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J§^                   '      ■    'j     ■<      X"
REPORT
ON
KENTUCKY   SURGERY.
READ BEFORE THE
KENTUCKY STATE MEDICAL SOCIETY,
AT ITS ANNUAL MEETING
AT |LOU^|lf^JJ(J^^r*"l8"54
   i?UWO*5Vr,,-*«.#if*Fj-.l-*r ;
   i    MD.-LV.-tyu;!
     ------------««.-------x:—   »  j
    By & DTGTTOSS, M. D. *
    LOUISVILLE, KY.
WEBB * LEVERING, MAIN STREET,
        1853. 

S-„ v>, Hiit*
.1
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 wo
  11
  AK4-
  G8r
  1853
s>L
 
  A year ago, I had the honor to be appointed by this  Society,
Chairman of a " Committee on Improvements in Surgery," with
the privilege of selecting two associates.  Not wishing to trouble
any one with a labor, the  nature and extent of which I did not,
at first,  myself fully comprehend, I determined to trust to my
own unaided efforts: and now appear before you as sole reporter.
For the same reason I shall, in rendering an account of my'un-
dertaking, use the pronoun "I," instead of the more imposing
•and, perhaps, dignified term, " Chairman " of  the Committee.
  I did not know until  after the publication of the proceedings
-of the first meeting of the Society, how indefinite was the nature
of the duty assigned to me.  The committee is expected to report
on  "Improvements  in  Surgery."   On what  improvements?—
Hardly anything could be more vague than this expression, and
I can scarcely suppose that it  was the wish of the Society to
restrict the labors of the  Committee to such narrow limits.  At
any rate, be  this as it may, it is to be regretted that its instruc-
tion was not more positive and explicit.  Were the Committee to
confine itself strictly to the duty prescribed by the Society, its
labors would, indeed, be light and unimportant; for no one will
pretend to assert that Kentucky has effected much " improvement
in Surgery," however rich and creditable may be her exploits in
this branch of the healing art.
   Instead, therefore, of doing this,—instead  of selecting a few
prominent topics and discussing them  in a minute and elaborate
manner, I have preferred to take up the subject of Kentucky Sur-
gery in its entire range, commencing  with the earliest period of
its  history, and  bringing  it down to  the present moment.   In  a
word, I have rendered my report as retrospective  as  possible, by
embodying in it an analysis, or, more correctly speaking, a synop-
sis, of the labors and contributions of our predecessors, as well as.
those of our  cotemporaries.  In this manner, and in  this manner
alone, could the Committee hope to do justice to the subject, or
exhibit it  in its proper and legitimate  aspect.  I  am not vain 
[4]
 enough to suppose that I have exhausted the subject; like a trav-
 eler who is exploring, for the  first time,  the resources of a new
 country, I have made extensive excursions, wandering hither and
 thither in  pursuit  of objects,  culling here and there  a choice
 flower, or picking up a  gem  by the way-side ; but many things
 have, doubtless, escaped my attention, and much is left to reward
 the research and  scrutiny of my successors.
   In the discharge of the onerous duty which I have assumed, 1
 have endeavored  to do justice to all; to  show partiality to none.
 If anything of importance has been omitted, it must be attributed
 to inadvertence, or to a want of co-operation on the  part  of my
 brethren in the  profession,  whose attention  was  prominently
 called  to the subject, months  ago, in a " circular," in both of our
 medical journals, and in almost every respectable newspaper in
 the State.
   I  have sought  information  wherever I thought it was to be
 found.   I have written numerous letters to professional and non-
 professional individuals,  with  a view of  hunting up, or tracing
 out, cases of special interest or importance in surgical pathology
 and practice.  I have consulted, for the same purpose, numerous
 medical journals,  and even occasionally monographs and system-
 atic treatises.  In short, I have spared neither pains, trouble nor
 expense, to do justice to my report.
   The  principal periodicals to which I have resorted for informa-
 tion are, the Transylvania Journal of Medicine and the Associate
 Sciences; Dr.  Drake's Journal of the Medical and  Physical
 Sciences; the Western Journal of Medicine and Surgery • Law-
son's Western Lancet; and  the Transylvania  Medical Journal.
 [ have  also consulted Chapman's Philadelphia  Medical Journal •
the American Journal of the Medical  Sciences;  the North Am-
erican  Medical  and  Surgical  Journal;  the American Medical
 Recorder; and the Philadelphia Medical Examiner. The Philadel-
phia Eclectic Repertory has supplied me with  the details of Dr.
 McDowell's first five operations of ovariotomy.
   My particular acknowledgements, for favors  rendered me,  in
reference to my report, are due to Dr. James Overton, of Nash-
ville, Tennessee;  to Prof. Drake, Prof. Lawson, and Dr.E. Wil.         ^
liams,  of Cincinnati; Dr. W. A. McDowell, of Evansville, In- 
                             [5]
diana; Dr. G. W. Bayless, of Missouri; and Prof. F. G. Smith, of
Philadelphia.  I am  also under  obligations, for similar reasons,
to Prof. Bush, and Prof. Peter, of Lexington; Dr. Gait, of Louis-
ville ; Dr. Robertson, of Nicholasville; Wallace W. McDowell, Esq.,
of Danville;  Dr. Gardner,  of Woodsonville; Dr.  Chipley,  of
Lexington; Charles F. Wing, Esq., of Greenville; R.  B. Bra-
shear, Esq., of Louisiana; Dr. J. M.  Mills, of Frankfort; and
Dr. Bemiss, of Bloomfield.
   Little appears to have been published by Kentucky surgeons
and  physicians prior to the establishment of the  " Transylvania
Journal of Medicine and the Associate Sciences," at Lexington,
in 1828.   In the first volume of  that periodical is contained, if
my information is correct, the first  contribution  to  professional
science ever made by Dr. Benjamin W.  Dudley,  at that time,
and  for many years  subsequently,  the  able and distinguished
professor of anatomy and  surgery  in  the Medical  Department
of Transylvania University, the oldest, and, for a number  of
years, the most celebrated and successful school of  Medicine in
the valley of the Mississippi.   The publication of the journal in
question opened  a new avenue to the practitioners of the South-
west for the  communication  of their observation and experience
to their brethren in other  portions of the  country, and we accor-
dingly find that there is not a volume of it that does not contain
original papers, upon medicine and its cognate branches,  of more
or less  interest and  value.   The  surgical material,  however,
which has been thus furnished is, it must be confessed, with few
exceptions, comparatively  meagre ;  consisting, as it does, for  the
most part,  rather of isolated cases  and facts than  of  connected
and  well-digested monographs.  Dr. Benjamin W. Dudley and
his immmediate pupils  are the chief contributors, and it strikes
the reader as not a little singular that many of the articles which
appear in the pages of  the Transylvania Journal, are filled with
the details of this distinguished surgeon's  own cases, or  of cases
expressly  designed to  illustrate  his doctrines and  practice.  I
know not of a similar instance of the kind in the United States,
where the influence of a preceptor has excited so strong and rev-
erential a devotion on the part of his pupils, or whose teachings
have sunk more deeply  into the hearts and minds of his  hearers. 
[6]
I do not believe that Dr. Rush,  the  ablest and most eloquent
professor of medicine in his day in this country,  enjoyed so wide
and controlling a popularity as Dr. Benjamin W. Dudley, or that
his doctrines and practice were received with as much enthusiasm,
confidence and oneness of feeling as were those of the Western
Corypheus of Surgery, in the  palmiest days of his usefulness and
renown.  Such  devotion is,  indeed,  rare  in any country, but
especially in this, where  every  one is disposed, from his earliest
childhood, to think and to act for himself; where, in short, "nul-
lius addictus jurare in  verba magistri?''  It exhibits Dr. Dud-
ley's popularity in  a light, alike  flattering to his own feelings,.
and creditable to those of his pupils.
  Dr. Ephraim McDowell, another of Kentucky's illustrious sur-
geons, never  contributed anything to any Western periodical.
The only papers, in fact,  which  he ever published were two short
ones in  the seventh and ninth volumes of the Philadelphia Eclec-
tic Repertory, detailing several  of his cases of ovariotomy, at that
time so  incredulously received by his professional brethren, but
which have since  created for him a world-wide celebrity.  Dr.
Brashear, another surgeon of distinction,  never wrote anything,
for our medical journals.
  In the prosecution of my labors, I do not deem it necessary to
adopt any  particular chronological arrangement: this, indeed,
would be impracticable.  As  marking the first  great  epoch in
Kentucky Surgery, I shall begin with  the subject of ovariotomy ;.
considering, afterwards,  in regular succession,   the lesions and
operations of particular regions and organs of the body.
OVARIOTOMY.
  To  Kentucky  belongs  the  honor of having  furnished to the
world the first case of extirpation of the ovary, for organic disease
of this organ.  This honor is  justly and exclusively due to the
late Dr. Ephraim McDowell, of Danville.  From a paper pub-
lished by this gentleman  in the seventh volume of the Philadel-
phia Eclectic Repectory,  it appears that  his  first operation was
performed in December, 1809.  It is not known, with any degree
of certainty, how often Dr. McDowell repeated this  operation; 
[7]
his published cases amount only to five,  but there is reason to
believe from what I have learned from his  nephew, Dr. William
A. McDowell, that he performed it not less than thirteen times.
  During the progress of my labor,  as Chairman of the Commit-
tee on Surgery, of this Society, I have, in  consequence  of letters
addressed to various gentlemen  in Kentucky, Ohio, and Tennes-
see, been made  acquainted with the particulars  of three cases
more, which, added to those published by Dr. Ephraim McDowell
himself, increase the aggregate  to eight.   It is to be deeply re-
gretted that Dr.  McDowell did not keep a record of his operations,
or communicate  the results to his professional brethren.  Such a
contribution would not only have greatly enhanced his own repu-
tation, as a bold and original surgeon, but it would have conferred
an inestimable boon upon suffering humanity.
  As the operations in question  reflect  the  highest credit,  not
only upon  Kentucky, and  upon  Kentucky's illustrious surgeon,
but upon the United States, and as they have been mainly, if not
exclusively, instrumental in directing the attention of the profes-
sion, both in America and  in Europe, to a subject which has, of
late  years, elicited so much interest, research  and skill, it is
proper that I should give a brief analysis of them, in order, more
especially,  that  the world  at large  may know  what knowledge
and  science,  when  aided by  intrepidity and dexterity,  may
accomplish even in a backwoods settlement of Kentucky.   Dr.
McDowell's first three cases are published in the seventh,  and
the last two in the ninth volume of  the  Philadelphia Eclectic
Repertory.
   Dr.  McDowell's first operation was  performed upon Mrs,
Crawford, of Kentucky, in  December, 1809.  The tumor inclined;
more to one side than the  other, and was so  large as  to induce
her professional attendant  to believe that she was in the  last
stage of pregnancy.  She was affected with pains similar to those
of labor, from which she could find no  relief.  The wound  was
made on the left side of the median line, some distance from the
outer edge of the straight muscle, and was  nine inches in length.
As soon as the incision was completed, the intestines rushed out
upon the table ;  and so completely was the abdomen filled by the
tumor  that they  could  not be  replaced during  the  operation, 
[8]
 which was finished in twenty-five minutes.  In consequence of
 its great bulk, Dr. McDowell was obliged to puncture it before it
 could be removed;  he then threw a ligature round the Fallopian
 tube, near the uterus, and cut through the attachments of the
 morbid growth.   The sac weighed seven pounds and a half, and
 contained fifteen pounds of a turbid, gelatinous looking substance.
 The edges  of the wound being brought together by the inter-
 rupted suture and adhesive strips, the woman was placed in bed
 and put upon  the antiphlogistic regimen.   "In five days," says
 Dr.  McDowell, " I visited her, and,  much  to my astonishment,
 found her engaged in  making up her  bed.   I gave her particular
 caution for the future;  and  in twenty-five days she  returned
 home in good health,  which she continues to enjoy."
   It will not be uninteresting here to state, that Mrs. Crawford,
 at the time of the operation performed upon her by Dr. McDowell,
 lived in Green county, Kentucky, from whence she removed,
 sometime afterwards, to a settlement on the  Wabash river in
 Indiana, where she  died, March 30th, 1841, in the 79th year of
 her  age.  There was no  return of  her disease, and she generally
 enjoyed excellent  health up to the period of her death.  She had
 no  issue after the operation.   Her youngest child,  our worthy
 citizen, Mr. Thomas H. Crawford, who has kindly communicated
 to me  these facts, was born in 1803, nearly,  or quite, six years
 before the operation.
   The second case was that of a negress.   The tumor is stated
 to have been very large, and  so firmly adherent to  the  bladder
. and uterus as to render any attempt at extraction perfectly futile.
   The operator, therefore, contented himself with making a free
 incision into it with a scalpel,  to let out its contents, which were
 of a thick, ropy  and  gelatinous character,   The incision was of
 the same length,  and made in the same situation as in the prece-
 ding case.   Upwards  of a quart of blood was  lost in the opera-
 tion.  The wound,  which  was dressed in  the  ordinary manner,
 healed without any  untoward symptom.  The  woman remained
 well for nearly five  years, when  the  tumor began to increase
 again, and in twelve months it was  as large as before the oper-
 ation.
    The third operation was performed in May, 1816.   The sub- 
                            [9]
ject was a negro  woman; and  the ovarium, which was much
enlarged, could be easily moved from  side to side, to the left of
which, however, it was adherent.  Dr. McDowell made an incis-
ion into the linea alba, from an inch below the umbilicus to within
an inch of the pubes, and then extended the opening towards the
right side, about  two inches above the  former  point,  to afford
himself more room. He next passed a ligature round the Fallopi-
an tube, and " turned out "'the left ovary, which was found to be
in a scirrhous condition, and to weigh six pounds.  The wound
was  dressed as in the preceding cases, and the woman was well
in two weeks, though the ligature did  not come  away under five
weeks.  No mention is made of the manner  in  which the adhe-
sions were overcome.
  Dr. McDowell performed hisfourth operation in April, 1817,
upon a colored woman from Garrard county, Kentucky; removing
a scirrhous ovary, weighing five pounds.   The incision was made
near the linea alba, but its extent is not mentioned.  The ligature
slipped from the Fallopian tube, after  its division, and, in conse-
quence, a great loss of blood took place.   Several arteries  were
then tied; but this not arresting the hemorrhage, a large ligature
was  passed round the whole stump of the tube, and secured in
the  most careful  manner.  Although the  woman was much
exhausted, she happily recovered, but  did not fully regain her
health.   " This, though the smallest ovarium I have ever extract-
ed," says Dr. McDowell,  "was much more troublesome to the
patient than in any previous case.  Besides experiencing severe
lancinating  pains in the parts, she was seldom able to discharge
her  urine without getting almost on her head, in consequence of
the  tumor  falling down into the  pelvis,  and compressing the
urethra."
  His fifth recorded operation, was performed by Dr. McDowell
on the  11th  of May, 1819.  The patient, likewise a negress, and
the mother of one child, was from Lincoln county, in this State,
and  was supposed by her physician to be laboring under ascites,
as the tumor was  very large and fluctuating.  After having given
herhydrogogue medicines for sometime without any benefit, Dr.
McDowell tapped her, and drew off thirteen quarts of thick, gelati-
nous fluid.    The  operation  was repeated  in two months, and it 
                            [10]

was now ascertained, after  the  matter was- all wacuated, that
there was a firm substance, of considerable size, which was evi-
dently a dropsical ovary.  Some months after this she was again
tapped,  and the opening was enlarged  so as to  admit the finger,
which was  freely used as a probe, that there might no  longer be
any doubt respecting the true character of the disease.  The in-
cision was made on the left side of the median  line, down to the
tumor,  which was  found firmly  adherent to the parietes  of the
abdomen and to the intestines, by slender cords, which were easily
separated by  the hands.   The ligamentous bands, attaching the
tumor to the uterus,  were surrounded  by ligatures,  after which
the tumor was opened, its contents  discharged, and the  sac ex-
tracted.   The fluid measured sixteen quarts, and was of a gelar
tinous character, intermixed with a considerable quantity of hair,
and a body resembling very much, in shape, the front tooth of a
cow.  Violent peritonitis ensued, followed by death on the third
day.  The uterus and right ovary were  perfectly natural, and the
ligatures were well applied,  and not in  a situation likely to injure
the adjoining parts.
  Dr. McDowell was assisted  in this operation by his nephew,
Dr. W.  A. McDowell, and it was performed in the presence of
Drs. Weissiger, Tomlinson, and Horr.
  It will thus be perceived  that, of these five  cases, three were
entirely successful;  that  one recovered, and remained wrell  for
nearly five years, when the tumor re-commenced growing; and
that one died from peritoneal inflammation within three days
after the extirpation of the  diseased mass.  This success is fully
equal to the average success attendant upon ovariotomy  in the
hands of modern operators.  According to the calculations of my
friend, Prof. Atlee, of Philadelphia,*  founded  upon an analysis
of upwards of two hundred cases, the  rate  of  mortality for the
operation in question is  26£ per cent.
   A highly  respectable  lady, Mrs.  O.,  aged  55  years,  of the
neighborhood of Nashville, Tennessee, consulted Dr. McDowell,
through her  professional adviser, Dr.  James Overton, in July,
1822, concerning a tumor in the left side of the abdomen, which

  * A Table of all the known operations in Ovariotomy, p. 32.—Pbilad., 1851 
                            JttJ

 3he  had first noticed  sometime during the previous December-.
 Being a member of a family  inclined to corpulency, she paid no*
 particular attention to it for several months, the more especially
 as it was free from pain and  soreness.  The enlargement of the
 abdomen continued to increase gradually,  and early  in  the fol-
 lowing May she felt distinctly, on. the left side and a little below
 the level of the umbilicus, a  small globular tumor, destitute of
 sensibility, and movable from side to side,  as well as from above
 downwards.   About the middle of June, by which time the swel-
 ling had considerable augmented in volume, the patient was seiz-
 ed with pains in the back,  hips, and thighs, much resembling the
 first pains  of parturition.   By the use of laxatives, warm bathing
 and anodynes, these symptoms were subdued, and she enjoyed an
 interval of ease and  health, until the latter part of July, when
 there was a recurrence of the local distress, in a more aggravated
 form, writh great tenderness on pressure.   The urinary secretion
 was  natural, both as to quantity and quality, and the uterus ap-
 peared to be perfectly sound.  No fluctuation could be discovered
 at this time in the swelling; and the integuments of the abdomen
 were quite lax, except  at the site of the enlargement, where they
 were very tense.
  When Dr. McDowell visited the patient, in the summer of 1822,
 the tumor filled nearly the whole of the abdomen, and  she had
 the appearance of  a female in the sixth month of utero-gestation.
 The  general health was a good deal impaired, from the absence of
 sleep, and the presence of fever,  and there was a sense of weight
 and  dragging in  the  pelvis, with acute  pain in the swelling,
 perinseum and thighs.
  Supposing  the disease to consist in a morbid  enlargement of
 the left ovary,  Dr. McDowell designed to extirpate it with the
 seal pel ,"*and for  this purpose made  an incision  from five to six
 inches in  length,  along the linea alba, over the most prominent
part of the tumor down to the  peritoneum.   Having laid bare this
 membrane, he proceeded  cautiously to divide it,  intending  to
make an opening sufficiently large  to admit of the removal of the
diseased organ.  In tlys, however, he was disappointed ; for  he
had  no sooner made his first  incision through the peritoneum,
than there gushed  out, in  a full stream, a bloody looking serum> 
[12]
 which continued to flow till the sac which had contained it was
 apparently entirely empty.  The quantity thus lost was about one
 gallon.  The edges of the wound were  then approximated  by
 several interrupted sutures, light dressings were applied, and the
 abdomen was encircled by  a broad bandage.   This  constituted
 the whole of the operative procedure.  No attempt was made, or
 even deemed practicable, to extirpate the diseased organ, inasmuch
 as it adhered so closely to the peritoneum  as  to render it impos-
 sible to distinguish  or separate it  from  it.  Indeed, Dr. Mc-
 Dowell  supposed  that he  was dividing the peritoneum  only
 when  the knife penetrated the ovarian sac.   The circumstance
 took him, as  well as every one present, by surprise, because it
 was entirely unanticipated.
   The wound continued to discharge  matter for sometime  after
 the operation, from the lower exrremity of the incision, where a
 tent  was  kept for that object.  The fluid  gradually  lost  its
 sanious character, and as it diminished in quantity  it assumed
 more and more the appearance of healthy pus. * The  wound was
 entirely healed at the end of about five weeks; and the patient,
 who lived from fifteen to twenty years after the operation, enjoy-
 ed excellent health; nor did she, at any subsequent period, suffer
 any pain or uneasiness which could be justly ascribed to disease
 of the ovary, or any other organ connected with the uterus.
   The interest of this case is heightened by the circumstance that
 the late President Jackson, who was a near neighbor of the pa-
 tient, was present at the operation, assisting in holding her hands,
 and supporting her resolution.
   For the above interesting and valuable  details, I am indebted
 to Dr. James Overton,  an eminent  practitioner of Nashville,
 Tennessee, who was present at the operation, and who had charge
 of the  case, both  before and  after the operation  by  Dr. Mc-
 Dowell, who visited the patient at her own residence.
    For the details of the next case, I am indebted to my venerable
 friend, Dr. W. C. Gait, for many years one of the most success-
 ful and distinguished physicians of Louisville.
    The  subject of this case was Miss Plasters,  of the neighbor-
 hood of this city, who was attacked in the winter of 1821,  with
. enlargement and pain of the right ovary.   The disease gradually 
[13]
increased, and in February, 1S23, she was tapped for the remo-
val of the contents of the tumor.  The dropsical symptoms, how-
ever, soon re-appeared, and believing that excision of the affected
organ afforded the only chance of permanent relief,  her medical
advisers, Dr. Gait and Dr. Ragland, requested her to consult Dr.
McDowell.  I have not been able to obtain any information as to
the age of the patient and the size of the tumor ;  but from a letter
written by Dr. McDowell to Dr. Gait, sometime after the operation,
I learn that the enlarged viscus filled the entire abdominal cavity,
and that out of nine cases that had presented themselves with this
disease, up to the period adverted to, that of Miss Plaster ap-
peared by far  the most  hopeless.  Upon her arrival at Danville,
she was so extremely debilitated  that it was believed she would
hardly be able to sustain the shock of the operation.
  The patient having undergone  the requisite preliminary treat-
ment,  the operation was performed on the 12th of May, 1823.
An incision was made into the abdominal cavity, extending the
whole length of the linea alba.  Finding the tumor so large that
it could not be removed entire, a free opening was made into it,
discharging about six pints of fluid.  The morbid mass was then
lifted from its bed, though not without difficulty, a ligature hav-
ing been  previously cast round its foot-stalk or uterine attach-
ment.   The abdominal  cavity having been cleared of  blood and
water, the edges of the wound were carefully closed,  in the usual
manner, and the woman put to bed.
  The omentum is said to have been much inflamed  and  thick-
ened, not, as Dr. McDowell supposed, from the effects of the pre-
vious tapping, but from organic disease of its own structure. For
ten or fifteen days after the operation, there was a bloody putrid
discharge  from the wound,  "which," says Dr. McDowell, "I
am well assured could  arise from nothing but sloughing of the
omentum." *
  Notwithstanding her debilitated condition before and for some-
time after the operation, Miss Plasters entirely recovered. On the
4th of August, less than three months after the removal of the
tumor, Dr. McDowell informed Dr. Gait that she was in  "perfect
health and spirits."
* Letter to Dr. Gait, August 4th, 1823. 
  In April, 1824,  the health of Miss  Plasters was so good  thai
she eno-ao-ed herself to marry in the spring.  About this period,
however, dropsy of the abdomen set in, rendering it necessary to
tap her, and after that Dr. Gait lost sight of her.  How long she
survived he does not know.
  In commenting upon  this case,  in  the letter  already referred
to,  Dr. McDowell  holds the following  language:  "This  case
proves that appearances  in surgery are often deceitful, and  that
while the taper of  life continues to burn,  although  it be faint,
there is yet hope; for  Miss Plasters  has certainly disappointed
most  of her friends and all that saw her.  My own hopes, at
times, were but faint."
  "HowTit  is,"  he continues, "that I have been so peculiarly
fortunate with my patients of this description, I know not; for,
from all the information I can obtain, there has not one individual
survived who has been operated on elsewhere, for diseased ovaria.
I can only  say that the blessing of God has  rested on my efforts."
Miss Plasters, it will be remembered,  was Dr. McDowell's ninth
case.
  For the  particulars of  the following case, in which the opera.
tian of ovariotomy was attempted,  but  not successfully  per-
formed, I am indebted  to the politeness of Professor Drake,  of
Cincinnati,  who saw the patient both before and after she fell
into the hands of Dr. McDowell,  and  who kept full notes of the
symptoms and other circumstances.  The operation was witness-
ed by the husband of the lady, a very intelligent gentleman,
who afterwards gave an account of it,  in a letter to Prof. Drake,
which I have carefully perused.
  Mrs. Delano, aged thirty-eight, a native of Kentucky, but now
a resident of Chillicothe, Ohio, has been married eight years, but
never had any children.   She is of a bilious temperament, has
always menstruated regularly, and was never sick until five years
ago.  In the autumn of 1822, she began to be conscious of a ful-
ness in the abdomen, between the hips and ribs, but this was so
slight as  to escape  observation.   For a year the local disease
made no apparent progress,  and her  general health was good.
In 1823-4-5, she suffered, at intervals, from nausea, colic and
attacks  of fever.   In December, of  the  latter  year, the  colic 
[15]
became constant, and there was great soreness in the sides and
limbs.  A hard tumor was discovered, about this time, in the
right ileo-hypogastric region, which has steadily increased in
volume, and now occupies the whole abdominal cavity, from the
pubic symphysis to above the umbilicus,  reaching outwardly as
far as the costal cartilages.   It is  hard, irregular, slightly mov-
able,  and cannot be traced under  the ribs.  It is somewThat sore
on pressure, as well as painful, though less so than formerly. The
bowels are usually regular; she lies  best on her right side; and
she has frequent vomiting, with some cough.
  The above memorandum was made, in substance, by Professor
Drake,  on the  24th of October,  1826; immediately after  which
Mrs. Delano went to  Danville, to consult Dr. McDowell about
the propriety  of an operation.  In the interview which ensued
between the parties, "I learned from Dr. McDowell," writes the
husband of the lady,  '• that he had  operated for diseased ovaria
in nine or ten cases, in eight of which he had  been successful.
Some of these, I believe, were of that character termed dropsy of
the ovary, the tumor consisting of a sac, enclosing a quantity of
liquid, gelatinous matter; in the other cases the tumor was solid,
and  appeared to be composed of a gristly,  cartilaginous sub-
stance.  In every instance, attended  with success, the tumor was
loose and floating, except in one or two cases,  where it was filled
with water, which was drawn off, the sac being suffered to remain.
In every  other  case, where the tumor adhered, the attempt to
operate w7as unsuccessful;  or, if  Dr.  McDowell succeeded in
extracting the morbid growth, as he probably did in one instance,
the patient died."  Such,  then, appeared to be the information
obtained from Dr. McDowell.
  I have  given the above  extract  from Mr. Delano's letter, be-
cause it shows how often, and with what success, Dr. McDowell
had  performed this operation, at the time the writer consulted
him about the case of his wife.  His first  case occurred,  it will
be recollected, in 1809, that is, seventeen years previously to the
one under consideration.
  From the difficulty, or rather, impracticability of moving the
tumor about, Dr.  McDowell naturally concluded that it must be
.extensively adherent.  Believing,  however, that extirpation was 
                           [16]

hot impossible, and the lady being anxious to be relieved, an
operation  was determined upon.  An incision was accordingly
inade in the usual manner, through the linea alba, and the tumor
exposed by separating the peritoneum and omentum, by  which
it was enveloped.  The patient, at this stage of the operation,
became so rapidly and excessively debilitated,  that apprehen-
sions were entertained for her immediate safety.  The tumor, as
had  been previously  conjectured, was  found  to be  extensively
and  strongly adherent, and its extraction was pronounced imprac-
ticable.  In about two weeks,  the wound was healed,  without
any  material change in the general health.
   Dr. Drake visited  Mrs. Delano on  the  11th of March, 1827,
about four months and a half after the operation,  and found her
excessively emaciated, with swelling of the right leg, and all the
symptoms of gradual exhaustion.  The cicatrice, from the opera-
tion, existed in the  linea alba,  and was about two inches long.
The whole abdomen was excessively protuberant, from the pubic
symphysis to the ensiform cartilage.   The liver, very hard  and
greatly enlarged, bulged out high between the short ribs and the
umbilicus, over into the left side.   Here, in contact  with the
ovarian tumor, in a kind of groove between them, the colon
passed across below the navel.  At the centre of the colon was a
small, flattish tumor, which felt very hard, and could be moved
along  the bowTel down into  the  sigmoid  •flexure.   The  ovarian
tumor filled the right iliac region, and extended, in front, nearly
to the umbilicus, crossing the linea alba,  and being, seemingly,
more prominent on the left than on the right side.   It was fixed
during respiration, and  appeared to  be immovable.  The liver,
on the other hand, obeyed the motions  of the diaphrahm.   Her
menses had ceased  only  about three  months ago.  Death occur-
red soon after Dr. Drake's visit; no examination  of the body
was made.
   The gentleman who next  undertook this operation,  was Dr.
 Alban G. Smith, of Danville, who executed it successfully, on the
 23th of May, 1823, four years after Dr. McDowell's last recorded
 case. ?  His patient was a negress, thirty years of age,  and the

   *  North American Medical and SurgicalJoumal, vol. 1, p. 30.  Phila., 1826. 
[17]
mother of two children: she had labored under enlargement of the
ovary for two years.   The tumor filled  the whole abdomen,  and
was productive of constant bearing down pains whenever she was
in the erect  posture.  Her general health was pretty good.  Dr.
Smith made an incision  from the umbilicus to within an inch of
the pubes; but the tumor was found to be so large that he was
obliged, before he could remove it, to let out a portion of its  con-
tents.  Several pints of " watery matter" having been  evacua-
ted,  the tumor was raised up, though not without difficulty,  and
separated at its pedicle, which, together with the Fallopian tube,
had  been previously surrounded by a  strong  ligature.   The
blood having been removed  from the abdomen, the edges of the
wound were approximated by five interrupted sutures, aided by
adhesive strips, a compress and  bandage.  Care was taken to
carry each stitch through the peritoneum.   The woman was then
put to bed, and took seventy-five drops of laudanum.  Becoming
soon after sick at the stomach, she took fifty drops more by the
mouth, and, in half an hour, two hundred by the rectum.  This
not allaying the irritation, a suppository of five grains of opium
was employed; after which she became composed,  and  slept an
hour.  The  nausea recurred for several successive days, and on
the 27th of May, she had so much pain in the abdomen that it
was  deemed advisable to bleed her to the amount of  eighteen
ounces.  On the 28th, she lost twelve ounces.  On the 29th, the
sutures were removed ; and on the 25th day, Dr. Smith took
away the deep ligature.  The tumor was of a scirrhous  appear-
ance, and was interspersed with a considerable quantity  of bony
substance.
   From this time on until April, 1848, a period of nearly a quar-
ter of a century,  ovariotomy  does  not seem to have been per-
formed in Kentucky.  During this year, my distinguished friend,
Dr. Henry Miller, Professor of Midwifery  in  the  University of
Louisville, attempted the operation,  and was blessed with a most
brilliant result.*  The patient, Mrs. McLaughlin, a married wo-
man, aged thirty-seven, from the  State of Indiana,  had a large
tumor in the right side of the abdomen, of an irregularly globu-

  * Western Journal of Medicine and Surgery, Third Series, vol. 2, p. 38.  1848
         2 
                            [18]

 lar shape, and of variable consistence, wThich she first noticed in
 the autumn of 1S37, in the right iliac region.  On the 29th
 of March,  Dr. Miller punctured the tumor with a trocar, in  the
 linea alba, about three inches below the umbilicus, and drew off
 six quarts of a whitish, albuminous fluid.  The operation, which
 was not followed  by any unpleasant symptoms,  had the effect of
 rendering the abdomen quite flaccid on the left side, but made
 only a very slight impression upon the right, especially the iliac
 region, which remained  hard and unchanged in shape.  The  wo-
 man, at this time, wras considerably emaciated,  her appetite  was
 poor, and her pulse betokened a hectic, irritable condition of  the
 system.
  The operation of excision, at which I had the honor to assist,
 was performed  on the 6th of April, the patient  being under  the
 influence of chloroform.  An incision was made along the linea
 alba,  from the umbilicus to the pubes, but this being found to be
 too small to admit of the escape of the tumor, two of the largest
 cysts were punctured to diminish its size, and facilitate the extir-
 pation. The fluid thus evacuated resembled that which had been
 drawn off by tapping, a week previously; but its quantity could
 not be clearly estimated, as it was suffered to run over the table
 upon the  floor.   Some  adhesions existed between  the  morbid
 growth and the  omentum and walls of the abdomen, which were
 carefully broken up, when the tumor was  raised out of  its bed,
 and supported upon the hand, while its pedicle  was surrounded
by a strong ligature passed through the broad ligament and tied
 round the Fallopian tube and ligament of the ovary: th^ connec-
 tion was then severed  by the knife.  Finding that the vessels of
:the outer extremity of the broad ligament were bleeding quite
 freely, another ligature was  passed around it, with the effect of
 at once arresting the  hemorrhage.  The cavity of the abdomen
 being cleared of blood and ovarian fluid,  the edges of the incis-
 ion were closed  by interrupted sutures  and adhesive strips,  the
 whole being supported by compresses and a bandage.  The liga-
 tures  were brought out at the inferior angle of the wound.
  No untoward symptom occurred  after the operation, with  the
 exception of some vomiting  during the first night.   The sutures
 were  removed on the 19th of April;  and on the 25th one of  the 
[19]
ligatures came away;  the other was detached on the 7th of May,
at which time the wound was firmly closed, except a small point
at the  inferior angle.   The next day the woman left Louisville,
to visit her friends at New Albany.
   The tumor, notwithstanding the tapping and the puncture of
two of its cysts, at the time of the operation, weighed nine pounds
and a quarter.  It was composed of numerous cysts, of variable
dimensions, filled with white, ropy, albuminous matter, and hav-
ing strong, thick parietes, with smooth, polished linings.
   The next case of ovariotomy occurred to myself, in June, 1849,
in the person of a young lady, of this city,  aged twenty-two
years.   Her general health had always been good, until within a
short time of the operation ; she had menstruated regularly, and
had  never experienced any  serious illness.  The tumor, when
first perceived, in the winter of 1848, was quite small, and occu-
pied the lower part of the abdomen, being perfectly movable and
free from pain.   It continued steadily to increase in size,  at first
gradually, and afterwards rather  rapidly, until  the following
autumn, when it was so  large as  to  occasion great inconve-
nience by its weight and bulk, as well as by its pressure upon the
diaphragm and abdominal muscles.  I first  saw the young lady,
on the 11th of May, 1849,  along with Dr. Knight and Professor
Miller, who kindly afforded me their aid and advice throughout
the case.   The tumor, at this time, was partly fluid and partly
solid, smooth and  uniform on the surface, and entirely devoid of
pain and tenderness on pressure.  The general health was still
good, though Miss D. was considerably emaciated.
   On the 5th of June, I introduced a trocar, and drew off three
gallons of a thick, ropy, drab-colored fluid, readily coagulable by
heat,  alcohol and acids.   The  operation  was followed by great
relief, but as the water soon  began to  re-accumulate,  it was
deemed best to resort to excision.  Accordingly, on the 19th,  an
incision was made along the linea alba, extending from near the
pubes  to three  inches above the umbilicus, being at least one
foot in  length.  The  tumor was very red and vascular upon  its
surface,  and extensively adherent,  inferiorly, by bands of false
membrane, which, however, were  easily severed by the hand.
The pedicle, which was quite narrow, was surrounded by a stout lig- 
                            [20]

ature and divided, when the morbid growth was lifted from its bed.
Although the ligature had been tied with great firmness, it imme-
diately slipped off after the part was tied, thus necessitating the ap-
plication of another.  Previously, however, to doing this, a large
artery, included in the pedicle,  and bleeding freely, was secured
separately.   The blood being removed from the peritoneal cavity,
the ligatures were brought out at the inferior angle of the wound,
the edges of which were next approximated  by nine twisted
sutures, the needles being carried through  the  muscular fibres,
about one inch and  a quarter from each other.   The dressing was
completed with ising-glass plaster,  a compress and bandage.
  On the 27th, that is, eight days after the operation,  the wound
was found to have united, throughout, by the first intention; the
bowels moved spontaneously, and every thing portended a happy
issue.  On the 8th of July, however, in consequence, apparently,
of exposure to damp and heavy draughts of air, occasioned by a
change in the weather, the patient was seized with a severe chill,
followed  by excessive prostration.  Means were immediately em-
ployed for producing re-action, but several hours elapsed before
she completely rallied,  and  she never was  well  afterwards.  It
was but too evident that peritonitis was doing its  work, and that,
notwithstanding the use of blisters and appropriate internal rem-
edies, the case must terminate fatally.  Miss D. lingered until the
17th of July,  nearly  one month after the operation,  when she
expired.
  The dissection, performed by my friend, Dr. T. G. Richardson,
Demonstrator of Anatomy in the University of  Louisville, proved
the correctness of our diagnosis.   The peritoneum was literally
one mass of disease;  the bowels and pelvic viscera were closely
matted together; and the abdominal cavity was divided into not
less than three distinct  compartments, two of which contained
each about half a gallon of  turbid serum, mixed with shreds and
flakes of lymph.
   The tumor consisted of a single sac, weighing about nine
pounds,  and being nearly twelve inches in length, by eight in
breadth.  Its walls were fully one  inch in thickness, and bore a
very close resemblance to those of the gravid uterus.
   In the following case the operation was performed in Septem- 
[21]
ber, 1849, by Dr. G. W. Bayless, formerly of Louisville, and now
of Missouri.
  His patient, Mrs. Dredden, was 31 years of age.  She was al-
ways thin and spare and of delicate constitution,  and was mar-
ried twice, namely, at sixteen and nineteen.   Seven years before
the operation, the tumor made its appearance on the left side.  It
grew but slightly for two years; at the  end of which time the
abdomen began to enlarge, and she was treated by internal reme-
dies for ascites.  Three years and a half before the operation Drs.
Sharpe and Duke, of Maysville, undertook  the management of
the case, when they found the abdomen greatly distended.  They
tapped her,  and for the first time  the nature of the disease was
ascertained.  A large immovable tumor was  found extending
from the left iliac to the left hypochondriac  region, with one of
smaller size on the right side.
  From the first tapping, in February, 1846, to the time of the
operation, Dr. Sharpe punctured the tumor seventeen or eighteen
times, at intervals of about twenty-five days ;  removing about six
gallons  of fluid  at each  operation.   Generally, acute pains and
soreness throughout the abdomen  followed  the tapping; and
about the fourteenth <or fifteenth operation,  quite a severe peri-
tonitis supervened.  In this and all other occasions the symptoms
were checked by calomel and opium.
  The above facts are stated with a view  of  showing the cause
of a serious difficulty in the operation,  namely, the very strong
adhesions around the tapping point, and the  universal attach-
ments of the tumors to the abdominal walls,  increased in extent
and firmness by the inflammation which 'Obviously followed the
use of the trocar.
  Early in September, 1849, when Dr. Bayless first saw the case,
the abdomen was greatly  distended, but the tumors, in extent
and irregularity of surfaee, could be easily distinguished through
its attenuated walls.   The usual embarrassment to respiration
and other attendants upon so large an accumulation were present.
The patient was sallow, feeble,  and quite  emaciated.  Manifest-
ly, the powers of life were about to give way.   She so regarded
the matter; and after a fair representation of the  danger of the
operation and the chances of recovery, she calmly, and even with 
[22]
cheerfulness desired that it should be done.  The same composure
and cheerfulness were exhibited throughout.
  On the 13th of September, 1849,  with  the  assistance of Drs.
Sharpe and Duke, and in presence of several other physicians and
students, the operation was performed.  No other preparation of
the patient was employed, except a free evacuation  of the bowels
the night before.  About 9 o'clock in the morning she was tapped,
when six or eight gallons of yellowish serum, mixed with  flakes
of lymph, were drawn  off.   No perceptible exhaustion followed,
and in fifteen or twenty minutes the  extirpation was proceeded
with.  Chloroform was administered, but the patient soon began?
to resist its use as exceedingly unpleasant;  she  became quite
excited and unmanageable, and it was therefore withdrawn.  At
first the operation was embarrassed by  this circumstance, but
as soon as the effects  of the chloroform  subsided she  became
calm.
  An  incision, which, in the distended state of the  abdominal
walls, was  about ten inches in length, was made along  the linea
alba,  from the umbicilicus  to  the pubes.  On penetrating the
abdominal  cavity, a confused abnormal  mass presented itself,
adhering all around the edges of the incision.  The attachments
varied  in  firmness  in  different  parts:   the  longest  were
around the tapping point,  and in the left side  and cavity  of
the pelvis.   The mass- was separated from its  connexions by
means of the fingers, the handle of  the scalpel, and edge of the
knife.  There was no difficulty in detaching the tumor  from the
abdominal  walls, but its bulk,  and the constant  discharge  of
fluid from  the  main sac,  at the opening made  by the trocar,
rendered the other steps of the operation tedious and embarrass=-
ing.  The pelvic cavity was completely  impacted  with a firmly
adherent mass.   Part of the separation here had to be done with
the knife; and from the form of the excavation, the bulky, slip-
pery mass, and the relations of the large vessels and nerves, the task
was very difficult.   In the course of the dissection  an artery  of
Borne size  was  cut, regarded at the  time as the right  ovari-
an.   It  was secured at  once  by  ligature;  the only one
used on account of hemorrhage.  There was no distinct pedicle
on either side, to guide in the application of a ligature.  It was- 
                             [23]

all a  confused mass; and hence  the artery was  cut before the
application of the ligature.
   There was an  adhesion also of the back part of the large tumor
to the mesentery, so firm that it was regarded as unsafe to tear it
away with the finger, or handle of the knife, for  fear of lacerating
the mesenteric vessels.
   No other difficulty presented itself in the operation.   The pa-
tient  was much  exhausted towards the close, but was sustained
by stimulants until its completion, and rallied  soon  after the
dressing.
   After the abdominal cavity and  its viscera  were thoroughly
cleaned of blood and other fluids, the  edges of the incision  were
brought together and secured by a number of twisted sutures and
adhesive strips.  The ligature mentioned as cast round the ovari-
an artery was brought out just  above the pubes.  Large  com-
presses  were required on the abdomen to fill up the depression
before a bandage could be applied, to restrain the motion of the
abdominal walls in  respiration.
   The morbid growth was  multilocular in its character.  The
parent tumor, ovoidal in shape,  was  about fifteen inches in its
long,  and ten inches in its short diameter.   There were a number
of smaller tumors, varying in size from six to eight inches down
to half an inch in diameter, all adhering together.  Most of them
were attached to the outer walls of the parent tumor and to those
of secondary size;  others, of smaller size, were found springing
from the inner surface, and showing themselves in the  cavity of
these.   They all contained a yellowish, ropy serum, mixed  with
more  or less lymph.   The walls of the tumors varied in thickness
from the third of an inch down to a line, according to their mag-
nitude  The parent tumor was entirely evacuated in the course
of the operation; and some  of the  smaller ones,  were also rup
tured.  Most of  the latter however, were  preserved with  their
contents; and,  in  this condition, the entire  mass weighed
eighteen pounds.
   The patient after the operation  remained  calm throughout the
day ;  but early next morning vomiting and straining ensued, and
continued, at intervals, for nearly forty-eight hours.  The vomit-
ing gradually ceased, apparently uninfluenced by any means that 
[24]
were used.  During and following the vomiting there were sharp
pains through the abdomen;  and the pulse was  considerably ac-
celerated.   The symptoms, however, did not indicate any active
inflammation ; and as similar phenomena had often been controlled
by Dr. Sharpe,  after tapping, by  means of calomel and opium,
this combination was  resorted to, followed by their removal in
three days.
  At the first dressing of the wound, four  days after the opera-
tion, a  sero-sanguinolent  fluid  was discharged at the opening
through which the ligature hung.  Except at this point, the edges
of the wound were adherent.   This discharge continued  for
seventeen days.  On the 20th day it  began to abate, and give
place to healthy pus,  which  was regarded  as  coming from  the
pelvic cavity, since  the quantity was too large to proceed from
the unhealed  walls  around the small opening for the ligature.
On the 30th day  from the operation, the discharge of pus had
nearly ceased.   The needles were all removed at the end of three
weeks.  The ligature, however, notwithstanding frequent trac-
tions, could not be brought away.
  Dr. Bayless saw the patient nearly six months after the opera-
tion, apparently in good health, and  attending  to  her domestic
duties as cooking, washing, &c.  The ligature still remained.   On
pulling  at it, it seemed to have a weight  attached to it, which
subsided when the traction ceased. It was inferred that the  lig-
ature had been applied to the artery pretty  near the uterus,
including a portion  of the broad ligament,  and  that it was this
organ which felt as if  suspended  to the  ligature.   It ultimately
came away at the end of eleven months.  The  patient remains
well up to the present moment.
  The last operation  of ovariotomy in  Kentucky, so far as my
information enables  me to determine, occurred on the 7th of Sep-
tember last, in the practice of Dr. W.  S. Chipley, of Lexington,
one of  the vice-presidents of this association,  who has  kindly
furnished me with the particulars.
  The subject was a negress, aged 36 years, fifteen  of which she
had  been  married, though  childless.   Her menstruation  had
always been regular, and unattended by any abnormal symptoms.
Her general health  had always been  good.   Five  years ago  a 
[25]
small tumor was felt  in  the  left iliac region;  it was  of slow
growth, and for sometime gave no other inconvenience than some
pain in the right side.  In 1849, when Dr. Chipley first saw her,
she  was suffering severely, having suppression  of  urine  and
enormous distention of the bowels,  with great  pain in the left
iliac region.  Similar attacks, with great uniformity of symptoms,
occurred from time to time until last August, when a sudden and
wonderful increase of the  swelling was discovered.   It had evi-
dently acquired  greater magnitude during the  preceding  four
months  than in the last five years.
  An operation having been determined upon, Dr. E. L. Dudley
made an incision along the linea alba,  from a point  just below
the umbilicus nearly to the pubic symphysis.  The hand being
introduced  into the  wound, the adhesions were found to be so
extensive as to preclude the possibility of removing the tumor,
which filled almost the whole cavity of  the abdomen, and dipped
largely into the pelvis.   Notwithstanding the size of  the morbid
growth and the extent of its attachments, every exploration prior
to the operation afforded the most flattering prospect of the prac-
ticability of its removal.  Its mobility  seemed to indicate  only
very slight  adhesions.  When it became evident that the tumor
could not be exsected, a trocar was plunged into it, but not a drop
of fluid  escaped; it  was a firm fibrous mass.  The wound was
secured  by  the interrupted suture, adhesive strips, compress, and
bandage.
  The patient improved until about the 20th; the wound appa-
rently healing kindly.  Next day she was in considerable pain;
the abdomen was tender and distended,  and the  pulse at 180.—
On removing the dressing  an abscess  was found at the upper
angle of the incision; the  matter was discharged, the unfavora-
ble symptoms rapidly subsided, and in a few days the pus ceased
to flow.   The woman continued to improve, and gradually re-
gained the  health which she had  enjoyed previously to the oper-
ation. 
[26]
   In dismissing the subject of ovariotomy, I cannot refrain from
 offering a brief sketch of the life and services of the " father of
 this operation."  Such a course will not,  I am sure, be regarded
 as irrelevant by the members of this association, whose desire it
 should be, as I know it is,  to collect and treasure up all informa-
 tion calculated to illustrate the history of the great men  of the
 profession in  Kentucky.   The exploits  of  her physicians and
 surgeons—her men of science and of letters—should be engraved
 in gilded capitals upon the entablature of her cemeterian columns,
 side by side with  those of her warriors  and  statesmen.  They
 form a part, a proud part,  of her greatness,  and serve as an ap-
 propriate heritage to those who are to come after us.  If a Com-
 monwealth may be proud of a citizen who adds to her  resources
 a blade of grass, or a grain of wheat, how much more proud
 should she be  of her medical men, whose province it  is to pre-
 serve the health and lives  of her subjects.
  The facts which I am about to present in regard to the personal
 and  professional history of Dr. Ephraim McDowell, were furnish-
 ed me, at my request, by his brother,  Col. Joseph McDowell, of
 Danville ; by his son, Wallace W. McDowell, Esq., of the same
 place ; and by his nephew, pupil, and partner, Dr. William  A.
 McDowell, formerly of Louisville, now  of Evansville, Indiana.
 The only regret  I  have is that the materials are so scanty and
 incomplete.
  Dr. McDowell was  born in Rockbridge  county, "Virginia,  on
 the 11th of November, 1771.  His father, Mr. Samuel McDowell,
 was  for many years a member of the legislature of that  State,
 and  appears  to have been  a man  of great popularity in his dis-
 trict.  In 1782, he was appointed, along with Mr. Caleb Wallace,
 and  Dr. Flemming, by the legislature of Virginia, a commission-
 er to settle the  land  claims of the territory of Kentucky, and
 entered immediately afterwards upon the discharge of the duties
 of his onerous and responsible office.
  The following year he moved his family to Kentucky, and set-
 tled  near Danville, where  he lived till the time of his  death  in
 August, 1817.  During his residence  here  he was  appointed a
judge of the District  Court of Kentucky, and, along  with  his 
[27]
associates, Judge Wallace and Judge Muter, assisted in organiz-
ing the first court at Danville, which was also the first court ever
formed in the district or  territory  of Kentucky.  He remained
upon the bench until within a few years of his death.
  In January, 1755,  Judge McDowell  married Miss McClung,
of Virginia.  The result of this  union  was twelve children, of
whom  Ephraim, the subject  of this sketch, was the ninth, and
the only survivor of  whom is Colonel Joseph McDowell, of Dan-
ville.
  When  scarcely two years  of  age, Ephraim  McDowell  was
brought by his parents to Kentucky. It is not known when he
began  to go to school;  but we are told that he was educated by
two gentlemen by the name of Worley and James, who conducted
a  classical seminary,  first  at  Georgetown, and afterwards at
Bardstown.   What proficiency he made under the tuition of these
teachers, or how long he remained under their instruction, I am
not informed.  The probability, howTever,  is that he never made
any great progress in his classical studies, and  that he  had but
little  taste  for this kind of pursuit.    The few  brief articles
which  he contributed to the medical journals, after he had attain-
ed to professional eminence, clearly indicate that  his early edu-
cation  was  defective.   His  brother,  Col. Joseph  McDowell,
referring to this period of his life, remarks that Ephraim was a
boy of studious habits, and of a mild disposition.
  Soon after leaving school, Mr. McDowell entered upon  the
study of medicine, his preceptor being Dr. Humphreys, of Stan-
ton,  Virginia, a graduate of the  University of Edinburgh.  He
read with Dr. Humphreys from two to three years, when, without
having, so far as  I can learn, attended any lectures in Philadel-
phia, at that period  the only seat  of medical education in the
United States, he went to Scotland,  to avail himself of the facili-
ties afforded by the celebrated school at the capitol of that country.
He was a member of the medical classes of the  University of
Edinburgh, for the sessions of 1793 and 94. This institution was at
that time at the very zenith of its  renown,  attracting pupils  from
all parts of the civilized world, and overshadowing every  other
medical school in Europe.  We  may well imagine with  what
interest and delight the young and ardent Kentuckian, thirsting 
                            [28]

