summer before, but when he got back he had so the Jewish people live or recently have lived. much to do that he thought he had lost more than There is not, however, anything essentially he gained, and said he would think twice before Jewish or Hebraic about them; there is nothing going again. With the majority the only change that makes them different from neurasthenic in the routine of life is the walk to and from work, symptoms in other races. According to the the visit to the butcher's or grocer's, or the chat testimony of physicians who come in contact with the neighbors on the doorsteps. with the prosperous and educated Jews, removed from those circumstances, their patients do not present the symptoms so commonly seen among the Jews coming to the hospital clinics. The same is true of the second generation of the Russian Jewish immigrants.

As I have mentioned above, 38 of the 51 cases studied were women. Moreover, as far as my own experience goes, and my experience has been chiefly with Russian Jews, as well as that of many that I have questioned on this subject, almost all married Jewish women, whether of the The Jew is markedly neurasthenic, but as the hospital class or not, some time or other get into a French author, Leroy-Beaulieu, says, "It is not to debilitated condition, and present symptoms simi- be attributed to his Oriental origin or to a peculiar lar to those of the cases here analyzed. They are anatomical structure. The predominance in the temporary affairs, but recur; all due to the mode Jew of the nervous system over the muscular of living, exhaustion or worry. I have observed, system is due to the mode of his secluded living, however, that imitation and tradition play some to the conditions of his existence, to his sedentary part in the etiology of these debilities. The and city life, with lack of physical exercise and undercurrent of thought on this subject seems weakening of the muscles, to the emotions and to be that from time immemorial women have cares of the occupations carried on by his fathers. been sick; it is a sort of privilege tolerated with For centuries he has owed his existence more to them; it is even expected of them. "A woman his brain than to his arm. Even now in Russia keeps on dying all the week, but recovers on the he succeeds in maintaining a miserable existence Sabbath," and "A woman has ninety-nine souls," only by a miraculous will and industry." Here are two Jewish sayings which show that this in America the effect which migration has upon feeling is deeply rooted. It is the subject for the nervous resources of the Jew must be conconversation when women get together; to be sidered, and at the present time, also, the effect sick gives one a standing in such circles. Gradu- of the atrocities committed upon his "flesh and ally it creeps into the young woman's subcon-blood" in Russia and other black spots on the sciousness, and she, too, begins to visit the doctor map. or the hospital.

In the Shattuck Lecture of 1899, Prof. J. J. I know, however, that the Jewish women in Putnam, says, "This or that American or IrishRussia do not complain as much as when they man or Jew cannot be treated to the best adcome here. They all boast of their strength and vantage so long as he is regarded solely as an good health there, and of the amount of work individual. His racial traditions and temperathey could do. The change is due, of course, to ment should be taken instinctively into account." the strenuousness of the transitional period which Because of the failure to do so, it seems to me, they are living through. I wish to call attention the treatment of the class of patients considered to another factor, a minor one though it may be. in this paper, both in private and hospital pracOne often hears of the great percentage of people tice, is as unsatisfactory as it is. When a woman seeking medical advice at the hospitals, but one comes complaining of pain in the side or back, seldom considers that many people seek medical or of headache, or of any other such symptom, it advice because there are hospitals. In Russia is not enough to say, "Oh, well! She is a neurasthe Jewish woman can hardly afford to consult thenic. Give her Mixture X or Tablet Y." a doctor for the least thing that ails her, and The patient so treated will keep on coming to the hospitals and dispensaries are very rare. In the clinic for some time, and then go to another, and American cities, on the other hand, it usually so on. The physician, especially with these so happens that the large hospitals are situated Jewish patients, must learn to appreciate their in the very centers of the crowded districts, not natural history, their temperament and tradito mention the many dispensaries and the lodge- tions, their modes of living and suffering, in a doctor system. These help the Jewish woman word, to understand them. Such an appreciation to keep her attention on herself; she goes to the will lead to sympathy rather than to repulsion, hospital or to her lodge-doctor for things which and instead of taking half a minute, he will take in her old home she had to overlook and forget. three or five, reassure his patient, gain her confidence, and instruct her to control her "pain sensations and to correct her diet and habits. My aim has been to bring out and emphasize A patient so treated, no matter how dull or several points which have become clearer by this ignorant, will show results; once or twice at the study. Is there such a condition as Hebraic hospital will be enough for her; besides, she will debility? Is there a debility peculiar to the become a missionary to her circle of friends. Jewish people? I cannot think so. I admit that I have mentioned before that the second the symptoms considered are, in their grouping, generation of Jewish immigrants, relieved from expression and frequency, peculiar to the abnor- many of the abnormal circumstances under which mal circumstances under which only a part of the parents labored, quickly get away from the

