right lobe of the liver, presumably guarding a perforating duodenal ulcer.

Posterior gastro-jejunostomy was done, using the rubber dam over the posterior one-half of the wound. Thirty hours after operation acute dilatation of the stomach took place. Stomach tube brought away three-fourths gallon of dark brown fluid with strong fecal odor and an enormous amount of gas. Gastric lavage was repeated as often as the slightest evidence of distention occurred. Third day bowels moved, gas passed freely per rectum; no nausea was present; patient took grape juice, malted milk and water in small amounts with no discomfort whatever. Temperature throughout course never above 99. Pulse during dilatation reached 130, but after third day was 90 to 100. He expressed himself as feeling perfectly comfortable and well. Eve of the eighth day he remarked that he felt a little sense of fulness in the stomach and suggested that the nurse call the doctor. The nurse stepped to the phone to communicate with the doctor and re

turning within ten minutes found the patient dead.

No postmortem being permitted, we may only conjecture the cause of the death as due to embolism. The suddenness of death almost preIcludes, under the circumstances, other causes.

I realize that this is too small a number of cases to be of great value, particularly in cases so complicated and atypical, yet it shows the procedure is not a complication and in the post-mortem specimen the anastomotic results were ideal.

Fig. 11.-Inner side of stomach laid open, same as Fig. 10.

(1) Pylorus slit open. (2) Anastomotic lumen. (3) Linen threads being extruded. (4) Gastric mucosa. Examination of this specimen would indicate that from this method there is not only no tendency to contracture of the anastomotic opening, but there appears to be no cicatricial material to favor such a tendency, as the union is linear and smooth, both on the mucous and serous sides. For illustration, see opposite page.

Organacidia Gastrica.

By MARK I. KNAPP, M.D., LL.B., LL.M., 616 Madison Ave.,

NEW YORK CITY.

Our duty primarily is to heal. That is why the patient comes to us; that is why the patient pays us; that it what the patient expects of us. Alleviation of the symptoms comes in as a secondary consideration, as an alternative only. Little does any layman care about a mere diagnosis. Can I be helped, is the only and the all-absorbing question are we ourselves, as patients, much different? Upon a critical analysis of the erudition of our men, who, somehow or another, achieved ephemeral and endemic fame, we find most of the time that their soothsayings are denied by their ownselves, if we only wait a little time, during which some such authorities have had time to learn their fallacies. However, I do not expect to bring about the millennium.

Our duty to ourselves and mankind is to

uphold the teachings of our luminaries, but only to such extent as they give positive results. The moment we have to find excuses for failures, it is time for us to begin to question either our abilities in diagnosis. or the adequacy of the advocated treatment. Our touchstone must ever be the relief the patient gets from our treatment. And, if we are sure that our diagnosis, as at present understood, is correct, yet the patient continues to suffer, our necessary conclusion must be that the applied treatment is wrong, no matter what high rank holds it sponsor. These ideas permeated me when I left college and was let loose upon suffering mankind. And the resultoh, I made enemies right along! But mighty rare are the tombstones whose silent principals had me ministering to them. This statement is very bold, but I believe founded upon truth. I became a dissenter when yet a student, and some of my views, differing from those of my teachers, I did not shrink back from announcing in my article entitled: "The

physiological and pathological influence of vegetables upon man," which was published January 20, 1894, in the New York Medical Record, before my graduation. Let us always beware of the "authority" who shrouds his knowledge in terms not only not understandable by his hearers but much less by himself. For instance, the medical profession is beginning to sicken of "neuroses, nervousness and nervous diseases," and already something of a substitute is being introduced in "vagotony." And we must be prepared in the near future to have a great deal of printers' ink used up on contributions regarding the nature and the whereabouts of vagotonies. How much better off is the medical profession? In law the burden of proof is upon the proponent; in medicine the burden of proof seems to be on the opponent. A certain disease is stamped nervous, not because the proponent has overwhelmingly and by positive evidence proved that the peculiar symptoms are actually due to some derangement of this or the other nerve, but because such authority can find no other adequate explanation. And then medicine says in effect: let him who doubts prove the contrary. A negative cannot be proved.

