Blood examination shows: 50 per cent. (Gowers); slight poikilocytosis, marked lymphocytosis, no abnormal forms.
Diagnosis.—Infantile scurvy.
Dietetic treatment with raw cows milk, meat juice and fruit juice.
Course.—After four days there was a decided improvement of all symptoms, the child's whole condition changed; after fourteen days more it was almost well and was taken home. Uneventful recovery.
Symptoms.—The majority of the symptoms were present in the above case.
1. An wmia.—Children formerly bright and rosy become gradually analnic and finally waxy-white. The examination of the blood shows. a fall in the htemoglobin content to as low as 40 per cent., a marked de cline in the number of erythrocytes, slight poikilocytosis, and leucocy tosis with a decided increase in the mononuclear at the expense of the polymorphonuclear forms (Ritter); thus relatively insignificant blood changes with absence of abnormal forms. The view advanced by Sen ator that the ainetnia is the result of a primary disease of the bone mar row is not justified by the pathological changes found in the marrow and the blood.
2. Pain on Morement.—At first the children cry very often with the ordinary handling, then move less than formerly and finally every movement or even a touch is painful. Movements of the legs are at. first the most painful, and upon careful investigation one finds especial tenderness at the ends of the diaphyses; finally the legs lie immovable, as in syphilitic pseudoparalysis. The thorax also is very frequently tender, the arms less often so. This tenderness of the bones may be absent notwithstanding other well-marked symptoms of infantile scurvy. The tenderness which often extends over the whole body is dependent upon pathological changes in the bones and less upon a general hyper resthesia.
3. Enlargement of the Bones.—Swollen areas appear upon one or more bones, most frequently at the lower end of the femur, so that these bones seem locally enlarged, and over them the skin becomes tense and glistening and the swollen part feels doughy to the touch. The swell ing seldom reaches above the lower third or at most the middle of the femur. Frequently both thighs are involved. No less frequently the osseo-cartilaginous junction of the ribs is enlarged so that the picture of a rachitic rosary appears, and confusion with rickets may arise. In
severe cases of rib involvement a separation of the cartilaginous from the bony portions of these bones occurs, so that the sternum and adja cent costal cartilages sink bodily backward. This phenomenon is almost specific for the disease.
Barlow says concerning this: "The sternum with adjacent costal cartilages and a small portion of the contiguous ribs appear as though they had been fractured by a blow from the front and had been forced: backward." The legs swell similarly to the thighs, and in association with the enlargement at the upper end of the tibia there is often found a swelling of the entire lower leg. These painful swellings may appear on the hu merus as well as on the bones of the forearm, the scapula, the jaws or any bone of the body. After they remain for a time the skin over them assumes a bluish or bluish red discoloration. Not infrequently with or without these enlargements, evidences of interruption of continuity, crepitation and displacement, appear at the ends of the diaphyses of the affected bones.
4. Themorrhogie swelling and softening of the gums is a very impor tant and frequent symptom. The dark bluish or purplish spongy gum closely surrounds and overlaps the teeth and shows a tendency to bleed. There is however, no tendency to destruction of the gums as in ordinary scurvy. This hremorrhagic change is noted only about the teeth which have already appeared or around those which are about to come through; in fact, in the depths of the tumefaction one often sees the points of teeth which first show themselves as the swelling subsides. In children without teeth this change is either not seen at all or only just before the teeth are cut.
5. themorrhagic swelling of the Eyelids and Esophthalnus.—Sub periosteal extravasations of blood appear also upon the cranial bones especially upon those of the orbit; they may press the eyeballs forward, and through infiltration of the blood into the loose tissues of the lids may cause the latter to become much swollen and of a bluish red color. This frequently affects both eyes and produces a marked disfigurement of the child.