after knowledge, drank in  the waters of science as they gushed
forth from the eloquent lips of a Gregory, a Black, and a Monro,
men whose fame was upon the tongue of every medical student
and physician in Europe and America.  We may suppose, too,
that, amid  the novel  scenes  which surrounded  him, his  mind
often reverted to his native country, lamenting its deficiencies for
the acquisition  of a sound medical  education,  and  regretting,
perhaps in  bitter terms, the time which he had spent, to so little
purpose, in the office of his Stanton preceptor.  We may imagine,
moreover, that one just fresh from the wilds of America must
have felt no  little restraint, and even  embarrassment,  in  the
polished and  refined  circle  of students in the modern  Athens.
His principal friend and companion, during his attendance upon
the Edinburgh school, was  Dr. Samuel Brown, afterwards  the
elegant and accomplished professor of the Theory and Practice of
Medicine in Transylvania University, and brother of the Hon.
James Brown, our Minister at the Court of France.  Of his mode
of living and his habits of  study, while at this far-famed institu-
tion, unfortunately nothing is known.  His nephew, Dr. William
A. McDowell, who was  intimately acquainted  with his  whole
history, states that the surgical lectures at the University were not
satisfactory to him, and that, in consequence, in  his second year,
he took a ticket to the private course of the celebrated Mr. John
Bell.   I am not certain who delivered the surgical lectures at that
period in the University;  probably they were given jointly by
Mr. Monro, the second, and Dr. Russell, the latter of whom was
always regarded as a great bore by his classes ; while the former,
although more  sprightly  and animated, was very dull and prosy
in comparison with John Bell, whose enthusiasm and ardor were
absolutely  boundless.
   It is difficult to conceive, at this distant day, the charm which
this great teacher infused into his subject, and the ambition
which  he  inspired in his  pupils.  All loved him;  many wor-
shipped him; not a few idolized him.  Among the latter was the
subject of  this memoir.  During his attendance  upon his  prelec-
tions, the  young American was enraptured  by the eloquence  of
 his teacher,  and the lessons which he imbibed,  while thus occu-
 pied, were not lost upon  him after his return to his native coun- 
[29]
try.  Mr. Bell is said  to  have dwelled  with peculiar force and
pathos upon the organic diseases of the ovaria, speaking of their
hopeless character, when left to themselves, and of the possibility,
nay practicability, of removing them by operation.  The instruc-
tion thus given, made a powerful impression upon  Dr. McDow-
ell, which, as has  been already stated, was not lost upon him after
he took his leave of the academic groves of Edinburgh.
  I am not able to say,  from the facts before me,  whether Dr.
McDowell was graduated at Edinburgh or not.  His brother Col.
McDowell, states that he was,  and in  this opinion he is joined
by his  son, as well as by his nephew, Dr. William A. McDowell.
My belief that he did not take a  degree in  Scotland,  is  based
upon three facts; first, that  no diploma of the  kind  has been
found  among his  papers; secondly, that Dr. Samuel Brown, his
class-mate at Edinburgh,  solicited him, after  he had attained to
eminence in his profession, to permit him and  his friends to draw
up an account of  his cases of ovariotomy, in Latin, in order that
it  might be sent to Edinburgh, to secure  him  a degree;  and,
thirdly, that in 1825, the University of  Maryland conferred upon
him the honorary degree of Doctor of Medicine;  a circumstance
which  would hardly have happened had he been  a regular grad-
uate.   Be this as  it may,  the fact that he was  or was not a grad-
uate, ought not, in the slightest manner, to derogate from his char-
acter as a professional man, especially when it is  recollected how
much more difficult it was then than it  is now to obtain a degree
in medical schools.
  I have already stated that Dr. Samuel Brown was a classmate
of Dr. McDowell, at Edinburgh.  When Dr. Brown returned to
the United States, he was asked, one day, by some of his friends
what  he thought  of Dr. McDowell, as a man of talents,  and a
close, assidious student,  it being supposed, from his intimacy
with him,  that he was  able  to pronounce a correct judgment.
His reply was,  " Dr. McDowell went to Edinburgh a goose, and
returned a gander."  It is much to  be regretted that we have not
more  birds  of the same kind.  It is  greatly to be feared that
many,  if not most, of the young men who visit Europe at the
present day, to improve themselves in their medical studies, go 
                            [30]

there as geese and return as geese.   The name of Ephraim
McDowell is immortal.
  After a residence abroad of about two years, during which he
stored his mind with a large amount of valuable information, Dr.
McDowell returned to Kentucky, in 1795, and settled at Dan-
ville, the scene of his future labors.   He  immediately  entered
upon his professional career, nor w\as he slow in acquiring busi-
ness. The fame of his foreign tour had preceded him, and served
to introduce him into practice.  It was known that he had been
a student of John Bell,  one of the most celebrated surgeons of
the age, and that he had devoted himself, with special assiduity,
to the study of anatomy and surgery, during his sojourn in Scot-
land. The consequence was that patients soon flocked to him, at
first, from the  neighborhood, and subsequently, from all parts of
the South-wTest, for his aid and advice.  Those who were unable,
on account of  the peculiarity of their ailments, or the roughness
of the roads, to come to him, he visited at their own homes, often
remaining with them several days,  or, when the case was unusu-
ally urgent, even  a week or two.  All the  important operations
that were required for hundreds of miles around, were performed,
for  a number of years, exclusively by him.  At that time he was
almost the sole occupant of the  field of surgery in the West.—
Dr. Dudley, since so celebrated for his surgical exploits, had not
yet commenced his professional studies, and  none of the larger
towns of Kentucky had any surgeons of distinction, or even ordi-
nary capacity.   The only exception, probably, to this statement,
was Bardstown, the residence of Dr. Brashear, who, early in the
present century, performed the first successful amputation at the
hip-joint in the United States,  and who enjoyed  for sometime
considerable reputation as an operator in Nelson, and the adja-
cent counties.   Dr. Brashear, however, was  scarcely a competitor
of Dr. McDowell, or if he was at any time, he did not long con-
tinue to be;  for, soon after the acheivement  above alluded to, and
while he was still a very young man,  he abandoned  his profes-
sion, and moved to Louisiana, where  he engaged in planting,
even then a lucrative and respectable pursuit. Cincinnati, too, was
at that time, and, indeed, for a long period afterwards, without a
surgeon  of any respectability or  eminence.  Thus, as I have 
[31]
already stated, Dr. McDowell was, for a number of years, in the
undisputed possession of the surgical field, not only of Kentucky,
but of the entire South-west.   How well he cultivated this field,
what  honor he conferred upon his  adopted  State and  upon the
country generally, is too well known to require any comment in
this place.
  In 1802, in the thirty-first year of his age, Dr. McDowell mar-
ried  Miss Sarah Shelby,  a young lady of great personal beauty
and excellence, and daughter of Gov. Shelby, one of the most
distinguished citizens of Kentucky.   The result of this alliance,
which greatly augmented his happiness, was eight children, only
three of whom survive.   Mrs.  McDowell died at Danville only a
few years ago.
  Dr. McDowell had practised medicine and surgery for fourteen
years, and had  secured  for himself a large share of reputation
for his bold and successful exploits, wThen, in the autumn of 1809,
he was cousulted by Mrs. Crawrford, the subject of a large ovarian
tumor, whose case has been already presented to your considera-
tion,  and which, from  its novelty and  attendant circumstances,
must  forever remain memorable in  the annals of our profession.
After a most thorough and critical examination of the case,  Dr.
McDowell informed his patient, a woman of unusual courage and
strength of mind, that the only chance  for her relief was excision
of the diseased mass. He explained to her, with great clearness
and fidelity, the nature and hazard of the operation; he told her
that he had never performed it, but that  he was ready, if she
were  willing, to undertake it, and to risk his reputation upon the
issue, adding that it was an experiment,  but an experiment well
worthy of trial.   Mrs.  Crawford listened  to  the  surgeon  with
great patience and coolness,  and at the close of  the  interview,
promptly assured  him that she was not only willing, but ready
to submit  to his decision; asserting that any mode  of  death,
suicide excepted, was preferable to the ceaseless agony which she
was enduring, and that she would hazard any thing that held out
the most  remote prospect of relief. The result has been  long
before the profession. Mrs. Crawford submitted to the operation,
and  thus  became the first subject  of ovariotomy, of  whom we
have  any knowledge. 
[32]
  It has been already seen that Dr. McDowell, during his resi-
dence at Edinburgh, attended the surgical lectures of Mr. John
Bell, who took special  pains to direct the  attention of his pupils
to the diseases of the ovaria.  It is not improbable that the young
Kentuckian,  while listening to  the  teaching of the  ardent and
enthusiastic Scotchman, determined in his own mind to extirpate
these organs in  the  first case  that should present  itself to  him
after his return to his native country.  The subject had evidently
made a strong impression upon him, and had frequently engaged
his attention and reflection.  He had thoroughly studied the rela-
tion of the  pelvic viscera, in their healthy and diseased condi-
tions, and felt fully  persuaded of the practicability of removing
enlarged ovaria  by  a  large incision  through the  walls  of the
abdomen.  He knew very well  that the  Caesarian section  had
been repeatedly  performed with success,  and he could  perceive
no reason why ovariotomy should be attended with more difficulty
to the surgeon, or greater hazard to the patient.
  When Dr.  McDowell undertook this  operation, he  was not
aware that it had ever been performed by any one else, a prece-
dence, which certain  writers have attempted to prove.   In speak-
ing of his first case, he distinctly states that he had " never seen
so large a substance  extracted, nor heard  of an attempt, or  suc-
cess attending any operation, such as this required." *   Nor was
such an operation ever performed before.   From all the testimony
that I have been able to collect upon the subject,  I am satisfied
that it was first executed by Dr. McDowell.
  Until I had carefully investigated  this  matter,  I was  of the
opinion, in common  with many others, both in  this country and
in Europe, that a foreign surgeon, L'Aumonier, of Rouen,  had
anticipated our countryman in this bold and daring undertaking.
The attempt to remove this organ is said  to have  been made by
this gentleman as early as 1776.   Upon inquiry, however, I find
that this was not the fact,  and that the case upon which he oper-
ated was one  merely of abscess of the ovary, consequent upon
parturition.   There was, of course, no necessity here for extirpa-
tion ; all that was done by L'Aumonier  was to puncture the

  *•  Eclectic Repertory, vol. 7, p. 242.  Phila., 1817. 
[33]
abscess, to give vent to its contents.  He never dreamed of exci-
sing the organ, and it is  surprising that Dr. John Mason Good
and other learned authors should ever  have referred to the case
as one of  ovariotomy.
  Equally unfounded, in this respect, are the claims of Professor
Dzondi and of Professor Galenzowski, whose names precede that
of Dr. McDowell, in  the  elaborate and valuable table of ovari-
otomy, by *my friend, Dr. Washington Atlee, of  Philadelphia,
himself so distinguished in this department of surgery. In a
work published by the former of these writers, at Halle, in 1816,
entitled,   "Beitraege   Zur  Vervoolkummung  der Heilkunde"
or, Contributions towards the Improvement of the Healing Art,
is an  account of a pelvic tumor, in which a cure was effected  by
drawing out the cyst through an incision in the wall of the abdo-
men,  and, after inducing mortification in it by means  of long
tents,  extracting it piece-meal  with a pair of broad  forceps. *
The tumor thus treated, however,  was not ovarian, nor was the
patient a female, but  a lad;  twelve years of age, of the name of
Christopher Shultz, who had a circumscribed  tumor as large as
his head,  in the hypogastric region.  Dzondi relates other exam-
ples of a similar nature, relieved by the same mode of manage-
ment, and he expresses the  opinion that this operation might be
resorted to with equal success  in  ovarian dropsy, provided  the
sac is situated superficially,  and is not affected with ulceration or
scirrhous.  It is difficult to conceive how such a case conld ever
have  been adduced as one of extirpation of the ovary, the more
so, when  it is recollected that the author himself never advanced
such  a claim.
   The case of Galenzowski, of Wilna,  was  also one very differ-
ent from extirpation of the ovary.  But this is not all; his opera-
tion was not  performed until March,  1827, eighteen years after
Dr. McDowell's now  celebrated operation  upon Mrs. Crawford.
The tumor, in  the  case in  question, was multilocular, of large
size, and  so firmly and universally adherent to the posterior wall
of the abdomen as  to  render its total extirpation impracticable.
Galenzowski,  therefore, made a large incision into its cayjMgr,

  * American Medical Recorder, vol. 3, p. 62.
          3 
[34]
according to the method of Le Dran ; and then, passing his fin-
gers into it, he tore up  its cells,  evacuated its contents,  and
secured the  sac with a ligature to the external wound, to prevent
the possibility of peritoneal effusion. On the thirty-second  day
a piece of the sac was found in the dressings; another was  dis-
charged  on  the fifty-second  day; and, finally,  a third  on the
sixty-second.  The patient was discharged on the seventieth day,
having only a small fistula in the  hypogastric region.
  The particulars of Galenzowski's  case, are contained in the
twelfth volume of Graefe & Walther's Journal der  Chirurgie ;
and in a translation of his paper, originally published in Latin,
in the ninth volume of the North American Medical and Surgi-
cal Journal, issued  at Philadelphia,  in 1830.  An abstract of it
will also be  found in Malgaigne's Operative Surgery, by Brittan,
p. 391, Philadelphia, 1851, and in  the Dictionnaire de Medicine,
T. 22, p. 592, Paris, 1840.
  In  consequence of the novelty of  Dr. McDowell's operations,
and of the loose manner in which they have been drawn  up for
publication, an attempt was made by certain writers, both in this
country and in Europe, to deny their authenticity,  and  to  cast
discredit upon the author's veracity.  Among the various detrac-
tors who busied themselves  in this way,  no one was more loud
and clamorous than Dr. James Johnson, * the editor of the Lon-
don Medico-Chirurgical Review,  a periodical well-known  in the
United States.  In  speaking of  Dr. McDowell's  first case, he
remarks: "  Dr. Mac. visited  the patient at the end of five days
though she had come to his own residence to have the operation
performed! 1  He found her engaged in making her bed!  She
soon  returned to her native place quite well.  Credat Judceus
non ego"  In adverting  to the second case, the reviewer says
" we  cannot bring ourselves  to credit the statement."  We have
already seen that Mrs. Crawford, the subject of the first  opera-
tion,  performed in 1809, and so sneeringly spoken of  by Dr.
Johnson, survived  until  a few years ago; and that  the authen-
ticity  of the second, concerning which  he  expresses so much
incredulity, is equally well established.

  * Eclectic Repertory, vol. 7, p. 242.  Philadelphia, 1817. 
[35]
    In a subsequent article upon this subject, published in October
 1826, the same writer  indulges in the following language:  " A
 back settlement of America—Kentucky—has beaten the mother
 country, nay, Europe itself, with all the boasted surgeons thereof,*
 in the  fearful  and  formidable operation of gastrotomy with
 extraction of diseased ovaria.  In the second volume of  this
 series, page 216,  we adverted to the  cases of Dr. McDowell of
 Kentucky, published by Mr. Lizars, of Edinburgh, and expressed
 ourselves as sceptical, respecting their authenticity.   Dr. Coates
 however, has now given us much  more cause  for wonder at the
 success  of Dr. McDowell;  for it appears that out of five cases
 operated on in Kentucky  by Dr. M., four recovered  after the
 extraction, and only  one died.  There were circumstances  in the
 narratives of some of the first three cases that raised misgivings
 in our minds, for which uncharitableness we ask pardon of God,
 and of Dr.  McDowell, of  Danville."  Such language needs no
 comment; it speaks for itself, for it carries with it its own con-
 demnation of the man who  uttered it.   When the learned, caus-
 tic, and  ungenerous  editor of the London Medico-Chirurgical
 Review indited  it,  he was ignorant—perhaps, wilfully  ignorant
 —of the fact, that he was  slandering the father of  ovariotomy,
 and speaking sneeringly of a State that has given  birth to the
 first lithotomist, and the first American statesman of the  nine-
 teenth century.                         *
   But it need not surprise us that Dr. McDowell's cases of ovari-
 otomy should have been treated with contempt abroad,  when
 attempts  were  made  to discredit them at  home.   What  effect
 these attempts exerted upon the professional mind of the United
 States, it would be useless, at this remote day, to enquire; suffice
 it  to say,  that they aroused  the assailed party to a sense of self-
 defence,  and the publication of additional cases, confirmatory of
 those that had previously appeared in the Eclectic Repertory of
 Philadelphia.
   It would seem that  Dr. McDowell kept no notes of any of hie
cases, and that he was prevailed upon, with the greatest difficulty,
to  publish an account  of the first three cases in the Eclectic

 * Medico-Chirurgical Review, for January, 1825, p. 216. 
[36]
 Repertory.  His nephew, Dr. John A. McDowell, states that he
 had to urge,  among other inducements, the debt of gratitude
 which his  uncle  owed to Mr. John Bell,  and his obligation to
 compliment that  celebrated surgeon with an  exhibition of the
 exploits of his pupil, in the execution of an operation, the prac-
 ticability of which he had been at so much pains to teach in his
 lectures.  This appeal had more weight in deciding Dr. McD. than
 any thing else that could be urged.   He finally drew up an out-
 line of his  cases, referring to his ledger for his dates, and to his
 memory for the facts.  They were not written out  with sufficient
 minuteness and precision; but they had, at least, two capital
 merits—truthfulness and brevity.  A copy of the paper,  with
 a letter of  acknowledgement, was forwarded to Mr. Bell, but this
 he  never received.   He was absent at  the time, traveling on
 account of  his health in Italy, whence he never returned alive.
 The paper  subsequently fell into  the hands of Mr. Lizars,  who
 published it, seven years afterwards, in the thirty-second volume
 of the Edinburgh Medical and Surgical Journal, in consequence
 of an attempt which he made to ovariotomize a female, to the
 peril of her life, who was found to be afflicted only with abdomi-
 nal obesity.
  Another  copy of these cases was sent,  in the autumn of 1816,
 to Dr. Physick, of Philadelphia,  with a request  that,  if found
 worthy, he  should have them published in some Medical Journal.
 It is not known whether the  "Father  of American Surgery"
 ever read the paper,  or investigated the  nature of the operation
 which is described;  certain it is, he never took any notice of it
 either to Dr. McDowell, his pupils, or any one else.  He had no
 time to bestow upon the subject, or the subject was unworthy
 of  his attention.  He might have thought  the author  of the
 paper a backwoods  imposter, or a man who was speaking  from
 Buncombe.
  Dr. William A. McDowell,  who was the  bearer of the above
 dispatch, was more  successful in his interview with  Dr. James,
 the modest, amiable, and benevolent Professor of Midwifery, in
the  University of Pennsylvania.   This gentleman had  been in
 the habit of depicting to his pupils, with every revolving lecture
 term, and in the most harrowing language, the fatality and utter 
[37]
 hopelessness of all attempts, past, present, and to come, to cure
 organic  disease  of the ovaria by  operation.  He  seized with
 avidity the intelligence communicated to him by the younger
 McDowell, and  immediately requested an account of the cases
 for publication in the Eclectic Repertory, of which  he was then
 one of the editors.  He also  read  the cases to his class, who
 received them with the most rapturous applause.
   The publication of the cases in the Eclectic Repertory received
 but little  attention.  Indeed, so far as could be ascertained, it
 encountered general incredulity,  if not positive ridicule.  The
 paper of Mr. Lizars,  in the Edinburgh  Medical and Surgical
 Journal, met with a better fate; for it at once attracted  marked
 attention, and produced strong excitement throughout the medi-
 cal circles of Europe;  a circumstance which reacted  with elec-
 trical force and  rapidity upon the United States.  The question
 of the reliability of the reported  cases, was at once thoroughly
 investigated and established, and the operation has since been
 repeatedly performed with success in nearly all  parts of the civ-
 ilized world.   Ovariotomy is now one of the established opera-
 tions of  surgery; and for this boon  our profession and mankind
 .are indebted to Dr. Ephraim McDowell.
   It is not positively known, even to his most intimate surviving
 .friends,  how  often Dr. McDowell  performed the operation  of
 ovariotomy.   Dr. William A. McDowell,  who was a member of
 Iris family nearly seven years, five as a student, and nearly two
.as a partner in practice, states that up to the period of his remo-
 val to Fin castle, Virginia, in 1820, his uncle had had seven cases,
 all, save one, successful.  Six of these operations Dr. McDowell
 witnessed, and in two he handled the knife under Dr. Ephraim
 McDowell's  direction.   "I acted,"  he modestly adds, "in the
 capacity, as I conceived, of a sort of an amanuensis."  " In  his
 first operation," continues this gentleman, "in 1809, Dr. James
 McDowell, who was Dr. Ephraim McDowell's nephew, partner,
 and brother-in-law, and a young man just commencing practice,
 used  the knife  under similar circumstances, as it respects the
 ■external incision.  Dr. Ephraim  McDowell had, at  the time,
•determined to decline practice in favor of Dr. James McDowell.
 The death of the latter occurring shortly afterwards,  changed the 
[38]
 arrangement.  Under the same circumstances, Dr. A. G. Smith,
 who succeeded me as a partner to  Dr. McDowell,  operated in
 two or three cases."
   Dr. William A. McDowell informs me  that he has reason to
 believe, from reliable testimony,  that his uncle  performed this
 operation altogether thirteen times, exclusive of the eases of Dr.
 Smith.  He states  that he is himself cognizant of two more suc-
 cessful cases; one,  that of Mrs. Overton, of Tennessee,  and the
 other,  that  of  Miss  Gilmore, of Pulaski eounty, Kentucky];
 making in  all,  eight  cures, respecting which there can be no
 mistake.  Dr. McDowell's success does not seem to have been so
 great in his latter,  as in his earlier operations,  but the  precise
 ratio cannot now, unfortunately, be ascertained.
   It  may not be improper to state, in concluding the considera-
 tion of this part of Dr. McDowell's professional services, that an
 attempt was made,  many years ago,  to deprive him of the credit
 of his first  operation, by ascribing the  performance of it to his
 nephew, Dr. James McDowell, at the time  his partner in prac-
 tice.   In consequence of this attack upon  his veracity and pre-
 tensions to  surgery,  Dr. McDowell was  induced,  in. 1826, to
 address a printed card to the "physicians and  surgeons of the
 West, and  particularly, to the medical faculty and class at Lex-
 ington," in  vindication of his claims.   After remarking that he
 had visited  Mrs. Crawford, the subject of the operation in ques-
 tion,  at her residence in. Green county,  Kentucky, a distance of
 sixty miles from Danville, for the purpose of examining her case
 and that she soon after came to  his own  house to undergo the
 operation of ovariotomy,  he says:  "my  nephew,  Dr.  James
 McDowell, whom I had brought up, had graduated a few months
 before this time, in Philadelphia, and had commenced business-
es my partner.   Being in, delicate  health at the time,  it was my
 intention to remove to the country in the spring,  or so soon as I
 could establish my nephew in business.
   "From the time of Mrs. Crawford's arrival,  he had made fre-
 quent attempts  to persuade me from operating; but,  finding my
 determination was fixed,  he agreed to be present, but not until
 the morning I operated, and as my partner, to assist; for should the, 
[39]
patient die, the responsibility was all my own; should the patient
live, it would assist him in his outset in business.
  " The day having arrived, and the patient being on the table, I
marked with a pen the  course of  the incision to be made; desi-
ring him to make the external opening, which, in part,  he did;
I then took the knife, and completed the operation,  as stated  in
the Medical Repertory.  Although the termination of this case
was most flattering, yet I was more ready to attribute it to acci-
dent  than to skill or judgment of my own; but it  emboldened
me to undertake similar  cases;  and not until I had operated
three times—all  of which were  successful—did I publish any
thing on the subject.  I then  thought it due to  my own  /reputa-
tion and to suffering humanity to throw all the light which I
possessed upon diseased ovaria."
  It is not necessary that I should enter into a formal examina-
tion of the claims of  Dr. McDowell as the author of the operation
in Mrs. Crawford's case.  The paper from which I have read the
above extracts, is accompanied by three certificates, all testify-
ing  to  the truth of Dr. McDowell's statement.  One of these
certificates is  from  Mrs.  Crawford  herself;  another from her
nurse, Mrs.  Baker; and the third from Mr.  Charles McKinny, a
private pupil of Dr.  McDowell, who, with Mrs. Baker, witnessed
the  whole  proceeding.   He  states,  expressly,  that Dr. James
McDowell  made  the external  incision  as directed by his uncle,
and that then the latter took the knife and extracted the diseased
ovary.  He asserts,  moreover, that he never heard Dr. James
McDowell  claim  the credit of the operation.  When we add to
these facts,  the statement of Dr. William A. McDowell,  that  he
and Dr. Smith both  assisted  Dr. Ephraim McDowell, on several
occasions, in the same manner, it follows, as  a necessary corollary,
that the claims set up in behalf of Dr. James McDowell, who is
said  to have been a young  man of great professional promise,
 must fall to the ground  as untenahle-
   I have endeavored to  establish  the claims of Dr. Ephraim
 McDowell,  to the operation in question, upon a firm and immu-
table basis.  My only motive for so doing, has been a wish to
defend  truth, to subserve the  interests of surgical science, and to 
[40]
 award credit where credit is  alone due.  How far  I have suc-
 ceeded in my effort, let others judge.
   But Dr. McDowell's claims to distinction do not, by any means,
 rest upon his exploits, novel and  brilliant as they  were, as an
 ovariotomist.  He ranked also deservedly high  as  a  lithotomist.
 For a time he was almost the  only physician in Kentucky  who
 performed this operation.  In the latter period of his life, he was
 eclipsed, in this branch of  surgery,  by his neighbor, Dr. Dud-
 ley, of Lexington, who, after the establishment of the Transylva-
 nia Medical school, for many years almost monopolized the stone
 cases in Kentucky and the adjacent States.   It is not known how
 often Dr. McDowell performed this operation ; but  it is positively
 ascertained that he had, up to  1828, two years prior to his death,
 executed it thirty-two times,  and  that without the loss of a single
 patient.  Such success is as  rare as it is creditable  to  Dr. Mc-
 Dowell's skill and judgment.  He confined himself to the lateral
 method, and early in life opened  the bladder with  the gorget,
 but afterwards made his deep incisions with the knife.
   One of his most interesting cases, not from any peculiar cir-
 cumstances or merit, but from  the exalted position afterwards
 attained  by the patient, was  that of Mr. James  K. Polk, late
 President of the  United States.   This gentleman had  suffered
 from symptoms of vesical calculus from an early period, and in
 his seventeenth year he was  induced to visit Danville in search
 of advice,  The operation was performed in the autumn of 1812,
 with Dr. McDowell's usual skill, and  a happy recovery was the
 consequence.   The calculus,  which,  through  the kindness of
 Wallace W. McDowell, Esq., of Danville, the only  surviving son
 of the distinguished operator,  I  have  the honor of exhibiting to
you this  morning,  was of small  size, very hard and heavy, with
 a rough  tuberculated surface.   Mr. Polk carried  it home with
 him, not in his blacker, but in his pocket, to show it to his friends
 and neighbors, with whom it was a source of great curiosity.  In
 a letter, dated in Maury county,  West Tennessee, December 3rd,
 1812,  he informs  his surgeon of  the progress  of  his cure, and
feelingly expresses his sense  of gratitude for the services  which
 he had received from him. This  letter, as a specimen of literary
composition, is far below mediocrity; it is badly spelled,  and 
[41]
 written  in  the  worst style.   In these respects, it is in striking
 contrast with another  letter addressed to Dr. McDowell,  nearly
 fourteen years afterwards, when Mr. Polk represented his adopted
 State in the Congress of the United States.   In this communica-
 tion, written with great  accuracy, and even eloquence, Mr. Polk
 again  expresses his gratitude to Dr. McDowell;  speaks  of the
 excellence of his health, and alludes to the manner  in which he
 spent his time since his  recovery from the operation.  " I have
 been enabled," he says,  " to obtain an education,  study the pro-
 fession of the law, and embark successfully in the  practice; have
 married a wife, and  permanently settled in Tennessee;  and now
 occupy the station in which the good wishes of my  fellow-citizens
 have placed me.  When I reflect,  the  contrast is  great, indeed,
 between the  boy, the meagre boy, with pallid cheeks, oppressed
 and worn down with disease, when he first presented himself to
 your kind notice, in Danville, nearly fourteen years  ago, and the
 man at this day in the full enjoyment of perfect health."  I take
 great  pleasure in alluding  to these letters  of Mr. Polk.  The
 career of this gentleman, and that of his surgeon, show how early
 obstacles may be vanquished by industry, and how perseverence
 enables men, from small beginnings, to attain to great ends.
  Dr.  McDowell performed  numerous other operations,  but of
 their  nature I am not apprised; nor could it be necessary, if I
 were, to refer to them  in a particular  manner on  this occasion.
 His anatomical knowledge, courage and dexterity,  were sufficient
 to enable him to execute any operation that might have  been
 required within the extensive circle of his practice.   It cannot be
 supposed, for a moment,  that the man who was the first to excise
 a diseased ovary, and who cut thirty-two patients for stone with-
 out a single failure,  would shrink from the performance of any
 surgical  duty,  however  novel or hazardous, provided he  was
certain that it was imperatively demanded by the  circumstances
of the case.
  He paid much  attention to the subject of hernia.  He often
operated successfully for the relief of strangulation, and perform-
ed many medical cures by means of the truss.  His reputation
in this  branch of surgery attracted patients to him from a great 
[42]
distance.  The late President Polk was  one of his subjects, and
one of those who were radically cured by his skill.
  As a surgeon, Dr. McDowell was exceedingly cautious.  He
never undertook an operation until his own mind and the patient's
system were prepared to his entire satisfaction.   Notwithstand-
ing his extraordinary accuracy in anatomical and surgical knowl-
edge, he never operated, in any important case, without carefully
reviewing the relations of the structures involved, and referring
to the best surgical authorities in his library on" the subject.   His
pupils were obliged to do  the same thing, as well as to examine
the case, and favor him with their opinion on it.  His assistants
were  carefully selected, and regularly  drilled, until, like  thespi-
ans, they perfectly understood their parts.
  He was remarkably kind  to  his  patients, sympathizing with
them in their suffering, and encouraging them by  tender and
soothing expressions.  His hand never quivered in an operation ;
nor did his mind quail; but his face flushed, and, even in the
depth  of winter, the  perspiration often started from every pore.
A gentleman. Dr. Alban G. Smith, now Dr. Goldsmith, who
knew Dr. McDowell  intimately, and who is himself an excellent
operator, writes me that he was the  best operator he ever saw, in
all cases where he had a rule to guide him.  He always preferred
to operate on Sunday mornings, saying  that he liked to have the
prayers of the church with him.
  He wTas an accomplished anatomist.  He made it a business to
dissect, more or less, every winter, and he took special pains, on
such occasions, to aid his pupils in acquiring a knowledge of the
human structure.  Subjects were not always obtained,  at that
period, without trouble and even risk.
  Dr. McDowell was no writer.   The only contributions he ever
made are his first five cases of ovariotomy, in  the seventh and
ninth volumes of the Philadelphia  Eclectic Repertory.  It is a
subject of deep regret that he should have felt, throughout the
whole of his life, such a deep repugnance to the publication of the
results of his experience.  Extensively engaged as he was  for so
long a period in the  practice of  medicine  and surgery, he must
have accumulated a vast amount  of knowledge, most valuable to
the profession and to suffering humanity, and eminently condu- 
[43]
 cive to the extension of his  own fame.  But such exercise was
 distasteful to him, and no remonstrance on the part of his friends,
 could induce him to engage  in it.   Temporary  notoriety and
 posthumous fame were subjects alike of indifference to him.  He
 pursued the " even tenor of his way," and his habits were so con-
 firmed that it was impossible to change them.
   Dr. McDowell was an honorary member of several medical as-
 sociations.    The Medical Society of Philadelphia, cne of the
 oldest and most respectable institutions of the kind in the coun-
 try, sent him its diploma in 1807.  In 1825, he received  from the
 University of Maryland, then in the height of its renown, the
 honorary degree of doctor of medicine,—a distinction which was
 a full acknowledgement of his  exalted reputation,—and which
 afforded him genuine gratification, the more  especially as it was
 unsolicited on his part.
   Had Dr. McDowell  lived in France he would have been elected
 a member of  the Royal Academy of Surgery, received the  cross
 of the Legion of Honor from the King, and  obtained a  magnifi-
 cent reward from the government, as an acknowledgement of the
 services which he rendered his  country, his profession, and his
 fellow creatures.  His own country, and especially his own neigh-
 borhood and State, failed to appreciate him.  I am told by gentle-
 men whose veracity is indisputable, that but few of his immediate
 fellow-citizens were capable of drawing a just distinction between
 him and the merest charlatans in his  vicinity. Such must ever
 be the fate of true greatness in all new communities.  Dr.  Mc-
 Dowell had  the misfortune to live before his time; he was  born
 in advance of his age.
   He was a kind-hearted, amiable man, an urbane and accom-
plished gentleman, a benevolent physician, a warm and generous
 friend, an excellent  neighbor, an affectionate husband, and an
indulgent and anxious parent.  His character, in all the relations
of life, was  most exemplary.   Of a lively, social  temperament
abounding in wit and  pleasantry, he  was the master-spirit and
delight of every company which he honored with his presence.
No man was ever more agreeable, none more amusing, none less
assuming.  Frank in his  manners,  and easy  of access, no  one 
[44]
could be a stranger in his society, or leave his presence without a
feeling of regret.
 ,  As a scholar he was entitled to no ordinary rank in comparison
even  with some  of his  most distinguished cotemporaries of the
learned profession  of which he was a member.  He  was much
devoted to study, especially  in early life, and was a most admira-
ble recitationist.  He was fond of the Greek  and Latin,  which
he read quite fluently, and a knowledge of which he retained long
after  his return  from Europe.  But  historical  and  belles-lettres
literature occupied more of his time  and attention than classical
and scientific works.  Burns and Scott were  his greatest favor-
ites.  In his readings of these authors,  he  rolled the Scottish
idiom upon  his  tongue  in a manner totally indescribable.  His
recitations from  Scottish dialogues,  adopting  his intonations  to
the supposed character of the speaker, were richer and  more exci-
ting than any theatrical exhibition.
   He was fond of music, and sung a variety of odes and catches
in Latin, English, and Scotch, in  good taste and with  fine comic
effect. His  favorite pieces—those of a comic and humorous char-
acter—he frequently accompanied with his violin, an instrument
to which he  was very partial, but upon which he was a poor per-
former.  Like  Themistocles, the Athenian, " he could not fiddle,
but yet he  could make  a small town a great city;" he could
achieve wonders in surgery,  such as had never been achieved be-
fore ;  and he could thus immortalize his State and country.
   His excellence in the Scottish dialect and melody is probably
attributable  to his summer rambles in Scotland, during the vaca-
tions of the  medical sessions in the University of Edinburgh.—
In company  with two of  his classmates, Drs. Brown and  Speed
both from Kentucky, he perambulated a  considerable portion  of
tnat " land o' cakes," much to their mutual delight and edifica-
tion.   They  travelled on foot,  each packing a change of  clothes
in a wallet.  In  the tour, Dr. McDowell met with several respec-
table  members of his family connection, who recognized  and
received  him as a  clansman, pretty much after the  style and
manner of hospitality commemorated and immortalized by Burns
and Scott.
   The travelers were well provided with  letters to distinguished. 
[45]
 personages ' en route,' who never failed to treat them with mark-
 ed attention and respect.   On approaching the residences of these
 individuals, they always hired a conveyance, and riding up in due
 form and style, were received accordingly.  They,  however, if
 their entertainment was to their liking, soon "let the cat out of
 the wallet;" immediately upon which all formality ceased, and
 they were carried about, all  over the neighborhood, either on
 horseback or in a coach, as they happened to fall in with a com-
 moner or a "gig-man," and exhibited to all  sorts of people as
 gentlemen from the extreme backwoods of America.  It is very
 questionable whether the United States have  had, at any  time
 since, the good fortune to be more creditably represented in that
 ancient and interesting country; a trio of equal  intelligence, of
 fine looks, wit, and  good  fellowship is rarely to be  found any
 where.
   After his return to Kentucky, Dr. McDowell frequently recur-
 red,  in terms of the greatest delight, to the happy hours spent in
 these peregrinations, recounting with peculiar glee the incidents
 which befell him and his backwoods companions.  He ever after
 cherished a warm attachment for the Scotch, their beautiful and
 romantic country, and their noble,  scientific, and charitable insti-
 tutions.
   His library was quite extensive for the period in which he lived,
 consisting of all the standard medical works, many  of which he
 had brought from Europe.  On the practice of physic  he always
 procured  and read the  most celebrated authorities; more,  says
 one of his pupils, on account of his students, of whom  he always
 had a considerable number, than  of his patients.   He was an
 ardent admirer of  Sydenham & Cullen, and never could appre-
 ciate any  advances worthy of note  upon these celebrated writers.
 With many of  his cotemporaries, he regarded the portraitures of
 disease, delineated by the hands of these  masters, as inimitable.
 In his judgment,  all other writers  on  the practice of medicine
 were  mere bunglers and copyists;  a decision in which nearly all
 intelligent professional men at that period concurred.  He was in
 the habit  of earnestly cautioning his students  against too free a
 use of medicines.  As a secret, he  apprised them of his impres-
sion that  the employment of medical drugs was more of a curse 
[46]
  than a blessing to the human race, and that quackery perpetrated
  much more mischief and destruction by  their means,, than the
 science of the profession could counteract.  In the surgical branch
 of his profession he took great delight;  he characterized it as the
 certain branch of the healing art, and spared no pains to advance
 and  perpetuate his knowledge of it.   He  does not seem to have
 had  any special fondness  for the practice of medicine, as he al-
 ways had a partner upon whom he devolved most of this kind of
 business, especially after he had  achieved some reputation as a
 surgeon.
   His fees  for surgical operations were regulated,  as  a general
 rule, by the ability of his patients.  As might be supposed, from
 the extent of his practice, and from  his benevolent  disposition,
 he occasionally, perhaps frequently, rendered his services gratui-
 tously.  Pauper patients, no doubt, often resorted to him from a
 great distance, and McDowell  would have been the last man in
 the world to turn  a deaf  ear  to their entreaties for  advice  and
 relief.  To a humane surgeon, appreciating his  duty to his God
 and to his  fellow-creatures, the claims of the sick  poor appeal
 with  irresistible force,  proving  paramount  to  every selfish  or
 pecuniary consideration; they are his best subjects, because, in
 the language of Boerhaave, God is their paymaster,  and because
 the expression of their gratitude is voluntary, not being extorted
 in the hope of obtaining a small bill for the services they have
 received from their professional attendant.
  Occasionally his fees were large; in one instance almost prince-
 ly.  I allude to the case of Mrs. O., upon whom  he performed the
 operation of ovariotomy, in the summer of 1822.  This lady lived
 in the vicinity of the Hermitage, in Tennessee,  the  residence of
 the late President Jackson, and Dr. McDowell had agreed to
operate upon her, at her own house, for five  hundred dollars.   He
 remained with her  for some days, and on the morning of his depart-
 ure her husband,  a highly respectable  and  intelligent citizen
gave him a check,  as he supposed, for the stipulated sum, on one
of the banks of Nashville.   On presenting  it, he discovered that
it was drawn for fifteen hundred dollars, instead of five hundred.
Presuming that a mistake had been made, he immediately dis-
patched his servant to the gentleman, who replied that no mistake 
[47]
had occurred, and that the services he had received from Dr. Mc-
Dowell more than counterbalanced the sum he had paid him.
Such generous liberality was alike honorable to the giver and to
the receiver.   So far as I know, this is the largest fee ever paid
in this country for a surgical operation.  Considering the value
of money at that time in the South-west,  or in other words, the
cheapness of living, and the comparatively small  compensation
for professional services, it was fully equivalent to  the celebrated
fee of a thousand guineas paid by Mr. Hyatt, a West Indian mer-
chant, for an operation performed upon his person by Sir Astley
Cooper.
   Dr. McDowell was  not wealthy; his estate at the time of his
death was estimated at from forty to fifty thousand dollars.   His
mode of living was plain and  unostentatious; he  was always
glad to see his friends, and to extend his hospitalities to them.
The " latch-string " always hung conspicuously  at the door.
   He was a man of  enlarged and liberal views.  He spent his
money  and his time  freely upon charitable  objects, and mani-
fested great interest in advancing the prosperity of Danville, the
scene of his  professional labors and professional renown.  Of
Centre College, located at that  town, and at present, thanks to
the talents and wisdom of President Young,  the most successful
literary institution in  Kentucky, he was one of the founders, and
one of the original  trustees;  subscribing liberally towards its
support.
   Dr. McDowell was  always a  decided Christian in his feelings
and conduct.   At the time of his settlement at Danville, in the
latter part of the last century, nearly the entire male population
of the village was  Atheistically inclined; and  not a few were of
the Robespierrian  School,  having achieved the grand discovery
that  " death is  but an eternal sleep." With these men, he had
no sympathy, though he was of too benevolent and  tolerant  a
 nature to fall out with any one for entertaining different tenets
 from his own.
   In 1828, two years before his  death, he united himself  with the
 Episcopal church, having made an open profession of religion at
 Lexington.  On his return from that city, he donated  a lot afc
Danville, on which  was afterwards erected  the present church 
[48]
  edifice of that town.  During the  two latter years of his life, he
  was earnestly engaged in building up a congregation.   He survi-
  ved  long  enough  to see that  his  efforts in the cause of  the
  Redeemer had not been in vain.  Although still small, the Epis-
  copal church at  Danville is now one of the most  respectable in
  the State.
    But  the close of his earthly  career was drawing near.   The
  sand in the hour-glass of life was rapidly disappearing; his days
  were numbered;  the summons had gone forth;  the  tall and
  sturdy  oak was  stricken, and waved to and fro  under the influ-
  ence of the mighty tempest; one  after another of its branches
  yielded to its resistless power, and all that was frail and mortal of it
  fell to rise no more.  Dr. McDowell expired at Danville, on the
  25th of June, 1830.   His disease was inflammatory fever, termin-
  ating his valuable life on the fourteenth day of the attack, and in
  the fifty-ninth year of his age.  For him death had no terrors,
  the grave no victory.  Confiding in the mercy  and promises of
  his Creator and  Redeemer, his God and  his Judge, he awaited
  his end with the patience of a Christian,  and the calmness of a
  philosopher.   He had "set his house in  order," and  met death
  with a serene and composed mind.  From the very moment of  his
  seizure, he had a presentiment that he should not survive it.
    To the professional pilgrim of the West, it will not be unin
  teresting to know that the remains of Kentucky's first great sur-
  geon repose  in  the family  burial  ground  of  Gov. Shelby, five
  miles from Danville.  His  tomb-stone, a plain  slab of marble,
  bears the simple inscription of his name, "Ephraim McDowell.
    In his person, McDowell was  nearly six feet in height, with a
  florid complexion, and very black eyes.  He was of a remarkable
  happy disposition, and rather inclined to  corpulency.  Up to the
  very time  of his sickness, he was one of the most active men in
  Kentucky.   As  an illustration of his  agility  and  muscular
  strength,  the  following anecdote, which  he often narrated  with
  special  glee,  affords a good  example.   While he sojourned in
  Edinburgh, a celebrated  Irish foot-racer, a sort  of Mike Fink,
  arrived, boasting that he  could out-run,  out-hop,  and out-jump
  any man  in  the city, and  bantering the  whole medical class.
% McDowell was selected  as their  champion.  The distance  sixty 
[49]
yards, and the stake ten guineas; the trial took place in the Col
lege grounds, and the American purposely allowed himself to be
loser. A second race for one hundred guineas, and at an increased
distance,  came off soon afterwards, and this  time the Irishman.
after much bullying, was badly beaten, much to his own chagrin,
and the gratification of the students.
  Dr. McDowell remained faithful to his profession until the last
moments of his life.  He literally died in the harness.  A  few-
months before his final illness, he commenced the building of a
large and beautiful  mansion in the country, two miles from Dan-
ville, where he had intended  to spend the evening of his life,
away from the cares and fatigues of a busy practice.  Death, as
has been already seen, frustrated this design.  The mansion  was
finished, but was occupied by other tenants.
  I have already  dwelled so long upon the  life and  services of
Dr. McDowell  that I  must bring this branch of my subject to a
close.   His whole character may be summed  up in one sentence.
He was a deep and original thinker, a bold, fearless, intrepid,
aud original operator, a faithful  and adroit physician,  an
honest,  upright, conscientious, and  benevolent man, whose
career,  in whatever aspect it may  be contemplated, affords  at)
example worthy alike of our admiration and imitation..
I.--AFFECTIONS OF THE HEAD,
             Injuries of the Skull and' Brain.

