The Understanding of Elephantiasis ca. 1800
In her letter to Wilhelm Schlegel on 19 July 1801 (letter 326), Caroline mentions that Philipp Veit had apparently broken out “with a proper case of elephantiasis, which has always lurked beneath his skin.”
Because Caroline does not mention the limb enlargement often associated with elephantiasis, but rather only a subcutaneous skin disease, see the following illustrations from Daniel Cornelius Danielssen, Wilhelm Boeck, L.-A Cosson, and J.-L Losting, Traité de la spedalskhed ou éléphantiasis des Grecs (Paris 1848), plates 2, 4, 12, 13, 20, 22, which focus on the latter phenomenon:
See William Turton, A Medical Glossary; in which the words in the various branches of medicine are deduced from their original languages; properly accented and explained, 2nd ed. (London 1802), 292:
Elephantíasis (ελεφαντιασις, from ελεφας the elephant). A horrible cutaneous disorder, in which the legs grow scaly, rough, and wonderfully [remarkably, extraordinarily] large, like the legs of an elephant.
See contemporaneous with Caroline’s remark The Edinburgh Practice of Physic and Surgery; preceded by an abstract of the theory of medicine and the nosology of Dr. Cullen (London 1800), 522–25:
Elephantiasis, Sauv. gen. 302. Vog. 321. Sag. gen. 128.
Elephantia Arabum, Vog. 322.
1. Description.] The best account of this disease is that by Dr. Heberden published in the first volume of the Medical Transactions. According to him, frequently the first symptom is a sudden eruption of tubercles, or bumps of different sizes, of a red colour, more or less intense (attended with great heat and itching), on the body, legs, arms, and face: sometimes in the face and neck alone, at other times occupying the limbs only; the patient is feverish; the fever ceasing, the tubercles remain indolent, and in some degree scirrhous, of a lived or copper colour, but sometimes of the natural colour of the skin, or at least very little altered; and sometimes they, after some months, ulcerate, discharging a fetid ichorous humour in small quantify, but never laudable pus.
The features of the face swell and enlarge greatly; the part above the eye-brows seems inflated; the hair of the eye-brows falls off, as does the hair of the beard; but Dr. Heberden has never seen any one whose hair has not remained on his head.
The alæ nasi are swelled and scabrous; the nostrils patulous, and sometimes affected with ulcers, which, corroding the cartilage and septum nasi, occasion the nose to fall.
The lips are tumid; the voice is hoarse; which symptom has been observed when no ulcers have appeared in the throat, although sometimes both the throat and gums are ulcerated.
The ears, particularly the lobes, are thickened, and occupied by tubercles.
The nails grow scabrous and rugose, appearing something like the rough bark of a tree; and the distemper advancing, corrodes the parts gradually with a dry sordid scab or gangrenous ulcer; so that the fingers and toes rot and separate joint after joint.
In some patients the legs seem rather posts than legs, being no longer of the natural shape, but swelled to an enormous size, and indurated, not yielding to the pressure of the fingers; and the superficies is covered with very thin scales, of a dull whitish colour, seemingly much finer, but not so white as those observed in the lepra Græcorum.
The whole limb is overspread with tubercles, interspersed with deep fissures; sometimes the limb is covered with a thick moist scabby crust, and not unfrequently the tubercles ulcerate. In others the legs are emaciated, and sometimes ulcerated; at other times affected with tubercles without ulceration. The muscular flesh between the thumb and fore-finger is generally extenuated.
The whole skin, particularly that of the face, has a remarkably shining appearance, as if it was varnished or finely polished. The sensation in the parts affected is very obtuse, or totally abolished; so that pinching, or puncturing the part, gives little or no uneasiness; and in some patients, the motion of the fingers and toes is quite destroyed. The breath is very offensive; the pulse in general weak and slow.
The disease often attacks the patient in a different manner from that above described, beginning almost insensibly; a few indolent tubercles appearing on various parts of the body or limbs, generally on the legs or arms, sometimes on the face, neck, or breast, and sometimes in the lobes of the ears, increasing by very slow degrees, without any disorder, previous or concomitant, in respect of pain or uneasiness.
To distinguish the disease from its manner of attacking the patient, Dr. Heberden styles the first by fluxion and the other by congestion. That by fluxion is often the attendant of a crapula, or surfeit from gross foods; whereby, perhaps, the latent seeds of the disorder yet dormant in the mass of blood are excited; and probably from frequent observations of this kind (the last meal always having the blame laid on it), it is, that, according to the received opinion, either fish (the tunny, mackarel, and shell-fish, in particular), melons, cucumbers, young garden-beans, or mulberries, eaten at the same meal with butter, cheese, or any preparation with milk, are supposed to produce the disease, and are accordingly religiously avoided.
