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Data Structures and Abstractions
with Java TM

Fourth Edition

Frank M. Carrano
University of Rhode Island

Timothy M. Henry
New England Institute of Technology

Boston Columbus Indianpolis New York San Francisco Upper Saddle River
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Editorial Director, ECS: Marcia Horton Procurement Specialist: Maura Zaldivar-Garcia
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Editorial Assistant: Kelsey Loanes Cover Designer: Black Horse Designs
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Marketing Assistant: Jon Bryant Web Development, Senior Manager:
Director of Program Management: Erin Gregg Steve Wright
Program Management-Team Lead: Scott Disanno Associate Web Developer: Barry Offringa
Program Manager: Carole Snyder Full-Service Project Management:
Project Manager: Robert Engelhardt GEX Publishing Services

Credits and acknowledgments borrowed from other sources and reproduced, with permission, in this textbook
appear on the appropriate page within text.

Oracle and Java are registered trademarks of Oracle and/or its affiliates. Other names may be trademarks of their
respective owners.

Copyright © 2015, 2012 and 2007 Pearson Education, Inc., All rights reserved. Printed in the United States
of America. This publication is protected by Copyright, and permission should be obtained from the publisher
prior to any prohibited reproduction, storage in a retrieval system, or transmission in any form or by any means,
electronic, mechanical, photocopying, recording, or likewise. To obtain permission(s) to use material from this
work, please submit a written request to Pearson Education, Inc., Permissions Department, One Lake Street,
­Upper Saddle River, New Jersey 07458, or you may fax your request to 201-236-3290.

Many of the designations by manufacturers and sellers to distinguish their products are claimed as
trademarks. Where those designations appear in this book, and the publisher was aware of a trademark
claim, the designations have been printed in initial caps or all caps.

Library of Congress Cataloging-in-Publication Data

Carrano, Frank M.
  Data structures and abstractions with Java / Frank M. Carrano, University of Rhode Island. — Fourth edition.
       pages cm
  Includes bibliographical references and index.
  ISBN 978-0-13-374405-7 (alk. paper)
1.  Data structures (Computer science) 2.  Java (Computer program language)  I. Title.
  QA76.9.D33C37 2015
  005.13'3--dc23
                                                            2014025945

10 9 8 7 6 5 4 3 2 1

ISBN 10: 0-13-374405-1

www.pearsonhighered.com ISBN 13: 978-0-13-374405-7
W elcome to the fourth edition of Data Structures and Abstractions with Java, a book for an introductory

Welcome
course in data structures, typically known as CS-2.
I wrote this book with you in mind—whether you are an instructor or a student—based upon my
experiences during more than three decades of teaching undergraduate computer science. I wanted my book
to be reader friendly so that students could learn more easily and instructors could teach more effectively.
To this end, you will find the material covered in small pieces—I call them “segments”—that are easy to
digest and facilitate learning. Numerous examples that mimic real-world situations provide a context for
the new material and help to make it easier for students to learn and retain abstract concepts. Many simple
figures illustrate and clarify complicated ideas. Included are over 60 video tutorials to supplement the
instruction and help students when their instructor is unavailable.
I am pleased and excited to welcome my co-author and colleague, Dr. Timothy Henry, to this edition.
Together we have given a fresh update to this work, while retaining the topics and order of the previous edi-
tion. You will find a greater emphasis on our design decisions for both specifications and implementations
of the various data structures, as well as a new introduction to safe and secure programming practices. The
new features in this edition are given on the next page.
We hope that you enjoy reading this book. Like many others before you, you can learn—or teach—
data structures in an effective and sustainable way.

Warm regards,
Frank M. Carrano

We are always available to connect with instructors and students who use our books. Your comments, sug-
gestions, and corrections will be greatly appreciated. Here are a few ways to reach us:

E-mail: [email protected] or [email protected]

Facebook: www.facebook.com/makingitreal

Twitter: twitter.com/Frank_M_Carrano

Website: frank-m-carrano.com/makingitreal

iii
 Organization and Structure
Brief Table of Contents

This book’s organization, sequencing, and pace of topic coverage make learning and teaching easier by
focusing your attention on one concept at a time, by providing flexibility in the order in which you can cover
topics, and by clearly distinguishing between the specification and implementation of abstract data types, or
ADTs. To accomplish these goals, we have organized the material into 29 chapters, composed of small, num-
bered segments that deal with one concept at a time. Each chapter focuses on either the specification and use
of an ADT or its various implementations. You can choose to cover the specification of an ADT followed by
its implementations, or you can treat the specification and use of several ADTs before you consider any im-
plementation issues. The book’s organization makes it easy for you to choose the topic order that you prefer.

Table of Contents at a Glance

The following brief table of contents shows the overall composition of the book. Notice the new Prelude
and nine Java Interludes. Further details—including a chapter-by-chapter description—are given later in this
preface. Note that some of the appendixes and the glossary are available online.

Introduction Organizing Data Java Interlude 6 Mutable and Immutable Objects

Prelude Designing Classes Chapter 16 Sorted Lists
Chapter 1 Bags Java Interlude 7 Inheritance
Java Interlude 1 Generics Chapter 17 Inheritance and Lists
Chapter 2 Bag Implementations Chapter 18 Searching
That Use Arrays Java Interlude 8 Generics Once Again
Java Interlude 2 Exceptions Chapter 19 Dictionaries
Chapter 3 A Bag Implementation Chapter 20 Dictionary Implementations
That Links Data Chapter 21 Introducing Hashing
Chapter 4 The Efficiency of Chapter 22 Hashing as a Dictionary
Algorithms Implementation
Chapter 5 Stacks Chapter 23 Trees
Chapter 6 Stack Implementations Chapter 24 Tree Implementations
Chapter 7 Recursion Java Interlude 9 Cloning
Java Interlude 3 More About Generics Chapter 25 A Binary Search Tree
Chapter 8 An Introduction to Sorting Implementation
Chapter 9 Faster Sorting Methods Chapter 26 A Heap Implementation
Java Interlude 4 More About Exceptions Chapter 27 Balanced Search Trees
Chapter 10 Queues, Deques, and Chapter 28 Graphs
Priority Queues Chapter 29 Graph Implementations
Chapter 11 Queue, Deque, and Priority Appendix A Documentation and
Queue Implementations Programming Style
Chapter 12 Lists Appendix B Java Basics (online)
Chapter 13 A List Implementation That Appendix C Java Classes (online)
Uses an Array Appendix D Creating Classes from Other
Chapter 14 A List Implementation That Classes
Links Data Appendix E File Input and Output (online)
Java Interlude 5 Iterators Glossary (online)
Chapter 15 Iterators for the ADT List

iv
What’s New?

New to this Edition

W hile the chapters are in the same order and cover the same topics as in the previous edition, reader
feedback convinced us to move some material from the appendixes or online into the main portion of the
book. Other changes are motivated by reader suggestions and our own desire to improve the presentation.
Here are the significant changes in this edition:
●● A new Prelude follows the Introduction and precedes Chapter 1 to discuss how to design classes. This
material was in Appendix D of the previous edition.
●● Relevant aspects of Java have been extracted from either the appendixes or the chapters themselves
and placed into new Java Interludes that occur throughout the book and as needed. By doing so, we
increase the distinction and separation between concepts and Java-specific issues. The titles of these
interludes follow, and you can see their placement between chapters on the previous page:
Java Interlude 1 Generics
Java Interlude 2 Exceptions
Java Interlude 3 More About Generics
Java Interlude 4 More About Exceptions
Java Interlude 5 Iterators
Java Interlude 6 Mutable and Immutable Objects
Java Interlude 7 Inheritance
Java Interlude 8 Generics Once Again
Java Interlude 9 Cloning
●● Safe and secure programming is a new topic that is introduced in Chapter 2, discussed in new Security
Notes, and reflected in the Java code that implements the ADTs.
●● Beginning with stacks in Chapter 5, most ADT methods now indicate failure by throwing an excep-
tion. Methods only return null when it cannot be a data value within a collection.
●● Expanded coverage of generics treats generic methods and bounded types.
●● Immutable, mutable, and cloneable objects are covered in Java Interludes instead of the online
Chapter 30 of the previous edition.
●● Additional Design Decisions continue to present the options one has when specifying and imple-
menting particular ADTs and provide the rationale behind our choices.
●● Illustrations have been revised to show objects specifically instead of as values within nodes or array
elements.
●● Vector-based implementations of the ADT list and queue are no longer covered, but are left as
­programming projects.
●● Line numbers appear in program listings.
●● Java code is Java 8 compliant.
●● Supplements now include a test bank.
Here are the significant changes to specific chapters:
●● Chapter 1 introduces the ADT set in addition to the bag.
●● Chapter 2 introduces safe and secure programming. The code changes suggested here are integrated
into all ADT implementations in subsequent chapters.
●● Chapters 5 and 6 use exceptions in the specification and implementations of the ADT stack.
●● Chapters 8 and 9 replace some Java code for sorting methods with pseudocode.

v
 ●● Chapters 10 and 11 use exceptions in the specification and implementations of the ADTs queue, deque,
New to this Edition
and priority queue.
●● Chapter 11 no longer covers the vector-based implementation of the ADT queue; it is left as a program-
ming project.
●● Chapters 12, 13, and 14 use exceptions in the specification and implementations of the ADT list.
●● Chapter 13 changes the array-based implementation of the ADT list by ignoring the array element at
index 0. The vector-based implementation of the ADT list is no longer covered, but is left as a program-
ming project.
●● Chapter 15 covers only iterators for the ADT list. The concepts of an iterator in Java are treated in the
preceding Java Interlude 5 instead of in this chapter.
●● Chapter 20 no longer covers the vector-based implementation of the ADT dictionary; it is left as a
programming project.
●● Chapter 23 defines balanced binary trees, which previously was in Chapter 25.
●● Chapter 24 no longer defines an interface for a binary node, and the class BinaryNode no longer
implements one.

vi
The topics that we cover in this book deal with the various ways of organizing data so that a given

A Note to Students
application can access and manipulate data in an efficient way. These topics are fundamental to your future
study of computer science, as they provide you with the foundation of knowledge required to create com-
plex and reliable software. Whether you are interested in designing video games or software for robotic
controlled surgery, the study of data structures is vital to your success. Even if you do not study all of the
topics in this book now, you are likely to encounter them later. We hope that you will enjoy reading the
book, and that it will serve as a useful reference tool for your future courses.
After looking over this preface, you should read the Introduction. There you will quickly see what this
book is about and what you need to know about Java before you begin. The Prelude discusses class design
and the use of Java interfaces. We use interfaces throughout the book. Appendixes A through E review
javadoc comments, Java basics, classes, inheritance, and files. New Java Interludes occur throughout the
book and cover advanced aspects of Java as they are needed. Note that inside the front and back covers
you will find Java’s reserved words, its primitive data types, the precedence of its operators, and a list of
Unicode characters.
Please be sure to browse the rest of this preface to see the features that will help you in your studies.

vii
 Features to Enhance Learning
Pedagogical Elements

Each chapter begins with a table of contents, a list of prerequisite portions of the book that you should
have read, and the learning objectives for the material to be covered. Other pedagogical elements appear
throughout the book, as follows:

Notes Important ideas are presented or summarized in highlighted paragraphs and are meant
to be read in line with the surrounding text.
VideoNote

Security Notes Aspects of safe and secure programming are introduced and h­ ighlighted in
this new feature.
VideoNote

A Problem Solved Large examples are presented in the form of “A Problem Solved,” in which
a problem is posed and its solution is discussed, designed, and implemented.

