Thorax (1948), 3, 15.

DISSOCIATED PARALYSIS OF THE DIAPHRAGMFOLLOWING PHRENIC CRUSH AND

PNEUMOPERITONEUMBY

WALLACE FOXBritish Legion Village Settlement, Preston Hall

In 1939 Douady and others reported for the firsttime dissociated paralysis of the diaphragm. Itoccurred in two patients during the course ofphrenic alcoholization and pneumoperitoneumtherapy for pulmonary tuberculosis. Since thenno further cases have been found in the literature.The object of this paper is to report another caseand to discuss the therapeutic and anatomicalsignificance of this occurrence.

CASE REPORTThe patient, a soldier, was diagnosed as having

pulmonary tuberculosis in September, 1945, when hewas aged 29. He had had a four-year history oflassitude and cough and had lost 1-I stone in weight.At the time of diagnosis he had a positive sputum,his blood sedimentation rate was 16 mm. in the firsthour (Westergren), and radiography showed consider-able productive disease of the right upper lobe withextensive cavitation. In October, 1945, a right arti-ficial pneumothorax was induced, but it was aban-doned in November, 1945, due to the presence ofextensive adhesions.On Feb. 6, 1946, a right phrenic crush was per-

formed under local anaesthesia. No accessoryphrenics were found at the operation, and com-plete hemi-diaphragmatic paralysis was obtained.On April 24 screening showed that the diaphragmwas recovering its function. The patient wasadmitted to Preston Hall on June 21, 1946, and atthat time he had full diaphragmatic recovery. It wasdecided to repeat the right phrenic crush and tosupplement it by a pneumoperitoneum as a prepara-tion for thoracoplasty. So on July 24 the rightphrenic crush was repeated, and again at operationno accessory phrenic nerves were found. Diaphrag-matic paralysis with paradoxical movement resulted.On Aug. 2 a pneumoperitoneum was induced(Plate IXa).

Screening on Dec. 11, 1946, showed that a partialdiaphragmatic recovery was occurring, and this re-covery was of a striking nature. The anterior andmedial part of the right hemi-diaphragm remainedparalysed and showed slight paradoxical movement,

whereas the lateral and posterior portion of thediaphragm was recovering its function, and withina few weeks displayed full active respiratoryexcursions.On expiration the right hemi-diaphragm was shaped

like a regular arc of a circle and there was only aslight point of demarcation between the paralysedand non-paralysed parts. On inspiration the appear-ance was strikingly altered. The posterior and lateralpart descended actively, producing a very definitedemarcation between the paralysed and non-paralysedparts of the diaphragm so that the regularity of con-tour was lost. This can be seen from the postero-anterior and lateral films taken on inspiration andexpiration (Plate IXb and Plate Xa, b, and c).The patient was observed for another six months

before being transferred nearer home for his opera-tion, and during this time the dissociated recoveryof the diaphragm remained unaltered.

The diaphragmatic movement was a muscularcontraction, and unlike the irregular movementsoccasionally produced by the presence ofadhesions in the lower part of the pleural space.It differed from the denting of a recoveringdiaphragm which is occasionally seen in the pre-sence of sub-diaphragmatic adhesions, and it wasunlike the serrated appearance of some diaphragmsin the presence of a pneumoperitoneum.

Anatomically, the immobile area of thediaphragm appeared to be the right leaf of thecentral tendon, the muscular fibres of the sternalorigini, and the anterior muscle fibres of the costalorigin. The area which had recovered its functioncomprised the posterior costal muscle fibres, thearcuate fibres, and the right crus. Hence, a truedissociated muscular paralysis of the diaphragmwas present.

DISCUSSIONDecker (1933) made passing mention of the fact

that dissociated paralysis of the diaphragm couldoccur after phrenic crush. He stated: " In onecase only a partial paralysis of the diaphragm was

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WALLACE FOX

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PARALYSIS OF DIAPHRAGM AFTER PHRENIC CRUSH

PLATE Xa.-Inspiration radiograph of May 19, 1947. The diaphragm isnow clearly divided into the medial paralysed portion and a lateralportion which has contracted actively.

PLATE Xb.-Expiration right lateral radiograph ofMay 19, 1947. The contour of the right hemi-diaphragm is seen to be smooth and regular,appearing to be a functional whole. The leftcupola is also visible.

PLATE Xc.-Inspiration right lateral radiograph ofMay 19, 1947. It can be seen that, whereas theanterior part of the diaphragm has remainedimmobile, the posterior portion has descendedactively on inspiration and the regularity ofcontour has been lost.

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WALLACE FOX

obtained. The central portion seemed inactive, butthe lateral peripheral portion functioned normally.A second operation was done, and then a sizablenerve, probably an accessory, was found on thescalenus medius muscle, overlapped by thescalenus anterior." Nehil and Alexander (1933)had a similar case in their series. Thus, it isoccasionally possible to see a dissociated paralysisof the diaphragm in the absence of a pneumoperi-toneum.On the other hand, in the two cases quoted by

Douady and others, the right hemi-diaphragmnappeared pariesed after the phrenic crush and ex-hibited movement of diminished amplitude but ofnormal direction. It was only when a pneumoperi-toneum was induced that it was possible to see thedissociated nature of the paralysis. It wouldappear that in these cases the liver had a dampingeffect on the movement of the right diaphragm,thus giving an overall diminished excursion, and itwas only when a cushion of air was introducedbetween the liver and diaphragm that the trueautonomy of the muscle was manifest, and thedissociated nature of the paralysis became evident.Hence, after phrenic crush, dissociated paralysismay become evident or may remain latent as anapparent diaphragmatic pariesis only to be recog-nized on the induction of a pneumoperitoneum.

