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right lung. In this example the murmur in the subclavian region was well marked, but only on a slightly forced inspiration.
The cases of anæmia were 172, males and females together. Out of these, there were 10 examples of subclavian murmur; viz., in 9 men, and in one woman. They were all patients who, shut off from fresh air, had been also overworked and badly fed ; their symptoms were the common ones of anæmia, without any apparent organic lesion: they all recovered under steel and an improved hygiene. In two cases there was anæmic murmur in the neck, which subsided on recovery. In these cases, as the general health improved, there was less intensity of subclavian bruit, but it did not disappear as a sound.
The total of the cases of dyspepsia was 281, males and females. In these, the murmur was present in seven instances, all men. The dyspeptic symptoms were those of pain after food, irregular appetite, eructations, and flatulency. The cases were not serious, and they recovered under an alterative tonic treatment with revised dietary and habit ; but in every case the murmur remained after the recovery seemed complete.
The examples of disease of the heart were 93 in number out of the 2,000; they were mainly chronic cases. The subclavian murmur was present in three of these patients, all males. Two cases gave the stethoscopic signs of mitral, the other of aortic valvular disease. They improved under tonic treatment, and were discharged relieved. The subclavian murmur, however, continued.
I would remark in this place on the singular fact that, in the list of diseases in which subclavian murmur was an attendant symptom, there is not one example of aneurism ; yet there were included, in the 2,000 cases, no fewer than six instances of aneurism, either of the aorta itself, or of the innominata, or of both. In these, aneurismal bruit was most evident, but without any special extension into the subclavian on either side. There was also one case, in which I diagnosed atheroma of the aorta, and in which a loud murmur extended along the whole line of the aortic arch, and upwards towards the neck. After death, I found atheromatous disease of the arch, extending into the trunks of the three great vessels springing from it. Nevertheless, this case supplied no evidence during life of the specific subclavian murmur at the present time under discussion.
To illustrate further the 51 cases of subclavian murmur, I have entered them down in the following table, with particulars relating to age, sex, disease, duration of disease, and occupation. The ages and other facts refer to the time when each patient first came under my observation. The occupations are classified together when two or more patients followed the same: the reason for this will be hereafter shewn.
1 year. | 2 years.
| George Pond 1
| Phthisis pulmonalis.
Box-maker. 6 months.
Sawyer. 6 months.
Ditto. 3 months.
Artificial flower maker.
From this table, we learn certain laws relating to the occurrence of subclavian murmur in diseased states, which are of considerable interest. A few illustrations may be given.
In the first place, there is no case of a child presenting the murmur. The youngest subjects named were eighteen years old. There were, nevertheless, many children included in the total of cases, the majority of whom were suffering from the diseases named in the table. In the case of every child, I examined with more than ordinary care for the murmur. I often found the common anæmic continuous murmur in the neck, but never the subclavian.
Next, we see that the subclavian murmur is rare in females. In the total of cases (2000) from which the deductions were drawn, there were more females than males in the proportion of about one per cent. ; yet there were 3 cases only of the murmur on the female side to 48 on the male side. The murmur in the female, moreover, when it did occur, was not to be heard without an effort on the part of the patient to bring it out, such as a long inspiration : it was also much more faint, and even more fleeting, in the women than in the men.
Thirdly, we see from the table, that the murmur as occurring in disease is most peculiar in certain forms of disease. Chronic bronchial affections are those which furnish most illustrations of it, according to my analysis, viz., 18 to the 2000; afterwards stands phthisis, yielding 12 cases; next anæmia, giving 10 cases ; next dyspepsia, yielding 7 cases; then heart-disease,