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LECTURE,
INTRODUCTORY  TO THE COURSE
ANATOMY,
Jcfurson Ptbiral «o!Ujt of f Ijilaklptna,
DELIVERED OCTOBER 17, 1856,
JOSEPH PANCOAST, M. D
PublisfitU i>8 tfje <Cla0B.
           PHILADELPHIA:
       JOSEPH M. WILSON,
27 SOUTH TENTH STREKT, BELOW CHESTNUT STREET.
               1856. 
 
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LECTURE,
INTRODUCTORY TO THE COURSE
ANATOMY,
$ rift rs on: UUbual (SnIUge of |]j)ihklp[)m,
DELIVERED OCTOBER 17, 1856,
JOSEPH  PANCOAST, M. D.
ISttblisfjcU bg tfj* CJasa. /o^'
  ft, 9 9 fa
          PHILADELPHIA:
      JOSEPH M. WILSON,
SOUTH TENTH STREET, BELOW CHESTNUT STREET.
              1856. 
 
CORRESPONDENCE.
                                              Philada., Dec. 15, 185C.
   Dear Sir,—We the undersigned, members of the present class of the Jef-
 ferson Medical College, having heard with much pleasure and instruction,
 your very able  and eloquent Introductory  Lecture, do most respectfully and
 earnestly solicit a copy of the same for publication, feeling assured that it
 will be read by many with interest and profit.
   Hoping that it may meet your wishes to accede to our request, we remain,
 with sentiments of highest regard and esteem,
                              Very respectfully and truly,
                                     Your obedient servants,
                           Humphrey Peake,      Wm. Snodgrass,
                           J. Richmond, Jr.,       E. B. P. Kelly,
                           John S. Coleman,      James B.Delaplane,
                           Marcus P. Stephenson, H. Orton,
                                                      and others.
         Dr. Joseph Pancoast,
 Prof, of Anatomy, Jefferson Med. College, Phila.

                                                Phila., Dec. 17, 1856.
 To Messrs. H. Peake, J. Richmond, Jno. S. Coleman, and others.
   Gentlemen,—Your letter of  the  loth inst., soliciting  a copy of my intro-
 ductory lecture  for publication, has just reached me. Expressing, as it does,
 the wishes of so large a number of gentlemen in whose medical education I
 have the happiness  to assist, it scarcely leaves me at liberty to do otherwise
 than accede to their request.  I therefore  place the manuscript at your dis-
 posal, fearful only that the lecture which was hastily prepared, may be found
too discursive and sketchy in its  character, to  prove deserving of the  high
 honour bestowed upon it.
   Be pleased to accept, gentlemen, the assurance of my highest regard and
attachment.
                                                  Joseph Pancoast. 
 
INTRODUCTORY  LECTURE.
   In the bewitching tales of the far East, in the wild
dreams of some of the chivalrous discoverers of our own
land, and in the old Fabliau de  Cocaigne, we have fre-
quent allusions to
              La fontaine de Jovent.
              Que faict rejouvenir le  gent:
but unhappily the existence of a fountain of rejuvenes-
cence where the faded  beauty might  be enabled to re-
store her charms, or the  man of science to renew his
energies, has proved but a poet's dream.  It has long
been taught, however, and I believe truly, that the
nearest approach to its realization, is to be found in the
change of scene which travel produces.
   A voyage across the broad Atlantic itself is not with-
out its attractions, nor  unattended  by salutary impres-
sions.  The broad misty limitless horizon; the heaving
swell or  mighty wave  of the mid  ocean; the seeming
absence in  air or water of every living thing, save the
little world immediately around  you; the unrestrained
invigorating breezes, with  the  occasional distant sail
to remind yon that yours is not the only ship on that
wide expanse; the dreamy existence in which the hours
move so rapidly on; the newly awakened interest with
which  you  watch every sleeping cumulus of  clouds or
fleeting squall, give an undeniable and exquisite charm, 
[  6  ]
 to a short sojourn in one of the floating castles of indo-
 lence with which the ocean is bridged.
   One who, like myself, has for the first time visited
 those European lands, the homes of his progenitors,
 and the  themes of thought from early childhood, may
 probably fancy that he will there find something utterly
 new in the sky above him, in the land and in the birds
 and beasts which inhabit it, and the various peoples he
 will meet.  If so, he will probably be doomed  to some
 disappointment.  He might pass diagonally across Eng-
 land, and scarcely, for any striking change that he would
 observe,  fancy that he had gone more than  a  day's
 journey from  one of our large  cities.   He would see a
 smaller region, more fully crowded with fine  estates,
 noble mansions, and magnificent cities so thickly spread,
 that the whole land appears, as it really is, the central
 capital to half the world.   But he  sees the  same class
 of faces, and hears the same voices with which he has
 been familiar at home.
   If he passes into La Belle France, he  is prepared to
 find a change in the language and modes of life, but the
.features  of the country will be found the  same in a
 great degree, as he has seen in various parts of our own
 varied domain; save in the little hamlets, or clusters of
 thatched roof cottages, scattered broad-cast over the land
 between the larger cities, and the farm-steads reduced to
 almost infinitesimal minuteness.
  In sunny Italy, that land where  almost every thing
 but man is divine, in which he is taught to look for
 celestial glories in the skies, ethereal softness in the air,
 and cerulean colours in the wave, he will find  the dif-
 ference greatest, but yet only in degree.  The skies, save
 in a somewhat greater depth of blue,—"the  deep blue
 sky of Rome," the sunsets only in slightly deeper tints, 
[  7  ]
prolonged a little farther up the great arch of heaven,
are precisely those that we see so commonly in America
on a fine  Summer's eve, and our own beauteous lakes
will rival in  colour, not only the blue waters  of the
midland sea, but the deep azure sky itself, which is re-
flected upon them.
