—The pathology of scurvy is obscure. It has been shown that gastric digestion is seriously at fault, that there is much intestinal putrefaction, that the urine shows great absorption of toxins, that the hematopoietic function is incomplete: that scurvy is a toxemic or chronic ptomain poisoning, which may in part or at times be due to the use of tainted food. Morphological changes are, however, neither distinct nor pathognomonic. It has been described as a disease of diet and occupation rather than of race, age, sex, or season. The ease with which hemorrhagic effusions occur, the degeneration of muscles and other tissues, the frequent detachment of cartilages, can be accounted for by conditions thus summarized, for which, however, we have no minute explanation. Scurvy may so complicate various other diseases, and usually does when occurring in large bodies of men—as in armies, prisons, among convicts, etc.—that it is hard to dissociate morbid phenomena and assign to each its proper place.
Symptoms.
—The disease begins by a condition of generalized prostration, with an icteric tint of the skin, malaise, mental torpor, loss of appetite, insomnia, etc. The first recognizable or distinctive local appearances occur about the margins of the gums. Here, in the intervals between the teeth, the gums become livid, friable, and bleed easily, while the breath assumes a characteristic fetid odor. The skin becomes dry and brittle, and covered with minute prominences, which give it the popular name “goose-flesh.” These appearances are followed by local pains, diversified and sometimes excessive, and extravasations of blood in the skin and under the visible mucous membranes, causing small ecchymoses, which by themselves would be considered as simple purpura hæmorrhagica. These pass through the usual phases of extravasations, while it is made evident by pain, nodular masses, etc., and by postmortem examination, that similar hæmorrhages occur in the deeper tissues, especially in the muscles, even in the bones and epiphyses. So easily do hemorrhages occur in advanced stages that there is often external bleeding, particularly from the gums and mucous membranes, while from points thus involved pyogenic infection may proceed internally. Near the close the victim presents a picture apparently of an animated corpse, with surface discolored and mottled, often appearing bruised, with ulcerations where extravasations have failed to resolve, and where infection has occurred, possibly with epiphyses loosened, and necrosis of the bones of the extremities. In such cases death results from marasmus and sepsis.
Treatment.
—As long as the patient is not in the desperate condition just described the prognosis and outlook for treatment are promising, as all the milder manifestations of scurvy can be dispersed by suitable feeding and medication. Loss of teeth and cicatrices of ulcers leave permanent traces, but function can be restored. The purpura is but one expression of the scorbutic condition. Nearly all cases of scurvy will present purpuric manifestations, but all cases of purpura are not necessarily scorbutic. The course of treatment may be summed up in proper diet and in the administration of certain drugs. Proper diet should be prescribed at once, but administered, especially in severe cases, with extreme caution. The food selected should be given in small quantities, but frequently. It should consist in large measure of fresh fruits and vegetables, while cranberries and lime-juice figure largely among the former. Buttermilk is excellent, and cider may be allowed; also lemonade, with but little sugar.
PLATE XI
FIG. 1
Rickets. Rib. Very low power. (Gaylord and Aschoff.)
FIG. 2