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0 N
RECENT IMPROVEMENTS IN SURGERY-
     INTRODUCTORY LECTURE

         TO THE COURSE ON THE

PRINCIPLES AND PRACTICE  OF SURGERY,

                 IN

JEFFERSON MEDICAL COLLEGE

          OF PHILADELPHIA.

        DELIVERED NOVEMBER 3, 1842.

     BY THOMAS D< MUTTER, M. D.



         PUBLISHED BY THE CLASS.
      PHILADELPHIA:
Merrihew & Thompson, Printers,
     No. 7 Carter's Allkt.
1812. 
wo 
CORRESPONDENCE.
                            Philadelphia, Nov. 10, 1842.
  Dear Sir,—At a meeting of the Class of Jefferson  Medical
College, held on Monday the 7th  instant, Thomas K. Price, of
Virginia, having been called to the chair, it was resolved, unani-
mously, to publish your very able and eloquent Introductory Lec-
ture to the present Class.   The undersigned being appointed  a
Committee  to solicit a copy, do earnestly add their wishes to
those of the Class, that you will comply with their request, which
will ever be appreciated by them, and by  us  individually, as a
source of the most grateful remembrance.
       We have the honor to subscribe ourselves,
             Your most obedient servants,
                          Thomas K. Price, of Va.
                          J. D. Robison, Ohio.
                          Lewis Paullin,  Florida.
                          Charles A. Phelps, Mass.
                          T. Dupuy Montegrier, France.
                          E. C. Chew, N. J.
                          William W. Watts, N. C.
                          F. L. Parham, S. C.
                          James T. Gee, Ala.
                          J.  F. Phileas Proulx, L.  C.
                          J.  Curtis, Conn.
                          J. B. Masser, Penn.
                          A. McFarland, N. H.
                          Frederick A. Rees, England.
                          William T. Core, Va.
                          Joseph H. Day, Ky.
                          A.  A. J. Riddle, Ga.
                          R.  N. Wright,  Md.
                          M.  Howard, Cuba.
                          Aaron Young, Jr.,  Me.
                          Jno. J. Bacon, N. Y.
                          T.  H. Payne, Miss.
                          Geo. W. Ewell, Tenn.
                          J. Von Britton, St. Thomas.
                          J. C.  Neves, Montevideo.
   To Professor Mutter. 
4
                             Philadelphia, Nov. 12, 1812.
   Gentlemen,—Your note requesting a copy of my Introduc-
tory Lecture  for publication, has just been received, and it will
afford me pleasure to comply with the wishes of the Class.   Be
pleased to accept my thanks for the flattering manner in  which
you have conveyed the sentiments of those whom you represent,
and believe me to be
                    Very truly yours,
                                       Thos. D. Mutter.
  To Messn. Thomas K. Price, &?c. &c. Committee. 
         INTRODUCTORY  LECTURE.


   Gentlemen,—Most of those whom I have the honour to
 address, are destined  to  become  physicians and surgeons.
 Not a few, I trust, will  add to the  renown of  an art,  the
 noblest of all, the first and  last and only object of which is
 the alleviation of human suffering.
   In the selection of a theme, for the usual initiatory lecture,
 I have been not a little animated by a desire to foster  in you
 an interest in the science of your adoption, and have there-
 fore, chosen as a subject fraught  with lessons of industry,
 patience, and laudable  ambition, while, at the  same time it
 is highly interesting,  "a restrospective view of  surgery for
 the last few years!"
   This has been called the "age of progression,"—the "age
 of advancement,"—and our profession, gentlemen, has par-
 taken of the general excitement.   It may with truth be said,
 that of late it has exhibited much of the " freshness and  vigour
 of youth," and none  can urge now as  in former times, that
 we continue in a state of comparative apathy, and content
 ourselves with servilely following  the  dictates of our  prede-
 cessors.   A contrary disposition,  indeed,  seems to prevail,
 we are too anxious to be  known as active men, and hence
 crude theories,  senseless innovations, and not seldom injuri-
 ous practical measures, have been  crowded into the science.
 But it is a surprising  as well as humiliating reflection, that
 even with all this energy and vigour, with all the lights of
 modern  science to  guide us, with all  the accumulated facts,
false as well as true, of the crowd of labourers in the field,
 there should exist such diversity of opinion  on subjects of
 the most constant observation.   No operation, no theoretical
 opinion, no mode of practice is broached, but there at once
 springs up a controversy attended, too often, with an acri-
 mony  and  harshness   disgraceful  to  all  concerned.   And 
r>
whence does this obscurity arise?  It may be traced, gentle-
men, to our eagerness to become  known as discorervrs, as
the inventors of something neiv, as  the  great lights of the
age; in consequence of which we leap to  conclusions, ere the
facts upon which these conclusions are based have been pro-
perly  investigated.   We have, in truth,
            " Rested contented in ideal knowledge;"

we have received as perfect, theories idle as day-dreams, and
the foundations of our art must crumble to the earth, unless
we learn more discretion and  better judgment in the selec-
tion of the materials of which  they are to be constructed.
   No theme could afford a more striking illustration of the
correctness of  the opinion just advanced  than the one select-
ed for this evening's discourse.  The numerous operations to
be discussed have been as indiscreetly puffed and eulogised,
as they have been injudiciously and hastily condemned ; and
nothing short of patient and unprejudiced investigation, aided
by experience and reason, can  enable us to place them in
their  true light.  It  becomes, then, a task of no  ordinary
difficulty, to exhibit  to you  such  an exposition  of these
mooted points as will satisfy all; indeed, I shall not attempt
it; my aim being rather to excite  in you a spirit of correct,
thorough, and  truthful  investigation, than  to establish the
the limits of questions still demanding great additional labour
for their perfect elucidation.   But notwithstanding this to a
certain  extent  erroneous course pursued by  our "authori-
ties,"  no one, not even  the veriest  stickler for ancient  wis-
dom and modern degeneracy,  would hesitate to declare, that
the present era of our profession is far in advance of  any
other that has preceded it; that our science is in reality  pro-
gressive.   Originating unquestionably in the necessities of a
race whose progenitors by the infraction of a divine law
                 " Brought death into the world
                  And all our wo,"
it has  gradually, as crjme  and luxury have increased these
necessities,  emerged from the  condition of a mean and lowly 
7
avocation, until at length, with all its defects, it  stands forth
like the " pillar of light,"  a sure beacon of protection and
succour to the wayworn and almost world-weary victim of
disease.
  From the brief period allotted to this address, it will be
necessary to omit  many subjects, to allude very briefly to
others, and to speak in very general terms of those  that I
shall bring before you.   I shall endeavour, however, to dis-
cuss those operations and measures in  which American as well
as European surgeons have been actively engaged, and which
are considered of most interest to the profession.
  Before  entering upon the discussion of the new opera-
tions, allow me to detain you for a few moments only with
the bare mention of the great and almost inestimable bene-
fits conferred upon the profession by the labours of Morgan,
Palmer, McCartney, Allison, Alco'ck, Liston, Gulliver, Bro-
die, Sanson, Dupnytren, Ricord  and Rasorl, in the depart-
ment of " Internal Surgery," or  what we usually designate
as the " Principles of Surgery."
  Although  the office of inflammation as a therapeutic
agent has long been recognised, yet are' we chiefly indebted
for clear and definite views upon this1 subject to these mo-
dern authorities, and to none more than to McCartney.
   To these same individuals do  we owe much practical in-
formation on the primary  treatment of injuries, and many
a poor creature is now saved in limb, as well  as life, by
prompt action and simple  and rational treatment,  who but
a few years since would in all  probability have lost both.
The excellent papers of Sir Rutherford Alcock on " injuries
of the head," "severe injuries  of  the joints," and "gun-
shot wounds," deserve all commendation, and while they
have conferred lasting reputation upon their  author, have
also contributed much to the alleviation of human  suffering
and the preservation of human life.   A great  improvement
has also taken place in the dressing of wounds.  That filthy
abomination in surgery, a poultice, is now restricted  in its
application to a few diseases, and is gradually giving place 
8
 to  the  mild, cleanly, and simple warm water  dressing !
 Union by suppuration, or what Mr. Hunter called " union
 by the second intention," is now almost universally avoided,
 and all  wounds, however extensive they may be, provided
 no indication exists for  the promotion of suppuration, are
 made to unite if possible by simple adhesion, or by the effu-
 sion of  lymph,  called by Hunter " union by the first inten-
 tion," and by McCartney  " mediate by lymph or blood."
 To accomplish  this mode  of union, rest, simple and light
 dressings, or the irrigating treatment with cold water, a
measure revived by McCartney and others, will be required.
   Diseases of the  arterial and venous  systems have of
late  attracted much attention,  and it  is with pride that
 I  refer  to the efforts of American surgeons in this  most
 important class  of lesions;  while very little has been added
 to our general knowledge upon the subject, much has been
done to  simplify details,  point out  fit cases for our efforts at
relief, warn us against dangers hitherto but little understood,
and demonstrate the propriety of operations once considered
almost  necessarily  fatal.  Porter  of Dublin, Morrison of
 Havana, Parker of England, Thurmon, DucoLand Deguise
of France, Chelius of Germany, Mott, Stevens, Nathan
Smith, Randolph, Barton, Peace, Power, and others among
us, have contributed much interesting and  highly practical
information in this  department.  The  recent brilliant and
 eminently successful operation for femoral aneurism  in
 which the common  iliac  was tied by my friend Dr. E.
 Peace, of  this city, is worthy of all praise, and reflects the
highest  honour upon  our science,  as well as upon the ope-
rator himself.
   In the arrestation of hemorrhage from small vessels, tor-
sion is gradually taking  the place  of the ligature, by which
means we get rid of a foreign body often productive of much
irritation.  In wounds of large vessels, however, the ligature
as the safest agent of the two, is always to be preferred.  A
new operation for the ligature of arteries has recently been pro-
posed by Tavignot, and is called by him the " subcutaneous
ligature," from the fact that the integuments arc barely punc- 
9
 tured, and the ligature passed beneath the skin.  It is how-
 ever a useless, uncertain, and moreover hazardous measure,
 inasmuch as  the surrounding parts being  included in the
 loop of the ligature, the artery cannot be properly divided.
   This being the age of experiment, a  M. Sarra has at-
 tempted to arrest  arterial  hemorrhage by the introduction
 into the vessel, of a piece of wax bougie, or some " solid
 plug,"(!) by which its calibre may be obliterated.   I need
 hardly say that this operation is indicative of the grossest
 ignorance on  the part of its proposer, and can never be per-
 formed by any one deserving the title of surgeon.
   Much of the dread, once existing,relative to the ligature of
 veins has subsided, and several excellent operations, especi-
 ally those on varicose veins, have  originated in the know-
 ledge that the vessel may in most cases be tied with impunity.
   It is the boast of modern surgeons, and well may  we
 boast, gentlemen, that a resort to painful and mutilating ope-
 rations is now much less frequent than formerly.  In other
 words,  diseases considered  but a few years since as invaria-
 bly  indicating a resort to the knife, are now readily cured by
 constitutional  treatment alone.   The  white swellings,  the
 scrofulous diseases of the bones, the enlargement of the glands,
 dependent upon the  same  cause, and many other  similar
 affections are  now almost  as  readily managed as a common
 inflammation of the  same organs originating in another in-
 fluence.   A few years since, before  the discovery of iodine
 and  its preparations,  either incurable deformity, permanent
 maiming by the knife of the  surgeon, or the quiet of  the
 grave, was the inevitable fate of the unfortunate victim of its
 selection.  That most terrible of all scourges  with which a
 wise Providence punishes  the crime  of adultery, has after
 the lapse of centuries had  its laws and phases so simplified
 and freed from  obscurity, that all who will take the trouble
 to learn may render  themselves  qualified  to  master its at-
 tacks  and thus prove of  incalculable benefit  to many an
 erring  though  often repentant fellow creature.  To  Ricord,
of Paris, a gentleman who although a citizen of the old world 
10
does not forget that to the new he owes his birth, and who
by his  labours is  reaping a golden harvest  of riches and
honor, is chiefly due the credit  of this great  work.   It is a
matter of no small  pride, however, that we are able to state,
that many of his views relative to the treatment of primary
symptoms, were long since taught by Dr. Thomas Harris of
this city, a gentleman who adorns  our  profession by  his
talent and honourable deportment, and whose speedy restora-
tion to health and  usefulness is ardently  desired by us all.

