The principles of surgery : clinical, medical, and operative an original analysis of pathology systematically conducted, and a critical exposition of its guidance, at the bedside and in operations ...

Front matter

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THE

CLINICAL, MEDICAL, AND OPERATIYE.

Preface

life, is shown to give birth to Principles, and of the earliest and most exact standard, in each of the aforesaid Departments of Surgery.

Until recently. Pathological Anatomy stood alone, as mere Morbid Anatomy, dead among the Sciences. Is its Power yet understood ?

The Principles thence derived impart a Preventive and Conservative character to the Practice of Surgery, — as also explained in the " Introduction," — extending to that of Medicine. Conservatism — as therein defined — presupposes the existence and operation of, what may be. aptly named, an iimate Restorative Power, — manifested by the natural course and tendency of injuries and diseases, individually, to, or towards, recovery. This also is a branch of Pathological knowledge only just dawning on Rational Medicine, and which I have endeavoured to develope as another prominent feature of these Principles. But does Pathology impart the Conservative character to our proceedings during Surgical Operations? Assuredly, if not obviously, it does this also.

The Operations of Surgery were formerly regarded as purely Anatomical performances. The " System of Operative Surgery, founded on the basis of Anatomy," by Sir Charles Bell, was a type of the period to which I refer. At length the influence of diseased and living conditions became apparent, and, like a dissolving view, the purely Anatomical era passed away, and the Pathological epoch began. Slowly, as out of a mist, the Pathological Man, clad in the tattered garb of disease, approached, and crept by stealth into the Anatomical theatre. The teaching of the Schools and their books on Operative Surgery thenceforth underwent some improvement, and advanced somewhat nearer to the requirements of the Practical Surgeon.

Still, however, freighted with relics and mummeries of the dissecting-room, these works abounded with details of the purely Anatomical method, and were garnished, not to say adorned, with pictures that bespoke their antiquated origin. The rude designs

PREFACE.

vii of the Gothic style were visible beneath the faciugs of the modern building ; and in the construction of even the most recent manuals of Practical Surgery in this country, the basis is, I conceive, too purely Anatomical.

The alliance of ' Surgical Operations' with a series of ' Dissections' is scarcely less unnatural than would be a marriage of the living with the dead ; and as ill-assorted is the association of dissecting instruments with surgical armamentaria. Yet such are the unavoidable inconsistencies that the Anatomical method would impose upon us.

Books of the class to which 1 allude would be less inconsistent were they intended solely for the use of those who may require to gain a mechanical knowledge of Operative Surgery, so far as this can be learnt in the dissecting-room, by handling instruments, making incisions of various shapes, and performing other simple mechanical operations on parts presenting their healthy relations to each other, and bereft of their living appearances and conditions ; but the guidance of (pure) Anatomy acquires a positively fatal tendency when practices on the dead subject, and matured perchance in the dissecting-room, are imported into Surgical works, and are ostensibly converted into (Surgical) Operations on parts in a diseased state, aud as found in living patients.

This evil inclination to the guidance of Anatomy alone is gradually eradicated, and the application of Pathology during Surgical Operations and manipulations acquired, by repeated observation of the peculiar relative position, physical properties, and living conditions presented by textures and parts, as successively seen and felt during Surgical operations, and not as they are exposed by dissection in the dead subject. True it is, that certain exceptional operations — e.g., amputations and the ligature of ■ arteries for aneurism — are executed at a distance more or less remote from the diseased or injured part ; but even such operations have been fashioned too much after the dead model — an error as grave as were a sculptor to presume to chisel the proportions of the living body by glances at a dead subject. In short — viii

PREFACE.

to conceive another metaphor — Surgical Operations, learnt from practice on the dead subject, are as if an artist M'erc to study a landscape in the winter, when the outlines only of the face of Nature are seen : the fulness of verdure is wanting to completely realize the picture ; every ice-boutid form appears stiff and lifeless, aud every rivulet is still ; while the order and regularity of healthy forms and arrangement of parts, as contrasted with the disorder and disorganization wrought by disease or inflicted by injury, is as if this same landscape — lifeless — presented the normal undulations of hill and dale, instead of the chaotic disarrangement of relative position, &c., left by an earthquake.

