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. Oserctzkowski[16] 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.
[Footnote 15: _Mémoires de l'Académie des Sciences_, p. 237, 1699, and
_Philosophical Transactions_, vol. xv.]
[Footnote 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]
[Footnote 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 {180} 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's[18] 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.
[Footnote 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. Opitz[19] 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.
[Footnote 19: _Prag. Vierteljahrschrift_, S. 153, 1861.]
{181} 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.
The urinary system supplies no prominent symptoms; the statements as to
the condition of the kidneys and the composition of the urine are
contradictory. The urine not infrequently contains albumen,
particularly in severe cases, but this is by no means indicative of
corresponding changes in the renal structure: on the contrary, this may
be found after death to be apparently free from disease.
The conclusions that would seem to be authorized by the statements of
various authorities are that the quantity of urine passed is decreased,
as well as that of the urea, while the amounts of the albuminoid and
mineral matters are increased.
Physical examination will reveal the frequent occurrence of enlargement
of the spleen, independent of malarial influences, and Krebel has
encountered one case in which the liver was involved in inflammation.
Some derangement of the visual organs is present in many cases. Foltz,
in the epidemic on the Raritan, reported four cases of nyctalopia and
two of hemeralopia, and other affections of the eye, such as
conjunctivitis, induration and irritation of the ciliary margins of the
lids, with a copious and acrimonious discharge, these conditions being
obviously due to the scorbutic diathesis. Medical Director J. Y.
Taylor, U.S. Navy, in a private communication to me states that
hemeralopia was a frequent premonitory symptom of scurvy that occurred
in the U.S. sloop-of-war Decatur in 1854 during a laborious and tedious
passage of three months through the Straits of Magellan. The men were
overworked and much exposed to cold and wet, and part of the time were
on diminished rations. The hemeralopia was at first erroneously
attributed to the reflection from the snow and glaciers--a species of
snow-blindness--but other phenomena speedily appeared in a majority of
the causes: a subacute inflammation, with considerable pain and
swelling of the small joints, especially those of the toes; sore and
tender gums, although only a few progressed so far as to exhibit
sponginess or bleeding; and debility, depression, anxiety, and
insomnia. In a few cases the blindness was so complete as to render
their subjects almost helpless after sunset. This was the most
pronounced and remarkable symptom and the one most complained of. These
incipient scorbutic symptoms were promptly arrested by the free use of
wild celery (Apium graveolens), which was found growing abundantly in
sheltered places. The short rations were also supplemented
advantageously by mussels (Mytilus edulis) whenever they could be
obtained. A few weeks later the crew appeared to be in ordinary health.
Hemorrhage may occur under the conjunctiva, raising it into small
pouches; into the anterior chamber, causing iritis and adhesions; and,
finally, into the choroid and vitreous humor, exciting a general
inflammation of the entire organ.
Dulness of hearing and buzzing in the ears have also been signalized as
occasional symptoms of scurvy.
{182} The phenomena of fever are always absent during the course of
uncomplicated scurvy, the temperature of the mouth sometimes falling as
low as 92° F., and being always one or two degrees lower than normal.
It is only in the later periods of the disease, when pathological
processes most often supervene in the internal organs, that an elevated
temperature and the other ordinary symptoms of fever are manifested.
The lowered vital resistance of scorbutic subjects particularly
disposes them to the incursions of fevers, especially those of malarial
and typhoid types: hence in the low, marshy districts of Northern
Europe and in sections of country afflicted by famine and overcrowded
dwellings these complications are very common.
DIAGNOSIS.--Little or no difficulty will be encountered in
discriminating scurvy from other diseases under the circumstances that
usually surround its development and prevalence. These circumstances
are altogether peculiar and characteristic, and involve the absence of
succulent vegetable food as the prime factor, and exposure to cold,
fatigue, mental despondency, or other depressing influences as
accessory in its production. This combination of causes has been
usually witnessed in all the outbreaks of scurvy in camps, besieged
towns, on shipboard, particularly on ships in Arctic service.
Sporadic cases may escape immediate identification in the absence of
some of these circumstances, but a close attention to the symptoms will
surely lead to a correct conclusion. The scorbutic cachexia denoted by
the sallow or earthy hue of the skin; the spongy gums; the
discoloration of the surface; pains in the limbs and joints; the sense
of weariness, and, later, the exhaustion, dyspnoea on the slightest
exertion; the bloody and fibrinous effusions into the connective
tissues and muscles about the joints, and into the pleuræ, pericardium,
and peritoneum; the stiffness and contraction of the legs,--furnish a
complexus of phenomena not met with in any other disease than scurvy.
