Scurvy

p913 "Sir, —In a foot-note to page 49G of his " Manual of Practical Hygiene,", fifth edition, (London, Churchill, 1878), Parkes says : —"For a good deal of evidence up to 1848, I beg to refer to a review I contributed on scurvy in the British and Foreign. Medico-Chirurgical Review in that year. The evidence since this period has added, I believe, little to our knowledge, except to show that the preservation and curative powers of fresh meat in large quantities, and especially raw meat (Kane's Arctic Expedition), will not only prevent, but will cure scurvy. Kane found the raw meat of the walrus a certain cure. For the most recent evidence and much valuable information, see the Report of the Admiralty Committee on the Scurvy which occurred in the Arctic Expedition of 1875-76 (Blue Hook, 1877)." 

I think that the last sentence in the above is not Parkes' own, but that it must have been added by the editor in order to bring it up to the date of the issue of the current edition. The experience since then of the Arctic Expedition in the Eira coincides with these. I refer to that portion of the report where the author tells us that "our food consisted chiefly of bear and walrus meat, mixing some of the bear's blood with the soup when possible." And again: "I do not think that, spirits or lime-juice is much use as an antiscorbutic, for if you live on the flesh of the country, even, I believe, without vegetables, you will run very little risk of scurvy. There was not a sign of scurvy amongst us, not even an anaemic face," (Lancet, Aug. 26th.) 

So that, as far as this question of fresh meat and raw meat and their prophylactic and curative properties are concerned, ample evidence will be found in other published literature to corroborate that of the Eira. But when you take up the question of the particular change which takes place in meat from its fresh to its stale condition, you will find a great deal of diversity and little harmony at opinion. Without taking up other authors on the subject, we stick to Parkes and compare his with Dr Ralfe's views on this point. Parkes thought "fresh, and especially raw meat, is also useful, and this is conjectured to be from its amount of lactic acid; but this is uncertain,"1 while on the other hand Dr. Ralfe repeats, as a probable explanation, too, of the reason of fresh meat being an anti-scorbutic, but that it is due to the absence of lactic acid. For, from well-known chemical facts he deduces the following: — "In hot climates meat has to be eaten so freshly killed that no lime is allowed for the development of the lactic acid : in arctic regions the freezing arrests its formation. The muscle plasma, therefore, remains alkaline. In Europe the meat is invariably hung, lactic acid is developed freely, and the muscle plasma is consequently acid. If, therefore, scurvy is, as I have endeavoured to show ("Inquiry into the General Pathology of Scurvy"), due to diminished alkalinity of the blood, it can be easily understood that meat may be antiscorbutic when fresh killed, or frozen immediately after killing, but scorbutic when these alkaline salts have been converted into acid ones by lactic acid decomposition. The view of the alkalinity of the blood coincides with Dr. Garrod's theory, which, however, appears to have as a sine qua turn the absence of a particular salt- namely, potash. I am inclined to think that, taking into account the nervous symptoms which are not infrequently associated with a certain proportion of scorbutic cases, resulting probably from the changes taking place in the blood, not unlike those which occur in gout and rheumatism, there must be some material change produced in the sympathetic system. In many of the individuals tainted with scurvy there were slight and severe attacks of passing jaundice in the cases which occurred in Afghanistan. Can we possibly trace this icteric condition to this cause? This is but a conjecture so far. But there certainly is in Garrod's observations an important point which, if applicable to all countries, climates, and conditions of life, is sufficiently weighty to indicate the necessity for farther research in that direction, and that point is this : the scorbutic condition disappeared on the patient being given a few grains of potash, though kept strictly on precisely the same diet which produced scurvy. 

—I am, Sir, yours truly, Ahmedabad, India, 30th Sept., 1882. 

JOHN C. LUCAS."

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X. SCURVY {Scorbutus). Deflnition. — 

A constitutional disease characterized by great debility with anemia, a spongy condition of the gums, and a tendency to haemorrhages. 

Etiology — The disease has been known from the earliest times, and has prevailed particularly in armies in the field and among sailors on long voyages.

 From the early part of this century, owing largely to the efforts of Lind and to a knowledge of the conditions upon which the disease depends, scurvy has gradually disappeared from the naval service. In the mercantile marine, cases still occasionally occur, owing to neglect of proper and suitable food. 

The disease develops whenever individuals have subsisted for prolonged periods on a diet in which fresh vegetables or their substitutes are lacking. 

