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JULY, 1895 
THE RESULTS OF DOUBLE CASTRATION IN 
HYPERTROPHY OF THE PROSTATE. 
WITH A CONSIDERATION OF ALLIED METHODS AND A TABLE OF CASES. 
By J. WILLIAM WHITE, M.D., 
OF PHILADELPHIA, 
Professor of Clinical Surgery in the University of Pennsylvania ; Surgeon to the University, 
Philadelphia; and German Hospitals. \ I THE RESULTS OF DOUBLE CASTRATION IN 
HYPERTROPHY OF THE PROSTATE.1 
J. WILLIAM WHITE, M.D., 
OF PHILADELPHIA, 
PROFESSOR OF CLINICAL SURGERY IN THE UNIVERSITY OF PENNSYLVANIA; 
SURGEON TO THE UNIVERSITY, PHILADELPHIA, AND 
GERMAN HOSPITALS. 
I SHALL ask the indulgence of the Association, if in the 
paper I am about to read I seem to go a little beyond the 
exact limitation of the title. I have divided it into,- 
(i) a Theoretical, (2) a Clinical, and, (3) an Experimental 
portion. 
I shall consider in part first a theory of causation which, 
though I must admit it to be vague, has seemed to help me to an 
understanding both of the results of the operation and of some 
of the clinical features of the growths. 
The second part contains a review of some illustrative cases ; 
a summary of a considerable number (111 in all) ; and a consid- 
eration of the objections thus far urged against the operation and 
of its relative merits and future prospects. 
In the third portion I have given the experimental and other 
evidence in regard to the value of,-(«) Unilateral castration ; (£) 
Ligation of the vas ; (r) Ligation of the spermatic and deferential 
arteries ; (d) Ligation of the entire cord. Tables of the 111 cases 
and of the fatal cases are appended. 
1 Read at the meeting of the American Surgical Association, New York, May- 
28, 1895 ; and at the meeting of the American Genito-Urinary Association, Niagara 
Falls, May 29, 1895. 
1 2 
J. WILLIAM WHITE. 
Part I. 
When in 1893 I read a paper before this association on the 
" Surgery of the Hypertrophied Prostate," I went at some length 
into the theories of causation. That of Guyon, that the disease 
is only part of a constitutional condition peculiar to advancing 
years and characterized by arterial sclerosis, etc., and that of Har- 
rison that the growth is compensatory in its character and second- 
ary to certain bladder changes seem untenable in the light of the 
information we now have. It may be admitted at once that we 
can demonstrate nothing whatever as to the essential cause of 
senile enlargement of the prostate. There seems some reason to 
believe that it is favored by prolonged ungratified sexual excite- 
ment, but as there can be no doubt that it tends to bring about 
undue sexual excitability, it is obvious that the relationship of 
cause and effect can readily be transposed. The same remark 
applies to the observation of Mr. Buckston Browne, who thinks 
he has noticed enlargement of the prostate in an unusual pro- 
portion of cases among men who had contracted second mar- 
riages late in life. It is at least an open question whether such 
marriages are the cause or the effect of the hypertrophy. 
The close relationship between the testicles and the accessory 
sexual glands-the prostate, Cowper's glands, and the seminal 
vesicles-naturally leads to speculation as to a possible connec- 
tion of the overgrowth with testicular changes coming on with 
advancing years. The testicles, whose highest and most special- 
ized function is to produce spermatozoa for the propagation of 
the species, seem, like the thyroid, to exert a wide-spread influ- 
ence over general nutrition and development. This is also true 
of the ovaries. " In man, as in the rest of the vertebrate animals, 
the male and female organs in the original state of the germ are 
entirely the same, and the differences of the two sexes only grad- 
ually arise in the course of embryonic development (in man, in 
the ninth week of embryonic life), by one and the same gland 
developing, in the female as the ovary, and in the man as the 
testicle. Every change of the female ovary, therefore, has a no 
less important reaction upon the whole female organism than CASTRATION IN HYPERTROPHY OF THE PROSTATE. 
3 
every change of the testicle has upon the male organism." 1 The 
removal of either testicles or ovaries in early life usually changes 
profoundly all the characteristics-physical and mental-of the 
individual. There is, however, abundant evidence2 to show that 
the testicles may lose, or may never have had, the sperm-produc- 
ing power and still possess the quality which enables them to hold 
the organism in its normal groove and to invest it with the full 
attributes of masculinity. When both testes fail in their descent 
they are incapable of producing spermatozoa, and in consequence 
the person is sterile. This has been shown by Hunter, Astley 
Cooper, Curling, Griffiths, and others, and is undoubtedly the 
rule, although there are occasional exceptions. In spite, how- 
ever, of the imperfection of the organs, such a person acquires 
all the external bodily characteristics of the male, and is in all 
respects, except in the power of procreating, like an ordinary 
man.3 It is not known whether this influence is exerted through 
a chemical product or not, but the fact that some indubitable 
effects are produced on the whole system by the injection of 
watery extracts of the testicles woulel seem to favor this idea. 
" The function of the testes is therefore clearly twofold,-viz., 
(1) to control and determine the development of the character- 
istics of the male sex, and (2) to produce spermatozoa for the 
reproduction of the species. These two functions are usually 
exercised together, but that the former may be exercised when 
the latter fails seems to indicate that the production of sperma- 
tozoa is the more specialized property and attained with more 
difficulty. In what manner is this sexual effect of the testes upon 
the body produced ? Is it through the medium of the nervous 
system as an ordinary reflex, or is it through the medium of some 
substance produced by the seminal cells (whether they form 
spermatozoa or not) and absorbed into the system, which by 
influencing the nerve-centres or in some other way controls 
growth and nutrition ? Brown-Sequard tried upon himself, when 
he was seventy-two years of age, the effect of the subcuta- 
neous injection of a watery extract of the testes of a vigorous 
1 Haeckel, The History of Creation, Vol. I, p. 244. 
2 Curling, 4th ed., p. 14. 
3 Griffiths, The Lancet, March 30, 1895. 4 
J. WILLIAM WHITE. 
dog two or three years of age, and relates that after five daily 
injections he lost his feebleness, felt many years younger, and was 
capable of doing more work. The testicle extract has since been 
used in various diseased conditions, chiefly those associated with 
nervous debility, but with only temporary results. During the 
last few years a watery extract of the thyroid gland has been 
administered with signal success in myxcedema, in which disease 
the thyroid gland atrophies and ultimately disappears. The dis- 
ease myxcedema arises from the want of the influence of some 
unknown substance, which the thyroid gland, as is supposed, 
elaborates upon the nutrition centres of the central nervous 
system. It maybe that the testis in like manner elaborates, irre- 
spectively of its spermatic secretion, some chemical substance, 
which by a similar influence not only controls the growth and 
development of the body at puberty, but maintains the manly 
characters then acquired throughout life." 1 Cabot has tried 
the injection of testiculin in mania following castration in one 
case with improvement of symptoms, whether post hoc or propter 
hoc cannot be determined. Whatever its mode of action, how- 
ever, it is probable that the need for this occult property of the 
sexual glands would begin to disappear after their essential pur- 
pose had been subserved,-i.e., after full adult life had been 
reached and the individual was cast in the mould intended by 
Nature. This need abrogated there would yet remain the func- 
tion common to both sexes, that of producing cells endowed with 
the property of perpetuating the species. The testicle and the 
prostate would thus at this time have a closer physiological re- 
semblance to the ovaries and uterus than at any other period of 
life. Both ovary and testicle would still possess the power of 
propagation, and with it a marked effect upon all the accessory 
sexual organs, while at the same time the necessity for a certain 
controlling influence would have been removed and larger oppor- 
tunity afforded for aberration in the growth and structure of the 
tissues involved. This may especially be the case, as with the 
cessation of the necessity for the exercise of this function (or for 
the evolution of the hypothetical product in question) the activ- 
ity of the testicle does not cease. The organ (that it may be able 
1 Griffiths, loc. cit. CASTRATION IN HYPERTROPHY OF THE PROSTATE. 
5 
to perform the other half of its work,-the generation of sperma- 
tozoa) is still preserved from atrophy. Nothing in the little we 
know of the origin of the so-called benign growths in the body 
contradicts the theory that overgrowth of normal structures may 
be favored or hindered by changes in the nervous and vascular 
supply of the region. The disappearance of the necessity for a 
given product without the coincident disappearance of the vital 
energy which was expended in producing it might conceivably 
result in hypertrophy of organs intimately associated with those 
which were the source of supply. 
The general law of correlation between the sexual organs 
and other parts of the body extends throughout the whole realm 
of organic life. " If one wishes to obtain an abundance of fruit 
from a garden plant, the growth of the leaves is curtailed by cut- 
ting off some of them. If, on the other hand, an ornamental plant 
with a luxuriance of large and beautiful leaves is desired, then the 
development of the blossoms and fruit is prevented by cutting off 
the flower buds."1 This principle, called by Goethe that of 
" compensation of development," which is thus used practically 
to secure the increased growth of one system of organs at the 
cost of another, may apply equally to different organs of the 
same system. Griffiths 2 says, " The whole genital system is an 
apparatus the potentiality of which mainly depends upon the in- 
tegrity of the testicles, one or both ; they control the extent to 
which the remainder of the sexual apparatus grows, the growth 
of the vas deferens no less than that of the prostate and other 
accessory sexual glands. I make this statement because in ob- 
servations upon castrated animals I have found that the testicle 
exerts such an influence upon the growth of the other parts of 
the sexual apparatus." 
The theory of tumor formation, recently advanced by Roger 
Williams,3 has a more or less direct bearing upon this question. 
He says that in the genesis of neoplasms, as in the genesis of 
other organic structures, we must take into consideration two 
factors,-the cells whence they originate and the force that regu- 
1 Haeckel, op. cit., p. 245. 
2 Op. cit. 
3 Diseases of the Breast, p. 138, 6 
J. WILLIAM WHITE. 
lates the cellular activities. He believes with Spencer that every 
component cell of the multicellular organisms has the inherent 
power of developing itself into the form of the parent organism ; 
that the enormous reproductive powers of the somatic cells have 
not been fully realized by pathologists ; and that these powers are 
only held or restrained in the normal individual by a " force" 
which regulates the growth and development of the tissues and 
organs in relation to each other and to the organism as a whole. 
He believes further that the essence of the neoplastic process is 
that certain cells of the affected part grow and multiply more 
rapidly than their congeners, and adds, " I explain this rejuven- 
escence as due to failure of the integrative force that normally 
restrains their activities within proper limits. Under these cir- 
cumstances, whenever there is a sufficient supply of nutritive 
materials, capable of being utilized for growth by the cells of the 
parts, there a neoplasm will arise,-that is to say, the abnormally 
emancipated cells will there grow and multiply more or less inde- 
pendently, regardless of the requirements of the adjacent tissues, 
and of the organism as a whole." 
If there is any truth in my theory, such a modification of 
the natural ovarian and testicular functions as I have suggested 
would, so far as the development of uterine and prostatic over- 
growths was concerned, be equivalent to a failure of the general 
restraining force. It is not demonstrable and may be regarded 
as not reasonable, but I have thought that its provisional accept- 
ance might serve as a step towards the understanding of the 
essential etiology of these tumors, which, on account of their 
enormous frequency and serious consequences, have a practical 
importance, that I hope may give even such metaphysical specu- 
lations as to their causation a certain amount of interest. The 
persistence of what might be called unexpended energy during 
the ovule- and sperm-producing life of the ovaries and testicles 
respectively, might thus offer a reasonable explanation of the 
overgrowths in question, while the final atrophy of the former 
organs would similarly be accompanied in many cases by such a 
withdrawal of nervous and vascular supply as to prevent the 
occurrence of hypertrophies or even to cause their disappearance 
if they had already formed. That this is the case as regards CASTRATION IN HYPERTROPHY OF THE PROSTATE. 
7 
uterine fibromyomata is a fact which clinical experience abun- 
dantly demonstrates. I have endeavored to show1 that there is 
reason for believing that it is equally true of prostatic overgrowth. 
Unfortunately, what may be called the accidental concomitants of 
the condition,-accidental in the sense of being due to anatom- 
ical propinquity,-the vesical and renal changes, usually cause 
death in those subjects whose advanced years might of them- 
selves, through sexual failure, prove curative. An examination 
of Messer's tables, founded on a dissection of 100 prostates 
in men over sixty years of age, discloses one interesting fact 
in this connection. Assuming arbitrarily that eighty may be 
taken as the age at which, in the great majority of men, the 
sexual life is absolutely and finally ended, we find that among 
those subjects whose prostates weighed over six drachms, the 
percentage of octogenarians or their elders was only 22.8, while 
among those whose prostates weighed less than six drachms, 
many of them less than normal, the percentage was 35.3, more 
than half again as great. 
This is not only confirmatory of Desnos's observations, that 
after a certain period of life the frequency of notable hypertrophy 
diminishes, but it suggests the possibility that in many of these 
cases physiological atrophy had already begun. The subjects 
were not selected from among patients, but just as they hap- 
pened to come within reach of the investigator. The uncertainty 
as to the exact duration of sexual life in the male also weakens 
the force of the statement that the condition does not manifest 
itself until after the period of life when it should occur if it were 
truly homologous with the uterine growth. In addition, it may 
be said that there is accumulating evidence that prostatic hyper- 
trophy begins much more frequently than was formerly supposed 
during middle life, and that the statistics on which we have been 
accustomed to rely, based on museum specimens and on the 
experience of surgeons to whom the patients apply only when 
distinct subjective symptoms have developed, are, to an extent, 
unreliable.2 
1 Annals of Surgery, August, 1893 
2 Annals of Surgery, August, 1893. 8 
J. WILLIAM WHITE. 
In some of the cases which I shall presently summarize 
living spermatozoa could not be found in the testicles at the time 
of removal, and yet the effect upon the prostate was as marked 
as in most of the others. If the theory which I have just 
advanced is the correct one, such cases indicate the persistence, 
but perversion of part of the twofold function of the testes after 
the reproductive factor had vanished. If the assertion that 
ovulation and menstruation are more independent of each other 
than has hitherto been believed1 be correct, we have a similar 
explanation of some of the anomalous cases of uterine fibroids 
which have remained, or, more rarely, developed after what was 
a menopause but possibly not a true climacteric. 
It was the apparent analogy between the uterine and pros- 
tatic growths which led me to the investigation that resulted in 
my suggesting this operation to the profession. This analogy, 
as it is part of the present argument (Velpeau, Thompson, White), 
may be briefly restated as follows: The prostatic vesicle is the 
analogue of the sinus genitalis in the female,-the uterine and 
vaginal cavities ; the structure of the prostate and that of the 
uterus are strikingly similar, and would be almost identical if the 
tubular glands found in the inner walls of the uterus were pro- 
longed into its substance; the histology of the growths, from 
small encapsulated tumors, easily shelled out, or polypoid 
growths intimately connected with the uterus or prostate up to 
the enormous growths which far exceed the original bulk of the 
organ itself, are identical; or there may be in either case a gen- 
eral hypertrophic enlargement affecting the whole organ; lastly, 
these disturbances occur at about the same time in the sexual life 
of the two sexes,-that is, during the latter half of the reproduc- 
tive period. This ends sooner in the female than in the male, 
and accordingly we find the growths appearing in the former at 
a somewhat earlier age. 
This analogy is said by the embryologists to be without 
foundation as regards any true homology between the pros- 
tate and the uterus. The clinical resemblances between the 
1 American Text-Book of Gynaecology, p. 95. CASTRATION IN HYPERTROPHY OF THE PROSTATE. 
9 
two forms of overgrowth are, however, none the less striking, 
and it may now be said that the results of castration in such 
cases are equally similar and remarkable in both sexes. I 
am quite willing to accept Moullin's way of putting it: " En- 
largement of the prostate bears the same relation to the testes 
that fibroid disease of the uterus does to the ovaries. But the 
fact that they bear the same relation to two different organs is no 
proof that they bear any relation to each other." I must add, 
however, that even although the prostate is not the absolute 
homologue of the uterus, as it contains and encircles the cavity 
which is said to be-i.e., the utricle or " prostatic vesicle,"-the 
relationship between the two is remarkably close. So, too, 
although the uterine growths begin as fibromyomata and the 
prostatic as adenomata or adeno-fibromata, the difference merely 
corresponds with the differences in structure of the two organs, 
the prostate containing normally more glandular tissue than the 
uterus. 
Pitfield Mitchell1 believes the frequency of fibrous, epi- 
thelial, and fatty growths, as compared with growths of more 
highly specialized tissues, to be due to " that inverse relation 
between reproduction and specialization seen throughout the 
whole organic kingdom. It has been established as one of the 
laws of reproduction that whatever energy is used up for increase 
of mass, for increase of structure, and for functional work, is so 
much deducted from the energy that might be available for pro- 
ductive processes. So that the relative scarcity of myoma and 
neuroma is in consonance with the fact that reproductive power 
tends to diminish as specialization or structural complexity in- 
creases. The indications of this law both in the animal and 
vegetable worlds are unmistakable, nevertheless the evidence of 
it is almost inextricably entangled as the generalization applies to 
neoplasia. For, taking the organism as a whole, we see in the 
case of myoma that this is an uncommon tumour, whether of 
striated or non-striated muscle, yet it is far from being so in the 
uterus. Here we may be confident the exception is due to 
exceptional circumstances." 
1 The Philosophy of Tumour Disease, London, 1890. 10 
J. WILLIAM WHITE. 
He might have added as a corollary that when energy of 
any sort is set free, as it were, it must tend to favor the " increase 
of mass" of which he speaks, and possibly the reversion of the 
tissues to the mode of genesis of unicellular organisms for which 
he is arguing as a cause of all tumors. " The generation of a 
tumour must be regarded as a reversion to an ancestral mode of 
reproduction ; as the resumption of a habit proper to the re- 
motest ancestors of the metazoa, the protozoa. It is a seeding 
of the natural plastids of the body. As reproduction for the 
entire individual is effected by organs-ovaries and testes-spe- 
cialized for the purpose, reproduction for the individual units is 
accomplished by the units themselves." 
The relation between the reproductive function itself and the 
growth of the individual is a marked one at the very beginning 
of organic life. When the continued existence of the whole 
organism is endangered, its entire energy seems to be devoted to 
securing the reproduction of the species. This is seen in many 
of the diatoms, infusoria, moulds, algae, and lowest forms of 
bacilli. In the latter it has the most widespread influence upon 
surgical practice, as the expiring effort of the microscopic 
organism whose life threatens the life of our patients is to pro- 
duce spores which have still more obstinate vitality. " This 
primordial trait has left its mark even upon the highest plants 
and animals. If the flow of sap in still growing trees is dimin- 
ished by ringing or other injurious action, they will cease to grow 
and begin to flower. In the shape of buds reproductive centres 
may be induced in bulbs by cutting out the embryo. The aphis, 
kept in an artificial summer, may for years be made to reproduce 
by parthenogenesis, but with want of food or a low temperature 
sexual genesis will set in. Similarly with the common hydra. 
A vestige of the trait probably remains even in man where death 
is often accompanied by the ejection of seminal fluid."1 
All this goes to show the direct relationship which exists in 
all living things between processes of growth and the organs con- 
cerned in reproduction, and makes it more reasonable to imagine 
that a diversion of any of the powers of those organs might result 
1 Mitchell, op. cit., p. n. CASTRATION IN HYPERTROPHY OF THE PROSTATE. 
11 
in grave modifications of those portions of the body most intimately 
associated with them. Even if it is thought that according to 
Mitchell's hypothesis the true explanation of the genesis of the 
uterine and prostatic growths lies in the gradual decline in the 
physiological life of the sexual organs which begins after middle 
age,1 the continued growth and increase of these new formations 
might well be encouraged and stimulated by the persistence of 
energies which have survived their usefulness.2 
There must be some explanation of the differences in the 
liability of different organs to new growths. " The most striking 
contrasts are met with. On one hand, primary tumours of the 
heart are scarcely known, and on the other, myomas of the 
uterus are so common that one woman in every ten is said to be 
afflicted," and the frequency of prostatic overgrowths is even 
greater. It is not in these instances, as Mitchell supposes it to 
be in some, the impending cessation of tissue vitality as a whole, 
permitting the reversion of cells to primitive conditions of growth 
and multiplication, for, as we have seen,3 the evidence is demon- 
strative as to the uterine growths, and almost equally so as to 
the prostatic, that after a certain period of life is reached they 
cease to make their appearance. 
He says himself4 that innocent tumors are the products of 
centres of growths set free by tissue whose reserve of vitality is 
relatively large, and explains in this manner the fact that " mature" 
(benign) growths are found at an earlier period of life than the 
"immature" (embryonic, malignant). An excess of " vitality" 
1 It would appear that when the contained energies of the cell are insufficient to 
maintain the balanced functions needful for individual life, the remnant of contained 
energies, being equal to the less costly function of reproduction, is consumed in a last 
effort to continue the species. So that a necessary condition of histogenic dissolution 
is a more or less gradual decline of life in the individual cell.-Mitchell, op. cit., p. 14. 
2 Thus, the most general and invariable condition of tumour-genesis is the dissolu- 
tion of pre-existing tissue accompanied by the birth of tissue; not the condition, be 
it most carefully observed, of tumour-growth. The genesis of a tumour is one thing, 
and the growth or increase of its mass is another. The processes are distinct in char- 
acter and different, often quite opposite, as to their conditions.-Mitchell, op. cit., 
P- i5- 
s Annals of Surgery, August, 1893. 
* Op. cit., p. 43. J. WILLIAM WHITE. 
12 
or of energy which has become purposeless, as I have suggested, 
would therefore seem to favor the occurrence of just such growths 
as those we are considering, and the withdrawal of the source of 
that energy (by oophorectomy or castration) might be expected 
on theoretic grounds alone to be followed by the retrograde and 
atrophic changes which after middle life are beginning everywhere 
throughout the organism, and would be relatively more rapid in 
organs or tissues which had become functionless. Clinical facts 
appear to indicate that both the uterine and the prostatic growths 
have some relation to sexual activity. Winckel, Roehrig, 
Emmet, and others1 have shown that uterine myomata (like 
mammary adenomata) are favored by marriage and fecundity. I 
have already alluded to the prevalent but unproved view that 
prostatic enlargement is related to sexual excess. It may be 
that in these facts there will be found further support to the 
theory I have advanced, as two separate but allied functions of a 
single gland are probably not readily dissociated, and activity of 
the reproductive and still purposeful function might cause or 
favor coincident but harmful activity of its fellow. 
I may seem to hold to this view (including the apparent 
analogy between the uterine and prostatic growths) with unwar- 
ranted persistence, and I do not desire to undervalue the argu- 
ments against it; but it must be remembered that we have no 
other which at all explains either the causation of the growths, 
their spontaneous disappearance (or failure to appear) at a cer- 
tain time of life or their cure by castration. So far as the 
theory of analogy is concerned, I said long ago that even if 
it were true it could scarcely be said to be a full explanation 
of the occurrence of the prostatic growths, but by allying 
them to a well-known group of tumors would certainly bring 
us a step nearer to their comprehension. Its provisional 
acceptance with this statement, and irrespective of the addi- 
tional views as to causation which I have just advanced, is 
not therefore to be regarded as concealing our ignorance, as 
Mr. Moullin 2 fears, but gives us a sort of working hypothesis 
1 Quoted by Mitchell, op. cit., p. 169 
2 Op. cit., p. 39. CASTRATION IN HYPERTROPHY OF THE PROSTATE. 
13 
which has certainly thus far stood the test of practical applica- 
tion. 
The clinical evidence of the truth of the statement that the 
hypothesis has stood the test of practical application will readily 
be found in the history of one hundred and eleven cases which I 
submit in tabular form for publication with this paper. It will, of 
course, be impossible for me to read them all to you in detail, but 
there are certain general facts which a few of them will serve to 
illustrate. I will take for this purpose three cases, each of which 
was seen by several observers and in regard to which I have 
fairly complete details. 
Part II. 
Case CVII.-The patient, aged sixty years, weight about 135 
pounds, a carpenter by trade, was admitted to the University Hospital 
November 16, 1894. He was much broken down by long-continued 
suffering, but was exceptionally intelligent for a hospital patient. He 
had begun to have symptoms of prostatic obstruction eighteen months 
previously. He had undergone various forms of internal treatment 
in spite of which he was urinating hourly, and had used the catheter 
(with increasing frequency) for years. His distress had become so 
great that he came for advice and for a rest in the hospital. He was 
examined by me, by several assistants, and by two members of the 
class. His prostate was estimated to be of the size of a small orange. 
The finger could not reach the upper border. The lateral enlarge- 
ment was very marked, the borders of the gland nearly touching 
the ischiatic rami. It was moderately firm, and slightly elastic upon 
pressure. A soft catheter went in with a little difficulty. Urine 
began to flow when the eye was about ten inches from the meatus. 
The amount of residual urine averaged six ounces. He was using a 
catheter from four to eight times daily and urinating, or attempting 
to urinate, from twelve to twenty-five times-occasionally oftener- 
in the twenty-four hours. The urine contained blood and pus, but 
no casts. It was stinking and loaded with mucus. 
Castration was advised but was refused. He was admitted to 
the ward, the bladder was irrigated daily, and the urine sterilized as 
far as possible by the administration of salol and boric acid; recum- 
bency with the pelvis slightly elevated was maintained and the diet 
carefully regulated, milk being given chiefly. He got some relief 14 
J. WILLIAM WHITE. 
from these measures, but there was no change in the quantity of 
residual urine. He was taught the proper use of the catheter and 
instructed how to keep it sterile, and left the hospital. 
On December 5 he returned and said that he was so much worse 
that he was ready for operation. This was performed December 12 
in the presence of the class. Ether was used ; the time of operation, 
including stitches, was three minutes. 
