Scurvy

SCURVY. By THOMAS BARLOW, M.D., F.R.C.P. In: CYCLOPÆAEDIA OF THE DISEASES OF CHILDREN MEDICAL AND SURGICAL. EDITED BY JOHN M. KEATING, M.D. VOL. II. PHILADELPHIA J. B. LIPPINCOTT COMPANY. 1892. Barlow’s book chapter is available at: https://archive.org/details/cyclopaediaofdis0002unse/page/264/mode/2up 1892 https://archive.org/details/cyclopaediaofdis02keatuoft/page/264/mode/2up 1891 https://archive.org/details/cyclopaediaofdis0000john/page/282/mode/2up 1890 https://archive.org/details/cyclopdiadiseas02keatgoog/page/264/mode/2up 1890 https://archive.org/details/cihm_01597/page/n305/mode/2up 1890 https://archive.org/details/39002079333093.med.yale.edu/page/264/mode/2up 1889 Biographies: https://www.ncbi.nlm.nih.gov/pmc/articles/pmc2056559 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc1987940 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc1561482 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc1550031 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc1036751 https://history.rcp.ac.uk/inspiring-physicians/sir-thomas-barlow https://en.wikipedia.org/wiki/Sir_Thomas_Barlow,_1st_Baronet Yellow is used to indicate the most relevant parts. This version was prepared by Harri Hemilä, MD, PhD, University of Helsinki, Helsinki, Finland. https://orcid.org/0000-0002-4710-307X https://pubmed.ncbi.nlm.nih.gov/?term=hemila+h+vitamin+c This text is available at: https://doi.org/10.5281/zenodo.15586835 1 SCURVY. By THOMAS BARLOW, M.D., F.R.C.P. In: Keating’s Cyclopædia of the Diseases of Children, 1892 https://archive.org/details/cyclopaediaofdis0002unse/page/264/mode/2up SCURVY is a disease which in adults is characterized by great anæmia, p.265 sallow muddy complexion, extreme debility and proneness to syncope, sponginess of gums, and ecchymoses in various parts of the body, but especially in the lower limbs, in which, also, brawny indurations occur. It has a definite relation to the deprivation of fresh vegetables, and is almost immediately ameliorated by their administration, but appears to be controlled also by fresh raw meat and by fresh milk. The object of this article is to show how far this disease, as it occurs (1) in childhood and (2) in infancy, agrees with and differs from the adult type. For purposes of definition, infancy is considered to extend from birth to the age of two years, and childhood from two years to ten years. GROUP I.—ILLUSTRATIVE CASES IN CHILDHOOD. Case A.—Elizabeth O., aged ten years.1 Had been a bottle-fed child. Had had measles, whooping-cough, and scarlet fever, though without obvious sequelæ. Always extremely fanciful about her food. The family, though poor, had meat once or twice weekly and vegetables daily, but this child would take little but bread and butter; “meat and vegetables she would not touch, and milk she did not like.” For the last four summers she had lost strength in her lower limbs, and had suffered much pain referred to her knees and ankles. On several occasions, it is said, the knees and ankles have been swollen and tender, but they have never been hot. At the same periods the child’s gums have become swollen. Sometimes the swelling would occur very suddenly in the night, and would on some occasions subside after a few days. Blood has oozed from them at times, and the smell has been very offensive. She has bled a few times from the nose, but no blotches have appeared on the skin. The child has also been subject during the last four years to what are called fainting-fits. These were specially apt to occur at the time of the joint-symptoms. In these attacks she would remain perfectly still for an p.266 hour, with her eyes open and her teeth clinched, but she was not said to be paler than usual on these occasions. During the winters she was better than during the summers, and she was then able to walk, and even to go to school, whilst during the summers she had been mostly bedridden. When admitted, on July 14, 1875, she was found to be a rather under1 I have to thank Dr. W. H. Dickinson for his permission to record the notes of this case, which I made when the child was under his care at the Children’s Hospital, Great Ormond Street, and subsequently when under my own care at the Convalescent Department. 2 grown child, presenting some signs of rickets in respect to the shape of the thorax. She was pale, and her face had a peculiar dirty-sallow color. The skin generally was rather dry and harsh, but free from ecchymoses, except that the front of each leg showed some ill-defined mottling. The gums of both jaws were spongy in front of and behind the teeth. Some of the teeth were slightly loosened. The child’s breath was extremely fetid. The tongue was clean. There were no abnormal chest-signs, except that the heart’s rhythm was not quite regular. The cardiac sounds were free from murmur; the pulse was one hundred and twenty in the lying posture. There were no abnormal signs in the abdomen. The child was unable to stand, and cried when her lower limbs were moved. They were generally kept extended. She drew up her thighs when told, but very slowly. She was extremely listless when left undisturbed. The child complained most when the popliteal space was touched on either side, but no swelling could be made out there. There was no sign of any effusion into the kneeor ankle-joints. There was some deep thickening of the lower third of the right thigh, which appeared to be periosteal. This part was definitely more tender on pressure than any other part of the