The symptom leading to the diagnosis of scurvy most often is tenderness or swelling of one of the extremities, as the antecedent clinical signs, comprising latent scurvy, are generally overlooked. These manifestations involve usually the distal end of the thigh or thighs. The tenderness is elicited most readily by pressure just above the knee, which causes the baby to wince, and to quickly flex the thigh, a reaction termed by Heubner “the jumping-jack phenomenon.” As a result of pain and tenderness, the leg lies often immobile in a state of pseudo-paralysis (Fig. 18). There may be tenderness elsewhere than in the long bones. Kerley refers to two cases showing tenderness of the spine, and we have seen a similar case. Not infrequently there is tenderness of the chest wall, the earliest symptom noted by nurse or mother being unaccountable crying whenever the baby is lifted by the thorax. This is largely due to the sensitiveness of the ends of the cartilage and bone which are pressed together at their junction.
Fig. 18.—Infant with marked scurvy. Characteristic posture and swelling of right thigh.
An early sign of infantile scurvy is beading of the ribs—the development of a “rosary” similar to that characteristic of rickets (Fig. 19). This has recently been described by Hess and Unger in an article devoted to this subject. That this rosary is truly scorbutic and not rhachitic is proved by the fact that it recedes rapidly when antiscorbutic foodstuff is given, and that it remains uninfluenced by treatment with cod liver oil. A similar scorbutic rosary occurs in guinea-pig scurvy, but has been termed “pseudo-rhachitic.” It is important that this sign should be recognized, as it is probable that much of the confusion regarding the relationship and frequent association of these two diseases is due to considering the beading rhachitic. The interpretation of infantile scurvy as “acute rickets,” the view held previous to the writings of Barlow, was based largely on the development of the rosary. To-day the error is made of regarding early scurvy as chronic rickets; the rickets supposed to be occasioned by a diet of condensed milk is probably more often scurvy. This beading differs generally from the round knobby “rosary” usually encountered. It is more angular, the junction taking on a step-like form, as if the abutting ends of the cartilage and the bone were of unequal size, and not well fitted to each other. In the accompanying radiograph ([Fig. 19]) it will be noted that the “beads” present an irregular appearance.
Fig. 19.—Same infant as in [figure 17]. Scorbutic beading of the ribs (rosary). This developed on a diet which included cod liver oil, and decreased when an antiscorbutic was given. Note peculiar ragged appearance of “beads.”
In Figs. [6], [16] and [17] will be seen illustrations of a separation of the epiphyses of the head of the humerus, and of partial and of complete separation of the lower ends of the femora. This is a frequent lesion of fully developed scurvy in infants, children, and even in young adults. It is most frequent at the lower end of the femur, the upper end of the tibia, the head of the humerus, and the costochondral junctions. It is to these epiphyseal separations that the term fracture or infraction usually refers. Union is remarkably perfect even where no splint has been employed, and nature has effected the cure ([Fig. 7]). Occasionally there is some deformity, as when coxa vara develops. The callus is often remarkably large; an old callus sometimes undergoes destruction in the course of scurvy.
Fig. 20.—Radiograph. Infant 14 months of age, showing “white line” at wrist some months after cure of scurvy.