Transcriber's notes:
In this plain text version, bold script is denoted by =equals signs= and
italic script by _underscores_. Underscores are also used with curly
brackets to represent subscripted characters (e.g. CO_{2}). Text that
was originally rendered in small capitals now appears in full capitals.
Footnotes are located below the relevant paragraphs.
The book contains numerous spelling inconsistencies. No change has been
made to those representing archaic spellings (e.g. 'somethimes', 'urin',
'feavers', 'joynts') and those occurring in quotations. Spelling
variants occurring with similar frequency have been left in their
original form (e.g. Röntgen/Roentgen, rachitic/rhachitic,
albumen/albumin - the correct spellings is used for egg albumen but both
are used randomly for serum/urine albumin). Most other spelling
inconsistencies have been changed to the more-frequent or more-accurate
form (e.g. twofold-->two-fold, guinea pig-->guinea-pig, oedema-->edema,
neuroedema-->neuredema, gm.-->g., Luborsch-->Lubarsch, Bauman-->Baumann,
McCluggage-->McClugage, Eijkmann-->Eijkman). Although the spelling of
'fæces' and its adjective 'fecal' is not consistent, the two spellings
are used consistently throughout the book and therefore have not been
altered. Similarly 'hemorrhage' and 'hemoglobin' are consistently spelt
thus, while other words relating to blood consistently use the æ
ligature, e.g. 'hæmatemesis', 'hæmatoma', 'hæmaturia', 'leukæmia',
'hyperæmia'.
Wrong or missing French accents and typos have been corrected where
necessary. German expressions in the bibliography contain various
apparent inconsistencies that have not been changed because of my
unfamiliarity with the language and what was perhaps legitimate at the
time of writing (e.g. 'Muench. med. Woch.', 'Muenchn. med. Woch.' and
'Muenschner med. Woch.'; 'Barlow'schen Krankheit' 'Moeller-Barlow'sche
Krankheit', 'Moeller-Barlow'scher Krankheit', and 'Moeller-Barlowscher
Krankheit'; 'Beiträge z.', 'Beitraege zur', 'Beitrag zur'). The term
'Gernest-mark' on p. 108 should probably be 'geruestmark' (or perhaps
gerüstmark) as used elsewhere in the book (pp. 96, 107, 108 and 128).
The book also contains numerous hyphenation inconsistencies. Some of
these have been altered to conform with the most common usage in the
text, but most have not been changed because hyphenation is notoriously
variable and subject to fashion.
Subheading use is somewhat inconsistent; for example, under the
subheading 'Alimentary Tract' in chapter IV, there appear various
non-alimentary items, and in the same chapter 'Microscopic Pathology'
appears as a stand-alone subheading whilst its equivalent 'Gross
Pathology' is relegated to a bold in-line paragraph introduction.
The bibliography contains two very similar references attributed to Gee.
The second appears to be a duplicate of the first, but it is probable
that the title is incorrect because the publication details (1889, XXV,
85) relate to a different paper by Gee entitled 'Bloody Urine the Only
Sign of Infantile Scurvy', and although there are several comments in
this book about scurvy and haematuria (blood in the urine), e.g. p. 204,
none cite Gee's paper.
The second entry for Morse, J. L. in the bibliography should be numbered
as (2) and the source should be Boston Med. and Surg. Journal, 1914,
CLXX, 504. (not Jour. Am. Med. Assn.).
Inconsistent punctuation in the bibliography list has been corrected
(e.g. semicolon-->colon).
* * * * *
SCURVY
PAST AND PRESENT
BY
ALFRED F. HESS, M.D.
CLINICAL PROFESSOR OF PEDIATRICS, UNIVERSITY AND BELLEVUE HOSPITAL
MEDICAL COLLEGE, NEW YORK CITY
_ILLUSTRATED_
[Illustration]
PHILADELPHIA AND LONDON
J. B. LIPPINCOTT COMPANY
COPYRIGHT, 1920, BY J. B. LIPPINCOTT COMPANY
PRINTED BY J. B. LIPPINCOTT COMPANY
AT THE WASHINGTON SQUARE PRESS
PHILADELPHIA, U. S. A.
PREFACE
Interest in scurvy has been stimulated in the last few years as the
result of a new and broader conception of nutrition. It has come to be
realized that in addition to the substances heretofore recognized as of
essential importance in the dietary--the proteins, fats, carbohydrates
and the salts--there is still another group, termed "vitamines,"
"accessory food factors" or "food hormones," which must be included in
order to render the diet complete and adequate. It has become
increasingly evident that the attention of physiologists and of
clinicians has been focussed too sharply and too narrowly on the caloric
value of foodstuffs. At the same time we have begun to appreciate the
existence of a group of nutritional disorders which depend largely on a
deficiency of these illusive vitamines or food factors, and which
evidently are of vital importance to the welfare of the individual and
of mankind. Scurvy is one of this newly-constituted group, and due to
this association has acquired a fresh and broader significance. It is in
this light that the intensive research work must be interpreted, which
has been applied within the past few years, both in this country and
abroad, to problems relating to this disorder. It is clear that the
subject is in its infancy, and is destined to participate in a
consideration of many of the nutritional and infectious diseases of the
adult and the child.
The World War has tended also to demand a renewed consideration of
scurvy. This disorder has played a rôle in all wars--in the campaigns of
the Cæsars, the pilgrim ages of the Crusaders, and the numerous wars of
the last century. In the recent war it existed among the various
armies, particularly those in the East, to an extent greater than at
first was realized. In Mesopotamia it is stated to have been one of the
decisive factors in forcing the surrender of the British at Kut. Its
incidence, however, was not limited to the military forces. Reports from
England and the continental countries clearly indicate that scurvy
prevailed among the civilian population during the past few years to a
degree unknown in peace times. This was especially true of infants and
children.
