the carotid, axillary, and femoral arteries with the stethoscope, and found in them no murmur. Percussing the chest in the subclavian regions, I discovered perfect resonance; but, on placing my fingers over the subclavian artery on each side, there was a distinct fremitus with each pulsation of the vessel. The patient himself was conscious of this fremitus, describing it as a gentle thrill beneath the fingers. On returning to the stethoscope, and divesting the ear of the murmur, the pure respiratory sounds were audible at every point; but now a further fact came out, viz., that whenever a long inspiration was made and the breath was retained, or whenever a long expiration was made, then the specific arterial sound was lost. I brought this patient to many medical friends, who expressed various opinions as to the nature of the disease; ultimately, however, the evidence became conclusive that the murmur was produced by posterior pressure on the subclavian artery.

The case being for a long time under my care, I made many observations upon it. Amongst these, it was distinguishable that the murmur underwent modification, according to the position of the arm corresponding to the side examined. When the arm was brought down close to the body, the murmur was lost; as the limb was raised towards a right angle, the sound recurred; at a perfect right angle, it rose to its acme; but at an acute angle, made by raising the limb towards the head, the sound declined; and when the limb was quite vertical, it was nearly lost.

From the time I have named, until the present year, the patient was under observation. He recovered his health on the administration of steel and quinine, and followed his business until 1859; but the murmur was always present, being specially developed after any excitement, as after a sharp walk, or mental worry. The last time I saw this man, he was suffering from distinct indications of tubercular deposit in the apex of each lung. He left London for the country; and has returned, I am informed, so much improved, that he is able to follow his work.

The occurrence of this case led me carefully to investigate other patients for the same symptom. I soon found that the murmur was an accompaniment of certain special diseased conditions, more or less severe. Thus in 2,000 patients of all ages, 1,011 of whom were females, and 989 males, who came under my care at the Royal Infirmary for Diseases of the Chest, from the 11th of November, 1858, to the 17th of August, 1860, and each of whom underwent careful examination for the murmur, I found it well marked in 51 cases, i. e. in 2:55 per cent. Among the 51, the murmur was found in enormous preponderance in males; there being 48 of the male sex presenting it, and 3 only of the female. The youngest patient in whom the murmur was heard was one John Clark, a coppersmith by trade, eighteen years old; he was suffering from simple dyspepsia : the oldest patient was one Edward Butler, a carpenter, seventy-four years old; he was labouring under subacute bronchitis.

The 2,000 patients to whom reference has been made, came with various diseases; there were cases of phthisis, of chronic bronchitis, of anæmia, chronic pleurisy, different forms of heart-disease, thoracic aneurism, stricture of the oesophagus, dyspepsia, diabetes, empyema, spasmodic asthma, morbus Brightii, cirrhosis of the liver, and a long list more. But the murmur itself was met with in five diseased states only; viz., in chronic bronchitis; in phthisis (during the first and second stages); in anæmia; in dyspepsia; and in valvular disease of the heart.

The cases of bronchitis, chronic and subacute, in the total of 2,000, were 610 in number, males and females together. Subclavian murmur was well marked in 18 of these; viz., in 16 males, and in 2 females. The bronchial affection was generally of long standing, and the mischief wide spread. The marked signs of disease were not always in the lung of the side on which the murmur was most distinct. There were three cases of subacute bronchitis.

The total cases of phthisis subjected to examination were 669. Of this number, 431 were males, and 238 were females. The murmur was presented in 12 of these patients, all of them being males. The tubercular disease, at the period when the murmur was well marked, was situated in the apex of the lung on one or both sides; the murmur was most distinct in the early stages of tuberculosis.

There was one mixed case, in a man aged 23, in whom, with old standing bronchial disease, there was evidence of tubercular deposit in the apex of the

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.

cases.

The examples of disease of the heart were 93 in number out of the 2,000; they were mainly chronic 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.