   Among the recent improvements in surgical pathology,
none are more deserving our attention, than  the  numerous
communications on the  subject of tumours.   Although all
confess the crude and unfinished condition in  which this de-
partment of our science  still remains, we must at the same
time acknowledge  that a great deal has been done to eluci-
date and render more certain, our views on its most impor-
tant features.   The splendid  results obtained by Miiller,
Laugenbeek, Schwann, and Valentin, through the agency
of  the microscope,  have  opened  a  new field  of investi-
gation,  besides throwing  a flood  of light upon a subject
hitherto the  most  obscure.  Brodie, Carswell,  Hawkins,
Cushing, Liston,  Syme,  and Warren,  have also  "done
good  service"  in  this  branch of  surgical  pathology.  I
should  be  wanting  in true American  feeling, did  I pass
over without further comment, the work  of Professor War-
ren of  Boston.   In this book, replete with lessons of sound
reasoning and excellent judgment, we find details of opera-
tions the most terrific and  yet resulting in the happiest man-
ner ; and as  we read them our conviction is strengthened
that for their execution, the most daring courage, intrepid
coolness, rigid anatomical  knowledge, and practical experi-
ence, were all required.  Let us then, as fellow countrymen
of one who has shed lustre  upon our land as well as upon our
science, claim for  Professor Warren  what he so  richly de-
serves, the gratitude and thanks of the whole  profession.
   I wish to impress upon you,  however, the fact, that the 
11
 subject of tumours their origin, growth, form, texture, and
 tendency, is still a rich  field for investigation,  and promises
 an abundant harvest for those who  will cultivate it with in-
 dustry and zeal.
   Much has of late been said about extirpating the thyroid
 gland  in cases of bronchocele.  Without stopping to argue the
 question, I may remark, that it appears to me wholly impro-
 per to subject a patient to the dangers of this operation when
 the disease is nothing more than an inconvenience; where the
 tumour degenerates or interferes with  the trachea or great
 blood vesselsofthe neck, and thus places the life of the patient
 in jeopardy an operation is justifiable, but  under no other
 circumstances.
   An  interesting fact not generally known, and one  first.
 pointed out,  I believe, by Dr. Thomas Harris of this city, is
 also  a strong objection to the performance of this operation.
 According to his observation, if we examine  the cases of
 goitre  originating in  districts to which the complaint is not
 endemic, we shall generally find the heart  and large blood
 vessels more or less diseased and the general health of the pa-
 tient proportionally depraved. My own experience quadrates
 with his.   This fact  strongly militates against an operation,
 as well as against the indiscriminate employment of iodine,
 the usual remedy in such cases, and  sustains  to a certain
 extent the notion that the thyroid gland is a diverticulum  to
 the heart.
   Cancer, in all its phases, has also been closely investigat-
 ed by  Miiller, Laugenbeck, Carmichael  and others,  but I
 fear much remains to be done ere we arrive at its true  ori-
 gin and proper treatment.  No  question seems  to exist as
to our power of communicating the disease by inoculation.
 If, for example, we mix a little cancerous matter with wa-
 ter and inject the  mixture into  the venous circulation of
any animal,  we  to a certainty induce cancerous deposites
in different parts  of the body, and  especially in the pulmo-
 nary veins. 
12
  Among the new methods of cure, those of Jobert, Lisfranc
ind Phillips, of Liege, have attracted much attention.
  Jobert's plan consists in the application of  a ligature  to
all the principal arteries  supplying the tumour, and the divi-
sion of its nervous filaments.   According to  him,  by this
process he  has succeeded in curing four cases of cancer of
the lip, and one of the tongue.   For myself, I can say no-
thing about the merits  of the practice from  any personal
experience, but entertaining the views which I do on  the
subject of  cancer, I must say that where any  operation is
proper, a circumstance very rare indeed, complete excision
of the tumour is much to be  preferred to  any other mode
of treatment.
   Lisfranc, in cases of  superficial cancer, proposes to cure
it by merely removing the diseased tissue either with  the
ligature or  knife, leaving the organ upon which it happens
to be located untouched.  When the disease penetrates, or
deeply involves an organ, he recommends excision  of the
tumor, along with a certain portion of sound  tissue.
   A most valuable operation, in  certain forms of cancer,
has recently been  proposed  by Mon. Charles Phillips, of
Liege, and  a repetition of his practice in my hands at least,
has been productive of the most satisfactory results.   You
all know how  difficult it is to heal, permanently, what is
called a  " cancerous ulcer," or  the wound  which  results
from the excision of a cancerous tumour, and also that even
where the disease has been entirely removed,  and the parts
have cicatrized, it is  exceedingly prone  to return in the ci-
catrix.   This constant disposition to reappear has been at-
tributed  to a  constitutional  taint and  such is the fact in
many cases, but there are others  in which the disease pre-
sents a strictly local character,  and yet the relapse  takes
place.  With our present knowledge on the  subject, it is
utterly impossible to explain this circumstance. It is, more-
over, well ascertained that the  predisposition to return is
very much modified by the mode of union adopted by the
surgeon in  the healing  of the  wound.  Dieffenbach was 
13
probably the first to direct our  attention to the fact, but to
Phillips is due the merit of having by positive experiment,
shown the correctness of the views of this great surgeon.
It appears that when the wound unites  by granulation,
there is much greater  danger of a  return  of the  disease,
than where union by the^r-s^ intention is adopted. To in-
sure the occurrence of the latter process, Dieffenbach  pro-
posed, and Phillips  carried  into  execution, the following
plan.  After the removal of a cancerous tumor, instead of
allowing the parts to heal by the " second intention," or to
be covered in by the simple approximation of the edges of
the wound, a plan  which in large operations is always ac-
companied by a straining and Unnecessary  as well as in-
jurious tension of  the flaps, he takes a piece of  sound skin
from the vicinity, and either by adopting the "  sliding pro-
cess," or, where this is impossible, partial  torsion of the
pedicle, covers in the wound completely.   Union by adhe-
sion usually takes place, and  the return of the disease  is
in most cases effectually  prevented.   How it  is  that the
application of healthy  tissue  to that hitherto more or  less
diseased, so modifies the action in the latter as  to  render it
normal, we cannot say. By  some it is attributed to a change
in the condition of the fluids of the part, healthy blood, for
example,  being mixed with  that previously  diseased;—
this, however, is  merj theory, and we  must rest content
with the fact, for fact it is, that " the application of a heal-
thy tissue to one hitherto diseased,  is often, although not
uniformly,  sufficient to render the latter perfectly sound."
   This doctrine seems to have  been well understood by
 Martinet de la Creuse, who published a paper on plastic
surgery in  the  Gazette Medicale for 1835.  But he com-
mitted'a  great error in its practical application, Lfor instead
 of attempting union by adhesion at once,  he allowed the
 surface from which the cancer was  removed to granulate
 freely, which usually required six or eight days, before he
 applied the flap of sound skin.  He thus lost time, and sub- 
14
 jected his case to all the risks of "union by granulation.
 (See, Autoplastic apres L'Amputation des Cancers, par Ch.
 Phillips, de Liege.  Bruselles, 1S39.
   A very interesting paper on "painful tumors of tVie female
 urethra," has  been published in the New  York Medical
 Journal, by Dr. A. Hosack, and to this source I would refer
 all who desire information upon a subject hitherto but lit-
 tle understood.

