Studies in Scurvy. Part V: Records of cases

STI]DIES II\ SOI]RYY BY J. ÂXEL HÕJEB X'omer ¡'i¡st ¡.ssistant at the Chil¡hen's Clinic of the Karolinska Institutef, gtockholm. (Chiet: Professo¡ I. Jundeu.) Thi.s worlc l¿as been, carried, out by øid, of gra,nts fronx the l{aroli,nslea Institattet ancl the Stced,ish Soci,ety for Medôcal, Research. UPPSALA 1924 ÀLMQVIST & \ryIKSEL],S BOKTRYCI(ERI-Ä.-B ACTA P.ry,DIATRICA REDÂCTORES: lN DANfA: C. E. BLOCH, xöreNnevN, S. MONRAD, rösnxul.v¡{. IN X'ENNIA: ELIS LöVEGREN, nor,- sINGFoRS, ARVP YLPPö, HELSINGFoRS. IN TIOLLANDIÄ: E. GORTER, LEIDEN, J.ITAVERSCITMIDT, IrrREcHr, CORNELIA DE LANGE, alrsronoau. IN NORVEGIA: TH, F.RöLICH, KRISTIANIA, AXEL JOHANNESSEN, xnrsrrlxr,l, CARL LOOFT, BERcEN. IN SUECIA: I. JUNDELL, srocrnor,nr,.{.. LICHTENSTEIN, srocxHow,WILH.'WERNSTEDT, srocKHoLM. EDrroR: I. JUNDELL, srocKHoLM Yol. III. Supplementum 17:Y. 1924 Almqoist û Witcselts Bolctrgclcer¿-Aktiebolag UPPSAI.A 1924 To Ørofn""or" -Qtn/ 9{o/"t ',/ TÁeodor Tral¡oÁ This worlt is reryectfully insuibed,.bg T.HE AUTHOR CONTENTS Preface Ïntroductory l'Iethods of experimental sc.rvy, from Holst to the lâtesô investigators Part I. Enanzinal,ion of the antiscorbttt'ic aaltte of som,e Desetuble ltroclucts. Survey of experiments Summary; discussion; concltrsions Part If. Hísto -p atho lo gi,c al s tt c d,i, es. Preliminary notes. Introclucúory The macroscopic changes Technique Nomenclatu¡e Classification of scurvy in different st¿ùges Grouping of the material within these stâges Chapter f. The bone formation in scurvy. ?èeth The endosmal ossification The enchontlral ossification. Cartilage * Four cases of infantile scurvy . t Summary ancl conclusions of Chapter I. Chapter II. Museìes. 'Ihe skeleton musculature Hearü Ohapter III. Liver Chapter IV. Spleen . . .. . Chapter V. Kiclney Chapter VI. Atlrenal Chapter VII. Salivary glancls . Chapter VIII. Lung Chapter IX. Blood ancl vessels. Hemorrhages in scurvy Chapüer X. Connective tissue . 8 I 2g 30 31 QO 0Õ so 38 48 50 60 64 18 22 68 79 QÐ 91 96 100 104 107 109 L74 Pørt III. Discussion of some scurug problems. Chapter I. Scurvy and infection Chapter II. Disposition Chapter III. Latent scurvy Chapter IY. The ca'lcium metabolism in scurvy Chapter Y. Scurvy ancl rickets Chapter VI. fnanition anil scurvy Chapter VII. ,t mocliûecl methotl for experimental rating of the antiscorbutic value of a protlucú Chapter VIII. Pathogenesis of scurvy. Relation of scurvy to other 11ó 1.22 r23 726 128 729 130 cleficiency tliseases Summarg a,nd, conclusi,ons of Parts fI and III Part IV. Scuruy and, tuberculos'is. Chapter I. Historical Chapter II. Experimental study on guinea-pig. Technique ancl survey of experiments fnfluence of scurvy on úuberculosis . fnfluence of tube¡culosis on scurvy . . . Chapter III. Experimental stutly on man. Survey of experiment Criticism ancl conclusion , . . Swm,marg and, concltcs'ions of Part IV . Part V. Re)cortls oÍ cases. Cases belonging to Part I . u), ,, Ð ,t oIY, , II ,),),,,IV,,ilI Literature cited: List of authors 94 nicrophotogrâms. 33 curves in the text. 6 colured plates. . t32 139 I40 t64 169 170 748 \64 L62 172 200 206 234 , 265 . 276 Preface. The work which is here presented was begun in July, 7922. rt would have been impracticable to fulfir it without the possibilities of technical aid offered by clinical laborato. ries. To Professors F. Hnrvscn¡w and G. Ificceulsr, who have allowed me to avail myself of these possibilities and, to whom I am also indebterl for much helpful advice, f beg to express my gratitude. My thanks are also due to professors I. ]u¡vopr,r and U. QurNsnr,, to Assistant professor Dr. C. Kr,rrve, Doctors R. Nonocnnr, G^. Vnsrnr:cr, II. D¡.v¡on, A. WlssÉN, S. Srvn, A. IMllr,cnnrv, Å. Årnnr,urvr, the Dental Surgeon Dr. G. \{.usrrrv, and others, for various reasons, some of which I have mentioned more particurarry in my book. speciar thanks are due to Doctor F. \4f^nr,annrv and Fil. Doctor L. G. Ro¡rnr,r, who have kinclly reacl the proofs. My late father, the historian Nrrs J. Ilö.rrn, who during all his life, beside his practical activity as a teacher, d.evoted himself to scientific work for science's sake, has been my model. My wife, Src¡rp Ilörnn, has been my helper. f have allowed myself as a respectful token of ad.mira_ tion to inscribe my work to professors Äxnr, rror,sr ancilrn¡ooon x'nör,rcn in christiania, the first investigators in the fieltt of experimental scuryy, whose work still remains unrivallecl. Even though the exaggeration is evicrent in x'unk's utterance (7922): usince the experiments of Ifoht and FröIich, no real progress has been macle (in.experimental seurvy), in spite of the numerous publications that have appearedr, yet his worcts show how high Holst and. Frölich's works rank among all the rest. Hagalund' sweden' T'ebruary 1924' J. Aret Höjer. PÄRT Y Recot"ds of cccses bel'ongi'ttg to Pc¿t't f. Eætt"ucts, Guinea-pigs No. l-96' Series 1-23. Series l. Animals 1-8. Basal cliet from July 11 (No. 1-4) or ,A.ugust ó (No. 5-8). Weight charts, Fig. 95. N0.7. For this a mote tletailetl extract from the recorcl is given as l specimen. &. Black-brol'n-white. (The coÌours are mentionecl in the orcler in rvhich they clominate.) 'zlt '[lne left hind-teg sornetimes liftecl in scurvy position. !'requent ancl cleep breathing. Drinks but little milk. Cries <¡ut at palpation of lefô knee. '3/, Batl afpetite. Skin dry. Coat rough. Priapism. 26/r Scurvy position of left hind-leg permanent. 'Ihe upper epiphysis.of left tibiaf¡aciured. Sits broocling. - tle Getting 'n'eaker and I'eaker. 2/s Drags the hincl clnarteri; fatÌing. 3/a Mo¡s. ale Post-ttlorterr¿ examination: Hair easily ìoosening in tufts. Bocly very lean. At' the stripping off of the sl<in, Jiac' tures in the upper epiphyseal lines of right tibia and troth humeri. Àlso diaplryses of thã tong bones more easily broken than normally. Upper jatu ìrrittie (a blunt pincette easily pierces this bone as 'n'ell as lhe l¡ottom of the cranium). 'I'he molars of the lower jarv sonervhat loose. Different joints, especially knee-joints, srvollen. The sn'elling is localizecl to t'he adjacent epiphvses. 'Ihe costochonclral junct'ions swollen, forming a distinct "os*"y, *oit'rnarl<ecl from the insi<ìe, partly clue to an argular bentl ('¡¿yonet position,) between cartilage and bone. Hemorrltages numerous in subcutis ancl muscles. Sometirnes they appear in the neighbourhoocl of f¡actures (left knee, man¡r ribs), otherr,'ise neâr the muscle connections arouncl knees, ankles ancl elbôrvs, and a¡e numerous under pleirra ancl pericardium viscerale. The adiltose tiswe, whídn is very sparse, is cleeply yellow 'r'vith a brorvnish tinge. iILe heart auri,cles are highly dilated' The section su¡- f¿ce of the l'íaet' shor.vs tìre cent¡al veins fillecl rvith blood. Otherrvise nothing abnormal ¡vas remarketl at the ocular examination. Microscopicalexamination was macle of 22 ribs (Fig. aa), elbows, rvrists, knees, ankles (Fig' 47), lower jarv (Fig. 34), teeth (Fig. 1a, 34) muscles ancl liver. 'l'he staining has been hematoxvlin, for tbe different lobes of the liver also sudan, for the ribs also methylene-blue. 'Ihe clescription of secüions from tlifferent organs forms the basis of the exposition in Part I ancl l'ill not be printed here. . Diu.gnosi.s: Scorbut gravior manifestus S'IUDIES IN SCURVY t73 No. 2. 9. Black-white-brorvn. Clinical progress ancl rnacroscopical finclings very like those of No. 1 Dead and autopsiecl 5/a. Not examinetl microscopically. Diagnosi,s: Scorbut gravior manifestus. 3to 525 ioo 2lt ,t0 20o t75 t60 ]L' I oo Tt 5o i rô 15 !o 25 3o ¡S qo cJ 5ô 65 Fig. 95. Series f. No antiscorJ:utic. ¿o 8nt No. 3. ð. B¡own-white-black. Clinical progress ancl macrosc.opical frnclings of a nature very like the prececling numbers, thongh of a more pronounced ttegree (lifetime 38 ctays). Teeth very loose both in upper ancl lower jaw, can easily be removetl with the piucette. Hemorrhages in all rib interstices, arouncl knees ancl elbows. Mi,croscopi,cøl eratnin'atíon of the same organs âs in No. 1. Tooth, Fig. 31. Musculature, Fig. 57. Di,øgnosi,s: Scorbut gravior manifestus. No. 4. d. Wbite-brown-bl¿ck. Clinical progress ancl macroscopical finclings as in No. 3. Teeth looser still, almost falling out. Deacl anìl autopsiecl to/e. Not examinecl microscopically. Diagnosi,s : Scorbut gravior manifestus. 174 J. ¡\XDL I{öJER No. õ. &. Blach-bros'n-¡r'hite. _ .l{h" scurvy syntptoms (joint.lesions, hearorrhages) in this case seemecl still âfter a month comparâtively little clevelopeã, but the animal .i-as exceedingly emaciated and dieit 10ô. Autopsied. ilre sarne day: no hemor_ rhages. submental ly'rph-glands srvollen. one of thern s'pp'räted, for.ming an .abscess large as. a good-sizecl pea. Teeth can easily bó ""-ouud. 'rhe costochondral junctions enlarged, ilrose of the upper sèven pairs show clistincüly the ¡vhiteor yellon-ish rvhite line. otherwise as No.-1. Histological examination of the same organs as No. 1, ancl besides of the spleen. Diagnosis: Scorbut gravior m¿nifestus. No. 6. d. Black-light brorvn. 25/s Walks rvith difficulty. Deacl a/0, autopsied 5/0. Histological ex¿- mination ¿s in r\o. 5. Diapbyses of slighily iricreasecl fr:rgility, ãpipbyses easily broke'. Hemorrhages only in a ferv rib interstices.- túé li""r äo"- tains 4enty of fat. No su'elling of lymph-glands. The rest as No. 5. I)iagnosis : Scorbut gravioi manilesius. No. 7. ?. Grey-white. - Deld ancl antopsiecl 3/0. llistological examination as in No. õ; spleen ¿lso stainecl rvith Giemsa. The macioscopic changes a'e similar ío ihn." of No. J, onìy in this case the¡e are no visceral heñorrhages and ûre teeth can easily be removed. Diagnosis : Scorbut gravior manifestus. llo. B. ð. Grey-yeìlo.rv. , ?u"9 r/0, autopsied 2,'c. Ilctuorrhnges around ctput humcri tìx (fracture)' both scapulae, both knees aud in the upper six ¡ib iuterstices. The epiph_yses of úhe long bones a'e easily broÌren, the diâphyses not. All teeilr very loose. The rest as No. 1. Histological examination of the same organs as in No. 5. Besides staining of ribs rvith Giemsa. Diagnosis: Scorbut gravior manifestus. _ _ Co.nclu,sion for Seri.es I: No antiscorbutic can be per.ceived in ilre basal diet. Series ll. Animals 9-12, ancl 33 (partly). Controls on complete dietary from J-uly 22 to December 11 (No. 9-tt). September I to Deõember 11 (ño. 12), July 22 úo October 28 (No. 33). 'Weight charts Fig. 96. No. L d. Blaek-brorvn-rvhite. Ilealthy titl it w¿s chlo¡ofornrecl 11/rz. Autopsiecl la/rz. Hístological examination as in No. 7, Everyw)rere normal contlitions. Diagnosis: No scurvy. No. 10. 9. tslack-white. Irregnancy stated 26¡lrr. At t}.e ltostntortent, examitration a fetus u,as founcl in one of the uterine horns, 5 cm. from ve¡tex to coecyx, (Fig. 32, 48). Pienty of fat peripherally in the liver acini. ,I'he ¡est äs No. 9. Dia¡¡itosis : No scurv¡'. STUDIES IN SCURVY 181 o lìbropurulent exudate. In the left pleura â sparse hemorrhagic exudate. On the pericarclium a fiIm of fibrin. In both lungs numerous small pneumoniae, partly forming abscesses. Spleen somervhat enlargecl. At úhe histological examination of the epiphyseâI ends of the long bones, the bone columns are found to be somewhat thin, fhe bone mârrow rather bright. Root of a tooth, Fig. 5. Hemorrhages in the rib musculature, otherwise none. Hyperplasia of the spleen. Liver.' diffuse fat, all over staining batllyD'iagnosis: Scorbut latens gr:rvior, bronchopneumoniæ bilaterales c. pleurit., pericarditis. ;\o. 30. 9. lYhite--Ìight t¡rorvn-black. Put on basal cliet 8/e, t'ith an âaldition of 10 ccm' recl whortleberry juice. On that tlate the animal had remained ât the same weight a u'eek. 21/e conjunctivitis purulenta. 22/e aleaal, a fortnight after beginning lvith the diet. Post-morten¡, examination the same tlay. No adipose tissue except around the kiclneys. Purulent exuclate in the conjunctiva. Pea-sized abscesses in the submaxillary lymph-glancls. Hyperemia in the lungs, diminishecl air content. Irregular sore in the mucous membrane of the cæcum in its most oral part 'lvith ¡ecrotic bottom, passing over to the adjacent part of the small intestine. The correspontìing part of the serosa has a purulent film; hyperemia in the mesentery. Possibly some s'welling of the upper epiphyseal line of the tibia. The epiphyseal ends of the long bones a,re more eâsily brokeh than normally. The upper back molar on the right rather loose. Diagnosi,s: Scorbut latens gravior; septicemia. tYo. 31. ð. ßlack-rvhite. 8/e put on basal tliet rvith an ¿cldition of 10 ccm' of n'hortleberry juice. Typical progress of scurvy. 1/g aliarrhea. ?/s dietl ancl rvas autopsiecl. Macroanil microscopical examination as in Series V. Liver enormously fatty. . Diøgnos'is: Scorbut manifestus gravior; iufectio. No. 32. &. \\¡hite-bl¿ck-bro'rvn. "ol" put on basal tliet t'ith an atldition of 10 ccm. of 'n'hortleberry juice. Shorving the picture of uncomplicatetl scurvy it proceeclecl to cleath after 31 clays, 25/0, ¿¡rd was autopsiecl the same day. '|he post-mortem exarnination coulcl not be conclutlecl. Diagnosis : Scorbut rnanifestus gravior. No. 33. 9. Àt firsô ferl cluling 160 days on complete diet (rveight chart, Fig. 96). During this time she vas cleliverecl oT trvins (No. 91 anct 03), antL shorved every sign of health. Put on basal cliet 28/ro rvith 10 ccm. of the s'hortleberry juice. Hacl scurvy sym¡rtoms arcl clied after 32 days, 2/rr. Äutopsiecl the same clay, shorving the same picture ¿rs the anirnals in Series V. No histological examination. Di,aqnosis: Scorbut manifestus grnvior. Conclttsion for Seri.es Vf : The dosage aclministe¡ecl (10 ccm.) of recl whortleberry juice with the origin rreutionecl has had no peltretrrtible antiscorbutic eflect. 182 J. AXI'I, HöJEIì Series Vll. Animals 34-37. The auimals had from Äugust 31 ó ccm' rarv fresh juice, imruetliately before the feeding pressecl from red.whortleberries bought in tûe market-piace. Progress, frndings at post-morttm examination, histological picture similar to those in Series V. Weight charts, Fig. L01' No. 34. 9. Yellorv--black-white. I)ied T/ro, autopsiecl 8/ro. Diagnosis: Scorbut manifestus gravior. c,Pd ì00 l¡o llco !50 27r 15/ ,r ?1Ò tco tolSþ{t Fig. 101. Series VfI. No antiscorbutic. No. 35. e. Yello'rv-black-rvhite. Diect and rvas autopsietl 5/ro. Musculature, Fig. 62; Iiver, Fig' ?3' D'iagnosis: Sco¡but manifestus gravior' No. 36. &. Yellow-black-white. Diect anct was autopsiecl 12/ro. Diagnosi's: Scorbut manifesúus gravior. No.37. Brown-rvhite-black. Diecl 8o/s. Autopsiecl 1/ro. Di,agnoeis: Scorbut manifestus gravior. Conclus'iott' for Seri,es VII: Tine animals have livecl on an average 37 days, rvhich is rÁther a long lifetime for animals on scurvy clieú. It ought STUDIES IN SCUR\¡Y 183 to be observecl that the animals in this series were heavier than the rest. No markecl antiscortrutic effect of the fresh, ra*' juice of retl whortleberries coulcl be perceivecl. Series Vlll. Aninials 38-41. The animals got basal cliet from Àugust 8, ancl besides each 2 ccm. of the juice from recl rvhortlebe¡ries ¡vhich hacl been bottlecl nearly a yea.r in rvater. The juice was pressecl out of the ber¡ies immecliately before the feecling. Histological examination of the same organs âs in Series Y. 'Weight charts, Fig. 102. 950 500 250 2oo lâo t26 tõ b 24 )o tî qÒ ,/ó 10 44 Series VIII. No antiscorbutic. to!5 Fig. 102 Àro. 38. ç. Blacli-light brorr-n. Kept in the same câge âs No. 64, rvhich tliett 12/¿ of acute infection. Diecl and was aut'opsiecl r6/e. No sign of scurvy l\¡as seen macloscopically. In the small intestine highly injectecl vessels and ulcerations of the mucous membrane, corresponcling to t'be localization of faecal lumps. Histological examination: root of a tooth, Fig. 4. The liver shorvs to a large extent the picture of acute necrosis. Di.agnosis: Scorbut latens gravior No. 39. &. Black-'rvhite-brown. Progress, examination and finilings similar to those in Series V. Diett a/0, autopsieil 5/0. Diaqnosi.s: Sco¡but manifestus gravior. No. 40. ð. Brorvn-black--r'hite. Progress, examination ancl ûnclings similar to those of Series V. Diecl ó/0, autopsied 6/0. Diagnosi,s: Scorbut manifestus glavior. 184 J. AXEL HöJER No. 47. ?. Black-brown-white. Proqress, examination ancl f.ntlings similar to those of Seties V. Die¿ 1¿l0, autoipsietì 15/e. Liver, Fig. 'î2, also stained for iron. Spleen, Fig. 81, 83; süained accorcling to Giemsa ancl on amyloiil. I)'iagnos'is: Scorbut manifestus gravior. Conclusi.on for Seri,es I¡11L No antiscorbutic effect was observecl from 2 ccm. of the juice pressecl in 1922 from berries preserved in rvater since 1921. 4æ J¡a tttollJ4¿J' DT tôo llJ ¿tì Fig. 103. Series IX lo li 1o ,r 10 dqg5. No antiscorbutic. Series lX. Animals 42-46. The animals hatl basal ciiet from August 8, rvith an atlttition of ? ccm. of the same juice as Series VIII. W'eight charts' Fig. 103' Progress, examination ancl fintlings similar to those in Series V. No. 42. ð. White-black-yello'rv. . Dead antl autopsiecl 6/e. Di.agnosis: Scorbut manifestus gravior. No. 43. d. YeIlo¡v-white-grey. Dead and autopsietl 2/0. D'iagnosi,s: Scorbuú manifestus gravior. No. 44. ð. Grey-white-brown. Deacl ancl autopsied 3/e. Di,øgnosis: Scorbut manifestus gravior. STUDIES IN SCURVY 18õ No. 45. d. Black-white-brown. Dead ancl autopsiecl ?/e. Liver, Fig' ?4. -A'clrenal examined on i¡on. Diagnos'is: Scorbut manifestus gravior' Conclwsi,on for Series IX: In a dosage of 7 ccm., the rvhortlebetry juice tested in Series VIII did not produce an antiscorbuúic effect a,ny mole than in that series. Series X. Animals 46-49. HacI basal cliet from Àrigust 8, and besicles 5 ccm. of a juice which at the beginning of the experiment r'ç'as pressecl from berries sti¡recl rarv, in the autumn of 1921, with the same quantity of sugar for an hour, and afterwartls kept in a glazed jar, tied over rvith waxed paper. Weight charts, Fig. 104. These charts all show the form which ãpþears when an animal with an acute infection is put on scurvy diet. 'Ihe initial rising of the s'eight cnrve is missing. 