Extracted from the American Journal of the Medical Sciences for July, 1880. 
THE DIAPHRAGM: A PROTECTOR OF THE HEART 
AND CARDIAC VESSELS; ITS INFLUENCE 
ON THE ORGANS OF CIRCULATION. 
A PAPER REAP BEFORE THE COLLEGE OF PHYSICIANS OF PHILADELPHIA, 
MAY 8. 
BY 
W. FORBES, 2s/L. ID., 
FELLOW OF TI1E COLLEGE, SENIOR SURGEON TO THE EPISCOPAL HOSPITAL, 
AND DEMONSTRATOR OF ANATOMY IN JEFFERSON MEDICAL 
COLLEGE, PHILADELPHIA. [Extracted from the American Journal of the Medical Sciences for July, 1880.] 
THE DIAPHRAGM: A rROTECTOR OF THE HEART AND CARDIAC 
VESSELS; ITS INFLUENCE ON THE ORGANS OF CIRCULATION. 
A PAPER READ BEFORE THE COLLEGE OF PHYSICIANS OF PHILADELPHIA, MAY 8. 
By W. S. FORBES, M.D., 
FELLOW OF THE COLLKGB, SENIOR SURGEON TO THE EPISCOPAL HOSPITAL, AND 
OF ANATOMY IN JEFFERSON MEDICAL COLLEGE, PHILADELP/If^j 
On opening the thorax and abdomen in living cats and dogs, while 
under the influence of ether, for the purpose of examining the motions of 
the heart, I have observed that the vena cava inferior opening through 
the pericardium and into the right auricle is held in a fixed relation to 
the vertebral column. Observing this fact I was induced to examine the 
vena cava inferior opening in the diaphragm, and its relation to the ver- 
tebral column in the human body. 
I find that the vena cava inferior opening in the diaphragm of man is 
stationary, and holds a constant and fixed relation to the inferior part of 
the right antero-lateral margin of the ninth dorsal vertebra, and that it is 
not moved upwards nor downwards from its position by the surrounding 
organs in the performance of their function. 
The diaphragm is a thin musculo-tendinous partition placed obliquely 
between the abdominal and thoracic cavities. It forms the floor of the 
thorax and the roof of the abdomen. 
It is elliptical in shape, its largest diameter being from side to side. It 
consists of muscular fibres which arch upwards as they converge from the 
circumference of the abdominal cavity to the marginal under surface of a 
tendinous structure in the centre. The muscular fibres arise, in front, 
by two short muscular slips, one on either side of the middle line, from 
the ensiform cartilage of the sternum; those placed more laterally are 
attached to the inner surface of the cartilages and bony portions of the 
seven inferior ribs, interdigitating with the transversalis abdominis; behind 
they are attached to two aponeurotic arches, named the ligamentum arctua- 
tum internum and externum; and on either side of the middle line poste- 
riorly they are attached, by means of two thick tendinous crura, to the 
bodies and interposed fibro-cartilages of the upper lumbar vertebra; the 
one on the right side to the first, second, and third, and the one on the 
left side to the second and third lumbar vertebrae. The tendons of both 
these crura curve forwards and upwards and unite in forming an arch over 2 
the aorta, which is placed between the crura and in front of the vertebra) 
and under the tendinous arch. Muscular fibres spring from the anterior 
aspect of these tendinous crura in two thick bundles and diverge as they 
pass upwards to the aponeurotic centre. They are called the pillars of the 
diaphragm. The innermost muscular fibres of each crus pass upwards and 
inwards and thus decussate with each other, those of the right side usually 
lying anterior to those of the left side, and curving upwards they limit an 
opening for the transmission of the oesophagus before ending in the central 
tendon. 
The ligamentum arctuatum internum is a fibrous band which extends 
from the body to the transverse process of the first lumbar vertebra, and 
arches over the upper part of the psoas muscle. 
The ligamentum arctuatum externum extends outwTards from the trans- 
verse process of the first lumbar vertebra to the last rib, arching over the 
front of the quadratus lumborum. From both ligamenta arctuata diaphrag- 
matic muscular fibres take their origin, and are directed upwards to the 
posterior part of the tendinous centre of the organ. 
