The American pediatric society's collective investigation on infantile scurvy in North America

ARCHIVES OF PEDIATRICS. VOL. xV.] JULY, r 898.  [NO7. critonal cons I unicRtionz. THE AMERICAN PEDIATRIC SOCIETY'S COLLECTIVE INVESTIGATION ON INFANTILE SCURVY IN NORTH AMERICA.* The subject of infantile scurvy has so recently come into prominence, and still presents so many mooted questions, especially regarding its etiology, that it was the decision of the American Pediatric Society a year ago to undertake a collective investigation of the matter, based upon the cases occurring in America. This seemed particularly needed, as no other such study upon a large number of cases has yet been made in any country. The committee, which is now making its report, was accordingly appointed. It has been diligently at work during nearly a year, and has used every means in its power to reach reports of cases of the disease. A list as accurate as possible was prepared of all the medical journals of North America, and a notice of the proposed investigation was sent to each, inviting correspondence on the part of all readers. Letters were sent to the secretaries of the county societies in a large number of the States of the Union requesting that notice be given at the meetings. Letters were also addressed to the professors of diseases of children in all the regular medical colleges of the United States. The " Index Medicus " was searched for the names of those who had published reports of cases, and letters were addressed to all of them, as indeed to all physicians of whom even the rumor had come of probable cases under their charge. Circulars were printed containing questions to be answered, and were sent to all the members of the American Pediatric Society, to all physicians applying for them, and finally wherever there seemed any chance of getting a response. The questions contained in the circular requested information on the following points: Whether the case was seen in hospital * Reported at the Tenth Annual Meeting, Cincinnati, June 2, 1898. 482  infantile Scurvy in .9merica. or private practice; the race, sex, and age; the hygienic surroundings, family history, and previous illnesses; full details of feeding from birth, and the influence which the food appeared to have had upon the development of the disease; the symptoms in detail, with special reference to pain and its location, apparent paralysis or inability to move, swellings, fractures, hemorrhages, the condition of the gums, the presence of fever, the condition of the urine and bowels, the presence of ana mia or mat-nutrition and of rickets or any other complicating diseases, and the character of the first symptom to develop; the treatment in detail, with duration of illness, and the time before decided improvement was discovered; the direct cause of death in fatal cases, and the post-worterr - I findings; and finally, whether the case had been published previously. The committee has been surprised and pleased at the large number of replies received. There are other cases of which it has knowledge of which no reports could be obtained, and undoubtedly many more whose existence was not discovered. But in all the committee has collected 379 cases seen by 138 observers. Some of the cases are very incompletely reported, but in the majority of instances the answers are for the most part satisfactory. No cases needed to be excluded as instances of mistaken diagnosis, although a very few were some.wbat doubtful. The topics covered by the questions can best be taken up for the most part seriatim, stating merely what the reports state, without vouching for the correctness of opinions. RACE. —The race to which the subjects of the disease belong is stated in 372 cases. It is not given with definiteness sufficiently often to allow of an analysis further than to say that there were 367 white, 4 black, and 1 Chinese. SEx.—Sex shows out of 372 cases, 189 male, i.e., 51 percent.; and 183 female, i.e., 49 per cent. ; a difference not decided enough to indicate that sex is an etiological factor. In the remaining cases the sex is not mentioned. AGE.—Age is a very important matter. Although strictly speaking, the age of the cases of infantile scurvy should be limited to those under two years, the committee has ventured to include a few in children slightly or decidedly older than this; since the etiology and symptoms are not different in any respect. Question IV. on the circular reads: "Age when seen years, 3 mo. " 6 11 7.00  3 72 4 j 2 if  7 8 6 7.00 I 4  2 " 6. 