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Cheyne-Sto^

Respiration,

6. A. Gibson, M.D., /),6'<".

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CHEYXE-STORES RESPIRATION.

CHEYNE-8T0KES

RESPIRATION.

GEORGE ALEXANDER GIBSON,

M.D., D.Sc, F.R.C.P.E, F.R.S.E.,

ASSISTANT PHYSICIAN TO THE ROYAL INFIRMAKY OF EDINPCROH ;

LECTUKER ON TUE PUINCII'LKS AND PRACTICE OF MEDICINE AT MINTO HOUSE ;

EXAMINEE ON MEDICINE AND CLINICAL MEDICINE IN TUE UNIVEUSITY OF

GLASGOW.

EDINBURGH: OLIVER AND BOYD.
1 8 y 2.

Digitized by the Internet Archive

in 2010 with funding from
Columbia University Libraries

http://www.archive.org/details/cheynestokesrespOOgibs

Sir DOUGLAS MACLAGAN, Kt.

M.D., LL.D., F.R.C.P.E.,

PnOFESSOR OF MEDICAL JUUISPKUDEKCE IN THE rxS'IVERSITT,

CONSULTING I'lIYSICIAN TO THE ROYAL INFIRMARY,

PBESIDENT OF THE ROYAL SOCIETY OF EDINBURGH,

THIS LITTLE WORK IS DEDICATED

IN TOKEN OF
ADMIRATION AND AFFECTION.

PREFACE.

— «♦

Tfie contents of tlie following pages have appeared from time to
time during the last three years in the pages of the Ediahurfjh
Medical Journal under the title of " An Examination of the
Phenomena in Cheyne-Stokes Respiration.' The somewhat
lengthy period over which the publication of these papers has
extended has not, perhaps, been altogether a disadvantage, as it
has allowed full opportunities for considering the many questions
involved in the explanation of a symptom so complex as that with
which tiiis work is concerned.

It is a duty as agreeable to, as it is incumbent upon, me to
express my warm thanks to those who have rendered me assistance
in ascertaining the views which have previously been advanced by
others on the subject. I desire gratefully to acknowledge my obliga-
tions in this respect to Drs Berry, Edinburgh; Billings, Wasliington ;
Bull, Christiania; Cowan, Dordrecht ; Edes, Washington; Grawitz,
Greifswald ; Langendorff, Konigsberg ; Pepper, Philadelphia ; and
Schepelern, Copenhagen.

I wish further to express my thanks for copies of the Transactions
of their re.spective societies, which could not be obtained except
througli their kindness, to the Secretaries of the h. Ic. Gesellscha/t
(hr Atrzte zu Wiev, Societc dc Mcdccine el de Pliarmacie de VIsere,
SocUU mcdicalc dc la Suisse romande, Uj^sala Ldharcforcnings
Selskahj and Wisconsin Slate Medical Society.

17 Alva Street, Edinbdroh,
26th September 1892.

CH 1'^ Y N ]>STO K l« RKSPI RATION .

T?EW symptoms have within an equally brief space of time
■^ excited so much discussion as that peculiar modification of the
respiratory rhythm which in every language bears the names of
Cheyne and Stokes, and, as so much has already been written on tlie
subject, there cannot fail to be some hesitation before adding
another to the many contributions towards its elucidation. In our
own country, however, the symptoms which frequently accompany
the type of breatluiig in question are but imperfectly known,
while of the many explanations that liave been advanced to account
for its appearance, very few have been seriously considered, and it
therefore seems unnecessary to give any reasons for bringing the
matter forward once more. During the last four years several
excellent examples of this type of breathing have been under my
observation, and these have led me to study the phenomena which
are linked with it, as well as to criticise the theories that have
been formed to explain its mode of origin. In the following pages
the results of these investigations are fully embodied, and as they
naturally fall into three classes, it will be of advantage to group
them in three divisions: historical, clinical, and critical.

IIlSTOUICAL.

The type of biuathing which forms the subject of the present
remarks has aroused a great amount of interest and produced
a corresponding number of contributions to medical science.
Occurring as it iloes in the course of many varieil conditions,
the symptom is, as miglit be expected, referred to in works
on many ditlV'reiit diseases. The literature of the subject has
tluMvfdrt' assunieil large proportions. Many of tlie writings which
lia\o been (.levitttnl to it are of bnt little value, ami yet they have
served a useful purpose by throwing light upon some of its phases,

A

2 CHEYNE-STOKES KESPIRATION.

or by recording its presence in conditions where it had not been
observed before. Others again are remarkable at once for their
clinical acumen and critical insight. Many even of the most
important are utterly unknown to the literature of this country,
and it seems to be my duty, even at the risk of being here and there
somewhat tedious, to mention, to an extent proportionate to their
value, the different writings on the subject.

Hippocrates, like many other writers of antiquity, has suffered at
tlie hands of his admirers, and his works have so often been wrested
to suit the individual views of subsequent authors, that his name
is only mentioned here with a certain degree of reluctance. It
seems almost beyond doubt, however, that in the First Book of
the Epidemics he makes reference either to the type of breathing
about to be considered or to some nearly allied form of respiration.
In describing the case of Philiscus, who died of an acute disease
of a somewhat indefinite kind, accompanied by an enlargement of
the spleen, he remarks : ^ — " Tovrecp Trveu/uLa Sia TeXeog, wcrxef
avaKoXovfjievw apaiov, jut-eya. In this case, the respiration until the
end, like that of some one recollecting himself, was infrequent and
deep;" or, as it has been rendered by Adams,^ "The respiration
throughout, like that of a person recollecting himself, was rare and
large." The last-named author remarks in a footnote, — " The
modern reader will be struck with the description of the respiration,
namely, that the patient seemed like a person who forgot for a time
the besoin de respirer, and then, as it were, suddenly recollected him-
self. Such is the meaning of the expression as explained by Galen
in his Commentary, and in his work, On Difficulty of Breathing."
In his learned address on Medicine, delivered before the Edin-
burgh meeting of the British Medical Association, Warburton
Begbie^ called attention to this observation of Hippocrates, and
the matter is put so clearly that it will be well to quote his
words : — " It is, however, in respect to the peculiar character of the
breathing that the case of Philiscus acquires its chief interest,
and it is in this particular that a resemblance is to be found
between the ancient and the modern examples now quoted. The
attention of Hippocrates had been arrested by the peculiar char-

1 (Euvres completes d' Hi2)pocrate, par E. Littre, tome ii. p. 684. Paris, 1840.

2 J%e Genuine Works of Hippocrates, vol. i. p. 371. London, 1849.

3 British Medical Journal, vol. ii. for 1875, p. 164.

irrsTOKifAL 3

nctcr nl tlic lutMtliiiiL,' wliicli existccl throughout tli<! Hital iUuess of
IMiihsfus. Purely it is inatLer of interest iind for rcth-'ctinii that
the ri'S|)ii:itioii (h'sfiihctl hy llippocrutus as apuiov fxtya, 'rare
iind liuuc,' ,111(1 In wliicli (lah'ii has attached the lueanin^', ' like a
persoji wlio IniLfot for a time the need of lireathint:, and then
suddenly rcn)end)er6d,' or 'the respiration throu^diout, like tiiat
of a person recollecting himself, was rare and large,' has attracted
great attention in quite recent times. The expression used by
French writers, ' besoin de respirer,' corresponds in some measure
to the meaning wliich is sought to be conveyed by the Greek
words. In Latin the rendering is, ' Spiratio huic perpetuo rara et
magna fuit.' Daremberg, the learned French editor of Hippocrates,
thus translates the i)assage: 'La respiration filt constamment grande,
rare coinme chez quel(|u'un qui ne respire que par souvenir.' "

Attention has recently been called by Gallois^ to the fact that
the type of respiratory rhythm about to be considered was observed
towards the close of last century. In a work by Nicolas, a physi-
cian of distinction at Grenoble, entitled, Histoire dcs maladies
epiddmiques qui ont regne dans la province de Dovj^hivy dejniis
I'dnnee 1780, and published at Grenoble in 1786, there is a
description of a respiratory phenomenon which appears to be
identical with Cheyne-Stokes breathing. Narrating the case of a
general ofhcer, aged 81, suffering tVom a complication of senile
affections, he describes the respiratory ]>hen(inienon, after re-
ferring to the .state of the pulse which was extremely irregular, in
the following manner: — "Mais ce qui etait bien plus extraor-
dinaire que cette irregularite, c'etait une suspension absolue, uue
f^riation des mouvements du poumon pendant vingt-cinq ou
trente secondes, a chaque trente-cinquieme ou trente-sixifeme
respiration ; alors le jeu de I'organe se retablissait pen i\ pen, et
])ar uue gradation trfes sensible, il reprenait son energie oidiuaire,
pour cesser de nouveau t\ pen prtis ;\ I'instant marqud."

It will be ol)Served that the a.scending phase of C'heyne-Stokes
respiration is accurately described in the quotation just given,
although there is no mention of a period of descending respiratit^n,
and it is impossible to avoid coming to the conclusion that

' Journal de In Svci^t^f de M^decine r( de PhcniiKtrie de PI.<rrf, 8"" aiuioo,
1>. 267, lfS84.

4 CHEYNE-STOKES RESPIRATION.

Nicolas had before him a typical example of the breathing now
under consideration.

With the exception of the observations made by the Father of
Medicine and by the learned physician at Grenoble, the peculiar
form of breathing which we are about to consider remained
unnoticed until Cheyne, who carried the torch of medical science
from our own shores to those of the sister island, observed
it anew. In reporting' a case of fatty degeneration of the
heart, he thus describes tlie type of the respiration: — "The only
peculiarity in the last period of his illness, which lasted only
eight or nine days, was in the state of the respiration. For
several days his breathing was irregular ; it would entirely cease
for a quarter of a minute, then it would become perceptible,
though very low, then by degrees it became heaving and quick, and
then it would gradually cease again : this revolution in the state
of his breathing occupied about a minute, during which there
were about thirty acts of respiration." Tn the description of the
dissection, it is noted that there were between three and four
ounces of fluid in the ventricles of the brain. A very interesting
observation, which has most frequently escaped the notice of
subsequent writers, is contained in a footnote, where Cheyne
remarks:^ — "The same description of breathing was observed by
me in a relative of the subject of this case, who also died of a dis-
ease of the heart, the exact nature of which, however, I am ignorant
of, not having been permitted to examine the body after deatii."

Berton^ mentions changes in respiratory rhythm as being a
common symptom in cerebral inflammations, and quotes some
remarks by Dance, in which breathing, not very unlike that
under consideration, is described. Subsequent French writers on
children's diseases follow in the same path.

It has been stated that Flourens, in the course of his celebrated
experiments, observed the occurrence of periodic breathing as the
result of injury to the nerve centres. But in the first edition of
his work* there is no reference to such a phenomenon, while in

^ Dublin Hospital Reports, vol. ii. p. 216, 1818.

2 Ibid., p. 222, 1818.

3 Traite des Maladies des Enfants, p. 67. Paris, 1837.

* Recherches Exp&imentales sur les Prop'ie'te's et les Fondions du Systeme
Nerveux, dans les Animaux Vertebre's, p. 168. Paris, 1824.

HISTORICAL 5

the second edition tlie exact condition wliidi is nienlionc.l admits
of considiTiible di)ul»t. In tlic second edition, wlien critici.sin;,' the
observations of Marsliall Hall, and describing the results of some
experiments on tlie medulla oblongata,* he says: — "Je repetai
cette experience, sur un lapin. L'aniinal survecnt a Toperatinn
pendant a pen prbs vingt-deux minutes: sa respiration netait
plus, k la verite, continue ; mais elle se reproduisait de temps en
temps, et surtout quand on irritait I'animal." Such arrests of the
respiration, as will be seen later, are regarded by some authors as
belonging to the same series as Cheyne-Stokes respiration ; they
are looked upon as essentially different by others.

West'^ briefly refers to irregularity of l)reatliing as frequently
occurring in intlammations of the brain and meninges, and later
authors in this country also do so.

Stokes, whose name, as well as Cheyne's, is now indissohibly
bound up with the peculiarity of breathing in question, made it
pathognomonic of fatty degeneration of the heart, Speaking of
the symptoms of this condition he says:^ — " Rut there is a symptom
which appears to belong to a weakened state of the heart, and
which, therefore, may be looked for in many cases of the fatty
degeneration. I have never seen it except in examples of that
disease. The symptom in question was observed by Dr Cheyne,
although he did not connect it with the special lesion of the heart.
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 apncea 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 ])atient. I do not know any more characteristic
phenomena than those presented in this condition, wiiether we
view the long continued cessation of breathing, yet without any
suffering on the part of the patient, or the maximum point of the

• Rechtrchfs Kxj>f'riiiu'titahs sur Us l'roprii(e's tt Us Foiic(i'»i.g du Syateme
Nerveux, dans Us Animanx Vertebre's, Douxi(iinc t-dition, p. 2(>(i, 1842.

2 Lectures on the IHstates of Infancy and ChiUlhood, p. 16. Lomloii, 1848.
» The Diseases of the Heart and of the Aorta, p. 324. Dul.liii, 1854.

6 CHEYNE-STOKl<:S RESPIRATION.

series of inspirations, when the head is thrown back, the shoulders
raised, and every muscle of inspiration thrown into the most
violent action ; yet all this without lale or any sign of mechanical
obstruction. The vesicular murmur becomes gradually louder, and
at the height of the paroxysm is intensely puerile.

" The decline in the length and force of the respirations is as
regular and remarkable as their progressive increase. The inspira-
tions become each one less deep than the preceding, until they are
all but imperceptible, and then the state of apparent apnoea occurs.
This is at last broken by the faintest possible inspiration ; the next
effort is a little stronger, until, so to speak, the paroxysm of breath-
ing is at its height, again to subside by a descending scale."

Hasse,^ writing a year later than Stokes, observes, in describing
the symptoms of tubercular meningitis, that " long pauses occur
now and then, as if the patients had for the time forgotten inspira-
tion." This may, however, have been an allied type of intermittent
respiration.

Schweig,^ writing in ignorance of previous observations, brings
forward periodic breathing as a new symptom, and it is clear from
liis remarks that he had the true plienomenon of Clieyne and Stokes
before him. He records several cases. In all there was a comatose
tendency preceding or accompanying the onset of the symptom
in question. After death, one was found to have thickening
of the skull, several ounces of fluid in the left ventricle, a flabby,
but otherwise healthy, heart, old tubercular masses in the
pulmonary apices, and abdominal adhesions. No notice is taken
of the state of the kidneys. The second, in which the author
states there was no change in the pulse during the phases of the
breathing, had thickening of the skull, dropsy of the ventricles, old
tubercular lesions in the lungs, and atheroma with cardiac hyper-
trophy. The state of the kidneys is not mentioned. The third
was a case of renal disease with hypertrophy of the heart, dropsy
of the pleurae, and oedema of the legs. Here again it is noted that
neither phase of the respiration had any influence on the pulse.
The head was not examined after death. In the fourth case there
was atheroma of the vessels with fatty degeneration of the heart,

^ Handbuch der speciellen Pathologic und Therapie, redigirt von Rudolf
Virctow, iv. Band, i. Abtheihmg, S. 473. Erlangen, 1855.
^ Aerztliche Mittheilungen mis Badev, xi. Jahrgang, S. 49, 1857.

HISTORICAL. 7

thickening of the skull, and a considerable quantity of fluid in Out
left ventricle of the brain. The kidneys receive no nnticn. lit;
lays stress in all these cases on the comatose tendency, and in the
three wiiose heads were e.\aniined <tn the sclerosis of the skull, and
the chronic hydrocephalus, but especially emphasizes tlie fact that
on the left side in these three cases the foramen jugulare was
greatly narrowed, and thus caused pressure on the vagus and
accessorius nerves. After these renuirks he describes another case
in which, after various allections especially connected with the
brain, pneumonia ensued, and was followed, after severe mental
troubles, b}' periodic respiration with gradual development of coma.
The author diagnosed thickening of the skull, narrowing of the left
cranial cavity, left-sided hydrocephalus, and stenosis of the left fora-
men lacerum. Tiie necropsy revealed thickening of the skull with
osseous deposits, ccdema of the pia mater, bleeding points throughout
the brain substance, distention of the left ventricle by fluid and some
also of the right, atheroma of the basilar-artery, and great stenosis of
the left jugular foramen, which was only one-third of the size of tlie
opposite one. The iieart was adherent to the pericardium and
enormously hypertrophied, with atheroma of the mitral and aortic
valves, great dilatation of the right side of the heart, a con-
siderable amount of fluid in the pleurne, which were adherent
in great part, and tubercular lesions in the lungs. The kidneys
escape observation. A sixth case is mentioned, still alive
when the paper was published, in which cardiac disease was
followed by mental allections accompanied by periodic breath-
ing.

Soon afterwards similar phenomena were produced experi-
mentally, for we find that Schifl'^ observed the characteristic
breathing as the result of luemorrhages involving the medulla
oblongata, but not directly aflecting the vital spot. He says : —
" Injury of other parts of the medulla oblongata than that
described above permit indeed life and breathing to go on, but
])robably through the accompanying luemorrhage, which itdluences
the respiratory centre, it may modify the respiration in two ways.

"a. Every slight hiemorrhage upon the medulla oblongata, and

* Cyclus onjanisch vcrbundener Lelirhiicher siimmtlichfr medicinischen Wissen-
schxften, lienui'<;_'0L,'i'1tfn von l)r C. H. ScliauL-iil)Ui>,', i.\. Tlu-il, i. Hainl, S. 324.
Luhr, 1858-59.

8 CHEYNE-STOKES RESPIRATION.

every pressure upon it, makes the breathing less frequent and more
laboured.

"h. If the haemorrhage be larger or the pressure greater, a
peculiar symptom is observed in different mammals, the like of
which I liave as yet sought in vain for in human pathology, and to
which I may direct the attention of physicians. The respirations
entirely cease for a quarter of a minute or half a minute, then begin
gradually, increase their rate, and afterwards wane, until a new
pause occurs. This appears to be caused by variations in the
amount of the pressure, which is of necessity dependent on the
power of the heart beat." From this it is evident that Schiffs
attention had never been called to the observations of Cheyne,
Stokes, or Schweig.

Eeid,^ in reporting two cases of aneurism with this symptom,
one of a man aged 60, the other that of a woman aged 59, notes
that the pulse was periodically irregular, becoming less frequent
during the respiratory distress, and more so when the distress was
lessened.

In another paper^ the same author describes a case of aortic and
mitral disease, without any change in the texture of the muscular
walls on dissection, and from a study of it he concludes " that the
symptoms of respiratory distress must henceforth cease to be looked
upon by me as pathognomonic of fatty degeneration of that organ."
He observes that in this patient " the pulse became invariably slow
%vhen the distress was greatest^ and as invariably quick when it was
subsiding, or whilst the patient had ceased to breathe." He is inclined
to think that this change in the pulse is not a mere coincidence,
" but that it and the distress stand towards each other in the
relation of cause and effect ; " he does not, however, venture upon
any theory.

Trousseau^ mentions, as characteristic of cerebral inflammations,
a symptom, which, if not exactly the same as Cheyne-Stokes
respiiation, has a great resemblance to some forms of that type of
breathing, as it has not only the cessation of respiration, but also
the ascending and descending phases.

Eeferring to this subject in the third edition of his treatise,

^ The Dublin Hospital Gazette, vol. vi. p. 308, 1859.

2 Ibid., vol. vii. p. 133, 1860.

3 Clinique Medicate de I'Hdtel-Dieu de Paris, tome ii. p. 318. Paris, 1862.

IIISTOIMCAL. y

Walslie^ remarks: — "I cannot avoid infenini; that tlie i»roxiniate
cause lies in a failure (»(' the special nervous excitant of the
respiratory act — in auiesthesia either of the vagus or of the medulla
oblongata itself." This opinion is simply adhered to in the last
edition of the work.-

Ill a lecture by Laycock, reported by Kopes,*'' there is a descrip-
tion of the peculiar breathing, and it is stated that the most
probable explanation of the phenomena " is that a sentient palsy
of the respiratory centre occurs, or a paresis of reHex sensibility of
the mucous membrane of the lung."

In a research undertaken with a view to solve some physio-
logical and pathological questions connected with the brain,
Leydeu^ notes that when the pressure is abnormally raised in
animals there are changes in the respiration. The breathing
became irregular, long pauses separating periods, during which
respirations rapidly succeeded each other, so that, as the author
states, there was a similarity to Cheyne-Stokes respiration ; there
was never such a regular periodicity of the events or transition from
the breathing to the pause. It is of interest to observe that
in this contribution, in addition to changes of sensibility,
mobility, and intelligence, the author noted alterations in the
pupils.

Head ^ recorded a case wliich presented this symptom, and in
which fatty degeneration of the diaphragm was found after death,
with atheromatous degeneration and dilatation of the aorta, and
aortic incompetence. In this paper is a full notice of the condition
of the pulse during the two stages of apnc^a and dyspnoea; from
tracings taken by Grimshaw it was observed that the pulse was
as strong during the former as the latter phase, while tracings
obtained from another case under the care of Little showed
stronger pulsations during the cessation of respiration.

This type of respiration is said by von Dusch" to occur in

^ ..-1 rmctical Treatise on the iJtseases of the Heart aiid Great Vuistls. Tliinl
eiUtioii, p. .345. Loiulon, 1862.

'■^ Iliid. Fourth edition, p. 407. London, 1873.

3 The McdUal Journal for 1864, \\ llG.

* Archil' fiir p(ith<Uo<jische Anatomie und Phijsiolugie und fiir Klinisclu
Medicin, xxxvii. Bund, S. 519, 1866.

° Dublin Quarterly Journal of Medical Science, vol. xliv. p. 405, 1867.

^ Lehrburh dir Ilirdrankluiten, S. 153. Leipzig, 18G8.

n

10 CHEYNE-STOKES KESPIUATION.

affections of the brain, and in iircemic coma, and he also states that
he has observed it in one severe case of pericarditis.

Little^ published a few cases in which the symptom was
prominent, one being an example of fatty degeneration of the
heart, another of aortic stenosis and hypertrophy of the left
ventricle, and a third of renal disease with atheromatous degenera-
tion and dilatation of the aorta, and thickening of the aortic valves.
The author of this contribution ingeniously argues that the cause
of the peculiar respiration is a loss of balance between the two
sides of the heart, either through diminished force of the left
ventricle, as in fatty degeneration, or when some abnormal burden
has been imposed on the left ventricle, under which it is unable
to get rid of blood as quickly as it is supplied to it, and the blood
accumulates in the left auricle and the pulmonary veins and
capillaries. Being fully oxygenated, this blood fails to excite the
terminal filaments of the vagus, as venous blood does, and the
respiration ceases. A few pulsations then displace this blood, and
the venous blood streaming in excites the respiration anew. He
also states his belief that the altered rhythm of the respiration is
only found when the lesion which has destroyed the balance
between the two ventricles has been rapidly produced ; that when
this is not the case the ventricles adapt themselves to the changed
conditions.

Benson^ describes a case of mitral disease in which cerebral
haemorrhage occurred followed by the type of respiration which we
are considering, and he gives expression to his opinion that the
theory propounded by Little is a " true account of the essential
mechanism of the phenomenon," but adds that he thinks " a certain
nervous complication is necessary to determine the accession of
this peculiar form of respiration, and without which it would not
occur." He also notes, in the description of his case, that it was
only while the patient was allowed to remain in the semi-comatose
state that the peculiar respiratory rhythm showed itself; when
roused up, the respiration became almost normal, and assumed the
ascending and descending character when the condition of stupor
was permitted to return. He distinctly states his belief that the

1 Dublin Quarterly Journal of Medical Science, vol. xlvi. p. 46, 1868.

2 Ihicl, vol. xlviii. p. 127, 1869.

HISTOHICAL. 1 1

nervous centres were incapacitated fnr woik l>y tlie cerebral lesion ;
that this produced arrest of the resjiiratioii, that the centres aft(!r
ft certain time re;^'ained their excilal)ility sulUcieutly to relh^t a
motor impulse, thus re-establishing respiration, but that btiiug
weak, the centres could not sustain tlie elTort and apurea again
occurred, and so on. He therefore concludes that tliere must in
every case be a diseased condition of the circulatory and of the
nervous mechanism, a ddulile patliological condition, wliich he
states as follows : —

" 1. A certain diseased state of the heart, by reason of which,
indirectly, the excito-motor impulse upon the nervous centres,
conveyed tlirough the pulmonary branches of the pneumogastric, is
diminished.

" 2. A certain weakened state of those nervous centres, by reason
of which the reflecto-motor impulse is diminished."

This brings us to the period of the classical clinique, in which
Traube expounded his theory, published by Frautzel,^ and re-
printed in his collected works.^ Describing a case of aortic and
mitral disease, with hypertrophy of the left and dilatation of the
right ventricle, in which the phenomenon appeared after a sub-
cutaneous dose of morphine, he takes the opportunity to mention
the first case in which he had met with this symptom — one of
cerebral haemorrhage — and refers to other instances of cerebral
haemorrhage, as well as cerebral tumours, tubercular meningitis,
and uroemic coma, M-hich presented it. He concludes, therefore,
that the peculiar type of respiration may occur in two classes of
patients: 1. Those M'ith healthy hearts, but diseased contents of
the cranial cavity ; 2. Those with healthy contents of the cranial
cavity, but diseased hearts. He further observes that the duration
of the periods may be .so short, and the pauses so inappreciable,
tiiat the phenomenon may escape notice ; that, towards the end of
long pauses, muscular twitchings may occur closely resembling
those seen when the artificial respiration is su.spended in slightly
curarised animals ; and that sometimes during long pau.ses the
tension of the arteries ri.ses, while the pulse-rate diminishes.
He proceeds to point out that all the cases in which the pheno-

' Berliner kl ill hche Wochfmchrift, vi. .laliiuMii;,', S- -77, l^fiO.
* Gesammelte Beitriige zur Patholoijii nnd I'Inj.'iiolojif, ii. Bainl, S. SS2. lUiliu,
1871.

12 - CHEYNE-STOKES RESPIHATION.

menon is present have one characteristic — they have all a diminu-
tion of the supply of arterialized blood to the medulla, where the
respiratory centre is situated. There is thus a smaller supply of
oxygen, of w^hicli v^e know that it, in a higher degree, influences
the irritability of the cellular nervous elements. Through this
lessened amount of oxygen the irritability of the nerve cells
becomes so much lowered that a larger quantity of carbonic acid
is required to cause an inspiration, and therefore the time within
which the carbonic acid will accumulate in suflicient quantity is
lengthened. This is similar to the effects of section of the vagi,
in which long pauses occur in the respiration, attended by dyspnoea.
The respiration may be excited in two ways : 1. By the pulmonary
fibres of the vagus, whose peripheral terminations are probably
washed by the blood, and whose central ends are connected with
the respiratory centre ; and 2. By the afferent nerves coming from
all parts of the body, which are able to send a sufficient stimulus
to the medulla, as in the case of dashing cold water on the skin,
and the well-known effect of the gastric portion of the vagus on
the respiration. The difference between these two is this, that the
pulmonary endings of the vagi are bathed in blood containing
much carbonic acid, while the others have a supply of blood which
contains but little. If both be equally irritable, then in health
only the pulmonic vagi will be called into action. If the vagi be
cut the respiratory centre can only be excited by the other nerves,
and this can only happen when the blood circulating throughout the
body is as rich in carbonic acid as that normally passing into the
lungs. It must be borne in mind that the number of the vagus
fibres is incomparably smaller than that of the other nerves ; when
these latter act, therefore, the effect is correspondingly greater, and
simple respiration becomes dyspnoea. Applying this reasoning to
the phenomenon in question, we find that the lessened irritability
of the respiratory centre, caused by the cerebral pressure, or
ursemic blood, or deficient arterial supply, requires a larger amount
of carbonic acid as a stimulus, and thus there is a long pause.
When this gas has accumulated in sufficient quantity it first
stimulates the pulmonary terminations of the vagi, but, as was
shown long before by Traube, the strongest stimuli applied to the
vagi never cause dyspnoea, and this only causes the shallow breathing
which appears first after the pause. The amount of carbonic acid

HISTORICAL. 1 ^

menntime increases sufficiently to cause stimulation of the nerves
coming from the skin and otlier parts of the hody, ami hence the
dyspnoea sets in. The (piantity of the gas is greatly diminished
hy the forcible breathing, and the e.xcitement of the other nerves
ceases, so with the action of the vagi alone shallow breathing again
occurs, until there is not enough carbonic acid gas to excite
the pulmonary endings of the vagi, and a pause sets in anew.
Traube ends by calling attention to the fact that the morphine
directly induced the peculiar respiratory rhythm by reducing the
irritability of the respiratory centre in a case where it was already
at a low ebb.

Mader' describes five cases in which Cheyne-Stokes respiration
was present ; an extravasation into the floor of the fourth ventricle ;
a tumour between the medulla, pons, and cerebellum ; an extra-
vasation reaching from the right optic thalamus to the medulla ;
an enlargement of the vertebral artery compressing the medulla ;
and, lastly, renal disease with a tumour of the pons. He main-
tains that the cause of the phenomenon must be sought in
anatomical changes in the medulla oblongata, and opposes the
vie'.v of Traube that the respiratory change can take place, without
any palpable changes in its structure, through alterations in the
circulation.

Hesky, - observed the occurrence of Cheyne-Stokes breathing
during the course of a fatal case of enteric fever. The chief point
of interest in his description is the fact that the pulse almost ceased
during the long pauses; the pulsation, indeed, appeared to become
less before the respiration began to diminish. The section
gave evidence, in addition to the characteristic abdominal
lesions, of congestion of the brain and medulla, particularly of the
floor of the fourth ventricle, and more especially of the points of
origin of the vagus and hypoglossus. The author is of opinion
that the cause of the symptom is a smaller access of oxygenated
blood to the centres, produced by the lessened activity of the
circulation.

Esenbeck^ describes the case of a man, aged G2, l)elonging to an
apoplectic family, and subject to no affection beyond nervous palpita-

* JViener mfdicinischc Jfochenscri'/t . xix. P>aii<l, S. 1147 iiml 14<)4, 1869.

* Jf'iener medicitiische Pnwr, x. Jahr^'ang, S. lloT uiul 1133, lb69.
3 Aerzliches Intelliijeiizblatt, S. 253, 1870.

14 CHEYNE-STOKES RESPIHATION.

tion, who had about a year and a lialf before been attacked by
apoplexy, which passed away without leaving any distinct sequelae
in its train. He was again suddenly seized with unconsciousness
accompanied by convulsive twitchings of the face and right arm,
which became absolutely paralysed. Seven days after the attack the
patient died in a comatose state. Thirty-six hours before death
the rhythm of Cheyne-Stokes breathing appeared, and continued
until death occurred. On section, fatty degeneration of the heart
was found. The skull was very thick, the meninges and ventricles of
the brain contained a considerable amount of exudation, the vessels
were turgid, and the brain substance showed " capillary apoplexy,"
but no patch of cerebral hsemorrhage. The medulla was quite
normal in appearance. The author points out that the result of
the post-mortem examination agrees with what has been described
by Stokes and Traube, and gives his adhesion to the theory advanced
by the latter.

Leube ^ mentions three cases which he observed in von Ziemssen's
clinique presenting this symptom, one being an instance of fatty
degeneration of the heart, another of cerebral hsemorrhage, and a
third, which he narrates at length, of mitral stenosis with dilatation
of the right ventricle, venous pulsation, hydrothorax, ascites, and
albuminuria, in which the characteristic rhythm of the respiration
came on after a subcutaneous injection of morphine. He remarks
that at the beginning of the pause the pupils were contracted and
underwent no change in size with alteration of light, and continued
in this state throughout the pause. With the first returning breath,
or, rarely, immediately before it, they dilated again. With the
movement of the pupils there was a peculiar lateral deviation of
the globes of the eyes, which was repeated with each change of
the size of the pupils. With the commencement of respiration
the globes became still, and during the respiratory period they
performed the usual movements in every direction. He also observes
that consciousness was entirely lost during the pauses, and further
notes that during this phase the pulse was always smaller and more
irregular than during the periods, but that the rate was unaltered
or slightly increased. He attributes the pupillary changes to the
action of the excess of carbonic acid in the blood on the oculo-

1 Berliner hlinische IFochenschrift, vii. Jahrgang, S. 177, 1870.

HISTOKICAL. 17}

])Ujiillaiv ceiitro, and rel'tTS to tlie observations of Vigouroux on
tlie iiction of the iiis in inspiration and expiration, and to tlie
ivsearclies of Kiissniaiil on the influence of the circulation on it, as
well as to the investigations of Adaniuk on stimulation of the
corpora quadrigeniina. I^istly, he mentions that in spite of deep
inspirations ])ro(luced by electric stimulation of the phrenic nerves,
the onset and course of the period of breathing were unaffected.
He notes that each deep inspiration thus produced by artificial
stimuli was accompanied by dilatation of the pupils ; this, however,
he says may be due to stimulation of the symi»athetic in the neck
l)y the current.

Haelmdel^ entei"S very fully into the whole matter in his
inaugural dissertation. After some historical and critical observa-
tions he mentions that he had frequently noticed the appearance
of groups of shallow or superficial respirations without any pause.
Such a phenomenon he considers to be a transition towards the
more fully developed form, and he explains it in a manner similar
to Traube's theory. He thereafter narrates seven cases of Cheyne-
Stokes breathing which he had personally observed : — Mitral
incompetence, with embolism of the right Sylvian artery ; chronic
endocarditis, with mitral and aortic lesions and thrombosis of the
left internal carotid artery ; aortic incompetence, with fatty
degeneration of the muscular structure and hypertrophy and
dilatation of the heart; sclerosis of the coronary arteries, with
cardiac hypertrophy, and stenosis of the inferior vena cava from
hepatic fibro-sarcoma ; mitral stenosis, with atheroma of the
arteries of the base of the brain, and softening of the left optic
tiialamus; chronic renal disease with unemia ; and, lastly, chronic
renal disease with mitral incompetence. In his remarks on these
cases he calls attention in one instance to the persistence of
consciousness throughout all the phases of the breathing, and in
another to the pupillary changes which were present, but which
did not in all respects coincide with the appearances described bv
Leube.

In this thesis the author refers to a case which he attributes to
Erb, in which cerebro-spinal meningitis was accompanied bv
Cheyne-Stokes respiration, the cau.se of which had been supposed

' Cebcrdas Chfync-Stokci>scli<: lUgpiratioHJi-Phuiiviiieii. Urv.-'lau, 1S70.

16 CHEYKE-STOKES RESPIRATION.

to be the presence of purulent exudation surrounding the medulla
oblongata. No trace of this observation is to be found in litera-
tare elsewhere, and Professor Erb informs me that he lias never
written or spoken on the subject.