  There is no subject within the whole range of surgery of deeper
interest or importance  than that of injuries of the skull and
brain ; endangering, as they so frequently do, either primarily or
secondarily, the life of the patient;  or, if he is so fortunate as to
escape from their immediate effects, the integrity of his  intellec-
tual and bodily powers.  It is for these reasons that this class of
affections, so common in every community, has always been an
object  of  particular  study with the surgical  pathologist, and it
has elicited an amount of inquiry and research that can  scarcely
        4 
[50]
be claimed for any other branch  of our  profession.   It affords
me pleasure to state that this subject has  not been neglected by
the surgeons and  physicians of Kentucky ; but, on the contrary,
that  it  has  received  from them more than ordinary  attention.
The paper of Dr. B. W. Dudley, of Lexington, entitled "Obser-
vations  on Injuries of  the  Head,"  in the  first volume of  the
Transylvania Journal of Medicine and the Associate Sciences, is
one of the most valuable and instructive contributions that have
been made to the  science of surgery during the first half of the
present century.   Indulging  in no  hypotheses, or speculative
views, it aims  to establish the treatment of this class of lesions
upon 'just and philosophical principles, deduced from the author's
own experience;  and no one who follows  him, as he is engaged
in tracing out these principles, can fail to be impressed with
their general soundness and  accuracy.  The  only regret  which
he experiences, is that the paper  is so short,  and that the lan-
guage in which it is couched  is not always free  from  ambiguity
and  inelegancies.
   The article of Dr. Dudley is comprised in about thirty  pages,
and  was published in 1828, when the distinguished author was
in the  meridian  of his fame  and usefulness.   It is impossible,
within the limits of this report, to present a perfect analysis of
the matter contained  in this paper, but it cannot be too strongly
recommended to  the consideration of the  profession, especially to
younger members of it.  My remarks will be restricted chiefly
to Dr. Dudley's account of some of  the secondary effects of inju-
ries of  the skull and brain.
   It is  well known that fractures of the skull, especially such as
are attended with depression, are  not unfrequently followed by
epilepsy.   For the relief  of this affection, thus induced, the ma-
 teria medica offers no hope.   Nothing  short  of the  removal of
 the offending piece of bone, with the elevator or trephine, answers
 the purpose, and this, unfortunately, does not always succeed.
 The first operation of this kind was executed  by La  Motte, * in
 1705.  His  patient,  however, was  only  partially relieved.  As

   *  Traite des Nerfs et de teurs  Maladies, par M.  TiBBot, T. 3.  parte  1,
 sec.  129, art. 20. 
[51]
long as the aperture,  made by the instrument, remained open,
he  experienced no recurrence of the disease; but as soon as it
healed up,  the spasms returned,  though not with their accus-
tomed severity.   Subsequently to this, the  operation was occa-
sionally resorted  to, sometimes,  by different  surgeons, for the
cure of neuralgia and other nervous affections of the head.  In
1800 it was performed successfully for the relief of epilepsy, by
Mr. Cline, of St. Thomas's  Hospital, in London ; and in 1804,
with  a like result, by Mr. Birch, of the same institution.   Mr.
Hemsted, a surgeon of Newbury, England, met with a favorable
case in 1822. In more recent times the operation of trephining for
the cure of epilepsy, has been executed with various  effects, by
different surgeons, in all parts of the civilized world.
  Dr.  Dudley's cases,  as narrated in the paper under review,
amount to five, of which three were successful, while the results
of the others have never been ascertained, owing to the fact that
he lost sight of his patients.  Subsequently, namely, in 1832, he
met with another instance, the particulars of which are contained
in the fifth  volume of  the valuable periodical  above quoted.   A
very brief outline of the case must suffice on this occasion.
  A carpenter consulted Dr. Dudley,  in September, 1818,  for a
severe pain in the  upper and  back part of  the cranium, which
had afflicted him for nine months, and which  was attended with
extraordinary sensibility  of the  scalp.   About Christmas  the
symptoms became aggravated, and epileptic convulsions, so severe
and frequent as to threaten life,  ensued.  The trephine was ap-
plied on the 16th of April, 1819, and two circular pieces of bone
removed in the direction of the longitudinal  sinus.  The pericra-
nium  was remarkably thickened and morbidly sensitive;  the
bone was  porous,  and pierced  by numerous vessels and fibrous
processes;  and a  "copious  secretion of fluid" existed beneath
the dura mater,  between it and  the  surface  of the brain,  which
was free from pulsation, and felt " as hard and unyielding as a
board."  When the dressing was removed, on the fifth day,  the
wound was suppurating abundantly,  the fluid deposit was  ab-
sorbed, and the brain  had regained its natural condition.   The
patient was perfectly restored at the end of three months, having 
[52]
experienced only two slight attacks of epilepsy after the opera
tion.   The cure was radical.
  A young man,  aged twenty-one,  received a blow on the upper
and  middle portion of the left parietal bone, followed suddenly
on the ninth day by apoplexy and paralysis of one side.  At the
end of two months, the effects of this attack had passed off; but
from  this time on he suffered constantly from severe pain in the
head, especially about the seat of the injury, was  liable to faint
after the slightest exertion, and became exceedingly delicate and
excitable.  About the age of fourteen, he was seized with epilep-
tic convulsions, which recurred afterwards at irregular intervals
of two, three, or four weeks; his memory became treacherous,
and  he stammered  in every attempt at enunciation.  A  cicatrice
on the side of the scalp, with a slight  depression, pointed out the
seat  of the original injury.  With  the trephine a disc of bone
was removed,  having a ridge upon its  inner surface, about an
inch in length, and about the size of a small  quill at  its base.
This spiculum had penetrated the dura mater, and communicated
with  a  large  preternatural sinus, more than an inch in depth,
from whence  issued a stream of blood as thick  as a man's little
finger.  The dura mater was diseased and of a dark blue color at
and around the opening in the skull.  Before the dressings could
be applied, several severe convulsions occurred,  followed each by
a copious stream of blood from the sinus in the dura mater.  For
six or eight hours after the operation, the patient lay in a state of
insensibility, when there was a return of reason and natural feel-
ing.   An immense amount of serous fluid,  estimated at two gal-
lons,  was discharged from the wound  during the first four days,
when it was  succeeded by  healthy pus.   No convulsions took
place after the first day; the speech, memory, and  mind rapidly
improved, and in six weeks he went home perfectly well.
  A young man, aged twenty-three, when five years  old  was
kicked by a horse, causing a fracture with depression  of  the
right parietal  bone.  No unpleasant effects ensued until his fif-
teenth year, when, without any assignable reason, he had for the
first time an epileptic fit, which recurred afterwards every second,
third, or fourth week, impairing  his general health, and destroy-
ing his memory.  The depressed bone presented on its inner sur- 
[53]
face a spinous process, about half an inch long;  and there was a
large sinus or cavity, filled with colorless serum,  and reaching
down to the petrous portion of the temporal bone,  near the base
of the skull.  The patient had two slight attacks of epilepsy on
the second and third days after  the operation; but on the fourth
suppuration was established, and from that period he  gradually
improved in mental and corporeal vigor.   At the end of the fourth
week, the wound was cicatrized, and the recovery complete.
  Of the  fourth and fifth cases no special  analysis is necessary,
as the result has never been  ascertained by the operator.   The
patients recovered from the use of the trephine, and went home,
but were not heard from afterwards.
  Dr. Dudley's sixth case was that of a man who received a gun-
shot wound on the  head, attended with  a comminuted state of
the right  parietal bone, and  followed by an escape of a small
quantity of cerebral substance.  After some months  of epileptic
convulsions,  with  great derangement  of  the  general  health,
enstied, and there was a constant discharge of pus from the seat
of the original injury,  which was indicated by a cicatrice two
inches and a half in length.   The trephine having been applied,
"isolated  portions  of  bone were  discovered beneath .the  dura
mater, in  a cavity of some dimensions, occasioned by the absorp-
tion of the brain.   Three of these, amounting in  size to the
thumb and finger nails, were removed,  together with a  morbid
growth from the surface of the wounded dura  mater.   Simple
dressings were then applied, and renewed occasionally for a week,
when the  patient was discharged,  free from all  embarrassment,
both in the .corporeal and intellectual functions."
  The cases here described are of great interest, inasmuch as
they serve to establish, along with those of Cline and other sur-
geons, two most important principles in pathology and  practice;
first,  that the brain may,  and  frequently does,  endure  a large
amount of compression and irritation, without serious detriment to
the general well being of the individual; and secondly, that they
often admit of entire and permanent relief by the use of the
trephine.
  The following remarks of Dr. Dudley will be read with inter-
est;  " The experience which time and circumstances have afforded 
[54]
in injuries done the head, induces me to depart from the com-
monly received  principles by which surgeons are governed in
regard to the use of the trephine.  In skillful  hands, the opera-
tion beyond the atmosphere of large cities, is neither dangerous
in its  consequences, nor  difficult  in the execution.  With the
views entertained  on  the  subject of the  all-pervading influence
of the chylopoetic organs, in producing a great variety of those
diseases called surgical, I do not feel apprehensive of committing
errors by the too frequent  use of the scalpel and the saw."
  Another valuable paper upon injuries  of the skull and brain
has recently appeared, from  the pen of  my friend, Dr. Hardin,
formerly of Greensburg, now of this city, in the Western Journal
of Medicine and Surgery,  for March, 1852.
  Dr. Hardin reports  six  cases of fracture of the cranium with
depression, five of which  exhibited no constitutional symptoms
of cerebral compression at  or near  the  time of receiving the
injury.  Two of the individuals, in whom the depression was suf-
fered to remain,  became epileptic and insane, and were relieved,
five months subsequently,  by the trephine.
  1844.  In the first case, a negro man, between thirty and forty
years of age, the injury was inflicted  on the left parietal bone, at
its juncture with its fellow,  and  a little anterior to the lamb-
doidal  suture, the crown of the largest trephine was just suffi-
cient to comprehend the depressed portion of bone.  Upon remo-
ving this, numerous spiculse of  the bone were found pressing
upon, but not penetrating, the dura mater,  and were carefully
removed.   The recovery of the patient from epilepsy and insanity
was complete in a few weeks; but his general health, which had
become very much impaired,  was not restored, and a year after-
wards he became the subject of paralysis of the lower extremities-
and died dropsical two years after the receipt of the injury.  No-
autopsy was made.
  1844.  The second  case, was that  of  a youth, aged  sixteen,.
who, in a fall from a tree, received a snag in the orbit, a portion
of which was broken off and remained concealed  in the wound
for several weeks.  After its removal, the  wound healed,  but
soon afterwards epilepsy, with furious insanity,  supervened.
Five months from the reception of the injury, the young man 
[55]
had from fifteen to twenty convulsion daily.  An opening was
made wTith the  trephine into the frontal sinus,  and the superior
orbitar plate found to have suffered comminuted fracture;  the
fragments were removed, and the patient perfectly recovered,
having had but one fit after the operation.
  1845.   The third case, was that of a little girl, twelve years of
age, who, from the kick of a horse, sustained a compound  frac-
ture with depression of the anterior inferior portion of the right
parietal  bone.   No  constitutional  symptoms supervened.  She
was trephined, the depressed  bone was raised, and she recovered
without a bad symptom.
  1846.   Case  fourth was a negro boy, aged fifteen years, who
sustained a compound  fracture of the parietal bone, mid-way
between its  centre  and posterior superior angle.   A piece of
bone, the average  diameter  of which was about half or three
quarters of an inch, of an irregular circular shape,  was entirely
detached, and  driven down upon the brain; the  fracture being
greater  in the internal than the external  plate,  required  the use
of the trephine for  its  removal.   There were  no constitutional
symptoms present, and the recovery was complete and permanent.
  1847.   The fifth case was that of a negro boy,  twelve  or thir-
teen years old, who was thrown againt a tree  by a horse, and
suffered a depressed fracture of the parietal bone;  profound coma
existed,  and the circulation was feeble.  On the day succeeding
the injury, he was trephined without producing any amelioration
of symptoms, and  on the day following he died.  No autopsy
was made.
  1847.   Case sixth was that  of a man, about thirty years of age,
who received a blow on the  forehead  with an  axe, producing a
fracture  running obliquely from a point  a  little external to the
centre of the right supercilliary ridge upwards and inwards nearly
to the median line of the frontal bone, and reaching about two
thirds the height of the forehead.  The upper portion  of the
fracture wras deeply depressed, the skin was unbroken.  No con-
stitutional symptoms existed—the trephine was used,  the  bone
elevated, and the  patient  recovered without  any untoward
symptoms.
  Dr. H. contends that the  immediate danger of  inflamma- 
[56]
tion and the more remote secondary consequences are far greater
than that arising from the  use of instruments, and that,  conse-
quently, in all cases of clearly ascertained fracture with depres-
sion, whether  simple or compound, the bone should be elevated
or removed.
  The paper of Dr. Hardin is one of much practical value, and
I beg leave, therefore,  to recommend it to your special consider-
ation.   The facts which he adduces are strongly corroborative of
the truth of the doctrine which he attempts to vindicate.  On
this subject, however,  we must wait for fuller experience; " ad-
hue subjudice Us est."  Two of the cases which Dr. Hardin has
brought forward, afford another happy illustration, if fuller illus-
tration were needed, of the beneficial effects of the operation of
the trephine in epilepsy, occasioned by depressed fracture of the
skull.
  A case in which the trephine was successfully applied for the
cure of  epilepsy has been reported by Dr. E. L. Dudley.*  The
disease was occasioned by a  depressed  fracture of the skull, at-
tended with the loss of a considerable portion of the frontal bone.
The accident occurred  in February, 1850, and in  the month of
June following, the patient,  who was a black man, aged thirty
years, and  who had been previously doing well, was seized with
a very  severe convulsion.   In  a short time another paroxysm
occurred, then another and another,  until scarcely a day  passed
without one.  The  man rapidly lost his sprightliness, began to
stammer, and acquired an idiotic  expression.  The operation of
trephining  was performed in July, 1851, about seventeen months
after the receipt of the injury, and a segment of bone, sufficiently
large to command the entire circuit of the depressed space, remo-
ved.  "Theremaining portion of the operation consisted in care-
fully dissecting the  scales off the internal table of  the os frontis,
some of which were turned edgewise upon the dura mater, others
embedded  in  masses  of lymph, and two sharp, thin processes
projected into the cavity of the skull from different  points of the
bone circumscribing the original seat of the injury.  These  last
were cut away with the rugine,  and in  this period  of the opera-

  * Transylvania Medical Journal, October 15, 1851, p. 85. 
[57]
tion, our labors were temporarily suspended by the occurrence
of a terrible  convulsion."  Simple dressings were  applied, and
four days passed in the most flattering  manner.  At the end  of
this time, the convulsions recurred with great violence, and con-
tinued, with little, if any abatement, for about fifty hours, when,
an incision being made  into the dura mater and a small quantity
of bloody serum discharged, they  entirely ceased, and  never re-
turned afterwards, except in a very slight degree, upon one occa-
sion.  The recovery wTas complete.
  The following cases of fracture of the skull deserve mention
here on account of the great extent of the injury both to the cra-
nial bones and to the brain.  The first is given by Dr. Abraham
Addams, of Cynthiana, in the fourth volume of the  Transylvania
Journal of Medicine and the Associate Sciences,  and occurred
in a boy, nine years of  age, from the kick of a horse.  The frac-
ture was two inches and a half in length, and was  seated in the
left parietal bone, which was broken into numerous fragments,
some of which were depressed and  forced  into the meninges,
which were torn to such an extent as to permit a  free discharge
of cerebral substance.  The patient, when seen, soon after the
accident, had laborious  respiration, irregular pulse, dilated pupils
and paralysis of the left arm, and was in a state of continual
restlessness,  "writhing and twisting like a worm."   All  the
loose pieces of bone being removed with the trephine and eleva-
tor, and the parts cleared of blood, the boy, under  an occasional
bleeding, and the daily use of cathartic medicines,  was progress-
ing favorably until the  eleventh day, when, in consequence of the
undue pressure of the  head-bandage, he was seized with violent
convulsions, lasting several hours.  About this time also a fungus
made its appearance, but soon gave way under the pressure of a
sponge and roller.  Two months after the  accident, the lad was
entirely well, the wound completely healed,  and the paralysis of
the arm relieved.
   A case of extensive fracture of the  skull  and rupture of the
meninges,  with loss of substance of the brain, and subsequent
recovery, is  given by Dr. John  Swain, of Ballardsville.*  The

  * "Western Journal of Medicine and Surgery,  vol. 5., p. 473.  Third SerieB,
1850. 
[58]
patient was a boy, 12 years of age, who was kicked on the head
by a horse, on the 13th of October, 1848.  An  hour and  a half
after the injury, he complained of but little pain, and was per-
fectly rational, answering all questions satisfactorily.   " The blow
covered the os frontis and the nasal bones, crushing the former,
depressing the latter, separating the head from the face, and mak-
ing an  external wound, reaching  from the outer angle  of the
right eye to the lesser canthus of the left, sufficiently open to
admit  the passage of the finger  behind the ball of either eye."
A portion of the frontal bone, one inch wide and one and a half
in length, and including the orbitar arch, and  a portion  of the
orbitar plate, one inch by four lines in size,  were completely de-
tached, and completely buried in the substance of  the  brain,
about a table-spoonfull  of which was lost in the dressing.   Small
fragments of the supra orbitar arch on the right  side were raised
and removed.   The edges of the wound were  brought together
by the interrupted suture, and covered with  lint, a compress and
a roller.  No untoward symptoms  arose;  the reaction came on
quietly and  slowly, and the pulse at no time exceeded a hundred
beats in the minute; and on the 8th of December the boy  was so
well as not to require any further attention  from his surgeon.
All his faculties and functions appeared perfectly healthy,  except
the sense of smell, of which he is wholly deprived.
  A case of extensive fracture of the skull with loss of cerebral
substance, has been sent to  me by Dr. Samuel R. Sharpe, of Mays-
ville.  A youth, of the name of  Dunlap,  aged 15 years, was
thrown from his horse into the  bed of a creek.  The. accident
was attended with extensive fracture of the right parietal bone,
depressing to the depth of three-quarters of an inch, a loose
fragment, one inch and a half in length by  one  inch in breadth
with sharp,  cerrated edges.  The  piece lacerated the membranes
of the brain in its entire length, and embedded  itself in the sub-
stance  of this  organ.  The lad was very restless and perfectly
insensible;  the extremities were cold, the pulse was feeble, and
every convulsive movement was followed  by the escape of more
or less medullary matter.   The accident  occurred in the dusk of
the evening, and the depressed fragments, eight or ten in number,
were not removed until the  next  morning, at  9 o'clock.  Two 
[59]
very extensive pieces, held only by some very slight spiculse, were
elevated and adjusted, in the  hope that, should the boy survive,
they might unite, and thus diminish the gap in the skull.  The
quantity of  medullary matter  lost must have been  from an ounce
and a half to two ounces.   Consciousness  returned partially on
the third day, but  the boy was  not coherent  for weeks.  Cold
water dressings were employed.   About the tenth  day, fungus of
the brain appeared, requiring  compression for its relief.  When
last heard from, a considerable period  after the accident, the lad
was entirely well, with the exception of a slight inability to arti-
culate certain words.
  Dr. William Kenney, of Millersburg,* states that he was called
to a youth of 17 years, who,  on the  night of the 25th of July,
received a stab with a common pocket knife, the blade of which
was two inches and a half in length and three-quarters of an inch
in width, tapering abruptly to a point.  The wound was situated
on the  left  temporal region,  nearly  midway between  the outer
angle of the eye and the auditory meatus.   The blade of  the in-
strument was completely  buried in the brain, and was so firmly
fixed in the skull that it was withdrawn with great  difficulty.  Its
removal was followed by the loss of ten or twelve ounces of blood,
vomiting, and stupor.  During its presence in the brain, as well
as for some time after, the patient complained of severe pain in
the  left  eye  and frontal  region.  The injury was followed by
symptoms of slight cerebritis,  which soon yielded  to the free use
of cold  applications to the scalp, mercurial purgatives, low diet,
and perfect rest.

                    Fungus of the Brain.

  In the treatment of fungus of the brain, an affection which not
unfrequently arises  after compound fracture of the skull and  the
operation of trephining,  Dr.  Dudley placed great confidence in
the employment of gentle and sustained pressure with dry sponge,
aided by the roller.   A knowledge of the capacity  of the brain to
accommodate itself to preternatural compression in apoplexy and

  * Western Journal of Medicine and Surgery, third series, vol. 4, p. 307,1849. 
[60]
■>»ther disorders, first suggested to him, it would seem, the advan-
tages of this  mode  of practice.  In the  first case in which  he
resorted to it, a dry piece of sponge was applied to the fungus,
and bound down with a bandage as closely as the feelings of the
patient would admit.  " By imbibing  the secretions of the part,
the pressure on the protruded brain regularly and insensibly in-
creased until the sponge  became completely saturated.  On the
removal of this dressing, its decisive influence and superior effi-
cacy remained  no longer a matter of doubt, although  it was
difficult to remove the sponge, in consequence of its being exten-
sively penetrated  by blood-vessels originating on the  surface of
the brain.  With a view to prevent this inconvenience in future,
a fine piece of thin muslin  was interposed.   By  the gradual and
regularly increasing pressure of the sponge, I was enabled, in the
course of a few days, without incommoding the patient, to replace
a mass of protruded brain,  equal  in magnitude  to a  small hen's
egg;  nor have  I, in any subsequent case, experienced any diffi-
culty whatever, relying upon the same mode of treatment."*

             Fungus  Tumor of the Dura Mater.

   Under this head may  be  mentioned a  remarkable  affection of
the brain and its membranes, communicated to me by my friend,
Dr. James C. Johnston, formerly  one of  the most eminent prac-
titioners of Louisville.
   An old gentleman, after having experienced, for nearly  six
months,  the most excruciating pain,  apparently of  a neuralgie
character, on the top of the head, perceived, early in April, 1817,
a slight-protuberance at the seat of his suffering, hard and firm,
immovable, indolent, and about the size  of a pigeon's egg.  As
it increased it gradually became soft and pulsating, thus inducing
the  belief that it was aneurismal.  Under this impression, an
operation was decided upon.  Accordingly  a  crucial  incision,
three inches  in length, was made across  the tumor, which, when
carefully denuded, was found  alternately to swell and retract
precisely like an aneurism.  Continuing the dissection, the tumor

   * Transylvania Jour, of Med. and the Asso. Sciences, vol. 1, p. 38. 
[61]
was next disengaged from its attachments to the periosteum and
dura mater, and elevated from its  bed in the skull, which wa&
perforated to the extent of about a quarter of a dollar in diame-
ter.  The hemorrhage  was inconsiderable, and  the wound was
dressed in the usual manner with adhesive strips, a compress and
bandage.
  The parts progressed favorably until the eighth day, when, upon
removing the dressings, the tumor was found to be springing up
again.  It grew quite rapidly, and by the fifteenth day after the
operation it had acquired the size of a hen's egg;  it was pedun-
culated,  and  presented a cauliflower  appearance. The tumor
was now excised a second time.  The hemorrhage was so profuse
that the patient came near dying before  it  could be arrested.—
The wound was dressed as before, and the antiphlogistic  treat-
ment strictly adhered to.   For a fortnight the symptoms were
favorable, when this hydra again reared its fearful head.  Prof.
Dudley, of Lexington, was now consulted, and the tumor treated
with compression, made with a sponge, and adhesive  strips long
enough to reach from  one side of the head to the other.  This
plan had the effect of checking the outward march of the growth,
but promoted  its extension inwardly, and after having continued
it till the 14th of October, it was finally abandoned.  The patient's
health, which had hitherto  been good, was now somewhat im-
paired.
  The tumor,  in a few  days,  again sprouted out externally, and
soon attained its former bulk.  It was now attacked, first, with
the nitrate of silver,  then with the knife,  next with the butter of
antimony, and, finally, with the actual cautery; the latter of which
alone had  any effect in  repressing it.   After continuing it for
about six weeks, it had to be laid aside from its mischievous ac-
tion upon the brain.
  In September, 1818,  the case fell into the hands of an empiric,
who  with  the aid of  his remedies,  removed the  whole of the
fungus in two weeks.  The growth now assumed a new charac-
ter  numerous pieces of bone, from a quarter to half an inch in
thickness, being intermingled with its substance.  The applica-
tions were continued until they had formed a cavity in the  brain
capable of receiving  a common sized  tea-cup.  Meanwhile, thir- 
[62]
teen pieces of bone, as big as an ordinary bean,  had come away
with the eschars, and the destruction of the cranium had reached
three inches in diameter.   Severe  ptyalism  supervened, lasting
two months.  Upon recovering from this, the general health  im-
proved so much that the patient determined to visit Philadelphia,
for the purpose of consulting Dr. Physick.   He accordingly  em-
barked for New Orleans, where, shortly after his arrival, he  was
attacked with fever, which prostrated him so much that he  was
obliged to abandon  his tour.  He lingered out a miserable exis-
tence till December, 1819, when he expired,  retaining to the  last
all his intellectual faculties and his power of voluntary motion.
What is remarkable, the patient never had,  at any period of the
disease, a symptom that indicated any aftection of the brain,  nor
was he ever sensible of  any of the applications that were  made
to the fungus.   No examination of the  body was permitted.   A
finger, however,  introduced into the parts, detected the presence
of stalactiform exostoses, extending downwards  into the brain,
and uniting at the bottom with a bone,  which was firm  and  im-
movable, and appeared to hav^ b^sn formed  expressly to protect
the brain from the influence of the fungus.   The scalp and outer
plate of the cranium,  round the tumor, were  sound.
   The above tumor, of which I can give only a faint outline,  was
supposed  by the patient to have been caused by a blow he re-
ceived upon the crown of the head  by bringing it in contact with
the sharp corner of a mantle-piece.

            Extirpation  of the Parotid Gland.

   The only operation  of this kind,  in Kentucky, was performed
in 1841, by Dr. Samuel B. Richardson, of this city.  I was pres-
ent on the occasion, and am happy to say that the result was  per-
fectly successful.  The following are the particulars of the case.
   The patient was a married lady,  aged nearly thirty, the mother
of several children,  wrho, about four years before, noticed some
enlargement and induration of the "right parotid gland, attended
with  uneasiness and  occasional pain.  In the autumn of 1840
the tumor was hard and unyielding, smooth on the surface, pain-
ful,  considerably elevated  above the angle of the jaw,  and  en- 
[63]
tending upwards in front of the ear, the lobule of which it some-
what displaced.  It dipped profoundly inwards  between the ra-
mus of the lower jaw and mastoid portion of the temporal bone.
admitting of but  little motion.  The head was considerably and
permanently extended  upon the spine.  Deglutition and  masti-
cation were performed with difficulty.  The pain  in the tumor
especially during the last four weeks, had been constant, at times
acute and lancinating, interrupting sleep and appetite, and radia-
ting among the surrounding structures.  The general health had
always been good  prior to the present malady, and the neck and
face were free from other enlargements.  The patient had already
been subject to different modes of  treatment, and her reluctance
to an operation induced Dr. Richardson to place her upon a pro-
tracted course of iodine,  both  internally and externally.  No ap-
preciable benefit resulted.   In fact,  the disease continued to ad-
vance, with an augmentation of all her suffering.   She  had
become weak and thin,  and labored  under severe  constitutional
irritation.
   On the  19th of  February,  1841,  with  the  assistance of Dr.
Donne, Dr. Caldwell, and myself,  Dr. Richardson performed the
following operation.  The  patient's  head  and shoulders having
been elevated, and the former fully extended,  a crucial incision
was made through the skin and cellular substance, over the centre
of the tumor, near its greatest elevation.  The first incision was
nearly vertical, extending from a point about three-quarters of an
inch in front of the upper  attachment of the ear, downwards to
about two  inches and a half below the  angle of the lower jaw;
the  second  cut was nearly at right  angles  with the preceding.
The flaps being dissected up, a double hook was plunged into the
body of the tumor, and handed to  an assistant, whose skillful use
of the instrument  greatly facilitated the subsequent steps of the
operation.   The temporal and masseter divisions of the  morbid
growth  were first  elevated, when the mass was forcibly drawn
forwards, and its attachments to the surrounding parts severed,
care being taken to keep the edge of the knife close to the mas-
toid portion of the temporal bone, to avoid  the external  carotid
artery.   The dissection was then continued inferiorly and anteri-
orly, behind the ramus of the  jaw, chiefly with the handle of the 
[64]
instrument,  until the vessel in question was  isolated near its en-
trance into  the  parotid.  A double  ligature was then passed
beneath it, and tied at two points, when the artery was divided
between  them.   The  deeper  attachments  were next severed,
mainly with the fingers and handle of the scalpel, as far as the
pterygoid and styloid  muscles  and the walls of the  pharynx,
when the pedicle of the tumor was surrounded by a ligature and
tied.  The styloid process was partly denuded.  The hemorrhage
was  free in the early stage of the operation, but inconsiderable
towards its close.  Being satisfied that the whole of the diseased
gland was removed, the lips of the wound were brought together
by sutures and adhesive strips.  During the progress of the oper-
ation, the jugular veins were carefully compressed  by an assis-
tant,  and quite a number of arteries, chiefly branches of the au-
ricular and temporal, were tied.
  Acute erysipelas attacked the wound on the  second  day after
the operation, extending to the face and  right  side of the head,
and necessitating the removal of the dressings.  A free discharge
of bloody and offensive matter followed.  In  less than a week,
the inflammation had nearly subsided, andthe greater part of the
wound was found to  have united.   From  this  time the con-
valescence was rapid.   The right  side of the face was paralyzed
by the operation, and  no saliva was  afterwards found to issue
from  the anterior extremity of the Stenonian  duct.   Dr. Rich-
ardson saw the woman  in good  health two years after the opera-
tion.  The paralysis of the face,  however, continued, and the
mouth on the corresponding side remained unusually dry.  The
centre of the cicatrice  was marked by a  deep depression, con.
trasting remarkably  with  the rotundity and smoothness of the
sound side.
  " Dissection,'* says Dr.  Richardson, " demonstrated that the
gland had undergone the fatty degeneration, nearly in its entire
extent.  Its cellular  arrangement,  however, seemed to be pre-
served, and an oily, greasy fluid exuded from its substance on
pressure.  Some portions of it were condensed, and the capsule
of the gland was much attenuated, being partly ruptured during
the operation.
  " An interesting case is mentioned  by Professor Gross, in his 
[65]
 valuable work on Pathological Anatomy, in which Dr. Parker,
 then of Cincinnati,  removed the parotid gland for a similar de-
 generation.  This, so far as I  know, is the first instance of this
 affection upon record."

                     Ophthalmic Surgery.

   Ophthalmic surgery, one of the most interesting departments
 of the healing art, has not been neglected  by our practitioners.
 Operations for cataract,  artificial pupil, entropion, ectropion and
 lacrymal fistula have been frequently performed,  and with a de-
 gree of success highly flattering to Kentucky skill and judgment.
 Dr. Dudley, in speaking, in his paper on " Calculous Diseases," in
 the  Transylvania Journal of Medicine, of the importance of a
 due  preparation of the system in all surgical operations, inciden
 tally remarks that he had failed in  only a solitary case of cat-
 aract,  from the supervention of inflammation, in a  practice of
 twenty-five years.  Few oculists,  any where,  can boast of such
 success.
   The operation of extraction of the cataract  has  not, I believe,
 been often attempted in our State.   In  my own practice,  I  have
 usually, where the circumstances have been propitious, preferred
 couching to every other process, and,  thus far, I have had no
 reason to regret my choice.  I have not  been able to learn the
 nature of the operation generally adopted by Dr. Dudley and the
 other surgeons of the State.   My experience has  furnished me
 with the important practical fact, that the operation for cataract,
 by the absorbent method, may commonly be performed with  little
 or no risk of inflammation, without prepaiation of the system, in
 children under three  or four years of  age, while such a risk is
 very great, without preparation, in older subjects.
   Extirpation of the  ball of the eye,  for  malignant disease, has
 occasionally been  resorted to, but in no instance, so far as my
 knowledge extends,   with  any encouraging  results.    My  own
 cases amounting altogether to about eight, have all been followed
 by a return of the morbid growth, and by the speedy death  of
the patient.  In  one instance, that of a Miss Evans, from Muhlen-
bur<>* county, who had enccphaloid disease of the right eye, I ex-
         5 
[66]
 tirpated, in the first instance, the whole of the contents of the orbit,
 and in less than four weeks I performed a second operation  for
 the removal of the new formation.  In a few weeks the disease
 re-appeared with all its former intensity,  and rapidly destroyed
 the patient.   A similar case was brought to me some years ago,
 from Cincinnati, in the person of a young gentleman, of the
 name of Murrell,  about thirteen years of  age, upon whose eye
 Dr. Mussey had already performed two operations.  The disease
 soon returned after the second operation, and when I saw the pa-
 tient, a few weeks after, it had made such progress as to preclude
 the possibility of another resort to the knife.
  Very little  has  been written on this organ  by Kentucky sur-
 geons.  Almost  the  only contribution upon the  subject is to be
 found in the  first volume of the Western  Journal  of Medicine
 and Surgery, of which it occupies about thirty-five  pages.  It is
 from the pen of Dr. William A. McDowell, formerly of this city,
 now of Evansville, Indiana,  and is entitled  " Surgical and Path-
ological Observations on the Eye."  The whole paper  is worthy
 of an attentive perusal.  The chief objects which  the author had
 in view in publishing it, were to  make known a supposed dis-
 covery in the anatomy of the eye, and to give  publicity to  an
 operation, the section of the conjunctiva,  which  he believes to
constitute an improvement in the surgical treatment of conjunc-
tivitis.
  The new structure described by Dr. McDowell  is situated be-
tween the conjunctiva and  the sclerotica, where it forms a thin,
but firm lamella, which the Chairman of  your Committee had
described sometime  previously,  in the  first edition  of his Ele-
 ments of Pathological Anatomy, issued at Boston, in 1839, and
 which he had  been in the habit of exhibiting to his pupils for a
 number of years prior  to that period, under the name of the
"ocular fascia."  The author, of the  paper in question,  gives a
very clear and  graphic account of the texture and relations of this
membrane, and of the important part which it plays in the  in-
flammation of the eye, especially in the  different varieties of
 conjunctivitis.  It is  surprising that this structure should have so
long escaped the notice of American and European  anatomists.
  The greater part of Dr. McDowell's article is taken up with a 
[67]
consideration  of  the different  varieties  of conjunctivitis,  of
which he has furnished a  very  excellent  account, and for the
more inveterate forms of which  he proposes the division of the
conjunctiva and ocular fascia, with the view of cutting off the
supply of blood to the cornea, the sclerotica, and the iris.  He
recommends the operation, which, it would seem, he has been  in
the habit of practising for the last twenty years, to be performed
with a common tenaculum and a  pair of slender scissors, having
a delicate probe-point, "a little longer than the  extremity of the
antagonizing blade."   The membranes are elevated with the for-
mer of these instruments, while with the latter  they are divided
entirely round the cornea,  from  one-eighth  to  one-fourth of  an
inch  from its connection with the sclerotica.  The  immediate
effects of the operation are, the  retraction of the edges of the
wound, and a free discharge of blood from the divided vessels,
followed by a rapid decrease of the inflammation.  The gap left
by the knife is gradually repaired by the adhesive process, and
is not succeeded by any perceptible cicatrice.  The practice here
recommended, and to the efficacy  of which I bear testimony from
personal experience, differs  from  that of Scarpa, Lawrence, Mac-
kenzie, and others, in being of a  more decisive character,  and  is,
therefore, more worthy of imitation in all cases of ophthalmia,
attended with infiltration of the cells of the ocular fascia, and  an
extension of the  morbid action to  the  deep-seated structures  of
the eye.
   Dr. Asbury Evans, of Covington, has sent me the particulars
of a case of congenital cataract,  in a young man, of twenty-one,
whom he restored to sight by the operation, by division.  The
lens  in the right eye was very soft, while in the left it was so
fluid that the moment the needle entered the capsule,  the cham-
bers were suffused with a whitish milky substance.  The instru-
ment was immediately withdrawn, as its movements could  no
longer be perceived.  The operation was done twice on each eye.
The  pupils soon  became clear,  but for a long  time the young
man  saw objects indistinctly, in consequence, as was thought, of
debility of the retina from long disease.   The operation wTas per-
formed in September, 1849, and when Dr.  Evans heard from the
patient recently, he could, with the aid of glasses, see a squirrel in 
[68]
the top of the highest tree, and was able to thread a fine cambric-
needle.
  A case, similar to the above, came under my observation in the
spring of 1851, in the person of a young girl, of the name of
Amanda McGuire, of  Mississippi.   The cataracts, which had
existed from infancy, were mainly capsular, and obstructed vision
so much that the patient was wholly unable to perceive objects
distinctly.  The operation was  performed with the needle, first
upon one eye, and, in a few weeks, upon the other, and was fol-
lowed by hardly any inflammation; absorption went  on rapidly,
and when Miss McGuire left, a few  months after, her sight was
most excellent.
  It was interesting, in this case, to witness  the joy which this
girl experienced at beholding the different objects that were, from
time to time, presented to her notice.  Things which she had long
been accustomed to distinguish by the sense of touch, were, when
placed before her eyes, such entire strangers to her that she was
utterly unable to recognize them.   She had no definite ideas of
form, color, bulk, or distance.   The appearance of a cat or dog
made the same impression upon the retina as that of an  inani-
mate substance, as a pitcher, tumbler, or bottle.  When held before
her eyes,  she could not tell the difference, but the moment she
touched them she recognised them,  and expressed her astonish-
ment.  She soon learned to know such objects as were used for
experimental purposes.   Her delight on beholding the moon was
unbounded, and this was still further increased,  in a short time
after, when she was able, on a clear night, to distinguish  the
stars, as they hung, like living lamps,  upon the firmament, daz-
zling and bewildering her  innocent and unsophisticated mind.
A  more full account of this case will shortly  be given  to the
public.
                   Polypus  of the Nose.

  Under this head may be mentioned a case of polypus, reported
by Dr. John C. Brent, formerly of this city. *  The tumor was of

  * Louisville Journal of Medicine and Surgery, No. 1, p. 44, 1838. 
[69]
 unusual size, and occupied the left nostril,  affecting the speech
 and respiration, compressing the nasal duct, and causing frequent
 and violent paroxysms of sneezing.   The extraction was effected
 by the joint agency of the ligature and forceps; and  the narrator
 lays much  stress upon the preparatory treatment, consisting  of
 the daily introduction, for three weeks, of bougies, catheters, and
 probes, to familiarize the  parts to the  contact of instruments —
 He expresses the opinion that without this treatment the attempts
 to apply the ligature would have proved abortive.  The reporter
 begs leave  to state, that in all his operations,  amounting to sev-
 oral dozen,  he has never been obliged to resort to the  ligature,
 except when the tumor projected into the fauces; having always
 been able to accomplish his object  with  the forceps, and  that
 without any special preparatory treatment.  In the case  under
 review, the  polypus was attached by a very narrow pedicle, and
 might,  therefore, have been easily extracted by torsion.   The
 narrator does not give the specific character of the tumor.

   Excision of the Superior and Inferior Maxillary Bones.

   No  one in Kentucky, excepting myself, has, I believe, ever re-
 moved either of  these bones,  for disease of their substance.  At
 all events, there  is no record, so far as my knowledge extends,  of
 such an operation.   I am aware that an attempt was made, some
 years ago, by an eminent surgeon of this State, to remove a med-
 ullary tumor from the antrum of Highmore; but his  efforts fail-
 ed, and the patient, a man, sixty years of age, died shortly after-
 wards from the effects of the malady.*
   I have now removed the superior maxillary bone, either in part,
 or entirely,  seven  times, and the inferior  maxillary bone,  five
 times; thrice at  the temporo-maxillary articulation, and twice at
 the symphysis.   The lower jaw cases have all .recovered, and are
 doing  well; while of the upper jaw cases, four have died,  two
 from a recurrence of the disease, for which they were subjected
 to the knife, one  from the effects of pneumonia, and one from the
reflects  of dysentery.  The particulars  of  these cases,  together

  •* Transylvania Medical Journal, February, 1850, p. 329- 
[70]
with an account of the more frequent diseases of the maxillary
bones, and the best method of effecting  their removal, will be
iound in the Western Journal of Medicine and Surgery, for Sep-
tember and October, of the present year.  The contribution to
this  department of  surgery, thus furnished, comprises nearly
seventy-five  pages.

              Immobility of the  Inferior  Jaw.

  To the abuse of mercury, so common in the United States, but
especially in the South-west, surgery is indebted for an extension
of its province,  or, to use a modern, and  somewhat cant expres-
sion, for the annexation of a most serious  and important class of
cases.  I allude to what is called,  immobility of the lower jawT
caused by  ulceration and  sloughing of the gums, cheeks,  and
osseous tissues, in consequence of the inordinate, or, perhaps,  I
should say, injudicious and unfortunate use of calomel and other
preparations of mercury.  The persons most subject to this affec-
tion, as far as my observation extends, are young children, under
ten years of age, of a weak habit, and a scrofulous temperament.
Not  unfrequently, however, it is observed in* those more advanced
in life, especially in delicate females, worn out by protracted dis-
eases, such  as typhoid and other fevers, or profuse discharges of
blood, leading to an impoverished state of  the general system.
Under such circumstances, the smallest quantity of mercury is
often followed by the most horrible consequences;  consequences
so well knowrn to every member of this Society,, that it would be
a work of supererogation to describe them.  It is for the relief of
these effects, so distressing  and disfiguring  to the poor sufferer,.
and so disgraceful  to the practitioner,  that the resources of sur-
gery are called into requisition.  Unfortunately, however, neither
the art nor the science of this branch of the profession  has hith-
erto  been of much avail.  My own  cases, amounting to eight,.
have, with three exceptions, been unrewarded  with any but the
most transient success,  notwithstanding the most extensive
thorough, and patient dissection imaginable.  In  the course of
three, four or five weeks, the adhesions were as firm as ever, des-
pite  the greatest care to prevent them by the employment of me- 
[71]
chanical  means.  My friend,  Dr. Samuel B. Richardson, of this
city, who seems to have had quite his share of such cases, informs
me that he has operated four  times, in three with very fair suc-
cess, and in one with partial relief.  All his cases were the effects
of mercury.  It affords me pleasure to be the humble instrument
of communicating to the profession any favorable results of this
kind.
                   Antrum of  Highmore.

  A case of wound of the superior  maxillary sinus,  treated by
Dr. William H. Donne, of Louisville, and reported by Dr. R. S.
Wendell,  in the sixth volume of the Western Journal of Medi-
cine and Surgery, may be briefly mentioned here, as it possesses
extraordinary  interest.  The patient, a German gardener, forty-
two years of age, was struck, in a rencontre, in May, 1840, with
a dirk-knife, which entered about an inch above the right super-
ciliary arch, and passed downwards and  backwards through the
corresponding eye,  evacuating its humors,  and penetrating  the
antrum.   After recovering from the primary effects of the injury,
the patient waited upon Dr. Donne, in August, 1842, stating
that for the last six months he had been annoyed by a rough,
projecting substance, which he had been informed was a piece of
dead bone, but which  he believed  to be the point of the knife
with which he had been wounded, upwards of  two years  ago.
On looking into the mouth a small black speck was seen, about
half an inch from the space between the  first and second molar
teeth.  The parts adjacent were  somewhat inflamed  and  tume-
fied. After dissecting around the speck with a bistoury, down to the
palate  process of the superior maxillary bone,  Dr. Donne  was
enabled to get a  firm hold of it with a pair of curved forceps,
with which he extracted, though  not without difficulty, a frag-
ment of the blade,  one inch and a quarter  in length, by three-
quarters of an inch in width.   A rapid recovery  was the  conse-
quence.
  Dr. Donne has  recently informed me that he removed,  six
months after the above  operation, another piece of blade nearly
as long as the first.  The patient has since remained well. 
[72]
                       Staphyloraphy

   I do not find, by a reference to our periodical  literature, any
mention of the operation of staphyloraphy by any  of our  Ken-
tucky surgeons, nor have I  received  any oral or written intelli-
gence of such  an undertaking.  The probability,  therefore,  is
that this department of the  profession has met with little atten-
tion in this part of the United States.   If there be any exception
to this statement, it is due  to myself who have performed this
operation four times within  the last four years.  Of these cases,
three were  entirely  successful, while the other  was a partial
failure.
   My first  operation was performed, in the  summer of 1848,
upon a young lady, aged fourteen,  from Paducah, in this State.
The cleft had existed from birth, and affected both the head and
soft  palate.   After having pared  its edges,  the parts  were  accu-
rately approximated  by four points  of the interrupted suture, in-
troduced by means of Schwerdt's  instrument, and perfect union
was  the consequence, except just at the anterior extremity of the
fissure,  when there was a complete deficiency of the soft sub-
stance.  An attempt was afterwards made to close this aperture,
which was hardly a line and  a half in  diameter, by dissecting the
mucous  membrane from the  surrounding parts, and  stitching the
flaps thus formed evenly together.  This also failing,  the young
lady now wears a small obturator, which, although clumsily con-
structed, answers  the purpose perfectly.   Her  articulation  is
much improved, and her condition is most comfortable.
  In my second  case, that of a young lady, of about fourteen,
from Alabama, severe inflammation supervened upon the opera-
tion, followed by the premature  detachment  of the  two upper
ligatures, and the want of union of the corresponding portion  of
the fissure.  Another effort was made to close the  aperture about
a week afterwards;  but this  also failing, and for a similar reason,
the patient was  sent home.   A year subsequently she re-visited
Louisville,  when two other operations shared  the same fate, al-
though every possible precaution  had been used  to prepare the
part and system for the undertaking.
   In the winter of 1850, I operated before the medical  class  of 
                            [73]

the University of New York, aided by the late Prof. Pattison,
upon  a young woman, twenty four years of  age, a resident of
Orange county, New York.   The success was perfect.  Four
stitches were introduced, as in  the previous case, and allowed to
remain there till the end of the fifth day, and the other till the
close of the sixth.   The patient's system was in  a most excellent
condition,  previous to the operation,  and the  result was  that no
undue inflammation followed its execution.
  My fourth case occurred last  winter, in  the  person of a young
gentleman, of the name of  Bowers, who  was  sent to me by Dr.
De Bruhler, of Rockport, Indiana.  The operation was performed
at my  medical clinique,  in  presence of the medical  class of the
University of Louisville, and with the kind assistance of Dr. T.
G. Richardson.  The patient was a man of immense strength,
and such wras the contraction of the muscles of the palate that it
was found  almost impossible to finish the  operation.   The parts,
however,  were at length satisfactorily approximated by  four su-
tures, and, to my surprise, united nearly in their entire extent by
the first intention.  A small gap was left a little above the centre
of the cleft, which was afterwards partially closed by two stitches.
After the  patient went home,  the  little orifice  which remained
was healed up by the repeated application of nitrate of silver, in
the hands  of Dr. De  Bruhler.  Although this patient was copi-
ously bled  and purged, as well  as thoroughly dieted for ten days,
before  the operation,  such  was the inflammatory disposition of
his system, that I was obliged to take blood twice afterwards from
the arm, and to keep him upon the most  rigorous antiphlogistic
regimen.
II.--AFFECTIONS  OF THE SPINE.
  The spine, as is well known, is an object of little surgical in-
terest, at least  so far as it concerns  the  operative part of the
science.  The principal affections demanding the care of the sur-
geon are, fractures, dislocations, curvatures and sprains; to which
may be added the peculiar malformations distinguished by the
name of hydro rachitis, spina-bifida, or cleft spine.
  Fractures of the vertebra  are  occasionally  attended  with de- 
[74]
pression  of the  lamellae and  spinous processes, giving rise to
paralysis of those parts of the body  which are supplied with
nerves by that portion of the  spinal cord which lies below  the
seat of the  injury.  The records of Surgery furnish several cases,
probably altogether eight or ten, in which  an attempt was made
to relieve the cord, from the pressure thus exerted, by an operation
similar to that which is so generally necessary in fracture of the
skull,  attended with  depression of the bone and  symptoms of
compression of the brain.
  The first operation of the kind was performed in the spring of
1814, by the younger  Mr. Cline, of London; and,  though fatal,
the result showed that such a procedure might not only be profit-
able, but even highly proper.
  Thirteen years later, namely, in 1827, a  similar operation was
undertaken by Dr. Alban G. Smith, formerly of Kentucky, now
Alban Goldsmith, of New York, with hardly any better success.*
  The case of Dr. Goldsmith is so interesting that I shall offer no
apology for giving an abstract  of  it.   A  young gentleman, in
falling from his horse, struck  his  back in such a manner as to
cause  a  fracture of several of the upper  dorsal vertebra.  The
accident, which occurred on the 31st March, 1827, Mas immedi-
ately succeeded by paralysis of the muscles of all the extremities,
with the exception of those above the elbow-joint.   The patient
had no control over  his  bladder and bowels, and was altogether
in a most  wretched condition.  In consultation with Dr. (now
Professor) Miller, an operation  was agreed upon, and performed
on the 5th  of October, 1827, as follows:—An incision, from five
to six inches in length, was made along the ridges of the vertebrae;
and another, which was transverse, and three inches and a quar-
ter in length, at each extremity of this, all down to the bones.
The soft parts,—common integuments, muscles and ligaments,—
were then dissected up as far as the heads  of the transverse pro-
cesses, close to which Iley's saw was applied, and the lamellae of
the vertebra carefully divided.   Considerable assistance was de-
rived in  the removal of the pieces, from a  small strong pair of

  * North American Medical and Surgical Journal, vol. 8, p. 94.  Philadel-
phia, 1829. 
[75]
 pliers or tooth-forceps.  The operator took out a part of the spin-
 ous processes of the first two vertebra?, half of the third, and the
 whole of the fourth ; the latter being the one which seemed to be
 most depressed.   The tent being placed at the bottom of the
 wound, the parts were brought together, and the patient put to
 bed.  He had a chill soon afterwards,  which was succeeded by
 a fever,  and some  bilious  symptoms,  which readily yielded to a
 dose of calomel.
    Some feeling gradually  returned to the extremities ;  and, for a
 while. Dr. Smith  supposed that  the  patient would soon entirely
 recover the use of his muscles.  This expectation, however, proved
 delusive ; for in a short time he became  as bad as ever.  He lin-
 gered on in a state of hopeless paralysis until some time in the
 year 1832, when he expired, from no other cause apparently than
 the  effects of  his  injury,  and without  having experienced the
 least benefit from the operation.
    Dr. Smith's  report of this  case  is defective.  For the date of
 the accident, the operation, and the patient's death, together with
 some of the other circumstances here stated, I am indebted to the
 politeness of Mr. J. R. Bryant, of Pleasant  Hill, Mercer county,
 Kentucky, who knew the  patient  intimately,  and was familiar
 with all the details of the  case,  from first  to last.   His letter tu
* me is dated September 6th, 1852.
  Hydro-rachitis, being generally,  and, from its very nature,
necessarily, a fatal affection, has  been made the subject of fre-
quent reflection and even experiment, with a view to the discovery
of some reliable mode  of treatment for its radical cure.  Unfor-
tunately, however, surgeons are no wiser, in this respect,  now
than they were centuries ago, when  the pathology of this lesion
was less  understood, and our  science was,  comparatively, in a
state of barbarism.  Under these circumstances it is  not without
pleasure  that I call your attention  to  a novel  and  ingenious
method of  treatment, proposed in  1840, by one of the Fathers of
the Profession, who, though not a practical surgeon, is thoroughly
acquainted with the principles of Surgery.  I allude  to Professor
Drake.  The treatment recommended by this distinguished medi- 
[76]
cal philosopher,* consists in emptying the abnormal sac by a
small puncture, and then filling  it with blood from the brachial
vein, or  temporal  artery of the little patient, care being taken
not to expose the fluid to the contact of the air in its transmission.
The retention of a small quantity of serum in the sac would not,
Dr. Drake thinks, be disadvantageous, as it would have a tenden-
cy to prevent the blood  from entering the theca of the  spinal
cord.  The blood thus  transferred would soon  coagulate; the
serum and coloring matter would be absorbed; and the fibrin,
gradually becoming organized, would  at length fill up and anni-
hilate the sac.   By and by, the fibrin itself would be removed,
just as in an aneurismal tumor, followed by a radical cure.  The
injection of blood might be repeated,  if necessary, two  or three
times.
  I am not aware that this suggestion has been put in practice
by an}r one, in Kentucky or elsewhere ; but, as it is founded upon
a thorough knowledge of  the  nature of hydro-rachitis,  and a
thorough acquaintance  with the  principles  of  physiology and
pathology, it is well worthy of trial, and I therefore recommend
it to your serious consideration.
in.—AFFECTIONS OF THE NECK  AND CHEST.
                   Tracheotomy in Croup.

