CHAPTER XVIII

Scrotum ("Oscheoplasty")

            Excision of the scrotum, when it has been grossly enlarged by elephantiasis or sarcomatous degeneration, is called "oscheotomy." When some of the skin is retained to cover the testicles and denuded penis it is called "oscheoplasty."
            Although we cannot agree that the formation of flaps in amputation of the limbs should be called "ente animale" (p. xix), yet we cannot deny that the formation of flaps, even if from the original scrotum, to cover the carefully preserved healthy testicles has more the character of a plastic operation. There is even less doubt that it deserves the title "plastic" when the skin is taken from somewhere else--the pubis (Bunger, see Stadler No. 2263) or the thighs. Operations of this sort are often recommended, but it seems that they are seldom carried out.
            I have not been able to separate the bibliography of the two operations, oscheotomy and oscheoplasty, because I did not collate all the relevant literature myself and so could not exclude anything that dealt only with the first procedure.
            Oscheoplasty is a recent technique. Although Guilielmus de Saliceto (No. 2261) has been given the credit for its discovery, it has not been confirmed that he mentioned reconstruction.
            Larrey, senior, who was well known as a determined opponent of plastic surgery (No. 852 and 853 and p. 106), was undoubtedly the first to consider retaining tissue to cover the testicles in excision of a diseased scrotum (No. 2246-2250). After him should be mentioned Delpech (No. 2230), Clot-Bey (No. 2223), and several other surgeons who lived in Egypt.
We should be grateful to Larrey, junior, for his excellent bibliography of this operation (No. 2251).
            Fortunately, diseases of the scrotum are very rare in our climate. This is the reason why there has been so little written (Graefe No. 2242, 2258, and Bunger No. 2263). But the cases, mostly in Egypt, which require oscheoplasty have tumors which reach to the knees or even lower, so that the operation is very traumatic and sometimes even fatal.
            All other plastic operations have very varied techniques. Here it is different, for nearly all operations consist of retaining two lateral flaps from the diseased scrotum to cover the testicles and, if necessary, a third central flap for the penis. The only important variation is that, in a few cases, it may be necessary to use skin from other adjacent parts instead of from the scrotum (No. 2233 and 2266).

Bibliography

2217. Bergeron. Thése sur l'éléphantiasis des parties génitales, Paris, 1845.

2218. * Bernard u. Huette. (See No. 479, p. 935.)

2219. * Boyer (See No. 495), Bd. 10, p. 278.
Some tumors of the scrotum which are loosely called sarcocele.

2220. Bulard, Gaz. d. hôp., 1833, is said by * Larrey (Rapport, p. 154) to have described a case. Two 6" incisions, 5" apart, were joined by a transverse incision inferiorly. This flap was used to cover the penis, and two lateral flaps for the testicles.

2221. Chervin. Arch. de l'acad. de méd., 1835, reports several operations by Gaëtani and Prunner.

2222. * Child. Case of elephantiasis scroti. The Lond. med. Gaz., 1850. 10:192-193.
Operation in Alexandria by Alex. Farquhar. A huge mass was excised under chloroform. There was no unusual bleeding, but' the patient gradually sank, and died four hours after the operation. T.J.S.P.

2223. * Clot-Bey. Histoire d'une tumeur éléphantiaque du scrotum du poids de 110 livres, extirpée avec succès chez un Arabe de la Haute-Egypte. Marseille, 1830. 8.° (26 pp.) Mit 4 Tafeln.
Clot-Bey reports four cases but describes only one operation in detail. Three flaps were raised, one for the penis and two for the testicles which, however, had to be removed, although they were healthy, because of disease of the spermatic cords.
               Also in * Gaz. d. hôp., 1831. p. 189.

2224. * -- -- (Details sur le service médical dans ces pays [Egypte].) Gaz. d. hôp., 1833. p. 387.
Brief mention of an operation for disease of the scrotum.

