecessary to grind the side wall if the phial is used for finger blood only (which is permitted to drop directly into the phial as the finger is milked), or if Mood is transferred from a syringe. The phial is stoppered (Stopper A), then placed in a suitable holder (a cork with a recess cut in it) and lowered into the metal tube of a centrifuge. It is centrifuged for a few minutes in the usual manner.

Ascorbic Acid Content of Blood

While numerous papers have appeared dealing with the ascorbic acid content of various plant and animal tissues, and urine, only a few refer to the quantity present in the blood. Van Eekelen, Emmerie, Josephy and Wolff, 1 and Emmerie and Van Eekelen 2 deproteinize blood, blood plasma, or serum with trichloracetic acid, precipitate interfering substances, chiefly SH compounds, with mercuric acetate, then treat with H2S, which not only precipitates the mercury but also reduces that portion of ascorbic acid which in blood occurs in a reversibly oxidized state. The H2S is later removed by a stream of nitrogen, and the ascorbic acid estimated by titration with 2:6 dichlorobenzenoneindophenol. 3 Gabbe 4 claims that loss of ascorbic acid occurs if a solution of pure ascorbic acid is treated with H2S in the presence of mercuric acetate, and therefore, omits this step. Tauber and Kleiner 5 describe a method generally applicable to plant and animal tissues (and to blood) in which the essential features of deproteinization, removal of interfering substances, and H2S reduction are preserved. They estimate the ascorbic acid present either by titration or by its ability to reduce potassium ferricyanide, with subsequent development of Prussian-blue upon the addition of the ferric gum ghatti reagent of Folin and Malmros. 6 Our experience with several of these methods disclosed a number of difficulties. Some of the methods require considerable quantities of blood. Mercuric acetate solutions must not be over two weeks old, or filtrates containing colloidal sulphides may be obtained, particularly when the method is applied to urine. Any colloidal material in the filtrate makes it impossible to obtain a satisfactory endpoint during the titration with the dyestuff. The endpoint with trichloracetic acid filtrates is not sharp. In the present study, we are chiefly concerned with finding some method whereby the relative ascorbic acid level of blood in infants and children may be determined as an aid in studying subclinical scurvy and following its course under treatment.

Invalidation of plasma ascorbic acid values by use of potassium cyanide.

Conclusion For dependable ascorbic acid values, blood should be centrifuged, the plasma deproteinized, and the plasma-HPO3 filtrate titrated in immediate sequence after the blood is drawn. Whole blood which stands in a closed small phial, with a minimum air space, may be depended upon to give results of clinical value for 1/2 hour. The higher values obtained with bloods to which KCN has been added represent an enhancement due to the action of KCN upon the 2,6-dichlorophenolindophenol, and in no wise a more accurate determination of their ascorbic acid content. This is particularly true with blood of low ascorbic acid value. KCN does not prevent the loss of ascorbic acid from blood. It is a pleasure to acknowledge our indebtedness to Mrs. Jessie Maaske for technical assistance, and to Mr. Herman Chinn for checking several titrations.

Influence of arsenicals, bismuth and iron on the plasma ascorbic acid level.

Several reports indicate that the poisonous effects of a number of drugs like benzene, lead, 1 phenylcinchoninic acid, 2 and glycerol 3 and especially the arsenicals1 may be counteracted successfully by giving suitable doses of ascorbic acid. From examination of the urine Dainow 4 concluded that patients who showed symptoms of intolerance to arsenicals were in a state of hypovitaminosis C. By administration of ascorbic acid, these hypersensitive patients became able to tolerate neoarsphenamine. Other investigators 5 6 7 8 9 10 11 reporting similar observations, emphasize the fact that in certain hypersensitive cases ascorbic acid gave favorable results after other methods of detoxification such as the administration of glucose, invert sugar, and calcium or sodium thiosulfate had failed. After a suitable method for determining plasma ascorbic acid had been developed, studies were commenced in 1938 on syphilitic patients showing symptoms of intolerance to arsenicals. A more extended systematic study of this problem was recently made possible in connection with our Nutritional Survey of the syphilitic patients attending the Municipal Social Hygiene Clinic, Chicago.∗ It was noted early in the work that patients hypersensitive to neoarsphenamine in whom treatment had to be discontinued because of severe reactions‡ required exceedingly large oral doses of ascorbic acid† to bring their plasma levels up to optimal values (1.0 mg % or above). When showing severe symptoms of intolerance, a decline of the plasma level occurred in spite of the oral administration of ascorbic acid during treatment. It was frequently observed that a marked lowering of the plasma level followed the administration of neoarsphenamine in patients showing no intolerance to the drug (Fig. 1). When bisniuth was given in doses routinely used for aiitiluetic treatment, no appreciable effect was observed either on the plasma ascorbic acid or hemoglobin levels.

Influence of Catharsis and Diarrhea on Gastrointestinal Absorption of Ascorbic Acid in Infants

Summary Ascorbic acid is excreted in small amounts in the stools of the normal infant studied. Large amounts of orally administered ascorbic acid are excreted in the stools of infants following catharsis and during acute diarrhea. The increased fecal excretion of orally administered ascorbic acid during acute diarrhea in the infant points to its failure of absorption in the intestinal tract, and explains the low blood plasma values and low urinary excretion.

Hemorrhages complicating deep pharyngeal infection

Summary Four cases of severe arterial hemorrhage from the pharynx andmiddle ear, arising as a complication of retropharyngeal and parapharyngeal infections, are here reported; all of these patients recovered. There infections originated from upper respiratory or ear infections;all of the four children here reported had previously had their tonsils removed. The erosion and the perforation of the large arteries of the neck by infection in the retropharyngeal and parapharyngeal spaces have been discussed. Criteria for the diagnosis of the particular artery involved in thehemorrhage have been enumerated. When the bleeding has been from a branch of the external carotid artery, its ligation has been advised. In three instances of direct perforation of the arterial wall or of false aneurysm of the internal carotid artery, we have successfully ligated the common carotid artery, and in one instance in which perforation occurred in a branch of the external carotid artery, this vessel was also successfully ligated. We have pointed out that this operation, while not without inherentdanger, is imperatively indicated to prevent fatal hemorrhage.

Intussusception in Infants and Children

This, the first monograph in a series of pediatric surgical monographs, presents a historical account, the incidence of occurrence, the clinical course, errors in diagnosis, pathological and experimental studies, and the treatment related to intussusception. An excellent diagram demonstrates the various types of intussusception that may be caused by the appendix or originate at the ileocecal junction. The operative treatment of irreducible intussusception is presented as an illustration and includes such procedures as exteriorization of the intestine with delayed division, and resection with primary anastomosis. Nonoperative reduction by barium enema with serial roentgenograms and case histories in the legends is easily followed by the reader. The case fatality figures quoted favor the nonoperative type of reduction. A brief account of the primary treatment with barium enema followed by completion of reduction by operation is given, and illustrative cases are cited. The author concludes that all children with intussusception deserve a