Scurvy, Past and Present

by Alfred F. Hess

There is a variability in the sign which signalizes the onset of the disorder—sometimes it consists of a flattening of the weight curve, at others of an inordinate excitability of the animal, or frequently of a tender joint, generally a wrist. The joints almost invariably become tender early in the disease, causing the animal to wince and cry when it is examined. Accompanying this tenderness there is often slight swelling due to edema, or perhaps some hemorrhage, which alters the sharp, clean-cut contour of the joint. This edema may extend upward along the tendon sheaths. Soon the animal becomes lethargic rather than nervously active, and may look ill, as manifested by a roughness of its coat and its unnatural posture. Frequently it sits on three legs with the tender hind leg drawn upward and outward so as to escape pressure—a posture termed by Chick, Hume and Skelton (1918, 2) “the scurvy position,” and indicative of hemorrhage into the joints or muscles. At times it lies curled up, with the side of its face resting on the floor, as if to support its painful or sensitive jaw; this they have termed the “face-ache position.” The two diagnostic signs, however, are the hemorrhages about the joints and the loosening of the teeth. The diagnosis frequently can be established by the twelfth to the fourteenth day; the earliest diagnosis was made on the eighth day. Hemorrhages appear somewhat later than tenderness, and are situated at the joints, most frequently at the knee, which may be markedly swollen and show a bluish or reddish discoloration, extending upward or downward for some distance. Other joints are often involved, frequently the wrist, the ankle or the shoulder. In other cases hemorrhages into the muscles are noted, especially of the leg or of the thigh, and later, especially toward the end, hemorrhages from the bowel. Fractures or separations of the epiphyses may be found on examination or may be occasioned by the physical examination. A frequent site of this lesion is at the wrist or at the knee, involving the head of the tibia or the lower end of the femur. These fractures knit rapidly when an antiscorbutic is given, but result at times in deformity.

Loosening of the teeth is another typical sign. It is, however, one which does not appear early and is somewhat difficult to elicit. The molar teeth are generally involved, especially those of the upper jaw, which may be so completely separated from their alveolar sockets that they can readily be removed by forceps. It is, however, impossible to examine the molar teeth satisfactorily during life. Far less frequently an incisor tooth becomes loosened; more often it loses its glistening appearance and looks dull and yellowish. Occasionally an incisor tooth fractures. The gums are rarely altered sufficiently to aid diagnosis; not infrequently they are congested or bluish, rarely hemorrhagic, and never ulcerous or spongy. This is the chief difference between the symptomatology of scurvy in the guinea-pig and in man, and probably is the result of lesser susceptibility of the former to infection by pyogenic bacteria. In general, however, the disorder in the guinea-pig bears a closer analogy to infantile than to adult scurvy; due to the fact, possibly, that young pigs are generally used for the experiments.

A sign of great interest, although not of diagnostic importance, is the “beading” of the ribs noted by many observers, and emphasized by Jackson and Moore. It has been described also in monkeys by Hart and Lessing. This is an enlargement or swelling of the costochondral junctions of the ribs, especially of the lower true ribs. It corresponds clinically to the “beading” and the “rosary” so characteristic of infantile rickets and mistakenly termed the “rhachitic rosary.” As pointed out, in discussing the symptomatology and pathology of human scurvy, this sign must be regarded as truly scorbutic in animals as well as in infants. The “rosary” is difficult to palpate in pigs which have considerable subcutaneous tissue; in thin animals, however, its course can be followed, the gradual development and subsequent disappearance. In this connection the enlargement of the epiphyses must be mentioned, another sign supposed to be characteristic of rickets in infants. Marked swelling of the wrists is frequently encountered in guinea-pigs suffering from scurvy—a bony enlargement involving the lower epiphyses of the ulna and of the radius. This is met with far more commonly in chronic scurvy than in the usual acute case. Where the disorder has existed for a long period, these bony knobs may persist indefinitely, constituting the sole residual sign of a former scorbutic condition.

The relation of loss of weight to the development of the scurvy requires consideration. In experiments carried out on rats to test the diets in respect to the water-soluble and the fat-soluble vitamines, the weight curve is used as the main criterion to judge whether the foodstuff is adequate. In guinea-pigs we cannot employ the weight curve as a criterion. Not infrequently an animal develops scurvy, and nevertheless does not lose in weight, but even gains slowly and steadily. This occurs when the appetite remains good, and the dietary is complete except for antiscorbutic vitamine. The same holds true for human scurvy, as we have noted in connection with the symptomatology. We have attempted to make up for this defect by adding to the charts a curve representing the clinical course (Fig. 10). Although this curve is computed on an empirical basis, it gives a comparatively true picture of the disease and is far more exact than attempting to portray the disease by means of a weight curve.[38] Indeed, when we rely on the latter method it is impossible frequently to illustrate graphically the reaction of guinea-pigs to various influences. Another disadvantage of the weight curve is that it is influenced by factors having no direct relation to scurvy, especially infections of various types which retard the gain.

Fig. 10.—Hay, oats, and water ad libitum during period I resulted in a lack of gain in weight, and in a development of scurvy. During period II, 1.5 c.c. of orange juice were given daily, and as will be seen there was a marked gain in weight and disappearance of the scorbutic signs, although, as is generally the case, they continue to develop for a short while after an antiscorbutic is given. When the orange juice was discontinued in the third period, the weight once more fell and the scurvy redeveloped. The broken line represents the course of the scurvy, and is a composite formed on the basis of the aggregate of the scorbutic signs. Each square represents a 2-day interval.

Guinea-pigs generally die of scurvy after having lost about one-third of their body weight; occasionally the loss is greater, reaching almost 50 per cent. This loss is due partly to the scorbutic condition, but to a greater extent to starvation occasioned by a marked lack of appetite. In this connection it may be noted that guinea-pigs frequently lose for a few days following the addition of an antiscorbutic to the dietary (Fig. 11). This reaction is evident from a perusal of the weight charts of other investigators, and occurs likewise in human scurvy. This loss is accompanied, as Gerstenberger has pointed out, by diuresis, which may be so marked that it is evident to the casual observation of those caring for the animals.

Fig. 11.—These guinea-pigs developed scurvy in spite of receiving a large quantity of the water in which young carrots had been cooked for only 20 minutes. It will be noted, however, that although the pigs developed scurvy they did not lose weight, as is usually the case. After they had developed definite scurvy they were given in addition the equivalent of 80 c.c. of a dried milk prepared by being heated to about 116° C. for a few seconds. The addition of this milk to the diet cured the scurvy, showing that it had largely retained its antiscorbutic vitamine.

Exophthalmos may be mentioned again in this connection as a very rare sign of guinea-pig scurvy. Hæmaturia also occurs at times; it is not known how frequently it is present, whether it is an early manifestation in the guinea-pig as in the infant, or whether the source of the blood is the kidney or the bladder.