The overshadowing influence of living conditions in all cases ; and their combination, in most Surgical operations, with morbid conditions of relative position of parts, and physical properties of the textures concerned, — are indeed modifying, if not effacing characters, which correct the purely Anatomical impressions of the Student, and can alone safely guide the Operating Surgeon.

Now this Pathological method of operating represents the least amount only, no less than the kind, of instrumental and manipulative proceedings necessary ; and thus fulfils the Conservative character during Surgical operations.

If, then, the Practice of Surgery (as an Art) be guided, regulated, and determined by Pathology ; the Principles which collectively express this Guiding Power, in the preparatory aud absolutely essential knowledge of Diagnosis, Etiology, aud Prognosis, tend — especially by virtue of their earliness and exactitude — to elevate Surgery (and Medicine, unitedly,) to the rank and dignity of a Science.

Such being the design of this work, its Educationally distinctive purpose is obvious.

While, however, professing to discover and inculcate Principles, properly so called; the Logical processes of Analysis, Comparison, Induction, and Generalization, by which they are discovered, exhibit the course of all Physical Investigation, — the

PREFACE.

ix very root of Medical Education, in contrast with that of the present system of Medical Teaching and competitive Examination, — i.e., the cultivation of only one faculty of the mind, that of memory, and perhaps also the power of observation. The faculties which are peculiarly elicited and strengthened by the process of Physical Investigation, are overlooked ; or if their cultivation be ostensibly provided for, by virtue of such branches of knowledge as Comparative Anatomy, Botany, &c., those mental faculties may be equally well educated and trained by the systematic acquisition — otherwise by memory alone — of Medicine and. Surgery ; more time being thus gained for Clinical observation ; on the one hand, without prolonging the duration of Medical Education ; on the other, without unnecessarily extending the boundary of such Education, — thus relieving the high-pressure work now imposed on Students in Medicine.

Moreover, this philosophic view of Medicine would no less tend to form that Scientific character of mind, which is itself the almost distinctive prerogative of the Medical Profession. And now perhaps, more than ever, this distinction should be cherished, to regulate the otherwise profligate, as well as prolific, propagation of ' Special' branches of Practice, and to nourish their otherwise sickly growth, when dismembered from the parent trunk of Medicine.

I am, indeed, not without hope that this innovation will supply a systematic course of Discipline for the investigation of Medicine as a Science ; while, as the Principles of Surgery (and of Medicine unitedly), it will prove also a faithful Guide to the Student and Practitioner.

F. J. Gant.

Having so frequently had occasion to consult original works and monographs on Pathology and Surgery, in the valuable library of the Royal College of Surgeons, I gladly avail myself

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PREFACE.

of this opportunity to publicly express my acknowledgments to Mr. Chatto, the Librarian, for aiding me with his extensive bibliographic knowledge, and for his obliging attention during a series of years.

The drawings from which the wood-engravings in this work were chiselled are from the pencil of Mr. Walter G. Searson. They cannot fail to extend his repute as an Anatomical and Microscopic Draughtsman. No less will the engravings themselves, by Mr. Hart, assuredly sustain his already well-known and deservedly-high reputation.

PEOSPECTUS OF CONTENTS.

THE PEINCIPLES OF SUEGERY.

Introduction, (p. 1 — 18.)

Historical Review of Medicine and Surgery — Origin of Pathological Surgery — The distinctive foundation and object of this "Work — Principles are attained by the analysis of General Pathology, and are coextensive with all Diagnosis — Etiology, respecting internal causes and their operation — Prognosis and Therapeutics : such Principles are earliest and most exact : their Preventive and Conservative character explained ; they extend to Medicine, and tend to elevate Medicine and Surgery unitedly to the rank of a Science ; wliile, by their character, they are eminently Practical.