9vor3 t21 ioo JîO 4?.. \--- Ll 4, 1 /o /f Jô Jî Jo Jî lo 11 .ta Fig. 104. Series X. l{o antiscorbutic. '1' No. 46. cf. Black-lvhite-brorvn. 25/e walks with difficulty; tlishevellecl. 2eis groaning, laborious bleathing. Resüless. 31/a dead. 1/o autopsiecl. Not very le¿n. .A subTaxillary lymph-glantl forms an abscess. Right lung pneumonic, in the left lung a,o ãbsõess, with a tliameter of ó u¡m. Three ulcerations in the large intestine. The epiphyses of the long bones easily breaking, the diaphyses not. The upper jaiv brittle. Teeth loose; the upper molars are easily lifte¿ out. Þyorrhea around the clental sac of the upper, loosenetl inciso¡s. No hemorrhages. Knee joints somervhat srvolleu. Diaqnos'is: Scorbut manifestus gravior. Septicemia' No. 47. 9. White-black-brorvn. Progress anìl finclings typica,lly scorbutic, similar to Selies V. No histological examination. Di.agnosi,s: Scorbut manifestus glavior. 186 ,I. AXIIL IIO.IIIR No. 48. ç. White-black-yellor.. ,A,fter a rveek less lively, grew gradually'n'enl<er ¿ncl ¿fter 22 days 'ñ,&s founal one morning lying flattenecl unclerneath its fello¡vs. Tlte ltostnzo¡'tem ex&min¿tion on the same day showed multiple hemorrhages in the upper three rib interstices on the left sicle ancl around the left scapula. Fracture of one tibia in the upper epiphysis. Other epiphyscs of the long bones easily broken, upper jalt b¡ittle. Some of the teeth loose. Venous stasis in the thorax. Ilistological examination as in Series V. Musculature, Fig. 59. Diaylnos'is: Scorbut manifestus gravior. Infectio? Suffocatio. No. 49. 9. White-bl¿ck. Progress as in the preceiling case. Deacl 3/s, autopsied the same tlay. Emaciatecl. Purulent submaxiÌIâry lynphaclenitis. Fracture of one wrist, rvhen taken out. For the rest only slightlv increased fragility of the epiphyses of the long bones. Teeth loose. No hemorrhages. Hyperemia arounrl the 5 upper ¿¡nterior cc¡stochontlral junctions on both sides. Livel¡r hyperemia of the colon and its mesentery. The mucous membrane in this place srvollen ancl retldened. Histological examination as in Series V. Diagnosi,s: Scolbut manifestus gravior. Lymphaclenitis suppur. Colitis. Conclt¡si,on for Seri,es X. No antiscorbutic effect observed from 5 ccm. of juice from retl lvl-ro¡tleberries a year old, stirretl 'rvith sugar. I ¿¿a /50 /,ir 5, î/Þ Fig. 10õ /¡¿bhtDrfaòtf10 Serier Xf. No antiscorl¡utic. do 1s Series Xl. Animals 50-63. Got basal cliet from Âugust 8, ancl besicles the juice of fresh raw blue whorôleberries, bought every tr,vo or three clays in the marliet-place. lVeight charts, tr'ig. 105. Progress, exaurination ancl finclings simil¿rr to those in Series V. No. 50:. ç. B¡orvn-black-rvhite. Died anil 'q'¿¡s autopsietl 7/s. fn tÌre sevent'h and eighth rib iuterstices STUDIES IN SCURVY 187 on the rigbt siale gra,ins in the musculature of a grnnulary, I'hitish yellol' mass (calcium), in shape ¿nd size like a threepenny bit. Àrouncl this there N'ere hemorrh¿tges into the musculature. Tooth, Fig. 1ó, 16. Di.aqnos'is: Scorbut manifestus gravior' No.51. 9. Brorvn-rvhite-black. Dead and autopsiecl 6/s. Di.a,gnosis: Scorbut manifestus glavior. No. 52. 9. Ätl rvhite (albino). Suffered. from tliarrhea during a couple of clays from 1/0. Dietl o,'s, autopsiecl 7ro. Di.asnos'¿s: Scorbut rnanifestus gravior. No. 53. d. Glevish brorçtr. Died 5/s, rvas autopsied 6/0. Dí.ctgttosi,s: Sco¡l¡ut m¿nifcstts gravior. Aotzchts'iott, for Series Xf : No antiscorbutic effcct has l¡een ol¡servetì from fresh blue lvho¡tleberry juice of the year 7922, in a dosage of 1 ccrn. Series Xll. ,A.nimals 54-57. HaiI basal.cliet from Äugust 8, together rvith 5 ccm' of the juice from fresh blue whortleberries bought in the markeü. Weight charts, Fig. 106. No. 54. 9. White-black-brorvn. Sho'rvetl continuous emacjation ancl increasing ctiflìculty of moving, till it was founcl 2?/e flattenetl out beneath its Tellows. 'i]te posftttorteln ex^- mination the next clay showecl no hemorrhages. Slvelling of the trvo uppermost pairs of ,bhe cóstochonclral junctions and of the epiphyseal ends ¿t the knees-. Tìre back molars in the lower jaw slightly loosenecl. Two lymphglancls in the mesentery of the large intestine someNhat srvollen, lentilJize¿. veno.s stasis in the tho¡ax. Histoìogical examination of the same orga,ns as in Series V. Di,agnosis: Scorbut manifestus gravior. fnfectio. l\oÐÐ9. White-bros'n-black. Progressecl to cleath in 3ó clays vith typical scurvy symptoms' Deacl 1ele, autopsiecl t8/s. l¡indings and histological examination similu to those in Se¡ies V. D'iagnosi.s: Scorbut manifestus gravior. hlfectio. No. 56. ç. Brown-black-rvhite. Deacl 0/s, autopsied 12/e. Progress, frndings at ltost-tttortetl¿ and hist'ological examination simila:r: to those in Series V. Diagnos'is.' Scorbut manifestus gravior. 188 .T. ÀXEI, HOJER 3lo J¡o /2t 'î b 2t J. tf 'to It lô lî !'ig. 106. Series XII. No antiscorbutic. 1\O, Ol, 9. Brown-black-r'hite. 8t/e a rhinitis wâs observed. Deacl the sâme dâ,y. Progress like that of Series V. A1, tlee ])ost-tixot'tenz examina,tion huntlreds of small and lârge hemorrhages were seen in the periosteum, perinephricâlly, around the consiclerably enlargetl costochoncl¡al junctions ancl the epiphyse¿ìl ends of the long bones v¡hich were very brittle, etc. Histological examination as in Series V. Tooth, Fig. 12 and 13. Di,agnosis: Scorbut manifestus gravior. Rhinitis ac. Concl'¿tsi,otz for Seri,es X11.' No artiscolbutic effect coulil be statecl of 5 ccm. of juice from fresh blue .whortleberries of the year 1922. Series Xlll, Animals 58-61. From August 8, they got juice from blue rvhortleberries, stewecl for one hour in 1921 ancl then kept for a year in a glazecl jar, tiecl over with waxecl paper. Weight charts, Fig. 107. The animals reached the maximum weight after 23-26 days; clisplayed scurvy symptoms, though later than the animals in the prececling series, and cliecl ¿fter 60, ó2, 39, ancl 61 ilays, resþectively. À-0. 58. ç. White-brorvn-bl¿cl<. Deacl 7/ro, autopsied 8/ro. Highly marliecl scurvy changes, teetLr very krose, the epiphyses of the long bones very s¡vollen and brittle, etc. At the costæ If, IV, VI, VIII sin., YI dx, about 1 cm. from the costochonchâl junction, lentil-sized grâins of a clry -rvhitish yellorv mass (calciurn) Iying against the barecl bone. Cìoser to the costochonclral junction the inte¡costal mtsculature is locally slvellecl in several interstices, ancl pale. Histological examination as in Series V. Tooth, Fig. 8; nltlscle, Fig. 56, 58; spleen, Fig. 81. Spleen also stainecl on iron, amyloitl, antl accorcling to Giemsa. Staining on iron also of knees ¿ncl ribs. Diagnosis: Scorbut manifestus mitior. STUDIES IN SCUR\¡Y 189 No. 59. &. White-yelloN'-black. In tlying conclition killecl rvith ethe¡ 2e/s. Autopsiecl immediately' Progress and. finclings very like No. 68. .A.round the enlargetl costochontlral junäions i¡ the fifth to èighúh interstices on the right sicle, the-inóereostal inusculature ¡l'as founcl to be srveìlecl into exorbitant, pale greyish-pink masses, which to the .rviclth of about 1 mm. fillect the space between the ribs. Histological examination as in No. 58. Di,agnosi.s: Scorbut manifestus mitior. No. 60. 9. White-yellor'-black. Progress, finclings anct histologicnl ex¿mi¡ration similar to the t$'o preceding nirmbers. Diért 16/0, a.topsiecl tt/s. Lymphoglancl*la sul¡mentalis formJ a pea-sizecl abscess. Aroun¿ the sixth antl seventh ribs on the right, fourth to eighth on the left sid.e, enlargements similar to those describecl above lying in the intercostal musculature belory the felscia, here they look like processes from the bountlary line. Diagnosi,s: Scorb[t rnanifestùs mitior. Lyrnphaclenit. ac. purulentn' sul¡mental. No. 67. d. Grey-bro'lvn. Deacl a/ro, autopsiecl 5/ro. Progress ancl ûntlings simil¿r to No' ó8' Àrouncl the seven upper ribs on both sitles, near the costochontlral juuctions, enlargements in the lntercostal musculât¡re looking like yo¡ng cornective tissue. No histological examination uuclertaken. Di,ctgttosi,s: Scorbuú manifestus mitior. Conchtsi,on .for Series XIII : The juice of blue l'horlleJ:er'ry compote, a year olrì, iD ir tlosage of 5 ccm. hm provetl to bc of n cert¡in ¡ntiscorbutic value (0.r m. pt. d.). t1 /5o Jzl )t 2o ii io ir 40 1Í îo îE lt 60 (r lo Ìl 1o ða5s 5 Fig. 107. Series XIII. 0.t ur. pr. d. 190 J. .IXEI, }IOJER Series XlV, A.limals 62-66. Got b¿sal diet together r,ith 10 ccm. of flre s¿rne 'biue rvhortlebeny juice ¿s the anirnals in Series XIII; No. 62-65 from August 8, No. 66 from August 25. Weight charts, I.ig. 108. No. 02. d. Black-bro¡'n-.çvhite, Got lean r,v'ithout showing signs of scutvy. Was founcl clead 18,/e, flatteuecl out bene¿th its fellows, ancl ¡vas autopsiecl ilre same tlay. -A.t the post-m,ortern examination there I'as no sign of scurvy or infectiõn. Histological examirration of teeth. D'ia.gnos,is: Scor'but mitior l¿tens levior. Infectio? groql 6' /o lt a 2J30 Jd 40 tt jo lj 60 6t lo 7l áo ðc¡: e1 I Fig. 108. Series XIY. 0.2 m. pr. d. No. 63. ç. Grev. 25/s not-very lively, clishevellecl ¿ncl clry. 26/s lymphogland. snbntental. as big as a good-sizecl pea, "/s as ¿ bean. Operated ,?/e (ethyl chloricl): an attempt to extirpate the purulent gland entire clid. not succeed. Tamponacle. 28/a improvetì.; eats; rvalks ¿ùbout. 31/s lively. s/o joints not srvolllen qr tencler. 6/s tleacl ancl autopsiecl. From the operation aperfure uprvards to the bottom of the mouth an abscess cavity, the size of an almond. Macroscopically the back molars in the lorver jarv I'ere fountl rathe¡ loose. Histological examination as in Series V sholvs markecl scorbutic pictures. nlusculature, Fig. 60. Di,agnosis : Sco¡but mitiol latens extensus. Lymphaclenitis submental. snppur. S'TIIJDIIìS IN SCURVY No. 84. ð. White-black-bro'rvn. Liver, I'ig. 75. Diø¡1nosi,s: Scorbut manifestns mitior. No. Bõ. d.. White-black-light brorvn. Diagnosis : Scorbut manifestus mitior. 114 197 5lô ,r tl6 xa 5b 20 t6 to 1t 4o tF 1o 61 eo 6t Fig. 113. Se¡ies XIX. 0.r m. pr. d. No. 86. ð. White-light bro'rvn-black. Liver, Fig. 76. 78. Liver also stainecl on i¡on. Di.agnosi.s : Sco¡trut manifestus mitior. Conclttsíott .l'or Series XIX: 3 ccm. of fresh juice from late-ripenctl tomatoes have sholvn u very inc<lnsiclerable antiscorbutic effect. Series XX. Ànimals 87-90. From October 4 they got, besicles cereal ancl bran, unboilecl milk, together 200 ccm., rvlrich they consunled.l After two weel<s the animals grerv quiet, reached the m¿tximum 'rveight after 10-23 clays ancl soon showetl srvollen, tender joints, scurvy position of the hincl'legs etc. lVeight charts, Fig. 114. No. 87. 9. White*black-light bro'rvn. Deatl 10/rr, autopsietl t2/rr. Hernorrhages arountl tlre costochondral junctions of the upper frve pairs of ribs, which are all enlargecl, and arounrì 1 'Ihe milk hatl been heatecl at 66" C. for 20 minutes antl w¡s given to the animals 24 hours later. 198 J, ,{XEL HöJER the swollen knees. .A.long the candal edge of the frfth, right rib a connectivetissue formaúion obliquely backrvarcls from lhe costochonclraÌ junction: lceth loose. Epiphyses fragile. Lymph-glands on the neck sv'ollen. Di,agnosi,s: Sco¡but manifestus miüior. Infectio ac. rYo. BB. ç. White-light brown-black. Dead 2f n, autopsied a/rz. Chalges similar to No. 87, but' quantitatively more cleveloped. Hemorrhages exceedingìy numerolls; epiphyses very brittle. Pale ¡nasses of connective tissue (Fig. 55, 61) filI up the lst - 7th interstices on both sides betr.r'een ùhe costochonclral junctions, t-hìch ¿re swollen. Iìibs stained 'with Weigert's fibrin stain, ¡rnd besitles, as a.lso knees, spleen ancl liver, on iron. Jal', Fig. 10, 11. D'iøqnosi,s: Scorbut manifestus rnitior. \z¡ 360 ttÔ 240 6 to lt tø 2õ 5o .l tto 14 ôo qo çx @øtP1r Fig. 114. Series XX. 0.t m. pr. d. No. 89. ?. Black-lighú brorvn-white. I)eatl to/rr, autopsied re/rr. Progress antl findings as in No. 87 D'iagnosis : Scorbut manifestus rnitior. No. 90. 9. White-light brown--black. Dead ¿ncl autopsiecl 10/rr. A sul¡maxillary lymph-glancl forms a large àbscess. fnfectious spleen. Hemorrhages arouùal the s'¡vollen knees and the enlargetl costochonilral junctions. Iìound these on the left side from the 4th to the 7th rib, srvellings of the intercostâI musculâture, as clescribetl above. Histological examination as in Series Y. Diagnosis:Scorbut manifestus mitior; lymphaclenitis srlppu¡. submaxillar'. Conclusi,on for Seües XX: In this series, rvhere the animals have l¡een able to conbume ¿ìt pleâsure the substance nhich was to be tested, thc lifetime has varied consialerablv. It is indicated that rbout 100 ccm. of STUDIES IN SCURVY 199 milk are necessâry for cornplete protection. The antiscorbutic value of milk, however, is highly variable, and. the milk given in this experiment seems to have been relativelv tleficient in this respect. Series XXl. Ànimals 91, born 10/e of No. 33, ancl 92, born 7/ro of No. 14. They got basal diet from October 28, ancl besicles 5 ccm. of raspberry juice, bought at a pharmaceutical chemist's as ,sympus Rubi idaei 1922'. The animals progressetì âs cases of absolute scurvy, with maximum lveight after 16 ancl 18 days, to tleat'h in 28 ancl 27 clays. Weight charts for Series XXI ancl XXII, Fig. 116. gÍ¿ßÉ tlø lto too tts tû t16 lo0 'u ,"' tâ tÞ 9õ 3ó 1â tlo 4â' 60 55 Fig. J.1.6, Series XXI-XXII. No antiscorbutic. No. 91. 9. Light brown-black' Deatl 2ó/rr, autopsied 2?/rr. Di.agnosi,s: Sco¡but manifestus gravior. No. 92. 9. Whiúe-black-light brown. Dead 2{/tr, autopsiecl 27/rr. D'iagnosis: Scorbut manifestus gravior. Conclttsi,on .for Ser'ies XXl: The preparation callecl raspbeiry juice has in trvo cases sholvn no antiscorbutic effect. bô ?ô 7î ao 96 200 J. AXEL HOJER Series XXll. Animals 93, born 0/s of No. 33, ancl 94, born 7/ro of No. 14. They got from Ocôober 28 basal cliet ancl besicles 5 ccm. of black curranú juice from the same pharrnaceutical chemistry as the juice in Series XXI. No. 93 progressecl as & case of al¡solute scurvy, with maximum rveight after 19 davs, to tleâ,th in 37 days. Histotogical examination as in Series V. No. 94 died âfte¡ six clavs 8/tr; the cause of cleath coulcl not be establishêtl (overIying ?) No. 93. &. Lisht hrown*black. Dead Vrz, autopsiecl a/rz. Di,øgnosi,s: Scorbut manifestus gravior. ]io. 94. ç. White-black. Deacl 3/2, autopsiecl 5/rr. The animal hacl been flattenecl against the floor of the cage by its fello'ws. Nothing paúhological founcl in different organs except 'lvhat was due to this circumstance. Diagnosis: Scorbut latens gravior. Causa mortis incerta. Conclu,si,on for Seri,es XXII: 'Ihe preparation callecl black curlant juice has in one case shol'n no ¿ntiscorbutic effect, Series XXlll. Ànimals 95 ancl 96. Healthy anima,ls, rvhich both at the first feetling rvith the recl whortleberry juice given in Series 4 blew it ouô through the nose; all their muscles relaxed antl they tliecl, one after having staggerecl a few steps in the cage, the othe¡ almost immediately in the hancl. The feecling was not managecl slo'wly enough. The abdornen became rapiclly antt strongly distendecl, lvhich at the post-mortem Ìrâs shown to have been caus' ed by the veritricle being fillecl rvith gas. Microscopical examiuation as in Series I. No. 95. 9. White (albino). Deail ancl autopsieil 2/s. Di,agnosi,s: Reflex cleaur? No. 96. 9. \Vhite-black. Dead anct autopsied 2/s. Ribs, Fig. 36. Diagnos'is : Reflex tleath? ßecord,s bel,ongðng to Pa,rt fft Cltøgttet' f. næh"acts. Gase L I{arl Albi.n P-ø, No. 11181. lrom the Hoslti.tøl record: Born ß/z 1896, admittecl that clay. Cli.nical d,iagnosis: 6/z 1896 conjunctivitis cat¿¡rhalis -l macroglossia; 8/o icterus neonaiomm; 18/r mastitis; 20/a lues suspecta; Ðlo eczema facjei; 6/rr gastroenterocolitis ac. + otitis med. pur.; r?,irr erysipelas capitis; 22/rr l¡ronôhitis bilat. ac. f otorrhoea bilat.;zaln abscessus capitis; 1897, January: atrophia; bronchitis; 8/z morbus Barlow; 1u/a mors. STUDIT]S IN SCUR\IY 20L Breast-fecl for nearly 2 months. 'Ihen the weaniug was begun antl completecl in 2 r'eeks; after that milk mixtures. The weighú increasetl steaclily, from 3,600 grams ât the birth on 6,/r to 5,600 at the age of 3 months (then, 8/ro, ctyspepsia). l'hen it satk uninterrupteclly to 4,200 grams on 17!n, and' after that clate rose agnin irreglìlarly; tluring the last weeks it sank from 5,200 to 4,600 grams. -Døihl rccord's: zalro nose-bleetl; 22/r meatus auclit. frIled lgith bloocly secretion; 28/r bloody clischarge from nose; 2sft llne gingiva over the incisors in the upper jaw imtribecl .with blood ancl srvollen over each tooth not .yet cut. 30/r Abunclant tlischarge {¡om the right ear of bloody secreúion like that from the nose. 6/z Consiclerable etlema in both legs. I3lootly tlischarge from nose ¿ntl left ear. Liver ¡ather hard, reacbes the navel plane; spleen reaches the front axillary line. Percussion area of heart from 1 cm to the Ieft of the mammillary line to tbe middle of sternum. 8/z Lower parts of tibiæ ancl fibulæ consitlerably srvelled antl tentler. t3/z Right thigh ditrusely swollen. Complete immobility of both legs. No sweliing of tìre arms rvhich he moves a little, but slowþ. Temp. about 87,5' C. 22/z Hemorrhage on the left upper lid. a/¡ Periosteal swellings, most, pronouncetl in the lorT'er part of the right femur, the upper and low'er parts 6f r,!e right fibula and iibia antl the lower encls of tbe left ûbula antt tibin. 