ELEPHANTIASIS⁷

Synonyms.—Elephantiasis Arabum; Pachydermia; Barbadoes leg; Morbus elephas;
Elephant leg; Elephantiasis indica; Bucnemia tropica; Spargosis; Fr., Eléphantiasis.

Definition.—A chronic endemic or sporadic disease of the skin
and subcutaneous tissues, usually of the leg or genitalia, characterized

¹ Quoted by J. Lewis Smith, Diseases of Children.

² Soltmann, loc. cit.

³  Crocker, Diseases of the Skin.

⁴ Blacker, Brit. Jour. Derm., 1898, p. 87 (case demonstration).
² Loc. cit.

⁶ Jarisch, Hautkrankheiten, 1900, p. 824.

⁷ Literature: P. Manson, Tropical Diseases, London, 1898; chapter on “The
Filariæ Sanguinis Hominis and Filaria Disease,” in Davidson‘s Hygiene and Diseases
of Warm Climaies, Edinburgh and London, 1893. Manson‘s earlier contributions on
this subject are practically reviewed in these publications, and references to the prin­
cipal observations of other writers are made. W. M. Mastin, “The History of Filaria
Sanguinis Hominis; its Discovery in the United States,” Annals of Surgery, Nov., 1888;
Esmarch and Kulenkampff, Die Elephantiasistichen Formen, Hamburg, 1885, with
numerous illustrations; full bibliography is given by Hyde, Morrow‘s System, vol. iii
(Dermatology), p. 451.

ELEPHANTIASIS

593

by enlargement and deformity, lymphangitis, swelling, edema, thickening,
induration, pigmentation, and more or less papillary growth. In the
description following the term non-parasitic will be applied to those
cases not due to filaria.

Symptoms.—The malady usually begins, in the endemic variety,
and less commonly in sporadic cases also, with general symptoms of
fever (elephantoid fever), chilliness, often nausea, and sometimes vom­
iting, and, in some instances, more or less rheumatic pain, especially
about the lumbar region. Along with these, concomitantly or precur-
sorily, there is an erysipelatous or pseudo-erysipelatous inflammation
of the part, with swelling, pain, heat, redness, and, as a rule, lymphan­
gitis. There may be considerable edema, varying somewhat in different
cases, and not infrequently, especially if there is marked lymphatic
involvement, more or less discharge of a clear or milky character. The
inflammation, in some cases, takes its origin in a local lesion, such as a
slight cutaneous abrasion, injury, or scar; but in the large majority of
instances manifests itself without any recognizable local cause. The
part is considerably enlarged, sometimes tense, and only pitting upon
pronounced pressure; or the condition, and especially after a few days,
is more of the nature of an edema, somewhat doughy, and which pits
quite readily. In several days the acuteness of the symptoms, both
general and local, has abated, the former often entirely disappeared, and
gradually the swelling, tenderness, and redness subside, and, after a few
weeks or longer, as a result of treatment or spontaneously, the affection
is apparently at end, except that the region involved is observed to be
somewhat larger than before the onset. This enlargement is, however,
in most cases, often scarcely perceptible after the first attack; later, with
each succeeding seizure, it becomes more and more noticeable. The
period of freedom or quiescence varies from several weeks to some months.

The amount of increase depends measurably upon the duration and
severity of the attack, the latter in some being slight and relatively
transitory, in others intensely acute and protracted. Exceptionally it
is of slight character, but practically continuous, and the enlargement,
though trifling, is steadily progressive. After months or one or more
years the enlargement or hypertrophy becomes conspicuous, the part
is chronically swollen, edematous, and hard; the skin thickened, the
normal lines and folds exaggerated, the papillae enlarged and prominent,
and with often more or less fissuring and pigmentation. This goes on,
there is gradual increase in size, the parts in some instances reaching
enormous proportions; the skin becomes rough and warty, eczematous
inflammation is often superadded, and, sooner or later, ulcers, superficial
or deep, either spontaneously or from injury or from varicose veins,
form—which, together with the crusting and moderate scaliness, and
sometimes with intermittent or continuous lymph-like discharge, present
a striking and characteristic picture. In a minority of cases, more
especially until the disease is well advanced, the surface remains com­
paratively smooth. The course of the malady, when once thoroughly
established, is usually steadily, although often scarcely perceptibly,
progressive; but there are in most cases periods of comparative inactivity,