The Elements of Pathological Anatomy ; being the foundation of the Principles advanced in this Work, are systematically described — The author's Tabular view of General Pathology, (p. 19 — 142.)

PATHOLOGICAL SUEGEEY.

THE PRINCIPLES OF CLINICAL SUUGEllT, OB- THOSE OF DIAGNOSIS, ETIOLOGY, AND PROGNOSIS.

The Surgeon at the bedside — The Preliminary Questions to be determined on behalf of Diagnosis — Etiology, respecting internal causes and their operation ; and Prognosis — Their Pathological character, and mutual relation to rational Therapeutics — The earliest and most exact solution of the Questions alluded to, and the establishment of corresponding Principles, in each of these Departments of Surgery, by the Analysis of Pathology, will become apparent in the course of this Work— The immediate bearing of these Pathological

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XII PROSPECTUS.

Principles on the Preventive and Conservative Practice of Medicine and Surgery re-explained and enforced.

The Analytical Method of Investigation explained by reference to the Principles of Diagnosis.

THE PEINCIPLES OF DIAGNOSIS,

OR OF THE ' earliest' AND ' MOST EXACT* DETECTION AND DISCRIMINATION OF THE STRUCTURAL CONDITION, SITUATION, AND EXTENT OF DISEASES AND INJURIES.

NEGATIVE PRINCIPLES.

Anatomy and Physiology are severally incompetent Guides to an Early and Exact Diagnosis :

This Principle illustrated by the Diagnosis of Wounds, and by that of Burns,

Pathology — Functional Disturbances only — is an insufficient guide to an early and exact Diagnosis.

Eunctional Disturbance does not invariably accompany, and does not at the earliest period accompany, injury or local disease; and the same disturbance of Function is no measure of the structural lesion existing, may also accompany the same injury or disease simultaneously in different parts of the body, or may accompany very different kinds of injury or disease. Eunctional conditions, therefore, are only symptoms — i.e., casual coincidences, and not exact signs of morbid conditions.

This negative Principle illustrated by the Diagnosis of Injuries of Mechanism — e.g., fractures, aneurisms, dislocations, respectively; also by Diseases of Nutrition — e.g.. Inflammation of internal parts, as strangulated herniai and ileus ; tumours of various kinds ; and degenerations of textural structure.

^POSITIVE PEINCIPLES.

Patliological Anatomy advanced as the Guide, during life, to the earliest and most exact Diagnosis.

PROSPECTUS.

xiii

The Diagnostic value of this fundamental Principle illustrated by the diagnosis of the several varieties of Fracture and Aneurism, respectively.

PATHOLOGICAL ANATOMY APPLIED DHBING LIFE TO SUPPLY THE EARLIEST AND MOST EXACT DIAGNOSIS.

The Diagnostic value of Clinical-Pathological Anatomy illustrated by the Diagnosis of the varieties of Dislocation.

CLINICAL PATHOLOGICAL ANATOMY, AND ITS DIAGNOSTIC GUIDANCE.

Pathological Anatomy applied during Life, through Physical Signs, to supply

the earliest and most exact method of Diagnosis. The value of Physical Diagnosis illustrated by the Diagnosis of Morbid Products

of Nutrition — e.g., Eatty Tumours, Cysts, and Cystic Tumours, respectively.

The insufficiency of Physical Signs as a Guide to the earliest and most exact Diagnosis.

Physical Properties are most readily recognised during life at the earliest period of disease (or injury) ; and, therefore, at a time when the morbid condition itself is least complicated, and most remediable by the simplest measures ; but such properties are nevertheless most equivocal (or inexact) signs of disease. Unaided Physical Diagnosis therefore fails in the practice of Medicine and Surgery.

