The pathologic affinities of beriberi and scurvy

1290 BERIBERI AND SCURVY-DARLING Joun. Ocr. À. M. Ä. 10,1914 special and unusual groups of nerves, that difficulty tions of the nerves are correspondingly or1 tlìe arises. In these one should watch for the slightest increase, but the text-books are significantly silent or sign of involvement of the more comnronly añected unenliglitening on the etiology of fu-nctional ánd degennerves. The clinical course will clear up the diffierative diseases of the nerves. It may be that the culties. recognition of neuritis as a deficiency disease, due to pnocNosrs a one-sidecl diet in which ordinary white flour is the This depends on how much clamage has been done, to what nerves, in what length of time, and the ability to procure the elements needed in the diet of the patient. The danger is great while the diet is defective, while the nerves to the heart and lungs show most involvement, and rvhen the onset has been rapid. Recovery vvill be complete if proper diet is instituted an<l rnaintained, no vital nerve has been affected sufificiently to cause death, al:d no other disease carries off the patient. If former habits of diet are resunred, recurrence in aggravated form is probable. TREATI\fENl Whenever an unbalanced diet is used, an atterupt should be made to regulate it better. When people depend mainiy on bread, whole-wheat flour should be used. Fresh meat, vegetables and other articles should be added when possible. Such foods as beans should be used when fresh meat and vegetables can not be obtained; and attention should be given to the method of cooking so that the preventive substances are not destroyed. Canned goods probably have these destroyed by heat. A patient rvith beriberi, whose symptoms have not gone so fa¡ as to be immediately dangerous, if put on a diet including fresh meat, whole-rvheat bread, beans, peas, macaroni and potatoes, will, u.ithin ten days, recover from all functional symptoms. His perfect recovery will depend only on the length of time necessary for the regeneration of the nerves alreacly affected, together with the correction of such pathologic conditions of deformity, rvasting, anemia, etc., as have strpervened. Absolute rest in bed is important at 6rst in all cases. During acnte attacks, such supportive treatmeflt as is indicated should be instituted, along with the attempt to introduce such food as will supply the lacking elements. When the stomach rebels, milk from mash-fecl colvs should be used. Digitalis must be used with care. Strychnin and quinin seem indicated by clinical and experimental observation (Cooper). A1l electric treatment and massage should be delayed until such time as progressive degeneration has ceased. While the antìneuritic substance is curative in minute quantities and has been separated, its preparation is too complicated at present for general use, and the use of proper foods is still the best way. In the severer cases, such a preparation rvould be life saving. It is to be hoped that in the future, it may be prcpared in sorne stable form capable of distribution. There is, possibly, a broader significance to the subject of deficiency netrritis than may be apparent to the average practitiorrer. Beriberi is thought of as a sort of extra disease that he doesn't have to bother with, a sort of tropical disease he will never see. It is easy enough to recognize in its "overforms," such as we see when a diet is obviously one sided. The vaguer symptoms and results nray be present when the <fiet is not so considered. Meat is getting dear, however, and foods are coming to be more and more denatured by raodern methods. I do not knorv whether affecprinciple factor, may clear up some previously unexplained cases of functional nerve trouble, neuritis, artd trophic disturbance. The cause of beriberi among rice eaters is an acceptecl fact. It is not generally recognized amoltg' rvheat eaters. Because of this fact Mr. Ohler has attempted to repeat rvith rvheat, some of the experiments which have been accepted