   On the subject of fractures, a good deal has been written
 during the last few years, but I regret that of this immense
 mass of what has been called correct knowledge, very little
 indeed deserves our attention or  adds much to our practi-
 cal information upon this highly important lesion.
   Professor Syme and Mr. Meade have detailed some in-
 teresting experiments in proof of the power of the periosteum
 to form bone, and have established the  fact so clearly laid
 down  by Sir C. Bell, and generally acknowledged by all,
 that this  membrane though  not  essential to the formation
 of callus, is nevertheless a very useful agent in the process.
 Muller having recently asserted that the periosteum was not
 at all concerned in the re-union of bone, these experiments
 were performed with a view  to test the correctness of his
 opinion, and clearly prove that for once, at least this great
 authority is in error.  The fact is, both bone and periosteum,
 and also  the adjacent soft parts, unite in the formation of
callus, while either can accomplish the task without the aid
 of the other.
   Some interesting, as well as very important details in the
statistics of fractures, have been published by Lawrie, Hey-
ward, Norris, and others.
  In their treatment we find,  as hitherto, great diversity of
opinion.   I shall  not of course, enter  into an enumeration
of all that has been said, or attempt to explain the different
new dressings, as they are called, but I cannot refrain from
directing  your attention, especially, to  a mode of treatment
as unphilosophical as it is—as usually employed—danger- 
L5
ous and unsuccessful; I allude to the immovable apparatus,
ox starch bandage.  The origin of this dressing, so far from
being recent, may be traced almost back to the time of Hip-
pocrates, yet it is usually spoken of as a modern invention,
from the fact of its having been revived and perfected by a
few  of our  contemporaries.   To Suetin, Louis, and Vel-
peau may be attributed the repute in which, for a year or
two past, this measure has been held; and a few of our own
surgeons have adopted their views upon the subject.  With-
out stopping to argue the point, it seems very clear that to
apply an immovable  and inelastic  dressing to a part con-
stantly undergoing a change in size, from the shrinking of
the tissues consequent to rest and peculiar position, with the
view of keeping this part perfectly steady and quiet, is  un-
philosophical;  its danger and want of success the records
of our courts are constantly proving.   Within the last six
months I myself  have  been summoned to give  testimony
in three suits  brought against medical men who had used
this apparatus, and whose patients either lost the limb en-
tirely, or were cripples  for life.   It may be said, perhaps,
that these cases are examples of the abuse of this dressing,
and not of its proper application; but surely the argument
 will not hold, when we  find that the gentlemen engaged are
 men of years and standing, and one a Professor of Surgery.
 While, then, I acknowledge that high authority sanctions
 the use of the immovable dressing, I cannot, so far as my
 own experience and that of most of the surgeons in Phila-
 delphia goes, give it my approval;  and whenever  employ-
 ed we should constantly bear in mind its dangers.
   A question of much  practical importance in the  patholo-
 gy  of fractures of the  cervix  femoris within the  capsule,
 seems at length  to be  set at  rest  by the observations of
 Dupuytren, Velpeau, Amesbury,  Adams of  Dublin,  and
 others and by certain specimens in the cabinet of Professor
 Warren, of Boston.  Can such a fracture unite by bone ? has
 long been a mooted question, and has given rise to as much
 bitter controversy as almost any other subject in  surgery. 
10
 We  can I  think  with safety  assert,  that  although very
 rare, especially in  old persons, such an occurrence may un-
 doubtedly take place.  Bearing this fact in mind, our treat-
 ment must  be modified to ensure if possible this truly  for-
 tunate result.
   I  should  be  wanting in respect  to  the   memory of
 that  great  surgeon, and most  excellent  man, Sir Astley
 Cooper, did  I  pass over  without mention his recent valua-
 ble contributions to the  subjects of fracture  and  disloca-
 tion, just published by his nephew, Sir Bransby  Cooper.
 To  this work, gentlemen,  I refer you, as a sound  and
 most trustworthy guide in practice.
   It  is with much pleasure that I direct your attention to a
 late  publication on the "Deformities resulting from badly
 treated Fractures,"  by my friend,  Dr.  George W. Norris
 of this city.    Like every thing else emanating from this
 source, it exhibits ample evidence  of deep research, impar-
 tial examination,  lucid deduction, and rigid truth, and con-
 tains  all the information  on the subject  up to the present
 date.
   Another most distressing result of fractures,  "artificial or
 false joint," has likewise been investigated by the same gen-
 tleman, and also by Dr. Hartshorne, jr.  of this  city,  who by
 his industry and talent is proving himself a worthy son of a
 most  honorable and distinguished father.
  A most useful remedy,  in the shape  of tenotomy  or my-
 otomy,  as the case may be, has recently  been introduced  by
 Dieffenbach  in the  treatment of  old  fractures,  especially
 those  of the patella and olecranon, where the fragments are
 separated to  some extent.   Time  will permit  me to do no
 more  than barely allude to the operation.
  In these cases the tendon or muscle is divided  above the
superior fragment, which is then brought down as nearly as
possible in contact with the lower, and there retained by an
appropriate bandage.   Sometimes it is  necessary to divide
the tendon attached  to the  lower fragment in fractures of the
patella,  before the requisite approximation  can  be obtained.
This  approximation, too, has often  to be made by degrees, 
17
the fragments being  daily drawn towards  each  other, and
when they are nearly in contact they should be  frequently
moved, and if possible rubbed  against each other, so as to
excite an ossific deposit in the space by which they are sepa-
rated.   This beautiful expedient, the principle of which is
so obvious, has frequently produced the most decided benefit,
while in other instances it has failed.  It is,  however, a sim-
ple, as well as safe operation, and where the usefulness of a
member has been to a certain extent lost by the extensive
separation of the fragments of  a  broken bone, we  should  not
hesitate to  advise its performance.   Like all similar  opera-
tions, the  pain, haemorrhage,  and subsequent irritation  are
comparatively slight.

   In the treatment of dislocations but little novel or useful
matter has been introduced, if we  except the  method em-
ployed  by  Dieffenbach in the management of those  of long
standing.   By the application of the Stromeyrian operation,
he succeeded in reducing a dislocation of the humerus of two
years standing.   In this case he divided the tendons of  the
"pectoralis major, the teres major, and latissimus dorsi,and
afterwards the bands of fascia, by which the bone was held
in its abnormal position ; the bone then went into its place
with little  difficulty.—(British  and Foreign Review, 1839.)
   In the present state of our knowledge it would be unsafe
to hazard an opinion as to the practical utility of this opera-
tion.   Cases, and well substantiated results are still wanting,
to enable us to say whether it is in reality an improvement,
or merely  an innovation.   At  first  sight it seems  contrary
to our present views of the injury, to  suppose that either the
head of the bone  or the cavity to which it naturally belongs,
should notwithstanding the lapse of two years preserve their
surfaces in such a state of perfectness as  to render them
suited to each other when brought  into contact.   We know
very well that this is not usually the case.   All  unreduced
luxations of Jong standing prove, that not  only the head of
            3 
18
the bone, but  also its articular cavity  undergo changes  by
which they are rendered totally unfit for each  other.   And
not only  is this  the case, but nature  has endeavoured to
supply the loss of the original  joint by the establishment of
a new one, in many cases almost as useful as the first.
  Before  resorting to the  section of the muscles, then,  we
should always  assure ourselves that  these  changes have not
taken place to  an  extent forbidding the proper apposition of
the bones ; and also, that nature is not disposed to make any
compensation for the loss of the joint by the formation of a new
one.  That tenotomy has  been of service  in certain cases of
luxation, there cannot be a doubt, and hence the measure de-
serves our attention ; but let me caution you against an undue
and hasty resort to an operation by which  your patient may
be subjected to much present  pain, and probable future in-
jury.
   During the last few years, the attention  of the profession
has been directed towards a subject of much interest and  ob-
scurity ;  I mean "Congenital  Luxations."  To  Dupuytren,
Gerdy, Bouvier,  Pravas,  Guerin,  Dieffenbach,  Stromeyer,
Adams, and Smith of England, we are indebted for the best
information relative to the pathology  and treatment  of the
defect.   Much yet remains to be done, however, ere all the
difficulties surrounding it are removed ; and I trust that some
of you who have time and inclination  will for the honour of
American surgery, investigate the  subject.

   Closely connected with the subjects just referred  to, are
the various affections of the joints, and no 'class of surgical
diseases has been  more carefully and profitably investigated.
Many terrible maladies and shocking deformities of this por-
tion of our frame, which, but a few years since were  con-
sidered either as  incurable, or necessarily fatal, are now in
consequence of our better knowledge rendered as tractable as
almost any other  affection to which we are liable.  That ter-
rible disease of the hip-joint, coxalgia,  is now, even after the 
19
second stage or that of shortening of the limb  has  exist-
ed for  some  time,  often  curable without  the least  de-
formity by the application of  gradual  extension to  the
shortened limb until it'attains its proper length.   I wish that
I could claim for one of our own countrymen the merit of
this novel and most useful method of treatment,  the details
of which I cannot now enter upon; but to Humbert, a German,
is due nearly all that we know upon this subject.   My friend,
Dr. Wm. Harris, of this city, had treated a case by the same
plan before those of Humbert  were published, and he is
therefore entitled to almost equal credit with the surgeon
whose  name has been appended to the method—(See Med.
Examiner, 1839).   In my own  practice the success of the
new plan  has been witnessed by several of my class, and I
have  now the cases of  seven  individuals, perfectly cured,
who under the usual treatment must  have remained cripples
for life.  To be useful the extending effort must be employed
in a  few weeks after the shortening has taken place, for if
longer delayed  the adhesions are so firm  that to break them
up a force much greater than the individual could bear has
to be exerted.  There is also some danger of exciting anew
inflammatory action, and by this means bringing on a relapse.
While, then, I advise you to pursue the practice of Humbert,
I wish at the same time to caution you against its improper
or injudicious employment.
  Another great improvement in the treatment of diseased
joints, first  recommended by White and Moreau, but never
very generally employed until recently, is the excision of
the diseased part,  instead  of taking off  the  entire limb.
Syme,  Liston, Key, and Velpeau,  of Europe ; Dr. Thos.
Harris, Dr. Buck, of New York,  my colleague, Dr. Pancoast,
and  some others in  this country,  have probably performed
the operation as frequently as any other surgeons.
   A new, most unphilosophical,  and most dangerous treat-
ment in true anchylosis, has of  late been  recommended by
Louvrier of Paris.   The object of M. Louvrier's operation is
by the aid of powerful machinery to extend the  anchylosed 
20
joint, " disregarding entirely all impediments, and the na-
ture of those  impediments!"  The resistance  must be over-
come; and to accomplish this but a few moments are  neces-
sary.  I need hardly caution you against a means which has
not even the merit of partial success to sustain it, and which
is so obviously dangerous.  It is Jooked upon, I believe, by
nearly all the surgeons of Paris as an arrant piece of  quack-
ery;  and by a recent report of the committee appointed by
the " academy," unfavourable to its merits, it will probably
be speedily consigned to " the tomb of all the capulets!"
   In striking contrast to  this operation  of  Louvrier, are
those for the same affection introduced by my friend Dr. J.
Rhea Barton of this  city: I do  not hesitate to assert that
the age has given birth to nothing more brilliant, more pro-
foundly philosophical, more eminently useful, or better cal-
culated to shed lustre upon our science.   They are besides
American inventions, acknowledged to be such, and have
contributed not a little to elevate us as a body in the eyes
of all Europe.  To the distinguished  individual who has
thus while conferring a benefit upon society richly endowed
the profession of his choice, I offer that which I know his
feeling heart will most truly prize, the thanks and blessings
of the human race.
   Connected with this subject is the new treatment for false
 anchylosis.  This plan consists in the gradual application, by
 an appropriate machine, of a force calculated to separate
 the  contracted members from each other, and the  facility
 with which we cure deformities, but a few years since con-
 sidered utterly beyond the reach  of surgery, is really  asto-
 nishing.
   The practice originated with  Stromeyer, whose screw,
 which I show you, is the instrument almost universally em-
 ployed.  Markham,in his paper on the surgical practice of
 Paris, tells us that Lisfranc  and Blandin, as well as other
 surgeons, have employed this measure  for several years.
 In  this  country it has been extensively employed by Dr.
 Detmold of New York, Dr. Chase of this  city, by myself, 
21
and  I suppose ere this  by almost  all the  surgeons  in the
country, and I cannot too strongly recommend it to your at-
tention.
  Goyraud  of Aix,  and Syme, have performed a very in-
genious operation for the  removal of cartilages or foreign
bodies from the joints.  " It consists in making the substance
to be removed prominent, and then in passing a narrow
knife through the skin at some distance from the joints, and
through all the intermediate tissues down to the foreign body.
Without enlarging the  opening in the skin, the  synovial
membrane and adjacent tissues over the loose substance are
now to be  freely divided, till, by pressure  on the  latter,
it slips out  of the joint through  the wound,  and lodges
itself in the subcutaneous cellular  tissue, or in some of the
other tissues between the skin and the joint.   After this, the
patient must remain at rest for several days, (the small ex-
ternal aperture being merely covered by adhesive-plaster,) till
all chance of the occurrence of inflammation has disappeared.
The foreign body dislodged from  the interior of the joint,
 will form a cyst for itself, and remain in its new position
 without producing  any annoyance; but if it be deemed
 necessary, it may easily be  removed by a simple incision
 through the skin over it, which will no longer be  likely to
 excite any inflammation of the joint itself!"
   Recollecting that the usual operation  for this disease is
 often followed by the  most serious results, the method of
 Goyraud and Syme  is certainly deserving our attention.
   An interesting  operation,  for the  relief of  chronic hy-
  drocephalus, has  recently been performed by Dr. Conquest,
 of England.  This disease had proved so fatal in the hands
 of almost every one that the profession  hailed with plea-
 sure the advent of a measure purporting to accomplish so
 much towards its cure.   I regret, however,  that although
 successful in several instances, the operation of tapping the
  head seems to be attended with much hazard, and in con-
  genital cases even Dr. Conquest himself tells us that  it is
  productive of merely palliative  results.  That it does oc- 
                           22

