It is found that over 75 per cent of the cases of scurvy occurring during the whole period of childhood arise between the sixth and twenty-fourth months, and hence the term "infantile scurvy" is fully justified. Scurvy is essentially a disease of diet, as a faulty diet will invariably be found to be the primary cause. Dr. Cheadle, who was the first to recognize the condition of infantile scurvy in this country, says: "In no instance have I seen the disease arise in an infant at the breast, or when fed on an ample supply of good cows' milk. Oatmeal and water, bread and water, various patent farinaceous and desiccated foods, peptonized milk, condensed milk, sterilized milk, 'humanized' milk, German sausage, bread and butter and tea, beef-tea, gravy and bread, in most cases with no fresh milk at all, in a few with a very small amount only, are the dietaries on which I have seen scurvy develop, and, latterly, most often on the peptonized and pan-creatized foods now so much in vogue".
The following facts in connexion with the aetiology of scurvy may be borne in mind: (1) Scurvy is a disease of defect, not of excess. (2) The defect consists in the absence from the diet for a prolonged period of a sufficient amount of the anti-scorbutic element in food. (3) Although the exact element is not known, the foods which contain it are known. (4) The anti-scorbutic element is found most abundantly in fresh or living food, more especially in fruits and vegetables, and the further we get from fresh food as the regular diet, the greater is the tendency to scurvy. (5) There is a class of prepared foods for infants (tinned foods, "proprietary foods," "infants' foods") in which, during the process of preparation, the antiscorbutic element has been entirely destroyed.
The preventive treatment of scurvy may be briefly summed up as the employment of a fresh food diet, suitable in quantity and quality to the age of the child. This has already been described. If cows' milk is the diet, the milk must be fresh, of sufficient quantity, and not altered by prolonged boiling or pasteurizing. Many cases of scurvy have been traced to the use of sterilized or pasteurized milk. This risk has been increased recently by the action of several of the large dairy companies, which are supplying pasteurized milk to all their customers, without any intimation that the milk has been so treated. As many of the customers proceed to boil the milk on delivery, the vital element in it will be in an extremely attenuated condition by the time the milk reaches the infant. The custom referred to is a recent one, but Dr. Coutts has already recorded a case of an infant suffering from scurvy who failed to improve on the dairy milk supplied. It was then discovered that this milk had been pasteurized, and on changing to fresh cows' milk, rapid improvement took place. Cases have also been traced to the use of milk from municipal depots, where undoubtedly the milk had been treated in an injurious way by prolonged heating. While the risk of scurvy is increased by prolonged pasteurizing or sterilizing, the domestic method of boiling the milk for a few minutes, or scalding it, is probably harmless. Sometimes over-dilution of the milk leads to scurvy. It is said that a quart of milk contains as much citric acid as an orange, and this citric acid is looked on by many as the anti-scorbutic element. But if an infant receives only one quarter or one half of a pint of milk daily, the amount of anti-scorbutic material may be so small that scurvy develops. It is therefore necessary to see that there is a sufficient quantity of fresh milk in the dietary, namely, 1 to 2 pints daily. Another curious fact about scurvy is that it often develops as the result of the prolonged use of some special food ordered for the cure of another disease or disorder. Thus, owing to indigestion of some form, an infant may have been put on peptonized milk, and after some months of this diet scurvy is produced; or condensed milk has been prescribed for gastrointestinal disturbance, and after some months scurvy appears. It must be remembered that predigested milk and condensed milk are liable to induce scurvy if employed as the sole diet for any length of time.
The direct connexion between the employment of a diet consisting of condensed milk and other patent " infants' foods," and the subsequent appearance of scurvy, has led all writers on the subject to regard such a diet as the chief cause of scurvy. Some of these foods are more frequently associated with scurvy than others, but this pre-eminence is due (1) to the larger sale of the food, or (2) to its use during the earliest months of life, or (3) to its exclusive use without the addition of any fresh milk. It is daily becoming clearer that these artificially prepared and preserved foods are not to be depended on in the feeding of infants, and in the preventive treatment of scurvy they must be abolished entirely from the diet, as it is practically impossible to confine their use within safe limits. After the age of two years scurvy becomes much less common because fruit and vegetables almost invariably form part of the diet. In rare cases one finds that there is a positive dislike to fruit and vegetables in any form, and in the absence of any anti-scorbutic material in the diet, scurvy may appear. In such cases the special dislike must be overcome by firm treatment.
