infiltration, and the ventricles may contain serous or bloody fluid.
Similar effusions have also been noted in the arachnoid. Most
frequently, however, the brain and its membranes present an anæmic
appearance, there is less blood than natural in the vessels, and the
tissues are pale. Very often no changes whatever are observed.
The heart is smaller than normal, relaxed, and flabby, its fibres
easily broken, and a cut surface presents the yellowish aspect of fatty
degeneration in certain parts, with occasional extravasations located
in the cardiac walls. The valves of the heart are relaxed and illy
adapted to accurate closure. In certain recent cases soft coagula or
dark fluid blood, and in others firmly coagulated blood, are found in
the cavities; in those which have been prolonged the blood is more
likely to be found fluid and the coagula diffluent. The endocardium is
often blotched to a greater or less extent by sanguineous imbibition.
The pericardium often contains serum, and in the worst cases is
inflamed, lacerable, and contains bloody effusions. The inner surface
of the great vessels at the base of the heart is stained by imbibition.
The respiratory organs are variously affected. The mucous membrane
lining the nose, larynx, and trachea is generally pale and flecked with
extravasations of a dark-red color; more or less frothy fluid, tinged
with blood, is present in these passages, and occasionally oedema of
the glottis is encountered. The lungs are, as a rule, infiltrated with
a bloody serosity, particularly in those cases with renal complication,
or with a fibrinous or bloody exudation. The posterior portions of the
lobes often present evidences of hypostatic congestion, or even of
gangrene, and in the latter case the tissue is easily friable and emits
a disagreeable odor. Their surfaces are mottled with superficial
discolored patches of varying size and outline. The lungs may, on the
other hand, be found pale, {173} with empty collapsed vessels and with
little or no effusion. The pleural cavities commonly contain a serous
fluid, or, in rare cases, a copious effusion of blood. Traces of
inflammation and discoloration by sanguineous staining are traceable on
the pleural surfaces.
The digestive organs furnish strongly marked lesions. The mouth
presents the most constant scorbutic feature, a stomatitis in which the
gums are infiltrated, spongy, livid, and the seat of fatty
degeneration; the teeth are loosened or have already fallen out. The
stomach and small intestines are thin-walled, and the mucous membrane
is often softened, and in places ulcerated; similar changes have been
noted in the solitary glands. Follicular ulceration of the large
intestine occurs, with softening and infiltration of the mucous
membrane. Hemorrhagic effusions into the mucous membrane, forming
stippling, flecks, or patches, occur in various degrees along the whole
extent of the alimentary canal. The pancreas is occasionally found
softened and containing hemorrhagic effusions.
The kidneys are, as a rule, found in the normal condition in cases in
which albumen has been observed in the urine. Occasionally they are
engorged, with infarction of the cortical substance, and the mucous
lining softened and thickened and covered with blood-tinged mucus, or
they may present various degrees of parenchymatous degeneration. The
ureters and bladder sometimes present ecchymotic spots, and the
contained urine is mingled with blood.
The liver is always more or less altered by fatty degeneration, and at
times replete with blood and softened, and its surface ecchymotic. The
spleen is occasionally greatly enlarged, and its tissues very
lacerable, laden with blood, and infarcted.
PATHOLOGY.--The essential character of scurvy consists in perverted
nutrition, in which the blood undergoes such peculiar and profound
changes that its fitness for the maintenance and renewal of the various
tissues and organs is impaired; hence the nervous depression, loss of
muscular power and tonicity of tissues, and the transudation of the
blood or of its constituent parts.
The processes of secondary assimilation are chiefly at fault, leading
to the blood-changes, and through these to the textural lesions.
Primary assimilation remains intact, as the bodily weight is little
altered as long as the food is in sufficient quantity. This loss of
nutritive balance between the blood and tissue is due to the absence of
certain elements furnished by fresh vegetable matter. What these are,
and how their absence acts in inducing this disturbance, have not yet
been determined; we only know that the mysterious harmony of the vital,
chemical, and physical relations which exist between the blood and
tissues in health is deranged by their absence.
Endless explanatory surmises and assumptions have been proffered. The
earlier explanations involve either the Galenical theory of
putrefaction of the fluids and humors, a breaking down of the
blood-corpuscles, or the later chemical theories of superabundance or
absence of certain salts, sulphur, etc., and hence there were an acid
scurvy, an alkaline scurvy, a muriatic scurvy, etc.