   He will not find here, as there, the pale poetic olive,
setting off picturesquely every hill or mountain steep,
vines that yield the  royal juices  trained in sweeping
festoons from tree to tree along  every  road-side, nor
the rice growing side  by side with  the indian corn, nor
the  madder by the wheat;  but all  these we have, or
ought to have, though more widely disseminated, in our
own extensive and varied clime, even to the orange and
the citron, and the fig, which there are but the products
of walled  enclosures.
   But in  that fair region, the traveller will suffer great-
ly from the molten summer sun  rarely  veiled with  a
cloud, from the perpetual dust about its great cities,
which fills the  avenues of sense,  and is  none  the less
disgusting from the  thought, that it .may possibly be
the  reliquiae  of the old Romans whose memories still
haunt every nook and corner of the land; will be hur-
ried from the  ruined  sites of former  glories by the de-
mon of malaria, tortured by the insects that infest, with
more than Roman obstinacy, forum and coliseum, bed-
chamber and church, be driven in summer by mosquitoes
from the Elysian fields of Virgil, and invaded with irre-
pressible thieves and  beggars on the resplendent slopes
of classic  Baias.
   The  peculiar and  beautiful scenery of Switzerland
will divide the palm with Italy,—made up as it is with
many a beauteous lake, and many an Alpine peak, with
intervening valleys here closed with mighty  glaciers 
[  8  ]
sloping for miles adown  the mountain-side, and there
vocal, with the mad streams which the glaciers feed, the
tinkling of the cow bells, and the lowing of the herds,
the dash of waterfalls, and the melancholy music of the
Alpine horn, to  all of which I have listened with rap-
ture, between the crash of avalanches falling from the
hoary peak of the Jungfrau.—But this is all.—The pa-
triotic cowherds of Morat  and Morgarten, and many an-
other field that rivals Spartan  story, have given place
to a population without nationality, without distinction
in literature and science,—a mingled race of French,
Germans, and Italians.
   If he  wanders through Bavaria, Saxony, Prussia, or
Germany, all occupied  by much the same people, de-
scendants from the old Teutonic stock, industrious and
frugal, living scarcely can it be said in the country, but
mostly massed in small villages, of which I could count
ninety from the walls of one town,* with their fertile
harvest  fields filling up all the spaces between, a people
much like what  we see in many parts of our  own land,
but imbibing there, with  their beer  and  tobacco, a sort
of passive philosophy that seems  to keep  them quiet,
and check the  spirit of constitutional freedom.—It is
necessary, howrever, to  make one grand exception  in
the case of Holland, that fountain place of national
liberty and republican government.   Here every thing
seems reversed;—the towns placed  below  the level
of the rivers; long  canals through  meadows in which
mighty ships are drawn by horses; ditches placed on the
tops of the banks into which the water is  lifted by wind-
mills; where the animals are driven up hill to water,
and the reedy canals are  so nearly on a level with the
tops of the houses that the frogs  might peep into the
                    * Nuremberg. 
[  9  ]
swallows' nests beneath the eaves; where there are towns
so fantastically neat, that neither horse nor wagon is
allowed to enter, and no one can smoke without a stop-
per to  his pipe, or  enter a house without  leaving his
sabots at the door; where the very cows wear petticoats
to protect them from the cold, are housed in winter in
the same  neat dwelling with their owners, their tails
at night—through motives of scrupulous cleanliness—
twitched up on pulleys; where sleds with greased run-
ners take the place of wagons in the streets, and where
the tongue of the carriage, which traverses their narrow
banks, has no connexion with the horses, but is turned
up short in front for the foot of the driver, who  guides
it with his heel.
   But in the great cities of Europe, the intelligent Ame-
rican will find much that to him is strange and inte-
resting.  The massive architectural structures, ancient
and modern;  those glorious old cathedrals, with flying
buttresses, and fretted  aisles, and  heaven-pointing
spires—Titanic creations of an age of deep feeling that
sent the famous crusades into the east—the grand libra-
ries, and the treasured miracles of art and science;—and
I envy not the man who  could return from a visit  to
the old world, without having  seen much  to admire,
and learned much to serve as models for imitation.
   The  objects.of my journey over the water have not
been purely professional.  I wished but to see the great
anatomists and surgeons a little nearer, to measure them
better, and at  the  same  time lead  for a little while a
life of somewhat greater ease than that to which I had
been accustomed.   But the old leaven was so  strong
that I found myself irresistibly drawn to the medical
colleges, museums,  and hospitals.   This has given me
an opportunity of  making some  observations,  and I 
[  io  ]
know that  you will expect  me to tell  you a little of
what.I have seen.  In doing  this I shall, as much as
possible,  avoid  making  personal  allusions to the dis-
tinguished members of our profession, who received me
with  great kindness and attention, for which  I think,
gentlemen, I must be indebted to you, as they had most
of them heard  that I had  long  been in the habit of
lecturing to one  of the largest classes, if not to the
largest single medical  class, in  the world.
  My attention has thus been in a good degree directed
to the collegiate institutions and hospitals, and  more
especially to the manner in which the two great branches
of Anatomy and  Surgery are there  taught,  with the
hope of rendering myself, by what  I might thus observe,
more  useful to  the classes in whose instruction I  have
the honour to assist.
  On as careful a comparison as  I could  make, it has
appeared to me, that  however excellent the European
system of medical instruction may  be  for their own
students  and their own people, the general  methods
pursued by the best appointed medical institutions of
this land are,  under all the peculiar circumstances of
the country, the best devised that we could adopt.
