Causation

Scurvy is a disease dependent upon malnutrition, which is customarily attributed fo lack of fresh vegetables in the dietary; but this statement is somewhat vague, in that it is not exactly known which articles of diet are most liable to produce the disease by their absence, although many believe that the cause is due to deficiency of salts whose acids - citric, malic, lactic, acetic, and tartaric - form carbonates, but no preventive food has been found which is absolutely successful in all cases. At all events, it is a disease due to omission and not to consumption of certain foods, and it depends rather upon the quality than quantity of food. In opposition to the theory that the want of fresh vegetables acts as a cause of scurvy in man, the fact is stated by Lieutenant Greely that among the Danish Eskimos, who have a population of ten thousand, not a pound of vegetables nor a dozen pounds of bread per man are eaten annually, and yet they are practically free from the disease, and the same statement is made in regard to the most northern tribes of Eskimos of pure blood who were studied by Lieutenant Peary, and also in regard to the natives of the Alaskan archipelago and some tribes of North American Indians who do not include either vegetables or cereals in their food.

It is an undoubted fact that the disease is much oftener present among people who have lived for some time in bad hygienic surroundings and in damp, dirty quarters, and who have been subjected to mental depression, monotony of occupation and diet, or excessive work and fatigue, as well as the abuse of alcohol. It has often been known in prisons. It is therefore possible for scurvy to occur in any part of the world among men affected by these conditions, but it is much less common at the present time than formerly.

In the British arctic expedition of 1875-'76 over 48 per cent of the men suffered from scurvy, and a still larger percentage existed among those who were exempt from field service and outdoor life.

When the potato crop failed in Great Britain and Ireland in 1846 scurvy became very prevalent. In the war of the Crimea twenty-three thousand cases occurred among the French troops alone.

Woodruff, referring to scurvy in the United States Army, writes: "If transportation is so deficient that only bacon, hard-tack, and coffee can be carried, actual scurvy is the result. The company commander must secure something else for his men. The lack of fresh vegetables and fresh meat is the chief fault. Why fresh things are needed is not known, but it is believed to be due to the fact that the body thus received certain salts and unknown substances necessary as stimulants or tonics to the tissues, which salts and substances are destroyed by the usual methods of preservation. It is not to be denied that men may live for many years without tasting such articles of diet, though it is rare for a man to be denied all three - meats, fresh vegetables, and fresh fruits. If they are so denied they are not possessed of that health which permits of the 'highest mental and physical development".

Scurvy contributed 15 per cent to the death rate from diseases in the late civil war, and it was formerly prevalent among seafaring men when upon long voyages, who lived upon salt pork or pickled meats; but the disease is encountered much less often at the present time, owing to the better means of preserving foods, securing variety in diet, and better hygiene. The regulations of boards of trade usually require that antiscorbutic foods and remedies should be carried upon vessels, and the development of scurvy on board ship, unless in exceptional cases of shipwreck or in voyages prolonged beyond the expected limit, subjects the captains or owners to indictment for criminal negligence. The English law early required that lime juice should be carried on long voyages, and this formerly earned the nickname of "lime juicers" for British sailors. Many almshouses have similar regulations.

Scurvy has been known to occur from failure of intestinal absorption, in which case it is less easily preventable.

Garrod holds that scurvy is caused by absence of potash, for in this disease the blood is deficient in potassium salts. He regards this fact also as an explanation of the muscular weakness which is a prominent feature, and observes that all good antiscorbutics - fresh milk, meat, lemons, and fresh vegetables - contain abundant potash.

Garrod's theory is modified by Immermann, who believes that a temporary lack of these salts may cause trophic disorders, which may continue for some time after the deficiency in salts has been made good, and Duchek has even found that in exacerbations of symptoms occurring in scurvy there may be an increased elimination of potash salts in the urine. The body is capable of retaining and reusing its various salts for a considerable time, so that withdrawal of the potash does not necessarily induce scurvy at once (Bauer).

Northrup and Crandall investigated the causes of scurvy in a number of infants, and report that they find the employment of proprietary, foods which for various reasons are substituted by the mother for fresh food is the most important cause of scurvy, and "even fresh milk in small proportions is not sufficient to insure perfection." Their report continues:

"The exact diet is known in thirty-three cases. We find that twelve of these children (36 per cent) were fed on a proprietary food exclusively, six (18 per cent) had received an exclusive diet of condensed milk or evaporated cream, while three received a combination of these two foods. Over 63 per cent, therefore, were fed upon a diet of proprietary foods and condensed milk. Two children received sterilised milk exclusively, and three a weak mixture of milk and water. One was fed on condensed milk, one on boiled and pep-tonised milk, and one on barley water.