The curative treatment proceeds on the same lines as the preventive. In the case of infants, fresh milk is to be given, and in order to secure the most prompt effect, it should not be treated by heat in any way. There is little doubt that unboiled milk is a more efficient anti-scorbutic than boiled, and whenever the purity can be relied on milk should be given unboiled. At the same time the anti-scorbutic element in cows' milk is small, although sufficient to ward off scurvy, and in the curative treatment larger amounts of the anti-scorbutic element are called for. Raw meat juice has been recommended by Dr. Cheadle and Sir Thomas Barlow for the anaemia which is usually present. It is not of great anti-scorbutic value, as hung meat only is used in this country, but is easily retained and digested. For an infant of twelve months, half an ounce of expressed meat juice may be given daily, in divided amounts and well diluted with milk or water.
The more special part of the dietetic treatment consists in the free administration of fresh fruits and vegetables, whose antiscorbutic value is great. The full list of these is a large one, but the following will be found the most useful, namely - oranges, lemons, grapes, potatoes and cabbages. In the case of infants under one year, the juice of oranges or grapes may be expressed, and half an ounce may be given in water three times a day. For older infants, boiled and sieved potato, mixed with milk, is a most effective anti-scorbutic. Dr. Hutchison recommends that the potato should be boiled in its skin, and that the floury part just beneath the skin should be used, as this is richest in potash salts. Another plan, suited to those with weak digestive powers, is to administer the vegetable juices through the medium of beef-tea or chicken-tea, in which potatoes and carrots have been boiled and strained off (Cheadle).
Care must be taken that the amount of fruit or vegetables is not in excess of the infant's digestive powers, in which case sickness, flatulence, diarrhoea, etc., may follow and interfere with the recovery.
The effect of this special treatment is one of the most striking in medical therapeutics. Improvement is often noted within a couple of days, and recovery from acute manifestations within a week, provided that the disease has not progressed too far. The child begins to brighten, milk is taken with avidity and relish, the haemorrhages cease, the swelling of the gums subsides, the tenderness in the limbs becomes less marked, and there is not that look of anxiety, from fear of movement, on the approach of an attendant.
We have pointed out in connexion with rickets that scorbutic symptoms may be associated with that disease. So it will often be found that scurvy is complicated by rickets. In other words, a double defect, absence of fat and of the anti-scorbutic element, is often present in the dietary at the same time and leads to the production of the two diseases. This fact must be borne in mind in connexion with the treatment, for a rachitic infant will not recover so rapidly if the scorbutic element is overlooked, and vice versa.
It has been held by some that if only the anti-scorbutic element is wanting in the diet, the same food may be continued in cases of scurvy with the addition of some orange juice. This is false reasoning, and a complete change of diet is almost invariably called for. In some rare cases it may be only over-dilution of the milk and starvation which has produced the disease. Dr. Colman has specially emphasized the fact that rapid improvement is not to be looked for in scurvy unless all preserved foods are omitted from the diet. He has seen three cases in which, although fresh milk, raw beef juice, and orange juice were freely administered, the pains did not subside until the patent food, which had been persisted with, was stopped. As soon as this was done, the subsidence of all scorbutic symptoms was immediate. An explanation of this failure of the treatment while the previous diet was continued may be found in the toxic theory of scurvy. According to this view there is not only an absence of fresh food material but there are toxic 'properties in the food used. Nansen found that scurvy did not arise in his Arctic expedition as long as the tinned provisions were wholesome, but the preservation was imperfect and scurvy broke out. Now tinned foods are largely associated with the occurrence of infantile scurvy, and although the food may be sound when the tin is opened, it is very liable to decompose after being exposed to the air. The contents of a tin have usually to last for some days, and it may be that during this time contamination and decomposition take place. For these reasons our aim should be to employ not the minimum amount of change in the diet which may bring about a cure, but to secure the maximum of benefit in the shortest time by a radical change of diet.