  If I might  be  allowed to speak  dispassionately,  I
should say, from all that I have seen abroad, that the
medical teachers of this country are at least entitled to
the great merit arising perhaps from the active compe-
tition of  schools which  have here in general  little ex-
ternal support, of devoting themselves energetically to
the rendering of  their courses not only lucid and well
illustrated, but attractive in manner  and form.  Many
of the most distinguished teachers abroad have seemed
to me to give their able lessons somewhat coldly; fur-
nishing their classes with the amplest opportunities to 
[  11  ]
 learn, but not inviting them to the effort with the deep
 personal interest which, in this country, we feel in the
 success of the class, whose prosperity and fortune make,
 as it were, a part of those of the institution from whence
 they proceed.
   The  students themselves assembled in classes, small
 when compared with ours, deported themselves in the
 lecture room like models of propriety, whether listening
 to the  dryest details, in uncomfortable amphitheatres,
 or to the quaint and sprightly lectures of Ricord beneath
 the lime trees of the hospital yard, rarely leaving  their
 places or in any  way embarrassing their instructors.
   The  complete separation of the profession in Great
 Britain into different branches is not, I think, an object
 for our imitation.  And, if  I am not greatly mistaken,
 the best minds among themselves not only regard it as
 an evil, but exhibit a growing desire to make one gene-
 ral degree of Doctor of Medicine, as I believe is the case
 in every other country, cover all the branches.
  The young surgeon, who  devotes himself exclusively
 to the one pursuit, must of necessity, in Europe, where
 the profession is  so  rich in distinguished  men,  wait a
 weary length of time before he can acquire profitable
 employment or position,—whilst with us he may  almost
 at once  engage in general practice, and the public with
 some reason expects, that he  shall obtain reputation
 as a medical practitioner, before he shall be believed,
 to the utmost degree, capable of managing the various
 complications, which surgical  maladies and  surgical
 operations add to the  more common affections.   The
 division of either of the branches of medicine and sur-
gery into specialities, a custom which has not been per-
haps without some advantages, is, I think, growing daily
less in vogue,—the profession coming round to the opi- 
                      [  12  ]
nion of Abernethy, that he who best qualifies himself
for all  the  offices of his  profession will be found best
prepared to  undertake any part, while the one who de-
votes his whole attention  but to an isolated portion, is
like a person attempting to survey an extensive pano-
rama through a chink.  In Great  Britain, indeed, the
surgeon of honourable rank, as with us, abhors speciali-
ties.   Continental surgery,, on  the  contrary,  except
in the hands of such men  as Velpeau, Jobert, and Nela-
ton, is divided into all manner of specialities.   It seems
to be a French peculiarity, and is exhibited ridiculously
enough, even out of the pale of the profession.
   In the Boulevart des Italiens, one of the most  beauti-
ful and  animated of the many charming streets of Paris,
between the habitations of a dentist and an aurist, over
stores whose single plate  glass windows  were  of the
size  of  an ordinary church door, I observed  in  large,
glittering, golden letters, these two signs,—speciality des
chemises, and specialite des jupons,—specialities of shirts
and specialities of petticoats.
   I found every where, in truth, some of the best ope-
rators on the eyes, and for calculus, among the general
surgeons.
   In respect to the methods of treating special and sur-
gical anatomy, I have observed but  little variation from
the custom in use  with us.   General  anatomy and his-
tology,  through the aid of the microscope  and the assis-
tance of fine injections, still  continue  to  be  favourite
pursuits in most of the great capitals of Europe.   I had
the pleasure of assisting  Professor Briicke, of Vienna,
and Gerlach, of  Hanover,  in some  minute  injections
made by their peculiar processes.   The  former threw
in, by the arteries, first, a solution of the ferrocyanide
of potassium, following it shortly after with  a solution 
[  13  ]
of the  sulphate of iron.   The preparation is  then
soaked  for  awhile  in water, taken  out, subsequently
dried to the consistence of cheese, and cut into thin
slices for the microscope.  Gerlach's injection is made
of carmine, dissolved by the aid of ammonia in water:
it runs very minutely, but is not translucent, and can
only be practised with advantage on an animal recently
killed.  Neither of these injecting  fluids ran by any
means so minutely as the ether and vermilion injec-
tions, introduced into use by Dr. Paul  B. Goddard, of
this city, and employed extensively by my  friend and
demonstrator, Dr. E. Wallace.
  That of  Professor Briicke had, however, this great
advantage, that it did not colour the surrounding  tis-
sues, and was  so translucent as to  admit readily the
underfalling light.   It ran  minutely enough to show
that, in the healthy state of the eye, the blood-vessels
do not  run over the cornea, but are reflected back on
the conjunctiva in loops, like minute mesenteric arches,
and that the formation of pannus or vascular cornea is
dependent  upon the morbid  extension  and  growth of
new  vessels from  these  loops,—a  simple  anatomical
fact, but which  the  skilful surgeon knows how to turn
to profit in the incisions which he makes for these affec-
tions, through  the  conjunctiva  at the  margin of the
cornea.
  The same distinguished gentleman wras engaged in
some  researches into the lymphatic fluid, which wras
obtained from  the  dog.   Two drachms of  laudanum
were thrown into a vein of one of its legs, which pro-
duced perfect stupefaction.  The skin of the neck was
then opened, and a  small metallic pipe introduced into
an absorbent vessel, from which an ounce of lymph was
in a little while collected.   This dog  moaned a little, 
                      [  14  ]
 but was nearly motionless;  while another was  moving
 about the room wistfully, and with a sort of semi-con-
 sciousness of the fact, that he was only waiting his turn.