16/a Died. n'ith lung svnptoms. - f)ost-mortem on r6ls. Patho-anatom,ical diagnosi's.' Ilaemorrhagiæ subperiostales, intramusculares et pulmonum * pneumonia ac. bilateralis * pachymeningitis haemorrhag. interna * hyperplasia lienis * otit. mecl. purul. sin. tr'rom, the post-llxlrtenz ','ecorcl: General complexion pale. In ühe tela snbcutanea on the lower part of the left leg and foot a quite consiclerâ,ble eclema. Ribs some'rvhat enlarged at costochondral junctions. Àt incision no sign of rickets is found. Right thi,gh: Thq muscnlature close to femur strongly inflltratecl r.ith blood ancl d¿rk retl. Periosteum raisecl all round by a layer of partly clottecl blootl, 1-6 mm. thick. Thus, a subpeliosteal hemorrhage extends f¡om the upper to the lowet epiphysis. Both epiphyses hail become loosenetl from the diaphyses. In the r'iqht lcg nainly the same picture with fracóures of both epiphyseal encls in tibia as well æ fibu'la.  similar picture in the left thigh and leg; epiphyseal fracture is absent only in the upper part of the left ûbula. On the right ancl left sicle slight periosteal hemorrhage in u'lna and radi,us. Joints and epiphyseal cartilages everywhere normal without any sign of rickets. Lu,ngs: The left upper lobe shorvs numerous miliary, dark red hemorrhages. Pneumonia in the rvhole of the left upper lobe antl in smaller areâs of the right upper lobe. Li,uer' : SlighL fatty infiltration. Microscopical eramination.: Left femur, lower epiph)'seal line anal the upper limit of right tibia ttisplay a marked picture of scurvy with low cartilage columns, >>Gerüstmark> and ))Trümmer' felclzone>. (Oetalt Fig. 49 â"). In the >>Fugenwinkel> there is inferior bone in splinters (nig. +O b) and in bone columns higher up in the marrow homogeneous places (fig. a0 c). Epierísis: Case of infantile scìrrvy, having clisplayed deffnite clinical changes in the seventh month and died, of lung conlplication less than 2 months later. No rickets. 202 .r. ^xDL Hii.rER Gase 2. Gösta Reinholcl lfm'atnt'el 1i.4, No. L1271. triom the Hospitat record,: Born 20/s 1896. Àdrnittecl 6/to 1896' Clinical cliagnosis: 8/:o intertrigo, bro-nchitis: '1/rs otorrh-o-ea; to/t 1897 abscessus ret¡oaui. sin. ; lr'a bronchitis ; 23ir lymphaclenitis ; e3/¿. otit" mecl. pur.; 'u/n pneumonia ac. tlx.; to/; excema capitis, es/c bronchitis;'8lro rachitisl ît/,r'petiostitis -l perichondritis humeri eô feuroris; le//rl enterocolitis ac.; t2/rr mors. The infant rvas entirely breast-fecl the first tv'o lonths; from 4 months fed solely ón cow's milk. Thé lveight increasecl for ó months, till 5,?00 grams., Loss in weight afterwarcls 1 Èg. during 4 months; then again increase, 11i: kg' in 3 months lill 6,500 grams â monúh before cleath. --" -'tj"¿li, ,ourlrltt t2l+ (six months olìl): Craniotabes * rosary' 20/e Mellin's foocl, 8 teí-spoonfuls; 2t/io very strongìy clevelopecl rosary' Dpiphyseal junctions of ankles and wrists eilargedl'Occipitãl suture somewhat soft; r/¡r tenclerness of body. crying out v'henever turnetl ove¡ from clorsal position. Looì<s poorlj and àttÀ little; rt/rr complexion dull, pale grey' 'llways lying on his îack'with his arms extenclecl clorvn his sicles and his legs t¡rnetl Jut$ards, stightty bent in the hip-joints. 1'highs somervhat swolle¡. Ät the slightest"touching of the extremities and ¡vhen moving pâssively,. the patientïoans rù great tleol; 12t'rr left arm fro^m acromion tlown towards joint Leavily srvollen; considereble tentlerness' .13/rr - quiet 1nd still when left alone. The left forearm swollen ât the epiphyseal junction above the wrist; tend.erness. ^A,s the symptoms--from the bone system_increasecl, the patient grew steaclily lvorse a;d-<lietl 2e/il, 14 nonths old. Post-m,ortemthe same cla¡r. paiho - nnatomi, cal cli ø g n o si,s; Hemorrhagiæ subperiost.tles (morbu s - Barlorv) "r enterocolit. folliculä". ac. + otit. meal. bilat. * lymphaclenit. chron. gland. mesenteric. * pachymeningit. hemorrh. interna * rachitis' ' lro* the ltost-ri'ortem ,ecord,t Dura mater, of orclinary thickness, shows on the insitle in pâ,tches a thin, mostly yelìowish brorvn, sometimes.pale, easily loosened meñbrane. In the lower lobê of the teft lung immecliately beloív the pleura clispersed miliary hemorrhages. He¿rt af ordinary size' IVlusculaturelale. Splee-n somewhat enlargecl; Malpighian corpuscles somervhat enlargecl. Iri large -portions of colon transversttm the solitary follicles, which a¡e not srvelletl, áre-founcl to be of a clark retl blood colour, darkest in the centre, lighter in the periphery. Betrveen these portions tlere are others .where'thJ foÌlicles geneially are sornervhaü srn'elletl, pale, antl only some ferv show hemorrhages like those tlescribecl above. The teJt bíachi,um. swollen. Musculature in tbe upper half tliscolourecl, pate yelloríish or yellorvish brown. Periosteum on left humerus loosenecl by a temoi"hage. The ieft upper humeral epiphysisseparatecl from the tliaphysis; a layer oi yellorv-tingect^ iissue, about Þ mm. thick, sticks to the epiphysis' The right lämur onlyshows a somewhat looser connect'ion between epiphysis anct cli"aphysis in túe upper part, rvhile the left femur ancl right h¡rmerus sho$, pictúres similar tã^ tnóse of the left humerus (muscle cliscolouring, fracturã of the ctiaphysis close to the upper epiphysis, s.bperiosteal hemorrhage). Hemorihale like this is also seen on ulna and radius of both siiles. The ribs are consiclerably enlarged every.vr.here at the junction l¡et¡r'een cartilage ânal borìe. Ât incisión the cartilage proliferation zone is founil to be a "great tleal wider than normally, gengJafl¡ 3-4 mm' l'ide' The caÌcification zone is exceeclingly irregulãr. -Ailjoining this the¡e is a yello'r'ish STUDIES IN SCfIRVY 203 zone âbout 1 mm. wicle of a soft tissue in which the bone is loos.enecl f¡om t'he cartilage. .Uncler the periosteum, which evitlently is slightly raisetl, a thin layer of clark red, not clottecl blootl extencls 1-2 cm. from the junction of the cartilage and bone. M'ía'oscopticøl eæaminatí,olt. Cut sections wele macle of the lower left femoral epiphysis anal a large number of ribs, 12ot decalcif,ed,; the specimens were treatecl âccorcling to \¡' Rncr<r,rxcHAUSEN with carmalum and. alumirrated glycerin. Left femur: The epiphysis has narro\ry bone columns, in the large majority normal injection. .Ln certai'n cllurnns onl!/ the co1"- puscles iwjected,, wítl¿out cd,na'Is. In another series next to the epiphysis are seen 1) narrow columns with complete injection, 2) colourless columns with injection of corpuscles, but no cânals' 3) colourless columns without any trace of injection, antl 4) some few recl-colourecl columns without injection. In the marrow spârse cells antl hemorrhages. (Note: 'When staining sections from the same place with hematox¡'lin ancl carmin, the majority of the columns are found. to become blue-colourecl, only a few tender columns recl-colourecl, in this martner proving that the bone columns are prevailingly calciferous, ancl only exceptionally osteoid') Rib. 1, not clecaleiffecl, treatecl according to v; Recklinghausen. In the parts next to the cartilage the bone columns are colourless, glossy, and. there âre no injected òorpuscles or canaliculi to be seen in them, or else only small corpuscles without canaliculi. Farther away froin the cartilage, however, injection of the bone column is found, in some places throughout the column, in other places there is injection in the central parts but rouncl those a narrow zone, uncolourecl ancl gÌossy, without injection of corpuscles or only of small, clwarfect ones without canaliculi. Other sections from the same rib show: 1) Next to the cattilage a narrow zone, in which there are numeÌous tencter columns of a recl-coloured tissue, which in some places seems to be quite homogeneous (remaining rests of the hyaline midtlle substance of the cartilage), but for the most part shows a structure of osteoitl tissue without injection of corpu-cles. In places there is iu the centr'e a more deeply recl-co]oured tissue of hyaline nature ancl outsicle this a narrolü' zone of osteoicl tissue (rest of hyaline cartilage surrounclecl by osteoict tissue). Alt these columns lie irregularly scatterecl, not parallel with the longitud.inal axis of the bone. The bone marrow in this zone is fairly abundant in cells, antl there have been both fresh anct earlier hemorrhages. 2) Then a zone, in which the bone columns are very tencler, not coloured, eviclentìy calcified, but without injection of corpuscles. 3) then again a zone with distinct injection of the bone canals. 204 J. I\XEL IIOJITIì Rib. 2. a. Cut section, hematoxylin-carmin' The cartilage proliferation zone wicter than normally' The calciffcation ,onJ i. ''ut"o*, ancl not seen i. the most peripheral parts. Next to this is a, zone of numerous small cletachecl pieces ãf catcifiecl cartilage tissue together with some columns of osteoi¿l ii..oe (rea-cotoureã) and" sorie of oalcified. bone tissue (Utuecoloured). b. not clecalcifiect, treatecl accoraling to v' Recklinghausen' In the zone next to the cartilage, scatterecl Ììarrow' gloss¡' columns, which a,re uncolourecl anct clo not show any injection with carbon clioxid, or only of a few corpuscÌes without canaliculi. This zone evid.ently extends higher on the outwarcl surface than on the pleural sitle. Epi,irisis. Case of infantile scurvy, dying at the -age of 14 month-s, having d.isplayed ctefinite clinical symptoms cluring the last months. Rickets. Case 3' Ered,rik Albert, born 6/rz 1896. Admitteci e/rs 1896' The lveaning Îegan 1/z and 'lvas completed rvithin 2 months' From 16/z Mellin's foodlvasadministerecl, 3 tea-spoonfuls, from 10/s rai..etl to 8 t"á.pãn"f"f.. The r.eight increase¿ ¿uring the frsú 4 rno.ths to 5,000 grams but äfterwarcls kept tó about 5 kg. (4.0-5.+) 'ntil cleath ¡t the age of 10 months. -- cl¿n;cat cl.iaonosis: 28ltz. 96 conjunctivitis catarrh. * clyspepsia; 1/2..07 otitis;-;õi;; n"ni1i.; 1o/; gastroenteritis; '3 o otitis; 28/e pncutuonia ac' sin'; 6/ro pneumoni¿ ac. sin.; ?/to mors. ' 'ih" daily records have not been found. The clinical diagnosis s'as: pneumonia ac. f sePticemia. Post-mortem dxamination on o/ro' pitlrlonoto*¡cal rTiagnosis: Pneumonia ac. bilat. * s'lenitis ac. le'is lnephrit. ac. parenchym. t*it + colit. follicular' chron' et ac' * lt'emorrhal¡ia su,Ltpet'iosfal. ,f'enzor. ambor. * otit. mecl. bilat' ' ' iioi, ihe post-ntr,rteyt, record,: ,l.he corpse is pale. In_the -upper sitle of the feet ratËer profuse eclema. Both tbiãhs quite considera,ltly srvollen. Musculature in the outer layers of pale flesh-colour, in the cleeper. ones discolourecl, pale grey-recl ot of a dirty yellow, alrvays, having a q:l'ttll^"t' transparení läok. "In a ferv small ptaðes in the musculature are seen slighl ü;;"i.;h;;;.. The periosteum on both sides raisect f¡om fe.r.r by a layer of bloocl, 1--5 cm. thick.' - Il[icroscoltical eædnxxnd,tion. series of sections from left femur, bothfromthetwoepiphysisentlsanctfromdifferentpartsofthe cliaphysis. Staining: ht*-eo*itt, htx-carmin ancl v' Gieson' Cut .""iion, from the same places, pïepare¿l accorcling to v' ReckÌinghausen. By way of example some of the sectiorls frorn the upper epiphysis encl are here clescribecl. S'IUDIES IN SCURYY 20õ .L Cut, section, carmalum (.t. R.). Tenrler bone columns, the large majority showing complete injection. In a smaller number, incompÌete or harclly any injection in the uncoulourecl columns. Some few columns are reilcoloured. ancl at the same time without injection (osteoid). 2. Cut section, s¿me treatment. Tencler bone columtrs, generally showing injectect bone corpuscles ancl bone canals throughout the column, but nearer the epiphysis not all the columns are found. to be injectecl; sometimes merely scattereal black corpuscles without canaliculi; sometimes a centre which is normal antl outsitle that a narrow zoue of white glossy colour rcilhout injected corpuscìes. 3. Detail of section showing (nlg. fO) an olcl bone briclge, on the epiphyseal encl of which there is an abundant layer of homogeneous, eosinophile bone, reaching the cartilage. The sections in the upper, lower ancl midclle parts of the left ttrigh show ever;'where an exceeclingly strong atrophy of the muscular fibres (Fig. 65 a and b). Epiu'ísi,s. .{ 10 months' child, who since the age of 4 months 'was entirely fecl on milk mixtures ancl cluring alÌ this time has kept the samé weight ancl in whom t'lne ltost-mortem examinalion revealed pronoun.cecl scurvy. Gase 4. Judit Teresia tr-1, born 8ic 1899. ,A,dmittect 1olo 1899. Cli.ni.cct't ãiasnosis: 31rls Lues heretlitaria; 8r'rr ulcus flennl. linguae; t3/tr bronchitis; iliecl 1á/rr 1899. 'Was from her birth fed ¡vith cov''s milk mixtures. \\'¿s given llilk pol'cìer from t5/s. Gainecl rveight slou'ly from 2,920 graìns on the clay of aclmittance to 3,790 at 3 months, aftert'ards ¡vent clorvn to 3,380 the day before her death, at the age of ó months. Treated s'ith llg per os after 1/s. Ttre first of thJ daily recorcls which is indicative of scurvy is of la/rr (the day befole death) and says: Swellings on the thighs. The soft parts are fìrm to ôhe touch and infiltrated. Srvellings on the upper side of both feet. Eats very litóle, fretful ancl rvhimpeting. Dietl 1ó/rr,'post-mortem examination 18/rr. Patho-anatontical d,iagnosis.' Henrorrhagiæ suhperiostales (morbus Barlolr') * pneumonia lobularis clx. * hyperplasia lienis. Eætracts fl"ont' the post'mortem recorcl: On the left thigh the musculat'tre (mostly crura,lis, but also vastus ext. et int.) is tliscoulourecl, of a grevish yellorv, sometimes a tittle yellowish brown, ancl als<l sholvs small ireshly occurred hemorrhages. RountL the whole fernur below the periosteunr * la¡rel of clotted bloocl, 1-3 mm. thick. The lorver right femoral epiphysis shorvs the cartilage proliferation zone ¿l¡out.2 mm. wicle; the calcific¿tion zone is just above 1 mm. wicle, greyish ¡'ello'rv, generally straight, but in some places uneven. The bone mÍì,rror\- next to this zone is changecl into ¿ clarl< recl ancl mùcldy pulp. 206 .T. .{XEI, HöJER Äround ilre lorver ends of both tibiæ and the right railius subperiosteal ìremorrhages, The upper epiphyseal line of tibia is similar to the Ìorver one of femur. The ribs show on tl-re pleural sicle, both at the posterior antl anterior epiphyseal junctions, fresh hemo¡¡hages belo$' the periosteum.- On. Ùhe sectioi ät thó j'nction of cartilage and bone, the cartilage proliferation zone is norv 1 mm., norv 1/¿ rnrn. rvide, yellorvish, on the ï'hole even towarcls the cartilage lcut ¡vith small notches. Microscopical eæ(inxinar¿o12. Staining: hematoxylin-eosin' alum. h.ematoxylin - v. Gieson, of the two femores, tibiæ ancl fibulæ, as well ât the upper ânal loweï epiphyseal lines as in the mictdle of the diaph¡'-sis; also the anterior ancl posterior epiphyseal junctions of two ribs. The upper encl of left femur: frame-work marrow 1 mm. high' Inferior bone covers the old bone briclges in the >>Trämmerfelclzone>>' It shorrs bone canals but hardly any other structure. The upper encl of left fibula: no cartilage trabeculæ, the bone formation seems altogether arrestecl. In the musculature' which is highly atrophic, pictures of legenerâtiori. Ribs, posterior enal: The bone columns' which are lying across in the frame-work marrow of 3 mm. width, are joineil to the cartilage through a system of columns of more homogeneous bone. Rouncl all the bone columns a thin zone of real tissue (osteoid) and spool-shaped osteoblasts (fig. f). Iu the ))FugenwirLkel> hyaline bulky bone. Epicrõsis. Scurvy in a child of 5 months (the mother syphilitic), from the birth fed ffrst with cov¡'s milk mixtures ancl then with milk powder. Recor"ds, trelonging to Pü"t"t fV, Cha'ptur ff. Eætl"crcts, Series XXIV. Animals 97-f03, 183, control anirnals on complete tlietary. Weight charts, Fig. ll6. No. 97 diecl of an acute infection, the others were chloroformed after 105 áavs, July Brcì, a'd autopsiecl immediately. Histological examination as in Series V. No. 97. ç. Light brown-black. Increas-ed cluring 50 days normally, then decreased^cluring 5, witli sympùoms of panting respi"ration.- Died rr/s'23. Autopsied 12/s. Histological exa' minatiori as in'Seriês V, and of l'ngs, shows an infection spleen, numetoqs foci in the lungs, whero the alvecli are filled oul s'ith recl blood-corpuscies. monoand polynucleate cells. Di'a¡¡nosi's: No scurvy. Bronchopneumonia ac. ,5TT1DI]IS IN SCUIì\IY 213 Large hemorrhages around right knee and the six upper pairs of rit¡s on the light side, These costochondral junctions swollen on both sides. Teeth can easily be removed. Upper jaw brittle. Lmphgl. inguin. dx., paraôracbeal, and submaxillar, slightly homogeneously swollen. Líver 23.5 grams, snleen 0.6 gram. Hisúological examinaüion of 10 ribs shows absence of ordered eartilage column layer and of ossification itr ühe light-coloured frame-work marrov'. fn ihe nrusculøtu,rø ol the right thiglt, there is a necrotizing granulation tissue, and arounil ühat an extraordinarily vascular zone. In the vicinity there are numerous small necroses of muscular fibres with embedded calcium lumps. Nowhere an¡r connective tissue is seen to bound or gror'v through the necrotic foci. In tlne spleen trlne lymphoid tissue is to a large extent replaced by epitheloicl cells, Tubercle bacilli â,ro very numerous. No amyloid. Liuer sltows abundant fat, and atrophy. Smail foci of epitheloid cells, fibroblasts, giant cells of uncl.ecided type, tubercle bacilli. fn lmphgl. submaxillar' hyperemia, epitheloid cells, tubercle bacilli. In the bronchi exudate. Adrenais, p. 102. Di,agno.sis: Scorbul manifestus gravior, Tbc. rnuscul. primar., lienis, hepatis, Imphgl. submaxillar. Bronchitis. { l,' t lt t *'l¡' /, )6ô The l.¿nes úitlL XX t'ept'esclú tub¿rcul(tr' o.nimals. Fig. 118. Series XXVI. No antiscolbutic. a5s No. 117. 9. \Mhite-b1ack. Progress to death 1/s. The finclings ãt line post-mortem, exannina'tion 3/¡ ancl at úhe histological examination ::esemble the cases of severesü absolute scurvy, that â,re desc¡ibed above. Small quantity of liquid in abdomen. Peritonoum parietaJ.e et viscerale thickenecl, not glossy. Liver and spleen with cleposits around lower edge or pole. In the descending part of duodenum, 214 J. AX]ìI, HOJ]'R fì small irregular sore of the mÛcous membrane and to. the bottom of this sore a whitã-gra¡r lymph-gland adheres' Lymph-glands of .right^ kneo.-antl groin wholly ãu,"èo.r". -f,u-mbar glands show c€,soous formation of a rni.iiary iocus in orrä pole. Histological examinaüion shows pictures similar -bo those in No. 116 coicerning primáry focus, spleen' Iiver, lung' In regional lymphglands neeroses, rrhich show numerous lymphocyte shadows, and very numerous iubercle bacilli. No disüinct ne*'1y-formed connective tissue. I)uodenal gland rvith la,rge necrotic foci rvithoul specific character, with numerous tubercle bacilli. Diagnosis: Scorbut manifesfus gravior. Tbc muscul' primar', ]tplgt' regional., li.enis, hepatis, pulmon. Bronchitis. IJIcus cluodeni. Peritonitis. No. 118. 