For the past seven years I have been engaged in an investigation of
scurvy both in the laboratory and in the clinic, and have treated
various aspects of the subject in a large number of articles published
in various medical journals. In the course of these studies there has
been ample opportunity for a comprehensive review of the
widely-scattered literature. No treatise on scurvy has been published in
English since the classical work of Lind in 1772. The time, therefore,
seemed opportune to gather into one volume the recent advances in this
field and to offer to the clinician, to the hygienist, and to the
biological chemist a presentation of the existing status of this
important nutritional disease.
It is with pleasure that I acknowledge my obligation to Dr. Lester J.
Unger, who has assisted in carrying out much of the work described in
this volume. Thanks are due also to Dr. Charles Gottlieb for the
radiographs which are here reproduced, and to Dr. Gertrude McCann for
seeing the work through the press. To my associates in the clinic who
shared in the observations, and to friends who read various chapters in
the course of their preparation, I wish to express my appreciation.
ALFRED F. HESS.
New York,
August, 1920.
CONTENTS PAGE
PREFACE iii-iv
CHAPTER I
HISTORY OF SCURVY 1
(_a_) OUTBREAKS ON LAND; (_b_) OUTBREAKS AT SEA; (_c_) INFANTILE
SCURVY; (_d_) SCURVY IN THE WORLD WAR
CHAPTER II
PATHOGENESIS AND ETIOLOGY 23
PATHOGENESIS: THEORIES; POTASSIUM DEFICIENCY; ACIDOSIS; TOXIC;
BACTERIAL; VITAMINE (ACCESSORY FACTOR)
ETIOLOGY: BREAST-FED INFANTS 35
ARTIFICIALLY FED INFANTS: PASTEURIZED MILK; BOILED AND STERILIZED
MILK; DRIED MILK; CONDENSED MILK; PROPRIETARY FOODS (EFFECT
OF ALKALIZATION) 40
AGE, SEASON AND CLIMATE; ECONOMIC STATUS; PSYCHIC ELEMENT;
PREDISPOSITION; EFFECT OF OTHER FOOD CONSTITUENTS; EXCITING
FACTORS
CHAPTER III
THE ANTISCORBUTIC VITAMINE 62
CHARACTERISTICS: RELATION TO HEAT, DRYING, AGING, ULTRA-VIOLET
RAYS, SHAKING 65
MODE OF ACTION--(_a_) DIRECT: AS A NUTRIMENT; ANTITOXIN;
CATALYZER; (_b_) INDIRECT: ENDOCRINE ACTION 69
FATE IN THE BODY: STORING; CONTENT IN BLOOD; EXCRETION; FATE IN
GASTRO-INTESTINAL TRACT; EFFECT ON DIGESTIVE PROCESSES 74
IRREGULARITIES OF ACTION; EFFECT ON GROWTH
CHAPTER IV
PATHOLOGY 81
(_a_) GROSS: GENERAL APPEARANCE; HEMORRHAGES; ANASARCA; HEART;
LUNGS; ALIMENTARY TRACT AND ITS GLANDS; URINARY TRACT; LYMPH
NODES; ORGANS OF INTERNAL SECRETION; BRAIN AND SPINAL CORD;
BONES;
(_b_) MICROSCOPIC: SKIN; MUSCLES; BLOOD-VESSELS;
LUNGS; HEART; INTESTINAL TRACT AND ITS GLANDS; KIDNEY;
ADRENALS; PANCREAS; THYMUS; CENTRAL NERVOUS SYSTEM; PERIPHERAL
NERVES; RETINA; BONES
CHAPTER V
EXPERIMENTAL SCURVY 111
HISTORICAL REVIEW
PATHOGENESIS 116
PATHOLOGY: EFFECT ON THE FOETUS; SCURVY IN THE MONKEY;
MICROSCOPIC PATHOLOGY; BONES; TEETH; NERVES; BLOOD VESSELS;
INTERPRETATION OF BACTERIA IN THE TISSUES 122
SYMPTOMS 135
CHAPTER VI
ANTISCORBUTIC FOODS 143
HISTORICAL REVIEW 143
MILK: RAW; PASTEURIZED; DRIED 150
FRUITS AND FRUIT JUICES: DRIED 153
VEGETABLES: CABBAGE; EFFECT OF HEATING. POTATO. SWEDE 158
DEHYDRATED VEGETABLES: CANNED FOODS (TOMATOES) 166
GERMINATED CEREALS AND PULSES; MEAT AND EGGS; BEER AND ALCOHOLIC
BEVERAGES; MISCELLANEOUS
CONCLUSIONS 173
CHAPTER VII
SYMPTOMATOLOGY AND DIAGNOSIS 176
IN ADULTS 176
IN INFANTS: (_a_) ACUTE; (b) SUBACUTE; (_c_) LATENT.--HEMORRHAGE
OF GUMS; SUBPERIOSTEAL HEMORRHAGE: SKIN; MUCOUS MEMBRANES
AND SUBCUTANEOUS TISSUES; HEMORRHAGES OF INTERNAL ORGANS;
NAILS AND HAIR; ECZEMA; EDEMA; TENDERNESS; BEADING OF RIBS;
SEPARATION OF EPIPHYSIS; "WHITE LINE"; CARDIOVASCULAR SYSTEM;
"CARDIORESPIRATORY SYNDROME"; NERVOUS SYSTEM; URINARY SYSTEM;
THE BLOOD AND BLOOD-VESSELS; NUTRITION AND GROWTH; FEVER;
COMPLICATIONS; EPIDEMIC FORM 183
DIFFERENTIAL DIAGNOSIS: RHEUMATISM; PURPURA; CONGENITAL SYPHILIS;
BONE TUMORS; OSTEOMYELITIS; POLIOMYELITIS, ETC. 219
CHAPTER VIII
PROGNOSIS 225
CHAPTER IX
TREATMENT 230
PREVENTATIVE; CURATIVE
NON-DIETETIC
CHAPTER X
METABOLISM 241
IN ADULTS: BODY EXCHANGES 241
IN INFANTS: BODY EXCHANGES; ANALYSIS OF ORGANS; CHEMISTRY OF
BLOOD 242
IN ANIMALS: MONKEY; GUINEA-PIG 245
CHAPTER XI
RELATION OF SCURVY TO OTHER DISEASES 248
BERIBERI; SHIP-BERIBERI; PELLAGRA; RICKETS; OSTEOGENESIS
IMPERFECTA; OSTEOMALACIA; HUNGER EDEMA; "MEHLNAERSCHADEN";
