Of the extraordinary breathing in both sexes (Inspiration). This, like ordinary breathing, is symmetrical: the clavicles, shoulders, sca pula, and superior ribs are raised, the sternum advances, the infra-clavicular region swells re markably upwards and outwards (particularly in females) like a rolling wave, the supra-cla vicular region is raised but this sometimes ap pears comparatively deepened (merely by the action of the sterno-cleido-mastoideus), the whole apex of the thorax is rendered more ob tuse, particularly in the antero-posterior dia meter. The lower ribs, at their cartilaginous extremities, spread outwards, increasing both the lateral and the antero-posterior diameter of the base of the thorax, the cartilaginous (go thic) arch formed by the junction of the 6th, 7th. 8th, 9th, and 10th ribs below the sternum, becomes more obtuse by their lateral motion, the abdominal space within this arch, down to the umbilicus, sinks inwards. Therefore this breathing is costal, commencing with the superior ribs, and terminating over the ab domen. The peculiar character of healthy breathing (and it is impossible to lay too much stress upon the movements of deep inspira tion, because they are so indicative of thoracic disease) is that the ribs expand in succession: There is an indescribable undulating roll, pro duced by the consecutive action of the re spective ribs, which always commences with a superior rib ; in costal breathing, a lower rib never moves first. In fact when we inspire deeply we feel as if we directed all our power to the four or five superior ribs, giving the greatest expansion to the very apex of the lungs, that most vulnerable part in phthisis pulmonalis. When we look at the thoracic cavity we see why this great power and mo bility is given to the upper part of the chest. We see that the six superior ribs encompass more space than the six inferior ribs. (See fig. 668.) So that where we command most movement, there is the greatest portion of lung tube expanded. The hand can measure most delicately this healthy characteristic swelling or filling up of the apex better than any instrument, because the hand covers a large field ofthe chest, and can distinguish the undulating movement. Standing behind the person to be examined, the fingers of both hands should be placed over the clavicles, so that the tips rest on the infra-clavicular regions, and the thumbs Over the inner borders of the scapulae. When a deep inspiration is taken the fingers and thumb of each hand diverge from each other, and we thus gain a perfect knowledge of the healthy "swelling expansion." If the deep respiratory movement is good, the ordinary movement is sure to be good likewise. The mere flat hand on the anterior and upper part of the chest (facing the patient) will likewise give the character, though less delicately. This movement or swelling of the apex by deep inspiration, is more distinctly marked on the female than on the male subject. If this fine swelling motion in deep breathing is absent .disease is present.
Pathological respiratory movements. We DOW speak of another class of breathing move ments, which are peculiar in this respect, that the " undulating swell" of the chest is wanting. The twelve intercostal mus cles move in every combination, as if to meet impending difficulties, tenacious of life, and yielding only by compulsion to the ad vance of disease. Throughout the long list of diseases which attack man these instinctive movements have to contend, shifting about, or growing less and less. We have noticed a man with lung disease, commence with costal respiration of the lower ribs, and, as disease advanced, he breathed with ribs higher and higher up, so that at last he said, " I breathe with my neck ;" and in truth it appeared so, His 1st, 2nd, and 3rd ribs only appeared to move. He pasSed through almost every variety of respiration before he died.
The breathing movements are quick to change, and the inquiry is interesting, what causes the change ? One great cause is the existence of dyspncea, a disproportion between the air passages and the volume of air to be displaced, which may be caused by an obli terated state of lung, by tubercles, fluid in the pleurae, hypertrophy of the heart, aneu rism of the great blood vessels, tumours of various kinds, the pain of local inflammation, pressure from the abdomen, whether ascites, obesity, distended stomach, gravid uterus, or any morbid growth bordering on the thoracic cavity, or lesion of nervous integrity requisitefor maintaining the respiratory movements.
Such conditions of themselves would oc casion deranged breathing movements. But again there are reasons for thinking that these movements may be changed from other causes not so purely physical ; because sometimes no dyspncea is to be perceived, and yet the movements are deranged, or they may change backwards and forwards as if aerating specific portions of the lungs, acting as a curative re medy to some incipient form of lung disease. in complicated diseases of the chest a know ledge of the breathing movements is highly useful. There is one condition in the res piratory act, which is indicative of a certain state of chest, which, if not useful as a po sitive, is at least so as a negative evidence of some existing state of things in the lungs.
The condition we allude to is a sinking in and bulging out of portions of integuments which cover the thoracic cavity. If we close both nostrils and make a violent inspiratory effort, the integuments between the sterno cleido-mastoidei immediately above the ster num, will be seen to sink inward from atmo spheric pressure. If we open one nostril, the same is less apparent. If both are open and the passages are free, it is not perceptible. In expiration (with the same obstruction) there is a bulging outwards of these integu ments. Sometimes, particularly in thin per sons, this may be seen on the integuments covering the intercostal spaces. This sinking inwards is an evidence of attenuated air, and the bulging outwards of condensed air in the lungs, near to the part. It is therefore an evi dence of some obstruction in the air passage.
Difficult breathing may be attended with this feature, or not ; therefore it is an evi dence of something existing in one state of dyspncea which does not exist in another.
Dyspncea without this "sinking or bulging" is a proof that there is no obstruction between the air cells and the external air. But, on the contrary, dyspncea with this " sinking and bulging," is a proof that there exists some obstruction either as a direct diminution in caliber of the air tube, or that more air is drawn through certain tubes than is natural ; that this obstruction must have air on both sides of it, and that the air on one side is more attenuated,. than on the other. For instance, when an aneurism on one of the large vessels of a well-developed chest is pressing upon one of the large bronchi, the respira tory sounds, and those elicited by percussion, may be good, but respiration becomes la boured, the case is obscure, but if there is alternate sinking arc) fulness of the lower part of the throat, we may be sure that there is some definite obstruction in the air passages. This, in connection with the history of the case, may lead to the detection of the cause and seat of the disease ; but dyspncea without this feature could not be caused by an aneurism or tumour, In emphysema of the lung this sinking and bulging is very manifest. This circumstance proves simply that there is air in the chest of different density to the external air ; and if so, there must be some impediment in the air tubes, preventing the restoration of at mospheric equilibrium.