FIGS. 6, 7, 8.-Sanctorius' Instruments (1626) for the perforation and extraction of stone from the urethra and bladder. Fig 6, the perforator closed. Fig. 7, the barbed stilet. Fig. 8, the forceps for extracting from the bladder the calculus when perforated.

In 1671, Ciucci, an Italian surgeon, speaks of a "tenacula tricuspis," (as the most effectual mode of curing stone,) with which the calculus was seized and broken up into fragments. In 1791, Thomassini established the possibility of breaking up small friable calculi in the bladder; and it is asserted that a Spanish surgeon named Rodriguez performed this operation at Malaga in the year 1800. The well-known facts of Colonel Martin and the Citeaux monk, I need merely allude to; the former delivered himself from calculus by filing the stone, the latter by percussion. Sir Philip Crampton mentions a fact long anterior to either of them: the history of an Irish gentleman, in 1559, who was cured of stone by some instruments passed into the bladder, and employed to break up the calculus.

These, gentlemen, are all isolated facts. It is impossible to determine from them the precise nature of the operation employed, or whether it was ever converted into a system. Besides, they were completely forgotten or unknown.

In 1813, M. Gruithuisen, a Bavarian surgeon, published two memoirs on lithotrity in the Saltzburg Medico-Chirurgical Gazette. These were remarkable productions in every respect; and if M. Gruithuisen did not discover lithotrity, we must at least acknowledge that he was very near doing so. If you look at the drawings of his instruments, you will find, 1stly, a straight canula, intended to pass into the bladder, and serve as a conductor for, 2ndly, a perforator, which was either lanceshaped or dentated; 3rdly, a wire for seizing and fixing the calculus; 4thly, a handle rapidly moved by a bow drill; 5thly, a branched forceps and a hook for the purpose of crushing the fragments of stone when divided by the perforator.

Here, then, for the first time in the history of lithotrity, we find a whole and complete system, embracing all the essential parts of the operation, such as it is performed at the present day; and we may conclude that if M. Gruithuisen had possessed but a tithe of the perseverance displayed by M. Civiale, the honour of having discovered lithotrity would have belonged to Germany, not to France. It should, however, be observed that the operation of lithotrity could never have been perThe formed with the apparatus invented by Gruithuisen. wire could never seize a calculus, and the forceps, from its shape and construction, could have little, if any, crushing power. It does not appear that the instruments were ever tried on the dead body,-certainly not on the living; the project received little attention, and was soon forgotten, like those which had preceded it. Besides, it does not appear that M. Gruithuisen's proposal exercised any influence on the subsequent discoveries of Civiale, to whom it was entirely unknown, and it is quite obvious that it would have remained

a

Fig.12.

FIGS. 9 and 10.-Gruithuisen's instruments for perforating and
crushing calculi, (1812-1813.) Fig. 9, the canula, perforator,
and wire loop for fixing the calculus. Fig. 10, the canula,
containing a toothed perforator.

FIG. 11.-Gruithuisen's forceps for crushing the calculus after
it was perforated.
FIG. 12. His hook for crushing fragments against the end of
the canula.

a barren speculation, perhaps for centuries, had not the genius of the French surgeon been directed to the same point, while his perseverance conducted him through a host of difficulties to a triumphant application of the principle..

The first idea of endeavouring to cure stone in the bladder, without having recourse to the knife, seems to have presented itself to M. Civiale in the year 1817. He was then a medical student of very limited means, and employed, I believe, as an

externe under Dupuytren. Having made a few experiments, and constructed some models in wood, he made an application to the French minister, in July, 1818, for pecuniary aid towards constructing his instruments; and at the same time forwarded a short memoir, with drawings, entitled, "Some Details of a Lithotriptic." The drawings of three different instruments were attached to the memoir; but I need only notice one of them, as the other two were of little or no value. The instrument to which I now allude consisted of two hollow metallic tubes, (see drawings,) gliding on one another, the internal one supported at its vesical extremity; six elastic steel branches, slightly curved at the end, and solidly fixed to the inner tube. In the original drawing, these branches are shown as being joined to the tube by hinges; but this was an error of the artist, for the text distinctly states that they opened by their elasticity; nor is any allusion whatever made to hinges. The lithotriteur was a long steel rod, either lance-shaped or dentated-in fact, exactly like those of Gruithuisen-fixed in a handle, which, it would appear, was to have been worked with the fingers alone. There was also a strong button-screw at the external end of the instrument, to control the movements of the tubes on each other; but, as you perceive, neither the screw nor handle are depicted in the original drawing. The Minister of the Interior sent, as is the custom, M. Civiale's memoir to the Faculty of Medicine, who appointed Barons Percy and Chaussier to report on it; but these gentlemen took no notice whatever of the poor student's invention. His memoir remained forgotten in the archives of the Faculty.