The two short muscular fibres coming from the ensiform cartilage form 
a narrow slip on each side of which there occurs an interval, in which the 
lining membranes of the thorax and abdomen are separated only by a small 
quantity of loose connective tissue. Consequently we find here a weak 
point through which diaphragmatic hernia may take place. 
The central tendon orcordiform tendon is a strong aponeurosis forming 
the central part of the diaphragm. It is elongated from side to side, and 
consists of three leaflets, partly separated by indentations; the right leaflet 
is the largest, the middle one is placed anteriorly, and the left which is 
elongated and narrow is the smallest of the three. 
The central tendon is surrounded on every side by the muscular portion 
of the diaphragm, the fibres of which are directly continuous with those 
of the tendon. 
There are in the diaphragm three large openings for the passage re- 
spectively of the aorta, the oesophagus, and the inferior vena cava; besides, 
some smaller holes or fissures which are less regular. 
The opening for the aorta (hiatus aorticus) is not a complete foramen 
in the diaphragm, being an osseo-aponeurotic opening formed by the ten- 
dinous arch thrown across the front of the bodies of the vertebra) from the 
crus on one side to that of the other. It is, consequently, behind the 
diaphragm. It transmits the aorta, vena azygos major, the thoracic duct, 
and, occasionally, the left sympathetic nerve. It is the most inferior of 
the three openings of the diaphragm. 
The oesophageal foramen is placed above, and, at the same time, ante- 
rior, and a little to the left of the aortic opening. It is elliptical in form 
muscular in structure, and bounded by the muscular fibres coming from 
the two crura. Its anterior margin is occasionally tendinous. It trans 
mits the oesophagus and the pneumogastric nerves. 3 
The foramen for the ascending vena cava is the highest of the openings 
of the diaphragm. It is more or less quadrilateral in form, tendinous in 
structure, and placed posteriorly at the junction of the right and middle 
leaflets of the central tendon. Its margins are bounded by four bundles 
of tendinous fibres which meet nearly at right angles. 
The right crus transmits the sympathetic and the greater and lesser 
splanchnic nerves of the right side ; the left crus transmits the greater and 
lesser splanchnic nerves of the left side and the vena azygos minor. The 
serous membranes of the diaphragm are four in number, three lining its 
upper or thoracic surface and one its abdominal surface. Those on its 
upper part are the pleura on either side, and the serous layer of the peri- 
cardium, which covers the middle portion of the tendinous centre. 
The serous membrane which covers the under surface is a portion of the 
general peritoneal membrane of the abdominal cavity. 
The diaphragm is arched, being convex towards the thorax and concave 
towards the abdomen. Its left portion is lower than the right by about 
three-quarters of an inch. It supports the base of the left lung and covers 
the great end of the stomach, the spleen, and the left kidney. 
The right portion forms a complete arch from before backwards. It 
supports the base of the right lung, and is immediately over the convex 
surface of the liver. The central leaflet supports the heart, is higher in 
front at the sternum and behind at the vertebra} than the lateral leaflets. 
The pericardium is a conical membranous sac in which the heart and 
commencement of the great bloodvessels are contained. The base of this 
sac is attached to the upper surface of the central tendon of the diaphragm; 
and ,on its anterior left side the muscular fibres of the diaphragm ascend 
on the pericardium and are attached to it, and in the new-born child play 
an important part to be hereafter described. The pericardium is a fibro- 
serous sac consisting of two layers, an internal serous and an external 
fibrous membrane. The serous membrane invests the heart, and is re- 
flected on the inner surface of the fibrous membrane and over the upper 
surface of the central tendon of the diaphragm embraced by the fibrous 
membrane. The fibrous membrane firmly and intimately attached to the 
central tendon of the diaphragm ascends and converging forms a cone, at 
the apex of which the great bloodvessels issuing from and going to the 
heart are supported in their relative position by means of transverse and 
oblique bands of fibrous tissue which are continued on the walls of these 
vessels in the form of tubular prolongations, and which are gradually lost 
upon their external coat; the largest and strongest of these tubular pro- 
longations is the one inclosing the aorta. 
