These glands produce many litres of secretions in a day, but most of this volume is re-absorbed.

The digestive system is divided into four main areas following the passage of food: the mouth and oesophagus, the stomach, the small intestine, and the large intestine.

Parietal layer. This lines the abdominal wall.

Visceral layer. This covers the abdominal
organs.

The potential space between the two layers is occupied by serous fluid to allow ease of movement.

A fold of peritoneum
attaching an organ to the abdominal wall is termed a mesentery.
Mesenteries not only support abdominal organs, they provide a route for blood
vessels, lymph vessels, and nerves.

Omenta

An omentum is a loose fold of peritoneum. The lesser omentum extends from the liver to
the stomach. The greater omentum is a large folded, fatty membrane
which starts at the stomach and hangs like an apron over the anterior of the
abdominal organs, ending at the level of the transverse colon.

The digestive process begins as soon as food is placed in the mouth, although no nutrients are
actually absorbed.

The pulp cavity contains nerves and blood vessels. Enamel, which is extremely hard, protects
the outer surface.

The teeth are set into the frontal opposing margins of the maxilla and mandible, and are arranged in a symmetrical layout.

[Figure 9 – 5]

There are 32 teeth in a full set for an adult:

Incisors. (8) These are the frontal cutting teeth.

Canines. (4) These slightly pointed teeth are used for tearing food.

Premolars (8) and molars. (12) These irregular shaped teeth are used for grinding food during chewing.

A section through a tooth showing the structure

The arrangement of the teeth

The start of a swallowing action is controlled by the conscious will, but the continuation of the
action is involuntary.

During the swallowing action, the soft palate prevents the food entering the nasal pharynx, and the epiglottis moves to prevent the entry of the food into the trachea.

Saliva is a mixture of secretions, containing mucin to ease the act of swallowing, ptyalin which breaks down starch into maltose (a sugar), amylase – a digestive
enzyme which initiates the breakdown of carbohydrates, and minerals. Calcium phosphate in saliva is deposited onto the teeth as tartar.

The formation of the oesophagus
follows the general structure of the alimentary canal.

Food is propelled down the oesophagus by peristalsis, waves of muscular contraction, controlled by the autonomic nervous system.

Sphincter muscles at the top and bottom of the oesophagus prevent unwanted flows: the cricopharyngeal sphincter protects against air passing into the oesophagus during
respiration, and the cardiac sphincter guards the entry into the stomach against regurgitation.

The folds of the peritoneum enclosing the stomach continue to form the greater omentum.The muscle layer is formed from three complementary layers of muscle fibre which allow for a churning movement of stomach contents, as well as peristalsis.

The mucous membrane contains numerous gastric glands which secrete gastric juice.

Very little actual digestion takes place in the stomach; it acts more as a reservoir for
ingested food, releasing it gradually into the small intestine.

Within the stomach, food and gastric juice mix to form chyme. This then passes from the stomach
into the duodenum via the pyloric sphincter.

Gastric juice contains around 0.5% Hydrochloric acid, and is thus strongly acidic. The enzymes
pepsin and rennin are also present.

Gastric juice serves the purposes of initiating the breakdown of proteins, and of destroying bacteria in food.

Duodenum. This is the first 250mm, connecting to the stomach.

Jejunum. This is the central part, and is approximately 2m long.

Ileum. This is the final, largest part, and is about 3m long. It connects into the large intestine.

The walls of the small intestine follow the general structure of the alimentary canal, but with some
modifications:

A mesentery attaches the majority of the small intestine to the posterior abdominal wall.

The mucous membrane of the small intestine contains small projections, approximately 0.5mm – 1mm
long, called villi.

The villi serve the double purpose of increasing the absorbent surface area of the intestines,
and of accommodating intestinal glands and lymph vessels. The surfaces of the
villi are covered with additional microscopic hair like projections known as microvilli.

The main digestive processes take place within the small intestine, aided by intestinal juice,
secreted from the villi. Intestinal juice is a mixture of the enzyme enteropeptidase, water and mucus. Enteropeptidase assists in the final digestion of most foodstuffs.

Additional substances from external glands assist the digestive processes:

Bile. This is secreted by the liver. It emulsifies fats.

Pancreatic juice. This is secreted by the pancreas. It assists in the breakdown of fats, carbohydrates, and proteins.