38

594                                      HYPERTROPHIES

or, after reaching a certain development, the disease may, for a time at
least, remain stationary. The accumulated crusts, composed of epider­
mis, discharge, blood and dirt, undergo variable change or decomposition,
and there is emitted an offensive, and often penetrating, odor.

The general and local symptoms in the endemic variety are essentially
similar whatever the part attacked, varying in intensity in different
patients. In the scrotal or genital form there is often a good deal of
pain in the parts themselves and along the spermatic cords. In both
the leg and genital cases the inguinal glands are enlarged to a varying
degree, and sometimes tender and painful. In the non-parasitic cases,
usually met with outside of the endemic districts or countries, the general
symptoms are rarely marked, and often absent, depending upon the in­
tensity of the erysipelatous inflammation. In these latter this inflam­
mation seems to be similar to, or identical with, ordinary erysipelas,
and according to extent and severity will the constitutional involvement
be insignificant or pronounced. In others, both of the endemic and non-
parasitic kinds, the disease is insidious, slowly progressive, and without
systemic disturbance. Much depends upon the character of the case,
its extent, and the nature of the operative cause or causes, as will be
referred to under etiology and pathology.

The regions involved in elephantiasis are most commonly the legs
(elephantiasis cruris) and, less frequently, in the severe forms at least,
the genitalia (elephantiasis genitaliurn). Other parts may, however,
be the seat of the disease, as more or less generalized, as in Felkin‘s case,¹
the arm and hand (Crocker, Mackenzie, Hoyer, and others),² the side
of the face (Richards, Hebra and Kaposi, Moncorvo, and others),³
eyelids (Gorand),⁴ and other regions. ‘ It is probable, though, that many
of these cases of anomalous localization are not true examples of the dis­
ease, but rather unusual forms of fibroma or the allied condition, derma-
tolysis. In elephantiasis of the leg quite frequently but one leg is in­
volved, and the right more commonly; in the endemic variety, however,
both legs are often invaded. In some cases, more particularly the spo­
radic, it may be limited to the foot and ankle, for a time at least. A ver-
rucous surface is not uncommon on the dorsum of the foot, usually cov­
ered with horny epidermis or sodden accumulation. Generally, how­
ever, the whole leg up to the middle thigh shows variable enlargement,
being most marked on the lower part, where it may reach three or more
times the normal circumference.⁵ While in some cases, more particularly
of moderate development, it is smooth, or relatively so, and well shapen,
as a rule it is rough and irregular or warty, scaly, crusted, and much de-

¹ Felkin, Edinburgh Med. Jour., 1889, vol. xxxiv, part ii, p. 779.

² Crocker, Diseases of the Skin, also refers to Mackenzie‘s case; Hoyer, Buffalo Med.
and Surg. Jour., 1885-86, vol. xxv, p. 452 (with illustration).

³ Moncorvo, Pediatrics, 1897, p. 481.

⁴ Gorand, Annales de la Polyclinique de Bordeaux, April, 1892, p. 105 (3 cases);
Schuster (Gussenbauer‘s clinic), Prager med. Wochenschr., 1880, p. 201, reports a case
of elephantiasic nose enlargement, developed after an injury, associated with, however,
fibromatous or fibroneuromatous general integumentary lesions; a tabulation of a
number of cases of localized elephantiasis with literature references is given; these
cases can scarcely be called, however, elephantiasis, as this term is generally understood.

⁵ McCall Anderson, Jour. Cutan. Med., 1868, vol. i, p. 180, records a case in which
the calf circumference reached 27 inches.