EXUDATIVE DIATHESIS; DISEASES DUE TO A FOOD EXCESS
APPENDIX: LIND'S RECIPES FOR PREPARING STABLE ANTISCORBUTICS 259
BIBLIOGRAPHY 261
ILLUSTRATIONS
FIG. PAGE
1. Dependence on potato as antiscorbutic 7
2. Weight curve of scorbutic baby. Effect of alkalization of milk 51
3. Lumbar cord in case of scurvy 104
4. Lumbar cord in case of scurvy. Focal degeneration 104
5. Bone in scurvy. Microscopic pathology 105
6. Subperiosteal hemorrhage and separation of epiphysis.
Roentgenogram 108
7. Complete restitution of epiphysis without deformity.
Roentgenogram 109
8. Curve of fecal excretion in scurvy 120
9. Diagrammatic representation of guinea-pig scurvy 128
10. Loss of weight in guinea-pig scurvy 139
11. Dried milk as an antiscorbutic 140
12. Dehydrated vegetables as a cause of scurvy 164
13. Cure of scurvy by addition of canned tomato 166
14. Failure of yeast as prophylactic 171
15. Temperature, pulse, and respiration in scurvy 186
16. Subperiosteal hemorrhage and separation of epiphysis.
Roentgenogram 192
17. Periosteal "tags" and "streamers." Roentgenogram 193
18. Infant with marked scurvy. Characteristic position 198
19. Scorbutic beading of ribs. Roentgenogram 198
20. "White line." Roentgenogram 199
21. Cardiac enlargement. Roentgenogram 200
22. Electrocardiogram showing "cardiorespiratory syndrome" 201
23. Stationary weight during cure of scurvy. Oliguria followed by
polyuria 206
24. Development of scurvy in spite of normal gain in weight 214
25. Retardation of growth in length when no orange juice was given
and supergrowth when given once more 216
TABLES
TABLE PAGE
1. Fecal flora of scorbutic infants 29
2. Necropsy reports of scurvy 82
3. Relative distribution of the antiscorbutic factor in the commoner
foodstuffs 157
4. Platelets and other blood cells in scurvy 209
5. Data of epidemic of scurvy 218
6. Duration of treatment before marked improvement was noticed 237
SCURVY
PAST AND PRESENT
CHAPTER I
HISTORY OF SCURVY[1]
[1] The best historical review of scurvy is to be found in Hirsch's
Handbook of Geographic and Historical Pathology, from which account we
have drawn many facts.
=Outbreaks on Land.=--Like many other diseases, the life history of
scurvy shows several distinct phases. We hear of it first as a plague,
infesting armies and besieged towns; then as a dread disease, decimating
the sailors of the navy and of the mercantile marine, and, since the end
of the last century, more often as a nutritional disturbance,
endangering the health of infants. Very recently it has acquired an
entirely new interest, as the representative of a class of disorders
which has revealed the essential importance to man of unknown dietary
factors.
It is difficult, as may be imagined, to define with precision the
earliest description of scurvy, as the older references are so vague as
to be open to individual interpretation. The reference of Hippocrates to
a large number of men in the army who suffered from pains in the legs
and gangrene of the gums, which was accompanied by loss of teeth, seems
sufficiently definite to be identified as this disease. The Greek, Roman
and Arabian writers do not seem to have been acquainted with scurvy.
This is as we should expect, for fruits and vegetables grew in such
plenty in these southern countries that scurvy must have been a disorder
of rare occurrence.
An interesting early description of scurvy, and one which is quite
convincing, is that of de Joinville, who accompanied the Crusaders in
their invasion of Egypt under St. Lewis, about the middle of the
thirteenth century. He refers to the lividity and spongy condition of
the gums, and describes how "the barber surgeons were forced to cut away
the dead flesh from the gums to enable the people to masticate their
food"; he describes their debility, their tendency to faint, and the
black spots on their legs. The disease broke out in Lent, during which
time the soldiers partook of no meat, but consumed a species of eel
which they believed "ate the dead people" and therefore led to this
loathsome disease.
It is probable that scurvy existed in the northern parts of Europe and
Asia ever since they were settled by man. We should hardly expect to
have records of this condition, in view of the low educational status of
the people, their greatly restricted literature, and their lack of
intercourse with the people in the southern countries. In the sixteenth
century, with the development and spread of education, we begin to hear
of scurvy from various sources. Claus Magnus, in his "History of the
Northern Nations," published in 1555, described the disease which he
tells us flourished among the soldiers in the camps and in the prisons.
About this time Ronsseus, Echtius and Wierus wrote special treatises on
this disease, and recommended many dietary measures which we recognize
to-day as most efficacious. The number of monographs on this subject
multiplied with great rapidity in the course of the next twenty-five or
fifty years; none of them, however, added anything essential to our
knowledge. In 1645 the Faculty of Medicine at Copenhagen published a
"consilium" for the benefit of the poor, treating of the causes,
prevention and cure of this disease, which was prevalent among the Danes
and other northern nations.