THESE DEBILITIES ARE NOT PECULIARLY JEWISH.

"

tendency toward debility. Moreover, these young people very frequently bring light into the households of their parents. I know personally of many instances where the parents have learned to lead more rational and comfortable lives through the influence of their children. It is through these young people, trained in American institutions and ideals, that the differences between the many elements of the population are to be removed.

SUMMARY AND CONCLUSIONS.

1. Debility is a common condition among the Jewish patients coming to the Massachusetts General Hospital; as a rule it is temporary, but is apt to recur.

2. The prevalent symptoms are pain, constipation and apprehension.

3. The etiology of these debilitated conditions is to be traced to the peculiar circumstances under which the Jews have lived and still live in eastern Europe. Here in America the economic strain during the early years after arrival is an important factor.

4. Debility is especially common among the Jewish women of the immigrant class, because the economic strain weighs very heavily on them. With them, also, imitation and tradition and the ease with which medical advice can be obtained are factors to be considered.

5. These debilities are peculiar not to the Jew, but to the abnormal conditions under which he has been living. As soon as he is relieved from these conditions his symptoms are not different from those of other races.

6. Finally, in the treatment of the cases considered it is well to bear in mind the importance of the old sentiment, not the disease only, but also the man."

Recreation:

Vacation regularly,

Vacation occasionally,

Massachusetts General Hospital.

CLINICAL MEETING OF THE STAFF,
NOV. 22, 1906.

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I. TWO CASES OF EXCISION OF ADENO-CARCINOMA
OF THE RECTUM, WITH PRESERVATION OF THE
SPHINCTER.

II. CANCER OF PROSTATE. COMPLETE PROSTATEC-
TOMY BY LORING'S METHOD.

III. DIVERTICULUM OF BLADDER.

NEAL REMOVAL WITH SUTURE.

BY C. A PORTER, M.D.

EXTRA-PERITO

On entrance, urine was of normal color; acid reac- An ulcerated infiltrating new growth about 4 cm. tion; specific gravity, 1,019; no albumin; no sugar. in diameter with a slightly papillary and infiltrating A month later (Jan. 8), urine the same with the excep-edge 5 cm. above rectum. tion that the specific gravity was 1,024.

Family history negative. He had always been well, and had worked hard. Many years previously had rheumatic fever, which was his only illness. He has had piles for twenty years, but they have never troubled him until about a year ago. Always been constipated. Denies venereal.

Microscopic examination. Shows irregular glands which had infiltrated the submucous tissue and, in some places, apparently has solid masses of epithelial cells. Adeno-carcinoma. Dr. Whitney.