Diseases of the stomach have been divided into two great branches: 1, such that we know; and 2, such that we ought to know. By a peculiar coincidence, the diseases that belong to the second branch are vastly in the majority. But a very euphonious term has been applied to that class; that class is called "the nervous diseases of the stomach." I shall busy myself in this article with only one disease belonging unto this class, with "organacidia gastrica.' The original article appeared in the New York Medical Record, September 6, 1902. Organacidia gastrica is that disease which is commonly called "the sour stomach." We are all familiar with the symptom complex, which goes with that torturing disease and which leads to grave conditions, which is most often misunderstood and which only too often leads to grave and unwarranted operations. I have coined the term "organacidia," because of the fact that the disease is produced by the presence in the stomach of organic acids; therefore, organacidia. It is the presence in the stomach of such fatty, acrid, volatile organic acids, which produce symptoms and subsequently also anatomical changes. At the beginning and, for a long time, there are no pathologico-anatomical changes discernible. That is the reason why this disease which is so

prevalent has been classed as a nervous disease.

I have originally distinguished three subdivisions, but have since added a fourth one. These subdivisions are: Organacidia gastrica simplex, gastrosia fungosa, zymosia gastrica and organacidia gastrica ab amylo.

Organacidia gastrica is that condition which is caused by the presence in the stomach of relatively excessive quantities of organic acids. In organacidia gastrica simplex the organic acids have been introduced by the patient with his food and drink as, for instance, by eating much of fruits, of salads, of pickles, etc. The manifesting symptoms are usually of an acute character, causing severe pains, cramps, vomiting, etc., but they subside with the passing out of the system of the noxious matter. The three other types of organacidia gastrica are of a chronic nature. I also wish to explain here my coining the names of "gastrosia," "zymosia" and also of "enterosia," which I shall mention in the course of this article. To the respective roots I have added the suffix sia, by which I denoted a pathologico-chemical condition in contradistinction to the suffix itis, which denotes a pathologico-anatomical condition. Thus, gastrosia means that there is in the stomach a chemico-pathological condition; that is, a condition which cannot be appreciated upon section by the usual anatomical earmarks, as evidenced by dissection. This term at once implies that, in order to find the lesion, chemical agencies will have to be resorted to to ascertain its presence. The term zym-o-sia means a chemico-pathological condition of the stomach caused by the presence therein of yeasts, the Greek term for yeast being zyme. And enter-osia means a chemico-pathological condition of the intestines, in contradistinction to enteritis, which means an inflammatory condition of the bowels. A little reflection will make it clear to us that gross anatomical conditions could not possibly occur and suddenly spring up over night; that long before there is anatomically objective evidence, the patients have had subjective symptoms and that such subjective symptoms have had their cause, not in hysteria or nervousness, but in irritation by chemical substances.

Great as is the teaching and progress initiated by Virchow's cellular pathology; nevertheless, there is a good deal of truth in the theory of the humoral pathology which the cellular pathology succeeded and,

The principle of packing for support which I advocate and use was suggested to my mind by the accompanying little drawing (Group A, Fig. 1) found in one of the older text-books, where it was used to demonstrate the surgical procedure of posterior vaginal section for the correction of retrodisplacements. The reasonableness and simplicity of the principle strongly appealed to me, and I immediately appropriated it and set about applying it in the non-surgical correction of uterine displacements, and it has served me well. However, in appropriating the principle for support, it will be observed that I have not accepted the method of packing given. While the one illustrated might serve perfectly with the patient in bed, it would not be applicable with her on her feet and attending to her household duties. It will readily be seen that such a packing would immediately gravitate downward and be expelled. How ever, the posterior "wad of gauze" would probably be grasped and held in the incision after expulsion of the vaginal gauze and closure of the vaginal canal beneath it. But what would happen to the uterus? How would its position be affected by the removal of the supportive pressure in front of the cervix? The next cut (Group A, Fig. 2) will show the transition, and will demonstrate that with the removal of the positive support the displacement has recurred. The packing of vaginal gauze-"the direction of effort being indicated by the arrow in Fig. 1-must be the point at which positive support is indicated for overcoming a retrodisplace

open

Dr. Harper's previous articles have attracted so much attention and fuller details have been asked by so many, that we asked for a full treatise upon the subject. This and following papers are in response to this demand.EDITOR.

GROUP A.

(Fig. 1.)

U, uterus; V, vagina; R, rectum; X, wad of gauze. The cul-de-sac has been opened, the uterus replaced, and the wad of gauze placed in the incision. The vagina is distended with gauze, which is not shown, but the direction of effort of the vaginal gauze is indicated by the arrow. (From Am. Text-Book of Gynecology, 1899). (Fig. 2.)