  The following interesting case, reported in the eleventh volume
of the Western Lancet,  occurred in the  practice of Dr. Asbury
Evans, of Covington:
  Dr. Evans was called on the 5th of February, 1850, to a negro
boy, two years old, who  had,  seven  hours before,  applied  his
mouth to the spout of a tea-kettle containing boiling water.   He
presented all the symptoms of scalded glottis.  A physician, al-
ready in attendance,  had applied  three leeches to the child's
throat; these Dr. Evans had increased to eight; he then admin-
istered  ten  grains  of calomel, and proposed tracheotomy.  In
consultation this  was over ruled, under the mistaken notion that

  * Western Jonrnal of Medicine and Surgery, vol. 1, p. 363. 
[77]
the scalding had extended into the lungs.  After the lapse of an
hour the  symptoms were found  to be much aggravated; the
anxiety, restlessness,  stinting of the  eye-balls,  blueness of the
lips, noisy, gasping, croupal cough and respiration, great rapidi-
ty of the pulse, distention of the  vessels of the neck, and cold-
ness of the extremities,  clearly indicated that the child was in
imminent peril of suffocation.  Dr. Evans  thought further  delay
would  be criminal, and  therefore proceeded to operate.
  He made an incision along the middle line, commencing at the
sternum, and reaching  an inch and  a half upwards;  the neck
was greatly loaded with  fat, and the hemorrhage profuse.  As
soon as this could be  arrested by pressure, an incision was  made
into the trachea, which could not be  seen  at the bottom of the
wound, and a curved  canula introduced.  Immediately after this
was done the breathing became perfectly easy, and the child fell
almost instantly asleep.  Calomel was  freely given  for several
days, and at the end of two weeks he  was restored to health.
                   Tapping  of the  Thorax.

  It has long been known to practitioners that pleuritis, both in
its acute and chronic forms, occasionally, indeed if not frequently,
terminates in the effusion of serum, or of  sero-purulent  fluid, in
such quantity as to render its absorption impossible, and exposes
the patient to the hazard of suffocation  from the  pressure which
it exerts upon the lungs, to say nothing  of the injurious effects
which its  presence is calculated to inflict upon the  heart and large
vessels.  For the cure of this  affection, technically denominated
empyema, surgeons, long ago, recommended tapping of the chest,
and the operation, although  generally unsuccessful, has some-
times eventuated in recovery.   A case of  the  latter description,
attended with some unusual symptoms, occurred  some years ago
in the hands of my friend, Dr.  YV. C. Sneed, of Frankfort, and is
recorded in  the Western Journal  of Medicine and Surgery,  for
1845.   The patient, a lad, 14 years of age, had an attack of acute
pleuropneumonia, terminating in a copious effusion of sero-puru-
lent matter  on the left side, displacing the  heart, and compressing
the corresponding lung.  A valvular opening was made, with a 
[78]
common lancet, between the sixth and seventh ribs, near  their
angle.  The fluid, after the first  operation, was drawn off  with
a silver catheter, which was introduced upwards of one hundred
times during the progress of the treatment,  extending  over a
period of four months.  Altogether not less than fifteen gallons
of pus and serum were evacuated. The patient was kept upon a
generous diet writh wine, and in a temperate atmosphere; circum-
stances which greatly promoted his recovery.   Much benefit was
also derived from the use of injections of oak-bark, once a day,
into the pleuritic sac.
  Appended to Dr. Sneed's communication is a letter from Dr.
Reed, of Owenton, Kentucky, detailing the particulars of a simi-
lar  operation  performed upon his  own person for a similar affec-
tion of the left side.  The discharge from the chest continued for
two years, and  it is estimated that the  quantity of matter which
escaped in this way, and by the mouth in coughing, amounted to
sixty gallons.
                     Mammary Gland.

  I record here, with much pleasure, an operation for the remov-
al of a very largo encephaloid tumor of the right breast, by Dr.W.
L. Sutton, of Georgetown.*  The tumor was nineteen inches and
a quarter in circumference at its base, exceedingly painful, soft
to the touch, and  covered with a  dark fungus,  the  result of a
previous puncture, made by a  physician  under the belief that it
contained  pus.  The patient, a negress, aged 50 years, was much
emaciated, and  had  not  enjoyed any sound  sleep for  seven
months; the  pulse was  frequent and irritable, and the  appetite
was entirely destroyed;  but the bowels were tolerably  regular.
The disease was of several years' standing.  After some  prelimi-
nary treatment, the tumor  was removed  with the knife, on the
29th of April,  1846.  About  a pint of  blood was  lost in the
operation, and three arteries required the ligature.  Upon laying
down the flaps, it was found that they were  too small to cover the

  * Western Journal of Medicine and Surgery, third series, vol.  1,  p. 489, 
                             [79]

 entire  wound; the portion  which  remained exposed  was four
 inches in one direction,  by an inch  and a half in the other, and
 was dressed with a tent spread with cerate.  By the 7th of May
 the flaps had united by the first intention, and by the 29th  of the
 month the raw surface had healed over, except  at a small  point,
 and the general health was much improved.  When the case was
 reported in April,  1848, two years after the operation, there was
 no return of the disease, and the woman was perfectly well.
   From a careful dissection of the tumor after extirpation Dr.
 Sutton thinks that there can be no doubt that it was of a o-enuine
 encephaloid character.  It was of the  color of  the  brain  but a
 little less consistent, and was invested by a thin capsule of con-
 densed cellular tissue.  If his inference is correct, and there is no
 reason  to question it, the case is a very interesting one,  as  show-
 ing how much may occasionally be done by an operation  even
 where  the  circumstances  which precede  are apparently of the
 most desperate natnre.
   In November, 1843, Dr. Joshua B. Flint,* of this city, removed
 from  a lady, aged about 25 years,  a fungus degeneration of the
 right mamma.  The disease had existed several months ; and the
 tumor had been punctured a week previously, the opening  being
 followed by the characteristic fungoid growth, which, at the time
 of the operation, was  already half as large as a fist, and giving
 rise to exhausting hemorrhage, rapidly threatening a fatal termi-
 nation.  The integuments of the breast were so extensively in-
 volved  that enough could not be preserved to  cover the whole
 wound, a considerable portion of which had to heal by  granula-
 tion.   The restoration was slow; and  during the progress of the
 cure this portion of the wound assumed several times a suspicious
 appearance; but finally, under the use of simple dressings, and
 the administration  of  tonics, the woman completely recovered
 remaining  well up to  April, 1850, at the time  of the operator's
 report,  and having, in the meantime, given birth to two healthy
 children. The morbid product exhibited, under the microscope,
the characteristic structure of fungus hematodes.
  Prof.  B. W. Dudley, in speaking of carcinoma of the mammary
* Transactions of the American Medical Association, vol. 3, p. 337. 
[80]
gland, holds the following language: "I have never removed a
scirrhous breast but with  a recurrence of the disease  at  a subse-
quent period.   I have witnessed the healing of a carcinomatous
ulcer, as large as a man's hand, within a month, under the influ-
ence of a fervid imagination,  and, just  as  the  last  point  was
expected to cicatrize,  the  force of the imagination gave way, the
ulcer  re-opened, and the patient died  in a few weeks.  I have
kept the carcinomatous action in check  for years by severe absti-
nence, but have never seen it cured/'*
  In regard to this subject, my own experience entirely coincides
with that of Dr. Dudley.  All my earlier operations,  save a soli-
tary one, have terminated unfavorably, and I am so well satisfied
that this result will generally happen,  that 1 have of late years
repeatedly declined all interference of the kind.  My conviction,
founded upon considerable experience, is, that patients  will, on
an average, live quite as long,  if, indeed, not longer, if the dis-
ease be permitted to pursue its  course,  than when an attempt is
made to arrest it with the knife.  By strict attention  to the diet,
bowels, and general health, taking care to maintain this constant-
ly as nearly as possible to the natural standard, the morbid growth
may often be kept in  abeyance  for several years.f
IV.--AFFECTIONS OF THE  ABDOMINAL ORGANS.
               Foreign Bodies in the Stomach.

  Foreign substances, of a very singular character, sometimes
find their way into the stomach, from  which they are frequently
extracted with great difficulty.  A most remarkable instance of
this description, calling forth extraordinary ingenuity on the part
of the  surgeon,  occurred in  1814,  in the practice of Dr. Bright,
formerly of New Castle, and now of Louisville.   The particulars
are too interesting not to be mentioned on this occasion.
  " A  child near New Castle, in this  State, playing with a fish-
hook, incautiously swallowed it, while the  line  to which it was
appended hung out of the mouth.  The mother instantly seized

  * Transactions of the American Medical Association, vol. 3, p. 331.
  t Ibid—vol. 3. p. 334. 
[81]
its hands, and  sent for Dr.  Bright, who arrived soon after this
embarrassing  occurrence.  Learning that  the hook was  one of
very small size, he made a  hole through a rifle-ball, and having
passed the line through it, he dropped  the ball into the  child's
throat, which  was immediately swallowed.   He then, by  means
of the line,  withdrew  the hook  from  the  stomach, whilst  the
bullet prevented  its point from injuring the  cardia or aesopha-
gus."*
  My friend,  Prof. Gibson,  of the University of Pennsylvania,
evidently refers to this case  in his work on Surgery; but he at-
tributes it, erroneously, to a New England surgeon.   Dr. Bright's
case occurred when he was quite a young man, and while he was
a student in Transylvania University, in 1823, he communicated
the particulars of it to the late Prof. Brown, of Lexington.
  It is known that foreign substances, accidentally introduced into
the stomach  and other  organs, will occasionally migrate to  a
great distance, and be at length eliminated through the skin.   A
very remarkable example of this kind occurred, not long ago,  in
the practice of Dr.  N. B. Anderson of this  city.f   A girl, aged
19 years, on the 20th of April, 1849, in a fit of laughter acciden-
tally swallowTed a large brass pin and a medium sized needle.—
Nothing of moment occurred for nearly three weeks, when pain
and uneasiness began to be felt at the cardiac  orifice of the stom-
ach, where it  continued for three  months,  when it gradually
changed its position, and fixed itself upon the  inferior lobe of the
left lung.   In  this situation it remained for about nine months,
without any disturbance of the respiratory function, with the
exception of occasional  cough and slight hemoptysis.  The pain
then shifted to the glenoid cavity of the scapula, and then to the
axilla, impeding the movements of  the superior extremity.  The
limb continued in this position until December, 1850, when the
pain and uneasy feeling gradually extended down the arm, and
at length settled  at the elbow, in the belly of the biceps muscle.
Here a dark spot  formed, quite sensitive to the touch, which soon
terminated in  an abscess, filled with bloody matter, and contain-

  *  American Medical Recorder, vol. 6, p. 581.  Philadelphia—1823.
  f  Western Journal of Medicine and Surgery, third series, toUS, p. 200,1851
         12 
                            [82]

ing the foreign bodies, situated about half an  inch apart.   The
pin was discolored, but the needle retained its polished  aspect.
  Thus it would seem that these two bodies travelled side by side
from the stomach  through the diaphragm, and thence through
the lungs and walls of the chest to the superior extremity, where
they finally excited suppuration, leading to their extraction by the
knife.
                          Hernia.

  In the treatment of hernia, Kentucky may justly claim the cre-
dit  of  having effected one  most valuable improvement.   The
truss, invented by  Mr. Stagner, and afterwards modified  by Dr.
Hood, has acquired  a world-wide  celebrity.  Although Stagner
was not a professional man, yet from the deep interest which he
took in the subject, not less than on account of the intrinsic util-
ity of his labors, his name deserves honorable mention in connec-
tion with it.
  Mr. Stagner  was  himself affected with a rupture, and was
obliged to wear a truss, which one day gave way at the pad.—
He immediately resorted to a piece of wood, as a temporary sub-
stitute, and found that it answered a much better purpose in pre-
venting the descent of the bowel than the material previously used.
After having worn it for some time, he was surprised to  observe
that the hernia did not re-appear, and that a permanent cure had
been effected.*
  The  instrument which he invented was valuable chiefly on ac-
count of its pad, which is a piece of wood closely resembling the
pad of a common truss; but a good deal smaller, more accumul-
ated at the  extremity near the spring, and quite rugose upon its
convex surface.  The object which he had in view, in constructing
the pad in this manner, was to excite irritation in the parts upon
which it pressed, and thereby promote their adhesion and consol-
idation.  In this  condition the truss fell into the hands  of Dr.
Hood, who  soon perceived  its defects,  and at once proceeded to

  *  Drake's West. Jour. Med. and Phys. Sciences, vol. 2, p. 315. 2d hexade.
 1835. 
[83]
remedy them ;  a task  for  which his mechanical genius, and his
intimate knowledge of the subject of. hernia,  well  qualified him.
He extended his improvements to all parts of the instrument, but
devoted  his particular attention to the block, to which he gave a
smooth surface, at the  same time that he adapted  its form, with
great accuracy, to the different canals and outlets which it is de-
signed to support.  Thus constructed, the truss of  Dr. Hood was
found to fulfil every indication to which  such a  contrivance can
be applied, its employment was no longer, as in the hands of its
•originator, productive of severe pain and other evils, but it serv-
ed the purpose of a most excellent retentive  apparatus,  while by
its  gentle and uniform pressure it  was admirably calculated to
effect, in many cases, a radical cure by promoting  the effusion of
plastic matter in and around the opening through  which the de-
scent takes place.
  The value of the invention of Stagner and Hood,  in this de-
partment of surgery, can be  fully appreciated by those only who
are familiar with the nature and treatment  of hernia, and of the
state of our knowledge thereof prior to their time.  The trusses
which were in  use in this country, and, indeed, also in Europe,
when they entered upon their labors, were, as is well known, of
the most clumsy, ill-contrived, and imperfect description.   The
pads were uniformly made of soft material, and therefore did not
answer the purpose even of retaining the bowel within the abdo-
men ; and, as to a permanent cure, no surgeon  hardly ever thought
of effecting it with an instrument of this kind.  I conceive that
our profession is very largely indebted to Stagner  and Hood, es-
pecially the latter, for the valuable service they have rendered to
the cause of humanity, as well as  to the science  of surgery, by
their labors and ingenuity.   Although  the  instrument which
bears their names was subsequently modified  by  the  late Dr.
Chase, of Philadelphia, yet there is no doubt that that gentleman
was indebted to it for all the improvements possessed by his own
trusses.  There is but  one regret connected  with the inventions
of Stao-ner and Hood,  and that is that they should have been
patented ; an objection, however, which applies equally to Chase's
instrument, and, in fact, to most contrivances of the kind in this
and other countries. 
[84]
  In Dr. Lawsou's " Western Lancet," for September, 1845, Dr,
E. L. Dudley gives " Several Cases of Hernia with Remarks," of
unusual interest.  The first was that of a man who had inguinal
hernia, for which he  had been obliged to wear a truss for several
years.   The tumor was inordinately  large and painful, and the
patient had been seized, about eighteen hours previously,  with
symptoms of  strangulation.  His  wife had returned the bowel
before Dr. Dudley's arrival, but the symptoms were unrelieved,
and death took place during the succeeding night.  On  dissec-
tion, two feet of the ileum were found  mortified ;  the sac remain-
ed  on the outside  of the ring;  and  there was no external
appearance leading to the inference that the bowel was  in this
diseased condition.
  The second case, also one of inguinal hernia,  occurred in the
hands of Professor B. W. Dudley.  The tumor was returned, but
the symptoms of strangulation persisted; the bowels remained
obstinately torpid under the influence of the most active cathar-
tics, and the contents of the stomach and  upper intestine  were
occasionally discharged by vomiting.  After several days the
pain ceased, and on the eighteenth day a copious alvine dejection
took place, accompanied by the discharge of the serous sac of the
hernia and eighteen inches of bowel, in a mortified state.  The
patient lived for a number of months,  seeming to experience no
inconvenience from his loss, and died of another malady.
  In the third case, the patient had labored under strangulation
for three days, the bowels were obstinately constipated, and the
most skilful efforts at reduction had been employed in vain.  An
operation exposed the ccecum,  three inches of which had protru-
ded behind the peritonaeum,  and become adherent to the sur-
rounding parts, requiring the use of the knife to liberate it.  The
wound was completely united by the fourth day,  and the woman
rapidly recovered her health and strength.
  In the fourth case, the tumor, about the size of a hen's egg, was
situated in the inguinal canal, but had not passed the external
ring.  It was exquisitely painful, and  the slightest touch of the
finger produced insupportable distress.  A vein  in  the  arm was
opened,  the patient being in the recumbent posture, and the blood
was permitted to  flow until the  system was completely relaxed. 
[85]
After the loss of four pounds of blood, the bowel receded under
very slight pressure.
   " In reviewing these cases, it will be remarked,"  says the re-
porter, " that, in the first, the tumor was reduced in twelve hours
after its protrusion, and the bowel was as completely destroyed
as if a ligature had been drawn  around it.  In the second, reduc-
tion was accomplished in much  less time, but the sac constituting
the stricture was cut off, and the patient singularly recovered.—
In the third, the bowel was not returned  for three days, and the
patient recovered, after an  operation,  in  the most happy  man-
ner."
   The following interesting case of strangulated scrotal hernia,
occurred in the piactice of Dr. W. C Sneed, of  Frankfort:
   On the 28th day  of April, 1844,  Dr. Sneed was called to a ne-
gro man, about 30 years of  age, for a strangulated hernia, which
had existed for several hours without yielding to the taxis, which
had been  made  by Mr. (now Dr.) Blanton; and learned on his
arrival that the patient had been the subject of  reducible scrotal
hernia, from his boyhood, but that it had never before been stran-
gulated,  and although it was very large, filling the entire scrotum
on the left side, it had never given him much trouble, and he
had been enabled, up to this time, to do the work of an ordinary
hand in  a brick yard.
   The effort at reduction by the taxis  was renewed,  and all  the
ordinary means of relaxing the system resorted to, and persevered
in  for several  hours,  without  affording  any relief.   Injections
failed to relieve the distention of the lower bowel, and although
the patinnt had been relaxed by blood letting, tartar emetic and to-
bacco injections, until he was  unable to raise his hand to his head,
the strangulation remained  as permanent as  when  first seen.
The bowel above the strangulation was  considerably distended
and painful, caused,  no doubt, by the  free use of sour butter-
milk, of which he had  partaken very freely early in the morn-
ing-
   It was between 10 and 11 o'clock, A. M., that Dr. Sneed  first
saw the patient, and his efforts were continued until 3 or 4 o'clock,
P. M., before he despaired of giving him relief without an opera-
tion.   A consultation being held, it was  decided to  renew the 
                            [86]

efforts at reduction, which  were continued until night without
success;  it was then agreed  to give  him a free opiate, and let
him rest till morning.  Up to this time the patient bore the treat-
ment well  and there were no indications of sinking, nor tender-
ness of the parts, which indicated mortification of the bowel.
After recovery from  the  effects of the relaxants, and the great
fatigue produced by the efforts at reduction the pulse rose to about
the natural standard,  and the  opiate  prescribed, produced a
pleasant  sleep  which lasted  for several hours..  Dr. Blanton re-
mained with  the case during  the night, but made  no further
efforts for his relief.
  At 9 o'clock, on the 29th, we again  met, and a further effort at
reduction was urged by  the  consulting physicians.  The warm
bath, blood-letting,  opiates in  large doses, and ice  to the tumor
were used,  and after  waiting several hours  without  finding  any
indications  of relief, it  was  then determined to resort to  the
knife.
  At 4 o'clock, P. M., thirty-two hours after Dr. Sneed first saw
him, he proceeded to perform the operation. The scrotal tumor was
now about  the size of the head of an ordinary child  at birth, and
was  unyielding and  rather tender to the touch.  The pulse  was
still  good,  but the patient complained  of great sickness of the
stomach, and was troubled, to  some  extent, with hiccough and
occasional efforts at vomiting.
  An incision, about eight inches long, extending from about
two inches  above the upper edge of  Poupart's  ligament to the
lower half  of  the scrotum, was made through the skin, and the
cellular tissue carefully dissected up  until the sac  was opened'.
An ounce or two of serum escaped from the sac when opened.
and the bowel was found firmly packed in the cavity.   After the
sac was sufficiently exposed to admit the finger, search was made
for the stricture, which was found at the lower and internal mar-
gin of the external inguinal ring.  A bistoury was passed up and
the stricture cut, but to his great surprise the bowel could not be
passed back after many  efforts.  The operator  was, therefore.
forced to turn the strangulated portion of the bowel out on a clean
silk handkerchief, and then seek for  the upper  portion  and re-
turn it, as  best he  could.  Seventeen inches of the large bower 
[87]
by measurement,  including the whole of  the  sigmoid flexure,
were confined in the  sac, and when thus exposed, it was found
that the difficulty in returning the bowel was caused by an adhe-
sion of its peritoneal portion of to that of the abdomen, in ex-
tent about the size of a thumb nail.  This was torn apart, when
the bowel  was  passed within the  abdomen,  without difficulty.
The wound wras then  closed by the interrupted suture, adhesive
strips, and bandage, and the patient put to  bed.
   The peritoneal coat of the bowel was in a highly congested
state, but showed no signs of mortification.   The patient bore the
operation well, and expressed great relief after he had been pro-
perly cared for.
   On  the  fifth day, traumatic  erysipelas  made its appearance,
and continued for a short time.  It was preceded by peritonitis,
which began a day or two after the  operation, and persisted, to a
greater or less extent, for two weeks.  The patient passed at one
time more than a tea-cup-full of purulent matter from  his bowels
by the rectum, and large quantities of pus  could be pressed  out
through the wound from the peritoneal cavity, and from between
the abdominal  muscles, for several weeks after  the  operation.
The wound in the scrotum  healed very kindly, and in  six weeks
after the operation, the man was able to ride to the house of his
mistress,  Mrs. Rudd, in Springfield, Washington county.  The
cure was perfect and permanent.
   The points of interest in this case are these:  First—the stran-
gulation of so large an amount of the bowel, for such a length of
time, without terminating in mortification.  Second—the difficul-
ty of reduction, caused by the adhesion of a portion of the bowel
to the walls of the abdomen.  Third—the discharge  of pus by
the rectum, showing, in all probability,  that the portion  of the
bowel  previously adhering had  ulcerated through, and that the
pus passed by the rectum  was from the peritoneal cavity; and,
Fourth—the perfect success of the operation ;  the patient having
Less inconvenience, and  being more  useful since than at any time
previous to the operation.
   Dr. Samuel B. Richardson, of this city, has communicated  to
me an outline of the particulars of six operations for  strangula-
ted hernia.  Four of the cases were males ; and all, except one, 
[88]
resulted favorably.  Five were  inguinal  and scrotal,  and  one,
that of a female, was femoral. _JFour were examples of enterocele,
one of epiplocele, and one of entero-epiplocele.  Of these cases the
first four were all reducible, while the other two were irreducible.
Of the latter,  the case of epiplocele was large and ancient; and
in the other, that is, the case of entero-epiplocele, the omentum
was adherent,  while the  bowel,  having recently descended, was
entirely free.  The fatal  case was a large  and old hernia of the
omentum, which had been strangulated seventy-two hours, when
the  operation  was performed.   Dr. Richardson resorted  to the
knife in twelve hours after  he first saw the patient.   Death hap-
pened on the eleventh day after the operation, from erysipelas  of
the wound and inflammation of the peritonaeum.
  The general success in the above cases is ascribed by Dr. Rich-
ardson to a prompt resort to the knife, after a short, but fair trial
of the taxis and  other known means.   The accuracy of this con-
clusion cannot be called  in question  by any one at all familiar
with this subject.   It has been stated by  an  able writer and an
accomplished surgeon, the late Mr. Hey, of England, that he had
often had  occasion to lament that he  had  performed this  opera-
tion too late, but never that he had performed it too soon. *
  In the tenth volume of the  American Journal of the Medical
Science, f  Dr. W.  L. Sutton, of Georgetown, has " Two cases of
Femoral Hernia, with  some remarks,"  which are of peculiar
interest, especially the first;  in which the stricture was divided
through the intestine, a finger having been previously inserted as a
guide to the bistoury.  The patient, a lady fifty years of age, had
been long afflicted with hernia,  which finally become strangula-
ted, and reduced her almost  to  a moribund condition. The tu-
mor being laid open, the bowel was found gangrenous for about
three inches,  and adherent to the neck of the sac.   Various at-
tempts were made to divide the stricture in the usual  way; but
these failing, on account of the impossibility of insinuating even
a probe between the sac and the obstruction,  a finger was  passed
within the gut, and upon this a probe-pointed bistoury,  with

  * Practical Observations in Surgery, p. 143.
  t New Series, p. 251, 1845. 
[89]
which the part was readily divided.   The woman remained in a
precarious  condition for sometime;  but  finally  recovered, the
wound healing, and the general health being excellent.  She was
still alive in January, 1852.
  This case is one of unusual interest on account of the  novel
method of dividing the stricture, and addresses itself, with great
force, to  the consideration of the operator.   I am not aware that
it has a parallel in the history of surgery.
  The other case was also one of femoral  hernia, the protruded
part consisting of a piece of omentum, about the size of a nut-
meg.   Strangulation took place, and the man died, nearly a fort-
night after,  without an  operation,  after repeated,  but fruitless
efforts at the taxis.   The disease was of recent standing, and was
occasioned  by  straining at stool; the tumor was not tender, much
less painful, and there  was an entire absence,  throughout, of
nausea and vomiting.  Tho  stricture was  found,  after death, at
the inner edge of Poupart's ligament, and the strangulated omen-
tum was  universally adherent to the  inner surface of the sac, the
small intestine, in the neighborhood, being extensively mortified.
Dr. Sutton, in commenting upon this case, says: "I do not know
of any authority which could justify an operation at either time
when I saw him; and yet I believe that a successful operation at
the first or second visit would have saved his life."
  The diagnosis of strangulated hernia is not always  very clear;
hence, the disease is occasionally mistaken for colic,  or intussus-
ception, and its true nature is revealed only after death.  An ex-
ample of this  description has been contributed by Dr. L. C. Ray,
of Paris, under the title of "History of an obscure case of Stran-
gulated Bowel," in the Transylvania Medical Journal, for Decem-
ber, 1849.   When the patient  was first seen  by Dr. Ray, three
days after the  attack, he had hiccough, troublesome eructations)
constipation of the bowels, pain,  tenderness, and fulness of the
abdomen, intense thirst, and a dry, coated tongue.   The  pulse
was seventy, soft and compressible.  A small hard tumor existed
in the right groin, which the man said had been there for five or
six months, and which,  as it was not unusually sore or tender,
was  regarded  merely as enlarged  lymphatic ganglion.   The
symptoms progressed;  and on the fifth day stercoraceous  vomit- 
[90]
in«- was superadded.  A consultation was now held, and  it was
decided that there was no hernia,  as it " lacked all the outward
manifestations of  the  disease."  The swelling  in  the  groin be-
came more tender; soon it felt as  if it contained fluid and air;
and on the eleventh day an opening w as made into it, giving vent
to foeted gas, followed by four ounces of pus and feculent matter.
Death occurred on the fourteenth day.  The cause of the obstruc-
tion was found to be a small knuckle of the ileum at the femoral
ring,  where it was bound tightly down by adhesive matter, and
presented two openings, permitting a discharge of faeces.  The
bowel was much thickened and inflamed, but not entirely occlu-
ded, as there was room  enough within for the passage  of a com-
mon sized catheter.
   It is evident that this was a case of  concealed femoral hernia,
and it is to be regretted that an incision was not made upon the
tumor in the groin,  at an early stage of the complaint, when the
patient was in a condition to be saved.   The rule of practice, in all
cases  of tumor of the groin, accompanied by obstinate constipa-
tion,  stercoraceous vomiting, and  other symptoms  of strangula-
tion, is to cut down upon the swelling,  and  thus ascertain its pre-
cise character.  This procedure, if hernia  really exist, removes
all doubt,  while, if the obstruction  is occasioned by other causes,
it cannot be productive of any serious mischief.
   Some attention  has been paid by the physicians of Kentucky
to the radical treatment of hernia.  Some years ago, u very res-
pectable graduate of the University of Louisville,  Dr. Bowman,
of Harrodsburg, showed me an instrument  for injecting the parts
immediately around the abdominal canals and apertures  with a
weak solution of iodine and other articles. It was constructed
upon  the principles of an ordinary syringe, and was provided
with  an extremely delicate nozzle,  intended to be introduced
through a small opening in the skin.  The object of  the injection,
which if free from danger and unattended with pain, is to excite
an effusion of plastic matter in the parts already mentioned, in
the hope that it may be followed by their adhesion  and consoli-
dation.   It should be aided by the  pressure of a well constructed
truss, worn day  and night.  Dr.  Bowman had employed this
practice, at the time he called my attention to it, in probably six 
[91]
or eight cases, about one-half of which had  been snccessful.  I
am not aware that he has published an account of his experience.
  Anodynes have long been employed for the relief of strangu-
lated hernia, sometimes successfully, at other times unavailingly.
Dr. Blanton, of Hardin county, in a communication in the Wes-
tern Journal of Medicine and Surgery, for October, 1848, gives
the particulars of two cases  of the  affection in  which he used
morphine,  with the happiest  effect.  In  one of the cases, the
strangulation had existed for forty-eight hours, in spite of every
effort at reduction ;  in the other, the disease was more recent, and
the remedy was resorted to at  once.  In both,  relaxation of the
muscles soon followed, and the bowel was  easily restored to its
natural situation.
  In  connection  with  hernia,  allusion  may be made  here to
wounds of the intestines / a topic which  has engaged much of
my attention, and which is well calculated to excite a deep inter-
est in every surgical practitioner.  In looking over the  records of
Kentucky surgery, I have been able to find only one case of this
lesion.  It  occurred in  the  practice of my young friend, the late
Dr. J. D. McBrayer, of Harrodsburg, a gentleman of great worth
and  of no ordinary professional promise.   The wound in the
bowel was  about four lines in length, and was closed with a sin-
gle interrupted suture,  performed with a common sewing needle
and a silk thread.   The  small intestines protruded to the extent
of about two feet, and were reduced with  some difficulty.   The
edges of the wound in the abdomen were drawn together by three
stitches, supported  by  adhesive  strips, a  compress and roller.
The patient, a negro, thirty years of  age, was able to walk about
on the twentieth day, and in six weeks he resumed his ordinary
business.
  I trust it will not be regarded as immodest in me, if I allude
here, for a  moment, to my own  labors, the more/especially as they
were  undertaken  with the  direct view of elucidating the subject
under consideration.  It is known, perhaps, to most of  the mem-
bers of this Association, that I performed,  about ten years ago,
a series of  experiments  upon dogs, amounting altogether to sev-
enty-twTo,  for the  purpose of  ascertaining,  if possible,  first, the
nature of these injuries,  secondly, their mode of reparation,  and 
[92]
thirdly, the best  manner  of treating them.  Nearly two years
were spent in these investigations, the results of which were
finally  embodied in a series of articles,  published, at first, in the
Western Journal of Medicine and Surgery, and, afterwards, in a
separate volume of nearly two hundred pages, under the title of
"An Experimental and Critical  Inquiry into the Nature and
Treatment  of Wounds of the  Intestines."  It is  illustrated by
numerous engravings, most of which are original, and has appen-
ded to  it an elaborate chapter on  artificial  cases,  exhibiting  an
account of the  various modes of  treatment  of  this loathsome
affection, and a description of a new instrument for dividing the
septum between  the two ends of the bowel.  As  this work  has
been a number of years  before the profession, any further allu-
sion to it here, would  be improper.
  Under the head of affections of  the bowels,  may be mentioned
a very  interesting and instructive case of  Amussat's operation
for artificial anus, communicated to me by Professor  Bush, of
Lexington.  The operation was performed,  in December, 1847,
upon a lady, aged thirty years, for complete occlusion of the rec-
tum, attended with enormous distention of the abdomen and the
most excruciating  pains.  For ten days immediately preceding
the operation, nothing had passed the bowels.  The  patient be-
ing placed  upon her right  side, in an easy and comfortable posi-
tion, Dr. Bush commenced the operation by making a transverse
incision,  extending from  near the extremity of the transverse
process of the third lumbar vertebrae, about three inches, through
the skin, fascia,  and muscles of the left lumbar fossa.  The cav-
ity of the abdomen was thus  laid open behind the peritonaeum,
and the descending colon, rendered unusually prominent by its
distended condition, fairly exposed, uncovered by the serous re-
flexions passing  off from its  sides.  A strong  curved  needle,
armed with a double ligature,  was now passed into the centre of
the bowel  as it appeared  at the bottom of  the wound;  the tube
was then drawn slightly forwards, and the crucial incision made
into it, when the operation was completed by stitching  each flap,
by a single suture, to the two angles and two sides of  the exter-
nal wound.  No hemorrhage attended  the operation, which was 
[93]
executed with great facility.   An enormous quantity of fceces and
gas escaped, to the immediate relief and comfort of the patient.
  The wound was healed by the ninth day, leaving a beautiful
valve-like opening between the skin and mucous membrane of
the bowel.  The ligatures were now removed,  and the artificial
anus covered with a simple "compress pad."   Although the case
had gone on  well  up  to this time,  unfavorable symptoms now
showed themselves, which progressed from bad to worse until the
fourteenth day, when death put an end to the poor woman's suf-
fering. The disease  necessitating  the operation  was cancer of
the terminal portion of the sigmoid flexure of the colon.
                   Excision of the Spleen.

  The surgical practice of Kentucky furnishes two cases of partial
excision of the spleen; one by Dr. Daniel C. Caldwell,* of Rus-
sellville, and the other by Dr. William Byrd Powell,f formerly of
Newport, now of Memphis.
  In the first case, the patient, a negro, was stabbed with a large
knife, • on the left side, between the last true  and the first false
rib, " about the  point of  their greatest convexity."  Though the
opening thus made an oblong body, from three to four inches in
length, protruded,  and which was  supposed by Dr. Caldwell and
the attending physician to be the small extremity of the pancreas;
but which, judging from all the circumstances of  the  case, could
have  been  nothing else than a portion  of the spleen.   An  at-
tempt to replace the organ into the abdomen was made the day
after the accident; but, this failing, the protruded part, now in a
state of strangulation, was cut off  with  a bistoury, after  which
the edges of the wound in  the skin were  brought together with
adhesive strips.  No hemorrhage followed the operation ; and the
man, whose age is not mentioned,  soon recovered.
   In the case of Dr.  Powell, that of a man of thirty, the wound
was situated on  the left  side, between the second and third false

  * Transylvania Journal of Medicine  and the Associate Sciences, vol. 1, p.
116.  Lexington—1826.
  t American Journal «f the Medical SeienceSj vol. l» p. 481.  Philadelphia
—1828. 
[94]
ribs,  about four inches from  the spine,  and was inflicted by a
knife, or  large dirk, passing  downward, inward  and forward,
into the cavity of the abdomen.  After cleansing the wound, which
was covered with soot and flour, to arrest the hemorrhage, a por-
tion of the spleen,  nearly  two inches  in  length, and  having a
considerable slit at its extremity, was found  to protrude through
it, and to be so firmly embraced by its edges as to render it im-
possible to replace it.  As  it was late  in the evening when Dr.
Powell  first saw the case,  he  concluded to wait until the  next
morning, at 9  o'clock, when the projecting part was encircled by
a strong piece of tendon,  and amputated close to the surface of
the body.   All attempts to restore the remainder of the organ to
its  natural situation proving fruitless,  the  external wound was
dressed in  the usual manner ;  and the patient being put to  bed,
was bled at the arm to the  extent of a pound and a  half,  and
placed upon light diet.  On the third  day,  high  constitutional
excitement manifested itself, followed, in a short time, by all the
symptoms  of peritoneal inflammation , for the relief of which, the
ordinary remedies were employed.   All treatment was discontin-
ed at the end of a fortnight, when the wound was nearly cicatrized ;
and nine months afterwards, when Dr.  Powell met the patient,
he was in the enjoyment of excellent health.
V.—AFFECTIONS OF THE PELVIC OEGANS.
             Lithotomy and Calculous Diseases.

  In no department of  Surgery has Kentucky acquired more re-
nown than in the treatment of calculous diseases.  The operations
that have been performed for the removal of stone from the blad-
der nearly equal, if, indeed, they do not exceed, all the operations
of lithotomy  in the other  States of the Union.  The gentleman,
Professor Dudley, of Lexington,  who  stands at the head of this
department of Surgery, not only in Kentucky but in America, if,
in fact, not in the world, has  alone  operated  two hundred and
seven times;  and, if we add to these cases  those that have  oc-
curred in the hands of other surgeons,  the aggregate will amount
to nearly, if not quite, four hundred.  It would afford me great 
[95]
pleasure to give, with exact accuracy, the number of operations
of lithotomy  that have been performed by different members of
the profession in different parts of the State, as well as  their re-
sults ; but, for the determination of this question, so interesting
and important to the profession, I have not, I regret to say, been
able to obtain the requisite data,  notwithstanding no pains have
been spared to do so.
   It is positively known that the late Dr. Ephraim McDowell, of
Danville, had operated thirty-two times several  years before he
died.  Dr. Alban G. Smith, now Dr. Goldsmith, thinks that,
during his residence in Kentucky, he had over fifty cases.*  Dr.
Gardner,  of  Woodsonville,  has  reported to me  fourteen cases.
Dr. Bush, of Lexington, has operated six times; Dr.  John C.
Richardson,  and  Dr. E.  L.  Dudley, of the  same city, each once.
Dr. John  Shacklcford, of Maysville, has had four cases;  and Dr.
Craig, of  Stanford, two.   Dr. W. A. McDowell, during his resi-
dence at  Danville, operated twice.   Dr. Henry Miller, of this
city, has had  two cases.   Dr. John Hardin, while practising med-
icine and  surgery at Greensburg, operated five times; Dr. L. P.
Yandell has operated four times ; Dr. William  II. Donne, once ;
Dr. Samuel B. Richardson,  twice; and Dr. Joshua B. Flint, —
times.f   My own cases amount to thirty.  Dr. Walter Brashear,
formerly of Bardstown,  occasionally  operated  for stone  in the
bladder, but  how frequently I am unable to say.  I am in posses-
sion of  a few of the particulars of one of his cases, which I shall
take occasion to relate in their proper place.  Dr. D. W. Yandell,
late of this city, has performed lithotomy four times.
   Reduced to figures, the number of cases of lithotomy, positive-
ly known to have occurred in Kentucky, stands about thus:
Dr. B. W. Dudley,	207	Dr. John C. Richardson,	1
" E. McDowell,	32	" John Craig,	2
" A. Goldsmith, uncertain,	50	'• W. H. Donne,	1
" W. Gardner,	14	" Walter Brashear,	0
" J. M. Bush,	6	" E. L. Dudley,	1
" John Shackleford,	4	" D. W. Yandell,	4
" Henry Miller,	2	' " L. P. Yandell,	4
" John Hardin,	5	" S. D. Gross,	30
" S. B. Richardson,	2		
* Letter to the Reporter.
f This gentleman has not honored me with an account of hi« cases. 
[96]
   It is an interesting fact, with reference to the etiology of cal-
culous affections, that most of the above cases occurred among
the  inhabitants  of  Kentucky and Tennessee.   The  remainder
were brought from  Alabama, Mississippi, Indiana, Illinois, Mis-
souri, Ohio,  and Virginia;  a few, perhaps,  from other States.
Nearly all occurred  in white males, the number of blacks being,
comparatively,  very small.   The great majority of the patients
resided in limestone regions.
   The following facts and cases,  illustrative of the operation of
lithotomy in  Kentucky, have been kindly communicated to me
by different gentlemen, during the progress of my labors.  It is
a  source of regret  to  me, that none  of the particulars of the
late Dr. Ephraim McDowell's operations  have been transmitted
to us.
   I have it in my power, through the politeness of Dr. S. M. Be-
miss, of Bloomfield, to present  you with a brief account of one
of Dr. Brashear's cases,  accompanied  with the calculus.  The
details are, unfortunately, imperfect.
   The operation was performed in the summer of 1811, in the
neighborhood of Bloomfield,  and in  the  presence of  Dr. Harri-
son,  of Bardstown, Dr. John Bemiss, and Dr. Merrifield, the lat-
ter of whom is the only surviving witness.  The subject, Mr. Fal-
kerson,  near sixty years of age, had  suffered so much, for  some
months previous to  the operation, that his constitution was great-
ly impaired in consequence.  Strong doubts seem to have  been
entertained by Dr. Brashear, respecting his ability to  endure an
operation of such magnitude; but his patient was tired of suffer-
ing, and wished to be relieved by death,  or a successful removal
of his calculus.   Dr. Merrifield thinks that  the  operation was
performed on the left side of the perinseum, with the gorget.
After the proper incisions were made,  the forceps were  introdu-
ced,  and an  attempt made to grasp the stone, but the blades of
the instrument  could  not be expanded sufficiently  to admit it.
The  patient soon  becoming exhausted,  the operator was obliged
to desist from any protracted efforts at extraction, hoping, per-
haps, that he might  be able to renew them shortly afterwards. In
this, however, he was disappointed;  for  Falkerson died during
the ensuing  night,  and  Dr. Merrifield  removed the calculus, 
[97]
which  I  here  exhibit to you, after  his death.  Its weight was
originally considerably over seven ounces;  but by attrition, drill-
ing, and  the evaporation of its fluid constituents, it has been re-
duced so much as to amount, at present, only to a little more than
four ounces.  It is of an oblong, ovoidal shape, rough on the sur-
face, and  laminated in its structure, but what its composition is,
I know not.  Its  short  circumference  is  six inches; the long,
seven and a half.
  Dr. Merrifield speaks in high terms  of the skill and celerity
with which  Dr. Brashear accomplished  his operation, and thinks
that the debility and exhaustion of the  patient were the only ob-
stacles to the successful removal of the calculus.
  In 1808,  Dr. Brashear performed the operation of lithotomy
upon  a boy, about twelve years of age.   The case,  which pre-
sented nothing unusual, was perfectly successful. *
  Dr. William A. McDowell, during his residence at Danville,
many years ago,  operated  twice for stone  in  the bladder.  The
first case, which was  remarkable on account  of the early union
of the wound, was that of a youth of eighteen, cut with the gor-
get.  No  urine passed through  the perinaeum  after the opera-
tion, the parts having closed by the first intention.   The recovery
was rapid and uninterrupted.
  In the other case, the  patient, a lady,  aged thirty-three, suf-
fered  great  torments from the calculous affection, in addition to
incontinence of urine.  In March,  1820, four stones, about the
size of walnuts, were extracted from the bladder by the lateral
operation.  The wound healed without difficulty, and with relief
from all annoyances, save the incontinence  of urine,  which con-
tinued up to the time of Dr. McDowell's removal to Virginia,
three months afterwards.
  In February, 1826,  Dr. John C. Richardson, of Lexington, per-
formed the lateral operation of  lithotomy upon a youth of twen-
ty-one, the  only  instruments used being  a scalpel and  a staff
grooved on  its left side.  The stone was of large size,  and could
not be extracted without the division of both sides of the pros-
tata, in the manner since so strenuously recommended by the late

