Elephantiasis

“ In the medical writings of Aretæus, Aetius, and the later school of Greek physicians, the disease is described under the title of elephantiasis, for (says Aretæus) “it is disgusting to the sight, and terrible in all respects (est visu fœdus et in omnibus terribilis) , like the beast of the same name.”149 The Arabian medical authors applied the corresponding term of “Das Fil,” “elephant disease,” 57or elephantiasis, to an affection entirely different, and one apparently unknown to the Greek physicians, namely, the tumid, Barbadoes, or Cochin leg of modern pathologists. ”

“ It is evident that, with varying degrees of infection of the general population with F. nocturna, we ought to have a fairly fixed ratio of elephantiasis, but up to the present we have no proof of this. The only thing we have to go on are impressions that the disease is common. ”

“ In the first instance I was myself led to conclude that some of the forms of elephantiasis might be due to other causes than obstruction of the lymphatics caused by the presence of Filariæ; but the explanations of Lewis, of Bancroft, and of Manson more especially, have almost entirely removed this doubt. Those who seek to explain away the connection between genuine elephantiasis and Filariæ will do well to study Manson’s last important memoir. He shows that “elephantiasis and allied diseases are much more frequently associated with the parasite than are other morbid conditions.” ”

“ Elephantiasis, a peculiar skin disease, accompanied with abnormal swelling; so called because the skin becomes hard and stiff like an elephant's hide; attacks the lower limbs and scrotum; is chiefly confined to India and other tropical countries.
Elephantine, a small island below the first cataract of the Nile; contains interesting monuments and ruins of the ancient Roman and Egyptian civilisations. ”

“ Elephantiasis is a disease in man, deriving its name from the elephant, who is also afflicted with a similar disorder. It is also called the Arabian leprosy. Medical treatises describe its appearances, mode of cure in the human being. As few readers possess elephants, it will not be necessary to say more of it, than that it is cutaneous; and that to prevent it in the elephant, the Indians apply oil to the animal’s skin, which, to preserve its pliancy, they frequently bathe with the unctuous fluid. ”

“ Most of the elderly men, by the way, had elephantiasis.
******
Because elephantiasis was something I had to meet as I went along, it may be apropos to explain what I have mentioned before: that it is not a disease, but the manifestation of a disease. The disease is filariasis, caused by the filarial worm, a long, threadlike creature that lives in the lymphatic glands. The eggs pass into the lymphatic and blood streams and hatch into microfilariae. The low power of a microscope will show them in a drop of blood, but their sex cannot be distinguished. ”

“ The first accurate ideas in reference to elephantiasis arabum are given by Rhazes, Haly-Abas, and Avicenna, and it is possibly on this account that the disease received the name elephantiasis arabum. The disease was afterward noticed by Forestus, Mercurialis, Kaempfer, Ludoff, and others. In 1719 Prosper Alpinus wrote of it in Egypt, and the medical officers of the French army that invaded Egypt became familiar with it; since then the disease has been well known. ”

“ Lemoine, as well as other writers on elephantiasis, has seen the disease become stationary by the removal of the patient to a colder climate. Europeans become susceptible to elephantiatic infection after a prolonged residence in tropical countries where the disease prevails. ”

“ The geographical distribution of Filaria bancrofti and of elephantiasis arabum corresponds; where elephantiasis abounds there the filaria abounds, and vice versa. (2) Filarial lymphatic varix and elephantiasis occur in the same districts, and frequently concur in the same individual. (3) Lymph scrotum, an unquestionably filarial disease, often terminates in elephantiasis of the scrotum. (4) Elephantiasis of the leg sometimes supervenes on the surgical removal of a lymph scrotum. (5) Elephantiasis and lymphatic varix are essentially diseases of the lymphatics. ”

“ Elephantiasis (Arabian) is usually situated in the lower extremities, in men in the scrotum and penis, in women in the labium pudendi, mons veneris, and the mammæ; more rarely it attacks the upper extremities or, indeed, the head. The disease develops during repeated attacks, which occur at irregular intervals of weeks, months or years, of fever accompanied by symptoms of lymphangitis and erysipelas (elephantoid fever) , and especially as the result of different accidental occurrences such as chills, bodily exertions, external irritation. ”

“ Seated on the ground, a man afflicted with elephantiasis pointed with his finger to his leg, massive as the trunk of an oak, covered with warts and yellow crusts, dotted with black or hardened spots, so voluminous that one would have said it did not belong to him. A blind man, on his knees, his hands stretched towards heaven in the attitude of an ecstatic, had under his high and bald brow two little blood-stained holes. ”

“ You will see that it has the appearance of a typical case of elephantiasis of both legs, and in a tropical country would have been accepted as a case of filarial elephantiasis, and the fact that no filaria were found in the blood would have been cited as a proof that it was caused by F. bancrofti, and that the obstruction had shut off the embryos from the blood-stream. But this case occurred in a country where the possibility of filarial infection was definitely excluded, and the obstruction was found to be due to a fibrosis of the lower part of the thoracic duct. ”

“ Well, in my opinion, did Aretæus the Cappadocian say, that the power of remedies ought to be greater than those of diseases; and that for this reason elephantiasis is incurable, because it is impossible to find a medicine more powerful than it. For if cancer, which is, as it were, an elephantiasis in a particular part, is ranked among the incurable diseases by Hippocrates himself, how much more is not elephantiasis incurable, which is, as it were, a cancer of the whole body? ”

“ The second suggestion is that elephantiasis and chyluria are due to impaction of the parent worm in some part of the lymphatic system—that there is a mechanical obstruction. So far as elephantiasis is concerned, I do not think that this is now seriously urged. It is certainly difficult to understand how a single live worm of the calibre of the F. bancrofti could produce such total obstruction as to lead to almost complete stasis of the lymph stream. ”

