No. 2191.

AUGUST 26, 1865.

LecturesON

D Y S P NΠA.Delivered at the Royal College of Physicians,

BY HYDE SALTER, M.D., F.R.S.,FELLOW OF THE COLLEGE;

LECTURER ON PHYSIOLOGY AND PATHOLOGY AT THE CHARING-CROSS HOS-PITAL MEDICAL SCHOOL, AND ASSISTANT-PHYSICIAN TO THE HOSPITAL.

LECTURE II.

What is dyspnœa? ? Phenomena of the simplest example of it.Dyspnwal distress varies as its remediability by qfort. Howthe normal conditions of respiration are modified in dyspncea.Modifications of range of movement; of length of interval ;of ratio of parts of act; of active moving powers; and ofsensation. Laws of disturbances of breath-elements.

DYSPNŒA-what is it ? How shall we define it ? Do wemean by it distressing, painful breathing ? Or need it be onlylaborious and violent ? Or must it be both ? For althoughthe two are generally united, we may have painful breathingwithout any labour or violence, and laborious breathing with-out any distress. I think either may be called dyspnœa; forthe meaning of the Greek 5us, answering to the Latin difficilis,

’

is not the same as our " difficult’*’; it has a wider, more genericsignification, and indicates merely something wrong or de-fective, something abnormal, in that to which it is applied.

Let us now take a given case of dyspncea, and let us analyseit, and see in what way those five characteristic circumstancesof healthy breathing that I have mentioned are modified ; andlet us suppose the simplest case of pure uncomplicated dys-pnoea, that we can imagine-the dyspncea of violent exercise ina healthy person. Suppose, then, a man has run a mile tocatch the train; he arrives just too late, and sits down in thewaiting-room to recover his breath : if we carefully examinenis respiration what shall we find ? In what does his dyspnosa,consist ?

There is, in the first place, a particular sensation present,an intense feeling of want of breath, that forces on him aviolent, panting, rapid respiration ; it is imperious, he cannotresist it, it drives him to such violent breathing that he isunable perhaps even to speak, he cannot spare a particle ofbreath for any purpose except the relief of this irresistiblesensation. This feeling, the besoin de respirer of the French,so difficult to describe, but with which we are all so familiar,is the first link in the chain, the cause of all the other phe-nomena of dyspnœa, and its intensity may be measured bytheir violence. I believe it to be, as I said just now, the samein kind as the ordinary feeling that prompts to a natural tran-quil inspiration, but so aggravated, so intense, as to give riseto results altogether dissimilar, and to seem to a superficialobserver quite a superadded and distinct sensation. If, how-ever, we hold our breath and watch our own sensations, I thinkwe shall find that it is merely an accumulation of the primaryfeeling; first, it suggests, then it commands, and then it com-pels to breathe. It is, however, a very difficult subject toform a correct opinion on. Moreover, it would be very difficultto define what the feeling is : it seems to consist partly in abursting feeling in the chest, a choking sense of fulness in thethroat, a feeling of fulness in the head and scrobiculus cordis,and a peculiar sensation beneath the sternum something like asense of heat. Of its cause there can be no doubt. It evi-dently depends on a condition of arrears in the lungs, the pre-sence of imperfectly decarbonized blood in them, and thecapillary congestion therefrom resulting. This disturbance ofvascular balance, this temporary capillary arrest, at once givesnotice of its existence by this peculiar sensation, probablythrough the intervention of the pneumogastric nerve, and thesensation at once induces the appropriate respiratory efforts bythe efferent nerves -the phrenics, intercostals, external re-spiratory, &c. Thus we see that the muscular phenomena ofc’tyspncea are of the same reflex character as those of ordinarybreathing, and that the segment of the nervous centres engagedin this renexion is the same-the medulla oblongata and theupper part of the spinal cord; and, further, that it seems to

belong to that class of reflex actions in which a certain 8ensa -tion forms an essential link in the chain, as we see, for ex-ample, in faucial deglutition. Dyspncea, then, as contrastedwith ordinary breathing, appears to be merely an example ofincrease of action from increase of stimulus.There are one or two curious things about this sense of

dyspnoea which I have observed. Under the influence of over-whelming emotion it seems to be entirely lost. If the breath-ing of persons suffering from intense grief is watched, it willbe seen that they breathe at very long intervals-that theirchest will remain for some time in a state of perfect quiescence,as if they were never going to breathe again-that their re-spiration consists of a succession of distant sighs, the intervalsbetween them being quite regular, and each respiration aseparate and voluntary act, and the time at which it shall beeffected a matter of choice. And this is really the case : allnecessity of breathing, all sense of dyspnœa on suspendingthe breath for an indefinite period, is lost. I have beentold by those who have described it to me, that they felt asif they never should, and never should want to, breathe

