avolsella." This treatment being given on alternate days to aid in the reposition of the uterus before inserting a pessary.

Percy (1910) advocates the use of tampons in displacements of the uterus. He says: "They should be of material that will permit of drainage, and nothing is better than lamb's wool. This will not pack down hard. It is expansile, and in this way. keeps up a firm but not dangerous pressure fixation... Tampons are of no value if they do not cause and maintain fixation. To apply a tampon containing some form of medicament with the idea that the medicine without fixation of the parts will do something useful, is practising a fraud on the patients."

should fill the fornices and be on a level with the external os. They should be firmly rolled and compact in order to compress well. Their being placed in position is the most important part of the columinzation; this is carried out by filling the vagina entirely with the tampons moderately compact. In order to pack the vagina use tampons of wool and gauze impregnated with glycerine and dusted with iodoform." (And they say we have progressed!)

Fig. 3, shows the common but incorrect method of packing to overcome the tendency to a retrodisplacement. If the idea were to maintain or induce this displacement, the method would be correct, for the weight must fall toward or over the support. (Study plate.)

Fig. 4, shows the very common. but incorrect method of packing to overcome the tendency to an anteversio-flexion. (See notes under Fig. 3.)

Dr. Monson of Denver (1911) recommends in retrodisplacements, a careful bi-manual replacement. "After the uterus is well in place, a lamb's wool tampon saturated with boroglyceride is packed behind the cervix to hold it there."

Fifty-three years since Dr. Nathan Bozeman outlined his method of treating for the correction of retrodisplacements, and in the year of our Lord 1913 precisely the same methods are being employed (I don't believe Bozeman mentioned the use of iodoform!). It begins to look as if the surgeons who voiced such radical sentiments have some ground for their conclusions. But what are we going to do about it? Almost anyone should be able to do a replacement of a displaced uterus, provided he correctly diagnoses the displacement; but how many can adjust a packing which will give no discomfor to the patient, one that will give the proper (temporary) fixation-support in such a manner as to permit of the re-establishment of normal conditions?

Hartman (1913) says that tamponing for retrodeviation and prolapse is often described under the head of columnization of the vagina. This plugging is carried out in the following manner: First, place a large tampon in the posterior fornix, and then successively smaller ones in the anterior and lateral fornices. These tampons

And this is the "missing link" (temporary fixation support) which even surgery has failed to supply. And here it is where non-surgical and surgical measures seem to converge, or overlap, or blend, one with the other. In treating for the reduction of dislocations and fractures of bones, the first thought is to restore normal relations of the parts; and the second is to provide a temporary fixation-support as an effectual aid to nature in re-establishing normal conditions. Absolutely the same rule applies in the treatment of pelvic displacements, and you can no more expect good results from a misapplication of surgical principles in one than in the other.

All seem fairly well agreed that to secure the best possible results from local treatment a proper replacement of the uterus must first be made, thus restoring normal relations of the parts; and next, that a packing be adjusted in such a manner as to give prefect fixation-support; but not as a prop, not as a plug, which, when displaced, leaves the parts all unsupported; but as a carefully applied splint-a crutch-which may gradually be dispensed with altogether, as the tissues regain their buoyancy and tone.

I have formulated a little rule which will serve as a very simple key to the principle of packing for fixation-support, which will

apply equally to any displacement, whether anterior, posterior or lateral:

Rule. The point at which force is applied in overcoming a displacement is the fixation-point for its correction (working from cervical pole).

Remember: In packing for the correction of anteversio-flexions, that posterior fornix represents the point of positive fixation-support (the point at which force is applied in overcoming the displacement), where packing should first be placed and tucked in firmly; and that anterior fornix represents negative support, where packing is next placed, and tucked in snugly.

Remember: In packing for the correction of retrodisplacements, that anterior fornix represents the point of positive fixation-support (the point at which force is applied in overcoming the displacement), where pack ing should first be placed and tucked in firmly; and that posteror fornix represents negative support, where packing is next placed, and tucked in snugly.

The principle of packing for fixation-support is a purely mechanical problem, which when worked out and properly applied, will make most tamponade a success instead of a failure.