Improvement in urination became manifest in the first twenty- 
four hours after operation. In a week the patient emptied the blad- 
der easily and painlessly; the urine was clear; the frequency of 
urination had decreased to five or six times daily. The residual 
urine as reported by Dr. Small, the resident physician, had dimin- 
ished to half a fluid ounce, and on December 26, but one fluid drachm 
remained after urination. This was verified by Drs. Martin and 
Wood. He was examined (before the class) five days after the oper- 
ation and the prostate was found to be merely a flattened fibrous 
mass, the upper border easily reached, the lateral borders shading off 
insensibly so that its limits in those directions were difficult to deter- 
mine. The bulging into the rectum, previously so unmistakable, had 
disappeared. The prostate itself might almost be said to have done 
so. A catheter inserted eight and a quarter inches drew a few drops 
of urine. The patient described to the class the change in the char- 
acter of his urination and said that he then felt as he did " when he 
was a boy in the fields." 
He remained as a helper in the surgical wards for four months. 
During this time he had on three occasions a little increased frequency 
of urination, each time associated with digestive disturbances. He 
left the hospital apparently entirely cured. 
Dr. R. H. Fitz, of Boston, examined the prostate per rectum a 
short time before the patient's discharge, and stated that " it was so 
soft and so small that its outlines were indeterminate. The prostate 
and the wall of the bladder felt very much alike." 
I have operated upon other cases which are included in the 
table and which are equally striking, but I prefer to select for 
the remaining two examples cases by other operators in other 
cities. 
Case III.-Dr. Beach, of Boston, kindly sends me the following 
interesting notes which I transcribe exactly as he wrote them : CASTRATION IN HYPERTROPHY OF THE PROSTATE. 
15 
" Patient, seventy years of age ; tuberculous family history. His 
habits had been good. Not addicted to the use of tobacco or alcohol. 
No history of venereal disease. Had always enjoyed good health 
until ten years ago, when he was obliged to pass his urine frequently 
and in small quantities. He had never been catheterized. Entered 
the hospital November 13 with his bladder much distended and his 
urine continually dribbling from him. By the rectum the prostate 
gland was found to be much and uniformly enlarged, extending nearly 
to the ischium laterally and as far as the finger could reach posteriorly. 
In front it projected at least an inch above the superior line of the 
pubes. The tunica vaginalis of the left side was moderately distended 
by a hydrocele. Upon examination of the urine it proved to be 
free from sugar, specific gravity 1020, containing a trace of albumen 
and a large quantity of pus and bladder epithelium. The urine was 
drawn by a soft rubber catheter carefully sterilized twice daily/ 
Meantime there was some dribbling. Mentally, he had been failing 
for a number of weeks. He remained in bed all of the time, barely 
rousing enough to open his eyes when spoken to sharply, or reminded 
of the necessity for passing his urine, and then would lapse again into 
the same dull and listless condition. The drowsiness slowly increased 
to deep stupor. By the 23d he ceased to pass any urine and the 
quantity drawn by catheter each time became less. December 5, 
catheter entered with much difficulty on account of the obstructing 
prostate gland. December 6, no urine passed for twenty-four hours. 
It had become impossible to pass either a silver gum elastic, or a soft 
rubber catheter (this including various sizes of each and the probe 
pointed and Mercier tipped elastic instrument). Suprapubic punc- 
ture and withdrawal by aspirator of the bladder contents. The 
hydrocele has increased to three times its size upon entrance. 
December 7. Same condition mentally and physically. Aspi- 
ration of bladder and an unsuccessful attempt made to enter by cathe- 
ter afterwards. This was repeated on the 8th, 9th, and 10th, when 
after the aspiration it was possible to enter a soft rubber instrument 
and to tie it in place. As soon as the patient was left for a few 
moments he pulled it out. The patient was examined by Dr. J. C. 
Warren, who concurred with Dr. Beach upon the condition of the 
patient and the expediency of an attempt at relief by castration. 
December 11. Castration. Afterwards the catheter was easily 
introduced and bladder emptied. 13th. No difficulty in catheteri- 
zation since the operation. Bladder washed out twice daily. 14th. 16 
J. WILLIAM WHITE. 
Mental condition improving. A little dribbling of urine between 
the times for catheterization. 20th. Has improved steadily and 
to-day passed three ounces of urine without a catheter. 23d. Pros- 
tate examined carefully by those who had examined it before opera- 
tion and found to be at least one-third in volume. It no longer 
projects above the pubes. 27th. Up to-day for the first time. 
January 2. Improvement continues. Passed several ounces of 
urine without catheter. 8th. Patient passed catheter to-day with- 
out assistance, later eight ounces of urine without assistance. Has 
walked a few steps. Is clear and intelligent. 9th. During the past 
twenty-four hours has passed all of his urine without catheter. Wound 
healed. There has been as much improvement mentally as physi- 
cally. 
The third case which I have selected was reported in the 
Medical Record for April 20, 1895. I copy it as described by 
Dr. Howard Lilienthal, the operator. He remarks that the case 
was one which had been carefully watched, both before and after 
operation, by at least three observers who may be considered 
competent. There was no lack of attempt at palliation by the 
usual methods before resort to the castration. 
Case LIII.-M. M., a private patient in Mount Sinai Hospital 
(New York), in Dr. Gerster's service, was fifty-six years of age, and 
the father of a family. He was a merchant by occupation and lived 
in one of the Southern States. For about ten years he had been 
troubled with frequent micturition, with occasional attacks of vesical 
tenesmus, and with a gradual increase in the severity of his symp- 
toms. About three years before coming to the hospital he had been 
catheterized for an attack of retention, but the exacerbation was of 
short duration. 
Still from this time he had to be catheterized with gradually in- 
creasing frequency until, on admission to Mount Sinai, he was in 
constant pain and felt an urgent desire to urinate at least once an 
hour during the night. By day his condition was much worse, the 
attempts at emptying the bladder occurring about every five to fifteen 
minutes. His urine was alkaline, and there was a severe cystitis, 
with great quantities of pus and bloody mucus, A full-sized sound 
entered the bladder without difficulty. Dr. Gerster examined the 
prostate by rectum, and found it enlarged to about three times the CASTRATION IN HYPERTROPHY OF THE PROSTATE. 
17 
normal size, but the cystoscope showed a well-marked middle lobe, 
which was thought to be responsible for the trouble in evacuating the 
bladder. For six weeks the patient was treated by catheterization, 
washings of the bladder, diuretics, oil of winter-green, and other 
internal antiseptics, but without improvement. Indeed, the man 
grew constantly worse. He was now emaciated, was thoroughly 
exhausted, and in a truly desperate condition. Dr. Gerster had pro- 
posed castration, and the patient had refused. The service now 
changed and I came on duty. At my first examination of the pros- 
tate by rectum I found the body about as big as a good-sized egg, 
not particularly tender to touch, but very firm and resisting. I made 
no cystoscopic examination, but accepted the positive observation of 
Dr. Gerster. When castration was again proposed the patient had 
become so hopeless that he decided to take his chances with the oper- 
ation. At my request Dr. Fluhrer saw Mr. M. and examined him. 
He also diagnosed the case as one of enlarged prostate, and on learn- 
ing that the treatment above outlined had been followed by no im- 
provement whatever in six weeks he agreed with me as to the 
advisability of castration. 
On February 9, under chloroform anaesthesia, I removed both 
testicles, which were nearly normal. There were signs of very slight 
bilateral epididymitis. The wounds were closed without drainage 
and the patient was out of bed in six days. The patient was cathe- 
terized every six hours, and his bladder was washed twice daily. For 
the first twenty-four hours there was a slight remission of symptoms, 
but on the third day he was almost as bad as ever. From the fifth 
day there was, however, steady and miraculously rapid improvement. 
Before the operation and immediately after, he could urinate only by 
drops, and there was always four to six ounces of residual urine. If 
he had allowed his bladder to become distended, practically all the 
urine was "residual," so that frequently at such times, after the man 
had exhausted himself trying to pass his water, ten ounces were 
withdrawn by catheter. The first improvement noted was that the 
patient could pass a stream. The residual urine rapidly diminished, 
the cystitis vanished, and in four weeks I presented him at a meeting 
of the Genito-Urinary Section of the New York Academy of Medi- 
cine. At that time he could hold his urine two hours at a time with- 
out discomfort, he passed a moderately powerful and full stream, and 
best of all there was but one ounce of residual urine. The urine still 
contained some pus but no mucus. It was acid and of the normal 
2 18 
/. WILLIAM WHITE. 
color. The man had gained many pounds in weight and enjoyed 
life. He could go to the theatre and could make the journey to 
Brooklyn, where he had relatives, without suffering by the way. It 
is needless to say that he is most grateful for what has been done for 
him. He does not for an instant mourn the loss of his testicles. 
No cystoscopic examination was made after the operation, but by 
the rectum the prostate, though still enlarged, is only about half the 
size it was before and feels flaccid. 
Both Dr. Gerster and Dr. Fluhrer have seen Mr. M. since his 
recovery, and express themselves as thoroughly convinced of the 
efficacy of the operation in this case. . 
A few days ago the patient returned to his home. Before leaving 
he again came to thank me and to say that catheterization was no 
longer necessary, the amount of residual urine being so small, I 
still advised the use of the instrument, however, once in two days, 
until there should be no residual urine. 
I have chosen these three cases because they appear to me 
to bring up all the points which have thus far been in dispute as 
to the cases reported as " successful." The critics of the opera- 
tion have said (<?) that they still regarded it as a physiological 
experiment; (A) that the reported cases lacked detail and did not 
prove that the same results would not be obtained by rest in bed, 
careful catheterization, regulated diet, etc.; (<) that the subsidence 
of the symptoms and of the bulk of the gland, as reported, was 
too rapid to be due to atrophy, but must be owing to the disap- 
pearance of congestion and oedema; (z7) that at any rate a true 
hyperplasia could not disappear in so short a time as has been 
reported ; (e~) that the estimates, both of the size of the hyper- 
trophied gland and of its reduction in size, were inaccurately ex- 
pressed ; (/) that it was unreasonable to suppose that a long- 
standing cystitis would vanish even if the prostate did shrink; 
(£•) that a vesical calculus in a post-prostatic pouch might be 
overlooked and only discovered later; and (7z) that the cases had 
not been observed for a sufficient length of time to make the 
results reliable. I shall try to reply briefly to these assertions, 
basing my statements chiefly on the facts contained in the table. 
(i) It seems to me that even a few such cases as those I CASTRATION IN HYPERTROPHY OF THE PROSTATE. 
19 
have described should remove the operation from the region of 
experiment to that of practical surgery, and show that it is at 
least as scientific and as certain in results as many of our ac- 
cepted operative procedures. Of 102 cases contained in the 
table in which the condition of the prostate is noted, 65 or 63.7 
per cent, are reported as showing some distinct decrease in size, 
while in twenty-four additional cases, eighty-nine in all (87 per 
cent.), the improvement in other symptoms renders the conclu- 
sion justifiable that the prostate had become smaller. In two 
cases autopsies have been made which demonstrate the exact 
nature of this shrinkage, and show that it is due to the same sort 
of atrophy, first of the glandular elements and then of the stroma, 
that I reported two years ago, as the invariable result in dogs. 
In one of these cases (No. 104, table) I confess I did the oper- 
ation with scarcely a shred of hope for a cure. The patient was 
a broken-down hospital wreck, eighty-two years of age, with a 
very large prostate, and with absolute retention; catheterism was 
impossible, and the urine was loaded with albumen and casts; he 
was profoundly adynamic and alternated between uraemic stupor 
and delirium. I did the operation practically without ether and 
in three and a half minutes. He died comatose on the evening 
of the second day. It was thought by all those who examined 
him per rectum that the prostate was already smaller. But 
the microscopic report is conclusive as to the beginning of 
changes which are now well recognized as preliminary to full 
atrophy. 
The report says: 
" Microscopical Examination.-The stroma of the gland 
shows beginning proliferation of the connective tissue cells, but 
especially of the muscle-cells. 
" The acini tubules are also becoming filled with proliferated 
columnar cells, and here and there some fine granular matter may 
be seen in the tubules; some of the cells appear to contain fine 
granules which have not taken the stain, evidently fat. The 
changes are typical of beginning atrophy." 
In case No. 8 (table), in which the patient died of popliteal 
thrombosis and gangrene, eighteen days after double castration, 20 
J. WILLIAM WHITE. 
the same changes, further advanced, were noted by Mr. Joseph 
Griffiths, F.R.C.S., Hunterian Professor in the Royal College of 
Surgeons, England. He describes in detail and figures1 the 
microscopical sections, summing up as follows : " In short, the 
cell elements first proliferate, and ultimately disappear, leaving a 
comparatively small amount of fibrous connective tissue in their 
place. . . . The gland, whether enlarged or normal, undergoes 
certain degenerative changes after removal of the testicles 
which lead to its conversion into a small, tough, and fibrous 
mass in which there are only remains of the glandular tubules 
and ducts." 
I have here the sections from my own case for examination 
by any of the Fellows who may desire to look at them. It is 
obvious that this, with other evidence, has been convincing to 
some members of the profession at least, as Sir Joseph Lister 
feels warranted in speaking of the operation as " a valuable addi- 
tion to our art;" Fenwick in stating " that there is no doubt that 
slow shrinkage of the prostatic tissue in many of the forms of 
senile enlarged prostate ensues upon double castration;" Moullin 
in writing, " Removal of the testes is followed in a large propor- 
tion of cases, if not in all, by complete and rapid absorption of 
the enlarged prostate. This has been proved conclusively. The 
gland entirely disappears ; nothing is left but a little fibrous mass 
and Cabot, in saying that, " the effect of castration in reducing 
the size of the chronically hypertrophied prostate is undoubted. 
Enough cases have been reported to show that." 
(2) There will be found also in the table, in addition to those 
I have detailed, many cases which had been previously treated 
by various palliative measures, including, of course, rest in bed, 
catheterism, vesical irrigation, etc. The statement that the re- 
ported improvement could have been brought about by these 
means rather than by operation, seems to me in the face of the 
evidence scarcely worthy of further attention. The palliative 
treatment of prostatic hypertrophy is now understood by every 
general practitioner, and I frequently find in cases which I see 
1 British Medical Journal, March 16,1895. CASTRATION IN HYPERTROPHY OF THE PROSTATE. 
21 
in consultation that every possible care has been taken and the 
best judgment shown in the use of the catheter, the regulation 
of diet, the hygiene of the patient, etc. It is inconceivable that 
many of the operators in these cases should have overlooked 
such obvious preliminary measures. To be sure, their employ- 
ment is specially mentioned in only a minority of the cases, 
but the omission was, I feel sure, a mistake of the writers, not 
of the surgeons. 
(3) The assertion that the subsidence of symptoms has 
been due to the disappearance of congestion and oedema is largely 
negatived by the facts already given,-viz., the previous failure 
of palliative measures; and the pathological evidence of actual 
atrophy. Certain facts which seem to afford an explanation of 
the rapidity of the improvement in many cases, which as Lister 
has said, is " as remarkable as it is satisfactory," ought to be 
mentioned. All the varieties of enlargement have the same his- 
tological structure, but it is interesting to note the following 
observations, which seem to have a definite relation to one an- 
other. Sir Henry Thompson long ago1 called attention to the 
fact that the posterior part of the so-called " median lobe" (" me- 
dian portion," "prostatic commissure," etc.), contains a larger 
proportion of glandular structure than most other parts of the 
organ. This is demonstrated microscopically. It has been con- 
firmed by others. Owing to its anatomical position the variety 
of hypertrophy, which affects this region, is of chief pathological 
importance. Watson has found it present in twenty-seven out of 
thirty cases examined by him. Nearly all the varieties of enlarge- 
ment are probably originally adenomatous, but such growths 
would naturally begin where glandular tissue was most abundant. 
Griffiths 2 and Kirby3 have shown that after castration it is the 
glandular tissue which first atrophies and disappears, and that 
this atrophy begins within a few days. 
A consideration of these circumstances seems to make the 
rapidity with which favorable changes, such as ability to urinate 
1 Diseases of the Prostate. 
2 British Medical Journal, March 16, p. 579. 
3 Annals of Surgery, August, 1893. 22 
J. WILLIAM WHITE. 
(66 per cent.); ease of catheterism (about 75 per cent.), etc., 
have occurred in some of the cases more readily understood. 
A very little diminution in a growth largely adenomatous and 
occupying this particular region would, undoubtedly, be at once 
attended by a noticeable amelioration of obstructive symptoms. 
(4) As to the disappearance of the hyperplasia, it must be 
remembered that the stroma consists largely of unstriped mus- 
cular fibres. Griffiths1 has shown that "the intrinsic muscle- 
fibres of the prostate are subservient in function to the glandular 
tubules, and that in the developing prostate the muscle could be 
seen running in fine bundles in close relation to the tubules, and 
in such a manner as to be capable of exerting compression upon 
them ; and also that after castration in the animals before men- 
tioned (dog, cat, etc.) and in man, the prostate, after the lapse of 
a year or more, becomes transformed into a mass of fibrous con- 
nective tissue, which contains the remains of the once active 
gland tubules and a small number of atrophied muscle fibres 
scattered here and there. The complicated and much branched 
prostatic tubules, together with the non-striped muscle which 
forms a pronounced constituent of the normal prostate, have dis- 
appeared almost entirely, leaving, however, some remnants both 
of the gland tubules lined by epithelium, which has lost its 
glandular or secretory function, and of the non-striped muscle 
fibres." 
Moullin says,2 " the stroma of the prostate, like the gland- 
ular tissue it supports, belongs to the sexual organs. It has to 
do solely with the discharge of the prostatic fluid, and, as Dr. 
Griffiths3 has shown, its development varies with that of the 
sexual organs. After castration it wastes as rapidly as the gland 
tissue." These facts would seem to explain satisfactorily the 
practical disappearance of the bulk of the gland, which has been 
said for a priori reasons to be impossible. 
(5) As to the lack of accuracy in the estimation of the 
original size of the gland, and therefore in the statements regard- 
1 Journal of Anatomy and Physiology, Vols. XXIII and XXIV. 
2 Op. cit., pp. 7 and 8. 
3 Loc. cit. CASTRATION IN HYPERTROPHY OF THE PROSTATE. 
23 
ing the exact degree of reduction in bulk, it must, of course, be 
admitted that precise measurements are both desirable and diffi- 
cult. But while it is not easy to express the dimensions of the 
enlarged prostate in figures, there is no trouble by combined 
instrumental and rectal examinations in making a close estimate 
and drawing a fair comparison with some well-known object like 
a " walnut," a " lemon," an " orange," or a " base-ball," all of 
which terms are used by the gentlemen reporting cases, and all 
of which convey a reasonably exact idea of bulk to the average 
mind. As to the change in size, almost any operator has enough 
of the tactus erudites to know w'hether or not a given body has 
shrunken one-half or one-third, or has decreased from the size of 
a lemon to that of a filbert. 
(6) The disappearance in fifty-two cases (about 52 per cent, 
exclusive of Moullin's ten cases of which I have no details) of a 
previously intractable cystitis has certainly been a surprising 
phenomenon. But, after all, it is in accord with certain well-known 
facts. The prostatic plexus of veins receives nearly all the return 
blood from the bladder. Congestion of the former plexus is one 
of the most common and invariable phenomena associated with 
enlargement of the prostate. The veins attain a relatively enor- 
mous size, their valves disappear, and the backward pressure 
inevitably produces congestion and swelling of the vesical mucosa. 
Septic infection of a healthy mucous membrane by the pyo- 
genic microbes of acute or chronic cystitis is not possible, as 
Guyon, Albarran, and others have shown, even though such bac- 
teria are present in the urine. When, however, the vesical mucous 
membrane is congested in consequence of obstruction to venous 
return and by distention of the viscus and frequently recurring 
contractions of the detrusor muscles, it offers but slight resistance 
to the microbic invasion. The pyogenic microbes are generally 
carried to the bladder by dirty instruments, or, if these are ren- 
dered sterile, through failure to cleanse the anterior urethra before 
the instrument is introduced into the bladder. Often cystitis 
develops independently of the use of instruments, probably as a 
result of infection conveyed by way of the urethral mucous 
membrane. The pathogenic microbes usually found are the 24 
J. WILLIAM WHITE. 
bacillus coli communis and the staphylococcus pyogenes aureus. 
These cause vesical lesion either by direct action or indirectly 
through their ptomaines, and acting upon the urea produce 
ammoniacal decomposition. The ammoniacal urine in its turn 
acts as a powerful irritant to the bladder-walls, but is the effect, 
not the cause, of the cystitis. 
Now, if the backward pressure is suddenly relieved and the 
vessels have an opportunity to regain their normal calibre and the 
bladder to empty itself more readily and more completely, it does 
not seem so unreasonable to suppose that microbic multiplication 
would cease; healthy epithelium with normal resistant powers 
would prevent further infection ; the urine could be voided before 
its urea had undergone decomposition; its normal acidity would 
thus be re-established, and a virtual cure of the cystitis be 
effected. 
According to Keyes,1 " Fels and Ritter, by inoculating the 
bladders of dogs, produced ammoniacal urine and cystitis, but 
only on condition of ligating the urethra. Upon loosening this 
ligature the bladder promptly resumed its condition of health." 
The shrinkage of the prostate seems to be the " loosening of the 
ligature" in many of these cases. The subsidence of the tenesmus, 
which is often so severe as to produce lesions of the mucous 
membrane at the neck of the bladder, and the avoidance of sim- 
ilar lesions, often caused by even the most careful use of the 
catheter, are, of course, important factors in bringing about a 
disappearance of the cystitis. 
(7) The lessening in the length of the urethra cannot pos- 
sibly be, as has been suggested, merely the effect of relieving an 
overfull bladder, as Finger2 has shown that on account of the 
inclusion of the pars prostatica in the bladder the urethra is con- 
siderably shorter when the bladder is full than when it is empty, 
a fact which he has demonstrated experimentally. " If, in an 
individual who as yet experiences no desire to urinate, an 
elastic catheter is introduced into the urethra until the first 
drops of urine begin to flow, and then the length of the por- 
1 American Journal of the Medical Sciences, June, 1894. 
2 Gonorrhoea and its Complications, 1894, p. 34. CASTRATION IN HYPERTROPHY OF THE PROSTATE. 
25 
tion of the catheter situated within the urethra is measured; and 
if the same procedure is repeated in this individual when the 
bladder is full and the desire to micturate already present, it will 
always be found that in the latter case the catheter needs to be 
inserted two to three centimetres less deeply before the urine 
begins to flow,-in other words, the urethra is so much shorter 
when the bladder is full. Repeated experiments, which I per- 
formed, as a matter of course, upon healthy individuals, showed 
that the length of the portion of the catheter when the bladder 
was moderately full and the desire to urinate absent, was eighteen 
to twenty-one centimetres ; when the bladder was very full and 
the desire to urinate pronounced, the length was only sixteen to 
nineteen centimetres." Now, as a rule, the measurements in 
these cases of castration have been made originally with the 
bladder more or less distended and later with the bladder nearly 
or quite empty, so that the reported improvement is probably 
understated rather than exaggerated. If the atrophy of the pros- 
tate is once admitted, however, the change in the urethra requires 
no further explanation. 
(8) The return of power in the bladder has been in some 
cases (66 per cent.) as surprising as the disappearance of the cys- 
titis. It is now quite certain that Sir Henry Thompson's asser- 
tion, that the return of voluntary power in the bladder is impos- 
sible after two years' use of the catheter, is incorrect. 
There has been much variation in this respect in the recorded 
cases. So far as I know, there is no certain method of determin- 
ing in advance whether a particular bladder is hopelessly dilated 
and atonic or still possesses power of recuperation. Of course 
in many cases the evidence of continued contractility will be 
unmistakable. But even after complete retention with the with- 
drawal of urine exclusively by the catheter for years there has 
been noted a satisfactory return of power in the detrusor, in 
some instances almost amounting to perfect health. 
(9) The possibility of operating in the presence of an un- 
detected calculus does not seem to me a very grave objection to 
the operation. The most unfavorable subjects for litholapaxy and 
for all forms of lithotomy are the advanced prostatics with cystitis 26 
J. WILLIAM WHITE. 
and deep post-prostatic pouches. If castration will, in even a 
minority of such cases, mitigate the vesical inflammation, and 
wholly or partially obliterate the cul-de-sac behind the prostate, 
it will certainly be deliberately adopted as a preliminary opera- 
tion by many surgeons. I did this in one case (No. 107) with the 
most satisfactory results. 
If the stone chanced to be found after instead of before 
castration, I cannot see that any serious difficulty would follow. 
Its removal would certainly be an operation both easier and less 
dangerous if prostatic atrophy had occurred. 
(10) The assertion that the cases have been reported too 
soon to make the results reliable is true of some, but certainly 
not of all. The successful cases may be grouped as to time of 
report in three classes i1 (1) Those reported immediately after the 
operation,-i.e., within the first two or three weeks, and from 
which nothing further has been heard ; these number seven, or 8.7 
per cent. (2) Those in which from a month to three months 
elapsed before the patient passed from observation, and in which 
the prostatic changes and the improvement in symptoms were care- 
fully noted. These number sixteen, or 20 per cent. (3) Those 
observed after three months, and in which the local changes seem 
to have reached their culmination and the health of the patient 
appeared to be permanently re-established. These were fifty- 
seven in all, a percentage of 71.3. 
It is obvious that enough cases have been followed for a 
sufficient length of time to warrant belief in the permanence of 
the cure when once effected. That there may be remote general 
effects from the operation not now known or appreciated is, of 
course, a possibility. But it seems unlikely that anything new 
will be observed in this respect as castration is one of the oldest 
known operations, and has been investigated both as to immediate 
and remote consequences with great detail and thoroughness.2 
The unfavorable results remain to be considered. The fatal 
cases have been twenty, a percentage of 18. But I would re- 
1 Mojon, M&moire sur les Effets de la Castration dans le Corps Humain. Genes, 
1813; Curling, op. cit; Launois, op. cit. 