 casionally prove  useful is shown by the number of cures
 which it is reported to have accomplished, in the hands of
 Conquest, Graefe, Symthe, and others; and  also by the
 manifest relief it affords in cases  of extensive effusions as
 shown by the cessation of convulsion; the disappearance of
 stupor and drowsiness ; the return of sensibility, and volun-
 tary motility, where these  functions had  ceased to  exist;
 and by a restoration, either partial or complete, of the men-
 tal faculties.  The principal ill consequences  supposed to
 attend its performance are inflammation of the  substance of
 the brain or its membranes, and cerebral collapse. Both of
 these results are grave objections to its general practice, and
 although the first may be guarded against,  by proper an-
 tiphlogistic measures,  and the second  by the  gradual ab-
 straction of the fluid, and subsequent compression of the head
 with a roller; yet I deem it safest  to advise you to  resort
 to all other remedies  ere the operation in  question be put
 into execution.  When all else fails, it should be performed
 as a palliative measure, just as tapping in chronic dropsies
 in the other cavities, is employed to afford relief.
   As the hazard of this measure is conceded by all,  many
 are disposed to substitute for it the plan of Barnard, which
 consists in the  steady and long continued  application of
pressure.   This  treatment is unquestionably useful, but
 should not, I think, be exclusively employed.
   In the British and Foreign  Medical Review, and in the
 Gazette Medicale, for 1841, you will find a new operation
 for the radical cure of spina bifida, proposed by  Dubourg.
 He  cuts out ttie sac, and then  unites the edges of the
 wound by the twisted suture, and in the two cases report-
 ed the operation was followed by a successful result.  More
 extensive  experience is required to  enable  us to say
 whether the measure is in reality one of much utility.
   Modern surgery has done much for the  relief of the ter-
 rible diseases of the maxillary bones, and  although the ex-
 tirpation of either of them seems an operation too hazardous 
23
to be undertaken, we yet find that many cases are recorded
in which it has been performed with the most decided suc-
cess.
   Numerous attempts have  recently been made to cure
hernia radically, by other measures then the truss. My friend
Dr. Pancoast has injected  the sac  with  tinct. of iodine, as
we do in hydrocele, with  the view of causing its oblitera-
tion.   Dr. Haller proposes the  insertion of a portion of the
integument covering the hernial tumour,  (after  the reduc-
tion of the protrusion,) into the inguinal canal as first recom-
mended by Jobert, but in addition to this  a  certain degree
of pressure is exerted, by means of a hard pledget of lint
carried up the canal, and there retained by a double liga-
ture.  (British and Foreign  Review, 1842.)
   Partial or complete success, according to  their authors
has attended all these measures ; but they are as yet open
questions, and cannot be  considered as  entitled  to  rank
among the established operations in surgery.
   In these days of  subcutaneous  operations, it has  been
proposed to divide the stricture in strangulated hernia by
this process.   No surgeon  accustomed to operate for this
disease, will probably ever adopt ameasure which effectual-
ly prevents his ascertaining the  condition of the viscus he re-
turns to the cavity of the abdomen, and which  in its exe-
cution obviously entails more hazard  than the  usual ope-
ration.
   I  cannot refrain from calling your  attention to a novel
and most  hazardous, yet, in  some cases, successful opera-
tion performed, a  short time since, by  Amussat of Paris.
When, from any  cause—such, for example, as tumours,
cancerous ulcerations, or the lodgement of foreign bodies in
the rectum—this passage is  completely and permanently
obstructed, he recommends the establishment of an artifi-
cial anus, in  the lumbar region.   The  same plan may be
resorted to in cases of imperforate anus, where the ordinary
operation for this defect cannot afford relief.
   Amussat, also deserves credit for another most ingenious 
24
 operation in certain varieties of imperforate anus.  In a case
 of this kind, where the rectum was deficient for two inches
 from the perineum, he  cut through the barrier, passed his
 finger between the vagina and sacrum, until he reached the
 pouch of the rectum distended with fceces, drew this down,
 and attached it by suture  to the  anal  opening  which he
 had made in the perineum, having previously opened  the
 pouch that  the stitches might be more readily passed, and
 the foeces  easily evacuated.   The success was complete,
 and no operation of modern  times is more deserving your
 admiration, as well  as imitation under  similar circum-
 stances.

   The danger, suffering, and frequent want of success at-
 tendant  upon all mechanical methods  of  removing stone
 from the bladder, have induced several modern surgeons to
 reconsider the question of medical treatment by solution.
 The waters of Vichy, those of Recoaro, the  various alkaline
 waters of England  and this country, the administration of
 weak acids by the  stomach in cases of alkaline calculus,
 and of alkalies in acid stone, and even the injection into the
 bladder of dilute acids, have all been recently recommend-
 ed ; but there are  few instances in which the temporary re-
 lief that they sometimes afford, has been followed by a per-
 manent cure.  That the pain usually accompanying stone
 in the urinary passages  has  been relieved for a time, and
 the formation of calculus matter checked, by a judicious ad-
 ministration of these agents, there cannot  be a doubt, but
 that a stone once formed has been dissolved through their ex-
 hibition, I do not believe.  The cause of relief has been va-
 riously explained.  Some, as Leroy d'Etoilles, account for it
 by supposing that the feeble solvent dissolves the outer laminae
 of the stone, and is then checked in its action by the layer
 of animal matter which is found between all the concentric
 laminae of a calculus.  This layer of animal matter being
less irritating than the hard, rough, stony one, the sufferings 
25
of the patient are diminished, and he fancies himself per-
fectly cured.
  Others suppose, that by changing the characters of the urine,
we render it less irritating.  The mucous coat of the bladder
—for example—being intolerant of an alkaline fluid, may
possibly bear with perfect comfort the presence of an acid
one, and vice  versa.   In alkaline stones, therefore, give
acids ; in acid ones give alkalies.
   Others attribute the benefit to the influence these agents
exert in strengthening the  whole system, especially  the
stomach and bowels, in consequence of which every organ
performs its function correctly, and there is no secretion of
sabulous matter.
   Whatever explanation you  adopt, recollect that in  the
use of these remedies, especially the strong alkalies, we may
do a great  deal of  mischief  by producing  diseases of the
stomach and  bowels, and even of the urinary passages
themselves.
   It is  impossible  for  me to  enter upon  the discussion
of the merits of the  different new operations invented for
the removal of stone from the bladder.   Many excellent
surgeons decry the crushing  and grinding processes, while
others  of equal weight contend that they are admirably
adapted to almost  all cases.  It may with truth be said, I
think, that  lithontripsy, which has gradually taken the place
of lithotrity, is an operation of the greatest value, and richly
deserves being classed among the modern improvements in
surgery; and, gentlemen, the establishment of its utility in
this country, at least, is due to Dr. J. Randolph of this city,
a surgeon who deservedly ranks among the first of the age,
and a gentleman whose social  virtues  have endeared him
to a large circle of friends.  That the operation cannot su-
persede the use of the  knife  all acknowledge, but  it is an
error to suppose where the case is properly  selected, that it
is a measure of equal danger  and suffering with lithotomy.
  Among those who still contend for the supremacy of  the
knife, is that excellent surgeon, Dr. Dudley, of Lexington,
                          4 
26
Kentucky, unquestionably the most successful lithotomist of
the age.
  While on this subject, it may be well to call  your atten-
tion to a recent operation  by Chavasse, of Birmingham.—
To  remove a calculus from  the female bladder, he passed
the " bistourie cachee" along the  meatus urinarius, and in
withdrawing it, "cut the mucous membrane of  the passage
through its length and depth, leaving the other textures en-
tire" !  He then introduced a dilator and distended the pas-
sage so that the calculus could be removed with the  forceps.
The usual distressing result after other operations—inconti-
nence of urine—did not take place.
  A new method  of treatment in seminal weakness  and the
effects of this most terrible complaint, has recently been in-
troduced by Lallemand.  In  many cases, though not in all,
the discharge is dependant upon chronic irritation of the neck
of the bladder or prostatic portion  of the urethra and unless
this condition is removed,  the disease remains incurable. To
accomplish this object Lallemand  proposes  the application
of  nit. argent, to the diseased surface, and the modus agendi
of this remedy is easily understood. You are well aware that
lunar caustic is one of the best sedative applications  that can
be  made to an inflamed  mucous  membrane and the daily
exhibition  of  this remedy in chronic  conjunctivitis, inflam-
mation of the  fauces, &c,  proves the confidence placed in it
by the profession at  large.  Now  it acts in the  same way if
applied to the  urethra.
   It is with surprise that I find some excellent surgeons ob-
jecting to this operation, on the ground of its hazard.   I can
 only  say  that if  properly employed,  nothing is more  easy,
 less painful, less dangerous, or more effectual; and  this I
 believe to be the experience of all  who have given it  a fair
 trial.
   I cannot say as much for  the treatment of stricture of the
 urethra, recommended by Lallemand and Chretien.  This plan
 called by them " dilatation brusquee," is nothing more than
 a modification of the old method by dilatation with bougies ; 
27
but the obstruction is removed much more speedily.  In the
course of thirty-six hours, the whole treatment is completed,
by the repeated and frequent introduction of bougies of differ-
ent sizes.  I have attempted in a few cases to overcome the
stricture by this plan,  but  have been obliged to desist  in
consequence of the pain and inflammation,  long before a
bougie of a proper size could  be introduced.
   A very interesting paper on hypospadias and epispadias, has
recently been published by Dr. Mettauer of Virginia, a gen-
tleman to whom the profession is indebted for many excel-
lent improvements in surgery.   It  is too voluminous, how-
ever, for me to do more than  mention it as a most ingenious
and valuable communication.
   No affection of the genital organs gives rise to more mental
uneasiness and often physical distress or is more frequently
mistaken for other diseases, than varicocele.  Hence we find
surgeons constantly occupied  in devising some plan for  its
relief; a few of the most recent of these  curative measures it
will be well for you to understand.  The most  simple, and
probably  the  safest and least painful operation,  is that pro-
posed by Velpeau, and  does not differ in the slightest degree
from the usual operation of this surgeon  for varicose veins in
any  other part of the  body.   Davat advises that the needle
should transfix the vein, rather than pass beneath it as pro-
posed by Velpeau; but the latter plan in my opinion is to  be
preferred.   Ricord recommends the subcutaneous ligature
of the veins  by a process which he  describes, but as yet the
method has been scarcely employed.  Breschet strongly re-
commends compression of the veins by a pair of forceps, the
pressure to be  kept up until the obliteration of the vessel  is
complete : but the measure is harsh and not more successful
than others of a less painful character.   The  method of Sir
A. Cooper,  which consists in  cutting out a portion of the
scrotum  has many advocates, although  in my hands,  it has
generally failed to afford entire relief.   The modification  of
this plan; recently introduced  by Dr. N.  R. Smith, of Balti-
more, is very  ingenious and  highly creditable to the excel-
lent and justly  celebrated surgeon its inventor. 
2S
   Many patients are exceedingly timid, and will not consent
 to the performance of any severe operation, and with such I
 have found acupuncture answer very well.  The needle is to
 be passed every day or two through and through the largest
 veins, and thus  by creating a chronic  inflammation, we
 thicken the coats of the vessel and  finally cause its oblitera-
 tion.   It is however, a tedious process, and must be assisted
 by a suspensory bandage.
  No  department  of surgery has  received more  attention
 within the last few years, than that relating to the " Diseases
 of the Eye."  But  a  short  time  since, the pathology  and
 practical treatment of many of these affections, were but im-
 perfectly understood ; and hence the success of the impudent
 charlatans many of whom by devoting themselves to  this
 branch of surgery, not only filled their own purses, but did
 much injury to the profession in general.   I cannot attempt
 here, even a cursory survey of the immense mass of informa-
 tion with which the science has been enriched by the labours
 of Lawrence, Mackenzie, Middlemore, Franz, Chelius, Eble,
 Vidal, Velpeau, Roux,  Cunier, Rognetta,  and others ;  ocu-
 lists whose reputations must survive even the withering hand
 of time.   Nor have we  been forgetful of our duty in this de-
 partment of our art.   The excellent institution in this city,
 founded by the late Mr. Wills, and  now under the direction
 of gentlemen  who bear the  highest reputation as surgeons
and physicians, has done much towards attracting the atten-
tion of the profession to this class of affections ;  and while it
 is the means of dispensing light and  almost a new life, to the
 unfortunate creatures suffering under the loss, either partial
 or complete, of that sense which has been  termed the "joy
 of man !" it is also adding to the reputation of the science.
 I cannot refrain from advising all of you having the opportu-
 nity  to avail yourselves of the excellent lessons there taught,
 and suggest as aids to their profitable hearing, the excellent
 work of Ur. Littell, of this city, and  the edition of Lawrence,
 now undergoing revision by a most competent oculist, Dr.
 Hays.  Our brethren  in New York and  Boston have  also 
29
been much occupied with this branch of surgery, and it is
with unfeigned pleasure that I mention the names of Stevens,
Kearney  Rodgers, Delafield, Post, Wilkes,  Kissam, and
Reynolds of Boston, as oculists deserving all commendation,
and who  by their labours, have contributed much  towards
elev.'iting  our profession in the eyes of the community at
large.
  I cannot refrain before leaving this subject, from calling
your  attention to a few of  the novelties in ophthalmic sur-
gery, some of which are highly meritorious and deserve your
confidence, while  others are but (he vagaries of knaves or
charlatans, introduced rather to gull the " dear public," than
to confer benefit upon their fellow creatures.