again; that after the suspension of the breathing for sometime they became alarmed at themselves, and voluntarilybreathed, fearing the consequences of longer suspending it. Ihave watched such breathing more than once, and I think Iam not exaggerating when I say that I have seen an intervalof half a minute between the sighing respirations, without,apparently, the slightest distress. I have observed the samekind of breathing in cases of extreme exhaustion, and accom-panying nervous headache.Another thing I have noticed is that the amount of dyspnoea,

at least of the sense of dyspncea, is not proportionate to theamount of injury inflicted on the respiratory organs and theimperfection with which respiration is performed, but that thedyspncea produced by some causes is much more intense anddistressing than that produced by others ; that a large amountof injury of one kind will produce much less respiratory dis-tress, less violent and agonizing efforts, than a small amountof another ; that pneumonic consolidation of the lung, for in-stance, to an extent that shall prove speedily fatal, will pro-duce less urgent and distressful dyspnoea than a degree ofasthmatic contraction of the bronchial tubes that may be bornewith impunity for weeks. A patient with phthisis may nothave a quarter of his lungs at his command for the purposesof respiration, but his dyspnoea will be nothing compared tothat of an asthmatic. And I think in this tendency of dif-ferent forms of lung-injury to produce different and altogetherdisproportionate amounts of dyspnoea, I have detected thiscurious law : that the amount of the sense of dyspncea pro-duced does not depend upon the amount of injury inflicted,but on the remediability of the abnormal condition by thoseviolent respiratory efforts that the sense of dyspnoea engenders.A man who has one lung consolidated is not placed under bettercircumstances by any amount of respiratory effort ; it cannotmake his solidified lung do any work, and the respiratorypower of his breathing, pervious lung it can but increase in theslightest degree. The respiratory distress, therefore, thatwould be useless, is not induced, and we see him lying on hisback, breathing short it is true, but with tolerable tranquillity:there is no violence, no agonizing urgency, no starting andstraining of the muscles. How different the condition whenthe source of the dyspnœa is such as violent respiratory effortsmay remedy! Take asthma, for example, where the lung-structure-the actual seat of the respiratory changes-ishealthy, but where the difficulty is in getting the air to andfrom it through the constricted air-tubes. Here the amountof air supplied to the lungs, and consequently the amount ofrespiration actually effected, will be in exact proportion to theamount of extraordinary effort with which the air is drawnand driven through the narrow tubes ; for rapidity of streammay in some degree compensate for its tenuity. And see howviolent these extraordinary efforts are : watch the asthmaticlabouring for his breath; looked at his raised shoulders, hisfixed head, his respiratory muscles contracted as tight as

cords, and recognise in the expression of his face the agony ofthe sensation that compels such effort. I think, then, thatthat source of dyspnœa will produce the greatest distress whichcan be the most remedied and bettered by violent respiration ;in other words, that the further the mischief is removed fromthe ultimate lung-substance the greater the dyspnœa-that thedyspnoea of asthma is greater than that of pneumonia, of laryn-gitis than asthma ; and I think that anyone who has watchedthe expression of countenance and the action of the diaphragmand sterno-mastoids in laryngeal narrowing will be inclined toagree with me.

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But to return to our belated traveller whom we left pantingin the waiting-room. If we watch his breathing we shall seethat, besides this particular sensation of which he himself aloneis conscious, it presents many points of divergence from thenormal standard of respiration; that the muscular phenomenapresent an exaltation proportionate to the exaltation of thesensation that gives rise to them; that the length of the respi-ratory interval, the range of movement, the proportion of thedifferent parts of the act of respiration, and the agency em-ployed, are all modified.

In the first place, he breathes short-the length of the respi-ratory interval is diminished; instead of performing sixteen oreighteen respirations a minute, he performs from forty to sixty,and this increased rapidity of breathing depends chiefly, as weshall see presently, on a shortening or suppression of certainparts of the respiratory act.

In the second place, the range of movement is increased-hebreathes deep ; instead of the hardly perceptible elevation ofthe ribs and sternum that we see in tranquil breathing, thechest is violently distended at each inspiration with a strongheaving action; if the dyspnoea is very great, the shoulders areraised and the head slightly thrown back every time the breathis drawn in, and if any part of the dress is tight it is unfastenedto give more room for the play of the ribs. The result of thisextended range of respiratory movement is, that three or fourtimes the usual amount of air is breathed at each respiration.

