Cardiovascular and arthritic lesions in guinea-pigs with chronic scurvy and hemolytic streptococcic infections

CARDIOVASCULAR AND ARTHRITIC LESIONS IN GUINEA-PIGS WITH CHRONIC SCURVY AND HEMOLYTIC STREPTOCOCCIC INFECTIONS MARK P. SCHULTZ, MD. WASHINGTON, D. C. In 1933 Rinchart and Mettier * described cardiac and arthritic lesions in scorbutic guinea-pigs with coexisting streptococcic infections and directed attention to certain points of resemblance between these lesions and those of rheumatic fever. The purpose of the experiments described here was to study further in guinea-pigs the pathologic effects, particularly in the cardiovascular system, of chronic scurvy and of chronic infection with hemolytic streptococci when present separately and when acting synergically. Coincidentally it was the purpose to determine the relative degree of scurvy and the type of infection requisite to the production of characteristic cardiovascular lesions. Cardiac lesions have been observed in most histopathologic studies of scurvy in guinea-pigs. Holst and Frölich ? frequently observed fatty degeneration of the myocardium; and Hojer,® reviewing the reports of others and summarizing the results of his own investigations on scorbutic animals both with and without infection, stated that the myocardium frequently shows “atrophy combined with necrosis which has a tendency to calicification.” He also noted a “weakness” of the perivascular elastic substance in the heart. Many subsequent investigations have yielded similar results. In a recent study in which attention was directed toward lesions other than those of the osseous system, Bessey, Menten and King * noted extensive foci of fatty degeneration in the myocardium. The combined effect of scurvy and infection also has been extensively investigated (recently reviewed by Robertson *), but histologic examinations have been made infrequently Findlay * produced chronic scurvy by giving 2.5 cc. of orange juice weekly to guinea-pigs deprived of other sources of vitamin C and infected them with pneumococci or From the Hospital of the Rockefeller Institute for Medical Research. 1. Rinehart, J. F., and Mettier, S. R.: Am. J. Path. 9:932, 1933. 2. Holst, A., and Frölich, T.: Ztschr. f. Hyg. u. Infektionskr. 72:1, 1912. 3. Höjer, J. A.: Acta pediat. (supp.) 3:8, 1924. 4. Bessey, O. A.; Menten, M: J., and King, C. G.: Proc. Soc. Exper. Biol. & Med. 31:455, 1934. 5. Robertson, E. C.: Medicine 13:123, 1934. 6. Findlay, G. M.: J. Path. & Bact. 26:1, 1923. SCHULTZ-CARDIOVASCULAR AND ARTHRITIC LESIONS 473 staphylococci. The animals survived up to fifteen days, but fatty degeneration of the myocardium was the only change observed in the heart. Rinehart and Mettier 7 have studied the pathologic changes in the joints and hearts of scorbutic guinea-pigs with especial reference to the problem of rheumatic fever. They examined the organs of animals with acute; subacute and chronic scurvy when uncomplicated and also after infection (chiefly with hemolytic streptococci) had been induced. In uncomplicated scurvy minimal effects were observed in the joints and in the valves of the heart, but in animals with coexistent infection there were distinct changes “fundamentally similar” to those of rheumatic fever. The lesions described included accumulations of “hyalin fibrinous material” within joint capsules, areas of “eosinophilic hyalin” in subsynovial, capsular and periarticular tissues, as well as hyperplasia and proliferation of synovial linings. Also, proliferative lesions associated with areas of fibrinoid degeneration were present in the valves of the heart and in the myocardium. Stimson, Hedley and Rose ® have reported recently the production of similar myocardial proliferations (no fibrinoid change was described) in acutely scorbutic guinea-pigs following intracardiac injection of the toxin produced by a strain of hemolytic streptococcus derived from a patient with scarlet fever. In the experiments described here an attempt was made to discover the effects of various definite grades of chronic scurvy, both uncomplicated and combined with spontaneous or induced chronic infection with hemolytic streptococci. METHODS Animals—Male and female guinea-pigs ® of mixed breeds were used; most of them weighed between 300 and 350 Gm. Diet Water and the basal diet (containing supplementary food factors except vitamin