In both of these cases, the sphincters have been One year ago, piles began to itch and burn; bled preserved; both had an ulcerated adeno-carfrequently, and came down outside anus at every cinoma on the anterior wall of the rectum about movement of the bowels; has used various salves 4-5 cm. in diameter. In the first case, an incision without relief. Complains chiefly of bearing down in was made from the lower end of the sacrum rectum, coming on before a movement of the bowels; down through the sphincter ani in the median also the annoyance which the piles cause him. No line behind. The coccyx was removed. This bad pain in rectum; no mucus or pus discharges; no incision was continued in the median line, through loss of weight. the posterior wall of the rectum, both edges of P. E. Poorly developed and nourished. Heart, the wound being then widely retracted, disclosing lungs and abdomen negative. Rectal examination: the ulcer on the anterior wall. This was freely on anterior wall of rectum, about three inches up from anus, is a soft, spongy tumor, irregular in outline, size excised, and the tissues behind the prostate and of a small hen's egg. Few small glands in groin. about the vesical seminals cleaned out. This Operation, Dec. 4, 1902. C. A. Porter. Ether. circular wound was then closed with buried catPatient lying on abdomen, with thighs moderately gut stitches, from above downwards. The posflexed. Sphincter dilated; rectum irrigated with terior incision in the rectum was closed in the corrosive 1-1000, and salt solution. same manner, laterally, and the sphincter muscle Incision 9 cm. in length, extending along cleft of sutured. A rubber tube was placed in the recnates, into rectum. Sphincter cut; incision carried tum, with posterior iodoform gauze drainage on down to bone. Coccyx separated from soft parts with either side. periosteum elevator, and removed with bone forceps. In the second case, the same incision Incision carried around rectum mucous membranes, was made down to the rectum. The sphincter just above external sphincter, and carried through the was divided, and the rectum cut just above the walls to the perirectal tissue. Keeping in the blunt internal sphincter. The rectal tube with surof cleavage, the rectum was separated and isolated for rounding fat tissue, was then freed and divided 12 cm. of its length. Walls of rectum were somewhat transversely an inch above growth. The upper adherent to prostate, but were separated cleanly. end of the rectum was then brought down and Peritoneal fold of anterior wall of rectum was pushed sutured in a circular fashion, and the mucous backward and upward, and peritoneal cavity was not membranes just above the internal sphincter. opened. Mucous membrane which was left covering Both sphincters were then sutured; rubber tube sphincters was dissected off the cylinder of rectum, in the rectum, and posterior gauze drainage as containing growth, and completely isolated, was cut away and removed; bleeding points tied. The incision was 2 cm. above its highest demonstrable limit of growth; one or two small perirectal glands were removed also. The divided end of the gut was then sewn to skin about margin of ends; this was done easily without undue stretching. The ends of the divided sphincters were approximated, thus encircling the transplanted gut very effectively. One silkworm stitch taken to close section wound. A drainage tube put down to the left of gut, and rubber dam to right. T. bandage.

Kraske operation (modified) for carcinoma recti. Patient was breathing laboriously and had poor color throughout operation. Sent to ward in fair condition; shock enema.

Reported later for poor pulse, which was irregular and easily compressible, although of good volume.

Wound discharged very little; no pain or discomfort. Patient was unable to evacuate bladder completely, and the residual urine increased, so daily catheterization was resorted to.

Examination of 19th showed that sphincter grasped finger very strongly, but apparently voluntary nerves are cut, for patient has no control. Bowels are loose, and movements occurred without knowledge of patient. Four months after operation, patient regained control of urine, and slowly regained control of sphincter ani. Was discharged Nov. 4, 1903; holds feces well for three to four days; sometimes a little blood co.nes away, but there is no pain. Examination of rectum shows scar wound, with no signs of recurrence.

before.

In both cases there was some fecal leakage but the sinuses were closed in six weeks.

II. Patrick J. Kelley, aged fifty-one, residing in East Boston, was admitted to my service, July 26, 1907; recommended by Dr. Lincoln in the Genito-Urinary Department. His history is as follows: Denies venereal; moderately alcoholic; bowels costive; indigestion at times; has lost no weight. Well nourished muscular man. For several months has been troubled with frequency of micturition at night, which wakes him three to four times. Four weeks ago, had to pass urine frequently during the day with scalding sensation. Has never had pain other than on urination. Rectal examination shows small, indurated and nodular prostate; not tender. No glands by rectum; no glands in groin. Testicles and cord negative. Urine acid; no albumin; no sugar; specific gravity, 1,015.