by the profession as proof in the case of rice. A report of these experiments will be found in the Journal of Med.ical Research..s Their f ull significance remains to be worked out. St. Anthony Hospitel. THE PATHOLOGIC AFFINITIES OiI BERIBERI AND SCURVY t'^i;"3^åi'^i";"^f o' . INTRODUCÎION During a recent visit to South Africa and Rhodesia w-ith General Gorgas, advantage lvas taken of the favorable opportunities there for observing scurvy. A number of post morterus were made and some pathologic material collected. I was struck at the first necropsy by the remarkable appearance of the heart, for it suggested at once the picture seen in a well-marked case of right-sided hypertrophy and dilatation in beriberi. Since my return, I.have examined miscroscopically the vagus and its br:rnches, as well as the heart muscle, in some of the cases, and found degenerative changes of the same type seen in beriberi. Eacl.r necropsy presented the same cardiac lesion, and following up the observations, a ntrmber of clinical, pathologic and epidemiologic observations have been macle rvhich show family relationships between scurvy, a classical example of a food deficiency cachexia, and beriberi, anci also as rüy'atkins-Pitchfordl pointed out in l9l2 with certain other members of the group of dietetic cachexias. At one extreme ís rickets, a type of pure "osteocachexia," to use Watkins-Pitchford's term; at the other extreme a pure "neurocachexia," such as polyneuritis gallinarum. Between these two types are scrlrvy, infantile scurvy, the experimental scurvy of guinea-pigs, ship beriberi, beriberi (two or more types), infantile beriberi, and epidemic dropsl' ¿¡d neuritis. The accompanying diagram shows qualitatively the aflnities of the differnt types of food deficiency cachexias; and following is a brief diagnosis of the types: Ricþets.-A disease of infants characterized by defective n[trition of the body and diminution of lime salts in growing bones, particularly the ends of the long bones and ribs at the junction of the ribs with cartilage ("rickety rosary" and "craniotabes"). Rapidly repeated pregnancies and suckling a child during preg3, four, Med, Research, xxxi, No.2, t. ìyVatkins-Pitchfo¡d: Tr¿nsvaal Mei. Jour., \{ay, 1912, Downloaded From: http://jamajamanetwork.com/ by a Simon Fraser University User on 06/09/2015 VoLUxE LXII¡ NuuaER L5 BERIBERI AND SCURVY-DAII.LING nancy (accorcling to Osler) seem to be important factors in tire production of the disease. It is nrost comnron in chilclren fed on condensed rnilk and food poor in fat and animal proteins (Cheadle). Inf antile Scurz'y.-A cachexia of infants or children in which there is profound anemia, subperiosteal, subplural, and other hemorrhages; spontaneolrs separation of epiplryses from shafts of femur and tibia, arrd separation of ribs from cartilages, as in extreme cases of scorbutus. The.gums, if the teeth have erupted, may be spongy. It is caused by proprietary foods, and there are instances, as in one of my necropsies, of its developing in breast-fed babies.2 Scuruy.-,\ disease occurring among laborers, or soldiers, in barracks and canrps, or innrates of asylums, etc., and in times of famine; follorving the continued consumption of a one-sided or overcooked diet and one free from fresh vegetables. It is characterized by nruscular joint subserous and subperiosteal hemorrhages; anernia, gingivitis, necrosis of bones, separation of costal cartilages from ribs in extreme cases, and Iright-sided cardiac hypertrophy, dilatation and fatty degeneration, with degeneration of the vagus and its branches (personal observation)]. Certain epi- !.ú' lc.lû * .DtCryæ. ot løA lora laêtoà at JtEìl@ o? rlù ed ¡àrto¿teal suùætâÉda t¡3cülatrsuÞæsG Joltrt ¡lßoÈha8Éa 59ora| ltarÈ Cs¡dt¡c lvÞêttþÞh!' âd ¿.Aanr!¿tl seen. It often appears in spite of the tlse of lime juice. Recovery is rapid when fresh food is supplied. - Beril¡eri.