2225. * -- Observation d'une tumeur éléphantiaque du scrotum de 50 livres, extirpée avec succès le 31 Juillet 1833. Gaz. d. hôp., 1833. Nr. 126, p. 488.
               * Revue méd., 1833. T. IV, p. 33.
               * Schmidt's Jahrb., 1834. Bd. 1, p. 220.
               * Mgz. Hamb. Aerzte, 1834. Bd. 28, p. 293.

2226. * -- Tumeur éléphantiaque scrotale avec complication de deux hydrocéles, extirpée par le docteur Clot-Bey. Observation recueillie par Mr. Grossi. Gaz. d. hôp., 1833. Nr. 127, p. 492.

2227. -- Diss. sur l'éléphantiasis. Berlin, 1838.
Quoted by * Larrey (Rapport p. 107), although I have not been able to trace It. Perhaps he refers to Redlich (No. 2258).

2228. * Covillard. (See No. 34, p. 207) Observ. XXI. Du scrotum gangrene.
Although recent French authors give Covillard the credit for having carried out reconstruction of the scrotum, in fact he refers only to the drawing together of the skin by scarring.

2229. * Curling, T. B. A treatise on the diseases of the testis and of the spermatic cord and scrotum with illustrations. London, 1843. 8.°
p. 502, Part. IV, Chap. VIII. Elephantiasis scroti.
No personal experience of the operation.
               There was another edition; and a French translation by Gosselin, in 1856.

2230. Delpech's Operation eines ausserordentlich grossen Gewächses des Hodensackes und cler Vorhaut mit Erhaltung der Geschlechtstheile. [Operation for an unusually large tumor of the scrotum and prepuce, with preservation of the sex organs]. New-York med. and physic. Journ., 1822. Juni.
               * Mgz. Hamb. Aerzte, 1824. Bd. 7, p. 498.
               * Fror. Notz., 1822. Bd. 1, p. 73.
               * Fror. chir. Kupfertfl., Nr. 126, Figs. 2-5.
This appeared in a French journal before the American, but we do not know where. (See No. 2241)
               The same in:

2231. * -- (See No. 523, T. II, pp. 5-67) Observation d'un cas d'intumescence énorme du scrotum, symptome d'éléphantiasis. (Plates 19-23).
One of the most important of all known cases of reconstruction of the scrotum.

2232. * Dieffenbach (See No. 527, Abth. II, p. 137)
               Transplantation of scrotal skin to cover denuded testicles.

2233. * -- (See No. 530, Bd. I, p. 512) Reconstruction of the scrotum (oscheoplaseines): 1. with scrotal skin; 2. with skin from a distance.

2234. Druitt, R. The surgeon's Vademecum. 7. edit., 1856.
* Schmidt's Jahrb., 1841. Bd. 29, p. 216.

2235. * + Esdaile, James. On the operation for the removal of scrotal tumors. The effects of mesmerism and chloroform compared. Lond. Med. Gaz., 1850. 11:449-454.
                        E. has operated upon 161 tumors of up to 100 lbs. weight, with the patient in a mesmeric trance. The operation takes three to six minutes, and the mortality is 5 %. He criticizes Child, and points out the dangers of chloroform when a large blood loss is expected. T.J.S.P.

2236. * Fergusson. Elephantiasis of the scrotum of the size of an adults head, and weighing six pounds, successful removal. The Lancet, 1861. 2:294-295.
               States that the whole scrotum was removed. So much skin was removed that there was difficulty in covering the testicles. Anethesia was by ice locally for four hours before the operation, and then chloroform. T.J.S.P.
                             
2237. * Gaëtani. Mémoire sur trios cas d'éléphantiasis du scrotum, operas par Fr. Gaëtani. (Sc. de l'Acad. de. méd. 27 Janv. 1835.) Gaz. méd. De Par., 1835. p. 77.
               --report only      

2238. Gillin. Obsérvations et réflexions sur l'éléphantiasis des Arabes. Montpellier, 1849.
According to * Larry (Rapport, pp. 141-143), there are descriptions of cases by Guyon, Saiget, Ceccaldi, and Mestre.

2239. * Goyrand, G. De l'autoplastie appliquée à la dénudation des testicules. (Oscheoplasie.) Malgaigne revue méd. chir., 1849. T. VI, p. 145.
               * Gaz. d. hôpl., 1849. P. 464.

