Part 22

DEFINITION.--Scurvy is an acquired condition of the body whose essential feature is a perversion of nutrition, which gradually arises from prolonged employment of food deficient in succulent or fresh vegetable matter, and progresses uniformly to a fatal issue, in a longer or shorter time, if the dietetic errors remain uncorrected. This condition becomes manifest by a change in the complexion to a dull yellowish or earthy tint, lassitude, marked decrease in the muscular power, depression of spirits and mental hebetude, breathlessness on the slightest exertion, minute flecks at the roots of the hairs, especially those of the legs; and, later, hemorrhagic effusion into the skin, forming blotches and spots of varying sizes and aspects, which may finally slough and lead to obstinate ulceration; sponginess of the gums, which bleed easily and break down into a detritus that impresses a malodorous taint upon the breath; ecchymotic staining of mucous and serous surfaces, and, in advanced stages of the disease, effusions of bloody serum or of blood into the cavities and tissues of the body.

HISTORY.--Obscure passages in certain of the ancient medical classics (Hippocrates, Celsus) and historical works (Pliny, Strabo) have been considered as descriptive of scurvy, but the earliest trustworthy accounts are to be found in the writings of the thirteenth century. Jacob de Vitry describes an epidemic which occurred among the troops of Count Saarbrücken besieging Damietta in 1218, and Sire de Joinville another epidemic among the troops of Louis IX. lying before the same town in 1249. On both occasions the sufferings of the men were inexpressible and the mortality fearful. The disease was directly traceable to defective supplies of fresh vegetable food, aided by exposure to wet and cold weather, fatigue, and mental depression.

{168} The almost total neglect of horticulture in Europe during the Middle Ages, especially in its more sterile northern portions, the habitual diet of salted, smoked, and dried flesh and fish, and the prolonged spells of cold and damp weather of this region, were conditions most favorable to the development of scurvy, and these regions were the very first in which its devastating effects were early observed and recorded. In the first half of the fifteenth century it prevailed epidemically in the north of Europe and almost everywhere endemically, more especially in the countries bordering on the Baltic and North Seas, although the largest and richest cities were frequently afflicted in the severest manner in consequence of imperfect food-supplies and the wretched sanitary conditions under which the inhabitants lived (Fabricius). The long voyages and imperfect diet of crews of ships furnished a large quota of harrowing nautical experiences with the scurvy, commencing with Vasco da Gama's voyage to India in 1497, and running up to 1812. In this interval it was all but universal on long voyages, both on single ships and in fleets, in the mercantile marine and in the navy.

In 1798, through the better insight into the causes of the disease, and especially through the exertions of Dr. James Lind in ameliorating the dietary of British sailors, it was practically stamped out of the navy or restricted to isolated occurrences. The influence of the success thus achieved was not lost upon the navies of other nations nor upon the growing fleets engaged in commerce, as the disease has become less and less frequent, constituting at present but a very trifling proportion of the diseases incident to seafaring people. This remarkable result is in part attributable to the fact that the chief maritime nations have enacted beneficent laws intended to compel the owners and masters of merchant vessels to observe certain sanitary and hygienic measures that protect the crews from scurvy. The number of cases returned in the English navy for 1881, in an aggregate of 52,487 cases of all diseases, was 4; in the Prussian navy, 3 in 8659; in the Austrian navy, 27 in 8096; in the U.S. navy, none in 13,387. Thus, in a grand total of all diseases in the chief naval services of the world of 82,629 there were only 34 cases of scurvy--a ratio of .41 per 1000. In the mercantile marine 62 cases occurred in 32,613 cases of all diseases, of which 43 were on the Pacific coast: this gives a ratio of 1.9 per 1000. Altogether, the 115,242 cases produced only 96 of scurvy--a ratio of .83 per 1000. The difference in favor of the naval over the marine service is accounted for by the greater attention paid to the health and comfort of the men in the former.

The U.S. steamer Jeannette spent two winters in the Arctic region, and had a single case of scurvy. The U.S. steamer Rodgers was wrecked, and the crew, during its sojourn of six months among the Siberian tribes, suffered severely.

The operations of armies in recent times have not furnished the frightful mortality which, from neglect of sanitary precautions, formerly afflicted them. During the rebellion of 1861-64, out of 807,000 cases there were but 47,000 of scurvy, or 5.8 per cent., with a death-rate of 16 per cent. The French army of 103,770 men during the Crimean struggle had 27,000 cases of scurvy, or 26.0 per cent., with a death-rate of 1.5 per {169} cent. In the Bulgarian campaign of 1877-78, in an army of 300,000 strong, there were, according to Pirigoff, 87,989 cases of disease, of which 4234, or 4.8 per cent., were frankly-expressed cases of scurvy. This gave a proportion of only 1.4 per cent. of the entire force--a result entirely due to the maintenance, both before and during the war, of a high standard of health.