3

Had M. Civiale contented himself with the first project it is evident that he would now be entitled to even less merit than Gruithuisen; but he was supported by the firm conviction that the principle of lithotrity was a valuable one, and being endowed with great perseverance he continued his researches with the very limited means at his command. In 1819, he reduced the six branches of the forceps to four, and in 1820, to three; in the same year, also, he added a bow drill, and made several other improvements of minor importance. With these improved instruments numerous experiments were publicly made during the early part of the year 1822, at the Hospital of La Pitié, and in the dissecting rooms of the Faculty. Many young men, who subsequently distinguished themselves, were present at all these experiments; and it is not surely going too far to imagine that M. Amussat and M. Leroy had become acquainted with their object, if not with the means employed to attain it. We thus find M. Civiale engaged since the year 1818, in successively improving his original instruments, and in making experiments with them on the dead body.

In the announcement of the principle, he was closely followed by Mr. Elderton, who published, in the April number of the Edinburgh Medical and Surgical Journal, 1819, a proposal for attacking calculi with a curved, two-branched instrument and a perforator. The invention of Mr. Elderton was considered at the time a mere speculation, and even passed over without attracting any attention whatever.

Thus, gentlemen, the idea of getting rid of urinary calculi by mechanical means, and without operation, presented itself in the early part of the present century, and about the same time, to a German, a French, and an English surgeon: to Gruithuisen in 1813, to Civiale in 1818, to Elderton in 1819. For two out of the three, the idea remained unproductive; the French surgeon had the merit of converting the theory into a practice. We left him in the early part of 1822, experimenting at the Ecole Pratique, attacking the hardest stones, and breaking up those as large as a small hen's egg, after five or six attempts.

Such was the history of lithotrity when M. Amussat, in April, 1822, described in a few lines an instrument which he had invented for crushing stone. This was a strong, twobladed forceps, acting laterally, concealed in a canula, and worked by a lever.

He was soon followed by M. Leroy, now better known as M. Leroy d'Etoilles. In June 1822, M. Leroy produced his

FIG. 17.-Mr. Elderton's instrument for crushing calculi, (1819). That part which forms the curve, (a, b, fig. 4) consists of two blades, (c, c, fig. B), placed laterally to cach other, and which, when in contact, present a solid, round form, (c, fig. 4) about the size of a large bougie. At that extremity of the curve answering to the point of the catheter (a,) the blades are connected by a joint; one blade being received within the other, and presenting this united and uniform smooth point. At an equal distance (e, fig. A), between the commencement of the curve (b.) and its extremity (a), a second joint connects the other half (c, b,) of the same side, This structure is common to both the right and left blade. At the commencement of the curve (6), there is another joint (d.) uniting the two blades, which are here fixed to a hollow metallic tube, made to slide readily within an outer canula, (b, g, fig. 4). A small steel spring, , fig. B), placed within the blades, at their extreme point, expands them, and they then present an opening of an ovate shape, (a, c, b, c, fig. B). The blades may be regularly and firmly closed, by simply drawing the inner tube within the outer one, while by pushing down the second tube, the blades may be expanded as before. When thus expanded, they constitute a pair of forceps (c, e, fig. B), well adapted, from their shape, capacity, and strength with which the blades may be closed, to grasp, and hold firmly, a moderately-sized calculus,

