12. -ter, tro, -trum, Sanskrit-root tar, to bring about; fere-trum bier, spec-trum causing to look, rast-trum (rad-o), ros-trum (rad-o), claus-trum (claud-o), vi-trum (video), mulc-tra (mulceo). The instrument or means to perform an action is designated by -τρο, τρον, ἀρο-προν plough, aratrum, 6-7pov ransom, didak-7pov apprentice-fee, rpa, §varpa horsecomb; (ξέω); also a place; ορχήστρα dancing place παλαίστρα wrestling school (from όρχεομαι and παλαίω.)

13. The formations in -tura are quite common in Latin, some even without the simple forms in -tor, so that their derivation can only be assumed; pressura (pressor, premo), fractura (fractor, frango) punctura (punctor, pungo), sectura (sector, seco), tonsura (tonsor, tondeo), unctura (unctor, ungo), litura (lino), junctura (jungo), genitura (genitor, gig/e/no), mensura (mensor, metior).

14. -orium, -torium, Greek Tov, sorium, (French -oi)r, for the design of localities, instruments and similar things; promunt-orium, tent-otium, accub-i-torium, suda-torium, an-ju-torium, ses-sorium, dever-sorium, terri-torium, calca-torium, emunc-torium, tec-torium, ἀκροατ-τήριον audi-torium ; δικας-τήριον judicial court (δικάζω).

(To be continued).

POST-PARTUM HEMORRHAGE.

BY HUNTER H. POWELL, A. M., M. D., Cleveland, Ohio.

Professor of Obstetrics and Pediatrics in the Medical Department of Western Reserve University, Cleveland, O.

[Written for the MEDICAL BRIEF.]

Post-partum hemorrhage is the result of a disturbance of nature's processes. In the main, it may be said that the great majority of post-partum hemorrhages are due to errors in the handling of the cases. As a teacher of obstetrics I have always warned my young men to be careful how they claimed to have been so successful in the management of post-partum hemorrhage, since had they managed their obstetric cases properly they would have had few cases of hemorrhage to report.

Among the chief causes of this dangerous accident are (1) the too hasty expulsion of the afterbirth by the Crede method, and (2) the too active and radical steps taken to prevent active hemorrhage.

A slight hemorrhage may be followed by no ill-effects, and the condition of the patient determines more than anything else just what measures must be taken. A good many inexperienced men are deceived in this respect, and do radical procedures, which are accompanied by more injury to the patient than the blood that has been lost.

The amount of hemorrhage varies so within bounds of the normal that the condition of the individual should indicate what treatment, if any,

should be resorted to, rather than hasty interference with the interior of

the uterus.

Post-partum hemorrhage, amounting to a serious condition, is extremely rare in the practice of men who are properly trained in obstetric practice.

In my own practice, until I see that the patient shows the effect of loss of blood, as indicated by pulse and respiration, I very rarely resort to those radical measures which are required for the internal handling of the uterus, or internal applications of any kind. If one has charge of the case and knows how much of the afterbirth has been removed, and whether anything is retained to cause hemorrhage, or whether the hemorrhage is due simply to an atonic condition from systemic cause or exhaustion, he is in position to know just what to do. For a physician always has in mind the possibilities of post-partum hemorrhage where labor has been long continued, or where chloroform or forceps are used, and is specially prepared to meet these emergencies.

Of course, there are many women who are temporarily impaired in health by loss of blood, even though death does not occur, if the puerperal period is prolonged.

Treatment will depend entirely upon the case. If due to retained afterbirth, this must be immediately removed. If the hemorrhage is due to an atonic condition, and does not respond promptly, boiled water, at a temperature of 115° F., should be injected into the uterus. Sometimes alcohol (50%) has a beneficial effect, but hot water is, I think, preferable. Of course, ergot is injected hypodermically. Once in a great while I resort to packing with sterile gauze, but this rarely, and is only done when, for some reason, the uterus will not contract, and we will have to create a solid mass.

