As the illness progresses it is often found that the swelling first noticed begins after a time somewhat to subside, and another limb becomes affected in a similar way. Thus, in Fiirst's case the earlier swellings appeared in the left femur and the tibim of both limbs. Next, enlargement was noticed in the right forearm, and afterwards in the left forearm and the right arm. At the time when these secondary swellings appeared the parts first affected began to recover, and the fever abated. Even after apparently complete recovery the disease is still liable to recur, under the influence, probably, of the same causes which provoked the original attack. Thus, in Mr. Thomas Smith's case the child was said to have suffered eleven months previously from like symptoms which had lasted over a period of two months.
Fever is not always present in cases of scurvy in the child. Sometimes, as has been stated, the thermometer marks an elevation of 101°, 102°, or ever higher, but the disease may run its course without the occurrence of pyrexia. Still, if the lnemorrhagic effusion is great and the tension of the periosteum correspondingly severe, a certain amount of fever is usually to be noticed.
When the patients recover, as they will usually do if suitable treat ment is adopted in time, the temperature falls, the tenderness subsides, the swellings disappear, the appetite improves, and the strength and colour re turn. A degree of thickening is left at first around the bone at the site of the swelling, but this after a time is no longer to be detected. Even the separated epiphyses will, under favourable conditions, become again con solidated with the shaft of the bone.
Diagnosis.—In all cases where a young child presents symptoms of rickets, and it is discovered that his feeding and management have been such as to favour the special deterioration of the blood which gives rise to scurvy, the symptoms of that disease should be looked for. These always supervene upon a state of ill-health, and never occur, as is the case with purpura, in a child whose condition is not in other respects unsatisfactory. Exaggerated tenderness, even in a case of rickets, is a suspicious symptom. In rickets tenderness is confined to cases where the bone-changes and general features of the disease are pronounced. If the symptom is noticed in a child who, although showing signs of rickets, is evidently suffering from the disease only in a mild form, it points very decidedly to scurvy.
When the swellings occur in the limbs the great enlargement without fluctuation, or redness, or local heat of skin, is unlike ordinary periostitis, and, indeed, this disease is not a recognized complication of rickets. If, then, the patient be suffering from rickets, the probability of the additional phenomena being due to the supervention of scurvy should be considered.
In many cases, especially if separation of the epiphyseal ends of the bone has occurred, with the symptoms of pseudo-paralysis, the difficulty is to exclude syphilis ; and if, as may happen, there is a history of miscar riages on the part of the mother, or of doubtful symptoms in the child himself shortly after birth, it may be impossible to exclude a syphilitic taint. Still, the diagnosis of scurvy may often be ventured upon. Syphilitic pseudo-paralysis is usually accompanied by enlargement of the spleen and all the signs of a profound syphilitic cachexia. The child is greatly wasted. He is hoarse and snuffles, the cranial bones have the characteristic thicken ing, and the skin has the peculiar dry, parchment-like appearance so com mon in the inherited disease. In scurvy the patients are not as a rule
greatly emaciated. Often their general nutrition is fair ; and the special characteristics of syphilis are absent. If the gums are spongy or signs of hemorrhage. can be noticed in the skin or elsewhere, the evidence is strongly in favour of scurvy.
the child be seen in time and measures are at once taken to improve the quality of his food and supply the lacking constituents to his blood, recovery may usually be counted upon. When children die in this disease they die from exhaustion. Much will therefore depend upon those who are entrusted with the care of the child, for scurvy is one of the maladies of which the treatment consists almost entirely in vigilant and judicious nursing.
all cases of infantile scurvy it will be found that the child has been deprived of fresh milk and fed upon Swiss milk and other kinds of tinned food, which are deficient in the material necessary for maintaining all the constituents of the blood at a normal standard. An immediate change must therefore be made in his diet. He should be given fresh cow's milk, diluted, if necessary, with bailey-water or thickened with a proportion of potato-gruel. If he be twelve months old raw mutton pounded in a mortar and strained through a fine sieve, may be given every other day alternating with raw meat-juice,' or if the meat be not well digested, meat-juice can be given every day. If the child refuse this food the juice may be sweetened with sugar, or what is much better with tur nip or carrot: Orange-juice is well taken as a rule, even by young babies, and is a valuable anti-scorbutic. If the patient be in a very exhausted state, twenty or thirty drops of brandy can be given every three or four hours ; or he may have one or two teaspoonfuls of burgundy or the. St. Raphael Tannin wine, diluted with an equal proportion of water. At the same time care should be taken to furnish a proper supply of fresh air. If the weather be suitable the child may be taken out frequently lying at full length in a little carriage. If he be confined to the house, open windows should be insisted upon, every precaution being taken to keep the cot out of the line of direct draught. The best medicine is cod-liver oil. This may be given with a few drops of the tincture of perchloride of iron, or in a draught composed of three of four grains of the citrate of iron and qui nine dissolved in a teaspoonful of lemon-juice, and sweetened with spirits of chloroform. An occasional powder of rhubarb and aromatic chalk can be given if there is an unhealthy state of the bowels.
When the gums are spongy and bleeding, they may be painted several times a day with a solution of glycerine of tannin and glycerine of carbolic acid, fifteen minims of each to the ounce. This application was used by Dr. Cheadle in his cases with the best results. For the swellings of the limbs Dr. Barlow recommends surrounding them with wet compresses thoroughly wrung out, and covered with dry cloths closely applied. An operation seems to be unnecessary, although Mr. Herbert Page has re ported a case in which he made an incision through the periosteum and turned out the extravasated clots without ill consequences. Still, it seems probable, from the results in other cases, that eventual absorption of the blood will take place if the child be put under favourable conditions for recovery. If separation of the epiphyses has occurred, the limb must be kept perfectly quiet in splints.