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THE ANATOMY of the THORAX in RELATION to the FLOW of TIDAL AIR Lecture Delivered at the Symposium Held by the Faculty of Anesthetists on 21St February, 1953 by G

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THE ANATOMY of the THORAX in RELATION to the FLOW of TIDAL AIR Lecture Delivered at the Symposium Held by the Faculty of Anesthetists on 21St February, 1953 by G THE ANATOMY OF THE THORAX IN RELATION TO THE FLOW OF TIDAL AIR Lecture delivered at the symposium held by the Faculty of Anesthetists on 21st February, 1953 by G. Causey, F.R.C.S. Sir William Collins Professor of Human and Comparative Anatomy, Royal College of Surgeons. That the thoracic cavity increases in volume during inspiration and decreases in volume during expiration is accepted by all, but exactly how this change in volume is brought about is by no means clear. On almost all points, whether of rib movements, of intercostal muscle activity, or of the quantitative contribution by the diaphragm, different and often opposing views are expressed. It may seem that enough has been written on the subject already, but I believe that, with the increasing use of muscular relaxants and controlled respiration in man, the search for a logically consistent hypothesis to explain the respiratory movements is not only an intellectual exercise, but a practical necessity. The bony skeleton of the thorax is formed by the thoracic vertebra, 12 pairs of ribs and their costal cartilages, and the sternum. The gaps in this bony skeleton are filled with fibrous and muscular tissues-the intercostal muscles and membranes at the side, the diaphragm below and the suprapleural (Sibson's) fascia, backed by the scalene muscles above. To the inside of this cavity, the outer surface of the lung is firmly held by the surface tension of the pleural fluid that needs a force of some 3600 mm.hg. per sq. cm. to break it. Every increase in the volume of this cavity is transmitted to the underlying lung and, assuming that the airway is patent, will draw air into the alveoli. The important features of this bony skeleton were discussed by Sir Arthur Keith in his contribution to " Further Advances in Physiology (1909). 1. The anterior concavity of the thoracic spine-part of the primary curvature and present before the appearance of the cervical and lumbar curves. 2. The obliquity of the thoracic inlet formed by the body of the first thoracic vertebra, the first pair of ribs and the upper border of the manu- brium sterni. This slope is really well marked. The head of the first rib articulates with the upper part of the body of the 1st thoracic vertebra, and the upper border of the 1st costal cartilage is on the level of the disc between the 2nd and 3rd thoracic vertebra, so that there is a vertical drop of two vertebral bodies and one intervertebral disc between the head of the first rib and the manubrium. The antero-posterior distance is only some 5 cm. so that the tangent of the angle of declivity approaches unity and the angle itself approaches 45°. 127 G. CAUSEY The second feature of the thoracic inlet is the continuity of the first costal cartilage with both its rib and the manubrium. There is no joint cavity either costochondral or chondro-manibrial. The third point about the thoracic inlet is the extent ofthe attachment of scalenus anterior and medius muscles to the rib. The usual way of thinking of these structures is to consider the superior surface of the first rib with a large artery and a large vein crossing it, then to make room for a lower trunk of the brachial plexus and have very little space left for the attachment of the scalene muscles. A more accurate impression is obtained by attaching a half cone of muscle to the superior surface of the first rib and then splitting the half cone into two very unequal parts by running the sub- clavian artery through the muscle. The fascia on the deep surface of the muscle cone is attached by a variable amount of areolar tissue to the fascia on the outer surface of the pleura over the apex of the lung, the whole fibrous element forming the suprapleural fascia. 3. The joint between the manubrium and body of the sternum. This joint is symphysial in structure, a fibrocartilaginous union sometimes having cavitation in the centre. The movement at this joint is small but of considerable significance in connexion with elevation of the thoracic inlet so that the manubrium is raised and comes to lie further forward, and the angle between the manubrium and body of the sternum is straightened out. 4. The ribs can be divided into four groups: (a) 1st rib; (b) ribs 2, 3, 4, 5, 6, and 7 (a and b are together the vertebro-sternal ribs); (c) ribs 8, 9 and 10, the vertebrochondral ribs, and (d) 11 and 12, the floating ribs. (a), the first rib, has been already discussed in relation to the thoracic