[From The Medical News, April 23, 1887.] 
ELEPHANTIASIS,ARABUM OF 
THE EXTERNAL GENITALS OF A NEGRESS. 
By WILLIAM E. MOSELEY, M.D^ 
AND 
ROBERT B. MORISON. M^V ft 
OF BALTIMORE. f 
Mrs. G., a large, powerfully built, dark negro 
woman, apparently between forty and fifty years of 
age, first presented herself at my private dispensary 
July 15, 1886. Although a fairly intelligent woman 
for one of her class, it was difficult to get anything 
like an exact history of her case. So far as I could 
find out, her family history was good, as had also 
been her own general health previous to the first 
appearance of her present trouble. Her early men- 
strual history was normal, and since her marriage, 
whenever she was neither pregnant nor nursing, the 
flow has recurred regularly and normally, except for 
an occasional menorrhagia, which, together with a 
free leucorrhoea (both vaginal and cervical), can be 
accounted for by the lacerated cervix and perineum 
and subinvoluted uterus which exist. She has had 
fourteen living children and several abortions. The 
last child was born four years ago, and the last abor- 
tion (at about one or two months) occurred in 
April, 1886, only three months before I first saw her. 
Some eight or nine years ago she first noticed a 2 
MOSELEY AND MORISON, 
decided itching and burning about the vulva and 
extending into the vagina, which condition was soon 
followed by what she called "blood boils" about 
the vu'va, and which were accompanied by a great 
deal of pain and discharge. Following this there 
was general enlargement of the right labium major, 
and about the same time itching and burning in the 
fold under each mammary gland, and a thickened 
condition of the skin in that location. 
From that time the disease steadily increased 
until, when I first saw her, her condition was as fol- 
lows : The skin in each axilla and in the fold directly 
under each mamma was much thickened and lying 
in folds. The skin over the mons veneris was thick, 
hard, and nodulated, as was also much of that over 
the nates and around the anus. The right labium 
major was a large pendulous mass, measuring fully 
7 inches in length, 4 inches in breadth, and 2^ 
inches in thickness. [The exact measurements of 
the growth, after being in alcohol for nearly five 
months, are, length 14 cm. (5% inches), breadth 
7.5 cm. (3 inches), thickness 5 cm. (2 inches).] 
The mass had a hard but rather boggy feel, the skin 
thickened, and in the lower portion it had a pecu- 
liar warty' appearance, due to the enormously en- 
larged papillae. The left labium major was about 
one-third the size of the right, was softer and more 
elastic, and the skin less thickened. The diseased 
parts were constantly moist, and the only complaint 
of the patient, aside from the inconvenience of 
having so large a mass hanging down between her 
thighs, was the intolerable itching and burning 
wherever the diseased condition showed itself, to- 
gether with certain "hot spells and pricking and 
crawling in the flesh all over." She is able to do 
considerable work, but is not as strong a woman as ELEPHANTIASIS ARABUM. 
3 
one would expect to find in a person of her age and 
build. Neither the nymphse nor clitoris were at all 
involved. 
As the weather was very warm, and any prolonged 
stay in bed would be most uncomfortable, I post- 
poned surgical interference until the fall, giving her 
a saturated solution of boracic acid for local applica- 
tion, and from the use of which she obtained great 
relief. 
On October 21st, under ether, I removed the 
right labium major, by means of a Paquelin knife, 
kept at the lowest possible cutting heat. In spite of 
every precaution, there was very free hemorrhage, 
the bloodvessels, especially the veins, being enor- 
mously dilated. Bleeding points were tied, and the 
line of incision sustained by a number of silver 
sutures. The wound was washed out daily, and 
dressed with iodoform and tarred jute. Healing 
took place very promptly, considering the method 
of operating, and the unavoidable sources of irrita- 
tion. About half the diseased tissue over the mons 
veneris was dissected off with a knife, and the edges 
brought together. This portion healed by first in- 
tention. It was thought best to leave the left labium 
major for a second operation; and as it is the cause 
of a good deal of discomfort, and is increasing very 
perceptibly in size, it will be removed at an early 
date. At this writing there is no sign of any return 
of the disease on the right side of the vulva. 
An item of some interest, as showing an anatomi- 
cal peculiarity of the male negro, is developed by 
recalling the fact that in spite of the decided ob- 
struction to coitus offered by the enlarged external 
lips, this woman aborted only three months previous 
to my first seeing her. 4 
MOSELEY AND MORISON, 
Microscopical Examination.1-The horny layer 
of the epidermis was normal in its thickness, nor 
was it changed in its general characteristics. It was 
intact and the flattened cells, of which it is com- 
posed, were unaltered in their relative position or 
their size. Where in the papillae the lymph vessels 
had become so much dilated as to occupy the entire 
papilla, and lower layer of epidermis, the horny 
layer stretched across the space forming its upper 
boundary. 