1 Exclusive of Moullin's ten cases. CASTRATION IN HYPERTROPHY OF THE PROSTATE. 
27 
spectfully ask that in considering this apparently high mortality 
due consideration be given the attendant circumstances. 
In the first place, while I have included the series of cases 
published by Mr. Faulds, of Glasgow, I do not believe they 
should figure in the statistics. I have put them in only to ask 
permission to throw them out again. They are absolutely lack- 
ing in all the details which would be necessary to give value to 
them. If the operation were one which was dangerous in itself, 
they should, of course, be admitted, as well as all the successful 
cases, some of which are equally without detail. But in this 
instance a mortality of 80 per cent, in a series of five cases 
certainly requires explanation. 
In only two of the cases is the age given. In only one is 
the size of the prostate estimated. In two the urine is said to 
have contained " pus and bloodno other urinary examination 
is alluded to. In only one is the amount of residual urine men- 
tioned. The condition of the patient as to general health is not 
once described. In other words, nearly all the factors upon 
which prognosis is based have been omitted. Moreover, it is 
stated of these patients that " some had been relieved, so far, of 
bladder and kidney disturbance by perineal section, all with the 
object of minimizing the immediate and remote effects of the 
operation." Perineal prostatotomy in such cases has a mortality 
of its own. It seems to me inconceivable that any one familiar 
with the literature of the subject should perform it " with the 
object of minimizing" the effects of castration. It will doubtless 
often be the operation of choice, and its previous performance 
need not necessarily prevent a later castration, but the combined 
operation would certainly have a higher mortality than either 
prostatotomy or orchectomy alone. 
It would, of course, be easy if patients were selected in the 
condition of the one I have already reported to you (Case 104) 
to keep the mortality at those figures. But it is only proper that, 
if the operation is done (as was mine in that instance), as a justi- 
fiable, although apparently hopeless, attempt to give the patient 
the only shadow of a chance that offered, it should be so re- 
corded. For these reasons, in estimating the true mortality of 28 
J. WILLIAM WHITE. 
the procedure I would omit Mr. Faulds's four cases (Nos. 13, 14, 
15, 16), and my own case (No. 104). Furthermore, it is re- 
marked of case No. 36 (Glenn) that the patient was moribund at 
the time of operation. Case 103 (Watson) was delirious at the 
time of operation, and at the same time underwent operation for 
the cure of double inguinal herniae. Case 52 (Lichty) was 
thought to be so unfavorable that the patient was only operated 
on when he expressed a preference for death as compared with 
a continuance of his sufferings. Case 43 (Haynes) lived for 
between two and three months. I have included it, but it can 
scarcely be considered an operative death. In case 13 (Faulds), 
a death from hemiplegia, nearly four weeks after the operation, 
seems scarcely chargeable to it, especially as the urinary symp- 
toms were said to be " mitigated." Case 28 (Finney) had been 
insane at intervals before operation and died insane. Case 39 
(Halsted) had a suprapubic cystotomy performed, as well as the 
castration. The prostate was " riddled with abscesses." Case 
47 (Horwitz) was in " a desperate state," and it was merely a 
question as to what operation offered some hope with the least 
risk. Case 82 (Souchon) recovered power in the bladder, and 
died of pulmonary trouble at the end of six weeks. He had had 
a previous suprapubic prostatectomy, and had a permanent 
fistula. 
Some of the others were scarcely less unfavorable, another 
of Halsted's being described as a " desperate case," in which 
something had to be done ; but if I may be allowed to withdraw 
these thirteen cases from the list, so that we may get the legiti- 
mate average mortality in cases operated on with a reasonable 
expectation of cure, we have left a total of seven deaths in ninety- 
eight cases, a mortality of 7.1 per cent. I believe it will be less 
in the future. If so, it will accord with the history of every new 
operation in the matter of mortality. A table of ninety-five cases 
of suprapubic prostatectomy, arranged chronologically, shows, as 
I pointed out in 1893, a mortality of 20 per cent, for the whole 
number, but of only 15 per cent, for the last half; the mortality 
of the first half was 25 per cent. 
I think a careful and impartial study of the cases in the CASTRATION IN HYPERTROPHY OF THE PROSTATE. 
29 
table of deaths will show that in every one as to which details are 
given there was little to be hoped for from palliative operations, 
and less from the unaided efforts of nature, while it seems highly 
probable that any other radical procedure would have been at 
least equally likely to result fatally. 
Moreover, even in these desperate cases it is most interest- 
ing to note that fifteen (75 per cent.) showed some distinct im- 
provement in symptoms or some shrinkage of the prostate before 
they died. 
But while there is little or no risk in the operation itself, if 
it is applied in the future as widely as it has already been,-i.e., 
to patients of all ages and all degrees of weakness, of uraemia and 
of toxaemia,-it will, undoubtedly, always have a considerable 
mortality. 
The average age of the eighty-six patients included in the 
table, whose ages were given, is sixty-six and a half years; the aver- 
age age of the fourteen cases among those who died, in which the 
age was given, is between sixty-nine and seventy. Although the 
years of the patient must be an important factor in determining 
the result in this as in other operations, it is the real age rather 
than that of the calendar which will tell. The senility of the 
tissues, the degree and extent of arterio-sclerosis, especially as 
affecting the integrity of the kidneys, are more important than 
the nominal age. This varies widely in just these cases, the 
relationship between general atheroma and prostatic enlargement 
being so close that so distinguished an observer as Guyon has, 
as I have already mentioned, based upon it a theory of causation. 
I am strongly of the opinion that when we have enough detailed 
cases for broad generalization, we will find that the mortality of 
this operation will have a very direct relation to a few factors, the 
most important being the presence or absence of renal infection, 
and the history of long-continued catheter life, or of a number 
of attacks of complete retention, or of a very large amount of 
residual urine. If these factors are conjoined, the case would 
be of the most unfavorable type, the suppurative disease of the 
kidneys following infection crippling to the point of uselessness 
organs already suffering from the effects of prolonged backward J. WILLIAM WHITE. 
30 
pressure. In the forty-seven cases in which the duration of the 
prostatic symptoms was stated definitely the average is seven and 
a half years. In the six fatal cases in which the duration was 
specifically given the average is only four years. In the twenty- 
two cases in which the period during which the catheter was 
used is stated definitely the average is four years. In the five 
instances in the table of deaths it is 3.4 years. 
Differences in the size, the density, and the shape of the 
prostatic overgrowth will probably be found to be minor factors 
in determining mortality, and more important ones in relation to 
the degree of improvement effected by the operation, and to the 
rapidity with which it occurs. After careful study of the cases, 
I do not think we have the data for positive conclusions on these 
points. Of the 111 cases only nineteen were not definitely stated 
to have been improved at the expiration of varying periods. Of 
these nineteen, nine were included in the table of deaths, leaving 
only 10 per cent, of apparent failures. But as in many of the 
whole number no mention is made of the density of the over- 
growth and no estimate of the size, it is impossible to say whether 
or not these failures were due to the fact that in these cases the 
enlargement was of the hard and fibrous variety, with an abun- 
dance of connective tissue and relatively little glandular structure. 
Prostates thought to show this kind of enlargement have been 
reported as shrinking with rapidity, but, of course, the observers 
may have been mistaken. It is encouraging to note, however, 
that the microscopic studies thus far made seem to indicate an 
atrophy of the stroma almost as rapid as that of the glandular 
element. 
The remote results of the operation cannot yet be de- 
termined. The cases of death with precedent mental symptoms 
described as " mania," " acute mania," " childishness," etc., are 
only such as every surgeon is familiar with in a certain propor- 
tion of cases of operation on aged persons whose mental equi- 
librium is easily disturbed, and can have no bearing on the ques- 
tion of later mental changes as a result of the castration. With 
greater accuracy we would probably classify the large majority 
of them as " uraemia," and some of the remainder as " traumatic CASTRATION IN HYPERTROPHY OF THE PROSTATE. 
31 
delirium." It is worthy of note that no mental or physical 
changes whatever (except favorable ones) have been noted in a 
single one of all the successful cases, some of them now dating 
back for nearly a year and a half. All the information we have 
on this subject-and it is far from scanty-leads to the belief 
that the removal of the testicles from persons who have reached 
full adult life, and a fortiori from aged persons, has no effect 
whatever on the mental functions or on the general physical 
characteristics. Impotence will undoubtedly be caused in the 
majority of cases, but even this is not inevitable (see Cases 7, 42, 
and 92). 
Properly to compare this operation with the other methods 
employed in the treatment of prostatic enlargement it seems 
necessary, as its position is still so indeterminate, to review 
briefly the procedures appropriate to various conditions and 
stages of hypertrophy. 
(1) Dilatation.-A patient who presents the symptoms of 
the prostato-vesical congestion of the early stages of hypertrophy, 
who is disturbed once or twice at night, who has an enlargement 
of moderate density, appreciable through the rectum, but not 
offering much resistance to the introduction of an ordinary cathe- 
ter, and who has but little residual urine, is likely to derive great 
benefit from the systematic introduction of full-sized steel sounds. 
This treatment alone often seems to relieve existing symptoms 
and to prevent or, at least, delay the development of further 
trouble. Of course, while this is the case no more radical treat- 
ment would usually be considered. 
(2) Catheterism should be systematically employed in cases 
in which the quantity of residual urine is three or four ounces or 
more, and in which the introduction of the instrument is easy 
and painless, and the urine is sterile. The frequency should be 
proportionate to the amount and character of the residual urine, 
a very good working rule (if the urine is sterile) being to use the 
catheter once daily (preferably at bedtime) for three ounces, 
twice for six ounces, and then once more for any additional two 
ounces. With sterile urine it is rarely necessary to use it oftener 
than once in every four hours. 32 
J. WILLIAM WHITE. 
It ' may be said at once that in those patients with but 
moderate obstruction, or with a high grade of compensatory 
hypertrophy of the bladder, with a small amount of residual 
urine, which remains sterile, and in whom catheterism is easy and 
painless, operation is not to be thought of. The time may come 
when, by perfecting our methods of diagnosis and our operative 
technique, this class of prostatics may be benefited by active sur- 
gical interference, but it has not yet arrived. Dilatation and 
catheterism, as above described, at present represent the best 
therapeutics, especially if the rigid observance of details of anti- 
sepsis is emphasized, insisted upon, and never lost sight of.1 But 
it must be remembered that these methods are, in the majority 
of cases, merely palliative, and that, as a rule, the introduction of 
instruments gradually becomes more difficult, cystitis and atony 
of the bladder result from the catheterism, which increases in 
frequency and painfulness and some operative measure must be 
considered. At this time castration will probably be rejected in 
the large majority of cases on account of the sentimental objec- 
tions to the operation. Launois has said truly that even men 
whose sexual powers have vanished desire to preserve the testes 
as evidence of a virilite passee. The dominating position of the 
sexual instinct throughout the whole animal kingdom makes this 
feeling on the part of the patient readily comprehensible. But I 
cannot so easily understand why the surgeon should be expected 
to regard this sentiment or, indeed, the function itself with rever- 
ence. I am strongly disposed to agree with a medical man who 
writes me, " When a man in advanced years suffers severely from 
the disabilities and dangers caused by an enlarged prostate, it is 
difficult to understand why the preservation of a sexual function 
which has become useless to humanity and a constant menace to 
his own comfort and safety should be considered as an especially 
sacred duty." 
I hope that this operation will occasionally, at least, be con- 
sidered at this stage when some operation is for the first time 
clearly indicated and justified, and when all operations would be 
1 Annals of Surgery, August, 1893. CASTRATION IN HYPERTROPHY OF THE PROSTATE. 
33 
attended by better results than if done later. It would then 
come in competition with,- 
(3) Over-Stretching of the Prostatic Urethra.-This pro- 
cedure is not likely to be followed by good results in cases in 
which the median lobe and the vesical neck are chiefly concerned. 
In those of lateral hypertrophy, in which the urethra is simply 
narrowed, and is narrowed and rendered tortuous, it might be of 
use. If it is tried it should certainly be conducted under ether, 
and should be carried to the furthest degree consistent with 
safety. This operation may be said to be indicated (tentatively 
or experimentally) in those cases in which palliative treatment 
has failed and more radical measures are declined. Its results 
are doubtful. There should, of course, be almost no mortality; 
but, on the other hand, nothing like a cure could be anticipated. 
(4) Perineal prostatotomy, with prolonged drainage or the 
formation of a permanent fistula, will undoubtedly be preferred 
in many cases. Its mortality is only about 4.5 per cent. It 
often relieves the cystitis and will sometimes effect a cure,-i.e., 
after withdrawal of the tube, or after cessation of the vesical irri- 
gations through the wound, the latter will close and there will be 
no return of obstructive symptoms. The precise mode by which 
it acts has not been demonstrated, but it seems probable that it 
is a combination of mechanical dilatation of the channel with a 
certain amount of cicatricial contraction in the substance of the 
gland, reducing its bulk in the immediate vicinity of the urethra 
and thus diminishing its obstructive power. 
I wrote, in 1893 / "The operation should be regarded as 
that of choice in all those cases in which, with marked diminution 
of expulsive force and with cystitis, there are also evidences of 
wide-spread degenerative changes or of distinct renal disease, and 
toxaemia and general feebleness are present. It is also to be pre- 
ferred, as a rule, even in the absence of renal or constitutional 
symptoms if the bladder is rigid and contracted, and will hold 
only a few ounces of urine, or if the atony is nearly absolute and 
does not tend to improve under careful treatment." It must be 
1 Annals of Surgery, August. 
3 J. WILLIAM WHITE. 
34 
said, however, that its proper place is among palliative operations ; 
that in the majority of cases the fistula must be kept open 
throughout life; and that it will often refuse to close even 
when it is desired that it shall do so. The inconvenience of 
this condition, and the undoubted risk of renewed vesical infec- 
tion attending a permanent fistula (which will often suppurate 
continuously), seem to me to compare very unfavorably with the 
results obtained in the average cases of castration. If the latter 
operation were done under the same circumstances as perineal 
prostatotomy, its mortality would probably be less and its results 
as regards re-establishment of function infinitely better. 
(5) Suprapubic cystotomy with prolonged drainage or with 
the formation of a permanent fistida has a mortality but little 
greater than the previous operation, gives equally good drainage 
if properly performed, and has the advantage of permitting a 
more thorough exploration of the bladder and of being converted 
into a prostatectomy if the condition warrant it. It offers no 
prospect of cure, however, is altogether inapplicable to cases 
with small rigid bladders, and even with Buckston Browne's 
excellent apparatus, or with McGuire's or Morris's ingenious 
modification of the operation, the patient's person and clothing 
are apt to be urinous and offensive, and there are many minor 
inconveniences. 
I believe that, with the " sentimental" objection put aside, 
there is little to be said in favor of the operation as compared 
with castration. 
(6) Perineal Prostatectomy.-The chief, clinical indications 
for this operation may be said to be those already enumerated as 
justifying prostatotomy, which may always be converted into a 
prostatectomy if the perineal distance permits the growth to be 
reached by the finger, and it is found to be of small size and 
limited to the median line posteriorly, or pedunculated and acting 
like a ball-valve at the neck of the bladder. The chief objections 
to the method as a formal procedure, when a radical operation 
has been determined upon, are that in only about one-third or 
one-fourth of the cases (Watson, McGill) could the growth be 
reached by the finger of the operator; that often, even when CASTRATION IN HYPERTROPHY OF THE PROSTATE. 
35 
accessible to the finger, it cannot be satisfactorily dealt with 
through the narrowed urethra; and that vesical projections are 
altogether beyond reach for accurate or careful manipulation. It 
has a mortality of 14.3 per cent., and on that account and on 
account of the comparative uncertainty of results should, I think, 
be only exceptionally employed, and will not often be weighed 
in the scale with castration. The practical advantages certainly 
seem to rest with the latter operation. 
(7) Suprapubic Prostatectomy.-Of this operation I wrote in 
1893 1 that it was "the operation to be preferred in all those 
cases in which, palliative treatment having failed, there are 
unmistakable indications that the local conditions are growing 
worse, the general health remaining as yet unaffected. The best 
possible period is that before the development of marked and con- 
tinuous cystitis, while some power still remains in the vesical walls, 
and the bladder is neither thinned and dilated nor rigid and con- 
tracted. Under these circumstances, in the presence of a patient 
who reports that he is disturbed at night with increasing fre- 
quency; that he is obliged to use the catheter oftener, and not only 
does so with greater discomfort but with less relief in the interval; 
that the urine is occasionally turbid and offensive; that he has 
recently had one or more attacks of retention, and that he is 
beginning to lose flesh and appetite, it appears to me that the 
indications for operative interference are unmistakable, and that 
the suprapubic method is obviously the one to be selected." 
Is this true to-day ? If the operation of castration holds its 
own, it will be because it has manifest advantages over the one we 
are now considering. I believe that those advantages exist and 
are as follows: («) The mortality of the first extensive series of 
suprapubic prostatectomies published was 25 per cent. The 
mortality of my table of a slightly larger number of cases is 18 
per cent., including every known death even when it occurred 
months after operation. The true mortality, as I have already 
said, I believe to be about 7 per cent. The death-rate will be lower 
in the future in both operations, but the proportional difference in 
favor of castration will probably persist or increase, as castration 
* Loc. cit. 36 
J. WILLIAM WHITE. 
is a simple, easy, rapid procedure, without danger per se, and 
requiring for its safe performance only a proper selection of cases. 
It seems to me not unfair to add that in the present instance the 
facts have been obtained largely by personal solicitation, and that 
unfavorable cases have not been suppressed. (V) The return to 
local and general health in the successful cases has been more 
complete and vastly more rapid than after prostatectomy. A 
re-establishment of almost perfect health appears to have occurred 
in fifty-one cases (51.2 per cent.1) within from four to twelve 
weeks, (r) Vesical contractility was re-established, cystitis dis- 
appeared, and all pain ceased in such a large proportion of the 
successful cases that it seems unlikely that any operation which 
opens the bladder and necessitates healing by granulation will 
secure equivalent results; certainly suprapubic prostatectomy has 
not yet done so. (</) A permanent fistula may follow supra- 
pubic prostatectomy and prove a continual source of annoyance 
even when all the other results have been favorable. (>) It is 
too soon yet to compare the relative dangers of relapse. Case 
81 (Souchon) is, however, interesting in this respect. The patient 
had been taught to use the catheter for himself after a suprapubic 
prostatectomy in October. In February he returned because the 
introduction of the instrument had become impossible. Although 
more than 70 per cent, of the cases of castration in the table had 
been observed for over three months, in not a single one did 
relapse occur. 
I concluded my paper in 1893 with the remark " that if we 
ever reach a point in certainty of knowledge in this direction 
comparable to that already attained in regard to oophorectomy 
in relation to uterine fibroids, and can promise equivalent results, 
there will be no lack of cases willing to submit to an operation 
almost painless, with a low mortality, and followed by no such 
unpleasant conditions as accompany persistent fistulous tracts, 
either suprapubic or perineal, even although the operation car- 
ries with it the certainty of sacrificing whatever sexual power has 
survived the excessive and often intolerable sufferings of such 
patients." 
1 Exclusive of Moullin's ten cases. CASTRATION IN HYPERTROPHY OF THE PROSTATE. 
37 
I find that Greig Smith 1 says that the general mortality of 
oophorectomy for myomata is somewhere near io per cent. He 
adds, " As to the results, we may, in every thirteen cases of 
recovery after operation, reckon upon complete cure,-i.e., 
shrinking of the tumor and menopause, in ten cases, improve- 
ment in two, and failure in only one." An examination of the 
table of castrations shows that with that as a basis we may in 
every thirteen cases of recovery count upon eleven being com- 
plete cures in the sense of shrinking of the tumor, one being 
improved, and one being unsuccessful. 
The analogy which I have always thought so remarkable 
between the two conditions and the indications for operation is 
thus even more strikingly illustrated by the results of operation ; 
and the number of cases already reported amply justifies the 
prophecy I ventured to make in regard to the willingness of 
patients to be operated upon. 
Part III. 
(i) Unilateral Castration.-A number of observations have 
been recorded from time to time seeming to show the same sort 
of relation between a single testicle and the corresponding lobe 
of the prostate that has now been demonstrated to exist between 
both testicles and the entire gland. 
Godard2 long ago showed that if a testicle undergoes an 
arrest of development, or if its migration is incomplete, the pros- 
tatic lobe and seminal vesicle of the affected side undergo atrophy. 
Others (Lennox, Watson) have made the same observation, 
and it is now quite clear that there is a definite relation or 
sympathy between each testicle and the lateral lobe of the 
prostate and the seminal vesicle on the corresponding side. A 
few illustrative cases will suffice. 
Bezangon3 has recorded a case which is of special value 
because it was possible to make a full histological study of the 
1 Abdominal Surgery, Second Edition, p. 187. 
2 Etudes sur la Monorchidie, Paris, 1857. 
3 Etude sur 1'Ectopie testiculaire du jeune age et son Traitement. These de 
Paris, 1892. 38 
J. WILLIAM WHITE. 
prostate. Launois's 1 abstract shows that in a man twenty years 
of age, with an undescended and atrophied testicle, situated in 
the left iliac fossa, there was atrophy of the prostate and seminal 
vesicle on the same side. The patient died of pulmonary tuber- 
culosis. The atrophy was of sufficient extent to be easily 
noticeable by sight and touch. The microscope showed it to be 
most marked as to the glandular tissue. Launois reports a sim- 
ilar case in a man forty years of age. He also records a case of 
one-sided atrophy of the prostate corresponding to a testicular 
atrophy following a number of attacks of gonorrhoeal orchitis. 
Much similar evidence might be adduced, but a brief study of 
the literature is convincing as to the possibility of influencing one 
side of the prostate by castration on the same side. These facts 
led me to write to the Medical News (February 9, 1895), asking 
for information from surgeons as to the effect of unilateral castra- 
tion upon the total bulk of the prostate. I remarked that existing 
evidence was scanty, but seemed to point clearly to one-sided 
atrophy of the prostate as a common result of the removal of 
one testicle and that some experiments which I was making on 
dogs corroborated this view, as did the observed condition of 
the prostate in monorchids. I added, " If it is found that the 
diminution in size extends to the other lobe, or if the shrinking 
of one lobe will in any large proportion of cases remove or lessen 
the mechanical obstruction to urination, the operation might at 
once be extended to a much larger number of patients and at an 
earlier and more favorable stage of the disease." Since sending 
this letter, the following communications have been published or 
have been received by me : 
H. E. Clark2 said that on February 25 he had performed uni- 
lateral castration in the case of a man sixty-five years of age, whose 
catheter history covered a period of five years. The patient had 
done well and was making a good recovery, but the time was too 
short to permit of changes in the prostate being noticed. 
Mr. Fenwick3 reported a series of interesting cases. In three 
1 Annales des Maladies des Org. Gen.-Urin., October, 1894. 
2 British Medical Journal, March 9, 1895. 
3 British Medical Journal, March 9, 1895- CASTRATION IN HYPERTROPHY OF THE PROSTATE. 
39 
cases of unilateral castration nothing definite was felt in two ; in the 
third the prostatic lobe on the same side was larger than its fellow. 
In two cases of monorchidism there was one instance in which the 
prostate was smaller on the affected side and one in which that side 
was the larger. In six cases of extreme atrophy'of a testis consecu- 
tive to inflammation there were two in which the prostate was sym- 
metrical and four in which the larger lobe was on the same side as 
the atrophied testis. In nine cases of extreme atrophy (cause un- 
known), seven had both lobes of the prostate equal, one had a smaller 
lobe on the side of atrophy and one a larger lobe. 
Mr. Fenwick adds, " I point out with some diffidence that these 
cases are mostly at variance with Dr. White's surmises. At the same 
time I am aware that rectal examination, however skilled, is as un- 
certain a guide to the activity of the prostate as it is unreliable for 
estimating the amount of urinary obstruction which may be present. 
Moreover, none of us know the normal shape of the prostate, for it 
varies with each decade and with each individual. Lastly, few seem 
to appreciate the fact that the prostate is often changed in rectal con- 
tour by posture, by vesical distention, and by excessive use." 
The following letter was sent February 16, 1895, by Dr. W. G. 
Fulton, of Scranton, Pa., to the editor of the Medical News, and 
was kindly referred to me,-"Sir: In reply to the request by Pro- 
fessor White, in the News of February 9, for information concerning 
the effect of unilateral castration on the prostate, I have a case which 
may be of interest. In November, 1893, Patrick M. entered the 
Lackawanna Hospital suffering from a diseased testicle. He had also 
an enlarged prostate, and could pass his urine only by aid of a catheter 
which he had learned to use himself. On December 1, I removed 
the diseased testicle, and before leaving the hospital, January 13, he 
could urinate freely without the aid of an instrument. The prostate 
at that time had perceptibly diminished in size, but I did not observe 
that there was then any marked difference in the size of its two sides. 
I have not been able to see the case since." 
Dr. H. W. Rand, of Brooklyn, wrote me that on examining the 
prostate of a patient, aged fifty-one years, whose right testicle had 
been removed for disease nineteen years ago, he found the right side 
of the prostate somewhat larger than the left. 
Mr. Aslett Baldwin,1 of the Middlesex Hospital, recorded the 
1 British Medical Journal, March 30, 1895. 40 
J. WILLIAM WHITE. 
result of an autopsy on a monorchid, aged forty-nine years, in which 
the prostatic lobe was only one-eighth inch smaller on the affected 
side than on the other. 
Dr. P. C. Remondino1 said that in four recent cases of unilateral 
castration for other diseased conditions in elderly subjects, two had 
had a well-pronounced prostatic enlargement, and in them the opera- 
tion was soon followed by a remarkable diminution in size. 
Dr. S. C. Graves, of Grand Rapids, Michigan, wrote me May 8, 
1895, as follows : " On October 20, 1894,1 removed the right testicle 
of a gentleman, aged twenty-four years, for syphilitic orchitis. I 
have examined his prostate, and find that the corresponding (right) 
side of the organ has undergone decided atrophy. The left side 
seems to be normal." 
