Scorbutus.
[Vitamin C deficiency.]
Synonym:—Scurvy.
Definition:—A chronic disorder due to a fault of nutrition from lack of variety of food, or from an absence of vegetable food, characterized by anemia, spongy gums, and by subcutaneous, sub-mucous and intra-articular extravasations of blood and by rapid failure of strength.
Etiology:—This disease occurs alike in both males and females, among those who are restricted in diet or who have no variety of food for a long period. It was common at the time of slow sailing vessels for sailors to subsist upon the same salted meat diet, with but little vegetable food, for months at a time. Explorers, those confined for a winter in the Arctic regions, and sailors, also miners and prisoners, and those confined in poorly kept asylums and almshouses, were subject to it. It is by no means as common a disease among the classes above named as formerly, as the needs of the human system are better understood and are scientifically provided for by our present incomparable methods of preparing and preserving all kinds of food, often unaltered, and in a conveniently condensed and compact form. Refrigeration as now practiced is of great assistance in food preservation. There are now marvelous improvements in general sanitation also. However, the modern habit, more prevalent among the wealthy, of feeding infants and young children artificially on mechanically prepared foods, has introduced the disease among this class, where previously it was seldom observed. It is caused by keeping the child on the same article of diet with no change for a long time.
A prolonged absence of those organic acids in the food which are present in fruits and vegetables, as well as potassium and other organic salts, seems to predispose to it. There is apt to be a deficiency also of free hydrochloric acid in the gastric juice. Autointoxication is undoubtedly an important element in this disorder.
The disease is found among the feeble and those devitalized by a dyscrasia, or by blood taint, or by malaria, syphilis, scrofula and tubercular disorders, and among the aged. Improper hygiene conduces to it. It differs in its essential underlying conditions from rachitis, and yet the two often coexist.
Symptomatology:—The disease is of insidious approach. The patient has lost energy and spirit, and becomes depressed and despondent. He is increasingly unable to perform either physical or mental labor, is wearied with any effort and soon exhausted if the effort is prolonged. He becomes pale or anemic and the countenance has a peculiar apathetic expression and is somewhat bloated, or has a bruised appearance around the eyes. The appetite fails, and breath is foul. The tongue is thick and pale and usually clean, although it may be covered with a heavy, moist, dirty coat. The gums present a characteristic appearance, which is pathognomonic of this disease. They are often greatly swollen and are of a dusky or purplish color, and bleed very readily; they are soft and spongy, and are prone to deep ulceration and to separation from the teeth, which become loosened and are frequently lost.
The salivary glands become swollen and often indurated, and petechiae or ecchymoses appear upon the skin in various places. While constipation is common, diarrhea may occasionally occur, or it may be present as a constant complication. The skin is dry and has a peculiar hue, and as cutaneous capillary hemorrhages prevail, it assumes a greenish tint similar to the later discoloration of a bruise.
There are extravasations of blood into the various parts or tissues of the body. These occur spontaneously around the ankles and in the skin of the lower legs first; subsequently, in the skin of the body and of the arms, neck and face. They involve the structures of the joints, and the joints become enlarged and tender, and they are also subperiosteal in the shafts of the long bone. A severe muscular strain, a blow, or any slight contusion will greatly increase this intercellular hemorrhage. With these there occurs in the muscles of the thighs and calves especially, although it may occur elsewhere, a peculiar brawny hardness or induration of the patches of the muscular structure, from the infiltration, which is painful on pressure.
The hemorrhagic tendency becomes general, and hemorrhage from the nose, lungs, stomach or bowels, from all the mucous surfaces and from the kidneys, may occur. This condition is accompanied with fever only in occasional cases where complications arise. In uncomplicated cases, the temperature tends to become subnormal, the pulse is feeble, soft, compressible, and hurried after any exertion, and the respiration is shallow and rapid. The urine contains albumin in most cases, is generally scanty and of high specific gravity and may contain disintegrated blood corpuscles or may be mixed with blood in large quantity. In an occasional case nephritis will develop.
