These observations, chosen at varying intervals | from which the nuclei can be seen escaping mean that from the record, may serve to show the hypo-leuco- the cell is being broken up-that nuclein, or some cytosis that was constantly present during the whole other antitoxin or germicide, is being set free—that course of the disease. There was no decided rela- the process is part of the body's antagonism to infection between the temperature-curve and the number tion? These questions, so important to us, because of leucocytes, though as a rule the highest counts of their relation to the treatment of disease, can be were coincident with the highest temperatures. The answered only by more extended and detailed study very low count, 600, on the third of January, was of leucocytotic conditions. confirmed by several examinations. At the time of the observation the patient was in a severe chill; his temperature was 104.5°; the surface of the body and the extremities were cold. The blood was very dark, and did not flow freely. A diminution of the leucocytes in the peripheral circulation during a chill has been noticed by other observers. The ante-mortem increase is also well known, having been many times observed.

The microscopical examination of the fresh blood showed many large swollen leucocytes, highly refractive; in several cases the nuclei could be seen slipping out of the cell. Many covers were stained, and differential counts made from these. These counts showed at all times an increase in the polynuclears and a diminution in the lymphocytes; no eosinophiles were ever found. The proportion

The observations made in these two cases confirm Cabot's statement that the blood does not give us any aid in the diagnosis between typhoid and acute tuberculosis. Whether the hypo-leucocytosis is a marked feature of the latter disease, as it is of typhoid, must be shown by further observations; but the fact that a decided diminution of the leucocytes is present should not in any doubtful diagnosis turn the scale in favor of typhoid fever; for these two cases certainly prove that there may be in acute tuberculosis, even when suppurating foci are present, a hypo-leucocytosis even more marked than that usually seen in typhoid. Therefore, though we are as helpless as before, so far as the differential diagnosis is concerned, these observations may serve in extending our knowledge of the tubercular affection, and save us from drawing conclusions based upon a misconception of its nature.

Further, this great decrease in the sum total of the leucocytes, with relative increase of the polynuclears occurring in a severe and general infection, leads to many interesting speculations. Is there an absolute decrease of the white cells, or is the decrease limited only to the peripheral circulation? Are the cells destroyed, or is the leucocyte-forming power of the body diminished? Do the swollen leucocytes

LABORATORY OF CLINICAL MEDICINE,
UNIVERSITY OF MICHIGAN.

NOTE. Since the above was written, the second edition of Osler's text-book has appeared. In the chapter on "Acute Tuberculosis" the statement quoted above has been modified to the following: "The blood may show a slight leucocytosis, but in the very acute cases where there are no suppurating foci this is absent."

CASTRATION is an operation as old as mankind; castration for the special purpose of reducing the hypertrophic prostate gland is a surgical success of the last two and one-half years.

Its surgery is a science of facts, and not of theoretical suggestions. The unquestionable honor of having performed the first double castration with. the clear and distinct aim mentioned above belongs to the Norwegian surgeon, Ramm. To the Philadelphia surgeon, White, on the other hand, belongs the honor to have been the first to suggest the operation theoretically; but while White was still busy with his experiments on dogs, Ramm had already performed the operation on man.

Haynes, Fremont Smith, White, Finney followed and reported successful cases, and by and by the operation was performed by many surgeons all over.

Wassidlo, early in 1895,2 published a series of forty-three successful operations, the ages of the patients ranging from sixty to eighty-one years. Before the operation there was great difficulty in emptying the bladder and more or less cystitis. In all of the forty-three cases castration was performed on both sides, and an improvement in the cystitis and micturition always resulted a short time after the operation. In all cases there was shrinking of the enlarged gland.

White, in his last paper, "The Results of Double Castration in Hypertrophy of the Prostate," re

1 Read before the Medical Society of the City of Denver and the County of Arapahoe.

2 Centralblätter für die Krankheiten der Harn- und Sexualorgane.

3 Annals of Surgery, July, 1895.

ports 111 cases, with a mortality of 18 per cent. (20 deaths); but on 13 of these 20 the operation was performed in extremis, or as a last chance, and the remaining 7 died of morbid changes of the kidneys and bladder which would have proved fatal without operation.'

The fact that hypertrophy of the prostate gland is in very many cases the direct cause of retention of urine and cystitis, ailments which are among the most troublesome and dangerous diseases of elderly people, has resulted in the proposition of many different operations, but their value cannot be compared with double castration.

