The neck-muscles drag up the comparatively immovable and rigid thoracic case, while the diaphragm descends. The inspiration here is the antithesis of the swell and fall of a woman's bosom. (Why a woman's boson? an unreflecting reader may ask. Because a woman's thoracic space is liable to be physiologically impaired from below by a gravid uterus; and when the full term of pregnancy is being reached, her respiration is almost entirely thoracic.)

In asthma the same laboured respiration may be seen. It may be cardiac asthma when the breathing is both laboured and rapid; or at other times, and more commonly, laboured and deep; or it may be true spasmodic asthma, with diminution of the lumen of the air-passages. When the air has to be forcibly drawn through narrowed air-tubes, then the breathing cannot well be rapid; it must be deep. Rapid breathing is incompatible with obstructed air-passages. They, at least, are unimpaired in rapid respiration!

The study of the character of the respiration in each case of thoracic trouble is highly interesting, as well as instructive. It is most easily carried out in large wards, where various forms of thoracic disease are lying side by side, when the character of the respiration in different forms becomes very manifest; and is, almost, in itself sufficient to indicate the malady, or the leading factor in a complex case.

Nor must the reader be under the impression that the typical barrel-shaped' thorax of emphysema is alone compatible with it. He will often be surprised to find extensive emphysema with the flat chest supposed to be peculiar to phthisis-the compensatory emphysema of Niemeyer.

The diaphragmatic breathing will depress all the abdominal viscera from the violent contraction of the diaphragm. Consequently the liver is displaced downwards, and this displaced liver might easily be mistaken for an enlarged liver by a careless observer. The emphysematous lungs overlap the heart, and abolish the area of cardiac dulness more or less completely; sometimes entirely. Abolition of the heart

dulness, and diminution of the liver-dulness till it is only found at the very edge of the ribs, are indicative of confirmed emphysema.

(Emphysema of the anterior fringe of the lungs is very common in athletes, and those who have been subject to efforts at once severe and prolonged. Sometimes the emphysema becomes more general; this may be termed 'the athlete's chest.' It is most commonly found in rather undersized men, where pluck has tried to make up for muscular power. In time the whilom athlete becomes comparatively broken-winded' from emphysema, and is less equal to effort than an ordinary person. This is a matter the devotees of athletics had better take to heart. Emphysema from over-effort is as surely a clinical fact, as that aortic valvulitis is causally linked with prolonged severe muscular effort.)

Effect of Effort. In relation to the matter of observation of the respiration, it is most important often to note the effect of effort. That we possess much spare lung for occasions-without which any unusual effort would be impossible is well known. Consequently in many cases the respiration is calm while quiet is maintained; but any effort reveals thoracic impairment by the respiration becoming quick or laboured. Here there is not enough of mischief to affect the respiration while the patient is quiet; but it becomes palpable enough when any exertion is attempted. The circumstances which give rise to it are exactly those which affect the respiration while quiet, only not so pro

nounced.

That such should be the case with disease of the respiratory organs is readily seen. Nor is it difficult to comprehend why effort should produce shortness of breath in valvular disease of the heart, especially mitral disease; the dam of blood at that point is increased on effort, and so the pulmonic circulation is gorged, and thus the thoracic space is diminished for respiratory purposes. There is one

other condition not so apparent where the effect of effort is to produce breathlessness, and that is in pronounced conditions of anæmia. There the red blood-corpuscles are sufficient for the requirements of the system in quiet; but effort produces breathlessness, compelling quiet.

