TREATMENT
"Seek the cure of scurvy neither in the armamentarium of the physician
nor in the apothecary shops. The druggist will be of as little aid to
you as the art of the surgeon. On the other hand, employ fresh
vegetables, the juice of fresh antiscorbutic plants, oranges and lemons
or the juice of those fruits preserved with sugar; in this way without
other means you will be able to overcome this terrible disease." This
reads like the advice of some modern therapeutist; it is, however, the
conclusion of a physician (Kramer) who wrote on scurvy almost two
hundred years ago, and shows that the treatment of scurvy has undergone
no fundamental change in the intervening years. Our resources, however,
have been amplified by an increased knowledge of the relative value of
antiscorbutic foodstuffs and by the introduction of some new ones.
=Prevention.=--In the Temperate Zone, under ordinary conditions, the
adult population consumes sufficient antiscorbutic foodstuff to protect
it from scurvy. Under exceptional circumstances, however--for example,
when the potato crop fails, or, in the case of individuals, when the
diet has been unduly restricted, scurvy will be encountered. This
disorder is still an important problem, however, in relation to the
health of adults in the Tropics, in military expeditions and in Polar
explorations. From what has been stated in the preceding chapter, it is
evident that, at the present time, no reliance can be placed on
dehydrated vegetables as a protective agent. The recent suggestion of
using germinated dried pulses and seeds, under circumstances where fresh
food is not available, is practical and probably will be resorted to in
the future. To this end the pulses (beans, peas, lentils) are soaked in
water for 24 hours, and then kept moist with access of air for about 48
hours at room temperature. During this period they sprout and develop
small radicles. They are cooked in the usual way and have been found to
possess an antiscorbutic value comparable to that of most vegetables. An
individual should receive about four ounces a day of these sprouted
seeds. In the treatment of some Serbian soldiers suffering from scurvy,
Wiltshire found that this amount of germinated beans brought about a
cure. There are, however, two drawbacks to their general use. The
prolonged cooking necessary for their preparation reduces their
antiscorbutic potency, and they have been found indigestible when
consumed in sufficient quantity.
Under similar conditions canned tomatoes can be employed; they have the
disadvantage of greater bulk, but are a more potent antiscorbutic,
require no preparation whatsoever, and are readily digested. They form
part of the present ration of the United States Army, in which they can
be given "in lieu of an equal quantity of potatoes not exceeding twenty
per cent. of the total issue."[50] The necessity of including an
antiscorbutic in the army ration has been recognized only in recent
years; during our Civil War and for thirty years thereafter there was no
such provision. It was stated at that time that a general scorbutic
taint pervaded the troops--a mere euphemism for the widespread existence
of subacute or latent scurvy. Even to-day the ration of the French and
of the Italian armies makes no definite provision in this regard and the
Russians provide merely for a variable quantity of vegetables.
[50] We have been unable to ascertain through inquiries from the
Surgeon-General's Office the nature of the experience which led to their
incorporation in the ration, and whether they were added specifically as
an antiscorbutic. They appear for the first time in the revision of the
Army Regulations of 1895. The only reference to the antiscorbutic
property of canned tomatoes which we have been able to find in the
literature is in the excellent treatise by Munson on Military Hygiene.
Recently it has been shown that lemon and orange juices (Givens and
McClugage) can be dried and still preserve their antiscorbutic value. It
is quite possible that concentrated preparations of this kind will be
serviceable for army use and in regions where fresh fruit or vegetables
cannot be obtained.[51]
[51] Since the above was written, an article has appeared by P. W.
Bassett-Smith (Scurvy: With Special Reference to Prophylaxis in the
Royal Navy. Lancet, London, 1920, I, 1102) showing that _lemon juice can
be prepared in tablet form_ and preserve its efficacy for at least three
months. Each tablet contained the equivalent of 24 c.c. of lemon juice,
and less than one-fifth of a tablet was sufficient to protect a
guinea-pig from scurvy. This therapeutic procedure seems of great
promise in providing an antiscorbutic ration for the navy or the army.