In the third place, the relative proportion of the threestages of a complete respiratory act-inspiration, expiration,and rest-is lost. The post-expiratory rest is altogether sup-pressed ; the moment the air is driven from the chest by expi-ration a fresh relay is demanded, there is no time to spare fora state of quiescence, the exigencies of the case do not permitthis lost time; the commencement of the inspiration, there-fore, starts immediately from the termination of the expirationwithout the intervention of any pause whatever; thus thewholeof the time of the respiratory interval is devoted to respiratoryaction. But not only is one of the stages of normal respirationthus wiped out, but the absolute and relative length of thetwo that remain is changed; both are shortened, but inspira-tion vastly more than expiration, so that, instead of the onebeing twice as long as the other, they are of about equal length--that is, the expiration is somewhat shortened, and the inspira-tion so greatly so that it takes no more time than the expira-tion. In tranquil breathing the muscular effort of inspirationis so slight (being in proportion to the exigency it has to satisfy)that it is some time in overcoming the elasticity of the parietesand the contractility of the lungs, both of which opposethe enlarging of the chest; but the muscular exertion employedin the violent breathing succeeding exercise is so great that theopposing forces are quite unequal to antagonize or impede it,and yield instantly to it as if they did not exist. Thus in-spiration is instantaneously effected, as instantaneously as ex-piration, which has nothing to oppose it but the friction of theair in the tubes. The deliberate and characteristic rhythm of Itranquil breathing is thus lost, and is converted into a rapidsee-saw.

In the fourth place, the active moving powers are altered.Of inspiration, not. The moving power of inspiration in naturalbreathing is muscular; in the dyspnoea of exertion it is alsomuscular. But the natural moving power of expiration hasbeen supplanted by a fresh one: it is no longer mainly elastic;it has become, like inspiration, muscular. The air is forcedout, as it has just been drawn in, by muscular effort : the ex-piratory muscles drive it forth, as the inspiratory have justdrawn it in. The result of this superaddition of muscularforce to the resiliency of the lungs and parietes is, that expira-tion is performed in a shorter time; and this shortening ofexpiration is the very object of this accessory force being calledin. The ordinary passive recoil of lungs and chest-walls, whenreleased from the action of the inspiratory muscles, would notdrive the air forth quick enough to satisfy the respiratoryexigencies which the exercise has created ; muscular force,therefore, comes in to help it, and pumps the air out in halfthe time. Thus, with regard to the motive power, there is achange in the dyspncea of exercise, both at inspiration and ex-piration : at inspiration a quantitative change merely, moreforce of the same nature; at expiration a qualitative change,one force being supplanted, or rather supplemented, by another.We see, then, that in this simplest exhibition of dyspncea-

that which consists in a mere increased activity of the functionin organs perfectly healthy-every one of the five conditionsof normal breathing is changed: the range of movement, thelength of respiratory interval, the ratio of its parts, the activemoving powers, and the sensation.

But these changes do not always coexist in the same way asin the instance which I have cited; nor where they do coexisthave they the same relation and proportion to one another.In some forms of perturbed respiration we find one of the con-ditions of normal breathing modified, and in some another; insome only one, in some several; in some the change is in onedirection, in some in the opposite; in some the variations fromthe regular standard are grouped in one way, in some in avery different one. And these peculiar departures from thenormal standard of breathing are not irregular or uncertain,but are constant, and are always present in those forms ofdyspnoea of which they are respectively characteristic, andbear an immediate and interesting relation to the particularway in which the dyspnoea in each case is brought about. Onesource of derangement of respiration will throw out one set ofrespiratory phenomena and leave the others unaffected; andwhat shall be thrown out, and what shall not, will dependentirely on the direction in which respiration is assailed. Thusa disturbance of the machinery of respiration of one kind willespecially affect the amount of movement; of another, thelength of interval; of another, the ratio of parts of the act ;and so on. To point out these interesting relations, to showwhat divergencies from the natural standard we get in oneform of perturbed respiration and what in another, and thushow the varieties of dyspnoea may become diagnostic of theircause, is the principal purpose of these lectures.’ Let me now, with the view of illustrating this point, directattention to the accompanying table.

We see, in the first place, that movement may be disturbedin two ways-on the side of deficiency, and on the side ofexcess. We have a good example of deficient respiratory move-ment in pleurisy, where, from the pain to which free respira-tion gives rise, the muscles refuse to raise the parietes of thechest. The movement is so superficial and slight as hardly tobe perceptible, and is often not sufficient to produce any re-spiratory sound; on listening over the affected side there isperfect silence instead of the natural respiratory murmur.What amount of air is changed at each respiration under thesecircumstances I cannot say, not having had an opportunity ofestimating it in a case of pleurisy ; but I should have no doubtthat it often fell below half the normal quantity. In asthma,too, although there are the most violent efforts, there is verylittle real movement; the chest-walls are almost stationary,and the respiratory murmur often nil.On the other hand, movement may be disturbed on the side