In comparison with former times it is now a rare disease. In seaport towns sailors suffering with the disease are occasionally admitted to hospitals. In large almshouses, during the winter, cases are occasionally seen.* On several occasions in Philadelphia characteristic examples were admitted to my wards from the almshouse. Some years ago it was not very uncommon among the lumbermen in (be winter camps in the Ottawa Valley. Among the Hungarian, Bohemian, and Italian miners in Penn- sylvania, cases of the disease are not infrequent. This so-called land scurvy differs in no particular from the disease in sailors. An insufficient diet appears to be an essential element in the disease, and all observers are now unanimous that it is the absence of those ingredients in the food which are supplied by fresh vegetables. What these constituents are has not yet been definitely determined. Garrod holds that the defect is in the absence of the potassic salts. Others believe that the essential factor is the absence of the organic salts prevent in fruits and vegetables. Ralfe, who has made a very careful study of the subject, believes that the absence from the food of the malates, citrates, and lactates reduces the alkalinity of the blood, which depends upon the carbonates directly derived from these salts. This diminished alkalinity, gradually produced in the scurvy patients, is, he believes, identical with the effect which can be artificially produced in animals by feeding them with an excess of acid salts; the nutrition is impaired, there are ecchymoses, and profound alterations in the characters of the blood. The acidity of the urine is greatly reduced and the alkaline phosphates are diminished in amount.

 In opposition to this chemical view it has been urged that the disease really depends upon a specific micro-organism.

Other factors play an important port in the disease. particularly physical and moral influences: overcrowding, dwelling in cold, damp qnartera, and prolonged fatigue under deprusing inflnernees, as daring tbe retreat of an army. Among prisoners, mental depression plays an important part. It is stated that epidemics of the disease have broken out in the French convict-ships en route to New Caledonia, even when the diet was amply sufficient. Nostalgia is sometimes an important element. It is an interesting fact that prolonged starvation in itself does not cause scurvy. Not one of the professional fasters of late years has displayed any scorbutic symptom. 

The disease attacks all ages, but, but the old are more susceptible to it. Sex has no special influence, but during the siege of Paris it was noted that the males attacked were greatly in excess of the females. Infantile scurvy will be considered in a special note. 

Morbid Anatomy.-- The anatomical changes are marked, though by no means specific, and are chiefly those associated with haemorrhage. The blood is dark and fluid. There are no characteristic microscopic alterations. The bacteriological examination has not yielded anything very positive. Practically there are no changes in the blood, either anatomical or chemical, which can be regarded as peculiar to the disease. The skin shows the ecchymoses evident during life. There are haemorrhages into the muscles, and occasionally about or even into the joints. Haemorrhages occur in the internal organs, particularly on the serous membranes and in the kidneys and bladder. The gums are swollen and sometimes ulcerated, so that in advanced cases the teeth are loose, and have even fallen out. Ulcers are occasionally met with in the ileum and colon, haemorrhages are extremely common into the mucous membranes. The spleen is enlarged and soft. Parenchymatous changes are constant in the liver, kidneys, and heart. 

Symptoms. — The disease is insidious in its onset. Early symptoms are loss in weight, progressively developing weakness, and pallor. Very soon the gums are noticed to be swollen and spongy, to bleed easily, and in extreme cases to present a furifeous appearance. The teeth may become loose and even fall out. Actual necrosis of the jaw is not common. The breath is excessively foul. The tongue is swollen, but may be red and not much furred. The salivary glands are occasionally enlarged. The lesions of the gums are rarely absent. The skin becomes dry and rough, and ecchymoses soon appear, first on the legs and then on the arms and trunk. They are petechial, but may become larger, and when subcutaneous may cause distinct swellings. In severe cases, particularly in the legs, there may be effusion between the periosteum and the bone, forming irregular nodes, which, in the case of a sailor from a whaling vessel, who came under my observation, had broken down and formed foul-looking sores. The slightest bruise or injury causes haemorrhage into the injured part. Edema about the ankles is common. Haemorrhage from the mucous membranes are less constant symptoms. Epistaxis is, however, frequent. Haemoptysis and haematemesis are uncommon. Hasmaturia and bleeding from the bowels may be present in very severe cases. 

Palpitation of the heart and feebleness and irregularity of the impulse are prominent symptoms. A haemic murmur can usually be heard at the base, haemorrhagic infarction of the lungs and spleen has been described. Respiratory symptoms are not common. The appetite is impaired, and owing to the soreness of the gums the patient is unable to chew the food. Constipation is more frequent than diarrhea. The urine is often albuminous. The changes in the composition of the urine not constant; the specific gravity is high; the color is deeper; and the phosphates are increased. The statements with reference to the inorganic constituents are contradictory. Some say the phosphates and potash are deficient; others that they are increased. There are mental depression, indifference, in some cases headache, and in the latter stages delirium. Cases of convulsions, of hemiplagia, and of meningeal haemmorhage have been described. Remarkable ocular symptoms are occasionally met with, such as night-blindness or day-blindness.

Prognosis: -- The outlook is good, unless the disease is far advanced and the conditions persist which lead to its development. During the Civil War the death-rate was sixteen per cent. 