Design Decisions To give readers insight into the design choices that one could make when
formulating a solution, “Design Decision” elements lay out such options, along with the
VideoNote rationale behind the choice made for a particular example. These discussions are often in the
context of one of the “A Problem Solved” examples.

Examples Numerous examples illuminate new concepts.

Programming Tips Suggestions to improve or facilitate programming are ­presented as soon

as they become relevant.
VideoNote

Self-Test Questions Questions are posed throughout each chapter, integrated within the text,
that reinforce the concept just presented. These “self-test” questions help readers to understand
the material,
VideoNotesince answering them requires pause and reflection. Solutions to these questions

are provided at the end of each chapter.

VideoNotes Online tutorials are a Pearson feature that provides visual and audio support to
the presentation given throughout the book. They offer students another way to recap and
VideoNote reinforce key concepts. VideoNotes allow for self-paced instruction with easy navigation,
including the ability to select, play, rewind, fast-forward, and stop within each video. Unique
VideoNote icons appear throughout this book whenever a video is available for a particular
concept or problem. A detailed list of the VideoNotes for this text and their associated loca-
tions in the book can be found on page xxvi. VideoNotes are free with the purchase of a new
textbook. To purchase access to VideoNotes, please go to
pearsonhighered.com/carrano

Exercises and Programming Projects Further practice is available by solving the exercises
and programming projects at the end of each chapter. Unfortunately, we cannot give readers the
answers to these exercises and programming projects, even if they are not enrolled in a class.
Only instructors who adopt the book can receive selected answers from the publisher. For help
with these exercises and projects, you will have to contact your instructor.
viii
Accessing Instructor and Student Resource Materials

Resources
The following items are available on the publisher’s website at pearsonhighered.com/carrano:

●● Java code as it appears in the book

●● A link to any misprints that have been discovered since the book was published
●● Links to additional online content, which is described next

Instructor Resources
T he following protected material is available to instructors who adopt this book by logging onto Pearson’s
Instructor Resource Center, accessible from pearsonhighered.com/carrano:
●● PowerPoint lecture slides
●● Solutions to exercises and projects
●● Test bank
●● Instructor source code
●● Figures from the book
Additionally, instructors can access the book’s Companion Website for the following online premium
content, also accessible from pearsonhighered.com/carrano:
●● Instructional VideoNotes
●● Appendixes B, C, and E
●● A glossary of terms
Please contact your Pearson sales representative for an instructor access code. Contact information is avail-
able at pearsonhighered.com/replocator.

Student Resources
The following material is available to students by logging onto the Companion Website accessible from
pearsonhighered.com/carrano:

●● Instructional VideoNotes
●● Appendixes B, C, and E
●● A glossary of terms
Students must use the access card located in the front of the book to register for and then enter the Com-
panion Website. Students without an access code can purchase access from the Companion Website by
following the instructions listed there.
Note that the Java Class Library is available at docs.oracle.com/javase/8/docs/api/.

ix
 Content Overview
Detailed Content Description

Readers of this book should have completed a programming course, preferably in Java. The appendixes
cover the essentials of Java that we assume readers will know. You can use these appendixes as a review or
as the basis for making the transition to Java from another programming language. The book itself begins
with the Introduction, which sets the stage for the data organizations that we will study.
●● Prelude: At the request of readers of the previous edition, we have moved the introduction to class
design from the appendix to the beginning of the book. Most of the material that was in Appendix D of
the third edition is now in the Prelude, which follows the Introduction.
●● Chapters 1 through 3: We introduce the bag as an abstract data type (ADT). By dividing the mate-
rial across several chapters, we clearly separate the specification, use, and implementation of the bag.
For example, Chapter 1 specifies the bag and provides several examples of its use. This chapter also
introduces the ADT set. Chapter 2 covers implementations that use arrays, while Chapter 3 introduces
chains of linked nodes and uses one in the definition of a class of bags.
In a similar fashion, we separate specification from implementation throughout the book when
we discuss various other ADTs. You can choose to cover the chapters that specify and use the ADTs
and then later cover the chapters that implement them. Or you can cover the chapters as they appear,
implementing each ADT right after studying its specification and use. A list of chapter prerequisites
appears later in this preface to help you plan your path through the book.
Chapter 2 does more than simply implement the ADT bag. It shows how to approach the imple-
mentation of a class by initially focusing on core methods. When defining a class, it is often useful
to implement and test these core methods first and to leave definitions of the other methods for later.
Chapter 2 also introduces the concept of safe and secure programming, and shows how to add this
protection to your code.
●● Java Interludes 1 and 2: The first Java interlude introduces generics, so that we can use it with our
first ADT, the bag. This interlude immediately follows Chapter 1. Java Interlude 2 introduces excep-
tions and follows Chapter 2. We apply this material, which was formerly in an appendix, to the imple-
mentations of the ADT bag.
●● Chapter 4: Here we introduce the complexity of algorithms, a topic that we integrate into future
chapters.
●● Chapters 5 and 6: Chapter 5 discusses stacks, giving examples of their use, and Chapter 6 implements
the stack using an array, a vector, and a chain.
●● Chapter 7: Next, we present recursion as a problem-solving tool and its relationship to stacks.
Recursion, along with algorithm efficiency, is a topic that is revisited throughout the book.
●● Java Interlude 3: This interlude provides the Java concepts needed for the sorting methods that we
are about to present. It introduces the standard interface Comparable, generic methods, bounded type
parameters, and wildcards.
●● Chapters 8 and 9: The next two chapters discuss various sorting techniques and their relative com-
plexities. We consider both iterative and recursive versions of these algorithms.
●● Java Interlude 4: This Java interlude shows how the programmer can write new exception classes. In
doing so, it shows how to extend an existing class of exceptions. It also introduces the finally block.
●● Chapters 10 and 11: Chapter 10 discusses queues, deques, and priority queues, and Chapter 11 con-
siders their implementations. It is in this latter chapter that we introduce circularly linked and doubly
linked chains. Chapter 11 also uses the programmer-defined class EmptyQueueException.
●● Chapters 12, 13, and 14: The next three chapters introduce the ADT list. We discuss this collection
abstractly and then implement it by using an array and a chain of linked nodes.
●● Java Interlude 5 and Chapter 15: The coverage of Java iterators that was formerly in Chapter 15
now appears before the chapter in Java Interlude 5. Included are the standard interfaces Iterator,

x
 Iterable, and ListIterator. Chapter 15 then shows ways to implement an iterator for the ADT list.

Detailed Content Description

It considers and implements Java’s iterator interfaces Iterator and ListIterator.
●● Java Interlude 6: This interlude discusses mutable and immutable objects, material that previously
was in the online Chapter 30.
●● Chapters 16 and 17 and Java Interlude 7: Continuing the discussion of a list, Chapter 16 intro-
duces the sorted list, looking at two possible implementations and their efficiencies. Chapter 17 shows
how to use the list as a superclass for the sorted list and discusses the general design of a superclass.
Although inheritance is reviewed in Appendix D, the relevant particulars of inheritance—including
protected access, abstract classes, and abstract methods—are presented in Java Interlude 7 just before
Chapter 17.
●● Chapter 18: We then examine some strategies for searching an array or a chain in the context of a list
or a sorted list. This discussion is a good basis for the sequence of chapters that follows.
●● Java Interlude 8: Before we get to the next chapter, we quickly cover in this interlude situations
where more than one generic data type is necessary.
●● Chapters 19 through 22: Chapter 19 covers the specification and use of the ADT dictionary.
Chapter 20 presents implementations of the dictionary that are linked or that use arrays. Chapter 21
introduces hashing, and Chapter 22 uses hashing as a dictionary implementation.
●● Chapters 23 and 24 and Java Interlude 9: Chapter 23 discusses trees and their possible uses.
Included among the several examples of trees is an introduction to the binary search tree and the heap.
Chapter 24 considers implementations of the binary tree and the general tree. Java Interlude 9 dis-
cusses cloning, a topic that was previously online. We clone an array, a chain of linked nodes, and a
binary node. We also investigate a sorted list of clones. Although this material is important, you can
treat it as optional, as it is not required in the following chapters.
●● Chapters 25 through 27: Chapter 25 focuses on the implementation of the binary search tree.
Chapter 26 shows how to use an array to implement the heap. Chapter 27 introduces balanced search
trees. Included in this chapter are the AVL, 2-3, 2-4, and red-black trees, as well as B-trees.
●● Chapters 28 and 29: Finally, we discuss graphs and look at several applications and two
implementations.
●● Appendixes A through E: The appendixes provide supplemental coverage of Java. As we mentioned
earlier. Appendix A considers programming style and comments. It introduces javadoc comments
and defines the tags that we use in this book. Appendix B reviews Java up to but not including classes.
However, this appendix also covers the Scanner class, enumerations, boxing and unboxing, and
the for-each loop. Appendix C discusses Java classes, Appendix D expands this topic by looking at
composition and inheritance, and Appendix E discusses files.

xi
 Acknowledgments
Acknowledgments

Our sincere appreciation and thanks go to the following reviewers for carefully reading the previous edi-
tion and making candid comments and suggestions that greatly improved the work:

Tony Allevato—Virginia Polytechnic Institute and State University

Mary Boelk—Marquette University
Suzanne Buchele—Southwestern University
Kevin Buffardi—Virginia Polytechnic Institute and State University
Jose Cordova—University of Louisiana at Monroe
Greg Gagne—Westminster College
Victoria Hilford—University of Houston
Jim Huggins—Kettering University
Shamim Kahn—Columbus State University
Kathy Liszka—University of Akron
Eli Tilevich—Virginia Polytechnic Institute and State University
Jianhua Yang—Columbus State University
Michelle Zhu—Southern Illinois University
Special thanks go to our support team at Pearson Education Computer Science during the lengthy pro-
cess of revising this book: Executive Editor Tracy Dunkelberger, Program Manager Carole Snyder, P ­ rogram
Management-Team Leader Scott Disanno, and Project Manager Bob Engelhardt have always be a great help
to us in completing our projects. Our long-time copy editor, Rebecca Pepper, ensured that the presentation is
clear, correct, and grammatical. Thank you so much!
Our gratitude for the previously mentioned people does not diminish our appreciation for the help pro-
vided by many others. Steve Armstrong produced the lecture slides for this edition and previous editions of
the book. Professor Charles Hoot of the Oklahoma City University created the lab manual, Professor Kathy
Liszka from the University of Akron created the new collection of test questions, and Jesse Grabowski pro-
vided the solutions to many of the programming projects. Thank you again to the reviewers of the previous
editions of the book:
Reviewers for the third edition:
Steven Andrianoff—St. Bonaventure University
Brent Baas—LeTourneau University
Timothy Henry—New England Institute of Technology
Ken Martin—University of North Florida
Bill Siever—Northwest Missouri State University
Lydia Sinapova—Simpson College
Lubomir Stanchev—Indiana University
Judy Walters—North Central College
Xiaohui Yuan—University of North Texas
Reviewers for the second edition:
Harold Anderson—Marist College
Razvan Andonie—Central Washington University
Tom Blough—Rensselaer Polytechnic Institute
Chris Brooks—University of San Francisco
Adrienne Decker—University at Buffalo, SUNY

xii
 Henry Etlinger—Rochester Institute of Technology

Acknowledgments
Derek Harter—Texas A&M University
Timothy Henry—New England Institute of Technology
Robert Holloway—University of Wisconsin, Madison
Charles Hoot—Oklahoma City University
Teresa Leyk—Texas A&M University
Robert McGlinn—Southern Illinois University, Carbondale
Edward Medvid—Marymount University
Charles Metzler—City College of San Francisco
Daniel Zeng—University of Arizona
Reviewers for the first edition:
David Boyd—Valdosta State University
Dennis Brylow—Purdue University
Michael Croswell—Industry trainer/consultant
Matthew Dickerson—Middlebury College
Robert Holloway—University of Wisconsin, Madison
John Motil—California State University, Northridge
Bina Ramamurthy—University at Buffalo, SUNY
David Surma—Valparaiso University
We continue to appreciate the many others who helped during previous editions. They include Alan
Apt, James Blanding, Lianne Dunn, Mike Giacobbe, Toni Holm, Charles Hoot, Brian Jepson, Rose Kernan,
Christianna Lee, Patrick Lindner, John Lovell, Vince O’Brien, Patty Roy, Walt Savitch, Ben Schomp, Heather
Scott, Carole Snyder, Chirag Thakkar, Camille Trentacoste, Nate Walker, and Xiaohong Zhu.
Finally, we thank our families and friends—Doug, Joanne, Tita, Bobby, Ted, Nancy, Sue, Tom, Maybeth,
Marge, and Lorraine—for giving us lives away from computers.
Thank you, everyone, for your expertise and good cheer.
Frank M. Carrano
Timothy M. Henry

xiii
This page intentionally left blank
Contents

Table of Contents
Introduction: Organizing Data 1
Prelude: Designing Classes 5
Encapsulation 6
Specifying Methods 8
Comments 8
Preconditions and Postconditions 9
Assertions 10
Java Interfaces 11
Writing an Interface 12
Implementing an Interface 13
An Interface as a Data Type 15
Extending an Interface 16
Named Constants Within an Interface 17
Choosing Classes 19
Identifying Classes 20
CRC Cards 21
The Unified Modeling Language 21
Reusing Classes 24
Chapter 1 Bags 31
The Bag 32
A Bag’s Behaviors 32
Specifying a Bag 33
An Interface 39
Using the ADT Bag 41
Using an ADT Is Like Using a Vending Machine 45
The ADT Set 47
Java Class Library: The Interface set 47
Java Interlude 1 Generics 53
Generic Data Types 53
Generic Types Within an Interface 54
Generic Classes 55
Chapter 2 Bag Implementations That Use Arrays 59
Using a Fixed-Size Array to Implement the ADT Bag 60
An Analogy 60
A Group of Core Methods 61
Implementing the Core Methods 62
Making the Implementation Secure 69
Testing the Core Methods 71
Implementing More Methods 73
Methods That Remove Entries 76
Using Array Resizing to Implement the ADT Bag 84
Resizing an Array 84
A New Implementation of a Bag 87
The Pros and Cons of Using an Array to Implement the ADT Bag 90

xv
 Java Interlude 2 Exceptions 95
Table of Contents
The Basics 96
Handling an Exception 98
Postpone Handling: The throws Clause 98
Handle It Now: The try-catch Blocks 99
Multiple catch Blocks 100
Throwing an Exception 101
Chapter 3 A Bag Implementation That Links Data 103
Linked Data 104
Forming a Chain by Adding to Its Beginning 105
A Linked Implementation of the ADT Bag 107
The Private Class Node 107
An Outline of the Class LinkedBag 108
Defining Some Core Methods 109
Testing the Core Methods 113
The Method getFrequencyOf114
The Method contains115
Removing an Item from a Linked Chain 116
The Methods remove and clear117
A Class Node That Has Set and Get Methods 121
The Pros and Cons of Using a Chain to Implement the ADT Bag 124
Chapter 4 The Efficiency of Algorithms 129
Motivation 130
Measuring an Algorithm’s Efficiency 131
Counting Basic Operations 133
Best, Worst, and Average Cases 135
Big Oh Notation 136
The Complexities of Program Constructs 138
Picturing Efficiency 140
The Efficiency of Implementations of the ADT Bag 143
An Array-Based Implementation 143
A Linked Implementation 145
Comparing the Implementations 146
Chapter 5 Stacks 153
Specifications of the ADT Stack 154
Using a Stack to Process Algebraic Expressions 158
A Problem Solved: Checking for Balanced Delimiters in an
Infix Algebraic Expression 159
A Problem Solved: Transforming an Infix Expression
to a Postfix Expression 164
A Problem Solved: Evaluating Postfix Expressions 169
A Problem Solved: Evaluating Infix Expressions 171
The Program Stack 173
Java Class Library: The Class Stack174
Chapter 6 Stack Implementations 181
A Linked Implementation 181
An Array-Based Implementation 185

xvi
 A Vector-Based Implementation 189

Table of Contents
Java Class Library: The Class Vector 190
Using a Vector to Implement the ADT Stack 190
Chapter 7 Recursion 197
What Is Recursion? 198
Tracing a Recursive Method 202
Recursive Methods That Return a Value 205
Recursively Processing an Array 207
Recursively Processing a Linked Chain 210
The Time Efficiency of Recursive Methods 211
The Time Efficiency of countDown 212
The Time Efficiency of Computing xn 213
A Simple Solution to a Difficult Problem 214
A Poor Solution to a Simple Problem 219
Tail Recursion 221
Indirect Recursion 223
Using a Stack Instead of Recursion 224
Java Interlude 3 More About Generics 235
The Interface Comparable 235
Generic Methods 237
Bounded Type Parameters 238
Wildcards 240
Bounded Wildcards 241
Chapter 8 An Introduction to Sorting 245
Organizing Java Methods That Sort an Array 246
Selection Sort 247
Iterative Selection Sort 248
Recursive Selection Sort 250
The Efficiency of Selection Sort 251
Insertion Sort 251
Iterative Insertion Sort 253
Recursive Insertion Sort 255
The Efficiency of Insertion Sort 257
Insertion Sort of a Chain of Linked Nodes 257
Shell Sort 260
The Algorithm 262
The Efficiency of Shell Sort 263
Comparing the Algorithms 263
Chapter 9 Faster Sorting Methods 271
Merge Sort 272
Merging Arrays 272
Recursive Merge Sort 273
The Efficiency of Merge Sort 275
Iterative Merge Sort 277
Merge Sort in the Java Class Library 277
Quick Sort 278
The Efficiency of Quick Sort 278
Creating the Partition 279

xvii
 Implementing Quick Sort 282
Table of Contents
Quick Sort in the Java Class Library 284
Radix Sort 284
Pseudocode for Radix Sort 285
The Efficiency of Radix Sort 286
Comparing the Algorithms 286
Java Interlude 4 More About Exceptions 293
Programmer-Defined Exception Classes 293
Inheritance and Exceptions 297
The finally Block 298
Chapter 10 Queues, Deques, and Priority Queues 301
The ADT Queue 302
A Problem Solved: Simulating a Waiting Line 306
A Problem Solved: Computing the Capital Gain in a Sale of Stock 312
Java Class Library: The Interface Queue 315
The ADT Deque 316
A Problem Solved: Computing the Capital Gain in a Sale of Stock 319
Java Class Library: The Interface Deque 320
Java Class Library: The Class ArrayDeque 321
The ADT Priority Queue 321
A Problem Solved: Tracking Your Assignments 323
Java Class Library: The Class PriorityQueue 325
Chapter 11 Queue, Deque, and Priority Queue Implementations 331
A Linked Implementation of a Queue 332
An Array-Based Implementation of a Queue 336
A Circular Array 336
A Circular Array with One Unused Location 339
Circular Linked Implementations of a Queue 344
A Two-Part Circular Linked Chain 345
Java Class Library: The Class AbstractQueue 350
A Doubly Linked Implementation of a Deque 351
Possible Implementations of a Priority Queue 355
Chapter 12 Lists 361
Specifications for the ADT List 362
Using the ADT List 369
Java Class Library: The Interface List 373
Java Class Library: The Class ArrayList 373
Chapter 13 A List Implementation That Uses an Array 379
Using an Array to Implement the ADT List 380
An Analogy 380
The Java Implementation 382
The Efficiency of Using an Array to Implement the ADT List 390
Chapter 14 A List Implementation That Links Data 397
Operations on a Chain of Linked Nodes 398
Adding a Node at Various Positions 398
Removing a Node from Various Positions 402
The Private Method getNodeAt 403