This general Principle illustrated by the diagnosis of Morbid Products of Nutrition, as, quasi-malignant varieties of non-malignant Growths — e.g., recurring-fibroid and fibro-nucleated Tumours, respectively.

the diagnostic guidance of clinical pathological anatomy

(continued).

The application of Pathological Anatomy during life (continued) by Structural characters ; and the superior value of their guidance to supply the earliest and most exact Diagnosis, xiv

PROSPECTUS.

Clianges of minute Structure can be detected at the earliest period, during life, by puncturing Growths and Deposits (situated near the surface of the body), and examining with the microscope these and all other Morbid Products found in Discharges and Secretions issuing from internal parts and organs.

Moreover, the alterations of Structure thus detected are more constant, in any given case, than alterations of Physical Properties, and are tlierefore more exact signs of the morbid condition in question ; and being also discoverable at the earliest period, — before the supervention of complications, — are thereby best adapted to supply the chief Method of Diagnosis, whenever such minute alterations of Structure are available.

The value of this general Principle illustrated by the earliest and most exact Diagnosis of Morbid Products of Nutrition, as Growths and tlieir respective varieties ; e.g., Pibrous Tumours — including the fibro-nucleated and recurring-fibroid varieties : Cartilaginous Tumours — including the myeloid and recurring varieties ; Cancer — encephaloid, scirrlms, and colloid.

The Law of Structural Retrogression applied.

the diagnostic guidance of clinical pathological anatomy

(concluded).

The application of Pathological Anatomy during life (concluded) by Chemical conditions.

The potential value of Chemical Pathology, to supply the earliest and most exact Diagnosis.

Alterations of Chemical Composition are, indeed, the most essential condition of Disease, but also the least readily detected and identified. This general Principle illustrated by Deposits of lymph, — forming false tissues, pus, tuberculous or scrofulous matter; and by the present state of Pathological Chemistry in general.

The practical incompetency of Chemical Analysis to supply the earliest and most exact Diagnosis; illustrated by the Diagnosis of several kinds of Biooddiseases — ' Scurvy ; symmetrical diseases, and diseases having seats of election.

The present value of Chemical Analysis to supply the earliest and most exact Diagnosis, illustrated by the diagnosis of certain Blood-diseases— e.^.. Cholera, Gout, and Rheumatism.

PHOSPECTUS.

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THE PEINCIPLES OF ETIOLOGY,

OB OF THE 'EABXIEST' AND ' MOST EXACX' DETECTION AND DISCEIMINATION DURING LIFE OP THE CAUSES OP DISEASES AND INJUMES, INDIVIDUALLY AND OP THE OPERATION OF SUCH CAUSES.

The causes of injuries and diseases are •external' or 'internal;* and either may be predisposing or immediate in their operation.

lutemal causes are ' local' or ' constitutional' morbid conditions.

The earliest and most exact Etiological knowledge respecting the operation of internal causes can be concluded ouly by special Clinical observation of their Functional manifestations ; but such knowledge implies the previous detection and identification of these causes, and a prior Diagnosis therefore of similar quality.

Hence the guidance of Clinical Pathological Anatomy to Etiology in respect of 'internal' causes.

Pathological Anatomy being the guide to the earliest and most exact detection and discrimination, during life, of Diseases and Injuries, respectively, suggests the Principle of Prevention in the Practice of Medicine and Surgery.

LOCAL MAT PROCEED PROM CONSTITUTIONAL MORBID CONDITIONS.

This general Principle of Etiology illustrated by the manifestations of Blood-diseases in their appropriate ' textures.'

1. In many textures — ^Pervading Blood-diseases — Syphilis, Scrofula, Scurvy,

Purpura. Growths — malignant. Degenerations.

2. In special textures.

Skin, Mucous Membranes, or both.