12 , 6 It will be seen that the disease is most apt to develop between the ages of seven and fourteen months, inclusive. The Youngest case was that reported by Dr. A. Matheson of Neillsville, Wis. This was a child of four weeks who had already been:ill five days when first seen. The child was fed at the breast. Its hygienic surroundings were poor. The disease exhibited perfectly typical symptoms and ended fatally. The oldest child, reported by Dr. J. H. Fruitnight, was one of nine years, and was also a typical case, rapidly recovering under dietetic treatment, The cause appeared to be improper diet. SOCIAL POSITION—Of 379 cases it is interesting to note that 83 per cent. occurred in private practice, and only 17 per cent, in hospital practice. Although no absolute class distinctions can be based on these figures, yet they point very positively to the greater tendency of the disease to occur among the rich or the well-to-do. This tendency is still further illustrated by the statements of the writers regarding the hjgienit s1,11 - roundings of AcE. 3 weeks, I/ months, 4 6 7 8 9 lU II 12 13 1 4 15 33 4 1 47  13.09 1 2 5 1  1 4 20 i 2 2 2; 25 22 17 . 2 7 1 16 months -27  2  •83 I7 • 55  1 9  9  2. 50 20  5  1,40 22  1~  3. 62 23  : c 9. 1 9 I 2 years, 1I.42 ! 2 1 4.73 I 9 AGE_ G[ No. of CASES. PERCENTAGE. 7 1.70 6 1.67 7 1, 70 4 I.II 2 .5 5 .2 7 I .2 7 2 • 55 I -2 7 r .2 7 1 r .2 7 I I - "7 -2 7 I I Infalxtile Scurvy in loterica, with Scury  4 ~' y, ' while XIV. reads: "Duration of Illness Before Treatment was Commenced." By combining the answers to these two questions, the age at which the illness developed could be determined in most instances. Reliable information was given in 359 cases; in the remaining number the age was unknown or was not stated. The accompanying tabular arrangement shows the number of cases developing at different ages: AGE WHEN SCURVY DEVELOPED. No, of  PERCASES.  CENTAGF. { t 4 84.  Infanflle Scurvy in _Imerica. the cases. In 303 cases these are described as good, and often the statement is volunteered that they were of the very best, In 5 they were doubtful, andin only 4o are they described as bad. The figures of the report would therefore seem to indicate that the influence of bad hygienic conditions upon the etiology of the disease is extremely limited. PREVIous HEALTH.—OUt of 285 cases suitable for study, it is distinctly stated in 167 that the previous health had been good. In 118 the child had suffered from various diseased conditions which may be enumerated as follows: Bronchitis, 5; chickenpox, I ; constipation, I ; convulsions, 3; cretinism, I ; diarrhoeal conditions, 45; eczema, I , furunculosis, I; indigestion, 22; influenza, 6; malaria, I; measles, 7; pneumonia, 5; rheumatism, I ; scurvy (previous attack), 1; scrofulous diathesis, I ; typhoid fever, I ; whooping cough, 1. It is evident that the occurrence of most of these diseases can only be considered as accidental. There is a striking preponderance of instances of digestive disturbance.  This probably is an indication that the faulty diet which occasioned the scurvy produced the indigestion also.  It is no proof that the digestive disease itself bore any etiological relation to the constitutional affection. This is clearly the view of the correspondents, for, in answer to the question of the circular, a belief in. any other cause than diet is expressed in only 24 instances. Rickets, ana mia, and mal-nutrition are not mentioned in the foregoing list. They will be referred to later. Attention may be called to the instance of a second attack of scurvy reported by Dr. L. E. Holt. The child was eighteen months of age at the time of the second attack, the previous one having developed four months before. The first attack followed the use of Mellin's food and sterilized milk. Recovery followed in a week upon a diet of sterilized milk and beef juice, no fruit juice being given. The second attack followed the use of Reed & Carm - ick's soluble food. The patient in this attack was in a wretched condition and died in eight days. The case of scurvy developing in a cretin, reported by Dr. A. Caille is also interesting. The child was a typical cretin of fourteen months. Scurvy followed the use of condensed milk, Recovery was very prompt under the administration of sterilized milk, fruit juice and cereals. FAh1ILy HISTORY. —This too appears to exert little or no influInfa7ztile Sczrrvy in e4merica.  4 8 5 ence. 