When we consider the unscientific methods employed by so many, we cannot but remark that Nature is wonderfully kind, for many cases do recover, if not as the result of treatment, in spite of it!

Conclusions: Tamponade should produce (temporary) fixation-support; and should not unduly distend the vaginal canal.

Why most tamponade is a failure: Most tamponade does not produce fixation-support; and most tamponade does unduly distend the vaginal canal.

MORBID MENTALITY FROM A PSYCHOLOGICAL VIEWPOINT.*

F. B. ERWIN, M. D., Wellston, Okla. The state of the mind impresses itself very forcibly upon the person's actions; the functions of the different organs and glands of the body. It likewise affects the manner in which he expresses himself in language. When the actions are referred to the movements or positions of all the muscles of the body are considered, especially the facial expression.

Under normal conditions the sensorial nerve endings receive and transmit impressions to the centers in a normal manner and they are interpreted normally. The differ

"Read before the Medical Association of the Southwest * Kansas City, Mo., October 8, 1913.

ent states of the mind in normal persons are indicated by the expressions and actions of the person. These are good indices to the psychical condition in either a normal or abnormal mind.

One of the first things to consider is attention. It is that state of the consciousness in which there is a concentration of the mind upon one thing for a longer or shorter length of time by means of some stimulus either internal or external to the person. This condition is frequently noted upon the face by a contraction of the frontal muscle. Intellectual work impresses itself very forcibly upon the expression of the face by the contraction of the superior portion of the superior oblique muscle.

External attention is obtained through the common and special organs of sense. The resting of the eyes upon some object arouses an interest therefore attracting attention. This may be obtained by means of luminous or colored objects. These objects may be at rest or in motion. In some psychoses the attention is frequently easily obtained but also very easily lost. In others hard to obtain and easily lost.

Auditory attention is obtained by means of sounds of different kinds. In certain forms of mental diseases, some forms of dementia precox, a whisper will attract the auditory attention more quickly than a loud noise. In some abnormal mental conditions the attention may be noted as obtained, not by the person turning his head in the direction from which the sound came, but in the opposite direction. Sometimes they will turn the entire body and frequently move away from the direction of the sound, as in paranoia. The force of the impression upon the mind can frequently be noted by the strong or weak motion of the eyes, face or body or the expression of the face.

The tactile and steregnostic attention is noted by the muscular contractions of the body, especially the trunk. The person frequently complains of the clothing being too tight or of the soles of the feet not feeling pain, that is seeming to them that they are walking upon a carpet and numerous other expressions which indicate the condition of the above stated attention.

The olfactory and gustatory attention are obtained mainly by the food and drink the person takes. In certain forms of mental diseases the person claims and firmly believes that they are being poisoned by something being placed in their food or drink. These ideas prevail in the paranoid form of dementia precox. The first sign of internal attention is the lessened regard for outside things. The second is the desire

to remain quiet and think. The desire to be alone; in a meditative attitude. In this state the parallel position of the optical axes is characteristic. The third sign is the dilatation of the pupils, which is due to a partial or complete arrest of accommodation. The fourth sign is the general inhibition of the reflexes, also the arrest of the general improvement of the body. The muscular tone of the body is lessened as well as the organic and glandular actions.

With a change in the internal attention there is always an increase or decrease in the volitionary powers. A concentration of the volition is accompanied by a strong contraction of the upper lip and increase in the muscular tone of the body. A strong will power is generally accompanied by a strong attention. Inversely a weak will Inversely a weak will power denotes a feeble attention. An open mouth and feeble muscular tone indicates a feeble will power. This last is very noticeable in idiots and imbeciles.

