Scurvy Past and Present.

by Alfred Fabian Hess.

PREFACE

Interest in scurvy has been stimulated in the last few years as the result of a new and broader conception of nutrition. It has come to be realized that in addition to the substances heretofore recognized as of essential importance in the dietary--the proteins, fats, carbohydrates and the salts--there is still another group, termed "vitamines,"

"accessory food factors" or "food hormones," which must be included in order to render the diet complete and adequate. It has become increasingly evident that the attention of physiologists and of clinicians has been focussed too sharply and too narrowly on the caloric value of foodstuffs. At the same time we have begun to appreciate the existence of a group of nutritional disorders which depend largely on a deficiency of these illusive vitamines or food factors, and which evidently are of vital importance to the welfare of the individual and of mankind. Scurvy is one of this newly-const.i.tuted group, and due to this a.s.sociation has acquired a fresh and broader significance. It is in this light that the intensive research work must be interpreted, which has been applied within the past few years, both in this country and abroad, to problems relating to this disorder. It is clear that the subject is in its infancy, and is destined to partic.i.p.ate in a consideration of many of the nutritional and infectious diseases of the adult and the child.

The World War has tended also to demand a renewed consideration of scurvy. This disorder has played a role in all wars--in the campaigns of the Caesars, the pilgrim ages of the Crusaders, and the numerous wars of the last century. In the recent war it existed among the various armies, particularly those in the East, to an extent greater than at first was realized. In Mesopotamia it is stated to have been one of the decisive factors in forcing the surrender of the British at Kut. Its incidence, however, was not limited to the military forces. Reports from England and the continental countries clearly indicate that scurvy prevailed among the civilian population during the past few years to a degree unknown in peace times. This was especially true of infants and children.

For the past seven years I have been engaged in an investigation of scurvy both in the laboratory and in the clinic, and have treated various aspects of the subject in a large number of articles published in various medical journals. In the course of these studies there has been ample opportunity for a comprehensive review of the widely-scattered literature. No treatise on scurvy has been published in English since the cla.s.sical work of Lind in 1772. The time, therefore, seemed opportune to gather into one volume the recent advances in this field and to offer to the clinician, to the hygienist, and to the biological chemist a presentation of the existing status of this important nutritional disease.

It is with pleasure that I acknowledge my obligation to Dr. Lester J.

Unger, who has a.s.sisted in carrying out much of the work described in this volume. Thanks are due also to Dr. Charles Gottlieb for the radiographs which are here reproduced, and to Dr. Gertrude McCann for seeing the work through the press. To my a.s.sociates in the clinic who shared in the observations, and to friends who read various chapters in the course of their preparation, I wish to express my appreciation.

ALFRED F. HESS.

New York, August, 1920.

CHAPTER I

HISTORY OF SCURVY[1]

[1] The best historical review of scurvy is to be found in Hirsch's Handbook of Geographic and Historical Pathology, from which account we have drawn many facts.

=Outbreaks on Land.=--Like many other diseases, the life history of scurvy shows several distinct phases. We hear of it first as a plague, infesting armies and besieged towns; then as a dread disease, decimating the sailors of the navy and of the mercantile marine, and, since the end of the last century, more often as a nutritional disturbance, endangering the health of infants. Very recently it has acquired an entirely new interest, as the representative of a cla.s.s of disorders which has revealed the essential importance to man of unknown dietary factors.

It is difficult, as may be imagined, to define with precision the earliest description of scurvy, as the older references are so vague as to be open to individual interpretation. The reference of Hippocrates to a large number of men in the army who suffered from pains in the legs and gangrene of the gums, which was accompanied by loss of teeth, seems sufficiently definite to be identified as this disease. The Greek, Roman and Arabian writers do not seem to have been acquainted with scurvy.

This is as we should expect, for fruits and vegetables grew in such plenty in these southern countries that scurvy must have been a disorder of rare occurrence.

An interesting early description of scurvy, and one which is quite convincing, is that of de Joinville, who accompanied the Crusaders in their invasion of Egypt under St. Lewis, about the middle of the thirteenth century. He refers to the lividity and spongy condition of the gums, and describes how "the barber surgeons were forced to cut away the dead flesh from the gums to enable the people to masticate their food"; he describes their debility, their tendency to faint, and the black spots on their legs. The disease broke out in Lent, during which time the soldiers partook of no meat, but consumed a species of eel which they believed "ate the dead people" and therefore led to this loathsome disease.

It is probable that scurvy existed in the northern parts of Europe and Asia ever since they were settled by man. We should hardly expect to have records of this condition, in view of the low educational status of the people, their greatly restricted literature, and their lack of intercourse with the people in the southern countries. In the sixteenth century, with the development and spread of education, we begin to hear of scurvy from various sources. Claus Magnus, in his "History of the Northern Nations," published in 1555, described the disease which he tells us flourished among the soldiers in the camps and in the prisons.

