“We Sing from the Diaphragm a Lot!”

“We're opera mad in Camelot! We sing from the diaphragm a lot!”[1]

This issue, co-edited by our board member Henning Gaissert, is dealing with a part of the thoracic cavity we tend to neglect or even forget, even in medical school —the diaphragm. Far from being simply a membrane separating the abdomen from the thorax, it is one of the most frequently, in fact, continuously moved muscles in our body, surpassed probably only by our never tiring friend, the heart. Eyelid-moving muscles are much lauded for being so busy, for instance by neurologists in the diagnosis of myasthenia, a fact that students eagerly learn. But the eyelids remain closed in most of us for a considerable and pleasant period of time of our lives, that is, during sleep, whereas breathing should rather go on.

In the training of a surgeon for congenital heart disease, there is a nerve that becomes as important as the recurrent laryngeal in thyroid dissection—the phrenic nerve. Phrenic palsy after an extensive procedure, maybe even one which leaves the child still cyanotic, significantly prolongs intensive care unit stay and increases morbidity. This is because children do rely more on the so-called abdominal breathing mechanism, which is generated by the diaphragm. Diaphragmatic plication techniques, in turn, should involuntarily be part of this training.

In the old days when adult cardiac surgeons still filled the pericardial cavity with ice water because cold is good for you, they had a good chance of freezing the phrenic nerve, and whereas the myocardial function was quite convincing, the breathing pattern of the patients usually was not. The nerve also has an awkward tendency to come close to the internal mammary artery in its most cephalad segment, and again, whereas an arterial graft is beneficial for the future of myocardial perfusion, it can become deleterious for respiratory exercise capacity when the nerve has been injured. Should the patient happen to be a professional singer or play a wind instrument, the career has suddenly come to an end. In summary, cardiac surgeons tend to have only unpleasant acquaintance with the diaphragm and would rather like to ignore it. But they cannot. The careful deliberations of the thoracic surgeons in this issue dealing with impaired diaphragmatic motility therefore are of utmost importance also for the “pure” cardiac surgeon. Awareness is the keyword.

As the Christmas season is drawing near (please note that we have a “Christmas Special” for the first time to get you into the mood), it is a logical consequence for your editor to finish the year off with a hint to a culinary delight. I will not dwell on the traditional roast goose or saddle of venison, but would like to draw your attention once again to (you may have guessed it) the diaphragm. Being a lean and overly trained muscle, it should be edible and enjoyable, and, of course, it is. The major problem is finding a butcher who knows about it and can provide you with an appropriate cut. The French call it onglet, the US Americans usually a hanger steak, the more reticent British a skirt steak. I am not really aware of a common term in German kitchens, but our Austrian neighbors do have their “Saumfleisch” or “Kronfleisch,” and the Swiss feast on “Leistenfleisch”—all of these are synonyma for the crura of the bovine diaphragm. Because it is so lean, it does require careful handling. Fergus Henderson, who prepares virtually all sorts of meat “from nose to tail” in his St John Restaurant in Smithfield, London, recommends quick cooking to a rare quality to be accompanied by mustard and mash (or chips, if you must). One minute on each side per half-inch of thickness on a very high heat should suffice. This will give you a delicious slab of steak looking a bit like an old rag, but full of flavor. Should you prefer a spicy touch over the tang of pure meat, marinating the cut in a concoction of olive oil and some red wine together with minced shallots, capers, and parsley with a touch of English mustard should do the trick. But remember that you are dealing with a thin piece, so do not soak it to death.

After having read this issue, you will appreciate that the diaphragm is a really delicate structure in every respect. Enjoy.

• References

• 1 Monty Python and the Holy Grail, 1975, EMI Films