-A'diseasè due to eating exclusively polished rice or other food from which some unidentified principle or "vitamin" is absent. It occurs endelnically in certain tropical or subtropical regions antl is characterized chiefly by degenerative changes in the peripheral nerves with n.rotor and sensory disturbances, dropsy, right-sidecl cardiac hypertrophy and dilatation with fatty degeneration. There are uncloubtedly several iypes õf this disease such as infarrtile and asylum beriberi, wet and dry' beriberi, and that seen in Brazil (Lovelace)5 "endernic dropsy," arrd endemic peripheral neuritis, etc. Decharnbre clescribed an epidemic of scurvy as occuring during the Siege of Paris, i¡r lvhich a few cases <iisplayed l¡eriberi symptoms. Polt'neu.ritis Callinaru.w of E,ijÞman.-A disease produced in birds by feeding overcooke<l foocl and rvheat flour, etc. Paralytic symptoms rapidly develop rvith subcutaneous edema, especially of the legs, and fatty degeneration of muscles of the heart; a disease resembling tropical beriberi rather than ship beriberi, neuritis being present more frequently than in slrip beriberi. Table 1 is meant to display the chief pathological features of the different diseases in this group in such manner that the affinities of the group may be see¡t at a glance. Funks mentions five groups of symptoms observerl in diseases caused by food theoretically deficient in "vitamins" t ' 1. Nerve degeneration with paralysis and contractures. 2. Cardiac: dilatation of right heart, dyspnea, cyanosis, oliguria. 3. Anasarca, hydropericardium, hydrothorax, ascites. 4. Scorbutus with mouth lesions, skin, subperiosteal hemorrhages and bone lesions. 5. Pellagra syndrome, stomatitis, gastro-intestinal lesions, skin erythema ancl multiple nerve svmptoms. While Funk may be right about the etiology of Grorrps l, 2, 3, and 4, it would seem to be unwise to include peilagra ín this group, for among other re¿rsons, rvhile pellagra is a disease "occurring in maizeeating countÅes par ercellencd' the eating of overcooked, undercooked and overmilled, kiln-dried maize in large quantities takes place among negro laborers and natives in South Africa to an enormous extent, for it is frequently their sole article of diet. yet pellagra is practically unknown arnong that cIass.T fhey do, Itoæever, suffer from scuray. TI{E CARDIAC AND NERVE DEGENERATIONS IN BERIBDRI It it can be shown that scurvy, a typical example of afo-od <leficiency cachexia, possessescertain paihologic features icleitical rvith those of beriberi, äbout u-hich the etiology in the minds of some is as yet undetermined, it will help to est¿blish a place for bériberi among the dietetic cachexias. It is rvell known that in beriberi the heart is usually enlarged; the enlargement is especially common on the right side, the right ventricle being usually hyper4. Vedder and Cla¡k: Philippine Jour. Sc., Sec. B, 1912, vii, 423. _ 5. L_ovelace: Peripheral Neuritis in the Amazon Valley, .+ni. Jou¡. Trop. Ðis.,_1913, i, l+0; The Etiology of Beriberi, lire ¡ouix* A. M. 4.. Dec. la, t912, p. ?1J4. 6. Funk: München. nred. \{ehnschr., 1913, No. 47. 7. Swift and -Brown: Jour.. Trop. I{ed. and Hyg., June 1, 1914, report six cases of pellagra in eight ycars at Bloemfontein'Asylu¡n. t29l Chart showing afrnities of the food de6ciency syndrones. demics display symptoms which disclose affinities rvith beriberi. E r þ erim ent al S curay of G ui,nea-Pig s.3-A disease, resembling Barlorv's disease, produced in guinea-pigs by feeding a one-sided, or overcooked and unaccustomed diet of various sorts of grain, groats, and bread. There are hernorrlrages, muscular, subperiosteal, and subcutaneous, often of the hind legs and ends of the ribs and between rib and cartilage, loose teeth and fragility of bone, and rarely polyneuritis and fatty degeneration of the heart. It is favorably influenced by "antiscorbutics." Shiþ Beri.lteri.