RonaldA.D. Daniel
1896 The Lancet  
I HAVE recently had occasion to remove the median lobe of the prostate from a patient nearly sixty years of age who was to all intents and purposes a monorchid. Shortly after birth the left testis had been subjected to a proceeding similar to ] bistourage at the hands of an attendant and, as a consequence, it had wasted away. The cord could be traced a short distance down from the external ring, but there was no sign of testis or of epididymis. The symptoms for which the patient consulted me
more » ... e characteristic of median valvular enlargement of the prostate. The residual urine amounted to ten or twelve ounces in spite of the fact that the bladder retained a fair amount of muscular power. So long as the patient was lying down and made no particular effort micturition was easy. If, however, he stood upright, and especially if any vigour was thrown into the attempt, the stream of urine stopped abruptly. Examination by the rectum showed but little change in the apparent size and relations of the prostate. The prostatic portion of the urethra was, however, more than two inches in length, and a metal catheter could not be passed without depressing the handle to a very considerable extent. A median incision was made into the urethra through the perineum, and the diagnosis confirmed by digital exploration. There was a pedunculated median outgrowth, nearly the size of a pigeon's egg, hanging in the orifice of the bladder and acting like a ball-valve. The lateral lobes were but little enlarged and were practically equal in size. This case is of much interest in connexion with the question of the treatment of overgrowth of the prostate by unilateral orchotomy. It shows definitely that the removal of one testis, even in early infancy, will not prevent obstructive enlargement of the prostate later in life. It is to be noted, however (and the fact may prove to be of some importance), that the removal was effected subcutaneously by absorption, and that the cord was not divided high up and ligatured as in the operation of castration. The results, so far as the prostate is concerned, of removal of the testis alone and of removal of the testis and a great part of the cord by operation may be identical, but though it is usually done this should not be assumed without further evidence. The improvement that has taken place in some of the cases in which unilateral orchotomy has been performed is probably to be explained by the differences in the development and growth of the prostate in different individuals. In man the prostate is in its inception essentially a double organ, as it is in many of the lower animals. In them it is developed in connexion with the vasa deferentia, and the two sides remain more or less distinct. In man the seat of origin, like that of the ureters, is displaced until the gland tubules appear to be connected with the urethra rather than with the ejaculatory ducts ; and the two halves approach each other until, like the uterus in the opposite sex, they fuse together. The degree to which this fusion takes placeand it varies very much in different people-is in all probability a measure of the extent to which each testis controls the whole gland. In patients in whom the enlargement is confined strictly to the lateral lobes the unilateral operation may succeed. In those, on the other hand, in whom there is a median outgrowth it can be of little use. From this it follows: (1) that much more accurate diagnosis of the particular kind of enlargement is required before the unilateral operation can be condemned-unfortunately, in the cases that have been published, successful and unsuccessful alike, only the vaguest details have been given ; and (2) that experiments with the view of determining this point, performed upon animals, in which the fusion is less complete than it is in man, are of no use, for the conditions are not the same. THE above condition being of somewhat rare occurrence, and the treatment most often unsatisfactory, a few notes of a case which has come under my care may be of some interest. The patient was twenty-eight years of age and had suffered from the complaint in question for over a year. It had come on gradually and was at first only apparent when he spoke publicly under exciting or nervous conditions. From this, however, it became more and more common, till at last any duties involving public speaking became most difficult. In ordinary con.. versation it was only occasionally noticeable, while singing could be performed without inconvenience. The patient described the effort to speak as being most distressing, as, though articulation proceeded, he was unable to. produce any sound for an interval varying from one to two minutes. A careful examination with the laryngoseope, revealed no abnormality of any kind, and his generaL condition was all that could be desired. He had been under medical treatment and tried various remedies, without, however, any, or but a little temporary, improvement. Under such circumstances I decided to call in the aid of electricity, and to this end used the constant current for from fifteen to twenty minutes every day for a fortnight, after which time, as progress was favourable, I reduced it to three times weekly. I employed sponge electrodes of such a size and shape as could conveniently be placed on either side of the larynx, and also varied the treatment on each occasion by directing the current antero-posteriorly, placing the anodal electrode over the larynx and the kathodal one on the back of the neck. The strength of the current used varied from two to three milliamperes, and the case was treated for nearly six weeks, improvement becoming more and more apparent. It ended happily in the disappearance of the patient's malady, of which two months afterwards there had been no return. Remarks.-This condition has been mentioned by Prosser James as " stammering of the vocal cords," a term which I think very aptly describes its distinctive features, for one must at once notice the striking analogy existing between it and an ordinary case of "nervous" stammering. In both there is the increased tendency when excitement or emotion comes into play, or where the subject attempts the process of public speaking, whereas in such efforts as singing a similarity exists in the disappearance of the trouble. Again, in the case mentioned above the patient was always for the time relieved by taking alcohol, but seemed worse after much smoking, menta.l worry, or marital intercourse, a condition of things which I have invariably found to apply in the case of stammerers. Furthermore, both disturbances would have a common effect in making the sufferer intolerant of society and unfit him for certain forms of occupation. With regard to electricity as a remedial agent, I have noticed some correspondence iD THE LANCET as to the relative efficacy of different modes of application. It seems to me, however, that it is impossible to lay down any hard-and-fast rule in its employment, for where such points as sex, age, and susceptibility so powerfully obtain cases are best treated on their respective merits. In neuralgic and other appropriate conditions I frequently obtain the best of results from the constant current applied as indicated above, the only drawback, of course, being the tendency to irritation of the skin. This, however, varies very much in different individuals and must be obviated by changing the position of the electrodes or , reducing the current. In order to obtain beneficial results the main point is, I should say, for the practitioner to apply the agent himself or see that it is done by a competent
doi:10.1016/s0140-6736(01)92000-8 fatcat:qrazeqmtjvcjna23mhiptc46v4