THORAX. 



1083 



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 

 pulinonalis. 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 

 to be expanded. The hand can measure most 

 delicately this healthy characteristic swelling or 

 fillingupoftheapexbetterthan any instrument, 

 because the hand covers alarge 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 scapulas. 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 

 now 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 dyspnoea, 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 pleurse, 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 "requisite 

 for 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 dyspnoea 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 inspirator^ 

 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 

 dyspnoea which does not exist in another. 



Dyspnoea 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, dyspnoea 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 and 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 ofthe cause and 

 seat ofthe disease ; but dyspnoea 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 