2. Causes.] Violent commotions of the mind, as anger, fear, and grief, have more than once been observed to have given rise to the disorder: and more frequently, in the female sex, a sudden suppression of an accustomed evacuation, by bathing the legs and feet in cold water at an improper season.
3. Cure.] The disorder by fluxion is what is the oftenest endeavoured to be remedied by timely applications; that by congestion, not being so conspicuous, is generally either neglected or attempted to be concealed, until perhaps it be too late to be cured, at least unless the patients would submit to a longer course of medicine and stricter regimen of diet than they are commonly inclined to do.
Several incipient disorders by fluxion have been known to yield to an antiphlogistic method, as bleeding, refrigerant salts, the saline draughts, and a solution of crystals of tartar in water, for common drink (by this means endeavouring to precipitate part of the peccant matter, perhaps too gross to pass the pores by the kidneys); and when once the fever is overcome, the Peruvian bark combined with sassafras is the remedy principally to be relied on.
The only topical medicine prescribed by Dr. Heberden, was an attenuating embrocation of brandy and alkaline spirits. By the same method some confirmed cases have been palliated. But, excepting in one patient, he never saw or heard of a confirmed elephantiasis radically cured. He adds, however, that he never met with another patient possessed with prudence and perseverance enough to prosecute the cure as he ought.
Dr. Temple speaks of the cure in the following way:
This disease has generally been found incurable. The warm bath should be ordered; if the patient is plethoric, and inflammatory symptoms are present, bleeding and cooling laxatives, such as cryst. tart, with a light diet, should be advised. When this state is removed, some advantage has been thought to have been derived from the cinchona. Issues are advised, and the following embrocation:
(No. 435.) ℞ Spt. vin. ten. ℥viij.
Aq. kali ℥j.
Aquæ ammoniæ ℥ij. M. fiat Embrocatio.
The following he also says may be tried:
(No. 436.) ℞ Calomel. ppt.
Sulph. antimon. præcipit. aa ℈j,
Mic. panis q. s.
Misce fiant pill. No. x. capt. j. vel. ij. mane et vespere quotidie.
That exploded remedy, the flesh and fat of vipers, it appears, has been lately again introduced into practice, and said to be of service in this disease.
In the New Medical Journal, white arsenic is recommended as a cure for the elephantiasis, in an extract from the Asiatic Researches. It is directed in the following manner:
Take of white arsenic, fine and fresh, one part; of picked black pepper, six parts.
Let both be beaten well, at intervals, for four days successively in an iron mortar, and then reduced to an impalpable powder in one of stone, with a stone pestle, and thus completely levigated, a little water being mixed with them, make pills of them as large as tares or small pulse, and keep them dry in a shady place.
One of these pills must be taken morning and evening, with some betel leaf, or, in countries where the betel is not to be had, with cold water; if the body be cleansed from foulness and obstructions by gentle cathartics and bleeding, before the medicine is administered, the remedy will be speedier.
Every practitioner, however, should be extremely cautious of employing this dangerous remedy, either in this or any other case. When it is employed, however, we are disposed to recommend the preparation (No. II.) in preference to the above formula.
Dr. Hugh Smith asserts that antimonial remedies are preferable in this disease to mercurials; but we apprehend they are best joined, as in (No. 137.) The doctor gives us the following formulae:
(No. 437.) ℞ Antimon. crud. 3ß.
Cons, cochlear. hort. ℈j.
Syr. simp. q. s.
Fiat Bol. bis die sumend. superbibend. decoct, seq. ℔ss.
(No. 438.) ℞ Cort. ulmi recent, ℔j.
Coque ex aq. fontan. q. s. ad colatur. ℔viij.
(No. 439.) ℞ Unguent, simp. ℥ij.
Ceruss. acetat. ʒij.
Misce fiat Linimentum partib. affect, applicandum.
The doctor also recommends the alterative pill (No. 116.).
See from slightly later Bartholomew Parr, The London Medical Dictionary, including under distinct heads every branch of medicine, viz. anatomy, physiology, and pathology, the practice of physic and surgery, therapeutics, and material medica, with whatever relates to medicine in natural philosophy, chemistry, and natural history, vol. 1 (London 1809), 597–98:
Elephantíasis; lazari morbus vel malum; Phœniceus morbus, is generally ranked as a species of leprosy (see Lepra Arabum); but is distinguished, from the leprosy by being seated in the flesh, while the leprosy only affects the skin, or, at the most, the integuments. This disorder receives its name from its often affecting the legs, so as to make them resemble those of an elephant; but in many instances the legs are not affected.
