Monday, 19 August 2013

Elephantiasis...and Indolent Dispositions in Diseases

 In this source text, John Hunter, the distinguished eighteenth-century surgeon  discusses unnatural growths, elephantiasis, and Indolent Dispositions:

Of the unnatural Growth of Parts.—These often form what may be called a species of monstrosity of parts, either diffused or circumscribed. They are generally situated in the cellular membrane, and feel doughy and soft, and are usually superficial, extending to the skin till it hangs as if by its own weight, sometimes having a broad base, but often hanging by a small neck : they appear to be in the cellular membrane what exostosis is in bone. These parts are less ductile than the natural parts. I have seen the double chin become one of these ; I have seen them on the belly. Perhaps they produce absorption in the parts on which they press ; for the bones underneath have been sometimes found deficient.

    Preternatural accumulations of fat take place in the same manner; not depending on a deposit of interstitial substance, nor being adventitious, but a preternatural growth ; and are common to every part of the body, not excepting the internal parts. People have died of fat on the pericardium, and sometimes it is found in the bellies of cattle, as sheep. In the human subject these accumulations acquire an immense size, being composed of very solid fat, and in some degree moveable, being in separate parts, or lobulated, when between the skin and muscles. They may in general be distinguished by the former being of a regular uniform softness, whilst the latter appear to be composed of solid pieces of fat, having a surface irregular to the feel.

The interstitial or diffused thickening of a part arises from the interstitial deposition of matter in the cells of the part, and is of three kinds.

Elephantiasis.—The first, or diffused, is very slow in increase, forming gradually. A whole leg will become stiff and feel tight by a loaded cellular membrane. It is most frequent in the legs, and almost peculiar to some countries and to some peculiar constitutions. A similar increase occurs in the thyroid gland : but this is of the second kind. The diffused is very common in the legs of Barbadoes' people; I have also seen it in this country, but very rarely. The legs of young people I have seen so swelled as to be all of a size. It arises from an extravasation of coagulable lymph equally diffused; the parts become firm and similar to dropsy, only there is no pitting : it may be a kind of dropsy, for dropsical swellings often degenerate into this kind of swelling; yet the cause of the two may be very dissimilar : it is most frequent in young people. From its being so diffused and general, and in the legs, and most at the lower parts, I should think one of its immediate cases was a depending situation, with a weakened action of the system in general, as a simple bandage to support these parts often prevents it. [A preparation was shown, in which a thickening of the leg put on the appearance of brawn.] There is no fixed cure. In the case I saw I recommended mercurial ointment to be rubbed into the parts, and a slight bandage. The ointment was omitted ; but the patient got perfectly well in a few months. If these had failed, I should have sent him to bathe in the sea. Pressure hinders the extravasation of more fluid, and we see that tight boots make the legs thinner.

   The second kind is an original disease, though it may be attended with pain and inflammation. It is not circumscribed, though confined to a spot, but gradually lost in the surrounding parts. It spreads in proportion to the power of continued sympathy. A node is similar in appearance to what this is of the soft parts, and perhaps is of the same kind.

    The pain of indolent swellings is very little or none at first, which is owing to the slow increase of the part not arousing the sensibility ; but afterwards they have a heavy dull pain, producing sickness. This is often from the size, as well as from the tumour itself pressing on some other parts; for sometimes there is more pain in the surrounding parts than in the tumour itself. I may also observe that they seldom or ever inflame, but continue increasing till they press on surrounding parts, and raise inflammation in these parts and not in themselves ; they are then often broken down into a curdly substance, but appear not to be dead, as they do not give the stimulus of extraneous matter: though the surrounding parts become thickened, yet they cannot properly be called encysted. If it appears to be scrofulous, the cicuta, sea-bathing, sal sodae, sea-water poultices, &c. are to be tried; but these are sometimes useless, and extirpation becomes necessary; or sometimes cutting into them is sufficient. They sometimes suppurate, and then the sores are very difficult to heal.

    The third kind consists in the interstitial increase of a circumscribed part. This is it when the swelling keeps to the original part, that part being circumscribed, as lymphatic glands, and also tumours or enlargements of the fiver or spleen. They seldom affect the cellular membrane till they suppurate, and often not then at first, which shows they have something specific in them ; for if merely indolent the surrounding parts would sympathise with them, as is often the case in the mixed cases. Although these diseases are interstitial increases, yet they often become similar to a tumour, and are understood as such.

      Observations on the Cure of Indolent Dispositions in Diseases.—We tnust first inquire whether they are wholly constitutional, partially so. or merely local, as upon this rests our treatment. We must not be satisfied with the present symptoms, but inquire into the constitution, whether it is indolent or irritable. Such as arise from the constitution are generally more diffused, and are often in many parts; and such constitutions as produce local complaints show something wrong in them ; however, the symptoms are not always satisfactory. I suspect these indolent dispositions of the constitution require a specific stimulus, having something specific in their nature. They do not spontaneously take on steps of cure, as inflammation does ; and if they suppurate, they do not suppurate kindly ; and a variety of things are required to assist them. The first thing to be done is to remove the cause, if practicable, which it often is not, as changing the country and situation. In all, resolution should be preferred, if possible, by absorption ; for suppuration will do much harm. To procure suppuration in such, a particular mode is required, for we are not to lessen the living powers, as in adhesive inflammation that is healthy, but to increase them. The earlier the treatment is pursued the better, before the habit has suffered, or the surrounding parts have sympathised : sometimes a constant application of mercury to the part, which produces a kind of irritation short of inflammation, is advantageous ; if this is insufficient, fumigations with cinnabar, or with plants which have essential oil in them, may prove serviceable. If these fail, we must remove the indolent disposition by exciting an action which they are incapable of taking on themselves. Salutary inflammation in surrounding parts will produce other good effects in indolent diseases, for indolence arises from a want of predisposition to healthy action ; thus, blistering the parts, and giving cordials internally, are often of use ; but the more violent the inflammation, the more effectually is the indolence of the part removed, if it can bear it. Many indolent swellings are content with their own natural actions, as natural parts are with theirs; but this is not so always ; but they take on an inflammatory action, not salutary, but leading to a bad kind of suppuration. The means of restoring the thickened parts is healthy inflammation, which, as it goes off, does not leave them in their former state, but occasions an absorption of the extravasated matter; nevertheless the part, after healing, often retains somewhat of the original disposition. This treatment will not do either in cancer or scrofula.

