Scurvy is not confined to the subjects of rickets, but most scorbutic children are found to be suffering from that disease. This is not to be wondered at, for the age at which rickets is most liable to occur is also that at which scurvy is chiefly found to prevail. The two affections are also, as has been said, induced by causes very similar in kind ; and the general impairment of nutrition of which rickets is the consequence no doubt renders the patient especially sensitive to the effects of a scurvy diet. In most of the recorded cases of scurvy in the young subject the patients have been under eighteen months old.
Illorbid Anatomy.—One of the most characteristic morbid changes in duced by the disease is a copious extravasation of blood into the tissues of the limbs, especially of the thighs. The muscles themselves are usu ally pale, but the tissues between them may be infiltrated with serum more or less blood-stained. Sometimes blood is extravasated into the substance of the muscles, but without any evident laceration of the fibres. The chief seat of the extravasation is between the periosteum and the bone. In many cases the investing membrane is found to be separated widely from the shaft of the bone, retaining its attachment merely at the epi physes. It is, moreover, greatly thickened and deeply injected. Between it and the bone lies a large, loosely adherent blood-clot in which the bone is embedded. When the clot is cleared away the bone is found to be perfectly smooth, although bare of periosteum. Another common feature is a separation of the epiphyseal ends of the long bones. This separation is not at the line of union of the epiphysis, but in the shaft of the bone just below the point of junction. The osseous structure at the seat of fracture can be noticed to be particularly loose and spongy. It is impor tant to remark that in all these cases where separation of periosteum has occurred no sign of caries or exfoliation of the bone is to be discovered. Nor does the extravasation of blood ever appear to end in suppuration. The shaft of the bone is curiously fragile and thinned. This atrophy is well seen in some cases in the ribs, which may appear to be reduced to the two bony plates by almost complete loss of their cancellous structure. Extravasation of blood never seems to take place into the articulations, as is seen in haemophilia ; for all the joints and tissues immediately connected with them are found to be healthy.
The above changes in the bones and periosteum are common to all fatal cases of scurvy in the child. Mr. T. Smith's case exhibited at the Patho• logical Society of London in 1875-76, under the provisional name of " hemorrhagic periostitis," showed the above changes in both lower limbs. The parts principally involved were the thigh bones, but the bones of the legs were affected, although to a less extent. In Dr. T. Barlow's beautiful
preparations shown at the Royal Medical and Chirurgical Society in 1883, the same characters were observed. The effused blood has usually been found of a deep marone colour and coagulated. Of other organs the ab dominal viscera are generally healthy in these cases. The same thing may be said of the chest ; but once or twice Dr. Barlow has found some effusion in the cavity of the pleura, and in iNk T. Smith's case there was a small haemorrhage in the lung. Often no sponginess or inflammation of the gums is to be seen, but little haemorrhages have been noticed at the point of the gum in the situation of the up-coming teeth. Other small extravasa tions may be present in the skin in various parts of the body. They may occur around the ribs, and may be discovered in the intestines and kidney.
The above morbid characters can leave little doubt that these cases are rightly classed under the head of scurvy. It has been objected to this view that although the symptoms observed during the life of the child do not, as a rule, point to any very marked deterioration in the quality of the blood, the lesions noted after death are the later manifestations of the dis ease, such, indeed, as occur in the adult only as a consequence of profound constitutional cachexia. Thus sub-periosteal haemorrhage, which is a late symptom in the adult, is produced early in the child ; and the affection of the gums, which is usually regarded as one of the earliest and most charac teristic symptoms of scurvy, may be absent in the young subject altogether. To this it may be replied that cachexia is produced very rapidly in the infant by acute disease, and that in some cases of scurvy in the child an ex treme degree of anaemia and debility has been reached. But granting that in many cases serious lesions have been discovered where the• general symp toms have been comparatively mild, this is not to be wondered at, consider ing the age and peculiarities of the patient. In a blood disease such as scurvy it might almost be anticipated that the tissues chiefly affected would be those in which growth and development are making most active progress. At the age at which young infants are usually found to suffer no tissues or organs are undergoing more rapid changes than the long bones, especially those of the lower limbs ; and it is exactly in these situations that the more pronounced lesions are observed. On the other hand, in the maxillary bones ossification and development are practically at a standstill ; for the child being (as he almost always is) the subject of rickets, the jaws have ceased for the time to increase in size, and the evolution of the teeth is completely arrested.