From the right and left external lateral surfaces of the fibrous membrane 
of the pericardium, and from near the apex of the pericardial cone, pro- 
longations of the fibrous tissues continue upwards as strong bands, forming 
the antero-lateral parietes of the superior portion of the posterior medias- 
tinal space and reaching the inner aspect of the first rib on each side, and 4 
coalescing with the thoracic fascia of Sir Astley Cooper, are held in a fixed 
position by this fascia which is stretched across the apex of the thoracic 
cone. These two strong bands continuous with the lateral portion of the 
pericardium thus form fibrous planes reaching from each side of the central 
tendon of the diaphragm to the bony apex of the thoracic cone. They 
form what may be called the superior tendinous crura of the diaphragm, 
upon the sides of which the phrenic nerves descend to reach the diaphragm; 
and by means of transverse and oblique bands of fibrous tissue connect- 
ing these tendinous crura together at and above the pericardial cone, 
a strong fibrous scaffolding is formed on which the great cardiac vessels 
are supported and protected. These superior tendinous crura of the dia- 
phragm are inextensible. Each crus of the diaphragm is fixed above to the 
bony apex of the thoracic cone, and by fibrous connection, to the thoracic 
fascia of Sir Astley Cooper, which is stretched across the thoracic apex. 
The thoracic fascia of Cooper is supported above by the deep cervical fascia, 
which is strongly attached to the processes of the cervical vertebra? and 
to the stylo-maxillary ligament on each side of the base of the skull. 
“The thoracic fascia,” writes 
Sir Astley Cooper, in his work 
on the Anatomy of the Thy- 
mus Gland, “ performs three 
important offices: 1st. It forms 
the upper boundary of the chest, 
as the diaphragm does the lower. 
2d. It steadily preserves the 
relative situation of the .parts 
which enter and quit the tho- 
racic opening. 3d. It attaches 
and supports the heart in its 
situation through the medium 
of its connection with the aorta 
and larger vessels which are 
placed at its curvature.” 
In continuing downwards 
and connecting itself with the 
lateral and superior parts of the 
pericardium the thoracic fascia 
forms on either side a mem- 
branous continuity with the dia- 
phragm, and in connection with 
that organ performs an import- 
ant function on the circulatory 
apparatus. 
The muscular fibres at the 
circumference of the diaphragm 
Fig. 1. 
The above wood-cut represents a vertical section of 
the pericardium and diaphragm. The heart and the 
serous pericardium are removed showing ihe open" 
ings for the lodgment in the fibrous scaffolding: 1, 
aorta ; 2, ductus arteriosus compressed in its ellipti- 
cal opening, divided and turned up ; 3, right and left 
pulmonary arteries ; 4, pulmonary veins ; 5, superior 
vena cava ; 6, inferior vena cava opening into dia- 
phragm. 7. Suspensory ligament of liver, the sec- 
tion is at a point midway between the cava opening 
in the diaphragm and the abdominal wall 8, mus- 
cular fibres a-cending on anterior left aspect of peri- 
cardium ; 9 and 10, fibrous planes ascending laterally 
from pericardium to reach the apex of bony thoracic 
cone. 11, cordiform or tendinous portion of dia- 
phragm below the heart. 5 
contracting, and the pericardial portion of the central tendon being fixed on 
a plane with the lower part of the body of the ninth dorsal vertebra, w hich 
cannot descend on account of the superior crura and the fibrous scaffold- 
ing which I have pointed out, the following parts are acted upon : the 
aortic arch of the diaphragm is drawn forward and made more free; the 
muscular oesophageal opening is contracted; the tendinous vena cava open- 
ing is held open to its fullest extent. Continuing to contract, the muscu- 
lar circumference of the diaphragm now exerts its force on the pericardium 
and the superior crura or lateral fibrous planes, and upon the fibrous 
scaffolding between these crura, thus holding it open and tense, open to 
allow the flow of blood to and from the heart, and tense in order to protect 
the heart and bloodvessels, which if not protected would have their func- 
tion greatly impaired by pressure on the part of the now expanding lungs. 