  Many of  you are aware  that surgeons for some time past
have  usually considered a wound of the supra-orbitar nerve
one of much importance, under the impression that  it almost
invariably gave rise to amaurosis.  The observations of Con-
stats  Walther, and others, show conclusively that  such is not
the case, and when loss  of sight follows wounds about the
forehead, it  is to  be attributed " to some simultaneous de-
rangement of the organs contained within  the orbit, or the
cranium,  and not to any direct injury of the frontal nerve!"

  Among the numerous remedies recently employed for the
cure of different affections  of the eyes,  myotomy appears to
have  attracted much  attention, and I say with regret, that
no measure  has been  more wantonly  put into execution, or
been  productive of less real benefit.   The affections in which
it has been chiefly employed are strabismus, already alluded
to,  myopia, amaurosis, and corneal speck.

  Guerin of Paris, was the first to perform the operation for
myopia, of which according to him, there are two kinds;
" the one mechanical or muscular, the other optic or ocular."
The  mechanical myopia is the result of " a primitive short-
ness  or of the active retraction  of the  muscles of  the eye- 
30
 ball," especially the recti.  To relieve this condition and thus
 change the axis of vision, he divides one or more of the mus-
 cles and according to his  statement, with the most  decided
 benefit.   Cunicr,  Kuh, Franz, Phillips, Bonnet and others
 have adopted his views and practice to a certain extent, and
 declare that several  cases of the  defect have been relieved.
 Phillips and Bonnet state that they have cured  myopia by
 the division of the oblique muscles only, but the correctness
 of their report is doubted—even by those who advocate the
 operation under all circumstances.

  The " bistoury maniacs," as those who hesitate not to cut
 for almost every known defect of our frames are called by  a
 recent writer, have not in their  zeal neglected to try their
 luck, not skill, upon persons afflicted with the " drop serene."
 Believing that certain cases of this disease were dependant
 upon a spasmodic or irregular-acting condition of one or more
 of the  muscles of the eye-ball, they have divided the  muscles
 supposed to be in fault; and, according to  their statements
 with decided  success.  I do not like  to charge any profes-
 sional  brother with  wilful falsehood, but it seems to me in-
 credible that such  a condition of the muscles should produce
 palsy of the retina; or, admitting the possibility of  such an
 influence, that any surgeon should possess  tact sufficient to
 detect  the muscle in which the defect resides.   I have  never
performed the operation myself, and unless much stronger
 arguments than those now adduced  in its support are  brought
 forward—never shall.
  The same operation (division of the muscles of the eye-
 ball), has recently been performed by M. Petrequin, Bonnet
 and others, for what is called Kopyopia, i. e. the disposition
to fatigue of vision.   The  results  of the experiment  were
very satisfactory to the gentlemen who conducted them, but
 I think it hardly probable notwithstanding all  that is said
in its favour, that any surgeon  who values his reputation will
 undertake its repetition.
  A very ingenious operation in cases of opacity  of the
cornea, the opacity being  so  situated as  to  prevent the 
31
transmission of light through the pupil, has recently been
performed  by  a celebrated  Balgian oculist, M.  Cunier.
The operation consists in displacing the axis of the eye by
the section of one or more of the muscles, so as to induce  a
certain degree of squinting.  Suppose, for  example, a man
has a speck covering the centre of the cornea only, the other
portions being transparent;  if we divide the internal rectus
muscle its antagonist  immediately draws the  eye out, pro-
ducing slight divergent strabismus, and placing the  transpa-
rent portion of the cornea over the pupil, thus enables  the
individuaPto distinguish  objects.   In some cases  it is ne-
cessary to divide the inferior oblique muscle  as well as the
rectus, in order to carry the eye outwards to a sufficient
degree. Where from the location of the speck, the eye must
be turned inwards in order to enable the patient to see, all
that we have  to do i's to divide the  external rectus muscle.
This ingenious and truly scientific operation demands our
respect and admiration, and  should always be preferred
when practicable,  to the doubtful  operation for  artificial
pupil  usually performed in these cases.—(Med. Chirurg.
Review, Jan. 1842.)
   A good deal of interest has recently been excited by the
statements of a Mr. Turnbull  of London, relative to the
use of concentrated prussic acid in  the form of  vapour, in
certain diseases  of the eye, and especially amaurosis.   I
have given the  measure a fair trial in thirty-three  cases of
the latter disease, and with a very discouraging result, only
three having been in the slightest degree benefitted; in no
case  was the cure complete ox permanent.  In cataract,
corneal speck, chronic inflammation of the conjunctiva, and
some  other affections of the eye in  which it is recommend-
ed by Mr.  Turnbull,  its application  produced no  impression
whatever.  When applied for a few moments to  the organ,
it produces rapid dilatation of the   pupil, a  sensation of
warmth in the part, and sometimes nausea and  vertigo.
As a thereapeutic agent in this class of diseases, (so far as 
32
present observation goes,) it may be  considered  as alto-
gether useless.

   Diseases of the ear have also attracted considerable  at-
tention within the last few years, and much useful informa-
tion relative to their nature  and treatment, has been fur-
nished; and  Itard, Deleau,  Royer, and  especially Krah-
mer, have done a great deal towards clearing away the
mist of obscurity in which, for so long a time, this class of
diseases was shrouded, hut there yet remains much to  do
ere we can consider the subject as placed  upon  its  proper
basis.  The popular operation of injecting the eustachian
tube, has frequently proved  useful, but as a  general rule
it may be said to  fail of affording the  relief so readily pro-
mised  by its authors.  The  same may be said of the ope-
rations performed upon the  membrana tympani, in cases
of obstruction of the eustachian tube.
   I am next to call your attention to a class  of operations
that for a time were considered almost as fabulous, excited
the ridicule of Butler, Voltaire, and the polished Addison,
and, even now, notwithstanding  the positive testimony of
the first authorities in their favor, are supposed by many to
be bare assertions, destitute of truth and as useless as they
are apocryphal.
   I allude to those operations which  have for their object
the restoration of lost organs or the correction of partial de-
formities  of the same, by the application to  the defective
part of a piece of integument, so shaped as to resemble after
its complete adhesion,  more or less  perfectly,  the  organ
whose place it is destined to occupy.  To these  operations
various generic terms have  been assigned, but that intro-
duced  by Zeis seems to meet with most  general approba-
tion.   By him the art of " restoring lost parts," &c, is call-
ed "plastic surgery,"  (from rtxasau, to mould.) Blandin,
of Paris, proposes the addition of the  adjunct auto (ovfoj—
self,)  to the word plastic, thus  making the  generic term
" autoplastic;" but  this  modification  signifying as it does 
                          33

"an innate power of reproduction in tissues," has been re-
jected as liable to lead to error. The word taliacotian, has
also been used as  the generic, in honour of an  Italian sur-
geon named  Taliacotius, who acquired great celebrity in
this department of surgery.   Adopting  myself the phrase-
ology of Zeis, I include under the expression plastic surge-
ry, all the specific terms employed in speaking of each par-
ticular modification  of the principle ; such as rhinoplasty
when the nose is made,cheiloplasty when the lips, blephero-
plasty when  the eye-lids, &c. &c.  It is now generally ad-
mitted that " plastic  surgery" originated in India, in which
country the peculiar punishments inflicted on criminals na-
turally stimulated individuals to the discovery of an art for
the practice of which such frequent opportunity was afford-
ed.  What the knife of the executioner called forth in  India,
disease and accident have excited in Europe and America.
Although no  one loses his nose here by the law, he may
yet find an executioner of another sort fully competent to
the removal of this most becoming part of the face.
   It appears that these operations were confined to certain
low caste priests who derived their origin from the  brah-
mins, and who carefully concealed their modes of proce-
dure.  So careful where they on this point, that it is impos-
sible to say whether  the art was known to either the Egyp-
tians, Greeks, or Romans;*  it seems  indeed  to have been
confined  almost  exclusively to  its originators, until  about
the latter part of the sixteenth century, when Taliacotius, a
surgeon of Bologna, became notorious by his operations,
and also by his dissertation entitled, " De Chirurgia  Cur-
torum per insitionem."   After this, one or two isolated
cases  were reported  by Cortesi of  Messina, Hildanus,
and Molinetti of Venice, but the ridicule  heaped  upon
these operations, which were almost in every case rhino-

