NFANTILE SCURVY is a disease of modern times and is attributable to altered conditions arising from over-civilization and from the crowding into cities, which makes it difficult or impossible for children to be fed in an ideal manner. There has been a steady diminution, during the last half century, in the number of children who are fed in the natural mammalian fashion,at the mother's breast. It is less than thirty years since the nature of the disease was recognised by Cheadle, his first paper appearing in 1878. His article, in which he insisted on the identity of infantile and adult scurvy, was published in 1882, but his views were somewhat slow in gaining general acceptance, and the truth of his contention was not thoroughly established until a paper was read by Sir Thomas Barlow on this subject before the Royal Medical Society in 1883.

"Scurvy is a constitutional disease due to some prolonged error in diet." Among its symptoms are spongy, bleeding gums, swelling and ecchymoses about the joints, especially the knee and ankle, hemorrhagę from the nose and occasionally from other mucous membranes, hematuria, extreme hyperesthesia and often pseudoparalysis of the lower extremities. These local symptoms are usually accompanied with anemia. Scurvy and rickets are frequently associated, but are not necessarily connected and are not different forms of the same disease. A large majority of the cases occur between the sixth and fifteenth months and half of them between the seventh and tenth months. The greater number are seen in private practice, often in the midst of the best surroundings. The only important etiological factor yet known to bear any relation to scurvy is the diet. The most marked effects of scurvy are seen in the bones, bloodvessels and the blood. The most marked lesion is sub-periosteal hemorrhage and may occur almost anywhere in the body, but chiefly affects the bones of the

1. Read at the meeting of the Elmira Academy of Medicine, September 5, 1906.

lower extremities and may reach from the knee to the great trochanter, or from the ankle nearly to the knee. Effusions may also be found between the muscles and blood may infiltrate the cellular tissue in the neighborhood of the joints. The bones themselves may also be affected. Separation of the epiphyses of some of the long bones, generally at the lower end of the femur or lower end of the tibia, is found in most of the fatal

cases.

In cases, which have been carefully observed, there may be noticed before the evidences of scurvy appear a pallor, general indisposition and fretfulness, with failing nutrition, but usually tenderness of the bones is the first symptom noticed. At first it may be only slight and indefinite in character, so as to cause the infant to cry upon handling. Later, it becomes constant and more acute. Swelling may appear about the ankles and knees. There may be some changes in the gums, which are more apt to appear if the child has teeth. They are of a purplish color, swollen, bleed upon the slightest rubbing, sometimes spontaneously.

Ulcerations are more apt to appear about the upper teeth. The child is cross, sleeps badly, loses color, weight, and appetite. Symptoms usually come on gradually and may continue for some weeks without any very marked impression upon the child's general condition. Not infrequently, however, symptoms appear rather suddenly, when they are usually ascribed to an injury, real or supposed. If the symptoms are not recognised, the pain and tenderness of the bones increase so that the child will lie motionless and no voluntary movement can be excited. Pain and tenderness are present in 95% of the cases. Paralysis is often suspected. Ecchymoses are frequently seen, especially about the large joints and often confirm the opinion previously formed, that the child has met with some accident. Bleeding may occur from the mouth, pharnyx, or bowels. Blood may be vomited or passed in the urine.

The urine was very carefully observed in 35 of Morse's cases. It was normal in 20 and abnormal in 15. In three of these, however, it was merely noted that it stained the diapers red or brown. Excepting pallor, it was the first symptom noted in eight of the proved cases of scurvy and was the only symptom in two. Unless recognised the symptoms increase in severity and conditions grow steadily worse until death occurs from general weakness, sudden heart failure, or from some complicating disease, such as bronchopneumonia or acute gastroenteritis. Separation of the epiphyses from the shaft of some of the long bones generally at the lower end of the femur or tibia is found in most fatal cases.

In 1898 the American Pediatric Society made a collection embracing 379 cases. Of these, twelve had breast milk, alone, in ten; five, raw cow's milk, without any other food in four; twenty, pasteurized milk-sixteen without any other food; sixty, condensed milk-thirty-two with no other food; one hundred and seven, sterilised milk-sixty-eight without any other food; and two hundred and fourteen had proprietary infant foods.

Cheadle gives details of the previous feeding in sixty cases of infantile scurvy observed by him; of these, forty-six were taking various patented foods, thirteen of these having a certain amount of milk said to be fresh, at the same time; and among the remainder three were taking peptonised and seven sterilised or humanised milk.

Morse, of Boston, in a recent article, reporting fifty cases occurring in his own practice, says: "From the point of view of modern ideas of reasonable infant feeding the food was irrational, in nineteen of the cases taking proprietary foods, in four of those taking milk mixtures and in the case of one on general diet, making a total of twenty-four. Milk was used in the preparation of the food in forty-one cases, while no milk was used in eight cases. In the forty-one cases in which milk was used in the preparation of the food, the mixture was boiled in twelve, pasteurised in nineteen and unheated in nine, while in one case there was no data as to whether or not heat was used. The food was also peptonised in four of the pasteurised and one of the unpasteurised mixtures. The mixture was too weak in five cases and the same mixture was continued for months in two cases. In only one case was a rational mixture being taken and that was prepared with barley water instead of water. The digestion was good in twenty-three and feeble in twenty-seven of these cases, apparently showing that the scurvy was not due to disturbance of digestion and that foods may cause scurvy without causing disturbance of digestion."

