paired, that such an individual would suc-
cumb to an injury or an illness, when an-
other would recover. Fifteen per cent, of
all applicants are rejected by Insurance
Companies on account of such evidence.
There are seeds sown in early life, by
habit or accident, that wait for a favor-
able condition to germinate and grow.
Why should not we consider any case
that comes into our care, from this stand-
point? Are we any more bound, in honor,
to the patient than to the company?
Remember that corporations use every
endeavor to prevent accidents and usually
do all in their power to ameliorate the
sufferings of the injured.
Remember the past history and the con-
dition of the patient, and remember that
we are not always careful in avoiding
injury.
With us the question of law suit often
rests, and we should always carefully
weigh the evidence and give nothing but
honest advice. Do not, as many have
done, make an attempt to get damages
because it will mean a positive payment
of your bill, if the claim is held valid in
court. Depend on your pay, in this case,
as you would in any othfer case, on the
patient himself. To him your services
were given, and to him look for your pay.
If at heart you believe a man respon-
sible for his own condition, you are not
justified in aiding him to a verdict. If
called to the witness stand, you should
give your honest convictions in evidence,
nothing else.
And, to go further, any physician who
takes part in any scheme to mulct a cor-
poration in any fake case, for what they
may swindle the corporation out of, is
just as dangerous to us, respectable practi-
tioners, as is a thief in any respectable
community, and should be shunned and
treated as such by us. ( "^^^l^
Digitized by VjOOyiC
May, 1904.
CONGENITAL ELEPHANTIASIS— VARNEY.
189
CONGENITAL ELEPHANTIASIS.
(Report of a Case.)
H. R. VARNEY,
Detroit.
Sporadic cases of chronic hypertrophy
of the skin and sub-cutaneous tissue, classi-
fied as Elephantiasis, are rarely seen in
the United States.
For hundreds of years, this term has
been applied to any extensive hypertro-
phied condition of the skin-connective
tissues, and in many cases it has no doubt
been misapplied.
The pathological processes differ so
greatly in the sporadic cases from those
of the endemic, that a consideration of the
congenital type of this disease, with the
report of a case, will be the subject of
this article.
This type differs not only in its origin
but in its general symptoms. The heredi-
tary tendency of this disease has been
shown by recorded cases. Nonne reports
four cases in one family, the disease ap-
pearing in the same locality on the body of
each member of the family. Moncorvo also
reports congenital cases, one of which, the
grandmother, had repeated attacks of lym-
phangitis, yet the mother was entirely free
from the disease or any of the predispos-
ing diseases, though she gave birth to a
child' afflicted with unilateral elephantiasis,
supposed to have been caused by a fall
during pregnancy. Barwell, Coley,
Wende, Jopson, and others all report con-
genital cases.
Virchow describes a congenital form of
this disease which he attributed to over-
nutrition. It was characterized by in-
creased vascular supply to the affected
area, which he termed "Elephantiasis
Telangiectodes," or Naevoid Elephantia-
sis.
On Oct., 1903, the patient whose case
I am about to report, was referred to me :
Miss E. S., now 18 years of age; Ameri-
can bom, always lived at home; general
health good. There is no history of any
such condition existing in either maternal
or paternal branch of family. During
pregnacy, the mother had fits of an epilep-
tic nature. Other children are normal and
healthy; mother's health is good; labor
during birth of this child was normal.
At birth, both mother and nurse noticed
a slight enlargement of the end of the mid-
dle finger, on left hand, with no unusual
discoloration. Little attention was given
this abnormal condition during childhood,
though there was a very gradual increase
of the enlargement, extending up the fin-
ger. The condition, as first seen by me,
is shown in the photograph. On first in-
spection one would conclude that a dis-
190
CONGENITAL ELEPHANTIASIS— VARNEY. Jour. M. S. M. S.
eased condition of the bone existed, as the
finger with the groove along its center had
the appearance of a supernumerary finger.
However, the accompanying Radio-
graph shows there was no change in the
bone structure, thus excluding Acrome-
galia. There was marked hyperplasia of
the skin and connective tissue, which could
not be pitted with pressure. The enlarge-
ment extended above the wrist with num-
bers of Keloid-like tumors upon the back
of the hand and wrist.