  * Galen states that the Egyptians understood the art, but that their
methods were kept secret, as well  aa those of the Indians.
                            5 
34
plastic, prevented the general introduction into practice of a
measure now known to be of the utmost value.
  This ridicule was probably engendered by a proposition
of Taliacotius which he, however, ultimately abandoned, to
make noses  from the skins of other people.   Some  of the
anecdotes told are amusing, and at the same  time explain
the cause of these operations having for so long a time been
disregarded.  Van  Helmont relates the case of  a  man for
whom Taliacotius had made a nose, by " transplanting the
skin from  the arm of a porter on to the  noseless face of his
patient.  All went well  for the space of thirteen  months,
but at the end of that period the borrowed organ gradually
lost, its temperature, and in a few days became gangrenous;
upon  inquiring, it was found that at the  self  same  period
the original  owner of the nose had died" !  To this  fiction
is probably  due the celebrated lines in  Hudibras,  Butler
taking the liberty, however, of giving  the  new organ " a
local  habitation,"  different from  that  assigned by our
author.
  The sympathy between the nose  and  its parent, was in-
deed most extraordinary.  Not only did the former die with
the latter,  but during life it  was effected by the pains of the
original proprietor.   We are told  says  a  writer of "three
Spaniards, whose noses were all cut from the  same  porter,
who finding  them one day shoot and swell  extremely, sent at
once to know how the porter was ;  they were  told that the
day before he  had  been severely kicked, and that he was in
bed in consequence of his bruises. This  was highly resented
by the owners of the noses, who considered the indignity as
offered to  themselves." He goes on to remark, "that in this
and several  other cases, it may be said the porter led the
gentlemen by the nose!"   In  consequence  chiefly of this
ridicule, no  attempt to perform these operations was made
after  this  period until  the  latter end of the  last  century,
when several criminals in Madras who  had lost  their noses
were  operated on with such success by a native surgeon, that
Linn  and  Carpue of London, determined to carry the plan 
35
 into execution:  Linn's case  failed, but the two operated on
 by Mr.  Carpue were  so  much benefitted, that an impetus
 was given to the science which has gradually been increasing
 up to the present day in Europe, as well as in this country.
 But even now plastic surgery must be considered in its in-
 fancy, for although much  has been done much remains to do,
 in order that the true value  of the  principle may be fully
 established.
   To Graefe, Dieffenbach, Zeis, Fricke, Chelius, Dalpech,
 Blandin, Dupuytren, Velpeau, Roux, Lisfranc,  Labat, and
 Jobert, on the continent of Europe, and to Liston and a few
 others in England,  are we indebted for much highly interest-
 ing as well as practical information, and to these authorities
 is due the credit of having fixed upon an imperishable basis
 an  art nearly lost, yet of the greatest value to mankind.  My
 friend Dr.  J. M. Warren of Boston,  was probably the first
 to introduce the successful application  of plastic surgery in
 the United States ;  I believe I may claim the merit of having
 perhaps added something to the same  subject, and my friend
 and colleague Dr. Pancoast has also devoted much time to the
 application of the art to different deformities, and by his suc-
 cess deserves our thanks.  Dr. Post  of New York, has re-
 cently published a case of blepheroplastic operation, and a
 surgeon  of Trenton,  one of rhinoplastic,  and  these 1 be-
 lieve are all the operations of the kind as yet made known ;
 there is no question however, but that others  have been per-
 formed, and the science may be considered as fairly entrusted
 to our hands.   As some  may still  doubt the possibility of
 making a "decent  nose," I beg leave to refer to the unique
 specimen before you taken from a patient of Dr. Pancoast's,
 and I hope to have  the pleasure of showing you the operation
 in a few days on a person  now preparing for it,  and thus de-
 monstrate its  practicability.

   You are probably aware, that for  sometime past I have
been much occupied in the investigation of the  various re- 
36
 medies for what are called " deformities."   Among these,
 not the least important is the division of tendons, fascia, or
 muscles, when these organs are in fault.  Like all  new  or
 novel  measures this  has met with its enemies as  well  as
 its advocates, and even how, although submitted to the test
 of several years experiment we find a difference of opinion
 relative to its merits.  Entering upon  the discussion of the
 question with no feelings of partisanship, and with every
 disposition to treat with deference the objections  of those
 who may differ with me, I trust that my remarks  will be
 attributed to no other motive than the desire of inculcating
 correct information as to the estimation in which the mea-
 sure is at the present time generally held.

  The term tenotomy has been applied to the division  of
 tendons;  that of myotomy  to  the section  of  muscles;
 while a similar operation upon fascia is called aponeuroto-
 my.  Inasmuch as all these operations, as now performed,
 are subcutaneous, Sedillot proposes the introduction  of a
 generic term deduced from this circumstance, and  he sug-
 gests the word Hypodermatomy, which signifies literally a
 subcutaneous operation ;  if generally adopted, this would
 probably answer better than any other.
  This class of operations may with truth be considered as
 modern, for the isolated cases of tendon-cutting reported by
 Minius in  16S5; by Jaeger in  the seventeenth century,
 and by Meckran, Roonhuysen, (see Heister,) Blasius, Ten-
 haaf, (see Chelius,)  and Cheselden, were  in reality mere
 attempts, and cannot be considered as having influenced in
 any way the introduction of these operations into  general
 practice.   The same may  be said  of those of Laurentz,
 published in 17S9  by Thilenius, (who, by the way, is  re-
 ceiving the credit of originating this surgical novelty, and
 in honour of whom it is sometimes called the " Tliilenian
 operation,") of Sartorius, reported in IS06, of Michaelis,
performed in 1811, and even  of that  unfortunate  case of 
37
Delpech, an account of which was published  in 1816.  It
was not, in truth, until the year 1S33, when the extraordi-
nary success of that most accomplished surgeon, Stroymeyer,
of Hanover, directed in earnest the attention of the profes-
sion to the subject, that hypodermatomy can be said to
have fairly arisen.  Since this period almost every surgeon
at home and abroad has  performed it; and in proportion
to his success, do we find him its advocate or its enemy.
So far as this country is concerned, Dr. Dickson  of New
York was  the first to perform the operation for club-foot,
but it was not until the publications of Dr. Detmold of New
York, and myself, that the question came fairly before the
American profession.  To Dr. Detmold is due the merit of
the first tangible information on the subject.

   The peculiar deformities for the relief of which hypo-
dermatomy has been  performed, are club-foot, contracted
joints, old luxations, fractures of the patella and olecra-
non, followed by permanent separation of the fragments
—some forms of torticollis, strabismus, facial palsy, rigid
jaw,and the contractions of the facia of the hand and foot,
so well described by Dupuytren.   Time will not permit me
to do much more than mention under  this head, the cases
for which  the operation in question is designed ; but some
 of these are at this moment attracting so much attention,
 that I deem it my duty to  state my own views in relation
 to their value ;  others have already been  alluded to.
   The most striking, and  probably the most interesting
 of these operations, from the controversy to  which it  has
 given rise, is that for Strabismus.

    As is ever the case with any supposed novelty, several
 have  laid claim to the  origination of this; but,  alas! we
 find the merit due to an itinerant  quack, who flourished in
  1738 and who, in a pamphlet entitled  Be  Verd  Caush
  Strabismi, gave an account of  this very measure.  The 
3s
 operation was also alluded to  only to be condemned, how-
 ever,  by Heuenmn,  a German  surgeon, in  1756.   Mr.
 White, of London, several years since certainly demon-
 strated its practicability by performing it on the lower order
 of animals;  and Dr. Ingalls, of Boston, it is stated by  Mr.
 Atwell, proposed  such a measure  in  his own case in the
 year 1812.—{Medical Examiner, 1S42.)

   Stroymeyer also suggested something of the kind, but
 Deiffenbach, of  Berlin, more than any  one  else, deserves
 the credit of  having successfully performed it on the human
 subject in 1S39.   Since this period it has been attempted
 by almost every one, and I think I may with safety assert,
 that no surgical  measure of modern times has  been  more
 shamefully abused.  Reports upon reports have been  cir-
 culated by men calling  themselves surgeons, but  who, in
 many  instances, have  turned out the  veriest,  quacks, in
 which  it has  been  declared that  in every case success  at-
 tended the operation.   Such assertions, known to be false,
 have induced the profession generally  to  receive "cum
 grano salis,"  the statements of all who have  written upon
 the subject.   Notwithstanding all that has been said and
 done to discredit it, however, I have no hesitation in declar-
 ing, that when properly performed, and  the case carefully
 selected, (for  there are many altogether unfit for the opera-
 tion,) it richly deserves being ranked among the modern
 improvements in our art.
  But its merit is still  an open question, notwithstanding,
 and I advise you to enter upon its investigation fully im-
 pressed with  the fact, that it will often fail  entirely in  af-
 fording relief, and not unfrequently give  rise to deformity
 almost as great as  that for which it has  been  performed.
 Two modes of operating are at present in vogue.  1st. The
 ordinary method by dissection, of which there  are  almost
 as many modifications as operators:  and, 2d. The  sub-
conjunctival operation,  in which the conjunctiva is barely 
39
punctured.  For my own part, I vastly prefer the former,
for reasons which will be given in another place.

   Nothing is niore characteristic of the present want of suc-
cess in the operation for strabismus than the numerous
methods proposed  to remedy the defects  which are de-
veloped by its performance. The peculiar staring appearance
occasioned by the abnormal prominence of  the eye-ball has
given much trouble, and we find almost every strabotomist!
proposing some measure for its relief.
   Rognetta, Guerin, Baudens and others,  have "stitched
the inner angle of the lower lid to the corresponding point
of the  upper one, the operalor having previously removed
with the  curved  scissors a crescentic fold  of the integu-
ments."   So bungling an operation scarcely deserves men-
tion, and besides  it in reality increases  the deformity,  for
while it does not diminish the projection of the ball  it  es-
tablishes  an epicanthus as disfiguring as the original defor-
mity.
   Cunier proposes instead of this plan, to excise a vertical
fold of  the mucous  membrane between the cicatrix and
the caruncula, and then to bring the edges of the wound
together and maintain them in apposition by one or two
stitches.  " The loss of substance in the conjunctiva and  the
fibrous membrane, induces a shortning and a closer adhesion
of them with  the ball so that this  will no longer retain its
abnormal prominence, and at the same time the caruncula
which may have been  more or less  displaced, regains its
natural situation."
   Different plans have been proposed by  Dieffenbach and
others,  but  it is  hardly necessary to enter into  their  de-
scription.
   A recent "resume" of the cases in which the operation for
strabismus has been performed, is highly unfavourable to the
general utility of the measure; not more than  half the per-
sons who submitted to it being  relieved.   It is more than
probable, however, that many of these cases were totally 
10
unfit for the experiment, and  hence we  should be careful
how we receive  as  correct the  statements  there  given.
You will find this paper in a recent number of the Medical
Examiner, and it is well worth your perusal.