The emotions are generally very clearly depicted upon the visage normally. Sadness expresses itself by the contraction of the muscles of the eye-brows. The internal angle is elevated and the external is depressed. The base sentiments are shown on the face by a contraction of the pyramidal muscle of the nose, thereby depressing the internal angle. The displeasure expresses itself by the action of four bundles of muscles of the face; elevating the upper lip and alae of the nose; elevating the superior proprius; elevating the angle of the mouth (the action of the zygomatic minor). Joy expresses itself by the combined contraction of the great zygomatic and the inferior orbicularis palpebrarum. The great zygomatic enlarges the mouth and produces a series of radiating folds near the external angle of the eye. The inferior orbicularis palpebrarum raises the lower eyelid and expresses good will. Disdain is depicted by a closure of both eyes and the lowering of the two commissures of the mouth. In extreme cases the mouth is opened. Dejection is expressed by a contraction of the muscles of the eyebrows in combination with the triangular muscle of the lips. Surprise shows itself by the contraction of the frontal muscle and a moderate contraction of the lower muscles of the inferior maxilla. Fright produces a contraction of the frontal muscles, skin and depressors of the lower maxilla to a maximum degree. Anger expresses itself by a contraction of the pyramidal muscle of the nose, the obricularis muscles, superior palpebral, masseter, buccinator, quadrate of the inferior lip, skin and muscles of the

body. Indignation is indicated by showing the teeth and at the same time making a motion with the fist. Sensual love is expressed by the contraction of the transverse muscle of the nose in combination with the great zygomatic.

There are variations of the physiognomy according to race, sex, etc. The peculiar characteristic of the caucasian race is the predominance of the superior palpebrarum orbicularis muscle upon the frontal. This is inversely true with the mongolian. The negro presents a coarse face with thick lips. The superior orbicularis palpebrarum is less developed.

In the first three months of the life of a normal child the external attention is developed. From the fourth to the tenth month the child receives impressions and begins to assimilate them. The last of the first and the beginning of the second year begins the development of speech. In the first of the periods the child is in a state of satisfaction and contentment. In the second period he begins the contraction of the superior orbicularis palpebrarum muscle. The movements are very lively under the influence of action and thought. In the third period the psychological forces begin to present themselves in concrete form. A certain number of the emotional and cognitive processes remain in an undeveloped state until the age of adolescence.

The principal peculiarities of the physiognomy which differentiate the man from the woman are the following: The muscular tone of the man is greater than that of the woman; the eyebrows of man are more rectilinear and lower; the feminine expression is distinguished by an immobility and a monotony less expressive of the acts.

Health is characterized by the following signs or symptoms: A strong muscular tone; a bold strong spirit and a contraction of the superior orbicularis palpebrarum muscle. Acts of gaiety are expressed by a contraction of the great zygomatic muscle in combination with the inferior orbicularis palpebrarum muscle.

Weakness of the mental state and fatigue are characterized as follows: A weakness of the voluntary muscles (flexion of the trunk). In fatigue of thought there is a feeble tension of the superior palpebrarum muscle. Where there is a lessened expression of gaiety there is a feebleness of the great zygomatic and inferior orbicularis palpebrarum muscles.

be

The following temperaments may noted: Bright and prompt; gloomy, strong and rapid; bright, violent and rough; gloomy, strong and slow; bright, feeble

and rapid; gloomy, strong and slow; bright, feeble and rapid; gloomy, feeble and rapid; bright, feeble and slow; gloomy, feeble and slow.

In examining the degenerates the predominance of the frontal and facial expression is noted. The characteristic expressions are the simultaneous contraction of all the frontal muscles; the putting, in sport or play, of the square muscle of the upper lip; the development of the infantile expression of the face; the relation or harmony of the face and trunk, which consists of a feeble sluggish muscular contraction together with dragging movements.

The different functional alterations are numerous and interesting, but this paper shall deal with them only in a very general manner. Different mental states very noticeably alter the respirations. In melancholia it is very frequently slow. Sometimes a long inspiration and a hurried expiration. In groaning and lamenting the expiration is brusque and rapid. In anxiety the respiration is extremely superficial. In extreme pain the respiration, is distinguished by great restlessness. In shame and modesty there is a predominance of inspiration. The respiration is superficial. The respirations are twice as great in joy as chagrin.

Often in degenerates the alteration in cardiac rhythm is observed. It is found also in nervous and traumatic psychosis. It is noted in the mentally defective secondarily and in the acute forms during the height of the disease. It is likely that the cardiac rhythm as here referred to shows itself more often in the psychoses than in

the cardiac affections proper. A modification of cardiac rhythm is found in the prodromal state of mental confusion which develops rapidly.

