REPRINTfOT EiiOM 
ANNALS 
OF 
SURGERY 
SEPTEMBER, 1896 
THE QUESTION OF CASTRATION FOR ENLARGED 
PROSTATE. 
By A. T. CABOT, M.D., 
OF BOSTON, 
Surgeon to the Massachusetts General Hospital. THE QUESTION OF CASTRATION FOR ENLARGED 
PROSTATE.1 
By A. T. CABOT, M.D., 
OF BOSTON, 
SURGEON TO THE MASSACHUSETTS GENERAL HOSPITAL. 
THE importance of the question of castration for reduction 
of enlarged prostate and the interest it has for a consider- 
able proportion of men who reach old age, makes it imper- 
ative that medical men should by frequent review of the facts as 
they accumulate, arrive as quickly as possible at a clear under- 
standing of the possibilities and limitations of the operation. 
Especially is it fitting that this Association should regard 
this question with solicitude, and should give it constant discus- 
sion until definite conclusions as to its scope are reached and 
widely accepted. 
It was to us that Dr. White first made his important sug- 
gestion of the possible utility of this operation, and to us he read 
his very able paper introducing the discussion of the subject in 
New York, in 1895. 
The present purpose of my remarks is to continue that dis- 
cussion then begun, and to bring out the experience of the past 
twelve months. 
In our efforts to determine the position of this operation 
after another year's experience of it, we have to consider both 
its rate of mortality and the restoration of function obtained by 
it. In connection with the latter inquiry it will be proper to 
examine the evidence bearing upon the question of what changes 
the prostate undergoes after the removal of the testes, and to 
determine, as far as possible, the kind of prostate which is likely 
to be affected favorably by the operation. 
1 Read before the American Surgical Association at Detroit in May, 1896. 2 
A. T. CABOT. 
Lastly, it is proper to inquire whether any remote physio- 
logical or pathological effects are to be looked for after the loss 
of the testes. 
Rate of Mortality.-It was a great surprise to many of us, 
when the results of the first year's work were published, to find 
that the question of mortality had any substantial weight in the 
consideration of this operation. The injury is so slight that we 
had expected the death-rate to be a trifling matter. Instead of 
this it assumed very considerable proportions. 
Further experience shows that this mortality was not an 
accidental happening in the first one hundred cases. The 
statistics collected for this paper show a continuance of the 
deaths in about the same proportion of cases as in Dr. White's 
first series. 
Before presenting the figures that I have deduced from 
the list of cases appended to this paper, I wish to say a word 
about the difficulties I have met, and the efforts I have made 
to correct, as far as possible, the tendencies to error that I have 
seen. 
The correct mortality rate of a new operation is always 
difficult to find. If statistics are collected from reported cases, 
our figures may be too favorable from the natural inclination 
to report successes, and from the tendency which unfortunately 
exists to put cases on record before sufficient time has elapsed 
for the determination of the final effects of the operation. 
These sources of error may be reduced to a minimum by the 
collection of statistics through personal solicitation of well-known 
operators for records of all their cases. 
In the preparation of the tables which accompany this paper, 
I have, in part, followed this plan and have sent to all members 
of the American Surgical Association and of the American As- 
sociation of Genito-Urinary Surgeons. I have also sent to all 
other operators to whom I have been referred by members of 
either of these associations. I have, moreover, written to many 
of the larger hospitals for records of all the results obtained in 
them. In this way I have aimed to get as fair an estimate of the 
severity of the operation as possible. But in spite of every effort. CASTRATION FOR ENLARGED PROSTATE. 
3 
the cases obtained from published reports outnumber those ob- 
tained by personal solicitation. 
In addition to the above difficulties, which are common to 
all operations, we have in the present instance other disturbing 
conditions which confuse our estimates. Many of the patients 
who submit to castration are already suffering from diseases of 
the bladder and kidneys that are constantly tending to a fatal 
issue, and many of them evidently die from these diseases rather 
than from the operation. 
Dr. White, acting upon the recognition of this fact, elimi- 
nated thirteen of the twenty fatal cases in his first series, and 
thus brought the calculated death-rate down from 18 to 7 per 
cent. 
Such a revision of statistics is proper when we are compar- 
ing this with other operations done upon patients in good health ; 
but it is manifestly improper when we are making comparison of 
results with other operations and procedures carried out upon 
this same class of patients. It is this latter comparison that I 
propose to make in this paper. 
All of these operations for the relief or cure of enlarged 
prostate are attempts to prolong the lives of patients already 
seriously handicapped by more or less advanced pathological 
conditions. The unsatisfactory nature of our material we have 
to accept, and in weighing castration with the operations of 
prostatotomy and prostatectomy it is evidently improper to rule 
out the cases in which death from pyelonephritis followed cas- 
tration, unless similar cases are excluded from the statistics of the 
other operations. 
Such discrimination is hard to exercise over series of re- 
ported cases : For the observation and report of the conditions 
before operation is usually not exact enough to enable the com- 
piler to accurately estimate it. It would seem better, therefore, 
to take all the cases as they come, trusting to the unfavorable 
ones to distribute themselves with tolerable fairness through the 
different sets of statistics. Whatever errors arise from this course 
will correct themselves in time. 
It may be urged that the simplicity and ease of the opera- 
tion have led some men to castrate patients so desperately ill A. T. CABOT. 
4 
that a more severe operation would not have been thought of. 
This is doubtless true; but we must remember that in the 
earlier days of prostatotomy and prostatectomy these also were 
looked upon as operations to which one must be driven by 
the extremest needs; and the first cases were therefore very 
unfavorable. 
Even now these operations are only resorted to by surgeons, 
and only allowed by patients, after the discomforts and dangers 
of the condition are past the ordinary means of relief. 
Finally, I have excluded from my table cases in which 
other serious conditions existed to complicate the prostatic 
hypertrophy, such as stone in the bladder and tuberculosis. 
The removal of a stone adds considerably to the dangers of the 
operation, and, on the other hand, it is a common experience to 
see symptoms apparently due to the prostate, disappear after the 
removal of a stone. 
I have appended a table of the cases thus excluded in order 
that all the data concerning them may be at the disposal of future 
statisticians. I have, moreover, revised Dr. White's table on the 
same lines, which reduces his number of cases to 104 with 19 
deaths, giving a mortality-rate of 18.2 per cent. 
I have succeeded in obtaining reports of 99 additional 
cases, of which 20 died. Adding these to Dr. White's cases we 
have 203 cases, with 39 deaths, and for the whole series the mor- 
tality-rate is 19.4 per cent. 
So high a death-rate for so slight an operation is surprising 
and requires explanation. In endeavoring to understand it, it 
must be remembered that an operation done for the relief of a 
serious pathological condition has its dangers greatly increased 
if it does not at once completely relieve the condition. This rule 
applies peculiarly to diseases of the urinary organs in which the 
kidneys are partly disabled. 
We see constant examples of this in the treatment of strict- 
ures of the urethra; and know that a slight surgical interference 
which does not wholly open the stricture is more likely to be 
followed by serious trouble than a far more extensive operation 
which entirely removes the obstruction and allows of the free 
escape of the urine. CASTRATION FOR ENLARGED PROSTATE. 
5 
In the enlarged prostate we have a closely analogous con- 
dition, and it is plain that the usually slow removal of obstruction 
by the shrinkage of the prostate after castration is of little im- 
mediate use in stopping the back pressure on the kidneys, which 
is especially harmful when an operation has just brought a stress 
of work upon them, and which, moreover, favors the extension 
of inflammatory processes from the bladder up the ureters to 
the renal pelves. 
This is a very real source of danger and may go far towards 
explaining why there is so slight a difference in the mortality- 
rates of castration and of prostatectomy. For the latter, though 
a much more severe operation, leaves the escape of urine amply 
provided for by drainage. 
In endeavoring to estimate the value of prostatectomy we 
meet the usual difficulty in following the patients after operation 
for a sufficient time to establish what the final and permanent 
degree of relief is. It is greatly to be desired that such statis- 
tics should be collected, for upon them must be based our final 
opinion of the operation. Even the mortality-rate is difficult to 
come at. 
This is peculiarly an operation in which a correct tech- 
nique and skill in carrying it out make the greatest difference 
in the fatality of the operation. As a result of this, its statistics 
show a constant improvement in the rate of mortality, and Dr. 
White found that the most modern statistics obtainable at the 
-time of his paper, in 1893, give a mortality of 14.9 per cent. 
Later, in comparing this operation with castration, he says, 
" The mortality of the first extensive series of suprapubic pros- 
tatectomies published was 25 per cent. The mortality of my 
table of a slightly larger number of cases is 18 per cent., in- 
cluding every known death, even when it occurred months after 
operation." 
This comparison is hardly just, for the first castration in the 
series was done probably with as much skill and safety as the 
last one; while in the case of prostatectomy this was quite 
otherwise, and the first cases, treated while the operation was in 
its experimental stage, showed a mortality which has been 
greatly reduced since. 6 
A. T. CABOT. 
It seems probable that with added experience, the greater 
improvement in the mortality will show itself in the more 
difficult and complicated operation rather than in that " sim- 
ple, easy, rapid procedure," which, as Dr. White says, is " with- 
out danger per se." 
The latest table of statistics that I have been able to obtain 
is that of Moullin, which contains 94 cases with 25 deaths, giving 
a mortality of 27.6 per cent. 
The death-rate of 14.9 per cent., figured out by Dr. White, 
was obtained by taking the cases in Moullin's table that were 
operated after 1889. He states that there were 47 of them with 
7 deaths. To arrive at these figures some of the cases must 
have been eliminated, as I find 51 cases after 1889 with 9 deaths, 
giving a somewhat higher rate of mortality,-namely, 17.6 per 
cent. There might well be a difference of opinion as to elimi- 
nating some of the cases, but I think the higher death-rate (17.6 
per cent.) the fairer estimate. 
Dr. Belfield's table, which includes many of the cases also 
obtained by Moullin, is compiled of cases operated after 1886 
and before 1890. It contains 55 cases of suprapubic prostatec- 
tomy with 14 deaths, which gives a mortality of 25 per cent. 
These tables are open to the objection stated earlier in this 
paper as applicable to all statistics,-namely, that successful cases 
are more commonly reported than failures. 
On the other hand, the technique of the operation has been 
greatly improved since their publication. (Belfield's in 1890, 
Moullin's in 1892.) 
I am inclined with some diffidence to advance the belief 
that the correct death-rate is certainly under 20 per cent. If 
this is true, the operation stands upon about the same footing as 
castration in its fatality when applied to all cases of advanced 
prostatic hypertrophy. This would leave the choice dependent 
on the functional results to be expected from each. It seems 
probable that the aggregate death-rate can be sensibly lowered 
by using both operations with a careful selection of the cases to 
which each is applicable. 
After-Effects of Castration.-Besides the mortality risks of 
the operation, we are constantly asked by patients whether there CASTRATION FOR ENLARGED PROSTATE. 
7 
is any danger of their suffering from eunuchism in any form 
after the castration. In studying the incidental after-effects of 
castration it is proper to consider what other functions the 
testes have to perform in the human economy besides that 
purely sexual. 
Dr. White holds that the power exerted by the testes in 
conferring upon the bearer masculine characteristics is the only 
non-sexual attribute which they have. Also, he states, that this 
power ceases in early adult life, after which only their sexual 
function remains. 