The discoloration of the skin in purpura, leucocythæmia, anæmia,
chlorosis, and hæmatophilia, or other conditions involving hemorrhagic
extravasation, are easily discriminated from those of scurvy when taken
in connection with the other symptoms and the history of those
diseases. In the beginning of scurvy the pains in the back and limbs
might divert the attention to rheumatism, but an examination at this
early stage will, in all likelihood, disclose the peculiar gingival and
cutaneous lesions of scurvy.
The rapid improvement of scorbutic cases under a fruit and vegetable
diet is also a noticeable feature not witnessed in any of the foregoing
diseases.
PROGNOSIS.--The prognosis of scurvy is always favorable in the early
stages, and even in the very worst recovery occurs under improved
hygienic surroundings with remarkable promptness and certainty. It must
not be overlooked, however, that sudden death may occur in seemingly
light cases from failure of the heart's action or from embolism. There
is a ready disposition to the recurrence of the disease under slight
causes, and it may so impair the health as to lead to the development
of other fatal maladies. The gravity of the case is to be gauged not so
much by its seeming severity as by the accessibility of proper
food-supplies, for without these the worst results may be expected.
Where the case is embarrassed with complications of the respiratory and
circulatory {183} organs, involvement of the bones, and intercurrent
diseases, the outlook becomes correspondingly grave.
Throughout the world, in recent times, greater areas of territory are
devoted to agriculture and horticulture, and the products are
distributed over wide extents of country by the increased facilities of
communication by the highways and railroads, so that it would now be
impossible for an epidemic of scurvy to devastate a region of country
so provided as it did a century ago, or might do and has done in
regions of country where tillage is neglected and communications are
cut off by an absence of roads from more productive centres, as in
Southern and Eastern Russia.
Hygienic improvements that have almost stamped out scurvy on shore have
also done good service for mariners, and thousands of ships now cross
the ocean on long cruises with perfect security from the disease. In
the naval services of the world, as has been already shown, the disease
is rarely encountered, and it is greatly diminished in the merchant
marine, from which, it is hoped, in a few years, by a more rigid
enforcement of existing laws for the protection of sailors, it may also
entirely disappear. Even in exceptionally long and arduous cruises, as
in the Arctic regions, the disease may be arrested, as was the case
with the Jeannette, which was drifted about, locked up in ice, for
sixteen months, yet only a single case of scurvy appeared.
It is of the first importance to enlist a healthy crew for long
voyages, free from previous syphilitic, scorbutic, or other
constitutional taint; then, by observing proper hygienic precautions,
to maintain their health. One of the prime factors in securing this
result is a suitable dietary. The improved methods of preserving food
afford facilities for storing up adequate quantities of both kinds,
animal and vegetable, to last the cruise. To economize these stores it
will be well to start with a stock of live animals and recent
vegetables, such as can be now had in almost any quantity in any
considerable maritime city, and not until these are consumed are the
canned and preserved supplies to be opened. All the ordinary meats, as
beef, mutton, veal, and lamb; most vegetable products, as asparagus,
beans, peas, potatoes, and a great variety of fruits, as peaches,
plums, berries, etc., are obtainable at moderate expense, and should
form an integral portion of the ration. Eggs can be easily preserved so
as to keep for months by simply packing them in plaster or in salt, and
they furnish a valuable and acceptable article of diet. Among articles
of great nutritive value milk takes high rank, and it can be preserved
sweet and pure indefinitely. Sauer-kraut is an antiscorbutic of
considerable virtue, and should not be overlooked in laying in stores
for a distant cruise. Cheese and oatmeal will be found useful additions
to the ordinary ration.
It may be proper to state in the event of the occurrence of scurvy and
the exhaustion of the fresh vegetable stores that various
quickly-growing vegetables, such as mustard, radishes, turnips, and
cresses, could be cultivated on shipboard if seeds are provided.
With such a varied dietary, comprehended in the above enumeration, it
would be impossible for scurvy to invade the ship's company, especially
when aided by other wholesome agencies, as cleanliness, well-ventilated
and dry sleeping rooms, and clothing adapted to the weather. The
antiscorbutic virtues of lime-juice were known long ago, being
mentioned by {184} Albertus in 1593, but it was not until many years
later that it became an integral part of the English navy-ration. The
law requires it to be carried on board all merchant vessels, and to be
served out ten days after the crew has been living on salt rations. The
juice keeps well if properly prepared and preserved from contact with
air, especially when fortified with a small quantity of alcohol, the
usual strength being about 10 per cent. It should be carried in vessels
containing just enough to furnish a few days' rations to the whole
crew, by which plan only a small amount need be exposed to the
decomposing influence of the air. The juice can be reduced by
evaporation to a very small bulk. This method was adopted in supplying
the Arctic cruiser Rodgers.[20] The juice was reduced to a paste, each
pound of which represented one gallon of the solution of the ordinary
strength. It has also been used in the form of lozenges and biscuit. It
may be stated that great reliance has been placed upon malt, the acid
wines, and cider as good antiscorbutics.
