HAEM ATOM YE LI A. By Aug. Hoch, M. D., Assistant Resident Physician, Johns Hopkins Hospital. [From The Johns Hopkins Hospital Reports, Vol. 11, No. 6, Baltimore, 1891,] HAEM ATOMY ELIA. AUG. HOCH, M. D. It is a striking fact that while we so often meet with hemorrhage into the brain, hemorrhage into the spinal cord, not produced by any trauma, belongs to the rarest affections known in neuro-pathol- ogy. It has indeed been denied that we can ever speak of a primary spinal hemorrhage, the idea being that a softening of the tissue of the cord must always precede, and that the hemorrhage is thus only a secondary one. Monod, as early as 1830, doubted its existence; but the chief exponents of this view are Charcot, and after him Hayem.1 This latter author has collected the cases, which up to his time were reported under the title of Haematomyelia, and has subjected them to a careful analysis. Among the thirty-one cases there was not one, Hayem thinks, in which we could reject the sup- position that a change had taken place previous to the hemorrhage and so altered the tissue of the cord as to produce an extravasation of blood. Such a position, however, has been taken only by the just mentioned authors, while all the later ones, as, e.g., Leyden, Eich- horst, Gowers, Erb, admit the existence of primary haematomyelia. Previous to Hayem, Levier2 in his monograph had given the histories of sixteen cases, fourteen of which are included in the thesis of Hayem. Since Hayem’s time eleven more cases have been described, a collection of which we find in Berkley’s paper on Syringomyelia.3 I have been unable to find any further one reported with autopsy. It would necessitate the writing of a monograph to review again all the cases and to discuss their exact nature, and it would in fact be an impossible task for, as Leyden4 and Eichhorst5 already have 2 Levier: Beitrag zur Pathologic der Euckenmarksapoplexie. Inaugural Disser- tation, Bern, 1864; also, Schweizerische Zeitschrift fiir Heilkunde, 1864, Band 3. 1 Hayem: Des hernorrhagies intrarachidiennes. These des Paris, 1872. 3 Brain, 1889. 4Leyden: Ein Fall von Haematomyelie. Zeitschrift fiir Klin. Medicin, Band xm, 1887, pp. 225-251. 5 Eichhorst; Beitriige zur Lehre von der Apoplexia in der Riickenmarkssubstanz. Charity Annalen, Berlin, 1876, pp. 192-205. 1 2 pointed out, we may be unable, even with a microscopical examina- tion, to settle the question whether we have to deal with a primary softening and a secondary hemorrhage or with a primary hemorrhage and a secondary softening, analogous to the condition in the brain. Eichhorst and Gowers, therefore, admit, in opposition to Hayem, the possibility that some cases described as myelitis are really haema- tomyelia. We see, therefore, that an anatomical diagnosis is not always possible, and that the clinical history with its different factors will be of great importance. Undoubtedly, however, not a few cases described as such are not true examples of primary haematomyelia, but on the other hand cases like that of Goltdammer1 e.g., cannot be interpreted in any other way. Recently two cases have been reported by Krafft-Ebing,2 diagnosed intra vitam, which we have every reason to call primary hemorrhage, also two cases by Sonnemann3 from the clinic of Mendel. It has been found by Charcot and Bouchard, and it is now a well- known fact, that the existence of miliary aneurisms in the cerebral arteries is a very common occurrence, so common that the above men- tioned observers found them in seventy-seven consecutive cases of cerebral hemorrhage which they examined. This is, therefore, the most common cause of cerebral hemorrhage. We know that we find arterio-sclerosis in the spinal as well as in the cerebral arteries, but the soft pulpy brain with its comparatively large arteries and a high arterial pressure must be a more favorable situation for the formation of aneurisms than the denser spinal cord with smaller arteries and lower pressure,—not only for the formation of aneurisms but also for a hemorrhage to take place, sufficient to produce perceptible symp- toms. Small hemorrhages are not unfrequently seen. But there are cases in which aneurisms similar to those in the brain have been described. Griesinger4 reported a case where he found aneurismal 1 Goltdammer: Beitrage zur Lehre der Spinal-apoplexie. Yirch. Arch., Bd. t.xvi, 1876. 