C) described by Rinehart and Mettier 7@ were supplied ad libitum. After a period of two weeks the animals were maintained in various grades of chronic scurvy by supplementing the ration with constant weekly allowances of 2, 6 or 9 cc. of orange juice, respectively, given by pipet in divided doses thrice weekly. Controls received the basal diet plus 5 cc. of orange juice daily or rations of hay, oats and cabbage. jä Infection —All artificially infected animals were inoculated with one strain (J20) of hemolytic streptococcus recovered from a guinea-pig with spontaneous lymphadenopathy (belonging to group C of hemolytic streptococci according to 7. Rinehart, J. F., and Mettier, S.R.: (a) Am. J. Path. 9:952, 1933; (b) 10:61, 1934. (c) Rinehart, J. F.; Connor, C. L., and Mettier, S. R.: J. Exper. Med. 59:97, 1934. 8. Stimson, A. M.; Hedley, O. F., and Rose, E.: Pub. Health Rep. 49:361, 1934. : : 9. Mouriquand, G., and Michel, P.: Compt. rend. Soc. de biol. 90:231, 1924. 474 ARCHIVES OF PATHOLOGY the serologic classification of Lancefield 10). The cocci were grown for twenty hours in “streptococcus broth,” +4 and 0.2 cc. of culture was injected subcutaneously into the right groin. Spontaneously infected guinea-pigs were taken from a stock in which purulent lymphadenopathy was rampant. Blood agar plates inoculated with pus from either the spontaneous or the induced lesions showed pure growth of hemolytic streptococci. The colonies were about 2 mm. in diameter and mucoid, with fairly wide zones of hemolysis. Pathologic Technic—The animals which did not succumb to infection were killed by a blow below the occiput. A microscopic examination of the heart was made in every instance, and in certain groups the aorta, all the costochondral junctions of one side and the left (uninfected side) knee joint also were included The lungs were examined microscopically when the diagnosis of pneumonia was in question. The tissues were fixed in Zenker’s solution, sectioned in paraffin and stained with eosin and methylene blue and the Van Gieson elastica stain. Bones were decalcified with 10 per cent nitric acid. Before being embedded each aorta was rolled in such a manner that the entire longitudinal extent was represented in each section. Several sections were made from each of the two blocks of the heart—one included the aortic valve and the left ventricle and the other the mitral valve (occasionally the tricuspid) and portions of both ventricles. DEGREES OF SEVERITY OF CHRONIC SCURVY INDUCED The several grades of chronic scurvy induced corresponded to the weekly supplements of 3, 6 or 9 cc. of orange juice. An attempt was made to estimate by different methods the relative degree of scurvy at each of these levels of dosage. (a) Rate of Growth of Teeth. —Dalldorf and Zall '? have found that the retardation in the rate of growth of teeth in scorbutic guinea-pigs constitutes a reliable index of the severity of the disease. By their technic, the left lower central incisor was clipped every five days, and the rate of growth of the stump was measured. The results are tabulated briefly in table 1. The rates of growth corresponding to different levels of the dosage of orange juice agree closely with those determined by Dalldorf and Zall. Judged by these criteria, the degree of scurvy in animals receiving 9 cc. of orange juice weekly was indeed “slight.” On the other hand, those receiving 3 cc., while designated as having “moderate scurvy,” showed a retardation of the growth of the teeth approximating that in animals with complete scurvy. The “mild scurvy” incident to weekly doses of 6 cc. of orange juice represented an intermediate grade. (b) Changes at the Costochondral Junctions —The pathologic changes at the costal junctions also were studied in several groups in order to determine the relative degrees of scurvy present. In evaluating 10. Lancefield, R. C.: J. Exper. Med. 57:571, 1933. 11. Swift, Homer F., and Hodge, B. E.: Proc. Soc. Exper. Biol. & Med. 30: 1022, 1933. 12. Dalldorf, G., and Zall, C.: J. Exper. Med. 52:57, 1930. SCHULTZ-CARDIOVASCULAR AND ARTHRITIC LESIONS 475 he results, the criteria of Holst and Frdlich,? Hess,** Wolbach and lowe * and Delf and Tozer ?