As hemorrhage usually occurs in from ten minutes to an hour after birth, the physician is, or should be, present. But the nurse should always be trained by the physician to cause the uterus to contract by manipulation from the outside with the hand.

The condition of the patient should also govern the use and kind of stimulants.

1861 Prospect avenue.

DIFFICULTY IN URINATING DUE TO TABES.

In the case of many old persons who complain of slow and difficult urination, and other urinary symptoms pointing to enlargement of the prostate gland, it is necessary to bear in mind the possibility of the trouble being due to tabes. Even though examination shows the prostate to be enlarged, it does not necessarily follow that it is the cause of the urinary disorder, and it is important to determine whether tabes may not be present.-American Medicine, March, 1908.

GENERAL VIEWS IN THE DEFICIENCY OF THE SPHINCTER

APPARATUS.

BY BYRON ROBINSON, Chicago.

[Written for the MEDICAL BRIEF.]

The vagina should engage more of our attention, because it is on this apparatus that the operation of colpoperineorrhaphy is applied, The primary factor which produces deficiency in the supports of the sphincter apparatus is parturition. Other factors play but a secondary rôle.

The pelvic fascia is not infrequently lacerated near the ischio-pubic rami; where the fascial sheath is ruptured the contained muscular fibers also suffer laceration. The results are cicatrices and loss of substance, which may be felt by palpation. The ventral vaginal wall generally escapes laceration, but the dorsal vaginal wall is often damaged, showing varied size and form of lesions. Relaxation is prominent and closure incomplete. Instead of the curved distal canal, with the perfect sphincter apparatus,there is a patulous, relaxed patent mouth, resembling a tobacco pouch which has lost its puckering string. Sometimes the vaginal mouth is closed by a ventral and dorsal vaginal fold, for a considerable distance proximalward in the vagina. The causes of the displacement of the sexual organs are so numerous-as elongation of the utero-rectal ligament, elongation of the cervix, laceration of the levator ani fasciæ, proximal and distal; muscles and triangular ligament, intra-abdominal pressure, splanchnoptosia—that all possible factors must be considered in repair. Repair must consist in correcting vicious forces, as the conical-pointed cervix should be amputated and turned dorsalward, the dorsal vaginal curve should be restored with a perineal body, return the rectal end dorsalward, and the lacerated levator ani fascia should be reunited.

An analysis should be made of the factors producing the displacements and lacerations in the genital organs. Deficiencies of the sphincter apparatus; however, both may be often combined. Yet, after all, our chief direction will be directed to deficiencies of the sphincter apparatus, for on it depends prolapse and lacerations, chiefly arising in it. Deficient primary supports give rise to vaginal inversion, as rectocele, vesicocele, bladder and rectal disturbances, and the vaginal mouth loses its puckeringstring condition. In colpoperineorrhaphy, the whole of the tissue of the pelvic floor should be utilized for support by forcing it into the median line. This will restore the tonicity of the pelvic floor, and form a firm cicatrix, which will prevent sacro-pubic hernia, and also reproduce the normal curves of the canals. To accomplish this, extensive denudations, or flaps, are requisite.

Successful colpoperineorrhaphy must make the pelvic floor as tense as possible, and the newly-formed cicatrix will aid materially in its success. The thickened tissues (columns) in the ventral and dorsal abdominal walls

are remnants of Miller's ducts, which should and are preserved in both Dr. Emmet's and Mr. Tait's flap operations. They furnish evident support from their fibrous masses. It may be observed that nearly all successful methods of perineorrhaphy make the denudations in the vaginal sulci on each side, and avoid sacrificing the thickened tissue on the dorsal and ventral walls. Reference to the labors of Bischoff, Martin, Hegar, Kaltenback, Schatz, Emmet, and others, will show this to be correct. After performing colporrhaphy dorsal, Martin makes what may be called an extension of the perineum ventralward. This is an excellent method of restoring the ventral curve of the distal end of the vagina. Any surgical procedure, to be successful, must conform to the anatomic structures. The

