Scurvy.

Synonym.—Scorbutus.

Definition.—A systemic affection due to lack of variety in the dietary, especially in an absence of vegetables, and characterized by anemia, hemorrhages into the skin, subjacent tissues, and sometimes into the articulations, spongy gums, and marked prostration.

Etiology.—It is still an unsettled question as to the specific cause of scorbutus. Nearly, if not quite, all writers agree that a prolonged diet on salted meat with an insufficient amount of vegetables, is the chief cause, and attribute the changed condition of the blood, from alkaline to acid, to an absence of the potassium salts, in which fruits and vegetables are rich.

Albertoni has shown, in some studies on the chemistry of the blood and of digestion, "that there is a serious deviation from normal in the free HCl of the gastric juice, that intestinal putrefaction is excessive and that the urine furnishes abundant evidence of the absorption of toxins, while the absorption of fats and carbohydrates is deficient." (Banks, in "Reference Handbook of the Medical Science.")

Unhygienic surroundings, overwork, and old age, predispose to the disease, while anemia, chronic intestinal diseases, chronic malaria, and syphilis, also favor it. It rarely appears as an epidemic in modern times, though formerly epidemics were not rare. The improved sanitary measures of army and ship life and a greater variety in the dietary of each, make scurvy a rare disease in this, the beginning of the twentieth century.

Pathology.—The most constant lesions are the soft, spongy, ulcerated condition of the gums and hemorrhages into the various tissues. The teeth become loosened and frequently drop out, while hemorrhage occurs beneath the skin, giving rise to ecchymotic spots. Submucous hemorrhages are common, and subperiosteal hemorrhage constant, with occasional bleeding into the articulations, muscles, serous membranes, and internal organs.

There may be fatty or granular degeneration of the liver, kidneys, and spleen. If we except anemia, the blood shows no characteristic changes. Ulcers are sometimes found in the ileum and colon.

Symptoms.—The onset is rarely acute, but comes on very insidiously. There is usually a history of gradual prostration, loss of appetite, full, thick, moist, dirty tongue, foul breath, and a dry skin of a dirty, muddy color; the face is slightly puffed or swollen, and the gums are soft, spongy, dusky in color, and bleed easily. Not infrequently the gums ulcerate, the teeth are loosened, and occasionally drop out.

With the change in the gums, hemorrhages take place in the various tissues. In the subcutaneous tissues, the most dependent parts suffer first, and ecchymotic or purpuric spots are first seen about the ankles, then upon the trunk, and finally upon the face. Although these develop spontaneously, they are hastened by blows or external injuries.

Where the hemorrhage is quite extensive and embraces the muscular, fibrous, and subperiosteal tissues, the part becomes indurated and painful. The articulations are frequently swollen and painful, the result of hemorrhages. The hemorrhage may occur from mucous surfaces, and epistaxis, hemoptysis, hematemesis, hematuria, and enterorrhagia are seen in rare cases.

As the disease progresses, emaciation increases, there is great mental depression, palpitation of the heart, and dyspnea on slight exertion. In the early stage the temperature is normal, but as the blood becomes impaired and anemia develops, a subnormal temperature is frequently found. The pulse, from the increasing debility, is feeble and rapid and the respiration hurried, especially on slight exertion.

The urine is scanty, high-colored, of high specific gravity, and generally albuminous. Diarrhea, dysenteric in character, with bloody mucous stools, is often present.

Diagnosis.—The diagnosis is readily made when we have the history of improper food for a long-continued period. In such cases there are a number of individuals involved, and the attention of the physician is readily turned to scurvy. The presence of soft, spongy gums, readily bleeding when pressed, the occurrence of hemorrhage in the various tissues, and the great prostration, make the diagnosis positive.

In sporadic cases, and to the inexperienced, the disease may be mistaken for anemia or some of the arthritic forms of purpura, but the spongy gums and the previous history will enable one to differentiate the one from the other.

It may be recognized from purpura hemorrhagica, the only other disease that might be mistaken for it, by the absence of the gingival symptoms, the brighter color of the macules, the cleaner color of the skin of the latter, and the greater swelling of the articulations.

Prognosis.—The prognosis is generally favorable, though much depends upon the progress of the disease, the complications, and the previous condition of the patient. When fresh vegetables and fruit-juices can be freely furnished, and there are no serious internal hemorrhages or enfeebled heart, and when syphilis is not a marked feature, recovery is the rule.

Treatment.—Scurvy being a preventable disease, a very important part of the treatment will be prophylactic, and consists in supplying vegetables, acid fruits, and fresh meat. Fortunately hygienic and dietary measures are being considered more than ever before, and the cuisine of all eleemosynary institutions are far more liberal than in former times.

The treatment is largely dietetic, and consists of furnishing the patient with green vegetables and fruit-juices. Lemon-juice diluted with water may be taken freely every one or two hours. Grape-fruit, oranges, pie-plant, and acid fruits and vegetables in general may be used. If there is great debility, the patient should be kept quiet in bed till the bodily strength is at least partially restored.

Broths, milk, eggs, cereals with cream, in fact, a rich and nutritious but fluid or semi-fluid diet, should be given.

Nux vomica, hydrastis, strychnia, berberis aquifolium, and like remedies, may be used with much benefit. Locally, as a mouth-wash, potassium chlorate and hydrastin will prove very efficient. To add tone to the spongy and softened gums, tincture of myrrh and glycerin will answer a good purpose.

The Eclectic Practice of Medicine, 1907, was written by Rolla L. Thomas, M. S., M. D.