These functions of the diaphragm on the organs of circulation take place 
though the lateral portions of the diaphragm may not be permitted to 
descend on account of the contraction of the stronger abdominal muscles or 
from artificial restraint of the abdominal walls. The muscular diaphragm 
will contract on its own planes and still perform its functions for the 
benefit of the vascular apparatus, though it may be prevented from 
descending, thus extending the vertical area of the respiratory organs. 
The right superior fibrous crus of the diaphragm is vertical in its direc- 
tion. It is at the foot of this crus, and on its inner aspect, that we find 
the vena cava opening of the diaphragm. It is the right superior inex- 
tensible crus which holds up under the concave surface of the diaphragm 
the entire weight of the liver, an organ in the adult of four pounds avoir- 
dupois. The falciform or suspension ligament of the liver is formed by 
tw'o folds of the peritoneum reflected from each inferior lateral margin of 
the fibrous vena cava opening in the diaphragm down to the lateral mar- 
gins of the vena cava fissure in the liver; the two folds meeting in front 
of the vena cava form the apex or point of the falciform ligament, which 
here is very short, holding the vena cava fissure in the liver close up to 
the vena cava opening in the diaphragm. 
At this point, the apex of the falciform ligament, behind wdiich the vena 
cava issues from its fissure in the liver to ascend to its diaphragmatic open- 
ing, the liver cannot descend. The base or anterior aspect of the falciform 
ligament is broad, and permits the anterior margin of the liver to fall and 
then to be elevated to and behind the ensiform cartilage by the action of 
the abdominal muscles. The lateral wings of the diaphragm and the 
muscular parietes of the abdomen in contracting and relaxing make lateral 
pressure upon the liver, and thus in a most positive manner advance the 
venous circulation and the flow of bile in the parenchyma of the liver, for 
the walls of the vessels in which these fluids are lodged have no muscular 
tissue. 
In the very young foetus the thorax and abdomen form one cavity as 6 
in birds, reptiles, and fishes. The diaphragm in the foetus is developed 
by a process of growth from the circumference to the centre, and when 
developed is in a passive state until birth. In the neonatus the muscular 
diaphragm is called into immediate action, and in contracting performs 
at once a most important function in compressing the ductus arteriosus, 
thereby diverting the current of blood into the two branches of the pul- 
monary artery, which go respectively to the right and left lung. The 
peculiarities in the arterial system of the foetus are the communication 
between the internal iliac arteries and the placenta by means of the 
umbilical arteries, and the communication between the pulmonary artery 
and upper part of the descending portion of the arch of the aorta by 
means of the ductus arteriosus. In the foetus and up to the birth of the 
neonatus the right and left branches of the pulmonary artery are, relative 
to the main pulmonary artery, very small, and come off'from the posterior 
aspect of the artery while the ductus arteriosus is in front of them nearer 
the sternum, and is much larger, and is in fact the continuation of the 
main pulmonary artery to the arch of the aorta, into which it opens 
just below the origin of the left subclavian artery, and so conducts the 
current of blood from the right ventricle into the descending aorta. 
The ductus arteriosus is lodged in an elliptical opening in the fibrous 
scaffolding beneath the descending portion of the arch of the aorta, which 
opening extends obliquely from above downwards and forwards and to the 
left, going in front of the descending aorta behind the “ vestigial fold” of 
Marshall (which is formed by a duplication of the serous membrane be- 
tween the pulmonary artery and the subjacent pulmonary vein), and above 
the left branch of the pulmonary artery. The tendinous fibres forming 
the margins of this elliptical opening embrace the ductus arteriosus and 
are connected to its external coat by connective tissue; they extend from 
the inner aspect of the superior posterior margin of the right fibi’ous plane 
or crus, downwards and forwards and to the left to become attached ante- 
riorly and below to the inner surface of the left fibrous plane or crus, and 
the muscular fibres of the diaphragm contracting at the first inspiration at 
birth the tendinous fibres of the elliptical opening are made to compress 
the ductus arteriosus and eventually close it. Especially is this compres- 
sion made by the contraction of those muscular fibres of the diaphragm 
which ascend upon and are attached to the anterior left aspect of the peri- 
cardium. The alternate pressure and relaxation made on the ductus arte- 
riosus by the contraction of that part of the muscular diaphragm referred 
to is exactly similar to the procedure we now adopt in closing by pressure, 
sufficient for the formation of a clot, the main artery in cases of aneurismal 
tumours, and the effect in both instances is exactly the same; in cases of 
aneurismal tumours while the clot is being formed the collateral circula- 
tion is being established by the distension and permanent enlargement of 
the collateral branches on the cardiac side of the point of pressure, though 7 
these branches are lodged in far denser tissue than the undistended foetal 
lung. 