xviii
 Beginning the Implementation 404

Table of Contents
The Data Fields and Constructor 405
Adding to the End of the List 407
Adding at a Given Position Within the List 408
The Methods isEmpty and toArray 409
Testing the Core Methods 411
Continuing the Implementation 412
A Refined Implementation 415
The Tail Reference 415
The Efficiency of Using a Chain to Implement the ADT List 418
Java Class Library: The Class LinkedList 420
Java Interlude 5 Iterators 427
What Is an Iterator? 427
The Interface Iterator 429
The Interface Iterable 431
Using the Interface Iterator 431
Iterable and for-each Loops 435
The Interface ListIterator 436
The Interface List Revisited 439
Using the Interface ListIterator 440
Chapter 15 Iterators for the ADT List 443
Ways to Implement an Iterator 444
A Separate Class Iterator 444
An Inner Class Iterator 447
A Linked Implementation 448
An Array-Based Implementation 451
Why Are Iterator Methods in Their Own Class? 454
An Array-Based Implementation of the Interface ListIterator 456
The Inner Class 457
Java Interlude 6 Mutable and Immutable Objects 469
Mutable Objects 470
Immutable Objects 472
Creating a Read-Only Class 472
Companion Classes 474
Chapter 16 Sorted Lists 477
Specifications for the ADT Sorted List 478
Using the ADT Sorted List 481
A Linked Implementation 482
The Method add 483
The Efficiency of the Linked Implementation 490
An Implementation That Uses the ADT List 490
Efficiency Issues 493
Java Interlude 7 Inheritance and Polymorphism 499
Further Aspects of Inheritance 499
When to Use Inheritance 499
Protected Access 500
Abstract Classes and Methods 501
Interfaces Versus Abstract Classes 503
Polymorphism 504
xix
 Chapter 17 Inheritance and Lists 511
Table of Contents
Using Inheritance to Implement a Sorted List 512
Designing a Base Class 514
Creating an Abstract Base Class 519
An Efficient Implementation of a Sorted List 521
The Method add 521
Chapter 18 Searching 527
The Problem 528
Searching an Unsorted Array 528
An Iterative Sequential Search of an Unsorted Array 529
A Recursive Sequential Search of an Unsorted Array 530
The Efficiency of a Sequential Search of an Array 532
Searching a Sorted Array 532
A Sequential Search of a Sorted Array 532
A Binary Search of a Sorted Array 533
Java Class Library: The Method binarySearch 538
The Efficiency of a Binary Search of an Array 538
Searching an Unsorted Chain 539
An Iterative Sequential Search of an Unsorted Chain 540
A Recursive Sequential Search of an Unsorted Chain 540
The Efficiency of a Sequential Search of a Chain 541
Searching a Sorted Chain 541
A Sequential Search of a Sorted Chain 541
A Binary Search of a Sorted Chain 542
Choosing a Search Method 542
Java Interlude 8 Generics Once Again 549
More Than One Generic Type 549
Chapter 19 Dictionaries 551
Specifications for the ADT Dictionary 552
A Java Interface 556
Iterators 557
Using the ADT Dictionary 558
A Problem Solved: A Directory of Telephone Numbers 559
A Problem Solved: The Frequency of Words 564
A Problem Solved: A Concordance of Words 567
Java Class Library: The Interface Map 570
Chapter 20 Dictionary Implementations 575
Array-Based Implementations 576
An Unsorted Array-Based Dictionary 576
A Sorted Array-Based Dictionary 581
Linked Implementations 586
An Unsorted Linked Dictionary 587
A Sorted Linked Dictionary 588
Chapter 21 Introducing Hashing 595
What Is Hashing? 596
Hash Functions 599
Computing Hash Codes 599
Compressing a Hash Code into an Index for the Hash Table 602
xx
 Resolving Collisions 603

Table of Contents
Open Addressing with Linear Probing 603
Open Addressing with Quadratic Probing 608
Open Addressing with Double Hashing 609
A Potential Problem with Open Addressing 611
Separate Chaining 612
Chapter 22 Hashing as a Dictionary Implementation 619
The Efficiency of Hashing 620
The Load Factor 620
The Cost of Open Addressing 621
The Cost of Separate Chaining 623
Rehashing 624
Comparing Schemes for Collision Resolution 625
A Dictionary Implementation That Uses Hashing 626
Entries in the Hash Table 626
Data Fields and Constructors 627
The Methods getValue, remove, and add 629
Iterators 634
Java Class Library: The Class HashMap 635
Jave Class Library: The Class HashSet 636
Chapter 23 Trees 639
Tree Concepts 640
Hierarchical Organizations 640
Tree Terminology 642
Traversals of a Tree 646
Traversals of a Binary Tree 647
Traversals of a General Tree 649
Java Interfaces for Trees 650
Interfaces for All Trees 650
An Interface for Binary Trees 651
Examples of Binary Trees 652
Expression Trees 653
Decision Trees 654
Binary Search Trees 658
Heaps 660
Examples of General Trees 663
Parse Trees 663
Game Trees 663
Chapter 24 Tree Implementations 673
The Nodes in a Binary Tree 674
A Class of Binary Nodes 675
An Implementation of the ADT Binary Tree 676
Creating a Basic Binary Tree 677
The Method privateSetTree 678
Accessor and Mutator Methods 681
Computing the Height and Counting Nodes 681
Traversals 682
An Implementation of an Expression Tree 687

xxi
 General Trees 688
Table of Contents
A Node for a General Tree 688
Using a Binary Tree to Represent a General Tree 689
Java Interlude 9 Cloning 697
Cloneable Objects 697
Cloning an Array 703
Cloning a Chain 706
A Sorted List of Clones 709
Cloning a Binary Node 711
Chapter 25 A Binary Search Tree Implementation 713
Getting Started 714
An Interface for the Binary Search Tree 715
Duplicate Entries 717
Beginning the Class Definition 718
Searching and Retrieving 719
Traversing 720
Adding an Entry 721
A Recursive Implementation 722
An Iterative Implementation 725
Removing an Entry 726
Removing an Entry Whose Node Is a Leaf 727
Removing an Entry Whose Node Has One Child 727
Removing an Entry Whose Node Has Two Children 728
Removing an Entry in the Root 731
A Recursive Implementation 732
An Iterative Implementation 735
The Efficiency of Operations 739
The Importance of Balance 740
The Order in Which Nodes Are Added 740
An Implementation of the ADT Dictionary 740
Chapter 26 A Heap Implementation 753
Reprise: The ADT Heap 754
Using an Array to Represent a Heap 754
Adding an Entry 757
Removing the Root 760
Creating a Heap 763
Heap Sort 766
Chapter 27 Balanced Search Trees 775
AVL Trees 776
Single Rotations 776
Double Rotations 779
Implementation Details 783
2-3 Trees 787
Searching a 2-3 Tree 788
Adding Entries to a 2-3 Tree 789
Splitting Nodes During Addition 791
2-4 Trees 792
Adding Entries to a 2-4 Tree 793
Comparing AVL, 2-3, and 2-4 Trees 795
xxii
 Red-Black Trees 796

Table of Contents
Properties of a Red-Black Tree 797
Adding Entries to a Red-Black Tree 798
Java Class Library: The Class TreeMap 804
B-Trees 804
Chapter 28 Graphs 811
Some Examples and Terminology 812
Road Maps 812
Airline Routes 815
Mazes 815
Course Prerequisites 816
Trees 816
Traversals 817
Breadth-First Traversal 818
Depth-First Traversal 819
Topological Order 821
Paths 824
Finding a Path 824
The Shortest Path in an Unweighted Graph 824
The Shortest Path in a Weighted Graph 827
Java Interfaces for the ADT Graph 830
Chapter 29 Graph Implementations 841
An Overview of Two Implementations 842
The Adjacency Matrix 842
The Adjacency List 843
Vertices and Edges 844
Specifying the Class Vertex 845
The Inner Class Edge 847
Implementing the Class Vertex 848
An Implementation of the ADT Graph 851
Basic Operations 851
Graph Algorithms 854
Appendix A Documentation and Programming Style 861
Naming Variables and Classes 861
Indenting 862
Comments 862
Single-Line Comments 863
Comment Blocks 863
When to Write Comments 863
Java Documentation Comments 863
Appendix B Java Basics (online)
Introduction
Applications and Applets
Objects and Classes
A First Java Application Program
Elements of Java
Identifiers
Reserved Words
Variables
xxiii
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Title: Scurvy, Past and Present

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Transcriber’s notes:

In this HTML version, page numbers are listed in the right margin, hyperlinks are indicated by a dotted underline, and transcriber
comments are marked by a red dashed underline; scrolling the mouse over such words will reveal the original text. Footnote markers in
the text are hyperlinked to the footnotes located at the end of the book.

The book contains numerous spelling inconsistencies. No change has been made to those representing archaic spellings (e.g.
somethimes, urin, feavers, joynts) and those occurring in quotations. Spelling variants occurring with similar frequency have been left in
their original form (e.g. Röntgen/Roentgen, rachitic/rhachitic, albumen/albumin – the correct spellings is used for egg albumen but both
are used randomly for serum/urine albumin). Most other spelling inconsistencies have been changed to the more-frequent or more-
accurate form (e.g. twofold→two-fold, guinea pig→guinea-pig, oedema→edema, neuroedema→neuredema, gm.→g.,
Luborsch→Lubarsch, Bauman→Baumann, McCluggage→McClugage, Eijkmann→Eijkman). Although the spelling of 'fæces' and its
adjective 'fecal' is not consistent, the two spellings are used consistently throughout the book and therefore have not been altered.
Similarly 'hemorrhage' and 'hemoglobin' are consistently spelt thus, while other words pertaining to blood consistently use the æ
ligature, e.g. 'hæmatemesis', 'hæmatoma', 'hæmaturia', 'leukæmia', 'hyperæmia'.

Wrong or missing French accents and typos have been corrected where necessary. German expressions in the bibliography contain
various apparent inconsistencies that have not been changed because of my unfamiliarity with the language and what was perhaps
legitimate at the time of writing (e.g. Moeller-Barlow'sche Krankheit, Moeller-Barlow'scher Krankheit, Moeller-Barlowscher Krankheit and
Barlow'schen Krankheit; Muench. med. Woch., Muenchn. med. Woch. and Muenschner med. Woch.; Beiträge z., Beitraege zur, Beitrag
zur). The term Gernest-mark on p. 108 should probably be geruestmark (or perhaps gerüstmark) as used elsewhere in the book (pp. 96,
107, 108 and 128).

The book also contains numerous hyphenation inconsistencies. Some of these have been altered to conform with the most common
usage in the text, but most have not been changed because hyphenation is notoriously variable and subject to fashion.

Subheading use is somewhat inconsistent; for example, under the subheading Alimentary Tract in chapter IV, there appear various non-
alimentary items, and in the same chapter Microscopic Pathology appears as a stand-alone subheading whilst its equivalent Gross
Pathology is relegated to an in-line paragraph introduction.

