Scurvy is a deficiency disease (state of malnutrition) resulting from a lack of vitamin C (ascorbic acid).[ Without treatment, anemia, gum disease, changes to hair, and bleeding from the skin may occur.][
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It takes at least a month of little to no vitamin C in the diet before symptoms occur.[ In modern times, scurvy occurs most commonly in Child neglect, people with , unusual eating habits, alcoholism, and older people who live alone.][ Other risk factors include intestinal malabsorption and Kidney dialysis.][
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While many animals produce their vitamin C, humans and a few others do not.
Treatment is with vitamin C supplements taken by mouth.[ Improvement often begins in a few days with complete recovery in a few weeks.][ Sources of vitamin C in the diet include raw citrus fruit and several raw vegetables, including red peppers, broccoli, and tomatoes.][ Cooking often decreases the residual amount of vitamin C in foods.]
Scurvy is rare compared to other nutritional deficiencies.[ It occurs more often in the developing world in association with malnutrition.][ Rates among refugees are reported at 5 to 45 percent.]
Signs and symptoms
Early symptoms are malaise and lethargy. After one to three months, patients develop shortness of breath and bone pain. may occur because of reduced carnitine production. Other symptoms include skin changes with roughness, easy bruising, and , gum disease, loosening of teeth, poor wound healing, and emotional changes (which may appear before any physical changes). Dry mouth and dry eyes similar to Sjögren's syndrome may occur. In the late stages, jaundice, generalised edema, oliguria, neuropathy, fever, convulsions, and eventual death are frequently seen.
Cause
Scurvy, including subclinical scurvy, is caused by a deficiency of dietary vitamin C since the human liver is unable to synthesize vitamin C. Provided the diet contains sufficient vitamin C, the lack of working L-gulonolactone oxidase (GULO) enzyme has no significance. In modern Western societies, scurvy is seldom present in average adults, although underfed people (drug users, the homeless, Child neglect and geriatrics) are affected.
Scurvy is one of the accompanying diseases of malnutrition (other such micronutrient deficiencies are beriberi and pellagra) and thus is still widespread in areas of the world dependent on external food aid.
Pathogenesis
Vitamins are essential to the production and use of enzymes in ongoing processes throughout the human body.
The early symptoms of malaise and lethargy may be due to either impaired fatty acid metabolism from a lack of carnitine and/or from a lack of catecholamines, which are needed for the cAMP-dependent pathway in both glycogen metabolism and fatty acid metabolism.
In the synthesis of collagen, ascorbic acid is required as a cofactor for prolyl hydroxylase and lysyl hydroxylase. These two enzymes are responsible for the hydroxylation of the proline and lysine amino acids in collagen. Hydroxyproline and hydroxylysine are important for stabilizing collagen by cross-linking the propeptides in collagen.
Collagen is a primary structural protein in the human body, necessary for healthy blood vessels, muscle, skin, bone, cartilage, and other connective tissues. Defective connective tissue leads to fragile capillaries, resulting in abnormal bleeding, bruising, and internal hemorrhaging. Collagen is an important part of bone, so bone formation is also affected. Teeth loosen, bones break more easily, and once-healed breaks may recur.
Diagnosis
Diagnosis is typically based on physical signs, X-rays, and improvement after treatment.[
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Differential diagnosis
Various childhood-onset disorders can mimic the clinical and X-ray picture of scurvy such as:
Prevention
| + Foods and their Vitamin C content per 100
! scope="col" | Item
! scope="col" style="max-width:6em;" | Vitamin C contents (Milligrams) |
| 2000.00 |
| 610.00 |
| 333.00 |
| 228.30 |
| 181.00 |
| 161.30 |
| 144.00 |
| 133.00 |
| 92.70 |
| 89.20 |
| 85.00 |
| 80.40 |
| 62.00 |
| 58.80 |
| 53.20 |
| 53.00 |
| 36.60 |
| 28.00 |
| 27.40 |
| 19.70 |
Scurvy can be prevented by a diet that includes uncooked vitamin C-rich foods such as amla, (sweet peppers), , broccoli, chili peppers, citrus fruits (lemon, lime, orange, etc), kiwifruit, and parsley. Other sources rich in vitamin C are dandelion, raw liver (23.6 mg/100 grams), sauerkraut, and many fruits such as guava, papaya, Strawberry, and tomato. It is also found in vegetables, such as , cabbage, , and spinach. Some fruits and vegetables not high in vitamin C may be Pickling in lemon juice, which is high in vitamin C. Nutritional supplements that provide ascorbic acid well above what is required to prevent scurvy may cause adverse health effects.
