to the time I saw her, and a week after, the autopsy revealed considerable ulceration of the epiglottis and upper part of the larynx, with rough and thickened vocal chords.

Of the non-fatal cases, some received slight benefit from treatment, but only two were really improved in a satisfactory manner. One was a man with a vomica in the right lung, who had had pulmonary affection probably for five years. He was treated with cod-liver oil internally, and the application of strong solution of nitrate of silver to the fauces and upper part of the larynx. After eleven weeks' treatment the voice was improved, the patient had gained 64 lbs. in weight, and the vomica became quite dry. The other was a young man who had had pulmonary disease for two or three years, and partial aphonia for a year. The application of blisters and strong solution of iodine externally removed all the soreness of the throat, and the voice improved considerably. Of internal local applications, I believe that the solution of nitrate of silver, useful as it is in cases of chronic inflamed fauces, possesses little virtue in real laryngeal ulceration, partly perhaps because in nine cases out of ten it never reaches the diseased part, though it may be supposed to do so. A free application

of tannic or gallic acid dissolved in glycerine is often of service in allaying irritation and soreness; but if any permanent good can be done, I feel confident that the most effectual and easiest mode of obtaining it is by the application of blisters or a blistering solution of iodine to the throat externally on each side of the pomum Adami; and sometimes the application of two or three leeches exerts the most marked benefit, even in extreme cases, as is evidenced by the following case:-G. O., aged twenty-nine, with a vomica in the right lung, and evidence of tubercles in the left, had had hoarseness of voice for two months, and was getting worse. Solution of nitrate of silver was diligently applied internally without relief being obtained; the disease gradually advanced in the larynx, which became so painful that the patient was finally unable to swallow even liquids. He lost strength rapidly, and was confined to bed from weakness. Two or three leeches were then applied to the throat externally, with the result of relieving the pain immediately, and next day he was able to swallow. From that period he began to gain strength, and in a month's time could walk out for two hours daily.

Fistula in ano.-On the subject of fistula I have only to remark, that whilst in surgical books it is said to be very frequently associated with pulmonary phthisis, it will be seen by the above table that such is the case only in a very small proportion of phthisical patients. Dr. Cotton's observations have also led him to the same conclusion, that "the common opinion regarding its frequency is incorrect." At the same time it may be equally true, that of the fistula cases that come under the observation of the surgeon, a considerable proportion of them are victims of phthisis, though this does not warrant the converse statement, that fistula in ano is a frequent complication of pulmonary consumption. All the five cases were male patients.

Prognosis. In conclusion, I have a few observations to make on

this subject, the practical importance of which must be fully apparent, as it is the one thing on which information is most anxiously and eagerly demanded from the medical attendant, and on which in many cases much may depend upon the correctness of the opinion given. It is a subject which demands considerable study from the very nature of the difficulties it presents, as seen by the observation of the great diversity in many points that exists in the course of any two cases; hence accuracy in prognosis can only be obtained in the way of generalizations, from which a certain ratio of divergence must always be expected, that will continually diminish according as we attain to perfection of knowledge and certainty on the subjects of the etiology and pathology of the disease in its different modes of manifestation.

The value, therefore, of any facts obtained from this analysis of cases must be estimated according as they assist in the development of this special subject.

Under this head, the points which it is desirable to determine are, the average or usual duration of a case of pulmonary phthisis, the conditions under which prolongation of life is attained, and those under which patients succumb before reaching the ordinary period of duration; and finally, how far the symptoms in any individual case enable us to predict with an approach to accuracy its probable duration and prospect of present improvement.

As regards the duration of a case, it is well known that the extreme limits are separated by a wide interval. That form which commences as an attack of pneumonia and terminates in the pathological condition of "cheesy hepatization," may bring its victim to the grave within a very short period. Cases also of "acute tuberculosis," and those which are hastened to their end by any fatal intercurrent attack-such as meningitis may of course be of much shorter duration than ordinary cases, and therefore should be omitted in endeavouring to ascertain the average duration of the latter class, of which the shortest that has come under my notice is that of a lad, aged nineteen, who, as far as could be ascertained, was in good health and quite free from cough four months before his death. One of the most protracted cases I have observed was that of a man, aged fifty-one, who stated he had had cough for twenty years. This, of course, is no decisive evidence of tubercular pulmonary affection having existed so long; but he stated he had had an attack of hæmoptysis at least ten years before I saw him, and the pathological appearances at the autopsy confirmed the opinion of the distant date of the commencement of the disease; and in another case I have positive evidence of at least ten years' duration of the pulmonary affection.