   Pathological anatomy is taught in  Europe more ela-
 borately, perhaps, but much in manner as with us, both
 in the regular courses, and by the exhibition of recent
 preparations in  the cliniques and  hospitals.   In the
 great hospital at Vienna, where every one that dies, is
 by law, subject to pathological dissection, the examina-
 tion is conducted with the most thorough  and formal
 precision;  it is  under the  supervision of one, who
 having no concern in the treatment,  may be regarded
 as a calm and dispassionate observer, the world-renowned
 Prof. Rokitansky, the  most  experienced of living pa-
 thologists.
   There seemed  to me a dread formality in the manner
 in which the dissection, the same in all cases, was made,
 and the general  narrative of lesions noted  down, as if
 the form might overlay the essence, and  I could not at
 times refrain from putting a startling question, which
 seemed  to  me of some significance, in respect  to the
 exact lesion of which the patients had died.   Through
 the characteristic kindness of this distinguished patho-
logist, I assisted  several mornings in  succession at his
 examinations, and spent some hours with him in view-
ing his immense  and valuable pathological museum.
  I have seen, of course, in the surgery that I have wit-
nessed, much that was not new to me, and a good deal
that I thought not superior  to what is common to the
best practitioners among  us.  To  what I  have  seen,
strange and novel, I  shall have occasion to make fuller
mention during our winter cliniques.
  In the treatment of calculous, prostatic and analogous
diseases,  though  I have  sought  it diligently in Great 
                      C  15  ]
Britain, in the wards of Civiale, and others, in Paris,
in Vienna and Berlin, I have found little new to add to
our previous stock of information.
   In plastic surgery, of which I have witnessed a good
deal, the chief novelty I have observed has been an  im-
provement in the process of Von Ammon for the restora-
tion of the lower lid.  This consists in the excision of a
portion of the integument of the upper lid, to which the
edge  of  the  new lid is allowed  to form  a temporary
union, to keep itself smoothly extended, and at a proper
elevation.  The removal of hemorrhoidal tumours I have
seen many times successfully made by the skilful Jobert
de Lamballe, with Vienna paste within  a metallic cap-
sule placed to protect the  soft parts,—and by M. Chas-
saignac, with his new instrument entitled the ecraseur.
This singular  and very powerful machine, I shall show
you  in its last modification, in which  I believe it is
brought up to the highest degree of perfection of which
it is susceptible.  It divides, by a slow and continuous
pressure, all the parts embraced in the chain loop, and
has been  employed  by various surgeons,  not  only for
those affections, but for the removal of tumours of nearly
every description, including the  female breast, and it
is even said for  amputation  of the leg.    The slow,
bruising division  it  makes, is commonly  attended  by
little  or no hemorrhage, even when large vessels  are
cut.   In  the course of the session we shall be  enabled,
I trust, to form an estimate  of its value, which I  am
disposed to consider not yet fully determined.
   The resection of diseased bones, as an alternative in
cases  so commonly subjected to amputation, is one of
the most prominent features of modern surgery, and at-
tracted much of my attention.  In resection, especially of
the upper jaw, the surgeons of Paris employ the chain 
[  16  ]
saw very generally, in cases where, both in this country
and  Great Britain we have found  the strong cutting
forceps more convenient and expeditious.  I saw seve-
ral resections of the joints of the upper extremities in
carious  affections,  made  after the usual manner,  and
found the experienced members of the profession de-
cidedly favourable  to the practice in well selected cases.
In regard to that of the wrist joint, I am inclined to
believe it is with us too much neglected; for the preser-
vation of the use  of the  fingers, even  with a stiff  and
anchylosed joint, is a thousand fold more desirable than
the best substitute that has yet been produced.
  In reference to the resection of the knee joint, which
has been latterly so much practised in Europe, there is
the greatest difference of opinion.   Mr. Bowman, of
London, did me the great  kindness to take me with him
to an operation of this sort on a private patient, a young
woman of about twenty-five years of age, who was in all
respects a favourable subject for it.
  The joint was opened in the ordinary manner by two
longitudinal incisions on the sides, crossed in front by a
cut through the patellar tendon.   The  ligaments were
divided close  to the bones, and an inch and a half on
the side  of the femur,  and an  inch on that of  the
tibia, removed with the saw.   There was little  bleed-
ing, and few vessels required to be tied.   The wound was
lightly dressed, and the limb well supported in a splint.
  It  is  impossible that the operation could have been
better done.  On a subsequent visit, four months and a
half  afterwards, I was informed by Mr. Bowman, that
the case had not done well, no bony union having taken
place.
  Mr. Ferguson, at one of whose clinics I was present
by invitation, and who accompanied me  round the wards 
[  17   ]
of his  hospital, showed me two cases in which he had
operated, and both seemed doing well—one indeed was
cured,  firm anchylosis  having taken place, and the pa-
tient, by the aid of a  stick, was stalking freely about
the wards.   But he  has lost one patient out of seven,
and failed  in one  more to obtain bony union or pre-
serve a useful limb.   Mr. Stanley exhibited a case at St.
Bartholomew's, on which he had previously operated,
by  taking away a very thin slice only from the ends of
the femur  and tibia,.and the result seemed most un-
promising.
  Dr. \Yilts, of the new, magnificent Bethany  hospital
of  Berlin,  showed to  me two cases he  had operated
on, one of  which certainly could  be deemed perfectly
successful.
  Professor Langenbeck had five times performed the
operation,  and  lost, if I remember  rightly,  through
pyasmic fever, three cases out of the five—a result less
favourable  than  he had met with in amputation of the
hip-joint for gun-shot injuries.
  Professor Schuh of Berlin, had had about similar suc-
cess, and neither of  these great surgeons was  very fa-
vourably impressed with the policy  of the operation.
