useful in obstinate diarrheas. Of the bromide, five grains was an average; ten grains a full dose as to bromide action, relieving congestive headaches, convulsive states, epilepsy, etc.

Rosh Leaman found nickel bromide best for epilepsies with infrequent regular attacks, where a mild impression is to be maintained for a long time.

Kolipinski chose the sulphate as affording nickel effects rather than those of the acid element. The dose he fixes at one grain four times a day, in pill, tablet or solution. The latter, 1:1900, proved a potent germicide and antiseptic. In 1- to 2-percent solution it cured impetigo contagiosa, pityriasis versicolor, ringworm, and eczema marginatum.

The patches of alopecia areata showed new hair in a week. It is a good application for acne, giving the remedy internally also if the patient is a young anemic. It is also good internally for urticaria from overwork, with nocturnal outbreaks, for the irritation of erythema and for chronic psoriasis.

Chorea was cured by nickel within four weeks, the nutrition improving under the remedy without the unpleasantness of arsenic. Stammering improved after two months' treatment, the nutrition and morale showing benefit. Tic douloureux was eased by nickel. In all migraines, it proved one of the best remedies.

Chronic enteritis gave way to nickel in connection with dieting; also in tuberculous diarrheas it prevented relapses. In epilepsy, the sulphate proved useless, although Kolipinski tries hard to make out a case for it. But it proved of value in the emotional and psychic weakness, the vague ideation, the instability of character and action met with in celibates of both sexes. These are termed neurasthenics. Nickel relieves their insomnia, dyspepsia and irritability, restoring failing vigor.

Nickel is a sedative tonic of peculiar and elective power in obviating the effects of sexual abuse; the heart action being the index of the trouble. Spermatorrhea is likewise benefited.

Dr. Kolipinski does not show a judicial attitude, but is trying to write up nickel.

His description of the effects of masturbation appears to have been copied from the advertisements of quacks. Despite his warm enconiums, we find no sufficient proof that nickel exerts any beneficial powers in itself. In diarrheas, it is like all other metals, somewhat astringent and antiseptic, but presenting no special advantages. In the diarrheas of the tuberculous-not necessarily or often tuberculous diarrheas— it does not approach in efficacy the copper salts. Most neuroses will show improvement after two or three months' care, even if nickel is not being given, provided the hygiene is judiciously regulated.

Nickel bromide is a good remedy, each grain equaling about 5 grains of potassium bromide. Apart from this, we are unable to see in the statement presented by Dr. Kolipinski anything to warrant a resort to the salts of nickel. In the sexual cases he dilates upon, there is no such radical and certain result from nickel as follows thymol-iodide applications to the prostatic urethra. In the neurotic conditions pertaining to celibacy, is there any reason in looking to a drug for relief, or for expecting any drug can beneficially aid in outraging nature? The remedy for celibacy and its train of ills is matrimony.

A PENALTY FOR EFFICIENCY

A blacksmith or a carpenter who is more skilful and efficient than others asks and receives a greater wage than is paid to his inferiors. A salesman who sells more goods than other salesmen is rewarded with an increased salary.

But the general practitioner whose knowledge and skill are so great that he cures his patients in half the time required by his less-gifted competitor gets only half as much remuneration as they receive. Often two visits suffice for him to overcome a condition that threatens to become serious, and he is paid for two visits only. Meanwhile friends and relatives see no cause for gratitude, for where the relief was so prompt they conclude there was "not much the matter."

But let a well-dressed incompetent take charge of such a case, and how different the tale. Day after day the visits, the discouraging headshakes and days, the patient is well again, though awfully the dosing continues until, perhaps, after many

weak and thin. But the doctor, who "was so faithful and attentive," is hailed as a savior; and his bill, paid in installments, as it may be, is looked upon as a sacred, material acknowledgement of the kindness of Providence in providing such a good doctor in the emergency. It would be more

equitable if doctors worked "by the job," instead

of by the visit.-Southern Medical Journal.