Uncooked fresh meat from animals, notably internal organs, contains enough vitamin C to prevent scurvy, and even partly treat it.
Scott's 1902 Antarctic expedition used fresh seal meat and increased allowance of bottled fruits, whereby complete recovery from incipient scurvy was reported to have taken less than two weeks.[ 26 The Heald, Mr. Ferrar, and Cross have very badly swollen legs, whilst Heald's are discoloured as well. The remainder of the party seem fairly well, but not above suspicion; Walker's ankles are slightly swollen. 15 After within a fortnight of the outbreak there is scarcely a sign of it remaining ... Heald's is the only case that hung at all ... and now he is able to get about once more. Cross's recovery was so rapid that he was able to join the seal-killing party last week.]
Treatment
Scurvy will improve with doses of vitamin C as low as 10 mg per day though doses of around 100 mg per day are typically recommended.
History
Symptoms of scurvy have been recorded in Ancient Egypt as early as 1550 Before Christ.[Hippocrates described symptoms of scurvy in book 2 of his Prorrheticorum and in his Liber de internis affectionibus. (Cited by James Lind, A Treatise on the Scurvy, 3rd ed. (London, England: G. Pearch and W. Woodfall, 1772), page 285 ) Symptoms of scurvy were also described by: (i) Pliny, in Naturalis historiae, book 3, chapter 49; and (ii) Strabo, in Geographicorum, book 16. (Cited by John Ashhurst, ed., The International Encyclopedia of Surgery, vol. 1 (New York, New York: William Wood and Co., 1881), page 278 )][
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The knowledge that consuming certain foods is a cure for scurvy has been repeatedly forgotten and rediscovered into the early 20th century.[Maciej Cegłowski, 2010-03-06, "Scott and Scurvy" . Retrieved 2016-05-31.] Scurvy occurred during the Great famine of Ireland in 1845 and also the American Civil War. In 2002, scurvy outbreaks were recorded in Afghanistan following the most intense phase of the war.
Early modern era
In the 13th century Crusades developed scurvy.[
] In the 1497 expedition of Vasco da Gama, the curative effects of citrus fruit were already observed[As they sailed farther up the east coast of Africa, they met local traders, who traded them fresh oranges. Within 6 days of eating the oranges, da Gama's crew recovered fully and he noted, "It pleased God in his mercy that ... all our sick recovered their health for the air of the place is very good." Infantile Scurvy: A Historical Perspective , Kumaravel Rajakumar, MD] and were confirmed by Pedro Álvares Cabral and his crew in 1507.["Relação do Piloto Anônimo", narrativa publicada em 1507 sobre a viagem de Pedro Álvares Cabral às Índias, indicava que os "refrescos" oferecidos aos portugueses pelo rei de Melinde eram o remédio eficaz contra a doença (Nava, 2004). A medicina nas caravelas - Século XV , Cristina B. F. M. Gurgel I; Rachel Lewinsohn II, Marujos, Alimentação e Higiene a Bordo]
The Portuguese planted fruit trees and vegetables on Saint Helena, a stopping point for homebound voyages from Asia, and left their sick who had scurvy and other ailments to be taken home by the next ship if they recovered.[On returning, Lopes' ship had left him on St Helena, where with admirable sagacity and industry he planted vegetables and nurseries with which passing ships were marvellously sustained. ... There were 'wild groves' of oranges, lemons, and other fruits that ripened all the year round, large pomegranates and figs. Santa Helena, A Forgotten Portuguese Discovery , Harold Livermore – Estudos em Homenagem a Luis Antonio de Oliveira Ramos, Faculdade de Letras da Universidade do Porto, 2004, p. 630-631] In 1500, one of the pilots of Cabral's fleet bound for India noted that in Malindi, its king offered the expedition fresh supplies such as lamb, chicken, and duck, along with lemons and oranges, due to which "some of our ill were cured of scurvy".[ Logo que chegámos mandou-nos El Rey visitar e ao mesmo tempo um refresco de carneiros, galinhas, patos, limões e laranjas, as melhores que há no mundo, e com ellas sararam de escorbuto alguns doentes que tinhamos connosco in Portuguese, in Pedro Álvares Cabral, Metzer Leone Editorial Aster, Lisbon, p.244][Germano de Sousa (2013) História da Medicina Portuguesa Durante a Expansão, Círculo de Leitores, Lisbon, p.129]
