PROGNOSIS
The outcome of scurvy, as we encounter it in peace time in the Temperate
Zone, is generally favorable, so that it plays but an insignificant
rôle in our mortality statistics. This results from the fact that we are
abundantly provided with a specific remedy, so that if the diagnosis is
made early and treatment is prompt and thorough, the patient will
rapidly recover and suffer no physical disability. Where antiscorbutic
foodstuffs are not procurable, however, this disease constitutes a
terrible scourge, causing many deaths and spreading among an army, a
ship's crew, or among the civil population with the rapidity of an
epidemic. For example, the ships of the East India Company in their
voyages round the Cape often lost nearly one-half of their crews, and in
Lord Anson's famous voyage round the world 380 out of 510 seamen
perished from the disease. Moreover, if the antiscorbutic treatment is
inadequate or the patient goes untreated for a long period, the cure may
be incomplete, a condition of malnutrition and weakness developing,
which may persist for years. To appreciate this clinical condition we
must refer to the account of physicians who saw thousands of cases of
severe and untreated scurvy among the sailors, who were of necessity
deprived of aid until they reached land. Lind laid stress on a type of
this disease which developed under these circumstances and which he
termed "obstinate scurvy." He writes: "I have met with numerous
instances not only among the common seamen, but of officers, with whom
it had taken such deep root in the constitution as to prove a lasting
affliction to them during a great part of their lives.... Persons are
likewise subject in different periods of their life afterwards to
habitual rheumatism, pains and stiffness in their joints; and sometimes
eruptions on the skin." In his treatise on scurvy, published in 1685,
Harvey refers to this chronic nutritional disorder as "inveterate
scurvy." He pictures patients who had gone untreated for a long time as
"molested with vagrant, ambulative, distending, creeping, vellicating or
lancinating pains of several parts of the body.... They are often loose
and subject to falling into violent fluxes of the belly, diarrhoea and
lienteries."
Infants as well as adults usually recover rapidly and completely from
scurvy, the result depending largely upon the early recognition of the
disease. We must always bear in mind, however, that from a histologic
standpoint the cure is not simultaneous with the magic disappearance of
the clinical symptoms, but that months probably elapse before the
tissues return to their normal state. It is difficult to give reliable
mortality statistics for infantile scurvy, for so many cases are of the
rudimentary form that percentages are necessarily misleading. Still
writes that in 5 out of 64 cases the disease proved fatal by diarrhoea
and exhaustion. The American Pediatric Society reports 29 deaths out of
397 cases, which gives a similar mortality percentage. When infantile
scurvy was not so generally recognized by physicians the mortality was
much higher, and we find that Barlow encountered 7 deaths in his first
series of 31 cases.
Even when the child recovers it may not regain its normal health if it
has continued for a prolonged period in a state of chronic scurvy. It
may remain pale and fail to gain in weight in spite of a liberal and
well-balanced diet. Cases of this kind are not infrequent. In this
connection it is worthy of note that 4 of the 41 cases of "coeliac
disease," an interesting intestinal condition described by Still, had
scurvy just before or during the onset of the disease. This observation
conforms to the experience that chronic bowel disorders often follow in
the wake of adult scurvy.
In adults the heart may be weakened by scurvy, and death may result from
cardiac failure. Cardiac disturbances occur also in infantile scurvy.
This involvement might be expected, in view of the tachycardia
(cardiorespiratory phenomenon) which is so frequent a symptom of
infantile scurvy. The heart may be rapid for months or even for years
after the disorder, and tachycardia may develop on the occasion of even
a mild infectious disease. For example, a fever of 101°, due to a common
coryza, may cause the heart-beat to rise to perhaps 180 a minute.
Children so affected succumb readily to infection, especially to
pneumonia, which may lead to sudden collapse followed by death.
An important factor in the prognosis of scurvy, as in that of other
disorders due to a lack of vitamines, is the marked susceptibility to
infection. Even latent or subacute scurvy causes a peculiar
susceptibility to diphtheria (especially the nasal type), to coryza,
bronchitis, and pneumonia. A perusal of the literature shows that this
susceptibility was noted by the older authors in relation to adults.
The local signs usually disappear quickly without leaving any trace. The
hemorrhages are absorbed and the eczema heals within a few days. The
fractures unite promptly with the formation of an unusually large
callus. The urine, which may have contained red blood-cells or have been
markedly hemorrhagic, quickly becomes normal and, in our experience,
gives no further evidence of renal damage. Still reports, however, the
case of a frail child who had a trace of albumen in the urine two years
after an attack of scurvy. A rare local injury, which may lead to death,
is cerebral hemorrhage. Recently Sammis reported a case of this kind,
which was characterized by convulsions during life, and in which
subdural hemorrhage was found at necropsy.
If we acknowledge an individual idiosyncrasy to scurvy we should expect
a tendency to a recurrence of the disease. Lind was of this opinion,
stating that "by observations made on this disease, it appears that
those who are once afflicted with it, especially in so high a degree as
that squadron was, are more subject to it afterwards than others." It is
difficult at the present day to express a personal opinion on this
matter, as clinical experience is meagre and the scurvy of guinea-pigs
is so acute that it cannot be used for comparison. Some of the
recurrences have been due probably to the fact that the patient had not
been completely cured of his first attack. We have met with two cases of
recurrences in infants, one of which is of particular interest as it
happened in spite of giving lemon juice in the intervening period. The
history was as follows:
In September, 1914, one month after the baby was admitted to the
institution, it developed scurvy of a moderate grade. It was then
six months of age and weighed 10¼ pounds. It was put on a simple
mixture containing from 24 to 30 ounces of pasteurized milk and was
given in addition ½ ounce of lemon juice a day. It improved, but
during the winter had bronchitis, otitis, enteritis, and later
furunculosis. In spite of the fact that it had been receiving an
antiscorbutic for almost this entire period, it developed scurvy
once more in February, at the age of 11 months, and when it weighed
14½ pounds. It was evident that this baby was peculiarly
susceptible to scurvy. It may be added that the second attack was
complicated by nasal diphtheria.
In this connection attention should be drawn to a peculiar and puzzling
clinical phenomenon, which we have noted several times. Even if the
antiscorbutic treatment is carried out incompletely and only for a short
period, recrudescences may not take place. We have seen cases where
orange juice was given for merely ten days or two weeks--that is, only
until all scorbutic signs had disappeared,--and yet the scurvy did not
return, the infants thrived for months thereafter, but were merely
somewhat pale and undernourished. In the case of two babies which we
have in mind, the diet remained absolutely unchanged, with the exception
of the short period of antiscorbutic treatment, but this seemed
sufficient to bring about a diminished susceptibility.