This is the cardinal diagnostic error in adult as well as in infantile scurvy--time and again, and in spite of urgent and repeated warnings, patients continue to be treated for _rheumatism_. Holt writes: "In fully four-fifths of the cases which have come to my own notice this (rheumatism) has been the previous diagnosis." Such has been our experience. The diagnosis should not be difficult. In sporadic cases, the individual has limited his diet usually on account of indigestion, or diarrhoea, or following some dietetic whim or medical advice given months previously. Where scurvy occurs _en ma.s.se_ it may follow an inability to obtain fresh food--as during war, on shipboard, in the Tropics or in the Arctic regions--or be the result of a misplaced reliance on some article of food--for example, dehydrated vegetables.

More careful investigation will disclose that the "rheumatic" pains and tenderness are not in the joints but in the muscles and tendons. The calf muscles are frequently painful and excessively tender and somewhat swollen or infiltrated; the hamstring tendons or the tendo Achilles may be sore and slightly swollen and the site of slight subcutaneous hemorrhages. In some cases there is bone tenderness, pain on percussion of the shins or of the sternum. These signs may be accompanied by, or even precede, hemorrhages in the gums. The diagnosis of rheumatism in infants indicates a lack of knowledge of pediatrics, as this disease is hardly ever encountered in babies under a year and a half of age.

It is not always easy to differentiate scurvy from _purpura_. In either disease the gums may be hemorrhagic and swollen, there may be scattered subcutaneous hemorrhages and pains in the limbs. Occasionally, as in a case seen a few years ago, we may be forced to resort to the dietetic test. A close inquiry into the previous diet, however, a history of previous attacks of purpura, the number, and especially the large size, of the subcutaneous hemorrhages, and above all, the diminished number of blood-platelets, should make diagnosis possible. In scurvy the platelets are almost always over 300,000 per cubic millimetre, whereas in purpura they are reduced to less than 200,000.

In the army it may be difficult to distinguish scurvy from _beriberi_, especially if they occur side by side as in the recent English campaign in Mesopotamia. There may be a combination of the two diseases, a picture similar to ship-beriberi, regarded by Nocht as a hybrid of these diseases. The diagnosis is rendered more difficult, as at times scurvy is a.s.sociated with signs of neuritis. We shall have to depend on the involvement of the gums and the hemorrhages in scurvy, and on the hyperaesthesia, paraesthesia, and anaesthesia in beriberi; marked edema points to the latter disease.

We have thus far had in mind frank and outspoken cases of scurvy. When we come to consider latent or early cases, the diagnosis is more difficult and may have to be merely tentative. All that need be added, in view of the clinical picture sketched above, is that this condition should not be forgotten in treating adults who have malaise and indefinite "rheumatic" pains and, more particularly, in relation to infants who fail to gain, whose appet.i.te is capricious, whose disposition has become fretful and who have developed the sallow s...o...b..tic complexion. This warning is particularly opportune at present in the United States, where pasteurized milk is fed so extensively to infants, and an antis...o...b..tic food is not always given.

In addition to the symptoms just enumerated, tenderness of the bones, especially of the distal ends of the femora, should be sought for, the urine should be examined carefully for red blood-cells, and perhaps the ends of the long bones radiographed for "the white line" of Fraenkel.

The experience of Comby with infantile scurvy is illuminating. Among the fifty-five cases which he has seen, the diagnosis was erroneous in forty-five, and among thirteen cases recently met with, the physician failed to recognize the disorder in all but two. The infants had been given sodium salicylate, had been treated with electricity and ma.s.sage for the supposed acute poliomyelitis, or given mercury for syphilis, or incisions or trephining had been carried out for acute osteomyelitis.

Some had been put into plaster casts for c.o.xalgia or for Potts' disease.

This experience requires little comment. It should be added, however, that in the course of an epidemic of poliomyelitis, such mistakes are apt to happen, and, to our knowledge, did occur in the recent epidemic.

In regard to "_the pseudo-paralysis" of congenital syphilis_ diagnosed as scurvy, it should be remembered that this lesion occurs almost always before the fifth month of life. A history of previous papular eruption, the bilateral enlargement of the epitrochlear glands, and the Wa.s.sermann test should suffice to establish the correct diagnosis.

Besides the clinical conditions enumerated above, we may add the following, which have been confused with scurvy: Neuritis, hemorrhagic nephritis, calculus of the urinary tract, renal tumor, orbital tumor, appendicitis, peritonitis, pleurisy and pneumonia. Holt writes as follows: "I have known two cases to be operated upon by eminent surgeons, once with a diagnosis of sarcoma and once of ost.i.tis of both tibiae. Not until the subperiosteal hemorrhages and epiphyseal separations were discovered was the nature of the trouble suspected."