of excess, as in the case of exercise; and this is the side onwhich it is disturbed in almost every form of dyspnoea. Andfor this reason, that as dyspnoea is always engendered by someimpediment to the discharge of the function of respiration, ordamage in its organs, it immediately suggests a wider range ofmovement as the most direct and efficient means of restoringthe respiratory balance, either by antagonizing the impedimentor enabling the uninjured portions of the lung to do doubleduty. The sequence of increased range of respiratory move-ment on any source of dyspnoea is inevitable ; it is indeedphysiological, and it may be said to take place in every caseexcept where the source of dyspnoea is of such a nature as toforbid it.The length of interval maybe disturbed in three ways : it

may be too short, too long, or irregular. In almost all disturb-

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ances of respiration the breathing is too quick, and for just thesame reason as the range of movement is too wide-in order todo more work in the same time, and so countervail as far aspossible the disadvantage under which the function is labour-ing. If a man is making forty respirations in a minute, he is,of course, changing twice the quantity of air that he is if hemakes only twenty respirations of equal depth in the sametime. This beyond a doubt is the final cause of shortened

respiratory interval, as its efficient cause is, I believe, and as Imay have occasion to show, the state of the pulmonary capil-lary circulation (the quality of its blood and its state of phy-sical balance) acting through the centripetal pulmonary nerves,and by means of that particular sensation to which I have.called attention.

In some cases, however, the respiratory interval is too long.And as with regard to range of movement those dyspnceas inwhich breathing is superficial are those in which deep breath-ing is forbidden, so, with regard to the length of interval, thosedyspnoeas in which breathing is morbidly lengthened are thosein which quick breathing is physically impossible. The greateause, in fact, of a respiratory interval unnaturally prolongedis such a narrowing of some part of the air-passages as makesit.impossible to get sufficient air through them to complete arespiration in the given natural period. We see a good exampleof this in cases of laryngeal constriction, where the chink ofthe glottis is often so narrowed, and the thread of air drawnthrough it so slender, that it takes three or four times as longto get the normal quantity of air into the chest as would sufficefor an ordinary inspiration. The same difficulty is of coursefelt at expiration ; so that the respiratory interval is oftentwice as long as natural. I have in such cases, when the wantof air has been agonizing, and the sufferer would have givenanything to have breathed quickly, counted only seven respira-tions in a minute.

There is, however, I must not omit to mention, one form ofprolonged respiratory interval in which there is no difficulty inthe air-passages, but in which the lengthening out of therespiratory acts, and their infrequency, depend on a suspen-sion of the besoira de respirer. We see this breathing, as I havealready mentioned, in cases of overwhelming emotion, such asextreme grief. The breathing is converted into a succession ofdistant sighs, sometimes a quarter of a minute apart, with asuspension of all respiratory action-a state of absolute rest-in the intervals. As I shall have to speak of this form ofbreathing presently I will not say more of it here.There is yet a third way in which the respiratory interval i,

may be disturbed-it may be irregular. There may be theproper number of respirations in a minute, and yet at one timethe breathing may be too quick, and at another too slow-atone time panting, and at another almost sighing. This kindof breathing is frequently met with in hysteria: indeed it ischaracteristic of all emotional states ; and I have not unfre-quently diagnosed hysteria on the very strength of it.The ratio of the parts of the act (expiration, inspiration, and

rest) is modified in two principal ways-by prolongation of ex-piration, and by shortening or suppression of the post-expiratoryrest. The former, the prolongation of expiration, is seen undertwo circumstances-1, when there is any impairment of theexpiratory force (the resiliency of the lung) ; and, 2, whenthere is any impediment to the free ingress and egress of air.How the first kind of cause would act in prolonging expirationis quite manifest: the motive power of expiration being im-paired, the act itself must necessarily be feebly and tediouslyperformed. As long as the elastic contractility of the lung isretained, its tendency to assume a diminished volume is sostrong that the air is instantaneously expelled as soon as theinspiratory forces have ceased to act. But when the lung hasno longer a tendency to assume a diminished volume-when itseontractility is gone-there is nothing to reduce the capacityof the thorax after inspiration has enlarged it, except the elas-ticity of the parietes. We see very good examples of this formof prolonged expiration where the contractility of the lung isdestroyed by emphysematous inflation, or by infiltration withtubercle.This form of prolonged expiration, and its rationale, have

long been recognised ; but I think the other form, due to im-pediment in the air-passages, has not been recognised. I thinkthe tendency of impediment in the air-passages to prolong ex-piration, in excess of its action on inspiration, has been entirelyoverlooked. Of the fact there can be no doubt; and, thoughpuzzled by it a long time, I think, now that I have hit uponit, that the explanation is simple and certain. What puzzledme was, that the impediment was of a nature to tell equally oninspiration and expiration ; and that all evidence agrees in

