MEDICAL ABSTRACT REPRINT, 
No. i. 
AMPUTATION OF SCROTUM FOR ELEPHANTIASIS 
1/ 
By Geo. A. Turner, M.D. A View of Current Medical Literature. 
The New York Medical Abstract, from which this reprint 
is taken, is published monthly at 93 Fulton street, New York, 
at one dollar a year. 
Each number contains from forty to forty-eight octavo pages 
of close-set matter with numerous illustrations. 
Among the journals from which selections are made may be 
mentioned the following : 
Mind, London, 
Lancet, London, 
Medical Record, London, 
British Med. Journal, London 
Med. Times and Gazette, London, 
Journal Anatomy and Physiology, 
Journal Psychological Medicine, 
Brain, London, 
Practitioner, London, 
Medical Journal, Glasgow, 
Medical Journal, Edinburgh, 
Medical Review, Birmingham, 
Journal Medical Science, Dublin, 
Medico-Chirurgical Jour. , Liverpool. 
Etc., Etc. 
The articles selected : 
1. Are such as are seldom re-published here and are by some 
of the most eminent members of the profession ; 
2. Retain the language of the originals, omitting mere theories 
and matter of purely local interest ; 
3. Are taken from journals of the month previous, and hence 
are as fresh as it is possible to make them ; 
4. Reproduce the illustrations of the originals ; for the first 
six months of the present year upwards of one hundred 
illustrations, many of them full-page, and lithographs, 
have appeared in our columns. 
In addition to the above, the titles of original articles, not se- 
lected, appearing in the medical journals both of this country 
and Great Britain during the previous month, are given ; the 
whole forming a general view of the current medical literature 
of Great Britain and the United States. 
Specimen copy sent on application. 
New York, July, 1882. Contents op the New York Medical Abstract for July, 1882. 
One Hundred and Thirty-Eight Cases Amputation of Scrotum for Elephantiasis 
Arabum, Geo. A. Turner, M.D., C.M., with lithograph, Glasgow Medical 
Journal. 
Mad Actors, Journal Psychological Medicine, London. 
Contagiousness of Pulmonary Consumption, I. Burney Yeo, M.D., F.R.C.P., 
British Medical Journal. 
Five Cases of Hare-Lip, James Whitson, M D., Medical lames and Gazette, 
London. 
On the Diagnosis and Prognosis of Idiocy and Imbecility, William W. Ireland, 
M.D., Edinburgh Medical Journal. 
Sodium Nitrite in Epilepsy, W. T. Law, M.D., F.R.C.S., England, Practitioner, 
London. 
Clinical History and Diagnosis of Hsematoma of the Dura Mater, James 
Finlayson, M.D., Glasgow Medical Journal. 
Therapeutic Properties of Quinine lodate and Bromate ; and Physiological 
Activity of Superoxidised Molecules, Charles A. Cameron, M.D., Dublin 
Journal Medical Science. 
Eserine and Pilocarpine in Glaucoma, and Eserine in Ocular Neuralgia, Simeon 
Snell, L.R.C.P., M.R.C.S., British Medical Journal. 
Syphilitic Azoospermism, John P. Bryson, M.D., St. Louis Courier Medicine. 
Codeia in Treatment of Diabetes, R. Shingleton Smith, M.D., British Medical 
Journal. 
Items—“Notes and Titles.” 
ONE HUNDRED AND THIRTY-EIGHT CASES AMPU- 
TATION OF SCROTUM FOR ELEPHANTIASIS 
ARABUM. 
GEO. A. TURNER, M.D., C.M. 
For the 12 years previous to 1880 I was resident in the 
group of islands in the South Pacific, as a medical missionary, 
and it was there that the cases which form the subject of this 
paper were met with. Samoa is the name of a group of volcanic 
islands in Central Polynesia. Elephantiasis arabum is extremely 
prevalent throughout the whole group, attacking natives and 
Europeans alike. Shortly after arriving in Samoa I was applied 
to by a native to remove an enormous tumour of the scrotum, 
which hung down below his knees and very much impeded his 
walking. Being single-handed I naturally felt reluctant to 
attempt such a formidable operation. The man was so impor- 
tunate, however, that I wrote to Sydney, N.S.W., to procure an 
aortic tourniquet. Such an instrument could not be obtained in 2 
Sydney ; and, before I could get one from England, H.M.S. 