2 Krafft-Ebing: Zur Kenntniss der primiiren Eiickenmarksblutung. Wiener Klinische Wochenschr., 1890, p. 939. 3 Sonnemann: 2 Falle von Haematomyelie. Inaugural Dissertation, Berlin, 1890. 4Griesinger: Archiv. fur Heilkunde, Band 3, 1862, p. 174. Quot. by Levier (loc. cit.). 3 dilatations in the cord of a boy who had died with tetanus, Heboid1 in a case in which he attributed them to obstruction from venous thrombosis. Of special interest is the observation of Eichhorst,2 who found in the case which he described as primary haematomyelia quite wide-spread aneurisms,—furthermore, the case of Wilkins3 whose patient died with an acute spinal paralysis, regarded by the author as haematomyelitis, and where the existence of aneurismal dilatations in the grey matter of the upper dorsal region was noted. While in the cases which we shall describe in this article we can- not entirely exclude the trauma, still we cannot class them under the head of the usual traumatic cases in which injury or concussion to the spine was immediately followed by a hemorrhage, since in one case six days, in the other three weeks, intervened between the acci- dent and the paralysis. The cases, therefore, seem to be of sufficient interest to be reported. I am indebted to Professor Osier and Dr. Thomas, the chief of the Neurological Clinic, for the permission to report these eases. Case No. II has been reported by Dr. Thomas as “A case of Brown-Sequard’s paralysis” before the medical society of the Johns Hopkins Hospital. Case I.—K. 1., aet. 40, an Irishman, laborer, came to the out- patient department on July 26th complaining of partial loss of power in his right arm and hand. The account of the family history of the man is somewhat incom- plete, since he has for many years not heard from his people. In previous years, and up to his present illness, he has had unusually good health and has not lost a day’s work in the past fifteen years. He denies very positively any venereal infection, and says that he has for the past six years been a very moderate drinker, while previous to that he drank too much at times. In the first week of June, 1890, while at work he was struck between his shoulders by a board which fell from the height of eight 1 Heboid, Otto: Aneurismata der kleinsten Eiickenmarksgefasse. Arch. f. Psych., Bd. 16, 1885, p. 813. 2 Eichhorst, loc. cit. 3 Wilkins: Case of spinal apoplexy. Montreal General Hospital Eeports, Vol. i, 1880, p. 111. 4 or ten feet. He was knocked down but immediately got up again and felt no bad effects from the blow except some soreness on the following day at the spot where the board had struck. He went to work and felt well in every way up to about three weeks after this had happened. He came home one evening after a usual day’s work, took his supper and felt quite well. He went on the street and sat down talking to a neighbor, only about half a square from his dwelling, when he was suddenly seized with a stabbing pain between his shoulders. He immediately arose and walked home, which he could do without assistance, noticing nothing at all in his legs. Soon he felt pain down the back, and when he lay down suffered from quite intense pain which had now also spread to both arms. The arms were drawn up across his chest and were tremulous. He remained in this con- dition for a few minutes and then completely lost power in his legs and partly in his arms, chiefly the right. The time which elapsed between the onset of the pain and the paralysis was not more than eight or ten minutes. He did not lose consciousness at any time. Both arms could be moved at the shoulder- joints to some extent; the left was less affected than the right. He did not feel the people who came and rubbed him, nor could he feel a mustard plaster which was put upon his abdomen. He thinks he lost sensation completely on the body from about a line with the nipples down and in the arms. The physician ordered him a “ sleep- ing powder,” which had the desired effect, and the next morning he had no pain but felt numb in