The frequent effusions of blood in scurvy led Andral to suspect that
the chief peculiarity in scorbutic blood was the decrease of fibrin;
which was {174} in perfect accord with a theory that he had formed that
this change was the uniform cause of passive hemorrhage. Magendie had
already given experimental support to this conjecture by inducing in
animals phenomena analogous to those of scurvy by the injection into
the veins of defibrinated blood or of alkaline solutions. Andral[7]
believed his views confirmed when in 1841 he analyzed on two occasions
the blood of scorbutic patients and found the fibrin reduced to 1.6
parts per 1000. Similar results were obtained by Eckstein and Frémy. On
the other hand, the blood was analyzed by Busk, about the same time, in
three well-marked cases of scurvy that occurred on the Dreadnaught
hospital-ship, and in all of them the fibrin was in excess of the
normal amount, the least being 4.5 and the greatest 6.5 parts per 1000.
In perfect accord with Busk's results were the analyses of the blood of
five scorbutic females, communicated in a note to the Academy of
Sciences in 1847 by Becquerel and Rodier. In no case was the fibrin
diminished, but in some it was sensibly increased. In a subsequent case
Andral found that the fibrin, instead of being less, exceeded the
physiological mean, reaching 4.4 parts, and he concluded that a
diminution of this element was not a necessary and common occurrence,
but only an effect--a result of prior morbid modifications, and a
consequence which was produced more or less frequently according to the
severity and duration of the disease. Parmentier and Déyeux found the
blood of three scorbutics to resemble inflammatory blood in respect to
fibrin, while Frick obtained in one analysis 7.6 parts of fibrin and
Leven 4.3 parts.
[Footnote 7: _Essai d'hématologie pathologique_.]
In mild cases of scurvy neither the color, the alkalinity, nor the
coagulability of the blood differs from that of blood in health, though
Wood alleges that the clot is loose and cotton-like, and Canstatt that
its coagulability, in consequence of the large proportion of saline
matters, is diminished. In Busk's cases the separation of the clot and
serum was as perfect, and took place as rapidly, as in healthy blood,
and in two of them the blood was both buffed and cupped, as it was also
in Leven's cases. In two of the most severe of Becquerel's cases the
blood coagulated firmly, and in a slight case the clot was dark and
loose. The albumen of the blood shows no marked change as regards its
quantity. The five analyses of Becquerel and Rodier showed the average
amount of organic matters of the serum to be 64.3 parts in 1000, the
smallest being 56.2 and the largest 69.2 parts. 1000 parts of the serum
of the same cases gave an average of 72.1 parts of organic matter.
Frick's single case gave 87.045 parts per 1000, and the average of
Busk's was 78.2 parts, while Chotin and Bouvier obtained only 62.3
parts. The last-mentioned writers have recorded a fact in connection
with the physical characters of scorbutic blood that deserves notice:
the blood in one case did not coagulate at the usual temperature (about
158° F.), but required a temperature some degrees higher for that
purpose. The red corpuscles in all the foregoing cases were notably
diminished, the largest amount given being 117.078 parts per 1000,
while the lowest was 47.8 parts. In Andral's second case the globules
had decreased to 44.4 parts per 1000, the lowest amount yet recorded.
The alkalinity of the blood seems not to be changed, although Chotin
and Bouvier noticed a slight increase. The saline constituents do not
{175} vary greatly from the normal standard. The average amount in the
cases of Becquerel and Rodier and Busk was 8.1 per 1000, the smallest
being 5.5 parts and the largest 11.5. In Ritchie's two analyses the
proportion of saline matters is given as 6.44 and 6.82 parts per 1000.
Opitz and Schneider have found less than the physiological mean. In
Frick's case the amount was 8.8, the iron being 0.721 parts per 1000,
and 0.782 to 127 parts of globules; lime 0.110, chlorides 6.846, and
phosphates 1.116 parts per 1000. The iron was in excess of that in the
normal blood, but in Becquerel's cases the mean was 0.381--less than
the normal. The proportion of iron in Duchet's cases was respectively
0.393, 0.402, and 0.476 parts, giving a mean of 0.423 parts per 1000,
which nearly approximates the normal. Garrod in one analysis of the
blood found a deficiency of the potassium salts, upon which he erected
his well-known theory of the etiology of the disease. It is an
interesting fact that in the physiological state the quantity of sodium
chloride is not subject to variation, any excess introduced with the
food being thrown off by the kidneys. The quantity in the urine bears a
relation to the amount introduced as food, but the proportion in the
blood is constant.
The quantity of water in the blood has been found to be increased in
all the analyses which have been made. Chotin and Bouvier estimated
water and loss at 831.1; in Frick's case it was 791.69 parts per 1000;
and in Becquerel's five cases it was put at 807.7, 810.9, 811, 813.7,
and 854.0 parts per 1000, respectively. In Busk's three cases the
lowest amount was 835.9 and the highest 849.9 parts per 1000. The
specific gravity of the defibrinated blood was in all cases low in
comparison with the normal standard (1057), the average in Becquerel
and Rodier's cases being 1047.2, the lowest 1083.3, and the highest
1051.7. In the single observation of Chotin and Bouvier it was 1060.
The specific gravity of the serum was also less than normal (1027), the
average of four of Becquerel's analyses giving 1023.8, the lowest
1020.8, and the highest 1025.5. Busk gives 1025 in one case and 1028 in
another.