The colonists of the northern part of America were sorely afflicted with
scurvy. It is said that the French met with such high mortality during
the severe winters in Canada, that they frequently debated the wisdom of
abandoning this settlement. This was true also in regard to the English
and their settlement in Newfoundland. Indeed, it was scurvy which forced
the early settlers in Hudson Bay to discontinue their intentions of
colonizing that region.
In an essay published in the eighteenth century (1734), Bachstrom
described an epidemic of scurvy which occurred in 1703 during the siege
of Thorn, in Prussia, by the Swedes, which caused the death of 5000 of
the garrison, in addition to a large number of the inhabitants. It is
interesting to note that this epidemic took place in the middle of the
summer, and not in the cold season. From this time on we meet with many
descriptions of scurvy in connection with the wars at various periods.
For instance, in the Russian armies, in the war between the Austrians
and the Turks in 1720; in the English troops who had taken Quebec from
the French in 1759; among the French soldiers in the army of the Alps in
the spring of 1795. It is unnecessary to review these accounts in
detail. This period is distinguished rather by the appearance of a great
classic on Scurvy, the work of the English naval hygienist, Lind (1752).
This book has intrinsic value to-day, and, at the time it appeared,
served to crystallize the conception of scurvy, which had been stretched
out of all proportions to include an ever-increasing conglomeration of
clinical conditions. Scurvy had become the Alpha and Omega of
professional routine, the catchword of the day, the asylum ignorantiæ of
the practical man. Into this chaos, as Hirsch expresses it, "the first
beams of light fell when Lind's classical work appeared."
It will be of little value to consider the great number of epidemics of
scurvy which occurred from this time to the present day. They may be
found in tabular form in the excellent survey of scurvy by Hirsch. The
literature of this long period may likewise be found in a work of
encyclopædic character, that of Krebel, which gives the titles, with a
summary of the various articles on this subject, appearing to the year
1859. If we look over the chronological table compiled by Hirsch, we
note a remarkable similarity regarding the incidence of the recurring
epidemics. In almost all cases they broke out among troops, whether in
Russia, in India, in Africa, or in our United States. The epidemics
which are not attributable to military life or campaigns are found to
have taken place generally in prisons, insane asylums, poorhouses or
houses of refuge and correction. It would seem that no war is omitted
from this list of sickness and death. There are in all 143 land
epidemics between 1556 and 1877, two occurring in the sixteenth century,
four in the seventeenth, 33 in the eighteenth, and 104 in the nineteenth
century. The marked increase in the nineteenth century occurred in
institutions, in asylums and prisons, rather than in the armies. This
fact may be ascribed to altered social conditions which led to a great
multiplication of eleemosynary institutions.
Coming down to more recent times, we learn that scurvy occurred
extensively during the Crimean War, and that it was prevalent also among
the troops in our own Civil War. In the "Medical and Surgical History of
the War of the Rebellion," we find the following statements:
"A scorbutic tendency was developed at most of our military posts
during the winter season, after the troops had been confined to the
use of the ordinary ration with the desiccated vegetables. The
latter in the quantities failed to repress the disease. At posts
which could be readily supplied with potatoes only the taint was
manifested, on account of a want of liberality in the issues." And
again: "Among the white troops during the five and one-sixth years
covered by the statistics, 30,714 cases of scurvy were reported; and
383 deaths were attributed directly to that disease."
Munson writes: "It (scurvy) prevailed among our troops during the Civil
War and its recognition was a surprise and shock to professional ideas
preconceived from practice in civil life."
As is well known, the besieged in Paris during the Franco-Prussian War
in the winter of 1870-71 suffered severely from scurvy. The accounts of
their pitiable condition have been portrayed for us by numerous French
writers (Delpech, Hayem, Lasèque and Legroux). The people lived mainly
on rice and bread, with an occasional addition of potatoes or horse
meat. The winter was exceptionally severe, which was supposed to have
intensified the scorbutic condition. Not only were the inmates of the
prisons on the Seine attacked, numbering about one thousand, but even
the patients in the military hospitals developed the disease. It is of
interest to remember that the siege lasted but little over four months,
from September 17th to January 27th, the date of the armistice.
In the Russo-Japanese War, after the siege of Port Arthur, it was found
that one-half of the garrison of 17,000 men had scurvy.
Although there are certain parts of the world where scurvy is of
frequent occurrence, no country has been entirely free from it. As might
be expected, it has been particularly prevalent in the North, where
vegetation is scanty--in Greenland, Alaska, Russia and the Baltic
States. It has likewise prevailed in the tropics when the crops have
failed. India has been conspicuous for its large number of epidemics;
some years ago scurvy occurred in Arabia among the English troops
stationed at Aden, both among the British and the native troops. A
recent communication from Aruba, a small island of Dutch Guiana, lying
north of Venezuela, illustrates how devastating scurvy still is in some
parts of the world. This account tells of 3000 cases of this disease
which occurred in 1915 among a population of less than 10,000, owing to
the fact that the crops had failed almost entirely during the years
1912, 1913 and 1914.
It is important for us to realize that we are still dependent on the
annual crops for our protection from scurvy; in other words, the world
is leading a hand-to-mouth existence in regard to its quota of
antiscorbutic food. The truth of this condition has been realized for
Ireland, sadly illustrated by numerous epidemics, notably the great
epidemic of 1847 reported by Curran. It was demonstrated by the
outbreaks of scurvy in Norway in 1904 and 1912, and was brought to the
attention of many in the United States in the spring of 1916. In this
year our potato crop fell far below the normal, with the result that
scurvy appeared in various parts of the United States, especially in
institutions (Fig. 1).