At this time, the middle finger of the
affected hand was three-quarters of an
inch larger in circumference than the cor-
responding finger of the other hand, and
the wrist of the diseased hand was one
inch larger than the other. The diseased
area involved the fore-finger, the inner-
half of the ring finger, and the back of the
hand and wrist. The thumb and little fin-
ger were not affected. The patient com-
plained of loss of power of the hand, and
a feeling of great weight, but never any
pain. There was almost entire loss of the
sensation of touch in the middle finger,
but only partial loss in the ring and fore-
finger.
Examinations of the blood were made
at midday and midnight. There were no
traces of filaria sanginaris, and the urine
was normal.
The etiology of sporadic Elephantiasis
is varied. Cases develop this type of dis-
eases from many causes. Any pressure
upon the veins and lyrtiphatics is consid-
ered an etiological factor.
This same etiology holds good in the
congenital cases. Some injury to the
mother, during pregnancy, is transmitted
to the unborn child, causing an inflaumia-
tion, or producing in some localized area
hypertrophy and overgrowth of the sub-
cutaneous tissue.
In the congenital cases reported by
Moncorvo, he advances the explanation
that from injury to the mother, strepto-
cocci found their way into the foetal cir-
culation, through the placenta, and thereby
produced tissue changes.
Wende states in reporting his case of
congenital elephantiasis, of which careful
microscopic examinations were made, that
no definite conclusion could be determined
upon. The etiology of this disease, ac-
cording to some authorities, is due
to many distinct causes, while other in-
vestigators agree that it is the direct result
of hereditary syphilis.
The cause of congenital elephantiasis is
truly difficult to get at. In adult life, it is
the result of recurrent inflammatory con-
ditions, or obstruction of the lymphatics,
and this must be true ni the congenital
type.
The treatment of these progressive, de-
forming congenital cases is of great im-
portance. It consists of thjtt-^lpsh^iwll
Digitized by
€5¥f§ir'
Mat, 1904.
CONGENITAL ELEPHANTIASIS— VARNEY.
191
best counteract the cause and its compli-
cations.
When the cause of the obstructive con-
dition can be discovered, as in growths of
different nature, both surgical and internal
treatment can be g^ven, with marked re-
sults that are permanent.
In the case I have reported, conservative
treatment was indicated; for if the pro-
gress of the disease could not be checked,
total loss of the use of the arm would
follow, with ultimate amputation.
The most startling, successful treatment
of this disease is reported by Thomasz.
He treated 29 cases with calcium sulphide
given internally, in increasing doses, and
iodoform ointment applied locally, the
diseased parts being tightly bandaged, and
patient kept at rest. All recovered, and
only one case recurred. Stelwagon states
that he has been unable to find a report of
similar treatment given, either favorable
.or imfavorable.
The reports of successful treatment are
mainly of cases that are seen early, when
the cause is easily removed. This is not so
in cases of the congenital type, the history
of which is obscure, or in those which have
existed for many years.
From results obtained in similar dis-
eases, as Keloid, Verruca, and Sclero-
derma, I was led to believe that the Ray
treatment might be beneficial in the case
which I am reporting. We know that
long continued, moderate exposures of the
normal skin will cause atrophy of the hair
bulb, and wrinkling of the skin, more
marked in all hypertrophic diseases in-
volving the skin and connective tissue.
Under Ray treatment, sensation re-
turned in the affected area, and Keloids dis-
appeared in the hypertrophic tissue. Care-
ful measurements were made, weekly, and
showed marked diminution in enlarged
condition. This treatment is the only one
to which the disease has responded in an
encouraging manner. All literature on
the subject agrees that this congenital form
is the most rebellious of all types of the
disease.
Mascat reports and exhibited a series of
photographs of a patient with Elephanti-
asis, that had completely recovered under
X-Ray treatments.
CONCLUSIONS.
1. The congenital type of the disease is
rare.
2. It differs in origin and general
symptoms, with no recurrent inflamma-
tory reaction. Yet is is progressive.
3. A history of injury in utero in this
case might have been an etiological factor.
4. The causes are as a rule, obscure,
rendering prognosis as to treatment,
guarded.
5. The Ray treatment should be tried.
BIBLIOGRAPHY.
1. Nonne — Virchow*s Archiv., Vol. cxxv,
1891.
2. Moncorvo — Pediatrico, 1897.
3. Coley— N. Y. Med. Journal, June 20, 1891.
4. Barwell — London Path. Society Trans.,
1881.
