greatly lessen, or perhaps extinguish, hope in the prognosis of the case. We attach so much importance to these several questions, that we advise the most careful consideration of each one of them, and as the opinion. to be formed respecting them is one of degree, it is often necessary that the case be watched for a time. before a correct judgment can be formed.

The importance of age seems to be less theoretically than practically. In persons aged twelve to fifteen years, or thereabouts, in whom the evidences of phthisis exist, we have found the disease less capable of arrest or cure than in those at a later age. This may be owing to the fact that the early attack of the disease may be in some degree evidence of the deep implication of the system, and probably it may be in part due to complications which arise in reference to the appearance of the menses, and the various rapid changes which occur in the organism and the passions at the period of puberty. But however it may be explained, we augur less favourably of a case in which the disease begins before æt. 16, than of one in whom it is deferred until twenty years of age or later. The unfavourable prognosis in advanced age is clearly associated with the progressing defect of the vital powers, the diminution in the expansibility of the lung which always proceeds at that period, and the diminished possibility of adopting some of the means which are necessary to a

cure.

There is an important relation between the state of the lungs and the general system, which we must always consider when forming a prognosis. A small

amount of lung disease, with a very enfeebled system, is far more unfavourable than a somewhat larger amount of the former, with a moderately robust state of the latter. Whilst there are many cases in which the general health appears to be moderately good when the lung disease is far advanced, the general rule is to find the system injured whilst the lung disease is yet very limited, and hence, after having ascertained that the latter is restricted within the narrow limits already indicated as hopeful, the whole question of prognosis rests upon the state of the general system.

CHAPTER XLV.

PROGNOSIS.

GENERAL AND NUMERICAL CONDITIONS,

WE purpose under this head to introduce a short summary of facts derived from a very extensive inquiry into the conditions which may be presumed to have modified the constitution of phthisical persons when in health, and to which reference has already been made in several parts of this work. The primary aspect of this inquiry is that of etiology, and had it been our purpose to have entered specially upon the causation of phthisis, we should doubtless have referred to the inquiry under that head, but as it has an important bearing upon prognosis in reference to the constitution of the patients, we purpose to insert the results in this place. We do not, however, intend to enter into much detail, since the computations were made only when this work was half through the press, and the subject has been treated at due length in a paper read before the Royal Medical and Chirurgical Society on March 20, 1826.

The inquiry embraced 1000 patients, of whom 600 were males and 400 females, and extended over several years. It was altogether made by ourself, and the

F F

diagnosis of phthisis in a marked stage of consolidation or of destruction was made by our colleagues or ourself. We will first consider the circumstances which refer to the parents, and then those belonging to the patients.

Fifty-four per cent. had lost the father, 46 per cent. the mother, and 28 per cent. had lost both parents. In 25 per cent. only were both parents living. Their average age at death was 50'8 years, with an increased duration of 47 years on the part of the fathers. The most frequent age at death was 35 to 55 years, whilst only 11 per cent. died under æt. 35, and some lived to upwards of æt. 95. 18 per cent. had experienced feeble health before the birth of the patient, and 34 per cent. throughout life. In 22.7 per cent. one or both parents had led unsteady lives, 21.1 per cent. of the parents had died of consumption, whilst in 2.8 per cent. the grand parents, in 23.3 per cent. the brothers or sisters, and in 9.1 per cent. the uncles or aunts had died of the same disease. They had suffered from rheumatism in 22 per cent., from asthma in 9:4 per cent., from liver disease and gout in 9 and 7.2 per cent., and from fevers, ague, insanity, and diabetes in between 4 and 5 per cent. Presumed scrofulous affections were extremely rare. In only six cases was there consanguinity of the parents.

The age of the parents at the birth of the patient was, in half of the cases, from æt. 25 to æt. 35, and only in 2 per cent. was it less than æt. 20. The number of children was very large, viz., an average of 7.5 to a family, and in some families there were 23 children.

The patient was the first child in 20 per cent., and the first, second, or third child in half of the whole cases. 40 per cent. of the parents' children had died.

Hence, in reference to questions involved in the idea of hereditary predisposition, it has been proved that in a large proportion of the cases the parents died in the middle of life, and had had feeble health. Their children had died in large proportion, and consumption occurred in one-fifth of the parents. But in all these matters there was a large proportion in which there was no evidence of feeble health or direct tendency to phthisis. The parents did not marry too early or too late, and the patient was neither the result of immaturity nor of senile exhaustion, so far as age may indicate those conditions, yet he was commonly amongst the earliest children born to them. They were unusually prolific.

The question of hereditary taint implies either the direct transmission of the elements of phthisis to the child, or a state of system in which phthisis is pre-eminently liable to occur. Neither of these ideas are supported by the results now given, as applicable to this class of cases as a whole, for they support the previously recorded statement of Dr. Walshe, that the hereditary transmission of phthisis from the parents, in hospital patients, is much less frequent than had previously been asserted. The results show that no one condition is dominant, but that phthisical patients are a mixed class of the community.

The average age of the patients at the period of the