Dr. N. Emmons Paine announces his retirement from the active practice of medicine. The treatment of nervous and mental invalids will be carried on by Dr. Edward Mellus in three of Dr. Paine's houses, as heretofore, and he will continue the use of the title "Newton Nervine" in connection with these houses. Dr. Paine will live in his own residence and will retain one cottage, with one special patient, underthe name of the "Newton Sanatorium." Appointments for consultations may be made as heretofore.

Dr. Wesley T. Lee, Secretary of the New England Hahnemann Association, has been appointed a member of the new Board of Health of the city of Somerville.

Dr. Anna Mann Richardson, class of 1901, B. U. S. M., has removed from Bloomfield, New Jersey, to 153 William Street, Orange, New Jersey. Dr. John E. Runnells, B. U. S. M., 1906, has resigned from the staff of the Massachusetts Sanatorium to accept the position of first assistant physician at the new Lakeville Sanatorium, opened on the first of January. Dr. John M. Wise of Waterville, New York, has been appointed his successor at Rutland.

Dr. Margaret Augusta Doolittle, class of '98, B. U. S. M., was married on December 29th to Mr. B. J. O. Nordfeldt, at Tangier, Morocco.

Dr. Leroy M. S. Miner has removed his office from the Pierce Building to 153 Newbury Street, near Dartmouth, where he has leased a house. He announces to the profession that he has for rental two or three very desirable offices.

A PSYCHO-THERAPEUTIC INSTITUTE. 't is reported that Mrs. Martha S. Jones, of Boston, has given to Dr. Boris Sidis, of Brookline, her entire estate at Portsmouth, N. H., for the purpose of establishing an institute to be called "The Maplewood Farms Sidis Psycho-therapeutic Institute." Here it is planned to employ modern methods of psycho-pathology and psycho-therapeutics in the treatment of functional organic diseases.

LECTURES IN BOSTON UNIVERSITY SCHOOL OF MEDICINE.— Lectures on Bacteriology, Hæmatology and Clinical Microscopy will be given by Dr. Watters to the students on Tuesdays, Wednesdays and Saturdays of each week after March 1st. This will include detailed consideration of the theory and practical application of immunization, opsonins, vaccine therapy, etc., as well as interpretation of uranalyses, blood examinations and various other laboratory tests.

Dr. J. W. Ward, President of the American Institute of Homœopathy, is planning to make a tour of a number of the annual meetings of the medical societies of the central States. Among others he expects to attend the meetings in Iowa, Ohio, Wisconsin, and Illinois.

Mr. and Mrs. Edward J. Beach of Dubuque, Iowa, are receiving congratulations on the birth of a son, January 29. Mrs. Beach was formerly Dr. Helen M. Junkins (class of 1903 B. U. S. M.) of Lowell.

Dr. Emma M. Woolley, B. U. S. M., 1894, after a long absence, has returned to Boston and has resumed practice at 820 Beacon Street.

Dr. Robert W. French, class of 1907. B. U. S. M., has removed from Wellfleet to 48 Washington Street, Malden, Mass.

Dr. W. C. Lincoln, class of 1909, B. U. S. M., after a short term of service at the Massachusetts Homœopathic Hospital, has taken up practice at 438 Washington Street, Providence, R. I.

There will be eighteen vacancies to be filled on the Interne Staff at the Metropolitan Hospital, New York City, on June 15th. Examinations for the positions will be held on April 1st at the Hospital. Applications should be addressed to Edward P. Swift, M.D., Chairman Examining Committee, 170 West 88th Street, New York.

THE NEW ENGLAND
MEDICAL GAZETTE

ORIGINAL COMMUNICATIONS.

THE PERSONAL EQUATION, AND END RESULTS IN OPERATIVE SURGERY.

BY HOMER D. OSTROM, M.D., NEW YORK CITY.