There is certainly, among all the reported cases that I have 
found, none in which, after castration performed in middle 
or advanced age, any loss of masculine characteristics or 
any appearance of feminine characteristics has been noted. 
Whether these patients will show less vigor as age advances 
than might have been expected of them, it is still too early to 
say. There are, however, some observations which it is proper 
to remember in this connection, and which should lead us to be 
watchful for evidence on this point. 
It is a somewhat prevalent opinion among neurologists that 
the testes do exert some influence on the nervous system even in 
old age. The nature of this influence does not bear very exact 
statement on account of the difficulty of investigating such a 
question. 
Brown-Sequard's experiments in the use of testicular extracts 
led him to claim for them a distinct power to increase the force 
of the nerve-centres, and consequently to improve the nutrition 
of the individual. 
If this is so, the numerous cases of castration done in the 
last two years ought to give the opportunity for the study of 
the effect upon the nervous system of removing the normal sup- 
ply of testicular fluids from the economy. 
Looking at our cases for evidences of special nerve disturb- 
ances, we find that in ninety-nine cases there were eleven in- 
stances of mental disturbance immediately following castration. 
A serious maniacal condition occurred in six cases, and in five 
others there was considerable loss of mental balance with, in 
several, a melancholic tendency. Of the six maniacal patients 8 
A. T. CABOT. 
one had shown symptoms of mania previously. The attack was 
apparently precipitated by the operation. 
In this connection it may be worth while to briefly allude to 
a case of my own which has been previously reported, but is not 
included in my table as it was complicated with stone. It is of 
sufficient interest to be repeated here. 
In December, 1894, I saw James W., a strong man of seventy- 
five years, who had been troubled for five years with considerable 
difficulty in connection with urination. At the time that I saw him 
the catheter was being used regularly, as he was unable to pass water 
without it. He was then suffering from an acute attack of inflamma- 
tion. This subsided somewhat after rest in bed, but during his 
treatment the catheter touched a stone and an operation was decided 
upon. 
On January 2, 1895, the stone was easily crushed and pumped 
out. The patient being in good condition at the end of this opera- 
tion the testes were removed. Previous to the operation the patient 
was for the most part clear mentally, but occasionally had slight con- 
fusion of ideas. He tore off the dressing after recovery from ether, 
and was in a distinctly bad mental condition the following day. From 
this time he continued in a mildly maniacal condition, which per- 
sisted through the month of January, and presented the typical form 
of confusional insanity, with occasional exacerbations when he was 
quite maniacal and noisy. For some days after the operation he had 
considerable pain and increased resistance over the right kidney. 
During this time the wound in the scrotum healed kindly, and 
the prostate diminished considerably in size, making the passage of 
the catheter much easier than it had previously been. On February 
14 he passed some water voluntarily. On February 19 he was as 
much confused as ever, his mind occupied with delusions and often 
much depressed, referring constantly in his talk to the loss of his 
testes and to his business troubles. It was now decided to try the 
effect of the injection of testiculin. 
On February 28, when he had been for eight days receiving from 
thirty to forty minims daily, the record was made: " The injections 
are very painful and are hurting him much. His mental condition 
has changed decidedly since they were started. His friends, who do 
not know the character of the treatment, are much pleased with the CASTRATION FOR ENLARGED PROSTATE. 
9 
change which they began to notice two days after the first injection. 
He is less restless, sleeps better, and worries less." 
On March 6 we have the record: " For the past four days the 
testiculin has been omitted, and there is a decided change for the 
worse, his condition having become much as it was two weeks ago. 
March 16, testiculin is being used every day. Mental condition 
constantly improving." 
After this, the injections having been very painful, they were 
omitted, and the mental condition continued steadily to improve. 
He was able to use a silver catheter himself, and finally left the hos- 
pital March 30. 
I heard later from his physician, Dr. C. D. Sawin, of Charles- 
town, that Mr. W. did quite well and went about with some degree 
of enjoyment and comfort. Some time towards the end of May, 
after a long ride in a carriage, he was again taken down with acute 
symptoms with considerable pain referred both to the bladder and 
the region of the right kidney. This was accompanied by high fever 
and delirium ; and he gradually failed and died. 
Dr. Sawin was able to get a partial examination and found the 
prostate about the size of a hen's egg. The third lobe was enlarged 
to the size of a pullet's egg, and projected upward and backward into 
the bladder. On its apex was a calcareous deposit firmly adherent. 
Posterior to this, extending forward in the body of the prostate, was 
a cavity with smooth walls which contained about a teaspoonful of 
gravel. The bladder wall was thickened and injected, and showed 
on its surfaces a few haemorrhagic spots. The kidneys were in a state 
of acute pyelonephritis, and the right was about one-third larger 
than normal. 
I know of no other instance in which testicular extracts have 
been used in such a case as this, but the immediate improvement 
which followed confirms the belief that the loss of the testicles 
had something to do with the mania, and suggests the impor- 
tance of a further trial of these extracts in similar cases. Care 
was taken that neither the patient nor the friends should have 
any idea of what was being given or what results were expected, 
so that the possible effect of suggestion should be reduced to a 
minimum. This would seem to be a necessary precaution in any 10 
A. 7. CABOT. 
similar trial ; for suggestion is a powerful therapeutic agent in 
such functional nervous disorders. 
Besides these immediate and psychic disturbances there are 
other cases in which the operation has a very decided depressing 
effect on the general strength of the patient, leading to an amount 
of shock quite out of proportion to the extent of the mutilation. 
In other cases, again, the patients have borne the operation 
well, the wounds have healed kindly, and still, at the end of a fort- 
night or, perhaps, a little longer, they have gradually failed with- 
out any marked change in their symptoms and have died. If a 
case of this sort comes to autopsy, it usually reveals a condition 
of pyelonephritis, and the death is perhaps sufficiently explained 
thereby. It is, nevertheless, a striking and suggestive fact that 
these patients who have been carrying the load of partially dis- 
abled kidneys for a long time, after a slight operation, which 
heals kindly, gradually succumb by progressive loss of strength 
without any evident increase of symptoms pointing to an aggra- 
vation of the renal condition. 
This seems to indicate that, by the removal of the testes, the 
vital force of the patient has been in some way diminished, 
and thus, in a measure, the theory of Brown-Sequard finds sup- 
port. 
As a further evidence of the effect produced upon the ner- 
vous system by the removal of the testes, it has been noticed in 
a number of cases that the patients afterwards suffer from uncom- 
fortable flushes of heat, similar to those experienced by women 
at the time of the menopause. Also distinctly hysterical phe- 
nomena have been observed after castration. On the other hand, 
cases are reported in which conditions of nervous excitability 
existing before have been relieved by the operation. 
Restoration of Function.-In seeking for a true appreciation 
of the functional results obtained by castration and by the various 
more direct operations upon the prostate, we meet even greater 
difficulties than in our search for the correct mortality rates. 
It is, in this investigation, even more important to have the 
patient under observation for a considerable time to determine 
the permanency of the result which follows immediately after the 
operative interference. It often happens that what appears a CASTRATION FOR ENLARGED PROSTATE. 
11 
very satisfactory degree of relief, as long as he enjoys the rest 
and skilled treatment of a hospital, will disappear soon after he 
assumes less regular habits of life. 
Indeed, the time which has elapsed since the operation of 
castration began to be practised is still too short to determine 
how permanent will be the changed condition brought about by it. 
A few cases of relapse have, however, occurred in which 
there has been a distinct return of irritability and obstruction. 
Dr. Gavin's case, which was one of the most brilliant of the early 
cases reported in Dr. White's table, is one of these. Time only 
will show how frequent these are to be. 
In the effort to obtain data upon this point I have written to 
the operators mentioned in Dr. White's table whose cases were 
reported but a short time after operation. I received answers 
from twenty-seven out of forty-one addressed, and most of the 
reports were favorable. 
An analysis of my table shows that seventy-nine cases sur- 
vived the operation. In eighteen of these the reports were not 
sufficiently explicit to enable one to form an opinion as to the 
functional result. We have left, then, sixty-one cases for our 
purpose. 
Of these, five cases showed no improvement; one case im- 
proved at first and later suffered a relapse. In four cases the 
catheter was still required, but entered more easily, and in these 
cases the irritability of the bladder was sensibly diminished. 
In twenty-seven cases retention, which existed at the time 
of operation, afterwards disappeared. In seven of these cases the 
retention was acute,-that is, had existed for less than a month,- 
while in the other twenty the retention was of long standing. 
In two striking cases a catheter life of eleven years in one case 
and eighteen years in the other was terminated by the operation, 
and comparatively normal urination was restored. 
The remaining twenty-four cases were ones in which the 
power of urination had not been wholly lost, but was greatly im- 
paired, making the act frequent and often painful. In all of these 
cases a decided improvement was reported; the gain showing 
itself in a diminution of pain and frequency and often a decrease 
in the amount of residual urine. A. T. CABOT. 
12 
Reducing these facts to percentages, we find that these 
cases show 9.8 per cent, failure ; 6.6 per cent, moderate im- 
provement ; and 83.6 per cent, of substantial or very great im- 
provement. 
If further experience justifies these figures, we shall be able 
to express the facts thus to our inquiring patients,-You have 
eight chances in ten of getting through the operation all right, 
and if you are successful in this, you have again eight chances in 
ten, or a little better, of getting very substantial relief from your 
urinary difficulties. 
Let us now compare these facts with the corresponding data 
in regard to suprapubic prostatectomy. 
Taking those cases in the table of Moullin which occurred 
after 1889,-that is, after the first experimental stage of the opera- 
tion was past,-we have forty-two cases : of these six are not suffi- 
ciently explicit for our use, leaving thirty-six cases. Of these, 
three showed no improvement, which gives 8.3 per cent, not im- 
proved; three cases, again 8.3 per cent., were somewhat im- 
proved ; while in the remaining thirty cases, 83.3 per cent., the 
power of urination was restored with a corresponding improve- 
ment in their condition. 
These figures, as will be seen, correspond very closely with 
those just deduced for castration. 
Wejiave shown, then, that, as far as can be judged from the 
statistics at our disposal, the two operations are astonishingly 
parallel in their results, both as to mortality and as to restoration 
of function. 
The Changes in the Prostate which follozv Castration and lead 
to a Diminution in Volume.-A few facts have been observed 
within the past year which throw some light upon the way in 
which the reduction in the size of the prostate comes about. 
Two theories have been advanced to explain this. First, 
there have been those who believed that the shrinkage of the 
gland was wholly or in greatest part due to an atrophy of the 
constituent parts of the organ. 
This atrophyjwas believed to affect mainly the glandular and 
muscular parts. Dr. White1 reports the microscopical appearances 
1 Annals of Surgery, July, 1895. CASTRATION FOR ENLARGED PROSTATE. 
13 
in a case of his own, in which the patient died on the evening of 
the second day, as follows : 
"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." The observations of 
Griffiths1 and Kirby2 seemed to show that it was the glandular 
tissue which first atrophied and disappeared. 
In endeavoring to estimate the value of these observations, 
the earlier investigations of Griffiths3 in regard to enlargement 
of the prostate are interesting. He believed that the hypertrophy 
consisted first in a growth of the gland tubules with their asso- 
ciated muscular tissue. This he called the first or glandular stage. 