Lutz' describes a case of scarlatina followed by suppuration of
the ear and cerebral symptoms, during the presence of which the
respiration assumed this peculiar rhythm,

Bjornstrom^ says that the phenomenon is probably not so rare
as might be imagined from the paucity of literature concerning it,
and describes three cases which he had seen. The first, a child
ihree months old, was ill with capillary bronchitis, and during the
last four days of life manifested this phenomenon. The second
patient, aged seventeen years, suffered from tubercular meningitis,
but here the symptom was not typical, and was accompanied by
divergent strabismus. The last case was that of a patient of the
age of seventy years affected by fatty degeneration of the heart.
The author regards Cheyne-Stokes respiration as lethal. He
does not approve of Traube's theory, but declines to formulate
another. He further objects to the name by which the symptom
is known.

In the discussion which followed the reading of this paper, Glas
mentioned that he liad seen stoppages of breathing in a case under
his care, and a description of the case is given further on^ in
the same publication. The patient in this case, who was a
man aged 70, suffering from traumatic gangrene, had pauses
in the respiration, without any change in the state of the
circulation.

Heidenhain,^ in a most interesting • paper on Cyon's theory of
the central innervation of the vaso-motor nerves, points out that
he has observed the Cheyne-Stokes phenomenon in chloralized
animals, and he gives a tracing showing the rhythm of the
respiration, which perfectly corresponds with that which we
obtain in cases of disease in man. He draws attention to the fact
that during the respiratory period the blood-pressure rose slightly.

^ Deutsches Archiv fiir klinische Medicm, viii. Band, S. 123, 1870.

2 Upsala Lakarefdrenings Fdrhandlingar, vi. Band, S. 307, 1870-1871.

3 Ibid., vi. Band, S. 315.

* Archiv fiir die gesamvite Physiologic des Menschen und der Thiere, iv.
Jahrgang, S. 554, 1871.

HISTORICAL. 17

liriukner' inaki's n liricf n-fcrrnci.' in IS71 t(j tin; fiict that lii.s
ilcceased fatlier liad, twenty-two years before the date of his
coniinuiiication.caHcd hi.s attention to the phenomenon of f.'lipyne-
Stokes respiration, and given it the name of " penduhini-like
breatliing," because the alternation of the breathing and the
]iaiises is as regular as tlie swinging of a pendulum. Tlie author
mentions that ho has fretjuently watched the .syniptom, particu-
larly in cases of tubercular meningitis.

Rehn''^ dcscril)es two cases (»f pulmonary disease in children,
which jiresented this symptom. One was a child of one year of
age, suffering from inieumonia; the other an infant si.\ weeks old
labouring under l)ronchitis. For the e.x'iilanation of the jilieno-
menon he accepts the theory that there is a lessened access of
arterialized blood.

MerkeP records a case in which the patient, who suffered from
renal disease with cardiac dilatation and pulmonary emphysema,
was attacked by apoplexy a year before his death. During the
cerebral symptoms, Cheyne-Stokes respiration made its appearance,
and during the pause, narrowing of the pupils and absence of
reaction to light were observed, along with dulness of the mind.
The autlior mentions that when a question was asked at the end of a
])eriod of breathing, it was answered at the beginning of the next
period after the termination of tlie intervening respiratory pause.
The patient recovered from this seizure, and on his death, about a
year later, it was found tliat in addition to granular kidneys,
emphysematous lungs, and a dilated and hypertrophied heart, with
cyanotic atrophy of the liver and spleen, there was destructive
disease in the corpus striatum, optic thalamus, and pons. In
another ca.se narrated subsequently,'* the .same author found tiiis
type of respiration in association with endocarditis and embolism
of one of the posterior branches of the right artery of the Sylvian
fossa. He found that even with total absence of reaction to light
the pupils became di.stinctly smaller at the beginning of the pause.

' Archil' fiir yatholo{iische Anatomie nnd Physiologie und fiir klinische
Median, lii. Band, S. inr), 1871.

- Jahrhiirh fiir Kinderheilknnde nnd jdiysinchc Erziehung, lunv Ki'l;,'^, iv.
JnliiKiin^', S. 432, 1871.

3 Deut.iches Archiv fiir klinijiche Mediciu, viii. I'aiul, S. 4-2\, 1>1\.

* Ibid., X. Baiul, S. 201, 1872.

C

18 CEIEYNE-STOKES EESPIUATION.

Scliepelern^ describes several cases in which he met with this
type of breathing, and adds to the rapidly advancing store of know-
ledge in regard to the symptoms associated with it. The first
patient was a man, aged 54. In this case the phenomenon
appeared after a period of breathlessness and palpitation. The
patient felt most comfortable at the beginning of the apnoea, and
became unconscious towards the end of it, but could be awakened
out of this state, and was able to talk during the pause. No con-
vulsive or involuntary movements were present in the muscles or
eyes. Ophthalmoscopic examination of the eyes showed nothing
beyond a slight patch of haemorrhage near one papilla, and fulness
of the veins. There was no variation in the size of the vessels of
the fundus during the changing phases of respiration. The
patient could be caused to breathe during the pause of respiration
by constantly ordering him to do so, and this lessened the subsequent
period of dyspnoea. Electric stimulation of the phrenic nerves
during the pause produced no result. The relative duration of
the apnoea and dyspnoea was not affected by sleep. The pulse
remained small throughout the different phases of respiration,
without apparent change in strength or tension, but the number
of pulsations was less during the period of breathing, probably
from intermission which was present. On section the heart
was fatty, the aorta and arteries, especially the vertebral and
basilar, atheromatous, the liver was fatty, and the kidneys
cyanotic.

The second case was that of a man, 75 years old, suffering from
bronchitis with ascites and albutninuria. The Cheyne-Stokes
respiration was well marked, but was not attended by muscular
twitchings or pupillary variations. The patient could be made to
speak during the pause, but could not be caused to breathe during
that phase, and electric stimulation of the phrenic nerves pro-
duced no result. There was no alteration in the rate or strength
of the pulse during the changing respiratory phases. There was
no examination after death.

The third case was that of a man, aged 69, of gouty habit,
suffering from aortic disease and cardiac hypertrophy with albu-
minuria. There was no autopsy in this case.

The fourth patient, a woman about 60 years old, was affected
1 Hospitals- Tidende, xv. Aargaiig, S. 77, 81, og 85, 1872.

HISTOIIICAL. 19

l>y mitral disease. On section there was stenosis and incompetence
of tlie mitral orifice and valve, with liypertrophy of tlie left and
dilatation of tlie riglit ventricle, and a fatty heart. There was
degeneration of the cerebral arteries and old tubercular disease of
the apex of the right lung.

Schepelern supports the theory of Tranbe.and believes the dulness
of the mental faculties to be caused by the presence of an excess of
carbonic acid in the blood. He does not approve of the view ad-
vanced by Traube, tliat the mental obscurity is the result of cerebral
anaemia. The dyspnoea he attributes to the action of the carbonic
aciil oil the sensory nerves, and he compares this to the forced
breatliiiig seen after section of the vagi, when the sensory nerves alone
act as the respiratory stimulants. He states that he has never seen
any deepening of the symptoms after the use of morphine or
chloral.

In conclusion, he describes another case, that of a man, aged 39,
who, after paralysis of the left side with loss of speech, suddenly
became uraimic, with delirium and sopor, and paralyzed on the
other side. During the unconsciousness, which deepened into
coma, the characteristic Cheyne-Stokes respiration appeared, and
with it changes in the pupils were observed. They became larger
during the period of respiration, even after the application of
atropine, and the author regards the dilatation, therefore, as purely
due to the influence of the sympathetic nerve. Nothing note-
worthy could be seen on ophthalmoscopic examination of the eyes.
On section, the kidneys were found to be granular, the heart
degenerated, the arteries atheromatous ; there was also thrombosis
of the cerebral vessels and patches of softening of the brain, but
the pons and medulla were healthy.

lioth places two cases on record,' — one, that of a child, aged 7
months, suffering frdin meningitis, the other, that of a girl, with
ura-Miia and eclampsia, in which the typical respiration was present.

Korber- describes the symptom as it occurred in a boy of 9
months, suffering from tubercular niLMiingitis, and notes that during
the pause a certain stiffness of the paralyzed limbs cnme on, while
during the period of breathing they were quite flexible.

> Deutsches Archiv fiir kliuMie Malicin, x. IJiuul, S. 31n. 1S72.
- Ibid., X. Band, S. C(K), 1872.

2D CHEYNE-STOKES KESPIRATION.

A paper by Filehne^ deserves mention here, as in it be points
out tbat after section of tbe vagi it is possible to cause apnoea, and
carefully discriminates between true apnoea, or arrest of respiration
from excessive oxidation of the blood, a;nd arrest of respiration
caused by other conditions.

Laycock^ enters very fully into the phenomenon of " Brief
Eecurrent Apnoea," as he terms the Cheyne-Stokes respiration, in
a very interesting lecture, but he cannot be regarded as adding
anything of importance to the pathology of the condition. It is a
singular, nay, even startling fact, that he makes no mention of
Traube in his remarks, although in them he does full justice to
most of those who had written on the subject in the vernacular.
He refers to the case which has been already mentioned in
connexion with his name.

The same writer immediately afterwards contributed another
paper on this subject to medical literature^ which is substantially
the same as that to which reference has just been made.

Two or three months after the publication of Laycock's remarks,
Bernheim,^ who had the good fortune to be present at the historic
clinique when Traube expounded his theory, gave an excellent
review of much of the work that had been done on the Continent,
along with an account of four cases which he had himself observed.
These four cases were respectively — heart disease with emphysema;
chronic alcoholism with nephritis ; pulmonary tuberculosis and
dilated heart ; and the result of a fall from a great height. He
points out that Cheyne-Stokes respiration is only the highest
expression of a series of similar phenomena, in the less marked of
which tliere is no pause, but alternations of deep and shallow
breathing, and he gives the result of a careful study of the eye
and pulse during the phases of the respiration. The pulse he
describes as being sometimes altered, and at other times unchanged
during the alternations of dyspnoea and apnoea. Like Leube he
found that electricity would stop the pauses for a time.

^ Archiv fiir Anatomie, Physiologie, und ivissenschaftlichen Medicin, Jahrgang
1873, S. 361.

2 The Medical Times and Gazette, vol. i. for 1873, p. 433.

2 The Dublin Journal of Medical Science, vol. Ivi. p. 1, 1873.

* Gazette Hebdomadaire de M^decine et de Chirurgie, Deuxieme Serie, tome x.
p. 444 et p. 492, 1873.

HISTORICAL. 21

Monti, ill an cxlianstive research inb) tin* jiliysical ('Xiiininiili<iii
of the thoracic viscera of chiMren/ gives it as his opinion that
Cheyne-Stokes respiration in chiUlren only occnrs during the last
stages of life, and that it is always to he attributed to disturbances
of the centres of the nervous system.

Kohrer^ describes a case of tuliercular nieiiingilis la wliich
Cheyne-Stokes breathing was present, and explains it by means of
Traube's theory.

Chvostek^ records a case of niilral incompetence in whicii the
phenomena of Cheyne-Stokes respiration were fully developed,
and goes on to discus.s and criticise the various symptoms present,
as well as those mentioned by other writers, after which he
states the theory of Traube. This paper is (jf extreme interest, as
it gives one of the best critical studies of the various appearances
which attend tiie type of respiration.

So far no one had ventured to oppose the theory of Traube, but
in the following year it entered upon a period of storm and stress
which has continued ever since. In that year Filehne* subjected
the theory to a searching criticism, and insisted on such modifica-
tions of it that we are quite justified in saying that he propounded
a rival theory. He states in his contribution that he has produced
Cheyne-Stokes respiration by the administration of ether and
chloroform to animals poisoned by means of large doses of
morphine, and grants that, for the production of this symptom,
there must be lowered irritability of the respiratory centre; he
asserts that this, however, is not enough, and that the irritability
of the respiratory centre must be less than that of the vaso-motor
centre, which is the converse, according to him, of the normal
relationship existing between these centres and the condition of
the blood. He states, further, that the phenomenon may occur,
although in a modified form, after both vagi have been cut ; and
he, therefore, is of opinion that it is not dependent on the integrity
of these nerves, whence he concludes that a new theory is abso-
lutely necessary. He points out tiiat the centres remain at rest
so long as they are supplied with a suflicient amount of Itlood

' OcsUrrciclii.^ch<^ JuJirbuch fiir /'ui/tK/nV, luiU' Fol^^c, ii. Baiul, S. 17i?, lb~3.

• Cornspoiuhn:.- lildtf fiir schuiiur .Ifr;/*', iii. Jaln<,'anij, S. 22."), 1^7;{.

2 H'itti'r m>tli:.i)U!<chf Jf'orh'usrltrijt, xxiii. Ja}ir;,'aiii:, S. S'JJ uiul !)J-_', IST.'}.

* Btrlimr kliuische li'ochenschvijt, \'\. Jahi-jjiiiig, S. 152 uikI l(Jii, 1X7 J.

22 CHEYNE-STOKES RESPIRATION.

containing an adequate quantity of oxygen ; that they are excited
whenever the blood-supply is insufficiently arterialized, or when,
although sufficiently arterialized, the supply is deficient in quantity ;
and that the excitement is greatest when the blood-supply is too
small and at the same time inadequately arterialized. He asserts
that in health venous blood excites, — 1st, the respiratory, 2nd,
the vaso-motor, and 3rd, the convulsive centres. Picturing a case
in which the phenomenon is present, he says that during the pause
the blood gradually becomes more venous and develops the
stimulus for the centres, but that, from the lessened irritability
of the respiratory centre, no respiration is caused, and the pause
therefore continues until the point is reached when the vaso-motor
centre is brought into action. This produces a diminution of the
blood-supply, which causes the respiratory centre to act and
originate the superficial breathing which is first observed. It is
some time, however, before the blood arterialized by these respira-
tions can reach the vaso-motor centre, and the time is lengthened
by the contraction of the arterioles caused by its activity ; it takes
time, moreover, before the vaso-motor apparatus can induce con-
traction of the arterioles, and time also before the contraction can
pass away; there is therefore a lengthening of the pause and
deepening of the dyspnoea. He states that when Cheyne-Stokes
respiration is produced in animals by the administration of large
doses of morphine, followed by the inhalation of ether or chloroform,
there is always a gradual diminution of the pulse-rate during the
pause, which sometimes goes the length of complete cessation of
the pulsation ; while during the period of respiration there is a
gradual acceleration until the normal rate is regained towards the
end of this phase. He states further, tliat in the animals thus
experimented on, the blood-pressure rises during the pause and
falls during the period of breathing. He mentions the case of a
man dying from a lethal dose of morphine and chloroform, who
showed during the narcosis Cheyne-Stokes respiration exactly in
the same form as seen in his experimental investigations. The
pulse underwent the same changes as he observed in the animals
on which he performed his experiments. Finally, in his criticism
of Traube's theory he asserts that the periodicity of tlie Cheyne-
Stokes respiration could only depend upon a periodicity of action
of the respiratory centre which has not been proved.

IlISTnltlCAL. 23

In the discussion which followed Filehne's paper, Ewald' stated
that he had examined during breathing as wcdl as pause the retina
of a patient in whom the pulse underwent alterations, but had
been unable to detect any distinct changes.

Traube'^ promptly came forward in defence of his theory. In
his reply he points out that Filehne had arbitrarily postulated
that the respiratory centre must have less irritability than the
vaso-motor centre, and that this postulate had been based on the
gratuitous assum])tions, — 1, that the vaso-motor system is always
iniplicat(Hl ; 2, that the vaso-motor is normally less irritable than
the respiratory centre; and 3, that two centres are not proportion-
ately affected by a proportional diminution of oxygenated blood.
He states, with regard to the first of these points, that there is
very often no change in the arterial tension during the different
phases of the })henomenon ; with reference to the second, that the
vaso-motor is more irritable than the regulator, while this is more
sensitive than the respiratory centre ; and he curtly dismisses the
third as absurd. He holds that a rhythmic periodicity of the
respiratory centre has been proved as distinctly as in the case of
the vaso-motor and inhibitory centres — all being dependent on the
changing quantity of carbonic acid and consequent stimulation and
exhaustion of the centres. Traube concludes his reply with a
restatement of his theory, pointing out that all cases in which the
phenomenon appears have lessened irritability of the respiratory
centre, and therefore require more carbonic acid to excite respira-
tion, which of necessity requires a longer interval of time. At
first the necessary carbonic acid will be in the lungs, and the peri-
pheral endings of the vagi are the earliest to be stimulated. This,
however, causes no dyspncea, only the superficial breathing, but
when the carbonic acid has accumulated in sufficient quantity to
excite the sensory nerves dyspnoea is produced. In consequence,
however, of the diminution of the carbonic acid, as well as on
account of the exhaustion of the respiratory centre by the powerful
irritation, the breathing loses its dyspnceic character, and as the
exhaustion of the centre gains ground more rapidly tlian the
accumulation anew of carbonic acid, the breathing becomes more

' Firliner klitiwhe IVorhen^rhrifl. xi. Juhi-ijai)',', S. 169, 1874.
■•* Ibid., S. 185 uiul 2o9, 1874.

24 CHEYNE-STOKES RESPIRATION.

and more superficial, ending in another pause. It is to be observed
that in this second enunciation of his theory Traube introduces
the factor of exhaustion.

Filehne^ again returned to the charge. In his answer to Traube
he reasserts the action of the vaso-motor system as the basis of the
Cheyne-Stokes phenomenon. He refers to his own experiments
and to the observations of Heidenhain on chloralized dogs in
support of his position, as well as the rise of arterial tension in
patients before the commencement of respiration, and the dilatation
of the pupil at the same stage, which, if not due to a dilator
pupillse muscle, must be caused by contraction of the vessels. In
this connexion he asserts that the finger cannot be accepted as
any criterion of the tension of the radial artery. He brings
forward the state of the fontanelles in little children presenting
this phenomenon as a proof of his theory, and states that he
observed in one case a depression of the fontanelles before the
commencement and during the early part of the period of breathing.
The normal condition was regained towards the end of the
respiratory period. This he holds to prove contraction of the
vessels. In the case of a child when the Cheyne-Stokes respira-
tion disappeared it could be brought back by the application of
pressure upon the fontanelles. He mentions the case of a woman
suffering from degeneration of the cord and medulla, in whom
Cheyne-Stokes respiration was present ; when nitrite of amyl was
administered the phenomenon disappeared and remained absent as
long as the inhalation was continued. He gives details of experi-
ments in which the peculiar type of respiration was produced by
interference with the supply of blood to the brain by alternate
compression and relaxation of the carotids and vertebral arteries
in the rabbit. He further mentions a rise of tension found in
some persons before the act of inspiration which is not normal,
and which he holds to prove that in them the vaso-motor is
affected before the respiratory centre. The paper ends with a
criticism of Traube's reply to his previous communication.

Heitler^ begins an interesting study of this symptom, by pointing
out that although far more common in unconsciousness it is not

1 Berliner kllnische Wochenschrift, xi. Jahrgang, S. 404 iiud 435, 1874.

2 Wiener medixinische Presse, xv. Jahrgang, S. 649 und 672, 1874.

HISTORICAL 25

invariably associated with that condition. He states tliat he has
seen Chcyne-Stokes respiration in cliroiiic hydrocopliahis ; in
typhoid tevur; in pneiinionia ; in tultcrcular nieiiiiiv^itis ; and in
tubercular laryngeal perichondritis where tracheotomy Imd Id be
nvsorted to. He calls attention to the fact, that although tlie fully
developed symptom cannot be re,;^arded as connuon, less [iro-
nounced forms of the same phenomenon are yet of frequent
occurrence, and constitute a r^radation between sliL,dit irregidarity
of the breathing and the Cheyne-Stokes respiration. A critical
description of the breathing follows, in which the author njentions
that he has not observed any very characteristic changes in the
condition of the circulation except in the most pronounced ca.ses
where tlie pulse underwent slight modifications. He then states
the later theory of Traube, and goes on to describe two of his cases,
one being chronic hydrocephalus and the other tuberculosis.

In tlie course of a case of insolation from which perfect recovery
took place, Zimmerhans^ observed the phenomenon of Cheyne-
Stokes breathing, for the explanation of which he accepts some
medullary change as the cause.

HcEpffner^ describes a case of cerebral disease in which Cheyne-
Stokes respiration was one of the prominent symptoms. In
this case electricity was applied along the course of the pneumo-
gastric nerve without effecting any change in the respiratory
symptoms.

An excellent summary of the discussion between Traube and
Filehne appeared at this time from the pen of Kicklin,^ in which,
liowever, no new facts or views were brought forward.

In some observations on intermittent respiration in the insane,
Zenker* narrates six cases in which he states that Cheyne-Stokes
breathing was developed. Some of these cases do not give in
their intermitting respiration the true features of Cheyne-Stokes
lireatliing, but in three of them it appears to have been undoubtedly
present. In none of the cases described was there any periodic

' IViener medizmische Presse, xv. Jalir^'aii;,', S. 771, 1874.

* Gazette m^dicale de Strasbourg, x.x.xiii* annee, p. 101, 1874.

^Gazette me'dicale de Parin, xlv* annee, 4* Serie, tome iii. pp. ')19, 530,
et 565, 1874.

* AlUjemriiie Zeitsrhrifl fiir Psijihiatn'c loii/ }>sychischg€richtliche Medicin^
XXX. Baii.l, S. 419, 1874.

•26 CHEYNE-STOKES RESMRATION.

variation in tlie state of the pupil or pulse. It is interesting to
notice that in two of these cases the periodic breathing was
associated with epilepsy, and Zenker points out in this connexion
that it is due to the proximity of the respiratory and convulsive
centres. In regard to the causation of the phenomenon, Zenker
says that there can be no doubt it is due to a disturbance of the
respiratory centre, for the explanation of which it is necessary to
clear up several physiological and pathological questions.

Baas ' describes the phenomenon under the name of " inter-
mittent respiration," which he prefers to the designation by which
it is commonly known. In his contribution he records the case of
a female child, not quite eight weeks old, who suffered from diar-
rhoea and hydrocephalus; the patient, amongst other symptoms,
such as coma with left-sided ptosis, and later, right-sided mydriasis,
developed Cheyne-Stokes respiration, which continued for the
last five hours of life until death took place. The author calls
attention in this case to the early period of life at which the
symptom occurred ; shows that it was caused by acute hydro-
cephalus ; that it was associated with unconsciousness ; that in
this, as in some other observations, the increase and decrease of
the respiratory energy was less characteristic than the regular
intervals of both phases of the breathing ; and points to the prob-
ability that the condition was caused by one-sided pressure on
the respiratory centre, as shown by the ptosis and dilatation of the
left pupil in the early stage.

Benson, whose previous observations on this subject have been
already referred to, brought the matter before the Medical Society
of the Irish College of Physicians,^ and in briefly detailing tlie
facts of a recent case, took occasion to mention some of the
theories which had been propounded, and to compare Traube's
explanation with his own. He points out that in the case which he
recorded, in which there was hemiplegia followed by cardiac failure,
the peculiar type of respiration did not appear until the cardiac
symptoms had added themselves to the cerebral, adding that in
the previous case which he narrated the phenomenon only appeared
after the cerebral symptoms had added themselves to the cardiac.

1 Deutsches Archiv fiir klinische Medkin, xiv. Band., S. 609, 1874, and Zur
Percussion, Auscultation und Phonometrie, S. 264, Stuttgart, 1877.

2 The Dublin Journal of Medical Science, vol. Iviii. j). 519, 1874.

IIISIOIMCAF,. 27

l''nl]n\\ iiiL: rxMi-^nii's iciiiaik^, Ilciiiy Ivriiiicilv iiiontioned^ that
lu; liiid lii'fii It'll tn (lie (;()iiclu.si()ii lliaL llic; sy iiii>L(tlii was more nr
less counseled with the iiervDUS system L^^eiieniliy ralJicr thaii wiili
any jiarl icular di^mii comiecLcil wilh llio chust, wliicli vic^w was
(j()iiliniic(l liy soiiK' coiiiiiion ]>li('n(jmi!iia, suuli as the altcralioii ftf"
brtMiliiii^ in slcc]), sliowin^? tluit the breathing may vary in health ;
the ciicliial liii Milling of Graves in fever; or the clianges
of respiration in hydrocephahis. lie thouglit there was evidence
enough to piovc that a temporarily modilied state of the nervous
system might be capable of altering and modifying the breathing.
]Ie mentioned an interesting fact that, in j)atients showing this
ty])e of respiration, the ascending and descending character dis-
apiK-aicd when tliey were placed on their sides.

A case of diphtheria in a boy 2^ years old afforded v. Hiitten-
l)renner- the opportunity of studying Cheyne-Stokes breathing,
whicii he attributes in this instance primarily to weakness of the
heart from the diphtheritic poison. He n^fers to the Traube-
lllehne controversy, but refrains from criticism.

Ihill'* has placed three cases on record in which the peculiar
breathing in question was noticed. The patients in whom it ap-
]iear(Ml siillrreil fiom chronic renal disease, with sclerosed arteries,
hypcrtro})hicd heart, and cerebral Inemorrhage ; granular kidney,
arterial atheroma, cardiac hypertrophy, and pericarditis ; and duo-
denal cancer, in which, after the use of morphine for the agony
caused by the disease, Cheyne-Stokes breathing appeared. In a
letter which the author has kindly addressed to me, he states that
he is not satisfied with any of the present theories.

Hayden fully discusses the phenomenon in his work,'' and gives
tlie following exj)lanation of it: — " I have already stated," he says,
"that the only lesion of structure with which ihythmical irre-
gularity of breathing lias been always found associated is athero-
matous or calcareous change, with dilatation of tiie arch of the
aorta, involving loss of elasticity in its walls. 1 lliiuk these
changes sujiply the conditions of a rational theory ol' the pheno-

' Till- Dublin Joimial of Medical Scituce, vol. Iviii. p. 521.

2 Jahrburh fur Kinderhcilkumlc timl jihijuische Erzii/ivtuj, luui' I-'ul^'c. \iii,
.ltibr;,'aii>,', S. 420, LsTf).

3 Norsk Mivinzin far Lmjcvideuskahfu, ill. Riu-kke, v. Bin<l. S. iSr), )87">.
< The Disi'osni of the Hunt and uf (he Aorln, p. G32, UiiMiu, 1870.

28 CHEYNE-STOKES RESPIUATION,

menon. During the period of greatest tranquillity of the heart's
action, viz., in sleep or repose, the systemic capillary circulation
fails, from want of the contributory aid rendered in health by the
elastic reaction of the aorta. Hence arises a suspension of tissue-
respiration, besoin de respirer, and accelerated or suspirious breath-
ing, as shown by the experiments of Flint already referred to.
Accelerated respiration must strengthen capillary circulation ;
first, through the lungs, and then through the tissues of the
body generally, by quickening the action of the heart and in-
creasing its force. In proportion as the systemic capillary
circulation becomes established, the lesoin de respirer is less
urgent, and respiration gradually subsides, till a period of
apnoea arrives. The descent of respiration below the normal
standard would seem to arise from its previous excessive activity
and the exhaustion of the patient. Now, again, comes a period of
feeble action of the heart, and failure of capillary circulation, with
its consequence of paroxysmal breathing. That imperfect circula-
tion of arterial blood in the respiratory centre contributes in a
special manner, and in a great degree, to the production of the
respiratory derangement I have no doubt ; but the effect of this
is not easily distinguished from that of a want of oxygen in the
tissues of the body generally." Hayden also states that he has
not observed marked alterations in the rate of the cardiac pulsa-
tions with the different phases of the phenomenon ; only, " as in
one or two cases, a slight acceleration during the period of dyspnoea,
and a gradual decline in that of descent, till a minimum rate was
reached on the accession of apnoea."

Hazard^ records the case of a gouty lawyer, aged 54, who met
with injuries in a railway accident at the age of 32 ; these caused
paraplegia, from which there was only partial recovery. A blow
on the head when 48 years of age impaired all his powers, and, in
addition to some mental symptoms, there was after this date such
evidence of a weak circulation as a frequent and irregular pulse,
cyanosis, and dyspnoea. When seen he had weakness of both
cardiac sounds without any symptom of valvular disease, and soon
afterwards symmetrical gangrene of both feet set in, with absence
of pulsation in any of the vessels of the lower extremities below

^ St Louis Clinical Record, vol. ii. p. 54, 1875.

HISTOUICAL. 20

Scarpa's triangle. The patient had a great tendency to fall asleep,
and when he do/ed Cheyne-Stokes res])iration apj)ear('(l. He dit-d
from gradual extension of the gangrene u|)\vards, and uiiforlunaluly
no post-ninitciii cxaiiiiiiat jnii was (ilii;iiiic(l. Tlic aulliur's diagnosis
was fatty heart anil tlirombosis of the arteries of the lower ex-
tremities. He enters into a long ])hysiol()gical argument without
reaching very (ictinitc conclusions with regard to the causation of
the res}>iratory rhylhni.

Claus^ entered upon a criticism of I'ilchne's tiieory, based up(jn
the observation of two cases under his care. The first part of iiis
paper is historical, entering fully into the controversy between Traube
and Filehne, and laying special stress on the statements made by
the latter in regard to the oscillation of the blood-pressure seen
when the vagi are intact, and absent when these have been
divided. He then describes a case in which nitrite of amyl had
no eflect on the periodicity of tlie respiration, which he tries
to explain away by supposing that in Filehne's case the abnormal
irritability of the vaso-motor centre was less pronounced than in
his own. He will not allow that there is any evidence in favour
of the view tiiat the cause of the phenomenon lies in any change
of the quantity of blood supplied to the respiratory centre. From
sphygmographic tracings, Claus concludes that there is an increase
of blood-pressure at the end of the pause and beginning of the
period of respiration, with a return to the normal pressure during
the period of breathing and beginning of the pause, and that there
is an increase of vascular contraction during the pause. He there-
fore supports Filehne's theory as to the cause of the phenomenon.
In a postscript to the paper the author narrates a second case, in
which one inhalation entirely removed the periodic character of
the breathing, while a second administration only partially modified
its type. These results, however, he considers as being in favour
of the theory to which he aiij)eai'S to have been predisj)n.seil.

In an elderly jiatient, wliu dieil ajijiarenlly from caidiac failure,
de Wette- watched the ]iheuomena of Cheyne-Stokes breathing
tor thirteen day.^ and after a brief description of the case, he refers
to Traube's theory.

' AUgei/ieine Zvitschrift fiir Puijclndtrit uud puijchuchjerkhtUclie Midicin,
xxxii. Biuul, S. 437, 187.'>.

- Con-espoiiden>BUtti fiir schiceker AcrJe, vi. .lalirgang, .S. 1-10, 187G.

30 CHEYNE-STOKES RESPIRATION.

In a case of thoracic aneurism in an old man, described by de
C^renville/ Cheyne- Stokes respiration was present for some days.
No mention is made of the state of the pulse in the varying phases
of the breathing, but the pupils are said to have remained in a
condition of excessive contraction. The author takes the oppor-
tunity of bringing forward an occurrence which seems to be unique
— a case of intermittent respiration in a baby, one month old, caused
by morphine taken by his mother. The mother had been suffering
from neuralgia, for which she took a large dose of morphine, and
next day the baby lost his appetite, became cyanotic, and fell into
convulsions, attended by periodic breathing, during which the
pupils varied in size, becoming larger with inspiration. Tlie infant
recovered under appropriate treatment. In a case of cardiac dis-
ease presenting Cheyne-Stokes respiration, de Cerenville found
that morphine caused a diminution in the extent of the respiratory
phenomenon, while neither digitalis nor bromide of potassium had
any effect of the kind.

Eoss^ describes the occurrence of Cheyne-Stokes breathing after
the hypodermic administration of half a grain of morphine to an
intemperate person of 40, who was found in convulsions almost
entirely confined to the left side, with pupils of natural size. After
the use of the morpliine the convulsions ceased and the pupils
became contracted, while typical Cheyne-Stokes breathing made
its appearance. The author notes that during the pause in the
respiration the limbs became rigid, and relaxed again when the
breathing began. This type of breathing made its appearance
within four and a half hours of the time of the administration of
the morphine, it remained for about six hours, and ceased five hours
before death. The thoracic organs presented no abnormal symptom,
and the urine was healthy. At the post-mortem examination the
various organs of tlie body were found to be perfectly healthy.

Biot^ carefully describes this type of breathing as it occurred
in the case of a patient suffering from aortic and mitral disease,
and for the first time publishes tracings of the pulse and respira-

1 Bulletin de la Socie'te medicate de la Suisse romande, dixieme annee, p. 152,

1876.

2 Canada Medical and Surgical Journal, vol. v. p. 544, 1876.

3 Contribution « Ve'tude du pMnomhie respiratoire de Cheyne-Stokes. Lyon,
1876.

HISTORICAL. 31

tion. The pulse was rehiLively more frequent durijig tlie pause
than duriufj the breathin<^, aiid llie tension fell durint; the former
phase. He mentions several of the writing's which j)rece(kMl his
work, ami criticises the rival theories of Traube and Filehne. He
especially refers to the lessened arterial pressure during the
apna'a, shown by his tracings, as being antagonistic to the theory
of Filehne, which requires stimulation of the vaso-motor centre,
and consc([uent contraction of the arteries duiing that jdiase. He
mentions that the pupil was contracted during the pause, and
states that chloral produced considerable benefit to the patient.
In summing up he points out that the theory of Filehne is not
applicable to all cases, but he declines, for the present, to formulate
another. As a postscript he mentions the pauses of the respira-
tion in meningitis, which he describes as being entirely irregular
and sighing in character. He will not admit that such cerebral
breathing belongs to the type of Cheyne-Stokes respiration, altlioufrh
it is related to it.

Pepper^ calls attention to the significance of Cheyne-Stokes re-
spiration in cases of tubercular meningitis, and records two such
instances in an interesting paper on the subject. In l)oth the cases
which he describes there were variations in the condition of the
circulation coincident with the changes in the state of the respira-
tion, the pulse becoming less frequent during the cessation of the
respiratory movements. The author regards the phenomenon as
being caused by "a paresis or state of impaired sensibility and
activity of the nervous centres of respiration," in which they
cease to respond to the small quantity of carbonic acid in the
blood when it has been oxygenated by active respiratory move-
ments. It is worthy of note that Pepper refers to Begbie's
mention of the case of Philiscus, described by Hippocrates,
alluded to in the early part of this monograph, and it is permissible
to (piote his words. " On reading the description of the case," he
says, "which may pr(il)ably iiave been one of acute nephritis, with
uriemia, in the original and in Dareml)erg's translation, however, I
cannot see that anyLliing more is intended than the infrequent,
deep breathing with long intervals, wliich is so often met with in
states of partial or complete coma."

' l'hiladeli)hia Medical Times, vul. vi. \>. IIG, 187G.