the places where the pain had been. His left leg could be moved a little and got better rapidly. About five days later he began to move the toes of the right foot, but tire right leg improved more gradually than the left. Three days after the attack he could not hold anything in his hands. Both arms improved, the left more quickly and much more completely, the improvement in the right being chiefly in sensation. In general, sensation returned with motion. He could not pass his water for about two weeks, and the catheter had to be used. For some days also he had no stool, and took about the fourth day a purgative which acted. There was no priapism. As stated above we did not see the patient until July 26th, i. e., about a month after the paralysis had come on. His condition then was as follows : 5 Status Praesens.—Rather tall man. Face thin. Expression anx- ious. Muscles fairly well developed, little adiposa. Intelligence good. No abnormality about voice. Eye-balls freely movable. Left pupil larger than right, both react to light and accommodation. No trouble with vision, and in general with none of the special senses. Muscles of face act equally. Motions of head executed normally and with normal strength. No tenderness and nothing abnormal about the spine. Trapezius (occipital portion) is more prominent on the right than on the left side. Shrugs shoulders and resists depression. Deltoids act on both sides and in all directions. Pectoralis somewhat subnormal on the right side. Rotates arm. Flexors of forearm act on both sides, somewhat weaker on the right. Extensors on the right very weak, on left strong. Motion about wrist on the right side is limited / O o to the slightest flexion and extension. No motion in fingers. No contracture. On left side all motions of hand and fingers are possi- ble, power is very subnormal. Muscles react to mechanical stimu- lation and upon being percussed a welt is formed at the place of contact. I shall here only give an extract of the electrical examination, which was then not so complete as a later one, which will follow in extenso. In the left arm there was no electrical change found to faradism; with the galvanic current the muscles and nerves could be excited with about 2M. A., K. c. c. with a corresponding A. c. c. In the right arm with the faradic the deltoid, biceps, triceps, supinat. longus, extens. radial., act well at about 41., as do the pector. and triceps—the triceps less than the others. Flexors do not act. Radial and ulnar nerve not obtained. With the galvanic the radialis, supinat. longus, extensor radial., biceps, deltoid, reacted quickly to a stimulation with 3m. a., k. c. The triceps reacted less readily and rather sluggishly, and the A. c. c. was even somewhat larger than the K. c. C. The extensor communis, extensor ulnaris, extens. pollic., extens. indicis, showed slow contractions of a tetanoid character. The anode, however, being larger than the kathode. The flexors were excitable but reacted slowly; there were no qualitative changes in the reaction. Roughly tested no sensory change was found. Heart and lungs were normal. The patient then left and did not return until Janu- 6 ary 31st, when he was again examined, and the following notes were made: Both legs look and measure equal. On a more careful examina- tion no change is found in sensation to touch, temperature or jmin, and faradism. Walks well. Pateller reflexes are active and equal on both sides, cremast. and plantar present. Electrically, all muscles and nerves of legs react well to galvanic and faradic, no diminution and no qualitative changes. Muscular strength good throughout in legs. Body and arms: The right mammary region looks somewhat flattened, so that the intercostal spaces are more visible especially towards the sternum. The back looks symmetrical. Deltoids equal, and the muscular strength good in them. There is only slight difference in the pectoral, in favor of the left. The right upper arm is considerably thinner, and at the triceps seems especially flabby. Forearm on the right side is also thinner. The flexors especially seem flabby here. The right hand looks somewhat glossy. The surface over the knuckles and on the fingers more even than in a normal hand. The fingers are slightly bent, the hand extended. There is distinct atrophy of the thenar eminence. The left hand looks natural, except that the thenar of this side looks also flattened. Measurements. Right. Left. Wrist 14.8 cm 16.0 cm. Over supinat., with arm flexed at right angle..,. 