Secretion is controlled partly by reflex nervous action, but more by a stimulating agent, secretin, which is released into the circulation whenever acidic stomach contents enter the duodenum.

Pancreatic juice is alkaline, to the extent that it neutralises the acidity from the stomach. It also contains three enzymes:

Trypsin. This assists in the digestion of proteins into amino acids.

Amylase. This breaks down carbohydrates into sugars.

Lipase. This breaks down fats into fatty acids and other simpler compounds.

The pancreas has a second function, as an endocrine gland; this is considered as part of the endocrine system.

It is composed of many small lobules, each receiving blood from both the systemic and portal circulations. The liver is thus an initial recipient of substances absorbed from food.

The liver is covered by a thin capsule, and partially by a layer of peritoneum, which acts as a main support.

The liver is formed in four lobes:

The large right lobe and smaller left lobe form the majority, with the caudate and quadrate lobes as small areas on the posterior surface of the right lobe.

Blood vessels, lymph vessels, and nerve fibres, together with the hepatic ducts, join the liver at the portal fissure (or porta hepatis) on the posterior surface.

Chemical breakdown. Amino acids, old tissue cells, alcohol, and hormones are broken down, mainly for later excretion.

Storage. Excess fats, glucose (as glycogen), vitamins, iron compounds, and copper compounds are stored, for release when intake does not meet the requirements of the body.

Synthesis. Vitamin A is synthesised from carotene. Some amino acids, plasma protein, and blood clotting factors are synthesised from amino acids available in the bloodstream.

Conversion. Glucose is converted intoglycogen in the presence of insulin. Glycogen is conversely converted to glucose by glucagon.

Stored fats are converted into glucose.

Heat production. The liver is the main heat producing organ in the body because of its considerable chemical activity.

Secretion. The liver secretes bile, which is used in the digestive process.

Bile is a slightly alkaline, greenish, viscous fluid. Bile contains complex salts, the pigment bilirubin as a by-product of old cell breakdown, as well as water, mucus, and cholesterol.

Bile from the liver passes via the hepatic ducts which link with the cystic duct from the gall bladder to form the common bile duct.

When bile is not required for digestive purposes, it flows through the cystic duct into the gall bladder.

The gall bladder [Figure 9 – 9] is a hollow organ, formed from the same four layers of tissue as the
alimentary canal, situated beneath the right lobe of the liver.

Its muscular layer allows it to contract and empty its contents into the duodenum, via the cystic duct and common bile duct.

[Figure 9 – 10]

The large intestine is formed from the same four layers of tissue as the main alimentary canal. The muscle layer is formed in bands, to give the large intestine a slightly bulging appearance.

Caecum. This is the first part, connecting to the end of the ileum at the ileocaecal valve.

The vermiform appendix is small closed tube leading from the inferior closed end of the caecum.

Ascending colon. This leads from the caecum, vertically up the right side of the abdomen to the right colic flexure or hepatic flexure, situated under the right lobe of the liver.

Transverse colon. This starts at the hepatic flexure, and leads across the abdominal cavity, in front of the stomach, to the left colic flexure or splenic flexure, anterior to the spleen.

Descending colon. This starts at the splenic flexure, and leads down the left side of the abdominal cavity.

Sigmoid colon. This is the continuation of the descending colon into the pelvic area.

Rectum. This is a slightly dilated section of the large intestine, and forms the end of the digestive areas.

Anal canal. This is the final part of the alimentary canal, leading to outside the body at the anus.

The main functions of the large intestine are those of absorbing water, minerals, and vitamins, and temporarily storing waste matter prior to excretion.

The chyme which passes into the caecum is liquid, although some water has been absorbed in the small intestine. The majority of water will have been absorbed by the time this chyme reaches the descending colon.

The absorption of water (particularly the reabsorption of most digestive enzymes) is an important factor in preventing the body becoming dehydrated. The residue remaining after final absorption has occurred is excreted as faeces.

The movement of matter along the large intestine takes place at infrequent intervals (not regular peristalsis). This is known as mass movement, and is often caused by ingesting food.

The opening of the anus is controlled by two sphincter muscles.

The internal anal sphincter is composed of smooth muscle and is under autonomic control. The external anal sphincter is composed of striated muscle and is under conscious control.

When a decision is made to defaecate, the external anal sphincter is relaxed. Abdominal pressure is raised by a lowering of the diaphragm, a contraction of abdominal muscles, and by trying to force air out of the lungs against a closed epiglottis.

