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.

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.

4 The writer adds that he believes that the health of the natives at home is protected by Kaffir beer, which they consume even to the amount of 3 gallons a day, and which is made from germinated Kaffir corn. This cereal is germinated by steeping it in water for forty-eight hours and is then dried in the sun. Only enough is prepared for one brew. The French prepared a similar fermented beverage for these South African laborers; the sole difference in its mode of preparation was that the corn had not been germinated.

5 The cases on which Wright based his theory were soldiers who developed scurvy during the siege of Ladysmith. It is probable that the men were suffering from starvation, purpura and dysentery. That they did not have scurvy is proved by the fact that they were cured by giving lactate and bicarbonate of soda.

6 In chronic mercurial poisoning the following suggestive symptoms occur: anemia, bleeding and spongy gums, loosening of the teeth, a quickened pulse, ulcers of the extremities. At times mercury attacks the nervous system, producing palsy. The resemblance is heightened by the fact that calcium metastases have been found in the muscle in experimental scurvy (Hart and Lessing) comparable to those characteristic of mercurial poisoning.

7 These figures constitute an irrefutable argument against the statement frequently made that a monotonous diet leads to scurvy. It is only when the monotonous diet does not contain an adequate quantity of antiscorbutic vitamine that it is to be feared.

8 This is not literally correct, as Doepp described an epidemic of scurvy in the St. Petersburg Foundling Asylum occurring in 1831.

9 During 1919 in Aruba there were 293 births and 30 deaths under one year, most of these deaths being due to intestinal diseases. The mothers subsist mainly on maize or guinea small corn, with some goat and sheep meat, and a little fresh fish, but no vegetables or fruit. The water is brackish.

10 Moore raises the interesting question as to whether a diseased condition of the cow may decrease the vitamines of the milk—whether a certain outbreak of scurvy among guinea-pigs might have been due to their having been fed on the milk of a cow suffering from experimental streptococcus mastitis. If such proves to be the case, it would have an important bearing on the question of scurvy and pseudo-scorbutic conditions in nursing infants.

11 In the case of the “lait maternisÉ,” which is a milk of high fat content, the dilution of the preparation also must have been a factor. Ounce for ounce, cream is poorer in antiscorbutic vitamine than an equal quantity of milk. It is also possible that the mere dilution of milk—quite apart from the absolute amount consumed—is not immaterial in affecting this highly sensitive vitamine.

12 It is to be noted, however, that Variot remarks that these infants frequently develop anemia unless additional diet is given, so that it must be considered open to question whether some of these babies did not have latent scurvy. Of course, unless it is certain that these infants were receiving only sterilized milk, and absolutely no other food, for a period of at least six months, they cannot be considered apposite to the question.

13 Carel reports an interesting case which points to the importance of staleness. A baby was taken to the country with a supply of sterilized milk sufficient to last for some weeks. At the end of this time it did not thrive, but regained its health when a fresh supply of milk was used. When this second supply became stale the infant again developed the same signs, and the condition was diagnosed as scurvy.

14 In making tests of dried milk particular attention should be paid to the age of the milk before it is desiccated. Investigators should also be certain that the milk has not undergone heating previous to the drying process. Some well-known brands of dry milk have been not only pasteurized, but subsequently evaporated before drying.

15 Ausset reports a definite case of scurvy developing in a baby nine months old, which had received buttermilk almost since birth. At the time of admission to the hospital it was getting 900 c.c. a day. This case is interesting on account of the acid nature of the food.

16 Malt soup is prepared by dissolving the alkaline malt soup extract in water, and mixing wheat flour with milk. These two mixtures are then boiled together for about three minutes. According to some directions, 11 ounces of milk are used; in our formula 16 ounces were employed.