The bibliography contains two very similar references attributed to Gee. The second appears to be a duplicate of the first, but it is
probable that the title is incorrect because the publication details (1889, XXV, 85) relate to a different paper by Gee entitled ‘Bloody
Urine the Only Sign of Infantile Scurvy’, and although there are several comments in the book about scurvy and haematuria (blood in the
urine), e.g. p. 204, none cite Gee's paper.

The second entry for Morse, J. L. in the bibliography should be numbered as (2) and the source should be Boston Med. and Surg.
Journal, 1914, CLXX, 504. (not Jour. Am. Med. Assn.)

Inconsistent punctuation in the bibliography list has been corrected (e.g. semicolon→colon).

SCURVY
PAST AND PRESENT
 BY
ALFRED F. HESS, M.D.
CLINICAL PROFESSOR OF PEDIATRICS, UNIVERSITY AND BELLEVUE HOSPITAL
MEDICAL COLLEGE, NEW YORK CITY

ILLUSTRATED

PHILADELPHIA AND LONDON

J. B. LIPPINCOTT COMPANY

COPYRIGHT, 1920, BY J. B. LIPPINCOTT COMPANY

PRINTED BY J. B. LIPPINCOTT COMPANY

AT THE WASHINGTON SQUARE PRESS
PHILADELPHIA, U. S. A.
 PREFACE
Interest in scurvy has been stimulated in the last few years as the result of a new and broader
conception of nutrition. It has come to be realized that in addition to the substances heretofore
recognized as of essential importance in the dietary—the proteins, fats, carbohydrates and the salts—
there is still another group, termed “vitamines,” “accessory food factors” or “food hormones,” which
must be included in order to render the diet complete and adequate. It has become increasingly evident
that the attention of physiologists and of clinicians has been focussed too sharply and too narrowly on
the caloric value of foodstuffs. At the same time we have begun to appreciate the existence of a group
of nutritional disorders which depend largely on a deficiency of these illusive vitamines or food factors,
and which evidently are of vital importance to the welfare of the individual and of mankind. Scurvy is
one of this newly-constituted group, and due to this association has acquired a fresh and broader
significance. It is in this light that the intensive research work must be interpreted, which has been
applied within the past few years, both in this country and abroad, to problems relating to this disorder.
It is clear that the subject is in its infancy, and is destined to participate in a consideration of many of
the nutritional and infectious diseases of the adult and the child.
The World War has tended also to demand a renewed consideration of scurvy. This disorder has played
a rôle in all wars—in the campaigns of the Cæsars, the pilgrim ages of the Crusaders, and the
numerous wars of the last century. In the recent war it existed among the various armies, particularly
those in the East, to an extent greater than at first was realized. In Mesopotamia it is stated to have
been one of the decisive factors in forcing the surrender of the British at Kut. Its incidence, however,
was not limited to the military forces. Reports from England and the continental countries clearly
indicate that scurvy prevailed among the civilian population during the past few years to a degree
unknown in peace times. This was especially true of infants and children.
For the past seven years I have been engaged in an investigation of scurvy both in the laboratory and in
the clinic, and have treated various aspects of the subject in a large number of articles published in
various medical journals. In the course of these studies there has been ample opportunity for a
comprehensive review of the widely-scattered literature. No treatise on scurvy has been published in
English since the classical work of Lind in 1772. The time, therefore, seemed opportune to gather into
one volume the recent advances in this field and to offer to the clinician, to the hygienist, and to the
biological chemist a presentation of the existing status of this important nutritional disease.
It is with pleasure that I acknowledge my obligation to Dr. Lester J. Unger, who has assisted in carrying
out much of the work described in this volume. Thanks are due also to Dr. Charles Gottlieb for the
radiographs which are here reproduced, and to Dr. Gertrude McCann for seeing the work through the
press. To my associates in the clinic who shared in the observations, and to friends who read various
chapters in the course of their preparation, I wish to express my appreciation.
Alfred F. Hess.
New York,
August, 1920.
 CONTENTS
PAGE
Preface iii-iv

CHAPTER I
History of Scurvy 1
(a) Outbreaks on Land; (b) Outbreaks at Sea; (c) Infantile Scurvy; (d) Scurvy in the World
War

CHAPTER II
Pathogenesis and Etiology 23
Pathogenesis: Theories; Potassium Deficiency; Acidosis; Toxic; Bacterial; Vitamine
(Accessory Factor)
Etiology: Breast-Fed Infants 35
Artificially Fed Infants: Pasteurized Milk; Boiled and Sterilized Milk; Dried Milk;
Condensed Milk; Proprietary Foods (Effect of Alkalization) 40
Age, Season and Climate; Economic Status; Psychic Element; Predisposition; Effect of Other
Food Constituents; Exciting Factors

CHAPTER III
The Antiscorbutic Vitamine 62
Characteristics: Relation To Heat, Drying, Aging, Ultra-Violet Rays, Shaking 65
Mode of Action—(a) Direct: As a Nutriment; Antitoxin; Catalyzer; (b) Indirect: Endocrine
Action 69
Fate in the Body: Storing; Content in Blood; Excretion; Fate in Gastro-intestinal Tract;
Effect on Digestive Processes 74
Irregularities of Action; Effect on Growth

CHAPTER IV
Pathology 81
(a) Gross: General Appearance; Hemorrhages; Anasarca; Heart; Lungs; Alimentary Tract and
its Glands; Urinary Tract; Lymph Nodes; Organs of Internal Secretion; Brain and Spinal
Cord; Bones;
(b) Microscopic: Skin; Muscles; Blood-vessels; Lungs; Heart; Intestinal Tract and its
Glands; Kidney; Adrenals; Pancreas; Thymus; Central Nervous System; Peripheral
Nerves; Retina; Bones

CHAPTER V
Experimental Scurvy 111
Historical Review
Pathogenesis 116
Pathology: Effect on the Fœtus; Scurvy in the Monkey; Microscopic Pathology; Bones;
Teeth; Nerves; Blood Vessels; Interpretation of Bacteria in the Tissues 122
Symptoms 135
 CHAPTER VI
Antiscorbutic Foods 143
Historical Review 143
Milk: Raw; Pasteurized; Dried 150
Fruits and Fruit Juices: Dried 153
Vegetables: Cabbage; Effect of Heating. Potato. Swede 158
Dehydrated Vegetables: Canned Foods (Tomatoes) 166
Germinated Cereals and Pulses; Meat and Eggs; Beer And Alcoholic Beverages;
Miscellaneous
Conclusions 173

CHAPTER VII
Symptomatology and Diagnosis 176
In Adults 176
In Infants: (a) Acute; (b) Subacute; (c) Latent.—hemorrhage Of Gums; Subperiosteal
Hemorrhage: Skin; Mucous Membranes and Subcutaneous Tissues; Hemorrhages of
Internal Organs; Nails and Hair; Eczema; Edema; Tenderness; Beading of Ribs;
Separation of Epiphysis; “White Line” Cardiovascular System; “Cardiorespiratory
Syndrome” Nervous System; Urinary System; the Blood and Blood-vessels; Nutrition and
Growth; Fever; Complications; Epidemic Form 183
Differential Diagnosis: Rheumatism; Purpura; Congenital Syphilis; Bone Tumors;
Osteomyelitis; Poliomyelitis, etc. 219

CHAPTER VIII
Prognosis 225

CHAPTER IX
Treatment 230
Preventative; Curative
Non-dietetic

CHAPTER X
Metabolism 241
In Adults: Body Exchanges 241
In Infants: Body Exchanges; Analysis of Organs; Chemistry of Blood 242
In Animals: Monkey; Guinea-Pig 245

CHAPTER XI
Relation of Scurvy to Other Diseases 248
Beriberi; Ship-beriberi; Pellagra; Rickets; Osteogenesis Imperfecta; Osteomalacia; Hunger
Edema; “mehlnaerschaden” Exudative Diathesis; Diseases Due to a Food Excess

Appendix: Lind’s Recipes for Preparing Stable Antiscorbutics 259

Bibliography 261
 ILLUSTRATIONS
FIG. PAGE
1. Dependence on potato as antiscorbutic 7
2. Weight curve of scorbutic baby. Effect of alkalization of milk 51
3. Lumbar cord in case of scurvy 105
4. Lumbar cord in case of scurvy. Focal degeneration 105
5. Bone in scurvy. Microscopic pathology 108
6. Subperiosteal hemorrhage and separation of epiphysis. Roentgenogram 109
7. Complete restitution of epiphysis without deformity. Roentgenogram 109
8. Curve of fecal excretion in scurvy 121
9. Diagrammatic representation of guinea-pig scurvy 130
10. Loss of weight in guinea-pig scurvy 139
11. Dried milk as an antiscorbutic 140
12. Dehydrated vegetables as a cause of scurvy 164
13. Cure of scurvy by addition of canned tomato 166
14. Failure of yeast as prophylactic 171
15. Temperature, pulse, and respiration in scurvy 186
16. Subperiosteal hemorrhage and separation of epiphysis. Roentgenogram 192
17. Periosteal “tags” and “streamers.” Roentgenogram 193
18. Infant with marked scurvy. Characteristic position 198
19. Scorbutic beading of ribs. Roentgenogram 198
20. “White line.” Roentgenogram 199
21. Cardiac enlargement. Roentgenogram 200
22. Electrocardiogram showing “cardiorespiratory syndrome” 201
23. Stationary weight during cure of scurvy. Oliguria followed by polyuria 206
24. Development of scurvy in spite of normal gain in weight 214
25. Retardation of growth in length when no orange juice was given and supergrowth
when given once more 216
 TABLES
TABLE PAGE
1. Fecal flora of scorbutic infants 29
2. Necropsy reports of scurvy 82
3. Relative distribution of the antiscorbutic factor in the commoner foodstuffs 157
4. Platelets and other blood cells in scurvy 209
5. Data of epidemic of scurv 218
6. Duration of treatment before marked improvement was noticed 237
 SCURVY
PAST AND PRESENT