This forces faeces from the rectum out of the anus; a continuation of pressure then forces expulsion of faeces from the descending and sigmoid colons.

The initial cause may not be identifiable – bacterial infection, together with a blockage of the
appendix, perhaps by solid food matter, are likely contributors.

Initial inflammation causes swelling and ulceration of the inner mucous membranes. This leads to pain – first in the centre of the abdomen, and then in the area around the appendix.

If the inflammation does not subside (with or without treatment), it will soon block the small lumen of the appendix and lead to an abscess. As this continues, the blood vessels associated with the appendix become occluded, the appendix begins to atrophy, and may well rupture – with serious consequences.

It spreads through faeces into water and food.

The disease has a sudden onset and causes serious diarrhoea, stomach and leg cramps, violent vomiting, and exhaustion. Hypovolaemic shock can result if lost fluids are not
replaced.

Cholera can be fatal, especially if not treated.

The condition leads to a failure of normal liver function, which in turn causes a general degeneration in health, weight loss, vomiting, jaundice, a build-up of fluid in the abdomen, and oedema of the legs.

Cirrhosis is incurable and may eventually prove fatal.

The problem may develop at any time of life.

The villi in the small intestine become damaged and are then unable to absorb nutrients properly. As a result, there is a risk of malnutrition.

Indications of coeliac disease vary widely from person to person, but will probably include
abdominal distension and pain, nausea and vomiting, diarrhoea, an unexplained
weight loss, and a general falling in the level of overall health.

It is a chronic condition, causing thickening and inflammation to the walls of the digestive
tract, which may then become deeply ulcerated. This then leads to abdominal
pain and diarrhoea, with a reduced ability to digest food.

The condition may be complicated by intestinal obstruction, and the creation of holes – fistulae
– between the intestine and other organs or tissues.

The cause is unknown, although infection may contribute, as may genetic factors.

An apical abscess occurs following decay of a tooth, with that decay extending through the pulp
and into the root area. Infection, usually bacterial, reaches the tooth
socket and sets up inflammation and an accumulation of pus.

An apical abscess is usually extremely painful, but if a chronic abscess forms, this may be
painless.

Dental caries

Dental caries is the decay and degeneration of teeth. Plaque – a mixture of food debris, bacteria, and saliva – forms a sticky coating over teeth. The bacteria then act on sugars in food and form
acids which attack the tooth enamel. Small cavities form, allowing the acids then to destroy the structure of the dentine.

Initially, this decay is painless, but if it reaches the nerve in a tooth, toothache will be
triggered.

Decayed tooth structure is not regenerated, so must be removed and replaced with artificial filling material if eventual complete destruction of a decayed tooth is to be prevented.

Gingivitis

Gingivitis is an inflammation of gum tissue, causing swollen gums which are prone to bleeding.

The cause of gingivitis is almost always a build-up of plaque, particularly in the areas of the teeth
nearest the gums.

Knocked out tooth

A tooth which has been knocked out of its socket may be replaced, and may well re-connect to the gum tissue as long as certain conditions are met:

Replacement is within 24 hours, and preferably within one hour.

The tooth has not been contaminated, or more important, cleaned and disinfected.

The severed root structures have not dried out or been further damaged, and have not been
contaminated by touching or cleaning them.

In the majority of cases, diverticula do not cause
problems or symptoms.

Diverticulosis or uncomplicated diverticular disease is the term applied to relatively mild and intermittent symptoms of the presence of diverticula.

Diverticulitis is a potentially serious condition which results from faeces being trapped in a diverticulum. Bacteria multiply around the blockage causing inflammation and infection.

Symptoms of severe abdominal pain, fever, diarrhoea (or occasionally constipation), nausea and
vomiting often start suddenly, without warning. There may also be a palpable lump in the abdomen, or rectal bleeding – originating from weakened blood vessels passing through the diverticulum.

There is a risk that diverticula may perforate or rupture and lead on to further infection and
peritonitis.

Most gallstones are around 6mm in diameter, although the size may vary from small sand-like
grains to up to 25mm in diameter – or more.

Gallstones tend to occur if the composition of the bile is abnormal, if the flow of bile is blocked,
or if a local infection occurs.

A susceptibility to developing gallstones may be inherited.

Gallstones form when substances – often involving calcium compounds – precipitate out of the bile.

