Anomalies And Curiosities Of Medicine Part 60

Cullingworth of St. Thomas Hospital, London, successfully removed from a girl of sixteen an ovarian cyst weighing over 80 pounds. The patient was admitted to the hospital April 30, 1895. She gave a history of a single menstruation, which took place in March or April, 1893, and said that in the latter month she noticed that she was growing large. She was tapped at Christmas, 1893, when a large quant.i.ty of fluid was removed, and again in February, 1894, and a third time in May, 1894, but without useful results. For the previous six months she had been almost entirely bedridden because of the great size of the tumor. There were no symptoms referring to the bladder and r.e.c.t.u.m. At the time she entered the hospital she was much emaciated, the eyes were sunken, and her cheeks had a livid hue. The chest was thin and the lower ribs were everted; dulness began at the lower border of the 3d cartilage, and the apex-beat was best felt in the third s.p.a.ce. Liver-dulness began at the 4th rib cartilage in the nipple line. The abdomen was enormously distended, and covered by large veins running from below upward to the thorax. About 3 1/2 inches above the umbilicus there was a sulcus with its convexity downward. There was dulness over the whole abdomen, except at the sides parallel with the lumbar spines, and a resonant band over the stomach. The greatest girth was 54 1/2 inches. By v.a.g.i.n.al examination the cervix was found to be pulled up and obliterated; the anterior v.a.g.i.n.al wall was bulged downward by the tumor. On May 3d abdominal section was performed. An incision eight inches long was made in the mid-line of the abdomen. A cystic tumor, formed of small cysts in its upper part and of somewhat larger ones in the lower part, was revealed. It was adherent to the abdominal wall, liver, spleen, and omentum. The adhesions were separated and the cyst tapped with a large trocar, and then the septa between the cysts were broken down with the fingers. The pedicle was rather small and was tied in the usual way, and the tumor was removed. Its seat of origin was the left ovary. The right ovary and the uterus were healthy, but poorly developed. The tumor weighed between 80 and 90 pounds,--the patient having weighed 170 pounds on the night before the operation and 79 1/2 pounds a week after the operation. Alarming symptoms of collapse were present during the night after the operation, but the patient responded to stimulation by hypodermic injections of 1/20 grain of strychnin and of brandy, and after the first twenty-four hours the recovery was uninterrupted.

Cullingworth thinks that the most interesting points in the case are: the age of the patient, the enormous size of the tumor, and the advice given by the surgeon who first attended the patient (insisting that no operation should be performed). This case shows anew the uselessness of tapping ovarian cysts.

In the records of enormous dropsies much material of interest is to be found, and a few of the most interesting cases on record will be cited.

In the older times, when the knowledge of the etiology and pathology of dropsies was obscure, we find the records of the most extraordinary cases. Before the Royal Society, in 1746, Gla.s.s of Oxford read the report of a case of preternatural size of the abdomen, and stated that the dropsy was due to the absence of one kidney. The circ.u.mference of the abdomen was six feet four inches, and the distance from the xiphoid to the os pubis measured four feet 1/2 inch. In this remarkable case 30 gallons of fluid were drawn off from the abdomen after death.

Bartholinus mentions a dropsy of 120 pounds; and Gockelius one of 180 pounds; there is recorded an instance of a dropsy of 149 pounds. There is an old record of a woman of fifty who had suffered from ascites for thirty years. She had been punctured 154 times, and each time about 20 pints were drawn off. During each of two pregnancies she was punctured three or four times; one of her children was still living. It has been said that there was a case in Paris of a person who was punctured 300 times for ascites. Scott reports a case of ascites in which 928 pints of water were drawn off in 24 successive tappings, from February, 1777, to May, 1778. Quoted by Hufeland, Van Wy mentions 1256 pounds of fluid being drawn from the abdomen of a woman in five years. Kaltschmid describes a case of ascites in which, in 12 paracenteses, 500 pounds of fluid were removed. In 1721 Morand reported two cases of ascites in one of which, by the means of 57 paracenteses, 970 pounds of fluid were drawn off in twenty-two months. In the other case 1708 pounds of fluid issued in ten months. There is a record of 484 pounds of "pus" being discharged during a dropsy.