Cystoscopic examination by Dr. Davis, July 25. "Kollman instrument introduced with considerable difficulty, requiring great depression of the handle. Some spasm of neck of bladder. Fundus trabeculated; whole floor of bladder ulcerated. Right lobe of prostate presents rounded tumor, size of marble, which runs off into a generally elevated surface, presenting little reddened excrescences suggesting a new growth. There is a black mass, about size of strawberry, which cannot be fully brought into view, and which moves from one part of the bladder to another. There was some hemorrhage. Ureteral openings not distinctly

seen. Diagnosis of incipient prostatic carcinoma made, irregular and to be increased markedly in numbers. and radical removal advised. This diagnosis was The muscle tissue is somewhat infiltrated with round concurred in by me from the rectal examination, owing cells, but not greatly changed. The whole increase to the nodular condition and the extreme hardness. in bulk is apparently in the number and size of these Operation, July 31, 1907. The patient in Trendelen- glands, some of which are clearly defined with firm berg lithotomy position. Horseshoe incision made in basement membranes; these, however, at one point perineum and dissection made exposing the bulbous or another, entirely lose their basement membrane, urethra and the prostatic lobes; considerable bleeding. and the cells can be seen growing freely in the muscular An oblique incision was then made through the right tissue, separated from any gland. All of the glands lobe of the prostate, and a wedge-shaped piece given to show marked hypertrophy, in the epithelial structures, the pathologist for examination. The report from the many of them being noticeably papillomatous. As frozen section given to Dr. Kidner, and confirmed by far as could be made out, however, the capsule is not Dr. Richardson, was probably carcinoma, and the infiltrated. radical operation decided upon. Section through the vasa afferentia and seminal A median incision was made just back of the mem-vesicles shows again great increase in the epithelial branous urethra and Young's retractor introduced. lining of these structures. In places the mucous memThe prostate was pulled down with strong traction, branes seem to have broken through its basement and with scissors and blunt dissection, the surrounding membrane and to be infiltrating the muscular layers of structures were freed from the prostatic capsule. The the tissue. bleeding was very troublesome, controlled by snaps and pressure. After the posterior and lateral parts Patient reported to me a week ago at my office. He were thoroughly freed, the urethra was divided at its can hold his water an hour and a half at night, but membranous portion; the whole mass pulled down- is incontinent during the daytime, wearing a urinal. ward, and with great difficulty and copious hemorrhage, There is a definite narrowing, admitting No. 24 French the prostate was freed from its pubic attachments. at the site of the suture. The urine shows slight The bladder was opened anteriorly, two strong silk cystitis. He has no pain; has gained weight and sutures being inserted at the edge in order to prevent color. retraction. The base of the bladder was then divided with scissors, well behind the internal sphincter, and the vasa deferentia and two thirds of the vesical seminal removed en bloc." A No. 12 English soft rubber This case is interesting, I think, in two respects: catheter was then introduced through the urethra into first, because an attempt was made, by saving the bladder, and with 00 chromic catgut sutures, the the membranous urethra, to restore partial conmembranous urethra was sewed about it to the bladder, tinence. In the operation as planned by Young, and the stem of the Y-shaped opening in the blad-the membranous urethra is removed. Up to the der closed in a similar fashion. This proved to be a

Adeno-carcinoma of prostate.

Rectal examination shows in region of the left vesical some fullness, but no nodulation.

very difficult manipulation, and the patient had to present time, however, this attempt has been be lowered from the Trendelenberg position owing to unsuccessful. Second, the question of diagnosis the retraction of the bladder. A number of tension sutures were placed about one inch from the urethral suture, passing through the muscular walls of the bladder and posterior part of the pubic bone.

Iodoform wicks inserted by the side of the newly formed urethra, extending on either side into the pubic region.

