to take oil of wintergreen. She took about two drams, and had all the symptoms of poisoning: collapse, pulse 42, deafness. It took her about three weeks to recover from this case of poisoning, but she kept her rheumatism. A short time after that a man wandered into my house one morning, and said he was almost blind, and that what little he could see looked green. He had taken carelessly perhaps six to eight drams of sodium salicylate, solution of unknown strength. He recovered quickly from the effects of the medicine, and he also recovered from his rheumatism. I give these two cases simply as illustrations of the possible effects of the sodium salicylate and oil of wintergreen.

DR. OWEN MCKEON (St. Michaels): In regard to the non-effectiveness of the medical treatment of rheumatism, I have no faith in this attitude at all. I know that experiments have been made in the treatment of rheumatism hygienically on the one hand and medically on the other and results reported overthrowing the efficiency of medicine, nevertheless it has never been able to shake my faith in the medical treatment of rheumatism. I think we have all had the same experience in our practice, of having been called into a sick room where a patient was suffering from most severe pains from rheumatism, and had been suffering perhaps for days, and we have been able by the aid of medical treatment to relieve that suffering within a few hours. In my experience in the treatment of rheumatism, I cannot say that I have been so successful with the subacute and lingering cases. I have almost invariably succeeded in overcoming the pain in from 24 to 48 hours by means of salicylates and local application of anodyne liniments. When we once lose faith in the efficacy of medicine in the treatment of rheumatism, it will be a sad state of affairs, and for my part I will say that nothing can ever shake my faith in medical treatment of articular rheumatism.

DR. JAMES MCKEON (Montgomery): I am sorry I was unable to hear the paper on rheumatism. I am a sufferer from that disease myself, and have been for many years, and if there is a cure to be derived from treatment I should like to know it. I am also a sufferer from ethmoidal disease, and have been operated on seventeen times, but it still keeps discharging, and if it goes without cleansing and an absorbing process takes place I have rheumatism. I have concluded that in my case rheumatism is due to streptococci, but whether that is true in all cases of rheumatism I am unable to say, and I mention this fact in order to stimulate this body to continue investigations along that line.

DR. E. A. HENSEL (Essayist): I will only take up the time for a few minutes in closing the discussion. Owing to the limited time I had difficulty in bringing the facts that were essential under

your observation, and in the remarks made by friends here there were some points brought out that I did not incorporate in the paper because the authors were mainly opposed to the use of those measures. The first one mentioned was the injection of sodium salicylate into the joint. I think if the doctor who mentioned this would look over the literature on the subject he would find the consensus of opinion is contrary to that idea. I may be mistaken, but I think I am right. It might be all right to use the injection in the hospital where you can have everything aseptic, but I would like to see anyone do it in a farm house twenty miles from town. In regard to massage, I think the consensus of opinion is opposed to massage in acute articular rheumatism. In reference to the treatment of heart complications, it is a well known fact that little can be done except systemically. Aconite and veratrum viride are both such dangerous drugs in heart complications that I hardly think anyone would dare leave either one in the hands of a patient unless in charge of a trained nurse, and perhaps not even then. In regard to the statement made that there is no remedy for rheumatism, I think anyone who has treated a number of cases will find the use of salicylates is of value. I do not think we can get away from that very well.

THE SURGICAL TREATMENT OF VARICOSE

VEINS

C. H. MAYO, M. D.

Rochester

Surgical procedures for the relief of varicose veins have now been so long instituted that they have an established position in the history of surgery. It is no longer necessary in a report of cases to partially apologize for the operation by stating how much relief is obtained.

While we cannot say that there is one operation suitable for all cases, sufficient time has elapsed since these operations were advanced to review the best methods and those modifications which tend to simplify.

In considering varicosity of the veins of the leg, without doubt the essential predisposing cause is a congenital defect in the vessels or their enervation. While some with such a tendency develop no serious condition, others aggravate their condition by occupation, injury, child-bearing, or constipation.

