512 J Neurol Neurosurg Psychiatry 2007;78:512–513

HISTORICAL NOTE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
doi: 10.1136/jnnp.2006.104919
Biot’s breathing

N
eurological disease may affect breathing cycles and What was Biot’s contribution?
rhythms.1 Several classic central periodic breathing Biot wrote two main articles on breathing patterns. One large
patterns have been described. Biot’s breathing—also exploratory work focused on his observations on Cheyne–Stokes
known as ataxic breathing—is a breathing pattern in patients breathing.3 4 In each paper, he described patients who were
with acute neurological disease, but is rarely mentioned in the admitted to the Hôtel Dieu Hospital with Cheyne–Stokes
neurological literature. It can be contrasted with Cheyne– respiration, his major interest. In his first article, curiously in a
Stokes breathing (periodic stereotypical crescendo–decrescendo postscript, he described a patient who had respiratory movements
hyperpnoea followed by apnoea) and apneustic breathing that gradually decreased and increased but were irregular (fig 2),
(periodic prolonged inspiratory hold). Biot’s breathing may be and he was one of the first to publish recordings of this type of
a rare phenomenon or just not noticed. Biot’s contribution is respiration in a 16-year-old patient with tuberculous meningitis
discussed here. (fig 3). He distinguished this breathing pattern from Cheyne–
Stokes breathing and named it ‘‘rhythme meningitique’’. The
Who was Biot? breathing pattern is irregular and rapid, with rhythmical pauses
Camille Biot was born in Chatenoy-le-Royal (Saône-et-Loire), lasting 10–30 s, but sometimes with alternating periods of apnoea
France, on 19 December 1850. He made his seminal observa- and tachypnoea. This breathing pattern lacked the crescendo–
tions while an intern in the Hôtel Dieu Hospital in Lyon, decrescendo cycles attributed to Cheyne–Stokes breathing and
France. After his residency, he practised medicine in Maçon in was completely irregular with varying periods of apnoea. In 1878,
1875. He wrote on other diverse medical topics unrelated to a larger thesis was published entitled: Étude de Clinique et
breathing, as well as articles about Greco–Roman–Maconne expérimentale sur la respiration de Cheyne–Stokes.4 This paper described
archeology. He became a member of L’Académie de Macon theories of the origins of Cheyne–Stokes breathing. Biot argued
(Société des arts, sciences, belles lettres archeology, agriculture that Cheyne–Stokes breathing included an increase in pulse
et encouragement au bien de Saône-et-Loire, fig 1). He died in during the pause and reduction of blood pressure during apnoea.
Macon in 1918.2 In this now discounted theory, the accumulation of carbon
dioxide would increase the activity of the vasomotor centre and
vasoconstriction would cause progressive ischaemia of the
respiration centre resulting in deep breaths.

Was Biot the first to point out this breathing pattern?

With notable modesty, Biot added a section on earlier observa-
tions of the breathing pattern.3 Others reported this respiration
as slow and as increasing to 10–20/min with accelerating periods,
with unequal chest expansion: some short and incomplete,
others long, deep and often interrupted by gasps.5–8 The
unevenness of breathing was not related to the heart rate.5 In
another report, vomiting, constipation and high fever along with
short, incomplete, intermittent and gasping breathing was
considered characteristic of meningitis. Similar patterns were
described in Trousseau’s textbook.7 Sigismond Jaccoud thought
this breathing pattern was an agonal phenomenon. In his
description, the pulse slows down, the breathing changes and
becomes irregular, and is interrupted with deep sighs that are
easy to recognise.8 Biot concluded that a big sigh comes before
the pause, and that the periods are irregular. These were the two
main characteristics that were always seen in meningitis and,
thus, should be considered characteristic but different from the
regular crescendo and decrescendo cycles of Cheyne–Stokes
breathing. With much aplomb, Biot concluded that this breath-
ing pattern should be considered separately and not as a variant
of Cheyne–Stokes breathing.

What are doctors taught about Biot’s breathing?

Biot’s breathing is often confused with cluster breathing, regular
cycles of deep breaths with variable periodicity. Many publications
have inappropriately described Biot’s breathing as ‘‘periodic and
consisting of groups of full respiratory effort’’.9 Furthermore, an
experimental study on Biot’s periodic breathing in cats created
confusion and called it cluster breathing.10 Lesions in the
pneumotaxic system of the rostral pons resulted in a breathing
pattern that the authors explained as possible cyclic hypoxaemia.11
There is very little mention of Biot’s breathing in clinical
papers, in particular those on meningitis.12 13 It is not frequently
Figure 1 Dr Camille Biot. a keyword, nor used in abstracts. There are very few PubMed

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Historical note 513

Figure 3 Tracing of breathing pattern described by Biot.

of breath in 1904, but the author also stated that he had not
observed this type of breathing, and in each case the breathing
pattern was more likely Cheyne–Stokes breathing: (‘‘Ich konnte
deese Atem Form Du oft beschrieben ist, niemals finden’’). In the
English literature, it appeared in 1911 in the title of a review
article by Connor, who observed seven patients, six of whom
had meningitis.17 Biot’s breathing was mentioned in text books
as early as 1913 in French’s index of differential diagnosis18 and in a
‘‘Companion to clinical neurology’’ in 2003.19 Biot’s breathing may
have become less obvious as a consequence of intensive care
technology. Patients with this type of irregular breathing will
likely be intubated as soon as they are seen, and have their
breathing drive regulated by mechanical ventilation.

ACKNOWLEDGEMENTS
I thank Larry Prokop of Mayo Libraries in researching material for this
manuscript. I also thank Jérôme van Wijland of the Departement of
Sciences et Techniques Bibliothèque Nationale de France for providing a
bibliography of Camille Biot and his portrait photo.

Eelco F M Wijdicks

Correspondence to: Professor E F M Wijdicks, Division of Critical Care

Neurology, Department of Neurology, Mayo Clinic College of Medicine, W8B,
200 First Street, SW, Rochester, MN 55905, USA; wijde@mayo.edu

References
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Science Publishers, 2003.
Figure 2 The first description of a breathing pattern different from 2 Biot M. Discours prononces aux obseques du docteur (Camille Biot) 1850–1918.
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14 Plum F, Posner J. The diagnosis of stupor and coma, 3rd edn. Philadelphia, PA:
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examination of the comatose patient, correctly identified the 15 Fisher CM. The neurological examination of the comatose patient. Acta Neurol
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kurzatmigkeit auf grund der atemkurve. Jena: Verlag von Gustav Fischer,
1904:25–8.
Is Biot’s breathing folklore? 17 Connor L. Biot’s breathing. Am J Med Sci 1911;141:350–60.
18 French H. French’s index of differential diagnosis. New York: J Wright
It is a hard task to find the article that introduced the eponym. Publishers, 1913.
In the German literature it appeared in Hofbauer’s book as 19 Pryse-Phillips W. Companion to clinical neurology, 2nd edn. Oxford: Oxford
‘‘Das Biotische Atmen’’16 on the differential diagnosis of shortness University Press, 2003.

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