“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 antiscorbutic 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 antiscorbutic foodstuffs and by the introduction of some new ones.

Prevention.—In the Temperate Zone, under ordinary conditions, the adult population consumes sufficient antiscorbutic foodstuff to protect it from scurvy. Under exceptional circumstances, 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 circumstances 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 antiscorbutic 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 antiscorbutic potency, and they have been found indigestible when consumed in sufficient quantity.

Under similar conditions canned tomatoes can be employed; they have the disadvantage of greater bulk, but are a more potent antiscorbutic, 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 quantity of potatoes not exceeding twenty per cent. of the total issue.”50 The necessity of including an antiscorbutic 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 scorbutic 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 quantity of vegetables.

Recently it has been shown that lemon and orange juices (Givens and McClugage) can be dried and still preserve their antiscorbutic 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

Lind makes numerous ingenious suggestions for preparing antiscorbutic 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 antiscorbutic 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 quantity of milk which they have found sufficient to protect, and also because milk itself differs in its antiscorbutic 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 antiscorbutic 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 antiscorbutics 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 scorbutic 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.

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 antiscorbutic 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 antiscorbutic 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 superstition 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 antiscorbutics, 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 illustrate 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 antiscorbutic should have wide applicability, especially in the United States.54

Another antiscorbutic 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 antiscorbutic 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.

Potato in the amounts usually consumed is a valuable antiscorbutic. It is not an exaggeration to state that it is the main antiscorbutic bulwark of man. In giving baked potato to children it is commonly advised to use the floury part just beneath the peel; this should be put through a sieve and mixed thoroughly with boiled milk so as to constitute a cream; for younger babies it can be prepared with water to form a diluent similar to the barley water so commonly employed to dilute cow’s milk (1 tablespoonful of potato to a pint of milk, cooked for 15 minutes). Little reliance should be placed on beef juice in the usual dosage and none on eggs.

Cure.—There is almost nothing in the realm of therapy which is so striking as a scorbutic patient’s prompt reaction to antiscorbutic treatment. It is all the more marvelous as the cure is effected by means of foodstuffs with which we are accustomed to associate no specific virtue. A magic result is seen frequently within 24 or 48 hours. A baby which has had a poor appetite, has been irritable and exquisitely tender, suddenly regains its appetite, is no longer fretful, and can be handled without occasioning crying. Within a week, if the case is mild, all definite symptoms of scurvy may have disappeared, and soon thereafter the infant is thriving and apparently cured. A table is here reproduced (Table 6) from the report of the American Pediatric Society showing the duration of treatment before marked improvement was noticed:

TABLE 6

In most instances a gain of weight accompanies improvement. In not a few instances, however, there is a temporary loss or cessation of weight, due in part to an increased excretion of urine. Occasionally there is observed a short exacerbation of the symptoms following the giving of an antiscorbutic—a swelling of the thigh or hemorrhage of the gums. A similar phenomenon has been noted in relation to the treatment of polyneuritis in birds and of beriberi in man.

In the cure of scurvy the same dietetic remedies are employed as in its prevention. Orange juice is the sovereign remedy, and should be given in a dosage of about 2 ounces a day.56 Canned tomato is also most efficacious. If these changes in the dietary are carried out, it is not absolutely necessary to alter the food, although it is advisable to do so. Some writers, for example Neumann and Czerny, treat the disorder by giving milk which has been scalded or brought to the boiling-point. Others lay particular stress on changing the source of the milk supply, believing that the sameness of the diet leads to the occurrence of scurvy. Such, however, cannot be the case, as otherwise breast-fed babies would be highly subject to this disease. In the report of the American Pediatric Society one case developed on condensed milk and was cured by sterilized milk, and another developed on pasteurized milk and was cured by sterilized milk and broths. These results are explicable; large amounts of milk were given to effect the cure. It may be said in general that in addition to giving fruit or vegetable juices the milk should be either raw or heated to as low a degree as possible (duration of heating as well as height of temperature). Furthermore, the antiscorbutic treatment should be continued for a period of months, as the clinical improvement far outstrips the restoration of the bones and other tissues. It seems necessary again to call attention to the fact that too great reliance has been placed on the use of beef juice, which has been shown, both in experiment and in the clinic, to possess comparatively weak antiscorbutic properties.

Orange juice may be given intravenously. This method may be resorted to where the patient is in an advanced stage of the disease or where food cannot be tolerated by mouth; for example, in cases such as that mentioned by Cheadle, where death took place owing to the fact that the antiscorbutic could be taken only sparingly, on account of the extreme prostration of the patient. For this purpose the orange juice is obtained in as sterile a manner as possible, boiled for about five minutes and is rendered neutral or slightly alkaline just previous to its injection by the addition of normal sodium hydroxide. Hess and Unger report three cases where this procedure was carried out without the slightest untoward reaction. In one instance, improvement was noted 16 hours after the injection. In view of the novelty of this treatment it may be of interest to cite a case:

A baby 16 months old had hemorrhage of the gums and tenderness of the legs, which were held in the characteristic flexed and everted position. Eliminative treatment was tried without avail; Dover’s powder and warmth to promote perspiration; caffeine to promote diuresis; and 2 tablespoonfuls of liquid petrolatum three times a day to increase elimination from the bowels. Intravenous injections of salt solution also proved of no value.

Four intravenous injections of orange juice were given—6 c.c., 12 c.c., 6 c.c., and 35 c.c. As was stated, improvement was noted 16 hours after the first injection. The infant was less irritable, the gums no longer hemorrhagic, and the “capillary resistance test” (that is to say, the development of petechial spots on the forearm when a tourniquet was applied for 3 minutes to the upper arm) changed from positive to negative.

Harden, Zilva and Still have recommended the use of a concentrated lemon juice for the cure of scurvy, constituting a form of “intensive” treatment. In four cases this proved to be of clinical value. Freise has made use of an alcoholic extract of turnips, and Freudenberg of a similar extract of carrots. These preparations did not seem to be markedly potent, and therefore possess no particular therapeutic advantages.

Non-dietetic Therapy.—There is little to be done for the patient in addition to the giving of sufficient antiscorbutic. No one has reported success with any drug. We have tried the use of atropin, adrenalin, thyroid and parathyroid extracts, cod liver oil, autolyzed yeast, lactose, sodium chloride, calcium chloride, etc., without noting any improvement. Mercurials are stated to be positively harmful, especially when ulcers are present. The patient should be kept in bed, and exertion not allowed on account of the involvement of the heart, which has led to sudden collapse and death. The gums may be treated with nitrate of silver stick or tincture of myrrh. If there is fracture of the long bones with displacement, splints should be applied. Under no circumstances should hemorrhagic effusions in or about the joints be incised. The patient should be placed in a room which is well aired and lighted, and should be handled and dressed as infrequently as possible, so as to avoid discomfort and pain. It is particularly important that intercurrent infections should be avoided by shielding patients from contact with those who have infectious diseases, especially respiratory infections.