[Illustration: Fig. 1.--A comparison between the requisitioned quantity
(in thousand pound units) of potatoes and other vegetables, and the
quantity received per month by an institution in which more than 200
cases of scurvy occurred at the beginning of April, 1916. The total
height of column represents the amount needed and requisitioned; the
solid black portion the amount received. The number of inmates in the
institution remained approximately the same.
The chart illustrates our great dependence on the potato during the
winter months. This is due not only to its intrinsic antiscorbutic
potency, but, probably quite as much, to the fact that fully twice as
many pounds of potatoes are consumed during the winter as of all other
vegetables combined. Therefore, if this crop fails or is dehydrated,
scurvy will develop in the spring.]
The fact that scurvy may occur in any land and climate, even in the
garden spots of the world, is strikingly shown by the epidemics reported
from Algiers, and the ravages of this disease among the gold seekers in
California in 1849. Nothing could be more incongruous than the
occurrence of a deficiency disease in this land of plenty.
=Outbreaks at Sea.=--It is doubtful, however, whether attention would
have been focussed so early and so sharply on scurvy, had it not been
for the voyages of exploration undertaken in the sixteenth century.
These long trips on sailing vessels, where for many months little or no
fresh vegetable or animal food was obtainable, were almost as if
designed to make a test of the dietetic origin of scurvy. The result was
inevitable--five to six months after the ships were out of touch with
land, the majority of the crew frequently were incapacitated by this
disease, thereby wrecking many an expedition.[2]
[2] The fact that crews of vessels which set sail in winter were more
subject to scurvy than those which set out in the summer must be
attributed to the existence of latent scurvy among the sailors at the
time of sailing, rather than to the season of the year.
The earliest account of the outbreak of scurvy at sea is that of Vasco
de Gama, who in 1497 discovered a passage to the East Indies by way of
the Cape of Good Hope. The narratives of subsequent explorers,
especially those of Cartier and of Drake, are replete with descriptions
of the ravages of scurvy. The expedition of Lord Anson in 1740 is
always cited as a memorable example of an undertaking which foundered as
the result of scurvy. After a cruise of four years, this expedition had
lost from this disease more than four out of five of the original number
of its crews. In striking contrast to this picture, and to that
furnished by the voyages of earlier navigators, is that of Captain Cook,
who in 1772 undertook a voyage lasting over three years, sailing from
52° north to 71° south, with a loss of but one of his crew from disease,
and that not from scurvy. This remarkable feat, more than any other,
centered attention on the feasibility of preventing scurvy, and resulted
in measures tending to eradicate it from the navy. Captain Cook
attributed the absence of scurvy among his crew to "sweetwort," an
infusion of barley, which he prepared fresh and served liberally. He
also prized the antiscorbutic value of sauerkraut.
We find accordingly in 1795, at the instance of Sir Gilbert Blaine, that
improvements were introduced in the victualling of the fleet. As the
result of a regular ration of lemon juice, the incidence of scurvy fell
precipitously. It is due largely to this provision that between the
years 1779 and 1813, according to the statistics of Sir Jay Barrow, the
morbidity and the mortality in the British Navy was decreased by 75 per
cent.
It has been shown that it took a generation after the efficacy of
antiscorbutics had been demonstrated in various expeditions, for an
antiscorbutic to be included in the ration of the navy. The merchant
marine of England was far more conservative, and for many years after
scurvy had been eradicated from the navy we still read of its occurrence
on the vessels making voyages to India, China and Ceylon. Gradually,
however, its incidence became less and less. Its toll of death, before
preventive measures were employed, may be appreciated from the fact that
it has been estimated that scurvy destroyed more sailors than all other
causes incidental to sea life, including the great slaughter of naval
warfare. Sir R. Hawkins stated in the latter part of the sixteenth
century that he could give an account of 10,000 mariners who had been
destroyed by scurvy during the twenty years that he had been at sea.
As is well known, scurvy has played an important rôle in Arctic and
Antarctic explorations, and has been the cause of the failure of many of
these expeditions. It is now realized that the development of scurvy is
quite preventable, that if a sufficient quantity of meat (especially raw
meat) is consumed, explorers can be entirely independent of a supply of
fresh vegetables. This fact was brought out by the Arctic Survey
Committee (British), who "were appointed to enquire into the causes of
the outbreak of scurvy in the recent Arctic expedition" (1877), and who
reported that it may result from an absence of fresh meat. That this
conclusion was sound has been proved by the experiences of Nansen and of
Johansen, who wintered safely in Franz-Josefsland on a diet of meat and
bacon. More recently Stefánsson has carried out successful Arctic
explorations, depending entirely on fresh meat as antiscorbutic
foodstuff and making no provision whatsoever for vegetable food.
=Infantile Scurvy.=--Glisson, to whom we owe the first description of
rickets, likewise was the first to recognize scurvy in infants. In his
classic treatise on rickets, written in 1668, he writes as follows:
"The scurvy is sometimes conjoyned with the affect. It is either
hereditary, or perhaps in so tender a constitution contracted by
infection, or lastly, it is produced from the indiscreet and
erroneous Regiment of the infant, and chiefly from the inclemency of
the air and climate where the child is educated."
"The scurvy complicated with this affect hath these signs: 1. They
that labor under this affect do impatiently indure purgations; but
they who are only affected with the Rachites do easily tolerate the
same. 2. They are much offended with violent exercises, neither can
they at all endure them. But although in this affect alone, there be
a kind of slothfulness and aversation from exercise, yet exercise
doth not so manifestly, at least not altogether so manifestly hurt
them, as when the scurvy is conjoyned with the Rachites. 3. Upon any
concitated and vehement motion they draw not breath without much
difficulty, they are vexed with diverse pains running through their
joynts, and these they give warning of by theyr crying, the motion
of the Pulse is frequent and unequal, and somethimes they are
troubled with a Palpitation of the Heart, or threatened with a
Lypothymie, which Affects are for the most part soon mitigated, or
altogether appeased by laying them down to rest. 4. Tumours do very
commonly appear in the Gums. 5. The urin upon the absence of the
accustomed feavers is much more intense and increased."
