bad to worse. Diseases of the stomach itself may terminate in dilatation. For example, chronic catarrh may combine with inactivity and stasis. When food, from any cause, stays in the stomach too long, decomposition takes place, with fermentation of carbohydrates and putrefaction of albuminoids. These changes evolve enormous volumes of gas and produce inflation, putting the muscular fibres on the tension and finally paralyzing them.

I have spoken in a very rambling manner of some of the nonsurgical causes of dilatation of the stomach which, in all events, is a terminal phenomenon, that is, dilatation is one of the last of a series of events that may be started in many ways. The termination is the samein all instances, presenting about the same group of symptoms. There is nothing to follow except real degeneration of the gastric walls with retrograde changes replacing what was originally a very firm, activeand resisting substance for fat cells, soft, non-glandular or thick, nonelastic low-grade tissue. While these degenerative changes are progressing the patient is exhausted by malnutrition and poisoned by auto-intoxication.

There are very many important features of the subject that must. be passed by unnoticed. The symptoms in advanced cases are usually unmistakable and the diagnosis easy. In the earlier stages, one cannot readily state at just what time the muscularis begins to give way.. There is a possibility of any case of chronic gastric disturbance tending toward dilatation.

Fermentive decomposition of food conduces to discomfort and offensive eructations. As a result of retention and accumulation, thereis a rather characteristic kind of vomiting. It is copious, offensive and occurs at intervals, usually, of two or three days. The quantity of material ejected at one time is more than a normal sized stomach can possibly hold. If the vomitus be permitted to stand in a glass vessel it can be noticed to form in strata. Fermentation continues and forms: a kind of froth in the top, the heavy particles gravitate to the bottom,. leaving a zone of more or less discolored fluid in the middle. The vomitus when it comes up burns, sets the teeth on edge, contains no hydrochloric, but abundance of organic acids. The appetite at times is wanting, at others, excessive with great thirst, because of the non-absorption of food ingested. The acidity of the vomited matter sometimes seems: to clean the tongue and leave it irritated and unnaturally red. The urine is small in amount, bowels constipated and general nutrition is: greatly interfered with. My own usual method of diagnostic procedureis, if not contra-indicated, to pass the stomach tube and, after filling, measure all that can be siphoned out. In one instance that I recall,

five quarts of water were withdrawn at a single siphonage. A safe measure in the kind of dilatation of which I am speaking, dilatation without ulceration or inflammatory or degenerative changes at the pylorus, is to inflate the stomach with carbonic acid gas. If the patient drinks a teaspoonful or two of tartaric acid dissolved in two ounces of water and immediately follows it with the same kind of solution of carbonate of soda, the evolved gas will immediately distend the stomach and bring its outline out upon the abdominal wall so that it can be examined by inspection. Percussion, both by gentle manipulation and violent agitation elicits some diagnostic evidences. A loud splashing of waves of fluid may be heard by vigorous manual agitation.

In regard to treatment, I am reminded of an anecdote of a prominent English physician who was called in consultation. He discovered. what had been overlooked, a marked acute endocarditis. The doctor in charge felt much chagrined at not having made a proper diagnosis, but was consoled by being told that if he had discovered the difficulty he might have undertaken to treat it. The best way to correct diseases is to prevent them. Non-anatomical gastric dilatation is in the class of preventable diseases. It is the sequel of many causes. cases of hyperchlohydra, nervous irritability and exhaustion, anæmia, persistent anorexia, delayed convalescence, over-work of muscle and brain and gastric unrest, and all like enervating conditions we should look for something worse and perhaps incurable to follow. The sequelæ are as numerous as the exciting causes. If in any of them the stomach seems irritable and digestion weak, we should administer our treatment with the danger of which we are speaking as of possible occurrence. I am of the opinion that the American restaurant and boarding house are not without danger in this regard. They develop the habit of unphysiological eating, saying nothing about the digestibility of the food. The patron eats rapidly, chews improperly or not at all, does not take his mind off his engrossing cares, is solitary and does almost every act connected with his meal in a manner to invite indigestion. It is a proverb that good company conduces to good digestion. One should dine, if possible, with a congenial companion, even if he has to pay for the additional meal occasionally. Indigestion means food stagnation to a greater or less degree, stagnation conduces to gas-production, gas-production to distension, and that to dilatation. Of the hygiene, dietetics and therapeutics of the stages preceding dilatation, I cannot speak, although it is a subject in which I am especially interested. Dilatation once having taken place the food should be selected, prepared and taken with great care.

It is almost a matter of routine with me to wash out the stomach in the morning before breakfast, although some maintain that the tube is tolerated better before dinner. The benefits are so apparent as to scarcely need mentioning. The stagnant, decomposed food, together with accumulated secretions, had best be removed before more food is taken. Not only is the stomach relieved of this irritating and poisoning burden but it is cleansed and put in better condition for the meal to follow. Everyone washes his face in the morning, why not his stomach, if soiled? I usually, after withdrawing the contents of the stomach, diluted with water, continue the lavage until the water runs clear and seems as fresh as when poured in. I am partial to a weak solution of hydrastis as a local medicament. Sometimes boric acid water is excellent. The same may be said of many of the milder and safe antiseptics. If some of the hydrastis water or boric solution be left in the stomach for a time it is as well. The question may be raised-if it is advisable to wash out the stomach one morning, why not every morning? The mechanical irritation of the tube upon the throat contraindicates too frequent use, if a little soreness is felt. After a few washings the benefits are so much that it can be safely omitted for two or three days. Many people stand daily lavage and enjoy it as a part of their regular toilet. The other benefits, dangers and contraindications of the tube I cannot mention for lack of time.

