An instance of subacute scurvy, which in many respects is typical, is the following:
I. F., girl, was seen when 3 months old, weighing somewhat over 8 pounds. She was given Schloss milk, 4 ounces, and then 5 ounces every three hours, and did well, weighing 11¼ pounds two months later. As she failed to gain for some weeks, although getting 6 ounces of food, it was thought that this might be due to the fact that she was getting pasteurized milk and had never received an antiscorbutic. Autolyzed yeast had been tried as a prophylactic antiscorbutic, but failed to bring about a gain. When, however, orange juice was substituted for the yeast, a prompt growth-reaction resulted, a gain of 1¼ pounds in four weeks. Accompanying this lack of gain in weight there were many of the other symptoms enumerated above; irritability, pallor, slight tenderness of the lower ends of the femora, albumin and a few red and white cells in the urine. The pulse- or heart-beat was frequently over 150, and the respiration 60 (Fig. 15). The diagnosis of subacute scurvy was substantiated by the prompt subsidence of all symptoms when orange juice was administered.
Fig. 15.—Chart of I. F., aged 7 months, showing a prompt effect on pulse, respiration and temperature of substitution of orange juice (30 c.c.) for autolyzed yeast (30 c.c.) and a further response when the former was replaced by potato (15 g.).
Infantile scurvy may be dormant for a long time. The diagnosis of latent scurvy is based mainly on the reaction to specific therapy, on the marked improvement when orange juice, tomato, potato or other antiscorbutic food is given. The symptoms themselves are suggestive, and do not enable an absolute diagnosis to be made. In our experience with many cases of this kind the usual course has been as follows: The infant has been generally from 6 to 9 months of age, and fed for a considerable period on pasteurized milk, which may or may not have been prepared with cereal decoction. Nor has it been material whether gruels also had been given. When about 6 months of age the baby ceased to thrive, to gain satisfactorily, to look healthy, and to feed as it should. The most careful investigation or physical examination has failed to solve the difficulty. On the other hand, the history of a diet of heated milk, especially if the quantity was not large, considered in conjunction with the pallor and poor appetite, the increased knee-jerks, and perhaps a rapid pulse and respiration (the cardiorespiratory syndrome), has awakened suspicion. Orange juice or canned tomato, prescribed in such cases with a view to diagnosis as well as to treatment, frequently brings about a magic result. The following case, the weight chart of which is reproduced ([Fig. 14]), is fairly typical of this abnormal nutritional state:
H. S., boy, born December 15, 1915, was artificially fed until January 4, 1916, when he weighed 6½ pounds. He was given 28 ounces of Schloss milk a day. (This was prepared from pasteurized milk which was not heated a second time. It contains per litre (quart) 140 c.c. of whole milk, 140 c.c. of 20 per cent. cream, 50 g. of dextrimaltose, 5 g. of plasmon, 0.2 g. of potassium chlorate, and 700 c.c. of water.) By March 1 he weighed 9 pounds, and gained three-quarters of a pound more in the course of this month. During April he gained only 4 ounces. As will be seen from the chart, there was almost a cessation of gain from April 10 to May 3, although yeast was added to the diet. May 2, orange juice was given. The weight advanced at once, the color and the general appearance improved, and an eczematous condition of the face rapidly healed. It will be noted from the chart that the gain occurred, although the food intake remained the same.
Epicrisis: A baby 4 months old with latent scurvy, which existed since he was at least 3 months of age.
This condition of latent scurvy is probably the commonest type of the disorder, especially in the larger cities where almost the entire milk supply for infants is pasteurized. It usually passes unrecognized. Most infants fortunately are given orange juice by the time they are 6 months of age, and may receive a small amount of vegetable or potato before they are much older, so that they are protected from serious harm in this way. But there is no doubt a considerable number, especially those peculiarly susceptible, who quite unbeknown to anyone pass through the state of latent scurvy.
If this large group of cases were included in the incidence of infantile scurvy, we should not look upon it as a disorder which occurs rarely during the first six months of life.
When scurvy goes unrecognized or untreated for a long time, or the antiscorbutic content of the food is exceptionally small, or the patient unusually susceptible, the disorder may progress and resemble the advanced cases described in connection with the adult type of this disease. Happily such instances are rare. One of the most typical and vivid descriptions of an extreme case of infantile scurvy is that reported by Vincent:
The infant lay in its bed extremely apathetic and barely conscious. Its face was ashy gray in color, the respirations were extremely frequent, the pulse-rate was 144 per minute, and the temperature 103.2°. When touched it moaned feebly, and made no attempt at movement. The mouth was kept open, the lower jaw hanging away from the face. There was a complete absence of muscular tone, so that the infant appeared to be quite incapable of voluntary movement.
The mouth presented a horrible appearance. No sign of the teeth could be discovered, though it was stated that several had appeared. All that could be seen was a purple mass, which was so extensive that on superficial inspection it was difficult to distinguish between the upper and lower jaws, despite their wide separation. Scattered over this purple mass were areas of necrosing tissue, the odor of which was extremely unpleasant.
Petechial hemorrhages were distributed over the back and limbs, and a large patch of extravasated blood was found in the region of the left hip.
Tenderness was present in all the limbs, as manifested by moaning and by the facial expression. There was a general enlargement over both humeri throughout their length; the ulna and radius did not appear to be thus affected, but the index-finger of the right hand was enlarged, especially at the junction of the metacarpal bone with the first phalanx, the enlargement being at each side of the joint. In the legs the signs were extreme. At both knee-joints the skin was tightly stretched over the swollen epiphyses; the tenderness also was greater than at any other part.
Bleeding from the gums and nose had occurred; no history of hæmaturia could be obtained. The motions were semisolid, green, and offensive. During the last twenty-four hours the infant had refused food.
The baby was given large amounts of lemon juice and subcutaneous injections of salt solution and the necrosing surfaces of the gums were scraped and swabbed with boracic solution. By the third day the pulse was 100, the temperature 99.8°, the odor from the mouth scarcely noticeable, and the general condition distinctly improved. It continued to improve and to gain in weight and when seen at the end of the sixth week of treatment it was doing well and was quite happy.