  The great professional weight of Mr. Lawrence, and
Sir B. C. Brodie, was thrown against it, believing, as the
former told me, that the cases most favourable for ex-
cision, were also those most appropriate for amputation.
I dwell, gentlemen, somewhat, even now, on this most
interesting  surgical topic, as it is one always of a ques-
tion between amputation and deformity, and the possi-
bility of a  cure, with  the preservation of the  natural
limb; and  you can  well conceive  how  thorough  the
knowledge of the surgeon ought to be, to enable him, in
such cases, to determine conscientiously and  rightly,
         2 
[  18  ]
which of the  alternatives ought to be urged upon  the
suffering patient.
  The greatest danger to be apprehended in these cases,
is the development of pyasmic fever.
  Have we any means by which we can protect the pa-
tient against the onset of this  fever, which is so surely
fatal?
  The fertile mind of Professor Simpson, of Edinburgh,
on account of the  good effect observed from renal pur-
gation in erysipelas  and puerperal  poisoning by  the
tincture of the chloride of iron, has suggested the use of
this article, for tw7o or three weeks prior to a severe surgical
operation, as a prophylactic against pyaemia, and I learned
from a respectable  Edinburgh surgeon,  who had made
some trials of it, that it had seemed to answer well.  Pro-
fessor Simpson is not a  general surgeon, but I have so
often, in the course of my life, received  most  valuable
surgical suggestions from similar great professional minds
not particularly devoted to that branch,  that I am dis-
posed to attach a value to the proposition.
  I had on another occasion an opportunity of witness-
ing,  at  St. Bartholomew's hospital, a most  interesting
surgical operation by Mr. Stanley, for the removal of a
piece of necrosed bone from the back part of the articu-
lar surface of the femur, in a partially anchylosed knee-
joint.
   The patient was a young woman, who, before puberty,
had suffered with a scrofulous affection of the knee, and,
in consequence, the limb was not developed like the other
either in length or thickness.  The  joint was fixed in
a slightly flexed position, with an ulcerated opening in
the ham discharging matter.
   A free incision was made upon one side of the joint,
cross cut  at the ends, so that flaps could be turned up 
[  19  ]■
to expose the bone, and a piece of dead bone about the
size of an almond was removed with the forceps.—With
the gouge  and forceps other suspicious portions were
taken away.
  Mr. Stanley remarked, that in all probability the re-
moval of the dead portion of bone alone, would have suf-
ficed, but in the uncertainty it was deemed best to make
the extirpation more thorough.   He mentioned, in sup-
port of this opinion, the case of  a gentleman who had
injured  his knee on. the field, at the day of the great
battle of Waterloo.   The joint  since that period had
been  subject to repeated inflammation and swelling, till
the consequent suffering began to tell upon the consti-
tution, so as to cause the gentleman to insist upon the re-
moval of the  limb.  Amputation was practised above
the  knee, and  recovery followed.  The joint was  not
disorganized, a dead piece of bone the size of a hazelnut,
was found  lying loose in the head of  the tibia, and this
excellent surgeon believed, if it had been removed with
the trephine, that the limb might have been saved.
   Besides  witnessing  some surgical  operations  by the
skilful  hand of Mr. Lawrence,  I accompanied,  several
times, that distinguished gentleman around his wards
at  St. Bartholomew, and must  call your attention to
one case, which I  trust the weight of so great  a name
will  cause you to remember.  It was a huge fungoid
tumour of the cheek in an old woman, which had closed
up the eye, rendering her hideous, and had for six years,
under mild treatment, remained about the same, and
would  not probably destroy her for  many more.  He
believed, if it had  been removed  by an  operation,  it
would not have been better for the patient.  A French
surgeon, to whom he showed the patient's tumour, pro-
 nounced it a fine  case for the extirpation of the upper 
[  20  ]
maxillary bone.  " So it is," said this wise surgeon, " but
suppose that it was your fate to suffer  such  a thing,
would  you have the operation done?"   "Ah," with a
shrug was the rejoinder: "that is quite another thing."
Here we observe a conscientious application of a test, that
it behooves surgeons in general to make, perhaps oftener
than they do.  We know too well, however, that there
is also  a risk of erring on the side which  seems at least
to be  the most humane, the surgeon sinning, at  times,
by allowing the  fatal ravages of a disease to  progress,
which  is susceptible of relief by  operation.
  The whole subject of the  treatment of cancerous tu-
mours  in  various parts of the body by extirpation  is
one of the  deepest  practical  interest.  I  saw them re-
moved, and especially cancers of the female breast, by
many of  the best surgeons of Europe, and was pleased
to find, as it so completely coincided with my own ex-
perience, that  the practice was to be regarded not only
as a mode  of alleviating suffering and prolonging  life,
but frequently as the means of effecting a radical cure.
  The excision  of the  nervous trunks of  the  two
maxillary branches of the 5th pair, in cases of tic dou-
loureux, I have for years abandoned through the failure
to effect permanent relief.   I am disposed, however,
from what  I have learned of the success  of Mr. Syme,
and especially of Professor  Schuh of Vienna, a high-
minded and  admirable surgeon, to take  the  subject
again into  deep  consideration.  The  thoroughness  of
the manner in which the latter gentleman makes the
extirpation, if it be practised at all, should be the model
for imitation; to wit, the opening up of the infraorbital
canal,  and the trephining of the ramus of  the lower jaw,
so as to reach a large  portion of the respective trunks.