The Philosophical Transactions contain the account of a case of hydronephrosis in which there were 240 pounds of water in the sac.

There are several cases on record in which ovarian dropsies have weighed over 100 pounds; and Blanchard mentions a uterine dropsy of 80 pounds.

The Ephemerides contains an account of a case of hydrocephalus in which there were 24 pounds of fluid, and similar cases have been noted.

Elliotson reports what he calls the largest quant.i.ty of pus from the liver on record. His patient was a man of thirty-eight, a victim of hydatid disease of the liver, from whom he withdrew one gallon of offensive material.

Lieutaud cites a case, reported by Blanchard, in which, in a case of hydatid disease, the stomach contained 90 pounds of fluid.

Ankylosis of the articulations, a rare and curious anomaly, has been seen in the human fetus by Richaud, Joulin, Bird, and Becourt.

Ankylosis of all the joints, with muscular atrophy, gives rise to a condition that has been popularly termed "ossified man." A case of this nature is described, the patient being a raftsman, aged seventeen, who suffered with inflammatory symptoms of the right great toe, which were followed in the next ten years by progressive involvement of all the joints of the extremities, and of the vertebrae and temporo-maxillary articulations, with accompanying signs of acute articular rheumatism.

At the age of thirty-one the pains had subsided, leaving him completely disabled. All the joints except the fingers and toes had become ankylosed, and from nonusage the muscles had atrophied. There were no dislocations, anesthesia, or bedsores, and the viscera were normal; there were apparently no gouty deposits, as an examination of the urine was negative.

J. R. Ba.s.s, the well-known "ossified man" of the dime museums, has been examined by many physicians, and was quite intelligent and cheerful in spite of his complete ankylosis. Figure 269 represents his appearance in 1887.

Percy speaks of a man named Simoore, born in 1752, who at the age of fifteen was afflicted with ankylosis of all the joints, and at different angles He was unable to move even his jaw, and his teeth had to be extracted in order to supply him with nourishment. Even his ribs were ankylosed; his chest puffed up, and the breathing was entirely abdominal. In spite of his infirmities, after his pains had ceased he lived a comparatively comfortable life. His digestion was good, and his excretory functions were sufficient. The urine always showed phosphates, and never the slightest sign of free phosphoric acid. He still retained his s.e.xual feeling, and occasionally had erections. This man died in 1802 at the age of fifty, asphyxia being the precursor of death. His skeleton was deposited in the Museum of the ecole de Medecine de Paris. In the same Museum there was another similar skeleton, but in this subject there was motion of the head upon the first vertebra, the lower jaw was intact, and the clavicle, arms, and some of the digits of the right hand were movable.

An ossified man has been recently found and exhibited to the Paris Academy of Medicine. He is a Roumanian Jew of thirty who began to ossify twelve years ago, first up the right side of his back, then down the left side. He has hardened now to the nape of the neck, his head is turned to the left, and the jaws are ankylosed. He can still move his arms and legs a little with great difficulty.

Akin to the foregoing condition is what is known as petrifaction or ossification of portions of the living human body other than the articulations. Of the older writers h.e.l.lwigius, Horstius, and Schurig speak of petrifaction of the arm. In the Philosophical Transactions there was a case recorded in which the muscles and ligaments were so extensively converted into bone that all the joints were fixed, even including the vertebrae, head, and lower jaw. In a short time this man was, as it were, one single bone from his head to his knees, the only joints movable being the right wrist and knee. For over a century there has been in the Trinity College at Dublin the skeleton of a man who died about 20 miles from the city of Cork. The muscles about the scapula, and the dorsum of the ilium (the glutei) were converted into great ma.s.ses of bone, equal to the original muscles in thickness and bulk. Half of the muscles of the hips and thighs were converted into bone, and for a long time this specimen was the leading curiosity of the Dublin Museum. In the Isle of Man, some years ago, there was a case of ossification which continued progressively for many years. Before death this man was reduced to almost a solid ma.s.s of bony substance.

