CHAPTER XIII

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SCURVY AND RICKETS.

SCURVY.

Scurvy is placed among the so-called surgical diseases, since it manifests many distinctly surgical features and is possibly of parasitic character, although this feature of its existence has not been incontrovertibly established. It is a _starvation_ disease, its principal characteristic being that of _malassimilation_, accompanied by profound _anemia_. Well-marked cases are seen during long sieges, like that of Paris, in 1871, or during long imprisonment, as in Andersonville prison. It has certain points of resemblance to that condition of multiple neuritis met with in warm climates, and known usually as _beriberi_. The former is apparently due to the absence of a vegetable regimen, while beriberi is largely due to the absence of an animal regimen, nature having intended that man’s diet should be mixed, and having ordained that suffering and disease always follow confinement to one or the other.

=Pathology.=--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.

[Illustration: PLATE XI

FIG. 1

Rickets. Rib. Very low power. (Gaylord and Aschoff.)

FIG. 2

Rickets. Flat Bone of Skull (Craniotabes). (Karg and Schmorl.)]

For the local condition in the mouth an antiseptic mouth-wash containing a fair proportion of hydrogen dioxide is advisable. Alcoholic stimulants are called for, at least up to a certain point. Strychnine and cinchona preparations will give force to the heart’s

## action, and the horizontal position, for a time at least, will prevent

sudden heart failure. Compound syrup of the hypophosphites, with meat preparations, will supply lacking material, while the hemorrhagic manifestations are best controlled by the fluid extract of ergot and aromatic sulphuric acid, separately or combined. Particular attention should be given to cleanliness and fresh air.

=Infantile Scorbutus.=--Infantile scorbutus sometimes furnishes the surgeon with very young patients who are brought to him especially for disability of the limbs, with pain and fretfulness, leading to immobility, followed by enlargement of the lower ends of the femurs (due to subperiosteal hemorrhages) with fixation by muscle spasm; this may be followed by “spontaneous” fractures. The gums will show the same changes as are seen in adults, while subcutaneous hemorrhages and infiltrated muscles, with foul breath, ashen pallor, listlessness and apathy, and perhaps several swollen joints, will complete an unmistakable picture.

Fresh milk with orange-juice in small amounts between feedings, combined with more strictly surgical measures if needed, will secure good results in these little patients.

RICKETS.

Rickets, or _rachitis_, is another of the diathetic conditions, in this instance not yet considered of parasitic origin, most commonly occurring in infancy and early childhood, although its resulting lesions may persist throughout life. It is characterized by nutritional disturbances and organic irregularities.

=Pathology.=--Rickets is generally referred to as “fetal” or “congenital,” according to whether the infant presents characteristic markings at birth or whether they develop later. The most marked constitutional defect seems to be in the supply of calcium salts, which leads apparently to formation of bone which has not sufficient compact tissue to make it strong. Especially along the line of junction between bone and cartilage do we see the most marked expressions of rachitic lesions. Here the cartilage is evidently actively growing, while the bone formation proceeds with difficulty, and the proportion of vascular tissue is excessive. The result is prolongations of soft vascular into the cartilaginous tissue, by which the latter becomes more or less absorbed, and this essentially interferes with _ossification_. In severe cases it may be lacking. At epiphyseal lines one may see a layer of osteoid tissue which is not cartilage and will not become bone. Because of its yielding nature it warps under the mechanical strain to which the bones of the extremities in young children are constantly subjected.

The obscure but unmistakable relations existing _between rickets and the status lymphaticus_ will be referred to in