ELEPHANTIASIS

595

formed, often deserving the term elephant leg, by which it is sometimes
described. The disease varies considerably, however, as to growth, and
cases of all degrees of severity are met with, from the comparatively
insignificant to the extreme condition which hinders the patient from
getting about.

Elephantiasis of the genital region may involve the entire parts or
only the scrotum or the penis. Almost invariably, however, even when
the hypertrophic changes are conspicuously pronounced on one part,
the other is enlarged also, but to relatively less extent. The enlarge-

Fig. 143.—Elephantiasis, with marked papillary growth (almost of ichthyosis hystrix
type) and pigmentation.

ment varies from insignificant to enormous dimensions, in one instance
the scrotal growth weighing no pounds (Clot-Bey).¹ The neighboring
lymphatic glands are usually enlarged.

The malady, when limited to the genitalia, varies very little, if at
all, from that of the legs, but is probably much more insidious and
progressive, with less tendency to extreme acute exacerbations than
the disease of the latter region. There is often considerable milky

¹Quoted by Schwimmer, Ziemssen‘s Handbook of Skin Diseases, p. 227; Manson,
Tropical Diseases, 1898, p. 483, states the largest recorded weight to be 224 pounds, but
gives no reference as to source.

596

HYPERTROPHIES

lymphatic discharge, and the enormous tumor, sometimes hanging as
far down as below the knees, is a source of great discomfort, a dragging
feeling, and often pain. Eczemas and ulcerations are frequently added,
and increase the patient‘s misery still further. In women the brunt of
the disease, when involving the genitalia, usually falls upon the labia
majora; the clitoris and other parts may, however, and almost always
in extreme cases, share in the hypertrophic process. The condition may
be a slight one, and give rise to but little discomfort, or it may eventually
be excessive.

Lymph-scrotum (varix lymphaticus; lymph tumors; nævoid elephan­
tiasis; milky exudation of the scrotum) is to be looked upon as a form
of elephantiasis, probably occupying a middle ground between this
latter and chyluria. According to Manson, the characteristic feature
of this affection is the presence, on the surface, of dilated lymphatics
and lymphatic vesicles, which often rupture and discharge coagulable
lymph. There is a certain amount of hypertrophic enlargement, and
often with attacks of erysipelatous inflammation and elephantoid fever.
Manson believes that the three diseases—elephantiasis, lymph-scrotum,
and chyluria—and their varieties may be considered as but accidental
modifications of the same pathologic conditions and etiologically identical.

Elephantiasis telangiectodes, which is also known as nævoid elephan­
tiasis and telangiectatic elephantiasis, is a hypertrophic development,
which, according to Virchow, has a congenital origin, and which sub­
sequently undergoes hypertrophy.¹ The elephantiasic enlargement may
be slight or may attain considerable dimension. The hypertrophic
growth is thought by Virchow to be due to the overnutrition of the part,
resulting from the underlying increase of the vascular supply, the deep
vessels often attaining considerable size. In some cases the tissue and
vessels enlarge progressively, and while the surface is not necessarily
changed, occasionally increased vascular supply ensues superficially and
a reddish aspect is presented.

Acromegaly² is a hypertrophic condition, first clearly presented in
Marie‘s classic paper, which deserves brief mention in connection with
elephantiasis. The bones and soft parts, especially of the face, feet,
and hands, undergo thickening and increase in volume, in extreme case
almost ‘giant­like in appearance. The affection is usually slow and in­
sidious, the individual scarcely knowing when the process began. The
arms and legs, especially toward the distal ends, share materially in the
hypertrophic enlargement, and all parts, even the trunk (as in one of
Dercum‘s cases), may be involved also. In the face, the lower jaw,

¹ Merrill Ricketts, Jour. Cutan. Dis., 1889, (with illustration), reports an inter­
esting case involving the chin, lower lip, and contiguous lower part of the cheeks, in
which increased growth did not ensue until adult life was reached.

