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 passed small quantities of hard feces once in eight or ten days, but the amount was so small that they constituted no more than the feces of one meal. Two or three days before the principal evacuation began the patient became ill and felt uncomfortable in the back; after sharp attacks of colic he would pass hard and large quantities of offensive feces. He would then feel better for two or three hours, when there would be a repetition 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 principal fecal accumulations 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 passed his stool by the anus, 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 arabum are given by Rhazes, Haly-Abas, and Avicenna, and it is possibly on this account that the disease received the name elephantiasis arabum. 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 arabum, 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 coarse and hypertrophied. The swollen limb presents immense lobulated masses, 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 illustration 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 masses; 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 mass. 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 circumference 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.

Elephantiasis seldom attacks the upper extremities. Of the older cases Rayer reports four collected by Alard. In one case the hard and permanent swelling of the arm occurred after the application of a blister; in another the arm increased so that it weighed more than 200 Genoese pounds, 40 of which consisted of serum. The swellings of the arm and forearm resembled a distended bladder. The arteries, veins, and nerves had not undergone any alteration, but the lymphatics were very much dilated and loaded with lymph.

(Editor：way)