The presence of worms has been frequently reported in the bowel or in the stool of patients suffering from beriberi. There have been no similar investigations in relation to scurvy. It would be interesting to inquire into this question, as it is quite possible that a lack of antiscorbutic foodstuff may favor the presence of parasites in the intestinal canal.
Before closing this consideration of the involvement of the alimentary tract, we would call attention to the relation of stomatitis to scurvy. Among adults this is a common complication. In infants it is uncommon, due to the absence of carious teeth and secondary infection; we have encountered it in but two instances. Stomatitis is of importance in this connection, as it frequently develops on the basis of malnutrition, scurvy being one of the disorders which may constitute the substratum. Such may be the case where stomatitis occurs in epidemic form —for example, among large bodies of troops. It may be remarked that stomatitis at times was a very common disease among the soldiers in the recent war.
| Name | Date | Platelets | Leukocytes | Erythrocytes | Hmgl. % (Sahli) | Remarks |
|---|---|---|---|---|---|---|
| M. H. | 5/ 3 | 280,000 | ...... | ......... | .. | |
| 5/ 4 | 248,000 | 10,000 | ......... | .. | ||
| 5/ 5 | ....... | ...... | ......... | .. | Boiled orange juice given. | |
| 5/ 8 | ....... | ...... | 4,300,000 | 35 | ||
| 5/16 | ....... | 15,900 | ......... | .. | ||
| 7/ 2 | ....... | 6,800 | 5,456,000 | 40 | Well but pale. | |
| A. L. | 5/ 3 | 300,000 | ...... | ......... | .. | |
| 5/ 5 | ....... | 21,000 | ......... | .. | ||
| 5/ 9 | ....... | ...... | 5,480,000 | .. | ||
| 5/11 | 320,000 | ...... | ......... | .. | ||
| 5/13 | ....... | ...... | ......... | 65 | ||
| 5/16 | ....... | 11,500 | ......... | .. | ||
| H. C. | 5/ 8 | 320,000 | 20,000 | ......... | .. | |
| 5/ 9 | ....... | ...... | 5,340,000 | .. | ||
| 5/13 | ....... | ...... | ......... | 70 | ||
| 5/16 | 362,000 | ...... | ......... | .. | ||
| B. B. | 5/ 4 | 496,000 | 21,000 | ......... | .. | A severe case. |
| 5/13 | 585,000 | 14,000 | 3,200,000 | 70 | ||
| 5/18 | ....... | 17,600 | ......... | .. | ||
| 7/13 | ....... | 40,000 | 7,672,000 | 82 | Has gained well lately. | |
| 7/15 | ....... | ...... | 7,640,000 | 88 | ||
| H. Y. | 5/15 | 560,000 | ...... | ......... | .. | |
| 5/16 | 424,000 | ...... | ......... | .. | ||
| 7/ 9 | ....... | ...... | 5,750,000 | 45 |
Scurvy is associated with an alteration of both the blood and the blood-vessels. The characteristic pallor, which is one of the most common as well as earliest symptoms, is due in a large measure to the anemia. This anemia is of the secondary type, but has definite peculiarities, and does not resemble that encountered in the course of tuberculosis, rickets or marasmus. The hemoglobin is greatly diminished, far out of proportion to the decrease in the number of the red cells. Not infrequently we will find a hemoglobin index of 0.5. Table 4, above taken from the article on this subject by Hess and Fish (1914), brings out the details of the blood-picture. It shows that there may be a polycythemica, which may persist after the other signs of the disorder have disappeared. Brandt has recently made similar observations, reporting in one instance over ten million red cells two months after treatment. In soldiers suffering from scurvy Wassermann has encountered cases where, during convalescence, the red-cell count has risen to over six or seven millions and the hemoglobin to 110 or 120 per cent. Under the microscope the red cells show poikilocytosis, anisocytosis and a lack of hemoglobin; they are slightly enlarged, with the occasional occurrence of exceptionally large cells resembling the “dropsical cells” described in connection with chlorosis. Sometimes a few nucleated red cells and myeloblasts are seen; megaloblasts are also reported.[48] The blood-picture bears a remarkable similarity to that of chlorosis, a point of interest, in view of the fact that both scurvy and chlorosis have been attributed to a disordered function of the endocrine glands. The “dropsical cells” suggest a disturbance of the salt balance in the plasma. In some cases we have found a decreased fragility of the red cells, which also has been described in chlorosis.
The total number of leucocytes is slightly increased. In our cases the mononuclear cells have averaged 66 per cent., which is somewhat high even for infants. This has been the experience of Labor, who, however, also describes an eosinophilia during convalescence, a phenomenon which we have not encountered. Some describe a marked increase in the polynuclear cells, which, probably, is to be regarded as the reaction to secondary infections. There is indeed a marked difference of opinion in regard to the morphology of the blood in scurvy in adults as well as in infants. Some found a large number of one type of cell—for example, nucleated red cells, myelocytes, eosinophiles—whereas others have failed to observe an increase of these cells. The divergent reports probably should be attributed to the fact that the investigators are describing scurvy of various grades of severity, of different stages of development, or complicated by intercurrent disease.
Nobécourt, Tixier, and Maillet have questioned whether there is always complete recovery from this anemia, which is severe from the standpoint of hemoglobin and iron. The older authors reported instances where men have been weakly and ailing for the remainder of their lives after an attack of scurvy. In some infants pallor and anemia may persist for months after apparent cure; however, this is the exception rather than the rule.
In view of the fact that scurvy frequently is classed as a hemorrhagic disease, and that hemorrhages play such an important rôle in its symptomatology, a consideration of the factors concerned in the coagulability of the blood is of interest. In an investigation (Hess and Fish) it was found that the oxalated plasma (of blood taken directly from a vein) showed a slightly delayed coagulation time—eight to fourteen minutes. The “bleeding time” carried out according to the simple method of Duke was slightly increased. Holt reports a case where a child bled to death following incision into an epiphyseal swelling at the lower end of the femur. The number of blood platelets is increased, running parallel, as is usually the case, with the number of red cells ([Table 4]). This increase in the blood-platelets, recently confirmed by Tobler and by Brandt, is a very exceptional phenomenon, and was not anticipated in connection with a disorder characterized by hemorrhage. The antithrombin content of the plasma is normal.
The investigation was directed to a study of the integrity of the blood-vessels in order to account for the hemorrhages. To this end the “capillary resistance test” was devised.[49] In the majority of cases this was found to be “positive” (the blood-vessels showing an increased permeability) and to become negative when antiscorbutics were given and the symptoms disappeared. This shows that the cellular structure of the vessels is altered in the course of scurvy, and indicates probably that this is an important cause of the hemorrhages. The edema of the face and ankles, the outflow of serum into the body cavities and into the muscles (Barlow) must be regarded as other evidences of the inadequacy of the vessel walls. The tendency of children with exudative diathesis to develop scurvy is perhaps still another manifestation of vascular weakness. This point of view has been strengthened recently by the pathological studies of Aschoff and Koch, who regard scurvy as a nutritional disorder in which there is a lack of some colloidal substance needed for the normal structure of the vessels.
When one makes a subcutaneous puncture in infants suffering from scurvy, a small hemorrhage very often develops at the site of the puncture wound. This is not the case when one makes a hypodermic puncture in a normal person or in a hemophiliac, although it does occur in cases of purpura. This “stick test” is not a constant sign of scurvy, but, like the capillary resistance test, was found in many cases and disappeared with the subsidence of the disorder. It shows that the cells of the skin and subcutaneous tissues are affected, and possibly that their thromboplastic power is diminished.