  In  the  local neuralgic pains  occasionally met  with 
[  21  J
 in other parts, Professor Simpson  has  found, when the
 ordinary measures fail, perfect relief at times afforded
 by  the  injection under the skin of  twenty-eight  to
 thirty drops of the solution of bimeconate of morphia,
 with the instrument of Dr. Wood of Edinburgh.  The
 injection of  this anodyne,   is attended  temporarily
 with symptoms analogous to intoxication, rendering it
 difficult, I should  think, to determine  whether  the  re-
 lief arose  from the  local action  of  the  fluid, or  by
 its influence on the nervous centres.
   In respect to the treatment of fractures and disloca-
 tions, I  have observed little  new  wherewith to occupy
 you.  The long straight splint for fractures of the thigh,
 has justly  displaced, in most of the hospitals of Europe,
 the double inclined plane of Percival Pott,—there being
 in  London, as I learned from  Professor Paget, but a
 single hospital where the use of the latter, as the general
 rule, can be observed at  all.   Many of my professional
 brethren know the extreme dislike, that I have long en-
 tertained towards the clumsy fracture box so commonly
 in use, and which  I have not for years  employed in my
 private practice.   My objection to its use has been that
 the lower end of the fractured limb, solidly fixed in the
 box, could  not turn or descend or rise with the body;
 every restless twist, or delirious start, or automatic move-
 ment in  slumber,  causing a  grinding  of the fractured
 surfaces  together,  and a  consequent increase of inflam-
 mation and swelling  at  the  place of injury.   It was,
 therefore, with great  pleasure that  I  found Professor
 Paget and  others  supporting  the same views.   In the
 wards of the latter gentleman, I was shown a neat ap-
paratus, which seemed to fulfil well  the proper indica-
tion  of treatment.  It was a light box, in which the
limb was slung according to  the principles of Mayor,
and  its whole weight  suspended by cords  on  a wheel 
                      [  22  ]

moving freely up and down, with  the slightest motion
of the patient, on a little railroad at the top.   In many
parts of the continent, the immovable apparatus, now
made most usually with the gypsum bandage, seems, and
in some  cases, perhaps, where  it should not, to have
supplanted every other kind of splint in fractures of the
limbs.
  The somewhat novel subject of the removal of goitrous
cysts, by an enucleating operation, as practised by M.
Luigi Porta of Pavia, led me, in consequence of my having
twice followed his example with success, to inquire as to
the estimation in which it was held by the surgeons of
northern Italy.  I found opinions much divided on the
subject;  the risk of attendant hemorrhage being felt as
the principal objection.
  Goitrous  disease and  occasional cretinism,  we  see
even in  our land, not in our mountain valleys alone,
but  even in our large cities.   But Switzerland  and
Savoy  are especially their home, and the places for the
investigation of the various causes, which are supposed
to produce them.  Goitre and cretinism are not neces-
sarily conjoined in the same person, but they  are found
in the  same sort of subject, and in the same  localities,
and originate from some  deep common cause of nutri-
tive depravation, like scrofula.  You do not meet these
affections on the high hills of  Switzerland, where  the
bracing mountain air is redolent with the sweet Flora
of the  Alps.   I passed by Muraine, the highest city in
Europe, seated on a mountain slope, below and in front
of the lofty Jungfrau, and learned both from observation
and inquiry, that neither disease  had  ever  prevailed
among its native inhabitants.
   It is in the narrow valleys that they are  met with,
where small flats are withdrawn between the edges of 
[  23  ]
mountains that rise precipitately on either side.   Here
we find small habitations or chalets, with but one story,
and that half sunk in the sloping ground; with small
windows and imperfect ventilation; enclosing often with
the family a cow, an ass, and a pig; placed on the allu-
vial greensward, which is perpetually moistened by  the
mountain springs, and in  summer heated highly with
the reflection of the sun from the gray mountain-sides;
the inhabitants forced, from the stony character of  the
ground beneath the alluvion, to drink of the  streams
• that come from the dissolving  feet of the glaciers, which
I found always in the Tyrol, in the Bernese Oberland,
and about Mont Blanc, white, turbid and disagreeable
to the taste.  A small fenced garden, rejoicing in  a
patch of potatoes,  cabbages, and the field  pea, and  a
flitch of rusty bacon hanging beneath the eaves of their
log huts, convey an accurate  idea of the coarseness of
the  nutriment upon which these poor ignorant  inhabi-
tants are known to subsist.  Can one conceive any con-
dition of life better fitted for the production of cachexia,
 and general depravation  both of mind and body.  No
 wonder, then, that one meets so often, in those  solitary
 valleys, children seeming old far beyond their years,
 stunted in their growth, upset as it were, crooked-backed,
 bandy-legged, and pot-bellied; and, when they grow older,
 seen so often as grinning cretins by the road-side, some-
 times with and sometimes without, the goitrous decora-
 tion of the neck.
   I have had the pleasure of witnessing much ophth-
 thalmic surgery in various places  during my short so-
journ abroad, and especially  in the practice of  Messrs.
 Sichel,  Desmarres, Jager, and  Von  Graefa.   In  the
 diagnosis of the different internal diseases of the  eyeball,
 a considerable advance has been made by the use of the 
[  24  ]
 ophthalmoscope.   As  the eye is  an organ filled with
 transparent fluids, and provided with a window in front,
 it is somewhat surprising, that the idea of concentrating
 rays of light into its interior, so as to have a magnified
 view of the parts within, had not earlier been practised.
 The condition of  the lens, and of the vitreous humour,
 of the bulbus opticus, the choroid and  retina, can  be
 readily determined by practice with this  instrument.
  In the very important and delicate operation for the
 removal of hard cataract, there is nearly as great a di-
 versity in regard to the mode, among the surgeons abroad;
 as with us.   I have seen  cases couched as the general
 rule in Italy, after the old manner of Scarpa; couched, but
 much more frequently extracted in Paris; both reclined
 and extracted in Vienna;  and, as the ordinary rule, ex-
 tracted in Berlin and Great Britain—and, according  to
 the statements given, with about equal success in all.
