muscle, must not be treated with purgative medicines. Now and then,
when a great deal of abnormal acid is formed in the stomach, calcined
magnesia, a grain or two given before each meal, will control that
disorder and at the same time keep the bowels open. But, as a rule,
every purgative after it has taken effect will leave the intestinal
muscular layer less fitted to perform its functions than before. Its
place may be taken by a daily enema of tepid water. Further indications
are--such a change in the food as will contribute to keep the bowels
moist and slippery, but principally such a modification of food and
such medical treatment as are known to prove beneficial when all the
symptoms of rachitis are fully developed. When the cause of the
infant's rachitis can be traced back to the mother or to an
insufficient quality of her milk, she must give way to a wet-nurse, or
the nurse must be changed for similar reasons. When neither mother nor
wet-nurse prove competent, or either be dangerous, artificial food will
take their place to advantage in the manner I have stated above.
Beef-soup or beef-peptone is to be added to the baby's food daily. Of
the two best farinacea, barley- and oat-meal, the latter is preferable
as an addition to cow's milk, because of its greatly laxative effect.
The percentage of cow's milk in the food ought to be more carefully
watched than in other conditions. Pure cow's milk or cow's milk mixed
with water only is borne worse in no other condition. Half a drachm or
more of table-salt and a few drachms of sugar ought to be added to the
daily mess. The general indications require the administration of iron,
which has no constipating effect in this ailment. Particularly is that
the case with the iodide of iron. Cod-liver oil, in three
half-teaspoonful or teaspoonful doses daily, acts very satisfactorily
both for its general rachitical and for its local effect on the mucous
membranes. Now and then massage, repeated many times a day a few
minutes each time, practised with the palm of the hand only, or gentle
friction, with the dry or oiled hand, of the abdominal surface, will
prove effective in bringing about peristalsis and strengthening the
intestinal muscle. An obstinate case may also require two daily doses
of one one-hundred-and-fiftieth or one one-hundred-and-twentieth of a
grain of strychnia for the same purpose, or such other improvements on
the above detailed plan as the judgment of the attending physician may
direct. At all events, the diagnosis of {165} any case, and the
appreciation of the cause of any ailment, are, to a well-balanced and
educated mind, of infinitely greater value than any number of specified
rules and prescriptions.[21]
[Footnote 21: _Jour. Obstetr._, Aug., 1869.]
It is not impossible that phosphorus, in substance, not in any of its
compounds, may prove of great utility in the treatment of rachitis.
Minimal doses of phosphorus render the newly-formed tissue at the
points of apposition of the bones more compact in a very brief time.
The new formation of blood-vessels in the osteogenous tissue gets
retarded by it. Larger doses of phosphorus, however, increase
vascularization, and osseous tissue is either less rapidly formed or
even softened. When the doses are still larger, vascularization and
softening may rise to such a point as to separate the epiphysis from
the diaphysis. Thus the administration of the drug results in an
irritation which, according to the doses employed, may give rise either
to normal condensation or to inflammatory disintegration. This
experience, arrived at by Wegner in a great many experiments made on
animals, Kassowitz has confirmed. For its therapeutic effect he tried
phosphorus in 560 cases of rachitis. Employing doses of one-half
milligramme (one one-hundred-and-twentieth of a grain) several times
daily (less will suffice), he soon found the skull to become harder,
the fontanel smaller, the softening of the bones of the thorax and
extremities to disappear, and all the other symptoms of rachitis to
improve. This result was obtained though no particular change in the
feeding of the patients was resorted to. To what extent this experience
will be verified by others we shall soon learn. My own is already
sufficiently extensive to base upon it a strong recommendation of the
plan of treatment I have detailed. My therapeutical results in other
diseases of the bones also encourage me to believe that phosphorus will
accomplish much in the treatment of rachitis. Ever since Wegner's
publications--viz. these thirteen or fourteen years--I have utilized
phosphorus in cases of chronic and subacute inflammations of the bones,
mainly of the vertebral column and the ankle-joint and tarsus. After
having taught the method for many years in my clinic and otherwise, I
made a brief communication on the subject to the Medical Society of the
State of New York.[22] Since that time, again, I have followed the same
plan in many cases of the same description, and feel sure that the
prognosis in this serious class of bone diseases has become more
favorable and recovery speedier. Infants of a year or more were given a
dose of one-eightieth or one one-hundredth of a grain of phosphorus
daily. One grain, dissolved in an ounce of oil or cod-liver oil, is a
convenient mixture, four or six drops of which may be administered
daily in two or three doses.