Glisson's description of scurvy was entirely lost sight of, overshadowed
by his description of rickets, so that for over two hundred years no
word of infantile scurvy is to be found either in the English or other
literature. There is no doubt that from time to time cases must have
occurred, but they were looked upon probably as rickets or as a
manifestation of one of the hemorrhagic diseases.
In 1859 Moeller described some cases which evidently were scurvy, but
which he termed "acute rickets." He realized that they presented a novel
clinical picture but failed to recognize that they represented a
disorder quite distinct from rickets.[3] This article was followed
within the next few years by reports of other German writers (Bohn,
Steiner, Foerster) who, accepting Moeller's point of view, considered
these cases merely as an acute form of rickets. They were led to this
erroneous conclusion chiefly on account of the lack of marked
involvement of the gums, which they considered an essential sign,
influenced by their conception of adult scurvy. This viewpoint has
pervaded the German literature even to the present day, when it is still
considered necessary to bring further evidence that infantile scurvy in
its pathogenesis and pathology is identical with adult scurvy.
[3] Infantile scurvy is frequently termed "Die Moellersche Krankheit."
There seems to be no occasion for giving Moeller credit for discovering
this disease, as he believed that he was dealing with rickets merely in
an acute form. He recognized the clinical similarity to scurvy, but in
one of his cases sharply differentiates it from adult scurvy by the fact
that "lemon juice and fresh vegetables" were of no avail in the
treatment.
In 1871 Ingerslev, an assistant of Hirschsprung in Copenhagen, wrote a
paper on "A Case of Scurvy in a Child," which is quite convincing. Two
years later Jalland, an English physician, reported a similar case of
"Scurvy in a Ten-Months-Old Infant." In 1878 Cheadle reported three
cases of infantile scurvy with typical tumefaction of the gums, and
obscure tenderness of the legs, and followed this paper by two others,
which appeared in 1879 and 1882. Cheadle clearly recognized the disease
as scurvy. However, as the title of his first paper--"Three Cases of
Scurvy Supervening on Rickets in Young Children"--indicates, he
considered it a condition engrafted upon rickets. About this time (1881)
Gee presented a brief but accurate account of five cases of scurvy which
he termed "osteal or periosteal cachexia."
In 1883, Barlow published his classical paper on this subject, the first
to furnish anatomical proof that this disorder of infants presented the
pathological changes characteristic of adult scurvy. Previous to this
publication there had been but one autopsy report, that by Moeller,
which had been incorrectly interpreted. The work of Barlow was accepted
remarkably quickly in England and in America, but less promptly on the
Continent. This was probably due to the fact that infantile scurvy was
occurring far more frequently in these two countries, and that the
subject was open therefore to more prompt investigation. This increased
prevalence of infantile scurvy in the two great English-speaking nations
has continued to the present time, and no doubt is due to the extensive
employment of artificial feeding and of proprietary foods. In 1894 not
less than 106 cases were reported to the Academy of Medicine of New York
City by various physicians, and in 1898 the comprehensive investigation
of the American Pediatric Society appeared, which was based on 379
cases.
It was soon evident that infantile scurvy occurred to a greater or less
degree throughout the civilized world. In France, Monfalcon had reported
a case in 1820 which is sometimes referred to as the earliest case of
infantile scurvy mentioned in the literature. It relates, however, to an
older child and was published as a case of scorbutic rickets. Netter
was one of the first in France to recognize the true nature of the
disorder, and published several papers in 1898 describing typical cases.
Infantile scurvy was, however, almost unknown in that country until what
is termed "lait maternisé" and "lait fixé" came into vogue. This is
apparent from a table prepared by Lecornu, which gives a list of all
cases in the French literature between 1894 and 1904, and of the diets
on which they came about. The former of these milk preparations is
subjected to various manipulations and then heated to a temperature
above the boiling point; the latter is shaken violently in a machine to
render the fat globules smaller, and is then sterilized by one of the
usual methods.
Switzerland has undergone an experience similar to that of France.
Previous to 1903 only five cases of infantile scurvy had been published
from that country. In this year Stoos published an additional five. In
1907 Bernheim-Karrer reported nine cases, all of which had developed on
homogenized milk, a process very similar to that employed by the French
to break up the fat globules. The increase of infantile scurvy in
Switzerland may be judged by the fact that a commission was formed in
the following year to investigate its occurrence.
In Germany there was for many years continued discussion as to the true
nature of scurvy. Some believed it to be a form of rickets, others a
form of scurvy; still others a combination of scurvy and rickets. Some
thought it merely hereditary syphilis, and not many years ago Naegeli
looked upon it as an entity distinct from scurvy on rickets. The subject
attained additional importance through an epidemic of infantile scurvy,
which broke out in Berlin in 1898, among infants who received milk from
one of the largest dairies. The episode led to prolonged discussion in
the Berlin Medical Society, and to several excellent papers, among
which that by Neumann deserves particular mention.
The disorder has been reported in Holland by DeBruin, who recorded
numerous cases; in Denmark, by Hirschsprung, who refused to recognize
its scorbutic nature; in Italy, by Concetti, and by others. It was not
long before there were reports of cases from almost every part of the
world, including Australia (Money) and East India (Nichols).
In view of the fact that scurvy is endemic among adults in Russia, we
should also expect to find infantile scurvy widespread in that country.