With the exception of one or two toes his entire frame was solidified.

He was buried in Kirk Andreas Churchyard, and his grave was strictly guarded against medical men by his friends, but the body was finally secured and taken to Dublin by Dr. McCartney.

Calculi.--In reviewing the statistics of vesical calculi, the strangest anomalies in their size and weight have been noticed. Among the older writers the largest weights have been found. Le Cat speaks of a calculus weighing over three pounds, and Morand is accredited with having seen a calculus which weighed six pounds. In his statistics in 1883 Cross collected reports on 704 stones, and remarked that only nine of these weighed above four ounces, and only two above six, and that with the last two the patient succ.u.mbed. Of those removed successfully Harmer of Norwich reports one of 15 ounces; Kline, one of 13 ounces 30 grains; Mayo of Winchester, 14 ounces two drams; Cheselden, 12 ounces; and Pare in 1570 removed a calculus weighing nine ounces. Sir Astley Cooper remarks that the largest stone he ever saw weighed four ounces, and that the patient died within four hours after its removal. Before the Royal Society of London in 1684 Birch reported an account of a calculus weighing five ounces. Fabricius Hilda.n.u.s mentions calculi weighing 20 and 21 ounces; Camper, 13 ounces; Foschini, 19 ounces six drams; Garmannus, 25 ounces; Greenfield, 19 ounces; Heberden, 32 ounces; Wrisberg, 20 ounces; Launai, 51 ounces; Lemery, 27 ounces; Paget, in Kuhn's Journal, 27 ounces (from a woman); Pauli, 19 ounces; Rudolphi, 28 ounces; Tozzetti, 39 ounces; Threpland, 35 ounces; and there is a record of a calculus weighing over six pounds. There is preserved in Trinity College, Cambridge, a stone weighing 34 ounces taken from the bladder of the wife of Thomas Raisin, by Gutteridge, a surgeon of Norwich. This stone was afterward sent to King Charles II for inspection. In his "Journey to Paris" Dr. Lister said that he saw a stone which weighed 51 ounces; it had been taken from one of the religious brothers in June, 1690, and placed in the Hopital de la Charite. It was said that the monk died after the operation. There is a record of a calculus taken from the bladder of an individual living in Aberdeen. This stone weighed two pounds, three ounces, and six drams.

In the Hunterian Museum in London there is a stone weighing 44 ounces, and measuring 16 inches in circ.u.mference. By suprapubic operation Duguise removed a stone weighing 31 ounces from a patient who survived six days. A Belgian surgeon by the name of Uytterhoeven, by the suprapubic method extracted a concretion weighing two pounds and measuring 6 1/2 inches long and four wide. Frere Come performed a high operation on a patient who died the next day after the removal of a 24-ounce calculus. Verduc mentions a calculus weighing three pounds three ounces. It was said that a vesical calculus was seen in a dead boy at St. Edmund's which was as large as the head of a new-born child.

It has been remarked that Thomas Adams, Lord Mayor of London, who died at the age of eighty-two, had in his bladder at the time of his death a stone which filled the whole cavity, and which was grooved from the ureters to the urethral opening, thus allowing the pa.s.sage of urine.

Recent records of large calculi are offered: by Holmes, 25 ounces; Hunter, 25 ounces; Cayley, 29 ounces; Humphrys, 33 ounces; Eve, 44 ounces; and Janeway, 51 ounces. Kirby has collected reports ol a number of large vesical calculi.

Barton speaks of stone in the bladder in very young children. There is a record of a stone at one month, and another at three years. Todd describes a stone in the bladder of a child of sixteen months. May removed an enormous stone from a young girl, which had its nucleus in a bra.s.s penholder over three inches long.