Prophylaxis.--The Regulations of the Board of Trade require that a sufficient supply of antiscorbutic articles of diet is taken on each ship; so that now, except as the result of accident, the occurenc of scurvy on board a vessel should lead to the indictment of the captain or owners for criminal negligence, an outbreak of the disease in an almshouse is evidence of culpable neglect on the part of the managers.

Treatment--The juice of two or three lemons daily and a varied diet, with plenty of fresh vegetables, suffice to cure all cases of scurvy, unless far advanced. When the stomach is much disordered, small quantities of scraped meat and milk should be given at short intervals, and the lemon-juice in gradually increasing quantities. As the patient gains in strength,the diet may be more liberal and he may eat freely of potatoes, cabbage, water-cresses, and lettuce

It is written on a letterhead: “J. H. Romig, M.D., 115 East Columbia, Colorado Springs, Colo. ... 1948 ...” and signed, in ink, “J. H. Romig, M.D.” In the first part of this paper he speaks of himself in the third person:

“When Dr, J. H. Romig went to the Bering Sea region of Alaska, in the year 1896, he found the Eskimos living according to tradition, ideology, and diet, the same as they had lived for hundreds of years before.” He gives the general impression of average good health and considerable longevity. He describes their houses and housekeeping and tells that during winter most of the men spend much of their time at what whites have called club houses or bath houses, the native karrigi or kadjigi.

“The women brought the largest meal of the day to their husbands, fathers, and sons. The food was in a wooden dish ... mostly game and fish ... Dried smoked salmon was much used, and other dried fish. Seal and fish oil was much in demand and was a necessity; no one could be well without fats. Their food was cooked mostly by boiling, and was rather rare; they ate as well, especially in winter, raw frozen fish and raw meat. They kept some wild cranberries for the favored dish of akutok — made [of lean meat and] of seal or fish oil mixed with warm tallow, sprinkled with cranberries, stirred, and hardened with a little snow.

“On this diet the people were strong, and did not get scurvy ... the did not have gastric ulcer, cancer, diabetes, malaria, or typhoid fever, or the common diseases of childhood known so well among the whites. For the most part they were a happy, carefree people ...

“With the advent of gold discovery, government schools and missions, and the high price of furs, came a new era ... They were able to buy white men's food and clothing, neither of which fitted their real need. The children were sent to school and learned white man's ways ...

“These people have changed from the old way, to eating pancakes with syrup and canned goods from the store. The children have poor teeth now, as well as the older ones. They have white man's epidemics, and neither the home nor the food that once was good for them ...

“The Government is now doing much to cover up and ease these changes in native life ... It is with regret that we can see the slow passing of these once hardy people ...”

Amundsen joined the Belgian Antarctic Expedition (1897–99) as first mate. This expedition, led by Adrien de Gerlache using the ship the RV Belgica, became the first expedition to winter in Antarctica. The Belgica, whether by mistake or design, became locked in the sea ice at 70°30′S off Alexander Island, west of the Antarctic Peninsula. The crew endured a winter for which they were poorly prepared. By Amundsen's own estimation, the doctor for the expedition, the American Frederick Cook, probably saved the crew from scurvy by hunting for animals and feeding the crew fresh meat. In cases where citrus fruits are lacking, fresh meat from animals that make their own vitamin C (which most do) contains enough of the vitamin to prevent scurvy, and even partly treat it. This was an important lesson for Amundsen's future expeditions.

Before the ninety-eighters came, everybody along the Slave and Mackenzie rivers had at least heard of both toothache and scurvy, and some knew one or both from their own experience. As to scurvy, it was well known that Company people did have it at the ocean ports on Hudson Bay, where victuals were cooked European style and where most of the food came from Europe by ship. 

At these seaports the Indian wives of white men got scurvy nearly as often as the white wives of others. But at the inland trading posts, where flesh foods alone were to be had, and where they were not overcooked, neither whites nor their Indian affiliates ever had scurvy. The like was the case with tooth decay — nobody suffered tooth decay on the Mackenzie except those who had brought decay with them in their mouths from some such place as Hudson Bay or Scotland.

It was all a matter, the bishop thought, of what food you ate and of how it was stored and cooked. Scurvy cured itself when you left the Bay for the interior. Decayed teeth were not exactly cured by the all-flesh diets of the inland posts, but the tooth cavities ceased growing larger.

This was what everyone formerly believed on the Mackenzie about toothache and scurvy. Many of the Athapaskans had never seen an active case of either; but with the gold rush a lot of people came into the fur lands who not merely had rotten teeth already but who also brought with them quantities of the sort of food that would help continue the decay processes and, as the event showed, would also produce in the Mackenzie District the sort of scurvy they had heard of as suffered by the Company's people on Hudson Bay.