and a choice of cases for this formidable operation. From my experience with this patient, and the few reported cases, it would seem an absolutely unjustifiable operation to do in case there was any reasonable doubt as to the presence of carcinoma. On going over other sections of this Operation lasted for three hours, and the patient prostate, mounted in paraffin and more careful was put to bed, suffering both from shock and hemor- staining, there is at present some doubt whether rhage. The operation seemed to me both a very cancer was actually present, but it is certain that severe and a difficult one. Convalescence, however, was there was an abnormal tendency for adenomatous satisfactory. At the end of five days there was some tissue to be found in the surrounding tissues, sloughing of the fat tissue, and some leakage due to suggesting at least the probability that adenosuture. The catheter remained in position forty days, carcinoma would develop, or might be found in at the end of which time, methylene blue showed no other places on further section. In subsequent leakage in the perineal wound, which was almost cases, I should advise enucleation of the gland, closed. Patient was discharged Sept. 19, about two if the frozen sections did not show definite carcimonths after entrance. The specimen consists of symmetrical prostate, noma, or the clinical signs were absolutely 4.5 by 5 cm. in diameter; its two lobes being practically characteristic. equal and not markedly lobulated. The capsule appears covering the whole mass. There is also a piece of the floor of the bladder about 2 by 2 cm. containing the internal meatus and the prostatic urethra. Be hind appear the seminal vesicles, which are dense and thickened. Also the vasa deferentia, which are filled with muco-purulent fluid. Both these structures are greatly thickened, hard, and suggest malignant feel. On section, the prostate is unusually homogeneous in structure, although the minute glands can be made out, scattered all through the cut surface. The structure seems to be unusually cellular. The capsule is not markedly adherent to the prostate itself. Microscopic examination through the prostate and capsule shows the glands to be everywhere extremely

III. Hudson H. Smalley, aged thirty-four, entered Dr. Cabot's service in April, 1906, with the diagnosis of cystitis. Twelve years before, he began to have bladder trouble; frequently scalding micturition, often passing fragments of tissue size of a pea, and once a piece as large as palm of hand. He was treated at the Maine General Hospital for ulceration of bladder. Denies venereal.

At present he complains of passing both fresh and clotted blood with a bad odor. Has difficulty in starting stream; dribbles, and he feels that he never fully empties his bladder. He has frequency of urination every half hour or more during occasional attacks of cystitis. Appetite is good; bowels regular.

Bladder is full, extending to umbilicus; no fever. lost weight and is utterly discouraged. On Sept. 8, I Urine: specific gravity, 1,015; slight trace of albumin; decided to make an attempt to remove the diverticula alkaline reaction. Sediment: some pus; bladder by Young's method. cells; triple phosphate crystals; numerous blood cor- Patient in Trendelenberg position; five-inch suprapuscles, both normal and abnormal; many bacteria. pubic incision to left of old scar. Everything was Catheterized and 19 oz. of residual urine found. On bound together by cicatricial tissue. Incision then the next day, residual urine 24 oz., and on the fourth made parallel to Poupart's ligament on the left, outday could not be catheterized on account of spasm. ward, for a distance of three inches. Dry gauze disDecided to go home against advice. section backward and to the left, freeing the upper Patient entered hospital again April 16, 1907; has part of the bladder which had been distended with lost weight and looks badly. Rectal examination boric solution. The peritoneum was opened and shows prostate moderately enlarged; base of bladder through this the base of the bladder was examined. uneven, tender, boggy and indurated. No. 11 English After carefully walling off with gauze, an elastic mass soft rubber catheter passed with some difficulty, about the size of a banana, and three inches long could drawing off 27 oz. ammoniacal urine. Patient put be made out extending backwards and to the left of on constant drainage, and three days of such treatment base of bladder firmly adherent to rectum and surroundcleaned up the urine somewhat, and patient was much ing structures. After freeing the bladder and divermore comfortable. Cystoscopy by Dr. Davis, who ticulum, it could be seen that the vas deferens ran found three diverticula from the bladder, one large obliquely inwards and backwards, anterior to the sac. one extending from the left side of the base, backwards An attempt was made along a line of cleavage to sepaand downwards. rate the rectum from the diverticulum, but this dissection was found to be too dangerous, so the bladder was opened suprapubically, and after much difficulty, the forefinger was hooked into the diverticulum and, the bladder with it, forcibly pulled forwards. After this maneuver with dry gauze, scissors and the finger nail, the rectum and surrounding tissues, after a half hour's dissection, were gradually separated from the wall of the sac. The diverticulum was then grasped with double hooks and firmly withdrawn, and cut off May 7. Copious leakage about tube and gauze wick; with scissors from the base of the bladder. The opentube removed, and inlying catheter inserted. Patient ing left was sutured with two layers of buried catgut sat up in bed; free drainage from the suprapubic stitches. The left urethra was not seen at any time, wound and urethra. On the 10th moderate suppura- but the left seminal vesicle was exposed in the dissection of prevesical space. Bladder irrigated with tion. The peritoneum was closed. The bladder argyrol, 5%; urine much clearer. On the 21st, washed out carefully, and sutured in layers, about a second operation by Dr. Mumford. suprapubic tube. The bed left, after the removal of the diverticulum, was packed with iodoform gauze, and a soft rubber tube and catheter was placed in the urethra. The operation I consider an extremely difficult one, requiring three hours of hard work. On the day following, however, the patient was in fair general condition.