*A disease appearing ustrally on board sailing ships during long voyagei, rvhich-may be due to eating preserved, dried, or tinned food in the absence of f resh vegetables. Symptoms are: weakness, shortness of breath and "othei symptons of lveak heart causing often sudden death from acute paralysi_s of lieart," edema of legs, and other parts of body. In a few cases sore gurils, crltaneous arid intrar¡¡uscular hemorrhages, and peripher¿l neuritis are 2. It nay be noted in passing that borh infantile beribe¡i and tite scurvy may develop in b¡east-fed babies, 3. Holst i¡d I¡rölich: Ztschr. f. tlyg. ufnfektionskrankh., L912. inf¿¡- May, Downloaded From: htþ://jama.jamanetwork com/ by a Simon Fraser University User on 0610912015 trophied ancl <lilatecl, this abnormal size of the right heart being often the only striking feature of the necropsy. There is some fatty myocardial degeneratron. these chauges are thought to be due to degenerative changes in the vagus and its cardiac branches. Hypertrophy and dilatatíon of the rigl'rt heart is recognized as being due to such mechanical processes as stenosis of the pulmonary artery, reduction of tlre vascular area of the pulmonary artery, as in emphysema and interstitial pneumonia, valvular lesions on right side, tumors and aneurysms pressing on the pulmonãry artery, and adherent pericardium. In addition to these, this lesion is constantly found in beriberi and the Ran<I type of scurvy.s Ii is the type known as excentric hypertrophy or hypertrophy and dilatation characterized by thickening of the muscle and an increase in the size of the cavity. It seems to be due to a gradual strain on the right ventricle from loss of vagus in¡ervatíon. According to Scheube, Ellis found the average weight of the heart in beriberi in 125 post mortems to be about 13.37 English ounces, or 378 gm., wirile in 204 other cases it was but 9 ounces, or 254 gm. This increase is due chiefly to the hypertrophy of the right ventricle. 1)rJ') Bone lesions at epiphyses of long bones Bone lesion at iutrction of ribs and caitilage Subperiosteal hemorrhages subcumusc¡e Spongy gums Nerve degeneration Cardiac hypertrophy degeneratìon 42 hearts 10 hearts 7 hearts Joint, subserous, taneoqs atrd hemorrhages BERIBERI AND SCURVY-DARLING Joun. A. M. AOcr. 10, 1914 in the bulb, togiether with axonal reaction in the cetls of thc intrinsic cardiac neuroses, and in cells of the postganglionic accelerator 6bers are conclusive evidence that almost the entire cardiac nervous system is afiected by the beriberi virus in acute pernicious be¡iberi. So extensive a poisoning of both inhibitory and accelerator systems accounts for a large measure of the cardiac symptoms iu the latter class of cases. The loss to the heart of the control normally effected through the accelerator and inhibitory systems leaves the organ in practically the same statc as the heart of a lower animal experimentally isolated from its guiding nerves, The rapidity of beat seeñs to indicate that the inhibitory mechanism is first attacked. Partial exhaustion and dilatation of right heart soor¡ follows. Arhythmia occurs. The right heart fails to empty itself and the pulmonary and venous circutation L¡ecomes surcharged. Dilatation of right side increases, CLINICAL OBSERVATIONS ON SCURVY OF î}IE RAND TYPE My first impression of the cases of scurvy in South Af rica was that the disease was of an infectious natrlre, but that rapidly gave way to a confirmed opinion that it was due to dieta.ry errors. The diet of the negro laborers was certainly onesided, considering the amount and character of the TABLE I._SHOWING AFFINITIES AND PAÎHOLOGIC FEATURES OF SCURVY, BERIBERI, ETC. Rickets Rickets Infantile scurvy fnfantile scurvy fnfantile scurvy Infautile scurvy Guinea-pig scurvy Guinea-pig scurvy Guine-pig scurvy Guinea-pig scurvy Guinea-pig scu¡vy Guinca.pig scufvy Guinea.pig scufvy Guinea-pig scurvy Scuny Scurvy Scurvy Scurvy Scu¡ly Scurvy Infantile scufvy Ship beribe¡i Ship beriberi Ship beriberi Ship beriberi Ship beriberi and Drcpsy Palsy ¡ May occur during adolescence but probably is not €ncount€red in adults. Beriberi Beriberi Beriberi Be¡iberi Polyner:ritis gallinarum Polyneuritis gallinarum Polyneuritis gallimrum Polyneuritis gallinarum Ioioto records ten necropsies in the cardiorespiratory foim of disease (beriberì) at