Pevers — Non-infectious: Inflammatory, hectic, gangrenous typhoid. Infectious : eruptive (exanthematous), typhus, typhoid, relapsing, measles, scarlatina, small-pox, chicken-pox, erysipelas, plague. Mucous Membranes.

Diseases, infectious — Hooping-cough, Influenza, Cholera (Asiatic). Cellular texture — Subcutaneous.

Cellulitis, Carbuncle, Boil.

Pibrous textures and Synovial Membranes.

Bheumatism, Gout.

The Pathological Principles which guide the Preventive view of these Diseases.

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PROSPECTUS.

Chemical Pathology applied to determine how far it is possible, in the present state of knowledge, to more early and exactly detect and discriminate these Blood-diseases, so as to prevent their local manifestations, by Rational Preventive measures, more appropriate and effectualthan those which Experience alone may have suggested.

Pathological Anatomy of these local manifestations applied to more early and exactly detect and discriminate the Blood-diseases from which they respectively proceed, so as to prevent those of infectious origin being propagated.

Preventive Measures.

Local may proceed from Constitutional morbid conditions; concluded by Injuries and Diseases of the Central Nervous System, in relation to disorder of the Heart and circulation ; the Lungs and respiration ; the Chylopoietic viscera and the process of digestion ; the Organs of Excretion — kidneys and bladder, skin — and the functions severally of these organs ; diseases of Nutrition ; organs of Reproduction and their functional derangements.

CONSTITUTIONAL MAY PEOCEED FROM LOCAl MORBID CONDITIONS.

This general Principle of Etiology, and the Principle of Prevention also, in a measure, illustrated by Injuries of Mechanism, and their constitutional effects — Shock (collapse, prostration). Reaction; Prostration with excitement, and Tetanus ; respectively following "Wounds, Bui-ns, Practures, and Dislocations.

The Pathological Principle which guides the Preventive view of these Constitutional Disturbances.

This presupposes a sufficiently early and exact detection and discrimination — Diagnosis of Injuries regarded as internal causes in operation.

Preventive Measures.

THE ETIOLOGICAL PRINCIPLE ADVANCED IN THE PRECEDING CHAPTER FURTHER ILLUSTRATED BY DISEASES OF NUTRITION, THOSE OF OTHER FUNCTIONS, AND . BY CONTAGION; SEVERALLY, IN RELATION TO THEIR CONSTITUTIONAL CON- SEQUENCES.

Various (Constitutional) Disturbances of the Blood, Nervous, and Vascular Systems, i.e. Fevers — inflammatory, hectic, and gangrenous typhoid — arise from inflammation, suppuration, and mortification, respectively.

Various (Constitutional) Blood-diseases arise from other perversions of Nutrition besides that of inflammation; also from those of the Digestive process, Excretion, aud Respiration, respectively.

PROSPECTUS.

xvii

Various (Constitutional) Blood-diseases arise from Contagion, illustrated by — Contagious matter derived from Animals : — Hydrophobia, Snake-bites,

Malignant Pustule, Glanders, Vaccinia, Contagious matter derived from the Iluman Species : — Hospital Gangrene, Puerperal Fever, Primary Syphilis — Chancres and Buboes. The Pathological Principles which Guide the Preventive view of these Diseases. This presupposes a sufBciently early and exact detection and discrimination —Diagnosis, of each one.

Preventive Measures.

Chaptee XI.

LOCAI, MAY PKOCEED FEOM LOCAL MOKBID CONDITIONS; OB, THE RELATION OF DISEASES OP NUTRITION — e.g., INPLAMKATION AND OF LOCAL NERVOUS AND MUSCULAR AFFECTIONS, RESPECTIVELY, TO THOSE OF PARTS (CONTINUOUS) CONTIGUOUS, AND REMOTELY SITUATED IN THE BODY. (p. 659 — 677.)

The Pathological Principles which guide the Preventive view of some of these Morbid Conditions.