32 CHEYNE-STOKES IlESPIEATION.

Heiu* begins an elaborate contribution to the subject by
stating that all arrests of respiration are not to be regarded as
instances of Cheyne-Stokes respiration. He says that such
irregular interferences with the usual rhythm are common in
infants and children. He mentions that he has observed six
cases of true Cheyne-Stokes breathing — two in patients suffering
from Bright's disease, one of whom had a fatty heart, and the
other oedema glottidis and pneumonia ; one in a patient who had
induced fatty degeneration of the heart through alcoholism ; and
three in patients dying of tubercular meningitis. He gives full
details of a seventh case. The patient on this last occasion was
an old lady, who had suffered for a long time from bedsores with
profuse suppuration, in consequence of being confined to bed after
a severe bruise to her left hip, and in whose case Hein diagnosed
fatty degeneration of the heart. During the course of the illness
Cheyne-Stokes breathing made its appearance, and, as it remained
for five weeks, the author of this paper was able to make careful
observations in regard to its phenomena. He calls attention
particularly to the condition of the consciousness. He noticed,
when she was sitting up, that during the respiratory pause, which
took place with the thorax in the position of expiration, the head
sunk forward as if in sleep, while with the commencing respira-
tions she raised it again like one awaking from slumber. During
the pause the eyes were shut as in sleep; she could be roused from
this condition by loud speaking, showed her tongue when asked
to do so, swallowed a mouthful of water, and could even speak a
word or two, but the senses were dull ; with the first superficial
respirations, however, the consciousness returned, she opened
her eyes and spoke spontaneously, complaining particularly of
her breathlessness. During the pause she could not be induced
to breathe. At the end of the pause slight twitchings about the
mouth were to be seen, but otherwise there were no involuntary
muscular movements. No pupillary changes corresponding to
the varying phases of the breathing could be determined, but
this point was rendered difficult by the fact that there was
a cataract in the left eye, while the lens and a piece of the iris
had been removed from the right eye in a previous cataract
operation.

1 Wiener medizinische Wochenschrift, xxvii. Jahrgang, S. 317 unci 341, 1877.

HI.STOniCAL. 33

Hein points out that the fluctuations in the condition of the con-
sciousness must be accounted fori)}' the same causes as those which
give rise to the respiratory plumomena, and asserts that this j^ives
a new position from which to consider the condition of tlie medulla
oblongata. He allows that changes in the state of the consciousness
have previously been noted in this condition, but shows that no
one has called attention to the simultaneous return of the con-
sciousness and the respiration, and holds that this fact is of such
importance that he can only reject every theory that does not
account for the return of the cerebral and medullary functions at
the same time. He points out that the relation between the irrita-
bility of the respiratory centre and the degree of respiratory stimu-
lation must undergo a periodic change.

Criticising the rival theories of Traube and Filelme, he remarks,
in regard to the latter, that he has observed in a child, aged seven
months, a fall of the blood-pressure in the great fontanelle at the
time of the return of the breathing, and states, on the authority of
Mayer and Friedrich, that amyl nitrite directly stimulates tlie
respiratory centre and may thus cause regular breathing. He
shows that the theory of Traube cannot account for the simul-
taneous return of consciousness and respiration, while his own
observation is in direct opposition to the hypothesis of Filelme,
for it does not agree with his experience that in a patient suffering
from cardiac weakness and its consequences, the dulness of the
sensorium would be removed by means of a sudden contraction of
the arteries and anaemia of the brain. Such an effect would sooner
be produced by an arterial hypersemia through paralysis of the
vessels, but such an explanation is negatived by the fact that the
fulness of the vessels of the face and neck remained equal during both
phases. He points out furtlier that the variations of the conscious-
ness and respiration must have the same cause, and shows that
in all his cases cyanosis was present, which, although arising from
different conditions, has the same result. Just as is the case with
tlie vitality in general, so in the medulla oblongata the irritability is
le.s.sened, and hence interruptions in the breathing are caused ; it is
open to question whether these breaks may not cause an influence
on the circulation, so that what was a consequence may in other
conditions be a cau.se. With a normal circulation such an effect
he holds to be impossible, as Cheyne-Stokes respiration may be

£

34 CHEYNE-STOKKS RESPIRATION.

imitated by the hour without any noticeable modification of the
circulation. It is otherwise, however, when the blood-stream is
retarded and oxygenation reduced, for if interruptions to the
respiration take place, the functions are alternately increased and
diminished, and such effects are shown in the medulla oblongata
through variations in its irritability.

The blood which has been arterialized during the respiratory
period reaches the capillaries in greatest part at the beginning of
the pause, at which time the circulation which had been quickened
by the breathing becomes slower, while the tissue change is most
active. The result is that the irritability of the medulla is again
increased and the breathing begins. By means of the passage, during
the breathing period, of the blood which has become venous during
the pause, the tissue- change for the vitality necessary to the
functional activity of the organ cannot be supported, the oxygen
in the tissues is consumed without adequate compensation, and
the irritability of the respiratory centre is lessened and suspended.
It is again restored after arterialized blood has coursed through
the vessels of the medulla and promoted internal respiration, as
occurs at the end of the pause. That the irritability shows a stage
of increase and a stage of decrease is due to the fact that the
alternation in the conditions of the circulation and diffusion is
gradual, not sudden. From the analogous conditions of the brain
and medulla it is to be concluded that the respiratory nerve centre
does not simply undergo a change in the degree of stimulation, but
a periodic alteration of its own condition.

Hein is of opinion that, although this theory of a periodic
activity of the brain and medulla caused by variations in the
amount of tlie tissue change is only hypothetical, it yet explains
what he thinks cannot be otherwise accounted for. He holds
that the frequent occurrence of the phenomenon in unconscious
persons does not oppose his theory, for in such cases the
periodic demand of tissue change may be so insignificant that,
although it is in a position to affect the activity of the re-
spiratory centre, it may not be able to influence the functions
of the brain.

Carrer' describes the case of a man, aged 60, who died of renal
disease and cardiac failure. Cheyne- Stokes respiration appeared
1 Guzeta medica Italiana, Provincie Venete, tomo xx. p. 403, 1877.

lIlSTOIMCAr.. 'Mj

after tlie patient had iireseiited various head symptoms for some
(lays, and remained h)n<^ enough to allow the author to mak(.' a
number of interesting observations. He mentions that during the
]»i>riod (if breathing the pupils were dilated, while they were con-
tracted in tiie ])ause. The ])ulse was less frequent during the
former than during the latter phase; and spliygmographic tracings
taken during these phases showed a difference in character, the
jtulsalions being larger, but less regular, during tlie dyspno-a than
(hiiing the apncea. It is of interest to note that the autiior f(juiid
the a})n(ea could be interrupted by powerful stimuli : the
aspersion of cold water, for e.\am{)le, caused a deep Ijreatli followed
by dyspnoea. The peculiar riiythm of the respiration remained
until the death of the patient — twenty-five days after its first
appearance. At the post-mortem examination it was found that
the ventricles of the brain and subarachnoid spaces were distended
with fluid ; the pleural cavities contained each a litre of fluid ; the
heart was hypertrophied ; the aorta dilated and atheromatous ;
and the kidneys contracted. There was, in addition, a perforating
nicer of the duodenum, Carrer, in conclusion, passes the opinions
of other authors in review.

Broad bent ^ describes the occurrence of Cheyne-Stokes breath-
ing in a case of apoplexy witli right-sided hemiplegia. There was
no alteration in the state of the pulse or heart during the varying
phases of the symptom, but movements of the left leg were
observed towards the end of the pause. He states that he has
often watched it in uraemic coma, and on some occasions in sinking
from exhaustion, as well as something very like it once in the case
of an elderly gentleman in his usual health. He thinks that the
effect of the phenomenon on the pulse varies, and remarks, " All
the theories on the subject are unsatisfactory, and I have none of
my own to of^er."

Wharry - places on record four cases in which tlie symptom
occurreil These were mitral disease with aortic dilatation,
aortic and mitral disease, nephritis, and typhoid fever with
pneumonia.

Andrew ^ describes the phenomenon as occurring in a case of
tyiihoid fever, which ended in recovery.

1 The Lancet, vi.l. i. for 1877, p. 3(>7.

- Ibid., \\ 3G8. 3 iii,i^ J, 385,

36 CHEYNE-STOKES UESFIRATION.

Treves ^ mentions the development of Cheyne-Stokes respiration
after haemorrhage followed by operation, and notes that drawing
the tongue forward diminished the pauses. On section the heart
was found to be healthy.

Frost gives some notes of a case of apoplexy ^ in which the
symptom appeared, and where no variation could be perceived in
the pulse during the different phases of the breathing.

One of the most valuable contributions to the subject is a study
of respiratory pauses by Frai)9ois-rranck.^ Having observed that
the respiration which followed tracheotomy had a great resemblance
to that with which we are concerned, and being inclined to explain
this as the result of a free supply of oxygen, he investigated the
conditions which influenced the phenomenon. He states that
with a larger supply of oxygen the pause arrives sooner and lasts
longer, while with a smaller supply the pause is later and shorter,
and that the pause (or apnoea, in the sense of Filehne) can be
stopped by compression of the carotids, which hinders the carriage
of oxygen to the brain, just as in calm breathing compression of
these vessels induces forced respiration. He attributes the pause
following the suspension of artificial respiration in animals to ex-
cessive oxygenation. Mentioning the pause in respiration which
is observed after the cessation of cardiac inhibition caused by
stimulation of the peripheral portion of the vagus, he explains it as
being due to excessive oxygenation of the blood lying in the lungs
during the cardiac inactivity, whic^h is thereafter supplied, on the
recommencement of cardiac action, to the centres, as observed by
Mayer. He describes experiments in which, after stimulation of
the central portion of the vagus, there is complete arrest of respira-
tion without any change in cardiac action. This pause, on the
cessation of the stimulation, is succeeded by large and frequent
respirations, which in turn are followed by a complete pause due
to excessive oxygenation of the blood. He further calls attention
to the pause which follows forced voluntary respirations in man —
a pause accompanied by total absence of the besoin de respirer — as
being caused in precisely the same manner. Turning now to the phe-

1 The Lancet, vol. i. for 1877, p. 481.

2 Ihid., vol. ii. for 1877, p. 238.

^ Journal de Vanatomie et de la physiologie normales et pathologiques de
I'homme et des animaux, 1877, p. 545.

IIISTOUICAL. 'M

iiomona of Cljcyne-SLokes respiriition.lK* inentidiis a case of iimuiia
in which this type of bieathin^ occurred. He points out that the
form of arrest in it difVers completely from that of apna3a in the
strict sense of that term, inasmuch as in Cheyne-Stokes respiration
the pauses are gradual in their development and cessation, while in
true apntea they are abrupt. In connexion with this case he men-
tions some experiments performed by Cutter, along with himself
and Jolyet. They injected ammonium carbonate into the veins of
dogs, in accordance with one of the theories of anemia, and found
that these injections were followed by arrests of respiration.
These, liowever, were very similar to the stop[)ages in apncea, and
had little resemblance to the pauses of Cheyne-Stokes respiration.
He also describes another example of Cheyue-Stokes respiration
observed in a case of mitral disease with cerebral embolism, in
wliich also the pauses had no resemblance to ttie arrests of respira-
tion in apncea. He mentions that in both the cases referred to
there was an adynamic condition, and tliiuks that perhaps the
suspension of the respiration may simply be due to the absence of
voluntary participation in the acts performed.

Sacchi ^ describes a case of aneurism of the ascending and trans-
verse aorta in wliich Cheyne-Stokes respiration made its appear-
ance. The pause of apncea could be broken by opening the closed
eyelids or by speaking to the patient. Cold aflusion and iidiala-
tion of amyl nitrite produced no effect, but the inlialation of oxygun
prevented the return of the pauses for an hour and a half. The
pupils contracted during the pause and dilated during the breath-
ing, and when the apnoea was broken by means of speaking to or
in any way rousing the patient, they also dilated. The pulse was
very irregular, and sphygmographic curves showed no constiint
relation between the circulation and respiration. The sensorium
was clouded during the existence of the symptom. Tlie post-
mortem examination showed that there was an aueurismal dilata-
tion of the ascending portion and arch of the aorta with hyper-
trophy of the heart. Both vagi were found to be compressed by
means of inflamed lymphatic glands below the origin of the
recurrent laryngeal nerves, a point of interest, inasmuch asTraube
states that for the occurrence of this plienomenon both vagi must
be intact. The brain was an;emic, and there was some etl'usion.
' liivista clinica di Buloyna, Secoiulo Seiio, tomo vii. p. 33, 1877.

38 CHEYNE-STOKKS KESPIEATION.

The author will not give his adhesion either to the theory of
Traube or to that of Filehne, and he holds that the result of the
oxygen inhalations is enough to disprove the view that the apnoea
is caused by too little carbonic acid in the blood.

Mosso^ describes periodic breathing of the Cheyne-Stokes type
as being a natural feature of the hibernation of the myoxus during
winter, when the temperature did not exceed a certain limit. If
the thermometer registers a heat of more than from 10°-16° C,
however, the animal awakes from the hibernating condition
Mosso further states that Cheyne-Stokes breathing is to be
seen in the sleep of healthy men, and this paper contains
several tracings of the respiratory movements taken in such
conditions.

Ottilie^ takes the opportunity, in describing a case of senile
degeneration of the brain, in which this symptom occurred, of
discussing the phenomena and causation of Cheyne-Stokes respira-
tion. He holds that however varying the cases may be in which it
appears, one condition is constant, an insufficient supply of arterial
blood to the medulla.

He further calls attention to the fact, that if the pulmonary
portions of the vagus are rendered incapable of performing their
functions, the sensory nerves from the rest of the body can induce
inspiration when the blood contains the amount of carbonic acid
gas which, under normal circumstances, is only found in the blood
of the pulmonary artery, and that tliis gives rise to long pauses.

Filatow^ describes two cases of Cheyne-Stokes respiration from
which recovery took place. One of these was a child, aged three
months, who suffered from dyspepsia and inanition ; the other was
also a child, ten months old, labouring under whooping-cough
accompanied by wasting.

The observations of Cuffer * throw some light on certain
aspects of the subject. These have already been referred to
in mentioning the work of rran9ois-rranck. After stating that

1 Archivfiir Physiologie, Jahrgang 1878, S. 441, 1878.

2 Transactions of the Wisconsin State Medical Society, vol. xii. p. 66, 1878.

3 Gentralzeitung fiir KinderJcrankheiten, Baud ii. S. 35, 1878.

* Recherches cliniqnes et exp&imentales sur les alterations du sang dans
Pur^mie et sur la pathogenie des accidents ure'niiques — De la respiration de
Cheyne-Stokes dans Vnremie, Paris, 1878.

IIISTOIIICAL. 39

tlie authors who have written on the suhject of uneniia make no
mention of the state of the hUnni curpwseles, or of the allinity for
oxygen shown hy the blood in cases of Bright's disease, he
describes a series of experiments performed to discover what
changes are undergone by the blood in that disease, and what role
is played by such changes. He shows that injections of urea have
no eflect on the number of the blood corpuscles nor on the capacity
of the blood for the absorption of oxygen, while injections of
ammonium carbonate and of kreatin reduce the former and
diminish the latter. Along with these effects the injection of
these two substances causes the appearance of a respiratory
rhythm similar to that of Cheyne-Stokes breathing. When the
actions of these substances upon the iilood are tested in vitro it is
found that urea has no eflect, but that carbonate of ammonium and
kreatin destroy the blood corpuscles. In Jiright's disease the
same effects are produced — lessened number of corpuscles and
diminished quantity of oxygen. Cuffer thinks it logical to con-
clude that in diseases accompanied by a diminution of urea there
is generally a lessened number of blood corpuscles ; that the
retention of urea, its possible transformation into ammonium
carbonate, along with the retention of other w^aste substances such
as kreatin and kreatinin, form the point of departure in that
alteration of the blood ; and he regards these substances as causing
the effects known under the term urremia by their action on the
blood. In Bright's disease the corpuscles are fewer as well as
more resistent; they do not undergo changes under the influence
of reagents — they are, in short, paralyzed, and their capacity for
absorbing oxygen is extremely diminished. Turning to dyspnoea,
the author shows that the reason of the frequent occurrence of
this symptom in Bright's disease is the reduced nunilier of
corpuscles, and that the acceleration of the respiratory movements
is in direct ratio to the dimiimtion of the number of the corpuscles,
in connexion with which he mentions that in leukiemia, chlorosis,
ami an;emia the same symptom depends on a similar cause. Car-
bonate of ammonium is much more active in the ilestruction of the
blood coriuLscles than kreaiin, and it is wurthy of note that the
effects upon the respiration are much more profound after injec-
tions of the former than is the case with injections of the lalli-r
substance. In cases of Bright's disease the author notes a s[)asm

40 CHEYNE-STOKES RESPIRATION.

of the arterial system, wliich he holds to be a powerful factor in
determining the accession of the exacerbations of the respiratory
disturbance. Entering next upon the consideration of Cheyne-
Stokes respiration as seen in urseraia, he deals, firstly, with this as
a clinical symptom, and, secondly, with the experimental produc-
tion of similar phenomena by means of injections of ammonium
carbonate and kreatin. He states that cases of Cheyne-Stokes
breathing fall into two classes, in one of which there is marked
dyspnoea, and in the other little more than a cessation of respira-
tion. These two classes he holds to correspond to the effects pro-
duced respectively by carbonate of ammonium and by kreatin.

He briefly narrates seven cases of renal disease in which Cheyne-
Stokes breathing was present, and which may be shortly sum-
marized as follows : — Mitral disease with consecutive disease of the
kidneys, in which no cerebral symptoms were to be seen ; mitral
disease followed by renal affection ; lead poisoning resulting in
interstitial nephritis with cardiac hypertrophy, where dilatation
of the pupils and muscular agitation accompanied the dyspnoea ;
chronic renal disease and cardiac hypertrophy ; interstitial neph-
ritis, in which the respiratory pauses were not complete, but were
represented by periods of shallow breathing ; chronic disease of
the kidneys ; mitral and renal disease ; gout and chronic renal
disease, in which Cheyne-Stokes breathing seemed to have per-
sisted for years; and chronic inflammation of the kidneys, in which
case the vascular spasm previously referred to was well marked.

Turning to the experimental aspect of the subject, he describes
his work in Marey's laboratory, where he had the assistance of
Fran^ois-Franck. The first series of experiments was performed
by injecting ammonium carbonate and kreatin into a vein, and the
results may be briefly summed up. After injections of the former
drug, the respirations assumed the character of Cheyne-Stokes
breathing, with violent dyspnoea and muscular agitation, as well as
dilatation of the pupils during apnoea. Injections of kreatin, on
the other hand, simply produced Cheyne-Stokes respiration of a
tranquil description. The employment of urea in similar experi-
ments caused no respiratory symptoms.

The second series of experiments was intended to elucidate the
cause of apnoea. After performing tracheotomy on animals, which
manifested symptoms of agitation during the experiment, apnoea

IIISTOUKJAL. 41

appeared ; ami llie iiullior refers in Lliis connexion to the same
syinptoMi a.s it occurs after openiii;; the trachea in children.
ApiKi'a was induced by keepiui,' up artilicial respiration in animals
alter (racheotomy ; and Cullfi-, hy means of several inj^eniou.s
exi)eriments which cannot he described here, proved that this c(jn-
dition was due to superoxygenation of the blood.

He, therefore, regards the stage of apnoia in tlie type of respira-
tion which we are considering as arising from excessive oxygena-
tion of the blood, caused by dyspnoea ; the recommencement of the
breathing and subsequent dyspncea as caused by the want of oxy-
genation due to the arrest of respiration ; the superoxygenation of
the blood and accompanying muscular fatigue determining in turn
a new period of apncea. He regards the phases as caused by the
action of the blood on the medulla as well as by the influence of
a reflex action having its point of departure in the lung, the lung
being the special regulator of the quantity of oxygen needed, and
having its essential stimulus in the condition of the blood which it
contains. The author, in concluding this most admirable investi-
gation, finally directs attention once more to the arterial spasm at
the beginning of the respiratory period, already mentioned as char-
acteristic of ura3mia, and points out how it iutiuences the condition
of the breathing.

Further observations having l)eeu made by Biot, subsequent to
the publication of his paper already reviewed, he embodied them
in a work^ of much value. After quoting the clinical descriptions,
given by Cheyne and Stokes, he lays stress on the differences exist-
ing between such breathing as may be frequently seen in meningitis
and that known as Cheyne-Stokes respiration, to emphasize which
he (piotes from, or refers to, the writings of many authors who have
described the former. He analyzes the cases narrated by Bernheim,
anil asserts that, the type of respiration in some of these was not
that of Cheyne-Stokes breathing, which he would like to keej) quite
apart from all other varieties of respiratory rhythm. Passing
from this subject he describes several cases, which may be briefly
referred to.

1. Man, aged 74, with atheroma, aortic dilatation, cariliac hyper-
trophy and degeneration, and pleurisy. L'. Man, aged 57, with

' Ktiidt' cliniijiie it t.rj)eriiii(.iilttle i<i(r Id ri.<j)iralu>)i ilc Cheijne-Sioktit. Tari.-',
1«78.

F

42 CHEVNE-STOKES KKSPIRATION.

atheroma, and aortic and mitral disease. Pulse less frequent in
dyspnoea; pupil dilated during that phase. 3, (Eeported by
Lupine.) Man, aged 47, with saturnine renal disease, cardiac
hypertrophy, and hemiplegia. Pupils contracted during apnoea.
4. (Reported by Clement.) Man, aged 70, with mitral disease and
cardiac hypertrophy. Pupils contracted in pause. 5. Man, aged
74, with cardiac hypertrophy and fatty degeneration. Pupils
contracted during apnoea, and muscular spasms in that phase.
6. (Reported by Prost, and already mentioned.') Man, aged 63,
suffering from apoplexy. 7. (Reported by Rocher.) Man, aged 46,
with aortic stenosis and incompetence as well as hemiplegia.
Pupils small during apnoea, but pulse less frequent instead of
more so, as in most cases. 8. (Reported by Clement.) Man, aged
60, with cardiac faihire, pulmonary apoplexy, anasarca, and hydro-
thorax. Pupils contracted during apnoea. 9. Man, aged 77, with
mitral disease and cardiac hypertrophy. No pupillary changes.

The author proceeds afterwards to analyze the symptoms presented
by these cases. Taking up the apnoea, he speaks of its duration
and frequency, and, as regards its causes, shows that it may be
produced physiologically by superoxygenatiou, and pathologically
by want of reaction of nerve centres. Turning to the dyspnoea, he
speaks of its duration and frequency ; and attempting to account
for its causation, he describes how he repeated Filehne's experi-
ments on the blood supply of the brain without attaining similar
results, which causes him to conclude that the theory of that
observer cannot be supported, and that the views of Traube are
correct. Taking up the state of the pulse, he finds the tension less
and the rate greater during apnoea. With regard to the condition
of the eyes, he usually observes contraction of the pupils and con-
jugate deviation of the globes during apnoea. As to the intellect,
it is usually clouded during apncea. Muscular spasms are often
seen at the end of apnoea, due to vagus irritation. As a means of
diagnosis, he holds the symptom to be a sign of a double affection
— cerebral and cardiac. As regards prognosis, he considers it to
be of very grave if not fatal significance. With reference to
medicines, he points out the uselessness of all remedies tried, and
lays stress on the hurtful influence of many drugs, such as

^ Vide antea, p. 36.

IIlST'JlilCAI-. 43

liypiiolics, narcotics, and substances reducing retlcx action. In
this connexion he narrates another case. 10. Woman, aged 53,
with bronchitis and enii)hy.st'ina, alowj^ with tricu.spid dihitation.
Ciieyne-Stokes breathing appeared, and after being pre.sent for
some time disappeared. To reliev^e dyspnoea she liad 7 nig. of
hydrocldorate of morphine, whicli caused tlie reappearance of the
Cheyne-Stokes breathing, followed by death. He show.s, finally,
l)y experiment that drugs wiiich induce or increa.se this type of
respiration ilo so by lessening the amplitude and frequency of the
respiratory movements, and by developing a pause at the end of
each expiration.

Filehne promptly replied' to the strictures of Biot, and pointed
out that the latter had not repeated his experiments, which were per-
foinied by stopping the current through the vertebrals as well as tlie
carotids, while Biot had only compressed the carotids, and therefore
left the blood supply to the medulla almost untouched. He further
observes that the clinical arguments advanced by Biot are not more
convincing, for the fact that the frequency of the pulse is greater
during the pause than during the period is not against the theory
of the author. The nuclei of the pneumogastric nerves may be
excited at the end of tlie pause at the same time as the vaso-motor
centre ; or, later than this, at the same time as the respiratory
centre, so that the lessened frequency of the pulse may be found
during the end of the pause or beginning of the ascending respira-
tions. Filehne refers Biot to his own tracings, which he holds to
be proof of this. He further expresses his opinion that the pheno-
mena of the pupils may be explained in a similar way. He ends
his paper by remarking that he is not called upon again to refute
the theory of Traube which Biot wishes to resuscitate, and adds
that in 1875 Traube addressed an oral communication to him, in
which, recognising liow well founded were his objections to that
theory, he accepted his views.

Biot at once answered- the criticisms of Filehne by the pub-
lication of an additional note on the subject. He regrets that, from
an error in the medium from wliich he obtained his knowleilge of
Kilehne's observations, he had been led to make a mistake in liis
control experiments, and accepts Filehne's assertion that the pheno-

' Revue viensuelle de me'decine et de chiriirgif, iU'U.\icnie aniu-o, p. G68, 1878.
» Ibid.y p. 935, 1878.

44 CHEYNP>STOKES RESPIRATION.

meiia of Cheyne-Stokes may be produced by alternately allowing
and preventing the afflux of blood to the brain. He again states
the distinction between Cheyne-Stokes respiration and other, more
or less irregular, modifications of respiration. He further reiterates
his statement that the arterial tension is higher during the period
of apnoea than during that of liyperpnoea, basing this upon tracings
and the application of Marey's law. He brings forward an interest-
ing fact, that when breathing is suspended the effect on the pulse-
rate depends on the phase of respiration during which the stoppage
takes place. When the breathing is stopped during the phase of
inspiration, there is usually slowing of the heart's action; when,
on the contrary, it ceases during expiration, tliere is always
acceleration. He refers to his previous work, in which he states
that the apncea in Cheyne-Stokes respiration begins in the phase
of expiration ; and again mentions that during the pause the
arterial tension falls, while the rate of pulsation rises. On the
other hand, with the period of breathing the reverse occurs.

He further criticises the work of Cuffer, in which he regrets the
absence of tracings, and expresses his opinion that Cuffer attributes
the dyspnoea of uraemia to a cerebral ansemia caused by a vascular
spasm — a theory which he regards as cousin to that of Filehne.

He concludes by maintaining his conclusions, that Cheyne-
Stokes respiration has a double origin — cerebral and cardiac.

Mickle^ has recorded three cases of insanity in which Cheyne-
Stokes respiration made its appearance. The diseases with which
the symptom was associated were in these three cases respectively,
general atheromatous change with cardiac hypertrophy and chronic
renal disease, pulmonary phthisis with dilated heart, and apoplexy
with epilepsy. The author fully discusses the pathological con-
ditions accompanied by the type of respiration in question, the
state of the pulse during its phases, the duration of these phases,
the disappearance of the symptom in some cases before death, and
the arrest of the peculiar breathing by means of various stimuli.

Zimmerman'^ describes the case of a drunken tailor, aged 55, who
was seen in an epileptic attack caused by excess. He had been
healthy up to within a few years of this attack, but latterly he had
suffered from breathlessness, and he had also been affected by

1 British Medical Journal, vol. ii. for 1878, p. 308.

2 Canadian Journal of Medical Science, vol. iv. ji. 112, 1879.

iiisiwKicAr,. 45

plilcrrnionous innanimatinn of Liu; lof;. After tlie epileptic seizure he
Ix^canie a'deiiiatous, with a return of the iiillaniination of the Ici,' and
severe dyspncca. TIk^ niinc cnniaiiKMl ncithrr alliuiiKMi nor tul»e-
casts. Ahoiit a month after heiiiL; Hrst set'ii the lircathiiii,' as.snint.'d
the Ciieynt!-Stokes character, and traces of albumen appeared in
the urine, hut Nvithout casts. The patient dit'il in a comatose state,
and it was found on post moitein examination that there was
chronic renal disease witli cardiac hypertroidiy, arterial atheroma,
and cerebral congestion. The author quotes Cuffer's cases and
explanation, and refers to the work of Biot. He further states
that since the paper was read he had met with Cheyne-Stokes
respiration in an old man of 80, dying of chronic bronchitis
and emphysema, and in a child 18 months old suffering from pneu-
monia of the right lung. In this last case the patient had many
symptoms pointing to tubercular meningitis, but recovered, and
the Cheyne-Stokes breathing in this instance was not continuously
present, but appeared and disappeared irregularly.

Luciani^ prefaces one of the most valuable contributions ever
made to this sul)ject by stating that he had, in the year 1873, com-
menced a series of experiments under the superintendence of
Ludwig at Leipzig, but that on account of various circumstances
he had not been able at the time to complete his investigations.
This paper begins with a brief retrospect of the work done by pre-
vious observers, after which the author describes some of the
results which he obtained by experiment. Finding, by means of
operations on the heart of the frog, that its rhythmic contractions
became periodic, the analogy between this phenomenon and
the character of the rhythm of Cheyne-Stokes respiration led him
to seek for their causes in a common condition. His experiments
were conducted by fixing a ral)l)it in Czermak's apparatus ; liga-
turing the carotid arteries to control hainorrhage during subsequent
operations on the medulla; connecting the respiratory passage, by
means of a canula, with a manometer, whose index recorded the
respiratory movements on a revolving cylinder ; exposing the
medulla oblongata ; and di\ iding it above the origin of the
vagi. The resjjiratory movements after section of the medulla
in this way fell into groups, but each group began with a deep

• Lo Sperimcntalc. A mm xxxiii. Tmno xliii. y. 341 v \>. ■14!I, ISTi).

46 CHEYiNE-STOKES RESHHATION.

inspiration and expiration, followed by a series of diminishing
respirations. Luciani states tliat if he had published these ob-
servations when they were conducted he would have deprived
Filehne of some of the novelty of his work, but he would at the
same time have been led to different conclusions. He was induced,
however, by the hope of obtaining more precise information, to post-
pone the publication of these results.

He afterwards turned himself to the study of apncea caused by
excess of artificial respiration. The method employed was to fix the
dog or rabbit ; to inject laudanum into the veins of the dog, when
such an animal was subjected to experiment, this proceeding not
being resorted to in the case of the rabbit ; to perform tracheotomy
and insert a canula into the trachea for the purpose of supporting
artificial respiration and recording respiration ; to expose the vagi; to
keep up artificial respiration until apncea was present ; to divide the
vagi ; and in some cases to join the canula to a reservoir of air lead-
ing by a tube to a Marey's tambour, by which means the result of
gradual asphyxia could be recorded. He found that, after the pro-
duction of apnoea by excessive artificial respiration, and without
section of the vagi, the respiration did not at once begin as ordinary
respiration, but in an ascending series; at the same stage, with
previous section of the vagi, an ascending series of respirations was
seen, but in this case the ascent was much more rapid ; after pro-
found narcosis had been caused and apnoea induced, it was suc-
ceeded by groups of ascending and descending respirations, separated
by long pauses ; after section of one vagus, the breathing became
deeper but less frequent, and after section of the other also it
became laboured and very infrequent ; when the animal was
allowed to breathe the air of the reservoir until death from asphyxia
took place, it was found that section of the vagi caused but little
effect, and the respiration became periodic when the animal was
almost asphyxiated.

Turning to the clinical aspect of the subject, Luciani remarks
that Cheyne-Stokes respiration may occur in diseases of the
brain, and of the heart and great vessels, in the coma produced
by different intoxications, during the agony of certain affec-
tions, and also in the sleep of healthy persons and the lethargy of
hibernating animals. He refers to its appearance after the use of
morphine in disease ; after the administration of morphine followed

iiisioiJii.Ai,. 47

liy ether (»r clilDrofKrin ; after tlie injection of cliloral, kreatin, and
anunoniuiii carbonate; after injury to the parts near the nieud
vital ; after the employment of artificial respiration, subsequent to
the injection of opium into tlie veins, so as to cause apnuia ; and
during tiie last stage of aspliyxia.

The respiratory phenomenon may appear in different forms.
Tlie movements may increase or decrease in amplitude without
change in frequency, or there may be more of the descending than
ascending phase — in fact, the latter may be absent. The number
of respirations during a period may vary from two to thirty, but
the larger numljers are only found in the Cheyne-Stokes breathing
of disease. The length of the pauses is very variable, and there
may be a similarity in the duration of the successive pauses or a
total want of equality.

The author then enters upon a long and careful criticism of the
theories of Traube, Filehne, and Hein, — into which it is, for
obvious reasons, impossible to follow him, — after which he submits
his own views on the subject.

He is of opinion that it is impossible to solve the problem of
Cheyne-Stokes respiration while resting upon the principle now
generally admitted or sustained, that the capacity and functional
activity of a nervous organ has always a direct and immediate
dependence on the stimulant and nutritive conditions extrinsic to
itself. That the life of an organ is intimately bound up with the
surrounding conditions and influences cannot be denied without
stilling science in the old vitalism ; but it does not follow from
this that the organ does nothing in every case but to transform as
much as it receives in a given time, both in the same measure and
in the same rhythm with which it receives it. Drawing a clear
line of distinction between reflex and automatic movements,
Luciani points out that the determining cause of the former is
extrinsic, while in the case of the latter it is intrinsic, and consists
in oscillations of the internal nutritive movements, to which cor-
respond as many oscillations of the excitability of the organ itself.
He was led to this new conception of automatism by the dis-
covery of the periodic grouping of the movements of the frog's
heart, before referred to, for no one could doubt that when extrinsic
conditions remained unchanged the cause of the alternate groups
of pulsations and pauses in repose was intrinsic.

48 CHEYNE-STOKES KESPIRATION.

Luciani therefore regards the diverse forms of respiratory
rhythm as extrinsic expressions corresponding to the oscilla-
tions of the nutritive changes taking place in the structure of the
respiratory centre. If it be granted that the respiratory centre is
automatic, it follows that the different forms of rhythm which con-
stitute Cheyne-Stokes phenomenon may be regarded as effects of
diverse kinds of automatic oscillations in the excitability of the
centre itself.

In a study of the action of morphine on the respiration, Filehne *
again discusses the respiratory and circulatoryphenomenaof Cheyne-
Stokes breathing, and somewhat modifies his original statements.
He says : — " To my former theory of periodic breathing would I
now make the addition that for its appearance it is quite sufficient
that the arteries of the medulla oblongata be stimulated simul-
taneously with the stimulation of tlie respiratory centre ; a previous
contraction will strengthen the phenomenon, and may occur in the
most pronounced cases ; it is, however, not indispensable, and per-
haps not always present." He further says that the difference of
opinion existing between his own and Biot's explanations of iden-
tical observations is a purely verbal misunderstanding ; and he also
replies to Hein by saying that the latter has concerned himself
more with 'the how than the ivhy.