body. There was no œdema of the lower limbs, nor was there any local heat of skin. Her axillary temperature on admission was 101° F. For five days it varied between 98.6° and 99.8°. Subsequently it was only on three occasions above 99°. The child showed hysterical objection to meat and vegetables. When these were brought to her she cried, and when given to her she at first made herself sick. But a very little resolute treatment was sufficient to make her take both, and in a few days her gums underwent marked improvement and the tenderness began to subside. In six weeks’ time she was sent to the Convalescent Department, her gums quite well and complexion completely altered, and she was able to stand and to walk a short distance. No other treatment than antiscorbutics was adopted. It was found, however, when the girl got about, that some thickening around the sheaths of the tendons about the ankles had taken place. This was most marked about the tendo Achillis, and there was a little pes equinus. Tenotomy was even contemplated; but within another six weeks the contraction had entirely disappeared, and also all trace of the thickening of the shaft of the femur. Case B.—A. S. (girl), aged four years. Condition when seen: Bluishbrown staining on forehead, result evidently of an ecchymosis. Sponginess p.267 of gums, extending above the teeth in both jaws from the lateral incisors outward. Unable to stand. Great tenderness when lower limbs flexed or extended. No heat of skin; no swelling to be detected. History: After being weaned at fourteen months, had been fed on bacon and bread, light pudding, and beef gravy. Never more than half a pint of milk in a day. Chief beverage cold tea. Had an extraordinary dislike of vegetables. Could not bear to see any vegetables on the table, or to use a spoon which had recently contained any vegetables. Would frequently go many hours refusing any food except cold tea. Had complained of pains in limbs for six months; had pointed to ankles, hips, and back. Had been unable to walk for a fortnight. A bruise-like patch 3 appeared on forehead a fortnight ago. Gums often swollen, but worse during last fortnight. Ordered potatoes, gravy, fresh meat, lemon juice. These were given, and the amount increased each day. In one week’s time she could bear movements of the limbs and could stand leaning against the chair, and her gums were nearly well. Case C.—James P., aged about four years. When brought, showed some rickets of wrists and ankles, and, besides this, extreme tenderness of lower limbs and inability to stand. He had a dirty-sallow complexion, spongy gums, and hysterical objection to meat and vegetables. He began to cry when a plate of meat and vegetables was procured for him, and when this food was given to him he immediately made himself vomit. Subsequently he was compelled to take it, and then kept it down. After a fortnight’s perseverance with meat and vegetables, the gums were found to be natural and the tenderness of the limbs had almost vanished. The boy was then able to stand leaning against a chair. Case D.—Mary O., aged two years and three months. A hand-fed child, the subject for the last eighteen months of severe gastric and intestinal dyspepsia. She had the most remarkable intolerance of milk, and was able to take only very small quantities of a very varied diet. She showed no naked-eye signs of rickets, and there were no evidences of tubercle. She was, so far as could be ascertained, a case of atrophy from non-assimilation of food. She had at length begun to gain a little in weight, and to keep down her food on a mixed dietary of very small quantities of the following: biscuit powder, veal jelly, Benger’s food made with whey, white of egg, and raw meat. She had taken this diet for about three months, and then had been taken into the country for about a month, so that she was no longer under the writer’s observation. There is reason to believe that for a few days the biscuit powder and veal jelly had been increased and the whey and raw meat diminished; but, without obvious cause or change in her circumstances, she suddenly developed sponginess of gums. When the writer saw the child a few days after the onset (at the end of the month of May), the upper gums protruded from the mouth and almost concealed the teeth, so great was the swelling. The lower gums were also swollen, but p.268 the swelling was not so extensive. The lower limbs dropped as though they were powerless. The child screamed on the slightest pressure, but with slight examination no swelling could be made out. The front of the chest presented a remarkable appearance. There seemed to have been multiple fractures at the anterior extremities of the ribs, and the costal cartilages appeared to have sunk back away from the ribs, so that they with the sternum were on a plane posterior to their normal situation. This had taken place within the last few days without any obvious cause. The child was excessively pallid2, but presented no ecchymoses. She lay on her back, and screamed with the slightest movement. She was ordered as additions to her food three dessertspoonfuls of boiled and sieved cabbage and the juice of one lemon daily. This the child took most greedily. In four days there was marked improvement, and in six days the gums were much less red and swollen and the tender2 Pallid. (of a person’s face) pale, typically because of poor health. 