These travel accounts did not prevent further maritime tragedies caused by scurvy, partly because of the lack of communication between travelers and those responsible for their health, and because fruits and vegetables could not be kept for long on ships.[Contudo, tais narrativas não impediram que novas tragédias causadas pelo escorbuto assolassem os navegantes, seja pela falta de comunicação entre os viajantes e responsáveis pela sua saúde, ou pela impossibilidade de se disponibilizar de frutas frescas durante as travessias marítimas. A medicina nas caravelas - Século XV , Cristina B. F. M. Gurgel I; Rachel Lewinsohn II, Marujos, Alimentação e Higiene a Bordo]
In 1536, the French explorer Jacques Cartier, while exploring the St. Lawrence River, used the local St. Lawrence Iroquoians' knowledge to save his men dying of scurvy. He boiled the needles of the aneda tree (generally believed to have been eastern white cedar) to make a tea that was later shown to contain 50 mg of vitamin C per 100 grams.[ Jacques Cartier's Second Voyage , 1535 Winter & Scurvy.]
In 1579, the Spanish friar and physician Agustin Farfán published a book Tractado breve de anathomía y chirugía, y de algunas enfermedades que más comúnmente suelen haver en esta Nueva España in which he recommended oranges and lemons for scurvy, a remedy that was already known in the Spanish navy.
In February 1601, Captain James Lancaster, while commanding the first English East India Company fleet en route to Sumatra, landed on the northern coast of Madagascar specifically to obtain lemons and oranges for his crew to stop scurvy.
Researchers have estimated that during the Age of Exploration (between 1500 and 1800), scurvy killed at least two million .[
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In 1593, Admiral Sir Richard Hawkins advocated drinking orange and lemon juice to prevent scurvy.
A 1609 book by Bartolomé Leonardo de Argensola recorded several different remedies for scurvy known at this time in the Moluccas, including a kind of wine mixed with cloves and ginger, and "certain herbs". The Dutch sailors in the area were said to cure the same disease by drinking lime juice.
In 1614, John Woodall, Surgeon General of the East India Company, published The Surgion's Mate as a handbook for apprentice surgeons aboard the company's ships. He repeated the experience of mariners that the cure for scurvy was fresh food or, if not available, oranges, lemons, limes, and tamarinds.
Besides afflicting ocean travelers, until the late Middle Ages scurvy was common in Europe in late winter, when few green vegetables, fruits, and root vegetables were available. This gradually improved with the introduction of potatoes from the Americas; by 1800, scurvy was virtually unheard of in Scotland, where it had previously been endemic.
18th century
In 2009, a handwritten household book authored by a Cornishwoman in 1707 was discovered in a house in Hasfield, Gloucestershire, containing a " for the Scurvy" amongst other largely medicinal and herbal recipes. The recipe consisted of extracts from various plants mixed with a plentiful supply of orange juice, white wine, or beer.
In 1734, Leiden-based physician Johann Bachstrom published a book on scurvy in which he stated, "scurvy is solely owing to a total abstinence from fresh vegetable food, and greens; which is alone the primary cause of the disease", and urged the use of fresh fruit and vegetables as a cure.[Johann Friedrich Bachstrom, Observationes circa scorbutum Observations (Leiden ("Lugdunum Batavorum"), Netherlands: Conrad Wishof, 1734) p. 16. From page 16: "... sed ex nostra causa optime explicatur, quae est absentia, carentia & abstinentia a vegetabilibus recentibus, ..." (... but this is explained very well by our supposed cause, which is the absence of, lack of, and abstinence from fresh vegetables, ...)][ "The Blood of Nelson" by Glenn Barnett — Military History — Oct 2006.]