17 It would seem, however, that the growing infant requires relatively more antiscorbutic vitamine than does the adult. We know that its caloric requirement is fully a quarter to a third greater. In regard to vitamine, judgment cannot be based on experimental evidence, but on comparative figures. For example, unless we take this viewpoint, we must believe that, as an infant of six months weighing 15 pounds requires 15 c.c. of orange juice daily to furnish its antiscorbutic quota, an adult weighing 160 pounds requires 180 c.c. daily—the juice of three good-sized oranges. On this basis the adult would require six quarts (6000 c.c.) of fresh milk daily, twelve times the minimum requirement for an infant, which is one pint (500 c.c.) a day. These figures are manifestly too high.

18 It would be of interest to know whether the negro infant is more susceptible than the white baby, in view of its markedly heightened susceptibility to rickets. There are, however, no reports or statistics to enlighten us on this point.

19 “Where the indisposition is but beginning, and even when the gums have been pretty much tainted, there have been numerous instances of a perfect recovery without having the benefit of fresh vegetables; provided the patient is able to use due exercise.... When it is advanced to what I have called the second stage it is hardly to be cured without their (fruits and vegetables) assistance.” (Lind.)

20 CaillÉ has described a case of scurvy in an infant suffering from Mongolian idiocy, and we have also seen a similar case.

21 Many of the older authors believed that mercurial drugs were especially prejudicial in cases of scurvy.

22 Vitamine is used throughout this monograph as synonymous with “accessory food factor” or “food hormone” as a convenient descriptive term, without any intention of connoting a definite chemical substance.

23 Freise cured a case of infantile scurvy by giving about 2 c.c. of an extract obtained from turnips by means of absolute alcohol. Seven weeks were necessary to cause a disappearance of symptoms. Freudenberg employed an extract of carrots, prepared with 96 per cent. alcohol, and effected a quicker cure.

24 Reference is made to a milk dried by the Just-Hatmaker process, containing about 3 per cent. of moisture. The clinical data on which this conclusion is based are given in the previous chapter.

25 The dates and quantities of the transfusions were as follows: March 26th, 200 c.c.; April 27th, 30 c.c.; April 28th, 35 c.c.; April 29th, 30 c.c.; May 2nd, 75 c.c.; May 3rd, 35 c.c.

26 This investigation was carried out by means of activating fuller’s earth with these fluids. This method is inapplicable to the antiscorbutic vitamine, which is not adsorbed by this material. An attempt to feed concentrated human urine to guinea-pigs resulted in their death.

27 Neumann, for example, writes that he has seen at least four children whose condition was not improved, although in addition to the milk, they took asparagus, spinach, and other vegetables or apple sauce. Some years ago we had a similar experience. It has likewise happened that infantile scurvy did not recur, although the diet was the same as that which originally led to the disorder.

28 For recent and comprehensive reviews of the vitamines the reader is referred to papers by A. B. Macallum (Trans. Royal Canadian Institute, Toronto, 1919) and by W. H. Eddy (Abstracts of Bacteriol. 1919, Vol. iii, 313.)

29 For details regarding the intestinal lesions in infantile scurvy, the reader is referred to Barlow’s description of the case of Stephen Mackenzie, to one necropsy report by Theodor Fischer, one by Hirschsprung, one by Meyer, and five by Schoedel and Nauwerk. The prevailing lesions are hemorrhages, pigmentation, follicular ulceration, and enlargement of the mesenteric glands.

30 The potato crop largely failed this year, and there was considerable scurvy in the spring, as described in the chapter on antiscorbutics.

31 Lind writes: “In the months of July and August I opened near seventy large swellings in the groin, proceeding entirely from scurvy.”... “We found the glands under their arm-pits much enlarged and surrounded with purulent matter, as well as the muscles of their arms and thighs.”... “The glands of the mesentery are generally obstructed and swelled. Some of these were found partly corrupted and imposthumated.”

32 In view of the report of Hart and Lessing of calcium deposits in the adrenal glands of monkeys suffering from scurvy, special attention should be given to this point in necropsies on human beings.

33 The beading may have the usual, rounded, smooth, knobby character. There may be, however, what one might term “angular beading,” the junction taking on a step-like form, as if the abutting ends of the cartilage and the bone were of unequal size and not well fitted to each other. The cartilage overtops the bone, so that on palpating the joint there is a precipitous fall as we run the finger outward from the surface of the cartilage, or a sudden elevation on palpating the rib from without inward toward the sternum.