'In 129 cases the family history is stated to have been good, and in 97 it is negative. In 74 the following diseases are mentioned in the family: Alcoholism, 2; anaemia, 2; asthma, 1; carcinoma, I; caries of spine, I ; diarnccea, I ; eczema, I ; gout, 2; neurotic tendency, 6, paresis, I ; pneumonia, I ; rheumatism, 16; sciatica, 1 ; scurvy, 1; syphilis, 7; tuberculosis, 29; uricacid.emia, 1. DIET.—The most important etiological factor,according to general opinion, is a dietetic one. Consequently, the committee has paid particular attention to this point. When correspondents did not make the matter quite clear in their answers, personal letters were addressed to them, asking for further information. A large number of such letters have been written, and replies received in most instances. Full details were asked regarding diet from birth onward, and the question of food used at the time the scurvy developed, or so shortly before that it might seem to be associated with it, was particularly emphasized. The question was also asked, whether in the opinion of each correspondent there was reason to believe that the disease depended on the nature of the food used. An affirmative answer was received in 275 cases; negative, and the disease attributed to other causes, in 24. The committee is not in a position to judge of the correctness of this view, nor can it claim that the disease du arise in any instance as the result of the diet employed. It would make merely the following statements of the food employed at or shortly before the symptons of scurvy were observed, according to the reporters' replies. Any accurate percentage analysis of the report is impossible, both because the correspondents have not always stated the exact nature of the food, and because in very many instances more than one form of food was given. Perhaps the following summary of some of the main divisions may be of value, remembering, however, that cases are repeatedly counted twice; e.b - ., one case may be counted in the condensed milk class and again in the sterilized mills division. FOOD USED AT OR SHORTLY BEFORE ScuRviDEVELOPED. Number of cases in which the character of the food is specified, 356. Food given as follows: Breast aIilA.—Alone, Io; with raw milk and amylacex, 1 ; With sterilized milk and amylacex, I ; total, 12. 486  Infantile Scurvy in America. Raau Milk.—Alone, 4; with breast milk and amylacex, I ; total, 5. OWlk (nothing said about heating).—Alone, 8. peptonized, 4; with amylaceX, 4; total, 16. Sterlli; ed Mlk.—Alone, 68; with proprietary foods, 2j,; with amylaceae, 8; peptonized, 10; total, I07. Tasteuri; ed OW/k.—Alone, 16; with proprietary foods, 2; with amylacew, I ; peptonized, I ; total, 20. Peptoni'~ed OW/M.—Nothing further stated, 3: sterilized, $; pasteurized, r ; with proprietary foods, I ; With amylacea t; total, 14. r,~rnylaceotts Food (not proprietary).—Alone, 6; with breast milk, 3; with milk, 5, with sterilized milk, 8; with pasteurized milk, I ; with peptonized milk, t ; total, 24. (9 of these were oat meal). Table Food.—Nothing else mentioned, r I ; with condensed milk, I ; total, 12. cATellr'n's Food.—Nothing further stated, 42; with condensed milk, 22 ; with sterilized milk, 16; with pasteurised milk, 2; with other proprietary food, I ; total, 83. O7LVted Dfilk.—Nothing further stated, 44; with..creim,a; with amylacea , I ; with other proprietary foods, 2; total, 48.. Condensed &Tilk.—Alone, 32; with milk, I; with cream ; t; with other proprietary foods, 3; with table food, r; total, j8. Weed & Carm - iek's Soluble Food.-13. lwpef - lal Gr - aii na.-6. , ebig's Food.—Alone, i ; with condensed milk I ; total, 2. Lactated Food.—Alone, 3; with condensed milk, I ; total, 4. Nestle's Food.—Alone, 1 ; with sterilized peptonized milk, I ; total, 2. Among other articles of diet mentioned by correspondents, each in one instance, are: Gardner's food, Robinson's barley, Ridge's food, Brush's food, animal broths, Bartlett's pepsinated food, Lactopreparata with Malted milk. There are a number of instances in which the writers mention "proprietary foods" without further designation. In all 214 cases (6o per cent.) were fed on proprietary foods. The effect of dietetic treatment has such an important bearing upon the etiological influence of diet that the whole matter will be discussed more fully under Treatment. SYAIPTO,rtS.—The symptoms in infantile scurvy are so typical and well known that they would appear to need little further Infantile Scur:cy iii america.  