® were followed. The results in all the animals studied from this point of view are summarized in table 2. Pathologic conditions at the costochondral junctions varied in severity corresponding to the degree of the restriction of orange juice. No differences, however, could be discerned between infected and noninfected animals receiving equivalent quantities of orange juice. The costochondral junctions of eight nonscorbutic guinea-pigs were examined microscopically, and of these only three showed slight alterations, such as occur in scurvy. Each of the five animals receiving 9 cc. of orange juice weekly presented slightly more definite changes. There were some shortening and irregularity of the columns of cartilage cells I I Tanta 1—Rates of Growth of Teeth with Different Dosages of Orange Juice in Chronic Scurvy Weekly Period of Supplement of Average Daily Number of Observation, Orange Juice, Growth, ? Guinea-Pigs Days Ce." Mm. Designation 12 16th-20th 0 0.31 Acute seurvyt 3 26th-30th 3 Moderate seurvyt 3 41st-45th 3 Moderate scurvyt 9 17th21st 6 Mild seurvyt 3 26th-30th 9 Slight scurvy 3 4ist—4oth 9 Slight scurvy 4 26th-36th 30 No seurv 4 41st-45th 30 8 1530 08=2000d Ot * The basal diet was given without supplement in each instance from the first to the fourth day. S E ee + Terms employed by Dalldorf and Zall (after Sherman) designating a similar rate of growth of the teeth. } Diet of cabbage, oats and hay. - in the epiphyseal cartilage, with a reduction in the size of the individual cells and occasional irregularity of the corticalis. An increased proliferation of the osteogenic zone of the periosteum was inconstantly noted. The slenderness, irregularity and decrease in number of the osseous trabeculae were definite in a few instances. In seven animals which received 6 cc. of orange juice weekly the changes just described were more constant, and in addition a decrease in the number of lymphoid cells was evident in the marrow at the end of the diaphysis, while in two instances the marrow in this region over very small areas was replaced by a reticulated matrix, Each of the four animals receiv13. Hess, A. F.: Scurvy Past and Present, Philadelphia, J. B. Lippincott Company, 1920. 14. Wolbach, S. B., and Howe, 15. Delf, E. M., and Tozer, F. M.: Biochem. J. 12:416, 1918. P. R.: Arch. Path. & Lab. Med. 1:1, 1926. 476 ARCHIVES OF PATHOLOGY ing only 3 cc. of orange juice weekly showed definite evidence of chronic scurvy. The corticalis was thin, irregular and occasionally fractured, while the bony trabeculae were in some instances reduced to fragments, and over considerable areas the marrow at the end of the epiphysis was replaced by a cellular matrix. Figure 10 represents an example of the changes noted. Taste 2—Changes Noted at the Costochondral Junctions in Scorbutic and Nonscorbutic Guinea-Pigs Both With and Without Infection J Epiphyseal sseous Marrow at E 5 5 Cartilage Corticalis | Trabeculae Epiphy 3 s a Sks — s = ae ots Fi = g SL o a ES 621 00o 5 S 0 Cane 00 o 0 o 0 0 o 0 + 0 0 0 st $ + 0000 €€ o 0 000 10) 05-10 0 Oa 205020 0 + eno el tO it OO nO eee DIET OTK 0 + + 0555] O) 0 - NU Cees + o Weal) N, AU Ot s = 0 0 00 oO + VERI =" 0 0 0 0 00 ae st Fi + + 0 0 < Ao + Pest 2000 tec ; Et) = Be eee Be TO. 9.01 10 Ee Oey Sa + + Of 0) 520 Oper EN ++ + 0-07 1110180 L ESR Maa BORG se VEE NS TSS att 0005000 i 5 + 5 ++ (c) Degree of Intercostal Myositis—Dalldori *° observed that the nature of the lesions of the skeletal muscles (especially the intercostal muscles) in scorbutic guinea-pigs varies with the character of the accompanying changes in the bones, and this offers an additional means of estimating the severity of the disease. Table 2 indicates that in this series the intercostal myositis increased in severity with the progress reduction in the quantity of orange juice supplied, and its cecurrenee sharply differentiated those animals with the mildest degree of chronic 16. Dalldorf, G.: J. Exper. Med. 50:293, 1929. SCHULTZ-CARDIOVASCULAR AND ARTHRITIC LESIONS 477 scurvy from the controls. There were opacity, fracture and marked eosinophilia of occasional muscle fibers and fiber groups adjacent to areas of loose, collagen-poor replacement connective tissue. Large histiocytes were sometimes present. An area of intercostal myositis is represented in figure 10. The differences found in the rate of growth of teeth, in the osseous structures of the costochondral junctions and in the severity of intercostal myositis permit an estimate of the degree of chronic scurvy occurring with the different amounts of orange juice administered. Thus, 9 cc. given weekly permitted a just perceptible degree of chronic scurvy; 3 cc., chronic changes of considerable severity, and 6 cc. weekly, an intermediate grade. Following in part the nomenclature employed by Dalldorf 1? and Sherman,?’ these grades are designated here as follows: The basal diet plus 9 cc. of orange juice daily produced “slight” chronic scurvy; the basal diet plus 6 cc. of orange juice daily, “mild” chronic scurvy, and the basal diet plus 3 cc. of orange juice daily, “moderate” chronic scurvy. Clinical signs of scurvy were not evident in animals with slight chronic scurvy. The animals with mild chronic scurvy showed a distinct disinclination to move, while the animals with moderate involvement were often inactive and frequently assumed the characteristic “face ache” position. None of the uninfected scorbutic animals died. CHARACTER OF THE INFECTION IN NONSCORBUTIC GUINEA-PIGS Local subcutaneous abscesses with enlargement of the adjacent inguinal lymph nodes developed in guinea-pigs inoculated subcutaneously in the groin. These lesions persisted for many weeks, and in about half the animals transient discharging sinuses appeared. Of the twenty-six artificially inoculated nonscorbutic guinea-pigs from an uninfected stock (table 4), seven died; in five of these and in four others that were killed purulent inflammation of internal organs was evident macroscopically at autopsy. In four of twenty-four control guinea-pigs (tables 3 and 4, acute spontaneous infection) from an uninfected stock, acute spontaneous infection with hemolytic streptococci developed while the animals were under observation, and one of them died. There were small subcutaneous abscesses in two animals, while the other two showed pulmonary abscesses at autopsy. Four young animals were selected from a stock in which spontaneous lymphadenopathy due to infection with hemolytic streptococci 17. Sherman, H. C.; La Mer, V. K., and Campbell, H. L.: J. Am. Chem. Soc. 44:165, 1922. 478 ARCHIVES OF PATHOLOGY was prevalent. Cervical abscesses developed in all of them and regressed in two instances; but in none of the animals was there any involvement of the internal organs, and none of them died (table 4, chronic spontaneous infection). CHARACTER OF THE INFECTION IN SCORBUTIC GUINEA-PIGS In scorbutic guinea-pigs infected experimentally larger, more edematous local and subcutaneous lesions developed than in nonscorbutic animals (table 5), and the mortality rate was much higher, although the internal organs were not more frequently involved in purulent inflammation. Of twenty-three scorbutic guinea-pigs artificially inoculated, fifteen died, and in seven there was purulent disease of the internal organs. There was a definite correlation between the degree of scurvy Taste 3.—Cardiac Data for Twenty Uninfected Nonscorbutic Guinea-Pigs Endocarditis Myocarditis Pericarditis Valvulitis — [a ms = 5 4 & as SS SE nao Pets A a g 2 5 = = E SESE a E 8E EES = ENS ass 5 5 53 3 E 5 & = Sa &= fa AA Number of animals showing respective Changes........- 9 2 0 5 1 5 1 0060 0 0 present and the mortality rate from induced infection: over half of those with slight scurvy survived, while all the infected animals with moderate scurvy succumbed. Acute spontaneous infection with hemolytic streptococci developed in four of the fifteen scorbutic guinea-pigs from ‘‘uninfected” stock (table 5) while they were under observation. None of them showed subcutaneous lesions, but they all died as a result of a purulent involvement of visceral organs. 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SINPIVOTDT — SIHPIVOOSIT SINPIVDOPU 3 yi ae ADI tae ae ee ee | 5 =. = 1 :i19r1t1+i+i1:s m x kaumas fo saaibag snowy Yio sh1g-voumao parafmun puo pardoju] 40[ VMA—'S VIIVI SCHULTZ-CARDIOVASCULAR AND ARTHRITIC LESIONS 487 In the groups of animals with mild and moderate scurvy, however, other experimentally infected animals and those with acute spontaneous streptococcic disease characteristic cardiac lesions developed. Areas of fibrinoid degeneration were present in the valves (figs. 6, 7, 8, 11 and 13) and in the pericardium, occasionally in perivascular areas. In those lesions the connective tissue was homogeneous, waxy in appearance and deeply eosinophilic. The character of the cellular reaction varied. Occasionally only a few shrunken, deeply staining nuclei