Recently we saw a case of fracture of the distal end of the femur diagnosed as infantile scurvy; the baby had caught its thigh between the bars of the crib and snapped the bone in trying to extricate itself.

Finkelstein adds acute endocarditis, hemorrhagic septicaemia with multiple bone swellings, and leukaemia as having been confused with scurvy.

In an interesting account of scurvy in the Russian army during the recent war, h.o.e.rschelmann states that tired soldiers at times feign scurvy. They produce a "pseudo-scurvy" by means of scratching the gums with their nails or rubbing them with tobacco, and at the same time bring about hemorrhages of the skin by means of trauma.

Scurvy in the breast-fed infant has been fully considered under etiology. We wish merely to state again that one cannot be too cautious in venturing this diagnosis in a nursing baby. The great majority of reported cases are not scurvy, but bacterial infections, syphilis, or various forms of intoxication. In establishing a diagnosis the same principles hold as in the case of bottle-fed infants.

The most important consideration in the diagnosis of scurvy is to keep in mind the heterogeneous character of its symptoms, and the manifold diseases with which it may be confused. Surgeons should be alert to this danger when about to perform operations for osteomyelitis or bone tumor. The mistakes occur because cases are infrequently seen and because the signs, being dependent largely upon hemorrhage, occur in such varied locations of the body. Where diagnosis cannot be made from the signs or symptoms, the most important aid is a thorough acquaintance with the previous diet of the individual and observation of his reaction to antis...o...b..tic treatment.

CHAPTER VIII

PROGNOSIS

The outcome of scurvy, as we encounter it in peace time in the Temperate Zone, is generally favorable, so that it plays but an insignificant role in our mortality statistics. This results from the fact that we are abundantly provided with a specific remedy, so that if the diagnosis is made early and treatment is prompt and thorough, the patient will rapidly recover and suffer no physical disability. Where antis...o...b..tic foodstuffs are not procurable, however, this disease const.i.tutes a terrible scourge, causing many deaths and spreading among an army, a ship's crew, or among the civil population with the rapidity of an epidemic. For example, the ships of the East India Company in their voyages round the Cape often lost nearly one-half of their crews, and in Lord Anson's famous voyage round the world 380 out of 510 seamen perished from the disease. Moreover, if the antis...o...b..tic treatment is inadequate or the patient goes untreated for a long period, the cure may be incomplete, a condition of malnutrition and weakness developing, which may persist for years. To appreciate this clinical condition we must refer to the account of physicians who saw thousands of cases of severe and untreated scurvy among the sailors, who were of necessity deprived of aid until they reached land. Lind laid stress on a type of this disease which developed under these circ.u.mstances and which he termed "obstinate scurvy." He writes: "I have met with numerous instances not only among the common seamen, but of officers, with whom it had taken such deep root in the const.i.tution as to prove a lasting affliction to them during a great part of their lives.... Persons are likewise subject in different periods of their life afterwards to habitual rheumatism, pains and stiffness in their joints; and sometimes eruptions on the skin." In his treatise on scurvy, published in 1685, Harvey refers to this chronic nutritional disorder as "inveterate scurvy." He pictures patients who had gone untreated for a long time as "molested with vagrant, ambulative, distending, creeping, vellicating or lancinating pains of several parts of the body.... They are often loose and subject to falling into violent fluxes of the belly, diarrhoea and lienteries."

Infants as well as adults usually recover rapidly and completely from scurvy, the result depending largely upon the early recognition of the disease. We must always bear in mind, however, that from a histologic standpoint the cure is not simultaneous with the magic disappearance of the clinical symptoms, but that months probably elapse before the tissues return to their normal state. It is difficult to give reliable mortality statistics for infantile scurvy, for so many cases are of the rudimentary form that percentages are necessarily misleading. Still writes that in 5 out of 64 cases the disease proved fatal by diarrhoea and exhaustion. The American Pediatric Society reports 29 deaths out of 397 cases, which gives a similar mortality percentage. When infantile scurvy was not so generally recognized by physicians the mortality was much higher, and we find that Barlow encountered 7 deaths in his first series of 31 cases.