Camp Saint Jacques. Svmotoms: dvsDnea, intense cardiac erethism, extrer:re aáxiåty, and'sridden death by syncoPe. Jojot notes the ocåurrence of hydropericardium, 180 c.c', and cardiac hypertrophy, 310 to 490 gm. Pekéiharing and Winkler,lo state that "hypertrophy of the rigl-rt-heart is always Present and associated with dilatätion, sometirnes snlafl, sometimes great, and not infrequently enormous." The muscular coat of the heart ìs oftên pale. Of 64 necropsies, 5 hearts weighed 250 to 300 gm. according to Hamilton Wright.ll Ol¡served atrophy in the terminations of the vagal inhibitory ûbers in the heart muscle, axonal reaction in the cells of the ambiguous and vagal portion of the combined nuclei labor required of them. It consisted, as General Gorgaslz has pointed out, too largely of carbohydrates. Five to eight feet of rock is no mean task to drill through in a day on a diet composed chiefly of cornmeal. Looking over the dietary, it was seen that the disease apparently had some relation to the following factors: Overmilled corn as the chief article of diet; overcooked corn as well as overboiled food of whatever kind; roasted meat, the natives customary way of cooking, was never supplied; and insufficient ancl overboiled vegetables. Cases, too, very definitely came on during a drought and in locations where it rvas impossible to supply fresh vegetables and fresh meat. Several types would appear. Dr. Peall, of Arcturus, Southern Rhodesia, r€ported the appearance of neuritis and ataxy \4'ith enlarged right heart and edema of tibiae. Thus confirming the observations of Balfour of Khartoum and other African observers in this particular. An interesting feature of the disease was brought out by ascertaining the incidence and death-¡ate among different types of natives, for during the year 1913, at one of the mines, the incidence per 1,000 per year was 12.j7 among Cape Colony "boys," while it was 12. Gc.-¡s. Sanitation on the Rand, THE JoüRrÂL A. M, 4., June 13, 1914, p. 1855, 300 to 350 sm. 350 to 400 gm. ,100 to 450 gm, weighed weighed weighed 8, Buzzard. in Reynoltls System of Medicine, 1870' Vol. f, nolcs cases of scurúy with fatal syncope and atttibutes it to th€ musci¡lar structure of hiart being rveakened by malnutrition' Thus, carciiac syn' cooe is also a feature æñnlon to beriberi and æurvy. '9. Joiot: Ann. d'hyg. et de méd' coloniales, l9l1' No' I' p. 38. 10. Þikettrari"g "nd-Witkler: Beriberi, 1887. li, Wright: Siudies Inst. Med. Research, F'ederated lfalay States, 1903. ii. No. 2. Downloaded From: http://jama,jamanetwork.com/ by a Simon Fraser University User on 06/0912015 v NOLUMÊ LXIIT UilBEß ¡J BERIBERI AND SCURI/Y_DARLING Diet of Native SoldiersI(ilos Rice F¡esh ever, during the samç p€riod, had only scurvy, with no symptoms of beriberr. TÁBLE 2._DTET AT OUTBREAK OF DISEASE .,.. r293 7.15 among -'tropicals,'1 yet the death-rate lvas only 0.19 per 1,000 per annum among the former, while ii yas 2.66,among the tropicals, ór 14 times as great. The tropical negro therefore gets scurvy in far more serious form. This may be explained from the observation that the scorbutic "troþical boy" had not yet begun to vary the monotomy óf his diet by purcháse of food at KafÊr.stores outside the mine coinpouncl. The clinical cases of scurvy seen varied in severity from those that hacl only spongy gums and very slighi infiltration of calves, to otherJr,vith severe and extërrsive hemorrhages of the mtrscles, joints, and serous mernbranes, or bone and cartilage lesions. The alpearan-ce of the patient was apathetic; many of them had been in bed six to nine weeks. Motion and locomotion were impaired, the recovering cases walked *jth * .slight straddle, but there was no foot drop. The sick ones lvere either unal¡le to stan<l or perha¡is stood rvell with one leg, while the other waspartiy flexed, i. e., the heel etevated, the toes and ¡äll of foot resting on the ground, apparently due to infiltration and atrophy of leg muscles. Their gnms were swollen-and pouting at-the margins, which úere bright red and