  * MS. letter of It. B. Brashear, Esq., to the reporter.
         13 
[98]
 Mr. Liston.  It was of the ammoniaco-magnesian phosphate va-
 riety, weighed  five ounces and a fourth, and was three inches and
 a half in its long, by two inches and a quarter in its short diam-
 eter.  The case, as I am informed by Dr. Samuel B. Richardson,
 of this city,  a brother  of the operator, was perfectly successful.
   Dr. Henry Miller, in 1830, during his residence at  Harrods-
 burg, operated upon a mulatto boy,  aged three years  and a half,
 for stone in  the bladder.  He belonged to Capt. Wm. Robinson,
 of Anderson county, Kentucky, and had suffered  from symptoms
 of calculus since very  early infancy.  The stone  was quite fria-
 ble,  and broke into a number  of fragments in  the extraction.
 The boy recovered, and had no return of the disease during the
 two or three years he was under Dr. Miller's observation.
   In August, 1849, Dr. Miller operated upon a young girl, in her
 fifteenth year,  from Meade county, Kentucky.   After  having
 given chloroform,  he introduced a pair of common curved poly-
 pus forceps  into the bladder, seized and  extracted  a  very rough
 stone, resembling a Jamestown bur, weighing 264 grains, and
 measuring a little over an inch in diameter.   The lacerated mu-
 cous  lining  of  the  urethra  hung out at the meatus, after the
" operation, and  was  clipped off with the scissors.  She had  no
 bad symptoms, and went home in a few days.   She  has remained
 well ever since.
   Dr. John Shackelford, of Maysville, writes that  he has oper-
 ated  four times for stone in the bladder, and in every instance
 successfully.   One of his patients, who became afterwards intem-
 perate, suffers occasionally from incontinence  of urine.
   Dr. S. B. Richardson, of this city, during his residence at Lex-
 ington, operated twice for stone in the bladder.  In  one of the
 cases he removed three calculi, two of which were so large as al-
 most to fill the organ.   The patient, three years  and a half old,
 had a speedy recovery,  although she labored, at the time, under
 serious disease of the rectum and bladder.
   Dr. L. P.  Yandell has operated for stone in the bladder, four
 times, using the gorget in every instance.  The first  three cases
 were successful; the fourth, a little boy,  four years old,  in bad
 health, died, never having fully recovered from the shock of the
 operation. 
[99]
  Dr. D. W. Yandell has performed the lateral operation of lith-
otomy four times—in all with the bistoury, according to Liston's
method, and in all with success.   Oue of the subjects was a man,
aged twenty years, who had suffered long with stone; the other
three were boys, in their fourth year.   The recovery in each case
was prompt and perfect. The patients all resided in Tennessee.
  Dr. Gardner, of Woodsonville, has performed the operation of
lithotomy fourteen times;  using the knife, and adopting  the lat-
eral method.  All his  patients,  save one, recovered.  Death,  in
this case,  was  produced, as was supposed, by the accidental frac-
ture of the calculus, in the attempt at  extraction, thereby neces-
sitating its removal piece-meal; a work of great pain, difficulty,
and danger.   Acute cystitis immediately supervened, and resist-
ing every effort to arrest it, terminated fatally on the fourth day
after the operation.  The patient was a man, aged twenty-five.
  Of the above cases,  four were from  Barren county, two from
Warren, two from Green, one from Taylor, one from Edmondson,
one from Hardin, and three from Hart, the residence of the oper-
ator.  In  all these counties the limestone formation prevails, and
limestone water is universally  used for  drinking and cooking
purposes.                                              *
  All the patients were males, and all, save one, were white.
One wras a blacksmith, and one the son  of a merchant; all  the
rest, except one, were farmers,  or the children of farmers.  Two
of the patients were brothers.   There  was not a single instance
of double or  multiple calculus, and  only one case  in which a
stone formed after the  operation.
  The ages varied from five  to forty-two, as follows:  5, 7, 7, 7,
7, 7, 9,  10|, 16, 17, 1^, 20, 25, 42.
  In one of his cases, Dr. Gardner, after having, in vain, endea-
vored to extract the stone by  the lateral operation, wras obliged to
open the bladder above the pubes.  The patient  was a man, aged
forty-two  years, for the last fifteen of which he had  suffered  un-
der symptoms of the disease.  Having incised the perinaeum,  the
operator was absolutely unable even to introduce the forceps into
the bladder, much less to expand them over the concretion,  the
weight  of which proved to be  nine ounces, while it measured
nine inches and a quarter in its greater  circumference, by three 
[100]
and a half in diameter.  Undaunted  by so unexpected an occur-
rence, Dr. Gardner at once determined to perform the supra-pubic
operation; and after some difficulty, owing chiefly to the large
bulk of the stone and the firm  contraction of the bladder, suc-
ceeded in accomplishing his object.  The patient recovered slowly,
but without much trouble, and by the eighteenth day was able to
walk  about his  room.  The upper wound soon  healed; but a
small fistulous aperture remained in  the  perinaeum for  some
months, when it finally closed.   Two years and a half after  the
operation, upon sounding the man, Dr. Gardner  found that  the
bladder again contained a large calculus.  A short time after this,
he was seized with an-attack of  intermittent fever, which, added
to his other afflictions, soon carried him off.  The body was  not
examined. *
  Several papers upon calculous affections  have  appeared from
the pen of  Kentucky surgeons and  physicians.  Of these,  the
first, in point of  time, as well as in respect of interest, is by Pro-
fessor Dudley, under the title of "Observations  on the Nature
and  Treatment of  Calculous Diseases."  It was published  in
1836, in the ninth volume of the Transylvania Journal of Medi-
cine and the Associate Sciences, of which it occupies thirty-seven
pages,<and is based upon the author's personal experience in one
hundred and forty-five cases, all of which, except ten, had been
subjected to the knife.  The  paper  is particularly  valuable, inas-
much as it contains a full account of Dr. Dudley's mode of oper-
ating, the manner of preparing  his patients, the after treatment,
and the result of his success.
  A year subsequently to this, appeared, in the tenth volume of
the periodical  just cited, Dr. James M.  Bush's " Observations on
the Operation  of Lithotomy; illustrated by»4ases  from the  prac-
tice of Professor B. W. Dudley."  As its title  imports, it is occu-
pied with  an account of the practice usually pursued by the Lex-
ington professor in the treatment of calculous affections, and its

  *  Dr, Gardner has kindly furnished  me with a detail of all his cases, which,
as Chairman of the Committee on "Lithotomy and Calculous Diseases," I shall
present to the Society at its annual meeting at Lexington, in October,  1853.—
When his paper reached me, a few days ago. the present report had already
attained ao great a bulk, that I did not feel authorized to give it in full. 
[101]
chief interest consists in affording additional evidence of the ex-
traordinary success of this gentleman's operations, which, at the
time of its publication, amounted to one hundred  and fifty-three.
Dr. Bush does not contribute any facts from his own observations
and experience.
  In 1846,  Dr. Robert Peter, published, in the  fifth volume of
the Western Lancet, an elaborate account of his "Chemical Ex-
amination  of the Urinary Calculi in the Museum  of the Medical
Department of Transylvania University, with remarks on the
relative frequency of calculus in  Lexington,  Kentucky, and the
probable causes."   As I shall have occasion to refer to this essay
at a future stage of this report, it is unnecessary to say any thing
further respecting it here, than that it is apparently characterized
by great accuracy  of observation,  and that it embraces a more
compact history of the subject than any paper that has ever been
published on  the  chemical analysis  of urinary calculi in  this
country.   It is not improper to  add  that this paper was  after-
wards  re-printed,  nearly entire,  along with  an   "Analysis of
Three  Urinary Calculi,"  in the  Transylvania Medical Journal,
for December, 1849.
  It will be seen that these contributions,  the only ones.of any
importance that have appeared  upon the subject, are  froVn the
pens of the Lexington professors; a circumstance  which is not at
all surprising when it is recollected that Dr. Dudley, until recent-
ly, monopolized the calculous practice of Kentucky. During  a
residence of twelve years in Louisville, my practice has furnished
me with only thirty cases of lithotomy, the particulars of twenty-
four of which are detailed, with great minuteness, in my Treatise
on the Urinary Organs,  pnblished  at Philadelphia,  in 1851.
Within the last eighteen  months,  I  have operated for stone six
times,  four times successfully, and twice with fatal results.  The
latter cases present facts of great interest, with reference to lith-
otomy, but the limits of this report will not permit an account of
them.
  In the remarks which I am about to offer, respecting  Dr. Dud-
ley's mode of operating for stone in the bladder, and his manner
of preparing his patients, together with his after-treatment and
results, I shall avail myself freely of his own paper and of that 
[102]
of Dr. Bush, already quoted.  In doing this, I do  not  deem it
necessary always to indicate by special references, the particular
document employed, as this would lead to useless citations.
  Dr.  Dudley's favorite instrument is the  gorget, and  the one
which  he prefers is that invented by Mr. Cline, of London, which
he thinks superior to every other.   In all his operations, he has
used but two sizes,  the smaller  seven-tenths, the  latter eight-
tenths of an inch  broad in the blade.   With the  latter instru-
ment,  he has made an  incision  admitting of the safe extraction
of a calculus, three inches and a half in  its long diameter, and
two  and a half in the short, by eleven  inches in circumference.
He has never used the scalpel or bistoury.   His mode of enter-
ing the bladder does not differ from that of other  lithotomists.
He directs the staff to be held firmly in  a  perpendicular direc-
tion, and insists upon the importance of making a small incision
into the prostate gland and neck of the bladder, being satisfied it
is much better calculated, than a free division of the parts, to pre-
vent urinary infiltration and peritonaeal  inflammation.   When
the calculus is unusually voluminous, or very disproportionate to
the incision, he prefers to dilate, and even  lacerate the  prostate
gland to cutting it.  He thinks it  better and  safer  to extract by
force  than to resort a second  time to the knife.  His extensive
experience has entirely convinced him that the danger, so gener-
ally ascribed to violence inflicted upon the deeper structures, by
laceration,  has been greatly over-rated, and that it is not at al)
comparable with the beneficial effects of such a procedure.   The
stone, where disproportionately large, should be extracted slowly
and gradually, not violently, in order that the tissues may  yield
to the  dilatory and tractive efforts, and not be dragged away; a
result which has never happened in Dr. Dudley's practice.
  The different steps of the operation, as  performed by Dr. Dud-
ley, are thus described by Dr. Bush.  "The convexity of the in-
strument—the staff—being distinctly felt  in the median line of
the perinaeum, the operator, seated  in a  convenient chair, with
his instruments spread on  his right, proceeds to the operation.
While his left hand controls the scrotum and perineum, the rio-ht
makes an incision, with a  middle size convex edge scalpel, be-
ginning a little below the  root of  the scrotum,  and terminating 
[103]
an inch,  more or less,  behind the verge of anus, and the inner
edge of the left tuber ischii.  This cut divides skin, subcutaneous
tissues, and perinaeal  fascia.  The second stroke of the knife is
not so  extensive; it divides only the posterior fibres of the accel.
lerator urinae  and transverse perinaei muscles.   Always at this
stage of the operation, if the perinaeum be remarkably  concave,
presenting an  inclined plane, or if the arch of the pubes be very
much  contracted, Professor Dudley introduces  the left middle
finger into the rectum,  and  draws off the bowel to the right.   The
fire-finger then placed  in the wound conducts the scalpel through
the membranous part of the urethra into the groove of the staff,
cutting from the rectum towards the bulb.   The scalpel is  now
laid aside and the gorget is taken up, the beautiful instrument of
Mr. Cline, with its cutting edge towards the pubic arch, its beak
is made to engage the groove of the staff,  while  the assistant re-
signs the latter to the surgeon's  left hand, who for an instant
playing the two instruments against each other, lateralizes  the
former, turning its cutting edge to the left,  poises it a moment,
perfectly horizontal,  before he plunges through the  prostate into
the bladder.  At the same moment the gorget is passed  with the
right, the left hand depresses the handle of the staff; the bladder
being opened, the staff is withdrawn, and the surgeon's fore-fin-
ger of  the left hand, directed by the gorget, is passed into  the
bladder,  and the instrument withdrawn ; the wound in  the neck
is dilated, forceps introduced, the calculus seized, and by steady,
firm, and dilatory movements, from below upwards, and from side
to side, the operation is completed by the extraction of the stone.
The bladder is  now cautiously  explored  with the scoop, and if
found  clear, is filled with  wasm  water from a syringe; the  pa-
tient is untied, turned to his left side, and  thus put to bed, and is
required  to maintain the position for from  two to four days."
  The time  occupied in performing the  operation varies  with the
circumstances of  the  case.  Dr.  Dudley makes it a principle
never to  operate against time, and he never allows himself  to be
thrown off his guard, but is- always prepared for any difficulties
or emergencies that  may arise.  While  he has occasionally com-
pleted the operation  in the short space of forty seconds, from the 
[104]
moment of commencing his first incision, he has sometimes con-
sumed twenty minutes in extracting an unusually large calculus.
  Great stress is laid upon the preparatory treatment.   In some
cases hardly any thing beyond a little rest and a dose of cathartic
medicine is necessary; but whenever there is much local distress,
with  derangement of the alimentary tube, and more or  less feb-
rile disturbance, more energetic measures are required before the
instrument is  passed  into  the bladder.   Nauseating doses of
ipecacuanha or of tartrate of antimony and potash are exhibited,
to reduce the pulse and relax the cutaneous surface; aided, occa-
sionally, by the w7arm bath, and even by emetics.   Cathartics are
never omitted.  Particular attention is paid to the patient's diet,
both as it respects its quality and quantity; none but the bland-
est articles are  allowed, and all excesses are carefully interdicted.
In a word, the  utmost caution is used, in all cases, not to employ
the knife until  the entire system is in the most perfect condition,
as far as such a thing is possible, when a fureign  body existed in
the urinary bladder.  The  period  occupied in the preliminary
treatment varies from a few days to two or three months, accord-
ing to the circumstances of each individual case.
  When the bladder has been cleared of its contents, the patient
is put to bed, and kept upon his left side,  until the surface of the
wound is thoroughly glazed with  plastic lymph.  This usually
happens within the first forty-eight  hours, and serves as a most
effectual  barrier  against urinary infiltration.  Nothing is inter-
posed between the lips of the wound, and the parts are not dis-
turbed,  even with sponge and warm water,  for twenty-four or
thirty-six hours.  The period of confinement after the operation
varies; and it  is  desirable that the  greatest  attention should  be
bestowed upon the general health, which should always be main-
tained in the best possible condition.   The patient should be kept
perfectly quiet, that the wound may close and cicatrize as speedily
as practicable, and in order, also, that it may not re-open, in con-
sequence  of ulcerative  absorption.   Dr. Dudley givetl^a case in
which, from neglect of this precaution, the parts experienced this
effect not less than four or five  times in as many months after the
operation.
  In the  one hundred  and thirty-five cases referred to in  Dr. 
[105]
Dudley's paper, union by the first intention was effected in eight;
of these, six had each a single calculus;  one had two of consid-
erable  size,  requiring unusual effort to  extract  them; and the
other had thirteen.   No reason  is assigned why union of the
wound did not occur in some of the other cases,  which were ap-
parently quite in as  favorable a  condition  for undergoing this
process as those just mentioned.   The  adhesive process does not
depend,  the author thinks, as much upon the keen edge of the
operator's instrument; upon any direct correspondence between
the size of the wound and the volume of  the stone;  or upon the
small number of times the  forceps are  introduced into the blad-
der, with a view to the seizure and extraction of the calculus; as
upon the state of the patient's general health before and after the
operation, a proper regulation of his diet, his position in bed,
and upon the attention  bestowed  upon the regular performance
of the  various important functions of the body,  throughout the
entire period of his confinement.
                   Varieties in Lithotomy.

  It has been already seen that Dr. Dudley has always employed
the gorget  in his operations; so far  as  I am able to learn, in
every one.   Dr. Ephraim McDowell, in his early career, used the
same instrument;  but subsequently he exchanged it for the scal-
pel.   Dr.  Alban Goldsmith, during his residence in Kentucky,
always employed the knife.  The same method has been pursued
by nearly all the other lithotomists of the State.  I have myself
never operated  in any other manner.
  The bi-lateral operation, as suggested by Celsus and Le Dran,
and perfected by Chaussier, Beclard, Dupuytren, and other mod-
ern surgeons, has never been performed in Kentucky.  The high
operation  has  been executed only once.  The operator was Dr.
William H. Gardner,  of Woodsonville.  His patient was a man,
42 years of ^%e, who had suffered  under  symptoms  of stone for
fifteen years.   Supposing that  he  should be able to extract the
calculus through  the perinaeum, Dr.  Gardner,  on the 14th of
April, 1844, performed  the ordinary lateral operation, but after
enlarging the incisions to the greatest possible extent, consistent 
                           [106]

with the safety of his patient, he found that it was impossible to
remove the foreign body, such  was its immense volume.  He at
once determined  to open  the  bladder above the pubes.   The
wound was from four and  a half to  five inches in length, and
after  much  difficulty he  extracted a  pear-shaped calculus,
weighing nine ounces, and measuring nine inches and a quarter
in its greatest  circumference by three  and a half in diameter.
Notwithstanding this double operation, and the violence necessa-
rily inflicted upon the parts, the patient slowly recovered, and in
less than three weeks was able to walk about his room.  He lived
upwards  of two years and a  half after the operation, when he
died from the effects of a return of the disease.
                        Lithotripsy.

  The operation of lithotripsy was first performed in Kentucky by
Dr. Alban G. Smith, now Dr.  Alban Goldsmith, of New "York.
I regret that I do not know  the date of his operation, but this
must have been prior to the  autumn of 1833,  when he removed
to Cincinnati.  He repeated the operation  once during his resi-
dence in Kentucky.
   In 1843, Dr. William A. McDowell, formerly of this city, now
of Evansville,  Indiana,* also performed this operation.  His pa-
tient was a young man, eighteen years of age, who bad suffered
from symptoms of stone in the bladder from his earliest infancy.
The urethra having been fully dilated by  three graduated bou-
gies of  " seasoned " slippery elm bark, the stone was seized with
Heurteloup's instrument, and  crushed at four sittings; the first
being on the 30th of August,  and  the last on the 16th of Sep-
tember. The calculus, as indicated by the scale of the instrument,
was twelve lines in diameter, and of great firmness.  The opera-
tion was productive of little pain, and the patient was never for a
 moment confined to his bed in consequence of it.  He walked to
 Dr. McDowell's office, a distance of nearly a mile, to^each sitting,
 and immediately after returned in the same manner.   The cure
 was complete.
* Western Jonrnal of Medicine and Surgery, vol. 8, p. 364. 
[107]
  A similar  operation was  successfully performed, in 1846, by
Professor Bush, of Lexington,  upon a  man, twenty-five years of
age, with Charriere's modification of Heurteloup's instrument.
The stone, which was remarkably hard, and of moderate size, was
completely crushed, and evacuated at the twelfth sitting.  During
the whole time, it was  never necessary to  allow more than one
day to intervene between the various operations, so favorable was
the condition both of the bladder and of the general system.*
  Soon after the above case  was reported,  Dr.  Bush, as he in-
forms me, performed a similar operation upon an old gentleman,
aged seventy-five years, who had suffered from stone for many
years.  He encountered no difficulty in using the lithotrite twice,
each time crushing a large calculus.  These two  essays were made
about two days apart.  Within twenty-four hours  after the last,
painful paroxysms were developed,  and these  continued  to in-
crease, becoming more and  more frequent, and resisting all the
means, both local and general, that were directed for their relief,
until the man was worn out,  with the most intense suffering,
about four weeks  after the last operation.  The autopsy exhibited
the whole interior of the bladder  extensively inflamed, much
thickened and ulcerated, with  several large abscesses in the coats
of the organ, one of which was discharging pus, and contained a
large fragment of the broken calculus.   Dr. Bush says he is sat-
isfied that this case could have been cured  by lithotomy.
           Chemical Analysis of  Vesical  Calculi.

  The following summary of his  chemical examinations of hu-
man vesical concretions, made at various times, up to the present
period, by Dr. Robert Peter, of Lexington, forms an appropriate
appendix to our remarks on calculous affections.  The results are
stated in the Professor's own language.  The concretions exam-
ined were a small portion of those removed by Prof. B. W. Dud-
ley, in his 207  operations,  with  some extracted by Profs. Bush,
E. L. Dudley,  and J. B.  Flint.   The patients were principally
from the west, and a large proportion of them from  Kentucky.

  * Lithotomy and Lithotripsy, p. 7.  Lexington, 1846. 
[108]
  The whole number examined,  exclusive of some sent me from
Ohio by Prof. Davis,  and several taken from the bladder of lower
animals, is 106 ;  which were extracted from 71 patients.
                           CALCULI
  CONTAINED IN THE TRANSYLVANIA UNIVERSITY MEDICAL MUSEUM,
      Lexington, Ky.; arranged according to their chemical composition.

  I-—Nucleus  Uric Acid.—36  Calculi from 6  Cases.
        A.—Nearly all Uric Acid,                               35
             Uric Acid, nearly  pure,    ...      1
             Uric Acid  with little Urate of Ammonia,      2
             Uric Acid  with ur. am., ur. lime and ur. soda 31 I a11 fr?m one
                                                        )  patient.
             Uric Acid  with ur. am. and oxalate of lime,   1

                                                     35
       B.—Body different from the nucleus,     ....     \
           Body fusible  phosphates; Crust do. with ox. lime,   -     1

  IL—Nucleus Urate of Ammonia.—41 Calculi from 38  Cases,
       A.— Urate of Ammonia, nearly pure,                      12
             Ur, Am. mixed with ox. lime in the exterior,  3
             Ur. Am. mixed with phosphates,      -     -  2
             Ur. Am. mixed with a crust of oxalate of lime ) ~
                                   beautifully polished, j
             Ur. Am. mixed with a crust of amorp. ox. lime, 3
             Ur. Am. mixed with a crust of phosphates,    2
                                                12
  B.—Bodies differing from the nuclei,    -   -    -    -    29
      Body.                          Crust.
Oxalate of lime,                 Fusible phosphates,        8
Oxalate of lime,                 Ox. lime and trace phosphs. 2
Ur. am. and ox. lime,            Ox. lime,                 1
Ur. am. and ox. lime,            Phosphates and clear crys-  ) „
                                 tals of oxalate of lime,  j
Ur. am. and ox. lime,            Fusible phosphates,        2
Ur. am., ur. ac. and ox. 1.,       Phosphates,               1
Ur. acid and ur. am.            Ox. lime and phosphates,    2
Ur. am. and fusible ph.,          Fusible phosphates,        6
Ur. am. and fusible ph.,          Oxalate of lime,            1
Or. ac. and fusible ph.,          Fusible and ox. lime,       1 
[109]
Ox. lime and phosphates,	Fusible,	1
Ox. lime and phosphates,	Clear crystals ox. lime,	1
Fusible phosphates,	Fusible,	1
                                                          29

III.—Nucleus Oxalate of Lime.—14 Calculi from 14  Cases.
      A.—Oxalate of Lime, nearly pure,.....9
          Body.                          Crust.
   Oxalate of lime,                  Oxalate of lime,          2
   Oxalate of lime,                  Phos. and cryst. ox. lime,  4
   Oxalate of lime,                  Same with same phos.,    1
   Oxalate of lime,                  Fusible phosphates,       1
   Ox. lime and ur. ammonia,        Clear crystals of lime,     1
  B.—Bodies different from the neuclei,    ....
      Body.                           Crust.
Ox. lime and phosphates,          Mixed phosphates,       2
Ur. acid and fusible,              Fusible phosphates,      1
Ur. acid and urates,               Clear crystals of lime,    1
Ur. am.  and phosphates,           Phosphates,             1
IV.—Nucleus Earthy Phosphates.—8 Calculi from 8 Cases.
      A.—Phosphates nearly pure   ,                 -   -     8
               Triple phosphates,                2
               Fusible phosphates,
               Mixed phosphates,
               Fusible, with trace oxalate lime,
               Fusible, with trace ur. am.,
               Body, phos. lime, Crust, fusible,
                  "   fusible,      "  ox. lime,
8
   V.—Nucleus a Foreign Substance.—4 Calculi from 3 Cases.
        A.—Nucleus a small bean,    --__..     2
  Bodies, triple phosphate, with little phos. lime and ur. ammonia;  Crust, the
samo. 
[110]
        B.—Nucleus a decayed bone,   ----__     \
  Body,  fusible phosphates, with trace of uric acid and urates;  Cortex, the
same.
        C.—Nucleus a small film ofanimal matter,    -              \
               [Probably the remains of a clot of blood.]
  Body and  Cortex principally fusible phosphates. *


  VI.—Nucleus Cystine.—3 Calculi from  2 Cases.
        All Cystine,   ------.._     3
  [Two of these were in the collection of Prof. B. W. Dudley, history unknown ;
the third was removed by Prof. J. B. Flint, of Louisville, in May last, from the
bladder of a gentleman from Tennessee.]
SUMMARY.
		PB CT
Calculi.	Cases	of the CASES
36	6	8.45
41	38	53.52
14	14	19.71
8	8	11.26
4	3	4.22
3	2	2.81
106	71	
  In a paper on this  subject,  published by Dr. Peter, in 1846
(in  the Western Lancet,  Vol. v, No. 4,) he attempted, by an ex-
amination of the statistics of calculi, to ascertain the influence of
limestone strata and limestone wTater on the frequency and com-
position  of  these  troublesome  concretions.    The  conclusions
arrived at were,
  1. That calculous disease is more frequent in limestone than in
freestone regions.
  2. That there is  a  larger  proportion of phosphatic and oxalate
of lime  deposits,—more urate of ammonia nuclei  and less  of
pure uric acid, in  the  limestone,  than in  freestone*regions   or
where the water is not contaminated with carbonate of lime. '
  These conclusions  have been corroborated by investigation in
other regions; especially   in  Ohio,  and  by  the examinations
which have been  made  by Dr. Peter, since the publication of

  *  Removed, six months after a previous operation, by Prof. J. M. Bush.
Nucleus uric acid,
Nucleus urate of ammonia,
Nucleus oxalate of lime,
Nucleus phosphates,
Nucleus foreign substance,
Nucleus cystine, 
[Ill]
the paper above mentioned.  It is a subject worthy of more ex-
tensive investigation.
                  Stricture of the Urethra.

  The subject of stricture of the urethra does not appear to have
occupied much of the attention of the surgeons of  Kentucky, at
least, if we may judge from what has been written upon it.  The
only contribution to this department of pathology  and practice,
so far as my information extends,  is  from the pen of Dr. E. L.
Dudley, under the singular title of "Interesting Case of Stricture
of the Urethra."*  This case occurred in the hands of Professor
Benjamin W.  Dudley, and the circumstances attending it are de-
tailed with much minuteness.  Preceding the account  of it, is an
outline of the practice usually pursued by  Professor Dudley in
the treatment of this affection,  which I deem of sufficient inter-
est to  give at some length.  That I may not misrepresent the
writer, I shall give his remarks in his own language.
  " Professor Dudley,"  says  the author,  " never resorts to the
use of the sound or bougie, except in his first examination, and
then to detect the nature and extent of  the disease.  His success
in the treatment of strictures, and by a system that dispenses with
the torture of  bougies and caustic, is a subject of intense interest
to the profession.  Arguing from the facts that stricture may fre-
quently exist for years without producing much uneasiness; that
the paroxysm  of suffering most usually, I might say, universally,
succeeds intemperance or exposure, and that the retention caused
by the determination of constitutional excitement to the disor-
dered part, is relieved as soon as the system is thoroughly relaxed
by bleeding and the warm bath, and the action of the  absorbents
excited he inferred that local means, alone, are not sufficient for
the cure of the disease; and was induced to employ a method of
treatment which  proposes the removal, the radical cure of the
stricture,  by acting upon the general system in such a way as to
induce thorough  absorption of the indurated material constitu-
ting the disease.  Reflecting upon  the  fact that the induration

  * Lawson's Western Lancet, for September, 1845, p. 199.  Lexington, Ky. 
[112]
 remaining after the ulcer is healed, or a boil matured, is speedily
 removed  by attenuating the system,  and inducing the  operation
 of that beautiful law by which new and adventitious deposits are
 removed  by absorption with more facility than healthily organi-
 zed and normal portions of the system, he thought it difficult to
 conceive why strictures, differing in no respect from the indura-
 tions just mentioned, all being produced  by the deposition of
 coagulable lymph, should not,  like them, be susceptible of cure,
 and by similar means.   He has, for a number of years, been in
 the habit of treating these cases by the plan deduced  from the
 above considerations, and a very extensive  experience has con-
 firmed  his confidence in it,   Heretofore, the  treatment of stric-
 tures has, at best, been but palliative.  A radical cure has been
 a circumstance so rare as scarcely ever to have been anticipated.
 There is one fact in the history of this disease, which would seem
 to prove its intimate  connection with a morbid state of the gen-
 eral system.  The  existence of stricture  is no evidence  of the
 violence of  the preceding disorder.  It seems, on the  contrary,
 to  be more commonly  a  sequence of those cases of gonorrhea,
 which were not  regarded as serious, and  were checked by the
 abortive treatment.   In almost  every instance, which  has come
 under my observation during the last five years, the patient, suf-
 fering with  contracted urethra, had been cured of gonorrhea by
 the familiar remedies and by injection.  Often the balsams alone
 had been employed,  and checked the urethral discharge in a few
days, the patient believing himself happily  cured,  until,  from
some cause, the stricture became irritated and produced retention,
or great difficulty and distress in evacuating the  contents of the
 bladder.  It may be granted that many cases of gonorrhea, cured
after this method, are not followed by stricture.  This, as far as I
have  observed, has  been a very rare sequence of  long  standing
chronic cases.  How are we to account for these facts?  Why
does stricture present itself in one instance, while others  enjoy
an immunity?  There is,  doubtless, an element,  efficient in the
production of these results, that is not generally recognized ; and
here, as in estimating the causes of the varying conditions or re
rcsults of ordinary  inflammation of other  parts, our  attention
must be directed to the  general condition of the patient, and es- 
                            [113]

pecially of the chylopoetic organs.  The universal sympathies of
these organs, and the acknowledged influence of digestive disor-
der upon local complaints, are perfectly understood, and regarded
by every physician  in the treatment of other diseases.   In addi-
tion to the stimulating effect exercised upon the kidneys by bal-
sam copaiba, squill, nitre, &c,  it is well known that these reme-
dies, after having been taken for a few days, disorder the stomach
very much.  That the entire system is very injuriously affected
by these articles,  is proven by the discolored skin,  and  irritable
stomach and bowels that always attend  their habitual use.   The
derangement produced by the  treatment is a cause, I  have no
doubt, of stricture in many instances.  This seems to be conclu-
sively established by the existence of the  disease where no local
applications  had ever been  made, and balsam constituted the
sole remedy, many  of which have been under Professor Dudley's
charge."
  The plan of treatment usually pursued by Professor Dudley in
this disease,  is well illustrated  in the case of a gentleman refer-
red to by the author, who had  been the subject of stricture for
thirteen years, during the greater portion of which he constantly
used the bougie to dilate his urethra and promote the discharge
of urine.   He had enlargement of the left testicle, the stream of
urine was  much reduced,  and,  at times, he labored under reten-
tion.  He had had gonorrhea twelve  or fifteen years previous to
his visit to Lexington, which was checked permanently by the use
of balsam, and he was now, upon his arrival, very much reduced
in flesh, with all the symptoms of a highly disordered state of
the alimentary canal.  The regular course of treatment was pre-
ceded  by emetics, given every other  day for two weeks.  "The
effect of these was  not of a satisfactory nature; the contents of
the stomach were thrown up, without presenting any appearance
of a salutary influence upon the liver.  Professor Dudley discon-
tinued  the emetics, and  substituted  nightly  doses of  calomel,
containing a small  portion of ipecac,  when the calomel failed to
act gently upon the bowels.  The effect of this prescription was
most favorable.  A few days-after commencing its use, the secre-
tions from the liver became profuse, and for several weeks Mr. R:
discharged  a large quantity of black and green matter.   It was
       °  14 
                            [114]

 interesting to observe the manifest influence of this  free action
 of the liver upon the stricture.  While the emetics were contin-
 ued, failing to produce healthful impressions upon the liver, and
 until the bile began to flow from the use of the calomel and ipe-
 cac, no beneficial change was observed in the urinary canal, and
 the ^patient was obliged to resort  occasionally to the use of the
 bougie, in order to relieve his bladder; but from the moment that
 he had  the first bilious discharge,  the stream  from the  urethra
 increased,  the bladder was evacuated with more ease, and  the
 swelling in the testicle diminished.  " This," adds the writer, " is
 a result w7hich I have witnessed in very many instances since I
 have been in the habit of attending to Prof. Dudley's cases."
   The case here detailed was perfectly cured in three months, the
 canal being restored to its natural caliber.   Several months after
 his return to the South,  the patient informed  Professor Dudley
 that he continued well.   "Two young gentlemen," proceeds the
 author, "had been  under  Professor Dudley's charge within the
 last  six  months, and were cured by  the same  treatment.  Two
 gentlemen,  from Mississippi, were treated  with  similar success
 during the summer of 1849, and numerous other  cases might be
 cited to swell the list."
  It is much to be regretted that Dr. E. L. Dudley, the author of
 the paper under consideration, has not informed us whether  the
 mode of treatment, so successfully pursued by his distinguished
 kinsman, and so much esteemed by him, is applicable to stricture
 of the urethra in all its forms and stages, to the hard and callous
 as well as the more mild and simple.   The inference, it is true
 plainly is, that it is, and that neither of the gentlemen ever re-
 sort to any other; but it would have been more satisfactory if the
 matter had  been stated in  direct terms.  My experience in  the
treatment of stricture of the urethra has been extensive, and in
 my work on  the Urinary Organs, published at  Philadelphia,  in
 1851, I have fully expressed my views of the nature and manage-
 ment of  this affection.  By a reference to that treatise, it will be
 found, that, while great stress is laid  upon a proper preliminary
 and  concomitant treatment, no reliance is  placed  upon diet and
 calomel, alone or with ipecacuanha, as exclusive curative agents.
 No one  can doubt that such a  mode of management might  an- 
[115]
 swer very well in the more simple forms of contraction; but to
 trust to it in cases of long standing, hard, callous, and almost im-
 passible stricture, would,  I conceive, be as unphilosophical as it
 is certainly opposed  to the experience of the  best  practitioners,
 both,of this country and of Europe.  It has been my lot, during
 my residence in Kentucky, to see quite a number of cases treated
 upcm this principle,  and I can solemnly aver that nota single one
 of them was permanently relieved.
   The practice which I  have generally found  most successful in
 the treatment of  this disease is that by dilatation; aided, or not,
 as the case  may  be, by cauterization and  incision.  The latter
 operation  I seldom omit when  the contraction is very firm, and
 within  a very reasonable  distance of the external orifice of the
 urethra. Under  such circumstances,  I  have often  succeeded in
 entering the  bladder with the largest  sized catheter, in a few
 seconds, in cases where all other modes of treatment had been
 unavailingly employed for months,  and even  years.  Whatever
 plan I adopt, it is &  golden rule with me,  always to pay the ut-
 most attention to  the  patient's diet and  bowels.   Ample experi-
 ence has satisfied me that mercurial purgatives, administered
 every third or fourth  night during the treatment, are  of the great-
 est benefit, in promoting the absorption of  the organized matter
 upon the presence of which the contraction depends.  In very
 old and  protracted cases, I do not hesitate to produce slight ptya-
 lism, taking care to keep it up for several weeks.
   When the  stricture is  situated in the membranous  portion of
 the urethra, and is exceedingly narrow  and callous, hardly any
 procedure, short of the division of the perinaeum, will afford per-
 manent  relief.  In 6uch  a case,  the  urethrotome is an uncertain
 and  unsafe instrument;  the process of dilatation is apt to be at-
 tended with the formation of false passages; and the mercurial
 treatment would not effect a thorough cure in a thousand years.
 The proper operation, under such circumstances, is that now gen-
 erally known as the perinceal section, so much resorted to by Mr.
Syme, of Edinburgh, by whom it has, perhaps,  been more fre-
quently executed than by any other  surgeon.   So far as my in.
formation extends, this operation has  been  performed only five 
[116]
 times  in  Kentucky, once by Dr. William Caldwell, formerly of
 Columbia, now of Louisville, and four times by myself.
   Mjr  first case occurred about eleven years ago, in this city, in a
 young man, twenty-one years of age, from the State of Illinois.
 He had ruptured  his urethra several years previously, by a fall
 astride the post of a chair.   The parts gradually healed, leaving
 a narrow  fistulous opening far back in the perinaeum, through
 which, with great difficulty, he voided his urine, none passing by
 the natural channel.   No catheter, even of the smallest size, could
 be introduced into the  bladder.  The operation  of dividing  the
 stricture, in which I was aided by my friend and late colleague,
 Professor Cobb,  was performed with hardly any trouble, and the
 patient remained perfectly well for  five or six months,  when,  in
 consequence of neglecting the use of the catheter, a relapse grad-
 ually took place,  and his symptoms  became as bad as ever. *
  Within the last eighteen months I have repeated this operation
 upon three gentlemen,  for organic stricture, the effect of  gonor-
 rhea, and in all with the most gratifying results.   In none of  the
 cases was it  possible to pass an instrument into the bladder, be-
fore the operation, owing to the remarkable and long continued
 contraction of the canal.  The part* were freely divided along the
 raphe of the perinaeum, and  healed  over a large sized catheter.
  In Dr. Caldwell's  case, an account of which  is contained in
the Western Journal of Medicine and Surgery, for June,  1846,
and in which the  stricture was likewise exceedingly tight and im-
 passable by catheters and bougies, the success wras also complete.
The patient, who had  been reduced almost to the last extremity
by his  protracted  suffering, rapidly recovered, and was able, more
than two years afterwards, to void his urine in a free, full stream,
like a man in perfect health.
               Foreign Body in the  Urethra.

  Under the present division of our subject may be mentioned a
Bingular instance of irritability of the urethra and bladder, pro-
 ______________________________________   *_____
  *  See the reporter's Treatise on the Injuries and Diseases of the Bladder,
Prostate Gland and Urethra, p. 649. 
                            [117]

•duced  by the  lodgement in the former of a hair. *   A married
gentleman, about fifty years old, of irreproachable character, was
seized with a tickling, itching sensation in  the fore  part of the
canal,  which, after having continued for  three months,  became
much aggravated.  The anterior third of the penis now began to
swell, and to be red and painful, and there was difficulty of urin-
ating, with a frequent inclination to empty the bladder.  Febrile
symptoms supervened;  the desire to micturate increased; and
there was a slight discharge of pus, and, at times,  also, of blood,
from the urethra.  Things remained  in this  condition for about
four days, when the patient discovered a hair  hanging four or five
inches from the orifice of the  canal.  From the sensation produ-
ced by pulling the  hair, which  was nineteen inches long, he
thought the seat of irritation  was an inch and a half from the
end of the penis.
  In addition to the above phenomena,  there was slight chordee
for a  day before the cause was removed;  and, for a short time
after this event, the symptoms closely resembled those of gonor-
rhea,  for which,  indeed,  they might  have been easily mistaken.
The patient gradually recovered, but not without undergoing con-
stitutional treatment.  What  is  very remarkable,  is that this
man,  about fifteen years before, experienced a tickling about the
head  of  the penis, similar  to that recently felt,  from a similar
cause, only that the hair was not so  long, and there was no in-
flammation of the urethra.
  Was the hair, which gave rise to the symptoms above  descri-
bed, generated in the urinary  organs,  or was  it entangled  by the
penis,  and gradually drawn into the  urethra by the remarkable
suction power of this tube ?  The case,  I  must confess, is one of
great interest to me.
A.—AFFECTIONS of  the genital organs in the male.
                         Hydrocele.

  In the Transylvania  Journal of  Medicine and the  Associate

  * Communicated to the Transylvania Medical Journal, for October, 1850, by
Dr. W. H. Shotridge. 
[118]
 Sciences, for 1828> is a long and elaborate article on  Hydrocele,.
 by Prof. Dudley, of Lexington, pointing out the nature and causes
 of this disease, together with what the writer claims as a new
 operation for its radical cure.  He also describes, under the name
 of encysted  hydrocele,  a  new variety of this affection.   "It is
 now ten years," says he, "since  I became acquainted with this
 peculiar form of hydrocele ; and there are sufficient reasons for
 believing that 1 first discovered this variety,  because of my pe-
 culiar mode of treating this disease, necessarily leading me to it,
 my practice being different from  that which is universally pur-
 sued in Europe and  the United  States."  Whether these claims,.
 advanced by our distinguished confrere, are well-founded, might
 form an interesting  subject of inquiry, which I have  not time to-
 pursue upon this occasion.  I shall content myself with  remark-
 ing that this variety of hydrocele  was unquestionably described
 long ago, as distinct mention of  it is made by Warner, Pott,  Sa-
 batier, Benjamin Bell, and other  authors ; and as for the "pecu-
 liar " treatment of hydrocele, that by incision, so far from being
 novel,  it is well  known that it was employed in the  time of
 Celsus, and  subsequently in the time of Guy De Chauliac.
  In connection with this paper  may be  mentioned a short com-
 munication  by Dr.  E.  L.  Dudley,  in  Dr.  Lawson's Western
 Lancet, for February, 1846, entitled a " Case of Sloughing of the
 Scrotum produced by injection to cure a Hydrocele."   The pa-
 tient was treated by Professor B. W. Dudley, but the operation
 was  performed by another practitioner.  The nature of the in-
jection is not  stated,  except that it is said to have been stimula-
 ting.  The testicle was completely denuded, and  but  a  small
 piece of the  scrotum  on the aflected side remained.   The parts
 were dressed with the bandage, and in six or eight weeks, were
 entirely cicatrized.  The case is  given as a warning against the
 practice of injection, so universal among surgeons, and  is made
 the occasion to  enforce the advantages of the operation  by inci-
 sion.  The paper, which is exceedingly concise, closes by stating
 that Professor  Dudley has cured many cases of symptomatic hy-
 drocele without any operation, simply by restoring the  general
 health and vigor of his patients.
  I am not aware that any operation for the radical cure of Vari- 
[119]
cocele has been performed by  any  one in the  State, except-
myself.  My mode  of treatment, founded  upon nearly a dozen
cases, is described in a short paper  in the  American Journal of
the Medical Sciences, for October, 1848.  It consists in exposing
the enlarged viens by  a  vertical incision, scarcely an inch in
length, along the anterior part of the  scrotum, in carefully separ-
ating these vessels from  the accompanying  duct, artery, and
nerves, and in firmly  constricting them over a short stout sewing
needle with a strong  ligature, carried round  the  instrument in
the form of the figure  8.  The cutaneous wound is carefully closed
with a twisted suture and  collodion.   At the  end of thirty-six
hours, the needle is withdrawn and the constricted vessels divi-
ded.
  The advantages of  this operation are,
  First—its perfect simplicity and the facility with which it may
be executed.  Secondly—its freedom  from pain and hemorrhage.
Thirdly—the certainty with which we may avoid injury to the
spermatic duct, artery and nerves.  Fourthly—the little inconve-
nience and suffering  which the patient experiences after its per-
formance ;  and,  Fifthly—the rapidity and   certainty of  the
cure.
  These  considerations ought to be sufficient to recommend this
method to the favorable regard of practitioners.   Most of the
operations described  in the books are complicated, severe, and
dangerous.
  Excision of the testis for malignant and other  affections  has
been repeatedly executed by our surgeons, in most cases  without
any ulterior advantage, the patient dying sooner or later from a
return of the malady.  An  interesting exception to this rule is an
instance  which occurred in the practice of Dr. Flint, of this city,
and a brief account of which is contained in the third  volume of
the Transactions  of the American Medical Association.   The
disease was encephaloid, under which the patient, a married man
with  several children,  had been  suffering  for several months.
The spermatic cord was sound.   The operation was performed
on  the 16th of March, 1840, and when the case was reported in
April, 1850, the man was quite well. 
[120]
    A very novel case, justifying, in my  opinion, excision  of the
  testes, came under my observation in 1849.  So far as my infor-
  mation extends, there is no account of any operation for a similar
  object upon record.  The patient, at  the time I firsb saw her—
  she had always been regarded as a girl, and had been so pronounc-
  ed by the accoucheur—was three years of age, having been born
  on the 10th of July, 1846.  At the  age  of two,  she began to
  evince the feelings and disposition of a boy; she  rejected dolls
  and  similar articles  of amusement,  and became fond of boyish
  sports.  She was well-grown, perfectly healthy, and quite fleshy;
  her hair was dark and long, the eyes black, and the expression
  very agreeable.  Upon making a careful  examination, I found the
  external genitals in the following very singular condition.   There
  was neither a penis nor a vagina ; but instead of the former there
  was a small clitoris, and instead of the latter a cul-de-sac, covered
  with mucous  membrane.  The urethra occupied the usual situa-
-  tion ; the nymph ae were unnaturally small; but the labia were
'  well developed, and contained  each a testis, quite  as large, con-
 sistent, and well shaped as they ever are in boys at  this age.
   ■ It being apparent from the facts of the case that it was one of
  monstrosity of the  genital  organs, usually denominated herma-
  phrodism, the question at once occurred  whether anything  ought
  to be done  to deprive the poor child of that part  of the genital
  apparatus, which, if permitted to remain until the age of puberty,
  would be sure to be followed by sexual desire, and which might
  thus conduce to the formation of an unfortunate matrimonial
  connection.  Such  an alliance, it was evident, would eventuate
  only in chagrin, disappointment, and,  probably, in disgrace.—
  Certainly no impregnation could ever occur, and even copulation
  could be performed but imperfectly.   I gave the subject all the
  consideration that I was  able  to bestow upon it;  I felt the res-
  ponsibility  of my position ;  a new question, involving the happi-
  ness of my  little patient and the deepest interests of her parents,
  was presented to me.  I appealed to the records of my profession
  but in vain, for a precedent.  Under the circumstances,  I sought
  the advice of a medical friend, Professor  Miller, in whose wisdom
  and integrity I had  unwavering  confidence; he saw the child,
  and examined her; he viewed the case, as I had done previously 
[121]
 in  all its aspects, physiological, legal and surgical, and his con-
 clusion wras that excision of the testes would not only be justifiable,
 but highly proper; that it would be an  act of kindness and hu-
 manity to the  poor  child  to deprive it of an appendage of so
 useless a  nature, one which might ultimately lead to the ruin of
 her happiness.  The  parents were already solicitous for an oper-
 ation, and having imparted to  them our  decision, I  no  longer
 hesitated  in regard to the course I ought to pursue.
   I performed the operation of  castration  on  the 20th of July,
 1849, aided by my pupils, Dr. D. D. Thomson, of this  city,  Dr.
 Greenbury  Henry, of Burlington, Iowa,  and Dr. William II.
 Cobb, of Cincinnati.  The  little patient  being put under the
 influence  of chloroform, I made a perpendicular incision into each
 labium down to the testis,  which was then carefully separated
 from the surrounding parts,  and detached by  dividing the lower
 part of the spermatic cord.   The arteries  of the cord being se-
 cured w7ith ligatures,  the edges of the wound were brought togeth-
 er with twisted sutures,  and  the child put to bed.  Hardly any
 blood was lost during the operation.   About two hours after, the
 left labium became greatly distended and discolored; and, upon
 removing the sutures, the source of  the mischief was found to be
'a small artery, which was immediately drawn out and tied.  No
 unpleasant symptoms of any kind  ensued after  this,  and in a
 week  the little patient  was able to be up, being quite  well and
 happy.  The  testes were carefully examined  after removal, and
 were found to be  perfectly formed  in  every respect.   The sper-
 matic cords were  natural.
   I have seen this child repeatedly  since  the  operation,  as  her
 parents live only a few  squares from my office, and have watched
 her mental and physical developments.   Her parents, who are
 persons of observation and intelligence, assure me that her dispo-
 sition and habits are those of a girl; that she takes great delight
 in sewing and house-work,  and that she no longer indulges in
 riding upon sticks and other boyish  exercises.   Her person is
 well developed, and her mind uncommonly active for a child of
 her years. 
                           [122]

                      Self- Castration.

  The following interesting case of self-castration has been com-
municated to me, through Dr. Frazee, of this city, by Dr. Samuel
R. Sharpe, of Maysville.
  W. O. N.,  aged twenty years, of a  lymphatic temperament,
light complexion, six  feet high, and weighing one hundred and
seventy-five pounds, a teamster and drover by occupation, came
to Maysville in the autumn of 1849, having emasculated himself
only the day  previous.  Calm, clear and collected upon every
subject, except that of his sexual organs, which he  said had
caused  him  more  trouble than all the  rest of his system put
together, he  viewed the act of mutilation in all its bearings and
aspects  with the utmost indifference, declaring  that it was far
better to part with the offending members than  to be a slave to
his  passions.   Looking upon the matter in this philosophical
light, he had not hesitated to perform  the operation, and now
that it was over both his  feelings and his conscience  fully ap-
proved the act.   He had no regrets, and he was satisfied that his
future would be far more happy than his past life.  This feeling
of self-approbation continued for more than a year;  but of late
his  conduct has been a source of deep chagrin and mortification
to him.
  The operation was performed in the woods, by himself, with a
razor, at least half a mile from any dwelling, about five o'clock
in the afternoon.  There was but little external hemorrhage ; but
the blood collected in the  scrotum, distending it to  the size of a
cocoa-nut.  To guard against bleeding, he scraped the spermatic
vessels, as he had often scraped those of the pig ; the first testicle
he removed, he said, in a very bungling manner, as his incisions
were all too light; but the other was taken away  very quickly
and neatly.   Hoisting his umbrella,  he coiled himself  up under
it, and in this condition remained until the next morning, passing
a calm  and quiet night, not  even thinking of the women.   It is
worthy of remark that this man labored under gonorrhoea at the
time of the operation, and that the removal of his testes complete-
ly cured this disease without  the aid of local  or constitutional
treatment.  The reporter of the case facetiously asks, what do 
[123]
you think of such a remedy  for clap ?  Do you  think it would
become popular?
  The treatment of the case, after it fell into  the hands of Dr.
Sharpe, was very simple.  Poultices of cinchona  and charcoal
were used until the coagula were digested off, when  they were
replaced with cloths, wet with warm water.  A mild vegetable
tonic  was administered, and a  nourishing diet  enjoined.   The
patient left Maysville in about a month.  Dr. Sharpe states that
he occasionally sees this man, and that he can observe a sensible
change in his hair and beard, both becoming thinner and softer.
His voice is unaltered,  and there  is  no increase of flesh or fat.
His industry and power of endurance are about the same as before
the operation.  He still retains some propensity for women, and
declares that he has indulged in sexual intercourse,  with feelings
of a pleasurable kind.
                          Priapism.

