Scurvy, Past and Present

by Alfred F. Hess

The urinary system is frequently involved in the course of scurvy. Among 38 cases Still reports that 89 per cent. gave evidence of urinary changes and that 60 per cent. showed hæmaturia. Finkelstein found urinary signs in at least a third of his cases. Our figures, the result of a study of subacute and mildly acute cases, correspond more nearly with those of Finkelstein.

The occurrence of pronounced renal hemorrhage as a first symptom of scurvy is emphasized in many descriptions of this disease, and has impressed itself in the minds of physicians. It is true that this occurs sometimes at the onset, as does hemorrhage into or about the joints, or hemorrhage behind the eyeball. It is well to bear these possibilities in mind, but they must be regarded as very exceptional early signs of this disorder. We have encountered frank hæmaturia but once in the early stage of infantile scurvy. The blood emanates generally from the kidneys, although the submucous hemorrhages of the bladder as well as in the urethra, described both in man and in guinea-pigs, indicate that the blood in the urine may have its origin lower down in the tract. This bleeding should be regarded not as a sign of nephritis, but rather as a hemorrhagic manifestation. It is less frequent in adults than in infants. O’Shea reports some degree of hemorrhage in 15 per cent. of his cases (adults).

A true nephritis, however, may occur in connection with scurvy. There may be albumen and many casts, or a urine loaded with casts and cylindroids. These peculiar casts may appear suddenly, as in the alimentary intoxication of infants, and disappear just as rapidly when antiscorbutic treatment is given. The urine may contain a large number of pus cells as in pyelitis. This condition may be accompanied by irregular fever, but in two instances we have encountered it where the temperature was normal. It is to be regarded, probably, merely as one of the manifestations of secondary infection so commonly associated with scurvy. Some pus cells may continue to be present in the urine for a period of months. This is likewise true of the red cells. We have under observation at present an infant which had subacute scurvy almost three years ago and still has red blood-cells in the urine.

Oliguria is a common symptom of both adult and infantile scurvy. Lind mentioned this symptom, and in this connection remarks on the beneficent effect of antiscorbutic treatment. Charpentier called attention to the fact that in a case of scurvy the urine decreased from 1250 g. to 800 g. The report of the American Pediatric Society mentions scanty urine in 9 cases and suppression of urine in one. This sign, however, was not emphasized until recently, when Gerstenberger, and Hess and Unger drew attention to its frequent occurrence in infants. It has some diagnostic significance and should be borne in mind where a decreased excretion of urine is reported. A counterpart of this symptom is the sudden outpouring of urine frequently noted after antiscorbutic treatment has been instituted. This polyuria accounts for the loss of weight or lack of gain which sometimes accompanies unmistakable general improvement, and which is difficult otherwise to understand (Fig. 23). It is interesting to learn that oliguria occurs commonly in both adult and infantile beriberi.

Fig. 23.—Joseph G., aged 9 months. Chart showing stationary weight (due to oliguria followed by diuresis) in spite of marked variation of fluid intake. A=Schloss milk; B=cod liver oil; C=egg yolk; D=1 ounce of orange juice; E=potato (orange juice stopped).

One of the earliest, as well as one of the most constant symptoms of scurvy, is a lack of appetite. It is a typical sign of latent scurvy, although occasionally we have met with cases where the appetite remained unimpaired until the hemorrhagic stage was reached. In adults there is sometimes bulimia and a marked capriciousness of the appetite. Anorexia is a true scorbutic symptom, disappearing with remarkable rapidity when antiscorbutic food is given, and not capable of alleviation by tincture of gentian or other vegetable bitters. Whether it depends upon a lack of secretions in the gastro-intestinal tract is not known, as there has been no thorough study of this aspect of the disorder. The hydrochloric acid generally is deficient in cases of scurvy. Recently McCarrison has laid emphasis on the importance of the impairment of the digestion and assimilative function in scurvy. This subject gains added interest in view of the recent reports of Uhlmann as well as of Voegtlin, showing that water-soluble vitamine acts as a stimulant for the various secretions of the gastro-intestinal tract.

As a result of McCollum’s statement that scurvy is due mainly to constipation, marked attention has been directed recently to the action of the bowels in this disorder. This question has been discussed in the chapter on etiology, and, therefore, will be referred to in this place merely from the clinical viewpoint. In our experience the activity of the bowel varies greatly in cases of latent or subacute scurvy. In a great many instances it has been normal; more often there has been slight constipation, and exceptionally there has been irregular diarrhœa. In other words, no causative relationship or parallelism could be observed between the emptying of the intestinal tract and the development of scurvy. This in general has been the experience of others. In the report of the American Pediatric Society the bowels are stated as having been regular in 74 cases, irregular in 15, constipated in 126, and diarrhœal in 65. It may be added that we were unable to cure scurvy by means of liquid petrolatum or phenolphthalein, either in infants or in guinea-pigs, and likewise unable to protect guinea-pigs from scurvy by means of various laxatives. On the other hand, opium given in the form of the camphorated tincture did not lead to an intensification of the symptoms, although, in one case, the bowels did not move for over three days.

As complications involving the gastro-intestinal tract may be mentioned the vomiting of blood, which is stated in the above report as occurring in 2 of the 361 cases, as well as bleeding from the bowel, which was noted in 37 cases, in 12 of which there was bloody diarrhœa. However, these are late symptoms, and correspond to the mycotic ulcers which are so frequently found, especially in the large intestine, in cases of scurvy. Mention may again be made of the fact that hemorrhages may occur under the peritoneum and give rise to symptoms simulating appendicitis or general peritonitis.

Jaundice has been described in connection with certain epidemics of scurvy. To our knowledge it has not been reported in infants.