22.5 cm 24.0 cm. Greatest circumf. of upper arm 12.5 cm 26.0 cm. With arm extend. 13 cm., above ex. malleolus 19.0 cm 21.0 cm. Muscular strength of bicipites is fair and almost equal. Triceps is normal on the left side, very much subnormal on the right. The right hand can be flexed dorsally, but is held to the inside (radialis extensor). The left hand is raised higher and in median line, and the muscular strength in these muscles is good. Hardly any palmar flexion is possible in the right hand, while it is good in the left hand. No motion is possible in the fingers of the right hand; the thumb can be slightly separated from the other fingers. The motion in the fingers and hand of the left side is complete. 7 Electrical Examination.—We would state here that the higher the number is, which is given as the point of the faradic stimulation, the stronger is the current, for the scale of our induction coils is ar- ranged relatively, 100 being the strongest current.1 A medium-sized electrode was put on the sternum and for the dif- ferent [Erb] electrode a button-electrode was used, and the smallest traction noted. Faradic Current RIGHT. LEFT. Biceps 13 17-22. Deltoid, anterior part...l 7-22 17-22. Deltoid, posterior part,..l7-22. Median nerve 28 (Pronat.) 28. Ulnar nerve Not obtained 28. Radial nerve Not obtained 22. Triceps 17-22, slight and sluggish...22-28. Supinator longus 17, good motion. Eadialis extensor 28, good motion. Ulnaris extensor Not obtained. Extensor communis Not obtained. Interossei.. Not obtained. l7-22. Thenar Not obtained 41-46, sluggish. Hypothenar Not obtained Adduct, pollicis, 41-46. Other small muscles Not obtained. Flexors Not obtained. Pronator 22. Pectoralis reacts less on right than left, the difference is mainly in the lower part of the pectoral muscle. Galvanic. Right Arm.— Biceps, 2 M. A., K. C. C. < 3 M. A., A. C. C. Deltoid, anterior part, 3M. A., K. C. C., 3M. A., A. C. C. On stronger current, Lateral part, 1.5 M. A., K. C. C. < 4.5 M. A., A. C. C. Posterior part, 2.5 M. A., K. C. C. < 3 M. A., A. C. C. Triceps, 3 M. A., K. C. C. < 5 M. A., A. C. C. Supinator, 2.5 M. A., K. C. C. < 4 M. A., A. C. C. K. C. C. > A. C. C. Ulnaris extensor, 2.5 M. A., K. C. C. sluggish < 3.5 A. C. C. sluggish. Extensor communis, 4 M. A., K. C. C. slow, 4 M. A., A. C. C. somewhat quicker. xThe apparatus is described by Dr. Thomas in the Bulletin of the Hospital, July, 1890. 8 Thenar, 1} M. A., K. C. C. slow. < 3 M. A., A. C. C. slow. Adductor pollicis, 1 M. A., K. C. C. slow. < 3 M. A., A. C. C. slow. Opponens pollicis, 1 M. A., K. C. C, slow. < 2 M. A., A. C. C. slow. Flexor profundus, 2 M. A., K. C. C. < 3 M. A., A. C. C. very slow. Sublimus, 3 M. A., K. C. C. < 5 M. A., A. C. C. very slow. Ulnar and radial nerve not obtained. Left Arm.— Radial nerve, 2.5 M. A., K. C. C. < 4.0 M. A., A. C. C. Biceps, 1 M. A., K. C. C. < 3.5 M. A., A. C. C. Triceps, 2 M. A., K. C. C. < 4 M. A., A. C. C. Ulnar nerve, 1.5 M. A., K. C. C. < 2.5 M. A., A. C. G, 2.5 M. A., A. O. G Supinator, 1.5 M. A., K. G C. < 2.5 M. A., A. C. G Eadialis extensor, 2 M. A., K. C. G < 3 M. A., A. C. G Extensor communis, 2 M. A. K., G C. < 3.5 M. A., A. C. C. Extensor ulnaris, 2.5 M. A., K. G C < 3.0 M. A., A. G C. Adductor pollicis, 2 M. A., K. C. C. < 4.5 M. A., A. C. C. Extensor minimi digiti, 1 M. A., K. G C. < 2.0 M. A., A. G C. Interrossei, 2 M. A., K. C. G < 3 M. A., A. C. C. Adductor pollicis, 2 M. A., K. C. C. < 2.5 M. A., A. C. C. rather slow. Thenar, 1.5 M. A., K. G G < 2.0 M. A., A. G C. As regards the diagnosis of this case we have anticipated it in the title of this article. But if authorities like Leyden have expressed their opinion as to the impossibility of diagnosing intra vitam a haematomyelia it seems only natural that the reasons should be given why this seems the most probable diagnosis. A short recapitulation of the case will, therefore, I think, not