Mr. Charles Morton 2 publishes the following interesting commu- 
nication : " Dr. J. William White3 requests surgeons to report cases 
of unilateral castration in which examination of the prostate was 
made. On March 7, I removed from a young man, aged seventeen 
years, an imperfectly-developed right testicle, which was lying just 
over the pubes and was surrounded by a 'congenital hydrocele.' 
Probably it had been retained within the inguinal canal in childhood, 
and had thus failed to develop. It was in constant danger of pressure 
against the pubes, the hydrocele only filling when he moved about 
and disappearing again during recumbency. I removed the testicle 
and hydrocele sac together. Seven weeks after the operation, and 
when he came to show himself at the hospital on April 25,1 examined 
the prostate and found most decided atrophy of the corresponding 
side. There was, indeed, nothing on the right side at all corre- 
sponding to the lobe on the left, which is very well developed. It is 
difficult to say whether this is due to the imperfect development or 
removal of the testicle. When we remember the rapidity with which 
atrophy has occurred in enlarged prostate after bilateral castration, it 
is quite possible that the small size of the right side in this case is 
due to atrophy following the operation, and I am inclined to think 
that this was the case, as, although the right testicle was much smaller 
than the left, yet it contained a fair amount of gland tissue which 
appeared normal in structure." 
1 British Medical Journal, April 6, 1895. 
2 British Medical Journal, May 11, 1895. 
3 British Medical Journal, March 2, 1895. CASTRATION IN HYPERTROPHY OF THE PROSTATE. 
41 
Dr. J. T. Haynes,1 of Sandusky, Ohio, reports the case of a man, 
aged sixty-three years, with a hydrocele and a history of prostatic 
obstruction dating back for ten years. For several years he had to 
resort to catheterism. Tapping and injecting the hydrocele sac was 
followed by sloughing of the testicle and scrotum, for which unilateral 
castration was performed June n, 1894. Dr. Haynes continues as 
follows: "The fourth day after operation the patient told the nurse 
that, much to his surprise, he had been able to pass some urine unas- 
sisted by the catheter. This condition gradually increased until the 
third week after operation, since which time he has not had the 
slightest difficulty in voiding his urine. He is to-day an inmate of 
the Home, enjoying the best of health, and perfectly free from dysuria 
or any complications resulting from operation. Rectal examination 
by finger shows a prostate gland much reduced in size, but possibly 
only atrophied on one side. I have given this case not to show any 
result as following the operation other than the effect produced upon 
the enlarged prostate, and, in honesty, I will admit that the atrophy 
of the prostate was not the point aimed at in the least in making the 
operation. But I am convinced of the beneficial effect to be derived 
from this procedure, and deem it, in all cases that will permit, the 
only course to pursue." 
Dr. Haynes (Sandusky, Ohio) also sends me, May 25, 1895, the 
following interesting description of a recent case : 
History.-Samuel H., aged seventy-two years; white ; bachelor. 
Admitted to hospital of Ohio Soldiers' and Sailors' Home, August 13, 
1894. Disability; hypertrophy of prostate associated with inconti- 
nence of urine and great vesical tenesmus during certain periods. In 
regard to past history, states that he has had gonorrhoea a great many 
times, and that he had syphilis during service in the late war. Has 
had frequent attacks of bladder trouble, and for seven or eight years 
has had gradually increasing difficulty in urination. States that at 
times physicians had failed to introduce catheter to relieve dis- 
tended bladder. 
Present condition is not good. Has pronounced valvular heart 
lesion and noticeable lack of good compensation; body fairly well 
nourished ; odor of urine ; examination of urine shows specific grav- 
ity 1021 ; no albumen; no sugar; pus found in large quantities and 
constantly present. By rectal examination prostate found to be 
exceedingly large, round, and the size of a lemon. 
1 Medical Record, May II, 1895. 42 
J. WILLIAM WHITE. 
Treatment.-General condition of patient with condition of 
bladder and urethra received firstattention. Strictures were dilated 
and bladder daily washed out with silver nitrate solution, which re- 
lieved to a considerable degree the vesical tenesmus and reduced in 
quantity the pus contained in the urine. Patient was told of operation 
for relief of hypertrophy and readily consented. 
Operation.-August 22, 1894. Ether given without difficulty. 
Parts previously prepared for operation ; were then washed with bi- 
chloride 1 : 1000. Incision about four inches. Entire scrotal con- 
tents of left side removed. Cord dissected up and tied. Wound 
closed by interrupted suture. Drainage. Iodoform dressing. Reac- 
tion good. August 24 dressings removed, but were a little soiled. 
Patient complained of pain at the internal abdominal ring, for which 
morphine was given. 
Results.-August 27, dressings removed and drainage-tube re- 
moved; no pain to speak of; dressingas before. September 2. Dressings 
changed. Nurse stated that when patient stood he could make his 
urine much better than before operation, ,8th. Dressing removed and 
scrotum placed in suspensory bandage. Patient urinates quite well at 
times, but occasionally is unable to void any. Examination per rec- 
tum shows prostate to be reduced in size and changed in form ; no ten- 
derness on pressure. 12th. Patient goes out walking; staying in ward 
but little. Rarely fails to urinate freely ; states that he feels like a 
new man. Prostate becoming much smaller. 20th. No difficulty in 
urination. Prostate much reduced. Form rapidly assuming that of 
normal. Nothing more is known of the case, as patient left a few 
days after this and has never been heard from. 
On February 20, 1895, I operated on a patient, aged seventy- 
four years, sent me by Dr. Black, of New Castle. The man had been 
suffering from obstructive symptoms for some years. He was markedly 
uraemic, passing only eighteen ounces of albuminous urine in the 
twenty-four hours. The urine also contained much blood and pus. 
Catheterism was difficult and painful. Urine began to flow through 
a soft instrument when the eye of the latter reached a distance of nine 
and a half inches from the meatus. By rectal examination the pros- 
tate seemed to be about the size of an orange. There were six ounces 
of residual urine. The patient had constant vesical tenesmus, and 
was attempting to use the catheter at such times as he aroused from 
his uraemic hebetude. His general condition was exceedingly unfa- 
vorable, and he and his family were strongly averse to complete cas- CASTRATION IN HYPERTROPHY OF THE PROSTATE. 
43 
tration. For these reasons I did a unilateral castration on February 
20 in the presence of the class, expressing frankly at the same time 
my very unfavorable views as to prognosis, which had already been 
communicated to the family of the patient. The operation was com- 
pleted in two minutes, and was done during the first stage of anaes- 
thesia. Chloroform was used. Some improvement in the urinary 
condition was noticed on the fourth day, when he passed a large quan- 
tity of urine with more ease, and it was found that the residual urine 
was only two ounces. 
But the uraemic symptoms gradually deepened, and the patient 
died comatose on the fourteenth day. 
Autopsy.-Section of lateral half. («) The side corresponding 
to the castration. The section marked a is filled with proliferated 
cells, both muscle and connective-tissue cells. Some parts of the field 
are more cellular than others, and where few cells are to be seen indi- 
cate the new connective tissue that is being transformed from the pro- 
liferated cells. There has been no special contraction of tubules, nor 
are they widely separated from each other. The tubules themselves 
are filled with small flat cells, and some still retaining in part their 
columnar shape; these are the original proliferated columnar cells 
which line the tubules. 
The cells in the lumen of the tubules are filled with fine granular 
matter, which has not taken the stain. 
Section of lateral half. (ti) There is only a trace of the usual 
cell-proliferation in the stroma. In some of the tubules there is 
beginning proliferation of cells, but it has not advanced sufficiently 
to show much. 
On March i, 1895, Mr. B., a man aged seventy-two years, and 
weighing 215 pounds, came to see me on account of marked prostatic 
hypertrophy. He had all the typical symptoms, and was apparently 
just at the beginning of a break-down in his catheter life. His pros- 
tate was at least as large as a small orange and was symmetrical. He 
had a half-pint of foul residual urine. He had had one testicle 
removed by Dr. D. Hayes Agnew, in 1885, for suppurative disease. 
I recommended removal of the remaining gland, but have not since 
seen the patient. 
Dr. R. W. Taylor, of New York (personal communication, May 
29, 1895), has had two cases as follows: 
An old gentleman with marked prostatic obstruction had a sup- 
purating and sloughing testis. After the gland had disappeared there 
was distinct relief of all the most urgent prostato-vesical symptoms. 44 
J. WILLIAM WHITE. 
An elderly patient with a very large prostate, apparently almost 
filling the rectum, and with intractable cystitis, developed tubercular 
disease of one testicle, which resulted in its removal. The prostate 
soon afterwards was found to be much shrunken, the urine cleared up, 
and all the obstructive symptoms vanished. 
Dr. Bryson, of St. Louis (personal communication, May 29, 
1895), has seen two cases of atrophy and disappearance of one tes- 
ticle, in one after an epididymo-orchitis, in the other after phlebectomy 
for varicocele. In the former, thirty-six years later, and in the latter, 
after eleven months, no difference could be observed between the two 
halves of the prostate. 
Mr. Langton, at a recent meeting of the Clinical Society of 
London,1 mentioned that many years ago, after removal of a senile 
tuberculous testis from a patient who also had enlarged prostate, that 
organ diminished in size on the corresponding side. Three years 
later the other testis was removed, as the tubercle had appeared in it, 
and this second operation was followed by diminution of the prostate 
on that side. 
Mr. Gould 2 removed a tuberculous testis from a young man in 
1893, and the second testis early this year. After the first operation 
there was no decrease of the prostate, but a great shrinking after the 
second. 
It seems obvious that, in view of the contradictory character 
of the observations above recorded, no safe deductions can be 
drawn from them at this time as to the practical value of 
unilateral castration in cases of prostatic enlargement. The 
clinical history of the cases of Dr. Fulton, Dr. Remondino, 
Dr. Haynes, and Dr. Taylor, and the microscopic evidence in 
my case, together with the slight but unmistakable improve- 
ment in urination in the latter patient, seems to encourage 
the idea that in a minority of cases this operation will be fol- 
lowed by enough atrophy of the prostate to mitigate the ob- 
structive symptoms. This view is favored by the observations 
of Dr. Graves and Mr. Morton, and by the unmistakable one- 
sided atrophy observed in monorchids, and in some cases of 
acquired disease causing atrophy of one testicle. It is opposed 
1 Quoted in Medical Record, June i, 1895. 
» Ibid. CASTRATION IN HYPERTROPHY OF THE PROSTATE. 
45 
by the observations of Mr. Fenwick, Mr. Baldwin, and Dr. 
Bryson. 
Some experimental evidence was obtained during an inves- 
tigation into the effect of ligation or section of various constitu- 
ents of the cord. In some cases the testicle on one side sloughed 
or atrophied, while the other remained sound. The prostate, 
however, did not vary regularly with the testicle, but in some 
cases showed no change at all; in others marked and general 
atrophy comparable to that caused by double castration. On the 
whole, it may be said that the evidence in favor of the operation 
warrants further investigation into its merits or demerits, but 
that it seems probable that the results, even though occasionally 
favorable, will be slow and uncertain compared with those fol- 
lowing the bilateral operation. 
(2) Ligation or Section of the Vas.-At the meeting of this 
association, in 1893, it was suggested (Dr. Mears) in the dis- 
cussion that followed my paper that perhaps ligation of the vas 
deferens might be as efficacious as double castration. In an 
interesting communication Mr. Reginald Harrison1 briefly re- 
ported a case of prostatic enlargement, in which, after declining 
to castrate the patient, who had importuned him to do so, he had, 
"as a compromise," divided the vasa deferentia subcutaneously 
immediately below the external abdominal rings. The patient 
thought he derived some benefit from the operation in a short 
time. Six or seven years later he was alive and well. 
Curling discusses at length the effects upon the testes of 
deficiencies or imperfections of the vas deferens. (Diseases of 
the Testis, Chapter I, Section II.) Fie shows from observa- 
tions of Hunter (1775), Cooper (1823), himself (1842;, Gosselin 
(1853), Godard (1857), and others, that the vas may be obliter- 
ated from birth, or may become so from injury or disease with- 
out, as a rule, interfering with the development or the apparent 
health of the testicle. He says, "The engorgement of the 
seminal ducts with sperm is liable, it is true, to cause inflamma- 
tion of the testicle, which may end in atrophy, but this is only 
a secondary and, indeed, a rare effect of the interruption in the 
excretory duct." 
1 British Medical Journal, September 23, 1893. 46 
J. WILLIAM WHITE. 
Griffiths 1 has recently confirmed these observations by ex- 
periments upon young dogs. He details the results in four 
cases and sums up as follows : " Accordingly, when the vas 
deferens is ligatured in puppies there is no immediate result 
either upon the epididymis or testicle; nor is the growth of the 
latter in any way interfered with,-that is to say, the ligature of 
the duct does neither hasten nor retard the growth of the gland, 
and the testicle acquires its maturity both of structure and 
function just as if the duct had been left alone in its natural and 
previous state. Again, when the vas deferens is ligatured in 
full-grown dogs there occurs enlargement of the epididymis, 
with tenderness. This enlargement in part subsides, leaving it, 
together with the portion of the duct up to the seat of ligature, 
permanently enlarged from the accumulation of semen. The 
structure of the seminal tubules remains unaltered, and they are 
after a few days or a few months just the same, showing the 
active formation of spermatozoa, like those of the normal testis, 
the duct of which is left natural and undisturbed; therefore 
ligature of the vas deferens induces a slight enlargement of the 
epididymis and of the vas deferens up to the seat of ligature, 
but it does not interfere in any way with the structure of the 
seminal tubules or the production of spermatozoa." 
In two other cases, however, the testicle showed structural 
changes, atrophy of tubules, disappearance of normal epithelium, 
absence of any traces of the formation of spermatozoa, etc. One 
of these cases was that of a hound eight to nine years old. The 
other was that of a man, aged twenty-one years, who had had 
the vas accidentally divided six weeks previously. Mr. Griffiths 
thinks it probable, in the light of his other experiments and of 
those that preceded his, that in these two instances some damage 
was done to the other structures of the cord. 
In none of the foregoing investigations was any special 
attention paid to the condition of the prostate. I accordingly, 
during the month of January, 1895, with the help of Drs. Wood 
and Kirby, made a number of experiments upon dogs with a 
view to determining whether or not any practical benefit was 
1 Lancet, April 13, 1895. CASTRATION IN HYPERTROPHY OF THE PROSTATE. 
47 
likely to result from the procedure we are considering. The 
report of Dr. Kirby on the microscopical sections, taken after 
different periods of time, was as follows : 
Dog No. 19.-Double ligature of the vas, without section, on 
both sides. Dog died on the eighth day. Weight of the animal, 
10.850 kilosweight of prostate, 9.070 grammes; about the normal 
weight for the prostate. Testicles apparently normal. 
Microscopical Examination.-Little if any change can be noted 
in the prostate. It seems about normal. Possibly there is some 
cellular proliferation of the stroma. The time was evidently too 
short to demonstrate atrophic change. The testicles are not yet 
examined. 
Dog No. 17.-Double ligature of vas, without section, on both 
sides. Dog died ten days after operation. Weight of the animal 
was 10.231 kilos; weight of the prostate. 4.310 grammes; showing a 
loss of weight in the prostate of 4.560 grammes. Testicles apparently 
healthy when removed from the animal. 
Microscopical Examination.-Prostate.-There has been con- 
siderable proliferation of the connective and muscle cells, but only a 
small amount of fully-formed connective tissue has resulted. As a 
consequence the tubules are not so widely separated from each other. 
There is a proliferation of the cells of the tubules, the latter being 
lined by three or four layers of these cells. The cells are becoming 
flattened and in some parts of the field are undergoing fatty degener- 
ation, as shown by the granular debris in the tubules. 
Testicle.-In the testicle there has been a round-celled prolifer- 
ation with no special change in the intertubular stroma. Some of 
the cells of the tubules are filled with fine granules (fat), and consider- 
able granular material can be seen in the tubules showing that some 
of the cells have already undergone fatty metamorphosis. 
Dog No. 20.-Double ligature of the vas, without section, on 
both sides. Dog killed on the twenty-fifth day. The weight of the 
animal was 15.419 kilos ; the weight of the prostate was 6.630 ; show- 
ing a loss of weight in the prostate of 6.370 grammes. Both testicles 
were apparently sound when removed from the animal, but at the 
time of the preparation of this paper were not ready for the micro- 
tome. 
Microscopical Examination.-Prostate.-There is a beginning 
proliferation of both the connective tissue and muscle cells, but as 48 
J. WILLIAM WHITE. 
yet they have not been fully transformed into true connective tissue ; 
although in some parts of the field the spindle cells are disappearing 
and but few are to be seen. The tubules have contracted, are some- 
what smaller than normal, and in most of the section are filled with 
the same proliferated columnar cells, but which have been transformed 
into the small, flat, cuboidal-shaped cells. Only a few spots of fatty 
degeneration can be made out in the tubules. 
Dog No. 6.-Vas cut between ligatures on both sides. Dog killed 
on the thirty-third day. The weight of the animal was 13.605 kilos; 
the weight of the prostate 2.480 grammes; showing loss of weight in 
the prostate to be 10.520 grammes. Testicles apparently healthy 
when removed from the animal. 
Microscopical Examination-Prostate.-The stroma of the gland 
is made up largely of fully-formed connective tissue, in which may 
be seen some small spindle-shaped cells. In other parts of the gland 
there is still evidence of marked proliferation of the connective tis- 
sue and muscle cells. In those parts of the field where the connec- 
tive tissue predominates, the tubules are contracted and somewhat 
irregular in shape. The tubules themselves are filled with the pro- 
liferated columnar cells, which have become flat and cuboidal in 
shape, and fatty degenerated cells very difficult to make out; only 
a small amount of granular material is to be seen in the tubules. 
Testicles.-Very little, if any, change is to be seen in the testicles. 
Dog No. 7.-Double ligature of vas with section on both sides. 
Dog killed on the thirty-seventh day. Weight of dog 9.977 kilos; 
weight of prostate was 1.010 grammes ; loss of weight in prostate was 
4.656 grammes. Testicles were not ready to cut. 
Microscopical Examination-Prostate.-There has been a great 
proliferation of the pre-existing connective tissue and muscle cells, 
and in some parts these cells have given way to the new-formed 
connective tissue, so that we find between the tubules broad bands of 
fibrous tissue running between and surrounding them. In those parts 
of the field where the connective tissue is mostly found only a few 
cells (spindle-shaped) are to be seen. The tubules are contracted and 
somewhat irregular. The lumen of the tubules is filled with these 
proliferated columnar cells, which have become cuboidal in shape, 
some are granular in character, while others have entirely disap- 
peared, leaving only a fine granular debris as a mark of their former 
existence. 
Dog No. 16.-Ligature of vas (two ligatures without section) CASTRATION IN HYPERTROPHY OF THE PROSTATE. 
49 
on both sides. Dog killed on the fifty-second day. Weight of the 
animal 22.222 kilos; weight of the prostate 4.350 grammes; showing 
a loss of weight in the prostate of 14.650 grammes. Testicles were 
apparently healthy when removed from the animal, but could not be 
cut in time for this paper. 
Microscopical Examination-Prostate.-There is beginning rapid 
proliferation of the muscle and connective-tissue cells. Long chains 
of these proliferated spindle cells may be seen between the tubules 
in various parts of the gland. In other parts of the field the cell 
elements of the stroma have in part disappeared, and have been 
replaced by connective tissue, in which may be seen a few spindle- 
shaped cells. The tubules are considerably smaller than normal 
and quite irregular in outline. They are filled with these fatty 
cuboidal-shaped cells. In the lumen of some of the tubules fatty 
debris is observed. 
Dog No. 18.-Double ligature of the vas on both sides without 
section. Dog killed on the fifty-second day. Weight of dog 19.300 
kilos; weight of prostate 7.450 grammes; showing a loss of weight 
in the prostate of 11.650 grammes. Testicles when removed from 
the animal were apparently healthy. 
Microscopical Examination-Prostate.-There has been great 
proliferation of the connective tissue and muscular elements. In 
some parts of the field there are large amounts of fully-formed con- 
nective tissue, in which may be seen a few spindle-shaped cells (con- 
nective-tissue cells). The tubules are filled with the proliferated 
columnar cells; some have undergone fatty metamorphosis, as shown 
by the granular material. In other tubules the proliferation has not 
gone far enough for beginning fatty change. 
These results have been a surprise to me. Mr. Griffiths's 
paper was not published when the experiments were made, but 
the conclusions of Curling have never been disputed, and are 
doubtless correct. Indeed, as will have been observed, there are 
comparatively few changes in the testicles themselves. There 
was, however, a constant loss of weight in the prostate in every 
dog that died after eight days. Even at ten days this loss is 
perceptible. In the dogs which were kept for fifty-two days the 
atrophic changes are unmistakable, and they are to be found in 
4 50 
J. WILLIAM WHITE. 
nearly every section. If these results are reliable it will cer- 
tainly be worth while to investigate still further the effect of 
obliterating the vas, although outside of these experiments there 
would seem to be every theoretical reason to agree with Grif- 
fiths, who says, " With regard to the suggestion made by Mr. 
Reginald Harrison of division of the vas deferens in cases of 
enlarged prostate, I have not sufficient experience to arrive at a 
conclusion ; but, seeing that obliteration of the vas deferens has 
so little effect upon the structure and secretion of the testis, it 
must be doubtful whether the operation will suffice to influence 
the enlargement of the prostate." 
Possibly I have wounded other structures in exposing 
and tying the vas, but I was very careful and the operation is 
easy. 
It may well be that the whole effect upon the prostate 
caused by the removal of the testicles is exerted through the 
medium of the nervous system. It would be easy to make a 
strong argument in favor of this view basing it on well-known 
physiological facts. And it may also be that in tying or cutting 
the vas certain nerves, more potential than others, are included 
or are themselves divided. In the dog they are all small and 
difficult of recognition without an extensive dissection. 
I wanted to tie or divide the nervous constituents of the 
cord alone and in a separate series of experiments, but the diffi- 
culty of finding them all and of avoiding damage to other struc- 
tures was so great that I gave up the idea after some trials. 
Still, I should think it feasible and hope to make the attempt at 
some future time. 
Dr. King, of Toronto, has, in two experiments on dogs, had 
results from dividing the vas precisely similar to those I have 
detailed, a fact which increases my confidence in my own experi- 
ments. 
(3) Ligation of Vascular Structures of Cord.-The following 
reports explain themselves : the changes here were less unex- 
pected, but in two cases, as might also be expected, the testicles 
sloughed, and in the third the epididymes were necrotic. CASTRATION IN HYPERTROPHY OF THE PROSTATE. 
51 
Dog No. 9.-Ligation of spermatic and deferential arteries on 
both sides. Dog killed at the end of the tenth day; weight of ani- 
mal was 15.873 kilos; weight of prostate was 4.510 grammes; aver- 
age loss of weight in the prostate was 8.490 grammes. The testicles 
were apparently of the normal size when removed from the animal, 
but the epididymes appeared to be gangrenous. 
Microscopical Examination-Prostate.-In this section some 
parts of the field are very cellular and apparently in that part of the 
gland in which the muscular tissue predominates, while that part 
between the tubules has been converted into true connective tissue 
with only a few spindle-shaped cells to be seen. Some of the 
tubules are greatly contracted in these connective-tissue areas and 
filled almost entirely with a fine granular debris, which has come 
from the fatty, degenerated, proliferated columnar cells lining the 
tubule. In other parts of the field the tubules may be seen filled 
with these cuboidal cells which, as yet, are not far advanced in the 
fatty change. 
Microscopical Examination-Testicles.-There seems to be an 
increased amount of connective tissue between the seminal tubules, 
but very few cells are to be seen. The tubules themselves are filled 
with proliferated small, round cells which are in an advanced stage 
of fatty degeneration. 
Dog No. 5.-Ligature of spermatic and deferential artery on 
both sides. Dog killed at the end of the nineteenth day. Weight 
of animal 38.547 kilos; weight of prostate 12.450 grammes; 
showing the loss of weight in prostate to be 18.550 grammes. Both 
testicles had sloughed away. The animal was very old. 
Microscopical Examination-Prostate.-In some parts of this 
section the stroma is quite cellular owing to the proliferated connec- 
tive tissue and muscle cells, while in other parts of the field the 
cells seem to have disappeared to a considerable extent, giving place 
to a connective tissue in which may be seen a few spindle-shaped 
cells. This is noticeable in those parts of the field where the tubules 
have undergone contraction. The tubules are lined with three or 
four rows of these same small flat cells, which are the proliferated 
columnar cells, and in some parts of the field they entirely fill up the 
lumen of the tube and are undergoing fatty metamorphosis. 
Dog No. 4.-Ligation of the spermatic artery and veins in both 
cords. Dog killed at the end of thirty-four days. Weight of animal 52 
J. WILLIAM WHITE. 
29-024 kilos; weight of prostate 3.100 grammes, showing a loss of 
weight in the prostate of 26.900 grammes, Testicles sloughed 
away. 
Microscopical Examination-Prostate.-There is a beginning 
proliferation of the connective-tissue cells, and much more of the 
muscle cells, but only a small amount of new connective tissue has been 
formed. As a result there is but little change in the size of the 
tubules in many parts of the field; where the connective tissue exists 
there has been some contraction. There has been some proliferation 
of the columnar cells lining the tubules; in some parts of the field 
they are beginning to take on the cuboidal shape, while in other parts 
of the field they have not entirely lost their columnar outline. Some 
of the cells of the tubules appear to be granular in character, while 
others have undergone fatty degeneration, as shown by the fine gran- 
ular material in the lumen of the tubules. 
It may be doubted whether any practical advantage would 
be gained by adopting this procedure. It would scarcely meet 
the sentimental objections, as the testicles would be lost finally, 
at any rate, not only functionally but actually. The same remark 
applies to the next group. 