4 ness of the limbs was so much lessened that she could be raised. The vegetables were increased and red gravy given, and the quantity of whey was also increased. In a fortnight more the child was able to sit up, and could chew malted rusk moistened with gravy. The swelling of the gums had almost vanished, and likewise the tenderness of the limbs. Her color was so much improved that there was even a touch of red in the cheeks, and she was able to assimilate her food better than had been the case for months. Six weeks afterwards, when seen again, I found, to my great surprise, that the ribs were reunited in natural position with the costal cartilages and that the shape of the anterior part of the chest was quite normal. There was no enlargement of the lower ends of the radii. She had cut two fresh teeth, and the gums were absolutely healthy. The limbs were perfectly free from any tenderness. Case E.—Lilian W., aged two years. Shows some signs of rickets, but also some swelling of shaft of right femur, with extreme tenderness and immobility of the right lower limb. Had been suckled twelve months, subsequently fed on beef tea, bread, and some milk. Child had the greatest dislike to fruit or vegetables or meat. The gums became swollen after the swelling of the thigh. There was some nose-bleeding, but no ecchymosis. Vegetables and meat were given, with much difficulty. In fourteen days some improvement, and in seventeen days decided diminution of swelling and tenderness. GROUP II.—ILLUSTRATIVE CASES IN INFANCY. (a) Those without Post-Mortem Verification. Case F.—A. B., a boy aged fifteen months. When first seen, in December, was excessively pale and sallow, lying on his back, with his left thigh kept slightly flexed and the right extended. He scarcely moves any part of his body except the head. He moans a great deal both night and day, screams if he is approached, and still more if he is touched. Both the p.269 left thigh and left leg are slightly swollen, so that the contour of the limb is different from natural, assuming in the thigh rather a cylindrical shape. Although very shiny and giving an impression of being tightly distended, the thigh and leg do not pit on pressure. There is no local heat or redness. There is no sign of fluctuation and no sign of effusion into any of the joints of the limb. The epiphyses at the knee and ankle are enlarged. The right thigh is free from swelling; the epiphyses at the right knee are enlarged. The right leg is free from general swelling, but there is distinct thickening to be felt down the shaft of the right tibia. Both radii are enlarged at the lower end, but the right more so than the left in circumference and in vertical measurement. It drops as though paralyzed, and is very tender on pressure. There is profuse head-sweating; a little thickening about the frontal region. The thorax presents definite beads. The child has cut the two lower incisors only. There is no sponginess or ecchymosis of the gums. The rectal temperature is 101° F. at seven P.M. The history was the following. The only child of a fairly healthy young couple in good circumstances and living in a healthy house in town. The child was suckled six weeks only, and seemed vigorous. His mother’s 5 milk then suddenly stopped, and from that time till the period when I saw him—viz., during twelve and a half months—he had had no fresh food. At first his diet consisted of grits and Swiss milk, then of baked flour, then of Nestlé’s food, then of Robb’s biscuits, then of Liebig’s extract, and finally of Swiss milk and saccharated lime-water. He had been considered a healthy child, although it was admitted that he had always been pale, that his stools had been unduly offensive, and that he had sweated much about the head since he was three months old. He had cut his first tooth at twelve months and his second at thirteen months. The child had been able to sit up and stand with assistance at thirteen months old. Five weeks ago he ceased to do either, and his left leg became swollen about the ankle. He became very peevish, and screamed directly he was touched. He was then taken to a well-known bonesetter, who said one of the bones of the spine was “out” and that an operation would be required to restore it to its proper position. Five days later the said operation was performed under chloroform; but, as the swelling of the left lower limb increased and the right wrist became swollen and the right hand dropped, it was determined to seek a further opinion, and then it was that the child’s condition was found as above described. The view taken by the writer on the ground of postmortems on other cases to be subsequently detailed was that the child had been for many months the subject of rickets, upon which had supervened scurvy. It was believed that there was blood effused beneath the periosteum of the left femur and tibia, and that the tenseness of this limb was due to effusion of blood into the deeper layers of the muscles and serum into the superficial layers. It seemed probable that there was also some blood-effusion around the shaft of the right tibia and also in the neighborhood of the junction of the shaft and the lower epiphysis of the right p.270 radius. The limbs were ordered to be invested with wet compresses tightly wrung out, and these to be surrounded with dry cloths. A complete change was made in the diet. The juice of a quarter of a pound of raw meat was ordered to be given daily. A pint and a half of cow’s milk was to be given in the twenty-four hours, the alternate meals having