To Rosenbach^ we owe a new explanation of the symptom in
question. After pointing out that the different phenomena accom-
panying Cheyne-Stokes respiration really constitute a complex of
symptoms, he disputes Biot's statement that true Cheyne-Stokes
respiration only occurs in cardiac diseases, and not in cerebral
affections. He points out that the descending part of the phase
of respiration is not so regular as the ascending, and agrees with
most observers that the circulation is sometimes involved and at
other times not. In some cases he mentions that there is a rise
of the pressure and fall of the rate during the ascending respira-
tion, while with the descending respiration the contrary takes
place, and in other cases there is no increase of rate, only lessened
frequency at the end of the pause. He shows that Filehue's ob-
servation on the sinking of the fontanelles of the child's head

1 ArcJdv fill- experimentelle Pathologie und Pharmakologie, x. Band, S. 442,
und xi. Band, S. 45, 1879.

2 Zeitschrift fiir Minische Medicin, i. Band, S. 583, 1879.

IIISTOICICAL. 49

before the 1)oi;inniiiLj of the respiratory pliase i.s not eorrect f(jr all
cases; the recession may occur aftt-r IIk; phase has be;4un or during'
the heif^ht of the breathing,', from which he concludes that the
sinking may be caused by an acceleration of the l)lood-flow from
the brain by means of the respiration. lie recalls Leube's state-
ment re^'arding stimulation of the phrenic nerves, and says that
stimulation of the vagi, causing a change in the pulse rate, effects
no change in the phenomena of Ciieyne-Stokes respiration, showing
that ihey are independent of tlie supply of arterialized blood to
tlic luaiii. lie lays stress on the contraction of the pupils during
tlie pause and their dilatation during the period of breathing, as
well as on the rolling of the eyeballs or conjugate deviation, and
the general twitchings of the body occurring during the period of
respiration. He further dwells on the changes in the sensorium,
and on the iniluence of such drugs as morphine, chloral, and
liromide of potassium, and recapitulates that there are changes in
Cheyne-Stokes respiration connected with the cortical as well as
with the basal centres, such as those of intellection, the muscular
system, the vision, the circulation, and the respiration.

Passing by Traube's first e.Kplanation, he states his second, which,
though not entirely tenable, has yet some good points. He points
out that it does not explain the ascending character of the respira-
tion. He then enunciates Filehne's earlier theory, based on
periodic changes of blood-supply, caused by a higher degree of
e.xcitability of the vaso-motor centre, and without hesitation rejects
it, inasmuch as in some cases the blood-pressure rises before tlie
recommencement of breathing, and when this rise is present it
attains its maximum at a point between the ascending and de-
scending respirations. Filehne's later theory, that the stimulation
(tf the respiratory centre and medullary vessels may occur simul-
taneously is also rejected, liosenbach is of opinion that both
]ihenomena are co-effects, and he is strengthened in his views by
the fact that other phenomena, such as the mental, visual, and
muscular, are bound up with the respiratory, not with the circu-
latory, symptoms. He emphasizes the dilferences between the
circulatory and respiratory phenomena in this type of breathing,
the great variability of the former and the monotonous similarity
of the latter being noteworthy. He brings forward the fact, noted
by Leuhe -dWil confirmed by himself, that artificial respiration during

50 CHEYNE-STOKES RESPIRATION.

the pause (which prevents accumulation of carbonic acid in the
blood) does not alter the next phase, as well as his own observation
that stimulation of the vagi and slowing of the pulse during the
descending period do not alter that phase, and holds that these
facts prove that within wide limits the condition of the blood does
not modify the type of respiration. He points out that the eye
phenomena are not dependent on the state of the blood, as the
widening of the pupils takes place along with the first inspiration,
and therefore before any change can be effected in the state of the
blood. In this connexion he refers to the work of Kiissinaul,
Eahlmann and Witkowski, Sander, Plotke, and himself, on the
relations of the eye and the central nervous system. He is there-
fore led to conclude that the beginning and ending of breathing in
Cheyne-Stokes respiration are independent of the blood-pressure
and the amount of gas in the blood, and that the clianges of the
pupils have no relation to the circulation or the blood, but to the
excitability of centres not directly dependent on the condition of
the blood. He points out that in health the vagus and vaso-motor
centres are more excitable than the respiratory, but that in this
phenomenon (with the highest pressure accompanying the deepest
respirations) they are sunk to the level of the respiratory. He asserts
that Filehne's theory postulates, in rhythmic contraction and dilata-
tion of the arterial system, conditions without analogy in nature.
He points out that at the end of the period of breathing there is no
apnoea, for the pupils, eyeballs, and mental state speak of fatigue,
not better arterialization, that amyl nitrite has often no influ-
ence or very little, and that the drug is believed by some to act on
the respiratory centre itself. He refers to Hein's explanation
of the observation that unconsciousness is present during the pause
and consciousness during the period as incompatible with Filehne's
theory.

Eosenbach seeks for an explanation of the phenomenon in the
alternation of activity and repose characteristic of nature. In the
respiration there is inspiration, expiration, and pause ; in the cir-
culation, systole, diastole, and pause ; in the nervous system, wakinp
and sleep ; while in curarized animals there are pei'iodic changes in
the rate and tension of tlie circulation which are quite independent
of the respiration. The origin of activity is in the cell, not the
Mood, and it is illogical to seek a cause of respiratory and other

IIISTOIMCAI,. 51

]iliriii)iii('ii;i ill lilt' hluiid. I'rrii)(licity of activity of all nervous
apparatus, tluTt'l'drc, (lc'])t'U(l.s on iniiuancnt pcciiliiiritirs of cltunciit-
ary structures, and the Ulood is nut the dii-ect stimulus tor the cells,
lull has its power in ,L;i\ iii<i; the cells the possibility of regulatiuf;
ti>sui' clinn-v. When the IiImhiI is altered there is necessarily a
iuii(liiic;iti()ii in the alisor[)Liuu ut' oxygen and removal of tissue
c]ianL,M' jirixhu'ts, and the mechanism will therefore be indirectly
atlectetl ; the blood is thus only one link in the chain of apparatus
needful for life.

The regular alteriialion of activity and repose characteristic of
lile is seen in the complex of pathological phenomena, of
which periodic breathing is only one symptom, and Cheyne-
Stokes res[)iration is therefore a condition in which the ex-
haiisiibilily of the central apparatus, normally following its
activity, is greatly increased. The resjiiratory centre has its
irritaljility lowered, as the breathing is at first shallow, but the
irritabiliiy } progressively increases, for in spite of better aeration
dyspncea gradually develops. The irritability then diminishes
and the descending phase begins. The supposition may be hazarded
that the first descending respirations following the deepest have their
origin in 1)etter arterialization of the blood, or in removal of waste
]iroducts from the centre, and that the fall in irritability begins
with the first normal breathing.

Rosenbach shortly summarizes his views in this way: — Throufrh
certain disturbances of nutrition, the brain suOers from lessened
How of blootl or altered quality of blood, and the processes of tissue
change are modified in the entire central organs, or in particular
]iarts (if it, especially in the medulla oblongata, and here a>'ain
more jiarticularl}' in the respiratory centre, so that the normal
irritability of the parts is lowered more or less, and the normal
jieriodic exhaustibility is increased even to complete paralysis.

Uosenbach mention.s, as an appendix to his paper, a case in
which a patient ill with tubercular meningitis suddenly ceased to
breathe except once or twice per minute, the pulse continuin*' to
beat. After artificial respiration had been employed the pheno-
mena of (Jheyne-Stokes breathing a])peared.

Purjesz^ describes a case whiidi he met with in the I'niversity

* J'ester medkinisc/i-chirunjimfie I'rcsn, xv. liuinl, SS. 771, 7^7, u. >4C!, 1>7J.

52 CHEYNE-STOKES KESPIRATION.

clinique of Wagner in Buda-Pestli. The patient, a man aged 57,
was suffering from emphysema, renal cirrhosis, cardiac hyper-
trophy, and general dropsy. During the last three days of his
life typical Cheyne-Stokes breathing was present. No changes in
the state of the pupils or alterations in the conditions of the
brain cortex were to be seen. The author mentions another patient,
in the same clinique, suffering from chronic renal cirrhosis, who
had Cheyne-Stokes breathing. In this case an improvement in
the patient's condition took place, and he left the hospital.
Purjesz reviews at considerable length several of the theories
which have been advanced to account for the phenomenon, but
gives no opinion of his own.

Edes^ has described five cases in which Cheyne-Stokes breathing
made its appearance ; and it is a most interesting point to find
that four of these instances belonged to the same family — a father,
aged 80 ; his wife, whose age is not stated ; and two sons, aged
respectively 50 and 45. The father was subject to attacks of un-
consciousness, during which the pulse was completely lost and the
periodic respiration appeared. The mother and the two sons were
affected by chronic renal disease. The fifth case was that of an
old woman with chronic renal disease, atheromatous arteries, and
hypertrophy of the heart, in whom left hemiplegia occurred from
plugging of the middle cerebral artery.

Kronecker and Marckvvald,^ by a series of experiments on the
rabbit, have shown some results of interest in this connexion.
The medulla was severed between the respiratory centre and the
brain, in such a way that the respiration was not much altered,
and the lower part was stimulated by single opening induction
shocks. At the right time such shocks strengthened the inspira-
tion and expiration, and when given during the interval between
the acts they induced others quite normal in character. When
the animal was brought into the condition of apnoea by means of
artificial respiration, the most powerful induction shocks failed to
cause any inspirations. When long pauses in the respiration with
intervening periods of dyspncea were produced by partial removal
of the respiratory centre, every induction shock given during the

1 Boston Medical and Surgical Journal, vol. ci. p. 734, 1879.

2 ArcTiiv fiir Physiologie, Jahrgang 1879, S. 592.

HISTORICAL. 53

pauses was foUowi-d ])y an ajiparently normal respiration. When
(luriiii^ a respiratmy pause successive rliyllitnic induction shocks
were t^'iven, phenomena were seen analogous to the chan;,'es in the
ventricle of the frog's heart observed by Kronecker and Howditch
(Rowd itch's stair).

From the pen of lioseubach^ came an excellent article on the
subject, based upon the views to which full reference has been
made. In this article he again advances his opinions that the
phenomena are not chiefly dependent on changes in the circula-
tion, that they are independent of any periodicity in the blood-
supply to the brain, and that they are co-ordinated by and
joint effects of one and the same cause occurring periodically in
the central organs, this cause being a periodic exhaustion of the
centres. The whole Inain may be affected, when the entire com-
plex of symptoms, to be termed Cheyne -Stokes phenomenon, is
produced ; or only limited tracts may be implicated, giving simply
Cheyne-Stokes breathing. He points out that, just as the respira-
tory centre alone may be deranged, so the vaso-motor or vagus
centre may be disturbed, as in tubercular meningitis, and cause
changes in the tension or rate of the pulse. Kosenbach compares
the periodic exhaustion with the normal pauses for rest shown by
all rhythmically acting systems. The different phases resemble
natural phenomena, but with longer intervals ; the period of breath-
ing, for example, is to be compared with a respiration, and the
period of apncea with the short pause following expiration. The
vagus and vaso-motor centres show similar variations. The ex-
haustion of the brain induces sleep, during which the pupils behave
as in ordinary slumber.

The centres are not only more easily exhausted, requiring longer
rest, but their irritability is reduced, and dyspncea comes on in
spite of better arterialization of the blood (which involves reduc-
tion of stimulus). The meaning of this is that the centre is
becoming more irritable although the stimulus is lessening. After
a time the normal irritability is regained, which is accompanied by
gentler breathing until the pause occurs.

The author holds that this theory differs from all previous
explanations in being based, not on periodic variations in the

• Iieal-EnrijrJu}mlie ihr gesammten Heilkumli', Hi-musgcgeltun von Dr Albert
Eulfiibei-y, iii. Band, S. 150. Wit-n luul Lt-ipzig, 1880.

54 CHEYNE-STOKES RESPIRATION.

amount of stimuli, but on periodic changes in the irritability of
the centre.

Caizergues^ describes the case of a man, aged 64, suffering from
mitral disease, in the course of which he laboured for some days
under severe dyspnoea, which was replaced afterwards by Cheyne-
Stokes respiration. During the pause the intelligence became
very cloudy, but the patient could be awakened by a loud noise ;
the eyelids drooped and the pupils contracted in this phase.
When awakened by a loud noise the regular periodicity of the
breathing was for a time arrested. Daring the period of
breathing the eyes were opened, and the face bore a look of
anxiety. The pulse, of which tracings are given, was more fre-
quent during the pause than during the breathing, and during this
latter phase it was extremely irregular.

After death it was found that there was mitral incompetence
with extensive arterial atheroma, more especially of the cerebral
vessels, with congestion of the kidneys and other internal organs.

BuU^ describes an interesting case in which the patient, belong-
ing to a neurotic family, and herself the victim of many nervous
symptoms, was seized, when 20 years old, with a hysterical affection
of the breathing. This consisted in spasms of the thoracic muscles
in the position of deep inspiration and deep expiration alternately,
the former lasting as long as forty seconds, and the latter to thirty-
five seconds. This condition cannot be compared with Cheyne-
Stokes breathing, as the only point of resemblance lies in the
pauses.

Blaise and Brousse,^ in a joint communication on this subject,
give a brief historical review of previous opinions as to the cause
of the phenomenon, and then pass on to the description of a case in
which it occurred. The patient in this case was a man, aged 88,
suffering from bronchial and pulmonary inflammation associated
with pleurisy, and accompanied by renal disease, as shown by
albuminuria and ursemia. The authors watched the type of
breathing under consideration for ten days ; it invariably ceased
during sleep, and it disappeared finally two days before death,

1 Gazette hehdomadaire des Sciences m^dicales de Alontpellier, tome ii. p. 337,
1880,

2 Norsk Magazin for Lcegevidenskaben, 3 Raekke, v. Bind, S. 165, 1880.

3 Movtpellier mAHcal, tome xliv. p. 287, 1880.

HISTORICAT,. 55

During tlie pauses the eyes closed, ami the pupils became small
and reactionlcss ; two or three seconds before the return of the
breathing the pupils dilated, and sometimes executed a series of
oscillations during the dyspncwa; during the i)eri<>d of hnsithing
they were sensible to liglit. There was considerable agitation at
the height of tlie dyspntea, at which time consciousness was unim-
l)aired, and there were no convulsions. By speaking to the patient
during the ])eri()d of l)reathing tliis phase could be prolonged con-
siderably. Sphygmograpliic tracings showed during the pause a
fall of tension and an increase in rate ; during the respiratory
period the reverse occurred along with irregularity of the pulse.
There was never a rise of tension at the end of the pause, but, on
the contrary, sometimes a fall.

After an excellent description of this case, accompanied by ad-
mirable tracings, the authors give a brief notice of another case,
under the care of Caizergues, which appears to be that previously
referred to.

They then proceed to analyze the symptoms attending this
phenomenon with great care, and subsequently criticise the views
of previous observers, to which they, in the early jiart of their
paper, had called attention. This brings them to consider the view
of their teacher Grasset, which they fully expound. According to
him, llie dyspnoea is the primordial fact, the apnoea being merely
a consequence of it ; and the type of breathing is a symptom of
excitement. The aniemia of the medulla, far from lowerin^^
increases the irritability of that organ. In anajmia of the nerve-
centres such phenomena of excitement as convulsions are common.
The diminution of the blood-current and consequent lessening of
the nutrition reduce the vitality of the nerve-cells. This increases
the irritability, but at the same time tends to produce weakness
and liability to exhaustion of the nerve centres. In short, it leads
to what the authors call, " that peculiar condition which the
English have so happily termed irritable weakness." This gives
the key to the causation of Cheyne-Stokes breathing: bulbar
anivmia produces greater irritability of the centres which it con-
tains; their usual excitant, carbonic acid, acts upon them with
unaccustomed intensity ; the breathing assumes the character of
dyspncea, which will be more marked if excitement of the vaso-
motor centre causes constriction of the arterioles, thus increasing

56 CHEYNE-STOKES RESPIRATION.

the bulbar anaemia. As the centres are easily fatigued, however,
their excitement progressively diminishes, until it passes away
entirely, whence the pause. After a time, the nervous elements
repair their forces, and the cycle recommences.

Franz,^ in the course of a paper on artificial respiration, takes
occasion to refer to the observation of Leube, pressed by Rosenbach
in opposition to Filehne's theory, that during tlie pause stimulation
of the phrenic nerves has no influence on the respiration. He
expresses his opinion that periodic breathing is not induced by a
periodicity in the respiratory centre apart from the degree of
arterialization of the blood, but that the origin of the periodic
event is a certain degree of venosity of the blood. He states that
in animals under the influence of morphine showing periodic
breathing, faradization of the phrenic nerves, when the trachea is
open, causes respiration, which he holds to show how little ground
Eosenbach has for citing Leube's and his own observations in
opposition to the theory of Filehne.

Marckwald and Kronecker,^ as the result of further observa-
tions on the respiratory movements, state that they have fully
confirmed Traube's observations, that the occurrence of Cheyne-
Stokes respiration is connected with the integrity of the vagi, for
after cutting these nerves in the neck the phenomenon never
appeared, and if present before section, it disappeared ; in fact,
with division of the vagi, all regulation of the respiration was lost.

Hein ^ asserts that neither the theory of Traube nor that of
Filehne can account for what he had previously described, i.e.,
variations in the state of consciousness, and he believes that there
must be the same cause for the cerebral and bulbar phenomena.
He therefore again states his theory. He quite agrees with Biot
that cerebral breathing is not the same thing as Cheyne-Stokes
respiration. In the former there is periodic breathing of atypical
form, often with long pauses, sometimes ascending and descending
in character, and having no constant relation between the eye and
breath symptoms ; but if the eye signs are present, the pupils are
wide during the breathing and narrow in the pause. It occurs in
many diseases, and the prognosis is not always unfavourable.

1 Archiv fiir Physiologie, Jahrgang 1880, S. 398.

2 Ihid., S. 441.

^ Deutsches Archiv fiir klinische Medicin., xxvii. Band, S. 569, 1880.

IIISTOUICAL. 57

Penodic brealliing of llie Cheyiie-Stokes type lie ImMs to l»t', iis
a rule, associatud with a state of iinconsciou.siies.s. Sonietinies
consciousness returns durin;^ the period of breathing, but is absent
in the pause, and if this is tlie case, tlie consciousness and the
breatliinjT reappear simultaneously. If j)upillary variations are to
be seen, the pupils are of middle size during respiration, become
narrower during the descending phase, and are small and insensitive
during the pause, gradually widening with the ascending respira-
tions. If the vaso-motor nerves are affected, there is higher
arterial tension during the respiratory period. This may pass
from regular Cheyne-Stokes respiration into the atyi)ical form at
times. The type of the respiration may be due to periodic varia-
tions ill activity of the respiratory centre alone or associated with
similar variations of other centres.

Lowil,^ from a careful study of tracings obtained by means of
the polygraph in a case of Cheyne-Stokes respiration, forms the
opinion that this symptom is not to be regarded as identical with
the periodic breathing produced experimentally by Filehne. He
holds that Cheyne-Stokes breathing does not depend upon varia-
tions in the condition of the circulation, but upon fluctuations in
the activity of the nervous mechanism of the breathing, such as
changes in the irritability of the respiratory centre from exhaustion
and recovery. The irritability of the respiratoiy centre alters
under conditions not yet perfectly known, but no doubt belonging
to the processes of tissue change. He regards this as the cause of
the symptom.

Winternitz,- writing nf Cheyne-Stokes respiration in eliiMren,
describes a case in which the patient, who was a highly hysterical
girl, was thrown into a state of great nervous irritability after a
painfid operation on the teeth, and in this condition developed
the type of breathing in question. It was present during a period
of thirty-six hours, and then disappeared. Another case described
is that of a little boy suffering from catarrh of the nose and throat,
with vomiting and diarrhtea, in whom the Cheyne-Stokes breath-
ing was present for twelve hours, until the patient improved.
During the pauses the pupils were contracteil. He is of eipinion
that in such a case the determination of blood to the intestines,

1 Frwjer mcdici n iache irucluiu^chn/i, v. Haii.l, SS. 461, 473, 481. u. tiil), 1880.
' Archil' fiir Kimkriuilkundi, i. Vmu\, S. 142, 188i>.

H

58, CHEYNE-STOKES RESPIRATION.

acting on a delicate and nervous organism, caused anaemia of the
medulla, and thus induced the Cheyne-Stokes breathing. He
suggests mechanical compression of the abdomen in similar cases,
but says he omitted it in his own.

Solokow and Luchsinger, in giving the results of a careful series
of experiments, contribute some interesting observations^ to this
subject. They state that when frogs, which have been immersed
for some hours in water, begin to recover from their stupor, they
show the Cheyne-Stokes phenomenon ; that when frogs in winter
are exposed to the action of heat, and the aorta is clamped, the
same phenomenon occurs on the removal of the clamp and on its
being again replaced ; that the periodic respiration is also seen on
clamping the aorta, after cutting the cord in the neck and destroy-
ing the spinal cord below that point, showing that it is quite
independent of conditions of blood-pressure ; that its occurrence
is not affected by any changes of pressure, or by the substitution
of saline solutions in place of blood ; and that the vagi are not
necessary for its appearance. They state that the conditions of
periodicity are no other than such as are developed in every tissue,
with growing asphyxia. Describing the administration of picro-
toxin hypodermically during ether narcosis, they mention that tlie
Cheyne-Stokes respiration and convulsions occurred synchron-
ously, and that on the administration of more ether the convul-
sions ceased while the periodic breathing went on. They compare
the phenomenon with the periodicity of lymph hearts as seen by
themselves ; with the periodicity of blood hearts described by
Luciani ; with the periodicity of the heart observed by Rosenbach
when a supply of defibrinated blood has been allowed to circulate
too long and has lost its colour ; and with the occurrence of the
contractions of exhausted Medusae in groups. They conclude that
the observations of comparative physiology as well as the results
of experimental analysis agree in showing the conditions of this
grouping of movements. Increase of stimulus and decrease of
elasticity show themselves to be the important factors. It may
without hesitation be supposed that the cause of the periodicity
is to be sought in the lessened elasticity and greater exhaustibility
of the organ, and this view is supported by direct observation.

1 ArcMv fur die gesammte Physiologie des Menschen mid tier Thiere, xxiii.
Band, S. 283, 1880.

irisTonicAL. 59

Tn answer to Fileline's question/ why the exliaiistion doo.s not
follow each respiration, instead of showing' itself after a series of
respirations, they reply that the irritabiliiy of a nervous or<,'an will
rise when after repose it is awakened to activity by stimuli, hut it
will sink if the activity has lasted too hnv^. They refer to tiie obser-
vations of Kronecker and Marckwald, already mentioned, as being
entirely analogous to the phenomena of Cheyne-Stokes respiration.

O'XeilF lays stress on the fact that the respiratory pause may
be present without any ascending and descending phenomena, but
is not prepared to say that arrests of this kind should be classed
as Cheyne-Stokes resi)iration. He mentions the case of a lady
suffering from chronic bronchitis and emphysema, with dilatation
and hypertrophy of the heart, in whom arrests of respiration
appeared, after an exacerbation of her pulmonary troubles, accom-
panied by general anasarca. The arrests of breathing disappeared
when the chest improved and the dropsy passed away. He
describes a case in which there was difficulty of articulation and
deglutition along with Cheyne-Stokes breathing, and he supposes
there was an affection of the medulla as well as of other nervous
centres. In this case the pauses appeared after the use of chloral.
O'Xeill states that in two cases nitrite of amyl produced no effect,
but that another patient suffering from renal disease, accompanied
by Cheyne-Stokes respiration, felt much relief from this drug,
^vhich on several occasions "restored and reinvigorated the breath-
ing when it was about to cease."

Lereboullet gives an excellent summary of the various views
held by several writers on the phenomena of Cheyne-Stokes
respiration.^ He is evidently of opinion that Filehne's investiga-
tions have tended to show that the primary cause of the symptom
is an affection of the vaso-motor centre, while the respiratory centre
is oidy concerned in its production in a secondary manner. Lere-
boullet adds no original observations of his own to the subject
with which he deals.

liosenbach* gives another critical study of the phenomena of

■ Ueher des Ch^yne-St' ikes'. ■<che Athmungsphanomen, S. 17. Erlangen, 1874.
'^ Lancet, vol. ii. fur 1880, j). 691.

3 Dictionnaire eticijclope'dique dis sciem-es m^icales, Pi-emi^re s^rie, tome
\xv., p. 322. Paris, 1880.

* Deutsche maliciuische Jf^ochenschri/t, vii. Jahrgang, SS. 27, u. 39, 1881.

60 CHEYNE-STOKES RESPIRATION.

Cheyne-Stokes respiration, in which he asserts t'.iat to this type of
breathing are to be referred all forms of respiration in which the
respiration is intermittent, or there is any periodic change in the
depth of the inspirations. He therefore inchides the effects of
morphine in the group of periodic changes of respiration, and
points out that as this drug lowers all the vital centres there are
usually changes in the functions linked with the respiration. He
then refers to the various symptoms associated with Cheyne-Stokes
respiration, and holds that any valid theory must account for all
of them. He goes on to state that the common characteristic of
these phenomena is an alternation of activity and repose, which
belongs to all nervous processes, and which is present in this case
with longer periods of repose. In addition, he points out how far
reacliing is the analogy between the phenomena of Cheyne-Stokes
respiration and the normal physiological processes. He ends his
contribution by stating the differences between the theory of
Traube and that which he proposed as follows : — 1. His own theory
is wider, and is concerned with symptoms unknown or insuffi-
ciently appreciated before ; 2. It takes little account of fatigue,
and looks to the excitability and non-excitability of centres; and
3. It holds the different phenomena to be independent of the
changes of the circulation.

A somewhat warm discussion took place between Filehne ^ and
Eosenbach ^ in regard to their respective theories, in which no new
facts or views were advanced on either side. The only points of
interest in Filehne's two articles are contained in his allegation
that Eosenbach's theory is not a new one, but merely a modifica-
tion of Traube's exhaustion hypothesis, and in his statement that
its author has only supported it by purely speculative reasoning —
a statement full of unconscious irony against its maker.
Eosenbach's reply to these strictures is a strong refutation of the
charges brought against his views, in which he has unfortunately
followed the polemical style of his critic.

Saloz^ devotes his inaugural dissertation to the subject of
Cheyne-Stokes respiration, and embodies in its pages a large

^ Zeitsclirift fiir klinische Medicin, ii. Band, SS. 255 u. 472, 1881.
2 Ibid., S. 713.

^ Contribution d I' Etude dinique et experinientale dii Phe'nomene Eespiratoire de
Cheyne-Stokes. Geneve, 1881.

mSTOHICAL 61

lunnLer of interesting facts, clinical and experimental. After
defining this type of respiratory rliytliin, an<l distingnisliing it
from such respiratory phenomena as are common in meningitis,
he proceeds to analyze its symptoms, taking up, in the first place,
the phenomena shown l»y the respiration, and, in the next i)lace,
tliose connected with tlie circulatory, psychical, vi.sual, and motor
apparatus. He lays stress on the variability of the circulatory
phenomena ; cm the necessity that any theory explaining the origin
of Cheyne-Stokes respiration must give a reason for the changes
in the mental state frequently accompanying it; on the support
which the oculo-pupillary symptoms give to llosenbach's theory ;
and on the inconstancy of the muscular phenomena.

He states that the appearance of Cheyne-Stokes breathing is
frequently preceded, and its disappearance followed, by a form of
res[)iratory rhythm which may be termed " intermediate," as it
forms a transition from the normal rliythni to that of Cheyne-
Stokes breathing, and calls attention to the fact that sleep is very
favourable to the development of tlie symptom. Casting a glance
at the views of CuHer and his division of the type into two classes,
he proceeds to review several of the theories advanced to account
for it, particularly those of Traube, Filehne, Luchsinger and Solo-
kow, and Cufl'er. In the course of this criticism he enunciates the
following proposition: — That the pathological physiology of Cheyne-
Stokes respiration must be based on the three conditions, — (1),
Diminution of the excitability of the respiratory centre; (2), Ilapid
exhaustion of this excitability by excessive action ; and, (3),
Gradually increasing recovery of this excitability, even amounting
to transitory exaggeration. In reviewing Cufter's work he observes
that in the renal cases which he has seen presenting this symptom
there have been, — (1), Alterations of the arterial system, embracing
the vessels at the base of the brain, leading to defective irrigation
of the medulla ; (2), Consecutive cardiac lesions augmenting the
circulatory troubles ; and, (o), An abnormal state of the blood,
which presented a great tendency to coagulate and cause thrombosis.

After some brief remarks on diagnosis, prognosis, and treatment,
the author goes on to describe his experiments. These, briefly
stated, were as follows : —

1. Pressure on the medulhi, which caused phenomena somewhat
resembling those of Cheyne-Stokes respiration.

62 CHEYNE-STOKES RESPIRATION.

2. Compression of the arteries supplying the brain, which pro-
duced effects distantly resembling Cheyne-Stokes breathing, but
not presenting a regular ascending and descending type, or corre-
sponding in time to the intermittent compression.

3. Injection of morphine, with or without subsequent adminis-
tration of chloroform, giving results closely resembling Cheyne-
Stokes breathing.

4. Injection of carbonate of ammonium and kreatin, with or
without previous nephrotomy, producing respiratory pauses and
spasms in no way comparable to Cheyne-Stokes breathing.

5. Various operations on frogs, leading to many phenomena like
those of Cheyne-Stokes breathing.

This leads to the description of ten cases personally observed by
the author, and of another communicated to him by Dr Mermod.
Summarized as shortly as possible, these cases were as follows: — (1),
Chronic renal disease in a man, aged 60 ; (2), Haemophylia in a boy,
aged 3J; (3), Chronic renal disease in a man, aged 48; (4), Chronic
renal disease in a woman, aged 84 ; (5), Chronic renal disease in a
man, aged 77 ; (6), Clironic renal disease in a woman, aged 41; (7),
Atheroma and chronic renal disease in a man, aged 70; (8), Chronic
renal disease in a man, aged 74; (9), Atheroma with thrombosis of the
carotid artery and cerebral embolism in a man, aged 65; (10), Chronic
renal disease in a man, aged 50; and (11), Mitral and aortic disease,
with consecutive renal affection, in a man, aged 70. Some of these
cases presented the fully developed phenomena of Cheyne-Stokes
breathing with its associated symptoms ; others were simply
accompanied by the respiratory changes alone.

The author concludes this excellent dissertation by drawing up
the following conclusions : —

1. The fundamental condition causing the phenomenon is dimin-
ished excitability of the respiratory centre.

2. This diminislied excitability is most commonly the con-
sequence of some obstacle to the supply of blood to the medulla,
such as some change in the vascular walls, some cardiac affection,
or some compression of the medulla.

3. This diminished excitability may also be caused by haemor-
rhages and poisons.

4. The apncea is not produced by excess of oxygen, but by
exhaustion of the respiratory centre.

mSTOHICAL. 63

5. The peculiar rharacters of Llie hyperpnoeji are caiiseil \>y llic
gradually increasing recovery of the centre and hy progressive
diminution of its excitability.

G. The role attributed to spasm of the vessels in the causation
of the symptom does not ajt[)ear to rest on suMiciently certain
facts.

7. The fri'ipu'iicy with which the .symptom is associated with
chronic renal disease depends less on tlic kidney aflection than on
the va.scular degeneration with which it is associated. The urinary
troubles only play a secondary part, by producing cardiac or
])uliiionary affections, ami by altering the state of the blood. The
development of the phenomenon in these cases does not seem to
have a direct relation to an intoxication by extractive matters or
ammonium carbonate.

8. Occurring in very diverse conditions Cheyne-Stokes breathing
has no precise diagnostic value.

9. The intermittent appearance of the phenomenon and its com-
plete disappearance prove that it does not depend on a profound
alteration in the structure of the respiratory centre.

10. Although most commonly the precursor of a speedy fatal
i.ssuc, the symptom may be compatible with survival for a long
period.

11. Without extolling narcotics it may be stated that in cases of
Cheyne-Stokes respiration they may render good service, and that
their dangers have been considerably exaggerated.

Langer^ describes a case of tumour of the pons in a young
woman, where Cheyne-Stokes respiration was present in its typical
development.

In an investigation into the periodic breathing of frogs, Langen-
dorff and Siebert- note that after the blood-supply to the medulla
has been cut off, frogs show a periodic rhythm of respiration, and
that the result is the same, whether the blood-supplv is cut
off by tying the aorta or bleeding the animal, while substitution
of a physiological solution of common salt for the blood sometimes
allows the ordinary type of respiration to continue, but often
modifies it in various ways. Stimulation of the skin during the
pauses between the periods of breathing causes the appearance of

' ^[ed^zinMle Jahrhiicher der k. k. Geselhchaft der Atntc in Jl'ten, S. 515, 1S81.
- Archivfiir Phusinlinju; Jahrj^uni,' 1881, S. 241.

64 CHEYNE-STOKES RESPIRATION.

a group of respirations. They regard periodic respiration as
conditioned by disturbance of irritability induced by modifications
of nutrition. The ascending character they attribute to the
gradual disappearance of exhaustion — the descending phase is
not so often seen.

Langendorff^ has further observed periodic respiration in frogs
after the administration of muscarine, which he regards as acting
directly on the respiratory centre, causing a true disturbance of
its nutrition. In the same paper he describes periodic respiration
caused by digitalin, which he attributes to the influence of the
drug on the heart, as the respiratory phenomena only appear
when the heart is brought nearly into the condition of arrest.

Sanson! 2 is of opinion " that the respiratory nerve centre is
dhedly influenced — that it suffers a paralytic lesion, and so its
irritability is impaired," but adds that "it may be doubted whether,
in some cases, the symptom may not be initiated by disease of
the heart-muscle itself."

Davy^ describes the case of a man, aged 70, subject to attacks
of cardiac asthma, who at times presented characteristic breathing
of this type.

Langer* commences an excellent contribution to the study of
this subject by defining the symptom and describing the pheno-
mena with which it is so often associated, after which he refers to
modifications in its type, and states that his observations lead him
to agree with Eosenbach that true Cheyne-Stokes respiration may
occur in cerebral cases. He afterwards analyses the various
phenomena, especially dwelling on those connected with the state
of the consciousness, the muscular condition, the changes in the
eyes, and the circulatory modifications. All of these he holds to
be explicable by one of two possibilities — either that the excita-
bility of the centres increases and diminishes, or that the stimuli
vary while the excitability remains constant. This leads him to
mention the rival theories of Filehne and Eosenbach.

He then narrates the case of a mason, aged 29, suffering from

^ Archiv filr Fhysiologie, Jahrgang 1881, S. 331.

2 Manual of the Physical Diagnosis of Diseases of the Heart. Third edition,
p. 38. London, 1881.

3 Cincinnati Lancet and Clinic. New series. Vol. viii. p. 492, 1882.
* Wiener medizinische Presse, xxiii. Jahrgang, S. 1253 u. 1289, 1882.

