In the cure of scurvy the same dietetic remedies are employed as in its prevention. Orange juice is the sovereign remedy, and should be given in a dosage of about 2 ounces a day.[56] Canned tomato is also most efficacious. If these changes in the dietary are carried out, it is not absolutely necessary to alter the food, although it is advisable to do so. Some writers, for example Neumann and Czerny, treat the disorder by giving milk which has been scalded or brought to the boiling-point. Others lay particular stress on changing the source of the milk supply, believing that the sameness of the diet leads to the occurrence of scurvy. Such, however, cannot be the case, as otherwise breast-fed babies would be highly subject to this disease. In the report of the American Pediatric Society one case developed on condensed milk and was cured by sterilized milk, and another developed on pasteurized milk and was cured by sterilized milk and broths. These results are explicable; large amounts of milk were given to effect the cure. It may be said in general that in addition to giving fruit or vegetable juices the milk should be either raw or heated to as low a degree as possible (duration of heating as well as height of temperature). Furthermore, the antiscorbutic treatment should be continued for a period of months, as the clinical improvement far outstrips the restoration of the bones and other tissues. It seems necessary again to call attention to the fact that too great reliance has been placed on the use of beef juice, which has been shown, both in experiment and in the clinic, to possess comparatively weak antiscorbutic properties.
Orange juice may be given intravenously. This method may be resorted to where the patient is in an advanced stage of the disease or where food cannot be tolerated by mouth; for example, in cases such as that mentioned by Cheadle, where death took place owing to the fact that the antiscorbutic could be taken only sparingly, on account of the extreme prostration of the patient. For this purpose the orange juice is obtained in as sterile a manner as possible, boiled for about five minutes and is rendered neutral or slightly alkaline just previous to its injection by the addition of normal sodium hydroxide. Hess and Unger report three cases where this procedure was carried out without the slightest untoward reaction. In one instance, improvement was noted 16 hours after the injection. In view of the novelty of this treatment it may be of interest to cite a case:
A baby 16 months old had hemorrhage of the gums and tenderness of the legs, which were held in the characteristic flexed and everted position. Eliminative treatment was tried without avail; Dover’s powder and warmth to promote perspiration; caffeine to promote diuresis; and 2 tablespoonfuls of liquid petrolatum three times a day to increase elimination from the bowels. Intravenous injections of salt solution also proved of no value.
Four intravenous injections of orange juice were given—6 c.c., 12 c.c., 6 c.c., and 35 c.c. As was stated, improvement was noted 16 hours after the first injection. The infant was less irritable, the gums no longer hemorrhagic, and the “capillary resistance test” (that is to say, the development of petechial spots on the forearm when a tourniquet was applied for 3 minutes to the upper arm) changed from positive to negative.
Harden, Zilva and Still have recommended the use of a concentrated lemon juice for the cure of scurvy, constituting a form of “intensive” treatment. In four cases this proved to be of clinical value. Freise has made use of an alcoholic extract of turnips, and Freudenberg of a similar extract of carrots. These preparations did not seem to be markedly potent, and therefore possess no particular therapeutic advantages.
Non-dietetic Therapy.—There is little to be done for the patient in addition to the giving of sufficient antiscorbutic. No one has reported success with any drug. We have tried the use of atropin, adrenalin, thyroid and parathyroid extracts, cod liver oil, autolyzed yeast, lactose, sodium chloride, calcium chloride, etc., without noting any improvement. Mercurials are stated to be positively harmful, especially when ulcers are present. The patient should be kept in bed, and exertion not allowed on account of the involvement of the heart, which has led to sudden collapse and death. The gums may be treated with nitrate of silver stick or tincture of myrrh. If there is fracture of the long bones with displacement, splints should be applied. Under no circumstances should hemorrhagic effusions in or about the joints be incised. The patient should be placed in a room which is well aired and lighted, and should be handled and dressed as infrequently as possible, so as to avoid discomfort and pain. It is particularly important that intercurrent infections should be avoided by shielding patients from contact with those who have infectious diseases, especially respiratory infections.
CHAPTER X
METABOLISM
Studies of the chemical exchanges in scurvy have been surprisingly few. It is a field that should repay investigation, promising to afford a clearer insight into the intermediary metabolism in this disorder. One of the first to touch upon this question was Garrod, who in 1848 reported that there was a diminution of potassium salts in the urine and in the blood of scurvy patients. In 1877 Ralfe confirmed the potassium deficiency in the urine, but denied its importance from an etiologic standpoint, as he was unable to benefit scurvy patients by administering potassium nitrate. He reported an increase of uric acid in the urine, a diminution of the total acidity, and a reduction of the alkaline phosphates. Litten found the analyses of the urine very contradictory in respect to potassium, but stated that beyond a doubt its uric acid content is increased at the height of the disease, although this diminishes rapidly with convalescence. These few and scattered articles comprise the sum of metabolic studies up to the last decade, and even during the succeeding period they have been very few—so few, indeed, that they furnish insufficient data from which to draw conclusions.
The first careful study of the mineral metabolism in a case of scurvy is that of Baumann and Howard, published in 1912. Its conclusions are not very definite. They may be summed up by their statement that “chlorin and sodium were retained during the fruit-juice period, but excreted in excess of the intake during the preliminary period,” and that “more potassium, calcium and magnesium were retained during the fruit-juice period.”