showing that the expiratory force is stronger than the inspi-ratory.* This being the case, one would think that the im-pediment would tend rather to prolong inspiration than expi-ration, as it would be the most quickly overcome at the timethe stronger force is acting-i. e., at expiration. But thisopinion rests on the fallacy that the strong expiratory power,that experiment has shown can be exerted in forced expiration,is actually exerted in ordinary breathing. Such, however, isnot the case. There is every reason to believe that the mus-cular element of normal expiration is an extremely weak one,and that it is effected mainly, as I have already stated, by thegentle and immediate collapse of the chest-walls and lungs themoment they are liberated from the distending action of theinspiratory muscles. Since, then, the force of ordinary in-spiration is a muscular force specially adapted to overcomeconstantly existing antagonizing forces, while the force of orcli-nary expiration is mainly elastic recoil to which nothing iffopposed, and for which, therefore, no strength is required, anyobstruction established in the air-passages, and telling equallyboth ways, would find to overcome it a strong inspiratory anda weak expiratory force, and would, of course, tell more onthe weak than on the strong. Hence any obstruction in theair-passages, no matter what, no matter where, is always at-tended with a prolongation of expiration ; a fact which hasbeen entirely overlooked by auscultators, and which greatlyinvalidates the supposed diagnostic value of prolonged ex-piration.And here I would insist on the importance of recognising

the difference between prolonged expiration expressed bymovement, and prolonged expiration expressed by sound.The greatest confusion prevails with regard to the use of theterm prolonged expiration": it is often used to signifynothing but unduly audible expiration, when really there isno prolongation of the expiratory act. Expiration sound thatis unduly audible from the acquisition of any amount of bron-chial character is always prolonged, always longer than thevesicular expiratory sound, although the collapse of the chest-wall-the expiratory movement-may be as short as natural.The cause of this (which I have explained elsewhere) is, thathowever short the collapse of the pulmonary parenchyma maybe, the outward stream of air in the bronchial tubes, andtherefore the bronchial sound, does not cease until the intra-thoracic air, compressed by the collapse of the chest, and theexternal atmosphere are in equilibrio; for when: the vesicularcollapse has ceased there is still an outward tide in the bron-chial tubes, and the larger the tube, the nearer the orifice, thelonger is it before this outward tide is brought to a standstill.Thus, in bronchial breathing the expiratory sound is alwaysprolonged, although the expiratory movement may not be.We get the highest type of this prolonged expiratory tube-sound in the windpipe, where the expiration sound is alwaysprolonged, let the collapse of the chest be ever so quick. WhatI mean by prolonged expiration is prolonged expiratory move-ment, or prolonged expiratory sound independent of bronchialcharacter.The other way in which the natural respiratory rhythm is

modified is by the shortening, or suppression, of the post-ex-piratory rest, so that the inspiration starts at once from thetermination of the preceding expiration-there is no pause. It

simply means that there is no time to spare, and characterizes,therefore, every form of difficult breathing.The moving power may be deranged in four ways-by dis-

placement, by substitution, by transposition, and by super-addition. By displacement, when, instead of being distributedover the whole of the thoracic parietes, costal and dia-

phragmatic, it is accumulated on, and restricted to, either oneor the other of these surfaces. Where breathing is entirelyperformed by the ribs, and there is no movement of thediaphragm, it is said to be costal, or thoracic where the ribsare stationary, and the diaphragm alone moves, the breathingis said to be diaphragmatic, or abdominal. The former is seenin peritonitis, where the diaphragm refuses to descend; thelatter in pleurisy, where the ribs refuse to rise.

Disturbance of the moving power by substitution-that is,where one force is substituted by another-is seen in the ex-

* Dr. Hutchinson (" Medico-Chirurgical Transactions," vol. xxix.) found,in 1500 observations, that the average greatest inspiratory power was equalto a column of mercury of 2’75 inches; while the expiratory force was equalto 3 97. Mendlessohn (" Der Mechanismus der Respiration") found that theforce of the most powerful expiration was greater than that of the most power-ful inspiration by about one inch of mercury. The most powerful espita.tions were, on an average, between 4’4 and 4’8 inches of mercury. Valentinarrived at a higher standard. He states that the strongest inspirations heobtained were equal to 5’6 inches of mercury, and the strongest expirationsto 8 inches. But in these experiments expiration was made through themouth, which gives the additional force of the muscles of the cheeks.