[Footnote 20: _Report of the Surgeon-General of the Navy for 1880_.]
In connection with the food-supplies it is proper to mention those
influences of a depressing character which have a tendency to favor the
development of scurvy. The first is dampness in the sleeping apartments
of the men. This should be prevented by ventilation, drying stoves, and
taking care that no wet garments are permitted to remain in the
apartments. They should be taken off immediately and hung outside to
dry, and under no circumstances should the men be permitted to sleep in
them, as is sometimes done.
Exposure to cold is unavoidable under certain conditions, and the men
should then be protected by proper clothing adapted to the weather.
Protracted fatigue is a third favoring circumstance, and the crew
should be spared all the strain of hard work possible, especially in
high latitudes. The apartments should also be kept well ventilated and
scrupulously clean; and, lastly, depressing mental emotions, which are
so apt to arise from exposure to danger and want, should be dispelled
by cheering assurances, constant occupation, and whatever amusements
can be had. These are the chief influences which are to be considered
in adopting measures to prevent the occurrence of scurvy in
communities, armies, on shipboard, or in persons confined in houses of
detention.
The therapeusis of scurvy presents no intricate problems for solution.
Its origin in dietetic errors is admitted by almost common consent, and
it is surprising with what rapidity patients apparently beyond hope of
recovery gather health and strength with a change in the character of
the food. This is indispensable in the treatment, as drugs have little
or no curative influence without it; and, therefore, the first object
should be to supply the patient with lemon-juice or acescent fruits and
fresh vegetables, as garlic, mustard, cresses, sorrel, nasturtium,
taraxacum among the wild plants, and potatoes, onions, turnips, beets,
radishes, etc. among the domesticated plants. And in conjunction with
these fresh meats, in the form of soups if the solids cannot be
masticated, may be used with advantage. Ordinarily, the dietetic
treatment alone will suffice to re-establish the health. Should,
however, convalescence be delayed, the vegetable bitters with the
mineral acids and ferruginous tonics and quinia will furnish useful
adjuvants. These are the standard remedies; others have been
recommended at various times, as the juice {185} of the maguey, a
Mexican plant, potassium nitrate alone or combined with vinegar,
tincture of cantharides, etc.
Attention will often be required to the various scorbutic
complications, especially stomatitis, which is always a source of
discomfort and suffering. One of the best local applications for this
is pencilling the parts with a solution of nitrate of silver, which
often affords marked relief. Mouth-washes, composed of solutions of
chlorinated lime, potassium permanganate, carbolic acid, are beneficial
by suppressing foul odors, exercising local stimulative action upon the
gums, and promoting healing. Should ulceration attack the legs, as is
often the case, the application of mild astringents and stimulative
ointments will be all that is required. The parts should, of course, be
kept clean and protected from irritation by protective dressings.
Hemorrhages from the nose, gums, stomach, bowels, or into the serous
cavities should be treated upon the general principles applicable to
their character, as the local use of cold, astringents, and the
internal administration of hæmostatic agents--lead acetate, ergot,
tincture of iron, and other remedies, vegetable and mineral, of this
class. In desperate cases effusions into the chest, threatening death
by interfering with the respiratory and circulatory organs, may render
operation necessary as the last resort for their removal.
During the treatment it is important to obviate any sudden or severe
strain upon the heart by premature movements or exercises, as this is
fraught with danger.
{186}
PURPURA.
BY I. E. ATKINSON, M.D.
It has been customary with authors to describe under the general
heading Purpura a number of affections presenting as a common symptom
the extravasation of blood into the tissues, more especially of the
skin and mucous membranes, quite irrespective of etiological or
pathological considerations. Thus, the tiny ecchymoses caused by the
bites of fleas have been denominated purpura pulicosa; the larger
bruises resulting from external violence, purpura traumatica; the
extravasations occurring in the course of scurvy, purpura scorbutica;
those encountered in malignant small-pox, purpura variolosa; and so on.
These affections, differing widely in nature, possess as a common
symptom the escape of blood from the vessels into the tissues. It is
evident, therefore, that in the sense often employed the term purpura
is used to describe a symptom or symptoms common to a variety of
non-related maladies.
If there be a peculiar morbid process having for its constant and
characteristic symptom the spontaneous escape of the blood from the
blood-vessels, it is plain that interstitial hemorrhage from external
violence or from the action of a definite poison circulating in the
blood and disorganizing it and its containing vessels, as in
phosphorus-poisoning, or from the influence of certain zymotic
diseases, should not be designated by the title properly belonging to a
substantive malady. The question, therefore, is: Are there groups of
symptoms indicating morbid action of definite character, but of varying
intensity, to which the name purpura may with propriety be applied?