Unilateral paralysis of the diaphragm and larynx associated with inflammatory lung disease.

Unilateral paralysis of the diaphragm, not the result of a deliberate operative procedure, is uncommon. It may have a variety of causes, but so far as I am aware pneumonia* has never previously been included amongst them. The commoner causes of unilateral paralysis are diseases of the cervical spinal cord affecting the anterior horn cells of the fourth segment, such as poliomyelitis, tumour, progressive muscular atrophy, myelitis, haemorrhage, and injuries and caries of the cervical vertebrae. Peripheral lesions of the phrenic nerve or its roots include neck wounds, polyneuritis (usually diphtheritic), destruction by neoplastic masses (usually near the hilum of the lung), and avulsion from birth injury as an extension of Erb's palsy, of which about 20 cases have been described. A number of cases occurring during the course of pulmonary tuberculosis have been ascribed to involvement of the phrenic nerve in scar tissue. Two instances in newborn infants, not associated with Erb's palsy, were attributed to intrauterine malposition (Blattner, 1942; Light, 1944). An aortic aneurysm may rarely be responsible (Sanguinetti and Galzerano, 1943). Eventration of the diaphragm, a condition in which the affected dome is much raised and thinned with fibrous replacement, may in a sense be regarded as a form of phrenic palsy. Though usually regarded as congenital, it may in some instances be the atrophic result of permanent interruption of the nerve supply. Diseases of the diaphragm itself, acute diaphragmitis (Hedblom's syndrome), trichiniasis, and the degenerations that may result from prolonged contact with purulent effusions, severe pneumonia and asphyxial states, all of course impair diaphragmatic function, which would imply impaired descent on inspiration. Whether they would cause actual paralysis is open to question. A search of the literature has failed to reveal any previous record of unilateral paralysis of the diaphragm due to pneumonia. Upward displacement of the diaphragm in pneumonia has been reported by Wu (1932), but such elevation is apparent only, being in fact a failure to descend during deep inspiration as much as the dome of the sound side. It is due to a loss of expansibility of the lung resulting from the consolidation, and is apparent only in radiographs taken in full inspiration. The extensive reviews by Graeser, Wu, and Robertson (1934), Davies, Hodgson, and Whitby (1935), and Heffron (1939) of the radiological findings in pneumonia likewise mention this apparent elevation during the acute phase, but