the fat globules smaller, and is then sterilized by one of the usual methods.
Switzerland has undergone an experience similar to that of France. Previous to 1903 only five cases of infantile scurvy had been published from that country. In this year Stoos published an additional five. In 1907 Bernheim-Karrer reported nine cases, all of which had developed on homogenized milk, a process very similar to that employed by the French to break up the fat globules. The increase of infantile scurvy in Switzerland may be judged by the fact that a commission was formed in the following year to investigate its occurrence.
In Germany there was for many years continued discussion as to the true nature of scurvy. Some believed it to be a form of rickets, others a form of scurvy; still others a combination of scurvy and rickets. Some thought it merely hereditary syphilis, and not many years ago Naegeli looked upon it as an entity distinct from scurvy on rickets. The subject attained additional importance through an epidemic of infantile scurvy, which broke out in Berlin in 1898, among infants who received milk from one of the largest dairies. The episode led to prolonged discussion in the Berlin Medical Society, and to several excellent papers, among which that by Neumann deserves particular mention.
The disorder has been reported in Holland by DeBruin, who recorded numerous cases; in Denmark, by Hirschsprung, who refused to recognize its scorbutic nature; in Italy, by Concetti, and by others. It was not long before there were reports of cases from almost every part of the world, including Australia (Money) and East India (Nichols).
In view of the fact that scurvy is endemic among adults in Russia, we should also expect to find infantile scurvy widespread in that country. In point of fact, quite the contrary seems to be the case. In connection with the great scurvy epidemic in Russia (1898–99), Tschudakoff personally examined over 10,000 persons and found 11.11 per cent. of the people sick with this disease. He states that in the course of this large experience he did not meet with a single case under the age of five years. Fuerst writes that Filatow, the great Russian children’s specialist, declared that he knew of no case of Barlow’s disease described in the Russian literature. This is not literally correct, as Doepp described an epidemic of scurvy in the St. Petersburg Foundling Asylum occurring in 1831. It serves to emphasize, however, the paucity of cases among infants in this great land of endemic adult scurvy. Lyabmow, in referring to the scurvy in Kazan, tells us that among 28,000 cases only a few infants were affected, and Rauchfuss made the statement at the International Congress at Copenhagen, in 1884, that although he had seen a great many cases of scurvy, he had never seen it in children one to two years of age. We shall not, in this place, comment on this interesting and apparently paradoxical situation, but shall have occasion to refer to it in considering the pathogenesis. It may be added that in Norway and Sweden, where scurvy is to some extent also endemic among the adult population, there is a similar lack of scurvy among infants.
Scurvy in the World War.—The greatest advance in medicine during the past generation has been in the fields of hygiene and preventive medicine. One might therefore have expected that the World War would have differed from previous wars in a notable absence of scurvy among the troops and the civilian population. This is true to a limited degree only. Reports which have been published in the course of the war, and especially since hostilities have ceased, show that the troops who were incapacitated by scurvy must have numbered many thousands. As was to be expected, scurvy occurred most often in Russia, where it is endemic. The largest number of cases was reported by Boerich, who as director of a Red Cross Central Station in Russia saw 1343 cases. Other German physicians who had charge of caring for the Russian prisoners give accounts of the occurrence of some hundreds of cases of scurvy. An article by Much and Baumbach gains added interest from the novel suggestion that scurvy is transmitted by means of vermin. That scurvy must have reached large proportions is shown by the fact that in July, 1916, a medical commission was sent by the Germans to investigate the scurvy in a Russian army corps, and that it was necessary to establish for this disease in every division a sanatorium comprising 100 beds. Hoerschelman, who wrote an account of this investigation, blames the bad hygienic surroundings, the lack of sleep, the overexertion, as well as the deficiency of food, for the occurrence of the epidemic. As usual, very few cases occurred among officers. He describes a number of instances where scurvy was feigned by rubbing the gums and making them bleed, or by irritating them with the juice of tobacco. These reports on scurvy in Russia bring us little new from a purely medical standpoint. They emphasize the occurrence of night-blindness as an early and frequent symptom. It is difficult to judge whether this manifestation was due entirely to the scurvy, or was in part the result of other deficiencies in the diet. For instance, Hift states that the night-blindness was cured by cod liver oil, or by the water in which beef liver had been cooked. This would point rather to a deficiency of the fat-soluble vitamine, as these substances could have little effect in curing scurvy. The cases reported by Wassermann, where neuritic pains in the legs played a considerable rôle, evidently are also not simple scurvy, but may well be the result of more than one food deficiency or a complicating ostitis. In the same way some reports show clearly that “hunger edema” complicated scurvy.
Scurvy occurred next in frequency among the nations neighboring Russia. Speyer tells us that a German sanitary commission was sent to Bulgaria largely with the object of investigating scurvy in that country. The excellent monograph on the pathology of scurvy just written by Aschoff and Koch was founded on an experience in Roumania among Turkish, German and Austrian soldiers. Added to its other woes the Servian army was visited by scurvy. Wiltshire gives us a description of this disease based on an observation of 3000 cases in the first half of the year 1917. In regard to scurvy in this part of the world, Morawitz writes that when he reached Roumania he was surprised to find scurvy the most prevalent disease in the army, and that since the spring of 1917 it was widely disseminated among the German troops. Lobmeyer writes of scurvy among the Turkish troops, and Disqué reports 500 cases among prisoners captured in Turkestan.
Along the Western front very few cases are described. There is an account by Korbsch of 51 cases in this area in 1915. Schreiber describes 30 cases among the German prisoners of war captured in the beginning of 1917, which were diagnosed as purpuric rheumatism. Arneth recounts that sporadic cases of scurvy occurred among the German troops, especially among the older soldiers, and that in many cases this was combined with the hunger edema. He attributes the scurvy to a dependence on dehydrated vegetables in the ration.
From all these accounts it is evident that scurvy played an important rôle in the general nutrition of the troops on the Eastern front. Probably it was of the latent variety, which is exceedingly difficult to diagnose, but which increases the susceptibility to infection, and intensifies the severity of all medical or surgical diseases. Von Niedner takes this point of view, stating that although scurvy had been largely prevented in this war, the obscure rudimentary type had not been eradicated. He remarks upon a fact, noted in our Civil War and other wars, that under these conditions eruptions assume a hemorrhagic character in typhoid fever, cerebrospinal fever, rheumatism and other infections. Pick made a similar observation at a medical meeting in Vienna in reference to scurvy in the Austrian army, drawing attention to the hemorrhagic diathesis existing among the troops and expressing the opinion that scurvy was occurring in this war as in previous wars.
Very little scurvy seems to have broken out among the British troops in Europe. Thirty-two cases were reported as occurring in the middle of 1915 at a divisional rest station in France. It made marked inroads, however, on the health of the Colonial troops in Mesopotamia. In the report of the Mesopotamia Commission we read that 7500 men were lost to the force in 19 weeks as a result of scurvy, and that this happened in the summer of 1916 although additions had been made to the ration in the previous spring. A conception of the extent of the scurvy may be formed from the accompanying table, published by Willcox:
| Scurvy (Indians) | Beriberi (British) | |
|---|---|---|
| 1916 (July 1—Dec. 31) | 11,445 | 104 |
| 1917 | 2,199 | 84 |
| 1918 | 825 | 51 |
It will be noted that thousands of cases occurred among the Indian troops. This was due to the fact that the British ate more potatoes and fresh meat. In his official report of the outbreak of scurvy among Indian troops, Colonel Hehir writes: “The only vegetable now allowed is 2 ounces of potatoes and the only fresh meat 28 ounces