Does it always work out in that way? Once in a while there may be a physician who is so much better skilled in the use of his tongue than he is in the tools of his profession that he is able to make the facility of the former repay him (not his patients) for the defects of the latter; still, in the majority of instances, I believe, reputations are won in medicine, as in trade or industry through quality of service.

Exactly the same specious reasoning is employed to excuse the plumber who makes the job that should take him but an hour to finish, last two, or the carpenter or bricklayer who defrauds his employer by stringing out his work to the limit of tolerance. People may be hoodwinked for a while, but when they "catch on," woe be to the hoodwinker! If there is anyone else available to fix their pipes, or build their barns, or cure their diseases, the man who has treated them dishonestly will be out of a job!

It is reasoning like that above which leads so many young physicians of weak wills and unestablished principles into the crooked path. They think that the one great motto of the business and professional world is, "Get the money!" The finger of admiration is too often pointed at the schemer, the half-crook, who has made. himself wealthy by questionable methods. They do not know-because no one has shown them--of the thousands who have risked all, and lost all, by resorting to deceit, or lies, or worse, for the sake of making (?) more or getting more money. What a serious, yes, what a damnable thing it is to trifle with human life! How can the physician excuse himself, morally, who neglects to adopt at once those measures which promise the most certain and the most speedy cure of disease? The unnecessary visits, the "discouraging headshakes," the unneeded and improperly used medicines, that do harm instead of helping, are all an indictment of that man's character.

Of late years the business world has come to understand that the two most important considerations in business building, more important even than a fine presence and a persuasive tongue, are "quality of goods"

and "excellence of service." They are just as essential in the professional world. The doctor's "goods" are his knowledge, not mere theoretical knowledge, but the knowing of anything and everything that can aid him to cure his patients, cito, tuto et jucunde. Instead of scheming how he can extract every possible dollar out of his victim, let the young doctor devote his time and his brains to exhausting the possibilities of curing every patient. The doctor's "service" consists not alone in the pills he administers or the bandages he applies; no, his service also lies in his way of applying the Golden Rule.

It is a pity that this insidious doctrine of giving little and getting much is being instilled into the minds of the rising generation. Perhaps it is a sign of the terrific stress from which our profession, like others, suffers at the present time. The time may come as surely it shouldwhen the new preventive medicine, advocated in these pages, shall become an actuality. When the physician's financial interest centers in the effort to keep people well, in that happy time the complaint that doctors prosper by keeping men sick will lose its force.

May such a day come soon! But meanwhile let us remember that all the success worth while is to be had by "quality of goods and excellence of service."

HOW TO BECOME OLD!

Each

Alcohol, tobacco, coffee, and food taken in excess of the need, each has been ascribed as the cause of premature old age. has its influence, but with each there have been cases cited where the free and even excessive use was continued beyond the century limit. A Savoyard woman reached the age of 114 years, although her principal food was coffee, of which she took as many as forty cups a day. Politiman lived to 140, although he got drunk every night. Ross, who died at 102, was an inveterate smoker. Mme. Lazennec, an inveterate smoker from youth, died at the age of 104. The writer's great-grandmother began to smoke at 16, and continued the habit until her death in her 100th year.

THE

Hysterectomy in a Girl of Fifteen HE first patient upon whom I purpose to operate this afternoon is a girl of fifteen who has suffered from more or less pelvic symptoms since the birth of her child about a year ago. Before this she seems to have had gonorrhea, judging from the history of pain and burning at micturition, copious purulent discharge from the vulva, and subsequent pain and tenderness on both sides of the lower abdomen and pelvis. She has menstruated regularly for the last several months, but her pains are intensified at the menstrual periods. She complains of frequent micturition even now, with slight tenesmus following. The urine contains considerable albumin, and its sediment shows abundance of leukocytes, but no casts. The reaction is acid. No particular tenderness in the base of the bladder is discoverable on digital examintion of the vagina. The uterus is normally anteverted, of normal size and not very tender. To the left of the uterus and extending into Douglas' cul-de-sac behind it, bimanual examination reveals considerable tenderness and a thickened cord running from the side of the uterus and ending in a soft, fluctuating, rounded mass. On the right of the uterus there is some tenderness, but I have been unable to detect any thickening or mass. A blood count made today shows 12,000 leukocytes.