of connective tissue cells remained; at other times large, pale mononuclear cells were noted occupying clear areas in the eosinophilic matrix (fig. 7), and in some instances there were fairly dense accumulations of large mononuclear cells about the borders (fig. 13). Areas of degeneration staining with methylene blue were also common, particularly in the valves, and were usually associated with rather compact collections of mononuclear cells. The two manifestations of localized degeneration were occasionally observed to be adjacent. There were occasionally areas in which the valvular endocardium was destroyed, but no concomitant thrombus formation was evident (fig. 8). Valvular proliferations of extreme degree were observed (figs. 6, 12 and 13). The entire structure of the valve was sometimes obscured by densely packed large mononuclear cells (fig. 12), but usually at least a strand of eosinophilic material was visible in such lesions (figs. 6, 11 and 13). Proliferations of the mural endocardium were occasionally seen (fig. 6). Myocarditis was noted infrequently. Sometimes there were areas of loose connective tissue surrounding deeply eosinophilic necrotic muscle fibers. In other myocardial lesions (fig. 2) the connective tissue was more cellular and the destruction of muscle less extensive. Rarely, small mononuclear cells were diffusely scattered through the myocardium. Nodular proliferations in perivascular regions were occasionally seen, chiefly in the epicardium. They were uniformly composed of mononuclear cells, some of them with little cytoplasm and round or oval, deeply staining nuclei and others with diffuse cytoplasm and large, irregular, deeply staining nuclei and several distinct nucleoli. A few polymorphonuclears were usually present. AORTITIS Although no macroscopic lesion was apparent in any aorta, microscopic examination of several specimens from each group frequently demonstrated the presence of slight aortitis. The inflammation usually was not extensive and consisted of accumulations of mononuclear cells and eosinophils, either localized or distributed in a seam at the junction between the media and the adventitia. Occasionally, similar cells were PEATE SIL SCHULTZ-CARDIOVASCULAR AND ARTHRITIC LESIONS 489 ExpLaNATION oF PLate II Fig. 9.—Root of the aorta; guinea-pig 540. Mild scurvy had been present for eighty-six days, and induced infection, for forty days. Enlargement of area 9 in figure 1, showing a nodular lesion in the epicardium with extension into the media of the aorta. Magnification, 45. Fig. 10.—Costochondral junction; guinea-pig 770. Moderate scurvy had been present for forty days, but no infection. The columns of cartilage cells are short and disorganized; the osseous trabeculae are few and deformed. The arrow indicates an area of intercostal myositis. Magnification, X 18. Fig. 11—Mitral valve; guinea-pig 548. Moderate scurvy had been present for sixteen days; there was acute spontaneous infection of unknown duration. An area of localized degeneration with a sparse accumulation of large mononuclear cells and lymphocytes is seen. Magnification, X 18. Fig. 12—Mitral valve; guinea-pig 540. Mild scurvy had been present for eighty-six days; induced infection, for forty days. Enlargement of area 12 in figure 1. The entire width of the valve is included, showing the types of large mononuclear cells involved. Magnification, x 360. SCHULTZ-CARDIOVASCULAR AND ARTHRITIC LESIONS 491 EXPLANATION OF PLAtE III Fig. 13—Mitral valve; guinea-pig 540. Mild scurvy had been present for eighty-six days; induced infection, for forty days. Enlargement of area 13 in figure 1, showing proliferative thickening of the valve with two areas of fibrinoid degeneration, one attended by an intense cellular reaction. Magnification, X 77. Fig. 14—Knee joint; guinea-pig 773. Moderate scurvy had been present for thirty-five days; chronic spontaneous infection, for a longer period of time. The joint space contains amorphous material. Magnification, X 42. Fig. 15—Myocardium; guinea-pig 639. Mild scurvy had been present for eighty-six days; induced infection, for forty days. There is degeneration of myocardial fibers about a nodular accumulation of lymphocytes and large mononuclear cells. Magnification, x 77. 