In point of fact, quite the contrary seems to be the case. In connection
with the great scurvy epidemic in Russia (1898-99), Tschudakoff
personally examined over 10,000 persons and found 11.11 per cent. of the
people sick with this disease. He states that in the course of this
large experience he did not meet with a single case under the age of
five years. Fuerst writes that Filatow, the great Russian children's
specialist, declared that he knew of no case of Barlow's disease
described in the Russian literature. This is not literally correct, as
Doepp described an epidemic of scurvy in the St. Petersburg Foundling
Asylum occurring in 1831. It serves to emphasize, however, the paucity
of cases among infants in this great land of endemic adult scurvy.
Lyabmow, in referring to the scurvy in Kazan, tells us that among 28,000
cases only a few infants were affected, and Rauchfuss made the statement
at the International Congress at Copenhagen, in 1884, that although he
had seen a great many cases of scurvy, he had never seen it in children
one to two years of age. We shall not, in this place, comment on this
interesting and apparently paradoxical situation, but shall have
occasion to refer to it in considering the pathogenesis. It may be added
that in Norway and Sweden, where scurvy is to some extent also endemic
among the adult population, there is a similar lack of scurvy among
infants.
=Scurvy in the World War.=--The greatest advance in medicine during the
past generation has been in the fields of hygiene and preventive
medicine. One might therefore have expected that the World War would
have differed from previous wars in a notable absence of scurvy among
the troops and the civilian population. This is true to a limited degree
only. Reports which have been published in the course of the war, and
especially since hostilities have ceased, show that the troops who were
incapacitated by scurvy must have numbered many thousands. As was to be
expected, scurvy occurred most often in Russia, where it is endemic. The
largest number of cases was reported by Boerich, who as director of a
Red Cross Central Station in Russia saw 1343 cases. Other German
physicians who had charge of caring for the Russian prisoners give
accounts of the occurrence of some hundreds of cases of scurvy. An
article by Much and Baumbach gains added interest from the novel
suggestion that scurvy is transmitted by means of vermin. That scurvy
must have reached large proportions is shown by the fact that in July,
1916, a medical commission was sent by the Germans to investigate the
scurvy in a Russian army corps, and that it was necessary to establish
for this disease in every division a sanatorium comprising 100 beds.
Hoerschelman, who wrote an account of this investigation, blames the bad
hygienic surroundings, the lack of sleep, the overexertion, as well as
the deficiency of food, for the occurrence of the epidemic. As usual,
very few cases occurred among officers. He describes a number of
instances where scurvy was feigned by rubbing the gums and making them
bleed, or by irritating them with the juice of tobacco. These reports on
scurvy in Russia bring us little new from a purely medical standpoint.
They emphasize the occurrence of night-blindness as an early and
frequent symptom. It is difficult to judge whether this manifestation
was due entirely to the scurvy, or was in part the result of other
deficiencies in the diet. For instance, Hift states that the
night-blindness was cured by cod liver oil, or by the water in which
beef liver had been cooked. This would point rather to a deficiency of
the fat-soluble vitamine, as these substances could have little effect
in curing scurvy. The cases reported by Wassermann, where neuritic pains
in the legs played a considerable rôle, evidently are also not simple
scurvy, but may well be the result of more than one food deficiency or a
complicating ostitis. In the same way some reports show clearly that
"hunger edema" complicated scurvy.
Scurvy occurred next in frequency among the nations neighboring Russia.
Speyer tells us that a German sanitary commission was sent to Bulgaria
largely with the object of investigating scurvy in that country. The
excellent monograph on the pathology of scurvy just written by Aschoff
and Koch was founded on an experience in Roumania among Turkish, German
and Austrian soldiers. Added to its other woes the Servian army was
visited by scurvy. Wiltshire gives us a description of this disease
based on an observation of 3000 cases in the first half of the year
1917. In regard to scurvy in this part of the world, Morawitz writes
that when he reached Roumania he was surprised to find scurvy the most
prevalent disease in the army, and that since the spring of 1917 it was
widely disseminated among the German troops. Lobmeyer writes of scurvy
among the Turkish troops, and Disqué reports 500 cases among prisoners
captured in Turkestan.
Along the Western front very few cases are described. There is an
account by Korbsch of 51 cases in this area in 1915. Schreiber describes
30 cases among the German prisoners of war captured in the beginning of
1917, which were diagnosed as purpuric rheumatism. Arneth recounts that
sporadic cases of scurvy occurred among the German troops, especially
among the older soldiers, and that in many cases this was combined with
the hunger edema. He attributes the scurvy to a dependence on dehydrated
vegetables in the ration.
From all these accounts it is evident that scurvy played an important
rôle in the general nutrition of the troops on the Eastern front.
Probably it was of the latent variety, which is exceedingly difficult to
diagnose, but which increases the susceptibility to infection, and
intensifies the severity of all medical or surgical diseases. Von
Niedner takes this point of view, stating that although scurvy had been
largely prevented in this war, the obscure rudimentary type had not been
eradicated. He remarks upon a fact, noted in our Civil War and other
wars, that under these conditions eruptions assume a hemorrhagic
character in typhoid fever, cerebrospinal fever, rheumatism and other
infections. Pick made a similar observation at a medical meeting in
Vienna in reference to scurvy in the Austrian army, drawing attention to
the hemorrhagic diathesis existing among the troops and expressing the
opinion that scurvy was occurring in this war as in previous wars.