be found out of place. Patient was struck between his shoulders by a board falling f>'om the height of eight to ten feet without producing any immediate effects save some soreness next day, which soon pjassed off and: left him quite well. Three weeks later he was suddenly seized with acute pain between the shoulders radiating down the spine and into the arms, followed by a contracture of short jduration in the arms, and ivithin eight to ten minutes by complete sensory and motor paralysis from the arms down (with the exception of the higher-situated muscles of the arm). Retentio urinae et alvi. Improvement in the left leg the following day, compara- tively rapid improvement also in the right leg and left arm, so that after three weeks there remained only paralysis of some of the muscles of the right arm, especially the forearm. On examination a month after, no sensory changes but paralysis with atrophy, showing the characteristic electrical changes of certain muscles of his right arm. 9 We have, therefore, to deal with a sudden spinal paralysis which has destroyed the grey matter in a certain region of the cord. Before going into the question to what the lesion is due, let us localize it as far as it is possible, by finding out which muscles—as indicated by their impairment in motion and visible atrophy and by the results of the electrical examination—are interfered with in their nutrition, and we can then draw conclusions as to their trophic centres in the cord. The muscles concerned are the following, classing them under two heads, namely, those which have completely lost their motion and show reaction of degeneration, and those which show only decrease in electrical excitability and some impairment in motion. It will be seen, however, in the tables of the electrical examination that even those muscles which are the most degenerated do not ful- fill all the requirements of the reaction of degeneration, as it has been given by Erb, but that we find the anode-closing contraction nowhere larger than the kathode-closing contraction, a condition which is not rarely seen. I. Muscles showing complete loss of motion and reaction of degen- eration. Extensor ulnaris, extensor communis ; all the flexors; small muscles of the hand. 11. Muscles shoicing decrease in electrical excitability and impair- ment of motion. Lowest part of pect. major and triceps. Now on what basis can we make an attempt to localize the lesion ? A very important contribution to the spinal localization has been given in the valuable work of Thorburn.1 From results of purely clinical observation he has mapped out a scheme of the distribution of the motor-nuclei, to which much importance is to be attributed, as the conclusions were drawn from a sufficient number of cases, observed and studied with care; and since they coincide in general with the anatomical investigations of Herringham 2 and the stimulation expe- riments of Yeo and Ferrier.3 According to Thorburn we have to place the lesion on a level with the vii and Yin cervical and i dorsal roots and partly upward in the VI cervical, and this as we will see seems to be the most plausible. Thorburn’s scheme is as follows : 1 A Contribution to the Surgery of the Spinal Cord, by Wm. Thorburn. Philadel- phia, Blakiston. * Proceedings Royal Society, No. ccxliii, 1886, p. 255. Quoted by Thorburn. 3 Proceedings Royal Society, No. ccxn, p. 12. Quoted by Thorburn. 10 vi. Subscap. pronat. teres, maj.; lateral dorsi. pectoralis maj.; triceps, serratus magn. vn. Extensor of wrist, vm. Flexor of wrist, i. Dors : Interossei and other intrinsic muscles of hand. The small muscles of the hand are by the three mentioned authors placed lowest down in the cord, the flexors and extensors in the region of the VII and vm, by Ferrier, also in vr, v, IV, by Herring- ham in vi. The pectoralis could be stimulated by Ferrier from the vn and vm, Herringhara could trace fibres into vi, vn and vm, while Thorburn refers its centre to the vi. It seems quite likely that the pectoralis has its centre in more than one segment of the cord. Both our cases, the one just reported and the one yet to follow, seem to point to this, for in both the lower part only was