² Literature: Paul Marie, Revue de méd., 1886, p. 297, and Marie and Marinesco
(pathologic anatomy), Trans. Internat. Cong., Berlin, 1890; Arnold, Virchow's Archiv,
vol. cxxxv, p. 1; Souza-Leite, De l' Acromegalie, Paris, 1890—abs. of 49 cases; trans­
lation by Syd. Soc‘y, London; F. A. Packard, Amer. Jour. Med. Sci., June, 1892, p.
657; Collins, Jour. Nervous and Mental Dis., Dec, 1892 (digest of cases since Souza-
Leite‘s publication), and Feb., 1893 (bibliography); Dercum, Amer. Jour. Med. Sci.,
Mar., 1893; Church and Hessert, Med. Record, 1893, vol. xliii, p. 545; W. G. Shallcross,
Philada. Med. Jour., April 20, 1901.

ELEPHANTIASIS

597

cheek bones, nose, supra-orbital prominences, and ears usually stand
out prominently. In the hands the parts are often huge, broad, and flat,
the fingers markedly increased in volume, and the ends blunt. The
nails are, as a rule, thick and flat, but not usually widened; as Bramwell¹
remarks, the nails appear to be small in proportion to the size of the
fingers, and in most cases grooved longitudinally. The hairs on the
affected regions are frequently stronger, and exceptionally there is a
tendency to more or less general hairy development (Weir Mitchell).
The skin, more particularly of the face and extremities, is more or less
thickened, and not readily pinched up into folds, and often exhibits
pigmentary spots; occasionally more or less general pigmentation de­
velops (Weir Mitchell). The sweat function is usually increased. Ac­
cording to Souza-Leite, headache is a frequent concomitant. The cause
of the’ disease is not known; Marie‘s suggestion of involvement of the
pituitary body and its enlargement has been noted in a number of
autopsies, but in other cases it has been found to be wholly normal.
Klebs‘s idea that it might be due to persistence and enlargement of the
thymus gland is also without sufficient corroborative data to give it
standing. In fact, postmortem findings have shown in isolated instances
enlargement of one or other of the various glandular structures, as well
as nerve and cerebral lesions,² but a judicial review of the cases leaves
nothing substantial as to its nature and causes.

Anatomically there is practically no change noted in the epidermis
except pigmentation of the prickle layer, but both cutis and hypoderm
are thickened, essentially consisting of collagenous hypertrophy (Unna).
Degeneration of muscles, blood-vessels, and nerves has also been observed,
the walls of the arteries and veins and the sheaths of the nerves are thick­
ened.

Etiology.—Elephantiasis occurs in all parts of the world, but is
much more frequent in tropical climates, where it is more or less endemic.
In the endemic districts it is chiefly in malarial regions, in the lowlands,
and also along the seacoast and sea islands. Manson has shown that
the mosquito is a probable factor—an intermediate host, the filaria
hominis sanguinis, being the essential agent. Poor food, unhygienic
living, and similar conditions are doubtless of contributory influence.
It is rare in the well-to-do and wealthy classes. It is not contagious,
nor is it hereditary. In endemic districts, it is true, owing to the facts
of the common exposure to the same influences, the disease is often seen
in two or more members of the family; according to Richards,³ in a large
percentage of cases (about 75 per cent, in his tabulation) the disease was
present in one or both parents. Occasional instances of the coexistence
of leprosy and elephantiasis have been observed (Richards), although the
association is purely an accidental one, the two diseases being in no way
related. The malady is seen in both sexes and at all ages, but is much
more frequent in early adult and middle life, although it is occasionally

¹ Bramwell, Atlas of Clinical Medicine, 1893, vol. ii, p. 104.

² In Waldo‘s case, Brit. Med. Jour., March 22, 1890, cavities were found both in
cerebrum and cerebellum.

³ Vincent Richards, chapter on “Elephantiasis Arabum,” in Fox and Farquhar's
Endemic Skin and Other Diseases, London, 1876.

598                                      HYPERTROPHIES

observed in childhood, and in some instances as a congenital affection.¹
The disease is largely confined to males, the proportion being about 3 to
1, and the darker races are the more susceptible.