“ Cossack ” called at Samoa, and in conversation with the staff- 
surgeon of that ship, Dr, G. V. M‘Donough, I mentioned the case. 
It happened that Dr. M‘Donough was a student in Dublin in 1844 
when O’,Ferrall’s operation took place and witnessed it. Hesug- 
gested the possibil of controlling the haemorrhage by a clamp 
composed of parallel bars, with screws at each end, applied to the 
neck of the tumour. I subsequently found that such a clamp is 
advised in the earlier editions of Dr. Druitt’s Vade Mecum. An 
iron clamp of this description was kindly made for the purpose by 
the chiefengineer of the “ Cossack,” and on July 9, 1872, the opera- 
tion was performed. The man was probably about 45 years of age, 
but looked several years older. The tumour measured 30 inches 
in circumference at the knees, and hung down nearly to the 
ankles. For about an hour before operation the patient was 
kept lying on the operating table with the tumour raised con- 
siderably higher than his body for the purpose of emptying it as 
far as possible of blood. The clamp was then fixed in position, 
but not screwed down. Dr. Horner administered chloroform. 
As soon as the patient was thoroughly under its influence we 
screwed the clamp tightly down. Dr. McDonough commenced 
the operation dissecting up three rectangular skin flaps, one from 
the upper and front part of the tumour, and two lateral ones— 
the centre one to form a new covering for the penis, and the side 
ones to cover the open surface after the tumour was removed. 
The penis was then dissected out and held up on the abdomen. 
The cords were next cut down upon and tied, it having been 
decided not to attempt to save the testicles. In each case the 
whole cord was included in one whipcord ligature, according to 
the old method. The rest of the pedicle was severed by a few 
strokes of the knife. The clamp was then slowly unscrewed and 
the arteries tied as they showed themselves. About 30 required 
ligature. The flaps were then brought into position and secured. 
The clamp answered its purpose admirably, there being no bleed- 
ing during the operation, except a little venous haemorrhage 
from the tumour. The operation lasted about an hour, and the 
greatest difficulty we met with was to support the mass. This 
had to be done by a plank passed under it and held at each end 
by an assistant. The tumour was found to weigh 77 lbs. 
This second case was not nearly so large as the former, the 
tumour, after removal, not weighing quite 30 lbs. The operation 
was performed precisely in a similar manner to the first one, 
except that in this the right testicle was dissected out from the FIG; ' A. 
FIG. AI. 
FIG. B. 
FIG. C, 4 
mass and retained. After operation the patient was removed to 
a house close by the one where the first patient was. Wounds 
in both cases were dressed twice a day with a solution of carbolic 
acid in oil. Both made a good recovery. The first, I have 
repeatedly seen since. After the operation he soon got quite 
strong and stout, and looked at least 10 years younger than he 
did before it. The success of the two operations described led 
many from all parts of the Samoan group, who were similarly 
affected, to apply to me for relief. In the eight years, 1872 to 1879 
inclusive, I performed 136 of these operations, and I am for- 
tunately able to show photographs of several of these cases. 
In one of the earliest operations which I performed, and in 
which I used the iron clamp above described, there was consid- 
erable difficulty afterwards from retention of urine. This, I 
thought, might be owing to the prolonged severe crushing of the 
penis between the bars of the clamp. I therefore procured from 
Fig. d. 
Sydney a brass clamp, which I now show you (Fig. d) and which 
differs from the original instrument only in that it has a piece 
cut out of the centre of the upper bat ; the object*of which is, as 
much as possible, to get rid of the undue pressure on the penis. 
This clamp I have used in almost all my subsequent operations, 
and I have never had any trouble from retention of urine after 
its use. 