With justifiable pride we turn to the records of modern surgery, and feel assured that our present methods of operating, while they necessarily vary, and must develop as we enter new fields of work and overcome former apparently insuperable obstacles, are based upon sound principles and well established physical laws. In consequence of this heritage the surgery of the future will be chiefly occupied with the elaboration of technic, and its broader application. But removed from the brilliancy of manipulation and exclusively operative achievements, if we contemplate the end results of some of our most brilliant operations, those in which operative skill and compelling technic have yielded perfect surgical results but left the patient unrecovered-possible more a neurasthenic than before-we are led to question whether we have not neglected to take cognizance of the personal equation, the ego, and regarded our patients too much in the light of subjects for exhibition, or for the demonstration of the limits of human resistance.

Our patients are more than this if we give them the benefit of all that modern medical science entitles them to; they are individuals, and their personal equation is a weight in the scale of prognosis. It is not enough to think only of the operative results; it is not enough to be satisfied with an aseptic course, perfect healing, and an uneventful convalescence. This may be the postoperative history of a case, and still the operation as far as a means of restoring health is concerned must be counted an absolute failure. The patient may be relieved of a local malady, and of the suffering for which the operation was undertaken, but she may be left a nervous wreck in consequence. As a matter of fact she may be in much worse plight through our entirely skillful and scientific efforts to give relief, and this because of a pruritus operandi warping our judgment and inducing us to operate, having but a single thought, to remove the local disease upon the assumption that it alone is

responsible for what we regard as "nervous reflex symptoms," the symptoms referred to the local pathology sinking into insignificance before their supposed manifestation.

Let me clear the way for a better consideration of the points I wish to make. I do not include emergency operations performed under the necessity of saving life: they must be done, and their primary object having been attained we are obliged to face the consequences. Neither do I consider physical conditions, diseases of the kidneys, the heart, the lungs. These organs always receive ante-operative attention, and in a measure the data gathered dictates the course to be followed. But I wish to direct attention to a less frequently investigated field, the patient's personal condition, the mental and nervous states, in other words, the personal equation, with especial reference to acute and latent neurasthenia.

Too much stress cannot be laid upon the question of operating on neurasthenic patients, and I feel that we are justified in refusing operation unless the neurosis can be shown to be due to organic disease that is removable surgically. Non-recognition of this rule is accountable for many of the disappointing end results in operative surgery; for our failures to relieve general conditions by removing a supposed local cause.

Especially is this true of the surgery of the uterus and its adnexa. In the early days of abdominal surgery when operators referred with pride to the number of ovaries they had removed, and the lightninglike speed with which castration could be performed-ten or fifteen minutes being sufficient to change a woman's nature and functions (I also must plead guilty to this accusation), there can be no doubt that many ovaries were unnecessarily sacrificed; that women, young and still within the child-bearing age, were ruthlessy mutilated upon the erroneous conception that every neurosis from which a woman could suffer must have its origin in her sex glands, and that many cases of neurasthenia had their genesis in some perversion of ovarian function. Hence, after a double oophorectomy, the removed organs frequently showing no appreciable lesion, the reflex (?) nervous symptoms not only continued but quite as often increased in severity; the shock of the operation, and violent withdrawal of ovarian secretion and function. adding to the already existing nervous exhaustion which was entirely independent of the local pathology.

We are learning wisdom, unfortunately sometimes at the expense of much unnecessary mutilation, and more exactly differentiate the operative from the non-operative neuroses of women, but we can not place too prominently before us the necessity of sifting by the most minute analysis every case of neurasthenia associated with conditions that may require surgical intervention; of eliminating by every diagnostic resource the sex glands from among etiological factors. For of this we may be certain, if we remove them under the mistaken impression that they are the causes of the neuroses, the condition of our patient will not be improved, and may

even be aggravated from the shock to the nervous system induced by the operation itself. We should at least delay operation, even though it be certain the ovaries enter into the causa morbus, until we have been able to repair in a measure the nervous exhaustion. Such a course is to be commended upon the ground that our compensation will be a more certain cure of the neurasthenia.

It is easy in surgery as in other matters to formulate rules, to say what must be done and what must not be done, but the fine lines of diagnosis that support either contention are more difficult o establish. Pathological lesions of the ovaries may or may not be associated with neuroses. This point we must not lose sight of, nor of the equally ascertained fact that ovarian diseases may coexist with neurasthenia, the two conditions bearing no closer relation than this, being indeed unrelated to each other.