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piration of any intense form of dyspnoea, as of asthma, wherethe elastic resiliency of the lung being no longer adequate todriving the air through the narrowed air-tubes, a musculareffort comes to its assistance towards the end of the expira-tion, and pumps the air out with a jerk. Elastic force hashere been substituted (or supplemented) by muscular. I be-lieve in all severe dyspnceas expiration becomes more or lessmuscular.By transposition I mean the transposing the fixed and

movable extremities of a muscle (or muscles) of respiration.By this means muscles that ordinarily have no respiratorypower may be made to contribute to the respiratory move-ments. Any muscle, in fact, that is attached by one of itsextremities to the head or spinal column, and by the other,mediately or immediately, to the ribs, may in this way be-come a respiratory muscle. Thus the sterno-mastoid, that isordinarily a rotator (or, the two acting in conjunction, a for-ward flexor) of the head, becomes, by the head being fixed, anelevator of the sternum and clavicle. And this transposition(or rather its attempt) takes place even in muscles whosemovable extremity is incapable of becoming fixed, and whichcannot have, therefore, really imparted to them a respiratoryaction. They belong to the class that can-to the class thathave a costal and a non-costal attachment; and therefore theyare set in action along with the others. But since their non-costal extremity cannot be fixed, their contraction results inthe movement of the part to which this is attached, and not inthe movement of the ribs. And thus we see, in extreme

dyspnoea, not only movements of the chest, but movements ofthe head and shoulders. A curious example of this is seen inthe descent of the jaw that accompanies each inspiration insome dyspnceas-as, for example, in asthma. The true expla-nation of this is, I believe, as follows. All muscles passingdown to the shoulders are muscles of extraordinary inspiration,and are called into action in violent dyspnoea, because, by ele-vating the shoulders, they enable the muscles passing downfrom them to the ribs to act with greater force. The omo-

hyoid is such a muscle; in dyspnoea it therefore contracts ateach inspiration. But unless the hyoid bone is fixed, theaction of the muscle could only issue in drawing this down,and not in raising the shoulder. With the view, therefore, offixing the upper attachment of the muscle, the elevators ofthe hyoid bone-genio-hyoid, mylo-hyoid, and digastic-con-tract at each inspiration; but the hyoid bone being held downby the omo-hyoid, these muscles, instead of elevating the bone,depress the jaw; hence the gaping movement at each inspiration.By superaddition I mean the calling in for the performance

of the respiratory act that vast array of muscles which we seein action in violent dyspnoea, but which are not used in ordi-nary breathing-in fact, superadding to the muscles of ordinaryrespiration the muscles of extraordinary respiration. Breath-ing can never become difficult without the muscles of naturalbreathing becoming supplemented by these exceptional muscles;the number of muscles so superadded, as well as the violenceof their action, corresponding to the intensity of the dyspnoea.

Lastly, the sensation that regulatcs the respiratory move-ments may be exalted or defective. In every form of perturbedrespiration that I am acquainted with, with one single excep-tion, the besoin de rc,81)irei, is exalted. It is the most intense inthose cases where, the integrity of the lung-tissue being un-affected and the supply of blood free, the access of air is pre-vented ; and its intensity in such cases is proportioned to thesuddenness and completeness with which the air is excluded.The conditions, therefore, of its greatest development are theconditions tending to flood the capillaries of the lungs withvenous blood. The same amount of suspension of aeration ofthe blood, if it is brought about by a cause tending also taexsanguine the parts of the lung affected (as in 1-)hthi,), or to.diminish the quantity of blood in the body (also as in phthi,3,is),may be attended with a hardly perceptible development of thesensation. In sudden impaction of a main air-passage, inlaryngitis, croup, and asthma, we see the best-marked speci-mens of its exaltation.But there is one form of dyspncea, and only one that I know

of, in which the sense of want of breathing seems suspended, orgreatly deadened. In the long-drawn, occasional, and sighingbreathing of intense grief, and the breathing of the same kindthat characterizes a state of exhaustion (as after tobacco.smoking), the besoin de respirer appears greatly deficient. Topersons in this condition it seems a matter of indifferencewhether they breathe at all or whether they do not: each actof breathing, and the time at which it shall be performed,seems a matter of deliberate choice rather than of necessity ;and the interval between one inspiratory act and another issometimes so long as to suggest a fear that another breath willnot be taken. I am sure, from observation on my own person,that this form of respiration, at least that manifestation of itthat is produced by intense emotion of a depressing kind, de-pends upon an almost complete suspension of the respiratorysense; there seems no more desire to breathe at the end of a

long interval of suspended respiration than at its commence.ment.

Such, then, are the ways in which these five elements ofactive respiration may severally diverge from their normalstandards. Many more examples might be given of each; butthose that I have mentioned are some of the best marked, andthey may suffice. It must not be imagined, however, thatthese perturbations occur separately-that in one case therange of movement is modified, and nothing else; in anotherthe length of interval, and nothing else ; in another the movingpower, and nothing else. The five conditions of normal breath-ing that I have indicated are so intimately associated that inalmost all forms of disturbed respiration more than one is in-volved, and generally all, or nearly all. And there are certainlaws of association of these disturbances which are not withoutinterest, and of which the following are those which my obser-vations have enabled me the most clearly to detect. They areindicated in the following table, the numbers of which havereference to the preceding table :-

a. Disturbed length of respiratory interval is generally ac-companied by disturbed ratio of the parts of the act, at leastthat disturbance of ratio that is involved in the suppression ofthe post-expiratory rest ; and for this reason, that respiratoryconditions that demand an increased range of movement areconditions that forbid the post-expiratory rest.

