Pathology.—The changes of elephan tiasic areas are more directly located in the subcutaneous tissues, the upper and lower strata alike sharing in the charac teristic phenomena. The skin, although presenting these changes, is more mark edly affected where papillary outshoots are observed. Upon cutting into the affected areas there is observed a yellow ish or grayish mass, which in some places shows a resemblance to fatty or larda ceous deposits, while in others gelatinous formations are simulated. Exuding lymph may be observed at many points. The changes from the normal are of a distinct hypertrophy: there :s decided proliferation of the epidermis. with hy perplastic increase of the corium, while the fibrous elements of the subcutaneous tissue are observed in hardened bands or meshes or noted to be soft or liquefied. Distended lymph - spaces are found throughout the microscopical section. All the soft parts, the blood-vessels, lymphatics, nerves, and their component parts, as well as the bony structures, share in the general enlargement and cell-infiltration. At times, the muscles and the glandular structures of the skin participate in the increase of size.
Obstruction is clearly the influence in the production of elephantiasis. The presence of the Filaria sanguinis hom inis in the lymph-vessels is directly the cause in endemic varieties of tbis condi tion. Manson states that the parent worm occupies some portion of the lymph-trunk, at which point it dis charges the ova into the stream of lymph; these are then carried forward to some of the grandular structures, in which they find a lodgment. -When hatched they enter the general circulation. Abstracted from the blood by the mosquito, and deposited again into a water-stream, the ova again reach man when contami nated water is employed. The more ag gravated the symptoms, the more numer ous are the parasites in the lymph-chan nels. Hmmorrhage and discharge of lymph may be observed in these types.
In sporadic types of the affection, in which the obstruction may be induced through encroachment of large tumors or other forms of pressure upon tbe veins and lymphatics, the same features are developed. Although they are indistin guishable, there is no mistaking the con dition. Eczema of a most chronic vari ety, frequent attacks of erysipelas or other forms of deep dermatitis, as well as tight bandaging of a part may also be the inducing factors.
Prognosis.—Although the disease does not tend to shorten life, much discom fort, as well as intercurrent maladies, may place the affected person in an un enviable condition. Endemic cases may be greatly benefited by a change from a malarious or sea district. Sporadic types are likewise improved by change of climate. The discomfort may alone be caused by the weight of the affected part, which may often be removed by surgical measures, thus insuring relief. Early cases should be immediately removed to other regions; if this is done, a favorable result will be reached early. This step often arrests even cases of long-standing.
Treatment.—In endemic cases which are preceded by the preliminary fever, with its accompanying phenomena, re course must be had to the measures gen erally adapted to most febrile manifesta tions. Salines, acetanilid, quinine, and cinchona, which influence miasmatic fevers and their consequent complica tions, should be administered. Tonics will be demanded in many cases in which the depressing effects of recurrent at tacks of erysipelas or deep inflammations are experienced. Codliver-oil, with or without the hypophosphites, iron, strych nine, certain mineral acids (hydrochloric or sulphuric), and possibly arsenic may be found beneficial. Again, all complica tions should be remedied as they appear in the several cases encountered. All cases of this affection should be removed from countries in which the disease is endemic or where malarial or other miasmatic atmospheres are found. Spo
radic cases are to be removed. as well to some healthy climate. Iodine (or its preparations) and mercury have been recommended for their absorbent quali ties. Sterilization of drinking-water at all times may have an indirect influence in the prevention of this disease.
Surgical interference, of one kind or another, may be productive of some fairly-good results. Large growths of enormous weight have been removed by this means. The penis and testicles have been restored to their normal conditions in a large number of cases.
Series of sixty operations successfully performed. The weight, of the tumors varied from one and a half to thirty nine pounds. The usual incision is made along the penis, which is thoroughly decorticated; and by vertical incisions over the cords, down to the fundus of the tumor, the testicles are enucleated, and, all blubbery material being care fully removed, the organs are placed on the pubes in a wrapping of gauze. The upper ends of the vertical incisions are joined to the wound over the penis. Lateral oblique incisions are made through healthy skin and fat along the sides of the tumor; they pass down ward, so as to meet just in front of the anus. The mass is then carefully dis sected off, exposing, on its removal, the accelerator urinw in the middle and the limbs of the pubic arch at the sides. All bleeding vessels are ligatured. One now sees the decorticated, but turgid, penis; the testes with cords of, it may be, eighteen inches' length; and a large triangular wound, fairly representing the superficial dissection of tlie anteiior half of the perineum. The skin and fat hounding the wound on either side are raised up from the fascia lata, over the hamstrings, for a distance of about three inches. The testes are united to each other in the middle line by three or four interrupted sutures. The edges 1 of the sliding lateral flaps are then brought together over the testes by a series of strong quilt-sutures. The penis is covered by the anterior end of the thigh-flaps, and by flaps raised from above the pubes, with or without the addition of Thiersch grafts. The whole wound-area, is dusted with iodoforin, and covered with .suitable dressings. It is essential that the dressings be kept in place by well-applied bandages. Ileal ing takes place throughout by first in tention in about eight days. Havelock Charles (Indian Med. :Record, No. 5, '97).
The cicatrical tissue following this treatment always gives a protective cov ering to the structures. Surgeons have abandoned the use of the ligature be cause of the likelihood of causing more disturbances to the already-obstructed circulation. The method of treatment generally resorted to by surgeons at the present day is compression. This may be considered as equal in value to ligature, but it is less likely to provoke other con ditions likely to promote enlargement. Pressure may be applied by the use of some form of bandaging. Elastic band ages, such as those advocated by Martin, or ordinary muslin of close texture, to in sure firmness, may be applied to the en larged areas, beginning at its lower and approaching the upper part in gradual pressure. This means has been followed, however, by untoward consequences, such as gangrene at one point or an other, and should be carefully watched Marked success from hypodermic in jections of calomel in a case of elephan tiasis in a woman 39 years old. Al though the patient developed symptoms of syphilis, yet the latter occurred after the appearance of elephantiasis. The author concludes that intermuscular in jections of calomel have a beneficial ef feel, on elephantiasis, but they must be continued for a considerable time, with frequent interruptions. Tiptseff (Medit zinskojc Obozrenije, vol. lvii, No. 9, 1902).