Let me now describe the various steps of the operation as 
practised by myself. The patient should be placed on the oper- 
ating table at least half an hour before operation, and lie quietly 
with the tumor raised considerably above the level of the body, 
that it may empty itself as much as possible of its blood. The 
upper bar having been removed, the clamp is then applied by 
raising the tumour and passing the screws up from behind on 
either side of its neck, the lower bar being held as far back to- 5 
wards the perineum as possible. The tumour is then turned 
down and the upper bar put on and fixed in its place by the 
thumb screws. These, however, at this stage, should only be 
applied to keep the clamp in position, and should not, in any 
way, interfere with the circulation in the tumour. Before apply- 
ing the clamp it is always well to make sure that no hernia exists ; 
or that if it does, that it has been wholly reduced. 
The clamp being in position, chloroform is administered, the 
tumour still being kept elevated. The clamp is rapidly and 
firmly screwed down on both sides simultaneously. The tumour 
should now be turned upwards to expose its posterior surface. 
If it be small it may simply be turned upwards on the abdomen, 
its weight being supported by the hand of an assistant. In the 
case of large tumours some other contrivance is necessary, and I 
have been in the habit of using a couple of large hooks, like 
shark hooks, attached to a block and tackle fixed to the ceiling. 
These hooks are passed through the leathery skin at the lower 
part of the tumour, and by means of the tackle the whole tumour 
is raised so as thoroughly to bring into view its posterior sur- 
face. A rounded skin flap is then raised from the posterior part 
of the neck of the tumour, the horns of the incision being at 
either end of the lower bar of the clamp. This flap should be 
about i 1 inches long in its centre, and should be dissected up 
close to the clamp. The tumoiir is now lowered and allowed to 
fall forwards so as to rest upon the leaf of the table. To enable 
this to be done the patient should be drawn well down to the 
end of the table, and his legs from the knefes downwards be made 
to hang down, one on each side of the leaf, and be fastened to 
the legs of the table. 
Either two or three skin flaps should now be raised from the 
anterior surface of the tumour. If the penis be superficial, and 
not covered up by hypertrophied tissue, it will be sufficient to 
raise a right and left rounded flap, having their outer ends at the 
right and left end respectively of the upper bar of the clamp, and 
meeting in the centre under the penis. Where the penis is buried 
in the mass of the tumour, as it often is, in addition to the right 
and left flaps, just mentioned, a third should be made between 
the two, and as this central flap is made for the purpose of afford- 
ing a new covering for the penis, care should be taken that it be 
formed of sufficient width to permit of its encircling that organ 
without any undue straining. The length of these flaps must be 
regulated by the probable bulk of the parts they will have to 
cover after the operation is completed. After dissecting up these 6 
flaps the penis is next dissected out. This is sometimes a matter 
of no little difficulty on account of the mass of hypertrophied 
tissue in which it lies buried. The best method is to start from 
the opening from which the urine escapes, which in some cases 
is found at the lowest part of the tumour, and from this boldly 
cutting upwards to expose the glans penis. This having been 
found, it is not difficult to dissect out the penis, which should 
then be held up on the abdomen, along with the anterior flaps, 
by an assistant. The next step is to find the testicles. These 
also, especially in the larger cases, are deeply buried in the sub- 
stance of the tumour. The easiest and quickest way of finding 
these is to cut diagonally across the face of the tumour, first on the 
one side and then on the other and partly by the use of the 
knife, and partly by tearing the hypertrophied connective tissue 
with the fingers, they are soon discovered. They should then 
be dissected up with their cords and held well out of the way. 
This having been done, a very few strokes of the knife will sever 
all the remaining tissues constituting the neck of the tumour, 
and the mass is removed. The testicles should next be examined. 
In some, even of the largest cases, they are found to be quite 
healthy ; and almost, if not quite, of natural size. In the 
majority of cases, however, there is more or less hydrocele on 
one or both sides, generally associated with very considerable 
thickening of the tunica vaginalis. I have always treated these 
hydroceles by freely incising them, and, where there was much 
thickening of the sac, excising a very considerable portion of it. 