The Anatomy of the Uterine System, unimpregnated or gravid, is so well known, that it is purposed only to notice such facts as more particularly connect themselves with the principles to be advocated in the present papers. The gravid uterus may properly be divided into its body and its cervix, each possess ing certain interesting peculiarities of structure. With respect to the former-the body of the uterus-the more important fact to be noticed is, that its fibrous or muscular fasciculi are not disposed wholly or principally in those regular longitudinal and transverse layers which many obstetrical physiologists have laid so much stress on; but the majority and stronger bundles of them run in all manner of directions throughout the whole of the body of the womb, as will be evident on consulting the admirable descriptive plates of Dr. Hunter. The uterus is, in fact, an organ intended to contract at all points at one and the same instant, and its muscles are so disposed as to ensure this effect, the grand object being, in the act of parturition, to compress the contents of the womb at all points of their surface, as it were, towards a common centre. For reasons which will hereafter be rendered evident, it is proposed to term the gravid uterus, as felt through the parietes of the abdomen," the utero-abdominal tumour." The Cervix.-The lower or cervical portion of the uterus presents essential differences from the body; it contains few, if any, muscular fibres, and consists of an elastic or expansive tissue; while the one is ordained for contraction, the other is in tended to dilate. Placed at the lower or more depending part of the womb, the cervix, at what may be termed the line of demarcation between it and the body, is connected with the vagina, into which it, in the unimpregnated state, projects, its more dependent or centrical part being perforated by an opening extending into the uterine cavity, and which is named the os uteri: the whole forming what may be designated as the cervical or orificial parts. A finger introduced per vaginam would detect a more or less bulging kind of tumour, which by way of distinction may be named "the uterovaginal tumour." In the latter periods of gestation this protuberant cervix experiences changes, to be hereafter adThe nervous constitution of the uterus is a subject of high importance; suffice it for the present to give a brief abstract of the clear and accurate description of Dr. Hunter, in his work on the Gravid Uterus. The upper part of the uterus receives minute nervous branches from the renal and spermatic nerves; the lower part, and particularly the cervix and vagina, from the larger division of the hypogastric nerve, which expands itself like the sticks of a fan upon the parts supplied by it, the greater number of rami running to the os uteri and adjacent parts. By virtue of this supply, it may be inferred that the cervical parts are possessed of a sensor cha racter, and are more immediately connected with the spinal brain; while the body of the uterus is mainly connected with the great sympathetic and ganglionic system, which renders it normally, like the heart and viscera, an involuntary and insensible organ.

verted to.

Normal Parturition or Labour takes place when the growth of the fœtus is sufficiently developed to enable it to exist independently of its maternal system. There are two important series of actions preparatory to its commencement which must be noticed.

Active Labour.-The above preparatory stage having been accomplished, the uterine muscles fall into contraction, the more immediate exciting cause of which will hereafter be considered; they now compress the contents of the womb with more or less force. Assuming the uterus to be a regular and uniform sac, whose parietes were throughout of equal thickness and strength, the result of such compression would be to impel the contents towards their common centre, and no tendency to expulsion would be induced. But this is not the case; the orificial and cervical parts possess few, if any, muscular fibres, and are of a distensible nature, and therefore give way to the pressure, so as eventually to form an opening, through which the contents of the uterus are expelled.

This expulsive property of the uterus, termed the parturient nisus, or vis expultrix, doubtless is produced by a determination of nervous principle to the organ, dependent on its peculiar nervous organization. The precise nature of the latter has not yet been fully demonstrated; but it is generally assumed that the effect is connected with two distinct kinds of nerves, the one termed nerves of sensation, the other nerves of motion; and that an impression or irritation applied to the former is propagated or conveyed to the latter: the subject, however, will be more fully entered upon in the subsequent papers. sence of this uterine contraction, and, if possible, the degree of It is practically important to be able to determine the preits energy; for these points are by no means proportionate to the sufferings of the patient-nay, the most painful, and it may be added, protracted cases, are not unfrequently entirely divested of it. There are two especial modes by which it is to be distinguished: one, by an examination of the utero-abdominal tumour, originally introduced by the author," the other by an examination of the utero-vaginal tumour. In the first case, if the hand be applied to the utero-abdominal tumour when the flaccid state; parts of the child may, indeed, be distinguished, contraction is absent, it will be found in a comparatively but the general feel is that of compressibility. As the coninto a tense hardness, so that, to speak emphatically, the part traction commences, the compressibility changes gradually becomes solid as a board; the more decided the effect is, the mination affords a delicate and excellent means of "trying a more vigorous is the accompanying action. This mode of exapain," and the information it gives is uniformly correct, its presence evincing the existence, and its absence the want of tion or the progress of the case; but, when these points have true uterine action. It will not indicate the state of presentabeen ascertained to be favourable, it may obviate the necessity for frequent examination per vaginam, while the information it is capable of affording may be acquired even through the mination of the utero-vaginal parts, made by an introduction dress of the patient, without apparent interference. An exaof the finger per vaginam, affords, as far as the utero-vaginal tumour itself is concerned, precisely analogous information, with the important additions, however, that it detects the presentation and actual progress the case has made, and is making under the action at the time going forwards, from which inferences of the first consequence have to be drawn. These, however, it is not necessary here to specify.