When the ductus arteriosus is being compressed by the margins of the 
fibrous opening in the fibrous scaffolding in which it is lodged, drawn 
upon by the muscular tissue alluded to, and while the clot is being formed, 
the right and left pulmonary branches going to the lungs are being dis- 
tended and permanently enlarged until their united capacity is equal to 
the entire volume of blood in the main pulmonary stem, and thus the col- 
lateral circulation is eventually established with the aorta by means of the 
appropriate organs. The ductus arteriosus in the mean time is filled with 
the clot becoming organized, which permanently closes it. We may be- 
lieve that in the case of the compressed ductus arteriosus, the collateral 
circulation with the aorta would take place though the lungs did not ex- 
pand, just as the collateral circulation w'ould be established on ligating 
any other artery, one in the extremities for instance. In short the expan- 
sion of the lungs, per se, has nothing to do with the closure of the ductus 
arteriosus. The expansion of the lungs is for the aeration of the blood, 
and they are made to expand by muscles of respiration independent of the 
descent of the diaphragm, and wre may believe the closure of the ductus 
arteriosus and the collateral circulation with the aorta w'ould be established 
by reason of the contraction of the diaphragm, though this diaphragm w’ere 
restrained from descending. 
The line of pressure exerted on the ductus arteriosus is nearer to the 
aorta than to the two branches of the pulmonary artery. The clot soon 
becomes firm and the closure of the duct is 
made complete by the eighth day. 
The further influence of the muscular la- 
mina, attached to the anterior left aspect of 
the pericardium on the fibrous surrounding 
of the ductus arteriosus, is observed in the 
future development of the branches of the 
pulmonary artery, for at maturity or in the 
adult the fibrous cord, the remains of the 
former ductus arteriosus, is found reaching 
from the aorta to near the root of the left 
branch of the pulmonary artery, the muscular 
lamina on the pericardium having drawn it 
in that direction awray from its former situa- 
tion in a line with the long axis of the main 
pulmonary artery. Sometimes, indeed, the 
fibrous cord is entirely removed by absorption 
following this pressure, and no vestige of the former organ is to be seen. 
Such is the function performed by the contraction of the muscular dia- 
phragm on the ductus arteriosus and on the pulmonary circulation of the 
newr-born child. “Post cor facile prin ceps. 
Fig. 2. 
Heart of infant showing the mode 
of disappearance of the ductus ar- 
teriosus after birth. 1. Aorta. 2. 
Pulmonary artery. 3, 3. Pulmo- 
nary branches. 4. Ductus arterio- 
sus becomiug obliterated. (After 
Dalton.) 8 
When the lateral wings of the diaphragm, contracting, are permitted to 
descend, then and not until then do they tend to form a vacuum in the 
thorax, and thus assist to promote the venous circulation in the thorax 
and consequently in the whole venous system in the body. The first and 
most continuous effect of the contraction of the diaphragm, whether it is 
permitted to descend or not, is for the protection of the central circulatory 
apparatus, and the promotion of the circulation of the blood. If the dia- 
phragm is injured the result of that injury is experienced first by the 
heart. This fact is verified in the clinical histories of injuries of the 
phrenic nerve and the diaphragm. Thus, it is well illustrated in the case 
recorded by Mr. Pollock in Holmes’s System of Surgery, vol. ii. p. G50, 
as being under the care of Mr. Caesar Hawkins, in St. George’s Hospital. 