Even when the child recovers it may not regain its normal health if it has continued for a prolonged period in a state of chronic scurvy. It may remain pale and fail to gain in weight in spite of a liberal and well-balanced diet. Cases of this kind are not infrequent. In this connection it is worthy of note that 4 of the 41 cases of "coeliac disease," an interesting intestinal condition described by Still, had scurvy just before or during the onset of the disease. This observation conforms to the experience that chronic bowel disorders often follow in the wake of adult scurvy.

In adults the heart may be weakened by scurvy, and death may result from cardiac failure. Cardiac disturbances occur also in infantile scurvy.

This involvement might be expected, in view of the tachycardia (cardiorespiratory phenomenon) which is so frequent a symptom of infantile scurvy. The heart may be rapid for months or even for years after the disorder, and tachycardia may develop on the occasion of even a mild infectious disease. For example, a fever of 101, due to a common coryza, may cause the heart-beat to rise to perhaps 180 a minute.

Children so affected succ.u.mb readily to infection, especially to pneumonia, which may lead to sudden collapse followed by death.

An important factor in the prognosis of scurvy, as in that of other disorders due to a lack of vitamines, is the marked susceptibility to infection. Even latent or subacute scurvy causes a peculiar susceptibility to diphtheria (especially the nasal type), to coryza, bronchitis, and pneumonia. A perusal of the literature shows that this susceptibility was noted by the older authors in relation to adults.

The local signs usually disappear quickly without leaving any trace. The hemorrhages are absorbed and the eczema heals within a few days. The fractures unite promptly with the formation of an unusually large callus. The urine, which may have contained red blood-cells or have been markedly hemorrhagic, quickly becomes normal and, in our experience, gives no further evidence of renal damage. Still reports, however, the case of a frail child who had a trace of alb.u.men in the urine two years after an attack of scurvy. A rare local injury, which may lead to death, is cerebral hemorrhage. Recently Sammis reported a case of this kind, which was characterized by convulsions during life, and in which subdural hemorrhage was found at necropsy.

If we acknowledge an individual idiosyncrasy to scurvy we should expect a tendency to a recurrence of the disease. Lind was of this opinion, stating that "by observations made on this disease, it appears that those who are once afflicted with it, especially in so high a degree as that squadron was, are more subject to it afterwards than others." It is difficult at the present day to express a personal opinion on this matter, as clinical experience is meagre and the scurvy of guinea-pigs is so acute that it cannot be used for comparison. Some of the recurrences have been due probably to the fact that the patient had not been completely cured of his first attack. We have met with two cases of recurrences in infants, one of which is of particular interest as it happened in spite of giving lemon juice in the intervening period. The history was as follows:

In September, 1914, one month after the baby was admitted to the inst.i.tution, it developed scurvy of a moderate grade. It was then six months of age and weighed 10 pounds. It was put on a simple mixture containing from 24 to 30 ounces of pasteurized milk and was given in addition ounce of lemon juice a day. It improved, but during the winter had bronchitis, ot.i.tis, enteritis, and later furunculosis. In spite of the fact that it had been receiving an antis...o...b..tic for almost this entire period, it developed scurvy once more in February, at the age of 11 months, and when it weighed 14 pounds. It was evident that this baby was peculiarly susceptible to scurvy. It may be added that the second attack was complicated by nasal diphtheria.

In this connection attention should be drawn to a peculiar and puzzling clinical phenomenon, which we have noted several times. Even if the antis...o...b..tic treatment is carried out incompletely and only for a short period, recrudescences may not take place. We have seen cases where orange juice was given for merely ten days or two weeks--that is, only until all s...o...b..tic signs had disappeared,--and yet the scurvy did not return, the infants thrived for months thereafter, but were merely somewhat pale and undernourished. In the case of two babies which we have in mind, the diet remained absolutely unchanged, with the exception of the short period of antis...o...b..tic treatment, but this seemed sufficient to bring about a diminished susceptibility.

CHAPTER IX

TREATMENT

"Seek the cure of scurvy neither in the armamentarium of the physician nor in the apothecary shops. The druggist will be of as little aid to you as the art of the surgeon. On the other hand, employ fresh vegetables, the juice of fresh antis...o...b..tic plants, oranges and lemons or the juice of those fruits preserved with sugar; in this way without other means you will be able to overcome this terrible disease." This reads like the advice of some modern therapeutist; it is, however, the conclusion of a physician (Kramer) who wrote on scurvy almost two hundred years ago, and shows that the treatment of scurvy has undergone no fundamental change in the intervening years. Our resources, however, have been amplified by an increased knowledge of the relative value of antis...o...b..tic foodstuffs and by the introduction of some new ones.

