E COMPLICATIONS
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not surprising that in a case of unilateral paralysis or impaired diaphragmatic activity in
cervical cord lesions, the reflex activity of the corresponding intercostal muscles is
greatly reduced as shown in Figs. 92 and 93. However, we found that even in the presence
of complete hemi-diaphragmatic paralysis the reflex activity of the intercostals is not
abolished, as shown in two of our high cervical lesions. If, as shown in one case, it may
at first be absent it will appear, however diminished, in due course (Fig. 97). It may be
noted that in cases with unilateral diaphragmatic paralysis the rhythmic respiratory
movement is maintained by the function of the diaphragm of the other side, as well as by
the function of accessory respiratory muscles, in particular sternomastoid. Moreover, it is
likely that the elastic expansion of the lung itself during inspiration acts as a contribu
tory force in stretching the intercostal spaces, thus serving as an additional afferent
stimulus to the reflex response of the intercostal muscles.
In the early stage of tetraplegia, the intensity of the compensatory respiratory function
of the sternomastoid varies, and its development to full strength as an auxiliary force in
the act of breathing, by exerting an upwards pull on the xiphosternum and thus increasing
the antero-posterior diameter of the chest and the vital capacity of the lung, may take
some time and systemic exercises are needed. Its auxiliary force, also assisted by the
trapezius and the scaleni, can be considerable, and may help to improve the negative
intrathoracic pressure which is diminished as a result of the paralysis of the intercostals
in the early stages following transection. Therefore, by increasing the negative suction
force the venous blood flow to the heart may be increased. By training, the sternomastoid
may develop a profound hypertrophy as shown in two patients with complete lesions
below 04 and C6 (Figs. 983 and b and 993 and b). My studies on the function of the
sternomastoid on the upwards movement of the anterior part of the upper thorax have
confirmed the findings of that great French clinical physiologist on muscle function,
G.B.Duchenne (1866). Recently, Silver & Moulton (1969) using the method of Davis &
Moore (1962), have amplified our findings on chest movement in detailed studies on
tetraplegics.
Conclusions
Although the diaphragm is the main contributor in restoration of the vital capacity
of the lungs, our findings indicate that the co-ordinated reflex function of the intercostal
muscles resulting from the rhythmic movements of the chest also plays a part in the
process of respiratory recovery. The intercostal muscles by regaining their tone once the
spinal shock has subsided help to restore by their reflex contractions the tension and
rigidity of the intercostal spaces essential for a more powerful function of the diaphragm.
Meteorism.
This is the result of the paralysis of the intestines in the immediate stage
following cervical injury and leads to an impairment of the function of the diaphragm
and thus increases the respiratory distress, even if the segmental supply of the phrenic
nerve is not involved. Therefore, immediate steps have to be taken to restore the intesti
nal function as quickly as possible, and injections of 0-3 to 0-5 mg Prostigmine every 4 to
5 hr have proved invaluable and even a life saving measure.