492 ARCHIVES OF PATHOLOGY diffusely scattered in the adventitia, but in such instances their occurrence could be accounted for by the presence of inflammation in a neighboring organ, e. g., pneumonia. There was no disease of the vasa vasorum or involvement of the external portion of the media. Rarely, in the intima and inner third of the media degenerative changes were evident. This slight degree of aortitis occurred in members of each of the groups, and its character and severity apparently were not influenced by the presence of either scurvy or infection. ARTHRITIS Clinically, slight swelling and stiffness were noted in the knees of guinea-pigs with moderate scurvy. There were thickening and induration of periarticular tissue, but the joint capsules were not distended with fluid. The involvement was apparently confined to muscles in the region of the articulation. Only in those instances in which there was direct extension of inflammation from a neighboring abscess was the joint modified by the presence of infection. In artificially infected animals edema and induration extending distally from an abscess in the left groin to the region of the left knee were freguently observed. The knee joints of eighteen guinea-pigs with either mild or moderate scurvy, some with and some without infection, were examined microscopically. In the case of infected animals the knee from the uninfected (right) side of the body was selected for study. The observations are summarized in table 6. In the neighborhood of the joints there was severe and extensive myositis which corresponded to the type noted in the intercostal muscles. Slight thickening and_ proliferation of the synovial lining was inconstantly present in the animals with mild scurvy but occurred rather regularly in animals with moderate scurvy. In the latter, small fibrin clots enmeshing a few lymphocytes and endothelial cells were occasionally seen free in the joint spaces or adherent to synovial or cartilaginous surfaces; and in the joint recesses similar masses in which some hyalinoid change had apparently taken place sometimes fused with or replaced the synovia. Such changes are illustrated in figure 5. Osseous lesions characteristic of scurvy and analogous to those described at the costochondral junctions were discernible in animals with moderate scurvy. These changes occurred principally at the ends of the diaphyses and were sometimes associated with subperiosteal hemorrhages. No areas of typical fibrinoid degeneration were apparent, and there was no evidence of periarticular inflammation except in the muscles. The arthritic lesions were not more severe or extensive in the infected than in the uninfected scorbutic guinea-pigs. SCHULTZ-CARDIOVASCULAR AND ARTHRITIC LESIONS 493 COMMENT The circumstances most conducive to the development of the characteristic cardiac lesions may in part be defined by studying the data presented in table 5. The degree of chronic scurvy present must be at least mild or moderate. There is probably a narrow margin between the severity of scurvy essential to the development of lesions in the presence of chronic infection with hemolytic streptococci and that which does not permit survival of the scorbutic animal under such circumstances. The requisite duration of infection may be only from five to eleven days (guinea-pigs 488 and 544). The severity of focal infection required cannot be closely defined, because the minimal response was a large inguinal abscess and in several such instances characteristic cardiac lesions developed (e. g., guinea-pigs 540 and 544). It is evident that the nature of the infection is a determining influence. In guinea-pigs 767, 773, 768 and 772 (table 5) the most extensive local and visceral purulent lesions were present, and these animals were subjected to the most severe degree of chronic scurvy for over one month. Despite this, the cardiac lesions were of slight degree. These were animals with chronic spontaneous infection. In contrast to this group were guinea-pigs 611, 555, 548 and 614, the scorbutic animals with acute spontaneous infection. In this group of animals, two of which were subjected to only mild scurvy, the most extensive and highly characteristic cardiac lesions developed. The difference in the behavior of these two groups cannot be accounted for by the presence of more extensive purulent visceral involvement in one or entirely by a difference in the duration of the combined action of scurvy and infection. For example, in