“ Pain lays not its touch upon a corpse.
ÆSCHYLUS.
Elephantiasis in its worst forms has taken a firm hold on the natives, especially the inhabitants of the near-by island of Moorea. There this disease can be studied in all its stages, from a slight enlargement of one of the extremities to colossal swellings, which, when the upper and lower extremities are affected at the same time, make it necessary for the patient to crawl on his hands and feet in dragging himself from place to place. ”

“ Vidal and Joannis assert that they have seen this libido in those Greek sailors affected with elephantiasis. After these proofs, it required some boldness to deny the possibility of this symptom, which to us seems 203 easily explained. Consider the nature of elephantiasis: while it affects the skin, it extends to the mucous membranes, where we find tubercles, ulcerations, softenings, &c. Why should the membrane, lining the genito-urinary passages, be exempt from these alterations? ”

“ The presence of these parasites seems at times to have little effect on the host, and men in whose system it is calculated there are some 40-50 million larvae have shown no signs of disease. In other cases very serious disorders of the lymphatic system are brought about, of which the most marked is perhaps Elephantiasis. ”

“ If he runs barefoot across the beach to have a swim, he will tread where an elephantiasis case trod a few minutes before. If he closets himself in his own house, yet every bit of fresh food on his table will have been subjected to the contamination, be it flesh, fish, fowl, or vegetable. ”

“ Edmondston of Lerwick, to trace out the history of the disease in the north, and that gentleman has made the following observations upon it in his work on the Zetland Isles:—
“Elephantiasis, known by the name of leprosy, was very frequent in Zetland about sixty years ago, but its occurrence since that time has only been occasional, and at present scarcely an instance of it is to be met with. A native of Zetland, a few years ago, was received into the hospital of Edinburgh, labouring under true elephantiasis. ”

“ Leprosy is often accompanied by elephantiasis; in fact, some medical authorities use the terms synonymously for the same disease. All through the South p136 Seas, where lepers and elephantiasis victims mingle with the other natives in their villages, the ones afflicted with elephantiasis are looked upon with more horror than the ones with leprosy, as the natives say elephantiasis is more catching, and that it develops more rapidly. At one island I was on, in the Society Group, it is estimated that one-tenth of the population has elephantiasis, or fey-fey, as they call it. ”

“ The health of the people on these islands is represented to be most excellent, owing to the perfection of the climate; but there is one prominent drawback to the locality in the presence and prevalence of elephantiasis among the natives, from which hideous disease the foreign residents are not exempt. It requires time to develop it in the system, and it does not attack persons until after a residence of eight or ten years. ”

“ After describing the horrors and course of elephantiasis or tubercular leprosy, the old Roman physician, Aretæus, adds, “seeing the infected with this disease are such, who would not fly them? (aufugiat) , or who would not turn aside from a leper, even although he were a son, or a father, or a brother, since there is fear lest the disease should be communicated? ”

“ But these immunities, even the best marked, disappear with time, and still more under the influence of conditions of existence. I will give you a curious example:
Elephantiasis is a hideous malady, peculiar to certain warm countries, which swells and deforms, sometimes in the strangest way, the parts of the body it attacks. In one of the Antilles, in Barbadoes, this disease was seen from the first among the negroes, but had constantly spared the whites, till 1704. That year a white person was seized, and since then the malady has extended in this race ”

“ The thickenings due to leprosy and those connected with filariasis were separated clinically by observers during the 17th and 18th centuries, Hilary, in 1750, having accurately described the progress of that form of elephantiasis connected with elephantoid fever and lymphangitis. In 1863 Demarquay discovered filarial embryos in the exudate of a chylous hydrocele and three years later Wucherer, in Brazil, found similar nematode larvae in the urine of a case of haematochyluria. ”

“ We should be able to remove the parasite and grow it outside the human body. 3. We should be able to re-introduce it into the human body or that of some lower animal and there reproduce a similar disease. 4. We should be again able to demonstrate the presence of the parasite. With reference to the first, I shall show presently the invariable association of F. nocturna has not being clearly proved; indeed, its absence in the case of elephantiasis is cited as one of the proofs of its association with the disease, and this difficulty requires explanation. ”

“ The other species with which the country people are in some instances affected is doubtless, from the description given of its dreadful symptoms, that severe kind of leprosy which has been termed elephantiasis, and is particularly described in the Asiatic Researches Volume 2, the skin coming off in flakes, and the flesh falling from the bones, as in the lues venerea. ”

“ In defining the genus elephantiasis, Dr. Good selects the second 56and third characters of Cullen as the most distinctive, and adds to these two others—viz. “ (1) eyes fierce and staring; (2) perspiration highly offensive.” In defining the first species of this genus (or the Greek elephantiasis of other authors) , he introduces as its three pathognomonic symptoms, the first and fourth characters of Cullen and a part of the second.148
Nomenclature of the Disease. ”

“ In cases where we have multiple elephantiasis, for example the scrotum, one leg, and one arm, we must assume three adult females, all injured and all aborting. It seems to me that here it would be more reasonable either to assume an obstruction of some of the main lymphatics in the abdomen, or else, as I shall suggest presently, some common cause of peripheral origin. ”

“ In fact this was about the same proportion that I found among the assorted natives brought to the hospital in Rabaul. Hookworm, on the other hand, was only 8.4 per cent as against 74.2 for the whole Territory. Why? Because the group was made up of narrow atolls, where the beaches were the latrines and the tide carried the infecting material away. Malaria and elephantiasis are both mosquito diseases (if you can call elephantiasis a disease—it is merely a symptom of filarial infection) . On one of the islands here I saw a woman’s breasts so enlarged that when she sat they touched the ground. ”