4 8 7 study. ` Nevertheless, the attention which has been directed to them by the questions of the circular has not been without fruit. FIRST SYNIPTOAA TO DEVELOP AND ORDER AND TINE OF OTHER SY,NIP:TOaAS. —In response to this question the answers have not been altogether satisfactory. Undoubtedly in a large number such early symptoms as anemia and mal-nutrition were overlooked or were not included by the readers as symptoms of the disease. Then in a large number, perhaps the majority of cases, answers have not made it quite clear whether the correspondent intended that a certain number of symptoms developed in the order in which the narnes are written, or whether they all were noticed at one time. Presuming that the first is the writer's intention, we make the following statement of the first symptom seen, basing this on 327 cases. The order of symptors is too complicated and too uncertain to warrant a statistical arrangement. FIRST SYMPTOMS SEEN. —Pain and tenderness, 145; affection of guns, 42; interference with motion, 36; anemia, 27; cutaneous hemorrhages, 22; swellings, 16; restlessness, 6: anorexia, debility, 5; diarrhoea, 5; constipation, 2; hemorrhage from nose, j ; hemorrhage from mouth, i ; hemorrhage from rectum, i.; Mematuria, 3; "hematoma of tongue," r : irritability, 3; vomiting, I ; fever, 1 ; opisthotonos, I ; sweating, I. PAIN ON MOTION OR HANDLING.—Pain is clearly a very prominent symptom of the disease. Generally it is evident only when the child is moved, or tries to move itself. Sometimes it is so intense that the approach of any one to the bedside is sufficient to cause the child to scream out through fear of being touched. Pain is reported present in 314 instances. In most of the remaining, no answer was made, and it is probable that the symptom could not have been a prominent one. The locality of the pain in the cases where there were accurate details was as follows. Legs, 12o; legs and arms, 2; ; legs and one arm, I I ; legs and body, 4; one leg, 13; one leg and one arm, r ; one arm, I; back,  back and legs, I ; back and leg, I ; back and thighs, r ; thighs, I ; hips and thigh, I ; one thigh, 2 - 1 one,hip, 2; knees, I ; knees and ankles, 2; knees, ankles and shoulders, I ; knees, ankles and wrists, 2; knees and arms, I ; one knee, I : one ankle, I ; ankles, I ; ankles and feet, I ; ankles and elbows, I ; elbow, I. PAIN WHEN AT REST.—In 91 cases pain seems to have been present, even when the child was still; while in 134 it is definitely stated as absent under this condition. 1. O gg  Infantile Scurvy in &4vterica. INTERFERENCE WITH MOTION.—The symptom dariously described as paralysis, pselrdopara4ysi's and disabdib , or 1111 .zlling )less to move is reported frequently. It probably depends in every instance upon pain, since there is no evidence thaVactual paralysis occurs in the disease. In 319 cases interference with motion of this nature existed. ,- iality is described as present in 96 cases and absent in 106. It is due to pain in most instances, but perhaps is others may have been occasioned or increased by the presence of swelling. The parts of the body in which motion has been interfered with in any way in the cases reported, and the locality mentioned in detail, may be enumerated as follows: Legs, 159; legs and arms, 55; legs and one. arm ;; 14; legs and one hand, 2; one arm, 3; legs and thighs, 1 ; thighs, 3;: one leg and one arm, I ; one leg, 27; one thigh, 2; hips, I; one hip, 2; one hip and thigh, I; one hip and knee, 3; hip ; .leg and shoulder, 1 ; hip, elbow and shoulder, i ; one knee, 4; one ankle, 2: ankles, knees, hand and wrist, I. POSITION OF THE LIMBS. —To a question regarding the position of the limbs, about which Barlowe speaks so definitely, there have been replies in 2o5 cases. In 17 of these the position was normal. In the balance we find the position of the limbs as. follows: Flexed, 152; extended, 23; - hexed and abducted, I ; flexed and adducted, I ; flexed and everted, I ; abducted, I ; everted; 3; everted and extended, 2; toes extended, I ; feet extended, 3. WEAKNESS OF THE Back.—The occurrence of weakness of the back, a symptom which Barlowe says is marked, is mentioned as present in 97 of the cases reported to the committee and as absent in tog. In the remaining nothing is said of it. DEPRESSION OF THE STERNUM.—This condition Is likewise emphasized by Barlowe as being sometimes striking and characteristic. It is mentioned in 34 cases, but said to be absent in 170 others. It is not certain in the cases of the report how frequently the condition had developed acutely as a result of scurvy and how often it had already been produced by a previously existing rachitis. SWFLUNcs.—The effort has been made by analyzing the cases collected to determine the position of local swellings, whether these were situated in the joints or the shafts of the limbs, in the soft tissues or in the bones, and whether any redness was present. The answers are not clear in every inInfantile Scurvy in america.  