9. White-black-Yeilorv. Èating and drinking with appetite to the last. Died and was autopsiecl a/s. Ha,ir lósening, thoug:h not só ãasily as otherwise in scurvy. Teeth everywhere loose. In iúe loq,e"r jaw they are easity lifted out. Only certain of.the cos¿ochondral junctions are onlarged in any considerable degree (3, 4 ancl 11 sin.). Hemorrhage arouncl both knees. Upper tibia epìph;rses extremely Sritile. Upper jáw not brittle. Liver I5.4 grams. A bean-sized ca,seous þmph-g-ianä'in the liver hilus. Lungs filled v'ith a large number. of,miliary' 'íf.lï.-g"""y foci, caseous in the centrel In the righü groin a bean-sizeclIy*phgtrr.a,"irrite pólvis lentil-sized glands, partially c¿ì,seous. In tho lymph-glancls ãi irté r""g hilus, bean-sizecl, pártiall¡'-caseous foci' rn lmphgl' subma'xillar' small rvhiió foci. fn the inneì part ôf the musculature in the right thigh a ha,zelmrô-sized, caseo's abscess cãvity, without macroscopical capsular formafion. Histological examination as in No. 116. Diagnosîs: Scorbul manifesüus gravior. Tbc primar' musculor', imphgl' regional., lienis, hepatis, pulmon. lphgl. divers' No. 119' 6. Light brown-white-black' Þ"og"ui. to death tt/n, findings a,l l;.'e post-nxortern exarnination 23/¿ and histãlogical examination showspicture of pronou-nced, scurvy' Also with regard. ío the lubercular changes in muscle, regional l¡lnph-glands, spÌeen ancl livér, No. II9 resembles No. 116 and 117. I-ivcr 19.5 grams, Spleen 2.2 gÌams. D'iøgnost's: Écorbut manifestui gravior. Tbc primar' musculor', lmphgl' reg^ional., lienis, hepatis, lmphgl. hilus pulmon. Conclusi'on lor Sori,es XXV:I: Neither in the primary musele-foci, in the regional glands, épleen or liver, nor in other affected organs fher-e is any tenaåc¡r seãn of re¿ictive connective-tisstle, macroor rnicroscopieall¡z' Series XXV|l. Anirnals120-127.No.I24-T2Twereinfectedwithtuberculosis. The animais were given basal diet ancll¡esicles 0.3 ccrn. of preservecl orange juice (0.r m. pr. d.). Weight charts, Fig. 119' No. 120. 9. \Ml-rite-light brown--black ðie¿ 1e/n withãuf having sho'vvn scurvy symptoms' Autopsied the same a"y. Ño cerlain changes tõ be observedal th" post-nxortenx examination' Ì;í", ie.o g.o-.. Splón 0.2 gram. HistoþBicat examinarion as in No. 5. Di,agtúsis: Scorbut latens extensus' In{ectio? STUDIIIS IN S(]Uß\'Y 215 No. 121. Black-rvhite. l\¡as founcl lying u'ith its head over the brim of the milk basin and its nose in the rnilk, 23/¿. Autopsied 2ó/c. Hair easily loosening. Teeth firm: l<nees swol.len, ribs slightl¡r enlàrged in costochonclral junctions. No hemorrhages. Lymph-glands of upper jaw nearly as big as brown beans. Liver 8.0 grams, spleen 0.+ grams. Ilistological examination as.in No. 5, and besicles kidney and aclrenal. Spleen, Fig. 84. Adrenal, Fíe. 93. D'iagn,os'is: Scorbut manifestus mitior. Infectio. No. 122. Yelloq'-Ercv. Progress to death ìb7ri fit.lingr a,L post-mortcnx examination 12/s and hisfological examination similar to those in No. 5. Spleen 0.5 gram. Liver 13.7 grams. Tooth, Fig-. 22. Di,crgnosis : Sco:rbut rnanifestus mitior'. 1..".. -x-. i ,o /, b 2t Ja Jî 4ô 1, to J! ¿o 6t la ìf XX tlû)eraLl 0r' a|ún als - Fig. 119. Series XXVII. 0.r m. pr. c.l. \to. 123. Black-white-brorvn. Dead and autopsied 30/a. Progress, findings ùl post'nxortern, and histological examinations similar to those in No. 5. Liver I0.7 grams, spleen 0.3ó gram. Swelling and reddening of the mucous memk¡rane in larynx and trachea. D'íagnosi,s: Scorbut manifestus mitior. Laryngo-tracheitis. No. 124. 6. Biack-rvhite. Deacl and autopsied 2rla:Lean animal. Teeth loose, can be removed with some clifficulty. The epiphyses of the iong bones brittle. Upper jáw briútle. Costochondral junctions and knees swollen. Ilemorrhages in the rib intersüices and around right knee. Necrosis focus in thigh musculature wiühout disüinct capsule. Lymph-gland of the righú groin shows small caseous foci. Spleen 0.9 gram, filled with granula,tions of the size of a pin's head. Liver l5.s grams. Tlistological exarnination shows the primary focus in the musculaúure borclered by a t'all of epit'heloid cells, among which some tuberculous foci 216 .r. ÀxEL HOJER of lymphoid cells. No connective tissue (Plate IV). Also with regard to l;zrnphglands, Iiver, spleen, the pictures are similar to those shorvn in No. 116 and t 17. Di,øgnosi,s: Scorbut manifestus mitior. Tbc primar. musculor,, lmphgl. regional., lienis, hepatis, lmphgl. divers. No. 125. Black-white-brown. Diecl 2?/¡, a,utopsied 30/¡. In. trachea a.ncl large bronchi mucous phlegm. No hemorrhage except, in the musculabure of the right thigh, where it is very extensive. Teeth in the lower jaw loose. Epiphyses brittle, diaphyses not. The costochondral juncúions of the ribs enlarged; some (C 6, 7' 8 sin.) surrounded by conneetive-tissue forrnations. Lymph-glands everywhere homogeneolsly swollen, In both groins and at right knee they are pea-sized, caseous' In a pelvis g'ìand a pre-caseous focus. Hisúological examination similar to that in No. 116 and ll7. Di,a.gnosi's: Scorl¡ut manifestus mitior. Tbc primar. musculor., lphgl. regional., lienis, hepalis, pulmon., lmphgl. divers. Tracheo.l¡ronchitis, pneumoniae, No. 126. Light brown-white-black. Dead and auüopsied 11/s. Progress, post-nxortenù èxaminafion and histolog' ical pictures similar to those in No. 125. On 6/¡ there was observed round the left õye a small region, hairless, covered wiúh bloody crustæ, which remained till death. No cerúain hemorrhage for the resù. Spleen 3.2 grams. Liver 21.8 grams. fn regional lymph-glands necrosos which occupy .the largest part of ihe glancl, with small calcium lumps in the centre. No distincü nev'connective 'tissuã. Hyperemia of periganglionar capsule. (Plate VI). In the mucous memb¡ane óf the btadder wa1l a necrosis, in the wall of which there are seen bacilli looking like tubercle baeilli. Diagnosi's: Scorbut manifestus mitior. Tbc primar. musc., Imphgl. regional., Iienis, hepaüis, vesicae urinae. No. 127. \Vhite-brown-black' Dead 15/¿, autopsied 16/a. Knees are somewhaf swollen, are fractured spontaneously when taken out. Ilemorrhages in muscles above right, knee. Tho cosüochondral junctions slightly sr¡'ollen. Teeth of lower jav' somewhat, Ioosé. Lymph-glands aú right knee and tracheal lymph-glands homogeneously swollen. The middle lobe of left lung pneumonic in its upper region. Liver 20.4 grams, spleen 0.* gram. Histological examination of 12 ribs, spleen, liver, focus in úhig'h muscuiature, gives pictures similar to those in No. 116. The alveoli of left tung in the above-mentioned region filled with recl blood-cor' puscles, fibrin and cliplococci. In bronchi also exudate of different ceils. - Di,agnosis.' Sco¡but manifestus mitior. Tbc primar. muscul., lmphgl. regional., lienis, hepatis. Broncho-pneumonia a,e. Conclusion lor Seri'es XXVII: Harclly in any place the tuberculous foci in different organs show a connective tissue, which appears as having to be considered reactive. Series XXV|ll. Anir¡rals 128-134. No. 139--134 were infected with tuberculosis. The animals had l¡asal diet ancl besides each 0.6 ccm. of preservecl orange juice (0.2 m. pr. d.). 'Weight charts, Fig. 120. No. .128. 9. White-light brown-black. Dead ancl autopsiecl 13/a. Hemorrhages in subcutis around both knees. STUDIiIS IN SC]IJR\:Y 2I7 Otherwise no macroscopical signs of scurv¡r' The large intostine fillecl rvith thin liquid contents. Hyperemia and hemorrhage in its lymph nodules (Peyer's plaqueÃ). Corresponding lymph-glands in the mesentery bean'sized, h-yperemic' hislological examination of the mentioned organs, 12 4bs' liver (I8.9 grams, spieen (ì..0 gram) shows pictures of early scurvv as in No. 127. ' Di,øgnos'is.' Scorbut mitior latens extonsus. Colitis ac. No. 129. Light brown-rvhite-blacl<. Dead and aulopsied 21/¿: IIair not loosening' No hemorrhag'e. Teeth firm? Upper jaw not b¡ittle. Somewhat increased fragility oJ epiphyses, noü of diáphyses; knees ancl costochondral junction slightly swollen' ¡>White line'> in the latter. Lively h¡'peremia of the mucous membrane of larynx, trachea, ventricle and duodenum. Liver 23.1 grams, spleen 1.0 gram. Histological exmination simila¡ to thaü in No. 127' - D'íagnos'is: Scorbut latens extensus. f,aryngo-tracheitis ac' Gastroduodenitis ac. t)l + l-'-"{.- ;È + tß Jta 3[ ta ,i h¿ /atà"| îto¡t¿o 1J to it 70 4! î0 ft aô (t ìo ìJ t0 x x hlberculdl' attinzuls. Fig. 120. Series XXVIII. 0.2 tn. pr. tl No. 130. Yellow-black-'r¡'hite. Progress to death 2e/n, findings al Line post-mortem examinat'íon 30/¿ and histological examination similar to those in No. I29. Spleen 1.8 g-ram. Tooth, Fig. 23. Di,øgnosis: Scorbut nritior latens extensus. Tnfectio. No. 131.. White-black-brown. Dead 1e/¿, autopsied 21/a. Rather fat animal. Hair easily loosening-. Knees srvollen in the epiphyseal lines. Ilemorrhages around several ribs. The costochondral junctions swollen, surrounded by pale grey enlargements (connective tissue). The teeùh are removecl with some difficulty f¡om üheir alveoli. Liver 18.9 grams. Spleen 1.5 gram. Hyperemia of the upper part of the large intestine. Histological examinalion similar to ì{o. 127. D,iagno.*î,s: Scorkrut mitior manifestus. Colitis ac. No. 132. é. Brown-grey-whiüe. Dead ancl auõopsiecl 1l/¡: IJair easily loosening. Teeth 'oomewhat loose, c&n not be liftecl out.. The cóstochondral junctions and knees somervhat 218 .t. ¡.xÐI H(i.rJ,l1ì swollen. The epiphyses of the lon¡t bones brittle, diaphyses ancl upper jau' not. No hemorrhaE¡es. The primary tuberculous focus in the musculature of the right thigh consists of an almond-sized caseous mass, bordered by a capsule thin as a knife-edge. Lmphgl. genu et inguen. dx., lumbal., for the greater part occupied by caseous foci. Other lymph-g-land-s slightiy enlargecl uniformly. Liver mottled, 18.5 grams. Spleen l.+ gram. Histological examination of all ribs and of linees shorvs plonouncecl scun'y changes, i. a., calcífied necroses in the muscles. Fc¡r ths rest the same orflans as in No. 104 are examined. Heart, Fig. 70. Heart and lungs also stained with cres;zlic violet, spleen on a,myloid. I)i.a,gnosis: Scorbut mitior manifestus. Tbc prim. ioc., lmphp.;Ì. region.; lienis; hepatis; lmphgl. clivers.; costar. duo. No. 133. 9. White-brovrr-black. I)ead ancl autopsied 23/s. Hair easil-nloosening. The mola¡s somewhal loose. The upper incisors easily broken. The costochontlral junctions show white line, somewhat swollen, as are also the knees. tr'racture of left ankle, healed in a wrong position, wióh sìight, soft callus. Increased fragility of the epiphyses of the long bones. Upper jaw britüle. No hernorrhage except il spleen, 20.t grams, and liver 39.8 grams, which shorv a ver¡r mottled picture. Local focus smaller úhan a hazol-nut, caseously chang-ed, surrounded try a thin capsule, which is glossily reflecting. Lymph-glands of right knee and groirr pea-sizecl, caseously changed. The lumbar glands bean-sizecl, homogeneously grey, as are also the bronchioles. Histological examination as in No. 132, and bôsides of kidney, adrenal, lung. D'io,gnos,is: Scorbuü mitior manifestus. lfbc prim. loc., lmphgl. region., lienis, hepatis, irnphgl. clivers. No. 134. Black--broç'n-white. No sign of scurvy. The stitch jn úhe musculature of ühe right thigh rvilhout reaction. Abdominal cavity filled by a turbid liquid, rvhich is scentIess and contains numerous fat-drops and tissue-fragments. In the place of the pancreas there are onlv seen some small strips of tissue lefú. Ri¡¡ht lrrng pneumonic. Histological exainination of spleen, Iiver, lung. .Diagnosi.s: Pneumonia ac. dx. Nec¡osis âc. pancreat. c. peritonit. Conclus'iom lor Seríes XXVIII: The two tubercularly infected animals that had lived ¡nore than a month, shou'a certain connective-tissue reaction, in the shape of a ühin capsule around foci in muscles and regional lymphglands. Series XXIX, Anima,Is 1.35-L42. Of these No. 139-142 were infected with tubercle bacilli. All had basal diet and besides I ccm. of the earlier described preserved orange juiee (0.s m. pr. d.). \\¡eight charts, Fig. 121.. No. 135. Black-white. Dead 1e/a without having shown scurvy s¡zmptoms. Autopsied the same day: Incisors not glossy, break easily. Teeth firm. Upper jarv trrittle. Bones for the rest firm. Joints noü swollen. No hemorrhage. In the abdominal cavity a couple of tea-spoonfuls of bioody liquid. Spleen 2.5 x 2.5 x 4 cm,, rveight I-î.+ grams, very much filled with blood and fragile. The upper pole adhorent to the back abdominal wall, bounding an abscess which is outwardlSr bounded by the llth and l2th ribs. An irregular rupturo through the spleen, big as the tip of a little finger leads into this abscess; Líver 44.r grams, Iarge, S'IUDI¡JS IN S(-]UR\-Y 2l9 .rvith swelling, mudcly section surface. Histological examination as in No. 5, and besicles of kidney' 'Iooth, Fig' 24. D,íagnosis: Scorbt.Lt mitior latens extensLrs. Abscessus lienis rupturat. No. 136. Blacl<-u'hite-brou'n. Deacl 1/e, autopsied 3/4. Progress, findings and histological examin¿tion (also adrenal) similai to those in No. 135. lleeth in lower jarv somewhat loose. The costochondral junction somervhaü swollen, the l<nees not. Spleen 3't1r grams, liver 33.5 grams. Atrscesses in spleen and liver, parüly into-the subst'ance, fartly outwarclly boundecl b)' abdominal wall and kidneys' No ruptute of these abscesses. D'iøgnosis: Scorbut mitior la,tens extensus. Abscessus lienis et hepatis' IJ' t ¡t, rt îo ?r tøàals þ )î Jb Jr' 10 It lO $ a. lt ìo lr 8o XX tubercul ar ilnimtlt9. Fig. 121. Series XXIX. 0.e m. pr. cl. l1l No. 137. Brown-t¡lack-rvhite. Dead 5/¡, aulopsied 6/4. Coat rough, thin. I{air coming off in tufts. Tho diaphyses of thè long bones are of an increased fragility. Teeth firm. Lymptr-glands at the angle of the jaws bean-sized. Splqen 0.ab gram., liver fO.o grams. Histological examinaúion of organs as in No. 5 gives pictures similar to those in No. 135. Di'agnosi's: Scorl¡uú mitior latens extensus. Infectio. No. 138. Black-white-brown. Deacl 8/s, autopsied e/s. Hair coming off in tufts. No hemorrhage. Teeüh firm. Upper jaw brittle. The epiphyses of the Jong bones 'b:ittle. Larynx filled witñ glassy phlegm. Liver 26.6 grams, spleen 1.7 gram. HistoIogiãal examination as in No. 135. Spleen, Fig. 85, also stained on amyloicl, iron, with Giemsa. Diagnosi,s: Scorbut mitior latens extensus. f.aryngitis ae. 220 .r.,\xì.1r, Hii.rÌ.lrì No. 139. ?. Grey-rvhite. Deacl and autopsied laie. Fat aninral. Hair easily loosening. No hemor'- rhages except in the subcutis of righú thigh, which is edematous. Walnutsizecl, caseous focus in the rnrrsculature, surrounrled by a connective-tissue capsula, I mm. thick. Lymph-g^land of right knee not macroscopicaliy changeil. In the right groin two pea-sized, yellowish rvhite glands, one of them caseous. Lymph-glancls for the rest homogeneously swollen. Teeth firm, excepú incisors, ¡vhich are rather loose ancl brittle. Upper jaw brittle. The epiphyses show increased fragiÌity, the diaphyses noú. The costochondral juncúions somewhat, swoÌlen, distinctly in C 2 dx. ancl C 3 sin., there an enclosing connective-tissue formation js seen. Knees and other joints not swollen. Liver ancl spleen considerably enlarged; liver grev-yellow, adipose, fairly firm, 44.2 grams; spleen 2 x 4 x. 6 ccm., 15.2 grams, profusely fillecl with bioocl, penetrated by rvhite, firmer foci, big as a pin's head and more. fn its upper pole a mpúure, reaching almosû ac¡oss the organ. fn the abdomen some tea-spoonfuis of bloody liquid. Histological examinafion as in No. 136. Rib, Fig. 38, also stained on iron and on fibrin according to Weigcrt. Diagnosis: Scortrut mitior latens extensus. Tbc prim. musc., Imphgl. region., lienis, hepatis, lmphgl. divers. Ifemorrhagia e ruptura lienis. No. 140. All white (albino). Dead-laf s, autopsiecl 16/¡. Hair somewhat loose. No hemorrhage. Teeth somewhat loose, incisors chalky. Slightly increased fragility of epiphyses, but not of cliaphyses. Upper jaw brittle. In ühe costochondral junctions the whito line of Fraenkel. fn the adductors of righü thigh a bean-sized dry caseous focus, with a ôhin buú distinct membrane-like capsule. The inguinal lymphglands lentil-sizecì. rvhiûe, hard as calcium, grate against thc knife. Other lymph-glancls homogeneously swollen. Liver 26.5 grams. Spleen 2l.z grams, profusely filled with bÌood, with large white soft portions of irregular form. Histoiogical examination as in No. I04. Rib, I'ig. 35. Spleen also stained on amyloicì. D'ictgtzos,ís: Scorbut mitior latens extensus. Tbc prim. musc., lmphg^I. region., lienis, hepatis, lmphgl. clivers. No. 141. Brown-white. Dead 22!s, autopsied 2a/s. Teeth somewhat loose, brittle. LTpper jaw rather brittle. Pairs of ribs 3-5 have enlargecl costochondral junctions. Knees slig'htly swollen in the epiphyseal regions. Ilemorrhage in subcutis around the left, elbow, From the inside of right knee the subcutis, upwards over the abdomen and for¡vards against both axillæ, is changed into caseous tissue, a couple of mms. thick. The pelvic lymph-glands are bean-sized and occupied to about half thei¡ volume by caseously purulent foci. Spleen 2.2 grams, Iiver 27.õ grams. Histological examinations as in No. 105. Di.ognos'is: Scorbut mitior latens extensìrs. Tbc subcutis, lmphgl. region,, lienis, hepatis. No. 142. 6. Brown--black-white. l)ead and autopsied 13/a: lean anirnal. Teeth firm. fncisors very brittle. No hemorrhage. No swelling of the epiphyses of the extrernities, nor of the costochondral junctions. Epiph¡'seg easily broken, diaphyses not. Primary focus in the thigh musculature big as a brorvn bean, with ôhin, translucent, capsule. Of some rice-shaped inguinal glands, one shorvs a small caseous focus, :rnother a similar focus which is partialty calcified and surrounded by a distinct connective-tissue capsule. Other lymph-glancls homogeneously STLIDIIìS IIi SCLÌÌI\'Y qr1 glassily swollen. Lar¡rnx reddened. Mucous membrane wrinkled and swollen, on its surface a slight quantity of phlegmy, turbid' bubbly fluid. Mucous mernbrane in trachea redclened. Liver 19.0 grams. Spleen 2.