E* COMPLICATIONS
183
tilting his head down 15°. Conversely, vital capacity was decreased by elevating the
head 15° above the horizontal. They attributed these postural effects to the paralysis of
the abdominal muscles, which allowed the intestines to bulge through the flaccid abdomi
nal wall, whereby the diaphragm assumed a lower position in the chest resulting in
smaller excursions. Talbot
et al.
(1957) and Wingo (1957) described similar reduction
in the vital capacity in tetraplegics.
Hemingway
et al.
(1958) found the vital capacity reduced in a group of tetraplegic
patients to approximately two-thirds of normal and the maximum breathing capacity
half of normal. These authors were surprised at the magnitude of ventilating capacity
which these patients had retained, since they only had inspiratory muscles. Stone (1962)
also found a marked reduction in vital capacity in tetraplegics ranging from 70 per cent
to 25 per cent. He made more detailed studies, including determination of expiratory
volumes, and found a reduced expiratory reserve volume ranging from 500 to 50 ml;
furthermore the maximum voluntary ventilation (MW) showed a consistent reduction
related to the loss of expiratory muscle function, ranging from 75 per cent to about
20 per cent. The residual volume of gas remaining after forced expiration was found to
be greatly increased, between 140 per cent to 200 per cent.
Grossiord
et al.
(1963) studied the action of the shoulder girdle and abdominal
muscles during breathing in tetraplegics, using a combination of spirometry and electro-
myography. They confirmed that the shoulder girdle muscle contracts during expiration.
(2) Auxiliary respiratory muscles
Reflex function of intercostals.
There is general agreement that the diaphragm, inter-
costals and abdominals are the most important respiratory muscles, and in tetraplegia
sternomastoid and trapezius are the most important auxiliary respiratory muscles to assist
the diaphragm in compensating for the loss of the intercostal and abdominal muscles.
In a previous publication on Physiotherapy (Guttmann & Bell, 1958), I put forward the
hypothesis that the paralysed intercostal muscles may participate in the act of breathing
by reflex action, once they have regained their tone after the stage of spinal shock has
subsided and the cord has regained its automatic function. Therefore, the problem of
reflex activity of the intercostals was examined electromyographically in a comprehensive
study (Guttmann & Silver, 1965) in a total of 19 patients with complete lesions between
€4 and C8 following fracture dislocation of the cervical spine (17 men and 2 women).
Their ages varied between 17 and 60 years. In these studies, both skin and needle
electrodes were used, the latter giving more distinct details of intercostal activity during
inspiration. Three groups of tetraplegics were considered:
1
Those examined during the stage of spinal shock and followed up until full reflex
activity of the isolated cord developed as shown in Table 3. Figs. 9ia-c of case A.PJ.
(complete 04/5 lesion) demonstrate the electromyographic findings during and after the
stage of spinal shock.
2 Tetraplegics with unilateral paralysis of the diaphragm in addition to the intercostal
paralysis. Figs. 923 and b of case M.S.C. (complete €4 on the right, C5 on the left with
additional paralysis of the right diaphragm) reveals almost no activity of the 6th right