It was not until 1747 that James Lind formally demonstrated that scurvy could be treated by supplementing the diet with citrus fruit, in one of the first controlled clinical experiments reported in the history of medicine.[ (Also archived second edition (1757))]
Lind explained the details of his clinical trial and concluded "the results of all my experiments was, that oranges and lemons were the most effectual remedies for this distemper at sea."
During the 18th century, scurvy killed more British sailors than wartime enemy action. It was mainly by scurvy that during George Anson's voyage around the world he lost nearly two-thirds of his crew (1,300 out of 2,000) within the first 10 months of the voyage.[" Captain Cook and the Scourge of Scurvy " BBC – History] The Royal Navy enlisted 184,899 sailors during the Seven Years' War; 133,708 of these were "missing" or died from disease, and scurvy was the leading cause.[A. S. Turberville (2006). " Johnson's England: An Account of the Life & Manners of His Age". ISBN READ BOOKS. p.53. ]
Although sailors and naval surgeons were increasingly convinced that citrus fruits could cure scurvy throughout this period, the classically trained physicians who determined medical policy dismissed this evidence as merely anecdotal, as it did not conform to their theories of disease. Literature championing the cause of citrus juice had no practical impact. The medical theory was based on the assumption that scurvy was a disease of internal putrefaction brought on by faulty digestion caused by the hardships of life at sea and the naval diet. Although successive theorists gave this basic idea different emphases, the remedies they advocated (and which the navy accepted) amounted to little more than the consumption of 'fizzy drinks' to activate the digestive system, the most extreme of which was the regular consumption of 'elixir of vitriol' – sulphuric acid taken with spirits and barley water, and laced with spices.
In 1764, a new and similarly inaccurate theory on scurvy appeared. Advocated by Dr David MacBride and Sir John Pringle, Surgeon General of the Army and later President of the Royal Society, this idea was that scurvy was the result of a lack of 'fixed air' in the tissues which could be prevented by drinking infusions of malt and wort whose fermentation within the body would stimulate digestion and restore the missing gases.
Cook did not lose a single man to scurvy, and his report came down in favor of malt and wort. The reason for the health of his crews on this and other voyages was Cook's regime of shipboard cleanliness, enforced by strict discipline, and frequent replenishment of fresh food and greenstuffs.
The first major long-distance expedition that experienced virtually no scurvy was that of the Spanish naval officer Alessandro Malaspina, 1789–1794. Malaspina's medical officer, Pedro González, was convinced that fresh oranges and lemons were essential for preventing scurvy. Only one outbreak occurred, during a 56-day trip across the open sea. Five sailors came down with symptoms, one seriously. After three days at Guam, all five were healthy again. Spanish Empire and many ports of call made it easier to acquire fresh fruit.
Although towards the end of the century, MacBride's theories were being challenged, the medical authorities in Britain remained committed to the notion that scurvy was a disease of internal 'putrefaction' and the Sick and Hurt Board, run by administrators, felt obliged to follow its advice. Within the Royal Navy, however, opinion – strengthened by first-hand experience with lemon juice at the siege of Gibraltar and during Admiral Rodney's expedition to the Caribbean – had become increasingly convinced of its efficacy. This was reinforced by the writings of experts like Gilbert Blane[Blane, Gilbert (1785). Observations on the diseases incident to seamen. London: Joseph Cooper; Edinburgh: William Creech] and Thomas Trotter
With the coming of war in 1793, the need to eliminate scurvy became more urgent. The first initiative came not from the medical establishment but from the admirals. Ordered to lead an expedition against Mauritius, Rear Admiral Gardner was uninterested in the wort, malt, and elixir of vitriol that were still being issued to ships of the Royal Navy, and demanded that he be supplied with lemons, to counteract scurvy on the voyage. Members of the Sick and Hurt Board, recently augmented by two practical naval surgeons, supported the request, and the Admiralty ordered that it be done. There was, however, a last-minute change of plan, and the expedition against Mauritius was canceled. On 2 May 1794, only and two Sloop-of-war under Commodore Peter Rainier sailed for the east with an outward bound convoy, but the warships were fully supplied with lemon juice and the sugar with which it had to be mixed.