CHAPTER I
HISTORY OF SCURVY 1

Outbreaks on Land.—Like many other diseases, the life history of scurvy shows several distinct
phases. We hear of it first as a plague, infesting armies and besieged towns; then as a dread disease,
decimating the sailors of the navy and of the mercantile marine, and, since the end of the last century,
more often as a nutritional disturbance, endangering the health of infants. Very recently it has acquired
an entirely new interest, as the representative of a class of disorders which has revealed the essential
importance to man of unknown dietary factors.
It is difficult, as may be imagined, to define with precision the earliest description of scurvy, as the older
references are so vague as to be open to individual interpretation. The reference of Hippocrates to a
large number of men in the army who suffered from pains in the legs and gangrene of the gums, which
was accompanied by loss of teeth, seems sufficiently definite to be identified as this disease. The Greek,
Roman and Arabian writers do not seem to have been acquainted with scurvy. This is as we should
expect, for fruits and vegetables grew in such plenty in these southern countries that scurvy must have
been a disorder of rare occurrence.
An interesting early description of scurvy, and one which is quite convincing, is that of de Joinville, who
accompanied the Crusaders in their invasion of Egypt under St. Lewis, about the middle of the
thirteenth century. He refers to the lividity and spongy condition of the gums, and describes how “the
barber surgeons were forced to cut away the dead flesh from the gums to enable the people to
masticate their food” he describes their debility, their tendency to faint, and the black spots on their
legs. The disease broke out in Lent, during which time the soldiers partook of no meat, but consumed a
species of eel which they believed “ate the dead people” and therefore led to this loathsome disease.
It is probable that scurvy existed in the northern parts of Europe and Asia ever since they were settled
by man. We should hardly expect to have records of this condition, in view of the low educational status
of the people, their greatly restricted literature, and their lack of intercourse with the people in the
southern countries. In the sixteenth century, with the development and spread of education, we begin
to hear of scurvy from various sources. Claus Magnus, in his “History of the Northern Nations,”
published in 1555, described the disease which he tells us flourished among the soldiers in the camps
and in the prisons. About this time Ronsseus, Echtius and Wierus wrote special treatises on this disease,
and recommended many dietary measures which we recognize to-day as most efficacious. The number
of monographs on this subject multiplied with great rapidity in the course of the next twenty-five or fifty
years; none of them, however, added anything essential to our knowledge. In 1645 the Faculty of
Medicine at Copenhagen published a “consilium” for the benefit of the poor, treating of the causes,
prevention and cure of this disease, which was prevalent among the Danes and other northern nations.
The colonists of the northern part of America were sorely afflicted with scurvy. It is said that the French
met with such high mortality during the severe winters in Canada, that they frequently debated the
wisdom of abandoning this settlement. This was true also in regard to the English and their settlement
in Newfoundland. Indeed, it was scurvy which forced the early settlers in Hudson Bay to discontinue
their intentions of colonizing that region.
In an essay published in the eighteenth century (1734), Bachstrom described an epidemic of scurvy
which occurred in 1703 during the siege of Thorn, in Prussia, by the Swedes, which caused the death of
5000 of the garrison, in addition to a large number of the inhabitants. It is interesting to note that this
epidemic took place in the middle of the summer, and not in the cold season. From this time on we
meet with many descriptions of scurvy in connection with the wars at various periods. For instance, in
the Russian armies, in the war between the Austrians and the Turks in 1720; in the English troops who
had taken Quebec from the French in 1759; among the French soldiers in the army of the Alps in the
spring of 1795. It is unnecessary to review these accounts in detail. This period is distinguished rather
by the appearance of a great classic on Scurvy, the work of the English naval hygienist, Lind (1752).
This book has intrinsic value to-day, and, at the time it appeared, served to crystallize the conception of
scurvy, which had been stretched out of all proportions to include an ever-increasing conglomeration of
clinical conditions. Scurvy had become the Alpha and Omega of professional routine, the catchword of
the day, the asylum ignorantiæ of the practical man. Into this chaos, as Hirsch expresses it, “the first
beams of light fell when Lind’s classical work appeared.”
It will be of little value to consider the great number of epidemics of scurvy which occurred from this
time to the present day. They may be found in tabular form in the excellent survey of scurvy by Hirsch.
The literature of this long period may likewise be found in a work of encyclopædic character, that of
Krebel, which gives the titles, with a summary of the various articles on this subject, appearing to the
year 1859. If we look over the chronological table compiled by Hirsch, we note a remarkable similarity
regarding the incidence of the recurring epidemics. In almost all cases they broke out among troops,
whether in Russia, in India, in Africa, or in our United States. The epidemics which are not attributable
to military life or campaigns are found to have taken place generally in prisons, insane asylums,
poorhouses or houses of refuge and correction. It would seem that no war is omitted from this list of
sickness and death. There are in all 143 land epidemics between 1556 and 1877, two occurring in the
sixteenth century, four in the seventeenth, 33 in the eighteenth, and 104 in the nineteenth century. The
marked increase in the nineteenth century occurred in institutions, in asylums and prisons, rather than
in the armies. This fact may be ascribed to altered social conditions which led to a great multiplication
of eleemosynary institutions.
Coming down to more recent times, we learn that scurvy occurred extensively during the Crimean War,
and that it was prevalent also among the troops in our own Civil War. In the “Medical and Surgical
History of the War of the Rebellion,” we find the following statements:

“A scorbutic tendency was developed at most of our military posts during the winter season, after
the troops had been confined to the use of the ordinary ration with the desiccated vegetables. The
latter in the quantities failed to repress the disease. At posts which could be readily supplied with
potatoes only the taint was manifested, on account of a want of liberality in the issues.” And again:
“Among the white troops during the five and one-sixth years covered by the statistics, 30,714 cases
of scurvy were reported; and 383 deaths were attributed directly to that disease.”

Munson writes: “It (scurvy) prevailed among our troops during the Civil War and its recognition was a
surprise and shock to professional ideas preconceived from practice in civil life.”
As is well known, the besieged in Paris during the Franco-Prussian War in the winter of 1870–71
suffered severely from scurvy. The accounts of their pitiable condition have been portrayed for us by
numerous French writers (Delpech, Hayem, Lasèque and Legroux). The people lived mainly on rice and
bread, with an occasional addition of potatoes or horse meat. The winter was exceptionally severe,
which was supposed to have intensified the scorbutic condition. Not only were the inmates of the
prisons on the Seine attacked, numbering about one thousand, but even the patients in the military
hospitals developed the disease. It is of interest to remember that the siege lasted but little over four
months, from September 17th to January 27th, the date of the armistice.
In the Russo-Japanese War, after the siege of Port Arthur, it was found that one-half of the garrison of
17,000 men had scurvy.
Although there are certain parts of the world where scurvy is of frequent occurrence, no country has
been entirely free from it. As might be expected, it has been particularly prevalent in the North, where
vegetation is scanty—in Greenland, Alaska, Russia and the Baltic States. It has likewise prevailed in the
tropics when the crops have failed. India has been conspicuous for its large number of epidemics; some
years ago scurvy occurred in Arabia among the English troops stationed at Aden, both among the British
and the native troops. A recent communication from Aruba, a small island of Dutch Guiana, lying north
of Venezuela, illustrates how devastating scurvy still is in some parts of the world. This account tells of
3000 cases of this disease which occurred in 1915 among a population of less than 10,000, owing to the
fact that the crops had failed almost entirely during the years 1912, 1913 and 1914.
It is important for us to realize that we are still dependent on the
annual crops for our protection from scurvy; in other words, the
world is leading a hand-to-mouth existence in regard to its quota of
antiscorbutic food. The truth of this condition has been realized for
Ireland, sadly illustrated by numerous epidemics, notably the great
epidemic of 1847 reported by Curran. It was demonstrated by the
outbreaks of scurvy in Norway in 1904 and 1912, and was brought
to the attention of many in the United States in the spring of 1916.
In this year our potato crop fell far below the normal, with the
result that scurvy appeared in various parts of the United States,
especially in institutions (Fig. 1).
The fact that scurvy may occur in any land and climate, even in the
garden spots of the world, is strikingly shown by the epidemics
reported from Algiers, and the ravages of this disease among the
gold seekers in California in 1849. Nothing could be more
incongruous than the occurrence of a deficiency disease in this land Fig. 1.—A comparison between the
requisitioned quantity (in thousand pound
of plenty. units) of potatoes and other vegetables, and
the quantity received per month by an
Outbreaks at Sea.—It is doubtful, however, whether attention institution in which more than 200 cases of
would have been focussed so early and so sharply on scurvy, had it scurvy occurred at the beginning of April,
not been for the voyages of exploration undertaken in the sixteenth 1916. The total height of column represents
the amount needed and requisitioned; the
century. These long trips on sailing vessels, where for many months solid black portion the amount received. The
little or no fresh vegetable or animal food was obtainable, were number of inmates in the institution
almost as if designed to make a test of the dietetic origin of scurvy. remained approximately the same.

The result was inevitable—five to six months after the ships were The chart illustrates our great dependence
out of touch with land, the majority of the crew frequently were on the potato during the winter months.
incapacitated by this disease, thereby wrecking many an This is due not only to its intrinsic
antiscorbutic potency, but, probably quite as
expedition.2 much, to the fact that fully twice as many
pounds of potatoes are consumed during
The earliest account of the outbreak of scurvy at sea is that of the winter as of all other vegetables
Vasco de Gama, who in 1497 discovered a passage to the East combined. Therefore, if this crop fails or is
Indies by way of the Cape of Good Hope. The narratives of dehydrated, scurvy will develop in the
spring.
subsequent explorers, especially those of Cartier and of Drake, are
replete with descriptions of the ravages of scurvy. The expedition of
Lord Anson in 1740 is always cited as a memorable example of an undertaking which foundered as the
result of scurvy. After a cruise of four years, this expedition had lost from this disease more than four
out of five of the original number of its crews. In striking contrast to this picture, and to that furnished
by the voyages of earlier navigators, is that of Captain Cook, who in 1772 undertook a voyage lasting
over three years, sailing from 52° north to 71° south, with a loss of but one of his crew from disease,
and that not from scurvy. This remarkable feat, more than any other, centered attention on the
feasibility of preventing scurvy, and resulted in measures tending to eradicate it from the navy. Captain
Cook attributed the absence of scurvy among his crew to “sweetwort,” an infusion of barley, which he
prepared fresh and served liberally. He also prized the antiscorbutic value of sauerkraut.
We find accordingly in 1795, at the instance of Sir Gilbert Blaine, that improvements were introduced in
the victualling of the fleet. As the result of a regular ration of lemon juice, the incidence of scurvy fell
precipitously. It is due largely to this provision that between the years 1779 and 1813, according to the
statistics of Sir Jay Barrow, the morbidity and the mortality in the British Navy was decreased by 75 per
cent.
It has been shown that it took a generation after the efficacy of antiscorbutics had been demonstrated
in various expeditions, for an antiscorbutic to be included in the ration of the navy. The merchant
marine of England was far more conservative, and for many years after scurvy had been eradicated
from the navy we still read of its occurrence on the vessels making voyages to India, China and Ceylon.
Gradually, however, its incidence became less and less. Its toll of death, before preventive measures
were employed, may be appreciated from the fact that it has been estimated that scurvy destroyed
more sailors than all other causes incidental to sea life, including the great slaughter of naval warfare.
Sir R. Hawkins stated in the latter part of the sixteenth century that he could give an account of 10,000
mariners who had been destroyed by scurvy during the twenty years that he had been at sea.
As is well known, scurvy has played an important rôle in Arctic and Antarctic explorations, and has been
the cause of the failure of many of these expeditions. It is now realized that the development of scurvy
is quite preventable, that if a sufficient quantity of meat (especially raw meat) is consumed, explorers
can be entirely independent of a supply of fresh vegetables. This fact was brought out by the Arctic
Survey Committee (British), who “were appointed to enquire into the causes of the outbreak of scurvy
in the recent Arctic expedition” (1877), and who reported that it may result from an absence of fresh
meat. That this conclusion was sound has been proved by the experiences of Nansen and of Johansen,
who wintered safely in Franz-Josefsland on a diet of meat and bacon. More recently Stefánsson has
carried out successful Arctic explorations, depending entirely on fresh meat as antiscorbutic foodstuff
and making no provision whatsoever for vegetable food.
Infantile Scurvy.—Glisson, to whom we owe the first description of rickets, likewise was the first to
recognize scurvy in infants. In his classic treatise on rickets, written in 1668, he writes as follows:

“The scurvy is sometimes conjoyned with the affect. It is either hereditary, or perhaps in so tender
a constitution contracted by infection, or lastly, it is produced from the indiscreet and erroneous
Regiment of the infant, and chiefly from the inclemency of the air and climate where the child is
educated.”
“The scurvy complicated with this affect hath these signs: 1. They that labor under this affect do
impatiently indure purgations; but they who are only affected with the Rachites do easily tolerate
the same. 2. They are much offended with violent exercises, neither can they at all endure them.
But although in this affect alone, there be a kind of slothfulness and aversation from exercise, yet
exercise doth not so manifestly, at least not altogether so manifestly hurt them, as when the scurvy
is conjoyned with the Rachites. 3. Upon any concitated and vehement motion they draw not breath
without much difficulty, they are vexed with diverse pains running through their joynts, and these
they give warning of by theyr crying, the motion of the Pulse is frequent and unequal, and
somethimes they are troubled with a Palpitation of the Heart, or threatened with a Lypothymie,
which Affects are for the most part soon mitigated, or altogether appeased by laying them down to
rest. 4. Tumours do very commonly appear in the Gums. 5. The urin upon the absence of the
accustomed feavers is much more intense and increased.”

Glisson’s description of scurvy was entirely lost sight of, overshadowed by his description of rickets, so
that for over two hundred years no word of infantile scurvy is to be found either in the English or other
literature. There is no doubt that from time to time cases must have occurred, but they were looked
upon probably as rickets or as a manifestation of one of the hemorrhagic diseases.
In 1859 Moeller described some cases which evidently were scurvy, but which he termed “acute rickets.”
He realized that they presented a novel clinical picture but failed to recognize that they represented a
disorder quite distinct from rickets.3 This article was followed within the next few years by reports of
other German writers (Bohn, Steiner, Foerster) who, accepting Moeller’s point of view, considered these
cases merely as an acute form of rickets. They were led to this erroneous conclusion chiefly on account
of the lack of marked involvement of the gums, which they considered an essential sign, influenced by
their conception of adult scurvy. This viewpoint has pervaded the German literature even to the present
day, when it is still considered necessary to bring further evidence that infantile scurvy in its
pathogenesis and pathology is identical with adult scurvy.
In 1871 Ingerslev, an assistant of Hirschsprung in Copenhagen, wrote a paper on “A Case of Scurvy in a
Child,” which is quite convincing. Two years later Jalland, an English physician, reported a similar case of
“Scurvy in a Ten-Months-Old Infant.” In 1878 Cheadle reported three cases of infantile scurvy with
typical tumefaction of the gums, and obscure tenderness of the legs, and followed this paper by two
others, which appeared in 1879 and 1882. Cheadle clearly recognized the disease as scurvy. However,
as the title of his first paper—“Three Cases of Scurvy Supervening on Rickets in Young Children”—
indicates, he considered it a condition engrafted upon rickets. About this time (1881) Gee presented a
brief but accurate account of five cases of scurvy which he termed “osteal or periosteal cachexia.”
In 1883, Barlow published his classical paper on this subject, the first to furnish anatomical proof that
this disorder of infants presented the pathological changes characteristic of adult scurvy. Previous to this
publication there had been but one autopsy report, that by Moeller, which had been incorrectly
interpreted. The work of Barlow was accepted remarkably quickly in England and in America, but less
promptly on the Continent. This was probably due to the fact that infantile scurvy was occurring far
more frequently in these two countries, and that the subject was open therefore to more prompt
investigation. This increased prevalence of infantile scurvy in the two great English-speaking nations has
continued to the present time, and no doubt is due to the extensive employment of artificial feeding and
of proprietary foods. In 1894 not less than 106 cases were reported to the Academy of Medicine of New
York City by various physicians, and in 1898 the comprehensive investigation of the American Pediatric
Society appeared, which was based on 379 cases.
It was soon evident that infantile scurvy occurred to a greater or less degree throughout the civilized
world. In France, Monfalcon had reported a case in 1820 which is sometimes referred to as the earliest
case of infantile scurvy mentioned in the literature. It relates, however, to an older child and was
published as a case of scorbutic rickets. Netter was one of the first in France to recognize the true
nature of the disorder, and published several papers in 1898 describing typical cases. Infantile scurvy
was, however, almost unknown in that country until what is termed “lait maternisé” and “lait fixé” came
into vogue. This is apparent from a table prepared by Lecornu, which gives a list of all cases in the
French literature between 1894 and 1904, and of the diets on which they came about. The former of
these milk preparations is subjected to various manipulations and then heated to a temperature above
the boiling point; the latter is shaken violently in a machine to render 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 Beriberi
(Indians) (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 a week. It is very doubtful whether this authorized ration, if not
supplemented by other vegetables and more meat, is sufficient to prevent scurvy.” In the account which
this officer gives of the medical conditions during the siege of Kut-el-Amara, it is stated that there were
1050 admissions for scurvy, fully developed, incipient and latent. It is remarked that those Indians who
ate horseflesh were decidedly less affected. From the fact that special hospitals for scurvy were
established in June, 1916, at Bagdad, Amora and Basrah, it is evident that a large number of cases
must have been encountered. Most significant in this connection, however, are the preventive measures
which were instituted by the British government. A body of 256 men, designated as the Madras
Gardener’s Corps, were dispatched to Mesopotamia to plant gardens all over the country and to supply
packets of seeds to various units. At Bagdad alone their output of vegetables was over 400,000 pounds.
This certainly constitutes a remarkable innovation in the hygiene of armies.
The French army was not entirely spared from scurvy. In 1917 Harvier, an army surgeon, was surprised
to discover that 95 per cent. of the 800 troops of which he had charge suffered from scurvy; he tells us
that other epidemic centres were recognized later outside this sector. Elsewhere we read of the
occurrence of scurvy in France, involving 40 per cent. of the 1700 men of the South African Labor
Corps, and that this disorder was still more serious in another company owing to the fact that it was not
recognized (Dyke).4 Benoit reported 63 cases which he discovered in 1917 among 300 laborers.
According to his account, all these laborers received the same food, and those with scurvy recovered
quite independently of any change in the dietary.
There are many accounts of scurvy among the Italian troops. Vannutelli gives a description of an
epidemic of some 200 cases of infectious purpura with manifestations of hemorrhagic scurvy. Another
writer informs us that in June, 1916, scurvy broke out among some Italian troops stationed at an
altitude of 1500 to 2000 metres (Gingui). Vallardi gives an account of 180 cases among Italian troops in
Macedonia, accompanied by slight jaundice and enlargement of the glands.
The American soldiers seem to have been practically spared from scurvy. This was due probably to their
ample ration and to the fact that they were in the field for a comparatively short period. The Surgeon-
General’s report to date, which has been kindly furnished me, showed but 5 cases in 1917 occurring in
Europe and the United States, and but 15 cases reported during the year 1918.
The civilian population of the various warring countries was by no means spared. There are no reports
from Russia to indicate the extent of scurvy, but from what is known of the food conditions prevailing
there toward the end of the war, one can be certain that the number must have been large. The
greatest amount of scurvy has been reported from Austria, more particularly from Vienna. Previous to
the war scurvy was a rare disease in this city, both among adults and infants. During the war, however,
as the result of a lack of fresh food and the dependence on dehydrated vegetables, a large number of
cases developed. Tobler reports over 200 cases in children between the ages of two and fifteen years,
which occurred in 1917 in child-caring institutions where the milk supply was markedly deficient, where
fresh vegetables were lacking, and the supply of potatoes gave out about Christmas, 1916. A
conception of the deficiency of the milk supply may be gained from the statement that there were but
sixteen quarts a day for about 1500 people. Some of these children were undergoing fresh-air
treatment and were out of doors in the “sun stations” day and night. For the cure of these children a
simple decoction of fir-tops was used, a therapeutic procedure stated by Lind to have been of value in
the Russo-Swedish War of 1708.
That scurvy must have occurred extensively among the infants in Vienna may be gathered from the
report of Erdheim, who records 31 autopsies on infants under the interesting title of the “Barlow Heart.”
In Berlin scurvy occurred also in the foundling asylums, as reported by Eric Mueller and by Brandt. This
was caused by a diet of pasteurized milk and dehydrated vegetables. In an article bearing the
suggestive title of “On a Marked Increase in Barlow’s Disease in the Years of the War 1917–1918,”
Epstein states that in Prague there had been an endemic increase of infantile scurvy since August, 1917.
The only information regarding scurvy among the adult civilian population of Germany is that furnished
by Morawitz, who states that this disorder occurred sporadically. Here again it is probable that there
were many latent or rudimentary cases which were not recognized.
In Great Britain there are reports which show that scurvy manifested itself in institutions caring for the
poor. In Glasgow we learn of 50 cases developing in the Poor Law Hospital in the course of fifteen
months, and in Newcastle of 16 cases appearing in the Poor Law Infirmary in the course of three
months.
It is probable that when more detailed reports are available, it will be found that there was far more
scurvy than was appreciated during the course of the war. It will be impossible, however, to gain even
an approximate knowledge of the extent to which this disorder prevailed, as in many instances it was
inextricably interwoven with other nutritional diseases. The situation which Enright describes in Cairo
among the Turkish prisoners suffering from war edema, where there was “evidently a scorbutic factor
involved,” probably held true for many other parts of the world. War and scurvy must still be regarded
as associated evils, for war is closely linked with famine and food deprivation—the dominant factor in
the production of scurvy.
 CHAPTER II
PATHOGENESIS AND ETIOLOGY
At the outset it may be stated that there is no longer any reason to doubt that adult scurvy and infantile
scurvy are one and the same disease, having an identical pathogenesis. For many years, far longer than
the facts warranted, there was discussion whether Barlow’s disease was true scurvy or merely a form or
a complication of rickets, or perhaps a distinct hemorrhagic disease. This question may be relegated to
the past, so that we may proceed to consider the pathogenesis of scurvy in the infant and in the adult
under a common heading.
There is no need of studying all the theories which have been advanced to account for scurvy. They
have been manifold and most of them have died a natural death. For many years the potassium
deficiency theory, suggested by Garrod, gained wide acceptance. That scurvy should be attributed to a
lack of this salt is readily comprehensible in view of the abundance of potassium in the antiscorbutic
foodstuffs, the fruits and the vegetables. It was not long before it was evident that this was not the
correct solution, as the salts of potassium served neither to prevent nor to cure scurvy. This theory was
accordingly modified to include only organic potassium. Experiment, however, failed to support the
validity of this hypothesis, and it was gradually abandoned.
Another theory which had a short but popular career was the citric acid theory, which was maintained
vigorously by Netter. This explanation seemed logical in view of the marked potency of the citrous fruits,
and particularly when it was shown that human milk contains a greater percentage of the salts of citric
acid than cow’s milk, and that some of these salts are lost in the course of heating. This hypothesis
withstood neither the practical test nor chemical investigation. It was found that the various salts of
citric acid, either singly or in combination, are unable to cure scurvy. This treatment has been employed
repeatedly on man and on animals with little or no success; we also have resorted to it in vain. It was
shown, furthermore, that it rested on an insecure chemical basis, as boiled milk contains but 0.1 g. per
litre less citric acid than raw milk—an amount which is negligible from a therapeutic point of view.
Before considering what may be termed the prevailing theories, a few lines must be devoted to the
acidosis theory championed by Sir Almroth Wright. According to this writer scurvy is due primarily to an
excess of acid compared with alkaline food.5 A theory of this nature was open to verification, and soon
collapsed when put to the test. It was found, in the first place, that an addition of alkali was unable to
cure experimental scurvy. It may be added that we have found it of no value in infantile scurvy. Holst
and Froelich pointed out that potatoes and peas, two excellent antiscorbutic vegetables, have an
alkaline and not an acid ash; that adding hydrochloric acid to dandelion juice improves rather than
diminishes its potency; that 1 g. of cabbage, which suffices to protect a guinea-pig from scurvy, does
not contain sufficient alkali to neutralize an acid state; and, finally, that scurvy is not encountered in the
well-established acidosis of diabetes.
Let us turn to some of the current theories of the etiology of scurvy. For years many have held to the
toxic theory, believing that poisons either were consumed in the food or formed in the intestine by
means of bacterial action. At present this view is held by the minority. The situation in this respect may
be compared to that of beriberi, about which there is also no consensus of opinion, a minority
attributing it to the action of an unknown toxin.
A consideration of the clinical course of scurvy sheds but little light on this aspect, and can be
interpreted as well for as against the action of a toxin. The nervous system, which is well known to be
particularly vulnerable to toxins, is but slightly affected—the cardiorespiratory phenomena (indicating an
involvement of the pneumogastric nerves), the occasional changes in the optic disks, and the
abnormality of the tendon reflexes constitute the aggregate. In a general way it may be stated that the
symptoms resemble those brought about by poisons of various kinds—the cottonseed poisoning in
swine, the toxic products of the wheat embryo, or even mercurial poisoning in man.6 The nervous
symptoms, especially the irritability of the heart, remind one of the enterogenous intoxication or
enterotoxic polyneuritis described by Von Noorden. Such analogies are interesting and suggestive, but
can be accorded little weight in deciding the question at issue.
If a toxin is to be regarded as the proximate cause of infantile scurvy, the question naturally arises as to
the nature of the toxin. Is it exogenous or endogenous? There is sound basis for believing that the
hypothetical poison is not introduced preformed in the food. In the first place, infantile scurvy frequently
develops in babies who receive milk of the very best grade indeed, in contradistinction to rickets, this is
not preëminently a disease of the poor. Furthermore, there is no relation between the concentration of
the food mixture and its liability to induce scurvy. For example, if among a large number of infants
receiving pasteurized milk from a common source, some are given the milk diluted by one-half, others
given it diluted by one-third, and still others whole milk, the last group will show the least tendency to
scurvy, which we should not expect were the poison contained in the food. Nor is it at all uncommon to
encounter scurvy in an infant which has been fed with a very dilute milk mixture. Another side of this
question should, however, be mentioned—stale pasteurized milk is more apt to produce scurvy than the
freshly pasteurized, but here again the injury is in inverse ratio rather than in direct ratio to the amount
consumed. There are reports of adult scurvy having been occasioned by decomposed food, such as
Torup’s investigation of Nansen’s polar expedition, but the diet had not been faultless in other respects.
The experiments of Jackson and Harley, who produced scurvy in monkeys by feeding tainted tinned
meat, cannot be unreservedly accepted, as they are substantiated by no pathological examination of the
bones, and the diarrhœa and the blood and mucus in the stools do not suggest simple scurvy.
Of those who held to the toxic origin of scurvy the majority had in mind an endogenous toxin, although
the conception of the nature of this poison varied greatly. The minority report of the American Pediatric
Society states that “scurvy appears to be a chronic ptomaine poisoning due to the absorption of toxins.”
Neumann considered scurvy a chronic poisoning, formed probably from the albumin of the milk, and
considered the fact that the infant refused to take the harmful food as weighty evidence of its toxic
nature. Kohlbrugge included scurvy in his group of “fermentive diseases,” due to the overgrowth of
harmful bacteria in the intestine, which are normally restrained by the acid reaction of the chyme.
McCollum and Pitz, on the basis of a study of experimental scurvy, suggested that as the result of a
break in the metabolism it might be due to the retention of fæces and consequent absorption of toxins.
Still more recently Gerstenberger suggested that as the result of the break in the metabolism of
carbohydrates, a defunctioning substance, possibly oxalic acid, is produced, which has a strong affinity
for calcium.
It is of no avail to discuss these various hypotheses—the formation of intestinal toxins—except where
they are based on observations which can be tested and controlled. This is true solely of the relation of
constipation to scurvy, and we shall confine ourselves therefore to a consideration of this aspect of the
question.
There can be no question whether retention of fæces of itself can bring about scurvy; this is excluded
by the marked instances of constipation frequently encountered among thriving babies. The majority of
bottle-fed babies and a large number of the breast-fed suffer from a greater or less degree of
constipation. On looking over our records of infantile scurvy from this point of view, and comparing
them with non-scorbutic infants, we have not been able to note a characteristic distinction. Some of the
infants had normal stools, others suffered from constipation, while the records of a great number
showed occasional loose stools. Furthermore, in cases of latent or subacute infantile scurvy, it was of no
moment whether a laxative was given or whether constipation was induced by means of opium. The
report of the American Pediatric Society shows that the majority have had a similar experience; the
bowels were regular in seventy-four instances, irregular in fifteen, constipated in one hundred and
twenty-six, and diarrhœal in seventy-seven. In this connection, it may be pointed out that the
preparation termed “malt soup,” the diet which in our experience has been most frequently associated
with scurvy, is essentially laxative, and, on the other hand, that one of the most potent antiscorbutics is
potato, which has no definite laxative property. It may be added, as noted elsewhere, that scurvy
developed in infants in spite of their receiving cod liver oil or olive oil for long periods. It is evident,
therefore, that the retention of fæces is not the essential factor in the etiology of scurvy. Its secondary
rôle, especially after scurvy has developed, will be considered later in this chapter.