Lind makes numerous ingenious suggestions for preparing antiscorbutic
remedies (Lind, pp. 7, 8 and 9) which have a practical as well as
historic interest. (Appendix 1.) One of these includes a formula for the
preparation of orange and lemon juice which may be preserved for years;
another gives a method for the preservation of berries and other fruits
which are to be picked when partly ripe and put up in earthen pots;
still another gives the recipe for preparing a simple decoction of fir
tops, which was found by the Swedes efficacious in preventing the
development of scurvy among their soldiers. It is interesting that a
similar practice was resorted to in Vienna during the recent war and
recommended as a prophylactic for scurvy in children (Tobler).
_The prevention of infantile scurvy_, especially in its rudimentary
form, is of great practical importance, because of its frequent
occurrence. There is no question but that breast milk and raw cow's milk
furnish sufficient antiscorbutic vitamine, but there is a difference of
opinion as to whether pasteurized milk, or milk that has been brought
just to the boiling-point, or even sterilized milk, is adequate in this
respect. Much of this divergence of opinion is due to the fact that the
various clinicians have not considered or stated the quantity of milk
which they have found sufficient to protect, and also because milk
itself differs in its antiscorbutic value according to its freshness and
probably also according to the fodder of the cows.[52] Without entering
once more into a discussion of this question, it may be stated that
unless the cow's milk is raw, the infant should receive additional
antiscorbutic foodstuff. Moreover, this supplement to the dietary should
be made as soon as possible, so as not to allow the vitamine deficiency
and inadequate diet to exist for even a short period. In our experience
there is no contra-indication to the giving of orange juice or of
strained canned tomato, the two antiscorbutics with which we have had a
large experience, to babies one month of age or even younger. The common
practice, however, is to wait until the infant is five or six months of
age, which certainly must allow a rudimentary scorbutic condition to
develop. At the age of a month one teaspoonful of orange juice may be
given; it should be diluted with water and sugar added if it is tart.
This may be administered notwithstanding the fact that a baby has a
tendency to looseness of the bowels, as orange juice, as recently
pointed out by Gerstenberger, has practically no laxative action.
Occasionally babies regurgitate orange juice, but the reaction usually
ceases after a day or two. If it does not, a small amount of an
alkali--for example, limewater or sodium bicarbonate--may be added just
previous to feeding; in this state the juice will be better
tolerated.[53] The amount of orange juice should be increased so that
when the baby is three months of age it receives one tablespoonful.
[52] It is not possible to say exactly how much raw milk a baby needs to
protect it against the development of scurvy. We may, however, reach an
approximate estimation of this figure. We know that it takes about 2
c.c. of orange juice to protect a guinea-pig against manifest scurvy,
and about 10 c.c. to protect a baby. The ratio, therefore, between the
guinea-pig and the infant in this regard would seem to be about 5 to 1.
We also know that it takes about 80 to 100 c.c. daily of fresh cow's
milk to protect a guinea-pig for long periods. If we assume the ratio of
5 to 1, it would therefore seem that it would require about 500 c.c. or
a pint, of fresh raw milk daily as a minimum to protect the baby. (It is
quite possible that a slight negative balance of the vitamine may exist
unless a still greater amount is given.)
[53] Orange juice undergoes a decided color change as soon as it has
become neutral or very slightly alkaline, assuming a more translucent
and far deeper yellow or amber color. This change may be utilized by the
attendant in determining the reaction, thus rendering titration or other
time-consuming methods unnecessary.
A few years ago Hess and Fish recommended the use of an infusion of
orange peel in infant feeding. The peel was finely grated, soaked
overnight in water (1 ounce of the peel to 2 ounces of water), and a
small amount of sugar added to this liquid. Animal experiments showed
that this preparation possessed decided antiscorbutic value. This
decoction may well be used for the sake of economy, and even when the
orange juice is employed the infusion of the peel may be added.
An antiscorbutic which vies with orange or with lemon juice in
adaptability for infant feeding is _canned tomatoes_, as recently
suggested by Hess and Unger. Tomatoes are not in good repute among food
experts in view of the small amount of calories which they contain--only
about 100 to the pound--and are regarded with suspicion amounting almost
to superstition by mothers and nurses as a food for children. In spite
of this fact, it may be stated without hesitation that they are fully as
well borne by infants a few weeks or months of age as orange or lemon
juice. In considering antiscorbutics, it has been shown that
notwithstanding the canning process and subsequent aging, they preserve
their potency. The dose is two tablespoonfuls for babies over three
months of age. The tomatoes are merely strained through a colander and
warmed (not cooked). To illustrate their innocuous character, it may be
added that as much as 6 and 8 ounces a day of this juice have been given
to a baby under one year of age without producing untoward symptoms.
