serve his purpose until he equips his library with one or more of the larger or more comprehensive treatises. The arrangement of subjects, the large faced type with which the paragraphs begin, the make-up, paper and binding all appeal to the eye of the expert as a splendid exhibition of excellent shop work. The scientific quality of the text is of the first order and embraces the important advances that have taken place since the first edition was put forth.

Bradycardia and Tachycardia. Part II. Disorders of Respiration and Circulation. By Prof. Edmund Von Neusser, Professor of the Second Medical Clinic, Vienna; Associate Editor of Nothnagel's Practice of Medicine. Translation by Andrew MacFarlane, M.D., Professor of Medical Jurisprudence and Physical Diagnosis, Albany Medical College. 12 mo, 150 pages. New York: E. B. Treat & Co. 1908. (Cloth, $1.25.)

Studies relating to the heart's action, and especially regarding the frequency of its beats, have been made with greater accuracy of late, due to increased laboratory opportunities in part and stimulated by the important bearing bradycardia and tachycardia have upon the clinical manifestations of disease. In this monograph are found the essentials of these two variations from the normal heart beat, as occurring in the more important diseases of respiration and circulation. An appendix contains a number of important references relating to the cause of the heart beat, to the Adams-Stokes symptom complex, and to the Adams-Stokes disease.

Mellin's Food Method of Percentage Feeding. 12 mo, pp. 183. Illustrated. Boston: Mellin's Food Co. 1908.

This is now the season when the summer diarrheas of infants are prevalent and when the utmost care in feeding must be exercised. Not only this, but the physician must possess rare skill and exercise the most perfect judgment in the management of children afflicted with these disorders. The Mellins food method provides the ways and means for percentage feeding without the necessity of making calculations. The tables and formulas presented in this book are the result of more than four years of strenuous work in the laboratories of the Mellin's Food Company, involving some 3,400 fat analyses in which 1,700 quarts of milk were used. This enormous labor was performed under the personal direction of Edward E. Babb, Ph. G., a member of the American Chemical Society, and may be accepted as reliable in the most perfect sense of the word. The medical profession is greatly indebted to the Mellin's Food Company for working out these tables and formulas, and placing them in this convenient book form at the disposal of physicians. The Mellin's Food Company will appreciate correspondence from physicians relating to the method of percentage feeding as detailed in this book, as well as on the general subject of infant feeding with Mellin's food.

Progressive Medicine, Vol. X, June, 1908. A Quarterly Digest of Advances, Discoveries and Improvements in the Medical and Surgical Sciences. Edited by Hobart Amory Hare, M.D., Professor of Therapeutics and Materia Medica in the Jefferson Medical College of Philadelphia. Octavo, 352 pages. Lea Brothers & Co: Philadelphia and New York. (Per annum in four clothbound volumes, $9.00; in paper binding, $6.00; carriage paid to any address.)

This number opens with a splendid article on hernia by Coley, which is well illustrated. The next topic is surgery of the abdomen in general exclusive of hernia, prepared by Foote. The third article is on gynecology by Clark; the fourth embraces diseases of the blood, diathetic and metabolic diseases; diseases of the spleen, thyroid gland, and lymphatic system by Stengel; and the fifth relates to ophthalmology and is prepared by Jackson. The volume is of excellent quality through and through and will add much to the reputation of this standard periodical.

A Manual of the Diseases of Infants and Children. By John Ruhrah, M.D., Clinical Professor of Diseases of Children in the College of Physicians and Surgeons, Baltimore. Second edition. 12mo, pp. 423. Philadelphia and London: W. B. Saunders Co. 1908. (Limp leather, $2.00.)

This excellent manual has received the commendation of the JOURNAL in its previous editions. Some minor changes have been made, chiefly in the interest of accuracy. The new sections relate to the medical inspection of school children, the duration of the danger of contagion after infectious diseases, and on the return to school of children after exposure to contagious diseases, Also a short bibliography of the current pediatric literature has been added. In its present form it is to be adjudged as one of the better manuals for the medical student. Its value as an aid to the study of the diseases of children cannot be overestimated.

BOOKS RECEIVED.

Medical Gynecology. By Samuel Wyllis Bandler, M.D., Adjunct professor of diseases of women, New York Post-Graduate Medical School and Hospital; associate attending gynecologist to the Beth Israel Hospital, New York. Octavo, pp. 676. With original illustrations. Philadelphia and London: W. B. Saunders Co. 1908. (Cloth, $5.00.)

The Natural History of Cancer, with special reference to its Causation and Prevention. By W. Roger Williams, Fellow of the Royal College of Surgeons. Octavo, pp. 519. Illustrated. New York: William Wood & Co. 1908. (Cloth, $5.00.)

Contributions to the Science of Medicine and Surgery by the Faculty in Celebration of the Twenty-fifth Anniversary, 1882-1907, of the Founding of the New York Post-Graduate Medical School and Hospital.

Transactions of the American Association of Genitourinary Surgeons. Twenty-first annual meeting held at the Shoreham Hotel, Washington, D. C., May 7, and 8, 1907, and joint session with the American Gynecological Society at the George Washington University, May 9, 1907. Vol. 2. Edward L. Keyes, Jr., secretary. New York: The Grafton Press.

Borderland Studies. By George M. Gould, M.D., Author of a Series of Medical Dictionaries, etc. Vol. 2, 12 mo, pp. 311. Illustrated. Philadelphia: P. Blakiston's Son & Co.

Golden rules of Dietetics. By A. L. Benedict, A.M., M.D., Author of Practical Dietetics. 12 mo, pp. 407. St. Louis: C. V. Mosby Co. (Cloth, $3.00.)