fungating. On pressure, the blood spurÉd on the adjoining teeth. The nrusctes of both legs rvere uniformly, or unequally inûltrated an<l the oveilying sl<in was smooth and shiny. After the infiltration had subsided, there was atrophy of the calves. with wrinklecl shiny skin. The kireé-jerks in those examined rvere gerierally slightly exaggerated in all save one case. In this, the right was normal, the left practically absent. Several cases, on auscultation, disclosed tachycardia as in beriberi. At Bulawayo, through the kindness of Dr. Eaton, a case was seen in which the gums at the time of examination were negative, the legs and tibiae were âlso negative, -yet the sternum had collapsed, due to separation of the costal cartilages from the ends of the ribs. One could feel the cup-shaped depression in the ends of the ril¡s. There was also a big hematoma over the left scapula and shoulder. Doctors at Bulawayo describe a condition known as "big leg," a condition of edema following active exertion, sucl.r as marching to the mine, occuiring in some cases after thiee weeks in the detention camp. This is of interest, because undue exercise seems to have been_an exciting or accelerating factor in precipitating attacks of beriberi and scurvy, as in solcliers ãfter á march. Not only has the Rand type of scurvy affiliations rvith beriberi, in that cardiac degeneration and degeneratiorr of the vagus occur in typical scurvy as well as irr beriberi, and by reason of ihe appearance of beriberi or neuritic features in ce rtaln epidemics of scrlrvy, but Dr, G. P. Turner of Jol.rannesburg has observed that many of the negro miners dying ofvarious diseases, at necropsy disclose slightly eãematous calves without any other sign of scurvy'or beriL¡eri. Scurvy has definite affiliations wíth rickets, and infantile scurvy too, for in the case seen at Bulawayo there had been extensive destruction of the chondrocostal junction, with depression of the entire sternum. Couvyls gives an interesting account of an outbreak of beriberi a¡rd of scurvy in a garrison of soldiers at Akjoucht ¡lvfauritanie, May-September, 1908). There were 150 natives and eleven Europeans. 'Beriberi appeared first among the n¿tives; later cases of scurvy appeared among them. The of;ñcers, howDiet of Europeans .0.500 Flour .0.500 Fresh .0.015 Fat , , Coffee Sugar Salt W'ine, Kilos 0.450 0.500 0.020 Salt Sugar meat .. .. .. . ' '0.010 drierl beans and preserves Amorg those suffering from beriberi, as well as scurvy, the suppression oÍ rice f¡om their diet and its replacement by other articles was followed by the disappearance. of cardiac troubles, asphyxia, pirlmonary edema, and subcutaneous edema, but had nó effect oi the classical lesions of scurvy-spongy gums, muscular pain, and induration of limbs. Ttlis instructive observation of Couvy illustrates the persônal racial or idiosyncratic factoi of this group of diseases, for, as far a! can be ascertained, follðwinþ the use of meat with one other article of food (pol-- ished rice.), lnd associated rvith excessive consumpiion of saltl4 (saline spring water), two distinct syndrõmes appeare_d among.the men who were getting-the same ration (native soldiers). This constitutional, or idiosyncratic. factor in the production of these diseases does not seem to have been sufficiently emphasized and certainly has not yet been explained. For example, a certain êxclusive ciiet will cause scurvy in guinea-pigs, yet the same diet causes polyneuritis in pigeons. On the other hand, a deficient dietary in a tropical African .tegto mine laborer causes severe scurvy, in a Cape Colõny African negro mine laborer, mild scurvy, añd in some African negroes a diet that causes scurvy in one set of men causes neuritis iú others. Furtheimore, an exclusive diet of rice, which usually causes beriberi in man, has caused scurvy in certain -instances, for Hölst and Frölichró call attention to the fact that "rice which is so often supposed to be the cause of tropical beriberi occasionally has provoked scurvy." Dejpechlu rnentions