This antiscorbutic should have wide applicability, especially in the
United States.[54]
[54] There is no relation whatever between the acidity of canned
vegetables and their possible contamination with tin. Experiments
carried out to determine this question demonstrated, for example, that a
"sample of red kidney beans showing the highest acidity contained the
least tin," and that those samples containing the most tin were all
relatively low in acidity. (Report of Conn. Agric. Station Bull. 200,
1917, J. P. Street.)
Another antiscorbutic which can be used in a routine way to prevent
infantile scurvy is _swede juice_, prepared by grating the raw vegetable
and squeezing the pulp in muslin. Chick and Rhodes report that this
juice has been adopted for use in some of the English infant-welfare
centres. It should be given in about the same dosage as the tomatoes,
and seems applicable where the swede can be readily obtained.
For babies over six months of age, reliance may be placed on the
ordinary household vegetables--potatoes, spinach, carrots, squash, etc.
Attention should be paid to the amount which is taken, as one or two
teaspoonfuls of a vegetable which is poor in antiscorbutic power, such
as carrots or beets, will be insufficient to protect against scurvy.
Especially is this true if the vegetables are old and stale and are
cooked for a long period;[55] some years ago two infants under our care
developed scurvy in spite of a small daily ration of vegetables.
[55] Salant, in experiments on rabbits, found that old or winter carrots
did not have the same protective action against tartrates as young
carrots, although their diuretic action is the same.
Potato in the amounts usually consumed is a valuable antiscorbutic. It
is not an exaggeration to state that it is the main antiscorbutic
bulwark of man. In giving baked potato to children it is commonly
advised to use the floury part just beneath the peel; this should be put
through a sieve and mixed thoroughly with boiled milk so as to
constitute a cream; for younger babies it can be prepared with water to
form a diluent similar to the barley water so commonly employed to
dilute cow's milk (1 tablespoonful of potato to a pint of milk, cooked
for 15 minutes). Little reliance should be placed on beef juice in the
usual dosage and none on eggs.
=Cure.=--There is almost nothing in the realm of therapy which is so
striking as a scorbutic patient's prompt reaction to antiscorbutic
treatment. It is all the more marvelous as the cure is effected by means
of foodstuffs with which we are accustomed to associate no specific
virtue. A magic result is seen frequently within 24 or 48 hours. A baby
which has had a poor appetite, has been irritable and exquisitely
tender, suddenly regains its appetite, is no longer fretful, and can be
handled without occasioning crying. Within a week, if the case is mild,
all definite symptoms of scurvy may have disappeared, and soon
thereafter the infant is thriving and apparently cured. A table is here
reproduced (Table 6) from the report of the American Pediatric Society
showing the duration of treatment before marked improvement was noticed:
TABLE 6
DURATION OF TREATMENT BEFORE MARKED IMPROVEMENT WAS NOTICED
==========================================================
| Days Cases | Weeks Cases | Months Cases |
|------------------+------------------+------------------|
| 1 19 | 1 47 | 1 6 |
| 2 58 | 2 27 | 2 4 |
| 3 46 | 3 8 | 3 4 |
| 4 26 | 4 1 | |
| 5 19 | 5 1 | |
| 6 1 | 6 1 | |
| 7 2 | | |
| 8 2 | | |
| 9 1 | | |
| 10 7 | | |
| 12 2 | | |
| | | |
----------------------------------------------------------
In most instances a gain of weight accompanies improvement. In not a few
instances, however, there is a temporary loss or cessation of weight,
due in part to an increased excretion of urine. Occasionally there is
observed a short exacerbation of the symptoms following the giving of an
antiscorbutic--a swelling of the thigh or hemorrhage of the gums. A
similar phenomenon has been noted in relation to the treatment of
polyneuritis in birds and of beriberi in man.