+ grams. Ilistological examinâtion as in No. 105, and besides of heart, lung. Kidney, Fig. 88. I)iagnos'is: Scorbut mitior latens extensus. Tbc prim. musc., l¡rmphgl. region. eú aliar., lienis, hepatis. Laryngo-tracheit. ac. Concl,usion lor Seri,es XXIX: Distinct, but slight connective-tissue reaction around tuberculous foci. Series XXX. Animals 143-f50. Of them No. 147-150 were infected with tuberculosis. All the animals had basal diet and with thaü each 1.5 ccm. of preservecl orange juice (0.5 m. pr. d.). Weight charts, tr'ig. 122. ,'*.--,tr"- '*-"'-xt47 î /o lt ú Jt i6 Jt 4a 1f, i0 s, [ô ß la ls Eo Er 1o f /ø htùj XX tubcrcular un¿malí. Fig. 122. Series XXñ. 0.s m. pr. cl. No. 143. White-black-brov¡n. Dead 26f t, aufopsied 30/s: very lean. No macroscopical sign of scurvy. Liver (lI grams) shows, Iike spleen (0.3 gram), lung, Iymph-g-land above the right adrenal, foci of irregular form and var¡ring sizes up to the size of a bean, peripherally hard, in the centre often purulent, of rvhite-yellow colour. Ilistological examination shows them to consist of a non-specific granulaüion tissue, Scorbuüic changes in 13 ribs, spleen. Di,øgnosi,s: Scorbut latens extensus. Infectio. No. 144. ð. Brolrn-grey-white. Chlorofo¡med and autopsied ze/c. No macroscopical sign of scurvy or infecfion. Liver 29.2 grams. Spleen 1.9 gra,m. A.b the histological examination of l1 ribs, normal junclion pictures are shor¡'n. Teeth, Fig. 25. Spleen also stained rvith Giemsa, heart, kidney, adrenal, muscle. Dì,agnosi,s: Scorbuú mitior latens levior. 222 .1. ¡\XIIL HöJltlì No. 1t15. Grey-white-black. Dead ancl autopsiecl ls/a. Incisors of lorver jarv chalky, somewhat^loose. For the rest, no sign that mighù indicate scurvy. Liver 18.8 grams.. spleen õ.ã g"r-. TÍre righ[ foot shor.vã pa-thological changes. The claw-bed is injected, ihu-"1u,*" partly !one. The lymph-glands_ at the_.knees to some degree swollen. Injection of tú"i" arteries. -The lun_qs h_ave climinished air contenüs. The ¡rårr"fri show purulent contents. Iústological oxamination as in No' 97, a.ra ¡esiaes of Ëeart (Fig-. 08, 69) and right, paw. . Hearl and lung also stained with cresylic violet'. Di,ainosi,s: Scorbuü mi',ior latens levior' Gangrena exiremitat' Bron' chitis purulenta. No. 146. é. White-black---bror¡'n. ðhloroformed and autopsied zsls L923. Incisors of the lower jaw possibly not quite firm. For the "esi tto pathological symptoms. Histological examination as in No. 97. Dc,agno.s'is: Scorbut mitior latens levior' No. 147. Black-white. Dead and autopsied 30/a: no macroscopical sign of scurv¡r or acute infection. Therightinguinalþmph-glandpea-sized,some-partiallychan-gedintoadry "r."o"! massl others"fi¡ro*s. Sufmaxillary lymph-glands pale, þomogeneously swollen. Lívet 24.8 grams with numerous foci, paqtly c1leating but otherwise ha".t, up to úhe sìáe of beans. spleen 2.t grams. The large intestine in l*o pf"ä"r adherent through the rnèsentery round a caseous lymph-glancl. Histótogicat examination u.-itt No. 104, ancl besideé of colon' ' - - D'in¡¡nos¡i.'.' Scorbut latens levior. Tbc prim' musc', lmphgl' region'' lienis, hepafis, pulmon., coli; lmphgl. divers. No. 148. Blaek-brown-white. I)ead and autopsied 2a/s. Upper jaw brittle' Diaph.vses -somewhât' easily broken. Epiphyses not. No sign of scu-rvy.' The caseatecl, a litüle more thari hazetmt-sirãci p"ltnr"y focus dóes not lie in the musculature but srrbcutaneously, sr.rrounãed b¡r a very thin, reflecting membrane' Lymph--glands at the righí knee and in ihe inguen pea-sized and a, little larger, with.small caseous fici, otherwise rather hârct. -SmaII quantity of t,rbid liquicl^inatraã-inat cavity and left pleura. Lower part of the lower lobe of left lung pneumonic, Þeritoneum parietalerose-coloured, downy, with fibrin films àn lefú lobe of the liver arid on spleen. Liver 21's grams' Spleen 1'2 gram' Histological examination as in No. 116. D'ic"gnosis: Scorbut mitior latens extensus' Tbc prim' musc',. lmphgl' region., líenis, hepatis, lmphgl' clivers' Bronchopneumonia ac' c' pleurit' et peritonii. ac. No. 149. é. Grey-brown. ðhlorofoimed and autopsied 2e10. No rnacroscopical sign-of scurvy or acute infection. The primàry focus i' the thigh musculature bean-sized, caseating though noü yet úotttog"tteou", outwardly borclered by a homogeneo's g"r.riuüì;g -u"scle surface. L;mph-glands everywhere hornogeneously-sw_ol1en. i$frort diïtinct foci. Splee' if .z g"ã-s. fn the lower-po-le a-pea-sizecl whitish yollow focus. Liver 43.4 grams, tráversed by stra,nds of whaü looks like connec- [lrr"-ti"""". Lungs filled"with a large number of small foci, miliar¡r in trefoil No. 171. 9. AII lvhite (albino). Killed anrl autopsiecl 30/0, Fat animal. No sign of scurvy. No macroscopical sign of tuberculosis. Liver 20.0 grarns. Spleerr 1.0 gram. it hìstological examinaüion of the thigh musculature in series of sections, a submiiiary foõus 'rvas found, consisting of epitheloid cells, lymphocytes and fibroblasts. No tubercle bacilli found in it. Nothing remarkable notecl in liver, spleen, jaw. Ilearb ancl lungs also stained with cresylic violet. D'iagnosi,s: No scurvy. Tbc prim. musc. pelacta. No. 172. White-brown-blaek. Dead.221a, autopsied 23/a. Fat animal. Hair not coming off. No sign of scurvy. Primary locus in thigh m.usculaüure rather more than pea-sized, hard-rinded rvith a, miliarSz abscess in the centre' In the regional lymphglands, v'hich are pea-sized, there are miliary, yellorv, very hard foci. -Spleen weighs more than I gram. Right lung in its upper parü pneumonic, adherent to pleura parietale. In the pleura bloody liquid' Histological examination as in No. 165, and besides of jaw. Region. lymph-gland, Plate V. D,iagnos'is: No scurvy. Tbc prim. musc., lmphgl. region., lienis, hepatis. Pneumonia ac, dx, ffi, .òtro. 173. White-black. tr'at animal. IIair not loosening. No sign of scurvy. Teeth firm. In.cisors of lower jaw brittle, easily broken. In ùhe musculature of the right thigh a more than almond-sized, caseous focus with a smooth capsule moro than a millimeter thicl<. One lymph-g'land in knee and one in groin, pea-sized with a miliary abscess, enclosed by rind-like connecüive-tissue. Other lymph-glands homogeneously swollen. Abdomen distenrled. fn the abdominal cavity a tea-spoonful of liquicl blood. The large intesüine considerably distended, by gases-. A rupture a centimeter long in the lorver pole of the spleen, v'hich is sr.vollen, congested, around a pea-sized greyish yellow focus. Uncler slight pressr-lre bloocl percolates from the rupture. Spleen l0'2 grams' Liver 35.5 grams. Histological examination of jaw, thigh focus, clifferent, lymph-glands, liver, spleen. Diagnosi,s: No scurvv. Tbc piim. musc., lmphgl. region., lienis, hepatis, Imphgl. clivers. Ruptura lienis c. peritonitícle. No. 174. 9. Brorvn-black-white. Died and rvas autopsied rl/s. No sign of scurvy. Betrveen the tendons of the add.uctors in the bencl of the right knee an almond-sized caseous focus, surrounded by connective-tissue rinds, a millimeter thick. Glancl in the bend of knee pea-sized, r,vhite, harcl. Other iymph-glands homogeneously swollen' Spleen 0.0 gram. A somewhat more than pea-sizecl splenculus aü the spleen hiius, largeþ caseous. Liver 18.0 grams, mottled, rvith differently sized, irregular white foci. Histological examination as in No. 172. - Dàagnosi.s: No scurvy. Tbc prim. musc., lmphg*I. region., lienis, hepatis, lmphgl. divers, costar. duo. STUDIIìS II\ IjCURYY 99(l Seri,es XXXIII: Strong reaction of a well developed ancl abonb tuberculous foci. Conclusi'on connective-tissue fo, in Series XXXIV. Animals 175-L82. Of theso No. 180-182 were intected with tubercle liacilli. All the animals had basal diet and besides 5 ccm. of preservecl orango iuice. The dose proved to be fully protective' Weight charts, Fig. 126. 230 J. ÀXìrr, HöJlrrì No. 175. White-black-brown. No sign of scurvy. AII claws partially gone. A metàüa,rsal joint openecl. Upper lobes of both lungs pneumonic. Hisúological examination as in No. 172. Dia.gnos'is: No scurvy. Pneumonia ac. bilat. Gangrena extremiúat. + ,,x----x" .¡ ,,*'.+- .. ' ì)¡ tlt t89 .-.-.+ + I 300 *' t16 þ Jî Jo l¡ to tr ro tl þ u /Ò 4to E 1o ?t tñ XX txtbercula| ulLímIls. Fig. 126. Series XXXIV. 1.? ni. pr. cl. No. 176. Brown-white-black. Died and was autopsied 12/e. No sign of scurvy. The epiphyses of ühe long bones are more easily broken úhan normally. Upper incisors somewhat loose. The right pteura is reduced to slits between thick fibrin coaús, through which the pnoumonic lower part of the lung adheres úo chesú wall and diaphragm. In the peritoneal cavity a moderate quantity of frothy, turbid scentIess liquid. Peritoneum rose-coloured. Liver 15,r grams, spleen 0.8 gram. Histological examination as in No. I72. Tooth, Fig. 30. Diagnosis: No scurvy. Pleuropneumonia ac. dx' et peritonióis ac. No. 177. Brown-rvhite. Died 26/¿, autopsied 2?fa. No sign of scurvy. Mucous membrane iu Iarynx rvrinkled, Ilncler the left mandible a pea-sized, half purulent lymph- STUDI]'S IN SCUR\]Y 231 gland. In both lungs miliary pneumonic foci. .Liver 12.4 grams, spleen 0'5 !ram. Hislological examination of spleen, liver, jaw. D,íagnosis-: No scurvy. Laryngotracheit' ac. Bronchopneumoni¿c a'c' No. 178. 6. Black-brorvn-white. Õhloroformed and autopsied 301e. Fat animal without rernark' Liver 39.9 grams. Spleen 1.0 gram. Histological examination of spleen, liver, jaw, kidney. Adrenal, Fig. 92. Di,øgnosis: No scurvY. No. 1'/9. ô. Greyish yellow. Óhto"oform"d and autopsied 30/e. No sign of scurvy. Hair loosening rather easily. Üpper lobe of right lung pneumonic. Lymph-glands in hilus homogeneo,isly ffoJlen. Liver 25.6 grams, spleen 0.7 gr:am' Histological examination of liver, sPleen, jaw. Di,agnosis: No scurvy. Pneumonia ac. No. L80. Grey-brown-rvhite. Dead and autopsied 6/r. No signs of scurvy. In the musculaturo on tho inside of the right úhigh very strong rind formation with a numt¡er of small caseous miliai=y foci.- Lymph-glands in the right groin and in p-elvis pea-sizecl, hard, with miliary, strongly white foci of greaü hardness, -without ähu"*u. Spleen (2.2 grams) 'shows a large number of larger and smaller soft parts of diiferent. red colour. Liver 21.6-grams, with a large_ nurnber of conical *ttiti*fr yellow parts localized at the border rvith hyperemia in-the edges (septic infarctsi. AII úie teft lung and central parts of the two upper lobes in the rig'ht Iung pneumonic, with turbid black fluid' Two Peyer's plaques hyperemic, swollen. Histological examination as in No. I04. Di,agnosi's: Ño scrr"n¡2. Tbc prim. musc., lmphgì. region., iienis, hepatis' Rronchitis ac. Pneumonia ac. No. 181. é. Black-yellow-white. Dead ancl autopsied s0/o' No sign of scurvy. ln ühe right thigh--muscuIature an irregular cävity reaching a goocl distance towâ,tds inguen, filled by a thin liquid l.ith st"ips of tissue ancl bordered by thick rinds of -connective üissue. IJymph-glands lying at right knee and groin, in left musculus quadriceps ancl ãt lðit Ènee, and in pelvis, pea-sized, with miliary andsma-ller caseous ,Ë""".."r, enclosed by thick õonnective tissue. A similar gland under tho jaw' In one of the pelvic glands a similar small focus with calcium in the capsule. Liver large, 3?.0 grams, congested, with some miliary.granulations,-greyish white. S-pleen Z.d'grams, liliewise. Histological examination as in No. I04' Di'ctjnosi's: No-scurv¡'. Tbc prim. musc.' lmphgl. region., lienis, hepatis, lmphgl. divers. No. 182. é. Black-brown. Killed ancl autopsied 30/e. No sign of scurvy. Not much hair loosening' The diaphyses of ühe long bones and upper jaw somewhaú more brittle than normaü!. In the adductors of the right thigh a narrow, less than almondsized. foäus of dry cheese, bordered, by a distincü capsule. In the left thigh, in lhe aclductors,'a lymph-gland, wiüh an abscess in the centre. and in the outer parts changecl into-a thick connective-tissue membrane' Lymph-glands aü Loth knees.pea-sizecl, rvhite, fibrous, no foci. Other lymph-glands generally 232 J. AXEL HöJDIì sv/ollen, grey, homo-geneous._ Liver-44.8 grams, mottled, filed with submiliar-,., somev¡hat irregularly formecl grey foci with hyperemic zone. Lungs likewisä. Also in the spleen some similar foci. Histological examination asin No. 104. Di,øgnosi,s: No scurvy. Tbc prim. musc., lymphg.l. region.; lienis, hepatis, pulmon., lmphgl. divers. . Conolusion for Seri,es XXXIV: Strong reaction of well clevelopecl connoc¿ive tissue in and around tuberculous foci. No. 183. é. Brown-white-blaek. I'rom the day of arrival, leis (weight 310 grams), the animal persistingly twisted its head to the left anclwould run round. rt was put o-n complétä clietary as series 2. standstill in weight till 'e1e, when incredse in weiehi followed. In the middte of May the above-mentionecl symptom disaipeared and the animal seemed afterwards to be weil. chloroforried. ancl aritïpsiecl "lr. Liver 33.0 grams. Spleen 0.6 gram. __. _ Hisúological examination as in No. 5 shows normal pictures in mosü organs. Kidney, p. 99. The nerves in the bend of the knees shoi, considerable chaiges: axis-cylinders irregul.arly swollen, mvelinic sheath irregularly segmeni.ed; here and there small þvperchromatic, spool - starshapecì-cells-¡,ith"roundecl nuclei. Di.agnosis: Beriberi (?) peracüa. Series XXXV. Animals 184-18?. These were put on relative general inanition with full dose of antiscorbutic from oct. L, Lg2B. Each anùnal had its o.wn cage and goú.a.daiiy ra,tion of 40 grams of chickweed and besicles a dose of preservõd ora-nge j'ice. -This was given to each animal with a pipet in a dose óf 3 ""*., and besides l0 ccm. were put into the cage, v'hich weré not always consumecl, weight charts, Fig. 127. The animals rètained. their iiveliness äf movemenr almost to the last day. No. 184. Black-brown-white. Dead ancl autopsi.ed 8/ro. Hair not coming off, Almost no fat. No sign of j9¡rr"y. Bones not brittle, teeth firm. Í-iver ll.0 grams, spleen 0.2 B,ram. Histological examinatio¡r of 12 ribs, jaw, muscles, hãart, iir/er, lung, shows ¡o changes like those described for the scorbutic an.imals. Kiclney, adrenal, salivary gland, spleen, show slight atrophic changes of the parenchymatous cells. Di.agnosi,s : fnaniöio. No. 1B5. White-bro¡vn. Died and was autopsied la/ro. Lean animal. No sign of scurvy. I{isto_ logical examination as in No. r84. Also liver (nuclei) anã heart (ela"stic;;mbranes) show slight atrophic changes. Hemorrhagô in the màrrow of tho adrenal. Diagnosis: Inanitio. No. 186. 9. \1¡hite-brown. Died and rvas autopsied 10/rr. Fincrings ancl histologicar exar.nination as in No. 185. Adrenal, fig. 94, Di,a,gnosis : Inanitio. S'IUDIES IN SCURVY 233 No. 187. 9. White-brown. öied and was a,utopsied ?l:rc. IIaít easily loosening' Lean anim-al' The clianhvses of the lone bonès are somewhat, too easily broken. No sign of scurvy. 1'*ã i"^pfr-elancls-in the lower jaw with miliary abscesses. Histological e*a*iiatitn'as in No. I84. Only kidney and adrenal show slighü atrophic changes of the parenchymatous cells. Ði,agnosis: Inanitio. Lymphaclenit. ac. supp. Concl'¿tsi,oït lor Ser'íes XXXV: lMith a dietary of about a third of thaú required for noráal incroase in weight, the animals lost in one to two weeks 29:_-g6 % of their initial weight. Thã lymphoid tissue of the spleen,_the elastic ,nemb"ulies of the large veisels, the parãnchymata of kidney, adrenal and liver showed slight atrophic changes. 9roô: ,'fr 2(' ¡Jo 225 'ì5l50 'tt 5o lat. 15 20 25 Io è.5s lìig. 127. Series XXXV Additional animals. Rel¿tive inanitifon No. ,/88. ,4. Lisht b¡own-white. Éad föm 1/ro chickweecl ct'd, tì'b., and was besides given 5 ccm' of preserved. orange juice with pipet. Killed and autopsiecl 10/ro. Everywhele normal conditions, ásô at the 6istological examination as in No' 5' Tooth, Fig' 3' Di,agnosi,s: No scurvY. No. 189. Black-bror'vn. From birth it has been fed on eonplete dietary by the breeder and.seemed healthy when bought; weight 300 grams. Was hilled immediately '/ro with chloroiorm ancl lvai autopsled. Examination as in No. 5 showed everyrvhere normal condit'ions. Radiograms of the ribs, Fig. 42 b' 234 ,: _ 1at J. ¡\XIII, HöJI'Iì Iìacr¡t"d,s beAongùtg to pcct"t fV, Ch.øyttet. fff, Terms and abbreviations, 2 1, D 1-2, D 2, D 2-J, l) J, Dulnes-< in five cJegrees. -l?øsp. respiraüi.on; øes. r'esicular; ðr. trronchial. -R Râles. ,scl. fossa supraela'iculatis; r, rr, rII erc. first, second, thircl etc. costar interstice; ssp fossa supraspinata; slo. spila; ,4 angulus scapuláe; lli A i"1l;"V beúrveen sp and A. Pøt. 2!13 patient seconcl among thirteen chilclren. Er,pect. expectoration. Infl,. ep. influenza epidemica,. Couple a. 1. Or. Erræt Bernhard L-n, born 18g0. Farmór. Oclensala. A'nctmnes'ís. Pat. 1/rr. Two brothers died of tbc. was w.eil till 1916, ¡vhen he had pleuritis exs'd. bilaú. aftern'ards subjectively *"n ãli-tlr" â.ulumn o1 1922; then c.ough,- expectoration, breathlesËness. 'The pfrysicia.n suspected tþc pulm. in December 1922. . No night_sweat; appetite f;irly;ad, d,ring the last few months no emaciation. N'ever hemopåysis, ;;.,"""p;"..- monta. ,_ _ Ad'mi'tted, ,'iz 1923. Btcúus 6fz: constitution fairty good. spare fresrr. ilIoderato cough rvith ¡nocl_erate. amount of expect. siitõrúng. urrä "i"uuirrg p¿,in. _lppe¿ite fairly good. Digestion and slêep goocl. X'ejs v,ell. pulse: about 100' Temperature: sub-febiile tin2sla, af¡eirvãrds 3B--g9. c. bt"*ã"n, nose, pharynx, larynx 0. Local status: D 3 overboth lunEs with bronchial respiraúi.n. Diffuse R, over troth lungs. rn the lower reft Ëicte lobe an ora,nge-siäed cavity, in the upperrighr side lobe a sm¿iler cavity. -'rbc of súage tïr. an o-,u" ti" i.*g". _ E¿tracts lrom, record,s.3¡a orange. e'/a: R lessenãd in the bases. The rest as bcforc. 