  Soft cataracts are treated commonly, as with us, by
division with the needle, introduced by the  sclerotic
 coat or the cornea.   But  in cases where the soft cata-
ract is without a hardened nucleus,Von Graefe, of Berlin,
 and Desmarres of Paris, resort frequently to the method
 of linear extraction.  This consists in making a good-sized
 puncture into the cornea, rupturing  the capsule, and
 with a gentle pressure of the finger upon the lid, forcing
 the fluid lens out through the corneal cut.   Indeed the
 choice  of the surgeon as to the form of operation, seemed
 in many cases to depend  upon the peculiar dexterity
with which he could  perform  the one  or  the  other.
 And those  who were  equally  dexterous with  all,  as
 every ophthalmologist should be, wisely in cases of hard
 cataract displaced or extracted according to the age  of
 patient, the size of the anterior chamber and the  promi-
 nence of the ball, finding that it requires fully as much 
[  25  ]
skill to couch or displace a cataract in the best manner
as to extract it.  After some inquiry as to the results of
these different modes of operation, I have returned none
the less confident, that the new operation for the removal
of firm cataract by lateral displacement, such as I have
practised  largely in private, and exhibited here to my
class  for  many  years,  has in  its results nothing  to
lose by comparison.   In the division of the cornea by
the upper section, the one now mainly practised in ex-
traction, Desmarres cuts a small flap at  the same time
out of the  conjunctiva,  a plan pursued likewise by
Alexander,  of London, and Riberi, of Turin.
   The very ready union which  ensues between the
divided portions of the conjunctiva, is said to  facilitate
greatly the  healing of the corneal  section, and the con-
sequent preservation of  the ball.   Since  my return I
have four times tested this method in my practice, and
found  it to answer well.
   There is,  as you know, an ugly  eversion and promi-
nence of the ball of the eye, sometimes consequent upon
a  badly performed operation  for ordinary strabismus.
This I have often succeeded in relieving by the opera-
tion of Dieffenbach, cutting the tendons on the side  of
the eversion, and fastening a thread upon its stump, by
which the ball could be held firmly drawn  inwards.
Von Graefe in addition to this, divides the internal rectus
and dissects it loose from its sheath, so  that it may ac-
quire a new  attachment, more in advance upon the ball.
   In the blepharospasmus of children, attendant  upon
scrofulous ophthalmia, the same distinguished gentle-
man produces a voluntary opening of the lids by a new
baptizing process.  Many a little tottling manakin have
I seen marching up  to his knees, his teeth gritted to-
gether, and  his eyelids closed with a will that  lifted up 
[  26  ]
his cheeks in lumps, and which, by the ordinary methods,
would have required much force  to separate.   Little
time was wasted with them.   An attendant lifted them
up at once by the feet, and immersed the entire face for
a few moments in a large  basin of cold water.   One
baptism frequently sufficed; seldom more than two or
three were required, to cause their voluntary opening.
If at a subsequent visit the little fellows  again  proved
contumacious,  the movement of a finger towards  the
baptismal font, would make their  eyes open as with a
spring.
  The operation  for artificial pupil, which we know,
when properly done, the eye bears with comparative
impunity, I have  seen practised under somewhat novel
indications—where there was no obliteration of the pu-
pillary orifice—so as to extend it laterally,  and form a
coloboina, or cat's pupil.  To wit, where a firm secondary
cataract had  occluded one half of the pupil, and  the
patient was  unable to remain in the hospital; where
there was a chronic inflammation of the choroid  and
the iris, which it  was said to alleviate by diminishing
the internal tension of the ball, and in cases of atrophy
of the globe, in which it was  alleged the operation gave
a new impulse to  the nutrition of the organ, by which
its form became restored.  In regard to the proper value
of these  rules for operation, I  am scarcely  prepared
to form an opinion.   They  are, however,  entitled to
most respectful consideration, as  the conclusions delibe-
rately formed by M. Von Graefe, a gentleman inheriting
one of the grandest names in surgery, young,  rich,  and
prepossessing, yet devoting himself, to the almost total
exclusion  of pleasure and amusement, with  so much
earnestness, intelligence, and success, to the aecumula- 
                      [   27  ]
tion of experience in his profession, that I would gladly
hold him up to you as a bright example  for imitation.
  I might, gentlemen, with pleasure to myself, were time
allowed, occupy you much longer with the narrative of
my observations, but I refrain partly on that account,
and partly from the fact that I shall have, in the course
of the session, ample time for that purpose.
   Throughout Europe I  found  the use of anaesthetic
agents, that  great blessing to the suffering, for which
the old world acknowledges its indebtedness to the new,
almost universal  among surgeons, and in operations of
every grade.   The employment of sulphuric ether, after
our own free  method, seemed  but little understood;
chloroform was the agent generally employed, partly
because it is supposed  to act  with greater rapidity, and
partly from  the  fact that the person of the surgeon
escaped the  disagreeable impregnation which ether
leaves.  It  was not, as it appeared to  me, however,
given in all places with that thorough assurance of im-
punity, that I had been led to expect.  Surgeons usually
administered it with their own hands,  and I saw many
operations performed,  where the more powerful agent
was not allowed to produce the thorough anaesthetic
effect  that we always obtain, by a  liberal use of the
fresh washed sulphuric  ether.  In London  and Edin-
burgh  I found it, however,  employed with  the  fullest
freedom, the  patients  not only being  kept thoroughly
under its influence during the operation, but sent out of
the amphitheatre subsequently,  with  the pulse  feeble,
lips and countenance pale, and the bead swinging life-
lessly like that of a drowned  person.  No apprehensions
seemed to be felt, and the resuscitation was confided to
the care of  the dressers and  nurses.
