Pains in the legs, joints, and loins are early manifestations: they closely resemble those of rheumatism, for which they are often mistaken. The pains are not exacerbated at night, but, on the contrary, are often more severe by day. Not unfrequently lancinating pains in the muscles of the chest are complained of. The sleep is not disturbed until the disease has made some advance, when it becomes broken and is no longer refreshing.
The appetite is usually unimpaired in the early periods of the disease, and even throughout its course the condition of the mouth alone prevents the patient from indulging his desire for food, even, as is occasionally noticed, to voracity. There may be a yearning for certain articles of diet, principally those of an acid character; but, on the other hand, some cases present exactly the reverse condition—a disgust for food in general or for particular varieties; or the appetite may be vacillating, at one time craving and at another repelling nourishment. There is no noticeable change in the normal thirst, except on the occurrence of febrile complications, when it is increased. The gums do not, at this stage of the disease, present the livid, swollen appearance of fully-developed scurvy, but, on the contrary, are generally paler than usual, with a slight tumid or everted line on their free margins, and are slightly tender on pressure. The breath is commonly offensive, and the patient complains of a bad taste in the mouth. The tongue is flabby and large, though clean and pale, and the bowels are inclined to be sluggish.
This preliminary stage is followed, after varying intervals of time, by certain local phenomena which are quite characteristic of the disease. There is a marked tendency to extravasation of blood into the tissues, either causelessly or upon the infliction of slight injuries or wounds. Fibrinous exudations occur sooner or later into the gums, which become darkened in color, inflamed, swollen, spongy, and bleed upon the slightest touch or even spontaneously, and finally separate from the teeth. These results are due, in part, to the considerable amount of pressure to which these parts are subject in mastication, and it is a conspicuous fact that the gums of edentulous jaws remain free from these changes. In a few cases the gums are but slightly altered, perhaps oedematous only or pitting upon pressure, or they become the site of bloody extravasations. In severer examples, in later stages of the disease, these various alterations progress to an extreme degree, and the extravasation is so voluminous that the gums present great, fungous, lacerable excrescences, which may finally break down into a suppurating, brownish, and very fetid mass, communicating to the breath an odor of a most offensive character. In certain epidemics of scurvy, notably in that of Florence described by Cipriani, the lesions of the gums were absent. The rest of the mucous membrane of the mouth remains unaltered, or at most slightly ecchymotic. Samson and Charpentier13 in a large number of cases saw this but once, and in one of Leven's14 cases the fungous growth invaded the palatal mucous membrane, extending to the anterior pillars of the fauces. The salivary glands are enlarged and swollen; the tongue is imprinted with the form of the teeth, while the latter become encrusted with tartar and more or less concealed by the exuberant gums, or, becoming gradually loosened from the alveoli, finally drop out. The morbid process may extend to the bone itself, and necrosis and extensive exfoliation follow. Mastication is more or less painful, and often impossible, so that the patient is reduced to the necessity of prolonging life by the use of fluid or semi-solid food. Under the influence of appropriate treatment it is remarkable how rapidly (in from two to four weeks) these marked changes recede and the parts resume their normal condition, yet it occasionally occurs that permanent, callous thickening of the gums results.
13 Étude sur le Scorbut, 1871.
14 Une épidémie de Scorbut, p. 28, 1872.
In the progress of the disease effusions of blood under the skin are of early occurrence. They are at first located in the superficial stratum of the cutis or just beneath the epidermis, especially around the roots of the hair, and present themselves as roundish, bluish-red flecks, varying in size from that of a pin's head to that of a split pea, not effaceable by pressure with the tip of the finger, but slightly, if at all, elevated above the surface, and enduring for weeks together. The nutrition of the hair-follicles is impaired, so that the hairs are often either lost, broken, or distorted. These petechiæ fade in color with progressive improvement in the case, and finally disappear, leaving brownish-yellow discolorations. They first appear on the extremities, particularly the lower limbs, then on the face, and lastly on the trunk. At a later period extravasations of a larger size and more irregular form occur in the deeper layers of the derma. They vary in size from that of a finger-nail to blotches two or three inches in diameter; at first reddish in color and subsequently of a bluish red. When recession occurs under appropriate treatment, the color passes through various shades of violet, blue, green, and yellow, as in ordinary traumatic ecchymosis. Outpourings of blood also occur into the subcutaneous connective tissue, notably that of the legs, and in localities where connective tissue is particularly abundant and loose, as in the ham and axilla. The dispersion of blood in this tissue may be so considerable as to cause the legs from the knees down to present a uniform dark-blue coloration that in form may not inaptly be compared to a stocking. The upper extremities also suffer, usually on their inner side from the armpit down, the extravasation rarely reaching, however, to the hand. These extravasations may take place after the infliction of very slight injuries, as from blows or the pressure of hard bodies, or even from the mechanical effects of prolonged dependency of the limbs, as in riding on horseback. Extravasations of a similar nature are occasionally present in the connective tissues of the muscles themselves or between them, giving rise to swellings of various forms and dimensions. Nearly always along with the sanguineous effusions there is more or less oedema, usually beginning at the ankles and gradually extending upward; in some cases there are puffiness of the face and general anasarca, so that deep pits remain on pressure.
This profound impairment of nutrition of the skin continuing, in the worst cases blood is effused beneath the cuticle, forming blebs of varying size, which finally break and leave superficial ulcerated surfaces, that ultimately become covered with flabby, exuberant granulations, pouring out a purulent often offensive sanies and bleeding upon the slightest touch.
In some cases the ulceration begins in the petechiæ at the hair-roots, and a number of these, running together, form a large ulcer. The destruction of tissue by ulceration is disposed to spread more widely and deeply, and is often of a most intractable character. Old cicatrices are the first tissues in these cases to take on the ulcerative action. Certain muscles, chiefly those of the legs, and notably the gastrocnemii, the abdominal and pectoral muscles, the psoas magnus, and pterygoids, may become the seat of fibrinous extravasations, which finally change, by lapse of time, into hard, firm tumors, impairing the functions of those parts and leading to contractions of the limbs.
The symptoms in certain epidemics of extraordinary severity have displayed alterations in still deeper structures. Effusions occur between the periosteum and the bone, forming painful, hard, and resisting nodes of varying dimensions, especially along the course of the tibiæ, upon the scapulæ, and upon the maxillæ. In young persons the epiphyses are separated from the shaft of the long bones, and in other cases the ribs become necrosed and disarticulated from the sternum, producing a creaking noise during respiratory movements, as related by Poupart.15 This occurs mostly on one side and about the middle of the series, yet it has been noted to occur on both sides, so that the sternum and attached cartilages, deprived of support, were perceptibly sunken. Oserctzkowski16 reports two fatal cases of scurvy attended with spontaneous fracture of the ribs. There was extravasation into and beneath the periosteum, and subsequent destruction of the continuity of the bone. In one case the ribs on both sides were affected, so that the anterior wall of the thorax sunk in and embarrassed the respiration, which was chiefly maintained by the diaphragm. Inflammation of the lungs succeeded, and the patient died in agony.
15 Mémoires de l'Académie des Sciences, p. 237, 1699, and Philosophical Transactions, vol. xv.