REPORTS OF CASES. A CASE OF ELEPHANTIASIS ARABUM OF BOTH LOWER EXTREMITIES. WILLIAM F. BREAKEY, M. D. Department of Dermatology. An American, aged fifty-two years, married, lumberman and farmer, came to the University Hospital on September 22, 1909, because of increase in size of legs. His family history is negative. Father died of senility at the age of eighty-two, and mother died at age of seventy-two of paralysis. He has one brother living-two dead of black measles and typhoid; also has three sisters all perfectly healthy. The patient was very rugged as a child, but had whooping-cough, measles, and typhoid, with good recovery. Up to three years of age the patient says he had excellent health. He has always labored very hard and has worked in water and swamps for the last ten years. About three years ago patient was compelled to quit work on account of an "all gone" feeling, and noticed at this time that he was very short of breath. About two months after he quit work he noticed large and small blisters on his legs, which when they opened would pour out a fluid that seemed to burn his legs very much. This he treated with pure carbolic acid and burned the tissue very badly. Two months later these burns healed. Then the patient noted that his legs had begun swelling and were increasing in size. About this time he began sitting in his chair at night in preference to lying down, for he says his chest seemed full and his legs would pain him if he attempted to assume the recumbent position. This condition has increased gradually until the present time. Laboratory findings show that the red blood corpuscles number 5,000,000; whites 8,000; hemoglobin eighty per cent. Repeated examination of blood by different observers has failed to reveal any organism. The urine shows no positive reaction. This patient presents conditions of such rarity in this climate as to deserve careful inquiry into the history, pathology, and etiology of his disease. The fact that cases apparently if not identically the same are endemic in some warm climates, together with the interest aroused in recent years in the study of parasitic diseases in the tropics, make it highly important to establish a correct diagnosis in every case. The term, elephantiasis arabum, variously named elephant leg, Barbadoes leg, Cochin. leg-fibroareolaris, hypersarcosis, mal de Cayenne, pachydermia, et cetera is a disease largely of tropical countries. One of the results of the invasion of the human body by the filaria sanguinis hominis, of which there are three varieties diurna, nocturne, and perstans,-is blocking of the lymph channels and capillary blood-vessels. These varieties of this nematode worm are so named from variations in their periodicity and constancy of occurrence, the embryos ranging the blood chiefly at night, the second chiefly in the day time, and a third more or less constantly at all hours. The parasite is usually sought for in blood taken at night. It is not necessary here from the clinical standpoint, to follow the incubation of the parasite through its evolutionary changes in the intermediary host of the mosquito to its final development in the lmyph and blood channels of the human body. The morbid symptoms following this invasion are sometimes slight, but in the majority of cases, results are serious, chiefly due, it is believed, to obstruction of the lymphatic channels. The feet and legs and genitals are usually the parts affected, though there would seem to be no reason why in this disease of parasitic origin, other parts of the body may not be affected unless posture and gravity cause it, as in edema of the extremities. The "lymph scrotum" sometimes becomes of enormous dimensions. There are sometimes circumscribed lymphangiomata on any part of the body and lymphangiectasis, superficial or deep. Conditions beginning as elephantiasis lymphangiectasis sometimes degenerate into various forms of multiple pigmented sarcoma, shown in photographs exhibited of sarcoma and granulomata. In some cases there is in the early stages a form of hypertrophy or acromegaly, and sometimes an osteomegaly. The x-ray plate of this patient, taken since he came into the hospital, shows no enlargement of bones. In the horse, the ass, and the mule, the filaria equi is found similar to that observed in man, though somewhat smaller. And it seems quite as possible that this disease might be transferred to man through some intermediary insect host, as that the vegetable skin parasite, the tricophyton, is communicated from the lower animals to man. Elephantiasis Grecorum is now classed as one of the forms of leprosy. Elphantiasis is found occasionally in sporadic cases, nonparasitic, socalled, and the question suggests itself in a speculative way-Is the condition due in any degree to an undemonstrated organism; or, as appears evident in this case, to structural changes interrupting circulation in the blood and lymph channels, the result of inflammatory action in skin and subtegumentary tissues, with or without other infection, producing warty, papulomatous nodular elevations with great thickening of the whole skin, fissures, serous exudate, and a train of symptoms so conspicuously shown in the history and behavior of this case. In this patient there may have been an unrecognized endo- or pericarditis at the time the "all gone" feeling became manifest, and the "shortness of breath." He had hypertrophy of the heart with mitral lesions, furnishing reason to believe that here was a large contributory if not primary factor in the etiology. His dyspnea was greatly aggravated by dorsal posture, and Doctor Hewlett kindly complied with my request to examine the patient's heart, and as he will discuss that feature of the case I will not dwell upon it. It is a significant fact that the patient had, about two months after being compelled to quit work, large and small blisters on his legs, the contents of which were acrid and irritating to the skin; also that he applied undiluted carbolic acid to these sores. Notwithstanding his exposure by wading in swamps it is improbable that he acquired a dermatitis venenata so long before the appearance of the bullous lesions described; neither does the description suggest