This table shows that the average age of attack in the number affected with family predisposition of both sexes, was earlier than the average age of attack in the whole number by 2 years in the males, and by 4 years in the females. There is also shown that it was earlier than that of those free from family predisposition by 3 years among the males, and by 6 among the females.

This is very striking; but, remembering that these statistics were of the upper classes only, and might only apply to certain circumstances connected with them, I determined to pursue the same inquiry among the lower classes, and for this purpose I had recourse to my Brompton note-books. Among 400 out-patients, the result was as follows:

The figures confirm the former results as regards the age of attack being rendered earlier by family predis

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position, but the relative influence on the two sexes differs. greatly from what we found among the richer classes. In the out-patients' class the age of attack was about the same for males and females, the males being attacked earlier than among the rich, the females later. The age of attack in those free from family predisposition was for both sexes considerably later, and the influence in the male sex greater than in the female-a result exactly opposite to that obtained among the upper classes. This remarkable influence of family predisposition in hurrying the onset of the disease, does not seem to have attracted much attention; and the only authority I can find who seems to have noticed it is M. Briquet,' who, in the smaller number of 95 cases of consumption, arrived at the conclusion, that hereditary tuberculosis developes itself in the form of phthisis at an earlier period of life than the disease does when acquired. In 89 of the cases with the history of hereditary transmission, 26 became phthisical before 30 years of age; while of 56 cases born of perfectly healthy parents, 31 did not become phthisical until after 30.'

M. Briquet's cases were rather too few to afford strong evidence, and he makes no attempt to separate the sexes, and trace the influence in each sex; but we have little doubt that his observations, as far as they went, were correct, and that the fact that family predisposition hurries the onset of phthisis,' as ascertained by his and our own researches, is one not to be disputed.

6

Let us now consider whether the presence of family predisposition exercises any decided influence over the type of phthisis. Have cases with family predisposition any distinguishing features?

We must confess that it is hard to trace any feature

1 'Recherches Statistiques sur l'Histoire de la Phthisie.' (Revue Medicale, 1842.)

which cannot also be found in other cases of consumption. In many instances, great transparency of skin, with veins clearly visible, and a delicacy of outline, is noticeable; in others, marked want of development, or else distortion of the thorax; in many, glandular enlargements come on at an early age. These and other features are to be found, often strongly marked, in hereditary cases; they are not invariably present, and, on the other hand, they are to be seen occasionally in non-hereditary cases. We are afraid we cannot point to one distinguishing point of hereditary phthisis. Dr. Pollock remarks that in acute cases of phthisis the influence of hereditary predisposition is undoubted, and he says that of 179 cases, only 34 could positively state that there was no family taint either parental or remote.

We subjoin a few well-marked instances of hereditary origin, some of which were attacked early and some later in life. We think they will be found instructive, as showing that the strongest hereditary taint does not hinder the beneficial effect of remedies, if persevered with.

CASE 7.-A lady, aged 34, first consulted Dr. Williams, June 20, 1859. Had lost her father and mother, and ten brothers and sisters, from consumption, and had herself been always liable to cough, and had one constantly since December. Three years previously she had hæmoptysis, amounting to a tablespoonful. At the time of her visit the expectoration was streaked with blood. She had lost much flesh and strength, and complained of pain in her chest: catamenia irregular and deficient. Dulness and tubular sounds in the upper part of both sides of chest, most marked on the right, where there was crepitation.-Ordered cod-liver oil in a mixture of hydrocyanic and phosphoric acids, with infusion of calumbo and orange; counter-irritation with acetum cantharidis; and a linctus containing morphia.

May 21, 1860.-Greatly improved under the above treatment, and has grown stout. Has hardly any cough or expectoration, but lately suffers from oppression of breathing and frequent boils.-Ordered oil in a mixture of chlorate of potash, nitric acid, and glycerine.

July 30, 1861.-Continued to improve till the winter, when had inflammation of the lung; and since the attack the expectoration has been sometimes gritty and sometimes fœtid. Is still stout and strong, but breath

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short. Has taken oil regularly, combined with strychnia. Dulness, tubular sounds in upper left back and right front.

April 19, 1866.-Has always wintered in Cornwall, and out a great deal in the open air; but lately stomach weak, and has not been taking much oil. Has lost much flesh; but cough and expectoration are less than during last winter, when they increased, and there was some hæmoptysis. Suffers from piles. Dulness, large tubular sounds in upper right chest.—To take oil, with phosphoric acid and hypophosphite of soda. An electuary of sulphate and bitartrate of potash.

ness.

