dicitis is an indication of a pelvic position of the appendix. On the second or third day the boy complained of pain on urination and defecation and on examination of the rectum I found a large mass protruding against the posterior wall. He was operated upon at the Presbyterian Hospital by Dr. Wharton and a large abscess was evacuated which occupied almost the whole right side of the pelvis. In view of Dr. Graham's patient having some irritation of the bladder since the operation, I would like to ask if there is any possible connection between this symptom and a pelvic location of the abscess.

DR. E. E. GRAHAM.—In regard to the question of a tumor in these cases, I think it depends upon the individual characteristics of the physician who is examining the case as to whether he decides that he finds a mass that can or cannot easily be determined in the abdominal cavity; much also depends upon the stage in which you see the case. The cases of intussusception during the first 48 or 24 hours almost all have a relaxed condition of abdomen so that an intussusception, even if small, is rather easy to outline and determine. The first case had existed for four days when I saw it and then the abdomen was enormously distended. The second case had lasted for several days and the abdomen was also enormously distended. A majority of observers maintain that where they see cases early a tumor can be outlined, later it is difficult to outline. In the first case the tumor could not be detected by a single finger passed into the abdominal cavity by the surgeon. That to my mind shows what a frail thing this sign is if an experienced surgeon passing a finger into the abdominal cavity cannot detect an intussusception in the small bowel that is at least three inches in length and had lasted for four or five days and, as always happens in these cases, at the constricted portion a certain amount of swelling takes place. If the abdomen had been relaxed, in that case I doubt if a tumor could have been detected. In the second case the tumor should have been detected if the abdomen had been relaxed. In regard to the giving of enemata, in looking up the subject of intussusception I have been struck by the fact that where enemata do good it is in the first twenty-four or fortyeight hours of the disease. The point that decides whether a case is going to get well in intussusception is whether the intussusception can or cannot be reduced. If you see a case in the first twenty-four hours your enemata have a

chance of reducing it, and as to the choice between liquid and gas, I prefer liquid; you can more easily handle it. In the second twenty-four hours and in the third twenty-four hours you might reduce; after the third day I question whether a physician is justified in acute cases. If you examine carefully that specimen you will see why enemata would do no good; in the first place the swelling practically constricted that bowel so that all liquid or air could do would be to jam the intussusception further down. Adhesions also interfere, to a certain extent, with a surgeon when he opens the abdominal cavity. The thing that prevents children from getting well is that the bowel is so swollen that reduction is impossible. I find where intussusception is reduced, the mortality is 38 per cent; where intussusception is not reduced the mortality is over 80 per cent. Enemata may do harm; for instance, in some cases the bowel is in such a condition that the careful handling of it by surgeons may produce rupture. If we see a case lasting more than three days the child's chances would often be better without enemata.

DR. DOUGHERTY.-I would like to ask Dr. Graham whether any waves of peristalsis were visible in either of these two cases. I do not know whether they would occur so late, but I believe that they are an important sign of strangulation or intussusception.

DR. GRAHAM.-I did not notice any.

DR. ALFRED HAND, JR., read a paper on a RAPId Method of RIDDING THE THROAT OF DIPHTHERIA BACILLI after the disappearance of the membrane. The method consisted of the thorough application to the mucous membrane, once a day for several days, of a solution of sixty grains of nitrate of silver to the ounce of

water.

DISCUSSION.

DR. ROBINSON.-I have been using the method Dr. Hand speaks of for three years and can endorse all he says of it. It was first suggested to me by Dr. Gibb.

D. L. EDSALL, Recorder,

330 South Sixteenth Street, Philadelphia, Pa.

BOOK REVIEWS.

ABDOMINAL SURGERY. BY GREIG SMITH, F.R.S.E. Sixth edition. Edited by James Swain, M.D. Two volumes. Philadelphia, 1897. P. Blakiston, Son & Co., Publishers. Price $10.00.

The sixth edition of this classical work by the much regretted Greig Smith is quite up to date and in every way a valuable book. It is far too well known to the medical profession to need more praise from us as the book from its first appearance was immediately accepted as standard.