a little strained gruel or a little barley-water added. Two teaspoonfuls of orange juice were to be given daily. In three days’ time the most striking change had occurred. The compresses seemed to have soothed the limbs, and he had taken the food greedily and without any indigestion. The rectal temperature had sunk to 99.4° F. The meat juice was gradually diminished, and the orange juice increased, as well as other vegetables given. After the result of the food had been conclusively established, a little cod-liver oil was given. The compresses were discontinued in a fortnight, the general tenseness of the left lower limb having then subsided. It was by this time easy to appreciate that there was thickening around the shaft of the left femur and left tibia, of the same kind as that felt in the right tibia at first, but greater in amount. At the end of six weeks there was still some thickening to be felt, although all tenderness had gone. Before this, also, the difference in size between the lower ends of the two radii had disappeared. After a month’s time shampooing and douches were commenced, and within two months the boy would voluntarily get on his knees and stand with a little support. His face was ruddy, and his skin and muscles were becoming firm. 6 Case G.—Mary C., aged ten months, when sent to me was extremely anæmic, and evidently in pain on the least movement. The legs hung down in a helpless fashion, and were extremely tender. There was distinct cylindrical swelling around the shaft of each tibia. Gums were spongy, but only over and around the two lower incisors, which have been cut, and over the situation of the on-coming upper incisors, one of which is just emerging. Presented marked rickets, anterior and posterior beads on ribs, head-sweating, and enlarged epiphyses. The history given by the mother was to the effect that the child had never had the breast; that it had been fed first on Nestlé’s food, then on Ridge’s food, then on Savory & Moore’s food, but that she had always had some diluted cow’s milk. Her present symptoms had started four months ago with great tenderness and swelling of the lower limbs, which had somewhat abated lately. Six weeks ago swelling of the lower gums had first appeared. One month ago there had been blueness and puffiness of the left eye, which had gradually subsided. The child was ordered fresh milk, with boiled sieved potato and orange juice; and the doctor who had sent her reported subsequently that the subsidence of the tenderness of the limbs and of the sponginess of the gums was most manifest, even within a couple of days. Case H.—Fred. O., aged eight months, was sent to me by an eye-surgeon on account of proptosis of one eyeball, with great tenderness of limbs p.271 and general cachexia. Healthy at birth. No breast-milk. Fed during first three months on Ridge’s food with cow’s milk and water equal parts, then on Savory & Moore’s food with milk and water. Liable to vomiting. Bowels not generally relaxed, but offensive. Two lower median incisors when seven months old. Mother thought the child was all right till four weeks ago, when whole body became very pale and sallow. Had been rather tender in the legs since he was quite young, but during the last week the tenderness had become excessive. The swelling of the upper eyelids had come on suddenly three weeks ago. The screaming during the last week had been almost incessant. The child when admitted into hospital was extremely anæmic and sallow. The right upper lid was of a purplish-red color, due to deep extravasation into its substance; there was no ecchymosis of palpebral or ocular conjunctiva, but there was proptosis of the eyeball to a slight but definite amount, suggesting that there was something in the orbit pressing the eyeball downward and forward. The left upper eyelid was also a little brownish purple in color, the result of former extravasation, but there was no proptosis of the eyeball. The gums around the two lower median incisors, which are the only teeth present, are purplish and slightly raised from recent extravasation. The lower limbs were moved voluntarily a very little; they generally lay everted, with the knees slightly flexed. The epiphyses at the knees and ankles were all enlarged, and the tibiæ showed slight internal beading, but the limbs were so sensitive to the slightest touch that a proper examination of the shafts could not be made. The upper limbs were moved by the child with much more freedom, and they were obviously not so tender. All the epiphyses were enlarged. The thorax was typically rickety, with anterior and posterior beats well marked. There were no visceral signs, except that the urine was slightly albuminous 7 and gave a definite blood-reaction to ozonic ether and guaiacum. Temperature 101.6° F. The child was ordered one pint of milk, some mashed and sieved potato, a little gravy, the juice of one lemon, and one tablespoonful of raw meat juice, daily. In three days the change was most remarkable. The child took the fresh food quite greedily. She slept very much better. The tenderness had greatly diminished. The ecchymosis of the eyelids was lessened, and the proptosis also, to a slight extent. The ecchymosis around the lower median incisors was lessened, and no fresh ecchymosis was visible. In four days more the child sat up in bed, moved her limbs quite freely, and allowed them to be handled without crying. Her color was greatly improved, the proptosis was lessened, and the albumen and blood had vanished from the urine. I may here state that slight albuminuria with a trace of blood was present in another of my cases, and in one communicated to me by Mr. Shoppee, also in two of Dr. Cheadle’s and in one of Dr. Gee’s. (b) Cases with Post-Mortem Verification. p.272 Case I.