The cystotomia with drainage and a permanent fistula is not a radical operation because the hypertrophied prostate is not reduced.

The perineal prostatotomia, or rather enucleation of the prostate, has only a mortality of about 5 per cent., but is often followed by a painful fistula. The suprapubic prostatectomia is a dangerous operation and also followed by a fistula.

The destroying of a small part of the hypertrophic prostate by the galvano-caustic methods from the urethra will reduce only a little of the gland.

Ligation of the whole spermatic cord or of the spermatic artery is sometimes followed by gangrene, and its effect on the prostate is also doubtful.

answer the above-mentioned indications, cases which will not succumb to other morbid changes of the organism a few days after operation, double castration will not have a mortality of 18 per cent., but will be a life-saving operation; but if we perform double castration just because an individual has retention of urine, cystitis, and a hypertrophied prostate, and if we neglect to study carefully the conditions of the other organs, in many cases the patient will die, and the operation will become discredited.

The question arises: Can we explain the effect of castration on the hypertrophied prostate? White, in the above-mentioned paper, summarizes his opinion as follows:

"The function of the testis, like that of the ovary, is twofold: I, the reproduction of the species, and, 2, the development and preservation of the sexual characteristics of the individual.

"The need for the exercise of the latter function ceases when full adult life is reached, but it is possible that the activity of the testis and ovary in this respect does not disappear coincidently, and that hypertrophies in closely allied organs like the prostate and uterus are the result of this misdirected energy, etc."

With this opinion White stands not alone. But The subcutaneous section of the vas deferens analogies are not explanation, nor can experiments seems to have some reducing influence on the on young, powerful dogs, full of vitality, be hypertrophic prostate, but it does not act so compared with operations upon old men with promptly as double castration, and, besides, it de- chronic cystitis, retention of urine, and other stroys also the physiological functions of the tes- morbid changes; and last, but not least, the physioticle. logical and anatomical relations between ovary and uterus are of a much more delicate and closely related character than those between testicle and prostate. I cannot believe in a misdirected energy where we have to deal with cystic and fatty degenerated organs in the stage of chronic inflammation (vide later).

Under certain conditions and in cases where we want a prompt and radical result of our activity, in cases, too, where the physiological functions of the testicles do not play any rôle, the double castration may be considered as the ideal treatment for hypertrophy of the prostate.

But the operation itself should be limited to severe cases of cystitis with more or less complete retention of urine, to cases not too far gone nor complicated with important morbid changes of the kidneys, as pyelonephritis or uræmic poisoning, otherwise the result will be a bad one, and the operation discredited.

To perform double castration on an emaciated individual in the stage of uræmic poisoning, or in a case complicated with pyelonephritis or other severe morbid changes of the kidneys, is as foolish as to perform tracheotomy in a case of membranous croup of the lower bronchial tubes, or in a case of general diphtheria.

If we are careful in selecting our cases which

1 White's table shows: 14 deaths from uræmia, 2 from pneumonia, I from nephritis, 1 from exhaustion, I from heart-failure, I from hemiplegia; total, 20.

Other authors claim that the effect is entirely due to some unknown influence from the central nervous system. Again, I cannot believe that the removal of a fatty and cystic degenerated organ which has ceased to fulfil any physiological functions, the removal of which, too, has no influence at all on the body or mind of the individual, can have such an effect on the central nervous system as to produce an immediate shrinking of another organ.

I think it must be possible to find the real cause of the fact in some anatomical or, better, pathological change of the respective tissues; and after a careful investigation in my case I believe this cause can be found in "pathological alterations of the circulatory system to some extent already existing before the operation." It is a fact that after every operation on the testicles the scrotum undergoes atrophy; it shrinks to a small lump of connective

tissue, fatty tissue, and skin. Not only the scrotum, but the penis too becomes smaller, and also the prostate gland. Very often after castration the patients complain of a cold feeling in the penis, as did my patient.

Now, atrophy is mostly a consequence of incomplete and imperfect nutrition and circulation, either from want of oxygen or from some morbid changes of the blood vessels.