(4) Ligation or Section of the Entire Cord.-This was done 
subcutaneously, and by the open method, with and without 
section of the cord between the ligatures. The results fol- 
low : 
Dog No. 13.-Ligature of the entire cord ; one ligature without 
section and on both sides. Dog killed at the end of sixteen days. 
Weight of animal 10.231 kilos; weight of prostate 3.800 grammes. 
The average weight of the prostate in dogs of 10 kilos, is 8.666 
grammes, showing an average loss of weight in the prostate of 4.866 
grammes. One testicle had sloughed away. 
Microscopical Examination-Prostate.-There is beginning rapid 
proliferation of the connective tissue and muscle cells. Great chains 
of these proliferated spindle-shaped cells being seen between the 
tubules in various parts of the gland. In some parts of the field the 
cell elements of the stroma have in part disappeared, giving plgce 
to connective tissue, in which only a few spindle cells can be seen. 
This change can be especially seen around the small and contracted CASTRATION IN HYPERTROPHY OF THE PROSTATE. 
53 
tubules. The tubules are somewhat smaller than normal, but not so 
irregular in shape as in the other specimens. They are filled with 
three or four layers of these small, flat, cuboidal cells. Some are 
granular in character, and the lumen of the tubes is filled with fatty, 
broken-down, columnar cells. 
Microscopical Examination-Testicles.-The tubules of the tes- 
ticle are filled with large quantities of fatty, degenerated and broken- 
down cells. A beginning proliferation of the connective-tissue cells 
in the intertubular tissue is observed. 
Dog No. i.-Subcutaneous ligature of both cords. Dog killed 
on the sixteenth day. Weight of dog 6.803 kilos; weight of the 
prostate 4.565 grammes. Testicles were large pus-cavities, so could 
not be cut. 
Microscopical Examination-Prostate.-The stroma in this sec- 
tion is quite cellular from the proliferated connective tissue and 
muscle cells. Fully-formed connective tissue is not present to any 
great extent. The tubules are contracted somewhat and filled with 
the proliferated cuboidal cells. Some of the tubules are filled with 
these cells with beginning fatty degeneration, as shown by the gran- 
ular debris. In some parts of the field the muscle-fibres can be seen 
gradually being transformed into connective tissue. 
Dog No. 3.-Subcutaneous ligature of both cords. Dog killed 
at the end of twenty-one days. Weight of dog 13.152 kilos; weight 
of prostate 4.040 grammes. The average weight of the prostate in 
dogs from 13 to 15 kilos, inclusive is 13.000 grammes, showing a loss 
of weight in the prostate of 8.960 grammes. 
Microscopical Examination.-Prostate.-There has been con- 
siderable increase in the intertubular connective tissue; a prolifera- 
tion of the pre-existing connective-tissue corpuscle. In some parts 
of the field very few connective-tissue cells are to be seen in the inter- 
tubular tissue, having probably disappeared by fatty degeneration, 
leaving some fibres of connective tissue, followed by contraction of 
the tubules. The tubules themselves are somewhat contracted and 
irregular in shape, usually filled with the lining columnar cells. The 
cells on the basement membrane are very small, cuboidal in shape, 
often irregular and flat. The central proliferated epithelial cells can 
be seen in beginning granular degeneration. 
Microscopical Examination.-Testicles.-The seminal tubules are 
filled with a mass of irregular-shaped cells and granular matter, evi- 54 
J. WILLIAM WHITE. 
dently fatty degenerated cells, and there is in some parts of the field 
a proliferation of cells in the intertubular connective tissue; in some 
parts small bands of fibrous tissue are to be seen between the tubules. 
The lining cells are very flat and irregular. 
Dog No. 14.-Cord ligated with one ligature on both sides, open 
method. Dog killed on the sixteenth day. Weight of animal 7.029 
kilos; weight of prostate .460 gramme. Average loss of weight in 
prostate was 5.490 grammes, assuming 5.950 grammes to be the aver- 
age weight of the prostate for dogs of 7 kilos weight. Testicles had 
sloughed away. 
Microscopical Examination-Prostate.-There has been con- 
siderable proliferation of the pre-existing muscle and connective- 
tissue cells, especially seen in that part of the field which is composed 
of the muscular elements. 
In the intertubular tissue these proliferated cells have disappeared 
in part, leaving here and there broad bands of pure connective tissue 
in wrhich may be seen the usual spindle-shaped cell. 
The tubules themselves are small and contracted, however, more 
or less regular in outline, filled in most parts of the field with these 
small cuboidal-shaped cells, which are the proliferated columnar cells 
lining the tubules. Some of these cells have a decided granular 
appearance (fat), while others have entirely disappeared, as shown 
by the granular debris in the lumen of the tubules (fatty degenera- 
tion). 
Dog No. 2.-Subcutaneous ligature of the entire cord on both 
sides. Dog killed on the twenty-first day. Weight of dog 7.369 
kilos; weight of prostate 1.790 grammes. The average weight of 
the prostate in dogs of 7 kilos is 4.950 grammes, showing a loss of 
weight in the prostate of 2.370 grammes. 
Microscopical Examination.-Prostate.-The stroma in this sec- 
tion is extremely cellular, owing to the proliferation of the connective- 
tissue cells and of the unstriped muscle-fibre cell. In other parts the 
field is made up of large amounts of connective tissue with a few 
spindle-shaped cells here and there, surrounding a few isolated gland 
tubules. The tubules themselves are in some parts of the field filled 
with the same small cuboidal cells, while in others three or four rows 
deep line the basement membrane. In some the proliferation has 
gone on to such an extent as entirely to block up the lumen of the 
tubules. Some of the tubules are filled with granular material (fatty CASTRATION IN HYPERTROPHY OF THE PROSTATE. 
55 
degenerated cells). In other parts of the field the muscle fibres can 
be seen in gradual transformation into the predominating connective 
tissue. 
Microscopical Examination.-Testicles.-The seminal tubes are 
lined with four or five rows of irregular-shaped cells and proliferated 
cells, in some parts of the field almost entirely filling up the lumen of 
the tubules. In other parts of the field considerable granular matter 
is seen (fatty degeneration of the proliferated cells which lined the 
tubules). Many of the cells are filled with granular particles. The 
intertubular connective tissue shows proliferated connective-tissue 
cells in a few spots, but is otherwise unchanged. 
Dog No. 15.-Both cords ligated with one ligature without sec- 
tion. Dog killed at the end of thirty-one days. Weight of animal 
10.231 kilos; weight of prostate .980 gramme; showing a loss 
of weight in the prostate of 7.646 grammes. Both testicles had 
sloughed away. 
Microscopical Examination-Prostate.-There has been great 
proliferation of the connective tissue and the muscle cells between 
the tubules ; chains of these spindle-shaped cells can be seen running 
between the tubules, while in other parts of the field the cell ele- 
ments of the stroma have in part disappeared, giving place to con- 
nective tissue in which only a few spindle-shaped cells can be seen. 
The tubules themselves are somewhat contracted, filled with masses 
of these proliferated cuboidal cells, which here and there have under- 
gone fatty degeneration, and appear as a fine granular debris in the 
lumen of the gland tubules. 
Dog No. 12.-The entire cord on both sides cut between liga- 
tures. Dog killed on the thirty-first day. Weight of animal 14.866 
kilos ; weight of prostate 3.200 grammes; loss of weight in the pros- 
tate 9.800 grammes. Both testicles had sloughed away. 
Microscopical Examination-Prostate.-In this specimen the cell 
elements of the stroma-namely, the proliferated connective tissue 
and muscle cells-have almost entirely disappeared, giving place 
to connective tissue. The gland tubules are widely separated 
from each other by the new connective tissue. They are very 
much contracted and irregular in shape, in some parts of the 
field filled with these small proliferated cuboidal cells, while in 
other parts of the field these have undergone fatty metamorphosis 
and appear as granular material in the lumen of the tubules. 56 
J. WILLIAM WHITE. 
Dog No. ii.-Cord cut between ligature on both sides. Dog 
killed on thirty-first day. Weight of dog 19.028 kilos; weight of pros- 
tate 4.730 grammes; loss of weight of prostate was 14.270 grammes. 
Testicles sloughed away. 
Microscopical Examination-Prostate.-There has been great 
proliferation of all the cellular elements throughout the entire gland. 
This can especially be seen in the non-glandular parts of the gland. 
In the intertubular tissue the proliferated cells have almost entirely 
disappeared in some parts, having been converted into a true connec- 
tive tissue, in which may be seen a few spindle-shaped cells. 
As a result of this new-formed connective tissue the tubules 
themselves have undergone contraction and atrophy. 
The true columnar cells have undergone proliferation, and, as a 
result of contraction, they have been changed into small cuboidal- 
shaped cells, which, in most parts of the field, fill up the entire lumen 
of the tubule. Some of the tubules show empty spaces filled with 
granular matter (cuboidal cells which have undergone fatty meta- 
morphosis). 
Dog No. 10.-Entire cord cut between ligature on both sides. 
Weight of dog 24.036 kilos; weight of prostate 2.490 grammes; 
loss of weight of prostate 18.510 grammes, taking the average 
weight of the prostate in dogs of 24 kilos, as 21 grammes. The 
testicles had entirely sloughed away. Dog killed at the end of 
sixty days. 
Microscopical Examination-Prostate.-In this specimen the 
stroma is extremely cellular, being filled with immense numbers of 
spindle-shaped cells, which are the proliferated connective-tissue cell 
and muscle cells. In some parts of the field these cells have given 
away almost entirely to the connective-tissue element. The muscular 
elements have almost lost their identity as fibres and have been con- 
verted into bands of connective tissue. 
The tubules themselves are small, contracted, irregular in shape, 
and widely separated from each other by the new connective tissue. 
They are filled up with the proliferated columnar lining cells, irreg- 
ular in shape, and not unlike lymphoid cells as regards their outline. 
Some of them are filled with granular material, showing that fatty 
degeneration has taken place. 
The results as regards the prostate in these cases are as CASTRATION IN HYPERTROPHY OF THE PROSTATE. 
57 
unmistakable as though a primary double castration had been 
done. I took many antiseptic precautions during the opera- 
tions, but it will be noticed that even in those animals whose 
cords were tied subcutaneously, the testicles never underwent 
a quiet atrophic process, but invariably sloughed. It might 
be possible to get better results in that direction in human 
beings. 
Summary. 
The conclusions which seem to me warranted by the argu- 
ments used and the facts set forth in the foregoing pages are as 
follows : 
(1) The function of the testis, like that of the ovary, is two- 
fold,-the reproduction of the species, the development and pres- 
ervation of the secondary sexual characteristics of the individual. 
The need for the exercise of the latter function ceases when full 
adult life is reached, but it is possible that the activity of the 
testis and ovary in this respect does not disappear coincidently, 
and that hypertrophies in closely-allied organs like the prostate 
and uterus are the result of this misdirected energy. This hy- 
pothesis would increase the analogy between the fibromyomata 
of the uterus and the adeno-fibromata of the prostate, which, 
from a clinical stand-point, is already very striking, and is further 
strengthened by the almost identical results of castration in the 
two conditions. 
(2) The theoretical objections which have been urged against 
the operation of double castration have been fully negatived by 
clinical experience, which shows that in a very large proportion 
of cases (thus far in approximately 87.2 per cent.), rapid atrophy 
of the prostatic enlargement follows the operation; and that dis- 
appearance or great lessening in degree of long-standing cystitis 
(52 per cent.); more or less return of vesical contractility (66 
per cent.); amelioration of the most troublesome symptoms (83 
per cent.) ; and a return to local conditions not very far removed 
from normal (46.4 per cent.), may be expected in a considerable 
number of cases. 58 
J. WILLIAM WHITE. 
(3) The deaths have been twenty in 111 cases, a percentage 
of 18. But of these there seem to be thirteen that may fairly be 
excluded in an attempt to ascertain the legitimate mortality in 
patients operated upon under surgically favorable conditions,- 
i.e., before the actual onset of uraemia or, better, before the kid- 
neys have become disorganized by the two factors rarely absent 
in advanced cases,-backward pressure and infection. This would 
leave a mortality of 7.1 per cent., which will probably be de- 
creased as advancing knowledge permits of a better selection of 
cases. It is important to note that even in the desperate cases 
which make up this series of deaths, fifteen (75 per cent.) showed 
improvement of symptoms or shrinkage of the prostate before 
they died. 
(4) Comparison with other operative procedures seems to 
justify the statement that, apart from the sentimental objections 
of aged persons on the one hand, and the real, entirely natural, 
and very strong repugnance to the operation felt by younger 
patients, castration offers a better prospect of permanent return 
to nearly normal conditions than does any other method of treat- 
ment. The relatively greater degree of improvement in success- 
ful cases should be considered, as well as the mortality, in com- 
paring the operation with the various forms of prostatotomy and 
prostatectomy. So, too, should the absence of any risk of per- 
manent fistulae, peritoneal or suprapubic, the ease and quickness 
with which the operation can be performed ; and the possibility 
of avoiding altogether the use of anaesthetics which, in these cases, 
are in themselves dangerous. 
(5) The evidence as to unilateral castration is at present 
contradictory, but there can be no doubt that in some cases it is 
followed by unilateral atrophy of the prostate, and in two cases, 
at least, it has resulted in a very marked improvement of symp- 
toms. It is worthy of further investigation. 
(6) My experiments on dogs have shown in nearly every 
case in which the vas deferens was tied or divided on both sides, 
that, without much change in the testicles, there were beginning 
atrophy and considerable loss of weight of the prostate. These CASTRATION IN HYPERTROPHY OF THE PROSTATE. 
59 
experiments need repetition and confirmation, as the absence of 
corresponding testicular change seems to make the results some- 
what anomalous. It is possible that the inclusion or severance 
of small but important nerves may account for the effect on the 
prostate. 
(7) Ligation of the vascular constituents of the cord, or of 
the whole cord, produces atrophy of the prostate, but in my ex- 
periments only after first causing disorganization of the testis. 60 
J. WILLIAM WHITE. 
No. 
Operator. 
Date of 
Opera- 
tion. 
Reference. 
Age of 
Patient. 
Duration of 
Symptoms 
Previous to 
Operation. 
Condition 
of Patient 
as to Sex- 
ual Power. 
Cystitis. 
Residual 
Urine. 
Duration 
of Use of 
Catheter. 
Frequency 
of Urination 
or of Cath- 
eterization. 
Estimated Size 
of Prostate before 
Operation. 
I 
Andrews, 
Chicago. 
June, 
1894. 
Tri-State Med. 
Journ., Mar., 
1895. 
75 
Power of 
erection 
had 
nearly 
ceased. 
Severe 
and con- 
tinued. 
20 years. 
Prostate began to 
enlarge at age of 
5°. 
2 
Bard, Ventu- 
ra, Cal. 
Dec., 
1894. 
Personal Com- 
munication, 
Feb. 9, 1895. 
72 
10 years. 
Abund- 
ance. 
Urinating 5 
or 6 times 
every 
night. 
Enlarged at least 
one-third. 
3 
Beach, 
Boston. 
(See p. 15.) 
Dec. 11, 
i894- 
Personal Com- 
munication, 
May 1,1895. 
70 
10 years. 
Greatly and uni- 
formly enlarged, 
nearly reached 
the ischium later- 
ally, as far as 
the finger could 
reach posterior- 
ly; in front, it 
projected an inch 
above the su- 
perior line of the 
pubes. 
4 
Bereskin, 
Moscow. 
Chirurg. Anna- 
len, 1894, p. 
802. (Rus- 
sisch.) 
70 
Urinated 10 
times dur- 
ing night. 
Greatly enlarged; 
long diameter, 5 
to 6 cm. 
5 
Reported by 
Moullin be- 
fore the Clin- 
ical Society 
of London 
Case under 
the care of 
Dr. Birch. 
British Med. 
Journ., May 
4,1895. 
74 
Persistent. 
Urinated 14 
to 15 times 
at night. 
Enormous size. 
6 
Bryson, 
St. Louis. 
Jan. 17 
1895. 
New York 
Med. Journ., 
Apr. 27,1895 
Mildgrade 
for 14 
months. 
7 
Bryson, 
St. Louis. 
Enlarged. 
8 
D. 
Carver, 
London. 
Reported by 
Griffiths. 
Nov. 16, 
1894. 
British Med. 
Journ., Mar, 
16, 1895. 
74 
Severe cysti- 
tis for 
many 
months. 
Yes, for 
many 
months. 
2 years. 
Urination 
very 
frequent 
and very 
painful, 
passed but 
a few drops 
at a time. 
Medium-sized or- 
ange. 
9 
Cole, Buena 
Vista, Col. 
Mar. 6, 
1895. 
Personal Com- 
munication, 
Apr. 4, 1895. 
1 year. 
Frequent. 
Size of hen's egg. 
IO 
Collins, 
Providence. 
Jan. 15, 
1895. 
Personal Com- 
munication, 
Jan. 30,1895. 
62 
10 months. 
6 months. 
Fully half the size 
of an orange. CASTRATION IN HYPERTROPHY OF THE PROSTATE. 
61 
General Symptoms and Condition. 
Time at which 
First Improvement 
was Noticed. 
Character of Improvement. 
Subsequent Course and Final Result; 
Other Remarks. 
Had not a day free from distress in 
twenty years. Frequent attacks of 
Prostate was diminished in size, but 
still caused an obstruction requiring 
Pain of testes and cystitis ceased at once 
(the latter had tormented him for twenty 
orchitis. 
the use of the catheter. Cystitis 
permanently cured. 
years). Patient has grown vigorous, has 
increased in weight, and resumed his 
business activity. The former remnant 
of his virility has disappeared. He has 
" hot flushes," like a woman after the 
menopause. 
Micturition frequent, distressing and 
interrupted urine loaded with mu- 
cus, ammoniacal. 
Reduction in size of gland and symp- 
toms very materially relieved. 
Sometimes able to pass the night 
without urinating, and never has to 
rise more than once or twice (Feb. 
9> i895)- 
Bladder much distended and constant 
No difficulty in pass- 
Dec. 20, has improved steadily and 
Dec. 27, out of bed, improving. Jan. 2, 
dribbling of urine. Moderate hy- 
ing catheter after 
to-day passed three ounces urine 
passed several ounces of urine without 
drocele on left side. Urine con- 
tained pus and albumen. Urine 
carefully drawn twice daily, still 
there was some dribbling. Has 
been failing mentally for a number 
of weeks. He was in bed all the 
time and was dull and listless, and 
later became stuporous. Nov. 23, 
passed no more urine voluntarily. 
Dec. 5, great difficulty in passing 
catheter. Dec. 6, no urine passed 
for twenty-four hours. Impossible 
to pass catheter. Suprapubic punc- 
ture. Hydrocele had increased to 
three times its size on admission. 
Dec. 7, 8, 9, aspiration and failure 
to pass catheter. Dec. 10, aspi- 
rated and passed small catheter 
which was retained. 
operation. 
voluntarily ; prostate found at least 
one-third less in volume. 
catheter. Jan. 8, patient passed catheter 
without assistance, later passed eight 
ounces of urine without assistance ; mind 
clear, and patient intelligent. Jan. 9, 
passed all the urine without catheter; 
much improvement, mentally and physi- 
cally. Results in this case confirmed by 
Dr. J. Collins Warren. 
Obstruction to passage of fseces. 
Earlier than five 
weeks. 
At end of five weeks, the prostate 
was greatly reduced in size, more 
force to stream of urine, urinated 
but three times in night. 
Two and one-half months after operation : 
the prostate is smaller than normal; the 
patient declares himself entirely well. Is 
not obliged to pass urine at all at night. 
Urine ammoniacal, bladder contracted 
so that it would hold but two 
ounces, intense strangury. Used 
morphine suppositories constantly. 
Longest period of sleep secured, 
three-quarters of an hour. 
The patient had dispensed with mor- 
phine, could sleep one and one-half 
hours at times, prostate smaller, 
stream of urine larger. 
One month after operation the urine was 
acid, the strangury had almost gone, the 
bladder could retain four ounces, and was 
much less sensitive, and the condition of 
the patient was immensely improved. 
The patient had a weak and dilated 
heart, irregular pulse, albumen and 
hyaline and pale granular casts. 
He came to the hospital to have 
suprapubic prostatectomy per- 
formed, but his condition would not 
permit of so grave an operation. 
Few weeks. 
Reduction in size of prostate and 
greater ease with which catheter 
may be passed. 
May 15, reduction in the length of the pros- 
tate, as measured by the catheter, from 
two and one-half to one inch. Distinct 
reduction in prostatic mass, as estimated 
by rectal touch. Frequency of urination 
day and night unchanged. Pus, albu- 
men, and specific gravity unchanged; 
quantity slightly increased. Rises four to 
five times at night to urinate; catheter 
passes with greater ease. 
One year. 
Shrinkage of prostate. 
Connection nearly a year afterwards. At 
end of year, improvement began in noc- 
turnal frequency of urination, and pros- 
tate had apparently diminished in size. 
Fifteen months later had absolutely no 
trouble with urination. 
The urine contains a large amount of 
mucus and pus. Urination was 
very frequent and very painful, only 
a few drops being expelled at a 
time. Had an attack of retention 
two years previously. As there was 
but little improvement from wash- 
ing out the bladder and the frequent 
use of the catheter, and as there 
was much pain with little prospect 
of relief, he consented to castration. 
Testicles of full size. In the left, a 
large spermatocele. In each there 
were numerous active spermatozoa. 
One week. 
At the end of a week, the patient 
could pass for the first time in some 
weeks a few ounces of urine without 
the aid of the catheter. During the 
second week, the general condition 
slightly improved, the bladder be- 
came quiet, and he was able to 
empty his bladder fairly well. To- 
wards the end of the second week 
he became sleepless, delirious. On 
the fourteenth day, the right pop- 
liteal artery became blocked, and 
gangrene appeared on the leg. The 
condition grew worse, and he died 
on the eighteenth day. 
Post mortem.-The right kidney much en- 
larged from chronic hydronephrosis, and 
there was suppuration of the distended 
pelvis and the remaining portion of the 
kidney substance. The bladder was 
much thickened, and the mucous mem- 
brane inflamed, as was also the right 
ureter. The prostate was still of large 
size, and was somewhat firmer than the 
gland is ordinarily. 
Bladder inflamed. 
One week. 
Voluntary urination. 
One month later gland size of walnut. Has 
not used catheter since one week after 
operation. Bladder and urine normal. 
Three weeks. 
Feb. 6, patient passed all his urine 
voluntarily, something he had not 
done for seven months. Prostate 
estimated to be one-sixth smaller. 
The urine has cleared up and is 
perfectly normal. 
The operation has produced a most happy 
result, and the patient declares that he 
has not felt so well in years. 62 
J. WILLIAM WHITE. 
No. 
Operation. 
Date of 
Opera- 
tion. 
Reference. 
Age of 
Patient. 
Duration of 
Symptoms 
Previous to 
Operation. 
Condition 
of Patient 
as to Sex- 
ual Power. 
Cystitis. 
Residual 
Urine. 
Duration 
of Use of 
Catheter. 
Frequency 
of Urination 
or of Cath- 
eterization. 
Estimated Size 
of Prostate before 
Operation. 
11 
Crisand, 
Worcester, 
Mass. 
Jan. 9, 
1895. 
Personal Com- 
munication, 
Jan.21,1895. 
68 
6 months. 
12 
Eastman, 
Indianapolis. 
April 20, 
1895. 
Indiana Med. 
Journ., May, 
1895. 
Yes. 
Had not 
passed 
any 
urine ex- 
cept by 
use of 
catheter 
for x 
year. 
• 
Transverse diam- 
eter, 2U inches. 
The third lobe 
extended up into 
the bladder, ren- 
dering the pass- 
age of any instru- 
ment except the 
most flexible im- 
possible. 
13 
D. 
Faulds, 
Glasgow. 
Dec. 24, 
1894. 
British Med. 
Journ., May 
4, 1895. 
66 
12 ozs. 
mixed 
with 
blood 
and pus. 
3 years. 
Very large ; its up- 
per limit could 
scarcely be 
reached through 
the rectum. 
14 
D. 
Faulds, 
Glasgow. 
Jan. 3, 
1895. 
British Med. 
Journ., May 
4, 1895. 
71 
15 
D. 
Faulds, 
Glasgow. 
Jan. 12, 
1895. 
Passedblood 
and pus 6 
years. 
16 
D 
Case observed 
by Faulds, 
Glasgow. 
Jan., 
1895. 
British Med. 
Journ., May 
4. 1895. 
17 
Faulds, 
Glasgow. 
British Med. 
Journ., May 
4, 1895. 
4 years. 
t8 
Fenwick. 
.... 
British Med. 
Journ., Mar. 
16, 1895. 
46 
10 years. 
19 
Fenwick, 
London. 
British Med. 
Journ., Mar. 
16, 1895. 
20 
Fenwick, 
London. 
British Med. 
Journ., Mar. 
16, 1895. 
45 
21 
Fenwick, 
London. 
British Med 
Journ., Mar. 
16, 1895. 
76 
Some years 
of feeble 
prostatic 
micturi- 
tion. 
Unable to 
pass any 
volun- 
tarily. 
22 
Fenwick, 
London. 
British Med. 
Journ., Mar. 
16, 1895. 
70 
6 years. 
Yes. 
Small per rectum, 
but by cysto- 
scope the lateral 
lobes are seen to 
project into the 
bladder, and the 
bar at the neck 
of the bladder is 
oedematous. 
23 
Fenwick, 
London. 
British Med. 
Journ., Mar. 
16, 1895. 
76 
Repeated at- 
tacks of re- 
tention and 
uraemia. 
Plump and elastic, 
only moderately 
enlarged towards 
rectum. 
24 
Fenwick, 
London. 
British Med. 
Journ., Mar. 
16,1895. 
76 
5 years. 
Yes. 
Catheter had 
to be used 
everyhour. 
• • 
25 
Fenwick. 
British Med. 
Journ., Mar. 
16, 1895. 
81 
Several 
years. 