Secondly, after a variable time, he found that a degenerative 
change occurred which converted the new tissue into more or 
less dense fibrous connective tissue, containing only the atrophied 
remains of gland and muscle elements. This he called the 
second or fibrous stage. In another place he says that " in the 
enlarged gland there is usually a tendency in small patches, here 
and there, to atrophy of the gland tubules and to disappearance 
of the muscular fibres in the stroma and to the formation of 
fibrous connective tissue, and this may in some instances extend 
through the substance of the gland." 
The changes thus described are so closely similar to those 
which he thinks he has found in a case of castration, examined 
after eighteen days, that there might well be doubt whether the 
condition which he thought due to the effect of castration might 
not have been one of degeneration already started before castra- 
tion was done. 
Albarran,4 who has also made microscopical study of pros- 
tates after castration, is unwilling to accept White's and Griffiths's 
observations as evidence of atrophic changes, and says that he 
1 Annals of Surgery, August, 1893. 
' British Medical Journal, March 16, 1895. 
3 Journal of Anatomy and Physiology. 
4 Annales des Maladies des organes genito-urinaires, December, 1895. 14 
A. T. CABOT. 
has seen similar conditions to those pictured by Griffiths in cases 
that had never been castrated. 
Moullin1 reports the examination of a case that died twenty- 
nine days after castration, in which Mr. A. B. Roxburgh was 
unable to make out any histological change, although the pros- 
tate was distinctly reduced in size. 
I have myself made examination of sections from the pros- 
tate of a patient who had been castrated seven days before death, 
and by comparison of them with sections from the hypertrophied 
prostate of a non-castrated patient, have failed to find any differ- 
ence which could be ascribed to the castration. 
In another case examined by me, Dr. Post had castrated the 
patient seven weeks before death. Immediately following the 
operation there was some improvement, the patient, who had 
required the catheter for four weeks previously, passed a little 
urine and after this there was some involuntary escape of urine. 
After six or seven days the catheter was again required. In the 
next month he passed considerable water but required the cathe- 
ter four to six times in twenty-four hours. Eleven days after 
operation the prostate was a little softer but no smaller. 
At the autopsy the prostate was about the size of a pullet's 
egg ; it was of firm, even consistency. The bladder wall was 
thickened and trabeculated. The right ureter was occluded by 
the encroachment of the right lobe of the prostate, and there was 
hydronephrosis of that kidney. 
A microscopic examination of the prostate showed an 
almost complete disappearance of all glandular elements with a 
great increase of involuntary muscular tissue. The fibrous tissue 
was in about normal quantity. 
The fact that there had been no considerable diminution in 
the size of the gland makes it improbable that the gland tissue 
had disappeared since the castration. There were no remnants 
of gland tissue or alveoli filled with debris, such as would be 
expected had such been the case. 
This observation would seem to show that the myomatous 
tissue of the prostate is not essentially affected by castration. 
It is, then, manifestly difficult to determine in a given case 
1 London Lancet, November 30, 1895. CA S TRA TION FOR ENLAR GED PR OS TA TE. 
15 
whether the conditions in the prostate, found after death, are due 
to changes following castration, or are degenerative changes 
already occurring in a pathological organ before the castration 
was done. 
This question, as to the correctness of such observations as 
are reported by Dr. White, and others can only be settled by an 
accumulated mass of evidence obtained by numerous examina- 
tions of the prostates of castrated patients brought in contrast to 
another mass of evidence obtained by control examinations of 
hypertrophied prostates from non-castrated patients. 
Such an array of evidence does not yet exist, and the exact 
pathology of the change remains to be worked out. When this 
evidence has been obtained we shall hope to understand why, in 
some cases, little if any diminution in the size of the gland 
occurs, while in others an enormous shrinkage takes place; also, 
why the changes appear so much more quickly in some cases 
than in others. 
The second theory accounts for the reduction in size by 
supposing it to depend largely upon changes in the vascularity 
of the organ. The quick relief of retention which follows, 
sometimes immediately upon the operation, is best explained by 
ascribing it to a diminution of the blood in the gland. Dr. 
White has expressed the opinion that a slight change in the size 
of an obstructing third lobe would often cause a marked improve- 
ment in urination, and is inclined to explain these cases of rapid 
improvement in that way. For, as he says, the third lobe is very 
rich in glandular elements, and these he believes to be the first 
to atrophy. 
These considerations seem hardly to account for the im- 
provement which occurs within a few hours; certainly too short 
a time for decided anatomical changes to occur. They also do 
not account for the return of obstruction observed in these cases. 
Indeed, this recurrence of retention opposes any belief in early 
anatomical changes. 
These phenomena are better explained by the vascular theory, 
and the observations of Mr. Mansell Moullin are interesting in 
this connection. He calls attention to the above-mentioned, not 
uncommon experience, that immediately following the operation 16 
A. 7. CABOT. 
there is a decided change in the prostate, often allowing a return 
of the power of urination, and that in a short time this restora- 
tion of function is again lost to perhaps reappear later when the 
more permanent changes occur. 
He seeks to explain this by supposing that nerve fibres, irri- 
tated by the tying and division of the spermatic cord, send im- 
pulses to the central nervous system which are reflected along 
the vasomotor nerves,1 and that in this way is brought about a 
temporary reduction of congestion and diminution in size. 
To support this view of reflected nervous influence he re- 
ports a case in which a painful spasm of the sphincter ani muscle 
followed operation, and subsequently disappeared as the first 
effect of irritation wore off. This effect produced through a 
nerve closely allied to those supplying the prostate certainly 
gives his theory strong support. The close relation between the 
nerves of the anus and those supplying the vesical neck is well 
known, and is constantly illustrated by the familiar observation 
that an irritation about the anus leads to retention of urine. 
The vascular arrangement in the prostate must be remem- 
bered in order to fully understand its importance in assisting 
encroachment upon the urethra. 
Griffiths, who has investigated this, says, " I have been struck 
with the regularity with which venous channels, almost amount- 
ing to a plexus, are found in the anterior wall of the prostatic 
urethra. These venous channels are more numerous towards the 
middle of the prostate, and they are placed immediately adjacent 
to the mucous membrane in the somewhat dense submucous tis- 
sue, being only covered by the epithelium." " These, in addition 
to similar, though less numerous and less prominent, veins in 
the hinder wall, and which are in like manner situated immedi- 
ately beneath the epithelium near to the neck of the bladder, 
explain the easily excited and considerable haemorrhage from the 
prostatic urethra, of not unfrequent occurrence after the passage 
of instruments." 
The venous arrangement above described, closely applied 
about the urethra, explains how any diminution in the determi- 
1 It is possible that some of the effect may be produced by contractions induced 
in the muscular fibres of the prostate. CASTRATION FOR ENLARGED PROSTATE. 
17 
nation of the blood to the part might at once considerably lessen 
the obstruction to urination. 
It is probable, then, that the alteration in the blood-supply 
plays a very considerable role in the changes observed in the 
prostate after castration ; while the atrophy and disappearance of 
portions of the gland may perform their part in the final perma- 
nent reduction in the size of the organ. 
The observations upon the prostate after death, during the 
past year, have not borne out the opinion that the third lobe is 
especially prone to shrink after castration. 
I have seen three specimens from castrated patients in which 
the third lobe existed as a large and obstructing body. 
The impossibility of telling exactly the size of the third lobe 
before castration prevents our forming any idea of the amount of 
atrophy that may have occurred in it. We can only say in such 
cases that the atrophy has not been sufficient to remove the ob- 
struction. 
While uncertainty exists as to the processes by which 
shrinkage of the hypertrophied prostate is brought about after 
castration, there is no doubt that in a great part, if not a majority, 
of the cases a considerable diminution in size follows the opera- 
tion. This is usually estimated by the rectal touch and by the 
shortening of the urethra, as shown by the length of catheter 
required to reach the bladder. 
Both of these methods are imperfect and sometimes mis- 
leading, but they are the best at our disposal, and upon them we 
have to rely for our information in this matter. 
I am not aware of any cases in which the size of the third 
lobe has been accurately mapped out and watched by intravesical 
examinations, either with cystoscope or sound. 
Choice of Operation.-It may now be profitable for us to 
consider what conditions should have an influence upon our 
choice between these two operations for the cure of an enlarged 
prostate. A study of our cases shows that a large succulent 
prostate gives the greatest improvement after castration, and in 
such a case where the close apposition of the lateral lobes plays 
a large part in the obstruction, relief after castration may be ex- 
pected with a good deal of confidence. 18 
A. T. CABOT. 
A case of this sort is especially promising if the bladder is 
still free from bacterial invasion, so that the danger of pyelo- 
nephritis is reduced to a minimum. These cases, too, are not 
especially favorable for prostatectomy, as, in order to relieve the 
obstruction, large portions of the gland have to be shelled out, 
and the operation assumes very serious proportions. 
When, however, the obstruction is due to a valvular third 
lobe, or to masses projecting back into the bladder and encroach- 
ing on the internal orifice of the urethra, we have a condition 
which has not shown itself to be greatly affected by castration. 
On the other hand, 'this condition is easily and radically 
treated by prostatectomy, and the injury inflicted by the opera- 
tion is not serious. In these latter cases the prostate is often not 
large, and yet the obstruction is very complete. 
Between these two conditions we have every degree of com- 
bination of obstruction by pressure and obstruction by valve, and 
this forms the debatable ground over which the two operations 
must contend for supremacy, and as yet we have not sufficient 
knowledge to properly apportion the territory between them. 
Of one thing I feel convinced, however, and that is that in 
a case of doubt the question of whether the urine was still in an 
aseptic condition would have considerable weight with me, and I 
should often dare to do a castration if the urinary organs were 
still uncontaminated, when if the urine already contained pus I 
should prefer the suprapubic operation with the drainage that it 
affords. 
A question which interests me in this connection is in 
regard to those cases of considerable dilatation of the bladder 
after long chronic retention, cases in which an attempt to insti- 
tute the catheter-life is not infrequently followed by a fatal 
haemorrhagic cystitis or pyelonephritis. It seems possible that 
in such cases a castration done without any interference with the 
bladder might sufficiently remove the obstruction to allow the 
distended viscus to gradually relieve itself without any of the 
dangers of infection so fatal under these conditions. 
As far as we know, the myomatous and distinctly fibroid 
prostates are not especially affected by castration. The difficulty 
of recognizing such a condition before operation must, however, CASTRATION FOR ENLARGED PROSTATE. 
19 
make the possibility of applying this knowledge extremely 
rare. 
Ligature and Division of the Vas Deferens.-In consideration 
of the nervous disturbances that follow castration in advanced 
life, it becomes interesting to study the cases in which ligature 
and division of the vas deferens have been practised. The idea 
naturally arises that if in this way the testicles can be retained 
and at the same time the shrinkage of the prostate can be 
brought about, perhaps the nervous depression can be avoided 
and still the obstruction be removed. 
I have obtained reports of twenty-two cases which give a 
most unfavorable showing for this operation, for seven of these 
patients died. Of these cases of death, two were due to hemi- 
plegia coming on shortly after operation; one was a case of 
suicide in a man who became maniacal after operation, and the 
others were due to internal conditions, usually of the kidneys. 
