in the tube of the forceps, and the clamps are transferred to the end of the vein. By a gentle pushing force, the ring or forceps is pushed down the vein held under tension for six or eight inches, tearing off the lateral branches, when the point of the instrument is forced against the skin from beneath, and a small incision made in the skin to the ring or forceps, which is pushed through the opening, holding the vein in like a thread in a needle eye. The vein loop is drawn out of the opening and also from the instrument, which is removed and re-threaded on the vein, and again forced through the new skin opening, following the vein, and is pushed down to a lower point where the small incision is again made, and the same process of removal repeated. The small lateral branches are torn off, and, as a rule, have enough muscle structure to close themselves. Below the knee the branches are larger, and the vein is more adherent, being more superficial, so that a short distance can be traversed. Hemorrhage is avoided first by position. An ordinary gynecological standard is placed in position, and the leg raised in straight or extended position and supported by the ankle. This position renders the limb partially bloodless, as well as secures elevation and accessibility of the field of operation. Should any branches cause more than momentary hemorrhage, they can be checked by a small pack, which is left for a few minutes in the incision from which it arises, or an assistant can usually instantly check hemorrhage by a pressure-pad held against the skin over the region from which the blood escapes from the vessels.

In a few cases where the veins are enormously and irregularly dilated the stripping process is impossible through the whole extent of the saphenous. The Bristol method is then used of torsion removal of the veins by forceps through open incisions, as an adjunct to the enucleation.

treatment.

Should there be a persistent eczema after a week's preparation previous to the operation, it is proceeded with as usual, the ulcer being excised before enucleation of the vein. The ulcerated area is skin-grafted. The eczematous area is now

painted with compound tincture of benzoin, which acts as an aseptic varnish, literally sealing the surface until the incisions have themselves become sealed against infection, serving a purpose for a longer period, yet acting somewhat like Murphy's rubber dam for abdominal operations. The dressing is applied, and the patient placed in bed with the leg somewhat elevated by two pillows. In twelve days he is allowed to get up, wearing an elastic porous bandage for a few months, for a support.

The method outlined has reduced the time for operation very considerably, and has placed it in the class of relatively trivial operations, although sepsis may render it one of the most serious.

DISCUSSION

DR. A. MACLAREN (St. Paul): I can agree very thoroughly with Dr. Mayo in the conclusions which he has come to. I had the pleasure of seeing him do this operation a little while ago in which he used this ring enucleator in a very satisfactory way. The next day I saw another surgeon do this same operation, where he himself and four assistants, all at work, did about the same amount of work in four times the length of time, using the old method. Any procedure which saves any considerable amount of time is very important, both to the patient and to the operator. My experience has been that the Schede operation is usually a very tedious one, and takes a long time. Mr. Mayo's operation is an excellent one, and I shall certainly try it the next opportunity that I have.

DR. J. E. MOORE (Minneapolis): I feel obliged to Dr. Mayo for his suggestions. This is a class of cases that the average surgeon would as soon not have come to him, because, as Dr. MacLaren voices our experience, it is a tedious operation and not satisfactory-never satisfactory when the patient is a number of weeks convalescing; and the cutting of the superficial nerves is not so simple an affair as many would have us believe. The patients complain a long time afterward, and they have a sensation a good deal like that of a patient with tabes. They cannot walk in the dark, and some patients never get entirely over it. The removal of a large· number of veins from an extremity through the length of each vein is a major operation, and I can understand that a beginner in surgery might think it a simple thing, and have a very serious time with his patient. I have practiced that same way myself, not cutting the whole length of the integument, but pulling the vein down. It is surprising in the upper part of the thigh, as the doctor has said, how easily that can be done, but in the lower part it is not

an easy matter to pull out a vein, and sometimes I have found it difficult to dissect it out. If we have not made an incision the whole length of the thigh, we can better afford to make incisions about the calf of the leg.