About this time Ronsseus, Echtius and Wierus wrote special treatises on this disease, and recommended many dietary measures which we recognize to-day as most efficacious. The number of monographs on this subject multiplied with great rapidity in the course of the next twenty-five or fifty years; none of them, however, added anything essential to our knowledge. In 1645 the Faculty of Medicine at Copenhagen published a "consilium" for the benefit of the poor, treating of the causes, prevention and cure of this disease, which was prevalent among the Danes and other northern nations.

The colonists of the northern part of America were sorely afflicted with scurvy. It is said that the French met with such high mortality during the severe winters in Canada, that they frequently debated the wisdom of abandoning this settlement. This was true also in regard to the English and their settlement in Newfoundland. Indeed, it was scurvy which forced the early settlers in Hudson Bay to discontinue their intentions of colonizing that region.

In an essay published in the eighteenth century (1734), Bachstrom described an epidemic of scurvy which occurred in 1703 during the siege of Thorn, in Prussia, by the Swedes, which caused the death of 5000 of the garrison, in addition to a large number of the inhabitants. It is interesting to note that this epidemic took place in the middle of the summer, and not in the cold season. From this time on we meet with many descriptions of scurvy in connection with the wars at various periods.

For instance, in the Russian armies, in the war between the Austrians and the Turks in 1720; in the English troops who had taken Quebec from the French in 1759; among the French soldiers in the army of the Alps in the spring of 1795. It is unnecessary to review these accounts in detail. This period is distinguished rather by the appearance of a great cla.s.sic on Scurvy, the work of the English naval hygienist, Lind (1752).

This book has intrinsic value to-day, and, at the time it appeared, served to crystallize the conception of scurvy, which had been stretched out of all proportions to include an ever-increasing conglomeration of clinical conditions. Scurvy had become the Alpha and Omega of professional routine, the catchword of the day, the asylum ignorantiae of the practical man. Into this chaos, as Hirsch expresses it, "the first beams of light fell when Lind's cla.s.sical work appeared."

It will be of little value to consider the great number of epidemics of scurvy which occurred from this time to the present day. They may be found in tabular form in the excellent survey of scurvy by Hirsch. The literature of this long period may likewise be found in a work of encyclopaedic character, that of Krebel, which gives the t.i.tles, with a summary of the various articles on this subject, appearing to the year 1859. If we look over the chronological table compiled by Hirsch, we note a remarkable similarity regarding the incidence of the recurring epidemics. In almost all cases they broke out among troops, whether in Russia, in India, in Africa, or in our United States. The epidemics which are not attributable to military life or campaigns are found to have taken place generally in prisons, insane asylums, poorhouses or houses of refuge and correction. It would seem that no war is omitted from this list of sickness and death. There are in all 143 land epidemics between 1556 and 1877, two occurring in the sixteenth century, four in the seventeenth, 33 in the eighteenth, and 104 in the nineteenth century. The marked increase in the nineteenth century occurred in inst.i.tutions, in asylums and prisons, rather than in the armies. This fact may be ascribed to altered social conditions which led to a great multiplication of eleemosynary inst.i.tutions.

Coming down to more recent times, we learn that scurvy occurred extensively during the Crimean War, and that it was prevalent also among the troops in our own Civil War. In the "Medical and Surgical History of the War of the Rebellion," we find the following statements:

"A s...o...b..tic tendency was developed at most of our military posts during the winter season, after the troops had been confined to the use of the ordinary ration with the desiccated vegetables. The latter in the quant.i.ties failed to repress the disease. At posts which could be readily supplied with potatoes only the taint was manifested, on account of a want of liberality in the issues." And again: "Among the white troops during the five and one-sixth years covered by the statistics, 30,714 cases of scurvy were reported; and 383 deaths were attributed directly to that disease."

Munson writes: "It (scurvy) prevailed among our troops during the Civil War and its recognition was a surprise and shock to professional ideas preconceived from practice in civil life."

As is well known, the besieged in Paris during the Franco-Prussian War in the winter of 1870-71 suffered severely from scurvy. The accounts of their pitiable condition have been portrayed for us by numerous French writers (Delpech, Hayem, Laseque and Legroux). The people lived mainly on rice and bread, with an occasional addition of potatoes or horse meat. The winter was exceptionally severe, which was supposed to have intensified the s...o...b..tic condition. Not only were the inmates of the prisons on the Seine attacked, numbering about one thousand, but even the patients in the military hospitals developed the disease. It is of interest to remember that the siege lasted but little over four months, from September 17th to January 27th, the date of the armistice.

In the Russo-j.a.panese War, after the siege of Port Arthur, it was found that one-half of the garrison of 17,000 men had scurvy.