Diet and drink should be regulated with great care. Thirst is sometimes annoying. The patient can ordinarily have a drink of hot water an hour before meals. Drinkers of beer and other grog are hard to control. The diet must be selected with the view of reducing the bulk and increasing the nutrient power. Bulky farinaceous articles must be prohibited. All foods would be better finely comminuted, as they will mix with the gastric fluids more readily and be passed with less hindrance. Scraped beef, meat meal, a moderate amount of milk, eggs, a small piece of toast or good biscuit, butter, gelatine and well-cooked rice are among the commoner articles. Pre-digested foods are highly recommended by most specialists. A minimum of watery fluid should be taken, especially with food. It is often advised to give no drink with meals.

Medicines.-Medical treatment gives only indifferent results, unless combined with gastric cleanliness and proper eating and living. I have referred to solutions that may be used in the stomach washing. Some of the more simple, non-fermentatives: one, Hydrastis, I believe, has a decidedly beneficial effect aside from mere local action. Its indications are debility, constipation, sour eructations, anorexia, vomitus, mixed with slimy mucus.

Nux vomica tones the exhausted muscular fibres and influences glandular secretion. It has the morning putrid taste, sullen, dyspeptic mentality and is a common and useful prescription. I am in the habit of administering it in the drink of hot water an hour before meals.

Argentum nitricum has volumes of gas with gnawing pain. From experience, I am disposed to believe it has been quite beneficial.

Perhaps there is not a remedy more closely symptomatically indicatd than Robinia. It has a constant weight and excessive acidity of the stomach, with sour vomiting setting the teeth on edge, thirst, great distension and constipation.

Graphites.-Has symptoms of bitter, sour regurgitations of indigested food and unabsorbed drinks. Jousset remarks that it answers well in cases of gastric dilatation.

DISCUSSION.

Dr. Nobles.-Dr. Hinsdale's paper covers a large and wide range, but it would seem to me that the importance of gastric ulcer in the causation of stomach dilatation should be mentioned. Medical literature of the past few years is filled with reports of cases of ulcer of the stomach which have been treated by gastro-enterostomy, and with such favorable results that the statement has been made that this operation can be performed, in capable hands, with a very small death rate. I have seen about forty or fifty cases of ulcer of the stomach treated by this method and the results, from what I have learned, have been exceedingly favorable. If it is done without very much danger to the patient, it would seem that this treatment should be more often advised and carried out. I think the way in which gastric ulcer causes dilatation is that the cicatrical tissue, which is the result of a gastric or duodenal ulcer, contracts the pyloric orifice and there is a compensatory dilatation of the stomach. In chronic cases where gastric lavage and massage are not successful, these patients can be advised to have this operation done.

PRESIDENTIAL ADDRESS.

By G. J. Damon, M. D., Medina, Ohio.

Mr. Chairman and Fellow-Members:

A short time ago our worthy president notified me that as he had been ill nearly all summer and was still indisposed, he would expect the vice-president to deliver the semi-annual address before this society.

The subject of fees was so ably handled by our president, Dr.

Cauffield, last year, that I shall only say that I hope that our committee appointed at that time have taken the matter up properly, and will keep the subject before this society in such a way that we shall be able to co-operate with each other and obtain in a small degree at least the compensation due us. It may need co-operation with other societies, Homeopathic and Allopathic, and especially the county societies, some members of which in our local county society I know to be adverse to the raising of fees. It certainly is one of the great drawbacks to medical practice that we do not get a proper remuneration for our services.

The following taken from an address of Dr. Halbert, delivered before the Illinois Homeopathic Medical Association, on May 10, 1904, on the subject of fees is to the point:

"When I look at the family physician, up at all hours of the night, exposed to the most inclement weather, tried by the direst of all responsibilities, my heart goes out in pity for one in such an unfortunate profession, but when I realize that a good majority of these never receive the pittance which belongs to them, because they do not demand it of those who can afford it, my pity is turned to a mild form of disgust. When I realize that men of our calling in the wealthiest of country localities, are taking care of confinement cases for five and ten dollars; when I am told that prescriptions and advice are offered at fifty cents per head, and visits are made for less than a dollar, I wonder who is at fault. If this sort of a reward is to continue on its present downward grade, it is a question as competition increases how long before the physician will become a missionary pure and simple."

Would further say that if physicians wish to be good collectors, they must use modern methods. I have recently installed a card system for keeping accounts in my office, which greatly simplifies bookkeeping.

The Macey Company, of Grand Rapids, Mich., have a physician's card system which is very fine. On front of the card is place for name and address, and for the itemized account. On back of card the diagnosis, treatment, etc., can be written in. You simply have your call book and desk pad. At night you transfer your calls from call book, and office treatments from desk pad to each person's card. Your account is always ready, and when a patient asks for the bill, instead of telling them to call again when you are not so busy, it is ready for their inspection and you get your money, when by waiting you may not get it at all, or you wait till their gratitude is exhausted and have to go to the expense of collecting it. Another advantage of