In the majority of cases, gallstones are asymptomatic. However, their existence may cause cholecystitis – inflammation of the gall bladder, with pain in the right hypochondriac
region, and possibly fever, nausea, and vomiting.

If gallstones block the bile duct, obstructive jaundice may result, with yellowing of the skin
and whites of the eyes, darkening of the urine, and pale coloured faeces. A gallstone passing through the bile duct into the duodenum causes intense pain (known as biliary colic) in the upper abdominal areas.

Bleeding into the stomach may also cause vomiting of blood or blood
stained faeces.

Gastritis has a variety of causes, including repeated use of medications such as Ibuprofen, swallowing of corrosive poisons, over-use of alcohol, infections, and extreme
stress. Other contributory factors include trauma, and failure of kidneys, or the liver.

A common cause is infection by either the rotavirus or the Norwalk virus. Alternative causes are infection by bacteria or other organisms.

Gastroenteritis causes abdominal pain, fever, diarrhoea and vomiting. The condition usually passes quickly, but a prolonged or severe attack may lead to dehydration and hypovolaemic shock.

Food poisoning

Food poisoning is a specific cause of gastroenteritis, associated with the ingestion of contaminated or inherently poisonous food or water.

Examples of causative agents include:

• poisonous materials such as Lead or Mercury,
• residues from insecticides and other chemicals,
• poisons in certain fungi or plants,
• bacteria such as salmonella, and campylobacter,
• toxins produced by bacteria such as Escherichia coli (E-coli), variants of
  staphylococcus, clostridium per fringens, and clostridium botulinum – which
  causes the very dangerous condition of botulism.

This occurs because of relaxation of the cardiac sphincter. There are many reasons for this,
including poor posture and dietary habits. Fatty foods, caffeine, chocolate, and alcohol may also encourage reflux.

The acid in the regurgitated material irritates the inner lining of the oesophagus, producing
discomfort and a burning sensation in the central thoracic area.

Severe heartburn may mimic the pain of cardiac problems.

Overdoes of some medications, such as Paracetamol, may also cause hepatitis-like conditions.The viral types exist in several forms: A, B, C, D, E, F, and G have been identified to date.

The most common forms are

hepatitis A – spread from faeces into food and water,

hepatitis B and
hepatitis C – both spread in the blood and by sexual contact.

Exact signs and symptoms vary with the type, but hepatitis usually causes abdominal pain, with nausea, diarrhoea and vomiting. The skin will probably be jaundiced.

If not treated, there is a risk that hepatitis will become chronic and lead to cirrhosis, eventually
proving fatal.

Hernias often occur spontaneously, and may be present at birth, but may occur through muscular strain associated with heavy lifting, a chronic cough, or persistent straining against chronic constipation.

Hiatus hernia. This is a breakthrough of part of the stomach into the thoracic cavity – through an enlargement of the opening in the diaphragm through which the oesophagus passes.

The hernia itself rarely leads to symptoms, but it will tend to lead to oesophageal reflux and
heartburn. Chest pain and difficulty in swallowing may also occur.

Inguinal hernia. This is more common in males. It appears as a swelling in the groin area or scrotum, and occurs when a portion of the peritoneum or the large intestine breaks through the lower wall of the abdomen.

Femoral hernia. This is similar to an inguinal hernia, but is more common in females. It occurs when part of the intestine breaks through the abdominal wall via the opening taken by the femoral artery, appearing as a swelling in the upper thigh.

Umbilical hernia. This is caused by a weakness in the muscles around the navel, allowing protrusion of the intestine.

Incisional hernia. This occurs when a wound or operation incision has not healed fully and a weakness in the containing
tissues has resulted.

Hernias are generally relatively minor problems, leading often to no more than a slight
compressible bulge under the skin. They are, however, susceptible to the complication of strangulation. This occurs when the herniated tissue becomes constricted and cannot be pushed back into the abdominal cavity. The blood supply to the strangulated portion is cut off by the pressure of the surrounding tissue, leading to gangrene.

Symptoms are mainly caused by abnormal muscular contractions in the intestinal walls, sometimes brought on by external factors.

Previous intestinal
infection, stress, low-fibre diets, and use of laxatives may contribute to the problem.

Symptoms include alternating diarrhoea and constipation, vomiting, abdominal pain and
tenderness, with abdominal bloating and a sense of internal gas.