While the filaria—for which Manson suggests the name of filaria
hominis nocturna, inasmuch as it is found circulating in the blood only
at night—is to be accepted as an important, if not the sole, factor in the
endemic disease, there are, however, many cases which present essentially
the same symptomatology which are entirely independent of this agent.²
In fact, whatever gives rise to inflammation or obstruction of the lym­
phatics and veins may lead to this hypertrophic development. For
example, disease and enucleation of the inguinal glands have been known
to be followed by elephantiasis, of varying degree, of the genitalia, both
in men and women, of which many cases have been reported in recent
years by Lassar,³ Riedel,⁴ Brouardel,⁵ Koch,⁶ and many others. Ob­
struction produced by various tumors, neoplasms, ulcerations, chronic
skin diseases, phlegmasia dolens, syphilis (Francis),⁷ gonorrhea (Hum­
bert, Farner, and others),⁸ and sometimes following local injury (Berry,
Hutchinson, and others).⁹

Pathology.—The pathologic changes are the result, as already
intimated, of lymphatic obstruction, and this may be due to various
causes. According to Manson, Lewis, Bancroft, Sabouraud, and others
there remains no doubt that in the endemic cases the obstruction is due

¹ Barwell, London Path. Soc'y Trans., 1881, p. 282 (unilateral—head and face;
bones and soft parts; with illustration); Spietschka, Archiv, 1891, vol. xxiii, p. 745 (a
case involving both legs, with illustration and literature references); Nonne, Virchow‘s
Archiv, 1891, vol. cxxv, p. 189 (4 cases from same family, in which it had prevailed
for several generations; 6 illustrations); Coley, N. Y. Med. Jour., June 20, 1891 (of
face and scalp, with illustration—apparently allied to fibroma or dermatolysis; good
result from operation); Uthemann, Deutsche med. Wochenschr., 1895, p. 826 (penis and
scrotum—apparently beginning at age of four—two illustrations, showing condition
and result of operation); Busey, Congenital Occlusion and Dilatation of Lymph Channels,
New York, 1878; Moncorvo, loc. cit., reports 2 new cases and refers to 10 others pre­
viously reported by him; Jopson, Arch. Pediatrics, 1898, vol. xv, p. 173, records 2
cases, brothers, aged one and one-half and four, involving feet and legs; father had
surfered from a similar affection in childhood, which was later outgrown; gives brief
review of the subject, with references.

²  Shattuck, “Ætiology of Elephantiasis,” Boston Med. Jour., 1910, clxiii, No. 19, p.
718, states that “filaria is an important factor in the production of endemic elephanti­
asis of some regions, but is not essential to the occurrence of the endemic type of
disease.”

³ Lassar, Dermatolog. Zeitschrift, 1894, p. 550.

⁴ Riedel, Langenbeck‘s Archiv, 1894, Bd. xlvii, p. 216.

⁵ Brouardel, Annales, 1896, p. 863.

⁶ Koch, Archiv, 1896, vol. xxxiv, p. 203 (Koch describes a number of cases of vary­
ing enlargement in women, and gives references to the contributions of Virchow, Mayer,
Neisser, Jacobi, Lesser, Fritsch, and Schroeder).

⁷ A. G. Francis, Brit. Jour. Derm., 1894, p. 225, gives notes of several cases asso­
ciated with tertiary syphilis; McDonagh, ibid., 1912, p. 24 (case demonstration—
syphilitic elephantiasis of the scrotum (syphilitic lymphangitis), with histolog. exami­
nation; free from streptococcic or staphylococcic infection.

⁸ Humbert, La Semaine Med., May 25, 1894 (case presentation—penis, consequent
upon a gonorrheal lymphangitis); Farner, Centralbl. für Gynäkologie, 1885, No. 17,
abs. in Münch, med. Wochenschr., May 7, 1895 (female genitalia—apparently originat­
ing from an acute gonorrhea).