[Footnote 22: _Trans._, 1880.]
From what I have seen of phosphorus in bone disease, and what is thus
far known by experience in rachitis, it appears to me that it will be
of decided advantage in that form of acute rachitis which is apt to
destroy rapidly with the symptoms of acute epiphysitis, rapid pulse,
diarrhoea, rapid diminution of strength, and scorbutic gum. In the few
cases I have seen these last years it appeared to me to act
satisfactorily, together with immobilization of the whole body.
Rachitical curvatures are very apt to become less marked while growth
is increasing and the limbs extending. But many of them are so marked
{166} that they remain for life. Many of these might have been
benefited by timely orthopædic interference. That the application of
Sayre's jacket is indicated in every form and stage of spondylitis,
though it be not equally valuable in all forms, goes without saying;
and that infractions ought to be straightened and supported by splints
when observed and when practicable, is self-evident. But, as a rule,
while the chronic rachitical process is developing in the long bones
the use of mechanical apparatuses is of doubtful merit; they ought not
to be resorted to before the healing has at least commenced. Nor is it
advisable to postpone mechanical interference so long that eburnation
of the bones has time to take place. Surgical operations for the
purpose of removing the curvature are of different nature according to
the different types to be treated. Mere straightening of the curvatures
is indicated, and successful with children under two years.
Osteoklasy--that is, fracturing of the curvature while the periosteum
is left intact--is successful in children of three (or four, according
to Volkmann) years. The fracture does not injure the periosteum, and is
always transverse. In later years osteotomy has proved successful to an
almost unexpected degree, and is one of the happiest achievements of
modern surgery.
Partly as a preventive, partly as a curative measure, Gramba of Turin
and Pini of Milan point to well-directed gymnastics as a requisite in
the treatment of rachitis. For older children they have established
schools in which systematic exercises are brought to bear on chronic
deformities.
{167}
SCURVY.
BY PHILIP S. WALES, M.D.
SYNONYMS.--_French_, Scorbut; _Spanish_, Escorbuto; _Italian_,
Scorbuto, are the various terms in the Romance languages used to
designate this disease, derived from the Middle-Latin word scorbutus,
which is evidently an offspring of one of the early Gotho-Teutonic
dialects, perhaps of the Low German word Schärbunk, Danish Scorbuck, or
the Old Dutch Scheurbuyck, from _scheren_, to separate or tear, and
_bunk_, the belly. These terms originally denoted rupture of the belly,
and afterward scurvy, or scorvy, as it is found in the English dialect.
It has also been traced to the Sclavonic word scorb, disease. The first
is now believed to be the true etymology.
DEFINITION.--Scurvy is an acquired condition of the body whose
essential feature is a perversion of nutrition, which gradually arises
from prolonged employment of food deficient in succulent or fresh
vegetable matter, and progresses uniformly to a fatal issue, in a
longer or shorter time, if the dietetic errors remain uncorrected. This
condition becomes manifest by a change in the complexion to a dull
yellowish or earthy tint, lassitude, marked decrease in the muscular
power, depression of spirits and mental hebetude, breathlessness on the
slightest exertion, minute flecks at the roots of the hairs, especially
those of the legs; and, later, hemorrhagic effusion into the skin,
forming blotches and spots of varying sizes and aspects, which may
finally slough and lead to obstinate ulceration; sponginess of the
gums, which bleed easily and break down into a detritus that impresses
a malodorous taint upon the breath; ecchymotic staining of mucous and
serous surfaces, and, in advanced stages of the disease, effusions of
bloody serum or of blood into the cavities and tissues of the body.
HISTORY.--Obscure passages in certain of the ancient medical classics
(Hippocrates, Celsus) and historical works (Pliny, Strabo) have been
considered as descriptive of scurvy, but the earliest trustworthy
accounts are to be found in the writings of the thirteenth century.
Jacob de Vitry describes an epidemic which occurred among the troops of
Count Saarbrücken besieging Damietta in 1218, and Sire de Joinville
another epidemic among the troops of Louis IX. lying before the same
town in 1249. On both occasions the sufferings of the men were
inexpressible and the mortality fearful. The disease was directly
traceable to defective supplies of fresh vegetable food, aided by
exposure to wet and cold weather, fatigue, and mental depression.
