16 Wratsel, No. 51, 1881.
Recently-repaired fractures have been known to recur under the influence of scurvy from the destruction of the callus.17
17 Anson's Voyage Around the World, edited by Walter.
The articulations as well as the bones in very severe cases of scurvy present evidences of disease, consisting in periostitic effusions which involve the surrounding soft parts, producing impairment of motion, enlargement, and false ankylosis, and even destroying the normal anatomical relation of the osseous surfaces, so as to determine deformities. These changes are usually attended with severe pain, and most commonly occur in the ankle-, knee-, shoulder-, and hip-joints, and disappear tardily, requiring perhaps months for their recession, if indeed this takes place at all.
The symptoms manifested by the circulatory organs are prominent from an early period of the disease. The pulsations of the heart are slower, feebler, irregular, and often intermittent; its impulse is decreased or becomes quite imperceptible; and when the associated anæmia has progressed to a certain extent a systolic murmur may be audible. The arterial and venous channels are of diminished calibre; the pulse becomes soft, of less volume, and tardier; and a venous murmur may sometimes be heard in the cervical veins. The remarkable nutritive changes in the capillary walls in part account for the numerous hemorrhages which occur both by rhexis and diapedesis. The most frequent is epistaxis; the slightest blows, sneezing, or blowing the nose will often determine it, or it may occur spontaneously, and in severer cases with such profuseness as to threaten impending dissolution, requiring nothing less than timeous introduction of the tampon to rescue the victim. Hemorrhage from the lungs is of rare occurrence, and when it does happen is rather indicative of pre-existing pulmonary disease, such as phthisis, or of the approach of a complication, such as infarction or gangrene, than a constituent feature of scurvy. Hæmatemesis is less uncommon, but is by no means frequent; the blood ejected from the stomach is usually small in quantity, but in isolated examples the bleeding is profuse, producing great exhaustion and a sense of cardiac depression which preludes speedy death. Hemorrhage from the bowels is also an ill-omened feature, completely blanching the patient and presaging early exhaustion and death. Blood may also appear as a product of a complicating dysentery which determines abundant, offensive discharges that may run on for several weeks before the patient is finally exhausted. Hæmaturia sometimes occurs, especially in broken-down and cachectic subjects and in an advanced stage of scurvy. All of these forms of hemorrhagic effusion, now mentioned as localized in the mucous membranes, are to be deprecated as exercising a pernicious influence, seriously aggravating ordinary cases and fatally jeopardizing the issue of severe ones.
Effusive and inflammatory complications are also encountered in the serous structures, and usually in cases of great severity, though they occasionally present themselves when the more common localized phenomena of scurvy are not particularly prominent. These complications may be marked by a gradual accession, or they may rapidly arise and involve the patient, just before in apparent security, in the greatest peril. These incursions are almost always attended by febrile exacerbations and the usual grouping of clinical characters denotive of the same pathological conditions arising under ordinary circumstances. The local complications may either affect the pleura or pericardium, or both. In Karairajew's18 60 autopsic examinations pericardial effusions were noticed in 30, pleural in 30, pericardial and pleural in 6, peritoneal in 7, and arachnoidal in only 1. The exudations are sero-sanguinolent or fibrinous in character, and sometimes reach the inordinate quantity of four or five pounds, occasioning the patient the utmost distress and embarrassing the respiratory and circulatory functions. Although these augment in a high degree the risk to life, yet under prompt and appropriate treatment recovery may take place and the effusions vanish with surprising rapidity.
18 Himmelstiern, Beobachtungen über den Scorbut, S. 50, Berlin, 1843.
Hemorrhagic extravasation into the nervous centres is a very rare occurrence. It has not been as yet recorded as having occurred in the brain-substance itself, but has in several instances been noted between the meninges, producing headache, dizziness, vertigo, and sometimes somnolence, delirium, and coma. Opitz19 relates an interesting case in which convulsions suddenly occurred with unconsciousness, followed by hemiplegia of the left side of the body and the corresponding side of the face. After twenty-four hours consciousness returned and the paralysis disappeared. There were, however, headache and hyperæsthesia of the upper extremities present; twelve days later these also receded, and the patient finally recovered. The same author records paralysis as occurring in one case from extravasation into the spinal meninges. Samson observed an instance in which a fibrinous effusion formed upon the sciatic nerve, with consequent pain.
19 Prag. Vierteljahrschrift, S. 153, 1861.
In the circulatory system symptoms always of threatening and often of fatal import may arise: embolism may occur at various points, particularly in the lungs and spleen, occasioning hemorrhagic infarctions, which have undoubtedly been the occasion of the sudden deaths sometimes observed in scorbutic cases not apparently of a very dangerous form nor attended with an excessive degree of exhaustion.