  Priapism, of a protracted and obstinate character, is occasion-
ally met  with,  and well deserves,  on account  of  the  suffering
which so generally attends it, the serious consideration  of the
practitioner.   Dr.  James Moore, of Shelbyville, gives a case in a
married man, aged forty years, in which this  affection continued,
with hardly any interruption, for  twenty-six days.   The patient
was laboring  under dyspepsy  and hepatic derangement at the
time of the occurrence of the accident, which ensued immediate-
ly after sexual  intercouse.   The virile  organ was  in a state of
complete  erection, highly  phlogosed, and  exquisitely  painful;
considerable febrile disturbance was present, the bowels were cos-
tive,  micturition was  performed  with great  difficulty,  and the
patient was wholly deprived of sleep.  The most active treatment,
both local and general,  was employed, as copious venesection,
scarification, and cold  medicated lotions, blisters to the inside of
the thighs, and injections of antimony into the  rectum, without
any material benefit, until  the twenty-third day, when bladders
of cold water were  resorted to,  and  kept  constantly  applied
to  the affected  member.   About the end of this  time, man-
ifest relaxation  took  place, and,  in  about  twenty-four hours 
                            [124]

more, it was complete.  It was found necessary, during the whole
treatment, to give catharties and enemata largely, as more relief
    obtained from  them than from any other remedy, save the
was
one just mentioned.
  For the particulars of a similar case, occurring in a stout robust
mechanic, thirty-three years of age, and continuing with great
intensity for nearly  two weeks,'the  Society  is referred to the
second volume of the Western Medical Gazette, published at
Cincinnati, in 1835.   In this case, which I visited several times
in consultation,  and which I reported in the periodical just men-
tioned, the  prominent symptoms were, a painfully tense and
rigid state of the member, pain in the perinaeum and neck of the
bladder,  infiltration  of the  subcutaneous cellular tissue of  the
penis, and obstinate  retention of urine, with little or no constitu-
tional excitement.  The priapism supervened  upon sexual inter-
course, after exposure to a heavy shower of rain. Several months
elapsed before the organ entirely  regained its  normal condition.

  Sympathy between the Genital Organs and  Cerebellum.

  The sympathy existing between these organs has  long been a
subject of remark with physiologists and pathologists, and is often
strikingly displayed  after injuries upon  the back of the  skull, ^
wounds of the cerebellum,  and apoplectic effusions.  Many ex-
amples, illustrative of this connection,  are contained in the wri-
tings of physicians,  as well as scattered  through  our  periodical
literature.  The history of Kentucky surgery  furnishes at least
two  cases of this kind, one  in the practice of Dr. W. H. Donne,
of this city, and the other in that of Dr. Asbury Evans, of Cov-
ington.
  Dr. Donne's case was occasioned by  a gun-shot wound. *  The
patient, a stout, athletic laborer,  aged  twenty-eight,  received an
injury from a rifle-ball, at the postero-inferior angle of the parie-
tal bone, a few lines from the lambdoidal suture; the ball pass-
ing  in a direction laterally downwards and backwards  through
the cerebellum,  and lodging in the interior of the skull.   Reac-
tion, which was  not fully established  until the third  day,  was
* Western Medical Gazette, 2, 295.  Cincinnati, 1834. 
[125]
soon followed by cerebral inflammation,  and by the escape from
the wound of a large quantity of cerebral matter.  Priapism su-
pervened  on the evening of the  fifth day after  the. injury,  and
continued, without  the slightest interruption, until a few  mo-
ments before death, at the end of the ninth day.   His language,
for a time, was very obscene, and his sexual propensities were so
great that his female attendant was obliged to quit his apartment.
   Dr. Evans's case  occurred in a youth of eighteen, in conse-
quence of a blow upon the upper part of the head by the handle of
a  windlass.  Death ensued in eleven hours after the  accident,
preceded  by priaprism and  symptoms of cerebral compression.
The patient  lay in  a state of insensibility for  upwards  of two
hours, and was trephined  without any relief.  A post mortem ex-
amination disclosed extensive fracture of  the frontal, parietal and
ethmoid bones,  with laceration of the anterior  lobe of the left
hemisphere of the brain,  and a copious  effusion 6f blood, both
here and  upon the  upper surface of the cerebellum, as well  as
around the Varolian bridge and the  oblong  portion of the spinal
cord.   Dr. Evans accompanies  the recital of his case with some
very judicious reflections, which, I regret, the limits of my report
prevent me from noticing. *
                     Syphilitic Diseases.

  In Lawson's Western Lancet,  for July, 1845,  is a paper "On
some Diseases  resembling Syphilis," by Dr. E. L. Dudley,  in
which this gentleman calls the attention of  the  profession to the
importance of a correct diagnosis between  simple non-venereal
and true venereal  ulcers,  to  the avoidance of harsh local reme-
dies,  and to strict treatment of the constitution.  He adduces
several cases, from his own practice and from that of his^friends,
in corroboration of his views;  and  the  article  is characterized,
throughout, by  good  sense  and discrimination.  He  speaks  in
terms of high commendation of the efficacy of emetics  in the
treatment of the non-syphilitic sore,  and of  their value in prepa-
ring the system  of the syphilitic patient for the use of mercury.

  * Lawson's Western Lancet and Hospital Reporter, October, 1851, p. 625. 
                             [126]

 "It is just as  important,"  he observes, " that the healthy train
 of associate actions should be established  in a patient about to
 undergo a course of mercurial medicine, as that a patient about
 to submit to a dangerous operation should be in good health."
   Of the truth of the above remark, no one, accustomed to treat
 syphilitic affections, can entertain a doubt.  My own experience,
 lono- ao-o, convinced me that there is not an ulcer, no matter how
 simple or how severe, whether benign  or malignant, syphilitic or
 non-syphilitic,  in any part of the body, that is not vastly bene-
 fitted or  improved by due attention to the constitution; and, on
the other, often immensely aggravated  by the neglect of this pre-
caution and^ by harsh topical  applications.  The connection be-
tween local and constitutional affections, or, more properly speak-
ing, the influence exerted  by the constitution  upon the progress
and character of local diseases, cannot  be too often brought under
the notice of the surgeon, or too forcibly enjoined in our writings
and prelections.  To regulate the diet  and  bowels, to correct and
modify the secretions of the more important orgrns,  to calm the
general system, and to improve the general health, is to deprive
any syphilitic ulcer,  whether primary, secondary, or tertiary,  of
half its power,  and to  place it in the  best possible condition for
speedy restoration.  Were this rule more frequently carried out
in practice, we should see infinitely less suffering and loss of life
from the  use, or, rather, abuse, of mercury and other severe and
unnecessary remedies.

    b.—affections of the genital organs in the female.
           Occlusion of the  Mouth of the Uterus.

  The orifice of the womb is liable, from various causes, to occlu-
sion, followed,  generally, especially in the adult, by retention of
the menstrual fluid.   The following cases are illustrative of the
nature and treatment of the affection.
  The first occurred in the practice of Professor Bush, of Lex-
ington, and a brief account of it is to be found in the Transylva-
nia Medical  Journal,  for November, 1851.  The patient, a ne-
gress, had experienced severe pelvic pains for several months,
and  had used the  ordinary remedies  for exciting  the menstrual 
[127]
function.   Her suffering gradually increased; and, upon exam-
ining her, the womb was found to be enlarged so much as to ex-
tend above the  pubes,  being fully as capacious as in the fourth
month of gestation.   The vagina was not more than an inch in
length,  and the orifice of the uterus could not be detected.  The
hymen was absent, and the parts had evidently been employed in
the way designed by nature.  The finger, inserted into the rec-
tum and vagina, readily discovered a fluctuating tumor, occupy-
ing the concavity of the sacrum.
   Dr. Bush passed a long trocar  through the septum, and then
with a bistoury made a crucial incision large enough to admit the
index finger.  A gush of thick semi-fluid substance immediately
occurred,  continuing for several minutes,  and followed  by the
subsidence of the pelvic tumor.   The patient recovered from the
operation without accident, and several years after became preg-
nant, but could not be delivered without surgical interference, on
account of the closure  of the orifice of  the uterus.  Her labor
had been  in progress for about twelve hours, and the head of the
child had descended nearly as low down as the vulva, when it be-
came necessary to make an incision several inches in length, ex-
tending from a small orifice, left by the previous operation, for-
wards through what was supposed to be the mouth of the  uterus.
The opening was subsequently enlarged, and soon afterwards the
child was expelled,  dead, and imperfectly developed.
   The subjoined case occurred  in my own practice;  the patient
promptly  recovered, and is  still living.  A widow lady, aged
forty-nine, the mother  of a  number  of children,  and of rather
delicate constitution, having a falling of the womb, was induced
to wear a  pessary, which occasioned excessive pain,  and  finally
so much inflammation  as to render  it necessary to withhold it
from the vagina.  At the next menstrual period it was discovered
that, although the  ordinary symptoms were present, there was
none of the proper discharge.  Things went on in this  manner
for several months,  with a gradual increase of the  local distress,
and  the formation of a well  marked pelvic tumor.  The  pains
became  more and more  frequent and severe, and  at length as.
sumed a neuralgic type,  recurring every afternoon, lasting a few
hours, and then passing off, very much like the paroxysms of an 
[128]
 ao-ue, only that they were not attended by chills and perspiration.
 The tumor augmented in volume, and at the end of a year it was
 as large as the womb  in the seventh month of gestation.   It was
 tender on pressure, movable, elastic, and fluctuating, both when
 felt through the abdomen and vagina, in the latter of which  it
 formed a tense semi-globular projection.   The general health was
 somewhat impaired.
  In 1842, the patient came to town,  and  placed  herself under
 the care of my colleague, Prof. Miller and myself.  An operation
 being agreed upon, a puncture was made into what was supposed
 to be the original orifice of the uterus, giving vent  to upwards of
 half a gallon of thick, grumous, dark-colored matter, evidently
 retained menstrual secretion, in an inspissated and highly altered
 condition.  Immediate relief followed the  operation.  The neu-
 ralgic pains never returned,  but the lady menstruated for some-
time afterwards, occasionally rather profusely, and suffering more
than usual in her back and pelvis.   Her health became gradually
re-established, and remains good to this day.
  Very recently another instance  of a similar nature came un-
der  my observation, and was  fortunately relieved in the same
manner.
                  Stricture of the Vagina.

  A case of this affection,  treated successfully with  the elm
bougie, has been reported to me by Dr. William A. McDowell,
formerly of this city.
  In October, 1839, a lady, aged thirty-seven years, much ema-
ciated, and of chlorotic appearance, consulted Dr. McDowell and
Dr. Powell,  making the following statement about her case.—
Three  years  previously  she had been  delivered by a  drunken
accoucheur, who, to suppress flooding, had recourse to his pocket
handkerchief for a tampon.  All went on well, with  the exception
of a gradually increasing uneasiness in the vaginal region, until
the sixth day, when the suffering became so  severe"5 that  her
physician was called.  He examined the part, and to his surprise
found his long lost handkerchief.  The process of extraction was
agonizing in  the extreme; and was succeeded by a protracted 
[129]
attack of fever.  On her recovery, she detected  the  obliteration
of the vagina; she had not menstruated since, but was troubled
with an incessant oozing of reddish fluid.
  An examination discovered a mere cul-de-sac at the mouth of
the vagina, not exceeding an  inch  in  depth, and walled round
with strong sound tissue.  Into this a conical piece of seasoned
elm bark, five inches long, and of the thickness of a crow-quill,
after having been immersed for fifteen  minutes  in tepid  water,
was  introduced, and gently passed  up  nearly its whole length ;
after  which it was  secured  in its  place by a  T bandage.  In
twenty-four hours this bougie had expanded to the size of a large
goose-quill; another and another, each successive  one  larger
than  the  previous, was inserted  day after day, until the canal
finally received one of an inch in diameter, composed of different
layers  of  the  bark,  notched  and tied together,  and rounded off
above.  This  was  deemed sufficiently large, and  was retained
daily, for  several hours, until its  presence ceased to irritate or
annoy.  In this manner the patient was cured without any ocular
inspection whatever;  and eleven months afterwards  she gave
birth to a son.
vm.—affections of the arteries.
                          Aneurism.

  One of the most remarkable circumstances, and one for which
no satisfactory explanation can be offered, is the infrequency of
spontaneous aneurism  in the inhabitants of the South-west.  In
a practice in Ohio and Kentucky of nineteen years,, in which 1
have witnessed almost every surgical disease to which the human
body is liable, it has rarely occurred to me to meet with an exam
pie of  this affection.   My  experience, in this respect, perfectly
coincides with  that  of my  professional brethren.  Professors
Dudley and Bush, of Lexington, have rarely met with an instance
of this disease.   In a letter recently received from  the latter of
these gentlemen, he  remarks, " Dr Dudley  says his experience
upon  the subject of  spontaneous aneurism  corresponds with
yours."  Dr. T. G. Richardson,  the  Demonstrator  of Anatomy
         15  • 
                            [130]

in the University of Louisville, has dissected several hundred
bodies without  meeting with  hardly a solitary  example of this
affection;  and the testimony of  Dr.  Bayless, who formerly occu-
pied the same position, is precisely to the same effect.  To what
this  extraordinary immunity is  ascribable, we have no data by
which to  determine.  Our population  is a mixed and laborious
one, made up from all parts of the civilized world, and pursuing
all  sorts of occupations, from the most  delicate and  refined to
the most severe and rigorous ; and yet  a case of spontaneous an-
eurism, in any class of  our citizens, is absolutely an anomaly.
Leaving to others the task of  ascertaining, if possible, the cause
of this exemption, so remarkable and so singular, I shall proceed
to point out to you such facts and observations as have a tendency
to illustrate the history of  this branch of Kentucky surgery.
  One of the most extraordinary cases  of aneurism of which the
records of science make  mention, occurred in  1841, in the prac-
tice of Professor Dudley, of Lexington.*  The patient was a
blacksmith, twenty-five years old, aflected with a remarkable pro-
trusion of the  right  eye,  attended  with great pulsation of the
part,  noise in  the head, wide  separation of the sutures of the
cranial bones of the  corresponding  side,  and  loss of function of
the right eye and ear.   He had occasionally suffered during the
last five or six years with intense pain in the  head,  for which
much had been done, both locally and constitutionally, without
any material benefit.
   The patient  having been subjected, for a few weeks, with great
amelioration, of his suffering, to a rigid diet, purgatives,  and al-
teratives, Dr. Dudley determined to secure the carotid artery,  as
 the only chance  of relief.   The moment the ligature wras tied, all
 pulsation in the part ceased,  the corresponding side of the head
 became perfectly quiet, and  the noise in the head,  which had
 been so  long  and so troublesome an  attendant,  disappeared.—
 Some fever and  biliary derangement ensued  four days after the
 operation; but  these soon yielded to mercurial cathartics  and
 "broken doses" of tartrate of antimony and potash.   By the

   * Transactions of the American Medical Association, vol. 3, p. 342.  The
 case is reported at length in the Quarterly Summary of the Transactions of the
  College of Physicians of Philadelphia, for Aug., Sept., and Oct., 1842. 
[131]
end of the second week,  the tumor had receded so far that the
disunited portions of the cranial bones had recovered their natu-
ral position, and the eye and car  their functions.  In less  than a
month, the man returned to his residence at St. Louis, to resume
his occupation as a blacksmith.
  Dr. Hall, of St.  Louis, who knows Dr. Dudley's patient well,
informed me, about six weeks ago, that there has been no  return
of his disease, and that the general health of the man is excel-
lent.   For about eighteen  months after the operation, he was
feeble, and unable to attend to much business.  Since then  he has
been regularly at work as an industrious blacksmith.
                       Carotid Artery.

   In Drake^s  Western Medical and Physical Journal, for 1826,
Dr.  Henry Miller, of this city, has recorded a case in which he
tied the carotid artery, on account of injury inflicted upon the
neck by a female  in an attempt at self-destruction.  There were
not  less than  five incisions on the  right side, dividing the body
of the  sterno-cleido-mastoid muscle, the internal jugular vein,
and the outer coat of the carotid artery.  The larynx was intact.
The hemorrhage from the jugular  vein was excessively profuse;
but  having ceased when her attendant arrived, he contented him-
self with the introduction of a few  sutures and the application of
a  compress and roller.  The accident happened on the 12th of
September, 1825,  and Dr. Miller  did not see the case until the
23d.  The hemorrhage had recurred with about as much loss as
in the first  instance, and was evidently  of a venous  character.
As the wound had healed,  except  at a few small points, it was
deemed best to trust again to compression.  On the 9th of Octo-
ber, in consequence  of an alarming  repetition  of the  hemorr-
hage, w7hich was now distinctly arterial, the wounded carotid ar-
tery was tied  below its bifurcation  with n single ligature, carried
round  the vessel with a common curved needle.  For three days
subsequent to the operation,  which was rendered  both  tedious
and  difficult, on account of the previous  division of the sterno-
mastoid muscle, and  the confused and matted  condition of the
parts,  the woman lay  in  a  state  of insensibility, and fainted 
[132]
 whenever she was raised up in bed.   She then began to recover*;
 the wound healed  rapidly; there was no further return of arte-
 rial hemorrhage; and in a few weeks she was entirely well.
  Dr. E. L. Dudley, of Lexington, tied the primitive carotid or
 the 12th  of August,  1851,  in a man aged  thirty, who, three
 weeks previously, had been stabbed in the neck with a knife.   A
 copious hemorrhage followed the accident;  and about ten days
 after, a pulsating swelling was observed at the site of the injury,,
 which  burst on several occasions, and the man very nearly lost
 his life by bleeding.   The carotid artery was  secured just above
 the angle formed by the omo-hyoid and  sterno-mastoid muscles.
 Some hours after the operation, upon removing the compress from
 the original wound, a  copious flow of blood, supposed to proceed
 from an opening in the internal jugular vein, took place, but this
 was easily checked, and did not recur until the 17th, when it was
 so great aS to  induce syncope twice.  The dressings were now
 more securely applied, and,  on the 22d, when they were taken
 off,  all danger  of  hemorrhage wras found to have passed; the
 wound suppurating kindly, while that made in the operation had
 nearly healed.
  On the 19th of August, that is,  seven days after the operation,
tetanic symptoms supervened, and gradually increased in severity
 until the morning of the 31st, when the man expired.  No active
 treatment  was employed after  the full development of the spas-
modic affection.  A large blister was applied  to the nape of the
 neck on the 28th;  but, although it produced thorough vesication
in a few hours,  no  benefit followed.   The ligature came away on
 the sixteenth day after the operation.
                    Subclavian Artery.

  To  Professor Benjamin W. Dudley, of Lexington,  is due  the
honor of having been the first,  in Kentucky, to perform the oper-
ation for securing the subclavian artery.   I was not aware, until
recently, of the existence of this fact, when I accidentally met
with it in reading this  gentleman's  article " On the use of  the
Bandage in the Treatment of Contusions, Lacerations, Effusions,
&c,"  in the second volume of the Transylvania Journal of Med- 
[133]
icine and the Associate Sciences.  I make this statement for the
purpose of accounting for the omission of this case in my paper
upon axillary aneurism,  published  in the Western Journal of
Medicine and Surgery, for June, 1841.
   Dr. Dudley's case occurred in the autumn of 1825, in an old
gentleman of sixty-five.   The disease was axillary aneurism, and
the tumor,  which pulsated upon all  points of its surface, was
"larger than a quart pitcher."  As a preliminary step, the parts
were placed in the most favorable situation for exposing the sub-
clavian,  by putting the patient in the semi-recumbent posture,
inclining the head to the sound side, and depressing the shoulder.
Several vessels, some of magnitude, were laid bare, and held out
of the way, while the artery was brought fully into view, and lig-
ated without the loss1 of a table spoonful of blood.   All pulsation
in the tumor, as well as at the wrist, immediately ceased, although
there was no  loss of temperature; and, on the twenty-first day
after the operation, the patient went home in good health.  It is
to be regretted that the details of this case are so meagre, as they
deprive it of much of its interest. *
   The second operation upon the subclavian artery was performed
in October, 1832, at the Louisville Marine Hospital, by Dr. Alban
G. Smith, now Dr. Alban Goldsmith, of New York, for the relief
of axillary aneurism in a  Spaniard,  named Lewis  Vergue, thirty
years of  age.  The patient had been struck, upwards of a month
previously, with a dirk-knife, which, entering near the top of the
left shoulder,  passed inwards and outwards so as to open  the ax-
illary artery.  The vessel  bled profusely, both at the moment, and
several times subsequently,  but the hemorrhage ceased  entirelv
in a few days, and shortly afterwards the external  wound healed.
When the case was first seen by Dr. Smith, the tumor was five
inches across its base, pulsated strongly, and was situated just
beneath  the clavicle.  The  general  health was much impaired;
the patient was feeble, and obliged to keep his bed; he was un-
able to move his left arm, and  sudden motion of the body pro-
duced 2u feeling of faintness.
   Having spent from two to three weeks in unavailing efforts to

  * Transylvania Journal of Medicine and the Associate Sciences, vol, 2, p,
362.   Lexington, 1829. 
                            [134]

 reduce the tumor by low diet, rest in the recumbent posture, and
 steady pressure upon the part,  Dr. Smith determined to tie the
 subclavian artery.  With a  bistoury two  incisions  were made,
 «»ne, three inches in length, along the upper border of the clavi-
 cle, and the other, two inches in length, parallel with the exter-
 nal margin of the sterno-cleido-mastoid muscle.  The fibres of
 the platysma-myoid muscle were next divided, when, taking the
 inferior edge of the omo-hyoid  for his guide,  he exposed the ar-
 tery just as it emerges from  between the  scalene muscles, and
 secured it with three cords  of  silk, conveyed beneath  it  by  a
 Parrish aneurismal  needle.   The  tumor immediately ceased  to-
 pulsate, and decreased one-third in size.  Hardly a gill of  blood
 was lost  in the  operation.  On the sixth day the pulse returned
 at the wrist, and on the eighth the ligature came away with the
dressings.  At the end of a fortnight the wound had healed, and
the tumor had shrunk down to a little hard lump.  On the eigh-
teenth day, the patient left for New Orleans, and was rapidly re
gaining the use of his limb. *
  The third operation in  Kentucky,  for ligaling the subclavian
artery, was performed by the Chairman of this Committee,  in
February, 1841, upon a colored  man,  thirty-six years of age, af-
fected with axillary aneurism, from the recoil of the butt end of
a yager.   The tumor, situated beneath the right pectoral muscle,
and extending from the clavicle  down to the  cartilage of the
fourth rib, wra& of an irregular conical shape,  and about the vol-
ume of a large fist, measuring fully four inches at its base in one
direction,  by three and  a half in the  other.   Though pulsating
strongly,  it was tense, as well as inelastic,  and the blood rushed
into it with a peculiar wheezing  noise.   The clavicle wras thrown
above its natural level, the pectoral muscle much stretched, and
 the whole limb,  from the top of  the shoulder to the  ends of the
fingers, benumbed^  painful, and nearly  deprived  of power.  For
the last four weeks, the local distress was so intense as to deprive
the patient, in great degree, of appetite and sleep, and, as a ne-
cessary consequence, the general health was much impaired.
  An operation being determined upon,  as the only probable
 means of  saving life, it was performed  on the  18th of February,

  * Western Medical Gazette, vol. 1, p. 320.  Cincinnati, 1834. 
[135]
before the Medical Class of the University of Louisville.  The
patient was placed upon a narrow table of moderate height, the
head and  chest were properly elevated with pillows, and the face
was turned a little towards the sore side, while an assistant pulled
gently at the wrist, so as to  depress as much as possible the af-
fected shoulder.  The  integuments over the clavicle being  next
stretched upon the chest,  I made my first  incision along the cen-
tre of that bone, beginning near the sternal origin of the mastoid
muscle, and passing  out towards the  acromion  process of the
scapula for about three inches and a half; thus dividing, at one
stroke, the skin, cellular substance, and platysma-myoid muscle.
The parts being now allowed to retract, left the lower margin of
the cut parallel, and on a level with the superior border of the
clavicle.  A second incision, about two inches in length, was car-
ried along the posterior edge of the mastoid muscle,  at a right
angle writh the preceding.  The triangular flap thus formed  was
then dissected  up and held out of the way, care being taken not
to interfere with the external jugular vein, or any of the smaller
arteries of the neck.   The cervical aponeurosis was now detached
from  the clavicle by cautious strokes of the handle of the scalpel,
which laid bare the brachial plexus of nerves and the omo-hyoid
muscle.   At this stage of the operation a small vein, a branch of
the subclavian, was laid open, and,  although it bled very little,
it was immediately secured  with a temporary ligature.  Taking
the omo-hyoid  for my guide,  I divided the loose cellular substance
in the triangular space,  bounded above by the muscle just  men-
tioned, by the  clavicle below, and by the  anterior scalene muscle
internally, and thus  approached the  artery as it  passed over the
first rib.   The vessel  here lay at some distance from the inferior
branch of the brachial plexus  of nerves, rather deeply behind
the  collar-bone;  and with  a  common  aneurism-needle, armed
with a double  ligature of saddler's silk, no difficulty was experi-
enced in  securing  it,  the instrument being  passed from before
backwards and from  below upwards.  It was  then drawn very
firmly with the fingers,  and tied  it with  a double knot within a
few lines of the anterior scalene muscle;  as soon as this was  done,
 all pulsation in the sac, as well as at the  wrist, ceased.   Not half
an ounce of blood was lost  during  the  operation,  which lasted 
                            [136]

twenty minutes.   The edges of the wound  being approximated
by three sutures and adhesive strips, the patient was put in bed,
and the limb, laid in an easy posture, wrapped in cotton wad-
ding.   In less than an  hour,  the  temperature, which had been
considerably depressed, was completely restored, the pain and
numbness had much decreased, and the patient expressed himself
more comfortable  than he had been for a month.
  Every thing went on well for upwards of a fornight, at the end
of which time the ligature came away, and the tumor had dimin-
ished fully one-half  in volume.  On the 13th of March he began
to complain of being somewhat unwell, and early  in the morning
of the  16th,  he was suddenly seized with  intense pain in the
chest, followed by excessive dyspnoea  and great acceleration of
the pulse, with an entire subsidence of the ancurismal swelling.
Notwithstanding the employment of the most vigorous anti-phlo-
gistic  remedies, death took place  on the  evening of the 20th of
March,  a little upwards of thirty days  from the time of the
operation.
  An  examination, made thirty-six hours after death, disclosed
the fact that the  fatal termination had been owing  to a rupture
of the aneurismal sac, and to an  escape of its contents into the
thoracic  cavity, followed by violent pleuritis, and  a  deposit of
nearly  three  quarts of bloody-looking serum, intermixed with
flakes of lymph  and laminated clots.   The  subclavian artery,
terminating abruptly at the outer margin of the  scalene muscle,
at the  point  of ligation,  was closed by a mass  of solid fibrin,
about one-third of an inch in length, which adhered firmly  to
the lining membrane, and this afibrded an efi'ectual barrier to the
passage of the blood.   The opening of communication between
the aneurismal sac and the thoracic cavity, was of an oval shape,
and about an inch  and  a  half in diameter; it was  situated be-
tween the first and second ribs, nearly equi-distant between the
sternum and  the spine, and was evidently the result of ulcerative
absorption, induced by the pressure of the  tumor.   Both ribs
were divested of  their  periosteum immediately round the open-
ing, and the  serous membrane there had a shreddy, ragged ap-
pearance.  The aneurismal sac, placed just below the clavicle,
and of a conical figure, was about the volume of  a medium sized 
[137]
orange, and contained a few laminated clots, closely adherent to
its inner surface. *
  It will not be out of place here to state that the paper in which
this case was published, is accompanied by an "Inquiry into the
Nature and History of Axillary Aneurism," with an analysis of
twenty-six cases in which the subclavian artery was tied for the
cure of that affection.
  In connection with these operations may be  mentioned a case
of traumatic aneurism  in the left axilla, in which Dr. J. B. Flint, f
of this city, attempted, in June, 1849, to tie the subclavian artery
above the clavicle,  but failed on account, as he remarks, of the
abnormal position  of  the vessel.   "The artery," to  employ his
own language,  " was  found an inch and a half from  the outer
margin of the anterior scalenus muscle, in a  direction upward
and  inward.  Only so  much of it could be exposed as could be
covered by the  point of the finger."   The parts were so matted
together as to  render all attempts to encircle the vessel fruitless,
and the operation was  therefore abandoned.   In three weeks, the
tumor  had ceased to pulsate, and was greatly reduced in volume.
Dr. Flint saw  the patient the following September, when the cure
was  complete.  Is it perfectly certain that the  aneurism in this
case was dependent upon lesion of the subclavian artery %
                      Brachial Artery.

  In the treatment of aneurism, at the bend of the arm, caused
by a wound of the brachial artery, Professor B. W. Dudley J speaks
in terms of high commendation of 6teady, systematic  compres-
sion with compresses  and bandages.  It would  appear that he
adopted this plan, with entire success, in a case of this kind in a
youth, as early as  the autumn of 1814.  Isolated  pressure,  by
means of linen pledgets, bits of wood, and pieces of sheet lead,
bound firmly upon the tumor, had been previously employed, but
were productive only of great pain and of  an aggravation of the

  * Western Journal of Medicine and Surgery, for June, 1841; also, Liston's
Elements of Surgery, hy Gross.
  f  Western Lancet, for November, 1849.
  %  Transylvania Journal of Medicine, for October, 1849. 
[138]
disease.  As the parents of the patient were averse to an opera-
tion, thick compresses were  applied to the aneurism and to the
brachial artery as high up as the axilla, and  tied firmly down
with a roller extending  from the fingers to the  shoulder.  The
dressings, which had the effect of moderating the circulation of
the entire limb, and which were borne with little inconvenience,
were obliged, in consequence of the  shrinking  of the  muscles
and of the gradual subsidence of the tumor, to be renewed every
second, third, or fourth day.  At the end of the third week, the
pulsation in the  aneurism was very languid, and in three weeks
more it was no  longer distinguishable.  The cure was complete
in two months.
  From the beneficial  effects in the case just  mentioned, Dr.
Dudley was induced  to apply the same mode of  treatment to all
aneurismal affections, of an accessible character, of  the arteries
of the  extremities,  and for many years past his success has been
of the  most flattering description.  He relates instances of trau-
matic aneurism of  the brachial, ulnar and anterior tibial arteries,
which  were all  cured in  this  manner, in from three  to  eight
weeks.  The treatment,  however, is not to be conducted without
due precautions, otherwise serious mischief may  be caused, as is
shown by one of Dr. Dudley's own cases, and which  is too inter-
esting and important to  be omitted on this occasion.
   A man having brachial aneurism, consequent upon  a wound,
was treated with the compress and bandage.  On removing the
third dressing, which had not been carried much  above the swell-
ing, an eschar was detached, followed by a gush of  arterial blood
from the sac.  This unexpected result is ascribed by the narrator
of the case to  the high inflammatory excitement,  both  of the
coats of the aneurismal tumor and  of the artery, for some dis-
tance above the seat of the disease; " a condition entirely at vari-
ance," he remarks, "with  what I have been taught, in our own
country and abroad, as regards the  weakened condition  of the
aneurismal artery."  "Observations made upon all subsequent
cases of  aneurism  have satisfied me  that the disease consists in
preternatural volume and power of contraction in  the  artery for
some distance above, as well as at the  seat of the sac,  while the
 old unsuccessful operation performed upon the artery as it enters 
[139]
the sac,  grew out of inflammation being above that stage which
is favorable  to  adhesion.  In accordance with  these views, no
difficulty was experienced in  effecting a cure in  all cases coming
under treatment, where compression could be satisfactorily ap-
plied upon the sac, and also upon the artery above, so as to em-
brace all the inflamed portion of it.''' *
   Professor Dudley, it will be noticed, here claims to have dis-
covered, first, that he was the first to ascertain the diseased con-
dition of the aneurismal sac  and of the cardiac portion of the
artery leading to it; and, secondly, that he was the first to adopt
and advise systematic  compression with the compress and roller
in the cure of this  affection.   Without wishing  to derogate any
thing in the slightest degree from our distinguished countryman,
as a discoverer,  your Chairman  deems it  his duty to  state,  as a
historical fact, that the former of these views has been known to
physicians  and pathologists almost from time immemorial, and
that the  practice of compression, so strenuously recommended by
Dr. Dudley,  is described, at length,  by Guattani,  in his treatise
" De Extemis Aneurysmalibus," published in Eome, in 1772.
   I had  occasion, in 1841,  to tie the brachial  artery at the bend
of the arm, on account of a wound received in  bleeding with a
thumb-lancet, in a youth, of the  name of Ragland, aged eighteen
years, from Henry county.  The accident, which had  occurred
about six weeks previously, was soon followed by great swelling
and discoloration of the limb, which gradually  extended down-
wards nearly to  the middle of the fore-arm,  and upwards as far
as the axilla.  The  pain was excessive, the appetite  much im-
paired,  the sleep constantly interrupted, and the countenance
blanched and expressive  of  the deepest anxiety.   About the
fourth week a large opening  formed at the  seat of the original
orifice, from  which upwards of a quart  of thick  grumous blood
was discharged.   He was brought to town on the  27th of Decem-
ber, and placed  under  the care of my friend,  Dr. Drane, now of
New Castle.  At this time his health was frightfully deranged ;
his strength  was much exhausted;  he had not slept for several
nio-hts;  and the whole limb, benumbed and  excessively painful,
was swollen from the  wrist to the  shoulder.  The parts pitted
* Transylvania Journal of Medicine, for October, 1849. 
                            [140]

under  pressure;  two small,  foul-looking ulcers  existed at the
bend of the arm; the skin was highly discolored ; and fluctuation
could be distinctly felt all the way up from  below the elbow to
the insertion of the deltoid muscle.
  With the assistance of Dr. Drane, an  incision  five inches in
length, was made over the course of the brachial artery; and,
after much difficulty, owing to the confused  state of the parts, a
ligature was placed  above and below the orifice, which was at
least six lines long.   All the grumous blood,  amounting to nearly
a quart, was squeezed  out, when the edges of the wound  were
brought together with adhesive strips and by a roller extending from
the fingers to  the shoulder.  Yery little sloughing took place;
and, notwithstanding the exhausted condition of the patient at
the time of the operation, a very speedy recovery was the con-
sequence.  *
  Dr. Samuel B. Richardson, of this city, informs me that he has
operated successfully,  in  one instance,  for  a similar affection.
The aneurism wras of the diffused variety, having been caused by
a large  puncture of the humeral artery,  five weeks  previously.
Three ligatures were applied, one to the  humeral artery, one to
the radial, and one to the ulnar.  The  aneurismal  tumor con-
tained  about a pound of coagulated  blood and fibrin, and had
been, almost daily, the seat of profuse hemorrhage ever since the
occurrence of the accident.  The patient  had a good recovery.
  In 1850, I operated upon a  man of the name of Moore,  aged
forty-four, from Mississippi,  for a circumscribed aneurism at the
bend of thfe arm, caused by bleeding  himself with a thumb-lan-
cet.  The tumor, of an ovoidal shape, and about the volume of a
goose's egg, was filled with coagulated  blood, and  caused im-
mense pain by its pressure upon the nerves.   The operation was
protracted on account of the difficulty of  finding the brachial ar-
tery, which, however, together with the radial,  was at length se-
cured, and the  tumor removed.  Severe erysipelas of the  limb
ensued; but under the judicious treatment  of Dr. Colescott, in
whose charge the patient was left, perfect recovery took place.
* Libtou's Elements of Surgery, by Gross. 
[141]
i                         Aneurism of the  Ulnar Artery.

             In August, 1842, I had occasion to tie this vessel, on account
           of an aneurism supervening upon a wound of the fore-arm, in-
           flicted by a scythe.  The patient was Mr. Shelby,  a verv respect-
           able farmer, aged  twenty-seven, from  Charlestown, Indiana.  The
           wound,  received six weeks previously, was situated three inches
           above the wrist, and extended, nearly in a horizontal direction,
           across the anterior surface of the limb, involving  the superficial
           muscles and the ulnar artery.   The hemorrhage was  so  profuse,
           at the time of the accident,  as to induce syncope.  The wound
           was dressed, several hours after, with adhesive strips and a band-
           age.  Every thing went on well until about the tenth day, when
           the parts gave wray, and a good deal of hemorrhage ensued.  A
           tumor, rather of a diffused character, gradually formed, impart-
           ing a faint feeling of pulsation, and attended with a good deal of
           pain and numbness of the limb, with an inability to incline the
           hand and wrist towards the radial side.  The fingers were stiff,
           and in a state of  permanent semi-flexion.
              An incision, three  inches in length, being made perpendicu-
           larly over the most prominent portion  of the tumor, the artery
           was laid bare at  the site of the original injury, and tied,  both
           above and  below  the wounded part.  On the second day a smart
           attack of erysipelas took place, and continued for nearly a week.
           The incision soon  healed, and the pain and numbness of the limb
           gradually subsided, followed by a better use of the hand and fin-
           gers.  The ligatures came away on the fourteenth day.
              In the Western Lancet, for February,  1846, is a short paper on
           "Hemorrhage caused by inefficient  Compression," by  Dr. E. L.
           Dudley, of  Lexington;  which, as it refers to a subject intimately
           connected  with the  one just  discussed, may be  briefly noticed
           here.  It is illustrated by an account of two  operations,  one for
           the removal of the testicle,  and the  other, for extirpation of the
           mammary gland; and, although it contains nothing novel, it may
           not be amiss to give a brief analysis of it.   It should be premised
           that both the cases occurred in the  practice of Professor B. W.
           Dudley.
              The first case was that of a negro  man, aged forty, and invol- 
                           [142]

ved the left testis.   The operation was  attended with more than
ordinary violence on account of the  indurated  condition of the
surrounding tissues; but the immediate hemorrhage was incon-
siderable, and all the bleeding  vessels were secured by ligatures.
A tight pledget of  cotton cloth, secured by a bandage, constitu-
ted the dressings.  Two hours afterwards, the scrotum was found
enormously distended with  blood, which  was issuing,  at  the
same time,  copiously from the upper portion of the wound.  The
dressings and cloths being removed,  it  was  ascertained that the
bleeding proceeded from the whole inner surface of the sac.  The
patient, by this time,  was excessively feeble.  Notwithstanding
the insertion of a  large  pledget into the upper  portion of the
cavity, in order  to keep the incision  open,  it was necessary,  on
the succeeding day, on account of the recurrence of the hemorr-
hage, to remove the dressings a second time.  A large clot had
formed in the lower part of the scrotum, and it was evident that
the blood proceeded directly from the surface in contact with
the coagulum.   The wound  was now thoroughly cleansed, and
stretched as widely apart as  possible.  The  bleeding ceased in-
stantly, and no dressing  whatever was applied afterwards until
all danger of hemorrhage was passed.
  In the second case,  which involved the removal of the mam-
mary gland, the wound was dressed  with adhesive strips and a
pledget to receive the  blood.  In a few  hours there was a gush of
blood from the  part,  to the great alarm of the patient.  The
edges of the wound were drawn so completely together as to pre-
vent the exit  of  the blood, which oozed from the minute vessels.
The bleeding ceased the moment the  dressings were removed and
the clots pressed out of the  cavity formed  by its accumulation.
"The only precaution afterwards observed, was to  preserve  an
outlet through the  wound."
  I do not  feel disposed to comment  upon these  cases,  as it res-
pects the manner  in  which the wounds were  dressed  after the
operation.  I  will  merely remark, that,  in  my own practice, I
have never, except in  a solitary instance, been obliged to remove
the dressings after excision of  the mammary gland ; for the rea-
son,  as I conceive,  that I always carefully approximate the sides
of the  wound with a large, thick compress, firmly supported by a 
L143]
bandage.   Where this precaution is used,  and all the vessels
have  been previously secured,  it is hardly  possible that there
should be any secondary hemorrhage.  After excision of the tes-
tis, my invariable rule is simply to approximate the edges of the
wound with a few stitches, to support the scrotum upon a hand-
kerchief secured to a body-bandage,  and to  keep the parts con-
stantly wet with cold water, or some  refrigerating lotion, applied
by means of a small bladder.
       Hemorrhage from the Arteries  of the Thigh.

  Our late President, Dr. W. L. Sutton,  of  Georgetown, hais
communicated to me a case of this kind,  occurring on the 3d of
November, 1828, in a man who was stabbed  on the outside of the
left thigh, about the junction of the upper with the middle third.
A physician, who was present at the time,  thrust  his finger into
the wound and  felt a decided current of blood.   A cord being
tied round the limb,  the bleeding was arrested, and did not re-
turn when the constriction was removed.  On the  16th, the hem-
orrhage having recurred several times, it was resolved  to secure
the injured vessel.  A probe was inserted two inches and a half
without causing any bleeding-   An incision, about five inches in
length, and embracing the original  wound, was made.  It was
now ascertained that the knife had passed behind the thigh-bone,
and about an inch beyond  it.   Rubbing the  wound would not
make the vessel  bleed.  Satisfied that the injured artery was on
the inside of the limb, it was proposed to tie the  profunda, near
its origin; but as this remedy was considered disproportionate to
the disease, the attendant concluded to trust  to  strict quietude,
 and constant, but moderate, pressure upon  the femoral artery.
   On the 22d,  the hemorrhage having recurred repeatedly, and
of late more frequently, it was deemed advisable to secure the
 profunda.  An incision being made down to the femoral, at  the
 root of the profunda,  a ligature was about  to be applied, when it
 was recollected that the circumflex is some times given off separ-
ately.  Upon making the wound bleed,  and pressing the artery,
 it was found that the hemorrhage could not be arrested.  A little
deeper and lower down a vessel was seen, pressure upon which 
                           [144]

 arrested the flow of blood.  This was tied with two ligatures, the
 first about an inch from the femoral, and the vessel  divided be-
 tween them.
   On the 29th, there was free bleeding from the last incision,
 which,  however,  was soon stopped by  pressure  on  the  pnbes.
 The parts being torn asunder, no  open vessel could be found, and
 the wound was, therefore, stuffed with lint and  the patient put
 in bed.  On the  2d of December,  in the morning, there was
 slight hemorrhage,  which was also easily arrested by pressure.
 The next day,  at  1 o'clock, the bleeding was copious,  and was
 stopped in the same manner.   The femoral  artery was  now tied
 about an inch above the profunda.  Shortly afterwards the pa-
 tient complained  of excruciating pain in the limb and bowels,
 the former of which, he said, felt as if it weighed a thousand
 pounds, and  was as large as a mountain.   There was some delir-
 ium, and the pulse was 120.   Laudanum was given internally,
and warm flannel  applied to the limb.  For some time sensation'
was entirely  destroyed ; but it gradually re-appeared in the upper
part of the thigh,  and ultimately extended down the leg and foot.
The  thermometer never indicated any loss of  temperature.  An
eschar formed  on  the heel, followed by an exfoliation from the
calcaneum;  the pulse came down slowly;  and the original wound
gradually cicatrized.
  Dr. Sutton thinks that well adjusted pressure with the  band-
age would have saved the patient a vast amount of suffering and
his attendants a  corresponding amount  of care and perplexity.
He is not satisfied as to the source of the  secondary hemorrhage*
whether it was in  the circumflex,  and caused  by its having been
tied  too  close, to  the femoral, or by the ligature having been
drawn too firmly;  or whether it was in the profunda, and occa-
sioned by its having been denuded, preparatory to being ligated.
     Treatment of Spontaneous Aneurism  by Rest and
                      Absolute Diet.

  Professor Bush,  of Lexington, has communicated to me the
particulars of a case of spontaneous aneurism of the abdominal
aorta, in which marked  relief of the symptoms seems to have 
[145]
 followed the observance of a most rigid diet.  The patient,  Mrs.
 Anderson,  a mid-wife,  aged sixty, resides  in  Madison county,
 Kentucky, and has led a very exposed and laborious life for many
 years.  When Dr. Bush first saw her, about three months ago,
 the tumor, situated just below the stomach, was about the size of
 a pullet's egg, and pulsated most violently, emitting all the usual
 aneurismal sounds.   The heart was involved in the trouble, labor-
 ing, and  irregular in its actions.  Believing that  the case wrould
 be  fatal,  Dr. Bush merely advised quietude and absolute diet,
 barely enough of the lightest and least stimulating articles to
 support life.  For a short  time she grew worse, and  her physi-
 cian, Dr.  Evans, informed Dr. Bush that a post mortem examin-
 ation could be obtained when she died.  Not long afterwards he
 learned that, under  a rigid adherence to the  treatment,  the
 woman was rapidly improving, in fact, getting well, with a deci-
 ded subsidence of all the local  symptoms.  "This," adds Dr.
 Bush, "is the whole  of my experience in spontaneous aneurism,
 excepting one or two  cases which I have  seen in the hands of Dr.
 Dudley, treated in the same manner, but not of Kentucky."
  The starving  plan  of treatment, first recommended by  Val-
 salva, and  so happily employed  b}r Dr.  Bush  in  the  above in-
 stance,  is worthy of the serious consideration of the surgeon in
 all  cases  of spontaneous  aneurism,  inaccessible to the ligature..
 When properly carried out, it may not only retard the fatal pro-
 gress of the disease,  but occasionally even  effect a cure, especi-
 ally in the milder and more recent forms of the affection.  Val-
 salva's plan, as is well known, was to subject his patients to  the
 most perfect rest in the horizontal posture,  and to diminish the
 quantity of fool  gradually, till only half a pint of soup was al-
 lowed in the  morning, and a quarter of a pint in the  evening^,
 with a very small quantity of water, medicated with  osteocolla,
or mucilage of quinces. *   This treatment was aided, particularly
 in robust  subjects, by the repeated abstraction of blood.  Pro-
 fessor Dudley asserts  that he has cured some cases simply by
restricted diet, without the use of the lancet; and a recent for-
eign journal mentions severar'instances of a similar kind relieved
by Dr. Bellingham, of Dublin.

  * Cooper's Surgical Dictionary, art. aneurism.
         16 
[146]
                     Burns and Scalds.

