Scurvy, Past and Present

by Alfred F. Hess

We have referred to use of röntgenograms in connection with separation of the epiphyses, subperiosteal hemorrhage, cardiac enlargement and beading of the ribs. In addition to its application in these connections, the X-ray may be of service to show a peculiar alteration of the ends of the long bones—the white line of Fraenkel. This is portrayed in Fig. 20. It is best seen at the lower ends of the radius and femur, and appears as a white, transverse, somewhat irregular band. Its diagnostic value has been greatly exaggerated, as it is frequently not present when the disease is advanced (observe radiographs illustrating separation of the epiphyses). This sign should therefore not be relied on for establishing the diagnosis. Furthermore, changes may be seen in connection with rickets (cases receiving antiscorbutic diet) which are very difficult to differentiate from the “white line.” It cannot be employed as a criterion of the progress of the case, as it may persist for months after all other signs and symptoms have disappeared.

The joints may be involved in scurvy. In most instances, however, where swelling of the joints is diagnosed, the lesion is periarticular. An effusion of serum or of blood does occur occasionally into the joints and has been found at operation, at necropsy, and by puncture. If these effusions are allowed to go undisturbed, to be absorbed as a result of antiscorbutic treatment, they rarely suppurate. Czerny and Keller report the articular fluid as invariably sterile.

The cardiovascular system has been given but scant attention in connection with scurvy. Adults complain not infrequently of palpitation and pain over the pericardium, or rather of a tightness or oppression in the chest. Little information is given regarding the size of the heart. Darling described enlargement of the heart, especially a right-sided hypertrophy, which he thought was pathognomonic of the Rand type of scurvy. The pulse is described in some cases as slow, and in others as rapid. In descriptions of infantile scurvy the entire subject is generally passed over without mention—for example, in the excellent report of the American Pediatric Society nothing whatsoever is stated regarding the heart’s action or the pulse. Barlow wrote: “There is nothing to note regarding the heart and lungs.”

Fig. 21.—Radiograph. Scorbutic infant 14 months of age, showing cardiac enlargement and broadening of shadow at base of heart.

In a paper written a few years ago, it was pointed out by the author that there is frequently enlargement of the heart, and more especially of the right heart. This can be elicited at the bedside and has been substantiated in numerous cases by means of the Röntgen-ray, which demonstrates not only enlargement of the heart, but also a marked broadening at its base, at the site of the large vessels (Fig. 21). These phenomena resemble closely the description of Reinhard in cases of beriberi.

Necropsy protocols usually are incomplete and unsatisfactory in their descriptions of the heart. The excellent monograph of Schoedel and Nauwerk, however, which reports five careful necropsies, contains the following data regarding three:

1. Pericardial fluid somewhat increased, both ventricles moderately dilated, the right somewhat hypertrophic.

2. The heart showed a hypertrophy of the right and left ventricles, as well as dilatation of the right ventricle.

3. The right ventricle dilated and slightly hypertrophied, the muscles pale and tough.