5. Jopson — Arch. Pediatrics, 1898, Vol. xv.
6. Wende — Ref. Hand Book Med. Sciences,
1901.
7. Merrill Rickett— Journal Cutan. Dis., 1889.
8. Thomasz— Ceylon Med. Journal, 1888.
9. Stelwagon— Treat, on Skin Disease, 2d
edition, 1903.
10. Busey, P., N. Y., 1878.
11. Muscat. Reported Academy of Science,
Paris, 1898. ^-^^-^^^^^^ ^y GOOglC
192
TUBERCULOSIS— HUNTINGTON.
Jour. M. S. M. S.
TUBERCULOSIS.*
W. C. HUNTINGTON.
Howell.
It is now agreed by those who have
given the most attention to the subject,
that tuberculosis occurs and ends in re-
covery far more frequently than was
formerly supposed. Osier says, in a recent
lecture before the Phipps Institute at Phil-
adelphia, 'The germ of tuberculosis is
ubiquitous; few reach maturity without
infection; none reach old age without a
focus somewhere." Farther on he says.
The only series which we have dealing
with this question in a satisfactory way is
in the study of 500 post-mortems in Prof.
Ribbert's Institute in Zurich, by Naegeli.
It is to be borne in mind that in his work
special examination was made of every
organ of the body, sections were made of
all parts with the greatest care, and the
individual lymph glands particularly in-
spected. Tuberculous lesions were found
in 97 per cent, of the bodies of adults. He
gives a very interesting curve showing
the incidence of different ages. Up to the
fifteenth year thefe was only 50 per cent.,
then there was a sudden rise in the eigh-
teenth year to 96 per cent., with a slow
rise, so that by the fortieth year a tuber-
culous focus was found in everybody.
This careful research demonstrates the
extraordinary susceptibility in man to
tuberculous infection, and an equally ex-
traordinary degree of resistance. In the"
tuberculin experiments of Franz on
healthy Austrian soldiers a reaction was
shown in over 60 per cent., so that w-e
must accept the conclusion that tubercu-
lous infection, latent tuberculosis, is more
♦Read before Livingston County Medical
Society, March 8th, 1904.
extensive than the manifest disease. He
says that von Behring refers all tubercu-
losis to milk, either from tuberculous cows
or containing germs received from the
air; that a focus is formed generally in
childhood, and remains latent until under
favorable circumstances it develops into
active tuberculosis. Osier does not fully
endorse these views, biit thinks that the
germs are usually received with the in-
spired air, and where they gain a foothold
enter at once upon their work, which is
much or little, according to the soil in
which they find lodgement.
In view of these differences we may
perhaps be forgiven for asking: since
a focus frequently forms in child-
hood and remains innocuous during all the
vicissitudes of a long life, and since all are
affected by it, at least once, why is it not
more frequently repeated in either case,
and may it not be that recovery, as in the
case of most very contagious diseases, con-
fers a large measure of immunity? This
would certainly l^e a more comforting
view than that of latency. Furthermore,
since it is proven that practically all child-
bearing women are tuberculous, what need
is there to make a scapegoat of the dairy
cow? If, as Koch affirms, human and
bovine tuberculoses are not the same, then
the cow is not at fault; but if as others
affirm, they are identical, then the same
conditions would occur in each. How
many of the cows that respond to the test
have anything but latent tuberculosis?
Practically none, except those that furnish
manifest symptoms of the disease. If the
milk of cows, with their small per cent, of
reaction is clangerg.u^^J|0)^^ij^^more
May, 1904.
TUBERCULOSIS— HUNTINGTON.
193
dangerous is human milk, and tb what are
we coming? If a tuberculous mother will
carry a fetus for nine months, furnishing
from her own system everything that en-
ters into it, and with their circulations
scarcely separated, without infecting it, is
it reasonable to suppose that she will af-
terwards do so through the mammary
gland and digestive tract? Too many
mothers with advanced tuberculosis have
nursed their offspring without infecting
them, to indicate that nature has made the
mammary gland an instrument for con-
veying disease. Is not the germ-laden air
a medium sufficient to convey the bacillus
to the exact spot that it is looking for?