4 8 9 stance, and are frequently somewhat contradictory, partly, perhaps, from failure of the observer to understand the question, and partly from lack of careful discrimination between sub-periosteal and other effusions, and between effusion into a joint and that about it. The great irregularity also of the distribution of the swelling renders an accurate tabular arrangement too complicated. Remembering that in many cases more than one part of the body was involved and that the figures given do not mean that only the portion mentioned is affected in these cases, the following division may be made: joints (or probably oftener about joints) involved in 165 cases. Location given in I o I ; vui.. : Knees, 73; ankles, 28; wrists, 12; hand ; . I ; elbow, 3; shoulder, 5; hip, 6. Shafts of limbs involved in 179 cases. Location given in 123; Thighs, 59; . legs (below knee), 61; "legs" (not further Stated), 1 i ; forearm, 5 ,, upper arm, 4; "arm," ? ; ribs, - I scapula, I ; ilium, 1. The gross results of the answers regarding the tissues in Which the swelling occurred give: Swelling in soft tissues, 97, Swelling, sub-periosteal, 114. Swelling in both situations, 16. In 69 cases the swollen parts were reddened also. It is stated that there was no redness in 121. A more general swelling, to be classified rather as edema, is described in 68 cases and stated to be absent in 98. In regard to the swelling or protrusion of one or both eyes ,which has been described by writers, the symptom is said to have been absent in I io cases and is reported present in 49. In 9 of these swelling only is mentioned, in 18 protrusion only, and in 22 both are referred to. Guts.—The condition of the gums and mouth is one of extreme interest. In 16 cases it is distinctly stated that the gums were entirely unaffected, while in 313 they were diseased. The degree of involvement varies from slight swelling to great sponginess and even ulceration. The degree and form of the affection in the cases suitable for study may be seen in the following table: Swelling, absent, 14; present, 293. Sponginess, absent, 2,7; present, 249. 490  Infanir.'le Scurvy in ~,4ynerica. Discoloration, absent, 23 ; present, 259. Bleeding, absent, 64; present, 188. Ulceration, absent, 1o1 ; present, 91. The relation of the affection of the gums to the presence of teeth is of much interest. In nearly all the cases of scurvy in this report teeth were present, but what influence this has is not quite clear, since experience teaches that curiously it is usually the gums of the upper jaw which are most affected, although the lower teeth naturally are the first cut. Statistics on the portion of the gums involved were not furnished sufticit~nily to allow of conclusions; but regarding the teeth it is to be noted that of 359 cases suitable for comparison, teeth had already appeared in 314 instances, i.e., 87.5 per cent.; white in only 4; cases, r".e., 12.5 per cent., were there no teeth. In studying more carefully these 45 cases of scurvy without teeth, we may malte the following analysis: No teeth; gums normal, 21 cases. No teeth; gums affected, 24 cases. The conditions present in the latter group were as follows: Swelling, i9 cases; sponginess, 14 cases; bleeding, 5 cases; discoloration, 17 cases; ulceration, 4 cases. This is a proof that affection of the gums may occur equally well when there are no teeth as when teeth have developed. The fact that in the great majority of cases of infantile scurvy the presence of teeth and the affection of the gums is associated, depends merely on the fact that the disease generally develops at an age when teeth naturally have been cut. CUTANEOUS HEMORRHAGES .--These have occurred with frequency in the cases reported. Accurate data are given in 353„ cases. Of these, cutaneous hemorrhage is reported present in 182 and absent in 171. There is much doubt about the accuracy of the writers in their classification of the hemorrhages according to size, and the proper use by them of the descriptive names employed, inasmuch as the question on this point did not specify clearly. In 99 instances the presence of " ecchymoses " is mentioned. In 83 "purpuric eruption" is reported and in 37 "petechix." In 13 the nature of the lesion is not specified. HEMORRHAGE FROM MUCOUS MFNIBRANES.—Data are available in 361. cases. Of these there were no hemorrhages from any mucous membrane in 196, while in 164 they occurred. In 93 cases there was hemorrhage from the mouth. This includes the Infiuttile Scurvy in -Ivlerica.  