Yes. 
9 years. 
6 or 7 times 
during 
night and 
3 times 
during 
day. 
Large and elastic, 
especially the 
left lobe. 
26 
Fenwick, 
London. 
British Med. 
Journ., Mar. 
16, 1895. 
60 
2 or 3 years 
dysuria. 
Prostato- 
cystitis. 
Occasion- 
al use. 
Prostate large lat- 
erallyand elastic. CASTRATION IN HYPERTROPHY OF THE PROSTATE. 
63 
General Symptoms and Condition 
Time at which 
First Improvement 
was N oticed. 
Character of Improvement. 
Subsequent Course and Final Result; 
Other Remarks. 
For two or three days 
after operation he 
passed a table- 
spoonful of urine 
several times a 
day. 
Condition of urine improved, much 
less sediment and color much 
lighter. 
In a month the prostate had reduced more 
than one-third. Catheter discarded. 
The prostatic condition complicated 
Twelve hours after 
Urine was voided naturally. It has 
May 24 (letter), patient is able to pass his 
by spastic spinal paralysis, ankle 
clonus, spastic gait, weakness and 
shooting pains in the lower limbs, 
exaggerated tendon reflexes, and 
temperature changes. (Lateral 
sclerosis.) 
operation. 
been unnecessary to use a catheter 
since (tenth day), if the patient wa- 
recumbent. In the erect position 
the urine passed naturally and 
easily. 
urine freely and without help,-lying, sit- 
ting, or standing. The third lobe has 
shrunken very much, and the body of the 
gland is reduced nearly to its normal size, 
soft and still sensitive to the examining 
finger. 
About a week. 
Dysuria was mitigated. 
Jan. 19, hemiplegia occurred, and the 
patient died on the following day. 
Six days after operation acute mania devel- 
oped, and death occurred on Jan. 13. 
A week after operation the patient became 
somewhat childish, mania appeared, and 
death occurred on the twelfth day after 
operation. 
Enlarged prostate with consequent 
distress. 
A few days after castration the patient ex- 
hibited acute mania and died. 
Patient suffered all the distress at- 
tending an enlarged prostate, fl r 
which he had undergone much un- 
successful treatment at various hos- 
pitals. 
Thirty days after operation no psychical 
phenomena were observed ; but there had 
been no mitigation in the urinary trouble. 
Applied after ten years of skilled 
treatment for an aggravated pros 
tatitis with great local pain, tender- 
ness, and severe and intractable 
neuralgic radiations. Increas'd 
frequency of urination. Sitting or 
walking almost unbearable. 
Prostate slightly smaller, but no other 
change as yet. Report too recent to 
determine result. Patient reports two 
months later that he " considers himself 
absolutely cured" (Brit. Med. Jour., May 
ix, i895). 
Patient says he is " decidedly relieved" 
(Brit. Med. Journ , May n, 1895). 
Entire genitals ablated for extensive 
epithelioma of the penis. 
After six months the prostate had been re- 
duced to the size of a small bean. 
Sudden and prolonged retention, ex- 
treme difficulty in catheterization. 
Prostate unusually hard and en- 
larged, especially left lobe. 
One week. 
The patient began to void a little 
urine spontaneously, and in three 
weeks he was able to do without the 
catheter. 
A later report says, " I have had no stop- 
page ; the stream varies; sometimes it is 
feeble, at other times there is high press- 
ure. Urinates sometimes every five to 
six hours, at others every two or three 
hours. Improvement maintained." 
Slight cysto-prostatitis with some 
mild pyelitis present. The inflam- 
matory conditions began a year 
before the operation. 
First week. 
Urine cleared, the stream improved 
in force, and the pain diminished 
After three months the stream had 
markedly improved in force, and no 
symptoms remained except slight 
variability in the power of the 
bladder. 
Improvement maintained. 
Catheterization most difficult. Supra- 
pubic drainage for months without 
improvement in the cystitis; double 
castration. 
Cystitis rapidly di- 
minished. 
Voluntary micturition was recovered 
in a fortnight, prostate slightly 
smaller at end of third week. 
Improvement maintained. 
Dysuria, not much relieved by the 
catheter. Irrigations had no con 
trol over the cystitis. 
Prostate slowly di- 
minished in size. 
Cystitis diminished, catheter needed 
only every six hours. 
Active occupation renewed. 
For past three months increasing diffi- 
culty in passing catheter, and the 
efforts were often followed by haem- 
orrhage. 
For three days after 
operation. the cath- 
eter was needed 
only twice in twen- 
ty-four hours, then 
four times in same 
period. 
At the end of three weeks, the pros- 
tate had slightly diminished in size, 
the cystitis had greatly decreased. 
The catheter still had to be used 
three times during the night. 
Intense pain after every attempt at 
Third day, volun- 
Slight shrinkage of prostate after two 
Pain gradually left, frequency of urination 
urination; finally, retention. 
tary micturition. 
weeks. 
became normal, prostate still plump and 
elastic; perhaps diminished one-eighth 
by fourth week. 64 
J. WILLIAM WHITE, 
No. 
Operation, 
Date of 
Opera- 
tion. 
Reference. 
Age of 
Patient. 
Duration of 
Symptoms 
Previous to 
Operation. 
Condition 
of Patient 
as to Sex- 
ual Power. 
Cystitis. 
Residual 
Urine. 
Duration 
of Use of 
Catheter. 
Frequency 
of Urination 
or of Cath- 
eterization. 
Estimated Size 
of Prostate before 
Operation. 
27 
Finney, 
Baltimore. 
Sept. 22, 
1894. 
Johns Hopkins 
Hospital 
Bulletin, 
Dec., 1894. 
64 
2 years. 
420 c.c. 
Constant use 
of cath- 
eter. 
Very much en- 
larged. 
28 
D. 
Finney, 
Baltimore. 
Very re- 
cently. 
Johns Hopkins 
Hospital 
Bulletin, 
Dec., 1894. 
63 
5 years. 
Unable to 
urinate for 
2 years. 
Frequent. 
Much enlarged and 
very hard. 
29 
Fowler, 
New York. 
Jan. 
1895. 
Personal com- 
munication, 
May 21,1895. 
73 
10 years. 
6 ozs. 
Partially 
depend- 
ent upon 
catheter 
for 3 
years. 
Moderate enlarge- 
ment. 
30 
Fremont- 
Smith, 
St. Augus- 
tine. 
Jan. 17, 
1894. 
Annals of Sur- 
gery, July, 
1894. 
69 
1 year. 
Yes. 
Smallest 
amount, 
6 ozs. 
31 
Gage, 
Worcester, 
Mass, 
Jan. 18, 
1895. 
Personal com- 
munication, 
May 21,1895. 
67 
Farm- 
er. 
Entirely de- 
pendent 
upon 
catheter 
for 8 years. 
Yes. 
All. 
8 years. 
Catheter 
used until 
Nov. last, 
every 3 
hours; for 
lasfz 
months 
every 45 
minutes, 
night and 
day. 
Roughly, the size 
of a large orange. 
32 
Gage, 
W orcester, 
Mass. 
Feb. 8, 
1895. 
Personal com- 
munication, 
May 21,1895. 
67 
Moul- 
der. 
Symptoms 
of pros- 
tatic ob- 
struction 
for 3 years. 
6 ozs. 
Size of closed fist. 
33 
Gavin, 
Boston. 
Oct. 19, 
1894. 
Personal com- 
munication, 
May 2, 1895. 
69 
Frequent 
and scald- 
ing urina- 
tion for 5 
years. 
Retention 
for 24 
hours. 
Pre- 
viously 
5 ozs. 
residual 
urine. 
4 months. 
Catheter 
had to be 
passed 
every 4 
hours, day 
or night. 
Size of a large 
orange; dense, 
smooth, sym- 
metrically en- 
larged ; occlud- 
ing the rectum to 
a considerable 
degree. CASTRATION IN HYPERTROPHY OF THE PROSTATE. 
65 
General Symptoms and Condition. 
Time at which 
First Improvement 
was Noticed. 
Character of Improvement. 
Subsequent Course and Final Result; 
Other Remarks. 
Inability to urinate and constant 
dribbling. Catheter withdrew four 
hundred and twenty cubic centi- 
metres urine. Up to time of opera- 
tion bladder was irrigated with 
boric acid solution without benefit. 
Six days. 
Urinated unassisted. Since this time 
has done well, barring one or two 
setbacks. Nov. 7, patient left hos- 
pital well. Prostate small and soft ; 
no residual urine. 
Patient put upon the regulation treatment 
of washing out bladder and internal medi- 
cation, but he was still unable to pass 
urine voluntarily. Five weeks after opera- 
tion, lateral lobes just palpable, are 
soft, not tender, and show marked atro- 
phy. Not more than fifty cubic centime- 
tres (one and one-half to two ounces) 
residual urine. April 20, patient re-exam- 
ined ; " same condition as when dis- 
charged,-well." 
A false passage had been made by 
catheter, and the passage of an 
instrument was very difficult and 
painful; had retention and constant 
dribbling. 
Fifth day. 
Urinated spontaneously and without 
difficulty. The prostate diminished 
rapidly in size. 
Patient died three weeks after operation 
from starvation. He was insane, and re- 
fused all nourishment. He had been sub- 
ject to temporary fits of insanity for sev- 
eral years. 
Double orchitis in summer of 1894, 
with suppuration of left testicle and 
consequent multiple fistulse. Com- 
pelled, after using catheter at bed- 
time, to rise three or four times 
during night to urinate. After ope- 
ration, was catheterized every six 
hours for six days 
Three months after operation the prostate 
is reduced one-third in size, residual urine 
averages less than two drachms, he does 
not rise at all at night, and he urinates 
during the day about once in four hours. 
Admitted to hospital Oct. 25, 1893. 
During the previous months, symp- 
toms of increasing obstruction had 
set in. During seven and one-half 
weeks after admission he had irreg- 
ular fever, urination was painful and 
frequent, especially at night; the 
urine was loaded with the products 
of decomposition and pus. Reten- 
tion attacks were frequent. From 
Oct. 25 to Jan. 17, the usual and 
approved treatment, internally and 
by bladder douches, was carefully 
conducted by Drs. L. Alexander, 
A. Anderson, and the operator, but 
the patient steadily declined. Dr. 
J. William White saw him Jan. 1, 
and advised castration. The re- 
peated attacks of acute cystitis, 
accompanied by increasing degrees 
of pus and septic fever, the harass- 
ing constancy of the desire to uri- 
nate, and the loss of appetite and 
sleep reduced the patient in seven 
and one-half weeks from one hun- 
dred and sixty-five to one hundred 
and thirty-five pounds. 
One week. 
During the week following the opera- 
tion, the patient was catheterized 
twice daily, at the end of this time 
he voided urine naturally, and the 
catheter was used twice a week for 
the purpose of estimating the resid- 
ual urine only. No local treatment 
was employed after the operation. 
March 1, patient was discharged. 
After the castration there was no fever, his 
appetite returned, the weight increased 
from one hundred and thirty-five to one 
hundred and sixty-three pounds, and the 
mental state, previously weak and mel- 
ancholic, made decided improvement. 
There was no recurrence of the retention, 
no cystitis, and the residual urine dimin- 
ished during the final week from three 
to one and one-half fluidrachms. The 
nocturnal desire to urinate was reduced 
from 12-15 to 4-6. The urine now pre- 
sented a sediment only on standing for 
hours, which contained under the micro- 
scope a moderate number of pus-cells. 
May 2, 1894, a brother writes, " the pa- 
tient's weight is one hundred and eighty 
pounds ; as to his water, he has no trouble 
at all, and no pain from that source." 
Was able to sleep two hours consecu- 
tively but once in past month. Pas- 
sage of catheter very painful, and 
often caused distressing erections. 
Had repeated haemorrhages, becom- 
ing more frequent (now daily). 
Pain in bladder constant and se- 
vere Perineum so tender he could 
not sit squarely on chair. Capacity 
of bladder, two ounces, urine am- 
moniacal, and contained blood and 
pus. 
Two weeks. 
Cystitis lessened. 
March 25, his physician reports, " But one 
haemorrhage since operation, can use soft 
catheter instead of one with stylet, and it 
passes with less pain and without erec- 
tions. Sleeps from one to two hours, has 
less pain in perineum, and can sit down 
and walk more easily; cystitis nearly 
cured, and general condition is better." 
The condition of this patient, and his 
surroundings, absolutely precluded any 
thought of drainage or prostatectomy, 
and he refused to be removed. 
For two years had passed mine every 
hour and a half, day and night. 
Jan. 27, acute retention. Feb. 3, 
passed some urine voluntarily, urine 
acid, no albumen. Feb. 4, complete 
retention again. 
Third day. 
Passed water freely without much 
effort, and has not used catheter 
since. Goes three to four hours 
without passing urine. 
Recent report from patient states that he is 
perfectly well, so far as his control of uri- 
nation is concerned. 
The symptoms increased rapidly, and 
the constantly recurring pain de- 
manded the use of the catheter 
more and more frequently, which 
was passed with difficulty. Came 
to hospital with distressing tenes- 
mus, tremulousness, and prostra- 
tion. Urine alkaline, and contained 
■ albumen and pus. 
5 
8 hours. 
The junior house officer was not 
called to catheterize the night fol- 
lowing operation. The patient 
passed urine eight hours after the 
operation, for the first time in three 
weeks. After forty hours the cathe- 
ter was no longer needed. Mor- 
phine was omitted, the patient 
passed urine without pain or tenes- 
mus, one week after operation 
stitches removed, wounds healed, 
prostate much smaller and softer. 
In five weeks, prostate one-fifth 
former size, urine acid, less pus, 
residual urine three ounces ; passes 
urine every four hours during day 
and two or three time at night, 
prostate one-sixth former size, urine 
clear. 
The usual remedies had been tried without 
any gain ; in fact, the man was growing 
weaker. There is no question of the 
great benefit he derived from the opera- 
tion. He has gained thirty pounds. 66 
J. WILLIAM WHITE. 
No. 
Operation. 
Date of 
Opera- 
tion. 
Reference. 
Age of 
Patient. 
Duration of 
Symptoms 
Previous to 
Operation. 
Condition 
of Patient 
as to Sex- 
ual Power. 
■ 
Cystitis. 
Residual 
Urine. 
Duration 
of Use of 
Catheter. 
Frequency 
of Urination 
or of Cath- 
eterization. 
Estimated Size 
of Prostate before 
Operation. 
34 
Gerrat. 
.... 
Chirurg. Anna- 
75 
Size of apple 
35 
Ibid. 
len., 1895. p. 
97. (Rus- 
sisch. Ab- 
stracted in 
Centralblatt 
f. Chirurgie, 
No. 16,1895.) 
Ibid. 
60 
equally enlarged 
on both sides. 
36 
1). 
Glenn, 
Nashville. 
May 16, 
1894. 
Personal com- 
munication, 
May 20,1895. 
82 
3 years. 
Size of lemon. 
37 
Halsted, 
Baltimore. 
Nov. 27, 
1894. 
Personal com- 
munication, 
May 20,1895. 
67 
3 weeks. 
IOOO c.c. 
Much enlarged and 
very hard. 
38 
Halsted, 
Baltimore. 
Mar. 23, 
1895. 
Personal com- 
munication, 
May 20,1895. 
59 
Col- 
ored. 
Has bad 
dribbling 
of urine 
since Dec 
1894. 
Yes, 
severe. 
Enlarged. 
?? 
Halsted, 
Baltimore. 
munication, 
May 20,1895 
40 
Halsted, 
D. 
Baltimore. 
munication, 
May 20,1895. 
41 
Hayden, 
New York. 
Dec. 11, 
1894- 
New York 
Med. Rec., 
May 18, 
1895. 
70 
5 years ago 
began with 
frequent 
urination 
at night, 
and soon 
after in the 
daytime 
also. 
Severe. 
4 ozs. 
Capacity 
of blad- 
der, 6 
ozs. 
Urinated jor 
6 times at 
night, and 
every half 
hour to 
hour dur- 
ing day. 
Drew off 
urine and 
irrigated 
bladder 
several 
times a 
day. 
Prostate hard, 
smooth, and 
fully twice its 
normal size; 
pressure causes 
pain and intense 
desire to urinate. 
42 
Haynes, 
Los Angeles. 
Dec. 12, 
1893. 
Pacific Med. 
Journ., Oct., 
1894. 
Old. 
Chronic. 
% pint. 
Catheter 1 to 
3 times 
daily. 
Moderate hyper- 
trophy. 
43 
Haynes, 
Pacific Med. 
Old. 
Intense 
Uses cath- 
Extreme hyper- 
D. 
Los Angeles. 
Journ., Oct., 
1894. 
degree. 
eter every 
hour. 
trophy. 
44 
Haynes, 
Pacific Med. 
Old. 
Incipient hyper- 
Los Angeles. 
Journ. Oct., 
1894. 
Personal com- 
munication. 
trophy. 
45 
D. 
Haynes, 
Los Angeles. 
Jan. 27, 
1895. 
62 
6 years. 
For 5 
years. 
5 years. 
Catheter had 
to be 
passed 11 
times a 
day. 
Large. CASTRATION IN HYPERTROPHY OF THE PROSTATE. 
67 
General Symptoms and Condition. 
Time at which 
First Improvement 
was Noticed. 
Character of Improvement. 
j Subsequent Course and Final Result; 
Other Remarks. 
Entered hospital with retention. Em 
Very soon after oper 
Two months after operation consider 
- Operation under local anaesthesia. Condi- 
physema of lungs, great atheroma 
of arteries, double hydrocele, anc 
inguinal hernia. 
ation. 
able decrease of prostate noted. 
tion always considerably better than 
before operation. 
Bladder punctured for complete re 
tention. 
Complete cure resulted from the operation. 
Urinating in drops every hour. Verj 
feeble, suffered severely. 
Four days. 
Four days after the operation the 
patient could urinate freely without 
the catheter. 
Died May 24. Death not charged to oper- 
i ation, as patient was nearly dead at time 
of operation. The author believes that 
1 operation three months earlier would have 
cured him. 
Admitted to hospital Nov. 17, 1894 
with retention of urine. Frequent 
desire to urinate, and the day before 
admission the act was difficult anc 
painful, only a few drops of urine 
could be passed at a time. Bladder 
large and sacculated. One thou- 
sand cubic centimetres of urine 
were withdrawn. 
Dec. 3. 
Voided urine naturally. Dec. 15 
1894; patient discharged as well. 
Prostate much smaller and softer. 
Admitted to hospital March 15, 1895, 
wit(i incontinence of urine and phi- 
mosis, and enlarged prostate. 
March 25. 
Voided urine in a stream. Dischargee 
April 15; improvement had been 
uninterrupted during the stay in 
hospital. Prostate diminished in 
size and much softer. 
April 17, patient returned on account of a 
1 return of the bladder symptoms. He was 
given irrigations of boric acid with great 
benefit. Patient passes his urine nor- 
mally, but there is still some residual 
urine. 
Desperate case, demanded immediate 
attempt at relief. Severe renal 
complications. 
Death due to failure of the renal function. 
Autopsy showed stricture of the urethra. 
The prostate was riddled with sinuses, 
one of which communicated with the rec- 
tum. There was a very marked cystitis 
and a double pyelonephrosis. Before 
death, it was necessary to perform a su- 
prapubic cystotomy. 
Case desperate, pronounced nephritis, 
but the urgent prostatic symptoms 
would not permit of delay to carry 
out preparatory treatment 
Death from nephritis, autopsy not al'owed. 
Vesical and rectal tenesmus. Urine 
cloudy and ammoniacal. While 
straining to urinate the penis be- 
came congested and there was a 
partial erection. Each act of uri- 
nation is attended with intense ves- 
ical and rectal tenesmus, and severe 
burning pain in prostate, urethra, 
and glans. Catheterization became 
very painful and almost impossible 
at times. Retention one year ago 
Urine cloudy, alkaline, ammoniacal, 
pus one tenth by volume. Catheter 
draws urine at nine and one-half 
inches. No shock followed the 
operation. 
Fifth day. 
A small rubber catheter passed into 
the bladder, this had not been 
possible for many months. Urine 
clearer, and less tenesmus and pain. 
Tenth day, No. 18 F catheter 
passed readily. Gland softer and 
absolutely painless. Twentieth day, 
patient felt much improved, and 
passed his urine freely without the 
aid of the catheter. 
Two months after operation the patient's 
general condition was greatly improved ; 
he gained weight, and resumed his work. 
Passed urine during the day at intervals 
of from two to three hours, and, at night, 
three to five hours. Since operation, has 
had no erections or sexual desire. Can 
hold the urine for half an hour after the 
desire is felt. Residual urine, two ounces. 
The capacity of the bladder has materi- 
ally increased April 0, patient is gain- 
ing more control over bladder. Urethra 
measures eight and one-quarter inches 
(March 17). Bladder now holds fifteen 
ounces. 
Had not urinated with ease for two' 
years. 
Shrinkage of prostate ; disappearance 
of cystitis. 
After three months considers himself cured. 
Urinates with ease, no cystitis, uses cathe- 
ter once in four days, to estimate residual 
urine (3 drachms). Prostates much 
smaller. Later, entirely well. March 15, 
1895, feels perfectly well, mind normal, 
prostate normal, three or four erections, 
accompanied with sexual desire in last 
five months. 
Bedridden for three months. Passes 
no urine without catheter. Mor- 
phinist. 
Sixteenth day. 
Passes at least one-third urine nat- 
urally ; catheter every six hours. 
After two months is about his room. Cys- 
titis almost cured, catheter twice daily. 
Passes all the urine naturally, except a 
residuum of two ounces. Takes no mor- 
phine. Prostate greatly diminished. Life 
saved by operation. Later, patient died 
suddenly from chronic renal suppuration. 
At autopsy, prostate natural size. 
Prostatic urethra so deformed it was 
almost impossible to pass catheter. 
At end of three' 
weeks. 
Doing very well. 
Patient entirely cured. 
Decrease in size of prostate. 
Wound healed by primary union. Two 
weeks after operation ursemic symptoms 
developed. A week later the patient died 
in coma. The autopsy showed dilated 
and suppurating kidneys and ureters and 
pouched bladder. Prostate thought to 
have diminished in size one-quarter; still 
about the size of a base-ball. 68 
7. WILLIAM WHITE. 
No. 
Operation. 
Date of 
Opera- 
tion. 
Reference. 
Age of 
Patient. 
Duration of 
Symptoms 
Previous to 
Operation. 
Condition 
of Patient 
as to Sex- 
ual Power. 
Cystitis. 
Residual 
Urine. 
Duration 
of Use of 
Catheter. 
Frequency 
of Urination 
or of Cath- 
eterization. 
Estimated Size 
of Prostate before 
Operation. 
46 
Horwitz, 
Philadelphia 
Jan. 1, 
1895. 
Personal com- 
munication, 
May 21,1895. 
67 
Far- 
mer. 
5 years. 
Desire ab- 
sent for 
past 6 
years. 
Yes. 
5 years. 
Catheter 
used every 
hour or 
hour and 
a half. 
Enormously en- 
larged, it quite 
filled up the rec- 
tum ; the over- 
growth was fib- 
rous. 
47 
D. 
Horwitz, 
Philadelphia. 
April 6, 
1895. 
Personal com- 
munication, 
May 24,1895. 
70 
Far- 
mer. 
16 years. 
None for 
toyears. 
Unable to 
pass 
urine 
without 
catheter 
for 6 
years. 
Catheter 
used every 
hour and a 
half. 
48 
D. 
Reported by 
Moullin be- 
fore the Clin- 
ical Society 
of London. 
Case under 
the care of 
Dr. Houchin. 
.... 
British Med. 
Journ., May 
4, 1894. 
Repeated 
attacks. 
All. 
15 months. 
Used cath- 
eter every 
hour, day 
and night. 
Exceedingly large. 
I?. 
S° 
D. 
Hughes, 
Meriden, 
Conn. 
King, 
Toronto. 
Jan. 3 
1895- 
Dec. 26, 
1894 
Personal com- 
munication. 
May 1,1895. 
Personal com- 
munication, 
Jan. 9, 1895. 
75 
73 
20 years. 
Inordinate 
cystitis. 
4 ozs. 
Catheter 3 or 
4 times 
during 
night. 
Enlarged. 
Apparently size of 
a small orange. 
51 
Frimann 
Koren and 
August 
Koren, Jr. 
July 18, 
1894. 
N. Mag. f. 
Laegev., No. 
1, 1895. 
66 
For one year 
had 
noticed 
failure in 
force of 
stream. 
Present. 
1500 gm. 
...... 
3 to 4 cm. high, 
about 6 cm. 
broad; not sen- 
sitive. 
52 
D. 
Lichty. 
Mar. 14 
1895. 
Personal com- 
munication. 
59 
2 years. 
Yes. 
2% OZS. 
Size of lemon. 
S3 
Lilienthal, 
New York. 
(See p. 16.) 
Feb. 9, 
1895. 
New York 
Med. Rec., 
April 20, 
i89S- 
56 
10 years. 
Severe. 
4 to 6 ozs. 
About 3 times nor 
mal size. Well- 
marked middle 
lobe. 
54 
McBurney, 
New York. 
June 12, 
1894. 
Personal com- 
munication, 
Jan. 18,1895. 
63 
9 years. 
Catheter 
used for 9 
years from 
7 to 10 
times in 24 
5S 
Mansell-Moul- 
lin, London. 
July 5. 
1894. 
Med. Press & 
Circular, 
Sept. 19, 
1894. 
81 
Some years. 
Yes. 
hours. 
Size of Tangerine 
orange. 
56 
to 
65 
Moullin, 
London. 
British Med. 
Journ., May 
it, 1895. CASTRATION IN HYPERTROPHY OF THE PROSTATE 
69 
General Symptoms and Condition. 
Time at which 
First Improvement 
was Noticed. 
Character of Improvement. 
Subsequent Course and Final Result; 
Other Remarks. 