TABLE 1
Fecal Flora of Scorbutic Infants
Scorbutic Source of Types of
Infant. Diet. Date. Remarks.
condition. material. bacteria.
M. Malt soup Dec. 1 Subacute Rectum B. acidoph. {Normal infant’s flora.
and cereal B. bifidus {Gram + bac. predominant.
M. ovalis {No spore-bearing or putrefac
B. coli {B. acidoph. about 40% viable
Do. Dec. 4 Do. Do. Do. Do.
Same, also Dec. 11 Subperiosteal Do. Do. {Relatively more B. coli.
20 c.c. hemorrhage {Many B. bifidus
liquid {No putrefactive bact.
petrolatum,
one week
Same diet, Dec. 21 Markedly Do. Do. Normal infants’ flora.
oil improved Bacteria as above.
stopped,
orange
juice 10
days

K. Malt soup Dec. 11 Subperiosteal Rectum Streptococci {Gram - bacteria predominant

and cereal hemorrhage B. coli {B. coli gram + diploc. numero
M. ovalis {B. acidoph. few.
Do. + Dec. 21 Markedly Do. B. bifidus {Gram + bac. predominant.
orange improved B. coli {Many B. bifidus
juice Streptococci {Streptoc. unchanged.
(60 c.c.), 8
days

S. Formula: Dec. 21 Mild scurvy Rectum B. lact. aerog. {Gram + and - bact. about eq
Cream, B. coli {Many lact. aerog.
water, M. ovalis {Putrefactive bact. in minority
flour, sugar, B. bifidus
also cereal B. welchii
Malt soup Feb. 11 More marked Do. B. lact. aerog. {Gram + bact. in great majori
and cereal M. ovalis {Spore bearers very few.
B. bifidus {Flora not at all putrefactive.
Dipheroids
In order to elucidate this question Torrey and Hess made a study of the relation of the intestinal flora to
the scurvy of guinea-pigs and of infants. In guinea-pigs they found in the intestinal tract merely such
bacteria as are encountered on the oats and hay fed these animals. The bacteria were few in number
and hardly any were actively proteolytic. Furthermore, there was no change in the flora on adding
antiscorbutic food, although the scorbutic symptoms disappeared. Recently Givens and Hoffman, as the
result of a similar study, have come to the same conclusion. The investigation of infants led to similar
results, and is illustrated in Table 1. It will be seen that the infants were all on a high carbohydrate diet,
and that in two instances the flora was compared, not only during the active scorbutic process, but after
orange juice had been given for a week or more. The bacteria were such as one should expect on a diet
rich in carbohydrates; putrefactive organisms were present only in small numbers; and in the case in
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