Shows the transition from anteversion to retroversion upon removal of the positive support, and the normal dropping together of the vaginal walls.

Another important point-and a vital one-in order that packing be perfectly effective in every way, it should be comfortable. The patient should never be uncomfortably conscious of its presence, the only evidence of its presence being the relief and comfort it produces. In order to be comfortable it should be made only large enough to easily fit the spaces or parts to which it is applied, permitting the vaginal canal to close down naturally over it, without producing any irritative pressure.

In the treatment of most cases, no matter what the deformity or other complications, I use what might be called the "universal packing," consisting of two lamb's wool tampons, medicated and packed-or tucked -well around and encircling the cervix, supporting the anterior and posterior pairs of ligaments; and the bell-shaped, cotton

and wool (lambs' wool center) tampon, medicated and applied directly to and capping the cervix.

This universal packing is applicable to any condition where support, medication or depletion-one or all are indicated, its supportive and corrective properties being dependent upon: (1) The proper reposition of the uterus; and (2) the proper individual adjustment of the medicated tampons, to give distinct supportive pressure at the point opposite the displacement to be corrected.

Remember that in all malpositions of the uterus there is a certain point at which definite supportive pressure must be applied in order to correct the displacement. The tampon placed at that certain point would represent positive support, and should be tucked firmly into place in order to give that definite support. The opposite tampon should be tucked in snugly, and will represent a somewhat more negative support. The bell-shaped cotton and wool tampon, within the soft bed of which the cervix is held, represents a somewhat active countersupport from below.

Remember-In packing for the correction of anteversio-flexions, posterior fornix represents positive support; anterior fornix, negative.

Remember-In packing for correction of retrodisplacements, that anterior fornix represents positive support; posterior fornix, negative.

Occasionally, in greatly relaxed and conge tive states of the uterus (subinvolution, etc.), with lax and overstretched ligamentous attachments, the organ may be carried too far over in the opposite direction, resulting in the opposite displacement or deformity. To obviate this tendency, indications should be watched carefully, changing about and shifting the positive pressure, when packing, so as to keep organs in equilibrium until congestive conditions are relieved and the tissues have set up a normal reaction, and the uterus settled down to normal position. The postural exercises of the patient at home should also be modified to meet conditions.

THE PRINCIPLE APPLIED.

In treating for correction of any malposition or deformity of the uterus there are three important points for considera

tion:

(a) Correction of the deformity;

(c) Packing for support (tamponade). 1. Correction of the Deformity. Reposition for a retroversion is a comparatively simple process, but when the condition is accompanied by a marked flexion, at the site of which may have occurred more or less decided fibroid changes, the process becomes a more complicated one. Follow back along the line whereby the deformity was developed, and by careful manipulation and moulding of the organ, reduce the deformity to a simple version. (Study plates carefully.)

(b) Correction of the displacement (reposition of the organ); and

GROUP B

GROUP B.

FIG 2

Bladder

Fig. 1. X, vagina unduly distended with packing (not shown), which encroaches upon rectum behind and bladder in front. With patient in standing position, the uterus presses down upon and expels such a packing, allowing the organ to drop down in prolapse. (Dotted lines show manner in which the vaginal folds close down normally around and beneath cervix, closing vaginal canal, holding the uterus swung within their grasp. Fig. 2. Compare with dotted lines in preceding cut. This cut shows how the proper method of packing actually supports by preserving the correct relations of the pelvic organs, interfering in no way with the physiologic activity of each, and permitting of perfectly normal freedom of movement between them. Observe the normal closure of vaginal canal.

Figs. 3 and 4 demonstrates incorrect methods of vaginal packing. The former shows large packing back of cervix, which encroaches upon the rectum, and soon becomes displaced, allowing uterus to gravitate backward in retrodisplacement, the very error sought to be corrected. Yet, this is the method advocated by many for the correction of retrodisplacements. Fig. 4 shows large packing in front of cervix, encroaching upon bladder. This is the common method employed for anterior displacements, and only induces or greatly aggravates the condition; packing soon becomes displaced and the fundus gravitates farther forward and downward.

A careful study of the six foregoing cuts, and application of the principles involved, should demonstrate to the reasoning mind their perfect simplicity and reasonableness; that the whole proposition of what should constitute proper treatment for the correction of displacements, resolves itself into the following: (1) Reposi tion and (2) Support; or, restoration of the normal relations of the pelvic organs and proper packing for support.

2. Correction of Position-Reposition. Now, with patient occupying the correct.