Pathological Anatomy applied, during life, to most early and exactly detect and discriminate the structural condition, situation, and extent of diseases (and bjories), regarded as internal causes, in order to the Prevention of their consequences,— by the extension of such local morbid conditions to textures and organs (continuous and) adjoining, and the sympathetic affections of organs remote ; also the disorganizing results in the texture or part first affected. Hlustrated by inflammatory diseases of the joints, thus considered.

Preventive Measures of some of these morbid conditions.

CONSTITUTIONAL MAY PROCEED PROM CONSTITUTIONAL MORBID CONDITIONS J OR, THE RECIPROCAL RELATION OF MORBID CONDITIONS OF THE NERVOUS AND VASCULAR SYSTEMS, (p. 677 — 689.)

General theory of Pever propounded by reviewing Constitutional Irritation — Shock with reaction, as compared with Inflammatory fever. Eruptive fevers, and Endemic fever — intermittent and remittent.

The Pathological Principles which guide the Preventive view of these Diseases concluded.

This, as usual, presupposes a sufficiently early Diagnosis. Preventive Measures, concluded.

SUMMARY OF ETIOLOGY, AS GUIDED BY PATHOLOGY, (p. 689 — 695.)

The association of 'internal causes' — their various co-operations and orders of succession in the animal economy.

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PROSPECTUS.

The Preventive view of such causes is consummated by the earliest and most exact detection of their manifold relations.

THE PEINCIPLES OF PEOGNOSIS,

OR OF THE 'EAELIEST' AND 'MOST EXACT* FOEEKNOWLEDGE OF THE COUESE AKD TENDENCY OF DISEASES AND INJUKIES, INDrflDTJALLT, 10, OB, TOWABDS, A FATOTJBABLE OK AN UNFAVOXJBABLE ISSUE.

The earliest and most exact foreknowledge respecting the course, tendency, and issue of injuries and diseases, can be concluded only by the experience derived from special Clinical observation of their continued functional manifestations ; but sucli Prognosis implies a previous Etiology, in respect of internal causes, and a prior diagnosis therefore, each of similar quality. Hence the guidance of Clinical Pathological Anatomy indirectly to Prognosis-

THE PEOGNOSTIC GUIDANCE OF CLINICAL PATHOLOGICAL ANATOMY.

Persistence, or not, of the immediate cause or causes, and therefore the question of an 'internal' cause, or more, being in operation, is the immediate foundation of the earliest and most exact Prognosis, unfavourable or favourable respectively.

The Prognostic value of this fundamental Principle illustrated by the career of injuries and diseases, from the whole range of General Surgical Pathology.

Chaptee XIII. (p. 722—728.)

THE PEOGNOSTIC GUIDANCE OF CLINICAL PATHOLOGICAL ANATOMY (CONCLUDED).

The earliest and most exact Prognosis of an injury or of a disease is regulated by the kind and extent of structural alteration that the organ or texture has undergone ; and, moreover, by the period during which such alteration of structure has been in operation as an internal cause of functional disturbances of the System. Nevertheless, an acute disease, or a recent injury, is, caiteris paribus, more unfavourable than a chronic lesion, to which the system has become habituated.

PROSPECTUS.

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The Prognostic value of the foregoing fundamental Principle illustrated by Injuries — wounds, other than simple (incised); fractures and dislocations, respectively, other than simple; and by aneurism— diffused. Also by diseases of Nutrition — results of inflammation ; Growths — malignant.

THE SUPEKIOB PROGNOSTIC GUIDANCE OF PATHOLOGY.

Pathology declares the course, tendency, and issue of injuries and diseases by their continued Punctional manifestations.

Principle I. — The comparative Functional importance of any organ or texture determines our Prognosis, unfavourable or favourable, as to the course and tendency of any morbid condition of structure it may_^have undergone.

Sub-Principle I.— Organs and textures which fulfil Functions by virtue of their vital endowments (and chemical composition) suggest an unfavourable Prognosis.