DR. W. E. ROCHFORD (Minneapolis): I have performed the Schede operation about a half dozen times within the past four months. One of the cases now in the City Hospital I looked at just before coming to the meeting this afternoon. I think up to the present time the Schede operation has given the best results, though no operation is always entirely satisfactory. It is not such a difficult operation. The particular thing about it, as in every other operation, is to be absolutely clean in your work. So far as dissecting out the internal saphenous vein, I think it is a good plan to remove six or eight inches of it. Cutting the saphenous nerves causes a loss of sensation for a few weeks or more, but does not seem to occasion any serious trouble. There is some edema, which soon passes away. The patient should wear an elastic bandage for a number of weeks after getting up. Dr. Ochsner suggests some modification in this operation. Instead of making a complete incision, he leaves about an inch opposite the spine of the tibia and the same amount on the posterior surface of the leg, thus avoiding a scar entirely around the leg. My cases have been confined to the bed for two or three weeks, and then I put on a bandage, and let them up. Where there is an ulcer I resort to skin-grafting. It does not always succeed at first, and it may be necessary to skin-graft again. The operation is simple, and can be performed by anyone at all familiar with surgical work.

DR. H. N. WHEELER (Grand Forks, N. D.): I do not know that I have anything to say, except in commendation of this procedure. The dissection of the whole vein is the method I have pursued. I have not had very much experience, but what cases I had have been successful, but I do not think you can make so long an incision in the skin without sooner or later having suppuration, and the operation described would diminish that risk, and is that much of an advantage.

DR. L. F. SCHMAUSS (Mankato): There is one thing that has been spoken of that is of the greatest importance, and that is absolute cleanliness, no matter what method is followed. One of the speakers referred to this, but he did not give the reason why we should be so careful in doing this operation. The fact is that if you get infection in connection with any work upon the veins, we are apt to have a very marked and serious reaction, and it is therefore especially necessary to exercise the most scrupulous cleanliness. In Cook County Hospital, we performed the Schede operation, but most often practiced simple excision of the most promin

ently dilated parts of the vein or veins, excising four or five inches of the vein at those points, and, as a rule, this gave very satisfactory results.

DR. C. H. MAYO (Essayist): The points brought about the Schede operation being successful depends upon whether we have a communication in the popliteal space with a deep vein and a superficial. In some of these cases they lie down, and the swelling goes down, and you can hardly see the line of the vein, but the minute they rise up you can see this circle, from the saphenous opening to the popliteal space, fill, and the Schede is not going to cure that circle. Nor is the Trendelenberg operation going to relieve, except very slowly where there is a great deal of trouble below the knee. The Ochsner method is not a complete Schede. The Schede is a complete circumcision, and may be a dangerous thing. Only a year ago a foot was amputated in Chicago following such an operation. The contraction of scar tissue, which takes place in a circular manner, cuts off circulation, and so this case has been reported as an amputation following the Schede operation on the leg. When we are to deal with a case for operation and the question of deep vein condition arises, operators may think they have had thrombophlebitis, and where edema is very marked for one or two years following, that it would be an easy matter to remove the saphenous veins, if we did not take chances of gangrene. If the patient in such cases can wear an elastic support for some time it is a very good thing, but if the support shuts off the superficial veins returning they cannot stand the pain, proving the potency of the deep veins. In regard to making a portion of them Schede, we made a good many of them, and I have kept watch of those patients for a considerable length of time, and they complain of a numb foot and edema. They keep wanting to know how long such a condition is going to keep up. In regard to skin grafting these ulcers, I will say that it is better to excise the ulcer entirely. Usually beneath the ulcer there is a vein and it is of no more good than if it were a rubber tube; it has no connection with the veins returning from the ulcer.

CULINARY HYGIENE: SOME HINTS ON PREPARATION AND SELECTION OF FOOD

MARY MCCOY, M. D.

Duluth

PRELIMINARY

My apology for writing this paper, if one is needed, is the woeful lack of knowledge manifested in the selection and preparation of the common articles of food. And as the physician in a large measure educates the laity in those things which pertain to hygiene, I thought a paper that would give in compact form some helpful hints would be useful.

One-half of the cooks and nurses cannot prepare an egg or cook a dish of oatmeal so as to render them digestible. The physical as well as the moral well-being of our patients depends so much upon what they are fed, that I beg indulgence for calling your attention to a subject so common-place as culinary hygiene, which perhaps after all is a misnomer.

Good food properly selected and prepared is the first step on the road to health, and this is what I am trying to tell you how to procure, albeit in a crude and imperfect manner.

I have consulted something like fifty authorities, and drawn largely from my own experience in the preparation of this paper, and I hope it will be interesting to you.

MEATS PROPER SELECTION OF

BEEF. The lean of an ox-beef should be fine and closegrained, bright red, well marked with fat, and have also a thick layer of fat. The fat should be firm and have a yellowish coat. Cow-beef has a lean of close grain and slightly paler red. The fat is white and firm.

When pressed with the finger all beef should rise up