=Prevention.=--In the Temperate Zone, under ordinary conditions, the adult population consumes sufficient antis...o...b..tic foodstuff to protect it from scurvy. Under exceptional circ.u.mstances, however--for example, when the potato crop fails, or, in the case of individuals, when the diet has been unduly restricted, scurvy will be encountered. This disorder is still an important problem, however, in relation to the health of adults in the Tropics, in military expeditions and in Polar explorations. From what has been stated in the preceding chapter, it is evident that, at the present time, no reliance can be placed on dehydrated vegetables as a protective agent. The recent suggestion of using germinated dried pulses and seeds, under circ.u.mstances where fresh food is not available, is practical and probably will be resorted to in the future. To this end the pulses (beans, peas, lentils) are soaked in water for 24 hours, and then kept moist with access of air for about 48 hours at room temperature. During this period they sprout and develop small radicles. They are cooked in the usual way and have been found to possess an antis...o...b..tic value comparable to that of most vegetables. An individual should receive about four ounces a day of these sprouted seeds. In the treatment of some Serbian soldiers suffering from scurvy, Wiltshire found that this amount of germinated beans brought about a cure. There are, however, two drawbacks to their general use. The prolonged cooking necessary for their preparation reduces their antis...o...b..tic potency, and they have been found indigestible when consumed in sufficient quant.i.ty.

Under similar conditions canned tomatoes can be employed; they have the disadvantage of greater bulk, but are a more potent antis...o...b..tic, require no preparation whatsoever, and are readily digested. They form part of the present ration of the United States Army, in which they can be given "in lieu of an equal quant.i.ty of potatoes not exceeding twenty per cent. of the total issue."[50] The necessity of including an antis...o...b..tic in the army ration has been recognized only in recent years; during our Civil War and for thirty years thereafter there was no such provision. It was stated at that time that a general s...o...b..tic taint pervaded the troops--a mere euphemism for the widespread existence of subacute or latent scurvy. Even to-day the ration of the French and of the Italian armies makes no definite provision in this regard and the Russians provide merely for a variable quant.i.ty of vegetables.

[50] We have been unable to ascertain through inquiries from the Surgeon-General's Office the nature of the experience which led to their incorporation in the ration, and whether they were added specifically as an antis...o...b..tic. They appear for the first time in the revision of the Army Regulations of 1895. The only reference to the antis...o...b..tic property of canned tomatoes which we have been able to find in the literature is in the excellent treatise by Munson on Military Hygiene.

Recently it has been shown that lemon and orange juices (Givens and McClugage) can be dried and still preserve their antis...o...b..tic value. It is quite possible that concentrated preparations of this kind will be serviceable for army use and in regions where fresh fruit or vegetables cannot be obtained.[51]

[51] Since the above was written, an article has appeared by P. W.

Ba.s.sett-Smith (Scurvy: With Special Reference to Prophylaxis in the Royal Navy. Lancet, London, 1920, I, 1102) showing that _lemon juice can be prepared in tablet form_ and preserve its efficacy for at least three months. Each tablet contained the equivalent of 24 c.c. of lemon juice, and less than one-fifth of a tablet was sufficient to protect a guinea-pig from scurvy. This therapeutic procedure seems of great promise in providing an antis...o...b..tic ration for the navy or the army.

Lind makes numerous ingenious suggestions for preparing antis...o...b..tic remedies (Lind, pp. 7, 8 and 9) which have a practical as well as historic interest. (Appendix 1.) One of these includes a formula for the preparation of orange and lemon juice which may be preserved for years; another gives a method for the preservation of berries and other fruits which are to be picked when partly ripe and put up in earthen pots; still another gives the recipe for preparing a simple decoction of fir tops, which was found by the Swedes efficacious in preventing the development of scurvy among their soldiers. It is interesting that a similar practice was resorted to in Vienna during the recent war and recommended as a prophylactic for scurvy in children (Tobler).

_The prevention of infantile scurvy_, especially in its rudimentary form, is of great practical importance, because of its frequent occurrence. There is no question but that breast milk and raw cow's milk furnish sufficient antis...o...b..tic vitamine, but there is a difference of opinion as to whether pasteurized milk, or milk that has been brought just to the boiling-point, or even sterilized milk, is adequate in this respect. Much of this divergence of opinion is due to the fact that the various clinicians have not considered or stated the quant.i.ty of milk which they have found sufficient to protect, and also because milk itself differs in its antis...o...b..tic value according to its freshness and probably also according to the fodder of the cows.[52] Without entering once more into a discussion of this question, it may be stated that unless the cow's milk is raw, the infant should receive additional antis...o...b..tic foodstuff. Moreover, this supplement to the dietary should be made as soon as possible, so as not to allow the vitamine deficiency and inadequate diet to exist for even a short period. In our experience there is no contra-indication to the giving of orange juice or of strained canned tomato, the two antis...o...b..tics with which we have had a large experience, to babies one month of age or even younger. The common practice, however, is to wait until the infant is five or six months of age, which certainly must allow a rudimentary s...o...b..tic condition to develop. At the age of a month one teaspoonful of orange juice may be given; it should be diluted with water and sugar added if it is tart.