Experience and reason both teach that
tuberculosis cannot be successfully at-
tacked by systemic medication. The tuber-
cle is non-vascular, and nature's favorite
method of cure is to surround it with in-
flammatory material, forming an inclos-
ing wall which cuts off all supplies, and
contracting, forces out the more fluid por-
tion and reduces its volume, so that all
osmosis is in an outward direction. The
complicating disorders may frequently be
helped by medication, but the prolonged
administration of medicine is as likely to
do harm, and the complications as well as
the original disease are usually best treated
by rest, fresh air (cold preferred), sun-
light, feeding and properly regulated ex-
ercise. These are best and most success-
fully applied in a sanatorium.
It is difficult to separate one*s self from
your environment, and hence environment
counts for much in tuberculosis. When we
consider how worry and apprehension de-
stroy appetite and disturb digestion, we
see the difficulty of inspiring with the nec-
essary hope and courage and at the same
time convincing the patient that his condi-
tion is so serious as to require him to do
such radical things. He will try it for a
while and then either get discouraged or
more likely consider himself well enough
so that it is no longer necessary. Could
I order rtiy sick son to sleep out in a snow
storm, or with the thermometer at 20°
below zero? And if I did, would he not
either consider it cruel or be filled with
apprehension at having a disease that
called for such radical measures? And
yet, at the sanatorium he enters into the
spirit of his surroundings and does it from
choice. We read of isolated individuals
doing this and being greatly benefited by
it, but it is those who Have reached des-
peration after loss of the most valuable
time and opportunity by the failure of
other measures. It is wholly impractica-
ble to send an inexperienced consumptive
away from home except to a sanatorium.
The great west has its fill of consumptives
and none are wanted unless at such insti-
tutions. If received elsewhere, they are
packed in with others of their kind in the
most unsanitary manner. A recent writer
in relating his own experience said that he
could not have been worse treated had he
been a lei>er. The situation at Liberty,
New York, will serve as an illustration.
The town has acquired a reputation as a
health resort. There are two sanatoria in
the town, an older and larger, the Loomis,
two and one-half miles out, and a Jewish
one a little farther on. The town is swarm-
ing with consumptives. A consumptive
physician whom I met at the Loomis San-
atorium told me that he came to Liberty
for the local advantages and stopped at
the best hotel, feeling that he was able
to care for himself, but saw so many con-
sumptives violating every sanitary law
that he felt his only safe place was in the
sanatorium. A fonner resident here, now
living near Liberty, who^I^v^s^ when
194
TUBERCUI.OSIS— HUNTINGTON.
Jour. M. S. M. S.
there, said that nearly every occupied
house in Liberty had boarders, that the
average number for good-sized residences
was about twenty-five; that these were
packed in in almost any way, and that the
uniform rate was seven dollars a week
each.
Is the sanatorium safe? Yes, absolutely
so, because everything is absolutely under
regulation. No one is allowed to expec-
torate anywhere except into a sputum cup
which each must have and deliver daily
for the disposal of its contents. A cup
with an exchangeable paper lining is used
in the rooms, and an aluminum pocket
flask for outside. Dr. Trudeau, the foun-
der of the oldest sanatorium in America^
at Saranac Lake, New York, says that
no employe of that institution was ever
known to acquire tuberculosis there, and
that the dust taken from all the buildings
has failed except in one instance to infect
guinea pigs.
The Loomis Sanatorium consists of a
large group of buildings located on the
southwest shoulder of a small mountain
of the Catskill group, two and one-half
miles from Liberty, Sullivan County, New
York. It is shielded from the northeast
winds by the mountain top and receives its
soutbwest winds from the mountains of
Pennsylvania. Its average elevation is
2200 feet. The principal buildings are the
administration building, which is a first-
class hotel, containing the dining rooms,
the physicians' and other administrative
offices and accommodations for employes
and transient guests; a chapel; the super-
intending physician's residence; a casino,
containing a piano, an organ, a billiard
table, a pool table, and opportunity for
nearly all indoor games and amusements;
a highly artistic library building contain-
ing most of the leading periodicals and
over 3000 volumes of well-selected books;
numerous cottages for the patients, each
having a veranda on the south side where
they can sit or recline in the fresh air and
sunshine, read or play games, or sleep
out at night; a reception room; a bath
room; and a bedroom for each occupant,
heated by hot water and lighted by elec-
tricity; the Annex, somewhat apart, for
thecare of the five-dollars-a-week patients;
and last, but best of all, the infirmary, for
here the most important ^ork is done. It
is here that the new-comers and worst
cases are treated until well enough to go
to their cottages. It has a veranda
along the south side and other necessary
conveniences. The room in which the
patient is put to bed for absolute rest, fresh
air, as cold as may be, and careful watch-
ing and feeding, is about ten feet square,
with a closet partitioned out of one cor-
ner. The bed is in the opposite comer,
and a door between admits from the cor-
ridor. At the foot of the bed is a radiator,
and opposite, in the space between the
closet and south wall, a dresser. Between
these are double sash doors, open upon the
veranda. These doors are kept wide
open, regardless of the weather, except
white eating, bathing, etc., and on sun-
shiny days the bed, which is on small
wheels, is rolled out on the veranda. Here,
especially when cold enough, the tempera-
ture is reduced and the appetite promoted,
and these, with the rest, increase the
weight and vitality until the patient has a
good start on the road to recovery where
that is possible.
