Blood-letting when uræmic coma is fully developed Cases illustrating effects of blood-letting Remarks on blood-letting in past times, and the errors attending the practice. Free blood-letting indicated in uræmia Not a certain remedy in all cases ib. ib. ib. ib. Effect of abstraction of blood dependent on the degree of occlusion Physical diagnosis denotes absence of pulmonic or valvular disease ib. Patient not conscious of this irregularity, though he sometimes Dyspepsia precedes cardiac apnoea Irregularity of cerebral circulation Pathology of Cardiac Apnœa ib. Cardiac apnoea not exclusively connected with disease of coronary Cardiac apnoea may not be fatal until some mechanical obstacle to Case of long-standing cardiac apnoea with fatty deposit and Fibrinous deposits in a healthy heart Changes external to the heart: ossification; pericardial adhesion; Condition of heart varies in cardiac apnoea dependent on poison at time of death Venous congestion of internal organs generally present Cardiac apnoea may occur without predisposing cause from the Symptoms during attack reducible to muscular spasm, pain, and Conditions necessary for perfect balance of muscular force ron with quinine or peroxide of hydrogen Tercury and digitalis to be specially avoided Alkalies indicated where there is deposit of fibrine Air, sitting or semi-recumbent position, and warmth Caloric necessary to muscular relaxation Heat best applied through the stomach CLINICAL ESSAYS. ESSAY I. ON SUBCLAVIAN MURMUR. The IN conducting auscultatory examinations of the chest, the physician now and then meets with a passing murmur under one or both clavicles. To the inexperienced, it is difficult to determine whether the sound is connected with respiration or with the circulation; for it obtains in many cases that the sound, which seems arterial, is so peculiarly associated with the respiratory act, that its source assumes a double character. sound has been described by few authors, but it is known to most persons who are extensively engaged in stethoscopic inquiries. I once heard Dr. Kirkes read a concise paper on the subject; Dr. Sibson has also referred to the murmur in explanation of its origin; and Dr. Thorburn, in the British Medical Journal for June 18th, 1859, has entered into a description of it in a paper entitled "A Peculiar Auscultatory Phenomenon". Dr. Thorburn, in certain doubts which he offers as to the origin of the B sound, expresses what is, I believe, a general feeling. I shall endeavour in the succeeding observations to clear up the obscurities of the phenomenon, and to exhibit it in its true and simple light. The importance of the labour, in a diagnostic sense, I cannot better explain than by stating the fact that, within the last three years, four cases have been referred to me as cases of aneurism in the thorax, which have proved on further examination to be nothing more than well marked examples of subclavian murmur; cases, as we shall hereafter see, very innocent in their nature when compared with aneurismal disease. I will follow out the description of subclavian murmur from its history, as it is written in the natural facts. OBSERVED FACTS AND ANALYSES. In 1856, a young man came before me at the Royal Infirmary for Diseases of the Chest, complaining of great lassitude, thirst, flatulency, depression of spirits, and palpitation of the heart. He was a tall, thin, anæmic man, by trade a cabinet-maker, and evidently of an irritable and what is popularly called "nervous" temperament. On examining his chest, I was surprised to hear under each clavicle a sharp loud murmur, synchronous with the systole of the heart, and resembling closely an aneurismal bruit. Tracing the murmur downwards towards the heart, I found it becoming reduced; whilst over the heart it was absent altogether. Each cardiac sound was clear, well defined, and natural. I followed out the courses of |