Although there are certain parts of the world where scurvy is of frequent occurrence, no country has been entirely free from it. As might be expected, it has been particularly prevalent in the North, where vegetation is scanty--in Greenland, Alaska, Russia and the Baltic States. It has likewise prevailed in the tropics when the crops have failed. India has been conspicuous for its large number of epidemics; some years ago scurvy occurred in Arabia among the English troops stationed at Aden, both among the British and the native troops. A recent communication from Aruba, a small island of Dutch Guiana, lying north of Venezuela, ill.u.s.trates how devastating scurvy still is in some parts of the world. This account tells of 3000 cases of this disease which occurred in 1915 among a population of less than 10,000, owing to the fact that the crops had failed almost entirely during the years 1912, 1913 and 1914.

It is important for us to realize that we are still dependent on the annual crops for our protection from scurvy; in other words, the world is leading a hand-to-mouth existence in regard to its quota of antis...o...b..tic food. The truth of this condition has been realized for Ireland, sadly ill.u.s.trated by numerous epidemics, notably the great epidemic of 1847 reported by Curran. It was demonstrated by the outbreaks of scurvy in Norway in 1904 and 1912, and was brought to the attention of many in the United States in the spring of 1916. In this year our potato crop fell far below the normal, with the result that scurvy appeared in various parts of the United States, especially in inst.i.tutions (Fig. 1).

[Ill.u.s.tration: Fig. 1.--A comparison between the requisitioned quant.i.ty (in thousand pound units) of potatoes and other vegetables, and the quant.i.ty received per month by an inst.i.tution in which more than 200 cases of scurvy occurred at the beginning of April, 1916. The total height of column represents the amount needed and requisitioned; the solid black portion the amount received. The number of inmates in the inst.i.tution remained approximately the same.

The chart ill.u.s.trates our great dependence on the potato during the winter months. This is due not only to its intrinsic antis...o...b..tic potency, but, probably quite as much, to the fact that fully twice as many pounds of potatoes are consumed during the winter as of all other vegetables combined. Therefore, if this crop fails or is dehydrated, scurvy will develop in the spring.]

The fact that scurvy may occur in any land and climate, even in the garden spots of the world, is strikingly shown by the epidemics reported from Algiers, and the ravages of this disease among the gold seekers in California in 1849. Nothing could be more incongruous than the occurrence of a deficiency disease in this land of plenty.

=Outbreaks at Sea.=--It is doubtful, however, whether attention would have been focussed so early and so sharply on scurvy, had it not been for the voyages of exploration undertaken in the sixteenth century.

These long trips on sailing vessels, where for many months little or no fresh vegetable or animal food was obtainable, were almost as if designed to make a test of the dietetic origin of scurvy. The result was inevitable--five to six months after the ships were out of touch with land, the majority of the crew frequently were incapacitated by this disease, thereby wrecking many an expedition.[2]

[2] The fact that crews of vessels which set sail in winter were more subject to scurvy than those which set out in the summer must be attributed to the existence of latent scurvy among the sailors at the time of sailing, rather than to the season of the year.

The earliest account of the outbreak of scurvy at sea is that of Vasco de Gama, who in 1497 discovered a pa.s.sage to the East Indies by way of the Cape of Good Hope. The narratives of subsequent explorers, especially those of Cartier and of Drake, are replete with descriptions of the ravages of scurvy. The expedition of Lord Anson in 1740 is always cited as a memorable example of an undertaking which foundered as the result of scurvy. After a cruise of four years, this expedition had lost from this disease more than four out of five of the original number of its crews. In striking contrast to this picture, and to that furnished by the voyages of earlier navigators, is that of Captain Cook, who in 1772 undertook a voyage lasting over three years, sailing from 52 north to 71 south, with a loss of but one of his crew from disease, and that not from scurvy. This remarkable feat, more than any other, centered attention on the feasibility of preventing scurvy, and resulted in measures tending to eradicate it from the navy. Captain Cook attributed the absence of scurvy among his crew to "sweetwort," an infusion of barley, which he prepared fresh and served liberally. He also prized the antis...o...b..tic value of sauerkraut.

We find accordingly in 1795, at the instance of Sir Gilbert Blaine, that improvements were introduced in the victualling of the fleet. As the result of a regular ration of lemon juice, the incidence of scurvy fell precipitously. It is due largely to this provision that between the years 1779 and 1813, according to the statistics of Sir Jay Barrow, the morbidity and the mortality in the British Navy was decreased by 75 per cent.