April 30. Operation by Dr. Mumford. Transverse incision above pubis; prevesical space opened; bladder wall thickened and friable; opened and a quantity of foul smelling fluid escaped. Upon exploration, two diverticula found, one about length of little finger, extending backwards and downwards. Radical operation was not attempted. A catheter was sewed into the bladder with a puckered stitch; wound closed with drainage.

Operation. Bladder opened suprapubically, and found almost as foul as at previous operation. Diverticula examined and found to be sacular, with a tight sphincter at the orifice. These sphincters were both widely dilated, and the diverticula packed with iodoform gauze. Rubber tube inserted through suprapubic wound and a No. 10 soft rubber catheter through urethra; prevesical space drained with gauze. On June 8, wound fairly clean; temperature normal; some drainage through suprapubic sinus; urine much clearer. On the 19th, suprapubic wound leaked copiously; hardly any urine by urethra. On the 24th, patient etherized and pus pocket found on anterior wall of urethra; 32 sound passed, and good drainage established through a No. 11 English web catheter. On the 25th, the powerful action of the muscle drove out the catheter.

June 30. Operation by Dr. Jones. Posteriorly, urethra explored through the wound, and several pockets found. Index finger passed into the bladder, and a large rubber tube inserted and sutured in position. July 3, patient has been draining well; little suprapubic leakage; urine less foul; no dependent drainage and frequent irrigation of bladder. On the 14th, catheter through urethra. On the 22d sleeping and eating better; urine clearer; draining well.

Sept. 27. Bladder draining well, both above and below.

Sept. 29. On doing dressing this morning, part of peritoneum overlying upper part of wound was found to have protruded through the wound with a loop of intestine within it. There were no signs of strangulation, and the little perineal hernia with its contents was pushed backward and held in place with gauze without further trouble.

Oct. 3. Bed rest. Amount of drainage daily increases; patient very comfortable, with normal temperature; good drainage through urethral catheter; bladder washed out twice daily. No leakage through wound into dressing.

Oct. 4. This morning, the urethral tube was found to have drained hardly any, and the suprapubic dressing was soaked. The tip of urethral catheter protruded through suprapubic wound, which has opened, so that the suprapubic drainage tube was quite loose. The latter was therefore removed, and the catheter poked back into the bladder. Pelvic packing removed, and replaced by plain gauze, and upper angle of wound tightly restrapped with adhesive plaster.

Oct. 6. Wicks all removed and replaced with similar ones; two in number passing down between bladder and rectum. The upper angle of wound drawn together with adhesive plaster.

Aug. 2, patient discharged, but urine still foul; unless on constant drainage, some suprapubic leakage. Re-entered hospital in my service, Sept. 20, 1907. Had been doing badly in the Out-Patient Department, and for the last five days pain in left renal region, and marked swelling of the left epididymis. Examination shows definite tenderness in the region of left kidney, with albumin and numerous casts in the urine, which Oct. 7. Patient draining well this morning, with is foul and full of pus. Patient had apparently devel-normal temperature, and little suprapubic leakage. oped a recent pyelitis as well as an epididymitis. Has Oct. 8. Wound cleaning up well, and much less