may appear. The symptoms, which are well known, consist of fullness or weight of the leg with edema and pain. This may lead to pruritus or eczema. Local hemorrhages are frequent and may lead to pigmentation and discoloration of the skin; or, the tissues may break down,. forming ulcers.

The so-called Trendelenburg phenomenon is tested by lifting the leg while the patient is lying down, and when the veins are empty the long saphenous is compressed above. The patient now stands erect and the pressure is removed and if the veins fill from below the valves are intact; and if the waves of blood descend the valves are useless. A few cases may be relieved by a change of vocation or climate, others are required to wear elastic supports such as bandages or stockings. Operative measures for relief are as old as the history of surgery and include ignipuncture with Paquelin or electro-cautery, cutaneous and subcutaneous ligation which are now seldom used, injections of irritants in and about the veins, multiple ligation and excisions, multiple incisions with torsion, removal, or Trendelenburg's operation which consists in ligating and removing a short section from the upper portion of the long saphenous. The more recent methods are subcutaneous removal in suitable cases and nerve stretching. To test the advisability of operation an elastic bandage is applied from the foot to above the knee. If this bandage can be worn with comfort the operation should give relief as the pressure shows that superficial vessels are not necessary to circulation of the limb.

The writer reports one hundred eighty-five cases operated upon, many times operation including both limbs. A number of changes or modifications have been made in the operation. To aid in the work a ring vein enucleator and a pair of forceps, the end of which forms a ring when closed, have been invented. This operation is described as follows:

"The vein is sought for and severed in the upper third of the thigh. The proximal end is ligated. The lower end is passed through the ring of the enucleator or placed in the ring of the forceps, and clamps are placed on the end of the vein. By a gentle pushing force, the vein being held to make tension and the tissues steadied on either side by an assistant, the ring or forceps is pushed down the vessel 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 is made to the ring or forceps, which is pushed through the opening, holding the vein like a thread in a needle's eye. The vein-loop is drawn out of the opening and also from the instrument, which is removed, rethreaded on the vein, and is pushed down to a lower point, where a small incision is again made and the process of removal repeated. The small lateral branches are torn off, and, as a rule, have enough muscle structure to close themselves. Should the main venous trunk break, a new incision is made below the knee, the vein

exposed and divided, and the enucleation made in both directions from this point. Below the knee the branches are larger and the vein is more adherent, being more superficial, so that a shorter distance must be travelled. If it is found that calcareous deposits, sacculations, or extreme weakness of the walls render the case unsuited to the enucleation method, and this occurs in about ten per cent of the cases, the principle of operation should then be changed to an open method, undermining only the section by the knee. Hemorrhage is avoided, first by position. An ordinary gynecologic standard is placed in position, and the leg raised in straight or extended position and supported by the ankle. The position renders the limb partially bloodless, and also secures elevation and accessibility of the field of operation. Should any branches cause more than ordinary hemorrhage, it can be checked by a pressure-pad held against the skin over the region from which the veins were removed, or by small packs, which are left for a few minutes in the incision from which it arises."

When ulcers are present the ulcerated area is excised and skingrafted. Eczematous areas are painted with compound tincture of benzoin or an acetic solution of gutta-percha which acts as an antiseptic varnish. The leg is kept elevated for twelve days. Recurrence. may come from widening of collateral veins, formation of new veins or, as is claimed, from the regeneration of the saphenous itself.

The dangers from operation are pulmonary embolism. Sepsis is rare, although a serious possibility, and difficult to guard against in some cases with ulcer and eczema.

PEDIATRICS.

BY ARTHUR DAVID HOLMES, M. D., C. M., DETROIT, MICHIGAN.

INFLUENCE OF FEEDING ON INFANT MORTALITY.

HOWARTH (Lancet, July 22, 1905), having investigated this question in eight thousand three hundred forty-two children, says the deathrate among the hand-fed was nearly three times as high as that among the breast-fed and twice that of children reared on mixed feeding. Among children who were first breast-fed and subsequently hand-fed the death-rate was not so high as among the purely hand-fed, showing the advantage accruing to children who have natural food supplemented by artificial, rather than an entire supply of the latter. Children fed on condensed milk show a very high mortality, and children reared on bread, rusks, arrowroot and other farinaceous foods come next. His deductions are as follows: The use of sweetened condensed milk, either whole or skimmed, should invariably be discouraged, and whole. unsweetened condensed milk only should be permitted where one is satisfied that the milk is being used with a proper degree of dilution and with the necessary additions, as in the case of modified cow's milk;

also that since the death-rate among children reared on patent foods is, on the average, higher than among those fed on diluted cow's milk, every attempt should be made to encourage parents to use the latter food and to educate them to an appreciation of the necessity for the additions to, and the dilution of, cow's milk to render it suitable for infant's food. The addition of patent foods to the dietary of very young infants is unnecessary, sometimes dangerous and always expensive. Furthermore, it must not be forgotten that the risks to which hand-fed children are exposed are considerably minimized by mixed feeding and that therefore every mother who is unable fully to satisfy her infant should be encouraged to continue to feed her child and to supplement any deficiency by means of artificial foods, and that only in case of absolute necessity should resort be had to artificial feeding alone.

OPHTHALMOLOGY.

BY WALTER ROBERT PARKER, B. S., M. D.

PROFESSOR OF OPHTHALMOLOGY IN THE UNIVERSITY OF MICHIGAN.