the animals with late spontaneous infection the scurvy had been present for from thirty to thirty-seven days, while in three of those with early spontaneous disease the duration of a combined effect of scurvy and infection could not have exceeded twenty-six days, although in one the interval may possibly have been eighty-six days. The animals in which infection was induced stand in an intermediate position with reference to the two groups just described. These observations indicate that spontaneous infection arising during the course of chronic scurvy is slightly more effective than induced infection in giving rise to characteristic cardiac lesions. Of greater significance, however, is the fact that the continuance of even asevere infection during chronic scurvy is relatively ineffective in inducing carditis if it has become well established before the induction of scurvy. It therefore appears that an important factor involved in the development of characteristic cardiac lesions is the state of immunologic reactivity of the animal during the period in which scurvy and infection coexist. 494 ARCHIVES OF PATHOLOGY A comparison of the characteristic lesions in infected scorbutic animals with those of patients with rheumatic fever is of interest. The outstanding experimental cardiac lesion was a focal interstitial valvulitis with areas of fibrinoid degeneration; there were occasional instances of focal nonpurulent myocarditis. On the other hand, no verrucous endocarditis was seen, and the architecture of the myocardial lesions did not closely resemble that of Aschoff bodies. In each affected heart the lesions were few and were not distributed as are the multiple granulomas of rheumatic fever. A synergic effect of scurvy and infection in producing arthritis was not observed. The scorbutic arthritic lesions were not granulomatous, and there was no marked exudative reaction, such as occurs in rheumatic fever. The myositis in infected scorbutic animals appeared to duplicate that of uncomplicated scurvy and was not of an infectious type. Chronic streptococcic infection in guinea-pigs is associated with a state of bacterial hyperergy of the tuberculin type.7® The resulting altered vulnerability of the tissues to injury incident to the presence of scurvy is possibly responsible for the lesions described. These probably additive effects have not, in my opinion, induced changes characteristic of rheumatic fever. CONCLUSIONS Chronic scurvy and chronic infection with hemolytic streptococci acting synergically may induce nonpurulent carditis in guinea-pigs. Valvulitis with fibrinoid degeneration and an intense proliferative reaction constitutes the most prominent lesion. The changes only slightly resemble those seen in cases of rheumatic fever. For the production of such lesions chronic scurvy at least of mild degree (resulting from a restriction of the vitamin C intake to an equivalent of 6 cc. of orange juice weekly) is requisite. Both spontaneous infection with hemolytic streptococci in guineapigs and that induced in them by inoculation with a strain originally isolated from the lesions of animals with this disease are effective synergically in inducing carditis if their onset does not antedate the development of chronic scurvy, but they are ineffective in this respect if scurvy is induced after a certain degree of antistreptococcic immunity has been established. i Chronic scurvy uncomplicated by infection induces proliferative lesions of minimal extent. In chronic scurvy of even mild degree there is extensive myositis of the intercostal muscles and of the muscles in the neighborhood of the knee joints. In more severe grades of chronic scurvy slight arthritic 19. Moen, J. K.: Unpublished work. SCHULTZ-CARDIOVASCULAR AND ARTHRITIC LESIONS 495 changes are demonstrable. These manifestations are apparently unaffected by the presence of infection. Small localized areas of endocarditis and myocarditis were seen in about half of the control guinea-pigs. There were lesions of similar character and distribution in scorbutic and in infected animals, although in the latter they were slightly more extensive and eosinophils were more frequently present. Slight aortitis was occasionally noted in all groups of guinea-pigs examined. The lesions were apparently not affected by the presence of scurvy, infection or a combination of the two processes.