86 REPORT — 1842. 



with the exception of the inconvenience arising from the paralysis, which was not 

 preceded by, nor is it accompanied with, any pain in the head or spine, nor any diseased 

 sensations in the skin or extremities indicative of cerebral or central nervous lesion by 

 which the paralysis might be explained. He is a joiner by trade, and about ten years 

 ago he first experienced a loss of power in the right arm and an inability to bring into 

 exercise all its movements. The principal inconvenience arose from the difficulty, 

 amounting to inability, of raising the arm above the head to more than a right angle 

 with the body. The loss of power gradually increased, and at the end of twelve 

 months the base of the scapula on the right side was noticed to stand out from the back, 

 and at the expiration of three years it assumed its present appearance. At the same 

 time from the commencement of the attack the right lower extremity began to fail 

 him, his gait becoming rather unsteady, and when in the bent position he experienced 

 a little difficulty in raising himself. About four years ago, being six from the com- 

 mencement of the attack, the arm of the left side became similarly affected, the 

 scapula being displaced and the lower extremity being affected as on the right side, 

 although he has retained more power in the left arm than in the right. The cir- 

 cumstance which more prominently strikes the attention in the present case, is the 

 appearance of the scapula?, more especially when the man attempts to raise and make 

 use of the arm. In the quiescent position, the base of this bone, instead of lying par- 

 allel to the spine, is approximated to it at the lower angle, and stands out from the 

 ribs a distance of an inch and a half, leaving between the scapula a deep hollow 

 channel, the upper angle being drawn high up into the neck, appearing on both sides 

 to the observer in front midway between the shoulder and ear. The clavicle in front 

 is in ite natural position, as is also the acromion process of the scapula to which it is 

 articulated. The acromion process stands considerably forward. When the patient 

 attempts to raise the arms all these appearances are much exaggerated. The base of 

 the scapula approaches nearly to a right angle with the spine, forming with the base 

 of the scapula on the opposite side a very obtuse angle, and they both stand out on 

 their whole length nearly three inches from the ribs. The arm cannot be raised be- 

 yond the horizontal position ; after stooping at a right angle to the lower extremities 

 he is quite unable to recover the erect position without help, and there is an evident 

 lateral curvature of the spine ; both which I conceive to be consequences of the loss 

 of power in the longissimus dorsi and sacrolum bales, and the deep-seated extensors 

 of the spine. In his ordinary position the upper part of the body is thrown back, evi- 

 dently to balance the weight of the head and upper part of the body, which in the 

 healthy person is supported in the completely erect position by the above muscles. 

 In analyzing the actions of the muscles attached to and influencing the movements 

 of the scapula, we found that he could raise and approximate to each other and to the 

 spine, the upper angles of the scapula, showing a complete freedom of the trapezius and 

 of the levator anguli scapulae ; he can also approximate to each other the bases of the 

 scapula, showing power in the rhomboidei. He can put his arm behind him freely and 

 with force, showing that the latissimus dorsi is not involved. It is however doubtful, 

 from the tilted-up position of the lower angle of the scapula, I conceive, that the slip of 

 the latter muscle passing over the angle and assisting to bind down the scapula to the 

 ribs, has lost its power, and do not pass beneath it. There is no reason to suppose 

 any paralysis in the teres muscles, as the action of drawing the arm to the side and 

 backwards is performed with ease. The sub- and supraspinous muscles are very 

 much developed, and the deltoid is of moderate size and retains complete power. The 

 condition of the subscapula muscle can only be conjectured, yet it appears to be 

 healthy and in good condition. The only remaining muscle connected with the 

 scapula is the serratus magnus, whose function in the motion of the scapula is, along 

 with the deltoid, to raise the arm above the horizontal position, and, making the in- 

 sertion into the scapula the fixed point, co-operates with the pectoralis major in those 

 more energetic dilatations of the chest which are on occasions required for respira- 

 tion. The power of this muscle on both sides is completely destroyed ; and this ap- 

 pears to be the most prominent lesion in the case. In elevating the arm above the 

 horizontal position, this muscle takes up the action which has been carried so far by 

 the deltoid, the supra and infra spinatus and the subscapularis. In the present case 

 this action so far is perfectly performed ; but the further action in the elevation of the 

 arm, to effect which the subscapularis is absolutely necessary, is in the present case im- 

 practicable. The muscle, in consequence of its paralysis, is wasted and can scarcely 