   The subject of burns and scalds has not escaped  the attention
of  the  practitioners and  writers of  Kentucky.   In  1829,  Dr.
Lloyd Warfield, of Paris, published, in the second volume of the
Transylvania Journal of Medicine and the Associate Sciences, a
long, and, in many respects, a very able Essay on Burns, which
might be referred to,  with great advantage, by every member of
our Society.  He divides lesions of  this kind into two classes, ac-
cording to their effects upon the tissues and  the system at large.
" The first is that," says he, " in which the vitality  is  injured,
and  both the part and general system retain,  and manifest, an
abundant power to re-act.   The second is that in which the vital-
ity, both in the part and the general system, is greatly exhausted,
and of course but very little power of re-action remains."
  After passing in review the two opposite, and apparently con-
tradictory,  modes of treatment laid down  by systematic writers,
he expresses his decided preference  for warm emollient poultices,
prepared of the starch of wheat-flour and of slippery elm.  These
articles, which he was in the  habit of using alone, and the for-
mer of which he considered as superior to the  latter, though he
had also a very favorable  opinion of this,  he recommends to be
spread pretty thick upon  linen cloths, which are then to be ap-
plied directly to the affected part, the surface  of the  cataplasm
being previously covered  with linseed oil.  The poultice,  thus
prepared, need not be renewed under twenty-four hours, and may
be continued until the establishment  of  suppuration.   Dr. War-
field asserts that it affords immediate  ease, assuages the  sense of
heat, moderates inflammation, promotes suppuration and slough-
ing, and forms a soft nidus in which the granulations  may repose
with safety and comfort.
  Dr. Warfield also speaks favorably of .inseed oil and  carded
cotton, as applications in superficial burns, but regards them as
inferior to warm emollient poultices, aud as objectionable on the
ground of their severity,  their desiccating  qualities, and the ne-
cessity of their frequent renewal.
  In the second class  of burns, the best remedies are, hot spirits,
oil of turpentine, spirits of camphor,  and other kindred articles. 
[147]
   The  constitutional means upon which Dr. Warfield seems to
 rely are, in his first division, abstinence,  cooling  purgatives,
 blooJ-letting, diaphoretics, and diluents;  and, in the second,
 wine, brandy, ether, and opium.
   An account of "Four cases of Burns and  Scalds, successfully
 treated with the acetate  of morphine," by Dr. T. W. Major, of
 Paris, is contained in the tenth volume of Dr. Drake's Western
 Journal of the Medical  and Physical Sciences.  The dressing
 consisted of a  plaster of basilicon, large enough to cover the
 whole of the aflected surface, and sprinkled with from three to six
 grains of the salt in question, according to the age and suffering
 of the patient, and the extent of the lesion.   The result, in every
 instance, was the prompt cessation of pain and restlessness,  and
 the induction of tranquil and refreshing sleep.   The application
 was renewed once a day, or once every forty-eight hours, and was
 soon followed by the formation  of a new cuticle.  The injury, in
 all these cases,  was superficial,  and it is worthy of remark,  that
 no bad  effect resulted from so liberal a use of morphine.
  In Dr. Bell's Bulletin of Medical Science,  for February, 1845,
 I published a paper on the use of carbonate of lead,  in the form
 of white paint, in the treatment of burns and scalds.   Since that
 period,  the article  has  been employed,  in  numerous instances,
 both by myself and others, and the result has  been to confirm
 fully the  favorable  opinion   which I  had  expressed.    The
 proper mode of  applying  the lead, is to mix it with linseed oil to
 the  consistence  of thick  cream, or molasses,  and to spread it
 upon the affected surface with a small brush, or camel's hair pen-
 cil, until it is completely concealed from view.   The part is then
 covered with carded cotton, or,  what is better,  because less heat-
 ing, a piece of old muslin, and supported with  a moderately firm
roller.   If  vesicles exist, they must be pierced with a needle, and
 the exuding  fluid wiped away with a soft sponge,  otherwise the
 paint will not adhere.   In the milder forms of  burns and scalds,
 one dressing generally suffices;  but, when the deeper structures
 have suffered,  a considerable  number,  applied at intervals of
twenty-four hours,  will be  necessary to  a cure.  Whenever the
dressing becomes saturated with secretions, the part is rendered
painful  and  the system irritable.  In mild cases, the paint and 
[148]
 epidermis form a sort of dry incrustation,  which generally drops
 off in four or five days,  leaving  the  subjacent surface entirely
 well, or of a slightly excoriated aspect.
   It is not merely in the milder  varieties of burns and scalds
 that this remedy is applicable; it may be beneficially employed
 whatever be the extent or depth of the lesion.  When the skin is
 converted into an eschar,  it matters not what is used;  the con-
 tact of the atmosphere can do no harm, and the great indication,
 so far  as the local treatment is concerned,  is to promote the de-
 tachment of the slough, and the  establishment of the granula-
 ting process.  After the latter has fairly commenced, or even be-
 fore, the paint again constitutes, according to my experience, the
 most soothing and eligible application.   It is proper to add, that
 I have never seen a case, or heard of one, in which the use of this
 remedy,  however liberally  indulged in,  was productive of the
 slightest injury.
  From the extraordinary efficacy  of white  lead, prepared and
 applied in the  manner above  mentioned, a certain quantity of
 this article should constantly  be  kept on hand  on board our
 steamboats, in breweries,  soap factories,  and similar establish-
 ments, where burns and scalds are of such frequent occurrence.
 It might thus always be employed with the least possible delay;
a circumstance of no little moment, both as it respects the imme-
 diate comfort of the  patient, and, in  many cases, his ultimate
 recovery.
ix.—affections of the extremities.
               Affections of the Articulations.

  Under this division of our subject, very little of novelty or of
interest is to be found, I apprehend, in Kentucky surgery.  Scrof-
ulous diseases, judging from my personal  experience,  are suffi-
ciently common,  and not generally, I think,  very judiciously
managed.  Much of this kind of business is in the hands of em-
pirics, who, under the confident assurance of their superior skill
and the superior efficacy of their  remedies, hold  out  delusive
hopes of cure in cases where none but the most consummate kwml- 
[149]
edge and the most devoted and assiduous attention can effect the
slightest benefit.  These remarks are particularly applicable  to
scrofulous affections of the  hip-joint, technically denominated
coxalgia, or morbus coxarius, which are  usually so stealthy and
insidious in their mode of invasion as to be overlooked, both by
the patient and his physician, until it is too late to prevent or-
ganic mischief.  Patients laboring under this malady are  con-
stantly  presented to my observation,  the true nature of whose
disease  has never been even suspected by their professional attend-
ants,  and the consequence,  with many, is that it is  too  late to
render them any essential benefit.  The  aflected structures are
disorganized, the joint is horribly deformed, and the miserable
subject  is a cripple for life.  In short, I know of no  class of af-
fections in which our practitioners are less informed, or in which
there is greater room  for  improvement  in our diagnosis and
practice.
           Lacerated  Wound of the Shoulder-joint.

  Dr. Samuel R. Sharpe, of Maysville, has furnished me through
Dr. Frazee, of  this city, the following interesting case of injury
of the shoulder-joint.  A stout,  muscular Dutchman, of middle
age, while engaged in  drawing logs from the river to a saw-mill,
had  his arm completely severed  at  the shoulder by a piece of
flange, armed with cogs.   The head of the humerus was  left in
the  scapulary socket.  The brachial artery was seen naked and
projecting about two inches and a half below the axilla, but did
not bleed.  The muscles were much bruised and  haggled, and it
was necessary  to smooth the  stump with the scalpel.   The
brachial artery was secured with a ligature,  to avoid the risk of
secondary hemorrhage.  Water dressings  were applied,  and in a
short time the patient was perfectly well.
                 Injuries of the  Knee-joint.

  In the tenth volume of the Transylvania Journal of Medicine
and  the Associate  Sciences, Dr. S. B. Richardson,  formerly  of
Lexington, now of this city, has a  paper on the " Nature and 
                            [150]

.Treatment of Injuries of the Knee-joint," the object of which is
to enforce  the importance, first,  of perfect bodily quietude, se-
condly, of  immediate closure of the wound, and,  thirdly,  of
maintaining the affected limb, previously bandaged from the
toes up, in an extended and  elevated position upon a cushioned
splint, from three to four inches in width,  and long enough  to
reach from the heel to the tuberosity of the ischium.  By pursu-
ing this simple course, commencing,  if possible, before inflam-
mation has set in, all morbid action,  the author thinks, may be
prevented, the wound will unite by the first intention,  and in a
week or ten days,  the patient will generally be able to  resort  to
moderate exercise of the  knee.  When inflammation takes place,
he uses, with almost certain success, equal parts of cider-vinegar
and  a saturated solution of camphor in strong alcohol,  applied
as an evaporating lotion.  Constitutional symptoms  are abated
by the usual antiphlogistic means, of which venesection and ac-
tive  purgation are the most valuable.  This mode of treatment,
Dr. Richardson considers, to some extent, as applicable to inju-
ries  of all joints;  a view in which  all judicious  practitioners
will, I am sure, heartily concur.   Dr. Richardson's paper is illus-
trated by the recital of three cases, inculcating the importance of
the measures here mentioned.
  Under the title of  "Injuries of the Superior Extremities," Dr.
W. L. Sutton,  of  Georgetown,  has  published, in the  Western
Journal of Medicine and Surgery, for October, 1842,  a valuable
paper on fractures and dislocations of the arm or fore-arm, inclu-
ding a case of gun-shot wound of the axilla, and a case in which
the left arm was torn off" from the body along with the scapula,
in consequence of the limb having become entangled  in the ma-
chinery of a paper-mill.  In the  latter instance, the accident was
complicated with injury of the abdomen, causing, as the writer
supposes, death on the eleventh day.   The subclavian artery was
of course severed,  but as there was no hemorrhage, no ligature
was applied.  The patient never complained of the shoulder, and
the wound progressed  favorably till the eighth day, when slight
sloughing ensued.   All his suffering was referred to the bowels,
the  tunics of which manifested decided evidences  of  inflam-
mation. 
[151]
  The same paper contains a singular case of fracture of the hu-
merus, just above the condyles, caused by a musket-ball, and
terminating in anchylosis of the elbow-joint.   An artificial joint
formed at the seat of the injury, which afterwards supplied the
place of the natural  articulation, and admitted of rotation of the
fore-arm in so perfect a manner that the patient was able to per-
form  any kind of labor.  This case is encouraging, as showing
that anchylosis of the elbow is not always so bad an accident as
is generally supposed.
                     Tumor of the  Thigh

   Under the title of " Tumor of the Thigh; affecting the Arte-
rial  System," Dr. E. L.  Dudley  reports *  the  particulars of a
case, which occurred, some years ago, in the practice of Professor
B. W. Dudley, and which is chiefly interesting on account of the
peculiar accelerated condition of the pulse of the patient, a black
man, of middle age.  The tumor was situated upon the inner
half of  the thigh, directly over  the  femoral artery, and was of
large size; but exhibited no  appearance of malignancy, either
before or after extirpation, notwithstanding the pulse, even after
a course of preliminary treatment for two months, was constantly
at 140.   The morbid mass was remarkably heavy, and  the greater
portion  of it was converted into bone.  In twenty-four hours after
the operation,  the  pulse  fell  to 90 in the minute,  and in a few
days to the healthy standard.  The patient, whose general health
seemed  to be  perfectly good from  the first, recovered  rapidly
without a single  unfavorable  symptom, and was perfectly stout
and  well two years after the removal of the tumor.   What was
the cause of this singular  change in the pulse ?
                     Ununited Fracture.

  Ununited fracture is a subject that has occupied much of the
attention  of  surgical practitioners within the last fifty years.
Various methods of treatment have been devised, among which

  *  Lawson's Western Lancet, for July, 1845, p. 112. 
                           [152]

 that by the seton holds a prominent rank.  The only case of this
 occurrence that has been relieved  in this manner, so far as  my
 knowledge extends, happened in the hands of Dr. W. II. Donne,
 of this city, and is reported in the fourth volume  of the Western
 Journal of Medicine and Surgery.  A laborer, aged twenty-three
 years, of intemperate  habits,  was  admitted  into  the Louisville
 Marine Hospital,  on the 14th of June, 1840, with a transverse
 fracture of the tibia, three inches below the knee.  The limb was
 treated with a roller and splints for six weeks, when, upon remo-
 ving the dressings, it was found that  no consolidation had taken
 place.  All dressings were now laid aside, and the patient was
 permitted to exercise about the ward upon  crutches for  three
 weeks; but no improvement ensued.
  On the 21st of August, upwards of nine weeks from the acci-
 dent, a seton was introduced between  the fragments, the operator
 having previously divided the skin  and aponeurosis at the seat of
 the fracture and detached a few of the fibres of the anterior tibial
 muscle, to facilitate the passage of the needle.  The hemorrhage
was  inconsiderable, and five days elapsed  before there was any
 evidence of inflammation.   The seton was removed on the 18th
day; and  on the 25th of September,  a  little  more than a month
from the time of its introduction, the wound made by it had
 healed.  An  abscess afterwards formed, and discharged about
 eight ounces of bloody pus.  On the  20th of October, the limb
 was free from pain, and at the end of  another week it was strong
 enough to enable the man to bear his  whole weight upon it.   By
 the middle of November he was discharged cured.
X.—TOE BANDAGE, CONSIDERED AS  A THERAPEUTIC AGENT.
  To Dr. Benjamin W. Dudley appertains the merit, whatever it
may be, of having been the first  in this country to call, in a dis-
tinct and prominent manner, the attention of the American pro-
fession to the employment of the  bandage, as a curative agent in
the treatment of surgical affections.  His first paper upon the
subject, to which his  mind seems  to have been directed at an
early period of his professional career, and to which he has pro-
bably devoted  more study and reflection than  any  other practi- 
                            L153]

tioner, either at home or abroad, was published in 1828, in the
first volume  of the  Transylvania Journal of Medicine and the
Associate Sciences, and earned for him, at once, the reputation of
a bold, if not a successful, innovator.  It is true, the application
of  the bandage  had been  recommended  long previously;  its
happy effects had frequently been noticed in various injuries and
diseases;  and the highest encomiums had been lavished  upon it
by  some  of  the  surgeons of  Europe, especially by  that  great
luminary of the Scotch profession, Mr. John  Bell;  but it  is
equally true that the precepts which they had taught with so
much earnestness and precision, had failed, in a great degree, to
arrest the attention and to secure the confidence of their readers-
In other and more comprehensive language, the bandage, despite
all  that had been said respecting it, remained unappreciated as a
great therapeutic agent.  The paper of Dr. Dudley,  therefore,
appeared  at a most auspicious period, and was well calculated,
from  the  position which he occupied as a  teacher and a practi-
tioner, to awaken the immediate  attention of the profession  to
the subject.  This  was particularly the  case in the South-west,
among Dr. Dudley's own pupils,  upon whom  the instructions of
their master made a deep and abiding impression in favor of the
remedy under  consideration.   Accounts  of  numerous cases  of
surgical affections, successfully treated by the bandage, flowed in
from  every direction, testifying to the  utility of this mode  of
compression.  These testimonials must have been eminently grat-
ifying to the Lexington professor, and must have had the effect of
inciting him to further efforts to establish his practice  upon just
and philosophical principles.  How far his efforts have been suc-
cessful, a perusal of his waitings and of those of his pupils will
abundantly attest.  A writer in a neighboring city, in his enthu-
siasm for Dr. Dudley and his  bandage, declares that Dr. Dudley
may be emphatically styled  the  hero of the bandage,  as he has
accomplished more with it than any other surgeon.
  It affords me pleasure to be instrumental in bringing Dr. Dud-
ley's views upon  the subject prominently before the members  of
this Society, and through  them before  our professional breth-
ren generally.  No one who has properly used the bandage, and
who is capable of properly applying it, can doubt, for a moment, 
                            [154]

 its utility as an important therapeutic agent; my own experience
 for the  last twenty years fully satisfies me that this is fact;  still,
 it is necessary that we should temper our enthusiasm,  and that
 we should not allow ourselves  to  be betrayed into a species of
 hobbyism, calculated to  mislead  our judgment, and  bring us
 into  ridicule.  We should recollect that the bandage, like the
 lancet,  calomel, and  tartar emetic, is a Sampson  to do evil as
 well as  good.   If it  be resorted to  indiscriminately, it  can-
 not fail to produce mischief,  and to be followed  by chagrin and
 sorrow and disappointment.   Where the hand of a master is not
 present to guide, let ignorance and presumption pause and reflect
 before they enter upon enterprises,  of which  they cannot perceive
 the end.  The evil effects of the bandage, in their  aggregate re-
 sults, can only be  less than the injurious effects of mercury and
 other powerful agents of the materia medica, because this agent
 is less frequently  employed  in  practice.   Numerous instances
 have come to my knowledge, where limbs,  and even life, have
been sacrificed to its injudicious application.  No  one seems to
be more fully aware  than Dr. Dudley himself, of the  mischief
that may be thus induced.  His language upon this  point is clear
and explicit, and cannot be too forcibly impressed upon the minds
of our practitioners.   " Like all other powerful agents," says he,
" it is capable of doing  much mischief, when resorted to under
improper circumstances,  or applied by those who  have neither
principles nor experience as their guide in practice."
  But it is time that Dr. Dudley should  speak for himself;  my
only  regret is that I cannot quote more largely from his writings.
  " The bandage is a remedy so accessible to all, so simple and
so plain in its mode of action, so extensive in its  application,  so
satisfactory and controlling  in its influence, that the  strange
manner in which it has  been  overlooked by those who have been
most reputably engaged in extending the usefulness of the pro-
fession,  is calculated to excite  astonishment.  The catalogue of
means by which the benefits of the science of surgery are secured
to society, can furnish no parallel to it.
  "When  properly understood, the bandage is calculated to su-
 percede, in a very great measure, the use of the knife and the 
[155]
 saw on  the field of battle; nor will it be found less valuable in
 naval, hospital and private practice.
   " A very large proportion of those cases which, in the exercise
 of the  surgery of the day,  are condemned  to  amputation,  are
 susceptible of preservation by the judicious use of the bandage;
 while the life of the patient is in much less  jeopardy than either
 after amputation or  under the influence of  common remedies
 directed with  a view  to the preservation of  the limb.  The  con-
 finement and  sufferings of the patients, as well as the attention
 necessarily given by  the surgeon, are all  much curtailed when
 fractures are put under the skillful application of the bandage."*
   In reference to the affections to which the bandage is more es-
 pecially applicable, the author, writing in 1828, observes: "Du-
 ring the  last  fourteen years i have  been constantly engaged in
 observing the effects  of the  bandage  on gun-shot wounds  and
 fractures; on  fistulous, indolent,  indurated,  irritable, fungous,
 varicose, inflammatory,  and sloughing  ulcers; on contusions,
 sprains, and effusions; on inflammation of the cutis, capillaries,
 veins, arteries, nerves, ligaments,  and capsules; on arterial and
 venous  hemorrhage, on aneurisms, on the secretions, on ulcera-
 tion, phlegmasia dolens, paraphymosis, and chordee,  on lacerated
 and clean cut wounds, on the stump after amputation, on perios-
 tosis, fungus cerebri,  and fungus testis;  on  the muscular, absor-
 bent, sanguiferous, and nervous systems; and  have daily and in-
 creasing evidence of its superiority over any other local applica-
 tion in the practice of the profession."
   The above extracts are, it will be perceived,  from Dr. Dudley's
 article " On the Use of the Bandage  in Gun-shot Wounds, Frac-
 tures, &c," in the first volume of the Transylvania Journal of
 Medicine and the Associate Sciences, published at Lexington, in
 1828.  The article occupies not less than thirty-six  pages of  the
 work referred to, and is illustrated by numerous cases, all tend-
 ing to show the  superiority  of this  method  of treatment.   In
 1829  he contributed to the second volume of the same Journal,
 an equally elaborate paper  " On the  Use of  the  Bandage in the
 Treatment of Contusions, Lacerations, Effusions, &c,"  setting

  * Transylvania Journal  of Medicine and the Associate Science?-, vol. 1, p
503.  1828. 
                            [156]

forth, at great length and with much pains, the efficacy of me-
chanical compression in these classes of injuries, and giving it a
decided  preference over all  other  modes  of  procedure.  Both
these communications are of great interest, and worthy of an at-
tentive perusal.  I regret that the limits of my report prevent me
from making further extracts from them; though this regret is
lessened by the fact that the more recent contributions of Dr.
Dudley  upon some of these subjects, especially gun-shot wounds
and fractures, will, in a great degree, obviate the necessity for this.
The following extracts from the paper just adverted to, published
in the Transylvania Journal of Medicine, for December, 1849,
and for  April, 1850, must close our remarks upon this interesting
subject.
  From a number of cases of gun-shot wounds, narrated by Dr.
Dudley, I select the subjoined one, as it fully illustrates the meth-
od and the efficacy of his mode of treatment.
  "A gentleman received a pistol shot,  which  shattered the hu-
merus a little above the elbow, and separated its condyles from
each other.  Preparations to meet casualties being at  hand, he
was immediately attended by my associate on the occasion.  After
cleansing, the integuments were drawn into contact, the fractured
bone having been properly adjusted.  Thick compresses on either
side, corresponding with the entrance and exit of the ball, with those
of less thickness in front, were applied and sustained by a roller
closely put on from the  fingers to the shoulder.  The disunited
condyles were thus placed, and  fixed immovably in close  con-
tact ; the integuments maintained  in close approximation;  the
mutilated soft parts sustained  free of all engorgement; all atmos-
pheric influence excluded; the entire limb was preserved  free
from swelling, of inflammation, of  deep-seatea* abscesses; while
the muscles were kept in a perfectly passive state.  These dress-
ings were moistened for the first four days, and then permitted to
remain  undisturbed for  eight days after.  The compound  was
thereby  converted into a simple fracture; the re-union of the
condyles  by bone  was  complete;  the muscles  regained their
power  over the limb; and at the expiration of a month the use
of the arm was restored.
  " The intelligent of the profession are doubtless surprised that, 
[157]
in this case, splints and machinery to control muscular contrac-
tion and prevent deformity should be overlooked;  yet in science,
as well as in practice, to remove the cause is certainly preferable
to making battle with the effect.
   " Being long convinced of the error propagated in the profession
regarding the peculiarity of these (gun-shot) wounds, my solici-
tude, in all cases which have been placed under my charge, has
been,  by the  aid of properly adjusted  pressure, to  preserve the
surfaces of the interior  lacerated fibres pressed closely together;
to close  the cutaneous  openings, and confer thereby all  advan-
tages upon this wound, which are known to attend one from sub-
cutaneous section;  to prevent all tumefaction,  inflammation, and
its consequences by the skillful distribution  of pressure  above,
below, as well as upon the seat of the injury;  to apply the dress-
ings with that very moderate force only which is necessary to se-
cure these purposes, and which, at the same time, imposes uncon-
ditional quiet on all the muscles involved in,  or associated with,
the wounded part."
   The  following extracts  afford a  good  idea of Dr. Dudley's
method of treating fractures:
   "When a broken limb is skillfully encased  in a sheath of pro-
perlv prepared  canvas, which is made to  embrace and compress
equally  all  points  of the  surface, not only contraction, but all
susceptibility   to muscular  action,   is  thereby effectually sus-
pended.
   "The time  and manner of its application are subjects  especi-
ally worthy of consideration,  and of the exercise of skill.  All
the muscles, which are to be placed under its control, should be
thoroughly extended, provided they are in a state of preternatural
contraction, preparatory to the application of the roller;  while
the force exercised  in  applying it must  be in  proportion to the
amount of  cellular tissue  in the limb,  or of the  interstitial  de-
posit  which may have  been the product of effusion  or of inflam-
matory action in the part.
   "The  muscles of the limb are thereby constrained  to  a per-
fectly passive 6tate, of which fact a  moment's  reflection upon
the  conditions necessary  to  contraction  will satisfy  the most
skeptical 
                             [158]

   "The pain and  suffering consequent  to isolated pressure,  the
 spasmodic movement of the muscles under the influence of ma-
 chinery, are unknown to the subject of the roller,  when this is
 skillfully applied;  whether he is resting quietly upon a couch, or
 subjected to the flying ambulance upon the field of battle; nor
 is difficulty experienced, or pain induced, in the removal and re-
 application of the roller, as this may be required,  either with a
 view to adapt it  to the reduced size of the limb, resulting from
 interstitial  absorption, or for the purpose  of removing soiled
 dressings.   An  extension of the limb, with a power only equal
 to its own gravity,  when it is elevated;  for the purpose of remo-
 ving and re-applying the roller, is accomplished without displace-
 ment, or the production of pain.
   " Fractures are occasionally attended by such a profound shock
 to the sound parts,  that the blood-vessels become extended be-
 yond their  capabilities for healthful reaction;  while at other
 times  destructive inflammatory excitement supervenes  to the
 injury.
  "These  two opposite conditions,  each involving immediate
 danger, cannot  occur  under  the  influence  of  a  well adjusted
 roller, while all the resources of the  profession besides are not
 equal to this in controlling them where they have supervened.
  "Morbid  contractions of the muscles,  attended by pain, swell-
 ing, and inflammation,  succeeding to  fracture, are the usual con-
 sequences of inappropriate treatment; and it is an extraordinary
 fact that authors of the highest celebrity enjoin upon the surgeon
 a practice, which renders deformity and imperfect use of the part
 almost certain; while  symmetry and utility may, in many such
 cases,  be perfectly  restored under the influence of  a different
 treatment, which is no less rational than successful.
  " That distressing disease which attacks the  terminal phalanx
 of the thumb and fingers, the bone-felon, is followed by the loss
of the bone and soft parts, as high as the second joint.  In the early
stage of the disease, and before suppuration  has taken place, it
may always be promptly cured by the  close  application of the
roller, using the precaution to destroy  the sensibilities of the part
first, by gentle and progressively increasing pressure with  the
 hand  for a few minutes; or the part  may be laid open with the 
[159]
scalpel and the morbid 83cretion removed from beneath the peri-
osteum  upon the point of the instrument.  But when suppura-
tion has taken place, and the matter is discharged by ulceration,
an early occasion must be sought to remove the phalanx by wrench-
ing it oft' from its connections with the capsule, ligaments,  and
cartilage of the joint.
  " When the  extraction of the bone is delayed for some weekn
after  ulceration has taken place,  some flatness of a dimple, on
the ball of the thumb  or finger, is liable to be present after re-
covery.  When the extraction of the bone by forceps is attempted
too promptly,  its connections with  the soft parts composing the
joints, will not yield to the instrument; while no difficulty will
be  encountered after waiting from ten to twelve days.  In  this
stage of the disease, the soft parts will be found in a tumid state,
and,  by gentle pressure in the palm of the hand, progressively
increasing,  much of the diameter may be thrown into the longi-
tudinal dimensions of the swelling.  From fifteen to eighteen
days  is generally occupied in a reproduction of the phalanx.
Sufficient pressure must be applied to preserve the proper length
of  the bone; while care may be taken to avoid so much as would
give it an  unnatural extent—an occurrence which appeared in a
case  under my charge, in the family of a cotton-spinner of this
place, Mr. P.,  who threatened a suit at law to recover damages,
on account of treatment which rendered the thumb too  long.
Quite recently, a young lady of this place, returned home from a
boarding-school abroad, where she had for some  weeks suffered
with  the ulcerated stage of bone-felon on the thumb.   The bone
was forthwith  removed by means  of a pair of forceps, and the
phalanx was  re-produced  under the influence of three or four
dressings; but there is to be observed a small  depression in the
ball of the thumb.  Similar cases, for the last twenty-years, have
been of frequent occurrence, with invariably successful results."
   As an appendix to this branch of my subject, it is proper that
reference should  be made here  to  the following contributions to
our periodical literature, comprising accounts of cases of gun-shot
wounds, fractures, ulcers, sprains, and other affections, success-
fully treated with the  bandage.
    Case of Gun-shot Wound of the Elbow-joint,  treated by the 
[160]
 Bandage.  By Dr. Jacob S. Swan, of  Henderson county.—
 Transylvania Journal of Medicine and the Associate Sciences, 3,
 570: Lexington, 1830.   A large buck-shot entered the articula-
 tion, at the lower edge  of the tendon of the biceps, and issued a
 little behind the radius.  The hemorrhage was profuse, and was
 supposed to emanate from the humeral artery.   No fracture ex-
 isted.  The joint recovered its functions entirely.
  A case of Fracture of the Thigh-bone.   By  Thomas L.
 Caldwell, M. D., of Louisville.  Louisville Journal of Medicine
 and Surgery, 1, 114: Louisville,  1838.   The fracture was com-
 pound, oblique, and situated  between four and  five inches below
 the great trochanter;  no permanent extending apparatus was
 employed, and the parts united without shortening of the limb.
  Cases  of Fracture  treated by the Bandage, by  Professor
 Dudley.  Reported by James M. Bush,  M. D.  Transylvania
 Journal of Medicine and the Associate Sciences,  9, 97: Lexing-
 ton, 1836.  The object  of this communication is to show the im-
 portance of the  bandage in the management of this  particular
 class of injuries.  "Few days," says the author,  "pass in which
 the remedy is not employed  by Dr. Dudley in the treatment of
 local injuries, and with the most  unvarying success.   Except in
ftactures of the fore-arm, he rarely finds  it necessary to  use  a
splint; and in his long and extensive practice he has amputated
 but a single leg in consequence of fracture, and  that was in the
 ease of a maniac, who could not be controlled.
  Remarks on  Mechanical Pressure, applied by means of the
 Bandage ;  illustrated  by a variety of cases.  By J. M. BusH,
 M. D.,  of Lining ion.   Transylvania Journal of Medicine and
 the Associate Sciences,  10, 53: Lexington, 1837.  "The promi-
 nent object," says the  author, "of these  very limited remarks
 is to detail a number of dissimilar cases of disease, treated in the
 exclusive surgical practice of Professor Dudley."
  Fracture of the Neck of the Thigh-bone within the Capsular
 Ligament.  A case of this kind, occurring in a girl eight years old
 and terminating in complete restoration of the limb, is given by
 Dr. Robert Peter, of Lexington. *  The accident was caused by a

  * Transylvania Journal of Medicine and the Associate Sciences, vol. 8,  v.
 453.  Lexington, 1836.                                         v 
[161]
violent fall upon the great trochanter against a fence.  The child
walked about for a week after the accident,  complaining merely
of a constant pain in the groin,  and having a limp in her gait.
The limb was  shortened, but was  easily restored to its natural
length, and the patient was unable to flex it upon the pelvis.  A
long cushion, made of wool, was interposed between the extrem-
ities, from the heels to the perinreum,  and to this both members
were secured by a common roller,  several turns of which were
also made round the  buttocks, to paralyse the  external muscles
of the pelvis.   The patient was  kept on her back on a mattress,
and the dressings were renewed  about every  forty-eight  hours.
At the end of a month, the treatment was discontinued, and  the
girl was able to walk about with the aid of a crutch.
   It is to be regretted that the reporter of this case has not given
a more circumstantial account of it.  The diagnosis of fracture
of the neck of the thigh-bone within the capsular ligament is
often exceedingly obscure, and,  in the present  instance,  it  has
certainly not been satisfactorily stated.  The accident is emphat-
ically one of advanced life.   I am not acquainted with a solitary
instance  in which it took place in  so young a subject.  In two
hundred and twenty-five cases, witnessed by Sir Astley Cooper,
only two occurred under fifty years  of age.  In the Medico-Chir-
urgical Transactions of London,  Mr. Stanly reports an instance
in a youth of eighteen.
   The Bandage in the treatment  of Fractures, Ulcers,  Gun-
shot Wounds, Hemorrhage, &c, &c.  By Theodore S. Bell, M.
D., of Louisville.   Two articles in the Western Journal of Med-
icine and  Surgery, for 1850.   The papers of this writer, embra-
cing together eighty-five pages, are replete with erudition, sound
criticism  and  practical discrimination.   He  avows himself a
warm advocate of the bandage,  in  the treatment of various sur-
gical affections, and adduces numerous cases in illustration of the
views which he so ably discusses.  His articles are written with
force and  clearness,  and afford  abundant evidence, upon  every
page, that he is thoroughly familiar with  his subject.   With  the
exception of the " hero of the bandage," he has probably pub-
lished more on the bandage than all other American physicians
17 
[162]
and  surgeons  put together.  We have room but for one extract,
the last paragraph of Dr. Bell's paper.
  "But I hope I may be indulged in the confident expression of
the belief, founded on long and well observed testimony,  that a
careful study of  the bandage is worthy the attention  of all medi-
cal men ; and I feel persuaded that he who is without the knowl
edge of its great capacity and  powers, is without the possession
of one of the most important elements of success in surgery."
                  Fracture of the  Clavicle.

  A simple, easy, and efficient method of treating fractures and
dislocations of the clavicle, has long been a desideratum with
professional men.  A vast amount of apparatus has been devised
for securing this object, but very little, if any, possesses the re-
quisite fitness  or adaptation, while much the greater proportion
is absolutely useless, or,  what  is worse, decidedly prejudicial.
Notwithstanding  his best directed efforts, the surgeon but  too
often finds, in these  lesions, that it is impossible to  effect a cure
without deformity, much to his  own mortification and the detri
ment of his patient,  who often remains a cripple for life.  Under
these circumstances,  the practitioner should hail  with pleasure
every suggestion calculated to aid him in the successful manage-
ment of this class of affections.   How far the treatment which I
am about to describe, may be free from  the objections that have
•been urged, and, in most  instances, urged very justly, against
the various contrivances that have been presented to the consid-
eration of the profession, I am not prepared  to affirm, as I have
never tried it.  It is described in a paper entitled  " Suggestions
in  Relation to the  Treatment of  Fractures and Dislocations of
the Clavicle,"  by Dr. E. L. Dudley, in the Transylvania Medical
Journal, for August  and September, 1851, and is founded upon a
knowledge of the practice taught by Professor B.  W. Dudley.
The subjoined extracts will convey an accurate idea of this new
process:
  " For  many years Prof. Benj. W. Dudley has managed these
cases with dressings composed of two large handkerchiefs, or of
a broad roller.  Remembering the relationship existing between 
                            [163]   *

the humerus and scapula—that they are  firmly connected  at the
shoulder-joint—and  that  the acromion is even more intimately
bound to the outer end of the clavicle, it is easily perceived that
the humerus may be employed as an agent by which to push the
shoulder upwards,  outwards, and backwards, and it is quickly
conceived that these movements tend  of necessity to increase the
distance between the sternum and the point of the shoulder, and
to remove all pressure from the clavicle which extends as a brace
between these points.
   " Imagine a case of dislocation or fracture of the clavicle, and
let us  attempt to describe the simple  process of dressing  as it is
practised by Prof. Dudley.  The surgeon, placing himself behind
the patient—who should be seated upon a stool or a chair with a
low back—places one hand under the elbow of the injured side,
flexes  the arm upon the chest, and with the other hand  passed
around the patient's neck, grasps the wrist.   Pulling upwards
now,  with both hands, the surgeon  should  draw the patient's
elbow towards the centre of the chest.  In this position the oper-
ator will find that he can exercise a vast amount of power, and
to the very  best advantage; it is almost impossible to pull upon
the arm without forcing  the  shoulder upwards,  outwards, and
backwards by the oblique pressure of the  humerus.  Directing
an assistant to hold the elbow of the patient and to maintain the
upward pressure, the surgeon examines  along the clavicle, and
increases or lessens the extension until the ends of the bone are
in perfect apposition.  Having a bandage  four inches in width,
and eight yards  long, ready for the purpose, with a loop at  the
end so arranged  as to fit nicely around the elbow, the application
is commenced.   The loop being placed around the  elbow,  a turn
of the bandage is made, passing over the injured shoulder, around
the body,  under the axilla of the  opposite side, and around  in
front until it has passed over the elbow of the  injured member.
A figure 8 turn around the elbow brings the bandage in the same
position as when the first turn was commenced,  and each suc-
ceeding circle thus made brings the extending power to bear in
the proper direction.  After  three or four circular passages of
this character, the roller is passed twice around the body, so as
» 
                           [164]

to secure the arm firmly against the chest, and secured at several
points with pins so as to prevent displacement.
  " The pressure thus applied acts only in the neck, and the back
of the arm and fore-arm.   The blood-vessels and nerves are not
at all involved,  and if a silk handkerchief is folded in the form
of a pledget and  placed on the back of the neck so as to relieve
that part from pressure,  the dressing causes very little inconve-
nience.   I have had patients to wear the dressing, thus applied,
until the bone had  united, and not  a single excoriation  was to
be seen.
  "In the treatment of children, handkerchiefs may be employed
with perfectly good  results,  but they require  careful application.
A bandage may be constructed in a few moments which answers
an  admirable  purpose.  A  neatly fitting pocket, of  triangular
shape,  should  be made,  adapting  itself perfectly  around  the
elbow, while the arm is flexed so as  to bring the hand to the op-
posite shoulder.  Straps are easily adjusted to the pocket, so as
to bring  the elbow  upwards in front of the chest, and to fix the
arm firmly to the body.
  " The advantages of this method are obvious.  It enables us to
place the bone in proper  position, and to maintain  it so for an
indefinite period, and at so slight a  cost of comfort as to cause
very little complaint. As to the precise degree  of force to be
employed—that must be  measured  by the  extent of resistance,
encountered in the  reduction of  the  fracture or dislocation.   The
reduction of the injury is easily observed, and the bandage should
be  applied with enough  power to secure the just apposition of
the two surfaces."
   Dr. E. L. Dudley is not very  fortunate when  he asserts  that
"the old apparatus  of  Desault,  with various modifications, is
the universally received  means of relief in  these  cases."  With
the exception of Professor Gibson, of the University of Pennsyl-
vania, I  know of no writer or practitioner in America who recom-
mends or uses this  apparatus.  If there is  any contrivance  that
is more frequently  resorted to than another in  fractures or dislo-
cations of the collar-bone, it is that  of Dr. Fox, of Philadelphia,
 which combines, it  appears to me, great simplicity with every
advantage that can be expected from any dressing of the kind. 
                           [165]

Whether it is equal to that of Professor Dudley I have no data
by which  to  judge.  I can only say that I  have employed the
apparatus of Dr. Fox, upon  various  occasions,  with the most
happy and gratifying results.
  The same Journal contains an account, by the  same writer, of
Professor B. W. Dudley's mode of treating fractures of the acro-
mion and  coracoid processes.   We regret that our limits will not
permit us to give an account of the  apparatus.
       XI.--ELM BARK, CONSIDERED AS A SURGICAL  AGENT.

  The American profession  are indebted to Dr. William A.
McDowell, formerly of Louisville,  now of Evansville,  Indiana,
for some very useful suggestions in regard to  the employment of
the bark of the slippery-elm tree—ulmus fulva of the botanist—
for surgical purposes.  He recommends it as  being particularly
adapted for bougies, tents, and catheters.  His attention, it seems,
was first directed to the subject by Dr. John Fleece, of Danville,
Kentucky, whose assertions of its  beneficial effects  have been
amply confirmed by his own  experience, extending through a
period of many years.
  In commenting upon this  article,  in  its surgical relations, I
shall  avail myself freely of a paper upon the subject by Dr.
McDowell, in the Western Journal of the Medical and  Physical
Sciences, for 1837.  Although the author, at the time of its pub-
lication,  was a resident of Fincastle, Virginia, yet he  removed
soon after to this city,  where he practised medicine and surgery
until a few years ago, and where he had frequent occasion to use
the elm bark.   For this reason, but more especially from the fact
that the remedy was first suggested to Dr. McDowell by a physi-
cian of Danville, where he had studied his profession under his
uncle, Dr. Ephraim McDowell, it may, with  great propriety, be
regarded as of Kentucky origin.
  The first case in which Dr. McDowell employed the bark as a
tent, was one of lumbar abscess, which had been punctured about
the middle of the thigh, and the opening of which had  been lia-
ble to frequent obstruction  by flakes of lymph and  inspissated
pus, much to the discomfort  of the patient, who seemed to be in 
                            L166]
a hopeless condition.  Considering an enlargement of the fistula
obviously called for, a piece of the  inner  bark of the slippery-
elm, smoothly  polished, rounded at the point,  and soaked  in
water,  was introduced  into  the  bottom of  the sac, where it re-
mained twelve hours  without  any  disagreeable sensation.   In
this manner one tent after another, the last  being always smaller
than the previous one,  was employed, until the opening was dila-
ted to the requisite dimensions to admit of  a free discharge.
  Dr. McDowell informs us that he has found slippery-elm tents
particularly useful in the treatment of mammary abscess, attend-
ed with long and deep sinuses.   The tents are to be made thin,
and softened in water until they are sufficiently flexible to admit
of their easy introduction.   As  soon as the secretion of healthy
pus begins,  the tents are to  be a little shortened every day, but
still used as wide as ever,  that  no violence may be done to the
granulations.
  "In  all  abscesses, sinuses, or wounds," says Dr. McDowrell,
" requiring tenting, the slippery-elm merits a preference. To widen
a sinus, or prepare it for the extraction of loose bones during the
process of exploration,  their superiority is obvious."  He gives a
case of gun-shot wound,  in  which this substance was used with
great advantage.
  Dr. McDowell  speaks  in  terms of high  commendation of the
slippery-elm bougie in  the treatment of strictures of the urethra.
Indeed, he  prefers it to every other article  of the kind,  both on
account of  the  facility  of its introduction, and on account of the
greater permanency of the cure.  "It is particularly adaptedT"
he thinks, " to  all strictures, proceeding from spasmodic contrac-
tion, or from circular thickening of the  membrane,  or from cal-
losity,  or indurated enlargement of the surrounding corpus spon-
giosum, or of the prostate  gland."  The bougie is made of the
inner bark of the elm,  shaped to the caliber of the urethra, ren-
dered perfectly smooth, and immersed, for a few minutes previous
to its introduction, in tepid water.
  It is well known that the elm-bark bougie, since it was brought
before  the notice of the profession, has occasionally broken off in
the urethra, or  bladder, and afterwards  become  the nucleus of a
urinary calculus.   Of its liability to  this accident, Dr. McDowell 
[167]
was fully aware, and he accordingly enjoins proper precautionary
measures in regard to its manufacture.   " Some caution," says
he, " is necessary in using bougies,  or  catheters of elm.  Al-
though this bark possesses a degree of tenacity surpassed by that
of few trees of the forest, yet when seasoned, and in a very dry
state, it wrould be liable, in the hands of a careless  or awkward
operator, to break off in the urethra or bladder.   To obviate this
danger, it should be immersed in water, for a longer period when
it is very dry, which will restore tenacity to its outer fibres."
  Dr. McDowell gives the following directions for the prepara-
tion of the elm-bark catheter.  "I take a thin strip of the inner
bark, from one to one and a half inches wide,  seasoned just so
much as not  to destroy its pliability, bevel the edges, and smear
them with mucilage  or glue, wrap the  bark either spirally  or
longitudinally around a stilet,  and  roll with tape.  The wire
should be  smeared thinly, but completely,  with bees-wax and
tallow, to prevent its  being retained by the glue."  Dr. McDow-
ell thinks  that an instrument thus constructed would  possess a
decided advantage over the ordinary  one, in case it is necessary
to leave it  in the bladder; as from the mucilaginous character of
its surface  it  would prove an excellent emollient to the inflamed
or lacerated parts with which it is brought in contact.
  "I have treated,"  says the author, "three cases of this disease
—fstula  lacrymalis—with  slippery-elm bougies.   In  two  of
them, a slender probe could  be  passed from the abscess through
the ductus ad nasum, into which  bougies were introduced.—
Cures were affected in each case in about a fortnight."
  A case has been mentioned already in which this gentleman
cured,  in a very short time, with the slippery-elm bougie,  a very
tight stricture of the vagina.
   My personal experience with the elm bark, as  a surgical agent,
is comparatively limited, and I am therefore, perhaps, not able to
speak of it as it deserves.   I have used it both  in the  form of
tents and  bougie6, and occasionally with very good effects.  As
a tent, it is better than the ordinary one in a great many cases of
sinuses especially in those consequent upon abscess of  the mam-
mary gland, psoas  abscess,  and hip-joint disease.  It is always
 easy of introduction, and is generally more agreeable to the parts 
                            [168]

than linen or muslin, the substance in ordinary use ;  at the same
time that it  answers much  better as a dilator.  In the treatment
of stricture of the urethra  it might be  employed as a  valuable
adjuvant, especially in the  milder forms of the malady,  and also
after division of the contraction in  the  callous variety.  On ac-
count of its brittleness, the  instrument should be used with great
caution,  for the reasons already stated.   On the whole, I feel
disposed to  recommend  a  further trial with this article for the
various purposes suggested by Dr. McDowell.  It is probable that
the construction of the elm bougie  might  be so improved as to
divest it of many of the objections that have been urged against
its employment, and  that it might  thereby be rendered a most
valuable acquisition to our  armamentarium.
Xn.—AMPUTATIONS.
  Accidents requiring amputation of the limbs are of frequent
occurrence in every community, and there is no class of cases in
which  the skill of the surgeon exhibits itself to greater advan-
tage.   Fortunately, the operation is much less common now than
formerly,  and there is reason to believe, that, as our knowledge
of the  healing art increases, the necessity for its performance will
still  further diminish.  It was the proud boast of the  Father of
American Surgery, that he never amputated a limb on account
of external violence, except in one instance, where the case was
under his  charge from its commencement.  Whether Dr. Physick
was  indebted  for this  circumstance to extraordinary luck,  or to
unusual skill in the exercise of his profession, the fact is wrorthy
of being recorded in connection with the department of surgery
under consideration.  It is much  to be feared, that, with all our
caution and  foresight, the  amputating knife not  unfrequently
takes the place of milder means, and that limbs are sacrificed to
an itching desire  for the notoriety which arises from an operation.
I am certain that I have been the means, more than  once, of pre-
venting this operation where there was no  earthly necessity for
its performance, and where the patients recovered, in due time a
very excellent  use of  their condemned limbs.  In Louisville,
where  in consequence of  the numerous accidents in our foundries 
                            [169]

and on board of our steamboats, amputations are rather frequent,
I have repeatedly had  occasion to  witness the extraordinary dex-
terity  with which this operation has been executed by some of
our  young surgeons.  From fifteen to twenty seconds generally
suffices for the  removal of a leg, a thigh, or an arm; two cuts,
and a few strokes of the saw, and the limb is off!   I do not think
that even Parisian skill could boast of greater speed than this.
  It is not generally known to the profession that  Kentucky has
furnished the first  case of amputation at the hip-joint that has
ever occurred in the United States.   The honor of having per-
formed this bold and formidable operation belongs  to Dr. Walter
Brashear, a  native of Kentucky,  and for a number of years a
practitioner at  Bardstown.  The case occurred in August, 1806,
eighteen years prior to the much eulogized case of Dr. Mott, of
New York. *   The subject was a mulatto boy, seventeen years of
age, belonging  to the monks of St. Joseph's, of Bardstown.  He
had a fracture of the thigh, complicated wTith severe injury of the
soft parts, and completely recovered, living in good health many
years after.  Dr. Brashear had  no precedent to guide him in his
hazardous undertaking, for the  cases of Larrey,  and other army
surgeons of Europe, had occurred  only a short time before, and
were then entirely unknown to the bold and adventurous back-
woodsman, and the operation was performed upon a very novel plan,
comprising two distinct stages.   In the first, the  thigh was remo-
ved about its middle, in the ordinary manner; and, in the second,
the remainder of the bone was separated from its muscular con-
nections,  by  a long incision on  the outside of the limb,  and dis-
articulated at the socket.  Although the method here pursued is
not in  harmony with the  science of  the  present day, in similar
cases, yet considering  the date of  its  performance, and the fact
that Dr. Brashear was  obliged to rely entirely upon his  own re-
sources,  it justly challenges our admiration,  and gives us the
most exalted  opinion of the operator's ingenuity, judgment and
skill.
  It is not a  little singular that  Dr. Brashear should  have been
so regardless  of his own reputation and of the fame of his native

  *  Velpeau's Operative Surgery, by Townsend & Mott, preface, vol. 3. 
                            [170]