FIG. 1-(Author) An illustration to demonstrate that in deep lacerations of the pelvic floor the levator ani fascia proximal and distal is torn with its intervening muscle, the levator ani. The rent or tear is shown by R-R and R-R on the right side. The needle, armed with the thread (X) will pass through the muscle and its two layers of fascia in order to restore the integrity of the pelvic floor, IL, iliac fascia; 1, the beginning of the obturator fascia superior at the ischio-pectineal line; OS, the obturator fascia proximal; WX, the white line; IO, the obturator internus muscle; F. the fat in the ischiorectal fascia; A, the levator ani fascia proximal; B, the obturator fascia distal; V, the vagina; S, the intrapelvic space; Y, the cervix; P, the deep transverse perineal muscle, and 2, the superficial; B, sphincter ani externus; M, the deep layer of the triangular ligament; S, superficial; N, the deep lever layer of superficial perineal fascia.

denudation of the lateral vaginal sulci, or the flap operations, conform to anatomic conditions, and so far have proved successful. The reason denudation in perineorrhaphy is so successful is because healing in the vagina occurs with considerable certainty.

METHODS OF PERFORMING PERINEORRHAPHY.

The methods of perineorrhaphy may be classified into three divisions, viz., Those which start at the pudendum (denudation); those which at

tack the distal vaginal portions (denudation); those which depend on the flap procedure (which embraces colpoperineorrhaphy).

Numerous methods of perineorrhaphy have been tried since the days of Ambrose Pare, Dieffenbach and Baker Brown, when they simply united the superficial tissue which was situated on each side of the visible laceration. This was a superficial pudendal procedure, and was of small value, except to prepare the way for more useful methods.

HISTORY.

If the ancients performed successful perineorrhaphy, I am unable to obtain the records. Colpoperineorrhaphy, as a modern operation, can scarcely boast of being more than a century old. Surgeons sought to prevent prolapse (sacro-pubic hernia) by excision of the vaginal wall, so that the resulting inflammation would produce a contracting cicatrix. Others applied caustics for the same reasons. According to Schroeder, Girardin-Laugier employed the blue stone. Phillips used "smoking saltpetre;" so did Laugier, Velpeau, Kennedy, Dieffenbach, Colles, and Simon. Chippendale sought to stir up inflammation and cicatricial contraction in the vagina by the very questionable method of infecting it with gonorrheal virus. Operators have attacked the pudendum or vagina. The pudendum was first attacked by such surgeons as Baker-Brown and Pare. Fricke was the pioneer who performed episiorrhaphy, which consisted of denudation of both labia and union by sutures. The failures of Fricke's episiorrhaphy induced later surgeons to operate more proximalward in the vagina, which finally resulted in the Emmet and Tait methods. Mende suggested denudation in the region of the hymen. Malgaigne thought it should be more proximalward in the introitus. Jobert cauterized the vagina when it protruded, and after the exfoliation of the eschar, united the raw surfaces with sutures. Desgranges employed chloride of zinc to produce cicatricial contraction. Marshall Hall was the first to employ elytrorrhaphy. He excised oval or long segments of the vaginal mucosa, and united the denuded surfaces with sutures. Dieffenbach formed flaps. Velpeau was one of the first surgeons to do successful perineorrhaphy. Langenbeck and Karl Braun were also pioneers in the operation. Early operators failed on account of lack of anatomic knowledge and prevailing sepsis. It is not many decades since surgeons learned the necessary anatomy to employ colpoperineorrhaphy. It was learned that the perineum must not only be elongated, but a solid, thick, unyielding pelvic floor must be constructed, that the sexual organs can not escape. Perhaps Simon, the predecessor of Czerney at Heidelberg, was the real founder of colpoperineorrhaphy, when, in 1867, he had not only performed but had added to it that of dorsal colporrhaphy. Simon freshened the vaginal wall with a scalpel, and a fenestrated speculum was placed in the