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