HI8T0HICAL. CJj

climiiic, HriL^ht's disease. In this case Cheyne-Stokes breatliin^'
was developed with chan<;es in the condition of tlie consciousnes.s
and in the movements of the eyeballs, but witiiout any alteratif)n
in the inipils corresponding; to the two phases of the breathint;.
After this had cniitiiiued tnr twenty-four liours, periodic changes
in the condition of the circulation showed themselves, the tension
of the pulse risinj;, and its rate sinking' with the ascending' phase
of the respiration, and the converse takin^j ])lace during; the
descending phase and the subseciuent [)ause. After tiuise condi-
tions had existeil for two days a change ensued, and on account of
an alteration in the relation of the pulse and respiration, it often
happened that the highest tension ami lowest rate of the former
coincided with a pause of the latter.

The author regards this observation as giving support to the
theory of Kosenbach, to which, as well as to the work of Solokow
and Luchsinger, and Hein, he refers in concluding his paper.

De Witt' records a case in which the patient, an elderly man,
fell down and probably struck the back of his head. He became
unconscious, and developed long pauses in the breathing. It is
open to question whether this case may be regarded as having any
close connexion with the subject under discussion.

Paterson- narrates the case of a middle-aged gentleman,
suH'ering from Bright's disease, who presented the symptoms
of Cheyne-Stokes respiration, which he is inclined to attribute
to cardiac hypertrophy and pulmonary oedema, acting injuriously
on the medulla oblongata.

Knoll,^ in a contribution to the study of irregular and periodic
breathing, distinguishes between spontaneous alterations in the state
of the respiratory centre and changes which are produced retlexly.
lie holds the latter class to be very much more extensive than the
former, traces out the mode of origin in both, and gives examples
of each. Amongst periodic breathing the author dwells on that of
the " meningitic type" of Biot, which he holds to be dependent on
a sinking of the irritability of the respiratory centre rather than
on a stimulus caused by the blood, leaving it in doubt, however,
whether other factors may not also be concerned in its production.

' Cincinnati Lancet and Clinic. New series. Vol. i.\. p. 2lK), 1882.

2 Lancet, vol. i. for 1883, \>. IJI.

^ Lotos, iieue Folj,'c, iii. ii. iv. liaii'l, S. 101), 1S83.

I

66 CHEYNE- STOKES RESPIRATION.

He also devotes some remarks to Cheyne-Stokes phenomenon,
mentioning the various methods by means of which appearances
more or less like it may be produced, and concluding that he
would not be justified in regarding the symptom as a reflex
phenomenon of deeply depressed irritability of the respiratory
centre, in opposition to any theory of blood stimulus.

FanOji in the course of some investigations on the red blood
corpuscles, observed that after removing the heart from a tortoise
the breathing persisted, not indeed with its previous regularity,
but in a periodic manner, the respirations being grouped together
and the different groups separated by long pauses. This observa-
tion, which he repeated more than once with different forms of
tortoise, and which he compares with the results of Solokow and
Luchsinger, led him to consider the origin of Cheyne-Stokes
respiration. Such experiments he holds to have entirely over-
thrown the theory of Filehne, already refuted by Luciani. Fano
proceeds to detail the methods which he adopted in his investiga-
tions, and afterwards criticises the theories of Filehne, Traube,
Solokow and Luchsinger, Langendorff and Siebert, and Luciani.

This is followed by a description of his experiments with
carbonic oxide and carbonic acid gases. He found that tortoises
were able to live and breathe for many hours when in an atmo-
sphere solely composed of either of these gases ; and he concludes
this fact to be enough to show that there may be some doubt as
to the production of respiratory movements by the state of the
blood. Other experiments, performed with oxygen, hydrogen, and
carbonic acid, confirmed his conclusions ; but at the same time, as
he remarks, made some of the nervous functions involved even
more mysterious and difficult of explanation.

The occurrence of Cheyne-Stokes breathing in a case of apoplexy of
the cerebellum, due to degeneration of the cerebellar arteries, has been
placed on record by Hurd.^ In this case marked congestion of the
whole medulla oblongata was found at the examination after death.

In an exhaustive article on variola, Zuelzer^ says of that disease
that the respiration in the early stages is usually hard and laboured,

' Lo Sperimentale, lomo li. p. 561, 1883.
'^ Boston Medical and Surgical Journal, vol. cix. p. 195, 1883.
^ Beal-Encyclopadie der gesammten Heilkunde, xiv. Band, S. 393. Wien unci
Leipzig, 1883.

HISTOniCAL. 67

and not inficqnently sliows at a later stage tin; irre;:,'ularity of
the Cheyne-Stokes respiration phenomenon, whicli continues more
or less rpyularly and distinctly, until towards tlui end in fatal
cases pneumonia or pleurisy appears.

ruddicoiiilic' records a case ot" apoplexy occurriuL,^ in a man,
n^fcd 04, ^vll() towards the end of the disease, in the last days of
his life, ilevelo])ed Cheyne-Stokes respiration. This cliaracteristic
form of lu'eailiiuL; niily appeared during sleep. The pauses could
l>e interrupted hy strong stin)uli, but as soon as these ceased
the patient again fell into the condition of apncea. Drugs which
increased the tendency to sleep made the patient worse instead of
better. The effect of nitrite of amyl is worthy of note. " Nitrite
of amyl," says the author, " on being held to his nostrils, stopped
the symptoms temporarily, but only by causing him to wake up,
which he invariably did after it had been held to his nose for
seven or eight seconds."

Dunin- describes three cases in whicli Cheyne-Stokes respiration
was present, two being in cerebral haemorrhage, and the third in
enteric fever. He is of opinion that in the last-mentioned case,
at any rate, the cause of the symptom was exhaustion of the
nerve centres in the medulla.

IMuri'i,^ after some historical remarks, considers the nature of
the phenomenon and the type of breathing to be designated l)y
tlie term Cheyne-Stokes respiration, wdiich leads him to mention
the investigations which he had previously carried out. He holds
that there is in this condition a regular increase and decrease of
the activity of the respiratory centre caused by a mechanism as
yet unknown. This definition is followed by a reference to some
of the views advanced by previous observers, particularly Traube,
Filehne, Luciani, Luchsinger and Solokow, IJosenlxich, Lowitt,
Langer, Saloz, and Fano, and this is in turn succeeded by a descrip-
tion of some of the more important work done by them, and a
thorough criticism of their theories.

Murri then turns to the influence of stimulants, and finds that
variations in {]\c amount of carbonic acid in the blood, as well as

» Tlie Lancd, vol. i. U>v 1883, ji. M(>.
- <l(i::ctu Ukiirda, R/.ail 2, tuiii iii. S. it!.'), 1883.

•'' liiristn clinica (U Boloyna, .serie terzji, tuiiin iii. ]>. 7.57, 1^83 ; aiul Airltiies
italienncs de Biologic, toiiit; v. \\ 1-13, 1884.

68 CHEYNE-STOKES KESPIBATION.

sensory stimuli, the effects of coughing, or of changes in the brain
circulation from pressure on the neck, together with the result of
moral impressions and the exercise of the will, can modify the
periodic breathing. He thinks that the respiratory centre has
several zones of different degrees of excitability corresponding to
different groups of muscles. In health the most sensitive zone
responds promptly to stimuli, and is therefore sufficient for the
function of respiration. If impaired, however, it needs stronger
stimuli, and these rouse the other zones, causing dyspnoea, by
means of which more oxygen is supplied to the blood, and there is
a more rapid current in the medulla, leading to a slowing of re-
spiration which ends in the pause, during which there is again an
accumulation of carbonic acid and a repetition of the cycle. The
decreasing or descending respirations are due to the continuance
of activity after the interruption of the stimuli ; the dyspnoea is
caused by the delay in the aeration of the medulla. It must be
admitted, as postulated by Traube, that the irritability of the
respiratory centre is impaired in order to have the necessary
conditions for the development of Cheyne-Stokes respiration, but
it is unnecessary that the pneumogastric nerves should be intact.

Tizzoni^ describes the lesions which he observed in two cases
under the care of Murri in which Cheyne-Stokes breathing was
a prominent symptom. In one of these, where the primary
disease was a cardiac lesion, there was chronic neuritis of the
trunk of the vagus, with sclerosis and atrophy of the gray matter
of the medulla. In the other case, where death was caused by
renal disease and uremia, the vagi were healthy, but there were
inflammatory changes in the internal or median nucleus of the
vagus as well as in the posterior nucleus common to the vagus and
spinal accessory nerves.

Bramwell,^ in his admirable and exhaustive work on cardiac
diseases, devotes considerable attention to Cheyne-Stokes respira-
tion as one of the symptoms of circulatory affections. After
describing its appearances and significance, he refers to the con-
ditions which may lead to its development, and gives a brief
sketch of the views of Traube, Sansom, and Filehne. This brings

* Memorie delV Accademia delle Scienze di Bologna, serie qnarta, tomo v. p.
331, 1883 ; and Archives italiennes de Biologie, tome v. p. 226, 1884.
2 Diseases of the Tleart and Thoracic Aorta, p. 68. Edinburgh, 1884.

HISTORICAL. 69

him to state the opini<ni wliiili he has been led to form, and as his
exitlaiiation of tlie plu'iionieuon is <^iven with t'(juiil hicidity and
brevity, it will be satisfactory to quote his own words.

"The respiratory centre in the medulla oblongata probably con-
sists of two parts — one connected witli inspiration (the inspiratory
centre), the other with ex})iration (the expiratory centre). Now,
according to liosentlial (quoted by Dr M. Foster), the inspiratory
centre is the seat of two conflicting forces, — one tending to generate
inspiratory impulses (the discharging portion of the inspiratory
centre, as we may call it), and the other offering resistance to the
generation of these impulses (the restraining or inhibiting portion
of the inspiratory centre), the one and the other alternately gaining
the victory, and thus leading to a rhythmical discharge.

" Further, we may probably with truth suppose that the two
parts of the inspiratory centre are differently acted upon by the
same stimulus; venous blood, for instance, which excites the action
of the discharging portion, depresses the action of the restraining
portion, vice versa arterial blood depresses the action of the dis-
charging portion, but strengthens the action of the restraining part.

" Xow, if we suppose that the discharging portion is in a con-
dition of irritable weakness, in which it is more easily excited to
discharge, but in which it tends to become more speedily and more
completely exhausted than in health — (or, better still perhaps, that
both portions of the centre are in this abnormal condition, i.e., a
state of irritable weakness), we have, I conceive, a condition of
things which will satisfactorily explain the phenomena.

"Let us suppose, as it is simpler, a case in which the discharging
portion is in a condition of irritable weakness, the restraining por-
tion remaining normal. Starting, as we did in considering Filehne's
theory, with the end of the period of apncea, i.e., with the blood
in a highly venous condition, we may suppose : —

"(1.) Tliat the venous blood gradually excites a paroxysm of
dyspncea: — Firstly and chiefly by acting directly upon the inspira-
tory centre itself, depressing the action of the restraining portion,
and arousing the action of the discharging portion, which has,
during the stage of rest or apncea, been gradually recovering from
the condition of exhaustion occasioned by the excessive discharge,
wdiich produced the preceding paroxysm of dyspn(va. Sccondhj,
by stimulating the action of the vaso-motor centre, in consequence

70 CHEYNE-STOKES RESPIRATION.

of which the arterioles are contracted, and the supply of oxygen
to the respiratory centre is still further diminished.

" (2.) Tliat in consequence of the excessive irritahility of the
discharging portion of the inspiratory centre, the discharges become
excessive, and a condition of dyspnoea is produced.

" (3.) That in consequence of the weakness of the discharging
portion of the inspiratory centre it speedily becomes exhausted —
over-exhausted ; and the dyspnoea tends to subside.

" (4.) That in consequence of the excessive respiratory efforts
during the paroxysm of dyspnoea, the blood (which was previously
venous) becomes arterialized ; stimulation of the discharging por-
tion of the inspiratory centre ceases ; stimulation of the restraining
portion is produced ; and in consequence of the deficient stimula-
tion and over-exhaustion of the discharging portion, the restraining
portion has full swing, and the condition of apnoea is produced.

" The arterialized blood acts firstly and chiefly upon the inspira-
tory centre itself, strengthening the action of the restraining
portion and depressing the action (removing the stimulation) of
the discharging portion ; secondly, by removing the stimulation of
the vaso-motor centre, in consequence of which the arterioles
dilate, and the supply of oxygen (arterial blood) to the respira-
tory centre is still further increased.

" During the stage of apnoea the discharging portion, which was
exhausted by excessive action during the period of dyspnoea,
gradually regains its irritability, and the condition required for
its stimulation, and for the removal of the control of the restrain-
ing portion, viz., a venous condition of the blood, is, in consequence
of the absence of the respiratory movements, gradually developed.

" By this theory we can, I think, satisfactorily explain : —

" (a.) The occurrence not only of diminished respiratory move-
ments after the period of dyspnoea, but the complete arrest of
respiration which occurs during the stage of apnoea — a point which
it is difficult to explain by the other theories.

" (&.) The remarkable fact that the respiratory centre is at one
moment violently discharging, and at the next in a state of
absolute quiescence.

" (c.) That the dyspnoea and apnoea follow one another with
rhythmical regularity ; and that the one condition gradually passes
into the other, and vice versa."

HISTORICAL. 71

Fano,' ill it'|ily to the criticism of Muni, <lt;ftincl.s the views
which he previuii.sly advanced, and in Liun criticises the theory
proposed by the latter.

O'Conneir- mentions the occurrence of Cheyne-Stokes respira-
tion in the case of a male infiuil wlm died in one of the respiratory
pauses twelve hours after biiLh. Xo post-mortem examination
was allowed, and the cause of the symptom therefore remained
unknown.

Fano-' describes the respiration of the allii^ator as not bein;,'
naturally periodic, but as assuming this character when the sur-
rounding atmosphere is cold. Ity spraying the animal with
etlier, for example, it was easy to render the respiration, which
was regularly rhythmic previous to the use of cold, periodic in
character.

Fabian"* gives an excellent critical survey of Cheyne-Stokes
respiration in regard to the various theories advanced to explain its
origin ; he gives the theory of Murri credit as being the most
satisfactory hitherto proposed, and gives a very good summary of
the views of that writer.

Piaggio^ devotes his graduation thesis to this subject. Beginning
with some introductory observations, followed by a brief historical
retrospect, he gives a clinical study of the phenomenon and its
associated symptoms, passes in review the normal physiology of
the respiration, and concludes that it is not the degree of arterializa-
tion nor the arterial tension, nor the rapidity of the blood current,
nor the action of the heart and lungs, but the cell itself that regulates
the amount of oxygen consumed by the organism. He supposes
that there are two respiratory centres, one of which presides over
the respiration of the tissues, and controls the respiratory centre as
usually understood. Passing on to consider the pathological
physiology, Piaggio grants for the appearance of Cheyne-Stokes
breathing a diminished excitability of these centres, and ex-

■ Lo Sperimentale, anno xxxviii., tmiin liii. ]>. 132, 1884.

2 British Medical Journal, vol. i. lor 1884, p. 220.

3 Lo Sperimentale, anno xxxviii., tonio liii. p. 233, 1884.

* 0 zjawijiku odiUrlwive'm Heyne-Stokesa. MatUtkovuki Ksieya j>ami4stkoiPa
Hoyerowi, S. 277, 1884.

^ Sur une noavelk TMoriedu PMnomine Respiratoiredi Chtyne-Stokes. Paris,
1884.

72 CHEYNE-STOKES RESPIRATION.

presses his opinion that the various circulatory changes which
accompany the symptom are of a compensatory nature. He does
not allow that the forced breathing is true dyspnoea, and compares
it with analogous symptoms seen in hysteria and other nervous
affections. After criticising some of the most recent work done
immediately before the appearance of liis thesis, he sums up his
views, stating that there is in Cheyne-Stokes respiration a constant
force whose intensity is invariable and subnormal, and whose
source is in the condition of the tissue, not in the state of the
blood ; that the tissue centre of respiration controls its subordinate,
the automatic centre of respiration, and that this latter may be
affected indirectly through disturbance of its superior centre or by
means of influences acting directly upon itself.

In an investigation into the action of sulphuretted hydrogen on
the respiration, Smirnow^ found that when the air breathed con-
tained from one-eighth to one-seventh per cent, of this substance,
" a classical Cheyne-Stokes breathing," as he calls it, appeared,
accompanied by variations in the diameter of the pupils, the
sensibility of the conjunctiva, and the rate of the pulse. The
condition was present as long as the animal breathed the mixture,
and disappeared when ordinary air was allowed to replace it. The
author mentions that on the periodicity and ascending and
descending character of the respiratory movements section of the
vagi and of both laryngeal nerves had no effect. He states that
the blood-pressure fell during the cessation of respiration and rose
when it recommenced, while the pulse became less frequent during
the pause. On dividing the vagi the change in frequency did not
appear, but the falling of blood-pressure remained. Smirnow was
able, therefore, to produce almost all the features of the Cheyne-
Stokes respiration phenomenon, and from his study of it he is of
opinion that the periodicity of the breathing is only conditioned
by weakness of the respiratory centre. He thinks that the
appearances presented by the circulation, pupils, and other organs
depend upon a synchronous affection of the other corresponding
nerve centres, which is not connected with the type of the respira-
tion.

1 Gentralhlatt fur die medicinischen Wissenschafien, xxii. Jahrgang, S. 641,

1884.

HISTORICAL. 73

Kaufinaini^ contrihuto.s a paper on some artificially ])roilucetl
phenomena in Choyiie-Stokes l)reatliin«,', which he observed in
the case of a man, aged 54, snllering from general tnherculosi?,
where it was developed after the use of chloral and morphine.
The periodic breathing was accompanied by changes in the
size of the pupils, in the movements of the eyeballs, and
in the state of tlie intellect, but not, so far as could be made
out by nutans of the finger, by any changes in the state
of the circulation. Kaufmann found that during the pause of
the breathing, respiration could be e.xcited by the application of
cold, by striking the surface of the body, by tickling the sole of
the foot, and by speaking loudly to tlie patient, and he gives
tracings of the respiration showing tiiese effects. These results
were usually accompanied by opening of the eyelids and widening
of the pujiils. He is of opinion that such effects could not be
produced if there were a total absence of irritability of the
respiratory centre or a condition of true apnoea, and he also thinks
theories based upon a conception of exhaustion of the centre
require the additional hypothesis that the increase of irritability
induced by external stimuli is so great as to prevent the exhaus-
tion from giving expression to itself. He comes to the conclusion
that much observation and experiment is required before we can
arrive at a satisfactory solution of the phenomenon.

Cantieri^ records a case of cardiac disease in a man aged 5*'.
who presented the symptom of Cheyne-Stokes respiration during
the course of the affection. After death it was found that there
was great hypertrophy of the heart with pericarditis, myocarditis,
and endocarditis — the latter especially affecting the left side and
particularly the mitral valve — associated with atheroma of the
aorta.

Bordoni^ descril)es two cases presenting Cheyne-Stokes respira-
tion, one being that recorded by Cantieri, which has just been
referred to, and the other patient being a man aged 76, who died
under the care of a colleague in consequence of pneumonia and
cardiac degenerati«jn. In the former case the pulse increased in

* Pru/jer medkini.^clu- iroch''iisr/iri/(, ix. Jalii-'^ani^, S. 344 u. ;};i4, 1884.
-' BulMino ddla Socirtii tra i Cidtori dcllc Scienze iiudiche in Siaui, anno ii.
p. 250, l,ss4.

2 //<(•</., aiiiK. ii. 11. i'.">3. 18-^4.

K

74 CHEYNE-STOKES KESH RATION.

rate and tension during the pause; the pupil contracted during that
phase, and dilated during the period of breathing. In the latter
case the rate and tension were greater during the period of breath-
ing than during the pause, and there were no periodic changes in
the size of the pupils. Bordoni mentions several of the writers
who have concerned themselves with Cheyne-Stokes breathing,
but restricts himself to facts, and abstains from making any-
theoretical remarks.

Oser^ describes the occurrence of this form of respiration in a
woman aged 74, suffering from aortic and mitral disease. The
symptom occurred during an attack of intestinal catarrh, and again
a few days before death ; and it is noteworthy that it could at any
time be produced when it was not present by compression of the
two common carotid arteries. At the post-mortem examination,
besides the cardiac lesions, nothing but the usual senile changes
could be found, along with some discoloration of the medulla
oblongata and upper part of the spinal cord.

Howard,^ in a paper on some of the varieties of dyspnoea met
with in kidney disease, after referring to the appearance of Cheyne-
Stokes respiration in one of his puerperal cases, suffering from
ursemic eclampsia, briefly describes its occurrence in a man, 52
years old, who was the subject of chronic renal disease. The chief
interest of the case lies in the fact that the periodic breathing had
persisted for two months before the author saw him in consultation
with another medical man, and that there was no appearance of
imminent danger when he was seen. Howard mentions another
opportunity which he had of observing Cheyne-Stokes breathing in
an aged man sinking apparently from senile decay. He is now
inclined to think that failure of the renal functions may have been
the immediate occasion of the symptom, and suggests that this is
probably the underlying cause of the symptom in many cases. The
author makes passing reference to the work of Cuffer, but shrinks
from entering into any discussion of the numerous explanations
that have been advanced.

Mosso, in an exhaustive monograph,^ has materially contributed

1 Wiener vudizinische Blatter, vii. Band, S. 1480, 1884.

2 Canada Medical and Surgical Journal, vol. xiii. p. 193, 1884.

^ Atti delta Reale Accademia dei Lincei, anno cclxxxii., 1884-86, serie cjuarta,
p. 457, 1885 ; and Archives italiennes de Biologic, tome vii. p. 48, 1886.

JllsTOi{if:.\l,. 75

to the knowleil^i^'e we jxisscss of (liis syniidom. Ilr l)(!<^ins liy
])()iiiliii^ (»uL that the moveiueiits of respiration are not always
uniform and reguKar. In the; profound repose and more especially
the deep sleep of man and animals, the respirations are grouped in
periods, and this pcriotlic hreathin^' is quite physiological. When
this periodic respiration hecomes more intense, pauses appear from
the remission or cessation of inspiration, and the author terms such
breathing remittent when there is a slight respiratory movement
during a pause, and intermittent when there is complete cessa-
tion for a time. He mentions l»i-eaks in breathing, as if a respira-
tion had aborted or failed, but points out that there is no conne.vion
between such a break and the succeeding respirations. Inter-
mittent respiration may be caused by injections of chloral, and this
cannot be moditied by making the animal breathe pure oxygen
through the tracheal canula, or by artitieial respiration from electric
stimuli to the respiratory nerves, from which the author concludes
that the internuttences cannot be altered by the intluence of
oxygen. He states that there are periods of tonicity of the
respiratory muscles independently of the rhythmic movements of
breathing, and that the circulatory vessels take no part in the
phenomena of periodic breathing, which disposes of the complicated
and imaginary tiieories of Traube, Filehne, and others. Oscilla-
tions in the tonicity of the respiratory muscles are closely united
with the phenomena of periodic breathing. In general, when this
tonicity is lessened there is a tendency on the part of the respira-
tory centre to lessen the force of the movements of respiration, and
a pause often ensues. It has been thought that the greater or less
activity of the respiratory centre represents a greater or less need
of provision Ity pulmonary ventilation for the chemical wants of
the organism ; but the author is of opinion that he is not far from
the truth in thinking that the respiratory movements modify
themselves according to the states of sleeping or waking, of
greater or less activity of the nervous system. He holds that the
mechanical and chemical parts of respiration are distinct, that the
mechanical is more representative of the vitality of the nerve
centres than of the chemical wants of the organism ; that if the
nervous excitability increases more air is inspired than is needed
for chemical wants, while on the contrary during sleep the
mechanical may lessen or become periodic without disturbance of

76 CHEYNI^-STOKES KESPIRATION.

the chemical f miction of tissue respiration ; and further, that when
the excitability of the centres is much lowered, it can be deter-
mined that the accumulation of carbonic acid by asphyxia causes
almost no effect on the respiratory movements.

Mosso agrees with Fano in hesitating to accept the hypothesis
of Luciani, but does not see how Fano's hypothesis can explain
remittent respiration, for, if it were true, periodic breathing would
always appear in animals whose nervous excitability gently died
away, which it does not. He points out that the ascending part
of the breathing is not due to arterialization of the blood, for it
appears j ust as before after the diaphragm has been cut, so as to
render the respiration useless. The periods of breathing appear
during sleep without any consciousness. The pauses have no effect
on the vaso-motor centre if they are not very long. If any influence
is shown, it is opposite in effect to that of psychic phenomena ;
during the intermittences there is a diminution in the tonicity of
the bloodvessels, while under the influence of psychic activity
there is an increase. Referring, again, to the hypothesis of Filehne,
he says it is a mere supposition, and adds that his results are con-
trary to his hypothesis. He has observed the fact described by
Murri, that during the pause there is an increase in the bulk
of the arm as tested by the plethysphygmograph, and is of
opinion that it is caused by dilatation of vessels during profound
slumber.

Although periodic respiration is not in direct or immediate re-
lation with vascular phenomena, alterations in the circulation of
the nervous centres may cause periodic respiration ; in chloralized
animals it appears on raising the head, and disappears when the
head is again lowered.

Mosso points out the intimate relations of periodic breathing
with sleep, as shown by the variations of the iris and the intelli-
gence. In discussing the phenomena of consciousness he points
out that there is no distinction in kind, simply a variation in
degree. He refers to a case under the care of his colleague,
Bozzolo, where all the reflexes, even those of swallowing, were
abolished during the pause. He does not believe that all cases
are due to conditions resembling sleep ; he has seen it, for instance,
under the influence of curara, where the arrest of the respiratory
movements caused by the motor paralysis produced sufficient

IIISTOHICM.. 77

excitemenl of llie iutvous activity to overcome the influence of
tlu^ curaviv on the nerves.

Davies^ gives an explanation by Foster of a case in which it was
noted "that the heart and respiration alternated in rhythm, tiie
heart being in full swing at the pause of the respiration, and being
inhibited during the height of the respiratory period." This
circumstance is explained by Foster as follows : — " Apparently
coincident with changes in tlie medulla oblongata leading to
Cheyne-Stokes respiration was a stimulation of the cardio-
inhibitory centre in the medulla, occun'ing alternately with the
former."

Fazio- has described Cheyne-Stokes respiration as a symjitom
occurring in the course of two cases of cholera.

Langendorff ^ points out that a change from regular to periodic
rhythm is not peculiar to the respiration, and as examples of
similar change of rhythm mentions the frog's heart nourished
by means of serum instead of blood ; the ventricle of the frog's
heart separated from the auricle; and the heart of the embryo
of the fowl. He then starts from the point of view that the
commonest cause of the periodicity of rhythmic movement is
asphyxia, and seeks to determine whether it can be produced ex-
perimentally in this way. In mammals asphyxia is too rapid to
induce periodic breathing, but in frogs, as he .showed before, he is
able to do so. He calls attention to the increased motor activity
during the period of breathing, which may even reach the stage of
convulsions. Frogs poisoned by strychnine and then asphyxiated
show convulsions during the breathing. Tlie movements appear
even after the removal of the brain, and cannot tlierefore be
voluntary. It has been observeil, further, that before the respira-
tory period the heart and lymph-hearts cease for a time to beat.
Langendorff interprets the various manifestations of activity asso-
ciated together in an attack as being the co-ordinated effects of a
periodic excitement of the gray substance of the brain and cord.
lUit in order to explain this periodicity in the Cheyne-Stokes
]»henomenon it is necessary to admit some opposition to the normal

' Lancet, vol. i. for ISh"), p. 1183.

* Rivutta Clinica e Ti'ra}>fn(ica, :mno vii. p. 4!)4, 1885.

3 linitlaiier iiiztlich'' Zeit.<fhnft, vii. I'aiul, S. IGI, 1885, uiid Biologisches
Cenlralhldtt, vi. liaiid, 8. 370, 1887.

78 CHEYNE-STOKES RESPIRATION.

stimulation, and the author regards the lowered irritability of the
respiratory centre in this light.

Bernabei^ records a case in which Gheyne-Stokes breathing
made its appearance as a symptom of meningitis following fracture
of the temporal bone. The patient was a man, aged 60, subject to
vertigo for two months, who, after having, contrary to his usual
custom, taken some spirits while fasting, became suddenly giddy,
and fell on coming down-stairs. The left temporal bone was
fractured, and, in consequence, there was left-sided facial paralysis
and deafness. This was followed by double broncho-pneumonia,
more on left, and meningitis, specially of right frontal region,
during which Cheyne-Stokes respiration appeared, and could not
be altered by any stimuli.

Wellenbergh^ begins a valuable and interesting contribution to
the study of Cheyne-Stokes respiration by a consideration of the
anatomical relations of the respiratory centre and nerves, and of
the bloodvessels which supply the nerve centres. He shows tliat
the quantity of blood within the skull may increase or decrease
under certain circumstances, and that such changes, when com-
pensated by movements of the cerebro-spinal fluid, may not inter-
fere with the physiological balance of function ; but that beyond
a certain point such alterations in the blood-supply must produce
disturbances. This leads him to draw an analogy between certain
mechanical contrivances and the probable causes of Cheyne-Stokes
respiration. He imagines a brook whose stream moves a wheel, the
motion of which is transmitted by means of an endless rope to the
sails of a mill. He compares the brook to a bloodvessel, the water
to the blood, the wheel to the respiratory centre, and the revolu-
tions of the sails to the respiratory movements. He then imagines
such an obstacle to the flow of the brook as a lock with a trap-
door, whose resistance is greater than the pressure of the water,
in consequence of whicli the door cannot open until the accumu-
lating water has sufficient pressure to overcome the resistance.
Before the trap opens the water beyond the lock will have flowed
away and the wheel will have gradually stopped. As soon as the
pressure of the water has overcome the resistance of the trap the

1 Bolletino delta Societd tra i Cultori delle Sciense mediche in Siena, anno iii.
p. 61, 1885.

2 Psychiatrische Bladen, iii. Jacargang, S. 30, 1885,

IIISTOUICAL 79

Wiiter will llow down llif liiook in ^M'oater (|iiaiiLity and with
greater loice than under ordinary circnnislances. Tlie Inook will
be filled, llie wheel will revolve, at lirst slowly, Ijut afterwards
with greater velocity than under ordinary circumstauces, and as
the brook falls to its usual size the rate will lessen until, from the
closure of the trap, the stream again fails and the wheel stops.
This is represented by a graphic schema, in which the wheel re-
volves noiiiiallv thri'c times a minute, as follows: —

Via. 1.— The figures 1 to 5 represent the minibcr of revolutioiis per njinnie, and tlie asterisk
denotes the moment wben the trap-door is closed.

The amount of resistance of the trap-door and the amount of
pressure of the flowing water are the two factors upon which the
endless varieties which the tracing may undergo depend, the size
of the wheel remaining constant.

The schematic tracing reproduced alcove is then compared by
the author with tracings from the chests of patients showing
Cheyne-Stokes respiration.

The author finds that although there is no ai>paratus within the
vessels analogous to the lock and trap-door, there is an external
force, viz., intracranial oedema, and he regards intracranial
oedema as the principal, if not the only cause of Cheyne-Stokes
respiration. He regards the phenomenon as the result of a
struggle between the pressure of the blood within the vessels and
the pressure of the adema outside of them, a struggle in which
these forces are alternately supreme.

He thereupon compares the appearances accompanying Cheyne-
Stokes breathing with the symptoms which would naturally be
expected to follow an alternate increase and decrease of pressure,
and is strengthened in his views by the comparison. The author
afterwards reviews a nnnibcr of liie tlieories which hav(> been
advanced, and concludes that the series of symptoms cdu hardly
be caused but by such a cause as he has suppo.sed.

80 CHhlYNE-STOKES RESPIRATION.

Murri^ combats the opinion of Mosso that Cheyne-Stokes
respiration presents a condition analogous to sleep. During
sleep the respiratory movements may cease without any injury
to the interchange of gases in the tissues and blood, because there
is less need for oxygenation. Eemittent and intermittent respira-
tion accordingly appear where a condition analogous to sleep is
developed in the central nervous system. There is lowering of
the irritability of the medulla oblongata, and Mosso differs from
other observers in his opinion that in this lessened irritability
there is a state analogous to sleep, whence intermittent breathing
is a physiological appearance instead of a rare phenomenon. He
therefore seeks to draw the conclusion that Cheyne-Stokes may
iiave a twofold origin — physiological and pathological. Under
ordinary circumstances the phenomenon is certainly associated
with sleep, but just as certainly in pathological conditions this is
not always the case. The origin of the symptom is often in such
lesions as interfere with the harmonious successive and gradual
working of the different parts of the respiratory centre. By means
of such disturbances of particular phases of its activity, its functions
are no longer continuous but periodic.

Storch^ records intermittent respiration, perhaps not a typical
instance of Cheyne-Stokes breathing, in a horse, 18 years old,
which died from what is known in Germany and Austria as
" Pferdetyphus," an affection characterized by general extravasation
and exudation. In this case there was much extravasation into
the mucous and serous membranes.

The author discusses several of the well-known explanations of
Cheyne-Stokes respiration, and states that he considers Eosenbach's
theory as the most probable.

Fano^ criticises Mosso's work, and points out that the views
therein expressed on the automatism of the respiratory centre are
essentially the same as those advanced by Luciani and himself He
has some hesitation, however, in regard to Mosso's sleep hypothesis.

Fenoglio,* to test the accuracy of Mosso's observation that in
sleep the respiration may become periodic, watched the sleep of a

1 Revista clinica di Bologna, serie terza, tomo v. p. 161, 1885.

2 Revue fur Thierheiikunde und Thierzuchf, viii. Band, S. 145 ii. 165, 1885.

3 Lo Sperimentale, tomo Ivii. p. 1, 1886.
* Ibid., tomo Ivii. p. 113, 1886.

HISTORICAL. 81

hundred old men, whose aj,'es averaged 75 years, uiid an vi[\\:i\
number (if ol<l wumeii averaging 70 years of age. He found
periodic breatliing in six men, but not in any of the women. In
two cases, wliere long pauses had been seen, post-mortem examina-
tions were obtained. In one case tliere were no changes in the
brain ; in the other there were chronic meningeal lesions, but the
medulla was healthy. Fenoglio is inclined to attribute tlie pheno-
menon to excessive fatigue and great need for rest, which speak
of exhaustion of the system tlirough severe disease.

Poole ^ has enunciated some views on the subject which are
singular in themselves, and are probably based upon an imperfect
appreciation of physiological facts. Stating that all the tluiories
previously brought forward are based upon the assumption that
impure venous blood acts as a stimulus to the nerve centres, he
asserts that venous blood is a depressant of nerve function. He
grants that for the appearance of Cheyne-Stokes respiration there
must bQ a condition of partial paralysis of the respiratory centre,
and that the blood is imperfectly arterialized. The heart, however,
continuing to beat sends some blood through the lungs during the
pause, which becomes oxygenated by means of the residual air ;
this reaching the nerve centres revives them and causes a dilata-
tion of tiie arterioles, which occurs simultaneously with the
laboured breathing. The inrush of blood into the lungs is too great
to allow of proper oxygenation, and the imperfectly arterialized
blood depresses the medullary centres, whence a pause again takes
place.