The indications for operating seem to be: continual attacks of more or less severe pain

in the lower abdomen and in the back, from which she and her friends demand relief, as also the presence of what appears to be at least an enlarged left tube ending in a cystic enlargement of the ampullar end or of a cystic ovary.

Removal of a Cystic Ovary

I make an incision just above the pubes of about two and one-half inches in length and find the omentum lying directly underneath. Passing my two fingers into the abdomen behind the pubes, I come upon the fundus of the uterus and, passing behind that, I feel a soft mass as large as a hen's egg lying close to the uterus and partly to the left. From this rounded cystic body I can trace the left tube running to the uterus, considerably thickened distally and becoming normally narrow at the uterine extremity. The mass and the tube are adherent to the uterus to the left broad ligament, in one or two places to the sigmoid, and behind to the sacrum and rectum. These adhesions are not very dense or strong and I can separate them without great difficulty. In this case the fingers can be gradually inserted. between the uterus and the tumor-mass, and, by carefully working through the line of cleavage, I can gradually shell out the left. tube and ovary from the bed of adhesions and bring it into view outside the incision.

As you see, there are two places where the tube is adherent to an epiploic appendage of the sigmoid but where it can easily be

freed therefrom. The cystic mass appears to be the left ovary, about as large as a small egg and exhibiting upon its surface many places where adhesions have been separated. The enlarged fimbriated extremity of the tube also shows these marks of adhesions. The uterine third of the tube appears to be healthy and there is no need of removing that portion.

We pass an eight-inch forceps over the broad ligament, just a little below the tube from the outside inward to within about one inch of the uterus. Now we pass a suture of catgut just beyond the end of the forceps and tie it. Now we take the scissors and cut away the broad ligament just above the forceps and cut off the tube just above our ligature. The cystic and possibly purulent ampulla of the tube is now removed. Next we whip the needle of our suture around the forceps from the point toward the heel, making several stitches over and over, including the broad ligament and the forceps. When we reach the end of the broad ligament toward the wall of the pelvis, we have the forceps loosened and removed through the loops of our running suture and immediately pull these tight, thus leaving a suture over the upper margin of our severed broad ligament. The suture is tied at the outer end.

Passing the sharp point of the scissors. into the opening at the end of our tubal stump, I will slit the tube about half an inch, in the hope of leaving an artificial ostium. With the sharp end of the scissors I open the cyst of the ovary, evacuate its contents, wipe away with gauze the velvety wall, resect the cystic portion and suture the rest.

On the right side there is to be felt only a tube and ovary of apparently normal size but more or less adherent to the broad ligament and the uterus. After separating these adhesions with the fingers, we will bring the tube and ovary into the incision. Since, barring the marks of the adhesions, both look normal, there is no reason for doing anything more with them and we will close the abdomen, after first looking carefully over our interabdominal wounds, to see whether there is any bleeding. Our method of closure of the abdominal incision is by catgut running suture for the peri

toneum, catgut locked running suture for the fascia, and the Michel metal clips for the skin.

Pyosalpinx Due to Gonorrheal Infection, in a Colored Girl

The next patient is a colored girl of eighteen who had a baby and presumably a gonorrheal infection about two years ago. The child died in the early weeks from convulsions. The patient has had a leucorrheal discharge for several years. Since the child was born the patient has suffered from much pain in the back and in the lower part of the abdomen, aggravated at menstruation, and has had for the past six months obstinate constipation, only relieved at intervals by large doses of cathartics.

Bimanual examination shows a bilateral laceration of the cervix of moderate degree, a uterus strongly retroverted and bound down to the posterior part of the pelvis. Closely attached to the uterus and not easily differentiated from it is a mass as large as a fist occupying the whole of the cul-de-sac and extending to each side of the uterus. The whole mass seems almost like one body with the uterus and is very tender on examination.