49 1 cases where bleeding from the gums is described by writers. In .33 cases there was bleeding from the nose; in 2 from the stomach, and in 37 from the bowels. Cases of ha rnaturia are not included here, and will be referred to later. FRACTURES.--Fractures in infantile scurvy are usually separations of the epiphyses merely. Even this would seem to be rare, for fracture of any kind is mentioned in only 9 of our cases. In 342 it is distinctly stated to have been absent, and in the remaining the question is not answered. FEVER.—Probably in the majority of the cases of the disease upon which this report is based no temperature record has been made. In 93 cases it is stated that there was no fever; in 182 it was present and in the remaining no answer is given. In the cases where present it is described as slight ,in i 16 instances, moderate in 23, high in 8, and irregular in 6. Clearly, fever is not a prominent symptom of the disease, and probably often, when present, depends on accidental causes. BOWELMOVEME\Ts. —The following conditions are mentioned: Bowels regular, 74. Bowels irregular, 15. Constipation, 126. Diarrhoea, 65. Bloody diarrhoea, 12. URINE.—Judging from the number of instances in which no answers have been returned, no examination of the urine has been made in most of the cases. It is reported as examined for albumin in 163 cases; in 33 of these albuminuria is reported and in 130 it was absent. Tube casts were present in 13 instances, absent in 1 3, and no observation reported in the others. Properly speaking the occurrence of ha maturia should be discussed under the title of hemorrhage. It is mentioned as present in 22 cases only. Of other abnormal conditions of the urine the following may be mentioned: Urine very acid, I ; urine scanty, 9; urine suppressed, 1 ; urine increased in quantity, 3; glycosuria, t ; hoemo g lobinuria, 1 ; pus (from cystitis), 1 phosphates increased, 1 ; chlorides increased, i. Ava NIIA; AIAL-NUTRITION. —These conditions, already referred to as often the earliest symptoms of infantile scurvy, may have been the first evidences of the disease in many of the cases on which this report is based. In other cases they must be regarded as complicating affections only. Answers are not full enough to allow ofsatisfactory conclusions on this point. a 49 2  Infantile Scn3'vy in e4merica. Anaemia is said to have been present in 254 cases,.as follows: Ana mia present (without specifying degree), 47Ana mia slight, 66. Anemia moderate, 32. Anaemia marked, Io9. Blood examinations were made in 15 cases and the conditions noted as follows: The percentage of haemoglobin was much reduced in all the cases, 8 in number, in which an examination was made, some being as low as a5 per cent. Of the 7 cases in which the red blood corpuscles were counted, all showed a reduction except 2. In these 2 the number was normal or nearly so, but the hemoglobin was 5o and » per cent., respectively. Leucocytosis was present in 5 cases. Poikilocytosis in-2. In only one instance was there a differential count ofthe leucocytes made: 01 ¢ 2117 cases in which the question is answered,.:e acialior, is recorded in r67 and is said to have been absent in.50. c~lfal-nutritioN was observed in 178 cases out of 216 ; in which replies were made as follows: Mal-nutrition present (without specifying degree), io8; slight, 20; moderate, 7; marked, 43. RICKETS,--Infantile scurvy has so often been described as "scurvy rickets" and "acute rickets," that the investigation of the actual relationship of the two diseases was one of the matters to which the committee directed especial attention. The question upon the circular reads as follows : (a) "Any symptoms of rickets present? (b) Slight or well marked? (c) What. relation in time of development did they bearto the scurvy?" Satisfactory answers were received in 340 cases; in 1 i2 of these (4 5 per cent.), there were symptoms of rickets present, slight in 72, marked in . 64, and the degree not mentioned in 16. In the remaining cases (S5 per cent.), rickets is definitely stated to have been absent. With regard to the relation in time of development, it is stated in ;o cases that the rickets was first present; in 14 that it developed with the scurvy, and in 2 after it. There does notseem to be evidence as far as this investigation teaches that the association of rickets and scurvy is at all intimate. Very possibly the same defect in diet which produced the one produced the other also, but the rapid recovery under treatment which the scurvy underwent did not apply to the rickets. This seems to indicate only accidental association of the two diseases: certainly not any causal relation between them. Infantile Scafruy in _4merica.  