{168} The almost total neglect of horticulture in Europe during the
Middle Ages, especially in its more sterile northern portions, the
habitual diet of salted, smoked, and dried flesh and fish, and the
prolonged spells of cold and damp weather of this region, were
conditions most favorable to the development of scurvy, and these
regions were the very first in which its devastating effects were early
observed and recorded. In the first half of the fifteenth century it
prevailed epidemically in the north of Europe and almost everywhere
endemically, more especially in the countries bordering on the Baltic
and North Seas, although the largest and richest cities were frequently
afflicted in the severest manner in consequence of imperfect
food-supplies and the wretched sanitary conditions under which the
inhabitants lived (Fabricius). The long voyages and imperfect diet of
crews of ships furnished a large quota of harrowing nautical
experiences with the scurvy, commencing with Vasco da Gama's voyage to
India in 1497, and running up to 1812. In this interval it was all but
universal on long voyages, both on single ships and in fleets, in the
mercantile marine and in the navy.
In 1798, through the better insight into the causes of the disease, and
especially through the exertions of Dr. James Lind in ameliorating the
dietary of British sailors, it was practically stamped out of the navy
or restricted to isolated occurrences. The influence of the success
thus achieved was not lost upon the navies of other nations nor upon
the growing fleets engaged in commerce, as the disease has become less
and less frequent, constituting at present but a very trifling
proportion of the diseases incident to seafaring people. This
remarkable result is in part attributable to the fact that the chief
maritime nations have enacted beneficent laws intended to compel the
owners and masters of merchant vessels to observe certain sanitary and
hygienic measures that protect the crews from scurvy. The number of
cases returned in the English navy for 1881, in an aggregate of 52,487
cases of all diseases, was 4; in the Prussian navy, 3 in 8659; in the
Austrian navy, 27 in 8096; in the U.S. navy, none in 13,387. Thus, in a
grand total of all diseases in the chief naval services of the world of
82,629 there were only 34 cases of scurvy--a ratio of .41 per 1000. In
the mercantile marine 62 cases occurred in 32,613 cases of all
diseases, of which 43 were on the Pacific coast: this gives a ratio of
1.9 per 1000. Altogether, the 115,242 cases produced only 96 of
scurvy--a ratio of .83 per 1000. The difference in favor of the naval
over the marine service is accounted for by the greater attention paid
to the health and comfort of the men in the former.
The U.S. steamer Jeannette spent two winters in the Arctic region, and
had a single case of scurvy. The U.S. steamer Rodgers was wrecked, and
the crew, during its sojourn of six months among the Siberian tribes,
suffered severely.
The operations of armies in recent times have not furnished the
frightful mortality which, from neglect of sanitary precautions,
formerly afflicted them. During the rebellion of 1861-64, out of
807,000 cases there were but 47,000 of scurvy, or 5.8 per cent., with a
death-rate of 16 per cent. The French army[1] of 103,770 men during the
Crimean struggle had 27,000 cases of scurvy, or 26.0 per cent., with a
death-rate of 1.5 per {169} cent. In the Bulgarian campaign of 1877-78,
in an army of 300,000 strong, there were, according to Pirigoff,[2]
87,989 cases of disease, of which 4234, or 4.8 per cent., were
frankly-expressed cases of scurvy. This gave a proportion of only 1.4
per cent. of the entire force--a result entirely due to the
maintenance, both before and during the war, of a high standard of
health.
[Footnote 1: Scrive, _Rélation Médico-Chirurgicale de la Campagne de
l'Orient_, Paris, 1857.]
[Footnote 2: _Krieg Sanitäts-Wesen_, Leipzig, 1882.]
ETIOLOGY.--Perhaps no disease has furnished a more fertile field for
etiological conjectures than scurvy. The father of medicine ranked the
disease in one place among those presenting enlarged spleens, and in
another with the twisted bowels. He recognized a putrescence of the
humors as the underlying factor--a theory that held sway until the
beginning of the nineteenth century. The disease attracted wide
attention in the seventeenth and eighteenth centuries from its frequent
epidemic and endemic occurrence in various parts of the north of
Europe, and was believed to be restricted to cold and particularly wet
districts--a view that has been long since abandoned with a better
knowledge of its habitats. It has been encountered alike in high
latitudes north and south, amidst sterile wastes covered with eternal
snows and ice, in the temperate zones and in the burning plains of the
equatorial regions of America and Africa.
