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The management of endemic (non-filarial) elecphantiasis of the lower legs.

The treatment of elephantiasis is viewed with pessimism by both the medical attendant and by the patient; treatment ofa presumed cause (e.g. filariasis, recurring non-specific infection) is rarely followed by much clinical improvement, and symptomatic treatment appears to offer little help. Modern therapy has included the use of corticosteroids, of fluid dispersants such as hyalouronidase, of diuretics, and of surgery. Surgical methods endeavour to create new lymphatic channels, lymphatic-venous bypasses, or excise affected tissues of large areas below the knee, followed by grafting, but with subsequent loss of sensation. None has offered much improvement on the elevation and compression recommended by Hendy in 1784, and none is suitable for application to an endemic condition. The treatments to be described are based on observations that in endemic elephantiasis, the obstructive lesion is an irreversible fibrosis of the peripheral superficiallymph vessels belowthe knee (Price 1972); this obstruction is seen to be sub-total, so that some lymph continues to drain from the limb. It is also noted that the insidious development of the disease can be arrested by the use of footwear, and that the damaging effects of repeated attacks of lymphangitis can be avoided. Further, it is found that most legs can, by a suitable compression regime, be reduced to a sizecompatiblewith the larger sizesof footwear. If then the limitations of treatment are realized, much can be done to alleviate symptoms and arrest the progress of the disease, and the acceptability of these methods to a rural African population is attested by more than 1,500 patients who have sought treatment during five years at an elephantiasis clinic at Princess Zenebework Hospital in Addis Ababa, Ethiopia. The prognosis and success of treatment depend on recognition of the clinical type of diseaseas described elsewhere (Price 1974). Since the type remains true to form throughout the disease, unless disturbed by repeated episodes of inflammation or of traditional caustic applications to the skin, a correct assessment of the type avoids frustration to the patient and to the medicalattendant. In summary, any case lies between two polar forms, the "water-bag" or "soft" type, and the "wooden" or "hard" type; in general, the "softer" the type, the more gratifyingthe treatment. In the "water-bag" type the skin is smooth, moderately thickened (up to 0.5 em), the oedema is mainly subcutaneous and more fluid than in other types; the ankle folds, if present, are cushiony, and, like the skin, can be picked up with the fingers, being mobile on the underlying tissue. In the "wooden" type, the limb is less grossly swollen but the skin is thick, fibrotic, coarse, often "verrucous", cannot be picked up with the fingers, being fixed to the deep fascia. It may develop hard nodular outgrowths which are often traumatized and then may ulcerate. The common case falls between these two extremes, and the skin is then "rubbery" to palpation with features of both types in varying degree. The present treatments were devised in order to meet the situation in which only a few hospital beds were availablefor a large number of patients, surgical facilities were limited, and the economic situation of the patient required that he be able to return home without delay. Acceptable treatment can then be offeredfor the followingpurposes: 1. to arrest progress of early disease. 2. to control the frequency of episodes of acute swelling of leg and of acute femoral (crural) adenitis. 3. to reduce swellingof the limb. 4. surgicalreduction of swelling. 5. to maintain reduction of swelling. In the present experience, patients who attended in the early days of treatment were often cases of gross and advanced disease; recently, however, they have been seeking treatment for early signs of the disease, hoping to prevent the development of the later disfigurement with its social, marital, and educational disabilities. Treatments are here presented in the reverse order, beginning with the care of minimal cases and ending with the care of gross disease since this gives a more logical approach to control of the condition.