34 There seems to be some misconception as to the pathogenesis of the subperiosteal hemorrhage in scurvy. In most reports this lesion is described as if it resulted from a hemorrhage burrowing its way beneath the periosteum and raising it from the subjacent bone. In point of fact, such an event is impossible, as will be fully realized when one experiences the great difficulty in separating periosteum from normal bone. Scurvy involves a periosteum which is not normal; it is insecurely attached to the shaft of the bone, so that it is readily stripped off by hemorrhage.

35 Hogs fed on 1.5 kg. of rye bread and 0.5 kg. of meat heated to 100° or 110° C. for a half hour showed the hemorrhages, loosening of the teeth and affections of the gums characteristic of scurvy, as well as the paralysis and neuritis typical of polyneuritis.

36 A guinea-pig requires about 80 to 100 c.c. of fresh milk per diem to protect it from manifest scurvy, if this constitutes its sole antiscorbutic quota. There is, however, a great difference in the amount of milk which individual animals consume, so that if we furnish it ad libitum our results will be irregular, one animal developing scurvy and another remaining well, according to individual appetite. Frequently guinea-pigs take very little milk at first, learning gradually to drink more and more, so that it comes to pass that only after some weeks, if at all, they take sufficient to afford protection. Under these circumstances, if any addition is made to the dietary after the experiment has progressed, the lack of development or cure of the scurvy may mistakenly be attributed to this newly introduced factor, whereas, in point of fact, it is due to an increased consumption of milk.

37 These changes are not found in every specimen, so that in order to be able to exclude scurvy definitely, it is necessary to examine a considerable number of ribs; several may be normal, only one or two showing the characteristic microscopic changes.

38 A maximum count of 35 was formulated, representing the highest degree of clinical scurvy. This includes three grades of beading of the ribs, four of tenderness of each knee and wrist joint, and four of swelling of each of these joints. It is apparent from the clinical curve (Fig. 10) that an animal may have developed a marked degree of scurvy (20 points), and gained rather than have lost in weight.

39 It is of interest that John Hall, the son-in-law of Shakespeare, and a prominent physician of Warwickshire, was one of the first to urge the use of antiscorbutics. In a quaint work entitled, “Select Observations on English Bodies, or Cures both Empericall and Historical” (1657 London), he describes how he cured scurvy by means of brewing a beer or ale from “Scorbutick hearbs, viz.: scurvy grass, water-cresses and brook lime.” This book, which ran through at least two editions, has not achieved the popularity of the works of the father-in-law.

40 Preserved mulberries which had been sugared and cooked for one-quarter to one-half an hour were found by Holst and Froelich (1912) to possess good antiscorbutic power three months later.

41 Dr. Guy’s evidence, Report of the Lords Commissioners of the Admiralty on the Outbreak of Scurvy in the Recent Arctic Expedition—1877 (cited from Chick and Hume).

42 The swede is a root vegetable of the natural order CruciferÆ. It is grown to a large extent in England, but is practically unknown in the United States.

43 “We find the College of Physicians at Vienna sent to Hungary great quantities of the most approved antiscorbutic herbs dried in this manner; which were found to be of no benefit. Many of these would have their virtues as little impaired by drying as spinage, e.g., marsh trefoil. Kramer tried almost every species of dried herbs to no purpose.” (Treatise on The Scurvy. James Lind, London, 1772, p. 143.)

44 The cabbage was subjected to a preliminary drying for 8 days at 37° C. It was then put in an air-tight desiccator which contained a dish of phosphorus pentoxid. (The pentoxid was replaced for several weeks until it ceased to liquefy.) It was then placed in cylinders which had been rendered air free by means of a suction pump and which contained phosphorus pentoxid. This was kept at 37° C. and examined after 10, 18 and 26 months. A similar result was not obtained when calcium chlorid was employed, the temperature held at 37° C. and the cabbage was kept in an air-tight cylinder rather than in a vacuum. However, under these conditions if the cabbage was placed in the ice-box at a temperature of 4°, 10° or 12° C. the antiscorbutic property was conserved after boiling.