A short time ago there was an epidemic of infantile scurvy in Berlin, among children supplied with pasteurised milk from an institution, but it was found to be confined to children whose parents, as an additional precaution, boiled it for some time after it was delivered to the house. Out of twenty-five severe cases seen by Colman in hospitals and private practice, nineteen were taking some kind of dried infant food as staple diet, seven having a certain amount of fresh milk as well, the remaining six were taking sterilised milk or humanised milk, or milk sterilised by long heating.

The disease with which infantile scurvy is most frequently confounded, is rheumatism. Holt says that fully four-fifths of the cases which have come to his notice, have had that diagnosis made. The extreme rarity of rheumatism under one year should

always make one cautious, and pain and tenderness in the legs only should in an infant invariably suggest scurvy rather than rheumatism. He says that many cases of scurvy come into the hands of the orthopedic surgeon. He has known a diagnosis of malignant disease to be made from the cachexia or discoloration and the pain. He has known two cases to be operated on by eminent surgeons, one with the diagnosis of sarcoma, and one of ostitis of both tibiæ.

The cases probably which are most easily missed are the slight cases where there is only hematuria or epistaxis present. Of the fifty cases reported by Morse, a correct diagnosis had been made in but five. The diagnosis in the other cases were acute nephritis 1, excess of uric acid with consequent staining 2, arsenical poisoning with inflammation of the kidneys 1, rickets 2, spinal or Potts disease 6, hip disease 1, periostitis 1, rheumatism 6, gout 1, syphilis of cord 1, difficult dentition 5-in four of which the gums had been lanced,-strain 1, injury 1, tuberculosis 1, gumma of eye 1. In two other cases the physicians stated they had no idea what was the trouble. While Morse himself states that he has mistaken congenital syphilis and hematuria from lead poisoning for scurvy.

Recently, Snow, of Buffalo, reported a very interesting case of hemorrhage into the orbit, with otherwise typical symptoms of scurvy, which had been seen by eight ophthalmologists without a correct diagnosis having been made. Yet the diagnosis of scurvy seldom presents any difficulty to one having once seen a case. If the essential features of the disease are kept in mind,— the soreness of the limbs, spongy, swollen gums, swelling near the large joints, a tendency to hemorrhage and a history of the prolonged use of some proprietary infant food, or sterilised, pasteurised or condensed milk. Scurvy is frequently associated with rickets. Of 340 cases reported in the American Pediatric Society investigations, in which this point was noted, symptoms of rickets are present in 152 or 45%, while in 55% rickets were absent. It is stated that in fifty of these cases the rickets antedated from the development of the scurvy. There were signs of rickets in forty-one cases out of fifty observed by Morse. The association of the two diseases is so frequent that by many of the English writers they are still spoken of as one disease-scurvyrickets.

The prognosis is always good if the disease is recognised early. No patients with symptoms so serious improve with such marvelous rapidity as those with scurvy under prompt management. It is only when the disease is of long standing and the malnutrition is severe, or when serious complications in

It is rare that scurvy

volve the digestive tract, that the issue becomes doubtful. Any case allowed to go on may result fatally. leaves any permanent effect. Recovery is not only, rapid but complete and relapses are extremely rare.

The treatment is simple; stop all proprietary foods, condensed milk, sterilised milk, and substitute a diet of fresh cow's milk adapted to suit the child's digestion. With this treatment, improvement will soon begin and recovery will follow. However, the addition of fresh fruit juice, preferably orange juice, is of the greatest value and when given improvement is much more rapid. From half an ounce to four ounces may be given during the twenty-four hours. Other things of value are fresh beef juice, and for older children fresh vegetables and potatoes. The general condition, anemia, and malnutrition, should receive the proper attention. The fact remains then that when a child is artificially fed this can nearly always be satisfactorily obviated by supplying the child with milk as little altered as possible after it is drawn from the breast of the animal supplying it.

The diet statistics quoted show that while scurvy may develop occasionally upon almost any sort of food, several stand out more prominently-namely, pasteurised, sterilised, and condensed milks and proprietary infant foods. Analysis of these tables seem to show that the absence of freshness and the heating of the food are very important elements in the production of scurvy. The farther food is removed in character from the natural food of a child, the more likely is its use to be followed by the development of scurvy. Long continued use of the same percentages, at one time proper, has been followed by the appearance of scurvy. Formulæ should be changed from time to time as needed, and if patent foods and heated or condensed milks are used, their effects should be carefully watched, and they should. not be continued as the sole diet for long periods. When scurvy and other diseases of nutrition have been proven to depend so completely upon diet, especially upon the use of patented foods, pasteurised, sterilised, or condensed milk, is it stating the fact too strongly to say that the use of these foods is radically wrong, may we not say it is almost criminal, for continuous infant feeding, when fresh, clean, cow's milk can be obtained?

In 1900 I reported to the Academy a fatal case of scurvy seen in consultation. The child was eleven months old and had the following history: was well since birth until about nine months. of age, when a week or two after a supposed contusion the thigh began to swell and when seen was several times larger than the other. The skin was red, somewhat hotter than normal, and apparently fluctuated under palpation. The child was anemic,