Diagnosis:—The diagnosis of scurvy will be suggested by the peculiar appearance of the gums, especially in infants. A history of restricted diet, greatly prolonged; the depression and rapidly failing health and strength; the hemorrhagic tendency, with the extravasations; and the rapidity with which recovery takes place upon an enlarged and sufficient diet, will fully confirm the diagnosis.
Prognosis:—This depends upon the ability to secure a sufficient quantity of correct food before the disease is too far advanced; upon the results of the hemorrhages and upon the complications. A patient in previous good health should make a full and speedy recovery with the proper treatment, and with sufficient food of the quality and character which the system demands.
Treatment:—Inasmuch as this disease depends upon the dietary, the consideration of the food is the most important part of the treatment. A knowledge of the disease and its causes has brought about a marked change in providing food for expeditions, for soldiers, sailors and for institutions of all kinds, and the demands of the government in food supplies have done much toward the prevention of the development of this disease, which for these reasons has become rare. Without an abrupt change in the diet, medical treatment has but little influence. Those substances which have been depended upon for food, and which have caused the disease should be omitted and vegetable acids and vegetable substances which contain the deficient potassium salts are to be supplied. Although the digestion is often seriously impaired, the restoration will take place very rapidly if the patient be given the ordinary vegetables, at first in small quantity, and increased as rapidly as can be taken without injury. Fresh oranges of good quality may be eaten freely and the patient should take lemon juice or lemonade as a beverage. Lettuce, celery, cabbage preferably raw, beets, pieplant, tomatoes, with potatoes and the cereals as desired, will materially promote the restoration to health, if no meat diet be taken. Fresh milk may be taken as a beverage and little by little a fresh meat diet may be resumed. This should be brought about with much care and judgment. Pickled, salted or dried meats, or otherwise cured, must be eschewed. This course may be inaugurated with meat juice, beef teas, and the white of eggs, and increased as rapidly as possible. The patient should be kept in bed, in a well ventilated room, in severe cases, until the extreme debility is in part overcome. Out of door exercise and sunshine with pleasant surroundings are actively conducive to the restoration of health.
The condition of the stomach should be restored by the action of specific tonics, such as hydrastis, nux vomica and capsicum. Hydrochloric acid dilute, in from five to fifteen minim doses, should be given after eating and may be repeated in half an hour or an hour. The condition of the blood will need iron in some easily appropriable form. If antiseptic measures are thought advisable from the indications, echinacea should be given or baptisia tinctoria, or perhaps yellow dock, and corydalis. Treatment of the mouth and gums may be necessary and for this purpose an infusion of white oak bark, strained, to which is added colorless hydrastis, distilled hamamelis, and the tincture of myrrh, used as a mouth wash freely, will prove of immediate benefit. If diarrhea persists with perhaps a slight tendency to hemorrhage, geranium maculatum will prove an excellent remedy. The tincture of capsicum applied over the areas of extravasation and over the enlarged joints will materially assist in restoring the normal condition of these parts.
The treatment of scorbutus in infancy—the condition known as Barlow's disease—consists also of making a pronounced change in the diet, as the symptoms are largely those of prolonged marasmus, efforts may have been made toward changing the diet previously, without results. Radical changes must be instituted. If the patient has been bottle fed, it is well to select a healthy wet nurse, correctly adapted to the age of the child, but with this milk the child should have from five to fifteen drops of bovinine, according to the age, every hour or two, or beef juice expressed from a partly broiled juicy steak, which at the time of using may be given in small doses frequently repeated. To this lemonade, or orangeade, should be added, properly sweetened, and later acid jellies may be diluted and given frequently in small quantities.
As rachitis is apt to be present at the same time, the course of medical treatment suggested by that disease will exercise a full restorative influence in this. The use of the tincture of the chlorid of iron or an elixir of the pyrophosphate of iron which contains free phosphorus in proper doses, and nux vomica, or strychnin in convenient combination should be given. The restorative influence of cod liver oil is of great importance in nearly all of these cases. The agent may be administered both externally and internally, or the oil may be given in proper emulsion, combined with the hypophosphites or the glycerophosphates.
There will be in all these cases occasional indications which will point to the demand for specific remedies. These indications should be promptly met, and only good results will accrue.