Language is the medium of communication between men. In the expression of spoken language much depends upon the voice as to height, intensity, duration, rhythm and the arrests or silences. In the different mental states these conditions, as stated, of the voice are noted very forcibly. In the manic form of the manic-depressive psychosis the increase in the height, intensity and duration are specially noticed. In the depressive form the opposite is noted.

An energetic and strong intellectual effort produces an excitation of the function. vasomotor constriction, an acceleration of the heart and respiration. Intellectual work of the duration of many hours relative immobility of the body produces an abating of the heart and diminution of peripheral circulation (capillary).

From the above we may note that the study of the abnormal mind in a psychological manner is very essential to the proper understanding of the different mental states. Also it helps toward the diagnosis. If one may understand the normal mind from a study of the actions of the person why not know the abnormal mind by careful observance along the same lines?

-Edward Rowland Sill.

IMPORTANT FACTORS IN THE ETIOL

OGY, PROGNOSIS AND TREATMENT OF PERNICIOUS ANEMIA.*

CARYL A. POTTER, A. B., M. D., St. Joseph, Mo.

The importance of oral sepsis in causing pathological conditions in the stomach and intestines favorable to the development of pernicious, or Addisonian, anemia has been pointed out by William Hunter, who, in a number of instances, has advocated the great importance of correcting pyorrhea alveolaris in treating this form of primary anemia. The evident possibility that the continuous swallowing of pathogenic bacteria-in many cases streptococci-may cause a severe acute or chronic gastro-intestinal upset has long been recognized.

The alimentary canal as an indirect or stimulating agent in the etiology of the disease seems uppermost in the medical mind at present and, in the treatment, Croftan has reported success in using hydrochloric acid per os to replace hydrochloric acid, which is low or absent in the gastric juice in the majority of cases. By forcing the intake of hydrochloric acid, ten to fifteen minims of the concentrated acid to the glassful of water through a glass tube after each meal, he has attempted to supply a requisite amount of acid. In addition, he has supplied the patient freely with proteins and fats.

Through a patient of Croftan, Mr. K. M., the writer was able to observe the effects of diet and hydrochloric acid in a case of pernicious anemia with subacidity. The patient, as reported by Croftan, was an active business man up to the onset of his illness when he became very anemic, lost weight and had severe attacks of indigestion and diarrhea.

Under treatment, as outlined by Croftan, the blood count became normal and the patient made an apparent recovery.

Since 1908 to the time of Mr. M.'s death the writer had many opportunities to observe and talk with him. He never ate a meal after commencing treatment without following it with 10 to 15 minims of concentrated hydrochloric acid in a glassful of water through a glass tube, at the same time paying strict attention to diet. He was advised to take the acid for the rest of his natural life, and did so faithfully to the time of the terminal attack the past winter. By careful use of the glass tube he had noticed no ill effects to his teeth. Up to the terminal attack, he had had no other

recurrence.

This case, therefore, must be omitted from the records as a possible cure of pernicious anemia, although hydrochloric acid seemed to benefit the symptoms depending on achylia gastrica.

In 1908, Mrs. C., of St. Joseph, Mo., consulted the writer's father, complaining of general debility and stomach trouble. Her husband was in very poor health and rerecently she had had domestic and business worries. She was often very dyspneic, and had had frequent attacks of diarrhea and abdominal cramps which bore no resemblance to gall-stone colic and disappeared after careful attention to the diet and relieving the diarrhea. The family history was negative.

On examination, she appeared to be a well-nourished woman with no evidence of recent atrophy of subcutaneous fat. Her skin and mucous membranes were pale; her eyes were prominent and she had a marked tachycardia. The thyroid was not palpable and there were no other symptoms to suggest exophthalmic goitre. On deep pressure over the region of the gall bladder, she showed a marked tenderness and her liver showed a slight enlargement. She had had pain referred to her right shoulder and, at the time of examination, had a slight fever. The lungs and heart were