It has been shown that it took a generation after the efficacy of antis...o...b..tics had been demonstrated in various expeditions, for an antis...o...b..tic to be included in the ration of the navy. The merchant marine of England was far more conservative, and for many years after scurvy had been eradicated from the navy we still read of its occurrence on the vessels making voyages to India, China and Ceylon. Gradually, however, its incidence became less and less. Its toll of death, before preventive measures were employed, may be appreciated from the fact that it has been estimated that scurvy destroyed more sailors than all other causes incidental to sea life, including the great slaughter of naval warfare. Sir R. Hawkins stated in the latter part of the sixteenth century that he could give an account of 10,000 mariners who had been destroyed by scurvy during the twenty years that he had been at sea.

As is well known, scurvy has played an important role in Arctic and Antarctic explorations, and has been the cause of the failure of many of these expeditions. It is now realized that the development of scurvy is quite preventable, that if a sufficient quant.i.ty of meat (especially raw meat) is consumed, explorers can be entirely independent of a supply of fresh vegetables. This fact was brought out by the Arctic Survey Committee (British), who "were appointed to enquire into the causes of the outbreak of scurvy in the recent Arctic expedition" (1877), and who reported that it may result from an absence of fresh meat. That this conclusion was sound has been proved by the experiences of Nansen and of Johansen, who wintered safely in Franz-Josefsland on a diet of meat and bacon. More recently Stefansson has carried out successful Arctic explorations, depending entirely on fresh meat as antis...o...b..tic foodstuff and making no provision whatsoever for vegetable food.

=Infantile Scurvy.=--Glisson, to whom we owe the first description of rickets, likewise was the first to recognize scurvy in infants. In his cla.s.sic treatise on rickets, written in 1668, he writes as follows:

"The scurvy is sometimes conjoyned with the affect. It is either hereditary, or perhaps in so tender a const.i.tution contracted by infection, or lastly, it is produced from the indiscreet and erroneous Regiment of the infant, and chiefly from the inclemency of the air and climate where the child is educated."

"The scurvy complicated with this affect hath these signs: 1. They that labor under this affect do impatiently indure purgations; but they who are only affected with the Rachites do easily tolerate the same. 2. They are much offended with violent exercises, neither can they at all endure them. But although in this affect alone, there be a kind of slothfulness and aversation from exercise, yet exercise doth not so manifestly, at least not altogether so manifestly hurt them, as when the scurvy is conjoyned with the Rachites. 3. Upon any concitated and vehement motion they draw not breath without much difficulty, they are vexed with diverse pains running through their joynts, and these they give warning of by theyr crying, the motion of the Pulse is frequent and unequal, and somethimes they are troubled with a Palpitation of the Heart, or threatened with a Lypothymie, which Affects are for the most part soon mitigated, or altogether appeased by laying them down to rest. 4. Tumours do very commonly appear in the Gums. 5. The urin upon the absence of the accustomed feavers is much more intense and increased."

Glisson's description of scurvy was entirely lost sight of, overshadowed by his description of rickets, so that for over two hundred years no word of infantile scurvy is to be found either in the English or other literature. There is no doubt that from time to time cases must have occurred, but they were looked upon probably as rickets or as a manifestation of one of the hemorrhagic diseases.

In 1859 Moeller described some cases which evidently were scurvy, but which he termed "acute rickets." He realized that they presented a novel clinical picture but failed to recognize that they represented a disorder quite distinct from rickets.[3] This article was followed within the next few years by reports of other German writers (Bohn, Steiner, Foerster) who, accepting Moeller's point of view, considered these cases merely as an acute form of rickets. They were led to this erroneous conclusion chiefly on account of the lack of marked involvement of the gums, which they considered an essential sign, influenced by their conception of adult scurvy. This viewpoint has pervaded the German literature even to the present day, when it is still considered necessary to bring further evidence that infantile scurvy in its pathogenesis and pathology is identical with adult scurvy.

[3] Infantile scurvy is frequently termed "Die Moellersche Krankheit."

There seems to be no occasion for giving Moeller credit for discovering this disease, as he believed that he was dealing with rickets merely in an acute form. He recognized the clinical similarity to scurvy, but in one of his cases sharply differentiates it from adult scurvy by the fact that "lemon juice and fresh vegetables" were of no avail in the treatment.

In 1871 Ingerslev, an a.s.sistant of Hirschsprung in Copenhagen, wrote a paper on "A Case of Scurvy in a Child," which is quite convincing. Two years later Jalland, an English physician, reported a similar case of "Scurvy in a Ten-Months-Old Infant." In 1878 Cheadle reported three cases of infantile scurvy with typical tumefaction of the gums, and obscure tenderness of the legs, and followed this paper by two others, which appeared in 1879 and 1882. Cheadle clearly recognized the disease as scurvy. However, as the t.i.tle of his first paper--"Three Cases of Scurvy Supervening on Rickets in Young Children"--indicates, he considered it a condition engrafted upon rickets. About this time (1881) Gee presented a brief but accurate account of five cases of scurvy which he termed "osteal or periosteal cachexia."