The contraction of the uterus, when strictly normal, is independent of volition, and not necessarily attended by painful sensation; for at the commencement of the paroxysm, either an abdominal or vaginal examination will detect strong contraction before the patient is in any degree aware of its supervention; it is only when a forcible pressure is made on the parts constituting the passage, that she becomes conscious of it, and then the sensation is analogous with what accompanies ordinary fæcal and urinary evacuation. The uterus is therefore entitled to be regarded, not only as an involuntary, but as an insensible organ.

Independently of the above, other arguments may be adduced to show that pain is not an absolute or necessary concomitant of parturition. Those writers who have advocated the contrary with respect to the human female, admit that the lower animals are exempt from it, and which they have attempted to account for by referring to a distinction in the structures concerned.

If this mechanism gave rise to necessary difficulty in women, as it is precisely or nearly the same in all women, they ought all to experience precisely or nearly, quoad hoc, the same degree of pain or difficulty. This, however, is not the case; and even

* Treatise on Midwifery, first edition, p. 24; second edition, p. 7, &c. + London Practice of Midwifery, p. 124.

6

the same woman will in one labour experience an excess of pain and protraction, and in another it will be quick and easy, the difference in the two cases depending on physical and not mechanical causes. Again, if the theory were correct, other animals ought to be exempt from certain difficulties to which women are liable, which also is not the case; for when civilized or domesticated, they occasionally bring forth their young with pain and difficulty. Thus it is well known that the forest varieties of sheep are much safer in yeaning than the more cultivated breeds. The author has known two instances of cats, who had previously expelled their young with facility, suffering intense pain in parturition, one of them dying in consequence, and the other relieved by the use of friction.

An unyielding state of the soft parts constituting the passage has been generally considered among the more influential causes of pain in parturition; and it cannot be denied that under an abnormal or morbid condition their resistance cannot be overcome without more or less painful sensation being induced; but if this necessarily took place under healthy states, no woman in health could escape it; and yet we find in many instances, and even with respect to whole nations, that parturition is almost entirely exempt from pain. In fact, the soft parts are by nature adapted to bear considerable distention without material distress; even the os uteri, in ordinary labour, may frequently be stimulated with the finger, without inducing pain, as the author has frequently noticed.

There are a few points relative to uterine action, which tend to practical utility. When the os uteri is well dilated, the membranes may be expected to rupture; if this be much delayed, it is proper to break them; but it should only be done while the contraction is at its greatest intensity, and if it has commenced receding, should be deferred until the next paroxysm. The reason of this is, that in the one case the uterus remains closed on its contents, and its action will soon repeat; while in the other, the liquor amnii escaping, it is left with a proportionate vacuity, which acts as an equivalent to a removal of insensible contraction, with a corresponding diminution of succeeding uterine action, sufficient to suspend the progress of the case for a greater or less period, or until the uterine fibres have recovered their tone.

The membranes being ruptured, the head of the child descends through the os uteri into the vagina, and, by the increased stimulus, excites the mucous follicles to secrete a greater quantity of lubricating fluid, which materially facilitates the delivery. If this be defective, as will frequently be the case, from various causes, and particularly the one just recited, the practice of introducing lubricating unguents is so far founded on a wrong principle, the more important object to be held in view being to increase uterine action, which, restoring the pressure on the mucous surface, the lubricity soon returns.

Upon nearly analogous principles, it is essential, the child's head having been expelled, not to allow the remaining parts of its body to be hastily drawn away, or at least without the concurrence of uterine contraction; for this will necessarily leave behind a proportionate vacuity within the womb, which is not unlikely to interfere with the subsequent expulsion of the placenta, and may not only occasion retention of the afterbirth, but induce hæmorrhage or hour-glass contraction. Let it therefore be an invariable rule to retard, and not to hasten, the delivery of the body of the child. In the delivery of the placenta, if it be suddenly removed, the membranes which ought to remain attached to it will be liable to be more or less broken off, and left behind within the uterus, where, by their irritation, they will give rise to severe after-pains, an occurrence which may in great measure be prevented by deliberately drawing out the whole of them in an entire state.

