Scurvy, Past and Present

by Alfred F. Hess

Microscopic Pathology.—Turning to the microscopic pathology, we find that the changes are similar to those described elsewhere in connection with human scurvy. It will be unnecessary, therefore, to give more than a general survey of the typical alterations. Little has been added to the description of lesions so carefully depicted in the first report of Holst and Froelich (1907). The bone marrow at the ends of the diaphyses in proximity to the epiphyseal junction loses its normal lymphoid character and is replaced by a reticular or fibrillated substance, the so-called “framework” marrow (Geruestmark of Schoedel and Nauwerk) containing a homogeneous mucoid tissue and only a few osteoblasts and marrow cells. The number of blood-vessels is considerably reduced and fresh hemorrhage or blood pigment is frequently seen. The osseous tissue itself shows marked changes, corresponding to the rarification and brittleness noted on gross examination. The osseous trabeculæ are fewer in number and those which remain are slender and irregular, and frequently appear as isolated islets. The cortical substance also becomes very thin. There are marked alterations in the intermediate cartilages, especially of the ribs.[37] Instead of the cells being arranged in orderly rows, they are irregularly placed, and frequently greatly reduced in size and number. The bone trabeculæ on which they abut are not well formed or of equal length, and do not present an even and transverse plane, but are misshapen, small, so that the line of junction with the cartilage is zigzag. In cases of marked scurvy the junction may be entirely disorganized and deformed, showing fractures of the rarefied bone and hemorrhages in the neighborhood. This leads frequently to a macroscopic deformity of bone, a bulging of the surface at the costochondral junction—the scorbutic “beading” or “rosary” of the ribs. Recently Delf and Tozer have described these changes, classifying them as those occurring in “incipient,” “definite,” “acute,” “chronic definite,” and “chronic acute” scurvy. [Fig. 9] shows these types in diagrammatic form. In this figure we see how varied may be the manifestations of this nutritional disorder, according to whether it has existed for a shorter or a longer time; in some instances the picture is very puzzling. The “incipient scurvy” corresponds to what we have termed clinically “latent scurvy” in infants, a condition which cannot be diagnosed and is manifested merely by a faulty nutrition which responds promptly to the addition of an antiscorbutic to the diet. There have been no histologic examinations in man at this incipient stage, but we may infer that they are similar to the bony changes found in the guinea-pig. When the scurvy has become chronic in an animal which has lived for months on a quota of antiscorbutic food sufficient to preserve life but insufficient to prevent the development of scurvy, we find a microscopic picture at the costochondral junction differing widely from that seen in the acute stage. Not only are the columns of cartilage cells represented merely by misshapen vestiges, but an ossified band (Fig. 9⁵) is seen at the junction. It is probable that this is frequently the cause of the marked cessation of growth which has been described in connection with this type of scurvy in infants. Delf and Tozer interpret this ossified band at the junction as “an attempt to strengthen the junction in an abnormal manner, the normal process having broken down.” If the animal is again deprived of antiscorbutic food the ossified band breaks down, the junction becomes deformed and disorganized, and a condition of “chronic scurvy (acute)” is stated to have developed.

1. Diagram of normal rib-junction.

2. Diagram of rib-junction to illustrate “Incipient Scurvy.” This rib-junction is very nearly normal, but shows what may be regarded as the first recognizable signs of the onset of the disease; these are: (a) An appearance of general abnormality (when compared with the normal). (b) Unevenness of the junction and slight disorganization of the rows of cartilage cells. (c) Shortening of the length of the rows of cartilage cells. (d) Shortening, and decrease in number of the trabeculæ. (e) Increased amount of blood in the marrow cavity.

3. Diagram of rib-junction to illustrate “Definite Scurvy.” Histological signs vary considerably in these cases (according to the severity of the disease), and may approach in appearance those characteristic of the “Acute” condition. The rows of cartilage cells may be almost normal, but are more often noticeably shortened and usually somewhat disorganized or arranged in circular groups. The trabeculæ are usually about half the normal length and have a truncated appearance. The junction as a whole may present an uneven, slightly disorganized appearance and there is sometimes a certain amount of macroscopic deformity.

4. Diagram of rib-junction to illustrate “Acute Scurvy.” In these cases the junction and rows of cartilage cells are often completely disorganized, causing a marked macroscopic deformity of the bone. The bone of the shaft is frequently fractured. The marrow is no longer in contact with the edge of the junction and the space is filled with a mass of connective tissue; this is very characteristic in cases of fracture. A condition in which the trabeculæ have almost disappeared and the rows are much shortened is also found in “Acute Scurvy,” in those ribs in which no fracture of the shaft has occurred; usually, however, there is little or no ossification across the junction. There is frequently hemorrhage into the marrow cavity.

Diagrams 5 and 6 illustrate types of “Chronic Scurvy.”

5. May be described as “Chronic Definite Scurvy.” The rows are much shortened but not disorganized and an ossified band extends across the junction.

6. May be described as “Acute Chronic Scurvy.” The junction is deformed, and the rows are very disorganized; the trabeculæ have disappeared and an ossified band extends across the junction. There is no connective tissue to be seen and no existing, or recent, fracture.

It has been noted by many investigators that changes in the teeth take place in the course of scurvy. They become somewhat yellow and lose their glistening appearance, and occasionally break off. The molars commonly become loosened, so that they can readily be removed from their alveolar sockets; less frequently this is true of the incisors. Until recently, however, this subject has not been studied in detail, and no significant histologic changes in the teeth have been described. Jackson and Moore showed that with marked changes in the teeth there was often “great dilatation of the veins in the pulp attended by more or less hemorrhage into the pulp,” and that “in guinea-pigs fed on oats and hay there was almost complete necrosis of the pulp of the incisor teeth, also more or less necrosis in the pulp of the molars.”