360 ASCORBIC ACID 



incisors. Red blood cells may appear in urine, stool, and spinal fluid. Retro- 

 bulbar, subarachnoid, and intracerebral hemorrhages may occur. Dyspnea, 

 cyanosis, convulsions, and death follow in rapid progression if treatment 

 with ascorbic acid is delayed. 



C. LABORATORY DIAGNOSTIC AIDS 

 1. Roentgenological Study of the Bones 



The earliest manifestations of scurvy in the infant appear in the bones 

 and can be demonstrated by x-ray techniques.'^ These lesions do not occur 

 in the adult patient, and therefore the x-ray is of httle help in the diagnosis 

 of adult scurvy. In the diagnosis of infantile scurvy it is of tremendous 

 importance. 



The earliest roentgenologic manifestations of infantile scurvy are usually 

 noted at the ankles first and then at the wrists, but at either area they are 

 radiologically identical, A defect appears at the anterior corner of the tibia 

 or at the outer corner of the lower end of the radius. At first the cortex in 

 these areas merely has a fuzzy appearance and there is sHght rarefaction of 

 neighboring cancellous bone, making the corners indistinct. Later a cleft or 

 crevice or the extrusion of bony spicules appears at the outer edge of the 

 cortex just underneath the lattice or epiphyseal line. This is called "the 

 corner sign." The fibula and the ulna are less regularly affected, but when 

 the lesion appears in these sites it is of the same general type. If anterior 

 and posterior clefts are very near to each other, epiphyseal separation may 

 occur and the epiphyseal side of the lattice appears to be curved and rests 

 against the end of the shaft. 



The most distinctive x-ray sign of scurvy is the dense white line lying 

 across the end of the shaft. It is composed of calcified cartilaginous matrix 

 which is not destroyed in the normal fashion. Much of its dense appearance 

 is due to the rarefaction of bone underneath it, through which the clefts, 

 fractures, and separations occur (see Pathology and Pathologic Physiology). 



The cortex of the bones is generally thinned out, gi^'ing a "ground-glass" 

 appearance. The thinned-out epiphyses with rims of heavy calcification at 

 the outer margins give the appearance of "halos" (see Fig. 13). The costo- 

 chondral junctions become broader, and the lattice is irregular. Fractures 

 occur just under the lattice, the ribs remain rigid, and the sternum sinks 

 back, producing the scorbutic rosary. 



Hemorrhages which occur under the periosteum and which arise from 

 the fractures through the rarefied zone cannot be visualized by x-ray except 

 as soft tissue shadows at the ends of the bones which do not involve the 



" E. A. Park, H. G. Guild, D. Jackson, and M. Bond, Arch. Disease Childhood 10, 

 265 (1935). 



