the past year, one after five and the other after seven days illness. In both cases pus was present and the appendix was perforated. In each of these cases, salines were used previous to operation.

There is just one more point in the saline treatment, and to my mind, equally important in after treatment of operative cases, and that is the use of salines as soon as any pain is present, or if the temperature reaches 100, or even in the absence of both, they should be commenced within twenty-four hours; by so doing you can avoid tympanitis. This I consider of great value and always follow it in laparotomies and with the most gratifying results.

I wish to thank the doctor for his excellent paper and also for his kindness in calling my attention to his form of treatment, as I can but feel that it has saved the lives of many of my patients, as well as robbed me of the opportunity of operating.

Finally, gentlemen, I think that with the statistics of 95 per cent. of cases relieved by salines, our course is plain. I enjoy operating myself, but I think we take too many liberties in this direction.

Dr. S. C. Gordon: Mr. President and Gentlemen:In reply to Dr. Bingham in regard to the pus, I think I should open and drain. For instance, if I find a case that I have had under my charge, and treated with salines for a few days, and then am satified that pus remains there, there is still a little fulness and a slight rise of temperature, by salines I have relieved the blood vessels at the part around the pus and nature has made a good wall around this localized

I do not call

peritonitis, I see no harm then in operating. that operating in the acute stage of the disease.

In reply to Dr. Woodward, why operate after the patient has recovered, the disease has its origin in the appendix, whether the appendix was ruptured or not. Even if we get no pus, we get adhesion of the appendix which will cause more or less pain and soreness, and I operate for that, but in the majority of these cases, there has been perforation of the appendix and the contents of septic nature has escaped from the appendix. After the

acute attack is over, after the patient has recovered, there is still left a disease which may give rise to another attack and frequently does, therefore, I remove it.

The term perityphlitis has now practically gone out of use, all those cases in which the appendix is involved being now classified as appendicitis.

I have never used the ice-bag, though I see no objection to it, but I prefer leeches; but more than all the rest I believe in salines, as by their use we deplete the mucous endo and reduce inflammation.

In regard to pain, and here to me is the most important thing, for I am called in consultation in so many cases where the physician will say this boy or this girl has suffered beyond all powers of description, and we must quiet this pain. I admit that sometimes it is hard, if the disease has gone on until muscular paralysis has taken place, but it is surprising how quick you can get an operation, and I find it the easiest thing in the world to control. You must have courage and quiet your patient by your own self-control, telling him that when he gets relief in this way it is permanent.

It does not take days nor many hours to get the full effects. Put the Seidlitz powder into hot water, as has been suggested, wait until the foaming is all over and you will be surprised to see how soon you will get relief. If the patient vomits one, give another powder in half an hour, give half a Seidlitz powder every half hour until you get relief. If the stomach does not retain them give them through the rectum in 4 oz. of water. Give it very, very slowly; put the patient on the left side with the hip lifted. I would use the bulb syringe so there shall be no air in the tube. Carefully withdraw the tube, very, very slowly, tell the patient to hold on as long as possible, the rectum very soon becomes distended, and you will have a good movement from the bowels. The patient is then relieved at once and relieved permanently. Here is the time when we must have courage and say to the patient "You must wait. Often, I get a movement within an hour from one Seidlitz powder, but here is the great thing. They have pain which is terrible and perhaps insist on my operating at once and here is the difficulty. I said in my paper Dr. Worcester would operate at once, as soon as diagnosis is made, but when we do so, that operating is always accompanied with danger of increasing the inflammation developed in the peritoneum in the region of the appendix. The moment you do that, you spoil the whole thing. Give salines by the mouth and by the rectum, and you will be sure of your reward.

The Border-Lands of Insanity.

By S. E. Lawton, M. D., Brattleboro, Vt., Superintendent of State Insane Asylum.

An early recognition of the premonitory symptoms of insanity is a subject of growing interest, and one that hardly receives the attention its importance demands.

If we are familiar with the early warnings of mental disease, many a useful member of the community may be spared and perhaps years of suffering averted. It is a wellknown fact that the chances of recovery from mental disease are lessened in proportion to the length of time it is allowed to run without being brought under the influence of appropriate treatment.

Winslow says: Incipient insanity, provided it be not the result of severe physical injury to the head or has not a congenital origin or is not associated with a strong hereditary predisposition, yields as readily to treatment as incipient inflammation or any other disease with which we have daily to contend."

"I think," says Dr. Woodward, "it is not too much to assume that insanity in its incipient form, uncomplicated, is more curable than any other disease of equal severity; more likely to be cured than intermittent fever, pneumonia or rheumatism."

Experience proves that nine cases out of ten recover if placed under treatment within three months after the attack. It is, therefore, specially the duty of the general practitioner who is first called to such cases to familiarize himself with the early symptoms of this distressing malady, in order that he may arrest its progress at a time when curative measures are most effective.

In response to our inquiry, when patients are brought to us, we are often told that insanity came on suddenly, without previous warning; but upon investigation we find, almost without exception, that there was a long interval during which the patient exhibited peculiarities and committed strange acts.

Some authors go so far as to declare that the sudden onset of mental disease never takes place, and all agree that it is of the rarest possible occurrence. The duration of the premonitory stage must, of course, depend greatly upon the intensity of the exciting cause and the strength of the predisposition, but it usually extends over a period of months, and sometimes for years before the final explosion takes place.

A young lady was recently placed under my care with a history of having been mentally unbalanced one month or possibly six weeks, but to me she confessed that for upwards of three years she had been greatly tormented by hallucinations against which she had waged a constant warfare, and from the influence of which she was enervated and considerably reduced. This is no uncommon case and did time permit I could cite no end of examples, but I must proceed at once to the object of this paper, namely, to point out a few early indications of mental disturbance. A description of all its varieties would be a difficult task