ETIOLOGY.--Perhaps no disease has furnished a more fertile field for etiological conjectures than scurvy. The father of medicine ranked the disease in one place among those presenting enlarged spleens, and in another with the twisted bowels. He recognized a putrescence of the humors as the underlying factor--a theory that held sway until the beginning of the nineteenth century. The disease attracted wide attention in the seventeenth and eighteenth centuries from its frequent epidemic and endemic occurrence in various parts of the north of Europe, and was believed to be restricted to cold and particularly wet districts--a view that has been long since abandoned with a better knowledge of its habitats. It has been encountered alike in high latitudes north and south, amidst sterile wastes covered with eternal snows and ice, in the temperate zones and in the burning plains of the equatorial regions of America and Africa.

Sex has no predisposing influence, and the fact that more males than females are affected during an epidemic simply indicates that the former are more exposed to the ordinary determining causes. During the siege of Paris, according to the tables of Lasègue and Legroux, there was a very large excess of male cases, and Hayem's figures show only 6 women in 26 cases.

Scurvy has been observed at all ages from infancy to advanced periods of life; it is believed by certain writers that adolescence is less predisposed than adult age.

The epidemic feature of the disease led many to the opinion that it was contagious--a view that retained its hold for many years. It was also considered to be of a miasmatic character, which, with the previous feature, seemed to assimilate it in nature with typhus fever and other diseases of the miasmatic contagious group. This view had a vigorous advocate in Villemin, who in 1874 read a lengthy paper before the Royal Academy of Medicine in its support. His arguments were specious, inconclusive, and inaccurate, the weight both of facts and authority being decisively against his view. Its occurrence among members of the same family led a few to regard it as hereditary, and it was thought to be transmissible from the mother to the recently-born as well as to nursing infants. The depressing influence of certain emotions, fear, anxiety, and nostalgia, upon the functions of nutrition has, as might have been anticipated, been noted as contributing indirectly to the manifestation of epidemics of scurvy in the presence of the essential determining dietetic causes.

Scurvy cannot be regarded, as Lhéridon-Cremorne has argued, as the last term of nostalgia, the other alleged causes being secondary; nor as the immediate result of mental depression, as Gueit believed from his experience in the ship Henry IV. during his service on the blockade in the Black {170} Sea in 1858, because the disease first invaded those laboring under nostalgia. The currency of such opinions may be readily explained by the fact that ordinarily depressing mental influences occur under the same conditions as those associated with scurvy--viz. during sieges, after defeat, in prisons, and in workhouses; and, further, the mental phenomena ordinarily occur as prodromes of the disease long before the pathognomonic phenomena present themselves. Out of these facts grew the mistake of regarding the mental change as causative instead of consecutive. Murray went farther and regarded mental despondency as at once cause and effect, and long ago scurvy was compared to hypochondriacal diseases. It may be concluded from the recorded epidemics that no degree of mental exhilaration could ward off the disease in presence of the determining causes, nor any degree of mental despondency induce it with proper alimentation.

The various qualities or changes in the atmosphere were regarded individually or collectively at various times as the determining causes. It was supposed that the air might become impregnated with putrid exhalations from various sources, as the holds of ships, or rendered impure by the vapors of the sea. The foul air of crowded habitations, vessels, or cities was appealed to, or the common cause was sought either in its temperature or humidity, or in both. The earlier observers gave prominence to cold as a determining cause of scurvy, and especially when combined with dampness, and hence its frequency in the north of Holland, Brabant, Belgium, Russia, and Germany. This was the current view in the seventeenth century. On the other hand, with equal confidence the disease has been supposed to be determined by excessively high temperatures, and its occurrence in India, South Africa, and the equatorial regions has been alleged in support.

Personal habits have been in the eyes of earlier observers an all-sufficient cause, and thus excessive exertion attended with fatigue and exhaustion has been considered the cause of several severe outbreaks on shore and at sea. In contrast with this opinion we find the English physicians placing great stress upon indolent habits and lack of exercise as a predisposing if not a powerfully determining cause.

The use of tobacco was inveighed against by Maynwaring and Harvey as a powerfully morbific cause, while to the lack of the same narcotic its occurrence was ascribed by Van der Mye. More recently it has been referred by Fabre to vaso-motor disturbance due to a miasm.