Several observers have reported the return ofdiaphragmatic function after phrenic avulsion. InMorin's (1932) series of 343 cases diaphragmaticfunction returned in 2.5 per cent, and in Wirth andvon Jaski's (1929) 185 cases 12.9- per cent haddiaphragmatic recovery. This recovery wasbelieved to be due to the presence of accessoryphrenic nerves that were anatomically intact afterthe avulsions. It would appear likely that someof these cases were examples of latent dissociatedparalysis, and that this occurrence is more frequentthan has been realized in the past. In this respect,it is interesting to consider a case reported by JohnAlexander (1937). The patient had had a phrenicavulsion resulting in a complete diaphragmaticparalysis lasting for several years. In time almostcomplete recovery of respiratory movement wasobserved, and at a second operation on the phrenicnerve a small accessory phrenic was found andsevered. Again complete paralysis resulted.Alexander comments: "This small root hadpresumably gradually assumed the functional loadnormally borne by the main phrenic trunk." Atthe initial phrenic avulsion the accessory phrenicnerve was probably traumatized, with a consequentinterruption of conduction of nervous impulses,and so complete hemi-diaphragmatic paralysis

resulted. Eventually the accessory phrenic re-covered, and because of the contact of thediaphragm with the liver the whole diaphragmmoved. But it is possible that if a pneumoperi-toneum had been induced in this patient a dis-sociated paralysis would have been found.

It is important to recognize dissociated paralysisof the diaphragm. Most tuberculous lesions aresituated posteriorly in the lung, and if after anoperation on the phrenic nerve the posterior andlateral part of the diaphragm function normally,as in the reported cases of dissociated paralysis, thepatient with a phrenic crush and pneumoperi-toneum will probably derive no more benefit fromhis treatment than he would from the pneumo-peritoneum alone.

In the patient reported in this paper it wasdecided not to repeat the phrenic crush in view ofthe possibility of producing a complete andpermanent paralysis of the right hemi-diaphragm.This was considered undesirable because a thoraco-plasty was the ultimate object of treatment.The anatomical implications are of interest.

Douady and others believe that in man theanterior and medial half of the diaphragm receivesits nerve supply from cervical 3 and 4 and that theposterior and lateral portion is supplied by cervical5. They were able to find an accessory phrenicnerve in one of their two patients, and division ofthis branch produced paralysis of the lateral andposterior part of the diaphragm. In addition ex-periments performed on the dog by Rodrigues andCarvalho (1939) support this opinion, for in onedog total resection of the right phrenic nerve pro-duced a complete hemi-diaphragmatic paralysis,whereas resection of the superior root of the leftphrenic nerve in the same animal produced aparalysis of the medial part of the left hemi-diaphragm and the lateral portion continued tomove normally.

In the patient of this report both the phreniccrush operations produc.ed complete diaphragmaticparalysis. It was only when four months hadelapsed after the second phrenic crush that thedissociated paralysis manifested itself. This fact,together with the apparent absence of accessoryphrenics at both operations, would suggest thatthere were no accessory phrenics present in thepatient and that all the phrenic nerve fibres lay inthe one nerve trunk. The rate of regeneration ofner% e fibres is very variable, but the fact thatdiaphragmatic recovery involved so exclusively thelateral and posterior part of the right hemi-diaphragm suggests that the arrangement of nervefibres in the phrenic nerve in this patient were such

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PARALYSIS OF DIAPHRAGM AFTER PHRENIC CRUSH

that at the second operation the fibres supplyingthis area of diaphragm suffered only physiologicaldivision, whereas the fibres to the anterior andmedical part of the diaphragm suffered anatomicaldivision. If the nerve fibres supplying the anteriorand medial parts of the diaphragm occupied acircumferential position in the phrenic nerve, andthe fibres to the lateral and posterior partsoccupied the central part of the nerve, the latterare less likely to suffer such severe damage as thecircumferential fibres. Furthermore, the presenceof perineural fibrosis as a result of the first phreniccrush would also protect the central fibres of th'!nerve at a second operation.

SUMMARYA case of dissociated paralysis of the diaphragm

occurring in the course of treatment of pulmonarytuberculosis by phrenic crush and pneumoperi-toneum therapy is described and illustrated byradiographs.

The fact that this condition may not be detectedis stressed, and the therapeutic and anatomicalsignificance is discussed.

I am indebted to Dr. F. Temple Clive, MedicalSuperintendent of Preston Hall, for his permissionto publish the case report, and to Dr. F. R. G. Heaf,Honorary Consulting Medical Director, and Dr. SimonBehrman for their adv:ce during the preparation ofthe paper.

REFERENCES

Alexander, John (1937). "Collapse Therapy ofPulmonary Tuberculosis." Charles C. Thomas,Springfield. P. 148.

Decker, H. R. (1933). J. thorac. Surg., 2, 545.Douady, Lardanchet, and Venator (1939). A rch.

med.-chir. Appar. resp., 14, 275.Morin, J. (1932). Schweiz. med. Wschr., 13, 721.Nehil, L. W., and Alexander, John (1933). J. thorac.

Surg., 2, 549.Rodrigues, A., and Carvalho, R. (1939). Arch. mue'd.-

chir. Appar. resp., 14, 27.Wirth, A.. and von Jaski, Kohn (1929). Beitr. klin.

Tuiberk., 73, 1.

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