The present edition, which has been somewhat remodeled and improved will be found a reliable guide to gynecological and general abdominal surgery, and on account of the easy style of the writing, excellent print and paper, will make enjoyable reading. ANNUAL AND ANALYTICAL CYCLOPEDIA OF PRACTICAL MEDICINE. By CHARLES E. DE M. SAJONS, and one hundred associate editors. Vol. I. Philadelphia, 1898. The F. A. Davis Co., Publishers. Price $5.00.

This work will be complete in six volumes, one to be issued every three months. Judging from the first of the set now be fore us the work will be a most excellent one for reference and will be of special value in that the articles represent a concise résumé of the literature up to date.

The work will cover all the branches of practical medicine, surgery and obstetrics and should be, we think, a most acceptable addition to all medical libraries, both private and public.

YELLOW FEVER. Clinical Notes by JUST TOUATRE, M.D. (Paris). Translated from the French by Charles Chassaignac, M.D. Published by the New Orleans Medical and Surgical Journal (Ltd.). New Orleans, La. 1898.

The publication of this little book is most timely and will ensure, we believe, as large circulation as the scientific value deserves. The editor's translation is smooth and pleasing, while the author's method is most acceptable. The special object seems to be to emphasize the great pathognomic value of the pulse-rate as formulated in Faget's law. We heartily commend the book to the profession as a fully up-to-date treatise, complete in all ways.

NEURASTHENIA: ITS RELATION TO THE PHYSIOLOGY AND PATHOLOGY OF THE FEMALE GENERATIVE ORGANS.*

F. SAVARY PEARCE, M.D.

Instructor in Physical Diagnosis, University of Pennsylvania; Physician to the Out-Patient Department of St. Agnes Hospital;-and

H. D. BEYEA, M.D.

Assistant Gynecologist, University Hospital;

Instructor in

Gynecology, University of Pennsylvania; Assistant Surgeon to the Gynecean Hospital.

THIS investigation bears upon a subject that has been considered in the past unconnectedly and in its side lights, mainly so from the depth and intricacy of the whole subject, and therefore we have not yet arrived at the desideratum of clear proof of cause and effect. Admitting from the outset the above statement in its fullest bearing, this study has been made by the writers from the gynecological and neurological standpoints, hoping that by combined action the most unbiased opinions may be expressed, and therefore be of greater interest to medicine;-that the contrariety of known facts may be in part dispelled, and perhaps new and better co-relation made of the complex whole.

* Read before the Philadelphia County Medical Society, June 22, 1898.

In the vast literature of the subject collected within the past fifteen years, and particularly within the past five years, it is shown that the treatment of diseases of women has come to be better understood, and since ovaries are removed with increasing frequency, and at the present time with little danger, the subject has become of still greater importance. The gynecologist has come to the time when he considers not only the surgical treatment, but to weigh more seriously methods of conservatism, and the associated medical or neurological diseases of his patients. He has come somewhat more harmoniously in action with the neurologist.

There has been in the past, and there is even at the present time, a great deal of controversy regarding the relation of certain diseases of the female generative apparatus to that of the nervous system. This controversy has been mostly in relation to gross neurological maladies-the neuroses; such as insanity, hysteria and epilepsy, and very little has been said as to those, to us more important and more frequent class of sufferers, the neurasthenic women.

Believing that disorders of the reproductive organs are more frequent, and as a rule more serious in the female, than in the male, we propose to limit the study to these more exaggerated states as occurring in women.

We know the various bearings of the subject, as indicated above, has been considered by the best men at home and abroad; but this consideration, we might say, has always been unconnected; i. e., on the one hand it has been considered by the neurologist without sufficiently definite knowledge of the gynecological disease, and its relation to the nervous system. He has been unconsciously biased in his opinions. On the other hand the gynecologist, with the rush that has been characteristic of this branch of surgery, has in the past, and even up to the present, practised mutilating operations on women without due consideration of their cause and effect. He, too, has been biased in his opinions, looking often to the perfection of his surgical case and the statistics of operation, rather than to the good resulting, or to the serious constitutional conditions that may remain as the aftermath.

Undoubtedly we must consider the seriousness of the heretofore widespread practice of ablation of the ovaries, but conserva