1/s: as before, yet the ìeft side ca.¡ity increased a.nteriorrv. zsri: r:"?]!"-î ç'eeks tho patient has constant heaclacire with vomiting. Èáù;"rf.¡, -,-, uppenherm +' stomach reflex 0, fooú clonrrs, durl pupiilar refrJxes. I(ernig -J-.. During^ the last^weeks temporarily x,andering in inina, cl.r"i.glaJJay" periocls of sopor. t 2e/s. l\feningit;s tUä. Tbc bacilli always {. Dr<aminecl every for:tnight. summary: Tbc of s_tage rrr. with cavities, whiàL increase cruring the orange period (efter 6 weeks). AÍrer 2 monühs meningitis trc. cyanotic'r"å* the first; dissuadeel fi'om sanatorium treâtment, beiüg "o".ia"*Jã-uoput""" case. Weigbt chart: 69 77 ì.g. t,''r - 71 lig. ¡1'r - 71.5 kg. 1/a - 6g.r kg. ra,'¿ - Il.b i ralt - 69.5 ,- tnl, _ i 2. Eri,lc tr'ridoll A-r,,-born r57o l8gl. Building carpenter. Ecl. ,. A:"y"!".t:.: Pat-..2ft. -{ rnaternal aunt diãd of'tbo. putm. One of thc patrenü's 3 children died of úbc. mening. well ¿ill the autùm. of Lglg, then infl. ep. with pneum. sin. After tirat periocls of coughing. After January STUDIES IN SQURVY 23ó lg20constantcoughv'ithcxpect'Nurseclin-theVäsby.-H^ospital'tult-'olo iäãö;i;ilã; diagn"osis ot tron'ctitis. On lair 1923 acutelv ill. fever, shivering^s' Srabbins pain in f"ft "i¿ä,"¿l'"p"ã*' -Á¿t"ict"cl to thoVäsby Hospital 16/r' ö"åä;"i"t"t¡ä ru". putm' ds' ouibh f"tu"' gradually lowered' "' ,'îà*¿í*à'tã tfrJSr."t""ium siz. Stc'ilÃ: I)e,líeLçio septi nasi, liypertroph. cor¡cæ med, sin. For the rest 0' Irocol' st&txts : n ¡ o,t"" Lotn hrngs, except in lov'er front part :f ligh|:i1?' SuUmetattc R, over both lungs' except in the above-mentloned place' Jrespl' "r¡råîäî.ugfttf"" bronchia,l chu'ia"te" itt the upper haìves of both lungs' Con- ;;tü,;;t; go?a, it"*¡ "p";. Slight cough *'iiË rather inconsiderablo expect' s;;bü;'frin, u"",rilìt"""t""". " App"tit", sleel: and dig-estion good' For the resf subjcctiveì¡- well' Entracts lrom' røcord's. 26/a R' ferver' Otherrvise as before' ?7r: Right lung' ,'ro n""ä""io"íy; D andìu.pi"ut'iott as before;.Ieft lung-' fower R' anÛeriorl5" ;l;, F";l; well, äut of bed without fever from 1'his clav' '"' -"Ëï*'*rrïu, ôo." of st"g"^ifi. withoub definite cävities (neither in elinical examination nor rvith il;;i;";;"ys) ancl rvithout' feverr steadily improving' 'Weight chart. 7/z - 66.s kg. 1ó,,, _ 67.ó , 1./B - 68.5 ) 14fB-69.5 > 31ii - 70 )' ltt, - It 1,t< - 72.i) Ð 16,. - 73 )' 1,1û - 78 )\ 1i//0 - ?3 t) }o,'c - 74á > Quantity of sPufum. 6/z _ 40 ctÌlr. rs,,, _ 30 ), 2t" - ¿'Cl )) 16¡'c - ó0 )' 1i4-30 ') 15,-,¿ _ B0 t's - 45 ) 1ál'ó _ 30 ,, 1.,0 _ 15 13ß26 u 1,'7 _ 25 ), Conclusion lor Couple r¿: The case rvith orange treatmenl has had tlre Iess favourable Progress. CouPle b' 3. Or' Albert Nicolctus 8-g, born 2070 1887' ;;;:;;;;;;."-f"i 1í. N". 1'died or tbc' pultn' at the ase,or-le in.re00' No. 3 diect of tbc. osteomyelit' at the age of tõ in 1901' -- In 1913 period of coushins for some -orliú.. Otherwisò well till the autumn of 1918' then ;ii:å;:""'ä ;;i;;.;:-"c;,'sh v'ith expect' at lea-st since Mart-'h re2l' since ffii,.,{i;;';I Ñå"ãr"r,"" igil "orr*ra'i co.'gh. No hernop+"ysis'/ -\Mas then ;;ñi|lìf *itn "ir¡¡i"g pain in lefb side, le'er' Not conüinuouslv in becl' Appeüite bad; night-swâat" fUc' pulm' statecl in M¿rch t92l' Abusus aeth¡rliôüs going on f-or a long time past' '^-'-- Tarí¿u"¿ 25¡n 192i. Statlrc 2s¡tt: Const'itution good'- tr'lesh somewhat "o"".. Modu"ale cotr.gh *ith *o.lu"áte expect.. No breathlessness. Appetite iåäã. Ëi"r'ii""*,"p ã -",-ii, resp. there brl - br' ves'; harcl R' a few-several' ;#äy;;fr;;;äiit.- e"Ìii'a,'"'p o 3,-ssp to a, D 2-D 1' resp' weak' uncletrr and. br. ves. Iì, same as in f¡nnt. Left 1ung, corresponcling parts D 1' resp' ì-ral:sh, unclear, no Il. lMeight: Bacilli: 2íltt I92L - 69.s hg. t'lr, 1921 + ,d,'" rg2'3 - 56.5 , t,t 1922 I Pa,t. not lveighec'lcluring thc orange periocl' 236 J. ÀXl'L HöJER Eøtracts lrom recorcls. Progressing steadily downwards till e/ø 1923. Cough about the same.a.s before, 1i)xpect. at times increased (rnore than 200 ccm.), almosü purulent. Continuous pain on both sides anteriorly. General condition worse, Staüus of lungs: over tbe -greater part of both lungs resp. br,, D 3 ancl metallic R'. On 2¡'e orange. 2?/a: During lasü rveeks diarrhea, abdominal pains. Attacks of dyspnea, weak pulse. Obj.: metaliic R, diffusely over both lungs. lhe lasü two clays abdomen continuously distended, violent abdominal pain; vomiting, not faecal, Exeessive tenderness diffusely all over the abdomen. Pulse very slight, quick; cold extremities. f 27/e. Temper. about 38' tilt Jan. 1922, afler*vards 38-40,+'; from 11/z-25¡s again about 33o. Sum,m.øry: Case in Stage III. with. destruction of both Lungs. Conlinually cleclining before tho orange diet was begun. A 'çveek afterr¡'ards symptoms of tuberculous enterocoliúis with supervening peritonitis. 4. Bror Jalcob HcLrry .M-n, born 25/s 1900. Upholsterer, Vaxholm. Ano,mnesi,s. Pal.3la. No. 4 has had pleuritis. An uncle tbo pulm. 191.9 tlie pat. hacl infi. ep. without cornplications. Enrolled for conscription in the spring of 1919, allolved respite on âccounl o{ feeble constitution. Began military service in 1921. WelI till beginning of April 1922, L}.en cough and expect., since continued. Hemoptysis (about a tabie-spoonful) in July ancl Sepf. 1922. fn becl v'ith fever up to 40' C. cluring Aprii-May 1922. A physician staterl bronchopneumonia. Afterrvards abotit and in work again till A.ug. 1922; in July a, physician stated tbc. pulm. Temperâ1,ure not taken for some time. trlarlier night-sweat. Appetite generally good. Slight loss of flesh. Never pleuritis. ,Adn¿i,tted, aaln 22. Status 15ln: Constitution somev'hai; feeble. X'Iesh spare. Coughs slightly vzith moderate expect. Appetite good.. I)igestion and sleep good. Feels l'ell.. Pulse: 96. Locctl stcttu.s: TJpper halves of both lungs D 3, resp. on right side feeble' r-rnclear, on lefó side l¡r. ves, Iì on ühe right some--a few, meclium-finer, posteriorly submetallio, anteriorly hard; Il on the left some-'a ferv, medium, srrbmeta.llie. Both lorver halves D I-D 2, more on úhe right side, resp. there not quite clear, on left side ves. No R. Eætrclcts ft'otn recorcls. 87r 23: Resp. everywhere a.s before. D in.creasecl posteriorly in the bases. Slight cough with perhaps increased expect. I{emoptysis once since lasü esamination (abou.ü 90 gr.). 'o/r: Since ¡¡,'r sensaúion of stabbing pain on the right sirte with rising. temperature. Mu.ch increasing D over thè iight sicle base with hardlr¡ audiblè resp. Test punctur:e 22/r. Resull a somewhat turbicl exudate. Tbc'bacilli'nle i. Loccrl slatus 26/r:'Leit lung, Il. audible all the way clown both anteriorly ancl postôriorly, some--a few, medium, harcì, in the upper half partly metal.lic; belorv A mixecl with {ricüion sounds. Resp. ancl D : 8ir. Right lung, belo¡v A D 2 increasing cìownwards to absolute; threo fingers' bread.th helorv A to thc limií of the lung resp. almost 0. Just above, occasional friction sound'o. The resü : 87r. Coug'h during the lasí 24 hours trying, with in.considerable expect. Feels fairly t'eII. General condition as before. 0/a: Il in left lung anrl in upper half of right lung more metallic. Tn lower halves of both lungs friction sounds liere and there (remains after ex. pleuriú.). Cough and expect. as before. Feels well. Continuousìy in bed. with fever. Coñdition of h.ealth declining. (Prognosis: mala.) t'lu status of lungs: 3 big cavities, one in the upner, one in the lower part of right lung; one caviúy in the middle of the left, lung*. Cough ancl expectoration as be{oro. General condition worsê. Feels better than bofore! 1/s: Since tho lasü examinalion the general condition has declinecl steadily. Drrringtho S'I'LIDI]ìS IN SCU]ì\'Y 237 last days eoarse partly metallic Ii cliffuse!¡' over both lungs. 4.11. ühe right a,nterior sicte sibilanf br. resp., motallic in the lower half. Since a fer,v clays intensely {ctid, abundant sputa. In lhe last days pulse qr'rick. Very slight tlyspnea. t ti¡. Weight LLln L922 5õ kg. Since then noü weighed. Occasional traces of alb. D'.rringthe last 4 mon'¿hs or more, remittent fever from 37-39" Cf the lasü fortnight rvith more than 3 degrees' variation a da5'. Sum,nzory: Case in Stage III. rvith grea,t virulence, In upper halves of both lungs incipienú desbruction. Quick progress towards cleath with large dcstruct'ion setti.ng in. Concl,u,sòon lor Cou,ple ó.' In Case 3, the lessening of the power of resistance through aethyiism seems to have been conducive üo the progress of the disease. In Case 4, similar progress. Couple c.i 5. Or. .KarI Eri,lc B-g, born 1t¡a I.902. Farm-orvner's son. Vâddö. zLnømnesis. Pab.5la. One brother diecl of tbc. puhn. fn 1918, afûer infl. e¡r. periods of cough, const'ant fatigue. Cough a,nd expect. afüer Ocü. 1920; stabbing pain in lefú side. Physician diagnosed pleurit. sicca sin. and tbc. ¡rulm. in Dcc. 1920. Nursed in the Serafimerlasarettet, Dec. 19^20. Attempts ât Forlanini. Ntrrsed in the Hålahult Sanatorium r4¡z Lg2l-18¡ø 1922. '\Mas ouü of bed there, without fever, all the time. Forlanini attempts with negative result. Hemoptysis rfz liüre in Aug., the same in Oct. I92I. Appetitc trad, almost continual loss of fiesh; since 1920 in all I0 kg. Ad,mittecl 75 1n. Status tsltz: Constitution fairty good, flesh spare, moclerate cough with moderaúe expectoration. Appeüiüe fairly goocl. Other organs 0. Status oll lungs: Chiefly affected on the left side' Right lung D I and D 2 in the apex, resp. unclear, interscapular R, anteriorly tlnd posteriorly. Left lung, ali D 3, R metallic covering the resp. sounds. .Flalracts lrorn recorcls. 27 ¡t 23 On the whole the sarne st'atus of lungs. R, ¡rossibl¡z somewhat, lessened. Feeis ¡vell. Less cough with less expec¿. l/a án orange a day. r0/o: No I{ anteriorly on right side, appetite better (subj.), been out of bed rvithout fever since then. Pleuropericarditis (slight sympùoms) as w'hen admittecl. 2ol+: T'ocaI status unchangecl. Coug'h inconsiderable, feels much better, but has not put on flesh. llacilli all lhe time. Temperature afebrile all the time. Ì'orlanini attempts without any markecl effect, on z6/s. Afterrsards süatus quo in the lungs, Weight chart: 1ó/¿ : 70 kg. 'ls - 70 1ó/¡ - 68.r " 1/; - 70 kg. t6ft _ 70 , 1ft-70 , 1/o - 6fì.0 kg 16ie - 67.s , 3oil6 - 68 ' Quantity of sputum: 'lt-ttl, - 90 ccm. tfc-t'ft - 50 )) Sumntcn'y: Case in Stage IIL, practicall¡z one-sidecl, rvith cavities on the lefú side. After orange cliet, local status improved on both sides, also appetite improvetl. 6. N'í/s Berti,L B-ø, born 16/rr 1906. Errand-boy. Spånga. Anørnnesi,s. Pab.3ls. No tbc. in the fa,mily. WeIl til.i 1919, when infl. ep. Coughing in winte¡time for a couplo of years. Constant cough with expÐc¿. 238 22iz - 63 ìig. 1,'s - 63.5, 14,,¡ _ 64 Ð 3t/¡ - 66 ) 2tt,) _ 5 cCr¡. 2alz - I0 ;w,, _ lD )) ''ll" - Bo ,> J. AXDI, IIOJER 1a,ir - 66.S kg. lfs - 67.5 , 1á,t¡ - 66.5 , Quantity of sputum: a,'¡ -- 30 ccn. t6/¡ - 1õ l,ir - 10 )) 15.r4 _ 10 lic - 65.s kg. 1i,r6 _ 66.ã " 3o/c - 66 > ),. _ 5 ccrtr. 16tz - !5 1/6 - 30 )t lá,io - 30 D in the autumn of 1922. Never hernoptysis. Last v'eeBnig-ht-srveat' I'bc. pulm. diagnosed in Jan. In the Mör6y'Hospital |'l\-t"l:' - Two Folla¡ini âttemrris ihere, 100 ancl 160 ccm. Thin, but not losing flesh' Àd*.ittert 22lz 23. rsúr¿úøs.' ConsüituÙjon lank. Habitus phtisicus. tr'lesh spare. Coughs slightly rvith ûrconsiderahle expect., Appetite' digestion, sieep gooct. -Locatr ltatus : Right I'ng, Ð I ¿nd D 2 in the apex,- r€sp' unclear. No n] Cniefly affected on the left, side. Left lung, upper half D 3, the-rest D Z. Resp. oi slightly bronchia,l character in úho apex. Otherwise enfeebled a.nd uncleår. R metallic in the apex. Srnaller changes than Case 4, but on Lhe rvhole similar. Other organs 0. Iìoenlgen 2? fz: All, th.e ieft lung ccmpletely fillecl with foci. Small cavitiós at the top. Pneumo"thorax treatment continued (up to 500 ccrn.). Apex aclherenü. Ertracts Jrorn ràcord's. 1/r: Continued decline' Appetite lessened' R occuning in righü lung -' gracluaily progrcssilg. Temp. afebrile' Bacilli found bãfore adâittance, br¡t not ab Väsby till 27is. trVeight chart: Sulnm'ary: Case of Stage IlI., practically rrnilateral' witlr cavities on the left sicle. Gror¡'n rvorse cluring the sta;z in the hospital' conalu,siott, lor coupte c: The orange case has progressecl more favourably. CouPle d. l. Or. Irans August H-g, born 1a/ro l8?0. Married, joiner' Spånga' Anamnesii. Pal.'2lz' Sister ciiod of tbc pulm., 40 ¡rears ago' Stepmother cliecl of tbc.pulm. Has 7 half-brothers and -sisters; 2 of them died of tbc.pulm. Married sinée 18g8. Five children, one of them died ¡r'it'h sequelae of pertussis. Always well tiil 1918, then infl. ep.; in bed^with high fever for a' week, did not srlmmon a physician. Cough and expecü. Sept. 1921. Unclerwent opera-tion irr the micldle'of-March 1922 lor abdominal tumour (nof ca.). shortly before' tbc. nulm. has bcen statocl. After this nursed in the serafimerlasarettet' for pneninonia hllãt.2? 12-24|s 1922. Appetite b¿d since 4 to 5 years back. Losing ilesh. Fever from the micldle of l\{arch to July 1922' Adrn'itted, 12ln 22. Stcttus 20ln: Const'itution perhaps somewhat rveak' Flesh spei.re. In'consitlerable cough ancl hardly any. 9lpect' -No 'stabbing pain; bieathlessness rvhen moving. Appeüite -n-orv fairly goocl' I)ig,^estion är.ra sleep fairly good. Feels rathei well. Cor: clull sounds. Syst. accompanimenüs over aärIa? X'or the rest 0. Right lung, Sc'l-I and Ssp D 1, resp' noÛ quite clear. I\I-VI D 3, resp. weak,--tinclear.- R' iaterall;'-from the mammilla jncl down'r,ards, isolated to alew meclium hard. Below A D 3, resp' enfeebled, nnclear, slightìy bronchial in the clepth. Lelt lu.ng, upper part to III¿,nd,rather more tiranitTr-A D 3-2, diminishing downv'ards, resp. br'-ves. R' in these Sl'UDIIlS II{ SCURVY 24ó Ad,m'ir,ted, zlln 22. Constitution 'r""'eakly, ver¡r thin. Coughs slightly with inconsiclerable expect. No breathlessness; appetite fairl¡r þad. Digestion tr:oublesome, often grþes ancl nausea. Sleep goocl, bui sweating at night. Local sücttws: 'Ib.e upper halves of both hLngs D 3; br. resp. ancl metalljc R,. Pulse 88. Eøtracts lrorm recorcls, 6/z: R rother <lec¡eased. 1/s: one orange a clay. 2lls left lung consiclerably improvecl, less R. ììight lung as bcfore. - Cough lessened *'itÈ expect. as ùefore. Digteslion norv all right. 21/r: right lung. R only in I-II. The same as beforo posteriorly. Lcft lung, anteriorly lessened R', posieriorlv lhe sarne. Cough, expect. somowhat clecreasecl. Feeling fairly wetl. Open-ait resting, walks. Bacilli 22/rz and in later examinations T' 'Weight cbart: tla - 54 Lg. 16lz -'o4.¡ , st ls - 54.s '-i{ -- Ð0 '/e - bb \rla - öõ 1,1c, - 5i:.5 " râ la - 'o6 ìtla - 66.5 , Quantity of spuüum: u, 15t 7ó ccnl 75 50 125 ) 100 ) 100 ,) 100 80 80, rlt - 'lu - t,lo to l, Strmnøøry: Case in Stage III. Cav!úy symptom,s in the-up-per halves. o{ botll lungs' ðenerally and locatly improved (generall¡' alread¡' before having the orange). 16. Br'ilø Mcirüct, (i-tt, born r7 ln 89. lYife of an engine-clriver' anatnnes'ís: Pat. 1/r' No tbc in {amil;'' Trvo healthy children' Ulcus ventriculi threo times, lasü tirne in 1919, nursed in Sú. \{a,ria's Hospital' Ar¡tumn l9l8 infl. ep. Nursed in the Sabbatsberg Hospital for saÌpingitis. -Two-abortions, in 1é19 and Nov. 1922. Pcrtussis March-Apúl 1920. In May hemopü5,sis (150 gr.). Slight hemopt¡rsis in May 1922. During a_year continuous äoügft *ltfr ãxpect. Breathless, tired. Appetite goo¡ at! t¡e-t^iAe' Inconsiclerabte losing of flesh. No night-sweat. Tbc stated i¡r July L922' Adnxi'tted' sl:' 23. r\'úoúøs.' constiùution fairly good. Flesh somewhat sDare. coughs slightlv with inconsiderable expect. slight breathlessness ,i,her, -orittg. Digãstión troublesome, can not support food; digestion_difficult. Sleep looct; feeling well. Pulse 90. Other organs without' remark (inconsiderabÎe -resistance õn the ìeft side of úhe pelvis [salpingitis] ] fluor). -[JoccLI stdtus: siighü ehanges cliffusely over both lungs, D I-Dz, changed, nowhere br. res!., in sorÃe places ìsolated hard R. Ertracts !ròm, records. 2¡lz: At' the beginning of the month in bed, temp' risen, stabbing pain in right iscp. Increasecl cough and expect. Obj' D 3' br. resp. and metallic R,ln the upper parü of the-right lung,anteriorly.and posteriàrly. fn oôher places fewer R,, oth.errvise the same. '/a: lìighú iscp' äccompaniments 'ot so harcl. Coughs oocasionally, now rvithout expect. Feeling rvell. 'e/s: righü lung posteriorl¡' again as^23/z' r'eft lung'-nothing' Coughã harclly eïer. --No exþeãt. X'eeling well. 2/e: lung status the same, "*""þt thot läterally on the-right there are no\¡¡-numerous fine, meclium R' Ño ä"gÌr, ,ro ""p"õt. Feeling-well. Afebrile. -Roentgen r2l'z 22: three cavities in I] II ancl IiI, respectively, the largesú in IIf. Pronounced pcribronchitic chaogus. Left lung: from hilüs outwaids peritrronchitis. Bacilli 'ol" -1 , toln and 3/s -, tolu +. Temp. a.febrile. 246 J. AXÐI, HöJER Weight charü: l/a - 6õ lig r6la _ 6-o u 3l'¡ - 66 tal¿ - 66.5 , tt - ot 15t /5 - bÐ.b ) lle-68 , Quantity of sputum: '/jÌ - -tÐ CCùt. tá/¡ - 65 '/a - Ð , 1ó/+ - 10 't6 - O ) "1"- o ) r9umrnary: case in stage rr. and -soon (before the beginning of the experi1ne1t) {I, Cough,_expectoration, r,veight e,nd subjective"condiíion impråved cluring this time. Lung sratus aggravãted. conclusiott for cou'ple /¿.'case 16 shows a less goocl res*lt than case 15. Couple i. 17. Or. Hi,Id,a L-m, born 28/e g8. Ifouse-maid. Dancleryd. . ^ 4!"!"?"sis.. Pat..l/ro. One brother, No. 5, dead of meningitis. No tbc in family otherrvise. Always well titl Jan. 22. ca*¡¡lrt coltt, gotlfever, in bed. for two weel<s. Since then continuous consh ancl expect. Augì_Oct. iZ "light hemoptyses, l_ tea-spoo*ful-r tabre-spooífur. ph-vsician ri"t"a ir" püì-. in Aug. 22. No emaciation. Ifoarse since childhood. -. _ Adnxì,tted.2tlz 23. ,\ta.ttr,s:2512; constit'tion and flesh fairly good. Coughs :_Iighily rvirh inconsiderabto ex.pect,. _Appefire, ¿ig".tiãrr, "iéui-irì¡"" såäa. Feels rather r,vell. cor: systoriã aecomþâniment ãll over, tho max." i¡i tne basePrilm. rr acc. rnconsiderable difiuse redcrening in ihe larynx. vocaÌ cords, nothing. Lung stcttus: righl lung, scl ancl ssp ó B, belo* õo II ancl A 22. Resp. anteriorly harsh, unclear; posteriorly ùr. ves._br. tiûge. Beiow II re¡p. not, quiûe clear. fsola,ted accompanime-nts. In ssp somË fewsub_ r-r-retallic R. Anteriorl5z in slc.