As the infirmary patients and the worst
cases in the cottages do not go to the din-
ing rooms, and as increase of flesh, blood
and color results from treatment, a health-
ier and happier-looking group can scarcely
be found than in the Loomis iiining rooms.
Digitized by VjOC
May, 1904.
TUBERCULOSIS— HUNTINGTON.
195
How different the picture from what is
popularly imagined of such places!
The old nutrients, cod-liver oil,
malt and whiskey, almost pure carbo-
hydrates, have been eagerly laid aside, and
now some seem inclined to the other ex-
treme and feed very largely with meat,
milk and eggs, which contain a large
excess of protein. It would seem that this
if carried too far, might throw too great
a burden upon the kidneys, if, indeed, it
did not also impair digestion. Others
advocate the balanced ration. The plan at
the Loomis seems to be to provide a liberal
variety of well-prepared, nutritious food,
and allow the patient to make his own
selections. This is probably the best plan,
for in the scientific feeding of cattle,
especially dairy cows, where the results
can be determined with much accuracy, it
is found that the best results are produced
from the balanced ration; but it is also
found that, if given sufficient liberty of
choice, the cow will select the balanced
ration as accurately as a chemist could,
and she will eat more, digest it better, and
yield better results if her appetite is fully
consulted.
What is hunger but the voice of the
system proclaiming its needs? And has
nature filled that voice with lies? Has not
nature made all unwholesome, organic
things obnoxious to the senses? Poison-
ous mushrooms would seem an exception,
but they have an acrid taste and unpleasant
odor. It is by frying in butter with salt
and pepper that these are smothered and
the mischief done. Tyrotoxicon occurs
only under equally artificial conditions.
While the sanatorium treatment of tub-
erculosis is much the best thus far devised,
it is but the first step in the right direction.
Its limitations are too great, and its
agencies too little under control. An
expensive and fatiguing journey must
often be taken to reach a suitable place for
treatment, sometimes only to find the con- ,
ditions prove unfavorable. The altitude
that is so beneficial to-day may promote^a
serious hemorrhage to-morrow with no
possibility of change until the patient can
rally sufficiently to abandon the place and,
perhaps, with it, hope. The cold which is
so beneficial, cannot be had at all seasons
except at altitudes too great for safety for
diseased lungs. The sunlight, which is
so helpful, is too inconstant, ,and the best
ventilation is too dependent upon the fickle
wind. A germ-free air is needed, for
while the bacillus tuberculosis is the
pioneer and orginator of the disease pro-
cess, the saprophitic and pyogenic germs
are the principal offenders. All of these
difficulties will eventually be overcome,
however, and sometime tuberculosis will
be much more successfully treated in any
locality than in the most favored places
now.
Let us build an air castle and after it is
completed we may consider whether the
idea might ever materialize in an actual
structure for the treatment of tuberculosis
with pure air, or must, like other air
castles, remain the fleeting fancy Of a
pleasing day dream.
Wewill build an infirmary much like the
one above described, but the ceiling will
be only high enough to clear a tall per-
son's head. The bed will be as high as
practicable so as to bring the patient up
toward the ceiling. There will be no out-
side doors or windows, and the door into
the corridor will be as tight as possible.
We will make an opening in the ceiling,
over the patent's head, connecting with a
blower, somewhat like those in factories
which convey the sawdust, shavings and
chips from the machines |o-^c^nlf|^ place
Digitized by
196
TUBERCULOSIS— HUNTINGTON.
Jour M.S.M.S.
of deposit. With this we hope to catch the
breath as it rises, lighter than the air