In estimating the average duration of a case of phthisis, a difference must of course be made between those who succumb only from the mere constitutional affection and pulmonary lesion, and those whose end is accelerated by the concurrence of some additional tubercular or other disease or accident-such as laryngitis, pneumothorax, hæmoptysis, &c. Of all the cases I have seen to their termination, an average of 1.93, or just two years, is yielded, which is increased by

half a year when only those uncomplicated cases which run a natural course are taken into account. The average of two years for all cases taken together is the figure arrived at by most investigators, as may be ascertained by reference to the abstract of Dr. Pollock's paper on Prognosis in Phthisis, in the Medical Times and Gazette' for September, 1859. Dr. Pollock himself inclines to place it higher, on the ground that cases are not always recognised at their commencement, an opinion with which I quite agree; and when it is remembered that in most cases we are dependent on the patient's own account merely in fixing the date of the commencement of his illness, I think that an average of two years and a half, as above mentioned, may be considered as the lowest figure by which to indicate the duration of uncomplicated pulmonary phthisis.

With regard to the conditions under which consumption assumes the chronic form, on examination of the notes of 48 such male cases, I find that more than half had passed the age of thirty, whereas, of all taken together, not much more than one-third had attained that age; 67 per cent. were free from hereditary taint, whereas the ordinary per-centage of such is only 58 among the male cases generally, and in 57 per cent. the pulse was below 100 beats per minute; therefore, a case may be expected to be chronic in a person of a more advanced age, in those free from hereditary tendency to the disease, and in those where there is an absence of hectic symptoms. On the other hand, cases may be expected to have an early termination where the reverse of these conditions obtains, and also when complications supervene such as laryngeal disease, tubercular peritonitis and meningitis, copious hæmoptysis or pneumothorax, which in the 220 cases occurred to the amount of fifteen per cent., and which must hence be considered as reducing in the same proportion the probabilities of a case attaining to the, in other respects, natural period of duration.

In a practical point of view, the most important thing for the medical attendant to be well acquainted with, is the probability of present improvement in any individual case at any time that it may present itself to his notice, to assist him in which, amongst other things, the chief elements for consideration may be enumerated as the question of emaciation, whether the patient have been losing or gaining weight recently, whether night-sweats are present or absent, and the condition of the pulse. How far the latter may be considered as a guide will be seen by the following statement: of 108 patients (male and female) in whom the pulse was above 100 at the time they came under observation, only 32-4 per cent. improved during the time they were under treatment; and of 96 in whom the pulse was at or below 100 per minute, 63-6 per cent. improved. Profuse nocturnal diaphoresis will usually be found in concurrence with rapidity of pulse, and indicates in the same manner in a general way advance of the pulmonary affection. Sixteen such cases, in which the diaphoresis continued unchecked in spite of treatment, got rapidly worse or died within a comparatively short period, whilst in nearly every case of cessation of the night-sweats a corresponding improvement in other respects took place.