-If and posferiorly below ,p "o*. few fine harcl Il,. Leftlung: scl-Il and.ssp---rvcll abôr,e 1/r A b l-D Zjresp. unclear, harsh. Around sp a number of fine.r, harcl R,. rn scl iscrated fine, hàrcr R. B;ro;r' rr ancl A resp. harsh, _ Eøtrcct lronr record's: 'ia: right lung anteriorry as trefore. posteriorry, R are.hea'rd not quite as far as A. otherrviãe as before. Lefú lung id.em. coughs oecasionally rvith inconsiderable. lessenecl expect. 28/s: Iungs, status qio. coughs occasionally rvithout exp^ec-t. a/o: R ire only írearcr ärr the righi i/r A-A and on úho left in ssp. ôtherwise nothirrg. 'Resp. ancl D u," Ëeio"e. Çoughs occasionally. Hardry any expect. susiicio's of ligrrter crottiing. Str-ango mind. Itrats plenty, good appetite. Wishing to leavi. ttr" eol u bed in another sanatorium. Temp.- afebrile. Spútum e*aminecl ,î7, a and 2? ls -. Weight chart: 2tlr - 67 kg. sl/c - 65.¡ kE. 1l¿-67 " lal¿-66 ; t'/s - 66 )) lls - 65 )) .. Surrynxã1A.. Case in Stage III with changes in both tjon on the lefú. Open tbõ. Disúinct imp"rovemenü decreasing rveight. Pharyngolaryngitis chron. 15/; - 6õ kg. '/c - 6B.s , apices, traco of destrucall the lime in spite of 18. I{n.ut L-g, born 13/r 02. X.arm lal¡ourer. Aclelsö. - .-Anamnes'is: Par.5ls. .a sister crea,cl of tbc in 1915. otherwise no rbc in family. Well till Jan. 2I, then co'gh, expeci,., breathlessness, emaciation ancl night,-sweat. Temp. not, taken.--Never hemoptysis' Tbc pulm' stated in Mav 2i'. Nursed. at Hamra 2s ¡e 2L-22¡z 22. Sometirnes in bed rvith a temperatnrä. aenerallv rvithouL fever and about. ' ,qa^Aæã roln 22. Status azln: constilution fairly good, fle'sh below the average. Sometiàes stabbing pain in the right side posteriorly. Ilreathlessness when"moving. Appetite, digestion, sleep gootl' Feelilg welì-' . Local, siato"ts i ihe upper hatf of right lung ancl the lower thirtì of left iung I) B, resn. br. ves., harsh,-irnclear; a mocl.erate number of mecliuni, harcl, partlSr metallic' lrì. Other parts, rsolatecl fine R, (catarrhal)' .øfrtracts irom'recor(ls. 23/rr: R in toto dirninished. Cough -climinished. tìxpect. as befôre. 5/r: left lunpç posteriorþ no R', anúeriorly as'beforo' R'ight lun'g anteriorly scl,-Il, "usp. þ"ónorttceclly br. { bron.chophon,v, posteriorly o* Ë"fo"u. Có'gh troublesomã. Feeling rvell' 1?/:: status iCem' .Cough as before. trìspectl somewhaú lessened. Feeling welì. a/+: in tred sinc_e -some weeks with i"rr"" ..p to 40" C, stabbing pain in right sicle a.teriorl5z and rìownwa,rd, increased cougft. Status: righi iu'e anteriorly D-3, b1' resp', especially distiáct in I-II, uád .otnu mecliirm partly melallic R. Otherr.vi.se such R ãitfusely over the .rvhole ltng, mingteil s'ith coarse rhonchi. Il posteriorly metallið 1¡z A-A. Left. lung: Iì ánterioriy and rlownwarcls more rnetallic than krefore. Ssp--ang,, isolaìed to somo ferv, medium hard ¡¡,, Below ang. isolated. coarse rironchi. Cough still üro*blesome rvith fairly abundant_expect. tr-celing tired, 1?/o: noli'here -rhonchi, Left lung, some to some few R' '/z A át tnJ'*r,y dorvn; harcl but *'ithout ¿istinct consonance' Righú lung, g-e1e1ally Iess consoäanee of R,. Otherwise status i¿er¡r. Temp. atl the time fetrrile- ,lr¡tr¡rit", constantl¡r sinking. cough ancl expect. Iessened. General conclition worse.Surønxtry: Case in Stage status and general condition. 'Weight chart: STUDI]'S IN $CUR\¡Y 247 Il.I. with a great change for the worse in h:rng Subfebrile. tl, 141 - ,tl, tlu \6 t^ ao,1e 77.r t<g. 77.s , 68.5 , 70 )' 70) 70 Quantily of sputum: .13 - /b ccrn. t6ls 7 6 1l+ - 750 > 15/¿ - 100 >) -13 - lÔ 15/¡ - 100 '16 - lb 1ó/o - 100 " Conclusion lor Couple ø; The orange case has progressed better' Couple k. 19. Or. Auqusl,a Karol'ina S-r, born 2¡e 9l' lvife of timber-yard l¿bouler' Ingarö' Anâmn.esi's: Pat.2!2. No tbc in family. One child, 15 years, healthy' since chilchood periodically evil-smelling secretion from right ,ear. Three partus arte premãturi owing to albr¡minuria. Since l9I4 after the last coniinement shd has felt weakly. InfI. ep. âutumn 1918. After*'ards cough and expect. Tbc stated in June 1919. X'our small hemopüyses, last time mid- *'.,i,'-"t lg2l, a couple of table-spoonfuls. Pneumothotax treatment in the Serafimerlasarettet Oãt. 1919-Junò 1921, interrupted on account of progression in the less affected lung. Nursed in the serafimerlasa,rettet June 1922 for hemoptysis. Appetite during the last months bad, emaoiation, temp' up to 390 C, 248 18r - 48 kg. tlz - 48 )) r5/z - 48 ), .]. AXEL HOJFJR Adnú,tted, tB jt 23. Status 22fr: Constitution weak; paie, flesh very spnre, Cyanosis; breathlessness. Appetite bad; feeling tired. Refuses to eat biead, bread and butter, fruit. Takes much milk ancl some meat. Otitis med. chron, supp. dx. eû sin. c. granulaúion. Hemoglobin 45 o/u (TalÌquist,). Local status: rafher more than half of both lungs from abovc D 3, resp. br., metallic R,. EØl,tcrcts lrorn records. 5/a: R, in toto cons^iderablv diminished. Feeling very tired. Coughs less, expect. diminishecl. 21a: an orange a day. 1lir: ñ considerably diminished, scl -fI and ssp-I/2 A. Left lung, pcsteriorly at the base catarrhal accompaniments. Cough lessened, expecú. likewise. Feoling considerably beüter, but the increase in v.eight is still unsatisfactor.v. 55 o/o hgbl. (Tallquist). 30/s: caúanhal accompaniments have disappeareä, otherwise as before. Cough and expecf. still less. >Appetite much better since two monühs>. Consumed ea,rlier almost exclusivelv liquid foocl, 65 o/o hgb. without tr.e treâtment. 20/r no bacilli, aftor 3o/r {." Weight chart: Ys - 48.s kg. lala -. 48.b kg. 'lu tils - 48 ,, tl" - 49.5 " 15la 31ls - 48 ,, t"l, - 50.5 , Sunøm,ary: Case in Stage III. with cavity symptorns, which have recedecl. General and local improvement, to some degree alread5' before the orange ü'as given. Considerably better resulú than hacl been expected. 20. Atz,nø Lox,i,sct, A-n, born s.1e 1860. Yada. Anamnes,ís: Married since 1884. 9 children. one deacl at the age of 23 in tlrc pulm. 1918. No. I has tbc pulm. A granddaughter has tbc pulm. IIas had r>gastric catarrh> for a long time. Since at loast l0 years back constant breathlessness when moving. lg04 pneumonia, nursed in the \ospitat of this place. *A.fterwards cough ancl expect,. in period_s; constantly since l9I8 when she had infl. ep. Nursed here in another department in thã spring of 1.922 for bronchitis: no tbc bacilli in sputum. Tahen violently ill in Oct'. 1922 *'ith high fever and bad cough. Blood-imtribed spuúa. Afterrvards in bed with fever till admitted into the hospital 18/r. lfbe pulnr. then stated. AdnLitted i,nto the sanatoriu.nt zsft. Status afz 23: ConsLitrrtion fairly good. .Flesh ,spare. Cotrgh moderate rvith mod.erate expect. No süabbing prit Breathlessness when moving. Appetite, dieestion, sleep fairly eoocl. X'eeling tired. Ri,ght lung: scl-Ill l) 3, resp. br., some--several mediumcoarser mctallic P'. Likervise in ssp-A, Bolo¡v anteriorly ancl posterioriy D 2, resp. uncloar, harsh; posteriorly almost br. ves. Lclt tung: Sci:III anã. ssp-V2 A-D 2, resp. of sìightly bronchial character. R, I-IIr and sp-l/2 A some few, fine-medium, hard. Below resp. harsh and unclear. Cor: h¡,pertrophy? Weak svstolic aceompaniment a,ll over the hea¡t. Pulm. Il äcc. Pulse 100, somewhat soft. Eøtract.s lrom record,s. 10¡,: Right lung anteriorly only isolated In I--II. Otherwise _nothing, posteriorl¡z as befo¡e. Left lung, no certain Iì. Coughs less ¡vith less expect. Feeling fairlv well. Complainingof b¡eathlessnðss. Cor: no distinct accomponiment. r/r and lal¿: examinations with same result. '/s: left lung posteriorly no R,. Otherrvise lung slatus about the same as orì llr. Çqrrgh rather trotblesome .r,r'ith somewhatlncreasecl expect. Feels tiled, breathiess. _ Appetite bad. 8þ: resp. and f) everywhere as l_¡efore: left lung, no R. Right iung posteriorly, resp. br., bronchophony interscapularl5'. D;ith - 51 kg. - 51.5, 11: - 56.5 kg 151: - 58 ) ri¡ - ó9 )) S'IUDIES IN SCURVY 'Weight chart: 1ól¡ - 60 kg. åt/¡ - 60 ' 14 4 - 60 kg. rls - 69.s " 249 metallic R. Below A resp. br.-ves. with some few harcl R, interrningled. with rhonchi and friclion "o.tãds. Iìight Lung anteriorly isolalecl fine _liar¿ R, irrt"t*ittelu¿ rviüh rhonchi. No incrèase of rveight d*ring the last month. Comfiái"Ë.i!"i" in the pit of the stomach, obj. tenderness. Leavos the sanaüori*m eonlr¿rv to advice. -'"--iåñ. u,f"b.it" during the first month, afterwards subfeL-rile. Last *eek toïards 39', remittingÏy. Bacilli examined 30/r a, and 3/s - ' 100-150 ccm. of mucopur. sPutum dail¡r' Swmrnary: Case in Stage III' with beginning destruction in the upper half of the right lüng. proceodlríg to a large civity' .I^'.o.cal,aggJav?l]:i:-lli::tt peneral iäprotement, afterwards gettine worse' (After leavrng the sanatorrum ñãï "."Jiti"" g""* riitl worse at -horne, where she hacl abo.t' ühr¡ same treat' ment.) co.otclusi,on lor couple /c.- The orange case has had the better progress' CouPle I' 21. Or' Mari'a Elisa'ber (Be.ny) E'n, born re/rr 02' Sl<ipper's daughter' ,Vätö' Anarnnesis: Pat' 6/s'- Father tbc' ¡zoungest child tbc of slrghü'clegree' .41*"y; ã;ü;;1". In the autumn lels infi' ep'.,|p"i"g l.ele -lry$"T:t" "otii,"tr"aæa withRoentgen in St. Maria's ÍIcripitatJnowdisappeared.. Mi<{- ."r"Låï iszz hemopüysií, about a coffee-cup' OnIy after thal continuous ,rnrrsh s'ith some expect. Tbc st'atecl in June 1922' """'--.1"'A*irr"ã--;;¡r-z:Z-. Stcttus 23lz: constiúution ancì flesh withouü rematk' CouEhs sliehtlv, almost n'i.thout óxpect. Appetite good'^ Locttl' status: b-ot]¡- ;t"ã;-D"t:^il;p. lrra"ee¿. a numtã¡ of rathèr fine Iì' 3/s.:-an orange a dav' íi,äáí*i"f"r.ãä-".'""rrä""". I) onrl resp. as before. Bacilli 27/z: none. 'u/a: no expect. 16/s: local status idem. Never coughs' No expect' Sum'm.artt: Case in Stage II in a stout person with goocl general con- ¿itior, iüli"rt" hr. i*p"orr"d. with lung status' Prog'ess better than was expected. \{eight chart: tsle - 64 Lg. lla - 65.r , rbls _ 65 >) 1lr - 66.s , 1614 _ 66 1/s - 66.5 kg. 13le -- 65.5 ' 1lc - 66.r, ' 1616 - 66 > 3o/o - 65.5 ' 22' scøø lli,lctor,ía Etroiro a-t, born 1?7e 07. Daug'hter of farm labcurer. llar' nt^"' nnt,mn"sis: par,. |ls. g harf-brothe¡s and sisters. No tbc in famil¡2. eutu*r, iSfS i"n. ep' Two years laúer pnerrmcria' Cough in aut'umn and .pJ.g.-Si""" auüuml 1922 inäreased "ough, bad appetite, emaciaüion' Never hemoptysis. Tbc stated in Jan. 1923. 260 J. ÄxEL ¡röinn ^ -Adrni,tted. stlt 23. Status: Constiôution somewhat r.veakly. X.lesh spare. co'ghs slightly, almost wiúhout expect. appetite not so góod. otheiwise r'vithout remark. other organs, nóthing abirormal. Lrn.g" støtus: in boilr base_s D 2-D 3, resp. in the right base br. ves.; enfeebled or.,. th" l"ft, R rather hard andlarge (rest of pneumonia with bronchial catarrh) D l-D 2 in boilr apices, more pronounced on úhe righú. rn the righú intersåap. and scl-r sìn. sorrre srna,ll hard R,. - .Ðøtracts frotn record's. 25/s: R considerabry lessened. status otherwise the same.- No -expect. sin<;e a fortnighü in bed with fever. obj. posteriorlv on the right below A friction sounds == dry pleuriris. since a u-eeË erythema nodosum on both legs-and left arm. Temo. sin.king. tr'eels v.ell. Nb pain. No bacilli ra¡2,212 ands¡a. 7,/s: norvhere certäin R, or accompaniments. ñever cougbs; no expect. X'eels rvell, p\unrrnary: Starved girl with slighú tbc. (Süage I-II). Afi,er passing ageravation (pleuritis) pronounied improvement. Ce-peratu'e afebriie. IÃreight chart: törlz _ 4g lla - 49 15ls - 48.r 3rl¿ - 47.s lal¿ - 49.s tls - 6l kg. 16ls - 52 1lc - 54 15ls - 52.5 , 3o/o - 53.5 , kg. r/z and r5/e no sputa, Aonalus,ion lor Couple 1: The orange case has had ôhe better progress. Couple m. 23. Or. Id,ø_llIargi.t Johonnø ll-n,born 2a7e 05. Da'ghter ol an enginge_foreman. I{ammarby. ^ .. .4n?*t "søs.'Par. 27a. Father has heared úbc. obherwise no úbc in family. x'elt tired ancl u'eak sinco rhe -spring of 1g22. Bacl appetite, rorirrg ãi'?iã.i, breathlessness when moving._No coigh or expeet. ñwe" rremopt!.i* --i¡" stated in J.one 1922 through rìo-entgen examination in the serafimlriasaretlet,. Adnxitted,6lz 29. Btatus rLlz: -constitution fairry good. r,r""t-..-"i"rr"t below. the €,verage. Never eoughs, no expect. B"uãthlu"rrr"*. *fiã, g"ìrg upstairs. -{ppetite, c{igestion, sleep good. 'Feoring welr. Locat st,,tus7 D r ljr.apìces ot both lungs. resp. changed. r dx., br. ves. resp. and. isolatecl fine R. 0ther organs, nothing. Eu.tracts from, records, 3/s: an orange a day. 2ã/a: nowhere cert¿lin R or a,ccompaniments. Co-ugþ _ occasionally withoút eipect. Ireels well. ,lu, lung status id"T. T .{y ? l. Coughs occasionally witlhout expect. Feels well. (rìoentgen: sm¿ll foci in left-apex and confrrrencon the righi.) Fihn on the 1!ght.ape.t.-^ Temp. the .¡¡holJtime afebrile. No bacilli ,'¡". 'tt¡u.;;;;;r. Dismissed 30ie. Weiqht chart: l/a - 56 kE. '1s-56 D rl+ - 56.s , 16lc - 57 kg,. lls-58 I 151; - 68 ,- 58 kg. - õ1.5 " -58 )) tlu ttl u to lu Suønna,ry: Case in Stage I., rvhich has proç¡ressecl to healing. 3/a - 64.1 kg rá1s - 66.5 , 3t/¡ - 67.¡ , S'TUDItrJS IN SCURYY lileight chart: la/r - 67.2 kg. 1ál; - 67.s kg. l/c - 68 251 21' Hukl,a Katcrdna ß-y, born 30/r 99. I{ousemaid. Dandei'ycl. Anømnesis: Pat, 3/e, tr,vin. Mother has had repeatecl lung hemomhages. Always rveli till Febr. 22; since ühen constantly tirecl, coughed up phlegrn in the mornin.gs' Hemopt¡'sis, about 100 gr:., June 22' Alterlvards subfebrile üemperature the whole surnmet. Appetite good all the tirne. No ernaciation. Tbc stated in SePt. 22. Aclm,i,tted, "¡i 23. ,gtatus 6,1s: constituüion and flosh ordinary. Someüimes hawks up a little phlegm in the morning. No cough. sometimes k¡reathìessness rvhen môving, ani palpiüation of t'he heart. Appetite, digestion, sleep good' Feels well. Obher organs, nothing. Phar¡znx, diffuse reddening, mucous coating. Ri¡¡hL lung: D 1-Ð 2 scl-Il, ssp--rather more than-4, harsh' unclear ñsp. -No R, Oôherrvise resp. everyq¡here unclear, in places ha¡sh or enfeebled. Etxtrd,ets lrom recorcls. 13/c: norvhere R, or accompanirnenis.- Never coughs. rStill slight amount of phlegm from the throat.r Feels rvell' 3r/s: status-ident. 6/o: lungs the same. Departs a,ü her clv/n request. No cough, slight phlegm frorn tliroat. Telnp afebrile. No extra treatment. No tbc bac. founcl at examinafion t" 1", '" l" ancl 26/<. Sum.mary: C¿se in Stage I-II withoul R. Lung; status unchang^ed Genera,I condition irnproved. Pharyngit. chron. Concl¿tsion lor Cowple m: Bobln cases show a favourable progress. Gouple n 25. Or. Agda Sytuia Ø-n., born 20/s 10. Skipper's daughter. \¡ätö. Siiter of Maria, Elisabot (No. 2l). Alt'ays well till the aut'umn of 1918, then lighü infl. ep. Afler that reCuced hearing. Otherv'ise felt rvell. Tbc pulm. Àtated by physician when her sister fell ill. She h¿d constantl¡' feli iirecl, however, sinèe a year baek. No fever and no niglrt-svveat. No hemoptysis. Appetite qood, no emaciation. Had a good home' " Ad,m¿ttcd, relz 23. *gtatus '3lz 23: constitution fairly good. Flesh a little below the average. No cough or expect. No stabbing pain' No b¡eathlessness. Appetite, digestion, sleep good. Feels weli. No heart hypertrophy. - Sys_tolic actãmpanimènt over ühe base. II pulm. acc. Pulse 100, normal. Lung stutuslD I scl-I on both sides, and on both sides interscap. Likewise D I on left sicle IV-VI anteriorly and at the base posteriorly. Resp. in +,herse parts harsh, unclear. ScI-II on both sides, interscaP., and l.aterally on ühe left isolated few fine, hard .R. Eûtrrl,cl,s lrorn recorcls. t/s: an orange daily. 6/e: r:esp. ancl^I) everywhere as before. No R. Never coug¡hs. No ãxpect. Feels well. lc/s: nowhere R or accompaniments. Never coughs. Gencral condition about the sâme as on aclmission to ühe sanato¡ium. -I:eels weli. Tenip.'the whole time afebrile' I)ismissecl 17/r. 252 .I. ÀXEL HOJER tslz - 47.a kg. lls - 48 )) 15la - 48 Surnmar3¡: Biiateral hilus übc with objectively distinct improvement. General condiúion about úhe same as r.vhen admitted to tho sanatorium. 26. Elsø Soliø M-m,-born L'¡z 07. Da,ughter of a, plumber. Södertä,lje. Ano,rnnes'is: Pal.2lz. Both parents have had tbc, mother died at Väsbv, father nursed in sanatorium. Brother, No. l, dead in unknown disease, other brothers and sisters healthy. Otherwise no tbc in family. At the age of 3 in bed for a, month, severely iII with fever; since then always easily.catching cold and getüing cough. Otherwise well till the age of ll; úhen lymphomata colli, operated at the Södertälje Hospital. Afterwards treated with Roentgen and quartz lamp. Cough withouù expect. since at leasü a year. Never hemoptysis. Appetite goocl, no emaciation. No fever or night-srveat. Tbc pulm. stated in Oct. 22. llorne conditions bad. A.d,mitted, 2ß¡z 23. Status alz: consúitution fairly ordinary, ra.üher thin. Coughs slightly without expect. Appetite, cligestion, sleep good. Feels well. Lymphomata on both sides of neck and lower jaw. Hypertrophia tonsillar. Lultg sta.üus: Hilus affection, with D l-D 2 in both interscap. and I-II rvith small fine R. Resp. harsh and unclear. Eúrd,cts lrom record,s. Nowhere R, or accompaniments. Never coughs. No expecü. tr'eels well. Incision of purulent lyrnphoma under the chin. T,arge quantities of yellorvish green, thicl< pus discharging. Tamponade. An open fistula from lymphoma on the lefú side of the neck is also secerning. " !o, quarlz lamp. 2e/s: norvhere R or áccompaniments. Never coughs. No espect. Feels well. Süill secretion from fistulæ. Ternp. afebrile. Sputa: 2?/e no bacilìi; r./e no sPuta' .weight chart: Weighú chart: lla - 47.6 kg. 161" - 47 .5 " 15/a - 48.5 kg. 