In considering this subject, too vast a one to be covered in a necessarily limited article, it will be well to fix two points in mind: (1) that the female sex glands perform at least two functions, quite irrespective of each other: the function of a gland by which a special secretion is furnished for the economy; and (2) the function. of ovulation, by which fertile eggs are discharged. It is therefore evident that neuroses depending upon the ovaries will relate to an imperfect performance of one or both of these functions.

Still closer analysis makes it probable that the normal secreting functions of the ovaries is to all intents and purposes continuous, from the development of the sex characters-even before puberty they are well marked-through reproductive life, until the folding up of the sexual organs; but that ovulation, the casting off of the mature ova, is irregular and may occur at any time within the period of sexual activity. It will be observed that I say mature ova, for it is probable that ova fall into the abdominal cavity in childhood, even in infancy; but these are incapable of fertilization and belong to physical immaturity.

Practically applied this generalization may assist in determining for or against the propriety of an operation. If for example we reach the conclusion that the neurasthenia is connected with a pathologically functionating ovary, the neurotic symptoms will be subject to little or no remission when the condition depends upon a deficient ovarian secretion. It is evident that such cases are not favorable for surgical operations, for if the quantity of the secretion is below normal, what can removal of the gland avail?

On the other hand, if the symptoms of neurasthenia manifest a periodicity in their recurrence that can be associated with ovulation, an abdominal operation may be undertaken with more assurance of success, either a conservative operation, in which, however, I place little confidence, for a part of the ovary that is capable of continuing the disease may not be detected, or a radical operation with complete removal of the pathological focus.

But even when an operation is finally considered necessary, the patient's nerves should, if possible, be protected against inevitable

shock by proper preliminary treatment. We cannot give too much time and attention to such preparations, and we must frequently supplement them with prolonged post-operative care.

The keynote for the management of all neurasthenics is rest, individualized it is true for each case, and we cannot condemn too vigorously the ambition some surgeons manifest to shorten the convalescence of patients and to "get them out" in the shortest possible time, for under the entirely erroneous impression that change and diversion are of benefit for "nervous women," their already exhausted nerves are further taxed, and deprived of the treatment they need most and call out for—rest.

I have dwelt somewhat at length on the relation between neurasthenia and pathological lesions of the ovaries, and the propriety of operating when such can be demonstrated to exist, for the reason that gynecologists are biased in favor of their special field of work, and also because there is a general impression that the neuroses of women must of necessity have more or less to do with their peculiar feminine functions, and sex organs. This is far from the truth, and the sooner we remove it from our minds the better it will be for our patients. We must realize that a woman is not all ovaries, and that she has other organs that exercise a strong influence upon her

economy.

As neuroses are more frequent in women than men, the propriety of operating on a neurasthenic patient becomes an especially pertinent question when considering any operation on a woman. In particular we should exercise caution when the abdominal or pelvic viscera are points of attack. These are in varying degree connected with the sympathetic system of nerves, and a technic that includes operations on them induces an exhaustion of the nervous system out of all proportion to the severity of the procedure, adding this to the general shock that must always be reckoned with.

It has long been a well recognized fact that operations on the kidneys, especially done with the object of fixing them in position, are frequently unsuccessful as far as relief of the accompanying neuroses is concerned, and for this reason surgeons select their cases with the greatest care, even refusing to operate unless under the most urgent conditions. A like restriction is placed on the surgery of the other abdominal and pelvic organs, but the prevalence of neurasthenia among women must not obscure the fact that men also are not infrequently neurasthenics, and suffer as well from operations on their abdominal and pelvic organs.

What is to be done for the neurasthenic patient who requires a surgical operation? As in every problem in surgery, we make an equation, and must strike our balance. When the question of saving life enters either as an emergency which admits of no delay, or a malady certain to terminate fatally, we disregard the neurasthenia and act as though it were not present. And if we are convinced that the pathological lesion is of such importance in the clinical ensemble as to dominate it, and stand in the relation of the exciting as