"It is a significant fact that the country which furnishes most of the literature of scorbutus in children is the same which is posted from end to end with advertisements of proprietary foods".

Louis Starr furnishes a list of the common dietetic causes of scurvy in infants, as follows (they will be seen to be very diverse):

"The different proprietary infants' foods administered without or with slight addition of cow's milk; these foods are responsible for the greatest number of cases, and the variety most harmful depends greatly upon the degree to which it is used; oatmeal or wheat gruel; barley and other farinaceae administered with water alone or with water and insufficient cow's milk; condensed milk and water; sterilised milk; properly modified milk mixtures, but subjected to a temperature of 2120 F. from thirty minutes to an hour or more; too dilute milk-and-cream mixtures; laboratory mixtures with too low albuminoid percentages." Scurvy is found more frequently in infants reared in luxury than in the very poor.

Scurvy in infants presents definite peculiarities due to subperiosteal effusions of blood along the femoral and tibial shafts, which are accompanied by hyperesthesia, local pain, tenderness, swelling, and immobility. Occasionally the cranial bones, ribs, and bones of the arms are involved. The pain and immobility formerly led to mistaken diagnoses of rheumatism, spinal cord disease, etc. Hematuria may occur.

It is astonishing to see the promptness with which improvement follows the giving of a rational diet in these cases, and a little fresh orange juice will often produce a remarkable change for the better.

Prophylaxis

So long as the hygienic conditions are good and the food is of the best quality and variety, and if proper discipline and regular habits of eating and sleeping are insured, scurvy may be prevented among soldiers and sailors, although fresh vegetables may not be obtainable. On American ships potatoes are always used. Cranberries keep well and are excellent antiscorbutic food.

The introduction of canned and compressed vegetables in seamen's rations has done much to prevent scurvy, but fresh, food is always to be preferred to preserved food of any kind. Dried legumes are quite useless. For travellers in the far North, Nordens-kiold advised the use of cloud berries (Rubus chamcemorus).

Dietetic Treatment

In mild cases of scurvy of comparatively short duration patients rapidly improve under proper dietetic treatment if it can be obtained. The juice of two or three limes or lemons, or a few fresh vegetables eaten daily, may be all that is necessary, and the former is one of the best preventives as well as curative agents.

A. E. Wright dissents from this view, at least in regard to such cases as may suffer from bleeding from the gums. He claims that the acids, tartaric and citric, have a decided inhibitory action upon intravascular coagulation when given per os, and maintains, contrary to general experience, that in scurvy with persistent haemorrhage the use of fresh lemon juice tends to keep up the oozing of the blood. He says that the neutral citrates and tartrates do not act in this manner, and they should therefore be prescribed instead of fresh lemon juice.

Stomatitis is often the most prominent symptom, and if the mouth is very tender, the gums are swollen and bleed readily, and the stomach is irritable, the diet must be limited to fluid or some solid food which requires no mastication. Beef tea, broths and meat soups thickened with vegetables, fresh vegetable purees, eggs, and milk are recommended. To these substances the juice of two or three fresh oranges, limes, or lemons should be added. If the patient is able to masticate food thoroughly and the stomach is not too feeble, fresh meat, baked or mashed potatoes, cabbage, sauerkraut, pickles, salad, and "greens," such as water cress, fresh mustard, or radishes, may be given. The citrate of iron, vinegar, acetic acid and potassium chlorate and bitartrate have all proved beneficial. During the civil war the expressed juice of sorghum was tried with some success.

The treatment of scurvy in children consists first in throwing away all proprietary foods, and then if the disease has not progressed too far, improvement and cure rapidly follow change to a normal diet of mother's milk or fresh cow's milk, expressed beef juice, and a little fresh orange or peach juice.

The following dietary is recommended by Louis Starr for scurvy in an infant eight months old:

"At 7 a. m., cream, ounce; milk, 4 ounces; milk sugar, 1 drachm; water, 3 ounces. At 9 a. m., one or two teaspoonfuls of fresh orange juice, according to effect on the bowels. At 10.30 A. m., same as at 7 a. m. At 11.30 a. m., two teaspoonfuls of raw-beef juice, free from fat, and with a little salt. At 1 p. m., one to two teaspoonfuls of fresh orange juice. At 2 p. m., same as at 7 a. m. At 3 p. m., two teaspoonfuls of raw-beef juice with salt. At 5 p. m., one to two teaspoonfuls of fresh orange juice. At 6 p. m., same as at 7 a. m. At 8 p. m., two teaspoonfuls of raw-beef juice with salt. At 10 p. m., same as at 7 a. m.

A substitute for orange juice may consist in scraped ripe apple or fresh grape juice. Iron is indicated. The body may be gently rubbed with warm olive oil".