The advance or arrest of emaciation may, as a rule, be looked upon as a very good indication of the condition of the patient, a gain betokening improvement; and a loss of weight indicating in almost every case advance of pulmonary disease. The emaciation so constantly attendant upon tubercular disease of the lungs is probably due to two circumstances-1st, defective nutrition; on account of the accompanying vitiated state of the digestive organs, and the retention of fat by the liver, evidenced by that fatty condition of the organ so frequently found in connexion with pulmonary phthisis, which is the result of resorption and retention of fat, and not of a fatty degeneration in its ordinary sense;* and, 2ndly, the decreased pulmonary surface available for the aëration of the blood: for if in the healthy body a certain amount of lung-tissue is provided, through which the blood circulates in a given time, in order to maintain the due interchange of elements necessary to the waste and repair of a certain weight of organized tissues, we may fairly conclude that a decrease in the weight of the body is necessarily attendant upon a decrease in the amount of permeable pulmonary tissue. To show how important and useful a criterion we have in the observation of the emaciation or otherwise of the patient, I may mention that of 46 patients who experienced a loss in weight of from two pounds and upwards, only 5 showed any symptoms of improvement generally, all the rest having become worse, in most instances with a degree of rapidity commensurate with the loss of weight; whereas, in 63 patients who gained weight to any marked amount, there were decided symptoms of general improvement in all, with more or less disappearance of physical signs in 38. In the other 25 the physical signs advanced, notwithstanding improvement in general health—that is, passed from the first to the second stage, or from the second to the third stage-which circumstance leads me again to notice the error of considering these conditions of lung as stages of the disease; for if a patient has sufficient strength of constitution to sustain the demand during the process of excavation, he is oftentimes, after the formation of a cavity, placed in a condition not only of greater ease and freedom from cough, but also much more favourable to the prolongation of life.

The occurrence of hæmoptysis is also said to be a symptom of chronicity, and such would appear to be the case from the fact, that of 40 male and female patients in whom it took place, in some even to a considerable extent, an average duration of 2-6 years is yielded; whilst of an equal number who never had hæmoptyis, an average of only 18 was the result. These statements may, however, be interpreted inversely, that those in whom the disease has continued longest are in the same proportion more likely to have had an attack of hæmoptysis at some period or other, though I think that in most of the hæmoptysis cases this symptom usually shows itself at an early stage of the disease, and therefore the idea of attendant chronicity may be lawfully used to allay the excitement and terror of those who are the subjects of these hæmorrhagic attacks.

* See Virchow's Cellular Pathologie, &c., p. 300 et infra.

In females we have an additional element in the catamenial functions, which we can call to our aid in forming an opinion as to the probable issue of a case, and its importance in prognosis will be seen by the accompanying groups of cases. Of nine patients in whom the disease had existed for a period of twelve months or more, and in whom the menstrual functions continued in a normal state, only two got worse whilst under treatment, an average of only about 22 per cent. Of twenty-five patients in whom there had been evidence of pulmonary affection for half a year and onwards, with absence of the catamenial discharge for at least three or four months, twenty lost ground with more or less rapidity, an average of 80 per cent.; and the most unfavourable cases, or those least amenable to treatment, will be found amongst those in whom the catamenia disappears nearly at the same time, or very shortly after, the pulmonary affection is manifested. Its reappearance in any case will, I believe, be always found coincident with some general re-establishment of health; for though its absence must not be considered incompatible with improvement, recovery under these circumstances very seldom occurs in any marked degree.

From these facts, then, we may conclude that for any individual case free from the more dangerous complications, the average duration of two and a half years may be expected; and this period will be more or less prolonged, and a degree of present improvement may be anticipated, according as the case in question presents those symptoms which are indicated above as warranting a favourable prognosis.

ART. III.

By

Vegetable Morphology: its History and Present Condition. MAXWELL T. MASTERS, F.L.S., M.R.C.S., &c., Lecturer on Botany, St. George's Hospital.

THE basis of botanical science, the most important of all its subdivisions, that one, indeed, upon which all the rest depend, is morphology, or the accurate investigation and observation of the plant and its varied parts, in order to obtain an insight into their mutual relations and significance, and by these means to discover the principles of their construction. The great value of some hypothesis as furnishing a centre round which the ever-increasing host of newly observed facts may be gathered, and their import explained, leads us to add a word of caution which may perhaps appear superfluous, but which the experience of every day proves is not so. We have no right confidently to assume that in laying down so-called "laws," philosophers have actually discovered the plan by which it has pleased the Creator to build the universe or fashion its inhabitants. It more befits our ignorance to acknowledge that such expressions as unity of type, special adaptation, and the like, are merely relative; that they serve our purpose of collating facts and rendering them intelligible, and that by their means we do really arrive at a clearer insight into the truth. Mr. Buckle, in his History of Civilization in England,' vol. i.,