Sex has no predisposing influence, and the fact that more males than
females are affected during an epidemic simply indicates that the
former are more exposed to the ordinary determining causes. During the
siege of Paris, according to the tables of Lasègue and Legroux, there
was a very large excess of male cases, and Hayem's figures show only 6
women in 26 cases.
Scurvy has been observed at all ages from infancy to advanced periods
of life; it is believed by certain writers that adolescence is less
predisposed than adult age.
The epidemic feature of the disease led many to the opinion that it was
contagious--a view that retained its hold for many years. It was also
considered to be of a miasmatic character, which, with the previous
feature, seemed to assimilate it in nature with typhus fever and other
diseases of the miasmatic contagious group. This view had a vigorous
advocate in Villemin, who in 1874 read a lengthy paper before the Royal
Academy of Medicine in its support. His arguments were specious,
inconclusive, and inaccurate, the weight both of facts and authority
being decisively against his view. Its occurrence among members of the
same family led a few to regard it as hereditary, and it was thought to
be transmissible from the mother to the recently-born as well as to
nursing infants. The depressing influence of certain emotions, fear,
anxiety, and nostalgia, upon the functions of nutrition has, as might
have been anticipated, been noted as contributing indirectly to the
manifestation of epidemics of scurvy in the presence of the essential
determining dietetic causes.
Scurvy cannot be regarded, as Lhéridon-Cremorne[3] has argued, as the
last term of nostalgia, the other alleged causes being secondary; nor
as the immediate result of mental depression, as Gueit[4] believed from
his experience in the ship Henry IV. during his service on the blockade
in the Black {170} Sea in 1858, because the disease first invaded those
laboring under nostalgia. The currency of such opinions may be readily
explained by the fact that ordinarily depressing mental influences
occur under the same conditions as those associated with scurvy--viz.
during sieges, after defeat, in prisons, and in workhouses; and,
further, the mental phenomena ordinarily occur as prodromes of the
disease long before the pathognomonic phenomena present themselves. Out
of these facts grew the mistake of regarding the mental change as
causative instead of consecutive. Murray went farther and regarded
mental despondency as at once cause and effect, and long ago scurvy was
compared to hypochondriacal diseases.[5] It may be concluded from the
recorded epidemics that no degree of mental exhilaration could ward off
the disease in presence of the determining causes, nor any degree of
mental despondency induce it with proper alimentation.
[Footnote 3: _Thèse de Paris_.]
[Footnote 4: _Thèse de Montpellier_, 1858.]
[Footnote 5: Dolée, 1684.]
The various qualities or changes in the atmosphere were regarded
individually or collectively at various times as the determining
causes. It was supposed that the air might become impregnated with
putrid exhalations from various sources, as the holds of ships, or
rendered impure by the vapors of the sea. The foul air of crowded
habitations, vessels, or cities was appealed to, or the common cause
was sought either in its temperature or humidity, or in both. The
earlier observers gave prominence to cold as a determining cause of
scurvy, and especially when combined with dampness, and hence its
frequency in the north of Holland, Brabant, Belgium, Russia, and
Germany. This was the current view in the seventeenth century. On the
other hand, with equal confidence the disease has been supposed to be
determined by excessively high temperatures, and its occurrence in
India, South Africa, and the equatorial regions has been alleged in
support.
Personal habits have been in the eyes of earlier observers an
all-sufficient cause, and thus excessive exertion attended with fatigue
and exhaustion has been considered the cause of several severe
outbreaks on shore and at sea. In contrast with this opinion we find
the English physicians placing great stress upon indolent habits and
lack of exercise as a predisposing if not a powerfully determining
cause.
The use of tobacco was inveighed against by Maynwaring and Harvey as a
powerfully morbific cause, while to the lack of the same narcotic its
occurrence was ascribed by Van der Mye. More recently it has been
referred by Fabre[6] to vaso-motor disturbance due to a miasm.
[Footnote 6: _Des Rélations Pathogéniques des Troubles Nerveux, etc._,
Paris, 1880.]
