Scurvy, Past and Present

by Alfred F. Hess

A form of hemorrhage which must be especially mentioned, although it is very infrequent, is that taking place into the orbit, leading to a proptosis of the eyeball, usually the left (Still). This sign should be borne in mind, as it occurs occasionally before other symptoms have rendered the diagnosis clear, and may lead to a diagnosis of tumor.

As mentioned above, hemorrhages into the muscles or between the muscle planes are very common in adults, leading to hard swellings, the typical “scurvy sclerosis.” Such effusions occur much less frequently in infants, due probably to their lack of activity. In addition to these hemorrhages there are serous effusions of the muscles similar to those which are found in the pleural and pericardial cavities. These effusions are very striking at necropsy, when one incises the muscles—for example, the muscles of the thigh. During life they are frequently mistaken for subperiosteal hemorrhages.

Less frequently there are hemorrhages into the internal organs. These, however, play a comparatively insignificant rôle in the symptomatology of this disease. At postmortem examination we find numerous hemorrhages of the pleura, pericardium and peritoneum, which rarely produce symptoms during life. Still records a case with marked abdominal pain and swelling, which he believed to have been due to hemorrhage into the wall of the intestine. As previously mentioned, O’Shea met with a case of hemorrhage into the cæcum which was mistakenly operated upon for appendicitis. Hæmothorax and hæemopericardium occur, especially associated with local inflammatory processes of tuberculous nature. The clinical aspect of hemorrhage of the gastro-intestinal and the genito-urinary tracts will be considered elsewhere.

In the scurvy of adults as well as that of infants, the nails and the hair are altered by the nutritional condition. Mention has been made of the hyperkeratosis recently emphasized by Wiltshire as an early sign, occurring especially on the thighs and legs. The skin is frequently dry, the so-called “goose skin” that is seen in some poor nutritional states. The nails are thin, brittle and lined; at times small hemorrhages will be noted beneath them. The hair also becomes thin and dry, and there is a tendency for petechial hemorrhages to develop at the roots.

In a paper on the therapeutic value of yeast and of wheat embryo the author called attention to the fact that eczema may occur in connection with infantile scurvy, and be cured by means of orange juice. We have met with eight cases of eczema in infantile scurvy, which, in almost every instance, have yielded promptly to an antiscorbutic, thus proving their scorbutic nature. A case of this kind is the following:

M. L., seven months old, was getting “Molkenadaptierte” milk, and in addition autolyzed yeast. On May 25th it developed nasal diphtheria, but soon afterward did well. On June 9th it was gaining, but its pulse was 160 and respirations 80. A few days later it developed marked eczema about the neck and to a less extent on the back and buttocks. The “capillary resistance test” was negative. Cardiographic tracings showed merely a simple tachycardia. A few days later petechial spots appeared at the site of the eczema. On June 17th orange juice was given. The appetite improved, the cardiorespiratory syndrome disappeared, and the child began to gain. The eczema also cleared up rapidly without any local treatment.

We wish to draw particular attention to this skin condition, as it is generally not mentioned, or has been regarded merely as a chance occurrence. The report of the American Pediatric Society includes two cases of eczema as a complicating condition. This symptom is of special interest in view of the fact that a similar skin lesion constitutes one of the typical signs of pellagra. In a case of infantile scurvy we have seen an eruption at the nape of the neck which was symmetrical and greatly resembled that of pellagra. Andrews refers to the occurrence of eczema in his description of infantile beriberi.

In a paper published a few years ago attention was drawn by Hess and Fish to the fact that infantile scurvy frequently is associated with the exudative diathesis of Czerny, a pathological condition which predisposes to the development of exudations of the skin and the mucous membranes. Infants suffering from this condition—intertrigo, eczema, recurrent bronchitis—seem to be particularly susceptible to scurvy and to develop it more quickly than others.

As is well known, edema constitutes a not infrequent symptom of adult scurvy. It has not, however, been accorded any place in the symptomatology of infantile scurvy. We do not refer to the edema in connection with subperiosteal hemorrhage or separation of the epiphyses of the long bones, but a mild and peculiar form which is seen early in the disease. It involves most regularly the upper eyelids, and the legs—especially the skin covering the lower part of the tibiæ. In the latter site it differs from edema as usually encountered, in that it does not pit on pressure; it is firm, tense, causing some glossiness of the overlying skin, which is rendered difficult to wrinkle or to pinch between the fingers. Not infrequently the skin is slightly reddened, a sign of interest, in view of a similar, although much more intense, hyperæmia seen in pellegra.

In addition to this very mild edema there may be marked swelling, resulting in what might be called, following the terminology of beriberi, “wet scurvy.” The legs, body and even the face may be swollen. This has been frequently described in adult scurvy, and occasionally in infantile scurvy. The first case of infantile scurvy described in America, that of Northrup, had marked edema of the scrotum. Edema is frequently met with in “ship beriberi,” a disorder considered by some writers to be a combination of beriberi and scurvy.