Bordoni- begins his inaugural dissertation on this subject by a
historical retrospect, and mentions that he has seen the symptom
on six occasions — twice in fatty heart with pneumonia; once in
inflammation of the endo-myo-pericardium (referred to at p. 73) ;
twice in cerebral apoplexy ; and once in fracture of the temporal
bone (referred to at p. 78). This is followed by a consideration of
the conditions present in the medulla oblongata, and of the cir-
cumstances, physiological and pathological, under which Cheyne-
Stokes breathing may appear. The author then considers the
phenomena presented by the .symptom and the various changes

' The Canada Lancet, vol. .wiii. p. l!)7, 1886.

^ Sill Tipu liejfpiratorio di Cliexjnc e Stoker, osservazioiu e rkerche sperimentali.
Siena, 188(j.

L

82 CHEYNE-STOKES RESPIRATION.

which are associated with it, entering into a masterly examination
of these appearances and of the conditions giving rise to them.

He then proceeds to discuss the occurrence of the symptom in
lower animals and its production by various agencies, and describes
some experiments performed by himself, whereby he found that in
frogs periodic breathing could be caused by digitalin, scillain, and
gelsemine.

The second part of his thesis is devoted by the author to an
able criticism of the various theories which have been advanced
by previous writers, and this leads him to support the views of
Luciani : — Firstly, that the normal type of respiration is the result
of continuous irritability of the respiratory centre and of the influ-
ence of varying stimuli ; and, secondly, that Cheyne-Stokes respira-
tion and all forms of periodic breathing depend upon variations of
this irritability, having their origin in transitory or permanent
changes in the respiratory centre.

Piaggio,^ whose inaugural dissertation on this subject has already
been noticed, again deals with the subject in an interesting paper.
This communication begins with a review of Langendorff's
observations and a criticism of his views. The author then calls
attention to the phenomena which accompany the respiratory
symptom. He is of opinion, as previously stated in his thesis,
that an asphyxia or insufficient access of oxygen to the tissues is
the determining cause of the phenomena, and he regards the forced
respiration of the period of breathing as a false dyspnoea. He
does not think that Langendorff has penetrated into the secrets of
the internal mechanism wliich account for the symptoms. He
holds that his interpretation implies an idea of resistance to the
passage of nerve force, thus determining periodic discharges, and
cannot admit it.

Unaware of the observations of earlier writers on the connexion
between the respiratory and pupillary phenomena, Eobertson^
brought forward the rhythmic contraction of the pupils in Cheyne-
Stokes respiration, as seen in two patients who had been under his
care. He gives a full and clear description of the eye symptoms as
well as of the alternate contractions and relaxations of the muscles

1 Le Pi'ogrh medical, xiv. ann^e, ii. serie, tome iv., deuxieme semestre, p. 690,
1886.

2 The Lancet, vol. ii. for 1886, p. 1016.

HISTORICAL 83

of tlie limbs, which were especially well marked in one of his
cases.

Being unacquainted at tlie time with the observations of Rosen-
bach and others wjio have disproved the statement that amyl
nitrite invariably produces a disappearance of the symptom, the
opportunity alVorded by a case of chronic renal disease in a
woman ai^^ed GO, accompanied 1)y Cheyne-Stokes respiration,
was employed by me^ as a means of testing the efticiency of
that remedy. In this case the drug, althougb effecting its
usual changes as regards the circulation, failed to produce any
modilications in the respiratory rhythm. The injection of nitrate
of pilocarpine was in this case resorted to for the relief of the
respiratory and other symptoms. It was followed by a disappear-
ance of the pauses, which only continued for about a minute. It
seemed to me, as stated in the paper referred to, that this brief
disappearance of the periodic cessation of breathing was caused
by the shock of the injection, and it also appeared extremely prob-
able that in cases where nitrite of amyl had been found efficacious,
its action was to be regarded as due to a stimulant effect upon the
respiratory centre. It has since come to my knowledge that this
view, as mentioned in an earlier part of this contribution, has also
been previously advanced.

Finlayson- prefaces some interesting remarks, made at the
Medico-ChirurgicalSociety of Glasgow, on the state of the pupil in
Cheyne-Stokes respiration, by expressing his opinion that the dis-
tinction drawn by several writers between Cheyne-Stokes breath-
ing and the less regularly intermittent respiration of cerebral
disorders is one of degree only, and that there is a perfect gradation
between the two varieties. The author enters upon the well-
known phenomena of the pupils which usually accompany Cheyne-
Stokes breathing, and states that although the reversed relation-
ship has been described, i.e., a dilatation of the pupil during the
pause and a contraction in tlie period of breathing, he has never
himself seen it.

The interest of Finlayson's communication, however, lies chiefly
in this, that he for the first time describes a rliytlmiieal enlarge-
ment of the pupil with each individual inspiration, and a subse-

' The rntctitinjirr, vul. x.vxviii. p. iS5, ly^7.

- GUxsyow MeilicalJouriuil, fourth serivs, vul. xxviii. \<. 2il, lss7.

84 CHEYNE-STUKES RESPIRATION.

quent narrowing with the succeeding expiration. He is inclined
to regard this phenomenon as being possibly but an exaggeration
of a physiological variation which has been alleged to occur in the
pupil with each respiration.

In the discussion which followed the reading of Finlayson's
paper, M'VaiP lays stress upon the reversal of the pupillary
phenomena to be seen in some cases of Cheyne-Stokes breathing.

Gowers,^ after briefly describing the phenomenon and shortly
mentioning some of the explanations advanced to account for it,
makes the following remarks : — " On the whole it may be said that,
unless the simple rhythmical tendency of the depressed centre is
adequate to produce the phenomena, they can be best explained
by the assumption that this rhythmical tendency is modified by
some other periodical influence, of which vaso-motor spasm is the
only one which, according to our present knowledge, can be con-
ceived as acting and adequate. Tlie gradual onset of the respira-
tions may be due to the fact that the vaso-motor dilatation exceeds
the normal (as it often does after contraction), and thus the
quantity of blood reaching the respiratory centre lessens the
stimulating influence of its quality."

Vierordt^ allows that the phenomenon undoubtedly depends
upon a disturbance of the functions of the respiratory centre in
the medulla oblongata, but is of opinion that all more explicit
theories are unavailing to explain it. He thinks that a simple
diminution of the excitability of the cells of the centre from the
presence of venous blood could only give rise to infrequent and
possibly irregular respiration, which might either be deep or shallow,
and that to ascribe a different degree of excitability to particular
cells or groups of cells is at least a refinement — in short, that we
are in want of a distinct explanation of the phenomenon.

Marckwald^ devotes a section of his admirable work on the

^ Glasgow Medical Journal, fourth series, vol. xxviii. p. 224, 1887.

2 A ManiMl of Diseases of the Nervous System, vol, ii. p. 118. London, 1888.

^ Diagnostik der inneren Krankheiten auf Grund der heutigen Untersuchungs-
Methoden, S. 64. Leipzig, 1888.

* The Movements of Respiration and their Innervation in the Rahhit. Translated
by Thomas Arthur Haig, student of medicine. University of Glasgow, and
revised by the Author; with an Introductory Note by John G. M'Kendrick,
M.D., LL.D., F.R.S., Professor of Physiology, University of Glasgow, p. 45.
London, 1888.

IIISTOHKAI,. 85

res|iirati(in to tlic sultject of pcriotlic hrcailiiiii,'. He shows that
the medulla may be divided in the rcj^'ion of the acoustic tulnMcles
without inducing any alteration in respiratory rhythm, but that if
the section is made lower down at the level of the aire cinerefe the
breathing at once becomes periodic. Periodic respiration may
follow the higher section if a blood-clot has caused pressure upon
the respiratory centre, or if the respiratory centre has been exposed
to the air. During periodic respiration he finds that the e.xcita-
bility of the centre has not in any way suffered, for stimuli to the
skin during the pauses are immediately followed by movements of
respiration. ]\Iarckwal(l was never able to produce periodic
breatliing by means of pressure upon the medulla in the region of
the aU\.> cineroie, the result of which was a cessation of respiration.
Section below the upper level of the aire cinereaj was always
followed by destruction of the respiration, which could not be
restored by any means. The author has never seen an ascending
and descending series of respirations produced artiticially, only a
descending group, but he recalls the fact that in Cheyne-Stokes
breathing the groups are sometimes also of this latter kind alone.
He is of opinion that periodic breathing only takes place when at
least a part of the higher brain tracts has ceased to act and has
lost its influence upon the respiratory centre, which he believes to
accord well with the mode of occurrence of Cheyne-Stokes
breathing, as, for e.Kample, in sleep and hibernation ; after the use
of certain drugs, which paralyze the upper nervous centres, or
lessen the circulatory supply to the brain ; and from various
experiments upon the nervous and circulatory systems. In this
connexion Marckwald mentions a case of hemiplegia which he
observed under the care of Lichtheim, where only the descending
series of Cheyne-Stokes Ijreathing was present. The patient in
this case was able to modify the breathing, but when left to herself
it was always periodic. In this case one-sitled deficiency of the upper
brain tracts was sufficient to produce Cheyne-Stokes breathing.

Marckwald points out that after the production of periodic
breathing experimentally, section of the vagi causes it at once to
disappear, and he is therefore of opinion that for the appearance of
periodic breathing it is necessary to have the peripheral branches of
the vagi in connexion with the respiratory centre. As stimuli during
the pause i)roduce respirations, he cannot admit that a diminished

86 CHEYNE-STOKES RESPIRATION.

excitability of the respiratory centre is the cause of the pheno-
menon.

Descourtis^ describes a case of Cheyne-Stokes breathing in a
man, aged 68, suffering from general paralysis. In this instance
the pulse, as ascertained by the sphygmograph, remained constant
in its characters throughout the varying phases of the respiration.

In a short abstract by Smart^ of a paper read by him at the
Medico-Chirurgical Society of Edinburgh, cerebral respiration and
Cheyne-Stokes respiration are grouped together as " Multiple Com-
plex Eespiratory Neuroses," but the author insists on their inde-
pendence of each other.

Stillman' has placed three cases on record in which Cheyne-
Stokes breathing was present. These cases were : — A man, aged
47, who had received injuries in a fall, from which he recovered
perfectly ; a woman, aged 76, dying of cerebral haemorrhage ; and
a man, aged 27, who had received an injury to the skull, from
which he died. The author is of opinion that " the starting point
in the chain of causation is found in the equilibrium between the
respiration and circulation being always disturbed by a relatively
weak heart."

A communication was recently made by me* with the view of
showing that, whatever may be the nature of the condition under-
lying the associated symptoms of Cheyne-Stokes respiration, it
may produce the effects which depend on it by affecting the lower
centres in the first place, and spreading upwards to the higher, or
by acting upon the higher first, and afterwards invading the lower
centres. This was illustrated by reference to the presence of Cheyne-
Stokes breathing in a case of pneumonia, in which small doses
of bromide of potassium had been administered, without any
changes in the pulse, pupil, mind, or muscles ; to its appearance
in a case of cardiac failure, in which it was accompanied by
circulatory, pupillary, and mental symptoms ; and to its occur-
rence in cases of urtemia in association with periodic alterations
in the circulatory, visual, psychical, and muscular condition.
These different classes of cases were regarded as presenting a

1 L'Encephale, vol. viii. p. 431, 1888.

2 The Edinburgh Medical Journal, vol. xxxiv. p. 529, 1888.

3 The Medical News, vol. liii. p. 555, 1888.

* The Birminrjham Medical Review, vol. xxv. p. 30, 1889.

IIISTOIJICAL. 87

roj,'ul;ir series of syiiiptonis, coiniuenciii<,' with those sliowiiig
conse(|ueiices depeiulinj^' u|)()ii some iillectioii of the lespinitory
centre ;Uone, and passing tliruugh otlier.s having a progressive
tendency to involve dillerent centres. The paper next attempted
to show that the periodic changes produced by alterations of the
centres may commence in, and be limited to, those which are not
concerned in vital phenomena. The case of a child sufTering from
wliat clearly seemed to be tubercular meningitis, but which, owing
to the recovery of the patient, may appear to have been possibly
an error in diagnosis, was taken to illustrate my meaning. The
patient was a little girl, aged three years, presenting all the
symptoms of subacute tubercular meningitis. During the course
of the disease, when watching her carefully one day, a periodic
closure of the eyelids attracted my attention, and on fuitiier
observation it was easy to determine that along with this closure
of the lids there was a simultaneous contraction of the pupils, an«l
a state of complete unconsciousness. This condition remained for
several seconds, the eyelids were then raised, the pupils dilated,
consciousness returned, and the child raised her head to look
about. The conscious state was present for some time, how
long it is not possible for me to say, as it did not occur to me to
notice the interval, and was in its turn followed by the uncon-
scious condition. In this case there was never, so far as my
observation went, any tendency to a periodic change in the rhythm
of the breathing. It seemed to me that such a phenomenon can
only be regarded as analogous in every way to intermittent re-
spiration, and, if this be granted, it follows that my contention is
to be regarded as highly probable.

This brings us to the end of the examination of the facts and
views embodied in the different works on the subject. In addition
to the authors who have been mentioned, reference might have
been made to many others who incidentally touch upon the
subject, but, in so far as my acquaintance with the literature is
concerned, these authors neither add anything to the store of facts
nor throw any light upon their explanation. It is, in consequence,
unnecessary to devote time and space to them.

Before leaving this division of the subject, a few remarks must
be made upon three unpublished observations which have been
communicated to me.

88 CHEYNE-STOKES KESPIRATION".

Dr Muirhead, of Edinburgh, informs me of an elderly gentle-
man, who for many years during his daily sleep after dinner
breathed in the characteristic Cheyne-Stokes type.

Dr Edes, of Washington, writes to me with regard to a lady
whose breathing has for many years been periodic or cyclical, as he
prefers to term it, during sleep. A most interesting fact is that
this lady tells him the phenomenon had been observed by her
mother in herself and her sister from childhood.

Finally, Dr Tuke has placed the following interesting communi-
cation in my hands : —

" Balureen,

"Edinburgh, 28th February 1889.

*' Dear Gibson, — Knowing you are specially interested in ' Cheyne-Stokes
breathing,' I send you a short report of a case which came under my observa-
tion last Saturday. On that afternoon my two favourite Dandie l^inmonts
were poisoned by strychnine, which had been laid down for rats in the stable ;
the one fatally — dying in opisthotonus — the other recovering after fifteen hours
of suffering. During all that time he was under my most careful observation.
After five violent spasms (opisthotonus) I bolstered the dog in such a way
that he could not move, as the slightest stimulus induced the attacks. By
this means the general spasms were averted, and only occasional jerks were
observed. But fifteen minutes after he was thus restrained well-marked
Cheyne-Stokes breathing set in — the number of respirations was about 25,
and the interval was somewhat longer than I have generally noticed in the
human subject. The pupils were fully dilated during the breathing, the iris
contracting slightly during the interval. So far as I could judge, the dog was
conscious all the time, often trying to wag his tail. The rate of the heart was
120, and its action was regular, which is curious, as, under ordinary circum-
stances, this dog's heart, like that of most dogs, is very irregular, and some-
times intermitting. Its usual rate is 104. The femoral pulse was full and
steady. When violent spasms showed themselves, the Cheyne-Stokes breathing
ceased. I kept my hand slightly pressed on the ribs ; when doing so the
breathing never reached dyspnoea, but when the pressure was removed the
symptom tended to show itself. After thirteen hours all the symptoms
disappeared — the Cheyne-Stokes breathing gradually growing less pronounced
— except stiffness of the hind legs. — I am, yours sincerely,

John Batty Tore."

So far as my knowledge goes, Cheyne-Stokes respiration has not
been observed as a consequence of the action of strychnine on
mammals by any of the authors who have devoted attention to
the subject.

CLINICAL. 89

Clinical.

Ill aiiproacliinp; the coii-sideration of Cheyne-Stokes respiration
fmiii the clinical point of view, it will lie necessary to i^roiip the
coiulitions, already mentioned in the historical sketch, in which it
has been observed. IJefore doing .so, however, it must be stated
that l)y the term om[)l()yed to designate the phenomenon is meant
a periodic form of respiratory rhythm. It would be out of place
to attempt, at this stage of the inquiry, any definition of the
symptom, l)ut it will certainly tend to simplify the subject if it
be distinctly understood that the term employed is limited in its
application. It will not, in this paper, be held to include any
irregular arrests of breathing, such as are frequently observed in
diseases of the brain, and which are generally classed together
under the term cerebral l)reathing. But in making this distinction
there is no intention of drawing a luird and fast line between the
regular periodicity of events seen in classical Cheyne-Stokes
breathing and the altogether irregular stoppages of respiration
characteristic of cerebral breathing. So many intermediate links
are to be found between the two extremes, that the existence of an
uninterrupted series of similar symptoms may safely be assumed.

From the observations of some authors there can be no
doubt that there is a hereditary tendency in certain families
towards the conditions under which Cheyne-Stokes respiration
arises, and in some cases an inherited liability to the symptom
itself has been found.

Amongst general diseases, Ciieyne-Stokes respiration has been
observed in the course of enteric fever, small-pox, diphtheria,
choli'ia, and w lioopiiig-cougli.

The nervous disea.ses in which it has been described are: —
meningitis, encephalitis, cerebral luemorrhage, cerebral embolism,
cerebral thrombosis, insolation, insanity, liysteria, cerebellar
luemorrhage, extravasation on the medulla oblongata, pressure
of an aneurism on the medulla, and tumour of the medulla and
pons.

The symptom has been very fretiuently recorded as a cense-
([uence of general arterial degeneration, attemled in some cases by
gangrene or degeneration. It has been obseived in hicmophilia,

M

90 CHEYNE-STOKES EESPIRATION.

as well as hsemorrhage following severe operation, and it has been
seen in such more restricted diseases of the circulation as peri-
carditis, myocarditis, fatty degeneration, valvular diseases, and
aneurism.

The respiratory affections in which Cheyne-Stokes respiration
has been found are : — ^bronchitis, pneumonia, and phthisis, and it
has been described as a sequel to tracheotomy.

Amongst digestive disorders, the symptom has been placed on
record as occurring in the course of severe catarrhal diarrhoea.

Chronic renal disease is, without doubt, the most common cause
of Cheyne-Stokes breathing, a large percentage of ursemic cases
presenting the symptom in some part of their course.

Before leaving this summary of the diseases in which Cheyne-
Stokes respiration has been observed, reference must be made to
two singular conditions in which it was present. Fatty degenera-
tion of the diaphragm was in one case associated with this symptom,
but disease of the aortic valves was also present. Narrowing of
the foramen jugulare was found in several cases presenting this
symptom, but in all of these there was also cardiac or renal
disease.

Cheyne-Stokes respiration has frequently been observed in the
ordinary sleep of apparently healthy persons, and it has often made
its appearance after the administration of bromide of potassium,
chloral hydrate, and morphine. In one most interesting observa-
tion the symptom was developed in an infant whose mother, while
nursing, had taken some doses of the latter drug.

In the lower animals, phenomena identical with Cheyne-Stokes
respiration have been of frequent occurrence. Such appearances
have been present during the deep sleep which has followed pro-
longed exertion, and also during the condition of hibernation.
Intermittent respiration has been produced by the administration
of chloral, morphine followed by ether or chloroform, ether along
with picrotoxin, muscarine, picrotoxin, digitalin, strychnine, sul-
phuretted hydrogen, urea, kreatin, and ammonium carbonate.

Periodic breathing has further been produced by considerable
changes of external temperature, by prolonged immersion (in
amphibians), by bleeding, by removal of the heart, by alternate
compression and relaxation of the carotid and vertebral arteries,
by section of the medulla oblongata, with or without section of the

CLINICAL 91

vaj^n, by pressurt' t-ii the iiiciliilla, iind by various injuries to iIm"
brain ami in('(hill;i, even after tbii aorta had been ticil. It is
particularly worthy of notice, that section of the medulla at the
h'Vi'l of the aUr. cincrecc, seems invariably to produce a periodicity
of the respiration. "When the medulla is divided above that level,
no ehani^fo in tlu' rhyllnn of the breathing' occurs, while section
below iliat U'Vcl ]irtMlurcs an cntii'e cessation of respiration.

Tuvnin^^f now from tlie cimsiilcration of the dillerent conditions
in which Uheyne-Stokes brealhinif has been observed, the nature
of the symptom in itself must be dwelt ui>on at somewhat greater
len.^th.

The ilescriptions given of thi.s phenomenon by Cheyne and Stokes,
which have so often been quoted, have never been surpassed, and no
attempt will be made here to describe a symptom which is now so
well known. The purpose of this part of the paper is rather to
analyze the different phenomena which make up the symptom.

In Cheyne-Stokes breathing the normal rhythm is interrupted
by distinct arrests of respiration ; there is an alternation of periods
of resi)iratory activity, and periods of respiratory repose. Under
ordinary conditions, the inspiration, the expiration, and the short
pause which succeeds the latter phase, have a tlefinite relation in
duration, and they are perfectly rhythmic in their recurrence.
The arrests of respiration occur usually at definite intervals of
time; they are therefore periodic, and it may be said that there is
a secondary, superimposed upon the primary, rhythm. This, how-
ever, is not all ; for an essential feature is that the period of
activity consists of two distinct phases, termed by Cheyne
ascending and descending. During the former phase there is a
gradual increase, not only in the amplitude of the respiratory
movements, but also in their rate ; while during the latter
phase there is a gradual decrease, both in extent and rate, of
these movements. The contrast between the period of repose
and the period of activity is very striking. I taring the former
phase there is an entire absence of all movement, and during
the latter the patient often appears as if labouring under
severe dyspntca, which is frequently accomi)anied Ity a lit of
coughing at the height of the breathing. Such are the appearances
in a simple instance of Cheyne-Stokes breathing. lUit Cheyne-
Stokes breathing is frecpiently associated with other symptoms.

92 CHEYNE-STOKES KESPIKATION.

and attention must be directed to changes in other systems besides
the respiratory.

There are in many cases alterations in the state of the circula-
tion. These appear to have been first observed by Eeid, whose
descriptions of the state of the pulse must be stated in passing to
be extremely careless in the use of terms. Such circulatory altera-
tions are at once inconstant and variable, presenting a marked
contrast to the regularity of the respiratory phenomena. In many
cases no change in the state of the circulation can be observed on
the closest investigation, as in cases described by different
writers.

Sometimes the rate of the pulse is diminished during the pause
in respiration, as in cases narrated by several observers. As
lias been mentioned in the previous part of this paper, Hesky
observed an entire arrest of the radial pulse during the period of
repose. On the other hand, the rate of pulsation has been observed
to be greater during the period of repose than during the period of
breathing.

Variations also in the volume and tension of the pulse have been
met with. The pulse has been described as of larger volume and
lower tension during the arrest of breathing than during the period
of respiratory activity. In other instances no such changes could
be detected, or the converse has been observed.

Filehne observed a recession of the fontanelles of children before
the arrest of resj)iration ; and, on the other hand, Eosenbach
describes the recession as occurring late in the pause, or even
during the period of respiratory activity.

In this connexion reference must be made to the experiments
of Heidenhain, who observed an increase in the blood-pressure
during the period of activity.

There are also certain appearances connected with the eyes
which occur in association with Cheyne-Stokes breathing. In
many cases the periodic rhythm of the respiration only takes place
during sleep, when, as may readily be understood, no changes are
observed in the eye. But in a large number of instances the
symptom is present during the waking, as well as the sleeping
hours. In a certain number of such cases Cheyne-Stokes breath-
ing is unaccompanied by any eye-changes. In a certain number,
hovfever, definite appearances make themselves manifest in con-

CLINICAL. 9:i

nexion with tlie visual apparatus, and tliesc must liave attention
devoted to them. As was lirst noticed by Ixjube, the eye is open
during the period of l)reathing, and closed durin^j the ces.sation of
respiration. The eyes, furtlier, glance about while the patient is
breathing, while, during the pau.se, on lifting up the eyelids, aeon-
jugate tleviation of tlie eyeballs may be ob.served. A still more
interesting fact is to be seen in some of the cases which present
eye-symiitoms. During the breathing the pui)il is wiilely dilated,
and tightly contracteil during the pause. As Leube pointed out,
the dilatation begins along with the early superficial respirations, or
the dilatation may even precede the active phase of the breathing
cycle. Appearances exactly similar in character were observed
by Leyden as the result of experiments on the medulla. This
is, however, not all, for Finlayson, on close scrutiny of the pupil,
found that it dilates a little with each inspiration, and con-
tracts slightly M'ith each expiration, until the height of the
respiratory phase is attained, and the pupil is widely dilated,
after which the converse occurs, and the contraction with each
expiration somewhat exceeds the dilatation accompanying each
inspiration, until at the end of the active phase the pupil becomes
fixed in the contracted condition. The contracted condition of the
pupil during the cessation of respiration is evidently analogous to
the appearances observed during sleep, and in this connexion it
may be remarked that the pu[)il in some persons enjoying perfect
health undergoes a considerable dilatation on deep inspiration and
contracts to an equal degree on forced expiration. As Merkel
first pointed out, the pupil reflex is absolutely abolished during the
cessation of respiration, and no reaction to light can be elicited.

It is a most important fact that no changes have been seen in
the condition of the ves.sels of the retina during the varying
phases of respiration. Both Schepelern and Ewald, who have
devoted themselves to the investigation of this point, are perfectly
confident in regard to the absence of any alterations in the calibre
of the vessels.

In many cases showing Ciieyne-Stokes respiration, the condition
of the mental powers undergoes fluctuations. The most usual
state of matters is, as Leube first showed, that the patient is con-
scious during the period of breathing, while during the interval of
repose he is bereft of perception and volition. This alternation of

94 CHEYNE-STOKIOS RESPIRATION.

consciousness and unconsciousness is frequently, but not invariably,
associated with the variations in the appearances of the eyes just
referred to. The interesting observation of Merkel has occasionally
been repeated since. He put a question to one of his patients to-
wards the end of the descending phase of the period of breathing. The
patient sunk into the state of absolute repose, but on the return of
respiration he made a suitable reply to the question which had been
put to him. This observation, to compare small with great matters,
is somewhat similar to the classical account of the officer who was
wounded in the head at the Battle of the Nile, when in the act of
uttering a command to his men, and who, after tifteen months of
unconsciousness, finished his order after the operation of trephin-
ing. Such cases as these, in which patients are only in possession
of their mental faculties during the phase of breathing, form a
marked contrast to others in which the patients are conscious
throughout, and often employ the pause in the breathing for the
purpose of conversing with other people.

Out of the many cases showing this symptom which have come
under my observation, a few will now be narrated in illustration of
the various appearances, and these will be arranged as far as
possible in a definite series, in order to emphasize the difference
which they present in the association of phenomena.

Case I. — Lady, aged 73 ; seen for tlie first time 29th March
1888, about the ninth or tenth day of an attack of croupous pneu-
monia affecting the lower lobe of the right lung. The rate of the .
pulse and respiration and the height of the temperature may be
seen on the accompanying cliart, Plate I., which is based upon the
very excellent graphic clinical chart of my friend Dr Handford.
There was free expectoration of rusty sputum, increased vocal
fremitus over the base of the right lung, dulness on percussion over
that region, and bronchial breathing, with increased vocal reson-
ance in the same situation. The pulse was of moderate volume,
low tension, and regular rhythm. The state of the heart was
healthy. The urine contained no abnormal constituent. There
was no delirium during either day or night. On the evening of
1st April, three days after the crisis took place, during the •
administration of ten grains of bromide of potassium with ten
minims of tincture of digitalis three times a day, Cheyne-Stokes

Plate

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CLINICAL. 05

hroiilliiiii,' uiiulc its iippoaraiice in typiial I'ashiuii. This symptom
})ersisteil tlirouglioiil tliu ftill(»\viii;4 four days, diirin;,' waking as
well as sleeping moments, and disappeared during the afternoon of
5th April, on the withdrawal of the bromide of potassium. The
periodic changes in the res[)iration were accomi)anied by no corre-
sponding alterations in the circulatory, visual, or mental processes.
The patient's pulse beat with a steady uniformity during the
waxing and waning phases of the breathing ; no modification in the
rate or rhythm was jiresriit, and not the least alteration in volume
or tension could be determiui'd in relation to the ascending and
descending respiration. In the same way not the slightest ten-
dency to closure of the eyelids during the arrest of respiration was
at any ])eriod present, and it was therefore an easy matter to
determine that the pupils underwent no modification in size,
except when vision was accommodated to near or distant objects,
or a change in the amount of light caused the usual retie.x altera-
tion in size. Similarly, the state of the consciousness was abso-
lutely independent of the pliases of the respiration. The patient
had a tendency towards somnolence, but when waked had as much
mental activity during the cessation of respiration as during the
period of breathing ; in fact, as is often the case, she employed the
pause by preference for the purpose of talking with those around
her.

This case forms an excellent example of the occurrence of
Cheyne-Stokes breathing in a patient who, in spite of advanced
years, showed no vascular degeneration, no cardiac allection, and
no renal disease, and who, it may be added, made an entirely
satisfactory recovery from the attack of acute pneumonia. It is
to be regarded as a specimen of the simplest type of periodic
respiration, in a patient entirely conscious of all her surroundings,
unattended by any of the other symptoms often associated with it.

Cask II. — Lady, aged 03, who showed the usual signs of chronic
vascular degeneration without very obvitnis renal complications.
On 7th February 1888 she was suddenly attacked by an
ajjoplectiform seizure. When seen during the al'tcrnoon she was
lying with a dusky Hush on her cheeks, and beads of perspiration
on her lurehead, in a state of profound uncon.sciousness. The
periodicity of breathing was very marked, nothing like the irregular

96 CHEYNE-STOKES EESPIEATION.

arrests of respiration, commonly called cerebral breathing, being
present, but the regular ascending and descending respiration,
with pronounced stertor and flapping out and in of the lips and
cheeks at the culmination of the ascending phase. The sensory
and motor functions were entirely abolished. The eyes were
closed, and on separating the eyelids the pupils were observed to
be contracted to the size of a pin-point, and to undergo no varia-
tions in diameter with the changing phases of respiration. The
pulse was extremely frequent and of very high tension, but per-
fectly regular, and manifesting uo alteration in tension, fulness, or
rate corresponding to the respiratory phases.

The Cheyne-Stokes type of breathing persisted until a few
hours before the death of the patient, which occurred during the
morning of the following day.

On post-mortem examination the cause of death was found to be
thrombosis of some of the branches of the middle cerebral arteries.
The arterial system was somewhat degenerated throughout, the
heart slightly hypertrophied, but otherwise healthy, and the kidneys
showing to a certain extent, although not very markedly, granular
clianges.

This case is to be regarded as furnishing an example of Cheyne-
Stokes respiration in a patient absolutely unconscious, which was
not associated with any of the other symptoms often linked with it.

Case III. — Farmer, aged 74, suffering from chronic arterial and
renal degeneration. On 6th March 1888, in spite of every pre-
caution, he showed symptoms of ursemia, and, notwithstanding the
most energetic treatment, he sunk gradually into a comatose con-
dition. During the last two days of his life he had, as one of his
symptoms, Cheyne-Stokes respiration almost without intermission.
Before the fully comatose stage of ursemia was reached, the patient
was, during the arrest of respiration, in a state of unconsciousness,
from which he could not be roused by any form of stimulation. But
with the superficial respirations which ushered in the period of re-
spiratory activity, the patient opened his eyes and looked around him,
speaking, during this phase, to those who were with him. It was
singular that the most rigid scrutiny of the eyes entirely failed to
reveal the slightest difference in the size of the pupils during the
opposite conditions of the respiration, and there never was the

(LINICAI,. 97

loa.st tendency to conjui,'atc deviation of the eyeballs. The pulse
was infrequent, of liit,di tension and al)Solute regularity, underj^oinj^
no changes in rate, volume, or tension throuf,djout the varyitig
phases of the respiration.

This case gives a good example of Cheyne-Stokes respiration
attended by varying degrees of consciousness, but without any
visual or circulatory jilienoniL'na accompanying the respiratory
phases.

Cask IV. — Housekeeper, aged (>0, suffering from chronic renal
disease.

Pnscnf condilio/i, Qlh November 1885. — The patient is of medium
height and slender build, with a pallid complexion, tending towards
an icteric tint, which is distinctly present in the conjunctivae. The
expression is anxious and restless, with staring eyes and dilated
pupils. The tongue is covered with a thick yellow fur. The
temperature is 9S°*2 F.

The pulse is 96 per minute, regular, tardy, and of extremely
high tension. The radial artery, like the arteries throughout the
body, is atheromatous.

The impulse of the heart is somewhat diffuse, and the diastole
is accompanied by a sinking inwards of the fourth, fifth, and sixth
left intercostal spaces. The apex-beat has its point of maximum
intensity in the fifth intercostal space, oh inches to the left of the
mid-sternal line. The impulse is forcible, and is followed by a well-
marked shock accompanying the second sound. No thrill is present.

The first sound is dull and thumping in its character, and in
the aortic area the second sound is much accentuated. No murmur
is present, but a to-and-fro friction sound is to be heard very dis-
tinctly over the base of the heart.

There are no morbid symptoms connected with the lungs.

The urine amounts to 25 ounces in twenty-four hours. It is of
a pale yellow colour, with a specific gravity of 1013, and a highly
acid reaction. It contains about one-fourth of albumin, and 75
grains of urea per ounce, or 187'5 grains per day. Microscopically,
the urine contains broken granular tube-casts, and amorphous urates.

J)i(tff)wsis. — Chronic granular kiilney, with some roughening of
the pericardium as the result of an intercurrent pericarditis.

The patient continued to grow worse in spite of free purgation

N

98 CHEYNE-STOKES RESPIRATION,

and other remedies employed. On the 12th November, after
two nights of wandering delirium, Cheyne-Stokes respiration was
first observed towards evening, and on the 13th it was fully
developed. It was accompanied by most of the appearances
usually associated with the symptom, but, as will be seen from
the sequel, there were few variations in the state of the circulation.
During the pauses in the breathing the patient lay perfectly
motionless with the eyes closed ; immediately before the first
shallow inspiration of the ascending series of respirations she
opened her eyes, and the pupils dilated ; as the respiration deepened
into dyspnoea her eyes began to roll about, her head was thrown
from side to side, and her hands jerked violently in various direc-
tions ; at the height of the breathing she attempted to rise up in
bed and muttered to herself; with the descending series of respira-
tions these phenomena passed away, and when the phase of arrest
was reached she had resumed her motionless attitude. The pupils
during the pause were found to be contracted. The pulse varied
very slightly, if at all, in its rate throughout the cycle of events,
never being less than 24 or more than 26 beats in a quarter of a
minute. The tension, so far as could be estimated by the finger,
varied still less.