Of the remaining fifteen, three showed no relief, improvement 
was moderate in five, but one of these subsequently relapsed, and 
great improvement followed in seven. 
The number of cases is too small to enable us to draw any 
conclusion either as to the mortality or the degree of improve- 
ment which can be expected from this operation; but even these 
few cases seem to show that the operation has no advantage over 
castration in point of mortality, while it is less satisfactory in 
obtaining relief. 
Unilateral Castration.-But few observations have been 
reported of this operation within the year, and these are not of 
any decisive value, as in some few of them a decided diminution 
of the corresponding lobe of the prostate was observed, while in 
others no change in the gland could be detected. 
The author has had one experience in this connection, 
having had an opportunity to examine a patient operated upon 
by Dr. J. W. Elliot. Examinations were made both before and 
after the removal of one of the testicles. The castration was for 
a very large hydrocele with possible testicular disease. 
In this case the diminution in size of the corresponding half 
of the prostate was very noticeable, showing both diminution in 
size and a softening in consistency. This observation was con- 
firmed by other observers. A. T. CABOT. 
20 
In this case there had been no obstruction to urination, so 
that no light was thrown upon the question whether this uni- 
lateral shrinkage makes the urethra more permeable. 
Conchisions.-The conclusions which, I think, we may draw 
by this examination of the subject are the following: 
(1) In the matter of mortality the operation of prostatec- 
tomy has a slight advantage over castration. It seems probable 
that, with later statistics reflecting the last improvements in the 
technique of prostatectomy, this advantage would be further 
increased. 
(2) Prostatectomy has the further advantage that it allows 
of a thorough examination of the bladder and of the discovery 
and correction of other conditions not before suspected. Stones 
are frequently removed in this way without adding to the gravity 
of the operation. In several reported cases of castration the 
absence of improvement has led to the subsequent discovery of 
stones which have required other operations for their removal. 
(3) Prostatectomy has, on the other hand, the disadvantages 
that it confines the patient for a longer time and that it is some- 
times followed by a fistula. This occurred in one of the forty- 
two cases used in this paper. 
(4) It is too early to know whether any permanent loss of 
vigor follows castration when done on old men. The nervous 
effects which sometimes immediately follow the operation sug- 
gest a suspicion that with the testes the system may lose some 
tonic effect exerted by those organs. 
(5) The functional results of the two operations seem, at 
present, to be as nearly equal as possible, and the tendency to 
relapse shows itself in about the same proportion of cases after 
either operation. 
(6) The reduction in the size of the prostate after castration 
is largely due to a diminution of congestion. Later a degenera- 
tion and absorption of considerable portions of the gland may 
occur. The glandular elements are particularly affected by this 
atrophy. 
(7) Castration would seem to be especially efficacious in 
cases of large tense prostates when the obstruction is due to 
pressure of the lateral lobes upon the urethra. CASTRATION FOR ENLARGED PROSTATE. 
21 
(8) Castration is of but little use in myomatous and fibrous 
prostates. 
(9) Prostatectomy has its especial field in the treatment of 
obstructive projections which act in a valvular way to close the 
urethra. There is, however, no form of prostatic obstruction 
which a skilful operator may not correct by prostatectomy. 
(10) Prostatectomy is then applicable to more cases than 
castration, and is especially to be selected when an inflamed con- 
dition of the bladder makes drainage desirable. A. T. CABOT. 
22 
Table of Cases of Castration for the 
No. 
V 
U) 
Date of 
Operation. 
Condition of Prostate, Bladder, and Kidneys 
as far as Ascertained. 
Immediate Effect. 
I 
57 
May 24, 
1895, J. W. 
Hauckley. 
Prostate enlarged and hypertrophied; 
haematuria; retention; irritability of 
urethra and bladder. 
Irritability of urethra and 
bladder immediately im- 
proved and able to urinate 
at will in twenty-four 
hours. 
2 
65 
March 15, 
1895, S. C. 
Gordon. 
Piostate very large, irritable, and pain- 
ful ; frequent micturition; catheter ; 
small amount of albumen. 
Prostate very much smaller. 
3 
73 
June 19, 
1895, S. C. 
Gordon. 
Prostate very large; bladder excessively 
irritable, requiring to be relieved every 
hour; hsematuria. 
• 
4 
83 
July 29, 
1895, S. C. 
Gordon. 
Incontinence of urine; severe cystitis; 
prostate very large; catheter used con- 
stantly. 
August 1 passed Jiv, and 
continued to empty blad- 
der without catheter. 
5 
68 
May. 1895, 
R. Park. 
Bladder sacculated; perineal distance 
greatly increased; urine alkaline. 
No immediate effect. 
6 
65 
July, 1895, 
R. Park. 
Constant use of catheter; tenesmus 
extreme; partial bladder paralysis; 
enlargement in all directions. 
7 
70 
December, 
1895, R. 
Park. 
About like Case 6; tenesmus not so 
urgent; prostate not quite as large. 
Improvement noticeable in 
two weeks. 
8 
7i 
D. 
April 13, 
1892, J. R. 
Weist. 
Prostate much enlarged; chronic cys- 
titis ; urination very frequent and pain- 
ful ; castration for chronic neuralgia of 
testes. 
No improvement of bladder 
and prostate. 
1 
9 
69 
June 8, 1895, 
J. R.Weist. 
Prostate much enlarged; urination pain- 
ful; catheter frequently employed; 
testes pa nful. 
* 
But little improvement for 
six months. 
IO 
55 
July 19, 
1895,L. S. 
Pilcher. 
Moderate enlargement; bladder di- 
lated, atonic; no cystitis; stillicidium; 
never used catheter,but catheter passes 
. readily. 
At end of two months still 
dependent on catheter, but 
can spontaneously void 
all over sixteen ounces. 
After seven days can spon- 
ii 
68 
July 3b 
1895, L. S. 
Pilcher. 
Moderate enlargement; bladder 
dilated, atonic ; stillicidium; catheter 
passes readily. 
taneously void all over 
thirty-two ounces. 
After seven days catheter 
12 
72 
October 10, 
1895, L. S. 
Pic her. 
Moderate enlargement; bladder 
dilated, atonic; stillicidium; catheter- 
ization difficult. 
passes easily; after twenty- 
one days complete spon- 
taneous evacuation of 
bladder. CASTRATION FOR ENLARGED PROSTATE. 
23 
Reduction of Enlarged Prostate. 
Post-Operative Mania. 
Final Effect of Operation on Prostate, mentioning 
Time when Change made Itself Observed. 
Subsequent History of Patient. 
Decided mania,more 
or less persistent 
now. 
No catheter required; discharged cured 
March 9. 
Was relieved in two weeks; discharged 
March, 1896. Continued 
July 10; able to retain urine three to 
to improve and now emp- 
four hours and passes most of it 
ties bladder voluntarily, 
naturally. 
but for safety uses catheter 
November, admitted with calculus; 
each night. 
Died from uraemia within a 
suprapubic cystotomy; found prostate 
week after operation for 
entirely absorbed except the capsule. 
calculus. 
Gradual improvement. 
Forty days later patient reports free 
February, 1896. Patient a 
"new man," urinates nor- 
from pain with fair expulsive power; 
catheter only to void residual urine. 
mally; no residual urine; 
no complaint of bladder. 
March 3, 1896. Very great 
general improvement in 
every respect; patient now 
quite comfortable. 
Mania followed in 
None; mania lasted six weeks; general 
ten days, lasting 
debility and melancholia until death 
six weeks. 
of uraemia, one year after operation. 
Catheter not employed after six months; 
In this case the scrotum and 
* 
cystitis nearly disappeared; prostate 
both testicles removed by 
much reduced in size. 
patient; scrotum was 
At end of six months condition un- 
stretched over a bench by 
a loop of bandage which 
was nailed to bench; a 
large chisel was employed, 
part of a brick being used 
as a mallet; patient is now 
very well and proud of his 
achievement. 
changed. 
Progressive improvement in local condi- 
After fourteen days 
tions up to date of death, two months 
later of dysentery. 
End of three months prostate nearly 
Mental condition much im- 
mind became dis- 
normal in size; function of urination 
proved as local healing 
turbed coincident 
normal. 
progressed, but at end of 
with suppuration 
• 
three months is still more 
and sloughing in 
feeble than before opera- 
wound. 
tion. A. T. CABOT. 
24 
Table of Cases of Castration for the 
No. 
V 
bJO 
Date of 
Operation. 
Condition of Prostate, Bladder, and Kidneys 
as far as Ascertained. 
Immediate Effect. 
13 
53 
1 October 23, 
1895, L. S. 
1 Pilcher. 
Prostate moderately en'arged; bladder 
contracted, much hypertrophied; 
chronic cystitis; entirely dependent 
on catheter for five months, off and on 
for five years. 
After six days began to uri- 
nate spontaneously. 
14 
65 
February 3, 
1896, L. S. 
Pilcher. 
Prostate greatly enlarged; absolute 
retention ; suprapubic cystotomy; 
bladder contracted and walls hyper- 
trophied. 
After ten days began to void 
urine per urethram ; end 
of three weeks no percep- 
tible change in size of 
prostate. 
15 
77 
October 31, 
1895, W. 
W. Keen. 
Prostate enlarged; five to six ounces 
residual urine; bladder irritated by 
constant use of catheter; kidneys in 
good condition. 
Three weeks later no change 
as to prostate or urine. 
16 
72 
October 25, 
1895, Jos. 
Ransohoff. 
Prostate greatly enlarged; suprapubic 
cystotomy; lateral lobes of prostate 
found enlarged, forming an almost 
complete ring, projecting an inch into 
bladder; kidneys normal. 
Negative. 
17 
60 
February 24, 
1894, Geo. 
R. Fowler. 
Prostate much enlarged; cystitis; re- 
sidual averaged seven ounces; was 
operated on by Dr. Cabot one year 
before (litholapaxy). 
End of two weeks micturi- 
tion every six hours with 
practically no residual. 
18 
80 
D. 
October 16, 
1895,J. B. 
Roberts. 
Middle lobe enlarged; not much 
change in lateral lobes. 
Negative. 
19 
79 
D. 
April 15, 
1895. 
(?) 
Prostate enlarged posteriorly, hard and 
smooth; pus, blood, and bladder 
epithelium in urine; urine alkaline 
and passed with difficulty. 
Urine passed involuntarily 
off and on first week. 
20 
64 
April 4, 
1895, J°hn 
Homans. 
Prostate enlarged; bladder weak and 
atonic; urine drawn by soft catheter 
when possible, by silver prostatic 
when not; kidneys fairly normal. 
Soft catheter passed with 
ease, and after this passed 
his urine without help. 
2I1 
D. 
December 
17, 1895. 
C. B. Porter. 
Chronic hypertrophy of prostate. 
22 
55 
February, 
1895, Dr. 
F. Henro- 
tin, opera- 
tor; re- 
ported by 
Dr. W. T. 
Belfield. 
• - 
23 
80 
D. 
September 
14, 1895, J. 
W. Elliot. 
Prostate symmetrically enlarged, 
smooth and hard, not tender; blad- 
der irritable; chronic cystitis; no 
kidney elements found in urine. 
No relief to retention. 
1 This case is repeated at No. 37, Its removal from the statistics improves the result slightly. CASTRATION FOR ENLARGED PROSTATE. 
