Fig. 25.—Showing retardation of growth in length during the period when no orange juice was given and supergrowth when it was given once more, O. J.=orange juice. O. P. J.= orange-peel juice. Lower curve represents the normal.
Fever.—Fever frequently accompanies scurvy. It is generally of a low grade, ranging between 100° and 101°, as may be seen in [Fig. 15]. There is a difference of opinion as to whether the rise of temperature should be considered as truly scorbutic in nature, as “scorbutic fever,” or regarded merely as a condition grafted upon the nutritional disturbance. A phenomenon which might seem to argue for its essential scorbutic character is the sharp subsidence on giving antiscorbutic food. On the other hand, this may quite as well be interpreted as due to a secondary reaction, checking the absorption of toxins or bacteria. High temperatures—for example, fever of 103° or over—are attributable to a complicating infection and should lead to careful examination for the source of the trouble; pyelitis should particularly be borne in mind. In a recent case fever of uncertain origin disappeared following the transfusion of blood.
We have already considered numerous complications of scurvy, and shall therefore not go over this ground again. Many of them are due to hemorrhages or to serous effusions in various parts of the body. Another large group in adults as well as in infants are the result of infection. The respiratory tract is particularly susceptible, pneumonia constituting the most common cause of death. In infants we meet with frequent attacks of “grippe,” widespread occurrence of nasal diphtheria, furunculosis and torpid ulcers of the skin, pyelitis, otitis, adenitis, etc. We have encountered nasal diphtheria—with typical bloody mucous discharge—so frequently in connection with scurvy, that where this local infection occurs among a group of infants they should be carefully examined for latent or mild scurvy. Aschoff and Koch recently have laid emphasis on the frequency with which diphtheria complicated scurvy among adults (soldiers). Dysentery is another complication resulting from an invasion of bacteria. Local infections occur more often in adults than in infants—cervical adenitis following gingival pyorrhœa, “bubo” of the groin following infection of the lower extremity, abscess of the calf of the leg following hemorrhage into this region.
Scurvy sometimes occurs in epidemic form, especially in the army, but also, as in Russia, among the civilian population. This results when a large group of individuals have been maintained on a limited and inadequate ration, and especially where this nutritional condition is complicated by intercurrent infection. It should not be interpreted as evidence of the bacterial origin of scurvy. A few years ago the author reported an epidemic of scurvy in connection with an outbreak of grippe in an infant asylum. Twelve infants in one ward were affected. The signs were atypical—an undue degree of hemorrhage occurring at atypical sites (Table 5). It will be noted from the table that the ages of the infants, the distribution of the hemorrhages, the development of signs (in some instances) in spite of antiscorbutic treatment, the sharply defined epidemic character, distinguish these cases from the scurvy commonly seen. This is an instance where latent scurvy was prematurely changed to acute scurvy by an intercurrent ward infection; an epidemic of grippe precipitated a pseudo-epidemic of scurvy. It is important, especially for army surgeons, to bear in mind that where latent scurvy exists a bacterial invasion will lend the disorder a hemorrhagic character. This has been noted during the recent war in connection with typhus fever on the Eastern front, and was remarked upon during the Crimean War and our War of the Rebellion. Some years ago Wherry made a similar observation in the course of experiments with the plague bacillus—guinea-pigs fed on a cereal diet developed far more hemorrhages subsequent to infection than those which received cabbage in addition.