Dr. Cullen places this genus of disease in the class cachexiæ, and order impetigines, and defines it a contagions disease, wherein the skin is thick, wrinkled, rough, and unctuous, divested of its hair; the extremities insensible, with respect to feeling; the face disfigured with hard tumours, called tubera; the voice hoarse and nasal. In different parts of the skin sometimes arise fungi, having the appearance of mulberries or raspberries.
Dr. Towne assures us, that negroes are very commonly the subjects of this disorder, and that it bears a great affinity to the best account we have of the lepra of the Arabians. He says those are the most subject to it, who, after severe acute fevers, long-continued intermittents, or other tedious diseases, are either much exposed to the inclemency of rainy seasons, and the cold dews of the evening, or who are constrained to subsist on bad diet.
On the first attack the patient complains of shiverings; these continue a few hours, and are succeeded by a pain in the head, back, and loins; a nausea and vomiting soon follow, with pain in one of the inguinal glands (never in both): a severe fever follows; the gland reddens, becomes hard, but seldom suppurates; a red streak runs down the thigh, from the swelled gland to the leg, almost an inch broad, and of a flesh colour: this streak soon swells, and then the fever abates, and the matter is thrown upon the leg by an imperfect crisis.
By degrees the leg is more and more tumefied, and the veins are formed into large varices, which are very apparent from the knee downward to the toes. Soon after, the skin grows rugged and unequal; a scaly substance soon forms on it, with fissures interspersed. These scales do not dry, but are daily protruded forward, until the leg is greatly enlarged. Though this scaly substance appear harsh and insensible, if it is very superficially touched with the point of a lancet, the blood freely oozes out.
Notwithstanding the monstrous size of the diseased leg, the appetite remains good, and in all other respects the patient is healthy: many continue in this state for twenty years or more, and make no other complaint than what the enormous size of the leg occasions. It rarely happens that both legs are affected. White people suffer from this disorder when in the same circumstances which produce it in the negro. The disease is infections, and often found to be hereditary.
The cure is uncertain: after cleansing the first passages, warm diaphoretics may be mixed with antimonials, and administered with the bark. The diet and mode of living should conduce to increase the vis vitæ. Mercury is said to be injurious; but experience has occasionally shown its utility, when joined with the remedies just mentioned.
Aretæus describes the elephantiasis with great accuracy. Towne is particular in the account of it. See Turner also in his Diseases of the Skin, and Brook’s Practice of Physic.
In the London Medical Transactions, vol i. p. 23, is inserted a description of the elephantiasis, as it appears in Madeira, with the method which in one instance was attended with success. In this country the disorder appears at first in the form of tubercles on any or all parts of the body; in time they ulcerate: if they occur on the beard or eyebrows, the hairs fall off; but this does not always happen on the head.
The legs swell, and are hard; white scales cover them, and fissures occasionally appear, though the legs are sometimes emaciated and full of ulcers. The alæ nasi are swollen and rough; the cartilage of the nose sometimes destroyed; the lobes of the ears are swollen; the voice hoarse; the nails are thick and scaly; the skin white, shining, and insensible; the breath offensive; the pulse weak and slow.
Many other very disagreeable symptoms occur in different patients. None are observed to receive this disorder from others by contact; but generally the children of the diseased are subjected to it.
It usually appears here as a chronic disease on the decline of life, and every circumstance shows a great deficiency of nervous power. We never saw, in the few cases that have occurred to us, any advantage from medicine; but the bark, with the following embrocation and blistering, is said to have relieved after mercurials and antimonials had failed. The following is the mode recommended: Applicetur emplastrum epispasticum nuchæ. ℞ Cort. Peruv. pulv. ℥i. ss. cort radicis sassafræ pulv. ℥ss. syr. q. s. fiat. electar. cap. q. n. m. majoris bis in die.
℞ Spt. vini tenuior. ℥viii lixiv. tart. ℥i. spt. sal ammon. ʒii. m. f. embrocatio qua inungantur partes affectæ mane nocteque.
The disease was, however, apparently mistaken, or the event unfaithfully related.
The cause is often indigestion, and it has been attributed, in the island of Madeira, to the poison of fish. Sometimes emetics, and in some instances cooling antiphlogistic medicines, are said to have been there serviceable. In the elephantiasis of the East (see Asiatic Researches), white arsenic is said to have succeeded. Dr. Semple advises mercury and antimony, with an embrocation, consisting of eight ounces of spirit of wine, an ounce of aqua kali, with twice as much aqua ammoniä.