⁹ Berry, Provincial Med. Jour., 1889, vol. viii, p. 284 (hand and forearm—2 illus­
trations—following a burn); Hutchinson, Clinical Jour., 1895-96, p. 29 (brief report—
developed after a crush of foot; leg subsequently amputated; later development in
other leg).

ELEPHANTIASIS

599

to the filaria, probably both directly by their presence in numbers block­
ing up the lymph-channels, and indirectly by the inflammatory condi­
tions of these vessels or glands which they may provoke. According to
Manson, only the embryo filaria is found circulating, the parent filaria
living in some part of the lymph-trunk, discharging its ova into the lymph-
streams, which find their way into some of the glands, in which they find
lodgment, and are subsequently hatched out, and then enter the general
circulation. Manson‘s investigations would make it seem probable
that the mosquito abstracts some of the embryos from the blood of an
affected individual, and, after undergoing some development, these
finally find their way into the drinking-water, and are thus conveyed to
man. In consequence of obstruction varices of the lymphatics, glandu­
lar structures, and veins result, in varying degree, in anastomes by which
the embryos get into the blood, and in some cases there is rupture of such
formations and discharge of lymph upon the surface.

Many of the non-parasitic cases,—almost all those of our own
country, for instance, Unna¹ believes, result from repeated attacks
of streptogenes inflammation (erysipelas, phlegmon, lymphangitis), and
independent of any circumscribed stagnatory cause. The persistent
recurrent attacks bring on doughy soft edema, and which later becomes
harder, with tissue increase and progressive enlargement. He is of the
opinion, therefore, that true sporadic cases may be said to develop
from incompletely healed erysipelas attacks, those which leave behind
disturbances of circulation, and the products of which are not completely
absorbed nor all the streptococci destroyed; to this variety he would
give the name elephantiasis streptogenes or elephantiasis nostras.
Examinations of this variety of the disease by Sabouraud² disclosed
during the erysipelatous attacks the presence of streptococci of Fehleisen.
With each attack or exacerbation, as Sabouraud remarks, there is a fresh
advance of edema, and that each new edematous infiltration is probably
followed by local organization of the emigrated embryonal cells into con­
nective tissue.

The anatomic studies (Virchow, Kaposi, Mosely and Morison,
Marcacci, Crocker, and others) of the disease agree substantially as
to the findings. The seat of the changes is essentially the subcutaneous
tissue, and the bulk of the enlargement is made up of hypertrophic
connective tissue. On section the tissues are found quite firm, with a
whitish or yellowish surface, usually exuding a lymph-like, yellowish,
sometimes gelatinous, fluid. In addition to the connective-tissue hy­
pertrophy the whole integument is thickened, sometimes moderately, in
other cases markedly so. As is to be inferred from the clinical verrucous
appearances in some cases, there is often papillary hypertrophy, the
papillæ being elongated and broadened. There is often also increase
in pigment matter; in the case examined by Mosely and Morison³ (a
negress) a large amount of pigment granules, chiefly in heaps, was found
in the corium beneath the line of the papillæ. There is, in addition,

¹ Unna, Histopathology, p. 493.

² Sabouraud, “ Sur la parasitologie de l‘elephantiasis nostras,” Annales, May, 1892,
pp. 592 and 629.                        ³ Mosely and Morison, Medical News, April 23, 1887.

6oo

HYPERTROPHIES

enlargement of blood-vessels and lymphatics. Secondarily, after pro­
longed duration of the disease, the underlying muscles undergo atrophy
and fatty degeneration, and the bones may show enlargement, uni­
formly or irregularly.

Diagnosis.—The diagnostic characters of beginning elephanti­
asis are the recurrent erysipelatous inflammation and the gradual en­
largement of the parts. To these, in the endemic or filaria variety, and
in some of the non-parasitic sporadic cases, the concurrent febrile dis­
turbance is an added factor. The appearances, later in the course of the
disease, such as increased size, thickening, induration, often varicosities
of lymphatic and venous nature, papillary hypertrophy, etc, are so dis­
tinctive that a mistake is scarcely possible. The filaria variety admits
of ready recognition by careful examination of the blood drawn during
the night, the parasites being quite characteristic; in some cases, how­
ever, they are not so abundant, and at least several examinations should
be made before an absolute conclusion is reached.

