IX. EFFECTS OF DEFICIENCY IN HUMAN RKINGS 



353 



fatigue and poor performance on a treadmill appeared after 90 days and 

 when the white blood cell ascorbic acid level had reached 4 mg. %.•' 



3. Clinical Deficiency State in the Adult 



The first clinical manifestation is the perifollicular hyperkeratotic papule 

 (see Fig. 6), wliich occurs on the legs and buttocks and later on the arms 

 and back. The hairs become fragmented, coiled, and buried in the lesions. 

 These closely resemble the follicular hyperkeratoses of \dtamin A deficiency 

 and appear after about 4 months of complete ascorbic acid deprivation. 

 Erythema and then purpura appear around these hair folHcles, producing 



Fig. 6. Perifollicular hemorrhages on the leg of a boy, age 16, with scurvy. 



the distinctive early sign of scurvy, the perifoUicular hemorrhage, which has 

 appeared in experimental subjects after 53^ months of ascorbic acid dep- 

 rivation and after the white cell-platelet ascorbic acid level had been zero 

 for l}4 months.'^' ^*' ^^ This is not a specific manifestation, however. Mor- 

 phologically identical lesions have been seen in patients with bacterial 

 endocarditis and folUcular hyperkeratosis. 



Purpura appears on the lower extremities first. It spreads upward and 

 has a predilection for areas around joints and parts frequently traumatized. 

 Minute purpuric spots may be seen along scratch marks, where garters or 

 brassieres constrict or where shoes exert pressure. The ecchymoses become 

 larger, coalesce, and may involve the skin of the entire extremity (see 

 Fig. 7). Hemorrhages deep in muscle occur, particularly in calf, thigh, and 

 forearm, causing painful brawny induration of the surrounding tissues. 