In March 1795, it was reported that the Suffolk had arrived in India after a four-month voyage without a trace of scurvy and with a crew that was healthier than when it set out. The effect was immediate. Fleet commanders clamored also to be supplied with lemon juice, and by June the Admiralty acknowledged the groundswell of demand in the navy and agreed to a proposal from the Sick and Hurt Board that lemon juice and sugar should in future be issued as a daily ration to the crews of all warships.
It took a few years before the method of distribution to all ships in the fleet had been perfected and the supply of the huge quantities of lemon juice required to be secured, but by 1800, the system was in place and functioning. This led to a remarkable health improvement among the sailors and consequently played a critical role in gaining an advantage in naval battles against enemies who had yet to introduce the measures.
Scurvy was not only a disease of seafarers. The early colonists of Australia suffered greatly because of the lack of fresh fruit and vegetables in the winter. There, the disease was called Spring fever or Spring disease and was described as an often-fatal condition associated with skin lesions, bleeding gums, and lethargy. It was eventually identified as scurvy and the remedies already in use at sea were implemented.
19th century
The surgeon-in-chief of Napoleon's army at the Siege of Alexandria (1801), Baron Dominique-Jean Larrey, wrote in his memoirs that the consumption of horse meat helped the French to curb an epidemic of scurvy. The meat was cooked but was freshly obtained from young horses bought from Arabs, and was nevertheless effective. This helped to start the 19th-century tradition of horse meat consumption in France.[Larrey is quoted in French by Dr. Béraud, Études Hygiéniques de la chair de cheval comme aliment , Musée des Familles (1841-42).]
Lauchlin Rose patented a method used to preserve citrus juice without alcohol in 1867, creating a concentrated drink known as Rose's lime juice. The Merchant Shipping Act 1867 required all ships of the Royal Navy and Merchant Navy to provide a daily "lime or lemon juice" ration of one pound to sailors to prevent scurvy.
The plant Cochlearia officinalis, also known as "common scurvygrass", acquired its common name from the observation that it cured scurvy, and it was taken on board ships in dried bundles or distilled extracts. Its bitter taste was usually disguised with herbs and spices; however, this did not prevent scurvygrass drinks and sandwiches from becoming a popular fad in the UK until the middle of the nineteenth century, when citrus fruits became more readily available.
Key lime began to take over from lemons, when Spain's alliance with France against Britain in the Napoleonic Wars made the supply of Mediterranean lemons problematic, and because they were more easily obtained from Britain's Caribbean colonies
The belief that scurvy was fundamentally a nutritional deficiency, best treated by consumption of fresh food, particularly fresh citrus or fresh meat, was not universal in the 19th and early 20th centuries, and thus sailors and explorers continued to have scurvy into the 20th century. For example, the Belgian Antarctic Expedition of 1897–1899 became seriously affected by scurvy when its leader, Adrien de Gerlache, initially discouraged his men from eating penguin and seal meat.
In the Royal Navy's Arctic expeditions in the mid-19th century, it was widely believed that scurvy was prevented by good hygiene on board ship, regular exercise, and maintaining crew morale, rather than by a diet of fresh food. Navy expeditions continued to be plagued by scurvy even while fresh (not jerked or tinned) meat was well known as a practical antiscorbutic among civilian whalers and explorers in the Arctic. In the latter half of the 19th century, there was greater recognition of the value of eating fresh meat as a means of avoiding or treating scurvy, but the lack of available game to hunt at high latitudes in winter meant it was not always a viable remedy. Criticism also focused on the fact that some of the men most affected by scurvy on Naval polar expeditions had been heavy drinkers, with suggestions that this predisposed them to the condition.