This may be administered notwithstanding the fact that a baby has a tendency to looseness of the bowels, as orange juice, as recently pointed out by Gerstenberger, has practically no laxative action.

Occasionally babies regurgitate orange juice, but the reaction usually ceases after a day or two. If it does not, a small amount of an alkali--for example, limewater or sodium bicarbonate--may be added just previous to feeding; in this state the juice will be better tolerated.[53] The amount of orange juice should be increased so that when the baby is three months of age it receives one tablespoonful.

[52] It is not possible to say exactly how much raw milk a baby needs to protect it against the development of scurvy. We may, however, reach an approximate estimation of this figure. We know that it takes about 2 c.c. of orange juice to protect a guinea-pig against manifest scurvy, and about 10 c.c. to protect a baby. The ratio, therefore, between the guinea-pig and the infant in this regard would seem to be about 5 to 1.

We also know that it takes about 80 to 100 c.c. daily of fresh cow's milk to protect a guinea-pig for long periods. If we a.s.sume the ratio of 5 to 1, it would therefore seem that it would require about 500 c.c. or a pint, of fresh raw milk daily as a minimum to protect the baby. (It is quite possible that a slight negative balance of the vitamine may exist unless a still greater amount is given.)

[53] Orange juice undergoes a decided color change as soon as it has become neutral or very slightly alkaline, a.s.suming a more translucent and far deeper yellow or amber color. This change may be utilized by the attendant in determining the reaction, thus rendering t.i.tration or other time-consuming methods unnecessary.

A few years ago Hess and Fish recommended the use of an infusion of orange peel in infant feeding. The peel was finely grated, soaked overnight in water (1 ounce of the peel to 2 ounces of water), and a small amount of sugar added to this liquid. Animal experiments showed that this preparation possessed decided antis...o...b..tic value. This decoction may well be used for the sake of economy, and even when the orange juice is employed the infusion of the peel may be added.

An antis...o...b..tic which vies with orange or with lemon juice in adaptability for infant feeding is _canned tomatoes_, as recently suggested by Hess and Unger. Tomatoes are not in good repute among food experts in view of the small amount of calories which they contain--only about 100 to the pound--and are regarded with suspicion amounting almost to superst.i.tion by mothers and nurses as a food for children. In spite of this fact, it may be stated without hesitation that they are fully as well borne by infants a few weeks or months of age as orange or lemon juice. In considering antis...o...b..tics, it has been shown that notwithstanding the canning process and subsequent aging, they preserve their potency. The dose is two tablespoonfuls for babies over three months of age. The tomatoes are merely strained through a colander and warmed (not cooked). To ill.u.s.trate their innocuous character, it may be added that as much as 6 and 8 ounces a day of this juice have been given to a baby under one year of age without producing untoward symptoms.

This antis...o...b..tic should have wide applicability, especially in the United States.[54]

[54] There is no relation whatever between the acidity of canned vegetables and their possible contamination with tin. Experiments carried out to determine this question demonstrated, for example, that a "sample of red kidney beans showing the highest acidity contained the least tin," and that those samples containing the most tin were all relatively low in acidity. (Report of Conn. Agric. Station Bull. 200, 1917, J. P. Street.)

Another antis...o...b..tic which can be used in a routine way to prevent infantile scurvy is _swede juice_, prepared by grating the raw vegetable and squeezing the pulp in muslin. Chick and Rhodes report that this juice has been adopted for use in some of the English infant-welfare centres. It should be given in about the same dosage as the tomatoes, and seems applicable where the swede can be readily obtained.

For babies over six months of age, reliance may be placed on the ordinary household vegetables--potatoes, spinach, carrots, squash, etc.

Attention should be paid to the amount which is taken, as one or two teaspoonfuls of a vegetable which is poor in antis...o...b..tic power, such as carrots or beets, will be insufficient to protect against scurvy.

Especially is this true if the vegetables are old and stale and are cooked for a long period;[55] some years ago two infants under our care developed scurvy in spite of a small daily ration of vegetables.