In some cases, where -there was excessive hypertrophy of the sac, 
I have removed the testicle on that side. The next step-is to tie 
all vessels which are seen in the stump. In all my operations I 
have used carbolised catgut ligatures, which were cut close off 
and left to be absorbed. The next thing is slowly to unscrew 
the clamp, being on the watch to tie anything that bleeds. At 
this stage of the operation, when sometimes a number of vessels 
show themselves simultaneously, I have found great advantage 
from the use of Dieffenbach’s small self-holding forceps, which 
while taking up very little room, control the haemorrhage effi- 
ciently, and give the operator time to tie the vessels one after 
another. In most of the larger cases there are usually some 20 
to 30, or even more, vessels which require ligature. 
If it should happen on loosening the clamp, as has occurred to 
me on two or three occasions, that some considerable vessel, 
which has at first been overlooked, slips behind it and bleeds 
freely, the best plan is at once to unscrew the clamp and throw 7 
it off, trusting to speed in securing all bleeding points. Too 
great care cannot be taken to tie every point from which it seems 
possible that bleeding may occur, as neglect of this precaution 
may give rise to very troublesome haemorrhage some hours after- 
wards. After all the vessels have been ligatured, the flaps are 
brought into position, and united with wire or catgut sutures. 
It is well to put a drainage tube on each side behind the testicles, 
A 1-20 aqueous solution of carbolic acid was freely applied before 
the wound was closed, and antiseptic dressings were invariably 
employed. 
Of the 136 operations already mentioned, the two largest were 
for the removal of the tumours (Figs, a and k). In both of these 
cases.the tumours weighed almost exactly 80 lbs. They were 
weighed about an hour after removal, and after a good deal of 
blood and fluid had drained away. In the case of a, the tumour 
had been years in growing. When he stood up it reached almost 
down to the ground, and measured 40 inches in circumference. 
It will be observed that his limbs were all enlarged from the 
same disease. At the time the photograph was taken his right 
calf measured 36 in. in circumference, and the left only an inch 
or two less. In this case the testicles were both of natural size, 
no hydrocele ; and they, with the penis, were preserved. The 
operation itself—formation of flaps, dissection of the organs out 
from the mass, and removal of the tumour—was completed in 12 
minutes. The wound healed very rapidly, and Fig. ai, taken 
on the 28th day after operation, shows the result. 
In the case marked B, the tumour, which also was of several 
years’ growth hung down nearly to the ankles, and measured 54 
inches in circumference. The elephantiasis in this case was 
almost entirely confined to the scrotum, the lett leg and foot 
being the only other part affected, and that only slightly. In 
this case there was hydrocele on both sides, the penis and right 
testicle were preserved, the left testicle being removed. 
The illustration, Fig. c, is interesting as showing the occa- 
sionally rapid growth of such tumours. The patient was a man 
about 2c, otherwise perfectly healthy, and the tumour had grown 
in two years. It weighed 54 lbs. after removal. Penis and both 
testicles were retained, and patient made good recovery. 
Of the other tumours removed one was over 50 lbs., three were 
over 40 lbs., and the rest were of various sizes, from about 7 or 
8 lbs. up to 37 lbs. In none of the cases was the penis removed, 
in none were both testicles removed, and in the great majority 
all the organs were preserved. In one case, in which the tumour 8 
was over 20 lbs. in weight, the wound healed almost entirely by 
first intention, and patient walked home, a distance of several 
miles, within a fortnight after operation. Dec. 22, 1874, I 
operated on four of these cases ; on the 23rd on one ; and on the 
25th on one ; and on Jan. 26, the last of the six went home well. 
Of the 136 cases I lost only two ; on the 10th and nth day 
after operation respectively. In the one case obstinate diarrhoea 
was the cause of death, and in the other, fever. In these cases 
the tumours weighed about 10 and 15 lbs. respectively. 