The Prognostic value of this Principle and sub-Principle illustrated by the course and tendency of Blood-diseases — e.g.. Syphilis, Scrofula, Gout, and Rheumatism; also, by disorders of the Nervous System — e.g , Constitutional Irritation; by disorders of the Nervo-Muscular System — e.g.. Tetanus; and by disorders of Secretion and Nutrition.

Sub-Principle 11. — Organs and textures which fulfil Functions by virtue of their physical properties and mechanism suggest a more favourable Prognosis.

The Prognostic value of this sub-Principle illustrated by the course and tendency of Injuries — e.g., incised flesh Wounds; reduced simple Fracture and Dislocation.

Priaciple 11. — Local disease or injury, per se, suggests a favourable Prognosis.

Principle III. — Local disease or injury, sustaining, or sustained by, some Constitutional disorder, suggests an unfavourable Prognosis.

The Prognostic value of this Principle illustrated by the course and tendency of unreduced Fractures and Dislocations; also by persistent Inflammation; and by poisoned Wounds.

Principle IV. — Constitutional diseases, implymg each some morbid condition of a texture or textures, of general distribution, as well as of predominant Functional influence throughout the system, suggest an unfavourable Prognosis.

The Prognostic value of this general Principle illustrated by the course and tendency of the same diseases of the Blood, disorders of the Nervous System, Nervo-muscular System, and of Nutrition, already adduced in illustration of the first Principle advanced in this chapter.

Modes of Dying.

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PROSPECTUS.

THE EESTOEATIVE POWER, — ITS EXISTENCE, OPERATION, AND EESOUBCES, — MANI- PESTED BY THE NATURAL COURSE AND TENDENCY OP INJURIES AND DISEASES, INDIVIDUALLY, TO, OR TOWARDS, RECOVERY,

This Principle illustrated by selections from the whole range of General Pathology.

The Restorative Power an innate property of the living body — Noticed by Hippocrates and by subsequent clinical observers — Van Helmont, Stahl — " Expectant cure" of the French School— German School — Acknowledgment of this Power in the practice of Medicine and Surgery, opposed by certain natural prejudices, specified — Prejudices remarked by John Bell and Bigelow —Mistrust of Nature by the influence of authority — Teaching of the Schools, Medical journals. Systematic works, and Medical literature generally — These fetters are shaken off by independent observation and reflection — Concessions of matured experience.

Definition of the Restorative Power, not identical with the physiological power of maintenance in the state of health and the prevention of disease — The power of reparation a phase of the Restorative Power, and not identical with that of nutritive maintenance, as alleged by Mr. Paget — His reasons answered, and the distinction of these two Powers illustrated — The power of reparation not necessarily identical with that of original formation, as alleged by Mr. Paget — His reasons answered.

The Restorative Power, including its reparative phase, not to be predicated by any knowledge of Physiology — Evidence of the existence, operation, and resources of this Power discovered only, and its conservative value appreciated only, by independent Pathological observation.

Indirect and inferential evidence, in eight general propositions, by Sir John Eorbes.

The author's direct evidence in serial illustrations of the natural course and tendency of injuries and diseases, severally to, or towards, recovery : —

Healing of Wounds : — immediate union, primary adhesion, suppurative granulations, scabbing — Modelling process of Macartney — Healing of Eractu'res, simple, compound — Healing of Dislocations, reduced, simple, unreduced, and natural formation of a new joint; healing of compound dislocation — General conclusions respecting the healing of non-contused, as compared with contused, lesions ; and of subcutaneous, as compared with open, lesions.

Development of new capillary blood-vessels — Spontaneous cure of aneurism — Natural modes of cure specified and exemplified — Healing of wounded arteries, when incised or lacerated — either kind of lesion being partial or complete.

PROSPECTUS.

