Other favorite sites are the scrotum, vulva, breasts and penis. Rarely the scalp or areas about neck or trunk may show involvement.
Fig. 100.—Elephantiasis of the legs. (From Ruge and zur Verth.)
Surgical treatment is the one usually followed. When an extremity becomes too much of a burden, amputation may be indicated. The employment of the method of lymphangioplasty, which consists in the introduction of silk threads into the subcutaneous tissues, to make a channel to the normal lymphatics, does not seem to have been attended with any degree of success or at any rate permanent results. These wounds tend to become infected and if this does not occur the new channels are speedily obliterated.
Castellani recommends the use of Merck’s fibrolysin in injections of from 2 to 4 cc. daily, for three to six months. After each injection the part is tightly bandaged with flannel or rubber bandages. The injections may either be made into the affected part or into the gluteal region. Massage prior to the bandaging may give better results. When the limb becomes smaller and the skin smoother, long strips of skin and subcutaneous tissue may be dissected out and the adjacent edges sutured.
In considering the advantages of operation in elephantiasis of the scrotum it is usually stated that the only question involved is the removal of a burdensome mass which in no way is a source of danger to the life of the patient. At the same time such patients are subject to attacks of elephantoid fever, a condition not without its dangers. There is one factor not usually brought forward and that is the remarkable effect of a successful operation on the mental state of the patient. This is well shown in the accompanying illustrations of the patient before and after operation. If sexual deficiencies are of so powerful an influence on persons of education how much greater must they weigh on an uneducated native with but few of the higher interests of life.
Prior to operation the patient should be kept in bed for a day or so to lessen the amount of fluid and to secure relaxation of tissues. Thorough scrubbing with soap and water the day of and the day before the operation and the use of alcohol as an antiseptic are important. Some prefer iodine.
Fig. 101.—Elephantiasis of the scrotum. Before operation. (Fauntleroy.)
For the operation the lithotomy position is employed. An assistant supports the scrotal tumor wrapped in a sterile towel. Fauntleroy, whose method I give, does not recommend a tourniquet to the base of the tumor as in his opinion it assists but little in controlling haemorrhage and endangers asepsis. Haemostats answer better and as the vessels which give most trouble are deeply situated the elastic cord would not affect them. In some cases there is very little bleeding. The upper part of the pear-shaped tumor usually affords sufficient sound skin next the thighs for the flaps. As a rule the elephantoid tissue does not involve the upper 2 or 3 inches of the skin anteriorly, which is thus available to cover in the base of the penis. In addition to this covering for the penis we have a long prepuce which has been considerably stretched so that after removing all elephantoid tissue there is enough sound prepuce remaining to cover the distal 2 or 3 inches, so that usually there is sufficient sound skin for a 5-inch penis.