b. The converse, however, does not always hold-that is,disturbed ratio of the parts of the act is sometimes not accom-panied by disturbed length of respiratory interval. For ex- Iample, a narrowing of the air-passages, while it prolongs ex-

I

piration and suppresses the post-expiratory rest, thus completelyderanging the respiratory rhythm, will yet directly preventacceleration of the breathing by rendering a rapid and free supplyof air impossible, so that the respiratory interval may be aslong as natural.

c. Range of movement, length of interval, and ratio of the

parts of the act, may all be disturbed without any respiratorydistress ; and this simply from the fact that increased re-

spiratory exigency may be sufficient to produce the one withoutbeing sufficient to produce the other; respiratory arrears mustbe considerable to produce distress; they need be but veryslight to modify the three first-mentioned conditions of normalbreathing.

d. Distressful breathing, however, never exists without thebreathing being modified in all other particulars ; because re-spiratory arrears sufficient to give rise to distress inevitablygives rise to disordered and violent breathing with the view ofrelieving it, and because the sensation is set as a taskmaster,as it were, over the act, as the regulator of it-its behests areabsolute and irresistible, and physiologically inseparable fromtheir execution.

e. The following is the order in which a gradually increasing

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respiratory exigency would modify the conditions of normalrespiration. The first thing modified is range of movement;then, length of interval, or ratio of parts of act (I am not surewhich first) ; then, the sensation; lastly, the moving power.For example : suppose there is something that taxes the breath-ing to the slightest possible extent ; it will be a little deeperthan natural, and changed in no other way. Supposing thebreathing is taxed a little more, it will then be not only deeper,but quicker, and the ratio of the parts of the act disturbed bythe shortening or loss of the post-expiratory rest ; still theremay be no distress or marked sense of breathlessness. If the

breathing is taxed a little more, it becomes distressful; stillthe moving powers may be normal-inspiration muscular, ex-piration elastic recoil. Tax it, however, to the utmost, andthe expiration becomes muscular-the air is pumped out bythe expiratory muscles to quicken the act as much as possible.Such are the principal laws of respiratory disturbance as far

as I have yet made them out. I have determined them partlyby self-scrutiny, partly by observation upon others, partly byexperiment.

TWELVE CASES OF COMPLETEDOVARIOTOMY.

BY I. BAKER BROWN, ESQ., F.R.C.S. (EXAM.),SENIOR SURGEON TO THE LONDON SURGICAL HOME, ETC.

I WOULD place on record, as bearing upon the recent discus-sion in the pages of THE LANCET, my last twelve cases of com-pleted ovariotomy. This I think to be due to myself, as myname has been freely used 1>y the disputants, and as I am oneof the oldest ovariotomists, and have spent more than thirtyyears in steady work on the subject of ovarian disease.CASE 1. -41-altilocular ovarian dropsy, twelve months’ duration;

ovariotomy,. recovery.-Miss V-, aged twenty-nine, suffer-ing from a large abdominal tumour, came under my care inNovember, 1864, on the recommendation of her medical at-tendant, Mr. Thorne, of Pimlico. She had been ill for twelvemonths, and attributed the first formation of the tumour toexcessive weakness after great excitement. The catameniahad been regular at first, but had afterwards ceased for fivemonths. Eight months prior to the time when first I saw her,she had an attack of inflammation of the liver.On examination, the tumour proved to be ovarian, doubtless

multilocular, and with very numerous adhesions. The patientwas extremely emaciated, and food always caused sickness. Shewas exceedingly anxious to have the tumour extirpated, and,after a short course of preparatory treatment, I operated onthe 21st of November. Dr. Cole of San Francisco, Dr. Martinof Berlin, Dr. Duke of Bengal, Mr. Thorne, and others, werepresent.Having made my primary incision, I found, as I had antici-

pated, very numerous and firm adhesions. In fact, the tumourwas adherent almost everywhere. One broad mass of adhesionto the parietes, situated near the upper end of the incision, Isecured by a double ligature, and retained it outside the abdo-men by transfixing it with a long-handled needle below theligature, so as to ensure sloughing outside the peritoneum.Besides this adhesion, there were adhesions along the wholeborder of the omentum to the liver and to the right pelvicfascia. All these I divided by the actual cautery in the man-ner I have lately advocated. Having first secured the adhe-sions piece by piece in a clamp, I then seared them through witha red-hot iron. The separation of the adhesions occupied onehour. The pedicle was secured by a clamp, and retained out-side the abdomen. The wound was closed in the usual way.