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Inflammation not a salutary mode of action — John Hunter's statement examined and disproved — The author's view — Inflammation is essentially a morbid condition, but a manifestation of restorative power, by virtue of its purpose or intention, whenever an extra and pressing demand is made on Nutrition, either to construct some new mechanism, or to restore some loss of structure — False membranes and other false tissues — Adhesive inflammation and its uses — Suppurative granulations with cicatrization, its uses — Sloughing, its uses.

Non-inflammatory lymph-deposits — Degeneration and quiescence of tubercle, grey and yellow — Disintegration and destruction of texture around tuberculous matter — its dislodgement and evacuation — a manifestation of restorative power — Obliteration of the cavity thus formed — Professor Bennett's observations — Natural cure of phthisis — New Growths, their natural history — Arrest of Cancer, different modes specified and illustrated.

Blood-diseases are "self -limited their natural course and tendency, to, or towards, recovery — Exanthematous Fevers, each a natural effort to expel some blood-poison — Cardiac reserve force and reaction from the shock of injury, analogous to reaction as a restorative effort against febrile oppression of the nervous system — Illustration of the self-sufficiency of the cardiac reserve force — Nervous reserve force as a restorative effort, illustrated by involuntary muscular actions connected chiefly with the functions of Respiration and Digestion — The respiratory efforts of sighing and yawning, to restore the balance of respiration whenever disturbed — Coughing and expectoration, a deep expiratory effort to clear the air-passages and recover a due supply of air — Sneezing, a similar effort on behalf of the nasal passages — Involuntary muscular actions associated with digestion — Vomiting a restorative effort, by which substances unfit for assimilation, or poisonous, are ejected — Diarrhcea, feculent, serous, mucous, bilious, an analogous effort to clear the intestinal canal — This canal also an excretmg organ to eliminate blood-poisons — Peyer's glands in typhoid fever.

Hunger and Thirst, considered as sensations indicative of the food requirements of the system in disease — The quantity required regulated by instinctive desire— a sure guide— Loathing, and ravenous appetite— Instinctive choice of this or that kind of food — an infallible guide — Food-fancies in protracted illness, and of the moribund, suggested by the inward want of that special

kind of food which the particular disease has rendered necessary Systemic

wants and stomach capabilities alike suited by these selective suggestions of Nature — Remarkable instance by Dr. William Hunter.

Excreting organs manifest restorative power by extra excretion, readjusting excretion, compensatory or vicarious excretion, and supplementary excrekxii PROSPECTUS.

tion ; double work — Examples of these restorative operations by the kidneys and skin respectively.

Organs of reproduction, in the female, considered during the active period of their career — Menstruation — 'Ovular' theory doubtful — The author's objections — An excrementitious discharge is probably one pliysiological purpose of this function — is supported by pathological evidence — Vicarious menstruation — examples of this compensatory discharge — Menorrhagia, a restorative effort by excrementitious discharge in extra quantity, or to readjust the balance of the blood's composition ? — The relation of human pathology to human pliysiology alluded to.

The final aspect of the Restorative Power — the readjusting power of Nature, during convalescence : illustrated by convalescence after natural labour — This process traced constitutionally, and, as regards the uterus, regaining its former size, locality, pelvic relations, and original structure — Lactation, and the safe subsidence of this temporary function, from time to time.

By the operation and resources of the innate Restorative Power, the balance of health is regained — This state of ease and comfort, the one ordained by Nature, — disease the exception — Frequency of self-restoration in the course of each individual existence — not confined to bodily restoration — Restorative Power of the mind, and recovery from its shocks, wounds, and tribulations, during this world's pilgrimage.

THE PEINCIPLES OF THEEAPEUTICS,

MEDICAL AND OPEEATIVE. (p. 827.)

The Guiding Principle of Therapeutics is established by considering all the preceding chapters on Prognosis, or foreknowledge of the natural course and tendency of Injuries and Diseases, individually, to, or towards, a favourable or an unfavourable issue.