Multiple Vesical Calculi.--Usually the bladder contains a single calculus, but in a few instances a large number of stones have been found to coexist. According to Ashhurst, the most remarkable case on record is that of the aged Chief Justice Marshal, from whose bladder Dr. Physick of Philadelphia is said to have successfully removed by lateral lithotomy more than 1000 calculi. Macgregor mentions a case in which 520 small calculi coexisted with a large one weighing 51 ounces.

There is an old record of 32 stones having been removed from a man of eighty-one, a native of Dantzic, 16 of which were as large as a pigeon's egg. Kelly speaks of 228 calculi in the bladder of a man of seventy-three, 12 being removed before death. The largest weighed 111 grains. Goodrich took 96 small stones from the bladder of a lad. Among the older records of numerous calculi Burnett mentions 70; Desault, over 200; the Ephemerides, 120; Weickman, over 100; Fabricius Hilda.n.u.s, 2000 in two years; and there is a remarkable case of 10,000 in all issuing from a young girl. Greenhow mentions 60 stones removed from the bladder. An older issue of The Lancet contains an account of lithotrity performed on the same patient 48 times.

Occasionally the calculi are discharged spontaneously. Trioen mentions the issue of a calculus through a perineal aperture, and there are many similar cases on record. There is an old record of a stone weighing five ounces being pa.s.sed by the p.e.n.i.s. Schenck mentions a calculus perforating the bladder and lodging in the groin. Simmons reports a case in which a calculus pa.s.sed through a fistulous sore in the loins without any concomitant pa.s.sage of urine through the same pa.s.sage.

Vosberg mentions a calculus in a patent urachus; and calculi have occasionally been known to pa.s.s from the umbilicus. Gourges mentions the spontaneous excretion of a five-ounce calculus; and Thompson speaks of the discharge of two calculi of enormous size.

Of the extravesical calculi some are true calculi, while others are simply the result of calcareous or osseous degeneration. Renal and biliary calculi are too common to need mention here. There are some extraordinary calculi taken from a patient at St. Bartholomew's Hospital and deposited in the museum of that inst.i.tution. The patient was a man of thirty-eight. In the right kidney were found a calculus weighing 36 1/2 ounces, about 1000 small calculi, and a quant.i.ty of calcareous dust. In the left kidney there was a calculus weighing 9 3/4 ounces, besides a quant.i.ty of calcareous dust. The calculi in this case consisted chiefly of phosphate of magnesium and ammonium. Cordier of Kansas City, Mo., successfully removed a renal calculus weighing over three ounces from a woman of forty-two. The accompanying ill.u.s.tration shows the actual size of the calculus.

At the University College Hospital, London, there are exhibited 485 gall-stones that were found postmortem in a gall-bladder. Vanzetti reports the removal of a preputial calculus weighing 224 grams.

Phillipe mentions the removal of a calculus weighing 50 grams from the prepuce of an Arab boy of seven. Croft gives an account of some preputial calculi removed from two natives of the Solomon Islands by an emigrant medical officer in Fiji. In one case 22 small stones were removed, and in the other a single calculus weighing one ounce 110 grains. Congenital phimosis is said to be very common among the natives of Solomon Islands.

In September, 1695, Bernard removed two stones from the meatus urinarius of a man, after a lodgment of twenty years. Block mentions a similar case, in which the lodgment had lasted twenty-eight years.

Walton speaks of a urethral calculus gradually increasing in size for fifty years. Ashburn shows what he considers the largest calculus ever removed from the urethra. It was 2 1/8 inches long, and 1 1/4 inches in diameter; it was white on the outside, very hard, and was shaped and looked much like a potato. Its dry weight was 660 grains. At one end was a polished surface that corresponded with a similar surface on a smaller stone that lay against it; the latter calculus was shaped like a lima bean, and weighed 60 grains. Hunt speaks of eight calculi removed from the urethra of a boy of five. Herman and the Ephemerides mention cases of calculi in the seminal vesicles.