'ls - 48 )' 15ls - 49 " - 47.r kg. -47 ) l/e - 50.1 kg. 16/s - 51 )) toif u - 51.6 , tl, 2of2 - 48 kg 1ó/e - 49.¡ , lf¿-48.5, Surnmøry: Hilus affection with purulent lvmphomata under the chin, which has improved locally in the lungs and possibly also with regard to the general condition. Conclusiom lor Coupl,e ø.' The orange case has progressed somewhat more favourably (?). Couple o. 27. Or. Ingri,rl Karoli,nct R-m, born 17a gg. Wife of shoe-factory workman. Nacka. Anam,nesis: Pat. e/e. No tbc in family. Married in May I g2l. Nullipara. Healthy till the age of 14, then operated upon for appendicitis. Afteru.ards feeling rveakly. I9I9 nursecl in hospital for cystitis wiüh inflammation of tho kidneys. Well till Dec. 1921, ühen pain in her throat, difficulty of swallowing, treate<l s'iúh serum by ph¡sician stpposine cliphtheria. The attack passed. Sinco then well till A:ug. 1922, then the same kind of pain in her throat. In the SerafimerlasaretteL the physician stated tbc laryngis et pulrn. Operaterl S'f UDIIìS IN SCUIì\'Y 253 in laryn.x 8/r. Afterq.arcls nrrrserl for a week in the Sabbatsberg Hospital. Cough and expect. since Dec. 21. Often blood-imbibed sputa. Often fever, ur-) tõ 38' C. Night-su-eat,. Appetite less goocl since l919: ema,eiation since then, A.dn'ùittcrl 5,'z 23. S['atus 8fu: Constitttion fairly good. Flesh spare. Pale; coughs slightly with inconsiderable expect. Very breathless rvhen moving. Often palpitation of heart. No longer an¡' pain in throa¿. Feeling somer'vhaü tired. Cor: slight hypertroph)¡ t'owârds the left. Slight systolic accon'panimetrt all ov-er the heart, stronEest over th.e base. Lu'ng status: D l-D 2 in l¡oth scl-II. On the right side posteriorly t'eil dorvn. to A, thc salne D; on the left dorvn to riz -4'. In the same areas resp. unelea'r, Resp. everylvhere in the lungs slightl¡' changed (enfeebled, nol quite cìear, harsh' prolonøed expiration). R, sparse, smail, fine in both I-II and on the left posöeriorly about 1/2 A ancl at, A. In larynx orr the back 'wall some infiltration, anrl epiglottis a liôtle swoilen., especiaÌly in the left part. Eûtracts ol recorcls. 21/z: since a fel' clays periodicali¡* palpitat'ion of hea.rl, general resôIessness, slight rise oî temperature (up to 38)' nasal aalan'r}', headache. No pain in chest. Cor: accompaniments rnore distinct. Pul¡¡. II more acc., sornel;imos a grating systolic accompaniment' over Pulm. II (superficiatly?). Lungstatus idem. 3/a: à1r. orange a da;. In the kreginning of March in bed v'ith ah'eolar abscess which 'lvas openecl ancl scrapecl out, tamponacì.e. Lookecl liko tbc pus. Pat. has earlier had some su.ch abscegses. Heaiing slowl¡2, secretion stoppecl orrly in June. 23/a: nowhere R, or accompaniments, Cough lessened ¡vith iess c;tpecb. tr'eels v'ell. No lon¡ler €rny -cympúoms from heart' Obiectively, no certain accompanimen.t. Larynx, sta,tus iden, but no srvelling oí the epiglottis. a/s: norvhere distinct R, but rcsp. ever¡rwhero unclear. Otherwise as-on 8i:. Cough for the rnoment somewhat, irritating rvith inconsiclerable expecll. La,st, rveeks oecasional head¿ches. Last days slight rise of temp. (acutc infect'ion of thrrrat). trVeight' chart: r/s - 50 kg. r6/s - 50 ,> 31/s - 51 ) 1a l+ - 'o0.5 , llz - 53 15le - 23 lla - 52.s , ttl,j - 52 ) Quantity 1i" -1;, ^ li , _ 1l13t tt 1õ .. of sputum: 20 ccnl. 16 ), 1ó )' 5" 10 ,' 10 >, 10 10 1/e: local staüus, no R,, othe¡wise a,s before. -Gene¡al-conclition improvecl, feeling well. Temp. afebrile. Bacilii exami.ned la/z and lala : O. Suntmary: Case in Stage II. with d-iffuse lighter changes over both lungs, bone abscess and lar¡'n¡ aflection (pericarditis?)' fn the anamncsis affliction of kidneys. Considerable improt'ement with clisappearing of Il ancl l¿r)'nx symptoms; bone affliclion healecl. Gene¡al condition consiclerabl5' improvecl. 28. Mari.ct Cha,riotta Viuelca R-i', born s lt 95. Telephonist 09. Ljusterö. Anamnesis: Pat. ala. .lVlother deacl oî tbc ren. Oüher'çr'ise no tbc in famil¡'. As a child often cou¡thing' Of inf¿ntile cliseases onl¡' morlcilli, slighü form. Spring I9I9 pain in the left renal area ancl urinary strain. In l9I7 pain at urination. I'requent ulinations cr,t nighú. Extirpation of tuberculous left kidney in the Serafimerlasarettet 1918. Autumn 1918 sÌight infl. ep' 254 .r. r\xEr, rr(i.rÐR Afterwards fatigue and rise of temp. a,utumn and spring. since a,utumn rg2r, slight.co.ntinuous coug-h, almosb wiihout expee.i. Át, oñe occasion, S_-g uão"" ag-o' slight spitting of blood.. -lfurp. d.ring rast ¡,ear s-it.h a tendency oì íi*ir-,g to 38o when moving. Periodica,ily night-Ju'eat,.' Appetite at, the e;d oi-last year bad, now again good._ Decreàsecl-in vreight s kg. ct.ring the lu'"t *"lilrr. llbc prrlm. statecl in Dec. lg2l. . --4d'rnitted' 23lz 23. ,stattts 26.i2: constituúion anc'r flesh. gooci. cougbs occalionally with inconsiderabre expect. ,App_etite good. c'áts aiar"rrå eusily. tr'eels tired at times, but g-eneraily r"e[. - iarynx slig;htrv recìdeneJ .irrrr."ry, ¡ome.wh¡1t_hrnertrophic tonsili rvith a fen' poryp. na.si sin. "rur.rg stotu*, üierlorl¡z s.I-Trr on-the right, scr-lr on the leit, þãste.iorlv ".o ori th. rieht, ssp- . '/zA nn the left, D l--D2, resp very harsh, unclear. In the lower partJ ot the. lungl resp. harsh. Rigbt rrln_g, r-rr ancl sp-j/: A isorateJ to o i"*"iiru to ha¡d R,. T,eÍt lung, no R.^. 15/c nowhere R^or aecompanirnents. Cáughs oc:casiona,lly without expect. Generally feels v-ell except ai the peribc{s of ihe menses, when tho¡e is often_a plin in the right renar region ancr j.st above t'he sympþygig on_ the left sicre. urine som.etiires a rittre iurbid. rl" "" ,"aiment in .rine. 1?/¡: nowhore R or accompaniment. Resp. ress harlr, ""J""- clear. I) as beforã. Never co'ghs. No èxpect. tr'eels v',eliC;;;. ;i;;"it-. No tbc bacilli. Weighl chart: 23lt - 64 kg tla - 65 lrlt - 6'o,5 , 31i's - 65.5 kg. 1tl/{ - OO.o Summarg: Case in Stac^e I-II locally ancl generally imprcved. Hni hacl kidney complications. c^o,.clusion foi, co*¡tl,e o.' Trit: or:a,nge câse rras progressecl somervh¿t more favourabl¡r. üfi i I couptelp. 29. Or. Maria r'irnea Jos^e!'ina o-n, bo-rn 20/ro 97. 'wife of erectrician. sundbvberg. . Anamn'esis : Pat,. 2 f a. Two of the other children deacr in ôbc purm. r\,Iärrieã since 1920. One child. two Srears old. Alwa-vs u,ell till airil f922, then pneumonia sin. After¡vards cough ancl expect, subfeb¡ile temp. since the same ti¡ne. sometimes night-sweat. rÌbc purm. stated in April'Ig22, when sanaüo¡ium t'reatrnent, was aclvised. Ap-petitã generally good. 'No "*ráirtioo.Ad'mi'tted, to the väsby Hospital 3lc 28.-.lfovecl-tð the sanatoriurn reia. An orange dailv from 3/q. . _ s¿atus 20/a: constit',rtion Tairlv goocl. Rather thin. co'.gr.r.s moderatery with moderate expeet. Breathlessneãs rvhen moving. Appetitã good. niges tion troul¡lesome, often diarrhea. sreep bad. othér o"$ao.s, ntit],,ing. tZcat stcttus: alr the iefü lung D 3, .pper half resp. t¡r. ancl s'bmetallic-mJtdti" R,, some-scme ferv. Lower part, resp. harsh, unclear, a, fel, hard, medium lì. internii-nglecl with frictio;n souncls. - Right lun¡1: scl, ssp, D 3. I:II a;J;p_ m_ore tha,n li2 A, D l-J) 2. Resp. over all tÀis arca õt br. c]raracter. Ti", all the way doy1r r$p. harsh, uncleàr. Scl-II and ssp-more llZ A.r;rrr;i;* partly submetaiiic R,. Late^raliy and below A isola,ted dry accãmpaniments. , Eøtracts t'rotn record's. 2/o: R in toto dinrinished. otherwiso eq,.iãt. corigr, and expect. as before. Temp. sinking-. Generar condition impråved. -Feéls v¡ell. 15,/a: ver¡' much the same. Ba.cilli 2o/r ¡. STUDIES IN SCURVY 261 Summ,ary: Bilateral hilus-gland tbc with peribronchites, rvithout certain R. General condition somewhat, improved alreacly belore starting the orange cure; after that consiclerable improvement of general condition and marked improvement, of lung status. 38. Ingr,íd, Li,nnea I{-n, born e/10, I9ll. Labourer's daughter. Hagaluncl. Anamnes. Pat. 1/s. No tbc in family. Morbilli, pertussis aü the age of 2tlz. At the age of 3 peritonitis. Since then rveakly ancl thin. Easily catching colcl. In the beginning of Dec. 1922 sh.e fell into the w-ater, aftel that cough and fever. Nursecl in the Allrnänna Barnhuset 1ln 22-2alz 23 for tbc pulm. (Roentgen). Ad,rni,tted,2alz 23. Roentgen: both hilus greatly enlargerl rvith peribronchites do¡vn'rvards. Sta.tus ? lz: le{t lung isc short tone and tlry Iì all the way dov¡n, Righl lung: isc somewh¿t short tone ancl buzzing resp. 'lvith accompaniments. Rather pale anrì lhin. Appelite fairh¡ good. Ertrocts lrom re,cord,s. 'o/a: left lting I-II and isc. isoiatecl dry accompaniments. For the rcst nothing. Right lung, everywhere unclear resp., buô no accompaniments. Still coughs a great deal. General condition improved. 2a/s: righú lnng. arouncl mamill. isolated clry accompanimcnts. Left lung: t/e A-dorvnr.r'ards in places isolatecl - some few dry Iì. Oüher'rviso nothing. Coughs less. Generally improved. 15/o: lung status idem. Temp. generallv subfebrile, sometimes a little above 38o C. Weight chart: 27lz -- 27 kg. llr - 27.+ kg. |âls -- 29 kg. ,la - 26 ,' ttl¿ - 28 , llo - 2g.b , 15la - 26.s, ,l¡ - 28.e ,' ,tlø - 29.5 " Summarg: tsilateral hilus tbc wibh perikrronchites. Generall¡r improvecì, locally sooner aggravated, like the cough. Less improved than mig'hü havo been expected. Con.clusi,on lor Couple l.' Greater improvement of the orange case. Gouple u. 39. Or. CarI Eaert .L-n, born 3/g 1919. Farmer's son. Ossebygarn. Ad,rnítterl, 1lz 23. Has tt¡c genu sin.; a year ago nursed in the Väsby Tlospital. Capsular changes v'ith smaii effusion (nothing ít tlrc bote). Local stalusT!z: both isc, more on the righl, resp. very harsh, not quite clear. fsolatecl rhoncus in right isc. Otherwise nothing. Roentgen 3/z: bilaterally enlarged hilus, rnore on the right. Ertract.s þ'om, recorcls. 2/a: an orange a day. ?/a: riglrt isc resp. harsh, Otherrvise nothing. 18/r: some.bimes in both isc isolatecl creaking acc,omp€ìniments. Never coùghs. General condition considerably improvecl. 2a/s: status idem. General condition impro-recl. 2e/u: resp. still harsh in both isc. Otherwise nothing. Never coughs. General condition greatly imptoved. 'Weight chart: 1/: - 16.1 kg. 1/s - 17.t kg. l/a - 18.2 kg. 16lz - L6.s , tslg - 17.s , rôle - 18.? , Noü w'eighed during the time r/¿--lõ/e on account, of a large plasterbandage. 262 8l' - 16.2 lxg. 16ft - 75.5 , lfz -- 16.5 , .T. AXEL HöJER lrlz - Ll .z kg 'fs - 77.s ,- 17.s kg. - 18.2 , Sumrnary: Bilat'eral hilus-gland tbc, more in right lung, with complications in left knee. Local symptoms unchanged. General condiüion improving the whole time. Appetite good all úhrough. 40. CarI Tlnre Lennørt J'n, r¡6¡r' ta/s 1919, Labourer's son' Solna' ' Anømnp-sis; Paü. 1/r. X'ather úbc in 1921, norv well' Pat. always weakly, pale, easily catching colcl. Bacl appetite. 2/r 23: Pirquet pos. - ¿an't¿tte¿\lt 2á. Status: Left side, both isc short tone, resp. very hatsh, unclear. suspicion of accompanimenüs. Temp. rnostly subfebrile with isolated hig'her points. ñøtr,zits from' record's, ?/¿: bronchitic symptoms. Rhonchi over bot'h lungs' Right lung below A and laterally to the left half-hard accompanimenls. -f-eft hie in tõùo shorter tone. Last clays increa,sed cough, General condition imp"roved, 7ls: left lung, shorter tono nearly over the whole lung, increasing downwards. Resp. harsh. tìight lung, resp' harsh, especially in isc. Nor'ç' no accornnaniments. Roeiltgen 1e/¿: enlarged hilus fields on both sides' 28/e: scraping at the back of nose-. Disnrissed. 3¡/¡ 23. 'Weight chart: t3l^ 30 /" Su,ntmørg: Bilateral hilus-g'land tbc. General conclition iimproved' Possibl¡z also some )ocal improvemenù. Coroclusion for Couple z.' Similar improvement. Gouple v. 41. Or. Eoctld, Torgny V-n, bornsle 19. Oarters' son. Lövö. Anan'¿nes'is: No tbc in family. \Mell till lasf spring, then bogan growing ühin and getting delicate. Perúussis aü midsummer, afterrvards bad general condition. Cough considerably lessened. Ad,mi,tted, Els 22. Status: genera\ condition bad, appetite bad. Local stdtus: \tppet half of left lung short tone. Lox'er half softened tympanism, specially clistinct belorr A. Resp. everywhere very harsh, isc almost bronchial. éiffoseiy over the wholo lung rhonchi and hard, almost creaking Iì' Rjeht lung: nôrvhere quit clear:lung tone, resp. everywhere harsh, not quite clear. In somo places isolated rhonchi and R (partly from elsewhere?). Dætiacts lro.rn record,s. 5/rr: changes in right hrn.g possibly increasecl. General condiúion irnproved. 1/rr: only below A on t¡oth sides isolated mostly dry accompa.niments.- tr'or the rest no aecompaniments or Il. 3/rr: Roenúgen' Left lung, disüincl shadorv from hilus upwards, also a liütle dorvnwards. Right iung, distinct enlargemenl of hilus. 2a/rr: rhonchi and Iì as on admission rliffusely over both lungs. 8/rz: diffusely over both lungs rather coarse Iì, especialiy posteriorly below A biiaùerally. Shorü úone on the right laterally and in isc. ao¡t 23 left lung, .numerous dry coarse R over the whole lung' mostly over the base. Right lung, isolated rhonchi diffusely over t'hewhole lung.' B,esp. and. I) everyrvhere as before. Still coughing as before. General conãition improved. 7 lz: I) | all over the right lung, D 2 over the left, stronger posteriorlJ¡. Resp. as beforo. Iìhonchi diffusely over both' Still fits of cough' STI]DIES IN SCURVY \4/eight chart: ttlt, - 1ó.r kg 263 ing, trut considerably less than before. General condition improwed. Roeubgeá tt/r: enlargecl hilus shacloq's wit'h peribronchites, mostly in left lung dolvnwa.rcls. Appeárance suggests tbc. 2/s: an orango a day. leis: right lung¡ below IIf, isolated - somo few fairly harcl accompaniments. For the rest, no R, or accompaniments. D and rosp, as befo¡e. Last week bad appeüite. General condition a,s before. r8/a: righù lung accompaniments as before. Left lung below A isolated rhorrchi. For tho rest rro Iì or accompaniments. Harclly ever coughs. General condilion improvetì. 2a/¡: no¡vhere R. X'or the rest, as on 7/2. Nevor coughs. 16/o: resp. everywhele very harsh. D inconsiderable in lsft scl and base. Right lung no D or R', but harsh resp. Norvhere R. Coughs hardly ever. Dismissecl 23/e. Sunmtørg: Bilateral hilus tbc with diffusely spread peribronchites. Before giving the orango general condition improved, k¡ut no local improvement. After the orange consiclerable improvement of local status and also of general conditiorr, specially of appoüite (flesh ancl weight woro good when the orange was first given). Greater improvoment, than might havo been expecôed. 8ln ttln ,l,o "lto 1l lll /11 '/12 13 14.3 15.3 1ó.8 76.2 76.2 76.b tlt 7É1 ll 1l 151^ kg. ,1, t5/. - 16.5 , - 16.5 > - .Lû.c r - I7.s , - 1¡.D - 77.s , t5l. - tlu - 16.2 kg 77.e , _t /.3 , 17.¿ , 773 , 77 >) Couple w. 43, Or. Gustat' Ruben T'-tz, born 8lt Ll. Carter's son. Hagalund. Anømnesis: No tbc in family. Always been weak and thin. Has had morbilli, perlussis and pneuirronia vrhen three years olC. Bronchial cat'arrh evorv vear since two yoars olcl. Is saicl to have had attacks of asúhma every year since he was 7. During the last years more fnequent attacks. Admitted 16/2. B¿d a,ppetite, thin. Bolh isc and I-III D 2. Besides, D 1-D 2 in right Iung below' A. Iìesp. in bcth isc of br. character with isolated inconstant mostl¡z clry accompaniments. lìight lung belorv A an<{ anteriorly laúerall¡r isolated fairly coarso dryR,. Rosp. ior tho rest in both lungs harsh.unclear. No consúant accompaniments. Roentgen 16/¿: both hilus considerabl"u* eniargecl, tho right more, with consolidation torvards the base. I øtro,ats front, record,s. 2/e: an oranqe a day, e/a: R only right isc, D and resp. as beforo, Never coughs. 1/r: Ð as before. No R. Iìesp. harsh, br. ves. as 'before. No cough. DiJmissed 26lt : rlt Appotite considerably improved after oranqe; general condiüion also. Breathlessness gone. trVeight chart: 1ßlz - 25.s lxg. 15lt - 27.r kg. \51+ - 29 kg. lls - 25.t ,, 1l+ - 29 > Surnrnarg: Bilateral hilus affecfion with slighú consolidaüion in baso of rig'ht lung. Both locally and generall¡' improved after tho orange. 44. Inga Maj lll'ísc¿bet P-ú, 4 years old. Nursed in the Allmåinna Barnhuset for pertussis f pneum. ac. dx. * tbc tphgl. bronch. June-Aug. 1922' Apparentl5r rvell in the mid.dle of Aug. Afterwa¡ds ntirsecl in the Sor¿r,fimerlasa¡eLtet till admittod into ihe Sanatoriurn 21/ro 22. Status 21ln: right lung, lower half D viith tymp. accompanirnents and unclear rcspiration verging on br. ves. Ifncertain accompaniments. Left lung t¡elow A, D g resp. harsh. fnconstant accompar¡iments in some places laterally. 3/rr Roentgen: enlarged hilus sha'do*'s on both sides, mosô on thei right. Shado¡v of +,he left b¿se. 80/rr: Left lung, l.ateraìly fairl¡r ¿s¡¿¿¡n fine accompaniments. For the rest status quo. to/r 2',1: right lung 1/z A-A isolated a,ccompaniments. Lefü lung: isolatecl rather dry accornpaniments laterallS'. tr'or the-. r'est as before. Coughs slightiy aü times. General conclition improvcd. '/e: righü lung, nowhere certain accompanirnents, Lefô iung' belorv A ancL laterallS' some sliglrt coârse accompanirnents. Otherwise as before. Hard1y ever coughs. General concli.tion improved. le/r: right lung below A sometimes suspicion of dr¡z accompaniments. Left hrng: no cerlain aceompaniments. General condii,ion as bðfore. Lasú '"'ç,eek bacl"appetite. 18/¿: righô lung I-III ancl isc resp. unclear, harsh, of almcsb br. character. On the right laterally resp. enfeebled. Norvhere certain accornpanimenls. Never coughs. No expect. Appetite better. General conclition ¿s before. 2a/s: Nowhere R or accompanimenis. I¡or the resú status quo. Bad appetite. Never coughs. 264 .1. .A.XDI, HOJER 15/: - 15.s kg. 1l't - L6 >) 15ls - 76 , llc - Ií.s " Summary: Bilateral hilus úbc, most on right side. Befol:e 1/s improved, afterwards aggravation rvith regarcl to general condition (appetite!) and also locally. Conchtsioit, lor Cou'ple u: Tl;'o orange case has imptoved more. \il'eight chari;: 15lr - 1,6.+ kg lls - 16 15/¡ - 1ó.3 , lls - 76 I.g 16la - !6.5 , tfz - 75.b ,