The following day, with the kind assistance of my friend Dr
James, some tracings were obtained with the cardiograph and the
stethograph, one of which is given in Fig. 1, Plate II. Tliis tracing,
which, like the others, is to be read from left to right, shows the
respiratory curve above and the cardiac curve below, with signals
from a time-marker registering every fifth second. It shows that
the number of respirations during the period of breathing was
about 36 ; that the period occupied about 25 seconds, and the
pause about 5 seconds ; and that the pulsations of the heart did
not vary much in rate, although the tracing is naturally modified by
the heaving of the chest during the period of dyspnoea. Unfortu-
nately all attempts to obtain a tracing with the sphygmograph
failed on account of tlie jerking which took place during the
breathing.

On the 15th the patient was in the same condition, and it was
deemed advisable to have recourse to the use of nitrite of amyl.
A few drops were administered by inhalation during a period of
respiration. Tiie drug at once caused flushing of tlie face and

^'^AJ

/

h-

^

Plate !l.

Frql

Fiff4.

Fiff. A

'V\/\/W^

/■I, 6.

ci.iNiCAr,. 99

neck, liut (lid nut intcrft'io with tlie periodic pause in the respira-
tion. Its ai'tion was tested by several inhalations, during sonic of
whieli tracings were obtained from the chest. Fig. 2, Plate II.
sliows the curve obtained while the drug was administered, and it
proves how slight was the elVect of nitrite of amyl on the respira-
tion. The lirst pause after the use of the drug appeared with its
wonted regularity, and before the second pause a period of shallow
breathing was found to intervene.

By the IGth the urine had almost become suppressed, and as a
last resource it was resolved to employ pilocarpine. One-quarter
of a grain of the nitrate was administered subcutaneously, and in
order to ascertain whetlier this substance had any effect on the
conditions leading to Cheyne-Stokes respiration, tracings were
taken with the stethograph. Fig. 3, Plate II., was taken immediately
after the injection, and therefore before the drug could have caused
any direct effects upon the central nervous system. It shows that
three pauses were only present in the form of shallow breathing, but
that the fourth pause was clearly marked. Fig. 4, Plate II., taken
five minutes after the injection, has three complete pauses and one
incomplete. Fig. 5, Plate II., taken ten minutes after administration,
shows very irregular breathing, with pauses intervening between
the periods.

On the 16th the power of swallowing was lost, and the patient
could not be roused ; on the 17th she sank steadily, and on the
18th she died. To the last the Cheyne-Stokes respiration was
present.

A post-mortem examination of the body was made, the day
after death, by my fiiend Dr Eussell, to whose kindness I am
indebted for the following description: —

The body was fairly well nourished. There was a decided
icteric tinge in the skin and conjunctiva?. liigidity and lividity
were present. There was no anasarca.

Tliorax. — There were 6 oz. of brownish-coloured lluid in the
right pleural cavity, and 13 oz. of a similar iluid in the left.
There were some old pleural adhesions on the right side. Both
lungs were congested and oedematous, especially posteriorly.
Otherwise they were normal.

The pericardium contained no lluid. The heart was lirndy
contracted. It was considerably enlarged. There was a large

100 CHEYNE-STOKES EESPIEATIOX.

deposit of fat on its surface, more especially on the anterior
aspect of the right ventricle. The coronary arteries were
markedly atheromatous, segments of them being converted into
rigid calcareous tubes. The anterior one contained a thrombus
not far from its origin, which may have been formed during
the process of dying. The muscle of the left ventricle was
firm and of a good colour, it varied in thickness from | inch
to I inch ; at the apex, however, it only measured I inch,
and part of the muscle was replaced by fat. At this point
a firm decolorized clot about the size of an almond, and not
of very recent formation, had been moulded into a depression
in the ventricular wall. The mitral cusps were somewhat
thickened, and their free edges slightly retracted. At the junction
of the posterior cusp with the cardiac wall there was a thick
nodular crescent of calcareous matter over which the endocardium
was intact. The chordce tendinece were also thickened. The
aortic valve was competent, but its cusps presented a few small
and hard calcareous nodules at their junction with the ventricular
wall. The aorta immediately above the valves showed a consider-
able tract of atheroma. The muscle of the right ventricle was
deeply covered with fat, the muscle itself measuring \ inch in
thickness. There was much tough blood-clot entangled in the
meshes of the columnce carnece and musctili ijctpillares. The
tricuspid and pulmonary valves were normal.

Abdomen. — The abdomen contained 20 ozs. of brownish-stained
serum. The surface of the organs was bile-stained. The intestines
in places presented traces of recent peritonitis, their coils being
agglutinated to one another by soft lymph.

Both kidneys were very small, hard, and tough. On sec-
tion the normal arrangement could be traced with difficulty and
only at a few points. There were numerous cysts both on
the surface and in the substance of the organs. The cortex was
practically obliterated in places. The interlobular vessels were
much thickened. The capsules were firmly adherent, and when
torn off left a coarsely granular surface. The organs, in fact,
presented the ordinary appearances of advanced atrophic cirrhosis.
The liver had some old and firm adhesions at its posterior
edge, and at this point there was a depressed cicatrix in the
centre, on section of which there was found a calcareous mass

CLINICAL. I'tl

twice tlie size nf ;m alinoiiil. Its left edge extended f;ir into
the left liypocliondriuin, and Wiis united to the upper border of the
spleen by old adhesions. The organ itself was congested and
fatty, with a slight increase of its connective tissue arranged in a
polylobular fashion.

The spleen was of normal size and somewhat linn consistence.

An examination of the head was not permitted.

The point which calls more especially for remark in a clinical
res])ect, in addition to tlie persistence of the chief .symptom, is
the fact that the pericardial serous membrane was quite healthy
— there were no adhesions, and there was no roughening of the
surface. The pericardial friction, therefore, was ap})arently caused
by the irregular and projecting anterior coronary artery rubbing
against the parietal layer of the pericardium.

In this case nitrite of amyl caused no change in the type of the
lireathing, although, as shown by the Hushing of the face and neck,
it produced its usual effects on the circulation. The injection of
pilocarpine caused a temporary disappearance of the periodic
pauses in the respiration.

In this case the periodic variations in the respiration were
attended by associated changes in the mental, visual, and
muscular functions, but in so far as could be ascertained by the
most rigid scrutiny, there was not any synchronous moditicatiou
of the condition of the circulation.

Case V. — Gentleman, aged 63, with a history of chronic alcohol-
ism, who had for four years suflered from paralysis of the right leg.
For some weeks he had been confined to bed on account of general
weakness, and when seen on the 7th June 18S9 he had general
anasarca. The urine was increased in quantity, but markedly
deficient in urea ; it contained albumin, but no tube-casts were
present. The pulse was of high tension, showing, however, a
tendency to failure of arterial pressure. The heart was dilated
and hypertrophied ; the second sound in the aortic area was
somewhat accentuated ; in the mitral and tricuspid areas there
were soft systolic murmurs. The lungs, in the presence of crepi-
tations at their bases posteriorly, gave evidence of pulmonary
anlenui. The ca.se was obviou-sly an instance of chronic giiiuular
kidney, with cardiac failure.

102 CHF.YNE-STOKES RESPIRATION.

The last pliase of his malady was characterized by the occur-
rence of uraemia, during the presence of which Cheyne-Stokes
breathing was a prominent and persistent symptom. Fig. 6, Plate
II., is a tracing of the respiratory movements of the thorax, obtained
on the 13th June by means of Marey's stethograph with the kind
assistance of my friend Dr Aitken, with whom the case was seen.
During the pauses in the respiration the patient lay quietly in a state
of unconsciousness, with the eyes shut, and it was difficult to rouse
him even by powerful stimuli. On forcibly opening the eyes during
this pause, the pupils were seen to be contracted to their smallest
diameter. At this period the pulse was small, regular, and of high
tension. After the lapse of from twenty to thirty seconds, the patient
moved his head a little and partially opened his eyes. The pupils
dilated to a slight extent, the pulse lost some of its tension, and these
changes were followed by a superficial respiration. This respira-
tion was succeeded by a slight and momentary contraction of the
pupils, followed immediately by dilatation to a greater extent than
at first, and succeeded by another respiration of greater depth than
the first. This alternate dilatation and somewhat slighter contrac-
tion of the pupil respectively preceded and followed each of the
ascending respirations, until at the culminating point the pupil
was widely dilated. The pulse during the phase of waxing
respiration gradually became fuller in volume and less in
tension.

Fig. 7, Plate II., is the tracing obtained by means of Marey's
sphygmograph during the period of repose ; Fig. 8, Plate II., during
the phase of activity. They show that the pulse was smaller and
more frequent during the arrest of respiration than during the period
of breathing. The patient became more and more restless as the
breathing deepened, until at the point of the most profound dyspnoea
he showed considerable tendency to spasmodic jerkings of the arms
and legs, and made efforts to converse with those near him. From
this point the reverse series of phenomena began to be manifest.
The respiratory movements became less in amplitude, the pupils
after each breath contracted to an extent greater than the dilatation
preceding it, the pulse-rate increased and its volume lessened, the
eyes gradually closed, and the patient sank into the state of pro-
found unconsciousness.

In this case the entire complex of symptoms constituting the

CLINK'AL 103

ClieyiieStokes iili('nniii(.'ii(ni uf tin; niDilciii (Iitimum S.Iioul funnfil
ji strikiiiLf and coiiiplutu clinical idclurc.

'I'lii.s group ot" live cases presents an almost perfect series of
j)liL'n<)niena, from the simplest form of Clieyiie-Stokes breathing,
unaltendcd hy any other periotlic chan^^es, to the complex of
symptoms— respiratory, circulatory, and nervous — known as the
Cheyne-Stokes phenomenon. In the sequel an attempt will be
made to analyze the conditions underlyini,' ihe diflurent appearances.

Another case, somewhat anomalous in certain respects, and of
much interest as throwing a strong side-light on the occurrence
of the periodic respirations, must, in conclusion, be described.

Case VI. — Gentleman, aged 65, seen 24th April 1886, suffering
from arterial degeneration and cardiac failiu'e. Face somewhat
cyanotic ; ankles slightly a3dematous. Pulse e.xtremely irregular
in rhythm and variable in rate, of low tension in spite of some
atheroma of tlie radial artery, as well as of the general arterial
system. Heart considerably dilated, witli diffuse pulsation. No
murmur couhl be detected, but the first sound was feeble, and the
second sound in the pulmonary area considerably accentuated. The
rhythm was extremely irregular. The lungs presented no abnormal
phenomena. The urine contained no albumin.

During calm waking moments and during sleep the breathing of
the patient was perfectly regular, but whenever he was engaged in
any mental effort the breathing fell into groups of ascending and
descending respirations, and in conversation he found it necessary
to employ the pauses for speaking. In this case the pulse showed
no corresponding periodicity in any respect, and there was not the
slightest approach to any changes in tiie opening of the eyelids or
in the size of the pupil. It goes without saying, from what has
just been described, that no alternations in the mental state
attended the respiratory changes.

This observation appears to me to be quite unique in the fact
that e.xcitement produced the cyclical breathing, the converse of
what has so often been previously observed.

104 CHEYNE-STOKES RESPIRATION,

Critical.

The most satisfactory method of entering on the consideration
of the conditions underlying the complex of symptoms, already
discussed from the clinical point of view, is obviously to be
found in a survey of the ground traversed by previous observers.
In the earlier pages of the present v^rork the gradual develop-
ment of clinical knowledge in regard to the phenomena, and
the continuous evolution of ^etiological doctrines with reference
to their causation, have been dealt with in simple chronological
order. But to have a thorough grasp of the entire subject it
will be necessary, in weighing the different views which have
been advanced, to arrange them in groups. Tiie discussion of
these opinions will lead in due course to certain definite and
substantive conclusions.

The earlier observers advanced no theories in explanation of the
periodicity of the respiration, for although Stokes regarded this as
a consequence of fatty degeneration of the heart, and Schweig
associated it with stenosis of the jugular foramen, causing pressure
on the vagus, neitlier observer offered any opinion in regard to the
possible means by which such lesions might produce the symptom.

Somewhat analogous in its vagueness is the opinion of Broad-
bent. In a work which made its appearance after the earlier portions
of this work had passed through the press, and which will be more
fully referred to in the sequel, he refers Cheyne-Stokes breathing
to hish arterial tension, and cites some cases of this kind in which
its presence was determined by the supervention of some complica-
tion. From the consideration of these observations he is led to
conclusions adverse to any hypothesis with regard to the respira-
tory centre, whether of exalted or diminished sensibility, and he is
of opinion that they point to a loss of the normal adjustment
between the systemic and pulmonary circulations. He gives no
explanation of the mode of operation of the loss of balance.

It seems a sufficient answer to these views to recall the fact that
periodic breathing occurs under very varied conditions. It is un-
doubtedly true that Cheyne-Stokes breathing is more commonly
found in cases presenting high arterial tension than in patients
who have a low arterial pressure ; but it is necessary to take into

CIMTFCAI.. 105

account cnses belon^ini,' to tlie latter class, and no hypothesis can
be accepted as even plausible if it fails to do this.

Broadbent's views, moreover, make no attempt to explain why
the high arterial tension, whether with or without a disturbance of
the normal adjustment lietwecn the systemic and pulmonary cir-
culations, shdidd induce such a strikinn change in the rhythm of
the respiratiiiii, and tiny dn iioi take iiitn consideration the various
associated symptoms occurring with the periodic breatliing. For
these reasons, as well as on accDunt of the I'act that Chcyne-Stokes
respiration often occurs witliont liigli arliiial tension, his views
cannot be entertained.

The earnest attempts to explain the occurrence of the periodic
phases of the breathing will now be considered according to the
classes into which they naturally fall.

There are, firstly, certain vague and indelinite views based upon
the hypothesis of a persistent diminution of the functional activity
of the respiratory nervous mechanism.

"Walshe mentions "anaesthesia of the vagus or of the medulla
(ibloiigata itself," a hypothesis wliich appears to be simply repeated
in a transposed form l)y Laycock with his " sentient palsy of the
respiratory centre," or " paresis of reliex sensibility of the mucous
membrane of the lung," The conceptions of many other writers,
such as San.som, are equally hazy.

No hypothesis of this kind is adequate. Simple reduction of
the excitability of the respiratory centre might cause infrequent
and irregular respiration, but it most assuredly could not by any
possibility lead to the regular periodicity of phenomena .seen in
Cheyne-Stokes respiration.

In the second place, many attempts have been made to explain
the regular periodicity of the breatliing liy varying conditions of
the stimuli which act upon the nervous mechanism controlling the
muscular functions of the respiratory apparatus.

Undoubtedly the earliest attempt of this kind is that of Little.
He thinks that the cause is a loss of balance between the two
sides of the heart, either when there is diminished force of the
left ventricle, as in fatty degeneration, or when some abnormal
burden has been imposed on the left ventricle, under which it is
unable to get rid of blood as quickly as it is supplied to it, and the
blood accumulates in the left auricle and the pulmonary veins and

o

106 CHEYNE-STOKES RESPIRATION.

capillaries. Being fully arterialized, tliis blood fails to excite the
terminal filaments of the vagus, as venous blood does, and the
respiration ceases. A few pulsations then displace this blood,
and the venous blood streaming in excites the respiration
anew.

This explanation forms in some respects a transition towards
the renowned hypothesis of Traube. It postulates an inter-
mittent stimulation of the vagus-endings by alternating conditions
of the blood contained in the lungs. It cannot be regarded as
meeting the case, for many diseases produce Cheyne-Stokes breath-
ing in which no disturbance of the circulation occurs. It fails,
moreover, in not giving any adequate reason for the ascending and
descending phases of the breathing ; and the assumed loss of
equilibrium between the two sides of the heart is absolutely
unproved.

Traube begins his explanation, as we have already seen, by
pointing out that all cases presenting Cheyne-Stokes breathing
have one common feature — a lessened supply of arterial blood to
the medulla, in which the respiratory centre is situated. Tiiere is
in consequence less oxygen, which influences the irritability of the
nervous elements. Through this lessened amount of oxygen the
irritability of the nerve cells becomes lowered, and a larger quantity
of carbonic acid is required to cause an inspiration ; the time,
therefore, within which the carbonic acid will accumulate in sufli-
cient quantity is lengthened. This is similar to the effects of
section of the vagi, in which long pauses, attended by dyspnoea,
occur in the respiration. The respiration may be excited in two
ways : 1. By the pulmonary fibres of the vagus ; and 2. By the
afferent nerves coming from all parts of the body. The difference
between these two is this, that the pulmonary endings of the vagi
are bathed in blood containing much carbonic acid, while the others
have a supply of blood which contains but little. If both be equally
irritable, then in health only the pulmonic vagi will be called into
action. If the vagi be cut, the respiratory centre can only be ex-
cited by the other nerves, and this can only happen when the
blood circulating throughout the body is as rich in carbonic acid
as that normally passing into the lungs. The number of tlie vagus
fibres is incomparably smaller than that of the other nerves ; when
these latter act, therefore, the effect is correspondingly greater.

CRITICAL. 107

A]i|iI\iiiL;' lliis lensunin^- Lo llic iiliciioiiiciinii in (incstiuii, llie less-
ened initiibiliLy of tlio respiratory centre, caused by cerebral
pressure, or uneiiiic blood, or deficient arterial supi)ly, requires a
larjrer amount of carbonic acid as a stimulus, ami thus tliere is a
loni; pause. When this j,'as has accumulated in sufTicient fpiantity
it lirst stimulates the pulmonary terminations of the vagi, but, as
was shown long before by Traube, the strongest stimuli applied to
the vagi never cause dyspncea, and this only causes the .shallow
breathing which appears first after the pause. The amount of car-
bonic acid meantime increases sufiiciently to cause stimulation of
the nerves coming from the skin and other parts of the body, and
hence the dyspncea .sets in. The Cjuantity of the gas is greatly
diminislicd by the forcible breathing, and the excitement of the
other nerves ceases, so with the action of tlie vagi alone shallow
breathing again occurs, until there is not enough carbonic acid gas
to excite tlic pulmonary endings of the vagi, and a pause sets in
anew.

This beautiful and ingenious explanation appears at first sight
to fuliil all the requirements of a good working hypothesis. It is
only on close inspection that it is found wanting. Tlie initial
difficulty is that a simple and constant reduction of the functional
activity of tlie respiratory centre could not by any possibility
induce a change from regular rhythm to periodic rhythm of the
respiratory movements, and that no real cause for the fluctuations
in the blood-supply is advanced. Under the trenchant criticism
of Filehne, indeed, the author found himself obliged to shift his
ground, and in restating his theory, as we have previously seen,
he fell back upon a tendency to rhythmic periodicity in the respira-
tory centre, as well as upon exhaustion of that centre produced
during the phase of breathing, and causing the subsequent pause.
Even this addition, however, leaves the ascending or crescendo
phase quite unaccounted for, and gives no valid cause for tiie
beginning of the periodicity.

It is hardly necessary to refer to the fact that Traube only deals
with the res})iratory plienomenon, and leaves untouched the dif-
ferent as.sociated .symptoms brought before the scientific world by
the elinical arunieu of Lcubc. And it is equally needless to add
that no theory can be complete tliat does not account for the
occurrence of the entire complex of .synqitoms which may be I'resent.

108 CHEYNE-STOKES RESPIRATION.

Hayden, reasoning from the fact that the only lesion with which
rhythmical irregularity of the breathing has been, in his experience,
found, is degeneration and dilatation of the aortic arch, involving a
loss of elasticity in its walls, considers that during the period of
greatest cjuiet of the heart's action, such as occurs in repose or
sleep, the systemic capillary circulation fails, from want of the aid
rendered in health by the elastic reaction of the aorta ; and there
are a suspension of tissue-respiration, hzsoin de respirer, and acceler-
ated or suspirious breathing. Increased respiration will aid capil-
lary circulation, first, through the lungs, and then through the
tissues of tlie body generally, by quickening the action of the heart
and increasing its force. As the systemic capillary circulation is
stimulated, the besoin de respirer is less urgent, and respiration
gradually subsides, till a period of apncea arrives. The descent of
respiration below the normal standard arises, he thinks, from its
previous excessive activity and the exhaustion of the patient. A
period of feeble action of the heart succeeds, with failure of capillary
circulation, and paroxysmal breathing. Tliat imperfect circulation
of arterial blood in the respiratory centre contributes in a special
manner, and in a great degree, to the production of the respiratory
derangement he has no doubt ; but he thinks that the effect of this
is not easily distinguished from that of a want of oxygen in the
tissues of the body generally.

In this explanation the train of reasoning bears considerable
resemblance to the arguments advanced by Traube in his second
liypothesis. All the objections which have been, or may be, urged
against the views of Traube may be, with equal cogency, brought
forward in opposition to the views of Hayden ; and it is hardly
necessary to add that in a considerable number of cases, exhibiting
the Cheyne-Stokes phenomenon, there is no structural alteration of
the aortic walls, or of any part of the circulatory apparatus.

Hein, starting from the consideration that the fluctuating con-
ditions of the cerebral and respiratory functions must have the
same cause, considers that the irritability of the tissues in general,
as well as of the medulla in particular, must be lessened by some
underlying condition, which in his own experience was cyanosis.
From the diminished excitability of the medulla pauses are pro-
duced which may, he thinks, have an effect on the circulation, so
that what was a consequence may in other circumstances be a

CUITICAL. 100

cause. Willi a iinnnal (.irLulation .such an eflect is impos.sible, as
Clieyiie-Stiikes ii'spiraiidn may be imitated by the hour without
any notioeabU' modilicaliou of the circuhitiun. It i.s otherwise,
however, whiii the blood-stream is slowed and oxygenation less-
ened, fur if interruptions to the respiration take place, the functions
are alternately increased and diminished, and such eHectsare shown
in the medulla oblongata through variations in its irritability. The
blood which has been arterialized during the respiratory period
reaches the capillaries in greatest part at the beginning of the
pause, at which time the circulation which had been quickened by
the breathing becomes slower, while the tissue change is most
active. The result is that the irritability of the medulla is again
increased and the breathing begins. By means of the passage, during
the breathing period, of the blood which has become venous during
the pause, the tissue change necessary to the functional activity of
the organ cannot be kept up, the oxygen in tlie tissues is consumed
without adequate compensation, and the irritability of the respira-
tory centre is suspended. It is again restored after arterialized
blood has coursed through the vessels of the medulla and promoted
internal respiration, as occurs at the end of the pause. That the
irritability shows a stage of increase aud a stage of decrease is due
to the fact that the alternation in the conditions of the circulation
and diftusion is gradual, not sudden. From the analogous con-
ditions of the brain and medulla it is to be concluded that the
respiratory nerve centre does not simply undergo a change in the
degree of stimulation, but a periodic alteration of its own con-
dition.

The explanation advanced by this author, so far as it is possible
to understand his meaning, seems to rest upon the conception that
alterations in the metabolic processes lead to an alternate increase
and decrea.se of the functional activity of the centre for respira-
tion. But in this theory there is absolutely no attempt to find a
real cause for the initial phenomena of periodic alternation.s — in
short, as was remarked by Filchne, it is solely concerned with the
hoa\ and leaves the why untouched.

At tlie conclusion of his argument, however, it must be noted,
he makes mention of a periodic variation of the condition of the
respiratory centre ; and, in his later contribution to the subject, he
lays still more stress upon the [leriodic variations in the activity

110 CHEYNE-STOKES RESPIRATION.

of the respiratory centre, with or without analogous fluctuations in
the activity of other nerve-centres. He leaves us, notwithstanding,
under the belief that tliis periodic variation of functional activity
is produced by variations in the condition of the blood-supply, and
offers no explanation of the original cause of this.

Filehne allows that for the production of Cheyne-Stokes respira-
tion there must be a lowering of the irritability of the respiratory
centre, but he asserts that the irritability of this centre must be
diminished to a greater dei2free than that of the vaso-motor centre.
He holds that these centres remain at rest as long as they have a suffi-
cient amount of oxygenated blood, and that they are excited when-
ever the blood-supply is sufficiently arterialized, or when, although
sufficiently arterialized, the supply is deficient in quantity. He
asserts that in health venous blood excites in regular order, — 1st,
the respiratory; 2nd, the vaso-motor; and 3rd, the convulsive
centres. When the phenomenon is present, the blood during the
pause gradually becomes more venous and develops the stimulus
for the centres, but, from the lessened irritability of the respiratory
centre, no respiration is caused, and the pause therefore continues
until the point is reached when the vaso-motor centre is brought
into action. This produces a diminution of the blood-supply, which
causes the respiratory centre to act and originate the superficial
breathing which is first observed. Some time, however, elapses
before the blood arterialized by these respirations can reach the
vaso-motor centre, and this is delayed by the contraction of the
arterioles caused by its activity ; it also takes time before the vaso-
motor apparatus can induce contraction of the arterioles, and time
also before the contraction can pass away ; there is therefore a
lengthening of the pause and deepening of the dyspnoea.

Filehne states that when Cheyne-Stokes respiration is produced
in animals by the administration of large doses of morphine, fol-
lowed by tlie inhalation of ether or chloroform, there is a diminution
of the pulse-rate during the pause, which sometimes goes the length
of complete cessation of the pulsation ; while during the period of
respiration there is a gradual acceleration until the normal rate is
regained towards the end of this phase. In animals thus experi-
mented on the blood -pressure rises during the pause and falls during
the period of breathing. In a man dying froui a lethal dose of
morphine and chloroform, who showed during the narcosis Cheyne-

CKITICAt,. 1 1 ]

Stokes respiration, (lie pulsr uiidrrwcuL tlie same cliaiij,'es as in
the animals on which hf in'irormcd his ('.\]M'iimenls.

J)iuiii,i,' his controversy with Trauhc, Fih'hnc refers, as previously
mentioned, to the fact, observed by him, that the arteriiil tension
rises befori' tiic be[,dnninj,M)f the jiha.se of respiratory activity; to
the depression of the fontanelles in children, who present the symp-
tom, before the adive phase ol' breathing ; to the disappearance of
Cheyne-Stokes breathing on the administration of amyl nitrite ; to
a rise of tension in some persons before inspiration ; and to the
production of periodic breathing by alternate compression and
relaxation of the carotid and vertebral arteries in the rabbit. In
later contributions Filehne found himself driven to admit that the
arterial changes may be synchronous with the periodic changes in
the respiratory activity.

This exceedingly complicated hypothesis rests, in the first place,
on certain assumptions which have not been proved ; and. in the
second place, on several observations whicli liave, without excep-
tion, been proved to be, to say the least of them, inconstant.

The statements in regard to the relative excitability of the
centres in tlie medulla rest upon no basis of fact, and with refer-
ence to an arterial spasm, upon a misconception.

Filehne's observations on the alterations of pulse-rate and
tension have been found \>y numerous writers to be altogether
incorrect, inasmuch as the changes, when present at all. have been
seen to be the converse of what he described, and to <iccur at a
period entirely different from that stated by him. An arterial
spasm, moreover, in a patient with a condiiinn of lessened cerebral
activity would probably lead to conseipiences quite the opposite
of those seen at the beginning of the phase of breathin". His
descriptiim of the cerebral movements seen in the fontanelles of
an infant is absolutely controverted by the observations made on
similar cases by Jlo.senbach and Ilein. Even the result of amyl
nitrite has been found by later observers to be in niany cases
ju'gative, and if any change has been produced by this drug it has
been through its ell'ects as a stimulant, as has been pointed out by
Mayer and myself. The results of his experinients will be dis-
cussed at a later stage. Meantime it is only necessary to state that
no basis for his elaborate hypothesis is left.

The views of Dram well are essentially those of Filehne, inas-

112 CHEYNE-STOKES llESPIRATION.

much as be postulates an arterial spasm, produced by the venous
blood, as the proximate cause of the excessive respiratory action,
and this excessive action as the cause of the subsequent pause,
through free oxygenation of the blood. The nmin points in which
he differs from Filehne are in his considering the possibility of a
different state of excitability in the discharging and restraining
portions of the inspiratory centre, and in his holding that there is a
state of irritable weakness in the centre, rendering it more easily
fatigued, and yet also producing more powerful effects when suffi-
ciently stimulated.

It is obvious that all the objections which have been advanced
against the theory of Filehne may be brought forward in opposition
to this hypothesis, and neither of them does account for the
starting-point of the periodic breathing.

Cuffer, as we previously saw, seems to have proved by his re-
searches with FranQois-Franck that excessive oxygenation of the
blood produces arrest of respiration. He has been led to consider
the stage of apncea as arising from excessive oxygenation of tlie
blood, caused by dyspnoea ; the recommencement of the breathing
and subsequent dyspnoea as caused by the want of oxygenation
due to the arrest of respiration ; the superoxygenation of the blood
and accompanying muscular fatigue determining in turn a new
period of apnoea. He thinks the phases are caused by the action
of the blood on the medulla as well as by the influence of a reflex
action having its point of departure in the lung ; the lung being
the special regulator oE the quantity of oxygen needed, and liaving
its essential stimulus in the condition of the blood which it con-
tains. He directs attention to the arterial spasm at the beginning
of the respiratory period, which is characteristic of uraimia, and
holds that it influences the condition of the breathing.

There seems but little difference between this view and that of
Filehne, and the same arguments may be brought against both.

The theory of Grasset, as stated by Blaise and Brousse, holds
that from deficient nutrition there is loss of vitality of tlie nerve-
cells producing a condition of irritable weakness, upon which the
venous blood acts strongly, producing dyspnoea. This oxygenates
the blood to a high degree, which removes the stimulus to respira-
tion, and a pause ensues, allowing the blood again to become
venous. So far the theory is similar to that of Traube, except that

cinricAi..

its autlior thinks the .Iffiriciit nutrition of tlic nervous elements
l)r(Hluces an excessive irritability, whereas that of Trauhe refers
the condition to a lessened irritahility. i'.ut Grasset goes on to stat«
that excitement of the vaso-motor centre may produce an arterial
spasm. Here we have the theory of Filch iie almost in its entirety.
On similar lines, hut consideraldy less delinite than most of the
hypotheses summed up in the preceding pages, are several opinions
stated hy di He rent observers.

The view of Piaggio, for instance, fully stated in the earlier part
of this work, is that a tissue-centre of respiration controls an
automatic centre, and that the condition of the tissues, not the
state of the Mood, is the determining cause of the periodicity.

Kaufmami is even less precise, and thinks that theories based
upon a conception of exhaustion of the centre require the further
hypothesis that the increase of irritability induced by external
stimuli is so great as to prevent the exhaustion from giving ex-
pression to itself.

Wellenbergh points out that, under ordinary conditions, there is
a provision for an increase or a decrease in the quantity of blood
in the cranium up to a certain point, but that, when the limit is
passed, changes in the blood-supply must cause disturbances,
lleasoning from the analogy of the mechanical contrivance de-
scribed previously in the extract from his paper, he seeks for some
mechanical cause of interference with the blood-supply, and is of
opinion that this is to be fouiul in oedema of the brain, and he
advances the hypothesis that the periodic breathing is the result
of a struggle between the pressure of the oedema outside the blood-
vessels and the blood-pressure within them, in which strug^de each
is alternately supreme.

It is a suthcient reply to this hypothesis to point out that many
ca.ses have no cedematous condition, and that the explanation is
therefore not valid.

Many observers simply give in their adhesion to one or other oi
the foregoing hypotheses based upon assumed alterations of the
external stimulation, and it is therefore unnecessary to refer to
them in this place.

We have to consider, thirdly, the theories which seek to explain
the regular i)eriodicity of the respiration by variations in the
intrinsic condition of the respiratory centre.

114 CHEYNE-STOKES RESPIRATION.

Observing, as we have previously seen, that in certain circum-'
stances the contractions of the frog's heart fell into groups, or
became periodic, Luciani was led by the resemblance of this
phenomenon to the character of Cheyne-Stokes breathing to seek
for some condition common to both as the cause of the two
phenomena. The experiments and observations which he has
made have already been fully referred to.

He does not think that Cheyne-Stokes breathing can be ex-
plained by means of the principle, that the capacity and activity
of a nervous organ depend on extrinsic stimulant and nutritive
conditions. No doubt the vitality of any organ is intimately con-
nected with surrounding conditions and influences, but it does not
follow that the organ in every case transforms only as much as it
receives in the same measure as well as in the same rhythm with
which it receives it. Drawing a clear line of distinction between
reflex and automatic movements, Luciani points out that the
determining cause of the former is extrinsic, while in the case of
the latter it is intrinsic, and consists in oscillations of the internal
nutritive movements, to which correspond as many oscillations of
the excitability of the organ itself. He was led to this conception
of automatism by the discovery of the periodic grouping of the
movements of the frog's heart, for it could not be doubted that
when extrinsic conditions remained unchanged, the cause of the
alternate groups of pulsations and pauses was intrinsic. Luciani
therefore regards the diverse forms of respiratory rhytlim as
extrinsic expressions of the nutritive changes in the structure of
the respiratory centre. If it be gi'anted that the respiratory centre
is automatic, it follows tliat the different forms of rhythm which
constitute Cheyne-Stokes phenomenon may be regarded as effects
of diverse kinds of automatic oscillations in the excitability of the
centre itself.

This theory presents us with views entirely different from any
which we have hitherto criticised. It is quite true that Traube,
in his later hypothesis, makes mention of a tendency to rhythmic
periodicity in the respiratory centre, and that Hein somewhat
briefly refers to a periodic variation in the activity of that centre ;
these authors, however, clearly indicate that such changes are
conditioned by extrinsic agencies. Luciani therefore makes
quite a new departure in advancing the view, that the change

riMTKAI,. 115

from rii,Mil;ir to periodic iliylliiu is iliu) t<» intrinsic con-
(lilioiis.

'Jilt' cliici" (lilliciilty, ;is rci^'ards this tlicory, api»('iirs to l)i^ placed
ill the ([ucsiioii wlii'tliiT the respiratory centre can be rejj'nrded as
really aiitoiiiatic. As will he shown in the sequel, there can now
be no nianiiiT (if doulit that the respiratory centre is truly auto-
matic ill its iictioii. And this being granted, it must of necessity
lV)lh)W that, although it is perhaps more influenced by external
agencies than any similar organ, the nerve centre mainly
concerned in the maintenance of resjiiration can modify its
functions independently of such extrinsic conditions. There can,
therefore, be no great obstacle in the way of accepting Luciani's
conclusions.

Kosenbach finds an explanation of Cheyne-Stokes breathing,
with its attendant symptoms, in the alternation of activity and
repose characteristic of Xature. In the resitiration we see inspira-
tion, expiralioii, ami iiausf; in tiie circulation, syst(jle, diastole,
ami pause; in the nervous system, waking and sleep; while in
curarized animals there are periodic changes in the rate and ten-
sion of the circulation which are quite independent of the respira-
tion. The origin of activity is in the cell, not the hloud, and it is
illogical to seek a cause of respiratory and other phenomena in the
latter. Periodic activity of all nervous apparatus, therefore,
depends on immanent peculiarities of elementary structures, and
the blood is not the direct stimulus for the cells, but has its power
in giving the cells the possibility of regulating tissue change.
"When the blood is altered there is necessarily a modification in
the absorption of oxygen and the removal of the products of tissue
change, and the mechanism will therefore be indirectly aflected ;
the blood is thus only one link in the chain of apparatus needful
for life.