Through castration a large number of bloodvessels, besides the spermatic artery and nerves of the dartos, are altered in such a way that many of them become obliterated, and thrombosis takes place; and this thrombosis, especially of the veins, may extend to some of the veins of the prostate gland, as there are numerous anastomoses between the venous plexus pudendalis and vesicalis. When the blood vessels are obliterated not only the smaller veins, but the capillaries and arterioles, as well as the respective tissues, are deprived of the necessary supply of blood and atrophy-fatty degenerationis the result.

married and the father of healthy children. In the last few years his condition has become worse; urination is more frequent and causes him to rise ounce or two of urine was always the result of active six or eight times each night. The passage of an abdominal compression and frequently attended by defecation.

In the latter part of September the patient, 'while fishing, stood for several hours up to the hips in cold water, resulting in complete retention of urine.

Examination. Bladder forming a round, pearof the abdomen; top of the bladder reaches the shaped tumor, easily recognizable on inspection navel; whole region sensitive to touch. The rectal examination shows an immensely enlarged, hard prostate gland the size of a man's fist. Left lobe especially enlarged. The covering mucous membrane is very tight and closely adherent to the gland.

urethra (which always may be used before catheterAfter injection of 1⁄2 per cent. cocaine in the ization in difficult cases), I relieved the patient of 5% pints of urine, of a dark yellowish-color; specific gravity 1024; alkaline reaction; abundant, whitish sediment; traces of albumin. The catheter, before entering the bladder, slipped through a narrow, hard mass, at least one and a half inches in

length, at which place patient had a peculiar gnashing and crashing feeling.

The microscopical examination of the urine showed the presence of chronic purulent cystitis, but no symptoms of nephritis.

Such obliteration of the blood vessels may also result from a direct nervous influence. We know that the plexus prostaticus of the sympathetic nerve is in close connection with the plexus vesicalis, which also gives branches to the vas deferens. These plexuses contain vasomotor fibres, irritation of which is followed by "narrowing" of the respective vessels. Without doubt the blood vessels in cases of chronic cystitis and hypertrophied pros-plete, and as it was impossible to apply a soft, pertate are already in such a morbid condition (mostly fatty degeneration and chronic inflammation of the vessel-walls) as to be "immensely predisposed to the formation of thromboid obliter-courtesy of Dr. See, a catheter of an old type,

ation."

And from such pathological facts, I believe that the "real cause of the shrinking of the prostate gland after double castration is impaired nutrition," as a consequence of obliteration of the bloodvessels caused by a combination of the reasons above

mentioned.

Report of a case:

Mr. J., from Denver, aged seventy years, called at my office complaining of a complete retention of the urine for the last two or three days. Patient is a robust man, and claims never to have been sick except for various ailments of the bladder. As a schoolboy patient had been troubled with a urinary disease of an unknown character. He remembers very well that his abdomen became swollen and that during the school-hours he frequently had to go out to urinate. As a soldier he was sometimes unable to serve as a sentinel, because he could not hold his urine for two hours of duty. In this time he had several gonorrhoeas and strictures, but no syphilis. Afterward he lived as an innkeeper and farmer; free drinker of beer and wine; is

Therapy. As the retention proved to be com

manent catheter, the bladder was emptied and washed out every twelve hours. As a few days later it prostatic, or a flexible catheter, I got, by the became impossible to introduce either a normal, a

which was recommended for such desperate cases long ago by Dr. Andrews, of Chicago. The application of this catheter was astonishingly easy.

As the patient was unable to apply the catheter himself, as the cystitis did not greatly improve, and as about a week after beginning treatment patient had two chills, with a rise of temperature to 100° and some somnolence, I insisted on double castration, which was performed on October 12th in the usual way.

The removed testicles were both degenerated on the surface, small cysts covering the tunica vaginalis propria; these cysts were filled partly with a mucoid and partly with a colloid substance. On the right testicle we found a hydrocele, tunica propria thickened; also tunica albuginea; glandular part of the testis atrophied, of a fatty, white, gross appearance; walls of the vas deferens of the spermatic artery thickened; lumen of the arteries gaping.

Microscopical examination after hardening in alcohol and staining with hæmatoxylin : Interstitial tissue of the gland not hypertrophied; seminiferous tubes partly fatty degenerated, partly filled with immigrated round cells, of a homogeneous or gran.

ular type, some with distinct nuclei; epithelium of | THE PATHOLOGY OF SOME UNUSUAL CONthe seminiferous tubes not recognizable; no spermatozoa; some seminiferous tubes are obstructed with a homogeneous light mass (hyaline). Chronic parenchymatous inflammation, fatty and hyaline degeneration.