SCURVY 409 



loss of substance has not occurred, steadily improves, the swelling disappears, 

 and restitutio ad integrum takes place. On the other hand, permanent changes 

 in the form of cicatricial retractions or hyperplastic thickening of the tissue 

 may remain, which, however, do not give rise to any difficulties. Of the 

 processes in the skin, the small hemorrhages improve most readily. They go 

 through all the changes that hemoglobin shows, and finally disappear. With 

 an improvement in the general condition, the cutaneous ulcers also pursue a 

 _ favorable course. Their surfaces become clean, and finally skin is formed 

 in which a dark pigmentation remains for a long time. The swelling in the 

 muscles and connective tissue also gradually recedes, although very slowly, so 

 that a callus is often evident long after complete recovery. Kot rarely, too, 

 connective tissue proliferation occurs (as in the gums), the result of which is 

 permanent contraction or fixation of the muscles and joints, with, for example, 

 the formation of club-foot. 



DIAGNOSIS 



In view of the marked symptoms, the conspicuous epidemic character of the 

 disease, and the extraordinary circumstances under which it usually arises, the 

 diagnosis of scurvy can scarcely be difficult. 



Difficulty arises only when we are dealing with sporadic cases, and even in 

 these a careful history of the previous conditions of the life and residence of the 

 patient will lead to a recognition of the affection. If we remember that the 

 greatest number of epidemics occur upon ships, in fortresses, among isolated 

 bodies of troops, or in penal and eleemosynary institutions, that quite definite 

 etiologic factors such as insanitary conditions of life, and, above all, improper 

 food have preceded the outbreak, no further proof is needed for us at once to 

 recognize the disease. The disease may break out in so many places that it is 

 only very rarely that symptoms are at all scanty in a given case ; almost always 

 a number of the usual symptoms appear simultaneously. Serious diagnostic 

 difficulties will, therefore, only occur in isolated cases of unusually mild char- 

 acter. But these are just the ones which to-day present themselves for pro- 

 fessional treatment. 



First among the external symptoms we have learned to recognize those 

 which almost always precede the local phenomena of the disease and increase 

 with its advance ; i. e., the general cachexia. Next come the various effusions 

 • of blood into the skin, into the deeply lying connective tissue and the muscles, 

 the rheumatoid arthritic pains occasionally present, and, above all, the affec- 

 tion of the gums. The number of diseases which may be confounded with it 

 is very small. First, those diseases which form a common group with scurvy 

 (hemophilia and morbus maculosus Werlhofii). Neither is epidemic in any 

 sense ; and as both are to be described later they need not now be considered. 

 I will state here, however, that, in spite of the external similarity of many 

 cardinal symptoms, the disease of the gums is the predominant feature in 

 scurvy, and is not present in either of the other diseases mentioned. 



Cutaneous hemorrhages, especially petechia and small ecchymoses, are met 

 with in a number of cachectic diseases. When associated with rheumatoid or 

 arthritic pains a confusion. of scurvy with peliosis rheumatica may occur. If, 