State,  as never to have published  an account of a case, which
was so well calculated to place  him in the highest rank of his
profession, both at home and abroad.  At that time but few suc-
cessful cases of amputation at the hip-joint  had occurred abroad,
and the performance of such an operation in the wilds of Amer-
ica would, had it been made public, have obtained for its author
a world-wide  renown.  In a word, it  would have covered Dr.
Brashear  with glory, and  formed then, as it unquestionably
forms now, one of the brightest gems in the diadem of Kentucky
surgery.
  I cannot refrain here from mentioning  an anecdote relative to
Kentucky's distinguished surgeon and Kentucky's late illustrious
statesman.  It is related in the  New Orleans  Medical Journal,
for July, 1845, and I beg leave to transcribe it for your gratifica-
tion.   "During the winter of 1843-4, when the Hon.  Henry
Clay was  on a visit to this city,  we had the pleasure," says the
writer, "  together with  some twenty-five  or thirty physicians, of
spending  the evening with him at the house of a medical friend.
Whilst at  table, one of the company proposed " the health of the
venerable  Dr. Brashear,  the first and only surgeon in Louisi-
ana, who has successfully  performed amputation  at the hip-
joint." Mr. Clay, who was sitting by the  side of Dr.  Brashear,
with characteristic good humor,  immediately observed, " he has
you on the hip, Doctor," to the great amusement of Dr. Brash-
ear and the rest of the company."
   Of the  personal history of Dr. Brashear not much is known.
From a communication with which I have  recently been favored
by his son, R. B. Brashear, Esq., of the Parish of St. Mary, Lou-
isiana, I learn that he was born  in Prince George county, Mary-
land,  on  the  11th of February, 1776.  Eight years  after, his
father, Nacy Brashear, emigrated to Kentucky, and  settled near
the Long Lick, within three miles  of Sheppardsville.  Walter
was the seventh son, and was,  therefore,  according to the old
idea, destined for the medical profession.   After a limited educa-
tion at such  institutions  as were  then within the reach of his
scanty means, he entered the literary department of Transylvania
University, where he acquired a knowledge of the classics,  espe-
cially  the Latin language.  In 1796, he commenced  the study of 
                            [171]

medicine  under the auspices of Dr. Frederick Ridgely, of Lex-
ington, a gentleman who had served with great credit as a sur-
geon in the Continental army.   Two years  after he attended a
course of lectures in the University of Pennsylvania, under Rush,
Physick, Barton, and other distinguished teachers.  In 1799,  he
sailed  to China as surgeon of the ship Jane, and while there am-
putated a woman's breast, which was probably the first operation
of the kind among the Celestials.  Having  learned the Chinese
method of clarifying ginseng, he now, abandoning the profession
for a time, devoted himself to mercantile  pursuits,  and proving
ultimately unfortunate, in 1813 he moved from Bardstown to Lex-
ington, where  his career as  a professional  man may be said to
have commenced.
  It was previous to this period, however, that, while merchant and
surgeon, he performed the amputation of the  hip-joint, above
described.  His method,  as we have already seen, was peculiar.
The operation  was done  in  the  presence of Dr. Burr Harrison
and Dr. John Goodtell, whose patient the boy was.  He seemed
to possess peculiar tact  in the  treatment of the diseases of the
bones and joints,  especially in cases of scrofulous enlargement,
vulgarly called white swelling.  He was also very successful in
the management of fractures of the skull, and had a set of tre-
phining instruments constructed,  under his immediate direction,
in Philadelphia, which he regarded as much  superior to those in
ordinary use.  We have already spoken of him as a lithotomist.
  He practised medicine and surgery in Lexington from  1813 to
1817, with great success, and  was the first, in the  West, to change
from the depleting to the stimulating plan of treatment in the
so-called " cold plague," prevalent, and very fatal, during a por-
tion of that period.
  Being seized anew with the ginseng fever, Dr. Brashear left
Kentucky, and in 1822 he removed his family to the Parish of
St. Mary, where he had previously held property.   He is now a
planter, in good health, and of great activity for one of his age,
practising  only among his  particular  friends  and neighbors,
whose  partiality induces  him to render them his services free of
charge.
  Dr. Brashear seems to have a mind of great originality, and of 
[172]
infinite resources.  Nature had evidently designed him for a great
man, and it is much to be regretted that he ever permitted him-
self to be drawn  aside from  his professional pursuits.   He has
been,  alternately or successively, doctor,  merchant, legislator,
lawyer,  and naturalist.  For some years  he served  his  adopted
State in the Senate of the United States.
  In  the Transylvania Medical  Journal, for June, 1851,  Dr.
Raphael, of this city,  gives a case of Chopart's  amputation for
caries of the foot, which deserves notice here, chiefly, because it
is probably the first operation of the kind executed in Kentucky.
The patient recovered,  with  an excellent use of his limb.  Last
summer I performed a similar operation for disease of the tarsal
bones, with a like happy result, upon a young farmer, of the name
of Stine, from Indiana.
  It is a source of deep regret that we have no statistics, eitner
of private or hospital practice, of the results of  amputations in
Kentucky.  Our neglect,  in this  respect, is unaccountable, and
has led  to the loss of a vast amount of valuable  matter;  matter
that might,  had it been carefully preserved, be most beneficially
applied to the amelioration of suffering humanity.   In the Louis-
ville Marine Hospital, of this city, until recently the only institution
of the kind within the limits of our State, and which, since it has
been placed  under the judicious administration of its present su-
perintendent, Dr. Fisher, is one of the best managed charities in
the country, no systematic record is kept of any of the numerous
cases  of disease and accident that are annually admitted into its
wards.  Such neglect is absolutely criminal;  and  I trust that the
guardians of that establishment, which has now been dispensing
its blessings for upwards of thirty years, and which was founded
by  the  liberality of one  of our most worthy citizens, will no
longer permit its existence.  There is not a solitary class of cases,
medical  or surgical, the nature and treatment of which might
not have been more or less thoroughly  elucidated, during the
period adverted to, had a faithful record of them been preserved.
Not only the medical profession, but every citizen of Kentucky,
should feel a deep interest in the subject.
  Dr. Samuel B. Richardson, of  Louisville, has furnished me 
                            [173]

with the particulars of an interesting case of amputation of both
thighs in the same subject.   The cause leading to the  necessity
of the operation was mortification of the legs and feet, conse-
quent upon a transverse fracture of both patellae.  The accident
was  occasioned  by muscular effort in jumping  into a sand-pit,
and  the patient, who was in good health at the  time,  had been
treated with the bandage.  The sphacelus came on about the end
of the third week, and resisted  every effort that could be made
to arrest it.  The  man was  thirty-five years of age, fleshy, and
addicted to the  free use of ardent spirits.  He recovered, and
became extremely fat.  Dr. Richardson is inclined to think that
the injudicious  application of the bandage was the cause-  of the
mortification.
   I am not aware that any surgeon in Kentucky, excjpt-ing my-
self,  has performed  amputation  at the  ankle-joint.  My case is
worthy of  mention,  because of the peculiar manner in which I
was  compelled  to form  the principal flap.  The  patient was a
poor Irish  girl, about twenty years of age, affected with caries of
the astragalus  and  calcaneum,  with  extensive  ulceration and
thickening of  the integuments of  the heel,  indeed, the soft
parts in this situation were so  extensively diseased that it was
deemed quite impossible to save them.   The flap was,  therefore,
taken from the upper part of the foot, and answered, I  am happy
to say, the purpose most admirably.  It was made by  dissecting
up the common integuments, with a small catling, nearly as far
forwards as the metatarsophalangeal articulations, and laterally
as far as the inner  and outer margins of the foot.  Disarticula-
tion was then  effected,  the tendo-Achilles  severed a  short dis-
tance  above its  attachment to the calcaneum, and the altered soft
parts cut away.   The  articular  cartilage being  perfectly  sound,
all that remained  to be done was to saw away the projecting ends
of the tibia and fibula, so as to form a smooth, square surface.
The anterior and  posterior tibial  arteries alone required a liga-
ture.   Only a  few  ounces  of blood were  lost.  The  flap being
found to be rather large, a portion was cut away, when the edges
of the wound were brought together with four sutures, adhesive
strips, and a roller.
   A considerable  part of the wound united by the first intention; 
[174]
 but the rest, owing to a slight attack of erysipelas, healed by the
 granulating  process.   The patient remained feeble  for several
 weeks; but when  I saw her last she was rapidly improving in
 health, and was able to walk about her room on crutches.  The
 stump was nearly well, and bade fair  to  answer an  excellent
 purpose.
  The ordinary mode of performing this operation,  is, as is well
 known, to make the principal flap at the expense of  the soft parts
 in the sole of the foot, which is always desirable when these parts
 are in a sufficiently healthy condition to admit of their  being re.
 tained.   Where the reverse is  the  case, a very useful cover for
 the bones may generally be obtained in front, as  in the instance
 above described.  When the calcaneum alone is involved, excision
of this bone, either in  part, or wholly, would be  preferable to
amputation at the ankle-joint.   Such an  operation has, of late,
been several times performed, with  excellent effect, by European
surgeons.
  Amputation of the ankle-joint, when practicable, should gen-
erally, I think, be preferred to removal of the leg  in its conti-
nuity ; inasmuch as the stump  is usually well calculated to bear
the superincumbent weight,  and admirably adapted  for the ac-
commodation of an artificial foot.
XIII.—TRAUMATIC TETANUS.
  Of this obstinate, and, unfortunately,  too frequently fatal dis-
ease, several cases have been successfully treated  by Kentucky
physicians;  and, although the means by which they effected this
result, comprise nothing whatever of novelty, yet the facts de-
serve to be recorded for the encouragement of practitioners.
  The first case to which I shall refer, occurred under the obser-
vation of Dr. E. F. Wilson, * of this city, in a girl nineteen years
of age, who, between three and  four  months  previously, had
wounded  the sole of the foot with a piece of glass,  which had
never been extracted.  When Dr.  Wilson first saw  her she had
had  twelve paroxysms of spasms,  and was laboring under well

  * Western Journal of Medicine and Surgery, vol. 3, p. 91, 1841. 
                            [175]
marked symptoms of opisthotonos.  The wound was nearly heal-
ed, though  there was still  some appearance of inflammation
about it.  Fifteen grains of tartar emetic were administered in
two doses, and in the course of an hour the muscular contraction
had  almost  completely subsided, followed  by great prostration
and coldness of the extremities.  Numerous sinapisms were now
applied, and the patient took twenty grains of calomel with two
of opium.   The next day she was much better; there had been
no return of her paroxysms; and she had rested pretty well the
previous night.   The wound  being  dilated,  four  fragments of
glass, of more than a quarter of an inch  in size, were extracted.
From this time on,  or, rather, from the time of the administra-
tion  of the  antimony, there was a steady improvement without
any  return  of  tetanic spasms.  On  the  seventh  day, she was
walking about, apparently in as good health as usual.
  The narrator of this case  ascribes  the  recovery of the patient
exclusively to the effects of the antimony; but it seems question-
able  whether it exerted any other agency than that of allaying
muscular contraction.  It is  reasonable to  suppose that the ex-
traction of the foreign bodies had great influence in establishing
the cure.
  A  case of traumatic tetanus, consequent  upon a wound of the
leg from a pistol charged with a large quantity of tow, is given
by Dr. Samuel S. Emison, of Scott county, in the Western Jour-
nal of Medicine and Surgery, for April, 1850.  The  patient, a
stout, athletic man, twenty  years old,  was hurt on the 25th of
December,  and symptoms of the disease showed themselves, for
the first time,  on the 13th of January, the wound  being  nearly
healed,  though there was still some  swelling of the ankle.  On
the 19th he was bled to the amount of sixteen ounces, without
relief* and,  on the following day, when Dr. Emison first saw him,
he took twenty-five grains of calomel  and two of ipecacuanha,
followed by an ounce and a half of castor oil. The purgatives
having produced free action, large doses of morphine and lauda-
num  were  resorted to,  and repeated frequently until the 15th,
when  at 6  o'clock in the evening, as little impression  had been
made upon  the disease, half a drachm of quinine was added to
the prescription.   A well marked remission followed, and the 
[176]
 next day one  drachm of quinine was given at one dose.  The
 spasms now became much less frequent and severe, and, under a
 continuance of the treatment for four or five days longer, they
 entirely disappeared.
   A case of a  similar kind is reported,  in the same Journal, for
 January, 1851, by Dr. Theodore S. Bell, of this city.  The attack
 was caused by  a severe wound of the thumb in a nervous, sickly
 young man, of twenty-two,  and manifested itself in  the third
 week after the  accident,  in the form of trismus, which was soon
 succeeded by emprosthotonos and opisthotonos.  The treatment
 consisted of active purgatives, and of the free use of extract of
 Indian  hemp and  McMunn's elixir of opium.  The wound was
 regularly dressed with warm  poultices, aided occasionally by the
 addition of laudanum.  The  strength was supported by wine and
 nourishing  food.   Throughout the whole of the tetanic attack, a
 period of four weeks, the wound of the thumb remained  station-
 ary, and it  was not until a month after  its disappearance that it
 was completely cicatrized.  The hemp, in this case, did not seem
 to exert any material  benefit in  mitigating  or  relieving the
 spasms, although it was faithfully employed up to the time of its
 termination. Active purgation,  followed by the  liberal use of
 McMunn's  elixir of  opium  was  generally productive of most
 benefit, though  it is not stated to what particular remedy, or com-
 bination  of  articles, the cure  was due.
  My own practice  has furnished me with only two cases of re-
 covery from  traumatic tetanus.  The first was that of a young
 girl, of fourteen, the daughter of Mr. O'Bryan,  on  the Flat Lick
 road, whom I visited in consultation with the late Dr. Buck, of
 this city, and who, nearly a month previously, had run a splinter
 into the right cheek in falling accidentally from a rail fence.  The
 puncture was situated about  an inch  from the nose, just above
 the attachment  of the upper lip.  The splinter was extracted im-
 mediately after the injury,  but the parts continued to be tender
 and even painful, and in less  than a week the girl,  who was of a
nervous,  delicate constitution, was  seized with  lock-jaw.   Dr.
Buck had treated the case with purgatives, opiates, and antispas-
modics,  and iodine and leeches had been applied to the affected
part, without any material  benefit.  The girl was  pale and fee- 
                    STATE MEDICAL SOCIETY.               *^

ble, and  had but little appetite.  Upon a careful examination of
the part, I found a small circumscribed spot, exquisitely tender
under  pressure, and of  almost fibro-cartilaginous hardness.  I
immediately  took my  knife, and  completely dissected out the
little tumor.   Quinine and iron, with nourishing food and wine
were then ordered; and in  a few days the patient was well, hav-
ing no further paroxysm of trismus after the operation.
  The other case to which  I refer, occurred near  Bardstown, in
Nelson county, in this State, where I saw it in consultation with
my friend, Dr. C. P. Mattingly, to whom I am indebted for some
of the details of the  subjoined  account.  Mr. John Foxworthy,
aged  fifty years, of a sanguineo-nervous temperament, a farmer
by occupation, a pretty free liver, and rather inclined to corpu-
lency, got the fore and middle fingers of the right hand mashed
by a wagon,  between the second and third joints,  on the 21st of
March, 1848.  The phalanges were completely comminuted, and
supported  merely by a few shreds of the common integuments.
A physician in the neighborhood of Louisville,  where the acci-
dent  happened, being sent for, removed the injured parts with
the scissors, and bound up  the ill-formed stumps with a compress
and bandage.  In this condition Mr. Foxworthy rode home, a dis-
tance of about thirty-five miles, and then sent for his family ad-
viser who, instead of amputating the mutilated fingers, contented
himself  with prescribing a dose of purgative medicine, rest, and
light diet, with some ointment for the sores.  The hand soon be-
came excessively painful; and on  the 28th of February, the pa-
tient was seized with a sense of stiffness in the  neck and jaw,
with contraction and jerking of the muscles of the back, and oc-
casional cramp in the  stomach.  These symptoms,  which  were
 always  much aggravated  by the  slightest draught  of air, were
 ascribed by  the medical attendant to the effects of cold.
   Dr. Mattingly saw the patient  for the first time on the 1st of
 March  and advised immediate amputation of the fingers,  as the
 only means  likely to save  his life.  To this, however, he obsti-
 nately refused his consent; and all, therefore, that Dr. Mattingly
 could do was to pick out all  the loose spicula of bone he could
 find  to apply emollient poultices, and  to administer calomel and
 opium at intervals of from four to six hours.
          18 
 "274            TRANSACTIONS  OF THE KENTUCKY

   On the  3d of March,  there was no improvement; instead of
 this, indeed, the patient had spasms of the dorsal muscles every
 five or six  hours, each lasting several minutes.   Next day he was
 worse, the  spasms being more frequent, longer, and more violent,
 notwithstanding the increased use of opium, anodyne injections,
 and a properly regulated  temperature of the apartment.   He now
 consented  to have his fingers amputated, and  I was accordingly
 sent for the next morning, when I performed the operation at the
 metacarpo-phalangeal articulations, the patient being fully under
 the  influence of chloroform.  I found the hand and fingers very
 much swollen,  and exquisitely tender  and painful: the  tongue
 was somewhat coated, and the pulse hard and accelerated.  The
 bowels had been thoroughly evacuated  by medicine the day pre-
 viously, but the appetite was much impaired, and Mr. Foxworthy
 had scarcely enjoyed any sound sleep since the occurrence of the
 accident.
   After the operation,  the patient had spasms for several days,
 but  they became gradually lighter,  shorter, and less frequent,
 until at length all the symptoms  of tetanus disappeared, and he
 entirely recovered.
   In the Transylvania Medical Journal, for  November, 1851, is
 a case of traumatic tetanus, treated by Dr.  E. L.  Dudley, and
 reported by Dr.  Robert Durret,  which terminated successfully,
 with very little treatment.  The patient, a man, aged twenty, had
 received a contused wound on the distal extremity of the middle
 finger, attended with the loss of the nail, seven days before. The
paroxysms  occurred very  frequently ; sometimes as often as every
 minute, and were most violent in the  morning  and during the
 night.  He was admitted into the Louisville Marine Hospital on
 the 11th of October, about three weeks after he was hurt; and
 on the 12th, almost every muscle in the body was in a rigid state •
 he was unable to open his mouth more  than one-fourth of an
 inch, his features were contracted and ghastly, and there was
 decided opisthotonos.  He was  ordered  to  be placed  near the
 stove, to be kept  perfectly  quiet, to take  nourishing broths
ad libitum,  and to apply  hot  bread poultices  to the finger.
On the 14th he was  much better; he had  slept  four  hours
the  previous night,  and  the spasms were  less  violent and 
STATE MEDICAL SOCIETY.
m
frequent.  From this time on the improvement was progressive ;
on the 18th  he had the last tetanic paroxysm ;  and on the 23d he
was discharged cured.   In  this  case no  medicine was adminis-
tered,  except an occasional  aperient.
  Dr. E. L. Dudley, in some remarks appended to the above case,
seems to lay great stress upon the fact that no active treatment,
or, indeed, treatment of any kind, was employed.  In an article
immediately preceding Dr. Durrett's report, detailing the partic-
ulars of a case of  ligature of the primitive carotid artery, where
death  was  induced by  tetanus, he  holds the  following  lan-
guage :   "  Not   the  least  remarkable  feature  in  the  case
is the fact that the man lived two weeks  after the first appear-
ance of the  symptoms of tetanus, and that during that period he
took none of the remedies usually employed in the desperate mal-
ady which finally  destroyed him.  In the succeeding article  of
the  Journal," he continues, "  is a report of several cases  of
tetanus which have fallen under  my observation  within the past
few months.  One of these, and the only one that recovered, was
discharged  from the Marine Hospital, of this city, a few days
since.  This case  was, in addition to the remarkable fact of his
recovery, interesting, because no active treatment was pursued."
  Dr.  Dudley evidently assumes here, that, because one man
recovered under this management, tAe nemia diligentia  is appli-
cable as a general  law, forgetting that in  the other instance in
which  it was tried it utterly faited, although  the patient  lived
two weeks after the disease began to manifest itself.  I presume
that few professional men wculd be willing to trust to such means,
or to leave ike task of curing so terrible  a disease entirely in the
the  hands of nature, skilful and competent as she no doubt oc-
casionally is even  here.  They would be more  disposed to adhere
to the axiom,  "Ad extremos morbos, extrema remedia."
  In the Transylvania  Medical   Journal for October, 1850, is a
short clinical letter on tetanus, with a cast, by Dr. Raphael, of
this city.   A careful perusal has not left upon my mind the im-
pression that it comprises  wiy  novelty, either in regard to  the
pathology or treatment of this m*lady, md I therefore deem any
further notice of  it unnecessary.  The case accompanying the
 discourse ended fatally, but no dissectioiwas made. 
8*76             TRANSACTIONS OF THK KENTl'CKY

                      XIV.--EXSECTIONS.
                 Exsection  of the Clavicle.

  This bold, delicate, and extraordinary operation wes executed
for the first time in America, in 1813, by the late Dr. Charles
McCreary,  of Hartford, in this  State.  The subject of the case,
as I learn from Charles F. Wing, Esq., of Greenville, who was
intimately acquainted both with the patient and his surgeon, was
a youth of the name of Irvin, fourteen years of age, laboring under
a scrofulous affection of the right collar  bone.  A disease of a
similar kind existed, at the period of the operation, in the right
leg, from which several small pieces  of bone were subsequently
removed, and which became so  much curved and  shrunken as to
be upwards of two inches  shorter than the other. By degrees
the parts got well, but the disease recurred two or three times af-
terwards, though it was always readily amenable to treatment.
   Mr. Wing informs me that Dr. McCreary removed  the whole
of the collar bone, and that  the patient survived the operation
thirty-five  years  without any return of the disease.   He died in
 Muhlenburgh county, in this State,  in April,  1849, aged forty-
 nine.  The loss of the bone did not seem to impair the functions
 of the corresponding limb.
   The operation of Dr. McCreary reflects great credit both upon
 himself, and upon the American profession.  Performed as it was
 in a remote and comparatively obscure part of the'United  States
 and at a period when surgical  science was but little  cultivated
 or appreciated, it is  surprising that h%  should hav^ ventured
 upon  so daring an enterprise,  an  enterprise requiring the most
 consummate skill, and no ordinary  share of anatomical  knowl-
 edge, for its successful execution.  Dr. Mott,* who performed ex-
 cision of the collar bone sixteen years later, deems the operation
 from the character of the structures involved in  it, as the most
  important, difficult and dangerous operation tiat can be performed
  on the human bod) ;  and so,  indeed, iwust be regarded by every
  one who has a proper knowledge of tie subject. Dr. Mott calls it his

   * Travels  in Europe and th«East, p. 64: New York, 1885. 
                    STATE MEDICAL SOCIETY.                 ^TwT

" Waterloo operation ;" and believing that he was the first surgeon
who performed it in the  United States, he proudly claims the
credit of it for his country, his city, and himself.  Dr. Johnson,
of New Orleans, who published  a short and imperfect account of
Dr. McCreary's operation, in the New Orleans Medical Journal,
for January, 1850, proposes to call it  the " Thames operation,"
and claims the credit of it,  and  that justly,  too, for  Kentucky,
and for Dr.  McCreary.
  It is proper to state that Dr. Mott's  operation was one of im-
mense difficulty, requiring nearly four  hours  for its  execution,
and the application of about forty ligatures, and that he employed
the term Waterloo, not because it  was  tedious, delicate and haz-
ardous, but  because it was performed on the  18th of June, the
anniversary of the battle  of Waterloo.
  I have been anxious to obtain some information respecting the
private and  professional  character of Dr. McCreary, but regret
to say that all my efforts have  been in vain.  To none of my
communications,  addressed for  the purpose to some of his rela-
tives and friends,  has any reply been received.  I  have learned,
however, incidentally, through one who knew him  well, that he
was a bold and fearless practitioner, as well as a hard student, and
that he died about the age of thirty-seven, from  the effects of
intemperance, to which he had been addicted for many years.
                    Excision of Scapula.

  The following case occurred in my own practice, and has never
before been reported:
  A gentleman, Mathew Gracey, aged forty, of Eddyville, Ken-
tucky, applied to me in September, 1850, on account of an enor-
mous tumor of the right shoulder, first perceived about nine
years ago.   His general health had always  been good, and was
so at the time.   The swelling, which arose  without any assigna-
ble cause was  fifteen inches in its vertical direction, and fifteen
and a half in the transverse.   Its surface was nearly every where
smooth  and its substance was hard and incompressible in its en-
tire  exteBt.   The skin  was sound, and there was no enlargement
of the subcutaneous veins.  Its  superior boundary corresponded 
278            TRANSACTIONS  OF THE KENTUCKY

with the shoulder joint; anteriorly it projected  into the axilla;
and below it reached as far down as the ninth rib.  During the
last three months, the tumor had been the seat of  a dull, heavy,
aching pain, extending about in different directions, most severe
at night, and aggravated by the recumbent posture.  The growth
had increased rapidly within  the last twelve months, and dis-
qualified the patient for active exertion.
  Having prepared the system by  a course of diet and  purga-
tives, I performed the operation  of excision  on the 26th of Sep-
tember.  An incision, sixteen inches in length, was made from
the superior angle of the scapula to the inferior extremity of the
tumor, its direction being  obliquely downwards  and inwards.
Another, beginning about five inches below the upper end of the
first, and terminating about the  same distance from its  inferior
end,  was  then carried, in a  curvilinear direction, so as to include
a small oval flap of the skin  a little  above the  centre  of the
tumor.  The integuments being reflected from the surface of the
morbid growth, and the elevator and trapezius muscles detached,
I sawed through the acromion process of the scapula, just behind
the clavicle,  and then divided  the broad dorsal and  anterior
serrated muscles; carrying my fingers next underneath the tumor,
and raising it up, I  severed its connections with  the ribs, cut the
deltoid and other muscles  of  the  arm, sawed  the  neck of the
scapula, and thus removed  the entire  mass  with  comparatively
little difficulty.
   Several vessels required the ligature,  and about twenty ounces
of blood were lost in the operation.  The edges of the immense
wound thus produced were brought together by three interrupted
sutures and adhesive strips, supported by a thick compress and a
broad bandage.
   No untoward symptom occurred after the operation;  nearly
the whole wound united by the first intention ; and at the end of
three weeks, my patient went home with every prospect of a long
and prosperous life. In descending the Ohio river, however,  he
took a severe cold, from the effects of which he never recovered.
A harrassing cough set in,  accompanied by  all the symptoms of
pleuro-pneumonia, which were followed, about the middle of De-
cember, by those of hectic  fever, under which he  gradually sank 
STATE MEDICAL SOCIETY.
279
three months after the operation.  No post-mortem  examination
was made.  It is proper to add that soon after Mr. Gracey reached
home, a small fungus appeared in the lower angle of the wound
which became red  and painful, and obstinately  resisted  every
attempt that was made to heal it.
  The tumor -weighed seven pounds and two ounces immediately
after removal, and belonged to the kind of  structure usually, but
vaguely, denominated  osteo-sarcomatous.
XV.--PLASTIC SURGERY.
  Plastic surgery has received very little attention in Kentucky;
at all events, it has thus far failed to  achieve any important tri-
umph.  Whether this is owing to the want of cases among us,
requiring the resources of this department of the  profession, or
to an indisposition on  the  part  of our  operators to  engage in
such enterprises, it is not in my power to determine.  I am not
aware that the Lexington surgeons have  accomplished  anything
in this field, and in Louisville, I know, very little has been done.
I have, in a few instances, resorted to autoplasty, with a  view of
remedying  the deformities  and  inconveniences occasioned by
burns and scalds ; but the results have  always failed to satisfy
me  or to confer any  material benefit upon my patients.
  In June, 1851, I witnessed, at the Louisville Marine Hospital,
in the hands of Dr. B. I. Raphael, a rhinoplastic operation, the
result of which was quite creditable to his skill and judgment.*
The patient, an Irish female, aged thirty, had lost the right ala
of the nose from the effects  of syphilis, contracted nine  months
before.  The operation  was commenced by paring the edge of
the remnant of the  nose, and raising from the cheek a flap, the
outline of which  had been previously traced in ink with the aid
of a piece of paper.   A pedicle, about  a quarter of an  inch in
lenoth by the eighth of an inch  in breadth, served to maintain
the&connection between the  parts.  The flap being twisted half
round was retained by four sutures and  adhesive strips, applied

  * Transylvania Medical Journal, for August,  1851, p. 28. 
280
TRANSACTIONS OF THE KENTUCKY
over the nose and cheek,  in such a  manner as  to avoid  undue
compression.  The wound was also closed by sutures.  The parts
united by the first intention, and the patient was soon after dis-
charged  entirely well,  and  with great  improvement  in the
features.
XVI.—TENOTOMY.
   This operation, so fashionable in Europe and  America a few
 yaars  ago, has  not been overlooked.  Still, it has  not, there is
 reason  to believe, received from the surgeons of Kentucky that
 attention to which its utility  and importance entitle it.  No one
 can doubt that the operation has been much abused, and that it
 has often been performed by ignorant and incompetent men  to
 the prejudice both of the profession and those who were the sub-
 jects of it; but it is equally certain that it is capable,  when pro-
 perly  executed, of  conferring immense  benefit upon  a class  of
 patients,  who, until the researches of Stromeyer,  of Hanover,
 less than twenty years ago, were generally regarded as  incurable,
 and therefore  abandoned to  their unhappy fate.   Experience,
 multiplied and reproduced in thousands upon thousands of cases,
 has fully  demonstrated the safety and practicability of the pro-
 cedure, at every period  of  life, and in  almost every form  of
 muscular, tendinous, and aponeurotic contraction,  whether oc-
 curring in  club-foot,  strabismus,  wry-neck,  spinal  curvature,
 or  false anchylosis.
   The  operation for the cure of club-foot has been repeatedly
 performed by some of the surgeons of this State, and, in  many
 instances, with the  most  gratifying  results.  One of the first,  if
 not the very first, of our  practitioners who have busied them-
 selves in this manner,  was Dr. S. B.  Richardson, of  this  city,
 who, in a long and valuable essay in the  second volume of the
 Western Journal of Medicine and Surgery, called the attention
 of the profession prominently to the subject, and adduced several
 cases in illustration  of the success of the operation, which he per-
 formed, it would seem, for the first time, in April, 1839.  The
 nature of the operation, then so novel and exciting, its safety and
its  applicability  to  an unfortunate class of individuals, are now 
STATE MEDICAL SOCIETY.
281
so well known and  appreciated by the profession  at large that
any further allusion to the subject  would be  out of place in a
paper of this kind.
  I was the first, so far as I am informed, who performed the
operation for strabismus in Kentucky.  My first case occurred in
February, 1841, in the person of a medical student from Alabama,
and was entirely successful.  Since that period I have repeated
the operation, probably upwards of one hundred times, wdth a
result of the most gratifying character.  An elaborate  clinical
lecture upon this subject, setting forth the nature and causes of
strabismus,  together  with  the  best  method  of performing the
operation for its relief, will be  found in the Western Journal of
Medicine and Surgery for 1842.
XVII.--ARMY SURGERY.
  The army surgery of Kentucky is remarkably barren of prac-
tical results.  It is reasonable to suppose, that,  during the early
settlement of the "dark and bloody ground," many interesting
cases of wounds and other injuries occurred in the rencounters of
the whites  with  the Indians;  but  of these, unfortunately, no
record has been  preserved;  at all events, none  has come within
my reach.   Doubtless, many traditional facts exist, which, if col-
lected and arranged, might prove of no little interest and value.
The tomahawk and scalping-knife might, could they now speak
as they once did,  unfold a horrid tale.
  During the late war with Great Britain,  Kentucky furnished
her quota of surgeons,  some of whom served with great distinc-
tion,  rendering themselves conspicuous  alike for their science,
their humanity, and their patriotism.  I am not  aware, however,
that they have left any contributions to our periodical literature
of the results of their observation  and experience.  We can only
express our  regret at such negligence, the cause,  no doubt, of the
loss of much useful matter.
  My friend, Dr. J. M. Mills, of Frankfort, has kindly furnished
me with a list of  the names of the surgeons and  their assistants,
as they are recorded in the Executive Journal of the State of 
Ittk
KS2             TRANSACTIONS OF THE KENTUCKY

Kentucky, from the 11th of August, 1812, to the 7th of Febru-
ary. 1S1.5, the period embraced by the last war with England.
                             1812.
    Surgeons.                      Assistant  Surgeons.
  W. H. Richardson,               Robert M. Ewing,
  William II. Craig,                G. C. Patrick,
  Daniel B. Potter,                 Daniel Nelson,
  Ardeinus D. Roberts,             Jesse Dodson,
  John  Todd,                     Thomas Donophan,
  James W. Tunstall,               Augustus M. Bowen,
  James McI>o\vell,                 Thomas  X.  Gist,
  John  A.  Knight,                 Dufif Green,
  Thomas C. Davis,                Samuel Merriweather,
  John  Moore,                    Moses Ferris,  )  Ass's attached to the
  James Moore,                   Gibson Taylor, j  Iwspital department.
                             1814.
  John  Bosley,                    Arthur Craddock,
  John  M.  Talbot, senior surgeon to the detachment.
                             1815.
  Patrick Major,                    Henry Winslow.
  During the Mexican war,  which  eventuated  so honorably to
our arms, and so advantageously to the cause of civilization and
the spread of Christianity, Kentucky was  again  favorably repre
sented.  Her surgical staff,  consisting of Drs.  T. L. Caldwell,
Hensley, and Hunt, with their assistants, Drs. Mathews, Blanton,
and Snell, were eminently qualified for the discharge of the ardu-
ous and responsible duties devolved upon  them,  and were ever
ready to minister, by all  the resources witliin their reach,  to the
sick,  the wounded, and  the  dying.  It is  to be regretted that
none of the  gentlemen thus  engaged have furnished the profes-
sion with a complete and connected history of  their campaigns.
The battles  of Monterey, Buena Vista,  and other  places  were
prolific in interesting and instructive cases of gun-shot, sword,
lance, and  sabre wounds, many of them of a  very  severe  and
complicated character, and  necessitating important operations.
With  the exception  of two short  and  detached  papers by Dr.
Blanton,  of Frankfort, in the  Western  Lancet, for  September,
1S47,  and the American Journal  of the Medical Sciences, for
January, 1849, nothing  has  appeared upon the subject.  These
papers, although interesting, are hardly of sufficient moment to 
STATE MEDICAL SOCIETY.
■282
require special consideration in a report of this kind.   The first'
comprises an  account of three  surgical  cases which occurred at
Buena Vista,  in February, 1847, and the latter,  a case of gun-
shot wound of the chest, in which the ball, entering between the
second and third ribs in front,  passed through the left lung, and
lodged under the scapula.  The patient lived upwards  of a year,
becoming very fat, and finally died of inflammation of the stom-
ach.  The left lung was  completely atrophied, not being larger
than a man's hand; the pleuritic cavity was intersected by dense
organized bands ; and the pericardium was every where adherent
to the  heart.  The ball,  composed of metal,  and weighing four
ounces and five grains,  was situated between the spinal column
and  the end of the fifth rib,  where it wTas  partially inclosed,
along with a  brass button, and a considerable quantity of dead
bone, by a thick membrane.
  Dr.  John  Mathews, of this  city,  who  was attached to Col.
Ormsby's regiment, and  who was present  at the battle of Buena
Vista,  has communicated to me some very singular facts respect-
ing gun-shot wounds.   After  the battle of Buena Vista he had
charge of a  hospital at Saltillo,  containing one hundred and ten
wounded Kentuckians.   Of these,  twenty-six were  shot  nearly
at the same  place, the ball entering the deltoid muscle,  ranging
upwards over the shoulder, and lodging in the neck and back,
from which it was afterwards extracted.  All these men did well,
and finally recovered.
  The  same  gentleman  has related to  me a case of gun-shot
wound  of the hip and  thigh,  attended  with  the  most firightful
laceration and contusion of the soft parts,  and followed  by com-
plete recovery.  The patient,  aged twenty-two, a private in the
2d Kentucky  regiment,  of good constitution,  had been eight
months in the service, when he was wounded by a ball.  He was
found  at night, on the battle field,  nearly speechless and  pulse-
less  and so  far exhausted that the surgeon who saw him in  this
plight  merely gave him  some brandy, and loosely bound up his
limb.   The  next  morning at day light  the man  was  put, along
with others, into a rough wagon, and hauled over the loose shingle
rock of the Sierra Madre, a distance of  five miles, to the hospi-
tal.  Dr. Mathews found him in the most miserable condition; the 
 I?"
 ™b4             TRANSACTIONS OF THE  KENTUCKY

 muscles of the right  hip and outer  and posterior part of the
 thigh,  as low down as the  popliteal space,  were almost entirely
 torn away,  the head of the thigh-bone denuded, and the pulsa-
 tion  of the  femoral  artery distinctly visible  on the inner side of
 the limb.   Desperate  as  the case seemed to be, an attempt was
 made to save the poor fellow without any more mutilation.  After
 cleansing the wound, and dissecting off the  dead parts, the band-
 age and cold water dressings were applied, and the man  was put
 upon stimulants  and a nourishing  diet.  A rapid improvement
 followed, and at the end of  three months he was so far recovered
 as to be able to return  to the United States, with a very good use
 of his limb.  I saw this patient several times after his arrival
 in Louisville, and a more remarkable recovery could  hardly be
 imagined.
   Dr. Mathews says that, much to his  surprise and gratification,
 not a single case of tetanus  supervened upon  the many frightful
 wounds occurring at the battle of Buena Vista.   At Monterey a
 few cases of erysipelas were witnessed  after  injuries of the scalp
 and lower extremities.  The same disease also made its  appear-
 ance  in camp from constitutional causes;  but  yielded readily to
 prompt and efficient treatment.
   It affords  me much pleasure to allude here, in connection with
the brief contribution of Surgeon Mathews,  to a paper " On the
Diseases of  the United States Army on the Rio Grande," by Dr.
William G. Proctor, who served in the Mexican war in the capac-
ity of hospital steward  to the Louisville Legion.   It is contained
in the Western Journal of Medicine and Surgery, for June, 1848,
and was originally presented, as an inaugural dissertation, to the
Trustees and Medical Faculty of the University of Louisville  for
the degree of Doctor of Medicine, in March, 1848.  It is by far
the most valuable and  instructive contribution  that has appeared
from  the pen of any  of the professional gentlemen who served in
M exico from this  State.
   In speaking of wounds, Dr. Proctor observes: " I am happy to say
that all ordinary wounds in sound constitutions  healed as prompt-
ly and kindly as could have been desired, though in broken down
and weak  constitutions I think there was probably more slough-
ing, and that convalescence  was not as speedy as it would  have 
                    STATE  MEDICAL  SOCIETY.                 43S-J

been under more favorable circumstances.  A fact which, he con-
tinues, I may as well notice here, is  the remarkable rapidity with
which  maggots were generated.  Wounds dressed one morning
were found on the succeeding morning to contain great numbers
of these animals.   If a dressing was allowed to remain on, or
great care was  not taken in cleansing the part, in forty-eight or
fifty-six hours they were found  collected in incredible quantities,
and of enormous size, frequently as large as  a small goose quill
and from three  to nine lines in  length.   They were productive of
no little pain from the irritation they produced in the parts, their
tendency to burrow between divided muscles, and the great horror
manifested by patients at their presence."  Dr. Proctor is inclined
to think that these  insects are of spontaneous origin, and he ad-
vances some very ingenious arguments in support of his opinion.
The  means which proved most destructive to them, were turpen-
tine, chloride of sodium or lime, and creasote.   The application,
however, of these substances, while it would generally kill one
growth, would not prevent the speedy generation of ano'.ner.
   Of twenty-three amputations, witnessed  by  Dr. Proctor,  in
Mexico, six were secondary, and of these  only one  was lost; the
others were primary, and  three were lost.  The most disagreea-
ble efiects which he noticed in  the secondary operations  were the
slower convalescence, and the greater drain upon the system.
   Dr. Proctor refers to the case of a volunteer in the  1st Missis-
sippi regiment, who recovered, after having refused to submit  to
amputation,  from a most violent wound of the knee,  destroying
the patella and a portion of the inner condyle of the thigh-bone,
and  causing  the most extensive exposure of the joint.  He also
mentions the case of a private in  the  1st Tennessee regiment,
who had a compound communicated fracture of the radius and ulna,
made by an escopet ball; his recovery was deemed almost impos-
sible •  he refused to have the limb cut off; and,  when Dr. Proc-
tor last saw  him, he had so far regained the  functions of his
hand as to be able to use it in eating, and washing his face. 
236             TRANSACTIONS OF THE KENTUCKY

        XVm.—SURGEONS AND PHYSICIANS OF LOUISVILLE.
  In drawing up this report, I have naturally felt some desire to
inquire into the past history of the medical profession of Louis-
ville; and, although this is a topic  which does not strictly fall
within the limits of the duties assigned to me by my associates;
yet I  hope that the brief sketch which I  am about to offer will
not be wholly devoid of interest,  or  regarded as  entirely irrele-
vant.   The materials have been kindly furnished me by my friend,
Dr. James C. Johnston, well known to us all as a most accomplished
gentleman, and as the head, for a number  of years, of the profes-
sion in this part of the State.
  Louisville was originally a  frontier post, and was not incorpo-
rated  as a city until 1780.  From this period to 1787,  the prac-
tice of medicine and surgery was confined to the surgeons of the
army, attached to the fortifications of  the West.  In this capacity,
Dr. Skinner, a native of Maryland,  was stationed at this place.
But little is known of him, beyond the fact that he was a highly
accomplished gentleman and physician, and  that he  served as
surgeon in the American revolution.  He was a man of great
popularity, and enjoyed  the confidence and good opinion of all
who were acquainted with him.
  Dr. Skinner was succeeded by Dr. Ellison and Dr. Carmichael,
both accomplished and experienced men in their profession, and
who had likewise served as surgeons in the Revolutionary army.
They left Louisville about the year 1787, and were succeeded by
men of less pretention and skill.   Among these were Dr. Richard
Jones Waters,; Dr. Elisha Lee Hall, Dr. Tate, and Dr.  O'Fallan.
Waters was a man of genius and cultivation, but hated  his pro-
fession, and, gentleman-like, practised only when he felt inclined;
he was intemperate, and finally fell a victim  to an ill-fated pas-
sion.  Hall and Tate had not regularly studied their profession,
and their fame extended only  to the cure of fever and  ague,
which was then, as well  as for a long  time afterwards, very rife
in Louisville.  Dr. O'Fallan was an old man when he settled here,
and survived only a few years.  He was the father of the  present
Col. O'Fallan, a very  wealthy and highly respectable  citizen of
St. Louis, and for many years an officer in the U. S. army. 
                    8TATE MEDICAL SOCIETY.

  Near the close of the last  century there appeared, all at once,
in the medical  horizon of Louisville, a galaxy of medical men,
all well educated, refined, and accomplished.   These gentlemen
were Drs. Watkins, Collins,  Gait, and Ferguson.  Watkins,  in a
short time, realized a fortune—whether by his practice, or some
other  means, I am not informed—and removed to Augusta, in
Georgia.   Dr. Collins  was a native of Massachusetts, and  was
educated at Harvard University.  He enjoyed,  it would seem, a
higher reputation  than any physician on this side of the Alle-
gheny mountains, and has been often represented  to me as a man
of real greatness.   He practised surgery  with uncommon  suc-
cess, and possessed, in an eminent degree,  the  confidence  and
regard of the community.  Dr. Collins fell a victim to consump-
tion in 1812.
  After the death of Collins, Drs. Gait and Ferguson held almost
undisputed sway in the profession, the members of which were
then comparatively few.  The surgical practice was done chiefly
by Dr. Ferguson, until about 1811, when  the  medical corps of
the city received a large and important accession in the persons
of Dr. James C. Johnston, Dr. John Croghan, Dr. George W. Smith
and Dr. Murray.  The first  two of these gentlemen were gradu-
ates of the University of Pennsylvania, the former having been
the private pupil of Dr. Chapman, and the latter of Dr. Rush.
Both were ambitious of high renown;  but fortune  spoiled their
fate, for  they had  not that impulsive power, necessity, to urge
them  on  in their career of usefulness and fame.  Croghan prac-
tised but a short time, and then retired to the country, where his
mansion  was for many years the seat of an elegant and refined
hospitality.  Few men, as many of the members of this Society
can testify,  ever did the honors of the table in a more graceful
and engaging manner.  Dr. Croghan was the brother of  Col.
Croghan, the intrepid defender of Fort Sandusky, in the last war
with  Great Britain.  He was the proprietor  of the Mammoth
Cave   which he sought, at one time, to convert into a place for
the accommodation  of consumptive  invalids.  His efforts, as is
well  known,  proved  a  signal failure.  Dr.  Croghan  died  of
phthisis,  at his  residence at Locust Grove, six miles from  this
city, in January, 1849.
•2ST 
•BiSr             TRANSACTIONS OF THE  KENTU0KY

  Dr. Johnston continued in the profession until 1835, enjoying
a high reputation as a gentleman, a scholar, and a practitioner,
and  performing  many  important surgical operations.  One  of
these operations has been already alluded to.  Although no longer
engaged in the strife and turmoil of the profession, Dr. Johnston
still  evinces the deepest interest in  its prosperity and advance-
ment.  Secure in the confidence of his friends and the commu-
nity, blessed with a noble, educated, and refined family,  and in
the possession of an ample fortune, long may he be spared to the
domestic circle, to Louisville, the scene of his early labors and of
his constant affection, and to Kentucky, for which he has  always
felt a Kentuckian's pride and a Kentuckian's regard.
  Dr. Murrv's health, at an early period, disqualified him  for the
arduous duties of the profession.  Grown prematurely  old,  he
yet lingers among us, like a venerable relic, happy in the confi-
dence of the community, and in the consciousness of a well-spent
life.  Dr. Smith still  practices his profession.  With a vigorous
constitution, and  a contented mind, he looks, as if, like the sturdy
oak of the forest, he might withstand many a storm, and out-live
many of his younger brethren.
  Of Dr. Gait, who may be emphatically  called the "beloved
physician,"'  I  fain would speak, but propriety forbids.  He still
survives, a noble link in the broken chain between the past and
the present.   No man,  in any walk  of life,  has ever  been more
universally respected; no physician, more honored and revered.
During a residence in Louisville of  twelve  years, I  have never
heard a breath or whisper of any kind  uttered against this excel-
lent, noble-hearted, and generous man.  In his intercourse  with
his professional brethren,  his conduct  was always regulated  by
the strictest principles of honor and integrity.  No  practitioner
was  ever more punctual  in  his engagements at a consultation;
none more frank and modest in the  expression of his views and
opinions.  His example in this respect, as well as in many others,
is worthy of the imitation of every member of the profession.  After
having borne  "the heat and burden of the day" for  upwards of
forty years, dispensing with a profuse and liberal hand the bless-
ings of his knowledge and his purse, he retired, a few years ago,
to his elegant country residence, where, in an atmosphere  redo- 
                            [193]

 lent with the fragrance of the rose and the lily, the product of
 his own taste and culture, he is spending the*evening of his life
 in the study and  contemplation of Nature and of Nature's God;
 a  befitting  close of  the career  of such  a man  and such  a
 physician.
   About the year 1822, so celebrated in our annals for its epide-
 mic fever, which  literally decimated our population, and steeped
 every family in the  deepest grief, several gentlemen of high pro-
 fessional pretensions  settled in Louisville.  Among these were
 Dr. Coleman  Rogers, Dr. Benjamin H. Hall, Dr. Gist, and Dr.
 Benjamin Tompkins,  the last three  of  whom are all  dead.
 Tompkins was a man of genius, a scholar, and  a thorough pro-
 ficient in his profession; and  although he fell a victim on  the
 altar of Bacchus, yet  he proudly contended, to the  last, for  the
 palm of precedence.  Hall was a native of Fredericksburg, Vir-
 ginia ; he was descended from a good family, was well educated,
 and was a good physician.  He died, some years ago, of cholera,
 in New Orleans, whither he had  gone, late in life, to repair his
 broken fortune.  He was fond  of  a pinch of snuff, a gold-headed
 cane, a fine coat,  a good dinner, and a  good anecdote.  Gist was
 a Kentuckian, and a man of genius, but without ambition.
   From the  preceding  facts and  observations it is evident that
 Kentucky surgery has neither been idle, inactive, nor stationary.
 When we reflect that scarcely eighty years have elapsed since  the
 adventurous Boone first planted  his foot  upon  the "dark and
 bloody"  ground, in pursuit of the deer,  the panther, and  of
 " elbow-room;" that our State is  hardly sixty years of age; and
 that less than three-quarters of a century have passed away since
 the first settlement of  the very spot upon which we are now as-
 sembled * we are struck with  wondeif and amazement at our
 achievements in this department of fche healing  art.  In origi-
 nality of conception and boldness of execution,  Kentucky sur-
gery may proudly challenge comparison with that of any of the
older States in the Un ion.   Its exploits in ovariotomy and lithotomy
alone are sufficient to entitle it to the highest rank in the annals
of American surgery.  The historian of Kentucky, in recounting
the services of her illustrious children, will not fail to enrich his
pao-es with an account  of the scientific achievements of her Mc-
         19 
                           [194 J
Dowell and her Dudley ;  he will assign them a distinguished po-
sition by the side of her statesmen, her jurists, and her warriors,
and he will pronounce them thrice-blessed, as benefactors of the
human race.   The operations of  these  distinguished  surgeons
are familiar to every scientific and enlightened physician in the
civilized world, and their names are just as much honored and
appreciated by their professional  brethren at home, as are those
of Clay and Crittenden by the American public at large.
  Looking at the past, may we not hope that the future career of
Kentucky surgery may be  equally prosperous and  happy ; that
the men who are now upon the field may rival the achievements
of those who have preceded them,  and   earn,  by their energy,
their skill, and their attainments, a  distinction  which, while it
shall immortalize their names, shall reflect imperishable lustre
upon their State and upon the age in which they  live.   Throwing
aside all  unworthy rivalry, all selfishness, and all  personal feel-
ing, let them strive to live  and to labor only for the glory of their
profession and the service of their fellow-men. 
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