In the army it may be difficult to distinguish scurvy from beriberi, especially if they occur side by side as in the recent English campaign in Mesopotamia. There may be a combination of the two diseases, a picture similar to ship-beriberi, regarded by Nocht as a hybrid of these diseases. The diagnosis is rendered more difficult, as at times scurvy is associated with signs of neuritis. We shall have to depend on the involvement of the gums and the hemorrhages in scurvy, and on the hyperæsthesia, paræsthesia, and anæsthesia in beriberi; marked edema points to the latter disease.
We have thus far had in mind frank and outspoken cases of scurvy. When we come to consider latent or early cases, the diagnosis is more difficult and may have to be merely tentative. All that need be added, in view of the clinical picture sketched above, is that this condition should not be forgotten in treating adults who have malaise and indefinite “rheumatic” pains and, more particularly, in relation to infants who fail to gain, whose appetite is capricious, whose disposition has become fretful and who have developed the sallow scorbutic complexion. This warning is particularly opportune at present in the United States, where pasteurized milk is fed so extensively to infants, and an antiscorbutic food is not always given.
In addition to the symptoms just enumerated, tenderness of the bones, especially of the distal ends of the femora, should be sought for, the urine should be examined carefully for red blood-cells, and perhaps the ends of the long bones radiographed for “the white line” of Fraenkel.
The experience of Comby with infantile scurvy is illuminating. Among the fifty-five cases which he has seen, the diagnosis was erroneous in forty-five, and among thirteen cases recently met with, the physician failed to recognize the disorder in all but two. The infants had been given sodium salicylate, had been treated with electricity and massage for the supposed acute poliomyelitis, or given mercury for syphilis, or incisions or trephining had been carried out for acute osteomyelitis. Some had been put into plaster casts for coxalgia or for Potts’ disease. This experience requires little comment. It should be added, however, that in the course of an epidemic of poliomyelitis, such mistakes are apt to happen, and, to our knowledge, did occur in the recent epidemic.
In regard to “the pseudo-paralysis” of congenital syphilis diagnosed as scurvy, it should be remembered that this lesion occurs almost always before the fifth month of life. A history of previous papular eruption, the bilateral enlargement of the epitrochlear glands, and the Wassermann test should suffice to establish the correct diagnosis.
Besides the clinical conditions enumerated above, we may add the following, which have been confused with scurvy: Neuritis, hemorrhagic nephritis, calculus of the urinary tract, renal tumor, orbital tumor, appendicitis, peritonitis, pleurisy and pneumonia. Holt writes as follows: “I have known two cases to be operated upon by eminent surgeons, once with a diagnosis of sarcoma and once of ostitis of both tibiæ. Not until the subperiosteal hemorrhages and epiphyseal separations were discovered was the nature of the trouble suspected.” Recently we saw a case of fracture of the distal end of the femur diagnosed as infantile scurvy; the baby had caught its thigh between the bars of the crib and snapped the bone in trying to extricate itself. Finkelstein adds acute endocarditis, hemorrhagic septicæmia with multiple bone swellings, and leukæmia as having been confused with scurvy.
In an interesting account of scurvy in the Russian army during the recent war, Hoerschelman states that tired soldiers at times feign scurvy. They produce a “pseudo-scurvy” by means of scratching the gums with their nails or rubbing them with tobacco, and at the same time bring about hemorrhages of the skin by means of trauma.
Scurvy in the breast-fed infant has been fully considered under etiology. We wish merely to state again that one cannot be too cautious in venturing this diagnosis in a nursing baby. The great majority of reported cases are not scurvy, but bacterial infections, syphilis, or various forms of intoxication. In establishing a diagnosis the same principles hold as in the case of bottle-fed infants.
The most important consideration in the diagnosis of scurvy is to keep in mind the heterogeneous character of its symptoms, and the manifold diseases with which it may be confused. Surgeons should be alert to this danger when about to perform operations for osteomyelitis or bone tumor. The mistakes occur because cases are infrequently seen and because the signs, being dependent largely upon hemorrhage, occur in such varied locations of the body. Where diagnosis cannot be made from the signs or symptoms, the most important aid is a thorough acquaintance with the previous diet of the individual and observation of his reaction to antiscorbutic treatment.