Mumps brings fever, swelling of the parotid glands, a dry mouth with a ‘furred tongue’, and swollen lymph nodes in the neck. There may also be difficulty in swallowing and earache.

The condition may lead to encephalitis and orchitis (swollen testicles) – more commonly in
adults.

Acute pancreatitis is usually caused by gall bladder problems, such as gallstones blocking the pancreatic duct, or by chronic alcohol abuse. The exact mechanism of pancreatitis is not known, but it is believed that trapped digestive enzymes become active inside the pancreas and
begin to digest the gland itself.

Haemorrhage, oedema, and tissue damage result. The enzyme damage may spread to surrounding tissues, and may be distributed via the circulation to cause more widespread damage.

The condition is marked by severe pain in the upper abdomen, often occurring within twelve hours of a heavy meal with alcohol. This pain may extend to all abdominal areas, the back, and the shoulders, with nausea and vomiting – maybe leading to hypovolaemic shock.

Complications may include bowel obstruction, bleeding into the bowel, and jaundice resulting from bile duct obstruction.

Chronic pancreatitis is often associated with alcohol abuse or chronic pancreatic duct obstruction, although a cause may not be identifiable.

The condition may follow attacks of acute pancreatitis and usually begins with severe high abdominal pain – extending through to the back.

Attacks often last for 24 hours or more and tend to recur. Inflammation and fibrosis slowly destroy the glandular tissue with knock-on effects on the effectiveness of the overall
digestive process.

Gastric ulcer. This occurs in the stomach. The main causes are the over-use of medications such as Aspirin or Ibuprofen, and infection by helicobacter pylori bacteria.

The ulcer may well produce no symptoms, but abdominal pain – increased after eating – and
vomiting are likely.

Duodenal ulcer. This occurs in the duodenum. It is usually caused by over-production of gastric acid, and infection by helicobacter pylori bacteria is very common.

Abdominal pain – increased when the stomach is empty – and vomiting are the most likely
indications.

All gastric ulcers are at risk of haemorrhage, which will lead to vomiting of blood (haematemesis),
or perforation, which will allow gastric contents into the abdominal cavity
and potentially lead to peritonitis.

Liver or kidney failure may cause peritonitis through a build-up of fluid in the abdominal cavity.

Bacteria may infect the peritoneum from the digestive system via a perforated ulcer, a ruptured appendix, from an inflamed pancreas, or because of a penetrating abdominal wound.

Peritonitis is indicated by abdominal pain (often sever and acute) and distension, a fever, and
reduced urine production. There may also be signs of shock or an inability to pass faeces.

The bacteria enter the lymphoid tissue of the intestines. They then spread to the liver, spleen, and
gall bladder via the circulation. Inflammation results, together with damage to the intestinal lymphoid tissue which leads to ulcers forming in the mucous membrane.

Initially, typhoid manifests itself with a high fever and headache.

As the condition worsens, it brings nosebleeds, spots on the thorax and abdomen, a distended abdomen, and constipation which then possibly changes to diarrhoea, and finally
delirium.

Intestinal haemorrhage and peritonitis may lead on to intestinal perforation which may be fatal.

There are many potential causes of vomiting, including: viral infection, reactions to medications,
poisons, motion sickness, migraine, hormonal changes (such as during pregnancy), food allergies, and visual stimulus such as witnessing an unpleasant or horrific situation.

The action is controlled from the vomiting reflex centre in the medulla oblongata. The mechanism involves a sharp downward contraction of the diaphragm, a pulling in of the
abdominal muscles, a relaxation of the stomach itself and an opening of the cardiac sphincter.

Monosaccharides. These are simple sugars, which are readily absorbed by the body. eg. glucose, fructose.

Disaccharides. These, in molecular terms, are combinations of two monosaccharides. eg. sucrose, lactose.

Polysaccharides. These are complex molecular combinations of many monosaccharides. eg. starches, cellulose.

Not all polysaccharides can be digested by the human body; cellulose and other similar vegetable
fibres pass through the alimentary canal virtually unchanged.

Carbohydrates provide energy for heat and movement. Excess carbohydrate is converted to fat and stored.

Proteins are split into their constituent amino acids during the digestive process, and absorbed
through the intestinal wall.

Amino acids are classed as either ‘essential’ or ‘non-essential’.

Essential amino acids cannot be synthesised in the body, and must be available from the diet.