In the cure of scurvy the same dietetic remedies are employed as in its
prevention. Orange juice is the sovereign remedy, and should be given in
a dosage of about 2 ounces a day.[56] Canned tomato is also most
efficacious. If these changes in the dietary are carried out, it is not
absolutely necessary to alter the food, although it is advisable to do
so. Some writers, for example Neumann and Czerny, treat the disorder by
giving milk which has been scalded or brought to the boiling-point.
Others lay particular stress on changing the source of the milk supply,
believing that the sameness of the diet leads to the occurrence of
scurvy. Such, however, cannot be the case, as otherwise breast-fed
babies would be highly subject to this disease. In the report of the
American Pediatric Society one case developed on condensed milk and was
cured by sterilized milk, and another developed on pasteurized milk and
was cured by sterilized milk and broths. These results are explicable;
large amounts of milk were given to effect the cure. It may be said in
general that in addition to giving fruit or vegetable juices the milk
should be either raw or heated to as low a degree as possible (duration
of heating as well as height of temperature). Furthermore, the
antiscorbutic treatment should be continued for a period of months, as
the clinical improvement far outstrips the restoration of the bones and
other tissues. It seems necessary again to call attention to the fact
that too great reliance has been placed on the use of beef juice, which
has been shown, both in experiment and in the clinic, to possess
comparatively weak antiscorbutic properties.
[56] It is difficult to state the exact dosage of orange juice which is
necessary. One teaspoonful daily has failed to cure, and rapid cures
have been accomplished by giving one tablespoonful. It is well, however,
to give a larger amount if it is tolerated.
Orange juice may be given intravenously. This method may be resorted to
where the patient is in an advanced stage of the disease or where food
cannot be tolerated by mouth; for example, in cases such as that
mentioned by Cheadle, where death took place owing to the fact that the
antiscorbutic could be taken only sparingly, on account of the extreme
prostration of the patient. For this purpose the orange juice is
obtained in as sterile a manner as possible, boiled for about five
minutes and is rendered neutral or slightly alkaline just previous to
its injection by the addition of normal sodium hydroxide. Hess and Unger
report three cases where this procedure was carried out without the
slightest untoward reaction. In one instance, improvement was noted 16
hours after the injection. In view of the novelty of this treatment it
may be of interest to cite a case:
A baby 16 months old had hemorrhage of the gums and tenderness of
the legs, which were held in the characteristic flexed and everted
position. Eliminative treatment was tried without avail; Dover's
powder and warmth to promote perspiration; caffeine to promote
diuresis; and 2 tablespoonfuls of liquid petrolatum three times a
day to increase elimination from the bowels. Intravenous injections
of salt solution also proved of no value.
Four intravenous injections of orange juice were given--6 c.c., 12
c.c., 6 c.c., and 35 c.c. As was stated, improvement was noted 16
hours after the first injection. The infant was less irritable, the
gums no longer hemorrhagic, and the "capillary resistance test"
(that is to say, the development of petechial spots on the forearm
when a tourniquet was applied for 3 minutes to the upper arm)
changed from positive to negative.
Harden, Zilva and Still have recommended the use of a concentrated lemon
juice for the cure of scurvy, constituting a form of "intensive"
treatment. In four cases this proved to be of clinical value. Freise has
made use of an alcoholic extract of turnips, and Freudenberg of a
similar extract of carrots. These preparations did not seem to be
markedly potent, and therefore possess no particular therapeutic
advantages.
=Non-dietetic Therapy.=--There is little to be done for the patient in
addition to the giving of sufficient antiscorbutic. No one has reported
success with any drug. We have tried the use of atropin, adrenalin,
thyroid and parathyroid extracts, cod liver oil, autolyzed yeast,
lactose, sodium chloride, calcium chloride, etc., without noting any
improvement. Mercurials are stated to be positively harmful, especially
when ulcers are present. The patient should be kept in bed, and exertion
not allowed on account of the involvement of the heart, which has led to
sudden collapse and death. The gums may be treated with nitrate of
silver stick or tincture of myrrh. If there is fracture of the long
bones with displacement, splints should be applied. Under no
circumstances should hemorrhagic effusions in or about the joints be
incised. The patient should be placed in a room which is well aired and
lighted, and should be handled and dressed as infrequently as possible,
so as to avoid discomfort and pain. It is particularly important that
intercurrent infections should be avoided by shielding patients from
contact with those who have infectious diseases, especially respiratory
infections.