International Clinics. A Quarterly of Illustrated Clinical Lectures and especially prepared articles on Treatment, Medicine, Surgery, Neurology, Pediatrics, Obstetrics, Gynecology, Orthopedics, Pathology, Dermatology, Ophthalmology, Otology, Rhinology, Laryngology, Hygiene and other topics of interest to students and practitioners. Edited by W. T. Longcope, M.D., Volume II., eighteenth series. Philadelphia and London: J. B. Lippincott Co. 1908. (Cloth, $2.00.)

The Baby. Its Care and Development. For the Use of Mothers. By Le Grand Kerr, M.D., Author of Diagnostics of the Diseases of Children. 12 mo. pp. 150. Illustrated. Brooklyn: Albert T. Huntington. 1908. (Cloth, $1.00.)

LITERARY NOTE.

LEA & FEBIGER, Publishers, Philadelphia, make announcement of a new edition of Gray's Anatomy. A thorough revision has been in progress for about two years and is so near completion that publication will be made during August.

Gray's Anatomy has maintained such a lead in its own field since its original publication fifty years ago that it has won the distinction of being the most important work in all medical literature. Hundreds of thousands of copies have started students at the beginning of their course in medicine, have been kept always at hand, and have been carried to their offices after graduation for guidance in the basic facts of medicine and surgery. Such an announcement as a new edition of "Gray" is therefore of primary importance to everyone concerned with medicine, whatever be his stage or station in medical life.

FOR

Well

OR RENT-Two floors at 191 Delaware Avenue, Buffalo. adapted for physicians or dentists. Hot and cold water, bath, both gases. All modern conveniences. Immediate possession. $75.00 for both floors. Apply to Buffalo Medical Journal, 238 Delaware Avenue.

BUFFALO MEDICAL JOURNAL.

VOL. LXIV.

T1

SEPTEMBER, 1908.

ORIGINAL COMMUNICATIONS.

The Surgical Treatment of Varicose Veins.

BY CHARLEs greene cUMSTON, M. D., Boston, Mass.

No. 2

HE physician is very frequently consulted relative to a surgical operation for varicose veins and he frequently is at loss as to what advice he may properly give. The case may merely be one of capillary varices seated on the calves or on the thighs. This condition gives rise to itching, edema and cutaneous infections, and although quite uncomfortable, surgical treatment is not to be resorted to. Their dissemination, small size and site, having no well defined territory, is quite in opposition to an operative interference.

In cases of varix of large veins the question is quite different. One should distinguish between patients presenting this condition with a normal vascular tension and those having a high tension. In varices with a high tension, the blood pressure, which is variable according to whether the subject is standing or lying down, quiet or exerting violent muscular efforts, varies in the central end of the saphenous between two to twenty centimeters of mercury. In certain strong subjects the tension may be even greater than twenty-five centimeters.

This enormous exaggeration of the venous tension can only be produced on the condition that the twelve or fifteen valves seated inside the vein are forced and that the weight of the blood column falls directly back from the iliac veins and the vena cava toward the small venous trunks of the foot. Trendelenburg has shown how varices with high tension can be recognised. The patient being seated or lying down, the diseased leg is raised and the blood being pushed out of the varices gives rise to a complete collapse of the dilated vessels. If now one compresses the trunk of the saphenous with the finger and the patient is made to stand, the veins of the leg will not fill up, while the blood will rush from above as soon as the pressure is removed. In these cases resection of the vein will be useful, more frequently resection of the trunk of the internal saphenous, more infrequently that of a mass of dilated veins. The latter operation should be resorted to if this large mass becomes painful and increases in size.

The operation is not serious and can be done with local anesthesia. One should also resect any ampullar dilatation of the internal saphenous at its entrance into the fascia, a condition which has sometimes been mistaken for a femoral hernia. Simple ligature

may sometimes be sufficient, but as it is not any more serious by far the surest method is to resect the vein between two ligatures. All this does not mean that varices of low tension are inoffensive, because phlebitis, disturbances in walking and edema. may appear and recur with the greatest obstinacy; the repetition of these accidents will occasionally oblige one to operate, but generally speaking this is exceptional.

In spite of every effort recurrences may take place. Complications make their appearance, such as central or peripheral thrombosis and early or late embolus. The possibility of these complications have caused certain surgeons to abstain from operating, because they believe that an operation in no way changes the intimate causes of the phlebectasia and that the suppression of the superficial venous currents can only result in forcing the blood of the limb into the deep veins and thus increase their dilatation. It has also been upheld that when phlebitis appears spontaneously it is in itself a curative process. This, however, is not always the case, because the phlebitis is not necessarily of the obliterating type; consequently the blood current can become reëstablished and the patient still remains exposed to all the possible complications of a future attack. On the other hand if a patient operated upon is menaced with thrombosis or embolus, the one not operated upon is not immune from this possibility. And, lastly, the functional troubles are certainly more especially due to varices of the superficial veins than of the deep ones, on which the muscular contraction exercises such a favorable action. According to Chretien the indications for operation should not be limited to pain and hemorrhage. If, in the well-todo class. rest in the horizontal position is possible the above two mentioned complications may perhaps be the only absolute indication for operating, but in the poor, who are obliged to earn their livelihood by daily effort, the question is entirely different. The edema, ulcers, trophic disturbances and difficulty in walking are all conditions which justify or necessitate surgical interferIn the army the same conditions are found. The signs of a valvular insufficiency, a localised phlebitic thrombosis, ampullar dilatations which greatly impede the patient on account of their seat and size, attacks of neuralgia due to compression of the nerve filaments, are all conditions which render the case fit for surgical interference.

ence.

An ulcer may create contraindications for operating in certain cases, when this process is of long standing, accompanied by