It is partly to secure the above proper contraction of the uterus that the use of a properly-adjusted bandage around the abdomen of the patient is essential throughout the whole of the process. The appliance of the bandage was formerly only recommended after the labour was finished; and the author believes that he was the first who adopted its use during the process. He generally applies it immediately on entering the patient's chamber, and tightens it from time to time, as the case proceeds; and particularly after the head and body of the child, and the placenta, have been expelled. His patients generally derive great comfort from its use; and in his practice placental difficulties and after-pains have been comparatively unknown.

ON THE

EMPLOYMENT OF CHLOROFORM INJECTIONS
IN THE TREATMENT OF GONORRHEA.
BY HENRY BEHREND, Esq., M.R.C.S. Eng.,

SURGEON TO THE LIVERPOOL DISPENSARIES.

I HAVE much pleasure in bringing before the notice of the profession a new method of treating gonorrhoea, which, as far as my experience hitherto enables me to judge, bids fair to be equally well adapted for most of the varieties of this tedious and frequently intractable disorder. It consists in the employment of chloroform as an injection, without the use of any other remedial agent whatsoever, either constitutional or local, except, of course, in such cases as present complications demanding special treatment. In the first few cases in which I employed the chloroform, I directed it to be injected in its pure and unmixed form; but I soon found that the pain which it occasioned was too severe to be borne, though at no time were such complaints made of it as so frequently follow the use of the nitrate of silver. Accordingly, I now have it mixed with twice the quantity of mucilage; nor does its action appear less prompt from this diminution of strength. The method of injection is the usual one, no special directions being necessary. The frequency must depend upon circumstances. I have not as yet found it advisable to order it more than thrice a day, but recommend its employment once a day for at least four days after all discharge has ceased. Beyond the ordinary avoidance of stimulants, undue exposure, &c., no instructions whatever are needed; and in no instance in which I have as yet tried this plan has it been found necessary to confine the patient to the house, nor have any evil results followed the application of the chloroform to the diseased surface of the urethra.

My object in publishing the following cases is a desire that the value of the remedy may be tested by those who have equal opportunities with myself for the institution of such experiments in the field of practice opened by public appointments, as I am of opinion that the concurrent testimony of many is absolutely essential before any method of treatment, however satisfactory it may appear to individuals, should be considered as fully established.

CASE 1.-Oct. 20, 1851: Mrs. F, aged forty-eight, contracted gonorrhoea from her husband about a week ago, but has undergone no treatment. Ordered the chloroform, in its unmixed state, to be injected thrice a day; no medicine whatever to be taken. It caused violent smarting pain, which lasted about an hour after each injection; but no dysuria or other unpleasant symptom followed. The first day the discharge increased in quantity, and became more viscid; but on the second it had rapidly diminished; and on the third (Oct. 22) had almost ceased. The fourth day I ordered her to inject morning and evening; and on the fifth the discharge had quite ceased. As a matter of precaution, she continued the employment of the chloroform every morning, until the tenth day, when, no trace of the disorder having recurred, she finally discontinued it.

CASE 2. Gleet.--Jan. 1, 1852: Martha B, unmarried, thirty-two years of age, has had a gleet for twelve months, the discharge varying in quantity, but at present profuse. She has gone through the usual routine of treatment, but has scarcely given many of the remedies a fair chance, owing to irregular habits of life; is at present taking balsam of copaiba, and using injections of sulphate of zinc, from which she derives no benefit. Directed her to discontinue these, and

inject with equal parts of chloroform and mucilage thrice

a day.

Jan. 5th.-The injection was painful, and at first increased the quantity and consistency of the discharge; but after the second day this became much less, and is now very scanty and thin. She suffers no other inconvenience, and is much elated at the prospect of recovery. The catamenia having come on, I deemed it prudent to suspend all treatment.

8th.-Last night the catamenia ceased; there is now a slight gleety discharge. Ordered to resume the injection.

12th. Not much change; the injection causes severe but temporary pain. To use it half the strength for the future; that is, one part of chloroform to two of mucilage. well.

15th. The discharge has quite ceased, and she is perfectly 19th-Continued injecting once a day till this date; no return of the symptoms.