After the operation a severe form of low peritonitis super- ’ivened, and she was only kept alive by very active and per-severing stimulant treatment. She was, however, able toleave her bedroom a month after the operation, and a week ’,afterwards she took open-air exercise. ’

CASE 2. Ovarian dropsy of five yn.ars’ duration; doubtful dia-gnosis; exploratory incision; extirpation; recovery. (Abridgedfrom notes by Dr. Bottle, House-Surgeon.)-Mary Ann A ,aged thirty-one, was admitted into the London Surgical Homeon the 7th of November, 1864. She was sent by Dr. Taylor,Queen’s-road, Bayswater. About five years before, she firstdiscovered a swelling of the abdomen on the left side, causingso much excitement of the nervous system and pain that shewas thought to be mad. The bowels were costive; the cata-

menia regular. On examination, a large abdominal tumourwas found, having a very indistinct sense of fluctuation. Thebowels were much disturbed from pressure of the tumour. Onan exploring needle being passed into the tumour no fluid

escaped. The patient was very hysterical, continually scream-ing and crying. Twenty-four hours after the explorationphlegmasia dolens of the left leg took place, and continuedtwo or three weeks.

After careful preparatory treatment, I operated on the 22ndof December, the patient being under the influence of chloro-form. The primary incision was about four inches long, andthe tumour was quickly brought into view. The nature andappearance of the tumour were peculiar. In colour it was ofa dark-brown, in form almost globular, with a very regularsurface. It was exceedingly elastic to the touch, was movablein every direction, and very much resembled an enlarged uterus.Having extended the incision two inches, the tumour waspunctured, and about half a pint of dark, sanguineous fluidescaped. The tumour was then withdrawn, numerous adhe-sions to the peritoneum being broken down by the hand. The

pedicle, which was of the same nature as the tumour, andproceeding from the right ovary, was secured by a clamp. Aportion of diseased omentum was removed by the red-hot iron,and several bleeding vessels were also stopped by the actualcautery. The wound was then closed in the usual manner.

This patient recovered slowly. Having a very irritablestomach, it was necessary to sustain her almost entirely formany days by beef-tea injections. The discharge from thewound was of an unusually offensive character. The clampwas removed on the fifth day, and the stitches on the thirteenth.She was discharged on January 17th, 1865, quite well, and upto this time has remained in perfect health.

This was a very interesting case from the difficulty of dia-gnosis. It will be observed that even the exploratory needlefailed to throw light upon it. It was only by an exploratoryincision that the true origin of the tumour was discovered.On examining the tumour after removal, it was found to be

composed of separate cells with true cystic linings; but thefluid was almost entirely sanguineous. This tumour was exhi-bited at a meeting of the Obstetrical Society.CASE 3. jMMOCM!?* ovarian dropsy, five months’ duration;

ovariotomy; recovery.-Mrs. Mary P-, aged forty-seven,came under my care in December, 1864. The following historyis from notes by Dr. Burchell, of Kingsland-road, the patient’susual medical attendant :-

Mrs. P- is married, and the mother of three children,the last born twenty-one years ago. She has not been preg-nant since. Although of rather full habit, she has always en-joyed good health, with the exception of suffering from analfistula seven years ago, which was relieved by operation. Thecatamenia ceased last June. In the middle of last August atumour was discovered in the left groin. She had suffered fromflatulence and pain on the right side for some weeks previously,but at this date there were no signs of effusion. Dropsy firstmanifested itself shortly afterwards, and rapidly increased.On examination, I discovered a very large multilocular ova-

rian tumour. It was evidently growing very rapidly. I there-fore advised immediate removal.The operation was performed on the 28th December, Dr.

Burchell, Mr. Clarke, and others being present. I extirpated.the tumour, which was attached to the left ovary. It containedabove three gallons of fluid, and the solid matter weighedabout six pounds. The adhesions were very extensive and un-yielding, more especially on the left side. So firmly was thecyst adherent to the peritoneum, that the latter was torn fromthe rectus muscle, and the tear required to be stitched up withtwo silver sutures. Actual cautery was applied to the bleed-ing vessels, and the pedicle was divided by Mr. John Clay’sadhesion clamp, and immediately allowed to sink back into itsnormal position.The wound was healed in a week, and the patient recovered

without an unfavourable symptom.CASE 4. -Jr2tltilocitla2- ovarian tumour of fifteen months’ dura-

tion; one previous tapping ovariotonay; recove1.y.-Miss B I.aged twenty-two, a patient of Dr. Greenwood’s, of Dalston,came under my care, by his recommendation, on the 25th ofFebruary in the present year. A tumour had first been dis-covered in the right side about fifteen months before. Thisincreased to so great a size that the patient was obliged to betapped six months back, when three gallons of thick brownfluid were drawn off. The cyst refilled rapidly, and soon be-came as large as before tapping. The general health was good,although the patient was not strong. On a careful examination