The results of the most recent analyses, those of Chalvet, are shown in
the following table, in which scorbutic blood is contrasted with that
of a healthy, robust female:
Scorbutic blood. Healthy blood.
Water 848.492 772.225
Solid matters 151.508 220.775
Dry clot 140.194 209.000
Albumen 72.304 68.717
Fibrin 4.342 2.162
Globules 63.548 138.121
Extractive matter--by absolute alcohol 10.312 8.013
by ether 1.002 1.300
Ashes of clot 3.000 5.691
Peroxide of iron of globules 1.060 2.259
Potassium of globules 0.329 0.625
From the conflicting statements of various observers the following
conclusions may be drawn: that in scorbutic blood water is in excess;
that there is, on the one hand, a marked increase of the fibrin, and in
a less degree of the albumen and extractive matters, while on the other
hand there is a marked decrease of the globules and in a less degree of
the mineral matters. On the authority of Chalvet it may be also stated
{176} that demineralization of the muscular tissue is a notable
chemical feature in scurvy.
So far, microscopic examination has been entirely negative. Hayem[8]
found no appreciable alteration from healthy blood, and in this view
Leven[9] concurs; while Laboulbène[10] notes the occurrence of an
unusual number of white globules.
[Footnote 8: _Mém. de la Société de Biologie_.]
[Footnote 9: _Communication to the Académie des Sciences_, 1871.]
[Footnote 10: _Epidemie de Scorbut_.]
Petrone Luigi[11] injected scorbutic blood into the connective tissue
of rabbits. In three instances the animals died, presenting on the ears
distinct evidences of the formation of petechial extravasations. The
viscera revealed everywhere bloody effusions of larger or smaller size.
The spleen was enlarged and its parenchyma and capsule distended. In
the blood were found oval, shining, spontaneously-moving corpuscles,
which he regarded as the bearers of the specific poison of scurvy.
[Footnote 11: _Annali Univers. di Med. c. Chir._, 10, 1880.]
SYMPTOMS.--The symptoms of scurvy are insidiously and usually slowly
developed under the influence of the efficient causes, and the disease
runs a chronic course, often extending over five or six months,
especially in cases in which the hygienic surroundings of the patient
have been imperfectly or not at all rectified. In light cases the
course is much shorter. A gradual alteration of the nutritive processes
first occurs, until what might be called a scorbutic cachexia is
established in a period varying from a few weeks to several months. The
initial symptoms consist in the skin losing its color and tone and
assuming a yellowish or earthy hue: it is relaxed, dry, unperspiring,
and rough; in the legs particularly this roughness is very marked, and
the skin, when rubbed, sheds an abundance of furfuraceous scales. The
cutaneous follicles, markedly on the extensor aspect of the lower
extremities, are prominent, similar in appearance and feel to the
condition known as goose-flesh. Rouppe[12] calls this the signum primum
pathognomonicum. Dark-red or brownish flecks, of a circular outline and
of varying but small size, not unlike flea-bites, appear on the face
and limbs. The cutaneous circulation is feeble and the superficial
warmth less than natural; slight depression of the atmospheric
temperature produces a sensation of chilliness, and the feet and hands
are cold. On assuming the erect posture the patient complains of
headache and dizziness. The muscles are relaxed and soft to the feel,
and a corresponding loss of vigor and strength is experienced by the
patient, who is indisposed to exert himself in the performance of his
customary duties and seeks repose and freedom from feelings of fatigue
and languor in recumbency. This prostration is occasionally so extreme
that the slightest efforts in attempting to stand or walk are attended
with rapid action of the heart, accelerated respiratory movements, and
a sense of suffocation and breathlessness. The general circulation is
impaired; the heart acts feebly; the arteries are contracted; and the
pulse is slow, small, and compressible.
[Footnote 12: _De morbis navigantium_.]
The mental powers are equally impaired. The face wears a haggard
appearance and depressed expression; gloomy forebodings of evil and
disinclination to turn the attention to the usual mental pursuits are
markedly present--a disinclination that may subsequently merge into
complete apathy or indifference to passing events, or even into
somnolency.
{177} 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 Charpentier[13]
in a large number of cases saw this but once, and in one of Leven's[14]
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 {178} 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.
[Footnote 13: _Étude sur le Scorbut_, 1871.]
[Footnote 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 {179} 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.