inlet. (b), the 2nd, 3rd, 4th, 5th, 6th and 7th ribs, articulate with two vertebra, one transverse process, and one costal cartilage, and the costal cartilage has itself a diarthrodial articulation with the side of the sternum. The same is true of (c), the 8th, 9th and 10th ribs, except that these cartilages articulate with each other and indirectly with the sternum. But between the articulations there is this other essential difference: the facet on the transverse process for articulation with 2, 3, 4, 5, 6 and 7 is concave, whereas on 8, 9 and 10 it is flat. Fig. 1 shows this marked difference between the facet on the transverse process of the 3rd and 9th thoracic vertebra from the same vertebral column; the change in shape of the joint surfaces is a part of the overall change of function in these sets of ribs. (d), the 11th and 12th ribs, are functionally a part of the abdominal wall; during inspiration their intercostal spaces increase in size as the musculature relaxes. The volume of the thoracic cavity can be increased by the increase of any or all of its three axes. We must therefore consider (1) those factors increasing the height, that is, movements of the diaphragm and thoracic inlet; (2) those factors increasing the antero-posterior dimension, that is the forward displacement of the sternum and its attached ribs and the 128 THE ANATOMY OF THE THORAX IN RELATION TO THE FLOW OF TIDAL AIR straightening of the thoracic vertebral column and (3) those factors which increase the transverse axis of the chest, the upward and outward move- ments of the ribs. Fig. 1. These movements occur, of course, in combination. The elevation of the thoracic inlet by the scalenes and sterno-mastoid throws the whole sternum forward as well as increasing the height of the thorax. The increase in height of the thorax is, however, most closely connected with the movements of the diaphragm. At each inspiration the diaphragm descends, the abdominal viscera are pushed downwards and forwards, and the muscles of the anterior abdominal wall relax. In deep inspiration, it is not difficult to imagine the condition where abdominal relaxation becomes limited and the continued contraction of the diaphragm will in fact then elevate the lower ribs. These ribs, as has already been mentioned, have flat facets on the tubercles and therefore an upward, outward and back- ward movement of the whole rib will occur, resulting in a small decrease in the antero-posterior diameter with a big increase in the transverse dimension of the lower part of the chest, that is, a big increase in the transverse dimension of the upper part of the abdomen with increased accommodation for the abdominal viscera. The downward movement of the diaphragm, the descent of the viscera, the anterior movement of the abdominal wall, have to be described as though they proceeded in steps, but they are in fact closely integrated activities that are adapting to each other throughout. The work of 129 10 G. CAUSEY Campbell and Green (1953) on the simultaneous recording of respiratory exchange, abdominal action potential and intragastric pressure illustrates this coordination. They have shown that even with volume exchanges of up to 90 litres per min. there is no alteration in intragastric pressure; the intragastric excursion remains less than 10 cm. water with increasing rate and depth of respiration, The mode of action of the diaphragm is generally accepted and it is more on the question of quantity that debate of diaphragmatic function is based. The general view can be summarized by quoting from three standard modern text-books: 1. Throughout life the diaphragm is probably the main muscle of inspiration (Nims in Fulton's Physiology). 2. Quiet breathing is almost entirely diaphragmatic (Lovatt Evans quoting Hoover). 3. The diaphragm is the chief inspiratory muscle (Gray). Before accepting these statements too rigidly, two points should be made: (1) Hoover (1922) showed in the dog that the tidal air was reduced by at least 53 per cent. if the intercostal and abdominal muscles were paralysed, and that this condition reduced the vital capacity even more, that is by 67 per cent. In the human, with paralysis of the intercostals but normal abdominal muscles, the loss of vital capacity was only 15 per cent. (2) Keith (1909) has drawn attention to the relation of the descent of the diaphragm to tidal air. Taking round figures, he finds that the area of the diaphragm in contact with the lung is 250 sq. cm., its descent is a little more than 10 mm. and therefore there is an increase in thoracic capacity of about one half of the tidal air. Another way of looking at the same point is to assess the area of the diaphragm, excluding the peri- cardial area, and to compare it with the area of the pleura lining the chest wall, excluding the mediastinal pleura.
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