25 
Reduction of Enlarged Prostate.- 
Continued. 
Post-Operative Mania. 
Final Effect of Operation on Prostate, mentioning 
Time when Change made Itself Observed. 
Subsequent History of Patient. 
End of three months spontaneous urina- 
tion has continued, but catheter is 
introduced every night to completely 
empty bladder; three to seven ounces 
residual urine always found. 
February, 1896, still has to use catheter 
once daily; three to four ounces resid- 
ual urine; is more comfortable than 
before operation. 
Gradual reduction; four and a half 
months later prostate is reduced one- 
half; uses no catheter; urinates twice 
in night; no pain. 
Mind had been fail- 
ing before coming 
into my wards at 
hospital. 
When last seen improvement in symp- 
toms seemed out of all proportion to 
extent of diminution in size of pros- 
tate, which was slight. 
No change observed; death occurred 
too early to permit of benefit. 
Died May 11; passed out of my hands 
May 1; records say, " he passed now 
clear and now bloody urine; mind 
failed rapidly until the end." 
January 28, 1896, no trouble in passing 
water since operation; prostate normal 
size to touch or rather small; general 
condition much better than before 
operation and works as teamster; 
piles were cured by operation. 
Died four days after operation at Massa- 
chusetts General Hospital. 
March 19, 1896. Patient 
writes that he is well ; 
organs performing func- 
tions freely and no use ioi 
catheter. 
Died fifth day; no autopsy ; 
death not due to operation, 
but to condition of patient, 
which was bad. 
Afterwards learned that this 
patient had attacks of 
dribbling and dysuria ofl 
and on for some time, and 
was sent to hospital be- 
cause attending physician, 
thought he would die. 
Eighty days after operation prostate two 
and a quarter inches long; no change, 
subjective or objective, in urinary 
symptoms nor size of prostate. 
Marked increase in 
senility; patient 
frequently out of 
his head before and 
No change noticed in size or character 
of prostate. 
Patient gradually failed' tilB 
death, October 5, 
secreted forty to fifty 
ounces daily Autopsy: 26 
A. T. CABOT. 
Table of Cases of Castration for the 
No. 
V 
bfl 
Date of 
Operation. 
Condition of Prostate, Bladder, and Kidneys 
as far as Ascertained. 
Immediate Effect. 
24 
64 
July 30, 
1895, M.H. 
Richardson. 
Bladder inflamed; prostate enlarged, 
tender, soft, congested; kidneys 
normal. 
25 
73 
D. 
April 25, 
1895, E. L. 
Keyes. 
Prostate size of mandarin orange, soft; 
moderate vesical catarrh; urination 
possible only with catheter; kidneys 
sound. 
Aggravation of pain, vesical 
spasm, and all other symp- 
toms followed operation 
till death; urgency and 
pain frightful in intensity 
and frequency. 
26 
75 
January IS, 
1896, J. H. 
Packard. 
Both testicles cystic; micturition fre- 
quent and painful. November 13, 
1895, suprapubic cystotomy and stone 
removed. 
January 28 is practically 
well; sleeping quietly six 
hours at night. 
27 
68 
December 
>7,1895,J. 
C. Warren. 
Moderately enlarged, smooth, and hard 
prostate; right lobe distinctly larger 
than left; cystitis; nothing renal. 
Passed water fifteen days 
after operation for first 
time in five weeks; nine 
days after operation pros- 
tate smaller and softer. 
28 
68 
D. 
July 2, 1895, 
R. W. 
Taylor. 
Prostate greatly enlarged laterally and 
posteriorly; cystitis ; chronic diffuse 
nephritis; four and a half ounces of 
residual urine. 
After operation patient 
could pass water without 
much straining and did 
not urinate as frequently at 
night as before. 
29 
62 
March 14, 
1896, T.W. 
Hunting- 
ton. 
Prostate greatly enlarged ; bladder seat 
of chronic inflammation; micturition 
frequent and painful; patient exces- 
sively nervous and begged for opera- 
tion; no evidence of kidney dis- 
ease. 
At first very slight im- 
provement, but enough to 
justify operation; pus in 
urine considerably less. 
3° 
77 
D. 
June 24, 
1895, b.W. 
Torrey. 
Prostate as large as small lemon ; slight 
cystitis; pyelitis ; intense distress; 
catheterized very frequently. 
Immediate relief; catheter 
not required for three days, 
then needed for rest of life, 
though not as frequently 
as before operation. 
31 
65 
March 15, 
1895, 
Maine 
General 
Hospital; 
reported by 
Dr. S. H. 
Weeks. 
Prostate much enlarged with consider- 
able inflammation of bladder. 
32 
74 
February 19, 
1896. 
Maine 
General 
Hospital; 
reported bv 
Dr. S. H. 
Weeks. 
Prostate much enlarged. 
Passes urine better. CASTRATION FOR ENLARGED PROSTATE 
27 
Reduction of Enlarged Prostate.-Continued. 
Post-Operative Mania. 
Final Effect of Operation on Prostate, mentioning 
Time when Change made Itself Observed. 
Subsequent History of Patient. 
after operation; 
mental condition 
much worse after 
operation. 
Post-operative mental 
irregularity,-not 
maniacal but 
febrile. 
Gradual diminution in size; perineal 
section June io, 1895; castrated be- 
cause we knew of nothing else to do. 
Prostate to rectal touch seemed softer, 
not otherwise changed. 
no middle lobe; kidneys 
practically normal. This 
patient died in the sum- 
mer of 1896. A large sac- 
culated stone was found. 
Slight improvement of 
powers of urination; dim- 
inution of painful spasm 
of bladder during efforts 
of micturition. 
Death in fifth week, appar- 
ently from exhaustion. 
March, 1896. This patient 
seems to be in excellent 
general health. 
March 14, 1896, prostate slightly en- 
larged ; has passed catheter but two 
or three times since leaving hospital; 
good general health ; " it was a grand 
success," patient declares. 
About ten days after operation patient 
began to lose ground, and died of ex- 
haustion on the nineteenth day; no 
change appreciable to exploration. 
Patient remains ner- 
vous and despond- 
ent. 
April 11, 1896, reports that gland is 
perceptibly smaller, and patient now 
leads a comparatively comfortable life ; 
before operation was as miserable as 
any human being could be. 
Developed senile de- 
mentia one month 
after operation. 
Rapid atrophy; size diminished one- 
half in about one week. 
March 12, 1896, patient asserts, " I am 
no better than before operation." 
Patient died August 21; 
developing senile dementi a 
about one month after op- 
eration. Operation and 
convalescence aseptic. 
Subsequent history so far 
has shown no improve- 
ment. 
Have not heard from him 
since he left the hospital. 28 
A. T. CABOT. 
No. 
V 
Date of 
Operation. 
Condition of Prostate, Bladder, and Kidneys 
as far as Ascertained. 
Immediate Effect. 
33 
56 
August 16, 
1895, s. J. 
Mixter. 
Retention and cystitis. 
' • • • • 
34 
68 
August 16, 
1895, s. J. 
Mixter. 
Cystitis; "catheter-life." 
35 
65 
September 
14, 1895, 
F. B. Har- 
rington. 
Symmetrical enlargement of prostate ; 
" catheter-life." 
36 
56 
December 7, 
1895, C. B. 
Porter. 
Symmetrical enlargement of prostate, 
both lobes; enlargement of middle 
portion; residual J xxvi. 
• 
37 
59 
D. 
December 17, 
1895, c. 
B. Porter. 
Prostate double normal size; symmet- 
rical catheter-life. 
38 
57 
December 28, 
1895, H. H. 
A. Beach. 
Prostate three times normal, " reaching 
from spine to spine (ischial);" reten- 
tion. 
39 
68 
January 9, 
1896, H. H. 
A. Beach. 
Prostate twice normal; residual 5 v > 
cystitis. 
40 
64 
D. 
March 14, 
1896, J. W. 
Elliot. 
Symmetrical enlargement of prostate; 
residual § xxiii. 
Apparent diminution. 
4i 
75 
D. 
John B. Dea- 
ver. 
Enlarged prostate. 
42 
62 
February, 
1895, 
Church. 
Symptoms: great pain and difficulty in 
passing water; began seven years be- 
fore, and had increased in severity; 
used catheter occasionally for a few 
years, but of late unable to pass it 
without excruciating pain; sometimes 
haemorrhage; slight cystitis; prostate 
greatly enlarged; patient losing 
weight and in great pain. 
At end of a week prostate 
appreciably smaller; pain 
trifling; able to pass water 
at times with catheter; at 
end of second week pros- 
tate one-third smaller; 
end of third week one- 
half former size. 
43 
71 
August 28, 
1895, Mor- 
ton. 
Increasing difficulty of micturition for 
some time, culminating in total reten- 
tion ; attempts to pass catheter caused 
haemorrhage; enormously hypertro- 
phied prostate; large as an orange, 
and soft; urine ammoniacal; much 
pus, and black with blood. 
Bleeding ceased almost im- 
mediately, though cathe- 
terization continued; slow- 
ly improved and* normal 
action three weeks after 
operation. 
44 
64 
D. 
Bangs. 
Enlarged prostate; distended bladder; 
kidneys involved; not considered a 
suitable case by Dr. Bangs. 
45 
Manning, by 
Moullin, 
Lancet, 
1896. 
Prostate as large as a small orange. 
In a few days urine passed 
in a fuller stream, and 
bladder had regained its 
tone. 
46 
69 
Albairan, Au- 
gust, 1895. 
Acute retention; prostate smooth and 
moderately hypertrophied; bladder 
Afternoon of operation 
passed twenty grammes; 
Table of Cases of Castration for the CASTRATION FOR ENLARGED PROSTATE. 
29 
Reduction of Enlarged Prostate.-Continued. 
Post-Operative Mania. 
Final Effect of Operation on Prostate, mentioning 
Time when Change made Itself Observed. 
Subsequent History of Patient. 
" Up and around," September 5, 1895. 
1 
Discharged much relieved October 5, 
1895. 
Discharged much relieved September 
21, 1895. 
Diminution of middle portion; residual 
May, 1896. Returned to 
hospital for stone, with 
great pain and much suf- 
fering and.discomfort. 
Discharged much relieved; 
result said to be excellent. 
January I, 1895, prostate normal; dis- 
charged much relieved. 
Died December 21, 1895. 
Autopsy revealed enlarge- 
ment of middle portion of 
prostate, with right kidney 
in advanced stage of cystic 
degeneration. 
Residual 5 * > discharged much re- 
lieved March 6, 1896. 
Died March 20, 1896. Autopsy re- 
vealed right kidney three times nor- 
mal size; left kidney size of hen's 
egg; left ureter occluded. 
Died of chronic uraemia some days after 
operation. 
March, 1895. Only slightly larger than 
normal; practically no pain; slight 
atony of bladder made occasional 
catheter necessary, but this was pain- 
less ; able to sleep four hours; general 
condition better. 
October 28, urinated four to six times 
a day with no distress; normal urine; 
prostate much smaller than two weeks 
after operation; very dense. 
Death in a week. 
One month later right lobe still enlarged, 
but smaller; left lobe normal. 
Two months after stronger 
than for years; no urinary 
trouble at all. 
July 25, 1895,prostate one-fifth smaller; 
catheter passes easily. 30 
A. T. CABOT. 
Table of Cases of Castration for the 
No. 