Calcareous degeneration is seen in the ovary, and Peterman speaks of a stone in the ovary. Uterine calculi are described by Cuevas and Harlow; the latter mentions that the calculus he saw was egg-shaped. There is an old chronicle of a stone taken from the womb of a woman near Trent, Somersetshire, at Easter, 1666, that weighed four ounces. The Ephemerides speaks of a calculus coming away with the menstrual fluid.

Stones in the heart are mentioned by medical writers, and it is said that two stones as large as almonds were found in the heart of the Earl of Balcarres.

Morand speaks of a calculus ejected from the mouth by a woman.

An old record says that stones in the brain sometimes are the cause of convulsions. D'Hericourt reports the case of a girl who died after six months' suffering, whose pineal gland was found petrified, and the incredible size of a chicken's egg. Blasius, Diemerbroeck, and the Ephemerides, speak of stones in the location of the pineal gland.

Salivary calculi are well known; they may lodge in any of the buccal ducts. There is a record of the case of a man of thirty-seven who suffered great pain and profuse salivation. It was found that he had a stone as large as a pigeon's egg under his tongue.

Umbilical calculi are sometimes seen, and Deani reports such a case.

There is a French record of a case of exstrophy of the umbilicus, attended with abnormal concretions.

Aetius, Marcellus Donatus, Scaliger, and Schenck mention calculi of the eyelids.

There are some extraordinary cases of retention and suppression of urine on record. Actual retention of urine, that is, urinary secretion pa.s.sed into the bladder, but retention in the latter viscus by inanition, stricture, or other obstruction, naturally cannot continue any great length of time without mechanically rupturing the vesical walls; but suppression of urine or absolute anuria may last an astonishingly extended period. Of the cases of retention of urine, Fereol mentions that of a man of forty-nine who suffered absolute retention of urine for eight days, caused by the obstruction of a uric acid calculus. Cunyghame reports a ease of mechanic obstruction of the flow of urine for eleven days. Trapenard speaks of retention of urine for seven days. Among the older writers Bartholinus mentions ischuria lasting fourteen days; Cornarius, fourteen days; Rhoclius, fifteen days; the Ephemerides, ten, eleven, and twelve days. Croom notes a case of retention of urine from laceration of the v.a.g.i.n.a during first coitus. Foucard reports a case of retention of urine in a young girl of nineteen, due to acc.u.mulation of the menstrual fluid behind an imperforate hymen.

The acc.u.mulation of urine in cases of ischuria is sometimes quite excessive. De Vilde speaks of 16 pints being drawn off. Mazoni cites a case in which 15 pounds of urine were retained; and Wilson mentions 16 pounds of urine being drawn off. Frank reports instances in which both 12 and 30 pounds of urine were evacuated. There is a record at the beginning of this century in which it is stated that 31 pounds of urine were evacuated in a case of ischuria.

Following some toxic or thermic disturbance, or in diseased kidneys, suppression of urine is quite frequently noticed. The older writers report some remarkable instances: Haller mentions a case lasting twenty-two weeks; Domonceau, six months; and Marcellus Donatus, six months.

Whitelaw describes a boy of eight who, after an attack of scarlet fever, did not pa.s.s a single drop of urine from December 7th to December 20th when two ounces issued, after vesication over the kidneys. On January 2d two ounces more were evacuated, and no more was pa.s.sed until the bowel acted regularly. On January 5th a whole pint of urine pa.s.sed; after that the kidneys acted normally and the boy recovered. It would be no exaggeration to state that this case lasted from December 5th to January 5th, for the evacuations during this period were so slight as to be hardly worthy of mention.

Lemery reports observation of a monk who during eight years vomited periodically instead of urinating in a natural way. Five hours before vomiting he experienced a strong pain in the kidneys. The vomitus was of dark-red color, and had the odor of urine. He ate little, but drank wine copiously, and stated that the vomiting was salutary to him, as he suffered more when he missed it.