October 1, 1870.--Returned to Cornwall, and improved again so much that for the last two years has taken no oil. Last February took cold, and cough again returned, and has been troublesome since, with frequent sickIn July went to North Wales, there caught fresh cold, and has been very ill ever since, with sickness, pyrosis, disgust at food, and great loss of flesh and strength. Urine pale and copious; sp. gr. 1010; no albumen. A number of red scaly spots on skin. Cough, and opaque expectoration. Dulness and tubular sounds in both upper regions. Collapse under left clavicle, with defective breath. Crepitus in lower half of right lung.

Heard of her death in December, about 12 years after her first marked symptoms.

CASE 8.-A young gentleman, aged 16, whose mother and sister had died of phthisis, saw Dr. Williams, August 28, 1855. He had had repeated hæmoptysis since Christmas, sometimes amounting to an ounce, and also cough, with some loss of flesh, and lately pain in right shoulder. Dulness and tubular sounds above right scapula.-Oil ordered, with sulphuric acid, and infusion of roses, &c., and acetum cantharidis liniment.

September 29, 1856.—Wintered at Hastings, and improved in flesh, strength, and health. Oil has been taken steadily, except for about three weeks, when it was omitted, and he lost flesh. Hæmoptysis has occurred several times, generally after some exertion, and once amounted to vi. Du'ness, tubular and obstructive sounds in upper right chest, with subcrepitus.

October 9, 1857.-Was ailing in May, but now better and free from cough. In last month has suffered from lowness of spirits, sleeplessness, and confused head. Chest clearer, but still some tubular sounds, with obscure breathing in upper right chest.

January 11, 1859.-Sleeplessness gradually improved, and spent spring at home; but, after three months in the Regent's Park, cough increased, and hæmoptysis came on to the amount of ii. Some dulness and tubular sounds in upper right chest, crepitation sounds above scapula.

July 11.-Went soon after to Madeira, and rode out a great deal. Lost cough, and ascended the Peak of Teneriffe. Now strong, ruddy, and able to walk six miles.

October 16, 1861.-Last two years have been spent in London. Has been free from cough and hæmoptysis, and his condition has been good, but breath short. Oil has been taken regularly for nearly two years. Still

loud crepitation, left front and right back, with dulness and tubular sounds above right scapula.

September 7, 1863.-Had been studying at Cambridge for a year, when had hæmoptysis, iii., after bathing; and pain in right chest. After Easter 1863, nursed his father (who died of Bright's disease), and had hæmoptysis to ii daily, for a week in July; has left off oil and is taking cream, and is much reduced in strength, though not in bulk. Much dulness, and obstructive sounds in upper right back. Tubular sounds both upper sides of chest.

April 8, 1864.-At St. Leonards; wonderfully improved in flesh, colour, strength, and breath. Walks fourteen miles at a time. Oil in sulphuric acid has been taken all the winter.

October 4, 1864.-Improved at Tunbridge Wells, and was able to walk ten miles briskly: physical signs became drier. Then returned to keep terms at Cambridge. Remained well till on a visit to Liverpool, had hæmoptysis to amount of iv. In February, 1865, was sent to Madeira, and gained strength, 7 lb. in weight, being much out riding; then spent summer in Hants; and returned to Madeira in following winter, there remained till April, when had fever and congestion of the lungs. Since then weaker, with more cough and expectoration, and often chills and heats, and has some expectoration, sometimes opaque, sometimes calcareous. Tubular and crepitation sounds in both backs, most in the right.

October 15, 1867.-Remained at St. Leonards till February, then went to Mentone till May, and gained lb.; improving also in strength and apppetite. Had been taking oil, 3vi. once a day. In warm weather improved in weight, strength, and breath, but worse lately. More crepitating and obstructive sounds in left front and right back.

CASE 9.-Miss F., aged 24, consulted Dr. Williams, September 17, 1857. She had lost her mother, two brothers, and one sister from consumption, and had herself suffered from cough for 1 year, accompanied by expectoration sometimes streaked with blood. Catamenia had been absent for 3 months, and she had lost flesh, strength, and breath. Extensive dulness, obstruction, and croaky sounds in upper left chest. Pectoriloquy below clavicle. Tubular sounds upper right chest. Oil ordered in tonic, and use of acetum cantharidis.

October 31st.-Under these means has much improved in flesh, strength, and appetite. Cavernous croak below left clavicle; more breath below.

September 20, 1858.-Continued better, taking oil till May, when omitted it for two months, and lost flesh and strength. Then resumed it for two months, and has improved, but has not yet regained the loss. Cavernous sounds in upper left chest, tubular and crepitating sounds upper right.

March 29, 1859.-Heard that she had been better till last two months, when she has had more weakness and sickness. No catamenia since May.

CASE 10.-Miss T., aged 21, whose mother had died from consumption, was seen by Dr. Williams, August 26, 1857. From the age of 14 to 16 had been