Frequent desire to urinate, especially 
at night; this increased until the 
desire was almost constant. Had 
attacks of haematuria; urine thick 
and offensive. Patient thin and 
anaemic. The urine was alkaline, 
and contained albumen and an 
abundance of pus and phosphates. 
Operation consumed but a few mo- 
ments, but there was considerable 
shock. A medium - sized rubber 
catheter could be passed with diffi- 
culty. 
Twenty hours. 
The patient passed his urine for the 
first time in five years without the 
use of the catheter. 
Feb. 16, discharged cured. Desire to pass 
urine much less frequent, does not use 
catheter, urine much clearer, and contains 
less pus. Prostate one-half its former 
size. March 4, patient in perfect health. 
Stronger than for years before. Does not 
use catheter. Passes urine six times in 
twenty-four hours, is not disturbed at all 
at night, urine normal, no sign of inflam- 
mation of bladder. Prostate not discerni- 
ble to touch per rectum. Eighteen days 
after being discharged (Feb. 16) it had 
undergone almost complete atrophy. 
Frequent attacks of haematuria, two 
attacks of retention, and one of 
uraemia attended with convulsions, 
and narrowly escaped death. Pa- 
tient thin and anaemic. No. 8 F 
hard rubber catheter passed with 
great difficulty, usually requiring 
five minutes for its insertion. Def- 
ecation greatly interfered with. 
Urine contained albumen, blood, 
phosphates, and casts. 
Four days. 
Catheter could be introduced much 
more easily. The prostate had dimin- 
nished fully one-quarter as shown 
by rectal touch. April n, urine 
passed without aid of catheter. The 
instrument could be passed without 
causing pain. April 14, urine passed 
without the use of catheter, urine 
much clearer, no blood, wound 
healed, dressings removed. Pros- 
tate but one-half its former size. 
April 16, symptoms of uraemia developed, 
and death occurred on the nineteenth, 
from suppression of urine. The prostate 
had shrivelled so as not to be detected by 
the finger. A large-sized catheter could 
be readily inserted without difficulty or 
pain. The urgent desire to pass urine 
had greatly diminished several days be- 
fore death. 
Enormously stout man; occasional 
haematuria. No urine passed ex- 
cept by catheter for fifteen months. 
On the ninth day, blood stained urine 
was passed spontaneously on sev- 
eral occasions. 
The operation was well borne, and every- 
thing progressed favorably for a week. He 
was then seized with extreme dyspnoea, 
which recurred again and again, and 
finally with haematuria and profuse diar- 
rhoea, and death ensued on the eleventh 
day. At the necropsy the heart was found 
soft and fatty, the kidneys (one especially) 
cirrhotic, and all the abdominal and thor- 
acic organs loaded with fat. The bladder 
contained a calculus, concealed behind the 
prostate ; its walls were deeply congested 
and ulcerated in places. The prostate, 
which was uniformly enlarged, was soft 
and flabby, and there were evidences of 
its recent diminution in size. 
It finally became impossible to pass a 
catheter. 
Seventh day. 
Patient passed urine without a cath- 
eter, a thing he had not done for 
years. 
On sixteenth, albumen appeared in the 
urine, and rapidly increased in amount 
until his death, Jan. 20. 
Twelve hours. 
Patient had normal desire to urinate 
and did not wish catheter used. 
Catheter employed after this to 
estimate residual urine only. 
The patient developed pneumonia on the 
twenty-ninth, and died on the thirtieth. 
The residual urine had been reduced to 
less than two ounces, and the prostate 
had diminished to less than half its former 
size. 
Aug. 2, urinated 
s p o n t an eously. 
Nov. n, prostate 
diminished to two 
centimetres, and 
did not protrude in 
rectum. 
On seventh day some softening of the 
prostate was noticed, and a decrease 
in its size 3x4 centimetres. 
" The hypertrophy of the prostate, with all 
its symptoms, has disappeared. The pa- 
tient rises but once at night to urinate." 
Frequent and difficult micturition, left 
lobe being the larger. Urine foul, 
very alkaline, and contained pus and 
mucus The patient was treated 
for the cystitis by internal remedies 
and daily irrigations of boric acid 
solution. There was no improve- 
ment at the end of three weeks. 
Able to urinate with greater ease; 
residual urine, one-half ounce. 
Chloroform anaesthesia, stitches removed on 
eighth day. Perfect union. Twelfth day 
after operation temperature rose, symp- 
toms of uraemia developed, and death 
occurred on the fifteenth day. After 
death, prostate found to be about half its 
former size. The condition of the kidneys 
was fully appreciated by the operator and 
patient before operation, but the man in- 
sisted on the operation, as his distress 
was too great to bear. 
Constant pain and an urgent desire to 
urinate at least once an hour during 
night. In daytime, every five to 
fifteen minutes. For six weeks he 
had been treated with vesical irriga- 
tions and internal remedies. 
Slight remission in 
first twenty-four 
hours; fifth day, 
miraculous im- 
provement. 
Cystitis diminished, and passed full 
stream, one ounce residual urine. 
Prostate flaccid and one-half former size. 
Suppurative disease of both testicles, 
great prostatic enlargement, and 
great interference with urination. 
Lost sixty pounds. 
Within two weeks. 
Catheterization very much easier, 
urine has cleared, there is no longer 
any distress, the patient passes a 
few ounces (three) of urine volun- 
tarily, and uses the catheter two or 
three times in twenty-four hours. 
Fifty pounds of flesh have been regained. 
Jan. 18, 1895, patient in robust health. 
Has no annoyance from difficulty in uri- 
nation, although he still retains a portion 
of it. " Upon my advice uses catheter 
two or three times a day." 
Catheter could not be introduced. 
Next day the urine 
came more freely. 
Tenth day after operation the prostate 
was much smaller. Three weeks 
after it had disappeared. 
The bladder was beginning to regain power. 
The urine had become acid. An ordinary 
silver catheter passed in easily, without 
requiring to be depressed more than 
usual. 
Referred to ten cases not previously re- 
ported. The cases did well, and are not 
suffering in any way from mental troubles. 70 
J. WILLIAM WHITE. 
No. 
Operation. 
Date of 
Opera- 
tion. 
Reference. 
Age of 
Patient. 
Duration of 
Symptoms 
Previous to 
Operation. 
Condition 
of Patient 
as to Sex- 
ual Power. 
Cystitis. 
Residual 
Urine. 
Duration 
of Use of 
Catheter. 
Frequency 
of Urination 
or of Cath- 
eterization. 
Estimated Size 
of Prostate before 
Operation. 
66 
Marks, Mil- 
waukee. Re- 
ported by 
Andrews. 
Tri-State Med. 
Journ., Mar. 
1895. 
59 
Chronic. 
Enlarged. 
67 
Martin, 
Philadelphia 
Nov. 9, 
1894. 
Personal com- 
munication, 
May 22, 
1895. 
68 
10 years. 
Lost. 
Yes. 
All. 
80 days. 
Size of half an 
orange, filling 
the rectum and 
preventing the 
examining finger 
from reaching 
the bladder wall. 
68 
Meyer & Hae- 
nel, 
Dresden. 
May 16, 
1894. 
Centralb f. die 
Krankheiten 
der Harn 
und Sexual 
Organe. Bd. 
v , Heft 7, 
1894. 
7° 
Some time. 
Present, 
urine 
ammo- 
niacal. 
120 tO I50 
c.cm. 
Evenly enlarged 
and about size of 
fist. 
69 
Packard. 
Philadelphia. 
Nov. 25, 
X894. 
Personal com- 
munication, 
May 27, 
1895. 
70 
2 or more 
years. 
70 
Piercy, 
Placerville, 
Cal. 
Aug. 8, 
1894. 
Med. Rec., 
Feb. 23,1895. 
71 
Prostate immense- 
ly enlarged. 
7* 
Pilcher, 
Brooklyn. 
Jan. 19, 
1895- 
Personal com- 
munication. 
May 25,1895 
74 
For 20 years 
had 
frequent 
urination. 
Marked enlarge- 
ment. 
72 
Powell, 
Bengal. 
1887. 
British Med. 
Journ., Nov. 
8, 1893. 
65 
For months 
had had 
retention 
of urine. 
Not given. 
Not men- 
tioned. 
Not given. 
Months. 
Not given. 
Not given. 
73 
Ramm, 
Christiania. 
April 3, 
1893. 
Centralb. f. 
Chirurgie, 
Sept. 2,1893 
73 
15 years. 
Not given. 
Not men- 
tioned. 
Not given. 
Catheter 
had not 
been 
used. 
Hourly 
urination. 
Small orange. 
74 
Ramm, 
Christiania. 
April 25, 
1893. 
Centralb. f. 
Chirurgie, 
April 28, 
1894. 
67% 
14 years. 
Not given 
Present 
for 1 
year. 
Not given. 
7 years. 
Sometimes 
used cath- 
eter 2 or 3 
times 
hourly. 
Very large; upper 
border could only 
just be reached 
by the finger in 
the rectum. CASTRATION IN HYPERTROPHY OF THE PROSTATE. 
71 
General Symptoms and Condition. 
Time at which 
First Improvement 
was Noticed. 
Character of Improvement. 
Subsequent Course and Final Result; 
Other Remarks. 
Had disease of both testes. 
After several weeks the cystitis was 
greatly benefited. 
Testicles removed for their condition, and 
not with any idea of influencing condition 
of prostate and bladder. 
Urination most frequent between the 
early morning hours and noon. For 
three years has urinated every half- 
hour during night. Suffered great 
pain at each act of urination Gen- 
eral failure of health for three 
months before coming under re- 
porter's care. Often rises twenty 
times during the night. For eighty 
days there was complete retention 
with overflow. Catheter always 
gave great pain, and at times could 
not be passed. Blood often fol- 
lowed the passage of the instru- 
ment. Urine ammoniacal, and con- 
tained large quantities of pus and 
mucus. At time of operation, tem- 
perature, ioo|°, pulse, 89 and fee- 
ble. Mental hebetude, wandering 
delirium at times. The patient 
was emaciated and rapidly losing 
ground. 
Fourth day. 
Passed three dunces of urine. Fifth 
day, four ounces, temperature nor- 
| mal, pulse 74. Sixth day, passed ten 
ounces urine ; from this time on the 
improvement was progressive. He 
i suffered no pain from the time 0: 
operation, passed no blood, anc 
there was a marked diminution in 
the amount of pus in the urine. 
Forty days after operation there are two 
ounces of residual urine, which still con- 
tains pus He has gained twenty 
pounds, and says he is as well and strong 
as ever; he passes a good stream of urine 
without pain or irritation. Rises at night 
to urinate two or three times, and passes 
urine four or five times during the day. 
He never uses a catheter. 
Great tenesmus during urination, fe- 
ver, insomnia. Cystitis had been 
treated with vesical irrigations, but 
introduction ot catheter caused 
great pain. 
Few days after oper- 
ation tenesmus had 
nearly gone, and 
catheter could be 
introduced with 
ease. 
May 24, some diminution in size of 
prostate. May 31, had diminished 
one-third. July 3, two-thirds 
smaller. July 25, almost normal in 
size. After fourteen days, contrac- 
tile power of detrusor muscle began 
to return. 
July 25, the following note is made: the 
prostate is about normal in size, the urine 
can be retained four or five hours, and the 
bladder can be completely emptied with- 
out the use of instruments. The urine 
can be projected from the penis in the 
normal curve, and there is no dribbling. 
Urinating every one to three hours. 
At first prolongation of intervals; 
general improvement; patient now 
thinks the intervals are getting 
smaller. 
The patient complains of " flashes" similar 
to those occurring in women at the meno- 
pause. No examination recently. 
Occasional retention, becoming more 
frequent. Very difficult to pass 
catheter. 
Day following passed 
urine more freely 
than before. 
After two weeks he had no further 
trouble passing water. 
Two months after operation prostate had 
diminished to one-half its former size. 
First seen by Dr. Pilcher, Jan. 18, 
1895. At this time bladder was 
distended and reached four inches 
above umbilicus; dribbling every 
few minutes, had existed some 
weeks. Catheter could not be 
passed. 
Fifth day. 
A catheter was passed easily and the 
urine drawn every eight hours, as 
the prolonged overdistention had 
so paralyzed the bladder that vol- 
untary evacuation was not to be 
expected. 
During the chloroform anaesthesia, efforts 
were again made to pass a catheter, but 
without success. There was no systemic 
disturbance. Patient has quite recovered, 
is able most of the time to urinate without 
the use of the catheter. Attends to busi- 
ness pretty regularly. May 25 (letter), 
by rectal touch, the prostate appears not 
diminished in size since before the opera- 
tion, he uses a catheter every three hours 
with ease and comfort, is able to pass 
about one ounce of urine at a time, and 
can,by occasionally voiding this amount, 
go six hours without using the catheter, 
when eight or ten ounces will be with- 
drawn. The paralysis from overdistention 
present at the time of operation has been 
recovered from, and he thinks his ability 
spontaneously to void urine is increasing. 
His general health has greatly improved, 
and is now excellent. 
Retention of urine requiring visits to 
out-patient department of hospital. 
Not given. 
Rectal examination showed marked 
diminution in the size of the pros- 
tate. 
Left testicle small and useless ; right testicle 
removed for a " nodule." Three months 
later no urinary symptoms. 
Complete retention at time of admis- 
sion to the hospital. 
Three days. 
Prostate was distinctly smaller. 
Twelve days after prostate was a " flat" 
mass. After the operation, and during 
the first two months, the catheter was 
passed three or four times to relieve tem- 
porary' retention. A year later he passed 
urine normally; only emptied bladder 
twice during night. 
Catheterism vert' difficult. Bladder 
distended, reaching to the umbilicus. 
The night after 
the operation. In 
eleven days. Six 
weeks. 
Patient passed about eighty cubic 
centimetres of water. Prostate was 
distinctly smaller. Could pass a 
good stream. 
One year later prostate was a small, flat 
mass, with a median ridge in position of 
urethra. He passed water four to five 
times only in the day, once at night, 
always without difficulty. The cystitis 
had disappeared. 72 
J. WILLIAM WHITE. 
No. 
Operation. 
Date of 
Opera- 
tion. 
Reference. 
Age of 
Patient. 
Duration of 
Symptoms 
Previous to 
Operation. 
Condition 
of Patient 
as to Sex- 
ual Power. 
Cystitis. 
Residual 
Urine. 
Duration 
of Use of 
Catheter. 
Frequency 
of Urination 
or of Cath- 
eterization. 
Estimated Size 
of Prostate before 
Operation. 
75 
Ramm, 
Tromso. 
July 10, 
1894. 
N. Mag. for 
Laegv. lvi t., 
p. 28-32. Ab- 
stracted in 
Revue Inter- 
nationale de 
Medecine et 
de Chirurgie 
pratique, 
April 10, 
1895. 
57 
For 10 years 
had reten- 
tion more 
or less, and 
great 
inconven- 
ience. 
Yes. 
76 
Rand, 
Brooklyn. 
May 18, 
>895. 
Personal com- 
munication, 
May 26,1895. 
69 
Frequent 
urination 
for the 
past 9 
years, 
most 
marked 
at night. 
4 ozs. 
At least double the 
normal size, mod- 
erate enlarge- 
ment of the me- 
dian portion. 
77 
Rand, 
Brooklyn. 
Feb. 24, 
1895. 
Annals of Sur- 
gery, June, 
1895. 
58 
More or less 
difficulty 
in urin- 
ating for 
10 or 12 
years. 
5% ozs. 
Enlargement of the 
median lobe pre- 
vented passing 
Thompson's 
searcher; lateral 
lobes moderately 
enlarged, the 
right, more than 
the left. 
78 
Rand, 
Brooklyn. 
Annals of Sur- 
gery, June, 
1895. 
65 
Yes, tu- 
bercu- 
lous. 
None. 
- 
79 
Ricketts, 
Cincinnati. 
Oct. 26, 
1894. 
Times & Reg- 
ister, Phila., 
1894. Per- 
sonal com- 
munication, 
May 18,1895 
74 
Extinct 
for 9 
Not given. 
Urinated 
about 30 
times 
daily .hour- 
ly at night. 
So 
Sinitzin, 
Moscow. 
1894. 
Lyon Medical, 
May 27,1894. 
75 
9 years. 
81 
Smith, Nor- 
wich, Conn. 
Mar. 29, 
1895. 
Personal com- 
munication. 
May 4, 1895. 
80 
Several 
years. 
Yes. 
Catheter. 
Fearful condition, 
odor of breath and 
body that of de- 
composing urine. 
82 
D- 
Souchon, New 
Orleans. 
Mar. 4, 
1895. 
Personal com- 
munication, 
May 1,1895. 
63 
4 years. 
Half the size of a 
small orange. CASTRATION IN HYPERTROPHY OF THE PROSTATE. 
73 
General Symptoms and Condition. 
Time at which 
First Improvement 
was Noticed. 
Character of Improvement. 
Subsequent Course and Final Result; 
Other Remarks. 
Came under operator's care July 9, 
1894, for retention. The bladder 
reached nearly to the umbilicus. 
The prostate protruded symmet- 
rically into the rectum; it was 
smooth and slightly hard. The 
patient had a painful cystitis. The 
bladder was irrigated regularly with 
boric acid solution, sodium bicar- 
bonate, or silver nitrate, with evi- 
dent benefit. 
The patient left the reporter's care 
Aug. 23. At this time he did not 
urinate more frequently than from 
one to three times at night, and 
three or four times in the daytime. 
The amount of residual urine varied 
from one to three ounces. On some 
days the urine is clear, at other 
times it contains pus and mucus. 
The prostate had diminished in vol- 
ume, and was very much flattened. 
Dec. 10, since the last report, the patient 
has never experienced difficulty in urin- 
ating. He has been exposed in his occu- 
pation as a gardener to rain, snow, and 
cold. He has had, however, mild, tran- 
sient attacks of cystitis. The urine is 
clear, acid in reaction, and the specific 
gravity is 10x6. The prostate remains as 
a flattened mass. 
For some months prior to operation 
patient had urinated three or four 
times at night, and during the two 
or three years previous to operation 
every half-hour or hour, and always 
with pain and straining. Has lost 
weight and suffers from loss of 
sleep. Both testicles showed cystic 
degeneration. Temperature had 
been from ioo° to xoi°. 
Five days. 
Slept all night, some seven hours; 
the first time in months he had been 
able to pass through the night with- 
out being obliged to urinate. Uri- 
nation diminished in frequency, less 
straining. 
The day after operation the temperature 
fell to 99$° F , and was normal after the 
next day. N0 shock or pain followed the 
operation. May 19, 11 A.M., residual 
urine three ounces. During the next 
two days the pain and frequency of urina- 
tion diminished. May 22, after three 
hours without urination, fourteen ounces 
of urine were withdrawn, showing an in- 
crease in tolerance of the bladder. May 
26, slept five hours at one time last night, 
straining diminished more than one-half, 
and better every way. Prostate much 
smaller. 
For several years he has had. more or 
less incontinence, and for two years 
nearly constant dribbling. Has 
been treated at different hospitals 
during past year for enlarged pros- 
tate without any relief There was 
great difficulty in passing catheter; 
as a rule, nothing would enter but 
a prostatic catheter. Length of 
urethra, eight and one-half inches. 
Second day. 
Voided twelve ounces of urine volun- 
• tarily, and with much less straining 
than he had been accustomed to. 
Six days after operation, there was 
one-half ounce of residual urine; 
the next day, none, although a little 
remained at times during the follow- 
ing week. March 17, appreciable 
diminution in the lateral lobes,-a 
sound passed into the bladder as 
though the former obstruction had 
been largely removed. 
April 5, there has been continuous improve- 
ment in the local symptoms. The urine 
passes naturally, without straining. Re- 
sidual urine generally absent; if present, 
but an ounce or less. The interval be- 
tween the acts of urination is growing 
longer. Length of urethra, seven and 
one-half inches. Prostate much smaller, 
and a small-sized sound drops in the 
bladder by its own weight. 
The patient came under Dr. Rand's 
care a few months after having had 
his testicles removed for tubercu- 
losis. At this time the prostate 
was slightly nodular, but there was 
no general enlargement of the lat- 
eral lobes, and no evidence of en- 
largement of the median portion. 
The urethra was not lengthened, 
and there was no residual urine 
He had frequent and painful urina- 
tion, and later, tubercle bacilli were 
found in the urine. The patient 
made the statement that after the 
removal of his testicles he had much 
less difficulty in passing urine than 
formerly, but the significance of 
this remark was not appreciated at 
that time. 
As attention had not been called to this sub- 
ject at that time, a close study of the sub- 
sequent course of the patient was not 
made. The following, however, seem 
worth noting : the small size of the gland, 
though tubercular, and his statement in 
regard to urination, coupled with his age. 
He lived nearly four years after coming 
under Dr. Rand's care, and died from 
tuberculosis of the bladder and kidneys. 
His prostate did not increase in size, and 
he never had residual urine. 
"Condition pitiable." Had severe 
pain. Could not obtain sleep. No 
kind of medication seemed to give 
relief. Could not pass catheter. 
Second day. 
Said he could urinate with greater 
ease, and that pain was less. Could 
sleep four hours at night; formerly 
had to urinate every hour. 
Left hospital on sixth day, during which 
time the improvement was constant. Jan. 
22, 1895, no obstruction, straining, or se- 
vere pain. Still passes urine too fre- 
quently, and has some burning and itching 
after micturition. Patient practically well. 
Not given. 
Two to three months. 
Considerable diminution in size of 
prostate. 
A year later all traces of hypertrophy had 
disappeared. 
Blood followed catheter every time. 
Had not passed urine for seven 
years. 
Forty-eight hours. 
Catheter passed readily and blood 
disappeared. 
No other treatment was employed. Sleeps 
all night, passes catheter every ten or 
twelve hours. 
Fourth day. 
Was able to pass a small quantity of 
urine through the urethra by closing 
the suprapubic opening with the 
finger. At end of a week and a 
half there was appreciable reduc- 
tion in the size of the prostate, it 
was also, softer. 
The patient was aspirated four years before 
the castration for retention, after failure 
to pass catheter. Oct. 27, 1894, patient's 
condition desperate. Suprapubic cystot- 
omy was performed. The middle lobe of 
the prostate was found much hypertro- 
phied ; this was excised, and the bladder 
drained. The patient still obliged to pass 
catheter after wound healed. A small 
fistula, however, remained. Feb. 23,1895, 
the patient returned for treatment, as he 
was unable to pass the catheter any 
longer. On April 13, the patient was 
seen, and he passed a stream as large as 
an ordinary goose-quill, but he still used 
catheter to thoroughly empty it, and for 
the purpose of irrigation. April 15, the 
patient died suddenly, of super-acute 
pulmonary trouble. 74 
J. WILLIAM WHITE. 
No. 
Operation. 
Date of 
Opera- 
tion. 
Reference. 
Age of 
Patient. 
Duration of 
Symptoms 
Previous to 
Operation. 
Condition 
of Patient 
as to Sex- 
ual Power. 
Cystitis. 
Residual 
Urine. 
Duration 
of Use of 
Catheter. 
Frequency 
of Urination 
or of Cath- 
eterization. 
Estimated Size 
of Prostate before 
Operation. 
83 
Spencer, 
Brandon, 
Mass. 
Mar. 30, 
1895. 
Personal com- 
munication, 
May 4, 1895. 
64 
Several 
months. 
Yes. 
Medium-sized or- 
ange; left lobe 
larger and harder 
than right. 
84 
Steinbach, 
Philadelphia. 
April 23, 
1895- 
Personal com- 
munication. 
May 22,1895. 
72 
Has suffered 
intermit- 
tently for 
the past 12 
years from 
retention 
on account 
of enlarge- 
ment of 
the pros- 
tate. 
85 
Stimson, 
New York. 
Jan., 
1894. 
Personal com- 
munication, 
Jan. 8, 1895. 
75 
A long time. 
Urine passed 
exclusively 
(?) by cath- 
eter at 
frequent 
intervals. 
86 
D. 
Stretton, 
London. 
Jan- IS, 
1895- 
Lancet, Mar. 
2, 1895. 
6c 
Some 
months. 
6 weeks. 
As large as a hen's 
egg- 
87 
Thayer, 
Waterville, 
Me 
May 12, 
1895- 
Personal com- 
munication, 
May 24,1895. 
74 
8 years. 
Yes. 
All capa- 
city of 
bladder 
6 ozs. 
3 years no 
urine 
passed 
except 
by cath- 
eter. 
Catheter 
used about 
every 4 
hours; its 
introduc- 
tion is 
painful. 
Markedly hyper- 
trophied, very 
tenderand dense, 
median lobe most 
enlarged. 
88 
J. D. Thomas, 
Pittsburg. 
Pittsburg Med. 
Review, 
Dec., 1894. 
65 
15 years. 
Urination 
very 
frequent. 
89 
Thomas, 
Pittsburg. 
Aug. 5, 
1894. 
Pittsburg Med. 
Review, 
Dec., 1894. 
60 
10 years. 
Virile 
powers 
lost for 
several 
years. 
Tried use 
of cathe- 
ter, but 
gave it 
up be- 
cause so 
painful. 
Both lobes uniform- 
ly and consider- 
ably enlarged. 
9° 
Thomas, 
Pittsburg. 
Personal com- 
munication, 
May 24,1895. 
76 
Several 
years. 
2 years. 
Used cath- 
eter every 
half hour 
or hour. 
3 times normal size. 
91 
Tupper, Bay 
City, Mich 
Reported by 
Walker. 
1877- 
New York 
Med. Journ., 
April 20, 
1895- 
56 
Used cath- 
eter daily 
or oftener. 
Very large. 
92 
Tupper, Bay 
City, Mich. 
Reported by 
Walker. 
1882. 
New York 
Med. Journ., 
April 20, 
1895. 
59 
Several 
years. 
Consider- 
able 
period. 
93 
Tupper, Bay 
City, Mich. 
Reported by 
Walker. 
1886. 