493 OTHER COMPLICATING CONDITIONS.—A variety of affections are mentibned complicating scurvy in a number of cases, as follows: Bronchitis, 5; cretinism, I; enlargement of inguinal glands, t; "cerebral symptoms," I : convulsions, 1 ; pneumonia, 2: boils, I; irritability, I; vomiting, 4; eczema, 2; enuresis, r; sweating of the head, I ; tympanites, 1 ; caput medusa ✓ , I ; diaphoresis, 1 : pertussis,  insomnia, I; anorexia, 2,, post nasal discharge, (- measles, r ; restlessness, I ; phimosis, I ; indigestion, 2; laryngismus stridulus, I ; cystitis, I . , DrAGNosrs.—The study of diagnosis has been only incidental, based upon the mistakes made before the disease was recognized in certain cases. The only disease for which infantile scurvy was repeatedly taken appears to have been rheumatism. In several instances the affection of the legs was supposed to be due to sarcoma. The apparent paralytic condition has also been the cause of error in some instances. DURATION OF ILLNESS AND PROGNOSIS,—The disease is essentially chronic; its course terminating only on the institution of proper treatment. This seems to be proved by the answers contained in the circulars. To the question concerning the Jurotit)n of the disease before the case carte under observation, replies were received in 3o6 cases, of which the following BEFORE TREATMENT WAS COMMENCED. DAYS,  - CASES. WEEKS. CASES, MONTHS.  CASES. 1 3 I I? I 18 3 3 2 33 2 4 2 5 3 58 3 3 1 8 I 4 22 4 14 9 10 I 9 5 6 8 2n 7 6 4 7 A 1 7 6 7 2 8 I IO I IO 3 12 r i 2 1 a yrs. 1 Intensely interesting in this connection are the replies to the next two questions: First. Duration of illness after tre,71Ment was romnje-aced, and second, Duration of treatment before warked improvement was noticed. To the first question replies concerning 3o8 cases were received. Of course those fatal during the attack of scurvy are not included here nor those which passed from observation. Still more striking are the answers to the second question, as analysis may be made; DURATION OF DISEASE Cases. 6 4 4 CASES. 47 27 8 I I 7 S 9 IO 12 7 2 DAYS.  CASES. I  I q 2  5 8 3  46 4  26 >  Ig d  I 2 r WEEKS. I 4 5 6 MONTHS, I 2 3 494  lirfcantile Scurvy in. :.4m-erica. to the time when marked improvement was. First noticed. There are ;I I cases suitable for study in this category, excluding fatal cases and those passing from observation.. as before. The replies are often astonishing. Nothing is more striking than the speed with which these reports show a grave constitutional disease disappearing under proper treatment. There is certainly no disease for which a more specific treatment can be said to exist. The replies to the last two questions may be conveniently stated in the following tables: DURATION OF TREATMENT BEFORE MARKED IM PROVEMENT WAS NOTICED. Reported as prompt recovery, 13; at once, 15; immediate, 1. DURATION OF TREATMENT 13EFORE RECOVERY WAS COMPLETE. DAYS, CASES. WEEKS. CASES. MONTHS. CASES. 1 6 j 1 4 8 1 28. 2 2 54  2 .14 3 4 1 8  i 3 4 3 6  3 14  4 5 6 i 6 14 d 10 2 17 7 1 '7 8 r 1 . I3 3 q I 1; 3 15 2 16 I Reported as immediate, 4; almost immediate, 9. TREATMENT. —Not so much could be learned of the value of treatment as could be desired on account of the fact that in nearly all cases we have a combination of diet and of medicinal measures, including the use of fruit juices, and it is impossible to determine absolutely which was the active curative agent. Infantile Scatr - ey in ~4inerica•  495 Taking - the cases in which treatment was effectual and which are suitable for study, the results may be stated as follows: I.  Cases recovering under treatment with drugs only (no change in diet),  -  -  -  0 It.  Cases recovering under the use of fruit juice alone (no change in diet),  -  _  _  3 ]lt, Cases recovering under the use of beef juice alone (no other change in diet),  -  -  _  -  2 IV.  Cases recovering under the use of beef juice and fruit juice combined, with or without drugs (no change in diet),  -  -  -  -  -  -  6 V,  Cases recovering under the combined effect of change of diet, often including beef juice, and the employment  Of fruit juice, with or without drugs,  -  - 257 V1. Cases recovering under change of diet, often including beef juice, and use of drugs (no fruit juice).  - 20 V1I. Cases recovering under change of diet alone, often including beef juice (no fruit juice),  -  -  - 38 These last two may be properly considered together, since there is no evidence that any treatment with drugs has an appreciable effect upon the disease. So many of the reported cases were treated with drugs alone without result before the correct diagnosis was made and other treatment instituted, that this belief is amply justified. Combining, therefore, divisions N' `l. and VII., and comparing the statements of the writers regarding the diet employed during treatment and that employed when the scurvy developed, we may make the following table based upon 58 cases. Again the committee would state that no claim is made that the recovery was the result of the change, but that it quotes merely the statements ofthe correspondents to the effect that recovery took place after the change was made. Vt. AND VII.—RECOVERY FOLLOWING CHANGE IN DIET ALONE, WITH OR WITHOUT DRUGS. (No FRUIT JUICE EMPLOYED). Mellin's food to milk and beef juice, - "  "  to raw milk and beef juice,  —  —  - I  to modified milk,  - 4 to modified milk and beef juice,  2  to diet and beef juice, -  -  -  - 1 and sterilized milk to beef juice and broths,  - I and sterilized milk to sterilized milk and beef  juice, -  -  -  -  -  - 0 - 2 I r only, 2 2 I I 6 49 0  !lzfantile Scurvy ire _merica. Mellin's food and condensed milk to modified milk, Condensed milk to fresh milk and beef juice, and sarcopeptone to fresh milk and beef juice, and condensed milk to raw milk, to sterilized milk and diet, to lactated food and raw milk, to sterilized milk,  - Malted milk to milk and diet, to raw milk and beef juice, and amylacere to modified pasteurized beef juice,  - Sterilized milk to diet and beef juice, to fresh milk and beefjuice, to raw milk, to diet,  - to raw milk and beef juice, to sterilized milk and beef juice,  - peptonized to raw milk and' beef iuice, to pasteurized milk and diet, - Pasteurized milk to raw milk,  -  - " to fresh milk and beef juice, °  " to sterilized milk and broths,. Raw milk to amylacex,  - Breast milk to peptonized milk and broths, "  "  to sterilized milk, Lactated food to raw milk and beef juice,  - Reed & Carnrick's soluble food to modified milk, to baked potato, to beef juice, Imperial granurn to raw milk and beef juice, Patented food to diet,  -  -  - Ridge's food to diet, -  -  -  - Diet (poor) to diet (better),  - Bartlett's pepsinated food to fresh milk, It must be noted with regard to this table and those following that the term ' ` modified " milk is used very loosely by the reporters. Occasionally it is specified to be laboratory milk, but much oftener this is not the case, and we are unable to -know whether the modification was done at home or not, and whether the mills was heated or not. Presumably it was pasteurized in -Waiattle Scurfy "I 4werica.  497 many instances. Where the term "fresh " milk is employed in the table, we have been unable to learn by additional correspondence whether "raw" milk is meant or whether only a chance from proprietary food to cow's milk is intended. The term "diet" as employed in the tables either expresses the fact that . a large and varied number of different forms of diet were tried, too complicated to be detailed, or else quotes merely the Statement of the writers that a change of diet was made, the original food probably being abandoned entirely unless otherwise stated. The following table shows the food employed in divisions 1., IL, 111. and IV., in which the diet was the same (except sometimes for the addition of beef juice) while the scurvy was developing and while it was recovering. RECOVER}' FOLLMti'fNG WITH NO CHANGE OF DIET DURING TREATMENT. I. Treatment with drugs only, 11. Treatment with fruit juice only, Mellin's food (milk sterilized), Sterilized milk, Ill. Treatment with beef juice only, Sterilized milk,  - Raw milk, IV. Treatment with combined beef juice and fruit Juic Sterilized milk, Sterilized milk and broths,  - ((  11  amylaceac, Table food.  - Division V. contains by far the largest number of cases, 257 in all.. The changes in diet employed are much too complicated to.bestated fully in a table. Moreover, they are of little value, singe the treatment was such a composite one, viz: change of diet combined with the use of fruit juice in every case, and often of beef juice and of drugs as well. A few of the more striking classes of cases may be selected as follows: V--RECOVER) , FOLLOWING CHANGE OF DIET COMBINED WITH FRUIT JUICE, W ITH OR WITHOUT DRUGS. Condensed milk to milk, variously treated,  - - 2 3 Imperial granum to milk, variously treated, _  7 Lactopmeparata to raw milk.. _  2 I I I I r I If  11 It  It milk and