The cause of the deterioration of the blood in scurvy appears k be, not the mere absence of potash salts, as Dr. Garrod believed, but rather, as Dr. Buzzard supposes, the absence of these salts in combination with organic acids. Dr. Ralfe has still further developed the latter hypothesis. This observer is of opinion that the primary change depends on a general Avant of normal proportion between " the various acids, inorganic as well as organic, and bases found in the blood, by which the neutral salts, such as the chlorides, are either increased relatively at the expense of the alka line salts" or these latter are absolutely decreased. He concludes that there is a diminution in the alkalinity of the blood, and that this produces dissolution of the blood-corpuscles and fatty degeneration of the muscles and of the secreting cells of the liver and kidneys.
Symptoms.—Children in whom the symptoms of scurvy are noticed are often large, flabby infants between twelve and eighteen months old. They usually show the milder phenomena of rickets, such as profuse sweating about the head, lateness of dentition, enlargement of the ends of the long bones, and beading of the ribs. In such subjects the course of the scorbutic disease is as follows : The patient shows signs of unusual and extreme tenderness. He dreads being handled, cries if put upon his feet, and if he had been able to walk, is quite taken off his legs. Next he begins to suffer from pains which seem to be constant. The child lies moaning in his cot, and screams if touched or even approached. Very soon swelling is noticed of a limb, usually a thigh—one or both. The affected part is enlarged by a cylindrical swelling which although not ac tually brawny to the touch is yet firmer than natural. In many cases it is distinctly oedematous, but it may not pit under the finger, although it often gives the sensation of containing infiltrated serosity. In the lower limb the swelling usually occupies the whole length of the thigh and often of the leg. There is no perceptible fluctuation, and no enlarged veins can be seen, but the tint of the skin is often livid or faintly lead-coloured, and in a case recorded by Furst its tint was red and glistening. There is no effusion into the joints, but these are usually swollen from enlargement of the articular ends of the bones. The upper limbs are less affected than the lower. The forearm just above the wrist is here the part in which swelling is most commonly noticed. In such a case if the swelling is not extensive, it is difficult to distinguish it from the ordinary epiphyseal en largement so commonly present in the rickety child. But besides the parts which have been mentioned, swellings from local periosteal extra vasation may be found at the upper part of the humerus and on the shoulder-blades, and sometimes similar extravasations are noticed in the skin and subcutaneous tissue. Petechim, bruise-like patches, and even small blood-tumours may be met with. There appears also to be the
same tendency to the formation of ulcerating sores on the cutaneous sur face which has been remarked in cases of scurvy affecting the adult. In one of Dr. Cheadle's cases—a little boy aged sixteen months—there were two unhealthy looking sores seated the one on the right wrist, the other on the fore-finger.
At first, when the swellings begin, the child keeps his limbs flexed, but later a new phenomenon is noticed. The patient ceases to flex his legs, and allows them to remain stretched out straight in the bed, as if he had lost all power of movement. It will now be noticed on examination that a soft crepitus can be defected in the neighbourhood of the joints from separation of the epiphyseal ends of the bones, and the wrist may drop from fracture of the carpal end of the radius. At this stage the joints can be examined without the child appearing to suffer pain from the move ment of the articulations.
In many of the cases in which the symptoms are well marked, spongi ness of the gums and other minor manifestations of the scorbutic taint are entirely absent. Sometimes, however, the gums are red and soft and gelatinous-looking, and may be so swollen as actually to protrude between the patient's lips. They bleed at the least touch. The swelling may ex tend to the mucous membrane of the palate, and this may be so spongy as almost to touch the dorsum of the tongue when the mouth is open Dr. Cheadle has reported some cases in which the affection of the gums was unaccompanied by signs of deep-seated extravasation in the limbs, but the two conditions may be present together. The child appears at this time to be the subject of marked cachexia. He is sallow and very emaciated his temperature is often raised, reaching to 101° or 102° in the evening ; his appetite is poor, and his bowels may be relaxed. Often profuse per spirations are noticed. If the mucous membrane of the mouth or gums is affected, the breath has a most offensive odour. The weakness is usu ally very great. The child ceases to be able to support himself in a sit ting posture, and when placed in that position falls on to his side at once if left alone. The urine may contain albumen and sometimes is reddened with blood. The abdominal organs seem to be healthy, and no enlarge ment can be detected of the liver or spleen. There may be cough, but the physical signs of the chest are usually normal, or consist merely in a few large bubbles heard here and there about the hack. In one of Dr. Gee's cases—a child aged one year—a curious recession of the chest was noticed. At each inspiration the whole of the front sank inwards, the ribs bending on each side at a point much outside the costochondral articulation, and the breast-bone receding instead of protruding as in rickets. Dyspnoea is not, however, mentioned in other recorded cases of the disease in early life.