Scurvy, Past and Present

by Alfred F. Hess

The adrenals not infrequently are large. This fact was first brought out by Rondoni and Montagnani, and is of added interest in view of its confirmation by McCarrison as well as by LaMer and Campbell. Its significance is discussed at length in the consideration of the adrenal gland in human scurvy. In view of the fact that fasting leads to a similar hypertrophy, and that guinea-pig scurvy frequently is complicated by fasting, these observations should be extended. In all investigations of this kind, bacterial cultures should be taken of the adrenals, or other organs, to be certain that there is no complicating infection.

There have been no reports as to the effect of scurvy on the size of the testicles, ovary, thymus, thyroid or parathyroid glands in the guinea-pig, such as have been made by McCarrison in relation to avian polyneuritis.

The alimentary tract occasionally shows macroscopic changes similar to the lesions found in man. The entire canal is frequently very empty, especially the stomach and the small intestine, due to the lack of appetite for some days previous to death. In the stomach we may find areas of congestion or numerous small superficial ulcers surrounded by congestion and covered with mucus; occasionally these ulcers are somewhat larger and deeper. The larger ulcers are more frequently situated in the first part of the duodenum, often proximal to the papilla of Vater. Holst and Froelich described this lesion in one of their early communications. More common than ulceration of the duodenum is a diffuse congestion of its upper part. This lesion is of note because it has been described frequently in the protocols of human necropsies, and is found in beriberi, in avian polyneuritis, and in pellagra in man. Its significance is unknown, and has indeed never been discussed.

Lower down in the bowel there are occasionally areas of congestion and ulceration, but no section seems particularly predisposed to these lesions. The contents of the bowel, especially of the cæcum, as mentioned above, depend more on the character of the food than on the existence of scurvy. If the diet has consisted of milk and oats, the cæcum will be found full and perhaps impacted, whereas if hay and oats have been fed, the cæcum will be less full and its contents semisolid.

In view of the fact that many of the animals have taken very little food for some days previous to their death, it will be well to describe briefly the macroscopic picture of simple starvation in guinea-pigs. When guinea-pigs are given only water they live about one week; if orange juice is added to this water diet they succumb a little later to starvation. Under all these conditions the striking pathologic change—absent in scurvy—is edema. It is true that the limbs may show slight edema in scurvy, and that the pericardial and the pleural sacs, and even the peritoneal cavity, occasionally contain a small quantity of serum, but it is comparatively an insignificant amount. Moreover it is difficult to decide to what extent this edema is due to scurvy, and to what extent to starvation. In typical starvation, on the other hand, such as occurs on the limited diets enumerated above, we find marked subcutaneous edema, sometimes a true anasarca, and frequently also ascites. We are reminded of the “war edema” and its frequent association with starvation. Another distinction between the two conditions is the fact that the marrow in starvation is yellow and not red as in scurvy. In passing, it may be mentioned that the ascites was greater when orange juice had been given than where the animal received only water.

In perusing the literature but one study has been noted on the effect of a scorbutic diet on the fœtus. This investigation was carried out on a large series of guinea-pigs by Ingier (1915). The following comprise her conclusions:

“1. Pronounced cases of Barlow’s disease may be produced in the fœtus as early as ten to fifteen days after the commencement of dieting pregnant guinea-pigs with oats and water. There are wide individual variations. The scorbutic changes in the skeleton are greatest in the earlier embryonic stages. The fœtuses of that period, with practically no exceptions, die and show marked traces of impeded growth.

“2. Fœtuses from the later period of pregnancy are born alive, and apparently fully developed, with comparatively slight changes in the osseous system.

“3. Even a short extension of the period of extra-uterine dieting on milk from scorbutic mothers, and later on oats and water, is sufficient to change the latent scurvy into a highly-pronounced case.

“4. The fœtus cannot be kept alive longer than the adult animal, about twenty-eight days, either by intra-uterine dieting alone or by combined intra- and extra-uterine dieting.

“5. The mothers show signs of the disease at an early period and are more severely attacked than non-pregnant animals. Death also occurs comparatively often in the first period of gestation.”

In these experiments intra-uterine fractures, premature births and still-born litters are frequently mentioned. This suggests naturally an inquiry as to whether similar occurrences have been observed in human scurvy. In considering the pathogenesis of human scurvy, we have remarked on the meagreness of the data on this most interesting aspect of this disorder. In view of the similarity between human and guinea-pig scurvy, we should expect not only miscarriages and still-births to result, but cases of congenital scurvy, especially of the latent or rudimentary type.

Scurvy Has Been Induced Also in the Monkey.—The most extensive investigation of this kind is that of Hart and Lessing, who brought about scurvy in several young Macaci Rhesi which had been fed for some months on boiled condensed milk with the addition of cooked rice and pig-nuts. Typical scurvy resulted in all but one instance, and in this case an old animal was used and a different pathological picture developed. These experiments require brief reviewing, as the clinical signs and gross pathology in monkeys differ somewhat from those encountered in guinea-pigs, and particularly as these distinctions render scurvy in monkeys and in infants practically identical.

Apart from general listlessness and lack of activity, the first sign is hemorrhage of the gums, the characteristic sign of infantile scurvy. This is stated to be constant; in the guinea-pig it is most exceptional. Another sign characteristic of infantile scurvy is the subperiosteal hemorrhage, which in the guinea-pig may be found as a small effusion near one of the larger joints or the costochondral junctions, but in the monkey consists of large effusions, similar to those described by Barlow. Subperiosteal hemorrhages of the cranial bones were constantly seen, and not infrequently involvement of the scapula and of the maxilla. Hemorrhage into the orbit leading to exophthalmos and to hemorrhagic discoloration of the upper lid—a lesion not infrequent in human scurvy—is also described; in guinea-pigs we have met with exophthalmos only in two instances. In all other respects scurvy in the monkey resembles that in the guinea-pig, even to the extent of the scorbutic rosary of the lower true ribs. Hart and Lessing describe the presence of the “white line” of Fraenkel, which is referred to at length in treating of the symptomatology of human scurvy. This is a shadow, seen by means of the X-ray, traversing the long bones near their epiphyses—a definite “shadow band” associated with a narrow light zone lying just beneath it. This “white line” has been noted likewise by Talbot, Dodd and Peterson in the scurvy of monkeys.