Of the Suppuration of Indolent Parts.—-Resolution cannot always be effected, and suppuration will take place, which suppuration seems to arise from defective animal powers, and not from exerted powers. The matter is glairy, and the superficial parts are so little susceptible of this that the matter is long in coming to the skin; so that stimulating medir cines must be applied to bring on, if possible, good suppuration, which can seldom, however, be done. Quick ulceration is best effected by exciting and hastening the inflammation: this is necessary in sound abscesses even, but much more necessary in indolent ones. The next thing is opening them, which should not be done too early, as the matter which remains in may increase the inflammation, which is necessary to the cure. When an opening is made, it should be as large as possible ; and even crucial incisions are frequently necessary : in many cases scarifying the sides of the abscess is proper, to excite quick inflammation, and if there are any sinuses these should be traced to their full extent: the parts then feel a greater necessity of action. But this is not always sufficient, for after good granulations are formed, the indolent state often returns, the granulations becoming dark-coloured, and the matter thin and glairy, according to the specific nature of the indolence ; this is the case often in old sores which have become habitual from bad treatment. In old indolent parts and encysted tumours the sac is often thickened, and even ossified, and the inflammation then is sometimes so violent as to threaten mortification. But these parts often become insensible to the common causes of inflammation, and when inflammation does arise it is sluggish. In such, nothing can cure but dissecting out the parts. Many abscesses, if out of the reach of surgery, or ill-treated, run into an indolent state. Many means are necessary in treating them, but we know of few useful ones : balsams and warm dressings are commonly used ; sometimes they do good, at other times they have no effect; and when they agree they lose their powers by continuance, when it becomes necessary to change them, or increase their power. These balsams should often be mixed with red precipitate. Tincture of myrrh also is often very useful in indolent sores, requiring to be applied often, as it soon loses its efficacy : solutions of alum, tincture of bark, solution of lunar caustic, aqua camphorata, &c., are often useful, and require to be applied as often as three times a day, or oftener if the disease is considerable.

Further Reading

Unlocking the secrets of the Elephant Man. BBC article.

Ablon, Joan. "‘The Elephant Man’as ‘self’and ‘other’: The psycho-social costs of a misdiagnosis." Social Science & Medicine 40.11 (1995): 1481-1489.
Angell, Katherine. "Joseph Merrick and the Concept of Monstrosity in Nineteenth Century Medical Thought." Hosting the Monster (2008): 131-152.
Cohen, M. Michael, John M. Optiz, and James F. Reynolds. "Further diagnostic thoughts about the Elephant Man." American journal of medical genetics 29.4 (1988): 777-782.
Darke, Paul Anthony. "The Elephant Man (David Lynch, EMI Films, 1980): an analysis from a disabled perspective." Disability and Society 9.3 (1994): 327-342.
Durbach, Nadja. "Monstrosity, Masculinity and Medicine: Re-examining'the Elephant Man'." Cultural and Social History 4.2 (2007): 193-213.
Graham, Peter W., and Fritz Oehlschlaeger. Articulating the elephant man: Joseph Merrick and his interpreters. Johns Hopkins Univ Pr, 1992.
    Holladay, William E., and Stephen Watt. "Viewing the Elephant Man." Publications of the Modern Language Association of America (1989): 868-881.
   Howell, Michael, et al. The true history of the Elephant Man. London: Allison & Busby, 1980.
King, Louise. "Saints and sinner Sir Frederick Treves." Bulletin of The Royal College of Surgeons of England 94.8 (2012): 284-285.
Larson, Janet L. "The Elephant Man as Dramatic Parable." Modern Drama 26.3 (1983): 335-356.
Massey, Janice M., and E. Wayne Massey. "Dr. Trevelyan and Mr. Treves: Sherlock Holmes and the Elephant Man." Southern medical journal 78.7 (1985): 854-857.
    Messer, Richard E. "The elephant man and the problem of suffering." Psychological Perspectives 12.2 (1981): 162-169.
Miles, A. E. W. "The Elephant Man." Journal of the Royal Society of Medicine 85.9 (1992): 589.
Pomerance, Bernard. Elephant man. Grove Press, 2007.
Porter, Roy. "The true history of the elephant man." Medical History 25.2 (1981): 218.
Sandell, Richard, et al. "In the shadow of the freakshow: The impact of freakshow tradition on the display and understanding of disability history in museums." Disability Studies Quarterly 25.4 (2005).
Smith, Andrew. "Pathologising the Gothic: The Elephant Man, the Neurotic and the Doctor." Gothic Studies 2.3 (2000): 292-304.
Tibbles, J. A., and M. M. Cohen Jr. "The Proteus syndrome: the Elephant Man diagnosed." British medical journal (Clinical research ed.) 293.6548 (1986): 683.
Treves, Frederick. The elephant man and other reminiscences. BiblioLife, 2009.
White, Ann K., et al. "Head and neck manifestations of neurofibromatosis." The Laryngoscope 96.7 (1986): 732-737.

Wilkie, Theodore F. "The elephant man—A tragic syndrome." Aesthetic Plastic Surgery 3.1 (1979): 327-337.

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