HOW A LIGHT SHOULD BE PLACED FOR READING. CRAVATH and LANSING, in The Electrical World, of January 6. The general lighting of small living rooms and parlors, together with the location of lights for reading in such rooms, is discussed, with criticism of special cases. The writers note at the outset that the general lighting of a small living room and the provision for reading lights are so closely connected that they must necessarily be considered together. They write:

"The reading light is the one that is likely to be used constantly and has so much to do with the comfort and eyesight of members of the family that it needs earnest consideration. There are three common ways of obtaining a reading light. One way is to illuminate the whole room so brightly that reading is easy in any part of it. This is usually undesirable for two reasons: One is that the eye is likely to tire more quickly in a room so brightly illuminated in all corners than it would be if it had an opportunity to rest by looking from the lighter to the darker parts of the room occasionally. The cost of lighting a room so brilliantly as this makes it out of the question in the majority of rooms. We will, therefore, leave out of consideration this method of securing a reading light and consider the second and third methods. The second method is to use a lamp placed near the reader and fitted. with a globe or reflector which will concentrate nearly all the light on the book or paper. If we do this, the reading lamp is likely to be of little value in the general lighting of the room and we will have to add other lights besides the reading lamp if the greater part of the room is not to be in comparative darkness. The third method, which is the one usually to be preferred where the greatest economy is an

object, is to use the same light both for reading and for the general lighting of the room by equipping the reading light with a. globe or reflector which will concentrate a considerable portion of its light within the area in which it is desired to read and at the same time allow enough light to radiate in all directions to give fairly good illumination over the rest of the room."

The popular impression that a portable table lamp is better adapted to reading than a lamp on a chandelier or bracket is regarded by the authors as a misconception, such table lamps being merely an inheritance from the days of the candle and oil lamps. They say:

"With electric light, usually much more satisfactory results can be obtained with a properly equipped reading light on or suspended from the chandelier or on a bracket on one of the side walls. The reason for this is that it is impossible with a table lamp to secure a reflector which will throw as large a proportion of the light where it is needed. for reading purposes as can be obtained from the proper reflectors on chandeliers and brackets. Most of the electric portable stand lamps throw the greater part of the light down on the table around the base of the lamp, so that the readers sitting around the table get only a small percentage of the light. If the portable stand lamp is used on a library table where the readers place their books on the table each side of the lamp its use is permissible, but such is not the usual condition.

"There is also considerable misconception as to the comparative distance from the reader of a lamp located six feet above the floor on a chandelier as against a lamp located on a table. The average person who has never measured these distances is under the impression that the lamp on the reading table is much nearer. As a matter of fact, the distances are nearly the same. There is really for the majority of cases only about one thing to be said in favor of an electric table lamp for reading as against a properly equipped lamp on a chandelier or bracket. This is that with the table lamp it is not as likely that a reader will get the regular reflection commonly known as "glare" from a page of white paper because the light comes so much from one side. In reading underneath a lamp on a chandelier or bracket the reader must turn the page at such an angle that he does not receive this glare from the paper. This is easily done, but many people undoubtedly suffer from this without knowing what is the trouble or taking pains to find out. Since this glare of regular reflection is likely to be more pronounced with electric light than with kerosene lamps, it is probable that this is responsible for the preference that some people have for oil reading lamps, even though electric light is available in the rest of the house."

In advocating the use of reading lamps placed on chandeliers and brackets rather than table lamps, the authors disclaim a desire to advise trying to read with chandeliers arranged for the general illumination. of the room. Chandeliers to be used for reading lights should be especially equipped for the purpose.

OTOLOGY.

BY R. BISHOP CANFIELD, A. B., M. D., ANN ARBOR, MICHIGAN.

PROFESSOR OF OTOLARYNGOLOGY IN THE UNIVERSITY OF MICHIGAN,

AND

WILLIAM ROBINSON LYMAN, A. B., M. D., ANN ARBOR, MICHIGAN.

DEMONSTRATOR OF OTOLARYNGOLOGY IN THE UNIVERSITY OF MICHIGAN.

A CASE OF ACUTE MIDDLE EAR SUPPURATION, COMPLICATED BY LABYRINTHINE FISTULA AND

PARALYSIS OF THE ABDUCENS NERVE.

HILL HASTINGS, M. D., in Archives of Otology, Volume XXXV, Number I. Twenty cases of paralysis of the abducens nerve have been reported. This case presented at re-operation a fistula through the inner tympanic wall as the probable avenue of extension of the infection. Gradenigo concluded that this syndrome of clinical symptoms is the result of a circumscribed simple serous leptomeningitis localized about the tip of the pyramid and caused by the diffusion. of the infection in the tympanum generally through the tegmen tympani.

The patient was a male, twenty-two years old, who had an acute ear trouble following a head cold. The ear showed some purulent discharge, sagging of the posterior superior canal and an inflamed bulging membrane with a small perforation. Moderate mastoid tenderness, chiefly over antrum and tip. Some tinnitis but no dizziness or other symptoms. A free incision was made in the membrane. Three days later the mastoid operation was performed with no findings of especial interest. After operation discharge and pain continued and gradually increased though the mastoid wound was clean. There was some dizziness and marked tinnitus. The membrane remained red and bulging and was incised two or three times to offer better drainage. On the twelfth day the patient complained of increased dizziness and double vision. Examination showed marked diplopia due to paralysis. of the abducens. No other motor or sensory disturbance. As this case was an acute one and the hearing had been normal a radical operation was deferred. As the paralysis continued and the pain and dizziness increased a radical mastoid operation was done on the eleventh day after the appearance of the paralysis.

The tympanic cavity was found full of granulations and pus; malleus and incus were normal. When the cavity was cleansed pus could be seen coming from the inner tympanic wall in the recess of the oval window apparently through that opening. The stapes was not found. The fistula was found to lead inward for half a centimeter before bony resistance was noticed. The opening was enlarged and the fistula swabbed out with bichloride solution. No other necrosis of the tympanum was found. A Ballance flap was made and sutured above; the posterior wound was left open. Facial twitching