It will be well to consider in detail the signs and symptoms which may develop in the course of scurvy.
Hemorrhage.—Hemorrhage of the gums is one of the characteristic signs of scurvy. For a reason not clearly understood it involves first and foremost the tissues about the upper incisors. If, however, we fix our attention too narrowly to this region we may be led into error; in several instances we have first encountered hemorrhages about the molar or the canine teeth, which had been overlooked because the anterior part of the gums had been found normal. Where teeth are absent or not in the course of eruption hemorrhages do not appear. At the onset the gums may be merely deep red or bluish red, especially if they overlie upper incisors which are close to the surface. Hemorrhage is particularly apt to occur where the edges of the teeth have just broken through the mucous membrane. In this connection the question arises as to whether every hemorrhage of the gums in infants is to be considered a sign of scurvy. This is a matter of some diagnostic importance. We have seen hemorrhages of the gums at the site of erupting molar teeth where, as prolonged observation proved, not even latent scurvy existed. This sign should not, therefore, be regarded as pathognomonic. In two infants entirely free from scurvy we have noted slight hemorrhage of the gums overlying incisor teeth. It should be well understood that such an occurrence is most exceptional; it is to be attributed probably to bacterial invasion or to a constitutional hemorrhagic condition. One of these cases was the following:
The infant was 8½ months old. It had been nursed by the mother up to this time and was well nourished, but when first seen had some fever, probably due to a grippe infection. About ten days later distinct linear hemorrhages of the gums were noted over the two upper incisor teeth. No treatment was instituted for this condition, and it healed within a week. There was no subsequent sign of similar hemorrhage or of other scorbutic manifestation in the months that the baby was under observation.
The localization of the hemorrhage in the gums is due largely to trauma, occasioned by the sharp contact of the jaws or of the nursing-bottle. Local infection plays almost no rôle in infants, although in the adult where there is caries of the teeth it frequently incites hemorrhage. Dental caries and gingival infection may lead to local hemorrhage, even where the nutritional conditions are normal.
Subperiosteal hemorrhage is a sign distinctive of infantile scurvy, although it must be borne in mind that it may take place in the scurvy of adults. It involves most frequently the lower end of the femur and the tibia, but occurs in connection with the humerus, the mandible, the scapula and other bones.[47] The hemorrhage usually manifests itself as a swelling which appears suddenly at the lower end of the femur or femora. It is brought about by trauma, at times in the course of diapering, or by manipulation in testing for local tenderness. The swelling is very tender, and varies in size from an enlargement which is difficult to appreciate, to one which renders the leg fully twice its normal circumference ([Fig. 18]). It may involve merely a small part of the long bone or extend up or down the shaft for a long distance. As might be supposed from the nature of this lesion, the enlargement persists for weeks, frequently long after the gums and the general symptoms have disappeared. During this period it becomes harder and less tender, and may develop the consistency of bone; it is in this stage that such swellings have been diagnosed as new growths, and that incision or even amputation of the leg has been resorted to. In subacute cases the swelling—which must be regarded as hemorrhagic rather than scorbutic—may be absorbed gradually in spite of the fact that no antiscorbutic food has been given. This has led to the mistaken conclusion that the scurvy has been cured without dietetic treatment.
Subperiosteal hemorrhage may be clearly seen by means of the fluoroscope or in X-ray photographs (Figs. 16 and 17). The shaft of the bone appears surmounted by an elongated blood-clot, which is more or less distinct according to its age and density. It may become calcified, as clearly seen in figures. More often the periosteum undergoes calcification or ossification, especially near the site of the separation of the epiphysis. This gives rise to a bizarre radiographic picture which may be difficult to interpret—the opaque strip or streamer being almost unrecognizable as periosteum (Fig. 17).
Hess and Unger observed that in several instances where subperiosteal hemorrhage had been diagnosed, X-ray examination disclosed that the swelling of the thigh was due mainly to infiltration of the muscles and subcutaneous tissue. It is surprising how an infiltration of serum gives rise to a swelling which resembles in appearance and consistency the classical subperiosteal tumor.
The skin, mucous membranes and subcutaneous tissues are frequently the sites of hemorrhage. There is a difference of opinion as to how frequently petechial hemorrhages occur in scurvy, particularly as to whether they are encountered early in this disorder. Great variation in this regard may be noted in individuals and in groups of cases occurring at different times. In the cases reported in 1914 by Hess and Fish, petechial hemorrhages were frequently an early sign, to such an extent that they led to a study of the blood and blood-vessels in this disorder. The hemorrhages in this “scurvy epidemic” were the result of a complication of scurvy with an infectious disease. It is not necessary, however, for infection to exist to bring about a rupture of the small vessels. The idiosyncrasy of the individual has to be considered as well as the fact that infants have a tendency to develop minute skin hemorrhages, especially such as have an exudative diathesis. In the course of scurvy, petechiæ may be found not only in the skin, but in the mucosa of the mouth, especially overlying the hard palate, and also in the palpebral conjunctiva, identical with the minute petechiæ so significant of general sepsis. In addition to these minute hemorrhages larger ones are not infrequently found in various parts of the body, especially in the neighborhood of the joints. They appear as discolorations of various intensities and shades, and are often interpreted as being merely the result of bruises. These have been encountered most often about the knee-joint, on the forehead, or in the concha of the external ear, where they may best be seen by means of transmitted light.