Nocturnal Dyspnoea.-In certain morbid states the patient is awakened out of sleep by a craving for air. In my own experience this occurs mainly in cases of chronic renal disease; still more when to such renal condition is added the effects of soporifics. Basham called them 'inexplicable dyspnoea.' What it is which palsies the respiratory centre in chronic Bright's disease is not known; but something does. The elimination of carbonic acid is checked until it accumulates to the extent of rousing the respiratory centre to extensive discharges, setting the accessory muscles of respiration into action; with the effect that the powerful inspirations rapidly get rid of the excess of carbonic gas in the blood after which the breathing becomes calm, and the patient, ere long, drops off to sleep. When to this morbid agent, be it what it may, is added the action of an hypnotic, such loss of sensibility in the respiratory centres is readily intelligible. This nocturnal dyspnoea is allied in nature to the paroxysms of palpitation, by which some persons are awakened when the heart is not in its integrity. Distension of the cavities, usually the right, goes on until it provokes active discharges in the cardiac ganglia (these and the respiratory centre are the rhythmically discharging centres of the organism, see, 'The Antagonism of Therapeutic Agents, and what it Teaches,' p. 60), which set up pronounced muscular contractions; and then palpitation is experienced. Or the patient may awake, feeling as if going to die, the heart's action being imperceptible from a marked fall in the action of the heart in sleep: indeed fainting, or syncope, in sleep is not unknown. It is well to ponder over this nocturnal dyspnoea in relation to the two conditions-cardiac dyspnoea, or cardiac asthma, and Cheyne-Stokes respiration.

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Cardiac Asthma.-The occurrence of cardiac asthma in the night not only alarms the patient, but also those in attendance upon him. It is usually seen with mitral disease, or failure of the muscular walls of the heart. The patient may have been sleeping soundly, when he awakens up suddenly with much embarrassment of the respiration. He sits up in bed gasping for breath, perhaps asking to be fanned; or he clutches the bedclothes convulsively, to fix the arms and shoulders so as to bring the pectoral muscles into play as respiratory accessories; and sits there, 'breathing for dear life.' The countenance tells of the distress he is enduring. The heart may be palpitating forcibly, telling of the energy of the contractions of the right ventricle-for here the right side of the heart is greatly distended. After a time the distended muscular wall recovers itself, and the patient, exhausted by the effort, falls back to sleep, or perhaps sits propped up; thankful the worst of the paroxysm is over, and yet far from being at ease! If the muscular fibres are free from degeneration it is surprising what the patient will endure and survive. He is quite sure another attack will finish him; but he survives another, and yet another. I remember a patient in Westmoreland, a quarry-mason, with a mitral lesion, to whom I was often summoned in the winter of 1868-69, in severe paroxysms of cardiac asthma, which lasted usually some three hours. He lived three miles away, and the attacks came on about two in the morning. So severe indeed were they, in spite of hot poultices back and front, hot spirits and water, ammonia, nux vomica, and digitalis (as well as a steady course of digitalis), that I frequently got out my lancet-case, and stood lancet in hand, ready to open a vein and relieve the right ventricle; if relief was not attained by the other measures. This, however, was never actually required. As spring went on the attacks ceased, the general condition improved from the enforced rest, and the patient went back to work; though past middle age. Ten years later he was working away;

never being laid up till the severe winter of 1880-81 gave him an acute attack of bronchitis, to which he succumbed. These paroxysms are very painful to witness; they are very exhausting, and if the medical man be either timid in his measures or inattentive to the indications, are fraught with great danger. These attacks are often strictly related to the patient's supper; a weight in the stomach, or a quantity of gas in it, pressing upon the distended right ventricle through the thin aponeurotic portion of the diaphragm, impedes its action, and pulmonary congestion with acute distension of the right heart follows; or the patient gets up to stool, and becoming chilled on getting into the cold bed, a paroxysm of dyspnoea is set up; and this may occur though a fairly good fire is maintained, especially in winter. It may occur at other times than in the small hours of the morning; but these are the ordinary times at which attacks of cardiac asthma manifest themselves. The injected features distinguish attacks of cardiac asthma from spasmodic asthma; and, as a rule, the patients are more seriously ill, though perhaps not more distressed!

Cheyne-Stokes Respiration.-This is a curious rise and fall in the respiration. Stokes describes it graphically (using 'apnoea' in a sense the opposite of the apnoea' of the modern physiologist): 'It consists in the occurrence of a series of inspirations, increasing to a maximum; and then declining in force and length, until a state of apparent apnoea is established. In this condition the patient may remain for such a length of time as to make his attendants believe that he is dead; when a low inspiration, followed by one more decided, marks the commencement of a new ascending and then descending series of inspirations. This symptom, as occurring in its highest degree, I have only seen during a few weeks previous to the death of the patient. The decline in the length and force of the respirations is as regular and remarkable as their progressive increase. The inspirations become each one less deep than