New York 
Med. Journ., 
April 20, 
1895. 
58 
Frequent 
use of 
catheter. 
Very large. 
94 
Reported by 
Tupper to 
Walker. 
Over 10 
years 
ago. 
N ew Y ork 
Med. Journ., 
April 20, 
1895- 
Old. CASTRATION IN HYPERTROPHY OF THE PROSTATE. 
75 
General Symptoms and Condition. 
Time at which 
First Improvement 
was Noticed. 
Character of Improvement. 
Subsequent Course and Final Result; 
Other Remarks. 
Frequent micturition, lack of force 
in stream, health broken down. 
The urine became acid. Incontinence 
Prostate reduced to nearly normal size. 
of urine, attributed to paresis of 
Left lobe now smaller of the two (April 
Urine alkaline. 
sphincter muscle. Health improved, 
pains gone, sleeps without difficulty. 
3°) • 
The patient employed a soft rubber 
Second day. 
On the day after the operation twenty- 
He left the hospital one week after the 
catheter, and at times required the 
two ounces of urine were drawn off. 
operation. 
aid of a physician, who occasionally 
Since that time the patient voids 
experienced much difficulty in intro- 
urine unaided and without any diffi- 
ducing the instrument. In April it 
was necessary to perform supra- 
pubic puncture to relieve the reten- 
tion. This was followed by a pre- 
culty. 
cystic abscess, which was evacuated 
through the bladder. Both testicles 
were removed, and at the same time 
a large left inguinal entero-epiplo- 
cele was operated upon. A small 
hernia on the right side was left 
undisturbed. 
Holds the urine for several hours; rises 
Castration for chronic non-tubercular 
inflammation of both testes. 
only once at night. He has discarded the 
catheter. 
Had not passed any urine except by 
catheter for six weeks. Urine con- 
Ten days. 
Passed urine spontaneously. 28th, 
When discharged from the hospital, Feb. 
passed eight ounces at one time. 
20, 1895, the patient was able to walk 
tained pus and dibris. 
The bladder was washed out three 
about, his urine was clear, and was 
times a day, but the urine still con- 
passed naturally, A few days later he 
tained pus, and the catheter was 
again became delirious, and, although he 
needed. The prostate was reduced 
partially recovered, he relapsed again and 
to one-half its former size. The 
died from exhaustion. The operation had 
right testicle was found to be tuber- 
materially reduced the size of the pros- 
culous. 
tate, and restored the power of micturi- 
tion. Had it been done earlier, it would 
probably have prolonged his life (Lancet, 
April 27, 1895). 
Considerable pain in perineum and 
Seventh day. 
The pain had somewhat decreased 
No shock followed the operation. May 24 
glans penis, causing him to grasp 
The pain in the glans is greatly les- 
(twelfth day), patient expresses himself as 
the latter tightly a great part of the 
sened. Catheter draws urine at nine 
feeling decidedly better. 1 he attacks of 
time. Has strong erections and a 
inches, prostate softer and less 
pain are much less frequent, and the irri- 
decided sexual desire, which he has 
tender. The morphine was with- 
tation of the penis is decidedly lessened, 
not gratified. For three months 
drawn, which caused some depres- 
and he scarcely touches it. The prostate 
has taken from a quarter to a half 
sion and an exhausting diarrhoea. 
has markedly decreased in size, and there 
grain of morphine daily. Urine 
cloudy, ammoniacal, and contains 
albumen. Catheter passed nine and 
is scarcely any tenderness. 
one-half inches before drawing 
urine. 
Is now obliged to urinate but three times a 
day. 
Urine came by drops and with severe 
straining. 
A few days. 
Improvement in function of urination. 
Retains urine two to six hours in 
Improvement kept up. The double castra- 
tion was done for tuberculous disease of 
day, and two hours at night. 
Marked decrease in size of pros- 
testicles. 
tate. 
No improvement followed rest in the 
It has not been neces- 
Now urinates every three hours during the 
recumbent position and irrigation of 
the bladder. Urine loaded with 
sary to use catheter 
since operation. 
day, and three or four times at night, 
always without pain. Prostate diminished 
pus. No propulsive power in blad- 
der. Frequent attacks of epididy- 
mitis. 
Enlarged and painful right testicle, 
frequent and painful micturition. 
Left testicle removed more than a 
more than one-third in size; the urine 
contains very little pus. 
Few days. 
By the time the wound had healed, all 
the bladder symptoms had disap- 
peared. 
Ina personal interview some years later he 
s dd he had no further trouble with mictu- 
rition. The removal of the left testicle 
year previously for supposed malig- 
had improved his micturition materially 
for several months, but the previous symp- 
toms gradually returned, with greater in- 
tensity than before, and he decided to 
have the right one removed. 
Painful testicles and persistent desire 
Second day. 
Could pass urine without the catheter. 
Six months after the operation he said he 
to urinate. Bladder had been as- 
pirated for retention. 
In about two weeks but little blad- 
der irritation remained. 
could urinate as well as ever, and he 
could enjoy intercourse more satisfactorily 
than for six years past. 
Persistent and exquisite pain in testi- 
cles of ten years' duration, irritable 
Three weeks. 
Entire relief from pain, and freedom 
from all bladder trouble. 
bladder. Both testicles enlarged 
and sensitive. 
Distressing bladder condition due to 
This patient was confined, on account of a 
enlargement of prostate. 
mania for exposing his person on improper 
occasions. He was castrated with a view 
to curing the mania. It " cured both the 
brain and the bladder troubles." 76 
J. WILLIAM WHITE. 
No. 
Operation. 
Date of 
Opera- 
tion. 
Reference. 
Age of 
Patient. 
Duration of 
Symptoms 
Previous to 
Operation. 
Condition 
of Patient 
as to Sex- 
ual Power. 
Cystitis. 
Residual 
Urine. 
Duration 
of Use of 
Catheter. 
Frequency 
of Urination 
or of Cath- 
eterization. 
Estimated Size 
of Prostate before 
Operation. 
95 
Van Pelt, 
May 11, 
Personal com- 
Yes. 
Toledo, 0. 
1895. 
munication, 
May 24,1895. 
96 
Walker, 
Jan. 23, 
New York 
65 
8 years. 
Yes. 
Over a 
Detroit. 
1895. 
Med. Journ., 
April 20, 
year. 
1895. 
97 
Walker, 
Feb. 6, 
New York 
71 
15 years. 
Yes. 
2 to 3 ozs. 
Desire to 
Very much en- 
Detroit. 
1895. 
Med. Journ., 
urinate 
larged, with a 
April 20, 
every 5 
median bar. 
1895. 
minutes to 
i'A hours. 
Uses cath- 
eter. 
98 
Walker, 
Feb. 26, 
New Y ork 
63 
7 years. 
Detroit. 
1895. 
Med. Journ., 
April 20, 
1895. 
99 
Warren, 
Nov. 24, 
Personal com- 
65 
9 or 10 years. 
Much enlarged, ex- 
Boston. 
1895. 
munication, 
May 1, 1895. 
tending from one 
side of pelvis to 
the other, and up- 
per border could 
not be reached 
by finger. 
Right lobe con- 
IOO 
Warren, 
Dec. 22, 
Personal com- 
64 
6 years. 
Nearly 6 
Catheter 
Boston. 
1894. 
munication, 
May 1, 1895. 
Boston Med. 
years. 
more and 
more fre- 
quently, 
and sev- 
eral times 
at night. 
siderably en- 
larged, remain- 
der slightly en- 
larged. 
IOI 
Watson, 
Jan. 3, 
58 
Several 
Yes. 
Could pass 
3 months. 
Voided a few 
Upper border could 
Boston. 
1895. 
and Surg. 
Journ., April 
years. Re- 
but 1 oz. 
drops of 
not be felt by 
tention 1 
of urine 
urine 
finger in rectum, 
18, 1895. 
year ago. 
sponta- 
every 15 
both lateral lobes 
and again 
neously. 
minutes 
markedly hyper- 
3 months 
ago. 
or so. 
trophied and very 
dense and hard, 
right more so. 
102 
Watson. 
Jan. 21, 
Boston Med. 
69 
Symptoms 
i year. 
Had to be 
Moderate hyper- 
1895. 
and Surg. 
of obstruc- 
catheter- 
trophy of lateral 
Journ., April 
tion for 3 
ized regu- 
lobes. Catheter 
18, 1895. 
years. 
larly. 
passed 9 inches 
before drawing 
Boston Med. 
urine. 
103 
Watson, 
Feb. 21, 
7° 
Several 
Yes. 
Constant 
Much enlarged. 
D. 
Boston. 
1895- 
and Surg. 
years. 
and pain- 
Journ., April 
Overflow 
ful desire 
18, 1895. 
of bladder 
to urinate. 
for several 
at times 
months. 
violent 
tenesmus, 
frequent 
dribbling. 
104 
White, 
Jan. 13, 
Philadelphia 
82 
Increasing 
Yes. 
Retention. 
Greatly enlarged. 
D. 
Philadelphia. 
'895. 
Hospital. 
difficulty 
in urin- 
ating for 3 
years. CASTRATION IN HYPERTROPHY OF THE PROSTATE. 
77 
General Symptoms and Condition, 
Time at which 
First Improvement 
was Noticed. 
Character of Improvement. 
Subsequent Course and Final Result; 
Other Remarks. 
Urine contains mucus, pus, and epi- 
thelium. 
Thirteen days after operation the 
prostate is only one-half its former 
size. 
Operation: fistulous tract in perineum 
opened, and three calculi-two as large 
as walnuts, and one the size of a hickory 
nut-were removed. The bladder was 
then injected with one ounce silver nitrate 
solution, thirty grains to one fluid- 
ounce, and afterwards flushed out. The 
All the symptoms of an aggravated 
cystitis. Frequent desire to urinate. 
Third day. 
Could retain his urine from three to 
five hours. On eighth day the use 
of the catheter was discarded, the 
urine was clear, and retained six to 
nine hours. Prostate diminished 
testicles were then removed. Condition 
verified by two medical friends. 
Letter in the latter part of March states that 
he is not cognizant of any difficulty in 
passing urine. The cystitis, which was 
very bad, has entirely disappeared. 
Usual cystic symptoms. 
Within a week. 
appreciably in size. 
Held the urine one time nine and one- 
half hours. After getting about, the 
Examination of the urine shows a manifest 
betterment in its condition. 
improvement was not so marked, 
and at times uses a catheter. 
Four years ago the writer removed a 
pedunculated median growth by 
perineal cystotomy, but the old 
symptoms of obstruction returned. 
Came into hospital with retention. 
Had been aspirated three times. 
Three days. 
Left operator's care in two weeks with 
decided abatement of his bladder 
symptoms. 
Nov. 28, instrument appeared to pass 
more easily. Patient able to urinate 
for the first time since Nov. 5. 
Letter dated March 29, 1895, says, " There 
is but little pus in the urine, entire sub- 
sidence of pain, urinates but about once 
in four hours, and does not have to use a 
catheter." 
Attempts were made for two weeks to keep 
a flexible catheter in the bladder, but it 
was passed with difficulty, owing to a 
false passage. The patient continued to 
pass increasing amounts of urine. Jan. 2, 
marked diminution in size of prostate 
(confirmed by Dr. Beach). 
Jan 12, 1895, much less smarting, and the 
intervals of catheterization had increased 
to four hours. There was no marked 
change in the size of prostate. 
Painful desire to urinate every fifteen 
minutes, day and night. Symp- 
toms seemed aggravated by use of 
catheter. 
Thirty-six hours. 
Had an interval of 
one and one-half 
hours without pain 
or desire to urinate. 
Second night, after 
Sixth day passed from two to four 
ounces urine spontaneously, pain 
decreased. Tenth day, free from 
pain, and urine contained less blood 
and pus. Three weeks later but 
one and one-half ounces residual 
Two months after operation the prostate 
was smaller than normal, there was but 
one ounce of clear, residual urine. The 
patient slept five hours at a time undis- 
turbed. Urinated in the daytime every 
three or four hours. Patient felt ten years 
Could pass but a few drops of urine at 
a time spontaneously. Urine con- 
tained considerable pus. 
operation, slept un- 
disturbed for two 
hours. 
urine, which was almost free from 
pus ; distinct diminution in size and 
hardness of prostate. 
younger, and worked at his trade (stone- 
cutter) as hard as ever. 
Forty-four days after operation there had 
been no perceptible change in patient's 
condition, save a diminution in the 
amount of pain. 
Admitted to hospital with retention. 
Patient beginning to be uraemic. 
Condition critical. 
Third day. 
Decided relief of bladder tenesmus 
and pain. 
Patient had double inguinal herniae of long 
standing, which were operated upon at 
time of castration. Patient was delirious 
before operation, and continued so. Dur- 
ing night following operation, the patient 
got out of bed, tore off the bandages, and 
forced down the hernias. His uraemic 
condition became worse, and he died on 
ninth day. Examination of testicles at 
time of operation showed spermatozoa to 
be absent. At the autopsy, marked en- 
largement of the prostate (nbro-adenoma- 
tous) was observed. There were no 
Stream slow in starting. Urinates 
ten times a night and with difficulty. 
Urine cloudy and foul. Six days 
before admission, complete reten- 
tion. On admission, retention and 
delirium, alternating with stupor; 
general condition profoundly ady- 
namic. No instrument could be 
passed, so bladder was aspirated 
above pubes, and sixteen ounces of 
decomposed urine withdrawn; al- 
bumen and casts. 
Twenty-four hours. 
Doubtful decrease in size of prostate, 
as felt per rectum. 
spermatozoa in the vesiculae seminales. 
There was extensive pyelonephritis of 
both kidneys. 
Operation completed in three and one-half 
minutes. Patient reacted well, but the 
delirium deepened, and he died on the 
evening of the second day in coma (urae- 
mia). The prostate was smaller than 
before operation. Microscopic section 
showed in the stroma of the gland be- 
ginning proliferation of the connective 
tissue cells The acini tubules are also 
becoming filled with proliferated columnar 
cells, and here and there some fine gran- 
ular matter may be seen in the tubules. 
Some of the cells appear to be filled with 
fine granules, which have not taken the 
stain, evidently fat. The changes are 
typical of beginning atrophy. 78 
J. WILLIAM WHITE. 
No. 
Operation. 
Date of 
Opera- 
tion. 
Reference. 
Age of 
Patient. 
Duration of 
Symptoms 
Previous to 
Operation. 
Condition 
of Patient 
as to Sex- 
ual Power. 
Cystitis. 
Residual 
Urine. 
Duration 
of Use of 
Catheter. 
Frequency 
of Urination 
or of Cath- 
eterization. 
Estimated Size 
of Prostate before 
Operation. 
105 
White, 
Philadelphia. 
Jan. 26, 
1895- 
Philadelphia 
Hospital. 
79 
8 years. 
Yes. 
6 ozs. 
Catheter- 
ized 4 to 6 
times 
daily. 
Prostate size of an 
orange. 
106 
White, Phila- 
delphia. 
Dec 12, 
1894. 
University 
Hospital. 
60 
18 months. 
Yes. 
6 ozs. 
Had used 
catheter 
for 
years. 
Urinated 
hourly. 
Size of small or- 
ange. 
107 
White, Phila- 
delphia. 
(Seep. 25.) 
Mar. 12, 
1895. 
Private 
patient, Uni- 
versity Hos- 
pital. 
74 
Several 
years. 
Yes. 
4 ozs. 
5 years. 
Urinated 
every hour 
or two. 
About 3 times nor- 
mal size. 
108 
White. Phila- 
delphia. 
May 18, 
1895. 
German Hos- 
pital. 
82 
Several 
years. 
Yes. 
All. 
Passed no 
urine 
without 
the use 
of cathe- 
ter for 
several 
years. 
Catheter 
passed 
roinches 
before 
drawing 
urine. 
Catheter had 
to be 
passed 
every 4 to 
6 hours. 
Size of large lemon. 
The finger could 
barely reach the 
upper margin. 
109 
White, Phila- 
delphia. 
Jan. 31, 
1894. 
Medical News, 
June 2,1894. 
69 
12 years. 
Extinct for 
some 
years. 
Present 
and 
marked. 
Complete 
reten- 
tion. 
Many 
years. 
6 to 12 times 
daily. 
Half the size of an 
orange. 
no 
Worthington, 
Los Angeles. 
Personal com- 
munication, 
Mar. 12, 
1895. 
65 
6 years. 
Chronic. 
Enlarged. 
III 
Worthington, 
Los Angeles. 
Personal com- 
munication, 
Mar. 12, 
1895. 
70 
Chronic. 
Enlarged. CASTRATION IN HYPERTROPHY OF THE PROSTATE. 
79 
General Symptoms and Condition. 
Time at which 
First Improvement 
was Noticed. 
Character of Improvement. 
Subsequent Course and Final Result; 
Other Remarks. 
Urinated five or six times at night. 
Occasional compete retention. 
Urine cloudy, contains albumen, 
pus, and mucus. 
Three days. 
Incontinence replaced retention. 
Operation completed in four minutes. April 
1, incontinence has ceased ; empties blad- 
der only about five times daily ; prostate 
greatly reduced. May 2, no return of 
urinary troubles. Urine clear. 
Frequent urination accompanied with 
distress; loss of sleep due to fre- 
quent calls to urinate; the urine 
contained albumen, pus, and mucus. 
The patient was put to bed two 
weeks, salol and boric acid were 
given internally, and the bladder 
irrigated night and morning with 
silver nitrate solution, x : 6000, with 
but slight improvement. Patient 
left hospital and returned to work, 
but applied for admission again 
Dec. 5, 1894, with the symptoms 
much aggravated. Urinating every 
hour. 
Twenty-four hours. 
Urinated only eight times in the 
twenty-four hours following opera- 
tion. He said the urine passed 
much more freely than before ope- 
ration, and he had less pain in 
bladder . Dec. 15, albumen, pus, 
and mucus diminishing in quantity 
in the urine. Urinated five times in 
twenty-four hours. Dec. 17, gen- 
eral condition much improved, the 
prostate has practically disappeared, 
the lateral lobes cannot be felt at all. 
Very little sediment in the urine. 
Dec. 19, residual urine, one-half 
ounce. Dec. 26, residual urine, one 
drachm. Dec. 28, urine normal. 
April 19, the patient continued to be entirely 
free from bladder symptoms. All his 
urine was passed naturally, he was healthy 
and strong, mental condition unchanged, 
and resumed active employment. 1 he 
patient experienced " flashes," such as 
occur in women during the menopause. 
May 25, patient considers himself cured. 
Had a stone in the bladder crushed in 
winter of 1893, but the vesical dis- 
tress was but slightly relieved, which 
grew constantly worse. Urination 
was painful, and the least jar caused 
great pain. Urine contained alb'u 
men, pus, and mucus. 
Two days. 
Pain on passing urine perceptibly di- 
minished. March 19, prostate about 
one-half size before operation and 
much softer. March 28, prostate 
smaller than normal. Before cas- 
tration, passed faecal matter of 
small calibre. One week after ope- 
ration it had assumed the normal 
size. 
This patient had a vesical calculus, which 
added very much to his sufferings; the 
enlargement of the prostate was so great 
as to contra-indicate litholapaxy; one 
stone had already been crushed and re- 
moved by another operator, but with 
rapid recurrence; double castration was 
performed especially to facilitate the 
crushing and evacuating of the stone. On 
March 28, the operation of litholapaxy 
was successfully performed. Convales- 
cence was rapid. The patient left the 
hospital April 4. His cystitis had disap- 
peared, urination was entirely painless, 
and he felt well in every particular. 'I he 
frequency of urination had diminished, 
but was still above the normal. The 
patient experienced " flashes" like those 
occurring in women at the menopause. 
The patient was feeble, there was a 
general atheromatous condition of 
the vessels. Urine alkaline, and 
contained albumen, pus, and phos 
phates. 
Forty-eight hours. 
Passed about three ounces of urine 
voluntarily. On the next day, 
varying amounts of urine were 
passed at different times. The ex- 
amination of the prostate showed 
appreciable lateral diminution in 
the gland. 
Operation performed in less than six min- 
utes. Ten days later (time of this re- 
port), patient was passing about half of 
his urine voluntarily and naturally, and 
said that if he were stronger, and could 
stand up. he thought he could pass all 
of it. The urine was clearing. 
General condition good. Catheterism 
difficult and painful. 
Four to six weeks. 
Disappearance of blood and pus from 
urine. Reduction in length of 
urethra from nine and one-half to 
eight inches. 
Nineteen weeks later, prostate normal in 
size. One year later still using catheter, 
but with ease and without pain. All 
symptoms of cystitis have disappeared. 
Dec. 4, began to pass a little urine (one- 
half fluidounce) at a time for a few days. 
Cachectic, in low, nervous state from 
pain and constant desire to urinate. 
Could not pass more than No. 4 
English bougie. 
No. 28 instrument passes easily now, 
there is no bladder trouble, urine 
normal. 
Patient increased fifteen pounds in weight. 
General condition excellent. Looks 
twenty years younger. Prompt disap- 
pearance of all his symptoms. 
Could pass only No. 3 English instru- 
ment. 
Prompt disappearance of all symp- 
toms in three weeks. 
Patient entirely free from any bladder 
trouble No. 22 passes easily. 80 
/. WILLIAM WHITE. 
Table of Deaths. 
No. of 
Case. 
Operator. 
Age 
of pa- 
tient. 
Time of 
Death. 
Improvement after Operation. 
Cause of 
Death. 
Remarks. 
36 
Glenn. 
82 
8 days. 
Urinated spontaneously four days 
Uraemia. 
" Nearly dead at time of operation." 
after operation. 
No autopsy. 
104 
White. 
82 
2 days. 
Prostate thought to be a little smaller. 
• • 
In profound uraemia at time of opera- 
Autopsy showed beginning atro- 
phy. 
tion. 
49 
Hughes. 
75 
17 
Seventh day patient passed urine 
« 
Four days before death urine became 
days. 
without a catheter, a thing he had 
albuminous. Proportion of albu- 
not done for years. 
men rapidly increased up to time of 
death. 
i°3 
Watson. 
70 
9 days. 
Decided relief of bladder pain and 
Delirious at time of operation; old 
tenesmus. 
double inguinal hernia operated on 
at same time ; night after operation 
tore off the bandages ; forced dowm 
the hernia. 
8 
Carver. 
74 
18 
Passed urine spontaneously at end 
Uraemia 
Pyelonephritis. Thrombosis of pop- 
days. 
of a week, first time for weeks; 
during next week could empty 
bladder fairly well. 
and gan- 
grene. 
liteal artery. Spreading gangrene. 
43 
Haynes. 
Old. 
Betw'n 
Sixteenth day. - Operator decides 
Uraemia. 
No autopsy. 
2 and 
patient's life was prolonged by the 
3 
castration. Passed one-third of 
months. 
his urine naturally ; cystitis almost 
cured, prostate greatly diminished, 
later passes urine naturally ; about 
two ounces residual urine. 
52 
Lichty. 
59 
15 
Able to urinate with greater ease; 
• • 
" Condition of kidneys was fully appre- 
days. 
residual urine one-half ounce in- 
ciated by both patient and operator; 
stead of two and one-half ounces; 
but the man insisted on operation 
prostate about half its former size. 
because he preferred death to a 
continuance of his sufferings." 
45 
Haynes. 
62 
3 
Prostate thought to have diminished 
• • 
Autopsy showed pyelonephritis .dilated 
weeks. 
one-fourth in size, still about the 
size of a base-ball. 
ureters. 
50 
King. 
73 
4 days. 
At end of tw'elve hours patient had 
desire to urinate naturally and did 
Pneumo- 
nia. 
Autopsy showed distinct beginning of 
atrophy. 
not want catheter used any longer. 
Residual urine had decreased to 
less than two ounces, and the pros- 
tate was less than half its former 
size. 
48 
Moullin. 
(?) 
Ninth day blood-stained urine was 
Heart 
Kidneys cirrhotic ; fatty heart; had 
days. 
passed spontaneously on several 
failure, 
had complete retention for fifteen 
occasions. At the autopsy the 
Haema- 
months. 
prostate was found soft and flabby 
turia. 
and appeared to have decreased 
in size. 
13 
Faulds. 
66 
26 
The urinary symptoms were miti- 
Hemiple- 
No autopsy. 
days. 
gated a week before death. 
gia. 
14 
7i 
10 
None. 
Acute 
Probably uraemia. No autopsy. 
(?) 
days. 
mania. 
15 
• • 
12 
• • 
Mania. 
<< 44 44 (( 
days. 
16 
• • 
(?) 
A few 
Acute 
(t 44 44 tt 
days. 
mania. 
39 
Halsted. 
(?) 
(?) 
Uraemia. 
Autopsy showed double pyonephro- 
sis. Prostate riddled with sinuses. 
Patient described as " desperate 
«8 
Finney. 
63 
21 
Uraemia; 
Patient had had attacks of insanity 
Halsted. 
(?) 
days. 
The patient voided urine naturally 
insane. 
for years. 
40 
(?) 
Nephritis. 
Patient described as " desperate 
on third day and continued to do 
so until his death. The prostate 
caseno autopsy. 
diminished rapidly in size. 
47 
Horwitz. 
70 
*3, 
Prostate had almost disappeared and 
Uraemia. 
" Patient's condition absolutely re- 
quired operation of some kind." 
days. 
the urgent desire to pass urine had 
almost disappeared also. 
86 
Stretton. 
60 
About 
The operation had materially reduced 
Exhaus- 
6 
the size of the prostate and had 
tion. 
weeks. 
restored the power of micturition. 
If it had been done earlier it would 
probably have prolonged his life. 
Passed urine spontaneously on 
tenth day; prostate reduced to 
one-half its former size. 
82 
Souchon. 
63 
6 
Improvement began on fourth day. 
Pneumo- 
Patient had had a suprapubic pros- 
weeks. 
Patient passed a stream of urine 
nia. 
tatectomy performed previously and 
■ before his death. 
had a permanent urinary fistula.