   The  patients  were, I  understood, sometimes  half  a 
[  28  ]
 da}' in recovering from its effects, less inclined to vomit,
 than in  cases where ether had been administered, but,
 if they did, got over the effects more spieedily.  It was
 usually  administered in two  drachm  doses  at a time,
 on a napkin held a little above the level of the mouth,
 to allow for the  gravitation of the heavy fluid, and  at
 sufficient distance to admit a free admixture  of the air.
   I saw it,  however, administered frequently by Dr.
 Snow of London, a  gentleman who has written much
 and ably upon the subject, by the aid of a metallic box
 supplied with a valve, very analogous in form to the
 instrument formerly employed in this city in the exhi-
 bition of sulphuric  ether.  This gentleman, who ad-
 ministers it for many other surgeons, told  me that he
 had had one fatality in many  thousand cases.
   There have, however, in all Great Britain, where it
 has been given some million of times, been,  it is said,
 about 70 cases of death attributed to it, and  I met in
 London,  with some  prominent surgeons, who, in  view
 of the greater, nay, entire safety of  the ether, were dis-
 posed  to coincide with me in  a preference  for that ar-
 ticle.
  So  far as I could observe,  there was not  any very
 marked difference between the amount of mental ex-
 citement, and convulsive  spasms of the  limbs, caused
 by the two anaesthetics—the  chloroform, occasionally
 producing its effects, in a shorter time than is required
 for the ether.
  The strongest advocate of the employment of chloro-
 form is the ingenious deviser of it, Professor  Simpson,
 of Edinburgh, who has employed it more frequently
than any other physician, and  he says without a single
casualty.  This may probably be owing not exclusively
to the skill of  the administrator, but in part to the pu- 
                      [  29  ]
rity of the article, which is made there, as I observed
on inspecting the place of its manufacture, with great
care, and is believed to be entirely free of any poisonous
element.   If you could  have heard this eloquent gen-
tleman discourse upon  the  subject,  however strong
might have been your  previous  prejudices against it,
and if you were sure of obtaining the same pure article,
you might, like me, have been disposed to reconsider the
subject of its employment.
   He has administered it, as we have here the ether, suc-
cessfully in infantile convulsions, keeping  children from
five to six weeks old, for a fortnight, more  or less under
its influence; and gave  to a lady of rank, while in the
puerperal  condition, at whose house I  made  a visit in
his company, one hundred ounces of chloroform in the
course of  thirteen hours, with the effect  of preventing
the agonizing spasms, which she had suffered in previous
labours.
   Gentlemen, in my visit abroad, I  have missed many of
the great names with which  I have long had mental as-
sociation,  and  have been strongly impressed with the
loss the world suffers when a great luminary in science
is extinguished.
   In Berlin, the places  of the elder Graefe and Dieffen-
bach  yet remain in some respects  a void.   In Paris, of
the recent galaxy of great surgeons, Boyer, Larrey, Du-
puytren and Roux, Velpeau alone remains, his full head
of hair silvered with the touch of time, his steps short-
ened  and  inelastic, but yet firm, with an eye undimmed,
and mind retaining all its wonted vigour, like an old war-
rior  conscious of a  long and victorious career, waiting
manfully with  harness on, for its close.  In Great Britain
Mr. Guthrie had just died, and of the historical names of
British Surgery, which  you have  so often heard men- 
                       [  30  ]
 tioned with reverence from this place, we have yet re-
 maining Mr. William Lawrence, in his  youth a house
 pupil of Abernethy, a surgeon, active, elegant, learned
 and wise, and  that urbane gentleman, the distinguished
 anatomist, physiologist and  surgeon, Sir  Benjamin Col-
 lins  Brodie, who  has not written a page, that does not
 bear the  impress of  sincerity  and  truth, or uttered  an
 opinion that is not entitled to the  most  respectful con-
 sideration.
   We  may justly feel a pride in a profession, which
 possesses such  intrinsic power to interest and charm, as
 to leave in gentlemen of this stamp, after  the realization
 of  every hope, that a laudable ambition could form,  an
 abiding active  affection for it.
   May they long  live, to dispense  their wisdom hived
 in  many a studious  year,  honouring  the  profession,
 which they have contributed so much to improve and
 adorn.   The sacredness of private  intercourse forbids
 that I should tell you of the professional zeal and ac-
 tivity which the latter gentleman has allowed me to wit-
 ness, or of the surgical wisdom that  flowed from his lips.
 1 cannot perhaps do better than close this lecture, with
 his words of counsel, addressed to a young graduate  of
 our college, who like myself was a recipient of repeated
 kindnesses at  his hands.   "If you wish, my young
 friend," said he, "to give breadth to your medical con-
 ceptions, and confidence to your hand, if you wish, in-
 deed, to make yourself a great surgeon, let me say to you,
 as I would to all with whom I have influence, never for
 a moment cease the cultivation of Anatomical Science."
  What  can I  say to enforce more vividly this wise
 counsel.   It  has been the ladder by which he and  so
many others  have reached their elevation.   The  same
means of ascent are open to  you all.  To inspire  you
with a steady spirit to mount its steps, to aid and  to 
[  31  ]
cheer you in the ascension, shall be my aim and my ef-
fort; and to see you all, or even many of you, progress
to the highest round, that  has  yet  been reached, ay, or
as may possibly follow, even to surpass us all, would be
to me and to every one of my colleagues a source of the
deepest pride and gratification.