Manual of Surgery by Alexis Thomson (book recommendations for young adults .TXT) 📖

Fig. 96.—Tuberculous Elephantiasis in a woman æt. 35.

On parts of the body other than the face, the disease is even more chronic, and is often attended with a considerable production of dense fibrous tissue—the so-called fibroid lupus. Sometimes there is a warty thickening of the epidermis—lupus verrucosus. In the fingers and toes it may lead to a progressive destruction of tissue like that observed in leprosy, and from the resulting loss of portions of the digits it has been called lupus mutilans. In the lower extremity a remarkable form of the disease is sometimes met with, to which the term lupus elephantiasis (Fig. 96) has been applied. It commences as an ordinary lupus of the toes or dorsum of the foot, from which the tuberculous infection spreads to the lymph vessels, and the limb as a whole becomes enormously swollen and unshapely.

Finally, a long-standing lupus, especially on the cheek, may become the seat of epithelioma—lupus epithelioma—usually of the exuberant or cauliflower type, which, like other epitheliomas that originate in scar tissue, presents little tendency to infect the lymphatics.

The diagnosis of lupus is founded on the chronic progress and long duration, and the central scarring with peripheral extension of the disease. On the face it is most liable to be confused with syphilis and with rodent cancer. The syphilitic lesion belongs to the tertiary period, and although presenting a superficial resemblance to tuberculosis, its progress is more rapid, so that within a few months it may involve an area of skin as wide as would be affected by lupus in as many years. Further, it readily yields to anti-syphilitic treatment. In cases of tertiary syphilis in which the nose is destroyed, it will be noticed that the bones have suffered most, while in lupus the destruction of tissue involves chiefly the soft parts.

Rodent cancer is liable to be mistaken for lupus, because it affects the same parts of the face; it is equally chronic, and may partly heal. It begins later in life, however, the margin of the ulcer is more sharply defined, and often presents a “rolled” appearance.

Treatment.—When the disease is confined to a limited area, the most rapid and certain cure is obtained by excision; larger areas are scraped with the sharp spoon. The ray treatment includes the use of luminous, Röntgen, or radium rays, and possesses the advantage of being comparatively painless and of being followed by the least amount of scarring and deformity.

Encouraging results have also been obtained by the application of carbon dioxide snow.

Multiple subcutaneous tuberculous nodules are met with chiefly in children. They are indolent and painless, and rarely attract attention until they break down and form abscesses, which are usually about the size of a cherry, and when these burst sinuses or ulcers result. If the overlying skin is still intact, the best treatment is excision. If the abscess has already infected the skin, each focus should be scraped and packed.

Sporotrichosis is a mycotic infection due to the sporothrix Shenkii. It presents so many features resembling syphilis and tubercle that it is frequently mistaken for one or other of these affections. It occurs chiefly in males between fifteen and forty-five, who are farmers, fruit and vegetable dealers, or florists. There is usually a history of trauma of the nature of a scratch or a cut, and after a long incubation period there develop a series of small, hard, round nodules in the skin and subcutaneous tissue which, without pain or temperature, soften into cold abscesses and leave indolent ulcers or sinuses. The infection is of slow progress and follows the course of the lymphatics. From the gelatinous pus the organism is cultivated without difficulty, and this is the essential step in arriving at a diagnosis. The disease yields in a few weeks to full doses of iodide of potassium.

Elephantiasis.—This term is applied to an excessive enlargement of a part depending upon an overgrowth of the skin and subcutaneous cellular tissue, and it may result from a number of causes, acting independently or in combination. The condition is observed chiefly in the extremities and in the external organs of generation.

Elephantiasis from Lymphatic or Venous Obstruction.—Of this the best-known example is tropical elephantiasis (E. arabum), which is endemic in Samoa, Barbadoes, and other places. It attacks the lower extremity or the genitals in either sex (Figs. 97, 98). The disease is usually ushered in with fever, and signs of lymphangitis in the part affected. After a number of such attacks, the lymph vessels appear to become obliterated, and the skin and subcutaneous cellular tissue, being bathed in stagnant lymph—which possibly contains the products of streptococci—take on an overgrowth, which continues until the part assumes gigantic proportions. In certain cases the lymph trunks have been found to be blocked with the parent worms of the filaria Bancrofti. Cases of elephantiasis of the lower extremity are met with in this country in which there are no filarial parasites in the lymph vessels, and these present features closely resembling the tropical variety, and usually follow upon repeated attacks of lymphangitis or erysipelas.

The part affected is enormously increased in size, and causes inconvenience from its bulk and weight. In contrast to ordinary dropsy, there is no pitting on pressure, and the swelling does not disappear on elevation of the limb. The skin becomes rough and warty, and may hang down in pendulous folds. Blisters form on the surface and yield an abundant exudate of clear lymph. From neglect of cleanliness, the skin becomes the seat of eczema or even of ulceration attended with foul discharge.

Samson Handley has sought to replace the blocked lymph vessels by burying in the subcutaneous tissue of the swollen part a number of stout silk threads—lymphangioplasty. By their capillary action they drain the lymph to a healthy region above, and thus enable it to enter the circulation. It has been more successful in the face and upper limb than in the lower extremity. If the tissues are infected with pus organisms, a course of vaccines should precede the operation.