In the drink and food, however, most observers have sought the exciting causes of scurvy. Instances have been reported where the disease seems to have depended upon the use of impure water, etc. The imagination has been tortured to seek in some quality or sort of food the specific origin of scurvy. With regard to quantity, it may be stated that in severe famines scurvy may or may not occur according as the food, though scant, is in due proportions of animal and vegetable, though it is true that the ordinary conditions of a famine preclude the procurement of succulent vegetables. The quality of the food has nothing further to do with the production of scurvy than by impairing the general health, for it has often happened that putrid food has been long used without scorbutic symptoms arising. The kind of food is equally {171} innocent, although various special articles have been charged with specific activity. The frequency of scurvy in Brabant was attributed by Ronseus to the use of aquatic birds; Sherwin and Nitsch assigned the same peculiarity to a free use of fish; and Henry Ellis to the too free use of spirits. Even the generally widespread and much-esteemed article of diet sugar was in disrepute with Willis. The too free use of salted meats has been often accused of causing the trouble. The fat rising on water in which salt provisions were boiled was considered by Cook and Vancouver to be of particular pernicious effect, and even the copper vessels in which they were cooked were condemned by Travis as able to communicate the scorbutic poison to the food. To the milk of animals browsing on verdure upon which pernicious dew had fallen was referred an epidemic which occurred in Silesia in 1591. Diseased potatoes were considered sufficient to determine scurvy in Ireland and Scotland by O'Brien.

The scurvy occurring on land was deemed to be different from that occurring at sea, and its frequency afloat brought into unmerited disrepute the sailor's salt diet, and its saline materials were even considered the chief offending cause. This idea was rejected by numerous observers, who assigned as the chief causative rôle in scurvy deficiency in vegetable food, especially of the fresh, succulent variety. The particular constituent of this sort of food, so powerful in warding off scurvy and of curing it when prevention has failed, has baffled discovery. Dr. Aldridge attributed it to mineral elements generally. Dr. Garrod singled out the potassic salts as the particular one to which the specific action must be attributed; but neither of these views has gained in credit. From all the facts, both positive and negative, we may reasonably assume that the essential dietetic error leading to the development of scurvy, in the immense majority if not in all cases, consists in a deficiency in the variety of food; that is to say, there is not the requisite proportion of animal matter with a diversity of vegetable substances. No single natural order contains plants that supply all the elements essential to the nutrition of the body and the right composition of the blood. The graminaceous and leguminous articles of food, for instance, are numerous, but not various; they all afford the same or analogous albuminous elements, which have about the same nutrient value as the corresponding substances in animal food, and hence health and vigor cannot be sustained on a diet of flesh, combined with wheat, rice, and oatmeal or with beans and peas, or with all of them together. Outbreaks of scurvy have occurred on shipboard, where the ration is made up principally of these articles; as in Anson's ship, when supplied with an abundance of fresh animal, farinaceous, and leguminous foods. It is clear, therefore, that in order to obtain a variety of materials required in nutrition, we must resort to several of the natural groups, those particularly which comprise the succulent vegetables and fruits.

MORBID ANATOMY.--The bodies of persons dead of scurvy are, in most cases, much emaciated, because the quantity as well as the quality of the food has usually been defective. When the food-supply is abundant and only lacking in the elements indispensable in warding off scurvy, the bodily weight is not noticeably decreased, although the characteristic tissue-changes of scurvy are present. This was noticeable in the cases recorded by Trotter of negro slaves dying of scurvy while their bodies {172} presented a fat and sleek appearance. Rigor mortis usually sets in early, and chemical decomposition invades the tissues speedily. The skin presents the discolorations and blotchings observed during life. The subcutaneous connective tissues are soaked with serous exudations, especially in the lower extremities, and in various localities are infiltrated with bloody or fibrinous extravasations. The same changes occasionally affect the muscles, the infiltration occurring beneath the fibrous sheaths and into the intermuscular spaces, and the fibres are more or less torn. These effusions occur most frequently about the knees, the elbows, and the pterygoid muscles of the jaw.

The bones are sometimes necrosed by the mechanical influence of copious effusion beneath the periosteum, forming nodes of varying sizes and obstructing the supply of blood. The joints are occupied by serous or bloody transudations; their synovial investment is destroyed in part, so that the cartilage is exposed; and the latter not infrequently is softened, and even separated from the subjacent osseous connections. Sometimes the morbid changes occurring in the joints are the results of disease in the subcutaneous connective tissues surrounding them.