  I wish that I could say  anything in  favour of  another
new operation, of this class; I allude to  the division of the
muscles of the tongue incases  of stammering.  It  appears
that this, like almost every  other operation in surgery, was
known  to  the ancients, that  is, if the "researches"  of M.
Jobert are to be relied on.   According  to him, Galen,
iEtius, and Paulus  Egineta, not only understood  the  na-
ture of the defect, but also that they  performed an opera-
tion very similar to  the one considered a " modern discove-
ry," for its relief.  It is  very certain  that in all  these
writers we find a good deal  relative  to the  treatment of
the mogilali or stammerers.
  Several centuries elapsed after the time of these authorities
before the attention of the profession seemed to  be directed
again to  the  subject, and it  was  not, indeed until  the
beginning of the fifteenth, when F. Hildanus undertook to
cure the  stammerer by an operation that we< find the mat-
ter referred to.  In 1672, Dionis proposed something of the
same kind, but it Was not in  reality until Dieffenbach in
1841  made public his cases, that modern surgery gave the
defect the slightest consideration, and to  him, therefore, is
due the merit, if merit there be, of resuscitating a measure
long since forgotten.
  He proposes three plans of operating.   In the first,  he di-
vides the root of the tongue transversly, the incision ex-
tending through nearly its whole thickness.   In  the second,
he divides the root of the tongue in the same  direction, but
leaves  the mucous  membrane  uncut  except at the  point
through which the knife is past.  In the third, he makes a
transverse section  of the root of the tongue, and then excises
a triangular piece throughout its whole breadth and  thick 
41
 ness, and this process he prefers to either of  the  others.
 That any surgeon of acknowledged ability should propose an
 operation so unphilosophical, so cruel,  and so  dangerous,
 naturally excites  our  surprise ; but this feeling is converted
 into one  near akin to indignation when we learn  that he re-
 commends it, after its repeated application had failed to afford
 relief, and even after it had  been  followed  by fatal results.
 It  has not I believe been  attempted by any American sur-
 geon and I trust it never will be.
   Other  operations in  which the  fraenum linguae, and the
 genio-hyo-glossi muscles are divided, have been  introduced
 by Amussat, Baudens,  Velpeau and others, for the relief of
 stammering, and  each  operator has a  method of operating
 peculiar to himself.  It matters very little, however, how the
 operation  is performed, inasmuch  as it is almost uniformly
 attended  by failure.  That it has occasionally been produc-
 tive of benefit there cannot be a doubt,  but in every success-
 ful case  the patient had laboured  under positive " tongue-
 tye," a  defect easily recognised and for  which the remedy
 is well known.  But that it ever cured a case of purely func-
 tional stammering, unaccompanied  by defective organization
 of  the tongue as some would have us  believe, it would be
 difficult to prove.   Compared with the operation  of Dieffen-
 bach, it has the merit of being much less painful,  less  dan-
 gerous, and sometimes  successful.
   Dr. Detmold of New York,  has proposed acupuncture
 in  those  cases of stammering in which the tongue is well-
 formed,  and  the   measure  has been  frequently  put  into
 practice by Mott and others.  So far, additional experiment
 is required to ascertain its utility ; but for my own  part I
 can only say that in all  my cases it has been productive of no
 benefit whatever.

  Myotomy has likewise been employed in cases  of rigidity
of the masseter muscle,  and here with decided effect. In the
American Journal of Medical Sciences for 1S39, you  will
find the details of a case of locked jaw of some years stand-
           6 
42
ing, for the relief of which I divided this muscle and with per-
fect success.   In the same Journal there is  another  case re-
ported by Professor Furgurson, and recently others have been
published  by Dr.  Smythe, in all  of  which the cure is attri-
buted to this operation.

  Torticollis or wry-neck is  another  deformity for  which
myotomy has frequently been performed.  Indeed it is more
than probable  that in the  time of Hippocrates the utility of
the operation  here was clearly recognised, and we  know
that it was performed long before the general application of
either myotomy or tenotomy in modern times.

  A very ingenious application of the  principle  under dis-
cussion has  recently been proposed by that most inventive
of all surgeons Dieffenbach, who seems  never to rest satisfied
with  what has  already been done in  any department of  our
art.   Struck with the inutility of the usual methods employed
for the cure of that  distressing defect,  facial hemiplegia, he
conceived the idea of curing by some surgical operation the
deformity to which  it gives rise.  His first  operation con-
sisted in " the excision of an elliptical  portion from the par-
alyzed cheek, the long diameter of the ellipse being parallel
to the perpendicular diameter of the face, and then uniting
the edges of the  wound by suture."  The experiment was
partially successful,  the wound healed in a few days, and  the
affected cheek shortened  by the loss  of its  substance, was
rendered  sufficiently strong to antagonise to a certain  extent
the muscles of the opposite side, "though the actions of speak-
 ing,  eating and laughing,  were sufficient to destroy  the equi-
 librium!"  Although the benefit derived from this opera-
 tion   was decided,  yet it was not  deemed  sufficient  to
 warrant  its repetition,  and  Dieffenhach from numerous ex-
 periments having discovered that " by the loss of  their na-
 tural antagonists, healthy muscles are  wont to become more
 firm and contracted," was led to draw an analogy between
 the consequences of the present affection and the contraction 
43
of muscles in certain cases of club-foot which takes place at
the expense of their paralysed opponents.   From this analogy
the idea of a similar operation  suggested itself, and the suc-
cess which attended its execution justified his anticipation of
its utility.  The operation consists in dividing the muscles
of the sound  cheek,  at  least all  concerned in the  defect,
by  means of a  small  knife,  passed directly  under the
skin and  introduced through a small puncture.  Two inci-
sions, one through the muscles of the upper portion of the
cheek, and the other through those of the lower part of the
jaw, are  generally required.   The  punctures are  dressed
with a little adhesive  plaster, and the parts kept at rest by
the dressing for fracture of the lower jaw.
   This operation is  comparatively slight, the pain, hemor-
rhage, and subsequent inflamation rarely amounting to any
thing of importance, and three  or four days are sufficient to
complete  a cure.   In  one  case of Dieffenbach's, however, ,
erysipelas and suppuration of the wound occurred,  and the
patient was under treatment for several months; nor does it
invariably succeed.  While, then, I consider this a beauti-
ful, most  ingenious, usually safe, and sometimes successful
operation, one that from authority you are justified in per-
forming,  I would have you bear in mind the possibility of
its proving of no avail to your patient, a fact of which you
should always advertise him.

   Division of the muscles has also been employed to correct
the distortions of the spinal column, and in spite of its want
of success the origination of the measure has been  claimed
by several.  It is a matter of little importance to whom the
merit  belongs, but Guerin of Paris, has generally received
it.   He is certainly its most ardent advocate, and  has un-
questionably put it into execution more frequently  than all
the surgeons of Europe  and this  country combined.—
 Guerin's  theory is  simply this:—according to him  "all
spinal distortions should be classed with club-foot, wry-neck,
contracted knee, &c, and as the muscles of the foot, leg, or 
44
knee, by  their contractions produce certain  deformities,
which arising from the same cause, perverted muscular ac-
tion, present  the same general character, and require for
their relief the same operation, division of the contracted
muscles; so also curvature of the spine may be considered
as the club-foot of the back, depending on  the contracted
state of the muscles of this region and requiring for its cure
theirdivision"! Time will not permit me to enter upon the dis-
cussion of the arguments in favor of and against this opera-
tion, but I agree entirely with Bouvier in the  opinion that
it is still " auceps remedium," and rarely if ever productive
of the slightest benefit.  Guerin on the other hand declares
it to be a safe, easy, and almost certain means of affording
relief.  Time and future observation must decide  the ques-
tion ; for my own part I have no confidence in  it whatever.
  The application of myotomy in old luxations and fractures,
has already been alluded to.
  In a certain form of spasm of the muscles of the thumb,
produced by excessive exertion of these muscles in writing,
myotomy has also been resorted to, but the cases reported
are too few and too hastily drawn up for us to  say whether
the measure is to be  relied on or not.  From the  fact that
the disease is confined to those who like scriveners write a
great deal, it has been called " scriveners' spasm."
  In  no deformities  has hypodermatomy  been performed
more frequently than in club-foot, and contracted limbs.  It
will be impossible for me to do more than contrast  its merits
with those of the mechanical treatment, as it  is called, in
the management of these cases.
  It has been well said by a recent writer, Dr. I. Parrish,
"that much of the evidence on both sides of the question
lacks that  certainty and philosophical  accuracy which should
distinguish medical testimony." (Retrospective Address  on
Surgery—Transactions of the College of Physicians, Phila-
delphia, IS42.) And why is this ? It originates gentlemen in
the crying sin of the age, one already alluded to, the desire
of being known as a discoverer, or at least an apt  follower! 
45
The advocates of both plans of treatment have been too eager
to publish their cases, and too prejudiced as a general rule'to
listen to the arguments or the facts  of the  opposite side.
Many also, totally unfit for observations of any  kind have
attempted to solve the difficulty, and  hence have  only made
"confusion worse confounded!"  The great error here as in
almost every thing else, consists in exclusiveism.  No sur-
geon who has studied the subject will think for an instant of
separating the two plans ;  they are so closely connected that
they must ever be considered as "bone of one bone and flesh
of one flesh." But much remains for us to accomplish in the
effort to establish a correct code of rules by which surgeons
are to be governed.  The indications under which tenotomy
is required, and  those which point  out the employment of
mechanical measures alone, the when and the where, have
not as yet  been fully explained.  Time, and further careful
unprejudiced observations,  are required to place each method
in its true position, and I trust that to some one among you
is reserved the honour of solving this difficult and most inte-
resting question.   But in the present state of our knowledge
to discard either, to confine ourselves to one mode of treat-
ment alone, would be in truth a casting away of the gem be-
cause we are ignorant of its value. It is much to be regretted
that the dangers of tenotomy have been so much  magnified,
for in truth if properly performed it is accompanied by none.
I cannot do better, however, to convince you of the position
it holds abroad among those who have given  it a fair trial,
than to quote the following extract from the excellent retro-
spective address of Mr.  Dodd.
  "The  relief,"  he observes,  "of contracted joints by the
division of tendons, is now finally fixed upon the basis of an
extensive experience, and the fears formerly entertained for
the injury of the tendons entirely dismissed!"  Again  he re-
marks—"It is seldom that an axiom shall  be  struck out in
practice of so simple a nature, and of so general application.
The fears which used to be entertained of injuring tendons,
and which, till very lately, entirely regulated this branch of 
46
 surgical practice, having by the successful issue of one part of
 the inquiry been dispelled, we now find scope for the appli-
 cation of the principle to an extent that  its  first promoters
 never dreamed of, and from the progress which has recently
 been made  in  the relief of deformities by this means, it is
 difficult to predicate the limits of its application.   Already
 has it been brought to  bear on all  the  principal joints, the
 spine, the neck,and the eye.   It is gratifying at all times to
 witness the  accomplishment of an important and palpable re-
 lief to human suffering, and in this as  in every other case,
 the amount  of  our admiration is much proportioned to  the
 simplicity of the  means, contrasted with  the magnitude of
 the result."
   Nor, gentlemen, is  this  the opinion of one individual
 alone; almost every surgeon in Europe and many of those
 at home, while  they caution us against unnecessary and too
 frequent operation, yet state distinctly  and positively that
 tenotomy is, and should be considered the least painful,
 least dangerous, and  most useful, of all our  means for  the
 relief of deformities of  various kinds.   The  most eminent
 authorities who at this time are advocates of the operation,
 are Stroymeyer, Dieffenbach,Scouttetin, Franz, Graefe, Von
 Ammon, Guerin, Bouvier,  Velpeau,  Roux, Duval, Liston,
 Brodie, Syme,  Whipple,  Little, Cooper, and Baird.  The
 late Sir A. Cooper, and  Sir C. Bell were  both  its supporters.
 In our own  country many of our best surgeons have given
 it their decided sanction, and that such  will  be  the case
 with all who candidly and without prejudice give the ope-
 ration their  attention, I verily believe.   But while you find
 in me a firm, uncompromising advocate of hypodermatomy
 you must not  suppose  that I advise its  employment in  all
cases, or with the recklessness of some  who hesitate not to
operate on children three days old for squint, (Dieffenbach
British and Foreign Review, January, 1840,) or who divide
the muscles of the spine in cases of long  standing curvature
or who divide forty-two muscles  in the course of twenty-
four consecutive hours (Guerin), or who cut the tendons in 
47
club-foot at birth, or who nearly cut out a man's tongue to
make him speak plainer !   All this ardor operandi is to be
condemned, unequivocally  condemned.   I  contend for
nothing of the kind, and caution you against giving way to
the temptation.  Before leaving the subject, I wish to refer
you to some excellent strictures against this operation when
unnecessarily performed, publishedby my friend Dr. R. Coates
of this city, in the Medical Examiner for 1S41.  They exhibit
great ingenuity on the part of their author, and morever will
serve in most cases  as correct guides for your practice.
  A very ingenious modification of tenotomy has been propos-
 ed by Stroymeyer, to be employed in cases of paralysis of the
 different muscles of the body, but especially in those of the leg.
 It  consists in cutting out a piece of the elongated tendon,
 and then uniting the divided extremities at once. It is obvious
 that by such an operation we shorten the organ and  hence
 stimulate the muscles to healthy action, and enable them to a
 certain extent to perform their natural office.  This opera-
 tion has been performed by Dr. Blackrnan  of New York,
 and in two cases by myself and with decided benefit in all.