The regular allcrnation of activity and repose characteristic of
life is seen in the complex of pathological pla-nomenn, of which
periodic breathing is only one symptom, and Cheyne - Stokes
respiration is therefore the result of a condition in which the
cxhaustibility of the central apparatus, normally following its
activity, is greatly increa.sed. The respiratory centre has its irri-
taliility lowered, as the breathing is at first shallow, but the
irritability progressively increases, for in spite of belter aiiration,

116 CHEYNE-STOKES RESPIRATION.

dyspnoea gradually develops. The irritability then diminishes,
and the descending phase begins.

The phenomena, tlierefore, according to Eosenbach, occur in
conditions of disturbed nutrition, but they are independent of any
periodicity in the blood-supply to the brain, and are co-ordinated
by, and joint effects of one and the same cause occurring periodi-
cally in tlie centi-al organs, this cause being exhaustion of the
centres. The whole brain may be affected, when the entire com-
plex of symptoms termed Cheyne-Stokes phenomenon is produced,
or limited tracts only may be implicated, giving Cheyne-Stokes
breathing. He points out that just as the respiratory centre alone
may be deranged, so the vaso-motor or vagus centre may be
disturbed, as in tubercular meningitis, and cause clianges in the
tension or rate of tlie pulse. Eosenbach compares the periodic
exhaustion with the normal pauses for rest sliown by all rhythmi-
cally acting systems. The different phases resemble natural
phenomena, but with longer intervals ; the period of breathing, for
example, is to be compared with a respiration, and the period of
repose with the sliort pause following expiration. The vagus and
vaso-motor centres show similar variations. The exhaustion of
the brain induces sleep, during which the pupils behave as in
ordinary slumber.

The centres are not only more easily exhausted, requiring longer
rest, but their irritability is reduced, and forced breathing comes
on in spite of better arterialization of the blood (which involves
reduction of stimulus). The meaning of this is, that the centre is
becoming more irritable, although the stimulus is lessening. After
a time the normal irritability is regained, which is accompanied by
gentler breathing until the pause resulting from exhaustion occurs.

This theory runs on the lines laid down by Luciani, and
assumes variations in the intrinsic condition of the centres as the
cause of the periodicity of the phenomena. This, as has been
stated, is an opinion which is difficult to refute. But the chief
import of Eosenbach's work is the masterly grouping of the
different phenomena, whether inherent or accidental, as one com-
plex of symptoms, conditioned by one and the same cause. The
great value of his contributions lies in the fact that he has mar-
shalled all these appearances, and given a satisfactory explanation
of their orimn.

CHlTICAr,. 117

Mosso, fidiii till' consiileration of ii long series of interesting
observalion.s and cxiicrinicnts, comlti(lt;.s that tlie respiratory
moviMiients an; inodilied according to the ainonnt of activity |»n'-
scnL in the ntMvous system, and points to tli<; intimate relations
existing Itetwccn periodic breathing and sleep. It has been
thought that the greater or less activity of the respiratory centre
represents a greater or less need of jtrovision liy pulmonary
ventilation for the chemical wants of the organism ; but the author
is of opinion that he is not far from the truth in thinking that the
respiratory movements modify themselves according to the states
of sleeping or waking — of greater or less activity of the nervous
system. He holds that the mechanical and chemical parts of
respiration are distinct, that the mechanical is more representative
of the vitality of the nerve centres than of the chemical wants of
the organism ; that if the nervous excitability increases more air
is insj)ired than is needed for chemical wants ; while, on the con-
trary, during sleej) the luechanical may lessen or become periodic
without disturbance of the chemical function of tissue respiration ;
and further, that when the excitaliility of the centres is much
lowered, it can be determined tluit the accumulation of carbonic
acid by asphyxia causes almost no elVect on the respiratory
movements.

These views are in the main in accord witli the opinions of
Luciani and liosenbach, but tiiey embrace one or two extensions
in different directions. In re<'ard to the relations existing between
periodic breathing and sleep, it has been urged that sleep is
impossible when ordinary stimuli are maintained ; it must never-
theless be borne in mind that, when the nervous centres are
exhausted, sleep occurs even during the presence of ordinary
stimuli.

(Jreater exception may probably with justice be taken to the
hypothesis that the mechanical and chemical functions concerned
in respiration may undergo (pi;iiitilati\e changi'S irrespective of
each other. There can, however, be no doubt, as will be fully
proved in the sequel, that the centres engaged in the processes of
respiration are endowed with a large measure of auton)atism, and
ir may fairly be concluded that there is no ab.solute ([uantilative
ri'lation between the mechanical and chemical functions.

With regard to the main theory, that the respiratory movements

118 CHEYNE-STOKES RESPIRATION.

ill periodic breathing are modified according to tlie amount of
activity present in the nervous system, it is only necessary to
remark that, like tlie two just discussed, it rests upon a sure
basis.

Murri has more especially attacked Mosso for holding the view
that Cheyne-Stokes breathing presents a condition analogous to
sleep, and he urges that if this were really the case, periodic
breathing would be a common appearance instead of a rare
symptom. But Murri is entirely incorrect in considering periodic
respiration as a rare phenomenon. In very many different but
physiological conditions various degrees of this type of respiratory
rhythm may be seen, as will be shown in the sequel.

The interesting observations of Langendorff and Siebert have
led them to the somewhat indefinite conclusion, that periodic
breathing is caused by disturbance of irritability produced by
changes of nutrition. Their views, notwithstanding a considerable
degree of vagueness, appear to accord for the most part with the
conclusions of most of the observers who are embraced in this
section, and they merit a similar place in regard to their scientific
value.

From the results of their observations, which have already been
fully referred to, Solokow and Luchsinger have come to the con-
clusion, that the phenomena are absolutely independent of changes
in blood- pressure, and that the conditions underlying the periodicity
of the respiration are such as are developed in every tissue
■with increasing asphyxia ; that the cause is, therefore, to be found
in the lessened elasticity and greater exhaustil)ility of the
centre.

These views are founded on a series of observations so complete
as to leave no room for any doubt in regard to the validity of
conclusions reasonably deduced from them, and the opinions of
these observers naturally fall in with and complete the teaching
of Luciani and Rosenbach.

The experiments and conclusions of Fano may briefly be classified
as strictly analogous to those of the two authors just referred to.

Lowit, from his clinical studies, and Saloz, from his experi-
mental investigations and clinical observations, have apparently
arrived at conclusions which closely resemble those alVeady dis-
cussed as belonging to the third group.

CHITICAL. 1 I'J

Muni lliiiiks tli.il in |icri(iilic breathing' tlicio is ,i regular increase
and decrease of the activity (»!' iIk; lespiratoiy centre, caused by
some mechanism at pii'sent unknown, lie hoMs, however, that
the irrilaliility nl' the re^piratiry centre is depressed ; and he is of
opinion that tlie resjiiralory centre must have several zones, curre-
s^tonding to dillerent grou[)S of muscles, ami (Miduwed with various
degrees of irritability.

So far his views are in accord with those placed in this group.
But he proceeds to argue that in health the most sensitive zone
responds promptly to stimuli, and is therefore sufficient for the
function of respiration. If imi)aired, however, it needs stronger
stimuli, and these rouse the other zone.s, causing dyspna-a, by
means of which more oxygen is supplied to the blood, and there
is a laiger supply to the medulla ; this gives rise to a slowing of
respiration which ends in the pause, with accumulation of
carbonic acid and a repetition of the cycle. The decreasing or
descending respirations are due to the continuance of activity after
the interruption of the stimuli ; the dyspncea is caused by the
delay in the aeration of the medulla. It must be admitted that
the irritability of the respiratory centre is impaired in ortler to
have the necessary conditions for the development of Cheyne-
Stokes respiration.

In this there is a complete adoption of the theory of Traube, and
Murri's explanation, therefore, embraces, firstly, tiuctuations of
activity in the centre, caused by some mechanism as yet unknown,
but probably intrinsic; and, secondly, alterations occurring retlexly
in response to extrinsic stimuli. The first part of his hypothesis
is probably founded on correct view.s ; the second, as has been
seen, is in itself at once inadequate and unnecessary. It is,
however, not improbaljle that as an additional and accidental part
of the i)lienomenon, .such processes are sometimes linked with
the more important automatic action of the centre.

In (uder to arrive at a real understanding in regard to the
conditions underlying Cheyne-Stokes breathing, it is necessary to
grasp the results of j)hysiological investigation into the nervous
mechanism controlling the respiratory movements.

In these complex movements there is one of the most wonderful
examples of co-ordinated muscular acts. The precision with which
the dillerent movements — facial, faucial, laryngeal, and thoracic —

120 CHEYNE-STOKES llESPIUATION.

are brouglit into harmony with eacli other, speaks fur a highly
specialized nervous apparatus. These various movements are not
merely complementary to each other under ordinary conditions, but
they may in altered circumstances become also compensatory. If the
phrenic nerves, for example, are severed, so that the diaphragm is
paralyzed, the intercostal muscles act much more powerfully in an
attempt to compensate for its inactivity. Such observations prove
that the centres controlling the respiratory movements have tlie
power of increasing the activity of certain muscles in order to
supply what is lacking on account of deficient efforts elsewhere.

It is, perhaps, unnecessary in this place to refer to the question
whether more centres than one are concerned in the maintenance
of the respiration, but a brief allusion to it will conduce to the
thorough comprehension of the subject. From the results of experi-
ments performed by severing the connexions of the medullary
centres, it is quite clear that in young animals at least there are
spinal, as well as bulbar, centres engaged in the movements of
respiration. This is analogous to the now thoroughly established
and more widely-known fact, that there are vaso-motor centres in
the spinal cord as well as in the bulb. In both cases there are
probably lower spinal, under the control of higher bulbar, centres.
In the respiratory mechanism of the adult mannnal, the functions
of the lower spinal centres, however, appear to be allowed to fall
into desuetude.

It will serve no purpose to enter upon any attempt to draw dis-
tinctions between inspiratory and expiratory centres : no such
differentiation is of the least use in the present inquiry.

The nervous mechanism concerned in respiration is remarkably
subject to the influence of external agencies. The movements of
respiration may not only be modified by processes taking place in
the higher nervous tracts, such as volitional impulses or emotional
impressions, but they are subject also to alterations in consequence
of any considerable stimulus of any part of the lower nervous
system.

The functions of the respiratory centre are also modified by
changes in the blood circulating through the nervous textures.
The presence of venous blood augments the respiratory movements ;
even after section of the vagi and spinal cord below the bulb, a
venous state of the blood increases the facial respiratory move-

CRITICAL. IL'I

mcnts. A lessened supply of blood, as after li;,'ation of the caroti«l
and vertebral arteries, produces dyspiKea, and the same result is
produced if the Idooil flowing upwards in the carotid arteries is
heated. Against these facts must, however, be placed the interest-
ing observation, that if by transfusion the normal blood circulat-
ing in tlie bulb is replaced l)y a tluid containing little or no luemo-
globiii, and therefore ImL little oxygen, dysi)noea is not produced.

The condition of apnoM may be caused by forced respiration, but
it has been found tliat this cannot be l)rought about so easily after
section of the vagi ; tiiis is what might be expected, seeing that the
inhibition of inspiratory movcnu'nts is largely tlie function of the
vagi, and, more especially, of the superior laryngeal branches.
The production of apnoea may be effected by forced breathing of
such an indifferent gas as hydrogen, and the positive ventilation,
as it is termed by Foster,' appears to act more as a mechanical
stimulus to the vagus terminations, than as a chemical stimulus
acting tln-ough the blood.

The regulative influences normally ascending tlie vagus nerves
are apparently twofold, and probably run along different sets of
fibres. N"o other conclusions can be drawn from tlie fact, that
when, after section of the vagi (producing deep and infrequent
respiration), the upper ends are stimulated, the respirations are
sometimes rendered more, and at other times less, frequent.

Very many of the plienoniena produced by external agencies
are purely reflex in their nature, but when this has been granted
there remain other facts which point to something more than
simple reflex action in the respiratory centre.

After section of tlie vagi, for example, the respiration is main-
tained, although considerably modified by the lack of the ascending
regulative influence of these nerves. This observation proves that
the movements of respiration are in their causation independent of,
although modified by, stimuli from the lungs.

If the spinal cord be severed from the bulb, and all the accessible
sen.sory cranial nerves be divided, so that the respiratory centre is
set free from almost all sensory stimuli, the respiratory movements
(if the face and larynx (.'oiitiiiuc, ahhou.;h the thoracic movements
necessarily come to an iMid. In this observation there is ch'ar

' .1 7Va7 Hook uf ritysioloijij, fifth cilition. Part ii. \^. 595, 1889.

Q

122 CHEYNE-STOKES RESPIRATION.

proof that the respiratory movements are independent of all sen-
sory stimuli.

Such facts demonstrate, beyond the shadow of a doubt, that the
respiratory centre is in its nature truly automatic.

The most scientific conception of the respiratory centre, there-
fore, seems to be tliat it is one endowed with an independent
automatism, but that it is subject to modifications of its activity by
impressions from without.

The next step in the inquiry is to find out whether periodic
changes in the rhythmic action of the respiratory centre may occur
under physiological conditions. Mosso, as has already been seen,
pointed out that in men and domestic animals, perfectly healthy, but
fatigued by exertion, the breathing tended to become periodic and
intermittent during sleep. This is an observation which has been
verified by subsequent investigations, and which may be confirmed
by anyone who has any doubt on the subject. During the after-
dinner nap of elderly persons there is also a great tendency to
periodic respiration, which may exhibit the phenomena of Cheyne-
Stokes breathing in its most pronounced form. This may, as in the
case communicated to me by Dr Muirhead and previously referred
to,^ occur day after day for years. But it is not necessary to look
for such periodic variations in the rhythm of respiration in con-
ditions of fatigue or of advanced life, where it may possibly be said
that the conditions are not absolutely physiological. Edes has,
as was previously mentioned,^ observed that in certain individuals
the breathing during sleep is constantl}^ periodic, and it seems
probable that the members of some families have a peculiar tendency
to tlie development of the symptom.

The periodic breathing may therefore be regarded as in many
instances a perfectly physiological appearance. This conclusion
divests the symptom in itself of any prognostic significance, and
any importance which it may have in this respect is to be
estimated by the conditions in which it is seen. In hibernating
animals, as Mosso showed,^ the breathing is very similar to Cheyne-
Stokes respiration. The case described on a previous page,^ in which
during mental efforts the breathing fell into gronps of ascending
and descending respirations, must be referred to in this connexion.

In all the diverse forms of disease, classified on a previous page,

» V. p. 88. " V. p. 88. 3 V. p. 38. * Case VI., p. 103.

CRITICAL. 123

presenting Choyne-Stokes broatliin;^, one condition nuiy Iju held to
be constant — a reduction of the activity of the higher nervous
structures. Whether the cause be in tlje nerve centres primarily,
or in other structures, such as those of the digestive, circulatory,
respiratory, or renal systems, or in general adections, such as the
specific fevers, there is, when Cheyne-Stokes breathing is jjresent,
the one constant condition of lowered nerve activity, such as
normally occurs in deep sleep, or after a full narcotic dose. It
must not be imagined, from the reference just made to circulatory
changes as a cause of Cheyne-Stokes respiration, that there is any
such direct nexus between the state of the circulalinn and the
condition of llie breathing as has been postulated by Filehne and
his followers. The fact that there is no cyanosis during the
pause is in itself enough to negative such views, against which
valid objections have been fully urged previously. There is,
however, a more general connexion between the state of the
circulation and the condition of the nerve centres. If at any
time the quantity or quality of the blood should depart from
the normal, the activity of the nervous structures suflers in a
direct ratio. In this way, but in no other, is there in Nature a
connexion between the function of the circulatory and nervous
mechanisms.

The explanation of all these phenomena is supplied by the
interesting series of investigations of ]\LuekwaId,^ from which he
has been led to the conclusion that periudic breathing can only
occur when some of tiie higher brain tracts have ceased to exert
their inlluence upon the respiratory centre. During sleep the
action of these higher tracts is in abeyance to a greater or lesser
extent; in certain individuals a greater degree may habitually be
present, in others it only takes place after great fatigue. It is
more likely to occur during the process of digestion, as in the
after-dinner nap, because the nervous energy is then carried oil" in
another direction. In Case \l. the accession of the periodic
breathing was obviously determined by the deviation of nervous
influences into other channels by mental ellbrt.

The eflect of many drugs which produce periodic breathing
amply confirms this view, as all of them whieh have been fouinl i.»
produce such changes have the power of lessening cerel»ral aclivitv.

' V. \K 81.

124 CHEYNE-STOKES EESPIRATION.

It is, however, extremely probable that in addition to the removal
of the higher influences the activity of the respiratory centre itself
must be lessened.

Such periodic phenomena are not confined to the respiration,
Luciani ^ has observed analogous phenomena in the amphibian
heart when removed from its normal nervous control, and Waller
and Eeid, in a recent investigation,^ have observed analogous
phenomena in the excised mammalian heart. Tano ^ and
Langendorff and Siebert'^ have seen similar appearances in the
excised heart of the embryo, and Solokow and Luchsinger^ in the
lymph hearts of dying frogs.

It was previously seen that the periodic movements of the
respiratory muscles in hibernation had been observed by Mosso ^
to become regularly rhythmic on elevation of the external tem-
perature. A periodicity of respiratory rhythm was caused by
Fano^ in the alligator by subjecting it to the influence of cold.
In these instances it is only a fair inference that the depressing
influence of the low temperature lowers the vitality of the animal
and diminishes the control of the higher nervous centres, while it
no doubt at the same time lessens the activity of the respiratory
centre.

It seems to be in accordance with some great natural law, that
rhythmic phenomena tend to become modified when the organs
have their vitality lowered or are still imperfectly developed.
This conception appears to be confirmed by Steiner's observations
on Medus£e. He points out ** that the rhythmic contractions of the
calyx fall into periodic groups separated by pauses from each other
when Medusae are kept in water which has not been sufficiently
often renewed.

Phenomena analogous to those seen in Cheyne-Stokes respira-
tion are observed in various conditions. Changes in the rhythm
of the pulse lead in many cases to more or less periodicity of

1 V. p. 45.

2 Philosophical Transactions of the Royal Society of London, vol. clxxviii.
page 218, 1887.

3 Lo Sperimentale, tomo Iv., p. 143 e 252, 1885. * F. p. 63.
^ V-V- 58. 6 F. p. 38. 7 F. p. 71.

8 Archivfiir AncUomie, Physiolngie, iind Wissenschaftlichen Medicin, Jahrgang
1875, s. 174.

CRITICAL. 125

groups of pulsations, and in certain circumstances, more especially
perhaps when the lieart has undergone degenerative clianges, tlie
pulse-tension manifests a marked tendency to show periods of
elevation and depression. Tiie Traube-Hering curves seen on
physiological investigation are probaljly in every way analogous
to this symptom.

Reasons have been adduced by nie on a previous page for
believing that in certain states of the nervous system there are
periodic fluctuations of consciousness which may be regarded as
similar to the periodic changes of respiration.

In most of the instances brought forward, the obvious character
of the change is the induction of a larger secondary upon tiie
smaller primary periodicity of the phenomena.

It has already been proved that the respiratory centre is to a
great extent endowed with automatism. It is like the other
organic centres possessed of much more vitality than the higher
centres, and can resist influences fatal to their integrity. When
from any cause the higher centres are rendered incapable of
performing their proper functions, the influence normally exerted
is in abeyance, and the organic centres are allowed free play for
their automatism.

From the investigations of Marckwald it must be concluded that
the automatic centre for respiration is under the control of a
higher regulating centre. "Whether the periodic respiration pro-
duced by section of tlie bulb in its upper part may not be in part
caused by disturbance of the automatic centre, by which its activity
is lessened, is a point that might be discussed. It seems clear
tliat when the activity of the automatic centre is reduced, its
functions have a tendency, common as has been seen to all vital
structures, to become periodic.

The relation of Cheyne-Stokes respiration to what is termed
cerebral breathing has from time to time been referred to in the
preceding pages. The essential difference between the two types,
when fully developed, consists in the perfectly regular periodicity,
as well as in the waxing and waning character of the former, in
contrast to the very irregular occurrence and the absence of any
uniform onset or end of each period of activity. But it cannot be
held that there is any absolute line of distinction between the two
phenomena; there are not only many intermediate gradations by

126 CHEYNE-STOKES RESPIEATION.

which they are linked together, but the same cerebral affections
may produce at times the periodic, and at other times the irregular
form of interrupted breathing. No reason has ever been given to
account for the different characters of the extreme varieties. It
appears to me not at all unlikely that the difference may lie in the
total removal of the higher brain influences in the case of perfectly
periodic Cheyne-Stokes breathing, and in the irregular discharge
of unequal impulses from the higher tracts in the case of that
type which is commonly called cerebral.

A careful study of the entire phenomena must lead to the adoption
of the view that Cheyne-Stokes breathing is but one of a complex
group of associated symptoms, as has been so clearly pointed out in
the suggestive contributions of Eosenbach. Why there should be
such diversity of phenomena connected with the pulse, eye, and
mind, it is at present impossible to answer. In one case there may
be no periodic phenomena except the respiratory, and in another
the entire complex of symptoms — mental, visual, cii-culatory, and
respiratory — may be present. It is only possible at this time to
hazard the suggestion, that the centres involved in each group of
symptoms may be affected singly or collectively. Eeasons have
been given for believing that there may be well-marked periodicity
of mental functions or of circulatory functions without any similar
change of rhythm in the other systems. In what respect these
various symptoms are linked it is not with our present knowledge
possible to state, and it is equally difficult to assign any reason for
the fact, that it may appear as an isolated phenomenon or as part
of a complex of symptoms.

The essential cause of the symptom is without doubt a periodic
variation in the functional activity of the automatic centre for
respiration, and the philosophical work of Luciani must be credited
with having for the first time established this fact. Whether the
periodic variation depends simply upon the loss of the influence of
higher regulatinG; centres, or whether it is also at the same time the
result of diminished vitality, in accordance with some great natural
law, it is not at present in our power to decide.

ArncNDix. ]'27

Ari'F.XDIX.

Since tlio earlier portions of this work appeared several contri-
butions liiivo been made to the subject, but it cannot be said that
nuu'li new liglit has been tliiown upon tlie symptom.

Tizzoni ^ has continued and extended his researches on chanjijes
in the methilla obloni^atii in a very interesting; article, while
Mancini- and Ilauer^ devote their attention to careful studies of
the clinical features of the symptom.

In the recent edition of Foster's work on Physiolof;y, the
author briefly considers Cheyne-Stokes breathing. After a short
description of its phenomena he says:^ — "A secondary rhythm of
respiration is tluis developed, periods of normal or slightly dyspnceic
respiration alternating, by gradual transitions, with periods of
apncea. Whether the waning and the waxing of the respiratory
movements be due to corresponding rhythmic changes in the
nutrition of the respiratory centre itself, or to a rhythmic increase
and decrense of inhibitor}' impulses playing upon that centre from
other parts of the body — for instance, from higher regions of brain
— has not yet been settled. . . . Closely similar phenomena
have been observed during sleep under perfectly normal conditions ;
and this fact is rather in favour of the latter of the two explana-
tions just given. Tlie phenomena present a striking analogy with
the 'groups' of heart-beats so frequently seen in the frog's ven-
tricle placed under abnormal circumstances."

In the above statement there appears to be a misconception of
the results obtained by Marckwald, as the experimental produc-
tion of periodic breathing depends not upon " rhythmic increase
and decrease of inhibitory impulses," but follows upon the removal
of such inliibilory influences altogether.

Macdonncll •'" gives a description of sonic of the princijial
characters of periodic breathing, and DImui Mann'"' describes

' Memorie delV Accademia delle Scieme di Bologna, ti'iun viii., p. .?, is-^G-vSS.
» Ihlldino ddV (hpednle di Santa Casa di Loretn, tomo i.,533, 1887-S9.
3 Pra(jer mediciiiiM-he irochensrhrift, Biuul xiv., s. 373, 1SS9.

* .1 Tixt Book of Phi/.tioloiji/, nt'lh etlition. Part ii. ]>. G05, 1889.

* Mimtrciil Mcdiral JiiHniaf, vol. .wiii., p. 21)4, 18SD-90.
« The British Medical Jounuil, vol i. for 1890, \\ 427.

128 CHEYNE-STOKES RESPIRATION.

changes in the bulb in connexion with Cheyne-Stokes respira-
tion.

West/ describing at the Pathological Society of London the long
continuance of Cheyne-Stokes breathing in a case of granular
kidney, mentions that the pauses at times disappeared, leaving
respiration of an ascending and descending type.

Mackenzie,^ in the discussion which followed West's remarks,
asked if patients ever recovered after they had developed Cheyne-
Stokes respiration ; and in answer to his question several cases are
recorded. Kingston Fox^ narrates one of influenza with broncho-
pneumonia, O'Neill* one of a febrile affection, Mallins^ one of
cerebral hfemorrhage, Flux^ one of puerperal septiccemia, Adams'^
one of epilepsy and one of hydrocephalus, Aylward one of phthisis^
in which morphine produced the symptom, Lawford Knaggs^ one
of renal disease, and Square ^"^ one of cerebral softening — all of
wliich recovered. It is very interesting to note that Knaggs found
a brother and a sister both suffering from renal disease and both
showing periodic respiration.

Pilkington^^ describes a case of cardiac disease with softening of
the left cuneate lobe, third right temporal convolution, and right
anterior pyramid of the bulb.

Downs^^ has described a case of ursemia in which Cheyne-Stokes
breathing occurred, and criticises some of the recent work on the
subject, while Brush^^ records the case of an insane patient with
chronic degenerative changes in the heart and bloodvessels who
showed the same symptom.

An important contribution to tlie subject is contained in
Broadbent's recent work on tlie Pulse.^* He is of opinion
that the symptom is mainly conditioned by a state of higli
arterial tension. 'No doubt the . periodicity of the respiration
is very frequently found in association with affections in which high
arterial tension is a prominent symptom, as, for instance, granular

1 The Lancet, vol. i. for 1890, p. 545.^

2 Ibid., loc. at. ^ Ibid., p. 571. •* Ibid., p. 260.
6 Ibid., loc. cit. " Ibid., loc. cit. "^ Ibid., p. 674.
8 Ibid., loc. cit. 9 Ibid., p. 744. lo Ibid., p. 776.

11 The British Medical Journal, vol. i. for 1890, p. 819.

12 Medical News, vol. Ivi. p. 589, 1890.

^Ubicl, vol. Ivi. p. 592, 1890. " The Pulse, p. 169, 1890.

Al'l'KNDlX. 1-"J

ilopjoncratiDii nl the kidney. I'm it lias to ho rcmenilMTo<l, on the
(iiio hand, that l)oth the liii^h hlood-prcssurc and the periodic
hrcivlhiii^ arc ronsecpienccs of the same (diani,'t', whih;, on the other
haml, that ( heyne-Stokes hreathin^,' is often seen with low arterial
jircssurc. l[ence, as was shown hefore, this view is untenalde.

Wertlieinier ' holds that Cheyne-Stokes hrcathinj; is produced
])y inhibitory inlluences resulting from irritation, and not pushed
so far as to cause total arrest of respiration, as it would do if the
inhibition were absolute.

Boyd- describes the earlier part of the furced respiration as
mainly inspiratory, and the latter as principally expiratory, and
icfers to tracings of the pulse to prove this. It may be mentioned,
however, in passing, that the respiratory curve shows nothing that
can be held to support this view, and that the numerous cases
unaccompanied by any pulse changes disprove it.

Huber^ describes a very interesting case of aortic aneurism, in
which, as shown by pulse-changes, the first inspiration after the
])ause caused an increase in the activity of the vagus anrl vaso-
motor apparatus.

Waller^ takes a broad and philosophic view of periodic breath-
ing. " Chcijnc-Stolccs hreathiwj" he says, " is characterised by a
waxing and waning of the amplitude of the respiratory movements.
In a typical and well-marked case, the movements alternately
decline to complete cessation and return to an amplitude much
above the normal. No definite or conclusive cause can be assigned
to this peculiarity of rhythm ; it is not — as was once believed to
be the case — characteristic of fatty degeneration of the heart, but
makes its appearance in a variety of disea.ses, or in the absence of
any disease at all ; during normal sleep, particularly in children,
a waxing and waning respiratory rhythm is of common occurrence.
All we can say in explanation is to point to the fact that the
Cheyne-Stokes rhythm is to the respiratory system what the
Traube-Hering rhythm is to the vaso-motor system ; both rhythms
are originated by medullary centres, and are of about the same

' Archives dc I'liysinUyit noniuiU d iHiUwUxjitive, v. si'rio, tiniic ii. i>. M. lS<lo.

a Tiie Bntish Medical Journal, vol. i. for 1891, p. 1337.

' Deutuchis Archil- fa r 1:1 ill ischf Medicin, T\i\}u\ .\lvii. s. 13. l"^'.)!.

* An InlnHlnctiuii to llumitn I'hijsioltMiij, ji. 127, ISiil.

K

130 CHEYNE-STOKES RESPIRATION.

frequency, viz., one to three per minute ; indeed, the association is
sometimes most definite and exact. On the rabbit, for instance,
after haemorrhage, phases of increasing and diminishing amplitude
of respiration coincide with rise and fall of arterial blood-pressure.
They are instances, among many others, of the common tendency
towards ' pulsatile or rhythmic activity ' manifested by all living
matter."

Since this expression of opinion, so far as it goes, closely agrees
witli the views urged in the concluding pages of this work, it is as
unnecessary as it is impossible to criticise it.

INDEX OF ArTIIOKITIKS KKKKKIiKD TO.

Adams, Francis, ji. 2.
Adiims, John, 128.
Adaiiiiik, IT).
Andrew, 35.
Aylwanl, 12S.

Ba.vs, 2G.

Bt-ybie, 2.

Benson, 10, 25.

Bernabei, 78.

Bernheini, 20.

Berton, 4.

Biot, 30, 41, 4'}.

Bjiirnstroni, IG.

Blaise and Brousse, 54, 112.

Bordoni, 73, 81.

lioyd, 129.

Branuvell, 68, 111.

Broadbent, 35, 104, 128.

Briickner, 17.

Brush, 128.

Bull, 27, 54.

Caizergues, 54.
Canticri, 73.
Carrcr, 34.
C^renvillc, do, 30.
Cheync, 4, 91.
Chvostek, 21.
Glaus, 29.
Cuffur, 38, 112.

Dance, 4.
Darenibcrj,', 3.
Davics 77.
Davy, (54.
Di'scourtis, 80.
Down?, 128.
Dunin, G7.

Dusch, von, '.).

EuES, 52, 88, 122.
Erb, 15.
Esenbeck, 13.
Ewald, 23, 93.

Fahian, 71.

Fano, GG, 71, 8o, 118, 124.

Fazio, 77.

Fenoglio, 80.

Filatow, 38.

Filehne, 20, 21. 24, 43, 48, 59, 60,

92, 109, 110, 111, 12.3.
Finlayson, 83, 93.
Flint,' 28.

Flourens. 4.

Flu.x, 128.

Foster, 77, 121, 127.

Fox, 128.

Fran<jois-Franck, 3G, 112.

Friintzel, 11.

Franz, 56.

Friedreich, 33.

Frost, 36.

(Jalen, 2.
Gallois, 3.
Gibson, 83, 86, 1 11 .
Glas, 16.
Gowcrs, 84.
Grasset, 55, 112.

Hakhnkki , 15.
Hall, Mai>hall, .5.
Ila.s.se, G.
Ilauer, 127.
Ilayden, 27, 108.
Hazard, 28.

132

INDEX.

Head, 9.

Heidenhain, 16, 92.

Hein, 32, 56, 108, 111, 114.

Heitler, 24.

Hesky, 13, 92.

Hippocrates, 2.

HoepfFner, 25.

Howard, 74.

Huber, 129.

Hiird, 66.

Hiittenbrenner, von, 27.

Kaufmann, 73, 113.

Kennedy, 27.

Knaggs, 128.

Knoll, 65.

Korber, 19.

Kronecker and Bowditch, 53.

Kronecker and Marckwald, 52.

Kussmaul, 15, 50.

Langendorff, 64, 77.
Langendorflf and Siebert, 63, 118,

124.
Langer, 63, 64.
Laycock, 20, 105.
Lerebonllet, 59.
Leiibe, 14, 93, 107.
Leyden, 9, 93.
Little, 10, 105.
Lbwit, 57, 118.
Luciani, 45, 114, 116, 117, 118, 124,

126.
Lutz, 16.

Macdonnell, 127.

Mackenzie, 128.

M'Vail, 84.

Mader, 13.

Mailing, 128.

Mancini, 127.

Mann, 127.

Marckwald, 85, 123, 125, 127.

Marckwald and Kronecker, 56.

Mayer, 33, 36, 111.

Merkel, 17, 93, 94.

Mickle, 44.

Monti, 21.

Mosso, 38, 74, 117, 122, 124.

Muirhead, 88, 122.

Murri, 67, 80, 118, 119.

Nicolas, 3.

o'connell, 71.
O'Neill, 59, 128.
Oser, 74.
Ottilie, 38.

Paterson, 65.
Pepper, 31.
Piaggio, 71, 82, 113.
Pilkington, 128.
Plotke, 50.
Poole, 81.
Puddicombe, 67.
Purjesz, 51.

Rahlmann and Witkowski, 50.

Rehn, 17.

Reid, 8.

Ricklin, 25.

Robertson, 82.

Rolirer, 21.

Rosenbach, 48, 53, 59, 60, 92, 111,

115, 116, 117, 118, 126.
Rosenthal, 69.
Ross, 30.
Roth, 19.

Sacchi, 37.

Saloz, 60, 118.

Sander, 50.

Sansom, 64, 105.

Schepelern, 18, 93.

Schiff, 7.

Schweig, 6, 104.

Smart, 86.

Smimow, 72.

Solokow and Luchsinger, 58, 118,

124.
Sijuare, 128.
Steiner, 124.
Stillmann, 86.
Stokes, 5, 91, 104.
Storch, 80.

TizzONi, 68, 127.

Traube, 11, 23, 106, 114, 119.

Treves, 36.

INDKX.

133

TrousHcnii, 8.
Tukc, 88.

ViERORDT, 84.

Vigonroiix, ITi.

"Waller, 129.
Waller ami lUi.l, 124.
Walslu-, 1), Kir..
Wi'lli'iihcrKli, 78, 113.
Wcrthciiiier, 129.

West, 5, 128.
Wptt^-, <!«', 29.
Wliarr}-, 3r,.
Wintcrnitz, 57.
Witt, tic, CO.

Zenker, 2.'>.
Ziniiiu'ihans, 2.'>.
ZiiiinuTiiiaiin, 44.
Zuelzer, 66.

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