Very little scurvy seems to have broken out among the British troops in
Europe. Thirty-two cases were reported as occurring in the middle of
1915 at a divisional rest station in France. It made marked inroads,
however, on the health of the Colonial troops in Mesopotamia. In the
report of the Mesopotamia Commission we read that 7500 men were lost to
the force in 19 weeks as a result of scurvy, and that this happened in
the summer of 1916 although additions had been made to the ration in the
previous spring. A conception of the extent of the scurvy may be formed
from the accompanying table, published by Willcox:
Scurvy Beriberi
(Indians) (British)
1916 (July 1--Dec. 31) 11,445 104
1917 2,199 84
1918 825 51
It will be noted that thousands of cases occurred among the Indian
troops. This was due to the fact that the British ate more potatoes and
fresh meat. In his official report of the outbreak of scurvy among
Indian troops, Colonel Hehir writes: "The only vegetable now allowed is
2 ounces of potatoes and the only fresh meat 28 ounces a week. It is
very doubtful whether this authorized ration, if not supplemented by
other vegetables and more meat, is sufficient to prevent scurvy." In the
account which this officer gives of the medical conditions during the
siege of Kut-el-Amara, it is stated that there were 1050 admissions for
scurvy, fully developed, incipient and latent. It is remarked that those
Indians who ate horseflesh were decidedly less affected. From the fact
that special hospitals for scurvy were established in June, 1916, at
Bagdad, Amora and Basrah, it is evident that a large number of cases
must have been encountered. Most significant in this connection,
however, are the preventive measures which were instituted by the
British government. A body of 256 men, designated as the Madras
Gardener's Corps, were dispatched to Mesopotamia to plant gardens all
over the country and to supply packets of seeds to various units. At
Bagdad alone their output of vegetables was over 400,000 pounds. This
certainly constitutes a remarkable innovation in the hygiene of armies.
The French army was not entirely spared from scurvy. In 1917 Harvier, an
army surgeon, was surprised to discover that 95 per cent. of the 800
troops of which he had charge suffered from scurvy; he tells us that
other epidemic centres were recognized later outside this sector.
Elsewhere we read of the occurrence of scurvy in France, involving 40
per cent. of the 1700 men of the South African Labor Corps, and that
this disorder was still more serious in another company owing to the
fact that it was not recognized (Dyke).[4] Benoit reported 63 cases
which he discovered in 1917 among 300 laborers. According to his
account, all these laborers received the same food, and those with
scurvy recovered quite independently of any change in the dietary.
[4] The writer adds that he believes that the health of the natives at
home is protected by Kaffir beer, which they consume even to the amount
of 3 gallons a day, and which is made from germinated Kaffir corn. This
cereal is germinated by steeping it in water for forty-eight hours and
is then dried in the sun. Only enough is prepared for one brew. The
French prepared a similar fermented beverage for these South African
laborers; the sole difference in its mode of preparation was that the
corn had not been germinated.
There are many accounts of scurvy among the Italian troops. Vannutelli
gives a description of an epidemic of some 200 cases of infectious
purpura with manifestations of hemorrhagic scurvy. Another writer
informs us that in June, 1916, scurvy broke out among some Italian
troops stationed at an altitude of 1500 to 2000 metres (Gingui).
Vallardi gives an account of 180 cases among Italian troops in
Macedonia, accompanied by slight jaundice and enlargement of the glands.
The American soldiers seem to have been practically spared from scurvy.
This was due probably to their ample ration and to the fact that
they were in the field for a comparatively short period. The
Surgeon-General's report to date, which has been kindly furnished me,
showed but 5 cases in 1917 occurring in Europe and the United States,
and but 15 cases reported during the year 1918.
_The civilian population_ of the various warring countries was by no
means spared. There are no reports from Russia to indicate the extent of
scurvy, but from what is known of the food conditions prevailing there
toward the end of the war, one can be certain that the number must have
been large. The greatest amount of scurvy has been reported from
Austria, more particularly from Vienna. Previous to the war scurvy was a
rare disease in this city, both among adults and infants. During the
war, however, as the result of a lack of fresh food and the dependence
on dehydrated vegetables, a large number of cases developed. Tobler
reports over 200 cases in children between the ages of two and fifteen
years, which occurred in 1917 in child-caring institutions where the
milk supply was markedly deficient, where fresh vegetables were lacking,
and the supply of potatoes gave out about Christmas, 1916. A conception
of the deficiency of the milk supply may be gained from the statement
that there were but sixteen quarts a day for about 1500 people. Some of
these children were undergoing fresh-air treatment and were out of doors
in the "sun stations" day and night. For the cure of these children a
simple decoction of fir-tops was used, a therapeutic procedure stated by
Lind to have been of value in the Russo-Swedish War of 1708.
That scurvy must have occurred extensively among the infants in Vienna
may be gathered from the report of Erdheim, who records 31 autopsies on
infants under the interesting title of the "Barlow Heart." In Berlin
scurvy occurred also in the foundling asylums, as reported by Eric
Mueller and by Brandt. This was caused by a diet of pasteurized milk and
dehydrated vegetables. In an article bearing the suggestive title of "On
a Marked Increase in Barlow's Disease in the Years of the War
1917-1918," Epstein states that in Prague there had been an endemic
increase of infantile scurvy since August, 1917. The only information
regarding scurvy among the adult civilian population of Germany is that
furnished by Morawitz, who states that this disorder occurred
sporadically. Here again it is probable that there were many latent or
rudimentary cases which were not recognized.
In Great Britain there are reports which show that scurvy manifested
itself in institutions caring for the poor. In Glasgow we learn of 50
cases developing in the Poor Law Hospital in the course of fifteen
months, and in Newcastle of 16 cases appearing in the Poor Law Infirmary
in the course of three months.
It is probable that when more detailed reports are available, it will be
found that there was far more scurvy than was appreciated during the
course of the war. It will be impossible, however, to gain even an
approximate knowledge of the extent to which this disorder prevailed, as
in many instances it was inextricably interwoven with other nutritional
diseases. The situation which Enright describes in Cairo among the
Turkish prisoners suffering from war edema, where there was "evidently a
scorbutic factor involved," probably held true for many other parts of
the world. War and scurvy must still be regarded as associated evils,
for war is closely linked with famine and food deprivation--the dominant
factor in the production of scurvy.