The most important consideration in the diagnosis of scurvy is to keep in mind the heterogeneous character of its symptoms, and the manifold diseases with which it may be confused. Surgeons should be alert to this danger when about to perform operations for osteomyelitis or bone tumor. The mistakes occur because cases are infrequently seen and because the signs, being dependent largely upon hemorrhage, occur in such varied locations of the body. Where diagnosis cannot be made from the signs or symptoms, the most important aid is a thorough acquaintance with the previous diet of the individual and observation of his reaction to antiscorbutic treatment. CHAPTER VIII PROGNOSIS The outcome of scurvy, as we encounter it in peace time in the Temperate Zone, is generally favorable, so that it plays but an insignificant rôle in our mortality statistics. This results from the fact that we are abundantly provided with a specific remedy, so that if the diagnosis is made early and treatment is prompt and thorough, the patient will rapidly recover and suffer no physical disability. Where antiscorbutic foodstuffs are not procurable, however, this disease constitutes a terrible scourge, causing many deaths and spreading among an army, a ship's crew, or among the civil population with the rapidity of an epidemic. For example, the ships of the East India Company in their voyages round the Cape often lost nearly one-half of their crews, and in Lord Anson's famous voyage round the world 380 out of 510 seamen perished from the disease. Moreover, if the antiscorbutic treatment is inadequate or the patient goes untreated for a long period, the cure may be incomplete, a condition of malnutrition and weakness developing, which may persist for years. To appreciate this clinical condition we must refer to the account of physicians who saw thousands of cases of severe and untreated scurvy among the sailors, who were of necessity deprived of aid until they reached land. Lind laid stress on a type of this disease which developed under these circumstances and which he termed "obstinate scurvy." He writes: "I have met with numerous instances not only among the common seamen, but of officers, with whom it had taken such deep root in the constitution as to prove a lasting affliction to them during a great part of their lives.... Persons are likewise subject in different periods of their life afterwards to habitual rheumatism, pains and stiffness in their joints; and sometimes eruptions on the skin." In his treatise on scurvy, published in 1685, Harvey refers to this chronic nutritional disorder as "inveterate scurvy." He pictures patients who had gone untreated for a long time as "molested with vagrant, ambulative, distending, creeping, vellicating or lancinating pains of several parts of the body.... They are often loose and subject to falling into violent fluxes of the belly, diarrhoea and lienteries."