The muscular system presents marked changes. The muscles undergo fatty degeneration in a remarkable degree. The changes begin first in the lumbar muscles, the fibres losing their striations and sarcolemma, and finally being replaced by granular and fatty matter.

The brain has been found in rare instances the seat of softening and infiltration, and the ventricles may contain serous or bloody fluid. Similar effusions have also been noted in the arachnoid. Most frequently, however, the brain and its membranes present an anæmic appearance, there is less blood than natural in the vessels, and the tissues are pale. Very often no changes whatever are observed.

The heart is smaller than normal, relaxed, and flabby, its fibres easily broken, and a cut surface presents the yellowish aspect of fatty degeneration in certain parts, with occasional extravasations located in the cardiac walls. The valves of the heart are relaxed and illy adapted to accurate closure. In certain recent cases soft coagula or dark fluid blood, and in others firmly coagulated blood, are found in the cavities; in those which have been prolonged the blood is more likely to be found fluid and the coagula diffluent. The endocardium is often blotched to a greater or less extent by sanguineous imbibition. The pericardium often contains serum, and in the worst cases is inflamed, lacerable, and contains bloody effusions. The inner surface of the great vessels at the base of the heart is stained by imbibition.

The respiratory organs are variously affected. The mucous membrane lining the nose, larynx, and trachea is generally pale and flecked with extravasations of a dark-red color; more or less frothy fluid, tinged with blood, is present in these passages, and occasionally oedema of the glottis is encountered. The lungs are, as a rule, infiltrated with a bloody serosity, particularly in those cases with renal complication, or with a fibrinous or bloody exudation. The posterior portions of the lobes often present evidences of hypostatic congestion, or even of gangrene, and in the latter case the tissue is easily friable and emits a disagreeable odor. Their surfaces are mottled with superficial discolored patches of varying size and outline. The lungs may, on the other hand, be found pale, {173} with empty collapsed vessels and with little or no effusion. The pleural cavities commonly contain a serous fluid, or, in rare cases, a copious effusion of blood. Traces of inflammation and discoloration by sanguineous staining are traceable on the pleural surfaces.

The digestive organs furnish strongly marked lesions. The mouth presents the most constant scorbutic feature, a stomatitis in which the gums are infiltrated, spongy, livid, and the seat of fatty degeneration; the teeth are loosened or have already fallen out. The stomach and small intestines are thin-walled, and the mucous membrane is often softened, and in places ulcerated; similar changes have been noted in the solitary glands. Follicular ulceration of the large intestine occurs, with softening and infiltration of the mucous membrane. Hemorrhagic effusions into the mucous membrane, forming stippling, flecks, or patches, occur in various degrees along the whole extent of the alimentary canal. The pancreas is occasionally found softened and containing hemorrhagic effusions.

The kidneys are, as a rule, found in the normal condition in cases in which albumen has been observed in the urine. Occasionally they are engorged, with infarction of the cortical substance, and the mucous lining softened and thickened and covered with blood-tinged mucus, or they may present various degrees of parenchymatous degeneration. The ureters and bladder sometimes present ecchymotic spots, and the contained urine is mingled with blood.

The liver is always more or less altered by fatty degeneration, and at times replete with blood and softened, and its surface ecchymotic. The spleen is occasionally greatly enlarged, and its tissues very lacerable, laden with blood, and infarcted.

PATHOLOGY.--The essential character of scurvy consists in perverted nutrition, in which the blood undergoes such peculiar and profound changes that its fitness for the maintenance and renewal of the various tissues and organs is impaired; hence the nervous depression, loss of muscular power and tonicity of tissues, and the transudation of the blood or of its constituent parts.

The processes of secondary assimilation are chiefly at fault, leading to the blood-changes, and through these to the textural lesions. Primary assimilation remains intact, as the bodily weight is little altered as long as the food is in sufficient quantity. This loss of nutritive balance between the blood and tissue is due to the absence of certain elements furnished by fresh vegetable matter. What these are, and how their absence acts in inducing this disturbance, have not yet been determined; we only know that the mysterious harmony of the vital, chemical, and physical relations which exist between the blood and tissues in health is deranged by their absence.

Endless explanatory surmises and assumptions have been proffered. The earlier explanations involve either the Galenical theory of putrefaction of the fluids and humors, a breaking down of the blood-corpuscles, or the later chemical theories of superabundance or absence of certain salts, sulphur, etc., and hence there were an acid scurvy, an alkaline scurvy, a muriatic scurvy, etc.