6. Extrarasations of blood into the skin and mucous membranes are seen as further evidences of the hremorrhagic diathesis, but on the whole, they are less frequent and are but slightly characteristic. Thus there arc small and larger lriemorrhages under the skin, usually in locations subject to irritation or in scars, haemorrhages into the oral mucosa in addition to the gingivitis, into the conjunctiva, the nasal mucosa, and that of the intestinal tract (bloody stools).
7. hrwmaturia occurs in ten per cent. of the cases (Heubner), and is sometimes the only evidence of the hremorrhagic diathesis. The urine shows a large amount of albumin, numerous erythrocytes and granular and red corpuscle casts; a true hremorrhagic nephritis is rare.
S. Ferer.—The temperature in about fifty per cent. of the cases is slightly elevated without definite type. and ill general seldom rises above 39° C. (102.2° F.). The duration of the fever is very variable; feverish periods alternate sometimes with those of normal temperature.
No characteristic symptoms referable to the other organs occur. The respiration is frequent on account of the marked arucmia, the pulse is accelerated, the heart is sometimes dilated and anremic murmurs may be heard. The appetite is poor; the bowels are normal, or sluggish, though there may be diarrhcea with traces of blood-tinged mucus, espe cially if the haemorrhage into the intestinal mucosa stimulates peristalsis. Bronchitis, pneumonia and severe intestinal catarrh are frequently met with as complications.
The course is decidedly chronic. Weeks or months are required for the full development of the clinical picture, and then the condition fluctuates backward and forward until death supervenes, apparently from cardiac weakness often aided by a complicating enteritis or pneu monia. Or a correct diagnosis leads to proper treatment and saves the life of the child. Without this the children usually die; the very slight cases may recover spontaneously. Apparently in many early cases, perhaps just beginning, a simple change in diet undertaken because the children were pale and dull, leads to recovery without infantile scurvy being suspected.
Schoedel-Nauwerk, Schmorl and Frankel agree that the pathological changes in infantile scurvy consist chiefly in a characteristic affection of the bone marrow which is most marked at the osseo-cartilaginous border, and comprises a change of the normal lymphoid marrow, which is rich in cells, into a tissue poor in cellular elements, which contains but few blood vessels and consists of a homog eneous ground substance containing spindle and stellate cells. The
transformation of the marrow with the associated destruction of osteo blasts, while normal bone absorption proceeds, must necessarily result in an abnormal thinness and insufficient density of the youngest por tions of the diaphysis, at the margin of growth. From this circumstance a great rarefication of the bone results both in the region of the first lamellae and in the deeper layers.
Consequently the ends of the shafts of the diseased bones become brittle on account of the thin cortex, the scarcity of strong trabeculic and the persistence of much calcified ground substance which has not been transformed into true bone. On this account even small traumata, such as the traction of the muscles at their attachments, lead to par tial or complete fractures at the extremities of the long bones and to displacement of the costal cartilages (see Plate 9). Breaks very rarely occur at a great distance from the epiphyses, as in the shafts. As a result of the fissures and fractures at the epiphyseal line, the epiphyses become loosened and dislocated but no true epiphyseal separation occurs. Severe displacement of the fragments is prevented by the fact that the periosteum is very seldom torn. The joints always remain unaffected.
Subperiosteal limiaorrhages of varying extent, surrounding the entire shaft, usually accompany the breaks in the bone and often lead to visible and palpable swelling of the limbs. These hemorrhages, however, may be absent notwithstanding severe bone lesions; they are dependent upon the severity of the htemorrhagic diathesis which accom panics the bone affection. This leads to haemorrhages, not only about the fract wed bones but also on other bones, especially \ vhere growth is very active, e.g., the jaws; also to haemorrhages in the bone marrow, into the parenchyma of the internal organs,• and into the intestinal mucosa (diffuse ecchymosis of the mucosa of the Hewn, FrOnkel). In several cases which had had htuinaturia Frankel found no inflammatory changes in the kidneys but merely haemorrhages into the tissue.