| Case | Age, Mos | Weight | Site of Hemorrhages | Date | Diet | Remarks |
|---|---|---|---|---|---|---|
| lbs. oz. | ||||||
| 1. J. H. | 6½ | 9 6 | Humerus, tibia, face. | Apr. 19 | Breast milk (1 week); pasteurized milk previously. | Grippe since end of February; nephritis; v. Pirquet negative. |
| 10 4 | Upper eyelid | May 9 | ||||
| 2. L. S. | 5 | 12 14 | External ear, parietal bones, vertebral column, abdominal wall | May 4 | Pasteurized milk formula; orange juice 1 oz. daily since April 22. | Twitchings and convulsions; signs of intoxication; red blood cells in urine fever to 101° F.; v. Pirquet negative. |
| 3. A. R. | 10 | 12 8 | Femur | Apr. 19 | Pasteurized milk formula; vegetables for a month; orange juice longer; getting orange juice and vegetables. | Grippe end of January; again in April; fever until April 17; v. Pirquet positive; gums negative. |
| Femur again swollen and tender. | June 4 | |||||
| 4. D. E. | 5 | 7 | Both ears; parietal bones. | Apr. 29 | Breast milk since April 19; May 30, changed to pasteurized milk. | Grippe throughout March; intoxication; nephritis; no relapse although no orange juice given. |
| 5. T. K. | 10 | 15 13 | Ear and face | Apr. 27 | Pasteurized milk, cereal, vegetable, soup; orange juice since April 15. | Two teeth; gums negative; v. Pirquet negative. |
| 6. P. G. | 4 | 8 4 | Tibia | May 8 | Pasteurized milk formula. | Grippe end of February and first half of March gained 20 oz. during last month; v. Pirquet negative. |
| 7. I. P. | 2 | 6 4 | Abdomen | Mar. 7 | Breast milk for past week; pasteurized milk previously. | Grippe; probable source of epidemic. |
DIAGNOSIS
A correct and early diagnosis of scurvy is the more important in view of the fact that we possess a specific remedy, and that the disorder is not self-limited. Recognition generally presents little difficulties for those who have seen cases, but is a stumbling block where the symptomatology has been gleaned merely from the textbooks. It has been our experience that medical students who were conversant with scurvy from a theoretical standpoint failed to diagnose a case presented to them in the clinic. Where diagnosis is uncertain, the most important aid is an exact knowledge of the previous diet, and observation of the reaction of the patient to antiscorbutic treatment. These diagnostic points should be constantly remembered in relation to the discussion which follows, and will not be reiterated in the differentiation of scurvy from the various other diseases.
The scurvy of adults and of infants are very similar. The main difference is the subjective symptoms in the adult—pains in various parts of the body—and the fact that the gums are frequently the site of infection and ulceration, as well as of hemorrhage. It might be thought that when scurvy occurs in epidemic form it would be readily recognized, but experience shows that for months it may permeate the ranks of troops or the inmates of almshouses, and pass as rheumatism. This is the cardinal diagnostic error in adult as well as in infantile scurvy—time and again, and in spite of urgent and repeated warnings, patients continue to be treated for rheumatism. Holt writes: “In fully four-fifths of the cases which have come to my own notice this (rheumatism) has been the previous diagnosis.” Such has been our experience. The diagnosis should not be difficult. In sporadic cases, the individual has limited his diet usually on account of indigestion, or diarrhœa, or following some dietetic whim or medical advice given months previously. Where scurvy occurs en masse it may follow an inability to obtain fresh food—as during war, on shipboard, in the Tropics or in the Arctic regions—or be the result of a misplaced reliance on some article of food—for example, dehydrated vegetables. More careful investigation will disclose that the “rheumatic” pains and tenderness are not in the joints but in the muscles and tendons. The calf muscles are frequently painful and excessively tender and somewhat swollen or infiltrated; the hamstring tendons or the tendo Achilles may be sore and slightly swollen and the site of slight subcutaneous hemorrhages. In some cases there is bone tenderness, pain on percussion of the shins or of the sternum. These signs may be accompanied by, or even precede, hemorrhages in the gums. The diagnosis of rheumatism in infants indicates a lack of knowledge of pediatrics, as this disease is hardly ever encountered in babies under a year and a half of age.
It is not always easy to differentiate scurvy from purpura. In either disease the gums may be hemorrhagic and swollen, there may be scattered subcutaneous hemorrhages and pains in the limbs. Occasionally, as in a case seen a few years ago, we may be forced to resort to the dietetic test. A close inquiry into the previous diet, however, a history of previous attacks of purpura, the number, and especially the large size, of the subcutaneous hemorrhages, and above all, the diminished number of blood-platelets, should make diagnosis possible. In scurvy the platelets are almost always over 300,000 per cubic millimetre, whereas in purpura they are reduced to less than 200,000.