disease occurring in the lower extremities, is without doubt, largely influenced by locality.

elephanti

As to the nature of elephantiasis, opinion widely Nature of differs. Many of those who, from their position in asis. India, have had extensive opportunities of witnessing this disease, pronounce in favour of its malarious origin, and of the close connexion existing between it and intermittent fever. In support of this theory Mr. Waring, whose experience is certainly considerable, adduces 226 cases of elephantiasis Arabum, of which no less than 224 had suffered from intermittent fever. There are, I think, strong objections to this view. In the first place it may be fairly questioned whether a febrile paroxysm, which happens but once in three, four, or six months, is at all identical with intermittent fever properly so called. In my own experience of the latter malady on the banks of the Indus, where it yearly prostrated a large percentage of our troops, I never observed the least tendency to elephantiasis among them, nor yet in the resident population. Again, the febrile paroxysm differs in the following particulars from fever of an intermittent type:-headache, approaching to delirium, is the rule in elephantiasis, the exception in intermittent fever, and there is not that enlargement of the spleen or liver which is seldom wanting to the latter in its confirmed stage. The pulse in intermittent fever is quickened during the hot stage: this is not the case in elephantiasis, nor do the remedies on which we rely for a cure of the one produce a sensible effect on the other.

In an early stage, and when situated in the lower Treatment. extremities, an attempt should be made to reduce the size of the limb by even pressure. For this purpose cotton bandages, or better still a flannel roller, should be

applied from the toes and carried beyond the line of the swelling. Ointment containing iodine, or iodine friction will be also of assistance. In some cases the biniodide of mercury, in the proportion of one grain to four drachms of cerate, rubbed into the part has been productive of benefit, and is recommended by Mr. Day. The first effect of its application, he says, is to occasion some irritative fever, and even an increase in the size of the limb, with more or less pain; but as the latter subsides the swelling diminishes. Combined with this treatment absolute rest is essential. To improve the general health, bark may be given, but no remedy possesses a specific action on the disease. I have known it arrested by the above treatment, and in one case it seemed to lessen from the exhibition of small doses of mercury. How far any change of climate might prove of service in this country I cannot say, but a removal to a distant station in India, unless the complaint be far advanced, is generally followed by a remission of the local symptoms. The swelling may even disappear, but a relapse is almost sure to arise on the patient's return to his former abode. If this resource prove unavailing, or the complaint occur in a cold climate, the only alternative is amputation at or below the knee. The operation may be safely undertaken in so far as the disease is not likely to recur, and the patient's health warrants such a procedure. those instances where the thigh is likewise invaded, delegation of the femoral artery offers the best chance of success. I do not remember by whom it was originally proposed, but in one case it was performed by Mr. Butcher, of Dublin. The patient recovered without a single bad symptom, and she was finally enabled to follow her occupation, which was that of a laundress. The diffi

In

culty in tying the artery in such a case is greatly increased by its unusual size, as well as by the risk of wounding, on account of their engorgement, the superficial or the femoral veins.

In elephantiasis of the genitals the tumour should be removed. In the native hospitals at Calcutta and Bombay, these growths have been successfully amputated when they have weighed 100 lbs. and upwards. In one case that came under the care of Professor Ballingall, at the Jamsetjee Jeejeebhoy Hospital, July 20th, 1862, he commenced the operation by transfixing the neck of the tumour in the middle line, the knife emerging at the perineum. A strong double ligature was then passed through the opening and brought up round each side. After tightening the ligatures by tourniquets, the whole mass beyond the testicles was rapidly removed by a double-flap incision. The tumour weighed, after removal, 106 lbs. The after-shock was very great, in consequence of reaction not being properly established for some days, and in consequence of a heavy loss of blood the following day. The after-recovery was, however, uninterrupted, and on the 4th of September the patient was discharged, cured.*

"On the Operation for Elephantiasis scroti, with Cases and Remarks,” Transactions of the Bombay Medical and Physical Society, vol. viii., p. 233, by Assistant-Surgeon G. Ballingall.

Warts.

CHAPTER XXI.

MORBID GROWTHS OF THE SKIN.

Warts are generally regarded as growths due to hypertrophy of the papillæ of the skin, and covered by epidermis, which is subject to great variation in thickness. This definition applies to only such as are small and represented by a single or a group of filaments confined within a small space. In a more advanced stage, and occupying a more extensive surface, they consist of fibrous or fibro-cellular tissue. Very vascular, they bleed readily when cut. Situated on an exposed surface, they are usually dark coloured and dry, but in other parts they are soft, and often attended by a thin secretion, which, by its contact, seems to possess the power, in certain cases, of causing other warts to appear. The blood from a wart is also popularly deemed to be a common source of contagion, but actual experiment negatives this idea, or at least very rarely verifies it. Warts are objects rather of disfigurement than of pain; and are neither connected with any peculiarity of temperament, nor determined by the state of the general health. Uncertain in their origin, they may continue for years or subside spontaneously.

They are most frequent in the young of both sexes, but unless congenital, are seldom seen in infancy or advanced life. Often abundant on the hands, they may

nevertheless occur in any part. On the scalp they are as a rule remarkable for their tenuity.

warts.

Warts are occasionally consequent on syphilis, or Venereal what is more common, especially in the female, they are attendant upon gonorrhoea or any foul secretion that is apt to collect about the parts of generation. They are seen on the external organs or on the mucous membrane, any portion of which is liable to be attacked. Sometimes they are confined to the verge of the anus, which may be thus completely enveloped by them. Venereal warts in the female occur for the most part in one of two forms, either as a single growth, when they are frequently of large size and more or less crescentic in shape, attached to the surface by a small base, and showing everywhere a number of excrescences resting on pedicles; or the root from which they are derived is of considerable extent, white on section, and fibro-cellular in structure. Every portion of its periphery is thickly studded with warts, which vary in size from a pin's head to a pea. Sometimes the whole track of skin from the mons veneris to the anus is covered with these growths. When seated about the genitals, warts are more than usually contagious. An offensive secretion mostly attends them; and if of large size, they are freely supplied with blood. In the male, venereal warts are often seen on the glans penis, under cover of the prepuce; favoured by the secretion which is not removed, and the moist mucous surface, they sometimes grow rapidly in this locality. When congenital phymosis exists, they have been known to perforate the prepuce and appear externally in such a case, the growth becomes often exuberant. A minute warts will someof crop very times encircle the free margin of the prepuce.

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