If one side of the diaphragm is lacerated, or if there is unilateral para- 
lysis of the diaphragm, the heart is pushed over to the opposite side of 
the thorax by the expanding lung, the lateral fibrous scaffolding being no 
longer supported on the side of the paralysis. In bilateral paralysis the 
heart is pushed backwards by the lungs advancing in front of it, and 
during inspiration the epigastrium and hypochondria are depressed, the 
heart, with the pericardium and its attachments to the diaphragm in front 
and at the base of the thoracic cone, being carried backwards by lung 
pressure in front; the anterior and lateral attachment of the diaphragm 
cause the depression of the epigastrium and hypochondria, phenomena so 
characteristic of bilateral paralysis. Duchenne informs us that if in these 
cases the phrenic nerves be galvanized the diaphragm acts again with 
proper strength, and during inspiration the thoracic and abdominal walls 
rise simultaneously. 
The descent of the diaphragm is not necessary to respiration, this is 
manifest from ordinary observation; but the contraction of the diaphragm, 
though it may not be permitted to descend, is necessary in order to pro- 
tect the heart from the movement of surrounding viscera, and in order 
to promote the free circulation of the blood through the vessels forming 
the cardiac roots. 
From this view, then, of the anatomy and functions of the diaphragm, 
this organ may be classed rather as an appendage to the circulatory appa- 
ratus, and not as the chief agent of respiration as heretofore believed. The 
natural history of the diaphragm would tend to confirm this view. It is 
found first in mammals. These animals require a diaphragm to protect 
the central organ of circulation from the encroachment of the neighbouring 
lungs and abdominal viscera, and by its contracting to act in promoting 
as well as protecting the functions of the heart. In birds and in turtles 
and tortoises, such an organ as the diaphragm is not required. In these 
animals the thoracic and abdominal viscera are in one and the same cavity, 
but the movement of the lungs is limited by means of pleural attachments, 
and the heart and its great vessels are protected by peritoneal folds which 9 
form restrictions by being attached to distant points of a rather fixed bony 
framework. In them the diaphragm is not found, as it is not needed. 
In the foregoing remarks we have endeavoured to demonstrate that— 
1st. The vena cava inferior opening, the highest point in the central 
tendon of the human diaphragm, holds a constant and fixed relation to the 
right anterior inferior border of the ninth dorsal vertebra. 
2d. That portion of the central tendon embraced by the base of the 
fibrous pericardium is prevented from descending in inspiration by the 
superior tendinous crura of the diaphragm which are formed by the lateral 
parts of the fibrous pericardium ascending on either side in two planes to 
be attached to the apex of the bony thoracic cone and through the deep 
cervical fascia to the processes of the cervical vertebrae, and to each stylo- 
maxillary ligament. 
3d. These superior tendinous crura of the diaphragm are connected 
together by transverse and oblique fibrous bands, thus forming a fibrous 
scaffolding for the support and protection of the heart and the great cardiac 
vessels. 
4th. The opening in the fibrous scaffolding for the lodgment of the 
ductus arteriosus in foetal life is closed by the contraction of the muscular 
fibres ascending on the fibrous pericardium from the anterior left side of the 
diaphragm in the neonatus. 
5th. The blood in the pulmonary artery of the neonatus is forced into 
and through the right and left pulmonary arteries and into the lungs by 
the contraction of the right ventricle, which at this moment has its walls as 
thick as those of the left ventricle, and by the elasticity of the pulmonary 
artery, and is not drawn into the pulmonary arterial branches and into 
the lungs by the expansion of the lungs. 
6th. The superior fibrous crura and the fibrous scaffolding between them 
are made tense and open for the lodgment and for the protection of the 
heart and its great vessels, and for the promotion of the circulation of the 
blood through them by the contraction of the muscular diaphragm, inde- 
pendent of the descent of its lateral wings, though in the descent of the 
lateral wings of the diaphragm the vertical area of the thorax is extended. 
7th. In the contraction of the muscular diaphragm its descent is not 
necessary as it contracts on its own planes, which may be supported by the 
contraction of the stronger abdominal muscles. 
8th. The diaphragm is rather an appendage of the circulatory apparatus, 
and not “essentially the chief agent in respiration.” 
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