ELEPHANTIASIS ARABDM OF THE LABIA MAJORA. A CASE OF SUCCESSFUL OPERATION BY EXCISION. BY HENRY I. RAYMOND, A.M., M.D., ASSISTANT SURGEON UNITED STATES ARMY. Eeprinted from The American Journal of the Medical Sciences, July, 1886. ELEPHANTIASIS ARABUM OF THE LABIA MAJORA. A CASE OF SUCCESSFUL OPERATION BY EXCISION. Ellen, a full-blooded Indian, set. twenty-eight, complexion that of a mulatto, hair black, physical condition good. She has lived all her life on the malarious banks of the Klamath, in California. It has been her habit since childhood to bathe and swim in the Klamath River, and her dietary has consisted largely of the hsh caught in those waters. Un- married, but became pregnant by a half-breed, and was delivered of a living child at full term three months ago. A venereal taint, although probable from the presence of two large condylomatous growths near the anus, is denied. A tumor of her genital lips, from the size of a walnut to that of a closed fist, has existed from birth. Though possibly congenital, the disease was not hereditary. The dimensions of the labial tumor at the time the patient conceived were about those of the double-clenched fists, but as the foetus grew the pudendal swelling in- creased pari passu, so that at the termination of pregnancy the hyper- trophic growth had attained nearly its present dimensions. Has occasional chills, and has had one since she came into the valley for surgical treat- ment. The cold stage lasts about half an hour, and then follow the hot and sweating stages. During the malarial paroxysms the tumor smarts and burns, and feels hot and tense, until relief comes in the sweating stage. On December 4,1885,1 saw the patient for the first time and found a pendulous mass of solid but elastic consistency hanging from the puden- dum, suspended by a strong pedicle, of horseshoe shape. The skin of the pedicle was slightly thickened, but not nodular; it was not adherent to the subjacent tissue, or abnormal in color. It was the natural skin of the abdomen drawn by virtue of its elasticity much below the pubic sym- physis; the pubic growth of hair was seated upon the body of the tumor. The skin of the tumor proper was thickened and rugose and in places nodular, and adherent throughout to the parts beneath. It was markedly pigmented. No increased sensitiveness in the tumor. A deep sulcus (three inches) extended along its posterior aspect from the anterior com- 2 RAYMOND, ELEPHANTIASIS ARABUI. missure of the vulva downward. No particularly offensive odor came from the parts. The urine on being voided ran down the sulcus and caused more or less irritation and burning. The cumbersomeness of this cutispendula greatly impeded locomotion ; when this act was performed the growth was swung beneath the thighs posteriorly. It attachments would not permit it to be carried upward over the abdomen. The largest circumference of the outgrowth was the horizontal, being thirty inches, the antero-posterior twenty-four inches, the latero-lateral twenty-two inches, shortest circumference of pedicle, eighteen inches.1 Front view of tumor. Operation.—On the 2d day of January, 1886, the patient was placed upon the operating table and the tumor compressed by an elastic bandage to drain it of its blood. To our astonishment, the pedicle became more solid and largely increased in bulk, while the fundus yielded to the palpating fingers the sensation of elastic fluctuation. The bandage was 1 The growth was forwarded to the Surgeon-General, U. S. Array, for the National Medical Museum. RAYMOND, ELEPHANTIASIS AEABUM. 3 removed at once and the growth allowed to hang pendent in the hope that it would revert to its original shape, as the increased bulk of the pedicle was objectionable. The shape the tumor assumed under compression found its explanation later in the histology of the morbid growth ; this latter was made up largely of fat and cellular spaces filled with albu- minous fluid. My only medical assistant was Dr. William Michel, phy- sician to the Hoopa Valley Indian Reservation, other assistants being six non-commissioned officers of Co. G., Bth IT. S. Infantry. Every precaution was taken to guard against excessive hemorrhage and shock. Actual cautery irons were at hand to sear the tissues if need be, after staying the flow of blood by Esmarch’s rubber tubing. I placed my chief reliance for the prevention of loss of blood, however, Back view of tumor. upon a cord tourniquet made by an Indian out of some peculiar fibre stronger than any white man’s thread, and applied after the manner of Fayrer’s whip-cord tourniquet, viz., with a ring slipped over a loop of the cord to keep the cords together when traction was made. The ends of the cord, attached to wooden handles, were entrusted to the care of two assistants. The device is the same as that used by stockmen in altering their cattle and stallions. 4 RAYMOND, ELEPHANTIASIS ARABUM. The patient having been put under ether, an incision through the skin nearly two feet in length was made around the pedicle from one labium to the other, sparing the sound skin, which was then reflected and the cord tourniquet adjusted. To prevent any possibility of its slipping or of allowing the pedicle to retract after excision, two long upholsterer’s needles were made to transfix the pedicle on a plane just anterior to the tourniquet and posterior to the contemplated excision. The tumor was removed by a few strokes of the knife. On loosening the tourniquet trifling hemorrhage followed, chiefly venous. This was arrested by hot water and compression, so that not a single ligature was applied. The operation lasted thirty-five minutes. Sufficient sound skin was saved to cover with flaps nearly the entire raw surface of the amputa- tion cut. Through drainage was instituted. Healing was accomplished in about two weeks, except over an area two inches square, which was left to cicatrize. The temperature ranged between 99° F. and 101° F. except on the fifth day when it touched 103° F., owing to defective drain- age. On the seventh day the temperature fell to normal, and thereafter intermitted each morning, but did not vary much from the norm. Several interesting features in the clinical history of Arabian elephan- tiasis are illustrated by the foregoing case: (1) The predilection of ele- phantoid disease for the dark races. (2) Its etiological relations to malaria and other climatic influences. (3) The unimportant role that heredity appears to play as a predisposing cause. (4) The impetus com- municated to the growth of the morbid mass by the advent of pregnancy. (5) The foetus was carried to full term, and delivery was not impeded by the immensely hypertrophied labia, as the parturient canal and outlet were not compromised in their distensibility and calibre. Fort Gaston, Hoopa Valley, California.