All the varieties of elephantiasis are found on the labia. Where the increase in interstitial tissue is in the deeper parts there exists dense swell ing; where certain portions develop greatly there result marked eleva tions (elephantiasis tuberosa). The pathology of the disease is ever the same. The least constant thing about elephantiasis of the ulva is the swelling of the lymphatic glands. The site of the disease on the vulva is, according to Mayer, in forty-six cases, of which number ten were personal, the labia majora with the other parts were affected in twenty-seven, the clitoris alone or with other organs in sixteen.
Little is known about the etiology of the disease. How can we explain its frequency in tropical climates, and its epidemic character in certain of the Antilles and Southern islands? Either the warm climate is a predis posing factor as favoring the development of erysipelas, or else the cause must be sought in a specific infection. Similar views have been held in regard to elephantiasis grfecorum or leprosy, and here a specific micro organism has been found. That the Maria sanguinis is not the cause of elephantiasis may be emphasized. Lewis has certainly found the filaria in a case of lymphatic elephantiasis of the scrotum, but he does not claim it as the certain cause. The disease ordinarily appears on the vulva during the period of sexual activity. In thirty-seven cases, which Louis Mayer grouped according to the age of appearance, we find: Krieger has reported a case which began in very early life, and where, at the age of fourteen, the tumor was twelve inches long and eighteen inches in circumference. Louis Mayer's case began at nine years. Be sides these two cases instances have been recorded by Delpech, Caswell, Clot-Bey, and Bryk, of elephantiasis during youth. The child seen by Delpech had a dense tumor on the mons veneris the size of a cherry. At puberty it had grown to the size of an apple, and rapidly increased so that at the age of thirty-one it reached as far as the knees, being 171 inches long and fifteen in circumference. Still more remarkable was Bryk's case, where a tumor the size of a bean remained stationary till forty-eight years, and thence in two years reached a circumference of 9} inches.
Heredity has not been noticed as a causal factor. On the contrary, cases of congenital elephantiasis are exceptions. Nande saw a new-born infant with small red spots, particularly on the labia majors and in the inguinal regions. They increased in size so quickly on the labia that at six weeks they were the size of a pear. They then grew more slowly than from their previous rapid development was to be expected. At fifteen the tumor was the size of a child's head. In Bainbridge's case there existed a tumor of the clitoris three inches long, and nearly two inches thick. In Verneuil's case the growth was on the mons veneris, the upper
half of the left and the entire right labium.
Of special interest are those cases where a transient or lasting injury preceded the development of the tumor. Louis Mayer has investigated them as carefully as possible to determine the influence of traumatism.
A woman seen by him, aged twenty-five, developed elephantiasis of the vulva as the result of deep injury to the right labium received by a fall downstairs. For a long time she complained of pain and of swelling on this side. The pain disappeared but the swelling persisted, until at the end of seven years it had attained the dimensions of a child's head. In another case (the ninth of Mayer's) the injury was received from a mangle.
At the end of a year the woman had a tumor the size of a hen's egg, and after some time it attained a length of 5i inches, a breadth of 3,1 inches, and a pedicle over inch thick. Caswell speaks of a blow on the vulva, Iliecken a wound from pushing a carriage. In Ilildebrandt's case, suffer ing from multiple molluscs, the woman laid her disease to her husband's habit of forcibly rubbing her genitals each night.
These observations and the oft-repeated opinion that masturbation caused the disease, are still not sufficient to prove such factors as true causes, since trauma preceding the disease is too rare, and trauma not followed by the disease too frequent.
Inflammatory affections of the skin as the basis of elephantiasis do not rest on any more certain basis. In these affections we include eczema, furunculosis, syphilitic infection. The soft chancre, when it has existed for a long time, does cause swelling of the nymphse. As the result of syphilis Louis Mayer saw twice irregularly-shaped and nodular tumors. Clott-Bey, MacClintock and Bryk have noticed the same. Many authors have noted that irritating vaginal discharges, intertrigo, and dermatitis, favor the development of elephantiasis. In a case observed by Atthill, tumor the size of a child's head developed as the result of the prolonged use of a wash prescribed for the relief of prurigo. Interferences with the pelvic circulation with great menstrual disturbances have often been suggested as causes (Larrey, Klewitz, Beige!) without throwing any special light on the etiology of elephantiasis. The influence of pregnancy and of the puerperium, which naturally leads to small hyperplasim only, is not granted. Some authorities have noted increase and others decrease in the tumors. Although we should naturally expect growth during pregnancy Louis Mayer witnessed decrease. That labor has any influence Hildebrandt was unable to state.