We will essay a diagnosis of probable double pyosalpinx with probable involvement of one or both ovaries. The uterus is evidently retroverted and held in its false. position by adhesions. The pressure of the mass and of the retroverted uterus upon the rectum probably accounts for the constipation. In the acuter stages of pyosalpinx there is often great pain on defecation from pressure of feces upon the inflamed tissues of the tube.

Technic of Removal of Ovary and Tube

After making an incision like that in the preceding case, I find that the uterus and the mass behind and on each side of it are all snugly bound together and to the posterior wall of the pelvis by adhesions. These I gradually and carefully separate, working down behind the uterus and between it and the tumor mass and finally shelling out from this bed the appendages of the left side.

As you see, as this mass is brought up into view, the tube is thickened and distended

to three times its normal diameters and is thickened even to the uterine extremity. The left ovary, except for the marks of adhesions, appears normal and therefore can safely and properly be left behind. Again we pass a forceps, clamping the broad ligament under the tube, and this time as far as the uterus, and tighten it upon the broad ligament. After cutting the uterine end of the tube away by a wedge-shaped incision into the uterine wall and sewing up the uterine wound, we cut away the whole tube from above the forceps with scissors, and suture the broad ligament over the forceps as in the former instance.

Turning our attention to the right side, we find that there is a rounded cystic mass there which, as we finally enucleate it and bring it up into the wound, proves to be the right ovary enlarged to the size of an egg by a cyst. The tube of this side appears normal and the passage of a probe into its fimbriated end shows it to be permeable. We will therefore resect the cystic portion of this ovary.

Next we must do something to prevent the uterus, which you can see now can easily be replaced into its normal position of anteflexion, from falling back into the denuded cavity where the tubes and ovaries formerly lay. The best thing for that purpose in this case is shortening of the round ligaments, with the intention of holding the uterus in the proper position long enough for the raw surfaces to heal over, for the sacrouterine and round ligaments to recover their normal tone, and for the other supporting structures of the uterus in the pelvic floor and the anterior vaginal wall to resume their normal characters. After that the uterus will remain in its normal position just as it did before it became imbedded in the mass of inflammatory adhesions in which we found it.

Shortening the Round Ligaments

The method of shortening which I have found the most satisfactory to myself is the simple one of folding the round ligaments upward and suturing them to the uterus just below the origin of the ligaments.

First holding the wound toward the left by the deep retractor, we grasp the left round

ligament about an inch downward from its uterine origin with an artery-forceps and pull this loop up to the uterus. The proper length of the round ligament will be determined in each case by trial. Holding the loop at the insertion of the round ligament into the uterus, it is fastened there by two catgut sutures; and then the process is repeated on the other side. It is very quickly done and is very simple. It surely does what we want of it. You now can see the uterus held in its proper position by the shortened round ligaments, and we will close up the abdomen as in the other case.

Shortening of the round ligaments is a far preferable operation to ventrosuspension or ventrofixation, because the uterus is not left tightly bound in an abnormal position where it may undergo much tribulation in a possible future pregnancy, or where its abnormal situation may cause it to press upon the bladder or draw upon that organ in a way inclined to produce many aggravating symptoms of bladder irritation or worse.

When to Operate

The time to operate in cases of this kind is determined largely by the acuteness of the symptoms. It is dangerous to operate in the stage of acute gonorrheal or streptococcic infection of the tubes and pelvic peritoneum. The patient at this time will exhibit symptoms of great pain and tenderness in the whole pelvis and lower abdomen, will have fever (often quite high), will be physically and mentally much depressed and, in short, will be acutely ill and a poor subject for any operation which is not demanded to save life.

Severe as these symptoms of acute salpingitis and pelvic peritonitis are, they almost always improve under palliative treatment, while very likely to prove fatal under laparotomy. At this time the operation will open up large areas for lymphatic, venous and peritoneal absorption of toxins. This is the time to treat such a patient by absolute rest in bed, very restricted diet, laxatives, colonic flushings, antifebrile medication, hot fomentations to the lower abdomen, and such palliative measures, combined if absolutely necessary with opiates. In a few days, as the symptoms, especially