In the rete Malpighii the epidermic cells, espe- 
cially those in the lowest layer which joins the con- 
nective tissue of the corium, were larger than nor- 
mal. They were swollen, their outer membrane 
more than usually distinct, and their nucleus or nu- 
clei also enlarged, while the nucleolus was small, 
and pushed apparently to one side in the nucleus. 
The peculiar arrangement of pigment in this layer, 
which is to be described later on, was its most strik- 
ing feature. 
The papillae were abnormally irregular in length 
and breadth. Here and there, owing to the dilata- 
tion of the lymph-vessels, they were entirely absorbed, 
and a thin layer of epidermis was all that held their 
portion of the skin intact. In many places where 
the vessels of the papillae were visible, the lymph- 
vessels were dibated and their contour uneven; 
no hair follicles were found in any of the sections 
examined. The sweat glands were the seat of a well 
defined round cell infiltration, and their bloodves- 
sels were enlarged, but their usual glandular appear- 
ance was not obliterated or altered. 
The vessels of the corium were somewhat dilated 
1 The histological investigation was made by Dr. Morison in 
the Johns Hopkins Laboratory. ELEPHANTIASIS ARABUM. 
5 
and were surrounded with round cell infiltration, 
which, however, affected more intensely the lymph- 
vessels. The latter vessels were dilated, uneven in 
A. Dilated lymph-vessel with the endothelium torn. 
B. Dilated lymph space containing fibrin,^nd surrounded by 
wandering lymph-corpuscles. 
P. Pigment granules, which are seen in clusters at various points 
in the corium and as ramifying lines in the epidermis. 
(We wish to acknowledge our obligation to Dr. A. C. Abbot, of 
the Pathological Laboratory, Johns Hopkins University, for this 
drawing.) 
outline, or completely filled with lymphoid cells. 
Their endothelial lining was thickened, and in the 6 
MOSELEY AND MORISON, 
tissues around them there was an infiltration of lym- 
phoid cells. The thickening of the endothelium in 
the smaller lymph-vessels was sufficient to render 
them impassable. All through the connective tissue 
of the corium, small and large dilatations of the 
lymph-vessels were seen. Many of these were lined 
with endothelium and filled with fibrin. The en- 
dothelium was thickened, the nuclei could be beau- 
tifully stained, while here and there it was torn away 
from the surrounding tissue, and lay with one free 
end within the space itself. See A and B. 
The connective tissue fibres were thickened, The 
smooth muscular fibres of the skin were enlarged 
and increased in number. 
The nerves, as far as an examination of them was 
possible, seemed to be unchanged. 
All the microscopical appearances here described 
point this specimen out as coming from a typical 
case of E. Arabum. The changes in the size and 
the contour of the lymph vessels and spaces, the in- 
crease in the size and number of the smooth mus- 
cular fibres, and the swollen appearance of the epi- 
dermis are all characteristics of this disease. 
Allusion was made above to the remarkable 
arrangement of pigment seen in this specimen. In 
the corium, underneath the line of the papillae, a 
comparatively large quantity of pigment granules 
was visible. It was collected together in small 
heaps within round and branching cells, and also ap- 
parently scattered about in fine granules without 
them. In the epidermis, besides the ordinary col- 
lection of pigment in the lower layers of the rete 
Malpighii, it was seen to run upward from these 
layers in chains of very fine granules, so that it made 
a network of dark lines, which surrounded the epi- 
dermic cells as far up as the horny layer. It gave ELEPHANTIASIS ARABUM. 
7 
the sections the appearance of having been stained 
with gold. (See P.) 
As this is a most unusual appearance in the skin, 
even of a negro, where the pigment is so profuse, 
the question of how it happened to be thus arranged 
is an interesting one. 
Experiments by Key, Retzius and by Unna tend 
to prove the fact that the lymph circulates in the 
epidermis between the epidermic cells. Injections 
of the lymphatics of an cedematous skin with void 
have shown that the gold will sometimes penetrate 
between the epidermic cells, as far as the horny 
layer. Unna supposes that, in an cedematous skin 
where the lymph spaces are enlarged, the pigment, 
if present in the lower layers, is taken up by the 
lymph-bodies and deposited between the cells of the 
epidermis. 
In the specimen here described, although in places 
the pigment was seen to be within cells, it was 
apparently for the most part without them. The 
fine network of dark lines was probably made by 
the lymph bodies, which deposited the pigment as 
they circulated between the epidermic cells.