Non-essential amino acids can be synthesised in the body from other amino acids, in a process called transamination.

Depending on their amino acid content, proteins are graded as either ‘first class’ – those
which contain all the essential amino acids – and ‘second class’ – those which do not.

First class proteins are derived from animal products and soya beans. Second class proteins are mainly of vegetable origin.

Amino acids from proteins are used for:

Growth and repair of body cell tissues,

Production of hormones, enzymes, and antibodies,

Production of energy (only when insufficient is available from carbohydrates).

Amino acids provide the only usable source of Nitrogen to the body.

Excess protein is broken down; the nitrogenous part is excreted via the kidneys as urea, and the
remainder is stored as fat.

Animal fats. These are derived from meat, oily fish, and dairy products. All animal protein sources also contain some fat. Animal fats are mainly ‘saturated’. ie. their molecular
bonding structure is fully utilised.

Vegetable fats. These are found in vegetable oils. Vegetable fats are mainly ‘polyunsaturated’.

ie. their molecular bonding structure is not fully utilised.

Vegetable fats are essential in the diet, and assist in the formation of prostaglandins and
blood clotting factors.

Fats, in general, provide energy to the body. They also serve the purposes of:

Transporting the fat soluble vitamins,

Contributing to the secretions from sebaceous glands,

Assisting in the formation of cholesterol, and steroid hormones.

Excess fats are stored in the body’s fat depots – under the skin, and in the mesentery.

Water is taken into the body either as a liquid, or as a constituent of other foods. A small amount is produced within the body as the result of Hydrogen from foods reacting with Oxygen.

Water provides a moist environment for living cells. It participates in, and facilitates, all
biochemical reactions in the body.

Water is a major constituent of blood, and acts as a transport medium for both benevolent and
malevolent substances.

Some water is excreted with faeces, but the majority of excess water is excreted as urine.

Vitamin deprivation causes specific disease depending on the vitamin involved.

Vitamins A, D, E, and K are fat soluble and excess amounts are stored in adipose tissue, mainly the liver. [Table 9 – 6]

The remaining vitamins are water soluble and are not stored; the effects of a reduced intake are
therefore much more rapid.

[Table 9 – 5]

(thiamine)

(riboflavin)

(niacin, nicotinic acid)

(pantothenic acid)

(pyridoxine)

(cyano-cobalamin)

(biotin)

(folic acid, folacin)

(ascorbic acid)

(retinol)

(calciferol)

(tocopherols)

(phylloquinone)

The condition is usually associated with a much reduced and poor diet as a result of poverty or deprivation. However, it may also result from a straightforward imbalance in the intake of basic foods – perhaps through personal desire – or from a metabolic disorder which prevents the proper uptake of nutritional
essentials.

The signs and symptoms vary widely, although weakness, a susceptibility to other diseases, and eventual death are common factors.

Anorexia nervosa

Anorexia nervosa is a psychological condition, which causes either a direct refusal to take food, or the use of laxatives or emetics to prevent the uptake of food.

The causes of the condition are complex, with factors such as emotional rejection being
contributory, and are usually based around a desire to lose and control body weight with an assumption that low body weight is desirable. Delusions of being overweight are often prevalent.

Beriberi

Beriberi is the result of a deficiency of vitamin B1. It is most common amongst those whose principal diet is based on rice.

Wet beriberi leads to excessive tissue fluid.

Dry beriberi lead to extreme wasting.

Degeneration of nervous tissue is a feature of both forms of the condition, with a common outcome of
heart failure and death.

Pellagra

Pellagra is a result of a deficiency of vitamin B3. It is most common amongst those whose principal diet is maize.

Pellagra leads to skin disease, diarrhoea, and depression.

Rickets

Rickets is a result of a deficiency of vitamin D. It is primarily a childhood condition. The lack of vitamin D causes there to be insufficient Calcium salts in the bones, which are then
soft and slightly pliable. They thus tend to deform. This shows mainly in the
long bones, particularly in the legs, which curve unnaturally.

Osteomalacia is a softening of the bones occurring in adulthood through a lack of vitamin D.

Bone pain is the main symptom.

Scurvy

Scurvy is a result of a deficiency of vitamin C. It may occur in alcoholics, or in those who eat very few fresh vegetables or fruit.

Initial indications are swollen and bleeding gums, followed by a rash of fine bleeding spots.
Subcutaneous bleeding is a late sign.