In the drink and food, however, most observers have sought the exciting
causes of scurvy. Instances have been reported where the disease seems
to have depended upon the use of impure water, etc. The imagination has
been tortured to seek in some quality or sort of food the specific
origin of scurvy. With regard to quantity, it may be stated that in
severe famines scurvy may or may not occur according as the food,
though scant, is in due proportions of animal and vegetable, though it
is true that the ordinary conditions of a famine preclude the
procurement of succulent vegetables. The quality of the food has
nothing further to do with the production of scurvy than by impairing
the general health, for it has often happened that putrid food has been
long used without scorbutic symptoms arising. The kind of food is
equally {171} innocent, although various special articles have been
charged with specific activity. The frequency of scurvy in Brabant was
attributed by Ronseus to the use of aquatic birds; Sherwin and Nitsch
assigned the same peculiarity to a free use of fish; and Henry Ellis to
the too free use of spirits. Even the generally widespread and
much-esteemed article of diet sugar was in disrepute with Willis. The
too free use of salted meats has been often accused of causing the
trouble. The fat rising on water in which salt provisions were boiled
was considered by Cook and Vancouver to be of particular pernicious
effect, and even the copper vessels in which they were cooked were
condemned by Travis as able to communicate the scorbutic poison to the
food. To the milk of animals browsing on verdure upon which pernicious
dew had fallen was referred an epidemic which occurred in Silesia in
1591. Diseased potatoes were considered sufficient to determine scurvy
in Ireland and Scotland by O'Brien.
The scurvy occurring on land was deemed to be different from that
occurring at sea, and its frequency afloat brought into unmerited
disrepute the sailor's salt diet, and its saline materials were even
considered the chief offending cause. This idea was rejected by
numerous observers, who assigned as the chief causative rôle in scurvy
deficiency in vegetable food, especially of the fresh, succulent
variety. The particular constituent of this sort of food, so powerful
in warding off scurvy and of curing it when prevention has failed, has
baffled discovery. Dr. Aldridge attributed it to mineral elements
generally. Dr. Garrod singled out the potassic salts as the particular
one to which the specific action must be attributed; but neither of
these views has gained in credit. From all the facts, both positive and
negative, we may reasonably assume that the essential dietetic error
leading to the development of scurvy, in the immense majority if not in
all cases, consists in a deficiency in the variety of food; that is to
say, there is not the requisite proportion of animal matter with a
diversity of vegetable substances. No single natural order contains
plants that supply all the elements essential to the nutrition of the
body and the right composition of the blood. The graminaceous and
leguminous articles of food, for instance, are numerous, but not
various; they all afford the same or analogous albuminous elements,
which have about the same nutrient value as the corresponding
substances in animal food, and hence health and vigor cannot be
sustained on a diet of flesh, combined with wheat, rice, and oatmeal or
with beans and peas, or with all of them together. Outbreaks of scurvy
have occurred on shipboard, where the ration is made up principally of
these articles; as in Anson's ship, when supplied with an abundance of
fresh animal, farinaceous, and leguminous foods. It is clear,
therefore, that in order to obtain a variety of materials required in
nutrition, we must resort to several of the natural groups, those
particularly which comprise the succulent vegetables and fruits.
MORBID ANATOMY.--The bodies of persons dead of scurvy are, in most
cases, much emaciated, because the quantity as well as the quality of
the food has usually been defective. When the food-supply is abundant
and only lacking in the elements indispensable in warding off scurvy,
the bodily weight is not noticeably decreased, although the
characteristic tissue-changes of scurvy are present. This was
noticeable in the cases recorded by Trotter of negro slaves dying of
scurvy while their bodies {172} presented a fat and sleek appearance.
Rigor mortis usually sets in early, and chemical decomposition invades
the tissues speedily. The skin presents the discolorations and
blotchings observed during life. The subcutaneous connective tissues
are soaked with serous exudations, especially in the lower extremities,
and in various localities are infiltrated with bloody or fibrinous
extravasations. The same changes occasionally affect the muscles, the
infiltration occurring beneath the fibrous sheaths and into the
intermuscular spaces, and the fibres are more or less torn. These
effusions occur most frequently about the knees, the elbows, and the
pterygoid muscles of the jaw.
The bones are sometimes necrosed by the mechanical influence of copious
effusion beneath the periosteum, forming nodes of varying sizes and
obstructing the supply of blood. The joints are occupied by serous or
bloody transudations; their synovial investment is destroyed in part,
so that the cartilage is exposed; and the latter not infrequently is
softened, and even separated from the subjacent osseous connections.
Sometimes the morbid changes occurring in the joints are the results of
disease in the subcutaneous connective tissues surrounding them.
The muscular system presents marked changes. The muscles undergo fatty
degeneration in a remarkable degree. The changes begin first in the
lumbar muscles, the fibres losing their striations and sarcolemma, and
finally being replaced by granular and fatty matter.