2240. -- -- Bull. Del la soc. de chir., 1853.
               * (Larry, Rapport p. 115.)

2241. * Hamel. Ueber die von Delpech verrichtete Operation, durch welche das Corium des männlichen Gliedes, und der Hodensack neu hergestellt wurden [Operation by Delpech to replace the skin of pens and scrotum]. Gr. U. W. Journ. d. Chir. u. Augenh., 1821. Bd. 2, p. 649.

2242. * Hollstein. Eigenthümlicher Ersatz eines wegen Elephantiasis exstirpirten Scrotums. [Unusual replacement of a scrotum removed for elephantiasis]. Gr. u. W. Journ. d. Chir. u. Augenh., 1838. Bd. 27, p. 147.
               * Schmidt's Jahrb., 1841. Bd. 29, p. 216.
                              Description of reconstruction carried out by Graefe. (See also no. 2258)

2243. * Jobert. (See No. 570, T. II, p. 230) Autoplastie scrotale.

2244. * (Key). Removal of a tumour fifty-six pounds of weight, extending from beneath the umbilicus to the anterior border of the anus. The Lancet, 1830-31. 2:86-89 (with a plate).
               * Mgz. Hamb. Aerzte, 1831. Bd. 22, p. 339              
                              Hoo Loo, a Chinese laborer, came to England for the operation which no one in his country would carry out. The operation to remove the whole mass took one hour and 45 minutes. The patient died on the table. T.J.S.P.

2245. * Labat. (see No. 580, pp. 336-341)
               L. mentions a second method by Clot-Bey, which only differs from the first in that the penis is covered with its own skin and not with skin from the scrotum.

2246. * Larrey, D.J. Relation historique et chirurgicale de l'expedition de l'armée
d'Orient en Egypte et en Syrie. Paris, 1803. 8. °
               p. 256. Du sarcocéle.
                              On p. 267 is the technique of retaining two lateral flaps to cover the testicales. Three cases are described, of which only one was operated.
              
2247. * -- -- -Mémoires de chirurgie militaire et campagnes. 4 Vols. Paris, 1812-17. 8. °
               Vol. II, p. 110. Pl. X. du sarcocéle. The same as in "Relation historique."
               German translation:

2248. * -- -- Med.-chir. Denkwürdigkeiten aus seinen Feldzügen. A. d. Franz. Leipzig, 1813. 8.°

2249. * -- -- Clinique chirurgicale exercée particulièrement dans les camps et les hopitaux militaries. Tom. III. Pars, 1829. 8. °
p. 80. du sarcocéle ou oscheochalazie. --  
                              Especially p. 91. Description of the operation
                              German translation:

2250. * -- -- Chir. Klinik oder Ergebnisse etc. A. d. Franz. Von Alb. Sachs. 3ter Thl. Berlin 1831. 8. °
p. 74. Von der Sarcocele oder Oscheochalasie.

2251. * Larrey, M.Hth Bon. Repport à la société de chirurgie sur l'Éléphantiasis du scrotum. Paris, 1854. 4. °
               Here there are many references which we have not quoted, because they are not concerned with reconstruction of the scrotum but simply with extirpation of the diseased scrotum (oscheotomy.)
               On pp. 115-116 Larrey advises that the remaining skin should not be sutured too tightly, for this only prevents the escape of pus, and these diseased skin edges then do not unite.

2252. * Lenoir. Éléphantiasis du scrotum traite avec succéss par l'excision des parties maladies. Arch. gén. 1846. Juin. T. XI, p. 229.
               * Oppenh. Ztschr., 1847. Bd. 35, p. 401.

2253. * Liston, Rob. Cases of large Tumours in the Scrotum and Labium, removed by operation. The Edinb. med. and surg. Journ., 1823. 19:566-568 (with a plate).
               In the first case the tumor was 42" in circumference and reached below the man's knees. "The flow of blood was compared by those present to the discharge of water from a shower bath, so instantaneous and abundant was it." 44 1/2 lb. removed. Recovery.
               In the second case a 10 lb tumor of the labium was successfully removed. T.J.S.P.