—Lillie S., aged ten months, was brought to me as an outpatient in October, 1881. She had never been suckled, but had been fed first on condensed milk, then on cow’s milk, then on a succession of “infants’ foods.” At the time when she was brought she was taking AngloSwiss food. There had been much head-sweating since she was three months old. The bowels had been constipated until two months before, when she had a severe attack of diarrhœa. After this her legs became very tender. Three weeks ago her wrists also became very tender. The child when brought was extremely fretful: she screamed when she was approached, and still more when she was touched. The temperature was 99.8° F. Her skin was pale to the last degree. There were ecchymoses in both upper eyelids; also underneath the mucous membrane of the gums in the lower median incisor regions, and in the lower molar regions, separate ecchymoses were seen. The child had not cut any teeth, but these ecchymoses were evidently in the situations of on-coming teeth. The lower end of each radius was much enlarged, and the left hand hung prone in a condition of pseudoparalysis. The left thigh was strongly flexed. There was deep thickening to be felt along the lower third of the shaft of the left femur. The epiphyses of the lower limbs were a little enlarged. There were rather prominent projections along junction of costal cartilages with ribs. The child lay on her back, and made no attempt to move. It was not expected that she would live, but the mother was ordered to give her raw meat juice and continue the cod-liver oil. In a week’s time she was not worse, with the exception that there was now slight proptosis of the left eyeball, as though there might have been some extravasation into the orbit. Eleven days afterwards this had subsided; but the child gradually sunk three weeks after having been first seen, and about three months after the onset of her illness. Post-mortem examination showed on both parietals a patch of subperiosteal hemorrhage about the size of a shilling, the bone beneath it being a little porous. The muscular walls of the thorax were pale yellow and watery, as though they had been bathed in serum. The periosteum of the ribs was extensively detached, thickened, vascular, and a little granular. 8 It was separated from the rib by a considerable quantity of chocolatecolored débris, evidently broken-down blood-clots. There was no lymph or pus. The ribs were extensively bare and white. They were distinctly wasted. What had been taken during life for beads proved to be simply the ends of the costal cartilages abutting against ribs which were so extremely wasted that their anterior ends by no means came into complete apposition with the whole of the ends of the costal cartilages. There were no beads at the posterior surface. It was a wonder that the ribs had not separated from the costal cartilages or fractured beyond, they were so exceedingly brittle. There was, in fact, nothing but a shell of bone containing a little soft red medulla. On the parietal pleura of both sides there were numerous petechiæ corresponding with the ribs. There was some p.273 blood-stained serum in the left pleural cavity, but no lymph. In the middle of the left lung there were two or three very small masses of caseous tubercle and a few gray granulations on the surface. There was no tubercle elsewhere, and no disease of the other viscera. Only a partial examination of the limbs was permissible, but some blood-extravasation was found into the periosteum of the ilium and into the muscles attached to it, whilst the superficial parts were pale yellow and pulpy. There was also subperiosteal hemorrhage in the region of the junction-area of the upper epiphysis with the shaft. The above post-mortem record need only be supplemented by a few details derived from three other cases, in two of which the examination was made by myself and in one by my friend Dr. Stephen Mackenzie. The age of each of these three cases was below two years. The lower limbs showed, on section, yellowish serum infiltrating the upper muscular layers of the thigh and leg, the muscles pale and slightly pulpy. Deeper muscular layers contained a little disseminated blood-clot. The periosteum of the femora and tibiæ thickened, vascular, and separated from the affected shafts in great measure by sheaths of blood-clot. In all three cases, fractures through the area just above the junction of shaft with epiphysis. No callus. The two bony surfaces rough, but not splintered. The medulla of the shaft soft and red, and the trabecular structure scanty and friable. Upper extremities.—In one of my cases, extensive extravasations of blood under the periosteum of both surfaces of the scapula. Slight deposit of new bone formed by the upraised periosteum. The bones of the upper limbs not so profoundly affected as the lower, but fracture found in one case below the upper epiphysis of the humerus. Some evidence of antecedent rickets in all the bones. Rib changes as described in the previous case. Visceral changes.—In addition to those before mentioned, a varying amount of interstitial hemorrhage in lungs, spleen, kidney, intestinal glands. 9