V 
bJO 
Date of 
Operation. 
Condition of Prostate, Bladder, and Kidneys 
as far as Ascertained. 
Immediate Effect. 
47 
74 
October 26, 
insensible; pus in urine; catheter 
necessary. 
Enormous prostate; urine foul, ammo- 
getting better constant- 
ly; residual urine dimin- 
ished. 
Ten days later prostate de- 
48 
65 
1894, Man- 
sell-Moul- 
lin. 
December 7, 
niacal; intense straining; used cathe- 
ter for years; worn out with 
pain and loss of sleep. 
Prostate enormously enlarged; great 
cidedly smaller by rectum. 
In a few days pain subsided, 
49 
1895, Stew- 
art and 
* Haynes. 
April, 1896, 
agony on account of inability to pass 
urine; symptoms worse for 'a year, 
and very severe for a month. 
Prostate enoi mously enlarged; had not 
and he began to pass urine 
easily. 
Passed urine six days after 
50 
72 
Parker. 
December 7, 
passed urine normally for six 
months. 
Diabetes for some years; prostate very 
operation, and has con- 
tinued to do so. 
5i 
66 
i895> 
Reeves. 
November 1, 
large; difficulty in passing water for 
over four years; entirely dependent 
on catheter for four months: passing 
urine every half to two hours. 
Long time had frequent and difficult 
Second day passed 5 xiv 
52 
64 
1895, G. A. 
Bright. 
May 20,1893, 
micturition; catheter many times 
daily; urine loaded with pus; poor 
general health. 
Difficulty in urination for two years; 
voluntarily; general ame- 
lioration of symptoms at 
once; intermittent malaria 
followed. 
Six days later residual 900 
53 
63 
Bockman. 
May, 1895, 
passed water every fifteen to thiity 
minutes; prostate size and shape of 
half a lemon; some general arterio- 
sclerosis; residual, 1500 grammes. 
Catheter at times for three years; cysti- 
grammes; prostate had 
begun to shrink. 
Five days after operation 
54 
(?) 
Ross. 
McGraw. 
tis; urethritis; prostate three inches 
long and firm. 
Passing purulent urine with some diffi- 
passed urine without 
catheter. 
Immediate relief. 
55 
D. 
December3i, 
culty; using catheter himself. 
Constant desire to micturate; sexual 
56 
69 
l895» 
Haynes. 
Boling. 
irritation; priapism. 
Prostate size of ordinary orange; resid- 
Cystitis developed seven 
57 
D. 
77 
May 14,1895, 
ual urine 5XXX*>> micturition every 
fifteen minutes at night. 
Catheter-life eighteen years; then im- 
possible, and aitificial suprapubic ure- 
thra; fair condition after this for three 
or four years; cystitis then grew worse, 
and prostate growing steadily. 
Prostate hard, size of an orange; urine 
decomposing and contained much 
blood; kidneys presumably normal. 
Entirely dependent on use of catheter 
days after operation. 
Thirty-six days after opera- 
58 
73 
Lerings. 
Septemberi 1, 
tion passed urine by ure- 
thra for first time in eigh- 
teen years. 
Seventh day passed small 
59 
1894, 
James 
Swain. 
Junear,1895, 
Bockman. 
amount of urine normally, 
this increased till at end 
of three weeks; passes all 
urine voluntarily. 
Able to pass urine volun- 
for over a year. 
taiily same night, and no 
occasion to use catheter 
since. CA S TRA TION FOR ENL A R GED PR OST A TE. 
31 
Reduction of Enlarged Prostate.-Continued. 
Post-Operative Mania. 
Final Effect of Operation on Prostate, mentioning 
Time when Change made Itself Observed. 
Subsequent History of Patient. 
One month later urgency and pain less; 
health better; frequently slept two 
hours; neck of bladder less sensitive; 
ordinary metal catheter passes easily. 
One month later voids urine like a boy. 
Passes urine naturally. 
Slight talkativeness. 
End of ten weeks still used catheter two 
or three times daily, though some urine 
passed without it; general condition 
improving. 
January, 1896, no pain on micturition; 
no need of catheter; general condition 
good; palpable diminution in size of 
prostate ; urine nearly normal. 
January, 1895, micturition twice at night; 
prostate considerably smaller, but still 
enlarged; 400 grammes of residual 
urine. 
May, 1896. Is still alive and 
in perfect condition. 
Six weeks later prostate had decreased 
in size one-half; cystitis relieved; no 
residual. 
Trouble began again; no sepsis. 
May, 1896. Patient considers 
himself cured. 
Died; no autopsy. 
Unconscious on 
eighth day. 
March 17, 1896, no suffering, never felt 
better; about 5 iv of residual; urine 
normal in color, odor, and quantity. 
Prostate had begun to shrink in size 
when he died on fourteenth day. 
Before August 17 prostate decreased 
about one-half in size; cystitis better, 
and severe pain gone. 
May, 1896. Improvement 
satisfactory. 
End of fifth week prostate soft and size 
of horse-chestnut; urine normal. 
No observations after three days. 
Decemberi 1.Thirteen weeks 
after operation, prostate 
rather smaller and firmer 
than at last examination; 
free from any difficulty in 
emptying bladder. 32 
A. T. CABOT. 
Table of Cases of Castration for the 
No. 
Ag«. 
Date of 
Operation. 
Condition of Prostate, Bladder, and Kidneys 
as far as Ascertained. 
Immediate Effect. 
6o 
79 
November 30, 
One week before operation passed water 
1895, Rick- 
on an average of twenty-two minutes; 
etts. 
passed §ii of pus daily. 
61 
Lillienthal, 
Enormously enlarged middle lobe; man 
In two weeks catheter un- 
operator; 
Gerster, the 
reporter. 
in constant agony. 
necessary. 
62 
April, 1895, 
Suffered fourteen years; suprapubic 
cystotomy done years before; unable 
In four weeks able to hold 
Lillienthal, 
ii to g iii, and pass it 
operator, 
and Gerster, 
for many years to pass urine himself. 
himself. 
reporter. 
63 
Parker. 
Prostate moderately enlarged; reten- 
tion for ten days; both testicles 
cystic. 
64 
73 
Junei3,i895, 
Enormous prostale; able to pass 5iii 
in twenty-four hours, and drew 3 lx 
Thirty-six hours after oper- 
Wetherell. 
ation passed 5 xii. 
by catheter; both testes cystic, and 
double hydrocele. 
65 
77 
February, 
Symptoms for five years ; perineal pros- 
Catheterization necessary 
1895, 
tatectomy in November, 1894; after 
for two months. 
Munn. 
six months ' systematic catheterization 
slight and temporary relief; in three 
months cystitis and difficulty of mictu- 
rition severe as ever. 
66 
D. 
Hodenpyl. 
Suffered intensely from obstruction of 
Shrinkage of prostate to 
bladder, due to enormous hypertrophy 
restoration of voluntary 
of prostate. 
micturition. 
67 
82 
April 18, 
Six years confined to house; almost in- 
Immediate relief; retained 
1895, Ken- 
cessant use of catheter; retention; 
urine four hours and 
dall. 
cystitis; prostate large; urine viscid 
and ropy; general health poor. 
passed it without pain; 
one or two attacks of cys- 
titis recurred. 
68 
70 
October 12, 
Immensely enlarged hard prostate; 
Catheter omitted after 
1895. 
chronic purulent cystitis; micturition 
twelve days, when shrink- 
Meyer. 
difficult; retention; cystic and degen- 
age of prostate easily rec- 
erated testes removed. 
ognized. 
69 
66 
Novemberi3, 
Frequent micturition growing worse, 
Night after operation cathe- 
1895, Me- 
and accompanied by desire to defe- 
ter only three times, in- 
Conkey. 
cate; complete retention since July, 
1895; prostate hard and sensitive, 
stead of eight to ten; 
passed water ninth day 
enlarged; emaciation, anorexia, fever, 
sciatic pain. 
without pain. 
70 
76 
May, 1895, 
Catheterized five times a day by attend- 
Three weeks after operation 
D. 
Post. 
ant; micturition impossible; great 
could pass urine up to 
1 
pain and discomfort; urine purulent; 
3 v; pusstillin urine; great 
poor mental condition. 
shock. 
71 
Orvill Hor- 
to 
79 
witz. 
So 
Horwitz. 
Si 
60 
October, 1895, 
Very large prostate; retention and in- 
Completely relieved for 
John W. 
continence; frequency of micturition; 
two weeks. 
Perkins. 
residual urine and cystitis; micturi- 
tion painful, and no straining. CASTRATION FOR ENLARGED PROSTATE. 
33 
Reduction of Enlarged Prostate. - Continued. 
Post-Operative Mania. 
Final Effect of Operation on Prostate, mentioning 
1 ime when Change made Itself Observed. 
Subsequent History of Patient. 
• • • 
One month later pus had disappeared; 
micturition about once every hour; 
, general health better. 
May, 1895, perfectly able to attend to 
business. 
Good result. 
Twelfth day passed x freely without 
pain; practically no residual urine. 
Shock pronounced; 
acute melancholia 
for sixty days. 
Acute attack of hys- 
teria. 
Marked improvement, with regained 
mental control; complete control of 
bladder in four months; prostate one- 
third previous size at end of four 
months; micturition once or twice 
in night. 
Death; perforation of bladder had oc- 
curred behind and a little above pros- 
tate ; general suppurative peritonitis. 
July, 1895, "prostate diminished con- 
siderably in size;" is well as thirty 
years before. 
Five weeks after operation shrunk to two- 
thirds or one-half former size ; can hold 
urine five to six hours; better than for 
fifty years. 
May, 1896, has not used catheter since 
January 11,1896; is improved in gen- 
eral health. 
No diminution in size. 
Died in July, 1895. 
In nine cases there has been a return 
to local conditions not very far from 
normal. 
In this case cystitis still persists in 
spite of every method of treatment. 
Prostate greatly reduced in size, but in 
many respects patient is as bad as ever; 
urinary symptoms still persist. A. 7. CABOT. 
34 
Table of Cases of Castration for the 
No. 
V 
bo 
<: 
Date of 
Operation. 
Condition of Prostate, Bladder, and Kidneys 
as far as Ascertained. 
Immediate Effect. 
82 
73 
November, 
1895, A.H. 
Lerings. 
Enlarged prostate; cystitis; large 
amount of residual urine, loaded with 
pus; almost daily irrigation of blad- 
der for one year and a half. 
83 
65 
D. 
June 10, 
1895, A. 
Vander- 
veer. 
Greatly enlarged prostate; chronic cys- 
titis ; evidence of pyelitis. 
M7. 
84 
65 
D. 
January 23, 
1896, A. 
Vander- 
veer. 
Greatly enlarged prostate ; chronic cys- 
titis ; evidence of pyelitis. 
Nil. 
85 
85 
July 14,1895, 
Roosing. 
Frequent and difficult micturition for 
fifteen years; retention eleven years 
ago; catheter-life ; prostate large ; 
constipation, sleeplessness, anorexia, 
increasing amount of pus in urine. 
Twelve days prostate one- 
fifth smaller ; in six weeks 
passed urine spontaneous- 
ly, thirty to sixty cubic 
centimetres; prostate re- 
duced one-half; catheter 
at night. 