pemphigus; and though he was driving horses none of them were ill or had lymphangitis. Nor does he know of other unfortunates like himself in the community where he had lived over thirty years. So we believe that the case is properly called sporadic, by reason of failure to find any parasitic origin, even if the cardiac lesions were not so evident. Just what role the carbolic acid played is largely conjectural without knowing more definite details as to its immediate effects, but it is quite safe to say that it aggravated the situation and probably caused deep adhesions. When the patient came into the hospital about two weeks ago there was a copious, offensive, malodorous, seropurulent exudate making it difficult to care for him and keep him tidy. There was also edema of the penis and scrotum. There has been under compression by bandaging a marked improvement and diminution in size and in the conditions of his legs, more especially in the left one. The treatment has been symptomatic-with best diet practicable. The prognosis obviously is not good. DISCUSSION. DOCTOR JAMES F. BREAKEY: This patient undoubtedly represents one of the sporadic cases of elephantiasis, such as are found in the north. The endemic cases occur mostly in the tropic countries and islands and along the coast. It has been claimed that true endemic elephantiasis is not found outside of the natives, or outside of those having an admixture of native blood. As regards the presence of filaria in the endemic cases,— while they are usually found they cannot be said to be the only etiologic factor, as they are also found in other conditions presenting no symptoms of elephantiasis. Among the sporadic cases heredity plays a rather important part even in the adult. Streptococci have been found somewhat similar to those present in erysipelas. Frequently sporadic elephantiasis begins by repeated attacks of erysipelas, subsiding and reappearing, and each recurring attack adding to the gradually increasing hyperplasia. Frequent erythematous eruptions may act in the same way. In this case we can undoubtedly look for the cause in the long continued exposure in the water, and the immediately succeeding irritation from the carbolic acid. As stated, the condition of the heart is a very strong factor in addition. Were it not for his heart, he would be able to recline, which would assist much in the drainage. I think the plate shows very excellently the degree of hyperplasia present. The contrast in the left leg is more or less distinct. And, of course, looking at the two legs one can see that the elephantiasis is less in the left than in the right. On the right side the thickness is so great that one can detect only a very slight shadow between the bone and the rest of the limb. The early skin changes in elephantiasis are usually found in the corium, but as the disease advances the skin becomes so changed and thickened that it is impossible to distinguish the different layers. As regards successful treatment, of course it is first prophylactic. Sporadic cases occasionally follow surgical procedures in which the lymphatic glands have been removed, as in amputation of the breast with excision of the maxillary glands. Here, elephantiasis of the arm may supervene. To guard against this, elevation and compression are indicated. Any line of treatment looking to improved circulation and drainage is of service. DOCTOR ALBION W. HEWLETT: This patient interested me particularly on account of the condition of his heart and the possible relation that this bore to the changes in his legs. His heart is extremely irregular and venous tracings show that the irregularity is of the permanent type with absence of auricular waves. This is always a serious condition and as is usual in such cases, the orthodiagraph shows a considerable enlargement of the heart. He began to suffer from shortness of breath before his legs enlarged and he has not been able to lie down for two years or more, largely on this account. In view of these facts it seems probable that the cardiac insufficiency bears some relation to the elephantiasis, the other factor being some chronic inflammation of the lymphatics or connective tissue. I have seen a similar condition in a woman with mitral valve disease who had her legs repeatedly punctured on account of the great edema present. Ultimately she developed a condition of the legs resembling elephantiasis. This seemed to be due to a series of mild and chronic infections following the punctures. A PATIENT WITH EXTREME CYANOSIS. The patient came to the hospital complaining of stomach ailment which proved to be due to hyperacidity and was relieved by appropriate treatment. His general appearance, however, was alarming on account of the extreme degree of cyanosis present. For fifteen or twenty years he has been moderately short of breath and has had a more or less continual cough. Up to about a year and a half ago he had a very red face and was often spoken of as the red-faced fellow. In the past year and a half, however, his color has changed from red to blue and his dyspnea has increased. He has also had occasional swelling of the feet. At present the cyanosis is often so marked as to be alarming. It is most intense in the lips, mouth, cheeks, ears, hands, and in the feet after they have been exposed to the air. The cyanosis is therefore a general one and the cause can hardly be due to compression of a large vein. The x-ray shows no definite abnormal shadow in the chest. The patient presents the classic signs of pulmonary emphysema with chronic bronchitis, and in my opinion this is the cause of his cyanosis. The small amount of albumin in his urine is probably due to the cyanosis. It is interesting that his condition should have changed about a year and a half ago and from a red-faced man he became a blue-faced man. Together with this change he seemed to become more short of breath and edema of the legs occasionally appeared. Possibly at that time the right heart, upon which extra work falls in chronic emphysema with bronchitis, weakened. under the strain and this was the cause of the change in his condition. The patient's larynx was normal. The cyanosis showed the usual distribution, |