45 The pulses, after having been soaked in water for 24 hours, were kept moist, with access of air, for about 48 hours at room temperature, and during this time germinated, developing a radicle usually about 1 cm. in length.

46 As the result of an experience with thousands of cases of scurvy in the Serbian army, Wiltshire has recently laid great emphasis on this follicular hyperkeratosis. He states that the earliest recognizable sign of scurvy is an enlargement of the hair follicles of the inner and anterior aspects of the thigh and upper leg, which show numerous conical elevations about the size of a pin’s head. A hair, broken or unbroken, frequently pierces the follicle.

47 There seems to be some misconception as to the pathogenesis of the subperiosteal hemorrhage in scurvy. In most reports this lesion is described as if it resulted from a hemorrhage burrowing its way beneath the periosteum and raising it from the subjacent bone. In point of fact, such an event is impossible, as will be fully realized when one experiences the great difficulty in separating periosteum from normal bone. The scorbutic process involves the periosteum so that it is no longer normal but becomes insecurely attached to the shaft of the bone, and is readily stripped off by hemorrhage.

48 Senator regarded the marrow in scurvy as being aplastic. NobÉcourt, Tixier and Maillet report postmortem examinations where the marrow showed an increased number of myelocytes and nucleated red cells of various kinds. They consider the typical blood change an intense myeloid reaction of the blood.

49 A blood-pressure band, or tourniquet, is placed about the arm, and the pressure increased until the forearm becomes cyanosed and the radial pulse is almost obliterated. The pressure is then maintained at this level for 3 minutes. The principle of this test consists in subjecting the capillaries and venules to increased intra-vascular pressure to observe whether this strain results in the escape of blood. In infants the pressure was usually raised to 90 mm.; in some cases it had to be raised higher in order to entirely obstruct the return flow of the blood.

The test is considered to be “positive” when the forearm shows many petechial spots. In normal infants petechiÆ were almost always absent, or there were few to be seen. This is not a specific test for scurvy, but demonstrates a weakness of the vessel walls, whatsoever may be the cause. It is found to be positive in the majority of cases of scurvy.

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 antiscorbutic. They appear for the first time in the revision of the Army Regulations of 1895. The only reference to the antiscorbutic property of canned tomatoes which we have been able to find in the literature is in the excellent treatise by Munson on Military Hygiene.

51 Since the above was written, an article has appeared by P. W. Bassett-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 antiscorbutic ration for the navy or the army.

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 assume 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, assuming a more translucent and far deeper yellow or amber color. This change may be utilized by the attendant in determining the reaction, thus rendering titration or other time-consuming methods unnecessary.

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.)

55 Salant, in experiments on rabbits, found that old or winter carrots did not have the same protective action against tartrates as young carrots, although their diuretic action is the same.

56 It is difficult to state the exact dosage of orange juice which is necessary. One teaspoonful daily has failed to cure, and rapid cures have been accomplished by giving one tablespoonful. It is well, however, to give a larger amount if it is tolerated.

57 Almost all of these cases were receiving liberal daily amounts of cod liver oil, which should exclude the possibility of complicating rickets.

58 There is no adequate reason for placing in this group “coeliac disease,” a nutritional disorder of children recently described by Still, and suggested by McCarrison as belonging to the category of the vitamine deficiency diseases. A case of this kind has come to our attention which resembled pellagra in many respects. It showed the bright red, denuded tongue, the intestinal symptoms, the occasional edema, marked loss in weight, and evanescent erythema—all symptoms of markedly disturbed nutrition but not distinctive of a lack of vitamines.

59 The only evidence in favor of a true interrelationship is furnished by a necropsy report of Hart and Lessing on one of five monkeys fed on a scorbutic diet. This animal died of disseminated tuberculosis, and the bones showed “the classic picture of severe rickets.” This occurrence cannot be explained, although illness and lack of exercise no doubt played a rÔle. Until similar cases are reported, the incident must be regarded merely as interesting and suggestive.