This section is from the book "A Treatise On The Materia Medica And Therapeutics Of The Skin", by Henry G. Piffard. Also available from Amazon: A Treatise On The Materia Medica And Therapeutics Of The Skin.
Elephantiasis is an affection more frequent in hot than in cold climates, and characterized by excessive hypertrophy of skin and subcutaneous connective tissue of the lower limbs and genitals. The affection is most commonly seen in connection with one or the other of the legs, more rarely of both, the scrotum, prepuce, and labia.
The course and symptomatology of the disease vary somewhat in different cases. In the majority, however, the disease is ushered in by a febrile attack preceded by a chill. These general symptoms are Accompanied by an inflammatory swelling of one of the legs, somewhat resembling a mild erysipelas. After a few days the febrile symptoms subside, followed by a more or less complete disappearance of the local inflammatory trouble. As a rule, however, the swelling does not entirely disappear, but leaves the leg a little larger than before the attack. After a varying and uncertain period, which may be a few weeks or even months, a recurrence of the febrile attack takes place, with renewed swelling of the limb. These phenomena are renewed from time to time, each recurrence being followed by a permanent addition to the size of the affected member. Later the febrile attacks cease, but the limb, nevertheless, continues to slowly enlarge, until it may ultimately attain an immense size. Sometimes the affection is confined to the foot and ankle, or to the foot and leg, or even the thigh may be involved. Occasionally both limbs are affected, but, as a rule, the disease does not attack the second limb until long after the first. In addition the scrotum, or prepuce, or both, may likewise enlarged, or the female genitals.
The hypertrophy in elephantiasis seems to be without natural limit; the limbs may attain a circumference greatly exceeding that of the waist, and the scrotum may form a pendulous tumor touching the floor, and weighing a hundred pounds or more. In like manner the labia may descend below the knee.
The color of the skin in the fully developed disease may be little altered from the normal, but is frequently darker. In consistence it is harder than normal. The surface may be smooth and tense, but more frequently rough, harsh, and nodulated. Soft nodules are sometimes found, which, on puncture, give exit to a thin, lymphy fluid. Ulcerations may occur and abscesses form, or a condition resembling eczema, with moisture and exudation, may be met with. Deeper lesions sometimes occur, the muscles and even the bones being the seat of pathological changes.
If proper care is employed little difficulty need be experienced in the diagnosis of Elephantiasis, the peculiar features of the disease being the repeated febrile attacks, accompanied with the pseudo-erysipe-latous inflammation, and often with very evident implication of the lymphatic vessels and glands. It must not be supposed, however, that every chronic hypertrophy of the skin is Elephantiasis, as enlargement to a moderate degree may arise from other causes, as from chronic eczema of the foot and ankle, syphilis, leprosy, etc., in the lower limbs, hypertrophic rosacea of the nose, and leprous infiltrations of the face and ears. These should and always can be differentiated by their history and peculiar symptoms.
Elephantiasis is always a grave disease, and at one time was regarded as almost incurable. At present, however, the prognosis is somewhat more favorable.
The etiology of this disease is obscure. We know that it is extremely prevalent in certain hot climates, and the periodical febrile Attacks have led some to regard the affection as due to some special malarial influence. On the other hand Dr. Manson, of Amoy, has recently (1877) advanced the idea that the disease is due to the existence of parasitic Filaria in the Mood, introduced into it through the medium of drinking water.
Before considering the details of treatment we should appreciate as thoroughly as possible the exact conditions that we have to-deal with. These are an immensely hypertrophied member, the increase-in size being due to lymphatic effusion, leading to hypertrophy of the connective tissue of and beneath the skin, with probably the formation of considerable new tissue in addition. The vessels, both sanguineous and lymphatic, are enlarged, and the latter frequently varicose. The enlargement and varicosity of these vessels is probably due to partial occlusion of the main trunks in the neighborhood of the groin.
This understood, we will consider the special treatment that is adapted to the different varieties of Elephantiasis, and more particularly of the lower extremity, of the scrotum, and of the labia.
The quickest way of relieving the patient of a member that is a burden rather than a convenience to him would be to amputate, and this has been done. Unfortunately, this would too frequently terminate fatally, and is, therefore, not to be recommended. Some safer, even if less radical plan, must be adopted. Such a method was proposed and carried into effect by Carno-Chan in 1851. It consisted in ligature of the femoral artery (153, Sept., '52). The operation was successful, and has been repeated a number of times by others, with varying, but usually unsatisfactory result. 1 do not regard this operation as philosophical procedure, as the fault is not that too much blood is sent to the part, but that owing to obstruction and sluggish circulation too little gets back. The statistics of the operation have been collated by Wernher (Deutsche Zeitschft. f. Chir., 5, '75 394). Among 32 cases death occurred three times, gangrene requiring amputation twice; relapse in ten cases; ultimate result unknown in five cases, leaving twelve cases in which the result was satisfactory.
The treatment recommended by Hebra in Elephantiasis is as follows: After the local inflammatory symptoms have been subdued by moderate antiphlogistic measures, be uses cataplasms and tepid baths or inunctions, in order to soften and remove the thick accumulations of epidermis and crusts which may exist. When this is accomplished, inunctions of mercurial ointment into the parts are practised, absorption being more easily effected after the removal of the thick masses of epidermis. A horizontal or somewhat elevated position of the affected limb in conjunction with inunctions will, in such cases, certainly produce a marked improvement, which can be tested from time to time by measurement of the circumference of the limb. By this procedure, the limb, which was previously painful, becomes so quiescent that compression of it by a bandage may be undertaken. An ordinary cotton roller-bandage should be employed, and after being dipped in water should be applied with the utmost nicety. Begin behind the toes and proceed upward in such a way that each turn overlaps the greater part of the preceding one. The bandage should be applied tightly. In a few hours, however, it will become slack and will require reapplication, and this is to be repeated when necessary. The diminution in bulk is much greater during the early part of the treatment.
The only inconvenience connected with this method of treatment is the necessity for the frequent application of the bandage, in consequence of its soon becoming loose, and the necessity for its reapplication by a skilled bandager. To obviate this diffculty, Vidal. employed successfully elastic compression at the Hopital St. Louis in 1872. Unaware of this case, I adopted the same procedure in 1873, using an Esmarch bandage on a patient, in my wards at the Charity Hospital (87, 325). Since then excellent results have been obtained by the same procedure at the hands of Verneuil, Besnier, and Broca.*
When it is remembered that the tumor may reach such a size that the scrotum drags on the ground, and after removal has sometimes been found to weigh more than a hundred pounds, it is almost needless to say that the only feasible method of treatment is amputation of the mass. This has been accomplished a great many times with success, but the average mortality following the operation has been between five and ten per cent. This is sufficient to deter the surgeon, unless the demand for the operation is very pressing. The details connected with the operative procedure are very thoroughly elucidated in the report of a case operated on by the late Dr. Thebaud of this (155, May, '67). I have but a single suggestion to make in connection with the operation: After the penis and testicles are dissected out and suitable provision, in the way of flaps, have been made for covering them, that the rest of the tumor be removed by the galvano-cautery instead of by the knife. This will obviate hemorrhage, and greatly lessen the danger of pyemia.
Elephantiasis of the vulva, when excessive, necessitates amputation.