in his article on scurvy in Paris,'lB7O-Zl, .,a patient who got the disease who for four months had eaten meat only four times; besides this he had noth_ ing but .lice." Other. scurvy patients, described by Bucquoyl? had eaten rice or breãd dmost exclusively. NOTES ON THE PATHOLOGY OF SCURVY Three severe cases of scurvy, practically free frorn complication (one had a little-tuberculosis), came to necropsy at one of the hospitals. The anaiomic finclings were closely similar and may be summarizecl in a composlte anatomic diagnosis: - Hemorrhagic extravasatio¡.r into muscles of both legs, lelt forearm and left psoas muscles, involving the muscle fasci¿. between muscles, old and recent. Subperíosteal hemorrhage, shaft of left femu¡. Hemorrhage into left knee joint. Old subcapsular hemorrhage (knee joint). Ulcerative gingivitis with hemorrhagés. Separation of mandibular periosteuÃ. Anemia of all viscera. Hypertrophy and dilatation of right hcart. F-atty degeneratio¡r of musculatuie of right heart. Hyperplasia of femur marrow. Edenra of lungs. Scaly desquamation of both legs, li. Couvy: Ann. d'tryg. et de mód. colonial€s, l9ll, No. 1, p, 97 Downloaded From: http://jama.jamanetwork.com/ by a Simon Fraser University User on06109l20l5 729+ UROCHROMOGEN AND' DIAZO TË-STS_SCHAFFLE JÙUR. Ocr A. M. A. 10, 1914 This is purely a picture of s"^urvy, without a single beriberic feature save, of course, the cardiac chauge. The picture presented by the heart in these cases is very striking. It is seen to be enlarged and very pale, but as it is lifted from its bed, the pallor of a yellowish tint is sharply limited to the broad right veutricular rvall. The left ventricular rvall externally is of good color. This is striking, but becomes accentuated when the heart is sectioned, for the left ventricle is seen to be of nornral thickness and capacity, contracted, not dilate<l, and the muscle of good deep color; while the right ventricular wall is definitely thickened 8 to l0 mnl. more or less in thickness, and of a yellowish pallor. The chamber is dilated and the muscle stands stiffiy out fronr the septal wall and does not collapse on it as in a norrnal heart. This lesion appears to be patlrognomic of the Rand type'of scurvy an<l it brings this type of the disease into relatioq rvith beriberi and other <lietetic cachexias. An examination of the cardiac muscle arid of the vagus nerve ancl its branches (Marchi þreparations) shows that tlrere had been extensive cliffuse fatty degeneration of the musculature of the right veutricle, the nruscle cells being stipplecl over with small fat rlroplets. There are also small areas in which the clroplets are larger. The intermuscular stroma coutain nrany extracellular small droplets of fat. The carrliac nerves do not appear to be degenerated. The sections of the vagus at different levels all show considerable tlegeneration of the fibers. This is different from the fin<ling of Pekelharing and Winkler in beriberi, rvho state that the nearer one approaches the periphery of the nerves, the greater the nervous degeneration; the nearer one gets to the center, the less distinct it is, and in the great nervous trunks and in the roots no changes are found in beriberi. It r.nay be urged by some that there is latent beriberi on the Rand and that many of the cases of scurvy overshadow the beriberic symptoms, This can definitely be ruled out, for in all the cases I examined with regard to this point the knee-reflexes were exaggerated, not absent, as in beriberi; there was no anasarca, aud no paralysis or extreme general atrophy as in beriberi. Besides, the pathologic material examined was taken from cases which anatomically were uncomplicated scurvy. Searching the available literature on scurvy for descriptions of this very striking cardiac lesion, it was seen that fatty degeneration had been described, trut no one seems to have noted the peculiar features of the cardiac hypertrophy and degeneration of the vagus. This may be accounted for in the following way. From a comparative study of