Bryce records a case of anuria of seventeen days' standing. Butler speaks of an individual with a single kidney who suffered suppression of urine for thirteen days, caused by occlusion of the ureter by an insp.i.s.sated thrombus. Dubuc observed a case of anuria which continued for seventeen days before the fatal issue. Fontaine reports a case of suppression of urine for twenty-five days. Nunneley showed the kidneys of a woman who did not secrete any urine for a period of twelve days, and during this time she had not exhibited any of the usual symptoms of uremia. Peebles mentions a case of suspension of the functions of the kidneys more than once for five weeks, the patient exhibiting neither coma, stupor, nor vomiting. Oke speaks of total suppression of urine during seven days, with complete recovery; and Paxon mentions a case in a child that recovered after five days' suppression. Russell reports a case of complete obstructive suppression for twenty days followed by complete recovery. Scott and Shroff mention recovery after nine days'

suppression.

The most persistent constipation may exist for weeks, or even months, with fair health. The fact seemed to be a subject of much interest to the older writers. De Cabalis mentions constipation lasting thirty-seven days; Caldani, sixty-five days; Lecheverel, thirty-four days; and Pomma, eight months; Sylvaticus, thirty months; Baillie, fifteen weeks; Blanchard, six weeks; Smetius, five mouths; Trioen, three months; Devilliers, two years; and Gignony, seven years. Riverius mentions death following constipation of one month, and says that the intestines were completely filled. Moosman mentions death from the same cause in sixty days. Frank speaks of constipation from intestinal obstructions lasting for three weeks, and Manget mentions a similar case lasting three months.

Early in the century Revolat reported in Ma.r.s.eilles an observation of an eminently nervous subject addicted to frequent abuse as regards diet, who had not had the slightest evacuation from the bowel for six months. A cure was effected in this case by tonics, temperance, regulation of the diet, etc. In Tome xv of the Commentaries of Leipzig there is an account of a man who always had his stercoral evacuations on Wednesdays, and who suffered no evil consequences from this abnormality. This state of affairs had existed from childhood, and, as the evacuations were abundant and connected, no morbific change or malformation seemed present. The other excretions were slightly in excess of the ordinary amount. There are many cases of constipation on record lasting longer than this, but none with the same periodicity and without change in the excrement. Tomma.s.sini records the history of a man of thirty, living an ordinary life, who became each year more constipated. Between the ages of twenty and twenty-four the evacuations were gradually reduced to one in eight or ten days, and at the age of twenty-six, to one every twenty-two days. His leanness increased in proportion to his constipation, and at thirty his appet.i.te was so good that he ate as much as two men. His thirst was intense, but he secreted urine natural in quant.i.ty and quality. Nothing seemed to benefit him, and purgatives only augmented his trouble. His feces came in small, hard b.a.l.l.s. His tongue was always in good condition, the abdomen not enlarged, the pulse and temperature normal.

Emily Plumley was born on June 11,1850, with an imperforate a.n.u.s, and lived one hundred and two days without an evacuation. During the whole period there was little nausea and occasional regurgitation of the mother's milk, due to over-feeding. Cripps mentions a man of forty-two with stricture of the r.e.c.t.u.m, who suffered complete intestinal obstruction for two months, during which time he vomited only once or twice. His appet.i.te was good, but he avoided solid food. He recovered after the performance of proctotomy.

Fleck reports the case of a Dutchman who, during the last two years, by some peculiar innervation of the intestine, had only five or six bowel movements a year. In the intervals the patient pa.s.sed small quant.i.ties of hard feces once in eight or ten days, but the amount was so small that they const.i.tuted no more than the feces of one meal. Two or three days before the princ.i.p.al evacuation began the patient became ill and felt uncomfortable in the back; after sharp attacks of colic he would pa.s.s hard and large quant.i.ties of offensive feces. He would then feel better for two or three hours, when there would be a repet.i.tion of the symptoms, and so on until he had four or five motions that day. The following day he would have a slight diarrhea and then the bowels would return to the former condition. The princ.i.p.al fecal acc.u.mulations were in the ascending and transverse colon and not only could be felt but seen through the abdominal wall. The patient was well nourished and had tried every remedy without success. Finally he went to Marienbad where he drank freely of the waters and took the baths until the bowel movements occurred once in two or three days.