Prognosis.—While the subjects of the disease are necessarily
rendered more or less miserable by the weight of the parts and hindrance
to locomotion, life itself is rarely endangered. In the endemic parasitic
variety much depends, as also in non-parasitic cases, upon the stage at
which the patient comes under observation; in the first months of its
development there is a possibility, and according to some writers a prob­
ability, that the disease can be checked or held in abeyance; when well
established, rarely more than palliation is to be expected, although some
cases are on record where remarkable benefit followed therapeutic
measures. In elephantiasis of the genitalia, more especially in the male
and when of the scrotum, the results of surgical removal are satisfactory.

Treatment.—In the endemic or filaria variety of disease the
general treatment’ during the febrile attacks and the cutaneous exacerba­
tions, really resolves itself into the ordinary measures indicated by the
symptoms—saline purge or aperients, quinin in full dosage, with or with­
out strychnin, and iron, according to circumstances, and sleep-producing
drugs, if needed, such as opiates, phenacetin, sulphonal, and the like.
The general management of the exacerbations in the non-parasitic cases
depends upon the severity of the erysipelatous outbreak, differing but
little, if any, from the above, when such attacks are severe; locally the
ordinary applications useful in erysipelatous inflammations, and, if very
painful, fomentations of lead-water and laudanum. Rest in the re­
cumbent position is useful in all cases, more perceptibly so in the ad­
vanced disease. An important measure in staying the progress of the
malady, and even curing it, as attested by Fayrer, is removal, in the early
stages, from the endemic region to one in which the disease does not pre­
vail. In the endemic variety Thomasz¹ some years ago reported brilliant
results, in the early stages, from calcium sulphid, 1 to 2 grains (0.065-
0.13) twice daily, but I have not been able to find a report of such treat­
ment by others, either favorable or unfavorable. Lawrie‘s² hopefulness

¹ Thomasz, Ceylon Med. Jour., Aug., 1888, p. 1.

² Lawrie, Lancet, 1891, vol. i, p. 364 (2 cases), and 1892, vol. ii, p. 1247 (letter
communication, referring to another case).

MYXEDEMA                                            601

as to thymol, in 2- to 5-grain doses (0.135-0.32) three or four times daily,
based on its apparently successful action in 2 cases of chyluria due to
filariæ, and therefore probably useful in elephantiasis, has been negatived
by the experience of Manson, Crombie, Williams, and others.¹ The
constitutional treatment of elephantiasis during the intermission between
the acute exacerbations is symptomatic—tonics, cod-liver oil, etc, if
indicated.

In elephantiasis of the leg, along with rest, certain local measures
have a value—absolute cleanliness, massage, and compression. Hard-
away² warmly suggested or indorsed the reducing influence exerted by
the rubber bandage well applied. Conjointly with such measures the
use of the continuous and interrupted electric currents is strongly rec-
commended by Aranjo.³ Ligation of the main artery of the limb
(Carnochan, Wernher, Bryant, Erickson, Leonard, and others)⁴ has often
been followed by material reduction in the size of the part, and some­
times with alleged cure. Nerve section has also been practised by Mor­
ton and others with decided improvement in a few cases, but there is
great risk of secondary trophic and sensory disturbances. As a measure
of relief Curl⁵ speaks favorably of the results of removing wedge-shaped
strips of skin and subcutaneous tissue from time to time; in this manner
the leg being considerably reduced in size. The treatment of elephan­
tiasis of the genitalia is operative, and recorded results, chiefly regarding
the male genitalia (Osgood, Fayrer, Charles, and others), are extremely
favorable, and have become more so, and practically without danger,
under the surgery of to­day.⁶

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