The success which attended these operations I attribute mainly 
to four things : 1. The completeness with which haemorrhage 
is controlled by the clamp ; 2. The covering in of the wound with 
skin flaps ; 3. The use of antiseptic dressing ; and 4. The fine 
physique, and coolness, and powers of endurance of the Samoans. 
In the last edition of Curling on Diseases of the Testis, Esmarch’s 
method of controlling bleeding is recommended in these opera- 
tions. But it is added, “In thin patients arterial haemorrhage 
may be further controlled by compression of the aorta with the 
abdominal tourniquet.” In two of my operations I made use of 
Esmarch’s tubing, and it answered fairly well ; but I prefer the 
clamp as the more effective method. In these cases, after the 
removal of the tumour, the elastic tube had a great tendency to 
slip off, and was only retained in its position with difficulty. But 
my greatest objection to it is that when it is employed the skin 
is drawn into folds, and the operation thereby rendered much 
more difficult. When the clamp is used, on the other hand, we 
have a flattened surface both anteriorly and posteriorly, which 
renders the operation very much more easy. Another great 
advantage which is gained from the use of the clamp is that, after 
the removal of the tumour, it is easy to slacken the screws, half 
a turn at a time, so as to cause any vessels which have been over- 
looked to show themselves, the bleeding being easily controlled 
by tightening them up again. 
In almost all my cases I used bichloride of methylene. I 
first used this aneesthetic on account of statements of Dr. Rich- 
ardson, Mr. Morgan, and others, who claim that it is “less dan- 
gerous than chloroform,” that “ its action is more rapid,” that 
“ recovery is more prompt,” and that “ if dangerous symptoms 
show themselves during its administration, they subside sooner 
on discontinuing the inhalation.” I have been thoroughly 
satisfied with it, and never had any difficulty in connection with 
its administration, though this was in almost every case done 
only by a native.—Glasgow. Medical Journal, June. FOR CONSUMPTION AND WASTING DISEASES. 
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S7APNIA 
PUR FIED OPIUM 
OR 
An°o*ne0*ne and 
ALKALOIDS 
CODEIA, 
NARCEIA 
AND 
MORPHIA, 
S°NO\JS £ CONVVJ''s’''5’'' 
ALKALOIDS 
THEBAIN, 
NARCOTIN 
AND 
PAPAVERIN. 
This article is not intended, for popular use, but only on prescrip- 
tion of the profession. It is to take the place of Opium in eases where 
that drug acts injuriously. 
DOSE, TdEXIE S-A-dVtZE -A.S OI>IXrM. 
Dr. John Harley, of London, in his “Old Vegetable Neurotics,” details a large 
number of experiments upon the human and animal system, with six of what he con- 
siders the narcotic alkaloids. He concludes that although all six possess both narcotic 
and hypnotic properties, yet these are so varied in degree and force, as to make their 
effects, when exhibited singly, very distinct from those following their exhibition in 
combination. 
Taking the experience of practical physicians with Dr. Harley’s results, as a basis, 
we would group them in the following order ; 
First Group. , ' Second Group. 
Anodyne and Hypnotic Elements. Narcotic and Convulsive Elements. 
1. Morphia. j i. Thebain. 
2. Narceia. ! 2. Cryptopin. 
3. Codeia. I 3. Papaverin. 
Now Svapnia is a distinctive name given to the first group. representing the 
anodvne and hrrM me elements; the second group, or the narcotic and convulsive 
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single constituent of Opium. 
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In Svapnia, there is retained all the Morphia and the greater part of the Codeia and 
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1 in inner as to render those constituents soluble and active. 
Svapnia is unifirm in its proportions, and is prepared toconform to a standard of 
Opium representing ten per cent, of Morphi a. This is done by a simple proportion of 
the neutral excipient, after determining the actual amount of the alkaloids obtained from 
the Opium used. 
We may safely affirm that the danger of bad results is much diminished by a resort 
to that preparation of Opium, in which the poisonous elements are eliminated,and the 
anodyne elements in such a state of combination, as to reduce their toxic, and enhance 
their hygienic effects, such as has been proved to be the case with Svapnia. 
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