The confusion is attributed to several factors:
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while fresh citrus (particularly lemons) cured scurvy, lime juice that had been exposed to light, air, and copper tubing did not – thus undermining the theory that citrus cured scurvy;
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fresh meat (especially organ meat and raw meat, consumed in arctic exploration) also cured scurvy, undermining the theory that fresh vegetable matter was essential to preventing and curing scurvy;
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increased marine speed via steam shipping, improved nutrition on land, reduced the incidence of scurvy – and thus the ineffectiveness of copper-piped lime juice compared to fresh lemons was not immediately revealed.
In the resulting confusion, a new hypothesis was proposed, following the new germ theory of disease – that scurvy was caused by ptomaine, a waste product of bacteria, particularly in tainted tinned meat.
Infantile scurvy emerged in the late 19th century because children were fed pasteurized cow's milk, particularly in the urban upper class. While pasteurization killed bacteria, it also destroyed vitamin C. This was eventually resolved by supplementing with onion juice or cooked potatoes. Native Americans helped save some newcomers from scurvy by directing them to eat wild onions.
20th century
By the early 20th century, when Robert Falcon Scott made his first expedition to the Antarctic (1901–1904), the prevailing theory was that scurvy was caused by "ptomaine poisoning", particularly in tinned meat.
In 1907, an animal model that would eventually help to isolate and identify the "antiscorbutic factor" was discovered. Axel Holst and Theodor Frølich, two Norway physicians studying shipboard beriberi contracted by ship's crews in the Norwegian Fishing Fleet, wanted a small test mammal to substitute for the then used in beriberi research. They fed their test diet of grains and flour, which had earlier produced beriberi in their pigeons, and were surprised when classic scurvy resulted instead. This was a serendipitous choice of animal. Until that time, scurvy had not been observed in any organism apart from humans and had been considered an exclusively human disease. Certain birds, mammals, and fish are susceptible to scurvy, but pigeons are unaffected since they can synthesize ascorbic acid internally. Holst and Frølich found they could cure scurvy in guinea pigs with the addition of various fresh foods and extracts. This discovery of an animal experimental model for scurvy, which was made even before the essential idea of "vitamins" in foods had been put forward, has been called the single most important piece of vitamin C research.
In 1915, New Zealand troops in the Gallipoli Campaign had a lack of vitamin C in their diet which caused many of the soldiers to contract scurvy.
Vilhjalmur Stefansson, an Arctic explorer who had lived among the Inuit, proved that the all-meat diet they consumed did not lead to vitamin deficiencies. He participated in a study in New York's Bellevue Hospital in February 1928, where he and a companion ate only meat for a year while under close medical observation, yet remained in good health.
In 1927, Hungarian biochemist Albert Szent-Györgyi isolated a compound he called "hexuronic acid".
21st century
Rates of scurvy in the developed world are low due to the greater access to vitamin C-rich foods.
In 2020, the overall incidence of scurvy in the US was about one in 4,000 people, up significantly from even a few years before. About two-thirds of all scurvy is found in autism people.
Human trials
Notable human dietary studies of experimentally induced scurvy were conducted on conscientious objectors during World War II in Britain and the United States on Iowa state prisoner volunteers in the late 1960s.
Men in both studies, on a diet devoid or nearly devoid of vitamin C, had blood levels of vitamin C too low to be accurately measured when they developed signs of scurvy, and in the Iowa study, at this time were estimated (by labeled vitamin C dilution) to have a body pool of less than 300 mg, with daily turnover of only 2.5 mg/day.
In other animals
Most animals and plants can synthesize vitamin C through a sequence of enzyme-driven steps, which convert monosaccharides to vitamin C. However, some mammals have lost the ability to synthesize vitamin C, notably and . These make up one of two major primate suborders, haplorrhini, and this group includes .
Animals that can contract scurvy all lack the L-gulonolactone oxidase (GULO) enzyme, which is required in the last step of vitamin C synthesis. The genomes of these species contain GULO as , which serve as insight into the evolutionary past of the species.
Name
In babies, scurvy is sometimes referred to as Barlow's disease, named after Thomas Barlow,
See also
Agustín Farfán
Further reading
External links
