At the present day scurvy presents few terrors to the inhabitant of the civilized world, for the means of inter-communication are now so rapid and cheap that practically every variety of vegetables and fruit can be procured at any season of the year, and the possibility of a vegetable famine is remote. To the explorer, however, and the resident in besieged cities, the problem of the prevention of scurvy will always remain, and its effects are writ large in the cemeteries of Port Arthur and of Paris.
Sporadic cases of scurvy do, however, now and then occur even in English towns, and may escape detection on account of their rarity, and there is little doubt that some cases of prolonged fever (enteric, for example) are followed by a protracted convalescence from their complication by this disease, usually the result of the prolonged use of sterilized or boiled milk. Frontier medical officers are well acquainted with the association which is of necessity more common among their patients, and are in consequence accustomed to seek for its effects in their malarial and dysenteric patients.
The essential point in the etiology of scurvy is the undisputed fact that a plentiful diet of fresh vegetables cures the disease. The converse proposition is not, however, equally true, and a dietary wholly devoid of vegetable elements is not necessarily provocative of the disease. Many of the residents in Arctic regions, for instance, live exclusively on an animal diet during the winter months, and Nansen and his companion lived without harm for nine months on Frederick Jackson Island on a diet of fresh walrus or bear's meat, without any fresh vegetables or lime juice. Babies at the breast, too, rarely if ever develop the disease, though it is not uncommon after the infant has been weaned.
The exact nature of the fault is, however, undetermined. Garrod suggested that the disease was due to a deficiency in the potash salts, while Buzzard considered that the organic potash salts were the vital factors. Ralfe thought that the disease was due to a deficiency in the alkalinity of the blood, and Sir A. E. Wright has recently investigated the point. He has shown by direct measurement that the alkalinity of the blood is lowered in cases of scurvy, and that the normal is regained with the cessation of symptoms. Vegetable food-stuffs contain an excess of bases over mineral acids, while meat and cereals contain an excess of mineral acids over bases; such foods as corned meat containing even less base from the abstraction of the blood and lymph during the process of preservation. The acid intoxication which results is, in his opinion, the immediate cause of the symptoms, and the essential treatment consists in the administration of oxidizable organic salts to restore the normal alkalinity.
Several writers have considered the disease to be the result of ptomaine poisoning or a specific infection. Jackson and Harley, from their experience in the Windward expedition, think that scurvy is the result of eating tainted food, the use of lime juice failing to prevent its occurrence while the subjects were on a diet largely composed of tinned and salted meat. Torup had already propounded a similiar theory.
Babes has isolated a micro-organism from cases of scurvy, and has produced a somewhat similar disease by injecting cultures of it into animals; and Coplans strongly supports the infective theory, as he found that the incidence of the disease in the concentration camps in South Africa varied in the different camps according to the habits of their occupants and the general sanitary arrangements.
If infantile scurvy is considered to be the same disease as the adult form, its lessons must also be considered. It may undoubtedly result from the use of boiled milk, and may be cured by the simple addition of fresh lime or lemon juice, without any other alterations in the food.
This fact seems conclusive evidence against any infective or toxic theory, and according to Dr. Hutchison, is in favour of the acidosis theory, as the process of boiling converts the amorphous soluble citrate of lime which it contains into a crystallizable and less soluble form, some of which is thrown out of solution, and so lost.
Gastro-Intestinal Symptoms are not very prominent in the majority of cases of uncomplicated scurvy. The sepsis and tenderness in the mouth necessarily render mastication imperfect, and dyspeptic symptoms are not uncommon, though they are rarely severe; a defective quality of food-stuffs will magnify the tendency.
Constipation is the rule, but diarrhoea, which may be of the dysenteric type, may occur. The combination of dysentery and scurvy has not infrequently been observed, and it is necessary to recognize their association.
It is important, in the treatment of scurvy, to limit the infection of the food-stuffs and of the stomach from the buccal cavity; and the food must be fluid or semi-solid as long as mastication is impossible.
The dietary should, if practicable, be composed wholly of fresh foods, and contain a large proportion of vegetables. Lettuce, cabbage, potatoes, yams, onion, cress, are probably the most useful vegetables, and apples, oranges, lemons, limes, the best of the fruits; but the variety seems a matter of relative unimportance, and I have seen good results follow the administration of carrots and vegetable marrow, which were the only fresh vegetables available at the time; and, in another case, of strawberries and cream ! Sauerkraut and potatoes are said to be the best form of preserved vegetables; and of the fruit juices those of the lemon and lime. All of these, however, lose their anti-scorbutic properties in time, though they are probably of value for at least two years. Milk, malt and claret are also said to be anti-scorbutic.
In cases where vegetables are not available, fresh animal foods may be utilized, the blood being probably the most important factor. Strong meat soups, raw meat juice, pounded raw meat, etc., may be given.
Any error in the personal or general hygiene should at the same time be corrected. Starvation, overwork, mental depression, insanitary surroundings, may all play their part in the causation of the disease. And on the assumption that the theories of Ralfe and Wright are correct, alkalies should be administered in full doses.