    No  complaint  more  truly deserves   the  attention and
 symp'athy of the surgeon, than procidentia uteri.  Painful
 in the  extreme and often incurable, it is not surprising that
 so many attempts should, from time to time, have been
 made for its relief.  I can only allude, however, to those of
 recent introduction—the most successful of which are such
 as have for their object, either the diminution of the calibre
 of the vagina at its middle or upper portion, or the occlusion
 of its orifice, so as to prevent the escape of the womb beyond
 that point.   Hall  and Phillips  of London;  Ireland  and
 Kennedy of  Dublin;  Dieffenback of Berlin ;  Fricke  of
 Hamburg; Laugier, Velpeau  and Jobert  of Paris; and
 Geddings of this country, have probably paid  more atten-
 tion to the subject than any other modern surgeons, and to
 their  papers descriptive  of the different operations  per-
 formed, I must refer you for all requisite information. 
48
    Many attempts have recently been made to relieve that
 most disgusting of all defects  vesico-vaginal  fistula.  No
 affection is more difficult from a variety of causes to cure,
 and  hence operation upon operation has been devised.  I
 shall call your attention to only one  or two.  When the
 fistula is small it may in some cases be  healed  by the
 cautery or suture, and sometimes the cure is spontaneous.
 The  little reliance to be placed upon either of these plans
 induced me some time since to employ a different method.
 The  edges of the wound being callous and our chief object
 in the treatment being to cause the  callous edges to  granu-
 late,  I  have tried along with  caustic the  following  plan :
 Take a double silver catheter of  large  size  and the usual
 length and curve  of the  female catheter.   On the  con-
 vexity of the instrument and at a point corresponding with
 the-fistulous opening in the septum let there be an orifice large
 enough to admit the passage of a skein of cotton thread,
 and  connecting with the  lower chamber  of the catheter.
 The  instrument is to be introduced   into the  bladder
 and  then a flexible stilet  armed with the skein of thread
 is passed along its lower chamber until it reaches the open-
 ing opposite the fistula.   As this chamber  ceases at the
 opening, the point of the stilet passes out at once, and then
 through the  fistula  into the vagina.   The  surgeon  then
 seizes it and drawing it out of the os externum, lodges the
 skein of thread to which it is attached in the fistula.  The ca-
 theter is then fixed in the urethra by the usual bandage and
 the ends of  the  skein tied to each other.  When properly
 applied it is obvious that no urine can escape  by the fistula,
the whole of this fluid passing out by the upper chamber of
 the instrument, and also that the irritation of the thread
 will cause a  swelling and granulation  of the opening.
 Every day the orifice is touched with lunar caustic and one
thread of the skein drawn out, until at length the whole has
been removed.  In two cases out of five this plan succeeded
perfectly.
  When the fistula is large, Leroy d'Etiolles .proposes to 
49
raise up  the posterior wall of the vagina and apply it over
the opening.  The  operation is difficult, and can only be
performed when the fistula occupies the middle of the vesico-
vaginal septum, and is therefore applicable to but few cases •;
when practicable it seems to promise much more than the
plastic operation of Jobert  in which a  long  flap is taken
from the thigh, rolled into a cylinder and then thrust into
the fistula—to the margins of which it is attached by sutures.
The arched flap proposed by Velpeau is also an operation
hardly to be relied on, although like every thing emanating
from this source it deserves our attention.
  A most terrible case of recto-vaginal fistula has recently been
cured  by a most ingenious and difficult operation invented
and executed' by my friend  Dr. J. R. Barton.   The details
of this operation are too voluminous to admit of their intro-
duction here; but I wish you all to refer to the case,which you
will find in a late No. of the American Journal of Medical
Sciences, inasmuch as the credit of the invention has in a
most  unaccountable manner, been  given by Guerin of
Paris, to Dr. Mott of New York.

   In this rapid and  hasty sketch of a portion of what has
occupied the time and talents of our brethren for some years
past, it must have been  obvious to you that American sur-
geons have been no laggards in the mighty race for profes-
sional  fame.  That they as well as their collaborators in
Europe, have been steadily engaged in adding each a stone to
the pyramid of modern  surgery !   The flame which burns
so brilliantly abroad has thrown  its  rays across the wide
Atlantic, and soon its genial warmth will be  felt from one
extremity of our country to the other.   Shall it be permitted
to subside ?  Will you who are  destined to  be the pillars
upon which the medical science of this country is to rest,
fail to add  fuel to this flame ? Will you by slothful indul-
gence, wasteful sensual gratification, ignoble and puny con-
tentedness which readily receives but never gives, let pass
this golden era ?  Will you not rather " gird up your lorn*" 
50
to the toil—and by your  diligence, morality, and laudable
ambition, wreathe  a new chaplet of glory for the  land of
liberty and equal rights ?   Show to the world  that if in po-
litics, religious  tolerance, and social virtue, America once
stood and will stand again, the foremost of nations, she may
also boast of her medical  science.
  Recollect that you are destined to sustain the honours and
prolong the glories of a science that has long been dignified
and adorned by the profound attainments, the elevated in-
tegrity, the high bred courtesy of a Hunter, a Cooper, a Bell,
a Pare, a Dupuytren, and a Physick !—What an inspiring
example!  What  an animating  incentive !   How proud
your obligation !   With  those lights  to guide you in the
path  to  excellence, hasten  to prove yourselves worthy of
receiving the bright mantle  of fame  with which a grateful
world has always been ready to clothe him who with ten-
derness and love ministers to the pangs and sorrows of  his
fellow man.
  There are many among you who  are discouraged from
entering  with ardor upon  the pursuit of the profession, from
the supposition that nothing or next to nothing remains for
them to discover.   Let no such idea take possession of your
minds; ours as I  have  already told you is  a progressive
science and far very  far  from perfection.  Mirabeau has
justly remarked "that to  suppose everything in any science
to be discovered, is like taking the horizon for the limits of
our earth!"  Fully impressed with this  fact, let me urge
upon  you  constant,  patient, unprejudiced   investigation.
The harvest is rich and he who  boldly thrusts in his sickle
will assuredly reap an abundant reward.  It is true that
" generation after  generation will probably pass away ere
a final victory  over  the  chaos  and confusion which still
reigns over us can be accomplished, but the  day will come
when our descendants, like the discoverers of old at the  pil-
lars of Hercules, may pause and say—"

          "Hie tandem stitimas, nobis ubi deficit orbis !" 
51
Dwell  not  then upon what  has  been done but what  re-
mains to do.
  Another influence well calculated to dampen  your ener-
gies is the success of quackery.  The dark clouds of igno-
rance, and  error, and presumption do indeed gather more
and more around and above us, and often the true votaries
of our noble art are  bowed down with dispair.  It comes
not within my province to discuss the causes of this increase
of the evil, but there is surely none more efficient than  the
facility with which a medical degree is usually obtained,
and consequently the little value set upon its possession by
the community at  large.  I  trust, however, that a better
state of things will sooner or later arise, and in the mean
time should any among  you be disheartened, let. him not
look to the boasted success of the lying and impudent quack,
but to the brilliant  examples  of wisdom, and intellect, and
honesty with which our profession is replete.  In whatever
direction  we turn, the trophies  of these  great men are  be-
fore us, and pointing to them, gentlemen, I would appeal to
you in the language of Demosthenes when pleading in  be-
half of the  Rhodians, he invoked the memory of the illus-
trious dead and pointed to the monuments of their valour to
rouse their sons to the same noble achievements ; " think,"
says he, " that your ancestors erected these trophies not that
the view might barely strike  you with admiration, but that
you  might  imitate  the virtues of the  men  who  raised
them !" Allow not then the temptings of the demon of ava-
rice to lead you astray—the gains of the  mercenary and
hard hearted empiric though  often alluring to the poor and
diligent, but honest and honorable votary of his art, can in
the end be productive of no comfort, no  satisfaction.  I
envy not the man  whose highest pinnacle  of  prcfessional
eminence is based  upon  money, whost loftiest aspirations
are bounded by an horizon of gold.   Alas !  he knows not
the charm that envelopes and hallows the charitable act;
he feels not the genial wamth which springs from the poor
man's blessing;  he cares not for the tears of the orphan and 
52
 widow; he thinks of and values only, the means by which
 he may heap up the poor, fleeting, perishable wealth of this
 world, and with every generous feeling callous, with every
 kindly sympathy locked up  in  his frigid heart, he  moves
 in the crowd not as a dispenser of health and comfort to
 the sick and needy;  not as the  cherished friend of  every
 homestead; not as  the harbinger at whose approach the
 pangs of death even, are subdued; but rather as the harpy
 who preys upon the very vitals of his patient.  Oh then,
 gentlemen, cherish  the  kindly feeling  of our  nature—de-
grade not by sordid motives that magnificent vocation, that
noble and admirable mission which shrinks from no  devo-
tion  and distributes its success ^impartially to the crowned
head and to the poor beggar—and in  conclusion let me re-
mind you in the glowing stanzas of a native bard, that,

            " Art is long and time is fleeting,
               And our hearts though stout and brave,
            Still like muffled drums are beating
               Funeral marches to the grave !

            Let us then be up and doing,
               With a heart for any fate ;
            Still achieving, still pursuing,
              Learn to labour and to wait."
                                       Longfellow. 
 
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