the pathologic features of the variotrs dietetic cachexias it is seen that there is a relationship among them. Scurvy shades off into ship beriberi in one direction and towards rickets in an other. All outbreaks of scurvy are not alike. Some appear in apparently well-nourished laborers of robust physique, while others appear in conditions of severe -starvation as in time of famine, in campaigns, in jails, asylums, etc. In some outbreaks there are very definite beriberic features, in others they are quite absent. We may presume then, that in certain outbreaks, or in certain cases of scurvy, the cardiac hypertrophy and degeneration which I have described may be seen, in others, it may be absent. As a matter of fact, I have seen one well-marked case of asylum scurvy associated with tuberculosis in which the peculiar cardiac hypertrophy rvas absent. It is likely that cardiac hypertrophy may not occur in scorbutic persons debilitated by starvation and associated chronic disease. Again the type of scu¡vy seen among tropical negroes on the Rand and in Rhodesia appears to be different from that observed among troops, irr jails, asylums, and in time of poverty and famine in that the former does not yield so readily to treatment as the latter is said to do. CONCLUSIONS The striking excentric hypertrophy and dilatation of the right heart with extensive fatty clegeneration of the same musculature, the left heart remainìng apparently normal, and the severe degeneration of the vagus nerve described here from several fatal cases of scurvy from the Rand furnish nerv and additional facts which shorv the intinrate relationship betrryeen scurvy and beriberi as. to etiology. The affinities between these two diseases and certain other cachexias lends emphasis to the opinion that they are all the result of the continued use of one-sided and deficient diet. A COIIVIPARISON BET\!EEN THE UROCHROMOGEN AND DIAZA TESTS IN THE PROGNOSIS OF TUBERCULOSIS* *"*'"::l*:åi:' * o As a result of personal dissatisfaction with the prognosis of tuberculosis, my attention was drawn to an abstract of an article by Moritz Weiss,t in rvhich the prognostic value of Ehrlich's diazo reaction in the urine of tuberculous subjects is emphasized. He also describes a test of greater reliability and simplicity rvhich was evolved from study of the diazo reaction. In the original article Weiss refers to his earlier writings on the subject, which date back to 1906. During seven years' observation he has confirmed the ideas of Koch and others by observing that death invariably followed the persistent presence of the diazo reaction in the urine of the tuberculous. In additiqn to his own work, Weiss refers to that of Dr. Heflebower, who reported similar results at the United States Government Sanatorium at Fort Bayard, N. M. Dr. Heflebower's article'? reviews the general literature and mentions Gwerder's use of potassium hypermangånate, with tþ_e 4iazo reagent. Heflebower, using the technic of Weiss, carefully compares his test rvitñ the diazo and demonstrates the superiority of the former. Early in hís observations, lMeiss was puzzled by the occasional absence of the diazo reaction in obviôusly advanced c¿ses and its frequent disappearance just before death. This led him to suspect that the unknown substance on which the diazo reaction depends was derived from an antecedent which does not give a positive reaction. On adding a 1: 1,000 solution of potassium permanganate drop by <irop to positive specimens and the reagent combined, he nõted that the characteristic red of the reaction became brown; also, when the permanganate solution was added to positive specimens alone, a canary yellow * Read befce the Philadelphia Pathological Socíety, May 28, lgt4. l- !lqo., M. ; Aid in Prognosis in Pulmonary Tuberculosis, Wien. \.lin. Wcùnschr., 19-13, xxvi, No. 42; absb., THE Jou¡NÄL A. M.4., Nov. 22, 1913, p, 1943. 2, Heflebower: .4,m. Jour Mcd, Sc., 1912, p. 221. Downloaded From: http://jama.jamanetwork.com/ by a Simon Fraser University User on 06/09/2015