The colder atmospheres do not occasion snch marked distress during- this early stage.
In patients suffering from elephantia sis onee or twice a month there is an excess of fever. The loeal symptoms ac companying, the fever are those of lym phangitis with ganglionic enlargements.
These attacks of lymphangitis with fever coincide with the invasion of the con nective tissue of the hypoderm and of the associated lymph-channels by mi crobes. The visible lesions are the result of hundreds of febrile crises, each ac companied by a fresh advance of °Aetna. Each new (edematous deposit• is prob ably followed by local organization of the emigrated embryonal cells in adult connective tissue. Tropical elephantia sis is usually due to the Piiirria 8uir giants honliniR. Sabouraud (Annales de Derm. et de Syphil., May, '92).
The course of the affection, whether occupying the leg or elsewhere, is char acterized by frequent exacerbations. Deeply-seated, recurrent forms of derma titis, or attacks of an erysipeliform (or true erysipelas, the streptococcus of erysipelas being found in some cases) in flammation, with, at times, involvement nf Ifrnrn nr chylous discharges may be noted with or without puncture) are encountered. -While these phenomena are primarily localized in the deeper tissues, the skin does not seem to be attacked until later, when it presents nodular increase iu size.
With proper measures these symptoms abate, only to reappear at some later period. At each successive attack the part is noted to have increased in size to an appreciable extent. These recur rences of fever and cedema may appear at intervals of weeks only, while months or years may intervene between each recru descence. At times the recurrences of these phenomena may be so frequent or so close that the previous inflammation has not had time to disappear. As each attack leaves an increase in size we may, after a time, find a gigantic enlargement of the part involved. These inflamma tory phenomena may not always be ob served, as the part may often be found to increase in size without their apparent assistance. It is difficult to cause pitting in these structures, owing to the general ' hyperplasia. The skin, as previously noted, does not appear to participate in this process early, but later it becomes likewise affected. It is tightly stretched, glossy or waxy, with pigmentary changes of color varying from brownish red or pinkish red to one of dusky brown. Upon its surface may be seen an accumu lation of sebaceous material, with here and there desquamations of epithelium.
The linear fissures of the skin may in crease so greatly that enormous sulci may be formed. Hard or soft tubercles may appear upon its surface at various parts, either showing some scaly d.esquamation at their summit or becoming denuded of epithelium; they present numerous bleeding-points OT the top of the tuber cles may be one bleeding surface. In fact, many cases seem to present a chronic eczema upon the skin of the thickened part, and this appears to fol low its -usual characters. In other cases shallow ulcers, which resemble ordinary breaks of continuity, may be found at points over the affected skin. The parts around the joints form decided strictures, and the overlapping enlargement thus causes deep fissures in which a milky or chylous exudation, intermixed with se baceous discharge, canse painful macera tion of the inclosed skin. At certain points the lymphorrhagia may be so ex cessive as to cause great depression of vitality-.
While this increase occurs in the softer parts of the affected structures, the bones alike share the enlargement in all their dimensions, and glandular involvement is often noted. The leg resembles closely its counterpart in the elephant both ex ternally and in size-proportion. The weight becomes out of all proportion to other parts of the body, and while sub jective sensations are, for the most part, encountered during the inflammatory attacks, they may be observed after the affected. portion has been allowed to re main in one position for an indefinite period. Pain is then found to follow ex cessive fatigue, and tearing, stabbing sensations are reverberated throughout the affected leg,. When other parts— such as the scrotum and penis or the labia and clitoris—are involved, the same process intervenes and the enlargement hangs down between the legs, and may weigh many pounds. The penis usually becomes indistinguishable in the large mass and an opening or g.roove is left through -which the -urine trickles. The face (cheeks and nose), shoulders, arms, forearms, and the hands may share in the tumefaction, but do not show the same complications observed when the leg or genitals are involved. Other en largements of enormous extent de scribed, such as the elephantiasis telangi ectodes of Virchow, which is of congen ital origin and affects the vascular tissues.