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in every spot where the course of a large artery could be superficially traced. In this instance there was murmur in the axillary artery, in the brachial, in the femoral in Scarpa's space, and in the popliteal. At all these points there was likewise fremitus, from vibration of the vessel, and rapid irregular pulsation, of which the patient was so conscious, that, without producing absolute pain, the vibration was to him a perpetual annoyance, and added greatly to his anxieties and sufferings.
BEARINGS OF SUBCLAVIAN MURMUR ON PRACTICE.
The existence of pure subclavian murmur supplies no special knowledge in regard to treatment. But, in diagnosis, it has much worth when carefully and judiciously studied. Unless caused by mechanical occupations, it indicates the existence of some pressure exerted on the artery by a structure posterior to the vessel—in most instances, we must infer, by the lung. Thus it affords one diagnostic indication both of bronchial disease and of tubercular deposit. The evidences of such amount of bronchial disease as is sufficient to produce the murmur, are sufficient also of themselves to express the extant mischief, without the superaddition of the murmur as a sign. But in phthisis the murmur may prove one of the earliest indications of tubercle. In two cases, where there were general symptoms of phthisis and a phthisical history, but where the ordinary physical signs of the disease were utterly wanting, I was supported strongly in the suspicion of actual tubercular deposition by the prominence of a subclavian bruit. In both these cases the suspicion was confirmed by after events: for one ended rapidly fatal from tubercle, commencing in the position which the murmur indirectly pointed out; and the other, although the patient still lives, passed on to true tubercular disease of the apex of the lung behind the murmuring artery. The arterial murmur may thus be important, both in regard to diagnosis and prognosis : but it must be taken for no more than it is worth, since it may occur, as we have seen, dependently on various other external producing causes, and may possibly in some examples be produced by a light stethoscopic pressure on an artery thrown slightly towards the surface. With all these objections to it, its presenee ought, notwithstanding, to have its diagnostic value in doubtful cases of tubercle in the apex of the lung.
But the point of most importance in regard to the murmur, is to know it in such perfect manner as not to mistake it for aneurismal murmur. I have shewn the fact of such error, and its consequences; and if this history shall prevent the recurrence of the like mistake, one at least of the main objects with which the essay has been written will be attained.
ON A DISEASED CONDITION OF THE NAILS.
There is sometimes seen in practice a peculiar disease of the nails of the fingers, or of the fingers and toes, which gives to the patient great annoyance,
if not suffering. The disease is recognised in France, I believe, under the title “ Psoriasis of the Nails”; but in this country it has no designation, in so far as I can learn: it is known, however, to many practitioners. When, in May last, I brought an illustration of this disease before the Medical Society of London, I found that various of the Fellows at once distinguished it, and knew well the difficulties of treating it. Indeed, the disease, when once seen, is so striking, that it is impossible to forget it again.
OBSERVED FACTS AND ANALYSES.
In 1856, Mr. C. Housley, now of Port Elizabeth, Cape of Good Hope, drew my attention to the first case I had seen of disease of the nails. He brought to me a patient, who presented the disorder in an intense form. The first indications of the affection in this gentleman had commenced two years before I saw him. His nails became very brittle, and chipped.
After a time, they suddenly became dark on the upper surface, and shining, appearing as though they had been coated with varnish. These changes were unattended by pain. The next indication was, that the surface of the nails began to be pitted—covered, that is, with fine indentations; then the nails were lifted from the fingers by a hard deposit; finally, the raised nails gave way in an irregular manner at the free margins, as though they had been bitten with small teeth.
When this gentleman came before me, every nail in both hands was affected. Some nails were destroyed nearly to the angular junction with the skin, a large and ugly gap being left in place of the nail ; other nails were half destroyed, the horny structure being raised a full eighth of an inch from the matrix, and being jagged at the free extremity like the occipital suture. The hands were unpresentable altogether. With all this, the health of the patient was good. There was no eruption of the skin, nor any sign of syphilis, albeit there was an admission of a syphilitic attack some twenty years ago. The hair was firm on the head, but inclined to grey: the age, about
, forty-two years. The patient himself was engaged as a master in the painting and decorating business. He had sometimes painted with his own hands, but not much. He was a full made, fresh looking man; irritable, I should say, but temperate in living ; taking a good animal diet, and a little ale, but not indulging in alcoholics to absolute intemperance. He was dyspeptic, and given to hypochondriasis.
A second case was as follows. A woman, 47 years of age, came before me with chronic bronchial catarrh. In the course of examination, she removed her gloves and shewed me her nails. They were diseased in the same way as in the case immediately preceding. Her history was clearly given. She had been the mother of six living children, and had suffered from one miscarriage. She was still menstruating regularly. Three years previously to the date on which she came to me (April 6th, 1860), she became affected with a scaly eruption, lepra vulgaris, which commenced about the head: there was also some falling off of the hair. I made the most rigid inquiries as to the nature of this eruption and its cause, and no information was withheld me, as I believe; but I could not see reason even for a suspicion of preexisting syphilitic. malady. The lepra continued alone until August 1859, when she first perceived a peculiar sensation beneath the nails. The surface beneath the nails felt benumbed ; and at times, especially in the evening, it was the seat of a tingling sensation, described in common parlance as pins and needles. The immersion of the hands in water moderately warm would bring out this sensation at any hour of the day; but it always occurred, spontaneously, about bed time. After a few weeks, the nails commenced to look glazed. They seemed," said the patient, “ as if they had been smeared over with varnish of a yellow tinge.” They then began to show little indentations all over the surface, as if they had been pricked with the point of a pin, and