86 
63 
October 10, 
1894, Liid- 
kens. 
Could not pass urine spontaneously for 
several years; catheter-life; cathe- 
terization difficult and painful; pros- 
tate large. 
Ten days showed positive 
decrease in size of left 
half of prostate. In twen- 
ty-seven days left half not 
to be felt; right lobe still 
size of walnut; catheter 
omitted in fifteen days. 
87 
74 
D- 
November 16, 
1894, Grif- 
fiths. 
Prostate much enlarged; both testes 
functionally active and of normal 
size; catheter-life; micturition fre- 
quent, and very painful chronic cys- 
titis. 
At end of first week could 
pass urine without cathe- 
ter ; second week able to 
empty bladder fairly well; 
general condition better. 
88 
F. Smith 
mentions 
case. 
Extreme prostatic obstruction and bad 
cystitis. 
89 
65 
D. 
January 9, 
1895, Wal- 
ker. 
Prostate enlarged; retention for two 
weeks, requiring catheterization two 
or three times a day; incontinence for 
two years; urine purulent; patient in 
peculiar mental state for a long 
time. 
Constant dribbling of urine. 
90 
61 
May 18,1895, 
Poulton. 
Frequency of micturition with noctur- 
nal incontinence; retention; cathe- 
ter necessary very frequently after 
retention till operation ; no cystitis. 
Eight days later passed 
urine voluntarily; prostate 
smaller and softer. 
9i 
60 
May 13,1895, 
Poulton. 
Acute retention six weeks before; 
prostate size of walnut; catheterized 
regularly. 
Fifteen days later passed 
urine; in five weeks re- 
siduum is CASTRATION FOR ENLARGED PROSTATE. 
35 
Reduction of Enlarged Prostate.-Continued. 
Post-Operative Mania. 
Final Effect of Operation on Prostate, mentioning 
Time when Change made Itself Observed. 
Subsequent History of Patient. 
Post-operative mania 
within three clays, 
and continued 
more or less until 
death. 
Acute mania, Febru- 
ary 28. 
Wounds did well, but patient died June 
20, 1895; no autopsy allowed. 
Death March 6, 1896; no trouble with 
wounds ; no autopsy allowed. 
September 28, can pass urine at night; 
went without catheter for two days. 
October 19, catheter once a day; con- 
tractility of bladder regained; gen- 
eral health better. 
March 4, 1895, all signs of prostatic hy- 
pertrophy had disappeared; entirely 
well. 
Now, six months after oper- 
ation, not more than a 
drachm of quite clear re- 
sidual urine, and the blad- 
der has not been irrigated 
for more than a month; 
patient well satisfied with 
the result of operation. 
End of second week 
Eighteen days after operation prostate 
Autopsy showed chronic 
sleeplessness fol- 
still large; died on eighteenth day of 
hydronephrosis of right 
lowed by delirium. 
gangrene of right leg from blocking of 
popliteal. » 
kidney and suppuration 
of distended pelvis. 
Mental state grew 
steadily worse; 
muttering and un- 
conscious of sur- 
roundings; sleep- 
lessness; maniacal 
outbreaks lasting 
ten to fifteen min- 
utes. 
Fifteen weeks later urination normal; 
cystitis cured ; gained forty-five pounds 
in weight. > 
Seventeen days after operation died, 
having developed Cheyne-Stokes 
respiration ; low muttering delirium, 
with maniacal outbreaks until death ; 
no autopsy. 
Two months later residual urine is Jjiv; 
three months later condition still im- 
proving. . 
Three months later residual urine sixty- 
one and a half ounces; prostate dimin- 
ished in size. 36 
A. T. CABOT. 
Table of Cases of Castration for the 
No. 
V 
bJO 
Date of 
Operation. 
Condition of Prostate, Bladder, and Kidneys 
as far as Ascertained. 
Immediate Effect. 
92 
69 
(?) 
May 13,1895, 
W.F.Fluh- 
rer. 
Prostate enormous; chronic interstitial 
nephritis; suprapubic cystotomy; Sep- 
tember 9, 1894, attempted suicide 
because of his symptoms. 
Sedative. 
93 
70 
(?) 
February 22, 
i896,W. F. 
Fluhrer. 
Prostate hard and very large; reten- 
tion ; catheter-life for fifteen years. 
Much relieved. 
94 
64 
April28,i895. 
reported by 
J. P. Bryson, 
Marked bilateral and median hypertro- 
phy ; dependent on catheter; mod- 
erate cystitis; kidneys sound. 
Some improvement third 
day; marked improve- 
ment in symptoms for six 
months. 
95 
67 
May 24, 
1895, re- 
ported by 
J. P. Bry- 
son 
Bilateral and median hypertrophy; cys- 
titis; slight pyelonephritis. 
Nocturnal frequency dimin- 
ished in fifteen days. 
96 
72 
July 27,1895, 
reported by 
J. P. Bry- 
son, 
September 19, 
1895, re- 
ported by 
J. P. Bry- 
son. 
Extensive bilateral hypertrophy; cys- 
titis and pyelonephritis. 
None perceptible. 
97 
72 
D. 
A marked case of advanced prostatism 
with beginning uraemia. 
None. 
98 
67 
May 6, 1896, 
A.T. Cabot. 
Prostate size of lemon, hard and 
slightly uneven; bladder distended; 
residual urine 5 xiv; only slight 
trace of blood with round cells ; uri- 
nates every half hour, and very pain- 
ful ; mental condition feeble. 
99 
July 4, 1895, 
King, op- 
erator. 
Section of two and a half inches of 
each vas removed in September 3, 
1894; following this unsatisfactory 
improvement for six or eight weeks; 
then pain in one testicle and over 
pubes; frequency of micturition in- 
creased ; both vasa united ; left testi- 
cle well formed; right somewhat 
atrophied ; castrated July 4. 
Two days after castration 
held urine for nine hours 
without distress; had not 
done so for years. CAST RATION FOR ENLARGED PROSTATE. 
37 
Reduction of Enlarged Prostate.- 
Concluded. 
Post-Operative Mania. 
Final Effect of Operation on Prostate, mentioning 
Time when Change made Itself Observed. 
Subsequent History of Patient. 
Change very gradual; now, May, 1896, 
prostate still large (has atrophied fully 
three-quarters), but urinates. 
May, 1896, prostate much smaller, but 
cannot urinate. 
Suffers very little from uri- 
nary trouble after hav- 
ing passed a calculus 
per urethram two months 
ago. 
None. 
One month later 3 viii residual urine. 
January 20, 1896. Com- 
plete retention after ex- 
posure ; prostatectomy 
done May 2, 1896, com- 
pletely dependent on 
catheter after January 20. 
Lost sight of; did not reply 
to three letters. 
None. March, 1896, condition reported 
to be the same. 
None. 
Uraemic sopor quickly deep- 
ened into coma; death 
fourth day. 
Delirious and un- 
able to control 
himself, particu- 
larly at time of 
desire for micturi- 
tion ; escaped from 
ward during night 
(May 6); drank 
specimen of urine 
at bedside (May 
7). 
May 19,1896. Prostate one-half dimin- 
ished in size and softer, particularly 
in spots, giving uneven feel; residual 
still more than x; urination every 
hour, with much less pain. 
One month later the patient 
was much improved with 
only §ii to iii residual 
urine. 38 
A. T. CABOT. 
Table of Cases of Ligature 
No. 
V 
bJO 
Date of 
Operation. 
Condition of Prostate, Bladder, and Kidneys 
as far as Ascertained. 
Immediate Effect. 
I 
65 
King, De- 
cember 7, 
1895. Ex- 
cision two 
and a half 
inches each 
vas. 
Prostate very hard; middle lobe most 
enlarged; patient in great distress. 
Great relief within five days. 
2 
7o 
July 11,1895, 
F.T. Brown, 
Double lig- 
ature both 
vasa. 
Wholly dependent on catheter; abso- 
lute retention for three weeks. 
Seventh day passed a little 
urine voluntarily; later 
patient had sensation of 
burning and itching in 
feet and legs, especially 
at night. 
3 
64 
Chabot, Feb- 
ruary 28, 
1895. Re- 
section one 
centimetre 
of each 
vas. 
Frequent micturition; occasionally 
urine blood-stained at end of mictu- 
rition ; prostate enlarged uniformly. 
Two months later micturi- 
tion nearly normal; pros- 
tate decreased one-half in 
size; testes smaller; gen- 
eral condition better. 
4 
64 
March, 1896, 
Finney; di- 
vid'd cords 
Prostate enlarged; suffered five years 
with frequent and difficult micturi- 
tion; catheter-life; urine foul with 
much pus. 
Improvement began about 
sixth day and has contin- 
ued. 
.5 
72 
Isnardi, June 
19, 1895. 
Enlarged prostate; symptoms not 
yielding to treatment; urine purulent 
and blood-stained. 
Twelve days later symptoms 
improved and in a month 
disappeared. 
6 
58 
February 11, 
1896, H. 
J. Schiff; 
ligature 
and 
excision, 
one inch of 
each vas. 
Enlarged prostate; slight cystitis; uri- 
nation very frequent and uses cathe- 
ter. 
Instead of urinating every 
half hour was able to re- 
tain it for from three to 
four hours. 
7 
67 
April 4,1896, 
H. J. Schiff; 
ligatureand 
excision 
one inch of 
each vas. 
Enlarged prostate; cystitis; catheter 
once a day; complains of desire to 
urinate at all times. 
Has not desired to urinate 
so frequently. 
8 
70 
Legueu, op- 
erator. Op- 
eration Au- 
gust 9, '95 ; 
section both 
vasa. Gu- 
yon, Con- 
gres, Fran- 
?ais de Chi 
rurgie, Oc- 
tober 21, 
1895- 
Complete retention for a month ; pros- 
tate quite firm, of moderate size; on 
left a considerable subacute epididy- 
mitis. 
One month later no change 
except disappearance of 
swelling in epididymis. LIGATURE OF THE VAS DEFERENS. 
39 
of the Vas Deferens. 
Post-Operative Mania. 
Final Effect of Operation on Prostate, mentioning 
Time when Change made Itself Observed. 
Subsequent History of Patient. 
Effort formerly required to start stream 
is now absent. 
Prostate diminished in size one month 
after operation; passed urine with 
comfort and ease, and never showed 
more than three ounces of residuum ; 
returned to work, a cab-driver. 
May, 1896. Functional im- 
provement ; almost a res- 
toration, and has re- 
mained unchanged for 
eight months. 
July, 1895. Frequent and complete erec- 
tions and indulged in sexual inter- 
course; general condition excellent; 
urine passed freely and easily. 
May, 1896. Can now hold water about 
three hours; urinates normally without 
pain ; feels better than for many years 
and can* attend regularly to busi- 
ness. 
Six weeks after operation urine clear ; 
can hold water seven hours and pass 
it without pain; testes diminished ; 
prostate impalpable. 
March 11, 1896. Has not used catheter 
since operation; gets up at night about 
twice to pass urine, where formerly it 
was five or six times. 
April 29, 1896. Complains 
again of frequent urina- 
tion. 
April 29, 1896. Shows no marked 
change as yet, and urination is about 
the same. 
October 14, 1895. Prostate unchanged; 
residual urine 250 cubic centimetres; 
is only passing catheter once in ten 
days. 