There is a record of a man who stated that for two years he had not pa.s.sed his stool by the a.n.u.s, but that at six o'clock each evening he voided feces by the mouth. His statement was corroborated by observation. At times the evacuation took place without effort, but was occasionally attended with slight pain in the esophagus and slight convulsions. Several hours before the evacuation the abdomen was hard and distended, which appearance vanished in the evening. In this case there was a history of an injury in the upper iliac region.

The first accurate ideas in reference to elephantiasis arab.u.m are given by Rhazes, Haly-Abas, and Avicenna, and it is possibly on this account that the disease received the name elephantiasis arab.u.m. The disease was afterward noticed by Forestus, Mercurialis, Kaempfer, Ludoff, and others. In 1719 Prosper Alpinus wrote of it in Egypt, and the medical officers of the French army that invaded Egypt became familiar with it; since then the disease has been well known.

Alard relates as a case of elephantiasis that of a lady of Berlin, mentioned in the Ephemerides of 1694, who had an abdominal tumor the lower part of which reached to the knees. In this case the tumor was situated in the skin and no vestige of disease was found in the abdominal cavity and no sensible alteration had taken place in the veins. Delpech quotes a similar case of elephantiasis in the walls of the abdomen in a young woman of twenty-four, born at Toulouse.

Lymphedema, or elephantiasis arab.u.m, is a condition in which, in the substance of a limb or a part, there is diffused dilatation of the lymphatics, with lymphostasis. Such a condition results when there is obstruction of so large a number of the ducts converging to the root of the extremity or part that but little relief through collateral trunks is possible. The affected part becomes swollen and hardened, and sometimes attains an enormous size. It is neither reducible by position nor pressure. There is a corresponding dilatation and multiplication of the blood-vessels with the connective-tissue hypertrophy. The muscles waste, the skin becomes coa.r.s.e and hypertrophied. The swollen limb presents immense lobulated ma.s.ses, heaped up at different parts, separated from one another by deep sulci, which are especially marked at the flexures of the joints. Although elephantiasis is met with in all climates, it is more common in the tropics, and its occurrence has been repeatedly demonstrated in these localities to be dependent on the presence in the lymphatics of the filaria sanguinis hominis. The accompanying ill.u.s.tration shows the condition of the limb of a girl of twenty-one, the subject of lymphedema, five years after the inception of the disease. The changes in the limb were as yet moderate. The photograph from which the cut was made was taken in 1875 At the present time (seventeen years later) the case presents the typical condition of the worst form of elephantiasis. Repeated attacks of lymphangitis have occurred during this period, each producing an aggravation of the previous condition. The leg below the knee has become enormously deformed by the production of the elephantoid ma.s.ses; the outer side of the thigh remains healthy, but the skin of the inner side has developed so as to form a very large and pendant lobulated ma.s.s. A similar condition has begun to develop in the other leg, which is row about in the condition of the first, as shown in the figure. Figure 273 represents this disease in its most aggravated form, a condition rarely observed in this country. As an example of the change in the weight of a person after the inception of this disease, we cite a case reported by Griffiths. The patient was a woman of fifty-two who, five years previous, weighed 148 pounds. The elephantoid change was below the waist, yet at the time of report the woman weighed 387 pounds. There was little thickening of the skin. The circ.u.mference of the calf was 28 inches; of the thigh, 38 inches; and of the abdomen, 80 inches; while that of the arm was only 15 inches.

The condition commonly known as "Barbadoes leg" is a form of elephantiasis deriving its name from its relative frequency in Barbadoes.

Figure 275 represents a well-known exhibitionist who, from all appearances, is suffering from an elephantoid hypertrophy of the lower extremities, due to a lymphedema. Quite a number of similar exhibitionists have been shown in recent years, the most celebrated of whom was Falmy Mills, one of whose feet alone was extensively involved, and was perhaps the largest foot ever seen.