2254. Mestre. Mém, de méd. et de chir. milit., 1851. Sér. 2, T. VIII.
* Larrey, Rapport p. 138.
Two incisions starting in the inguinal region from within outwards, joined underneath by a curved incision to make an anterior flap.

2255. * Peixoto. Diverses obsérvations de chirurgie. (Rapport par Gilbert et Velpeau.) Bull. de l'acad. impér. de méd. Paris, 1853-54. T. XIX, p. 452.
Brief mention of four successful cases of extirpation of the diseased scrotum.
The thesis itself is first published in * Mém. de l'acad. imp. de méd. Paris, 1855. T. XIX, pp. 16-23. Éléphantiasis du scrotum.

2256. Prunner in Chervin, Arch. de l'acad. de méd., 1835.
* Larrey, Rapport p. 131.
Operation with two lateral flaps.

2257. * + (Raleigh) Lancet. 1844. 2:43-44. Report of a successful operation for elephantiasis of the scrotum (reaching down to the patient's knees) by Professor Raleigh, with after-care by Mr. Andree. R. had carried out sixteen similar operations in the past two years, with two deaths.

2258. * Redlich, Bern. Jos. De elephantiasi scroti, additis morbi historia et tabulis quatuor, Diss. Berolini, 1838. 4.°
Description of a case in which Graefe carried out the operation with preservation of the testicles. (See also No. 2242)

2259. Roux. Observation d'une tumeur très volumineuse des bourses. Mélanges de chirurgie et de physiol., 1809.
* Larrey, Rapport p. 122.
Not certain whether this is oscheoplasty.

2260. Ruan, W. H. [Case of elephantiasis of the scrotum, successfully extirpated]. Americ. Journ. of the med. sc., 1830. 6:311-315
* Mgz. Hamb. Aerzte, 1831. Bd. 21, p. 507.

2761.* de Saliceto, Guilielmus. Chirurgia, nunc primum suae integritati restituta; accedit ad Guidonis Cauliaci Ars chirurgica etc. Venetiis, 1546. Fol. (vulgo Collectio Veneta.)
Fol. 303a Liber primus. Cap. LI. De • hernia ventosa, aquosa et carnosa. Fol. 319b.
               This chapter has been interpreted as if Salicetus taught reconstruction of the scrotum. He, however, only refers to excision of the diseased scrotum together with the testicles.

2262. * Seerig. Fall von Elephantiasis scroti. Rust's Mgz. f. d. ges. Heilk., 1836. Bd. 47, p. 119. mit 2 Tafeln.
* Schmidt's Jahrb., 1838. Bd. 17, p. 197.

2263. * Stadler. Beschreibung einer sarcomatösen Hautentartung am Hodensacke, etc. [Sarcomatous degeneration of the scrotum]. Casp. Wochenschr., 1835. pp. 273, 294, and 326.
Description of an operation by Bünger. Excision of the skin of the scrotum and penis, which was covered by skin from the pubis.

2264. * Titley, John Maddox. A Case of an extraordinary enlargement of the scrotum, with an operation successfully performed for its removal by Titley. Communicated by Th. Blizard. Med.-chir. Transact.,. 1815. Vol. VI, p. 73.

2265.* + -- -- . A practical treatise on diseases of the genitals of the male etc. Second. edit. London, 1833. 8.°
Part. III, Sect. VII. pp. 299-325. Elephantiasis of the scrotum.
               The case previously reported by Blizard is also described here. The testicles
were also removed. However, it is not correct, as Larrey reports, that there was not enough skin to cover the defect--for it is stated that it was united.

2266. Wells, E. W. Case of a Scrotal and Anomalous Tumor, successfully extirpated. Americ. Journ. of the med. sc., 1828. 2:110-114
               * Salzb. med.-chir. Ztg., 1832. Bd. 1, p. 365.
               * Mgz. Hamb. Aerzte, 1829. Bd. 17, p. 138.
Flaps of local healthy tissue were raised to form a new scrotum and to cover the penis.