• 40 
A. T. CABOT. 
Table of Cases of Ligature 
No. 
o' 
bfl 
Date of 
Operation. 
Condition of Prostate, Bladder, and Kidneys 
as far as Ascertained. 
Immediate Effect. 
9 
70 
Guyon, ibid.; 
double sec- 
tion of vasa 
on June 11, 
1895- 
For more than ten years complete re- 
tention of urine; at time of opera- 
tion catheter had to be used constant- 
ly ; orchitis due to catheterization; 
passage of sound caused bleeding 
from prostate, which rectal exam- 
ination showed very large and soft; 
right lobe especially large. 
In a few days micturition 
less frequent, and catheter 
easily passed; after six 
weeks catheterized only 
every three or four hours. 
IO 
70 
Guyon, ibid.; 
section of 
both vasa in 
June, 1895. 
Complete retention for several years ; 
for six months catheterization had to 
be more frequent and was more diffi- 
cult, though no bleeding; prostate 
very large and everywhere equally 
hard. 
At end of a few days cathe- 
terized only every five or 
seven hours; no change 
in size or consistency of 
prostate. 
11 
70 
Isnardi; lig- 
ature of 
vasa. 
Complete retention for five years; cys- 
titis for three months, requiring cathe- 
ter every half hour. 
Left bed three days after 
operation. 
12 
82 
D. 
? 
Isnardi; lig- 
ature of 
vasa. 
Large hydrocele and prostatic enlarge- 
ment on left side; trickling of urine 
for two years. 
Day after operation diurnal 
incontinence disappeared. 
13 
82 
D. 
Isnardi; lig- 
ature of 
vasa. 
Dysuria many years; retention for five 
months; bladder greatly distended; 
urine alkaline; prostate enlarged on 
right side; for a month had used 
catheter twice a day with difficulty, 
often followed bv bleeding. 
Catheterization much easier 
on day after operation; 
second day voluntarily 
emptied bladder several 
times. 
14 
68 
D. 
Isnardi, 
Th erap. 
Woch.,No. 
21, 1896; 
also pub- 
lished in 
Therap. 
Gazette, 
April 15, 
1896. 
June 25, 
1895; bilat- 
eralligature 
and divis- 
ion of vasa. 
Testicles of normal size ; prostate size 
of small apple; bladder distended; 
dysuria three years; incontinence 
long time. 
Six days after operation 
trickling ceased; volun- 
tary micturition every 
hour; distention gone; 
two weeks later could 
hold water four hours; 
prostate markedly atro- 
phied. 
15 
7i 
Isnardi; lig- 
ature of 
vasa. 
Dysuria eight years; straining and 
passing a few drops every half hour; 
bladder could not be emptied; septic 
fever for some days; urine acid, 
and not markedly altered; false pas- 
sages in urethra. 
Nine days after operation 
could urinate sponta- 
neously ; residual urine 
diminished by three- 
fourths ; fever gone; ca- 
theter no longer needed. 
l6 
69 
D. 
(?) 
Isnardi; 
right vas 
dividedand 
ligated. 
Symptoms of prostatic hypertrophy for 
several years; retention for four days, 
not relievable by catheter, resulting 
in coma; left varicocele ; right hydro- 
cele; prostate hypertrophied on right, 
atrophic on left, though left testicle 
was enlarged. 
A week later catheter 
passed readily. LIGATURE OF THE VAS EE IE RENS. 
41 
of the Vas Deferens. - Continued. 
Post-Operative Mania. 
Final Effect of Operation on Prostate, mentioning 
Time when Change made Itself Observed. 
Subsequent History of Patient. 
At end of six weeks great diminution of 
engorgement of prostate; right lobe 
considerably diminished; testes un- 
changed ; did not recover power of 
voluntary micturition. 
After two months still no change in 
prostate, and no recovery of voluntary 
micturition; testicles remained normal. 
No change in symptoms a month after 
operation; six weeks after opera- 
tion cystitis was cured; used catheter 
every three hours ; no restoration of 
function. 
Last week of life had nocturnal and 
diurnal incontinence. 
Died of apoplexy in a 
month. 
Prostate at death size of hen's egg, and 
soft testicle of gray color. 
Eleven days after operation 
died of senile marasmus. 
At death both testicles atrophic; pros- 
tate small, especially on left; bladder 
trabeculated and showed signs of 
earlier submucous bleeding. 
Died September of 
marasmus. 
Passed urine three to four times a day 
normally. 
Twenty-three days later 
died of apoplexy; n©> 
autopsy. 42 
A. T. CABOT. 
No. 
0 
Date of 
Operation. 
Condition of Prostate, Bladder, and Kidneys 
as far as Ascertained. 
Immediate Effect. 
17 
55 
D. 
(?) 
Isnardi; lig- 
ature of 
vasa. 
Dysuria two years; had been twice 
operated for haemorrhoids, and sud- 
denly lost after the last operation 
power of evacuating bladder after- 
wards having to use catheter; a cys- 
titis had been cured by nitrate of 
silver; violent and obstinate tenes- 
mus ; contemplated suicide. 
Four days after operation 
passed better stream than 
for years; pain not re- 
lieved ; he was compelled 
to use catheter. 
18 
80 
Isnardi; lig- 
ature of 
vasa. 
Dysuria several years, often compli- 
cated by complete retention; used 
catheter all this time, often with diffi- 
culty ; attacks of bleeding and fever 
being not uncommon. 
Day after operation catheter 
discarded, and all symp- 
toms disappeared; able to 
hold water three hours, 
but suffered from repeated 
and harassing tenes- 
mus. 
19 
64 
D. 
Isnardi; lig- 
ature of 
vasa. 
Serious disease of heart and kidneys; 
some years of prostatic hypertrophy ; 
retention for fourteen days; catheter- 
ization very difficult and caused bleed- 
ing; false passage and suppurative 
cystitis; prostate size of hen's egg; 
cystitis grew worse, with permanent 
catheterization. 
On day of operation mictu- 
rition possible but diffi- 
cult ; next day acid urine 
free from pus passed. 
20 
70 
Isnardi; lig- 
ature of 
vasa. 
Retention for a month; catheterized 
two or three times a day without im- 
provement ; urine contained pus; tes- 
ticles and prostate small. 
Two days after operation 
passed water twice; next 
five days micturition fre- 
quent and catheter dis- 
carded. 
21 
65 
Isnardi; lig- 
ature of 
vasa. 
Prostatic obstruction many years; some 
months tenesmus recurring every 
quarter hour, day and night; pros- 
tate and testicles of medium size. 
Day after operation micturi- 
tion easier and less fre- 
quent; tenesmus com- 
pletely gone, and general 
condition improved. 
22 
76 
D. 
Isnardi; lig- 
ature of 
vasa. 
Prostatic hypertrophy for several years, 
frequently using catheter, thus caus- 
ing epididymitis; urine ammoniacal; 
catheterization very painful and diffi- 
cult ; vesical spasms day and night. 
Day of operation passed 
large amount of urine; 
pain disappeared imme- 
diately; thirty hours after 
operation urine acid and 
very little pus; next day 
more pus. 
Tables of Cases of Ligature LIGATURE OF THE VAS DEFERENS. 
43 
of the Vas Deferens. 
;.-Concluded. 
Post-Operative Mania. 
Final Effect of Operation on Prostate, mentioning 
Time when Change made Itself Observed. 
Subsequent History of Patient. 
Became hopeless and com- 
mitted suicide 
Able to empty bladder with only slight 
burning; hopes for improvement with 
time. 
At death could urinate spontaneously. 
Five days later died of 
visceral troubles. 
Micturition sometimes frequent though 
usually normal. 
/ 
In two weeks urine absolutely normal. 
• 
Passed some urine spontaneously, but 
had to depend mostly on catheter after 
second day. 
Hippuria, a sequel to ne- 
phritis, which proved fatal 
in two weeks after opera- 
tion. a. T. CABOT. 
44 
Cases of Castration 
No. 
•< 
Date of 
Operation. 
Condition of Prostate, Bladder, and Kidneys 
as far as Ascertained. 
Immediate. Effect. 
I 
75 
December 
26, 1895, 
w. s. 
Forbes, 
Philadel- 
phia. 
Enlarged prostate; bladder trouble for 
many years; complete retention at 
times; haemorrhage in passing cathe- 
ter ; stone removed twice previous to 
castration. 
Seventh day prostate had 
shrunken, but was still 
one-third larger than nor- 
mal, but was soft. 
2 
75 
D. 
January 2, 
1895, A-. T. 
Cabot. 
Cystitis and stone. Litholapaxy and 
castration. 
3 
7i 
D. 
February, 
1895, R. 
Park. 
Condition execrable ; largest prostate I 
ever felt. 
4 
7i 
D. 
March, 1895, 
R. Park. 
Vesical calculus; enormous prostate. 
5 
64 
D. 
November 
20, 1894, 
Mansell- 
Moullin. 
Very stout man; prostate of great size; 
cystitis; haematuria; unable to pass 
urine; catheterized with great pain 
every hour, day and night; bladder 
fair size and good muscular tone. 
In a week passed a small 
amount of urine naturally 
for first time in fifteen 
months; eighth day haem- 
aturia and dyspnoea. 
6 
66 
July 15,1895, 
S. C. Gor- 
don. 
Constant use of catheter at time of 
operation; could use No. 6 soft; 
prostate very large. CASTRATION COMPLICATED BY STONE. 
45 
COMPLICATED BY STONE. 
Post-Operative Mania. 
Final Effect of Operation on Prostate, mentioning 
Time when Change made Itself Observed. 
Subsequent History of Patient. 
Recovery much re- 
January 3. Operation for stone, and 
the bladder completely freed from all 
He is now able to go about 
tarded by an attack 
his work and is more com- 
of acute insanity, 
fragments of stone; after this the 
patient was free from his distressing 
fortable than for years, 
but slight febrile 
having to draw his water 
movement, and 
symptoms excepting there was and 
at intervals of from three 
temperature at no 
is still total retention; before opera- 
to seven hours; otherwise 
time above IOI° 
tion great difficulty in introducing 9 
his health is excellent. 
F. 
linen catheter; now passes with ease 
17, American scale, soft rubber 
catheter. 
Serious mania; tes- 
Discharged, much relieved, March 30, 
Death reported May 31, 
ticulin inj ected 
with relief. 
I895- 
1896. 
Suprapubic cystotomy and orchidecto- 
Death ninth day from ex- 
my. 
haustion. 
Suprapubic lithotomy and orchidectomy. 
Death next day from ex- 
haustion. 
Distinct evidence of reduction in size of 
Tenth day dyspnoea and 
haematuria returned; 
gland and of a reopening of prostatic 
urethra. 
death on eleventh day; 
fatty heart, emphysemic 
lungs; stone back of 
August 6. Found stone; suprapubic 
prostate; bladder wall 
ulcerated. 
• 
This patient was seen by 
operation, and found prostate almost 
Dr Cabot on June 19, 
entirely absorbed; discharged, October 
1896. He then had a 
22, with almost normal bladder. 
March, 1896. Now a very active busi- 
very large prostate ; pros- 
tatic urethra long, resist- 
ness man. 
ant. Dependent upon 
catheter entirely, and was 
obliged to use it every 
hour; he had a stone in 
the bladder.