The symptoms caused by varicose veins may be fullness or a sensation of fullness of the leg, edema, pain from nerve irritation increasing in severity with use, distension of the veins with at times a venous circulation in the internal saphenous from the saphenous opening to the popliteal vessels. Pruritus occurs often, with or without eczema, also pigmentation and discoloration of the skin and varicose ulcers. Some aggravated cases suffer from all these symptoms, some with one or two; others with greatly distended veins complain not at all.

Clinically, then, these cases come to the physician to have a diagnosis confirmed and obtain relief, or they come complaining of one or more of the various symptoms produced

by the disturbed venous return. According to the severity of the case, it is treated hygienically or mechanically by supports and massage, possibly aided by various lotions, or surgically by one of the various methods elected by the physician in charge.

The older methods of treatment by pressure, pin-ligation, and the like, we pass over as merely a bit of interesting history of surgical progress. Of the methods in use to-day, probably the Trendelenberg operation, or ligation and section of the internal saphenous in the upper third of the thigh, and the Schede circumcision operation in the leg, are the most popular. Multiple open ligation and the excision of the veins are also common operations. The Trendelenberg operation is simple of performance, and checks the superficial venous return at a high point. The intercommunication of the superficial with the deep veins and the external saphenous veins in the popliteal region, at least delays, and at times prevents, recovery. The benefits therefore from this method alone are slowly manifested, yet in time marked relief is afforded. The Schede operation of circumcision of the leg through all the superficial structures to the muscles, with ligation of the large veins and coaptation of the skin, impedes all the circulation below the incision, but many of the patients complain nearly or quite as much of the numbness from section of the cutaneous nerves, and slight edema following, as they did of their previous condition. There is also some danger from gangrene of the foot. If the venous circle of the thigh existed, it was, of course, but little benefited, and either required ligation or excision above the knee, yet in most cases the ultimate results were good or fair. Excision of the veins was an operation which gave good results, but was slow of performance, and opened a large cutaneous area for increased possibilities of infection. The region of the knee from flexion often developed a form of keloid or scar eczema. Operations upon the veins below the knee by local incisions and ligations give benefit at least for a time, but do not control sufficient area as a rule, unless

made more extensive than apparently warranted by the condition.

We have operated upon 125 cases of varicose veins, many times operating upon both limbs. The complete Schede operation we have not made for several years, but a partial Schede or oval incision above a large ulcer is frequently made, combined with excision of the ulcer and skin-grafting; at the same time the Trendelenberg operation, or the more extensive excision of the internal saphenous vein from the upper third of the thigh to a point 6 or 8 inches below the knee, is also performed. The removal of short areas of veins is reserved for those cases with involvement of the veins of the posterior thigh of the external saphenous. We have always been partial to the excision of the long saphenous for the majority of cases. The earlier operations were by a long incision over the vein. It required considerable time to close the wound, and seemed to be quite a serious operative procedure, especially in the time involved to accomplish what should apparently be the trivial removal of superficial veins. This we partially overcame some years ago by a long incision both in the thigh and in the leg, leaving five or six inches of skin intact at the side of the knee. The vein was separated above and below, and under slight tension a pair of forceps was employed to enucleate and loosen the vein in the uncut area. Gradually the method of subcutaneous enucleation was increased until the whole vein was removed by means of three to five incisions of one inch in length. More recently we advised a ring vein enucleator which consists of a one-fourth-inch ring of steel with a long handle, the whole instrument being not unlike a blunt uterine curette, which would possibly serve the purpose with the ring bent at a more acute angle. We have also had made a pair of long heavy forceps which are hollowed out in each blade so as to form a long tube when closed about one-fourth of an inch in diameter. The vein is sought for and severed in the upper third of the thigh. The proximal end ligated, the lower end is clamped an inch from the end which is passed through the ring of the enucleator or placed