396 THE HEMORRHAGIC DIATHESES 



intestinal fermentative processes have prepared the way. In 167 of 373 chil- 

 dren in the first year of life^ scurvy was preceded by another disease, usually 

 disturbance of the digestive organs. The nutrition prior to the appearance 

 of scurvy had consisted in 10 children of breast milk exclusively, in 4 of unster- 

 ilized, in 68 of sterilized, milk, and in the remainder of artificial foods. 



We shall now consider what other factors may also be regarded as causes 

 of this disease. 



It is certain that age and sex do not play a role in scurvy, although it has 

 been erroneously maintained that in single epidemics particularly persons of 

 a definite age, or of one sex, have been attacked (for example, according to 

 Fauvel, in the Salpetriere in Paris in 1847 only old women had the disease). 

 Scurvy occurs more frequently in men than in women; the reason for this 

 is quite obvious, for it is men who are chiefly exposed to the causes of the 

 disease. 



The siame circumstances make it apparent why the disease usually appears 

 during middle life, but no age can be said to be exempt, as the disease has 

 been noted in the aged, occurring epidemically, and also in foundling asylums 

 which were improperly conducted. The so-called infantile scurvy occurs in 

 nurslings in the first year of life, particularly in the ninth and tenth months; 

 it has so far been impossible to determine that any particular variety of food 

 is the cause; breast-fed children are affected as well as those brought up on 

 sterilized cow's milk or artificial foods. It has lately been maintained of 

 Barlow's disease that milk which has been cooked too long, or that which has 

 been subjected to too high a temperature, may be the cause. Those who adhere 

 to this view may easily assign the same cause for infantile scurvy. 



It has been shown in most scurvy epidemics that individual predisposition 

 plays a certain role as well as the constitution of the patient. It is unques- 

 tionable that persons who have recently recovered from other diseases, 'or are 

 still suffering from them, are particularly liable to an attack of scurvy. As 

 predisposing diseases we may mention malaria, dj'sentery, enteric fever, tuber- 

 culosis, trauma as well as syphilis, especially after a very active mercurial 

 treatment (Krebel). It is needless to enumerate all of the predisposing dis- 

 eases, but I should like to point out that I have repeatedly observed isolated 

 cases of severe scurvy in immediate connection with influenza. Quite recently, 

 too, I treated three cases of the severest form of scurvy, two fatal cases in 

 female children of thirteen and fifteen years, in whom the' disease was con- 

 nected with measles and tuberculosis, the third case in a diabetic aged sixty- 

 four. Moreover, I should like to emphasize that occasionally cases of scurvy 

 with very extensive cutaneous hemorrhages and intense oral implication occur 

 in absolutely healthy and well-nourished individuals, living under the most 

 favorable circumstances, in whom not one of the recognized causes can come 

 into question at all. Such obscure and entirely incomprehensible cases con- 

 vince us that up to the present time we have no absolute knowledge regarding 

 the cause of the disease; they make it probable, however, that we should consider 

 the view, sometimes expressed and constantly rejected, that predisposition to 

 scurvy may be hereditary, even though to-day a discussion of this question 

 does not appear to be timely. The facts mentioned have nevertheless been 