diseased, and we would conclude then that the centre for the lower part is situated lower (vi), while that for the upper is placed higher (v). Another interesting point as regards localization is that we find the radialis extensor entirely preserved in our case. Thorburn does not speak of any nucleus for this muscle on a separate level from the others, while we find it especially mentioned by Herringham (vi and vn cervical). It is most probable that this muscle is represented higher up in the cord than the other extensors, for we have evidence of complete destruction of the anterior grey horns at the place where they are represented, while the extensor radialis remains quite intact. We see then that in general, according to the localization given by Thorburn, the muscles which we find diseased are represented in the cord in close connection, so that we can well understand how a hem- orrhage in the grey substance, extending over somewhat more than three levels, can destroy their nuclei. So much then for localization. Before going into the differential diagnosis, I propose to give the notes of the second case. Case lI.—L. 1., aged 21, railway brakeman, came to the surgi- cal ward of the Hospital complaining of trouble in his hip, which proved to be a haematoma of considerable size. He was operated upon for this and left the Hospital well, as regards his surgical trouble, in the middle of January, 1891. On October 18th, 1890, he was sent to the neurological clinic for examination because he complained of not being able to move his whole right side freely, the leg especially being somewhat stiff; he had also some disturbance in sensation in the left side. 11 Anamnesis.—Patient had always been healthy and strong. Some- times he has been drinking rather heavily. He denies any venereal infection. On the 18th of July patient met with an accident. While standing on a freight car he was knocked down and fell under the cars in the middle of the track, so that he was somewhat injured by two other box cars passing over him. He did not lose con- sciousness. The only wounds he had were on the forehead, and at different places on the scalp, and also on left foot, but his spine was uninjured and there was no sign of paralysis. Six days after—he had meanwhile been brought to a hospital— he felt some pain in his right arm and leg, and did not sleep very much that night; when he awoke in the morning the right side, with the exception of the face, was completely powerless. His speech was not impaired. Pie slowly improved, the first sign of improve- ment being in the deltoid, then in the leg, while the fingers for some time were in a semi-flexed position, so that he neither could flex nor extend them entirely. Soon after the paralysis of motion he noticed also that on the sound side he could not feel as well when pinched as he could on the other. There was retention of urine and faeces for a few days and he had to be catheterized once. Status Praesens.—December 12th. Strong-looking man. Walks with difficulty, on account of the haematoma on the left hip and apparently some weakness in the right leg. The hip is bandaged. Facial muscles act well and equally. Eyes are freely movable, nor- mal. There is no abnormality seen on the spine and no tenderness. Shoulders look equal; the lower part of the right pectoral is some- what flattened, as compared with the left. The triceps feels more flabby on the right side; the upper and lower arm somewhat thinner. The arm and hand held in natural position. The interosseal spaces are more marked on the right hand. The thenar eminence is quite flattened. Every motion seems possible. Measurements.— Right. Left. Upper arm, largest circumference 28} cm 29} cm. Fore arm, largest circumference 28} cm 31} cm. Wrist 20} cm 20} cm. Muscular Strength.—Deltoids good and equal. Pectorales: The left pectoral muscles are stronger. On contracting them the lower 12 part of right pectoralis major is seen to be distinctly wasted. Ex- tensors of the forearm: good on the left, much subnormal on the right. Flexors of forearm fair and equal on both sides. Dorsal flexion of the hand is possible to a greater extent in the left hand and the muscular strength there is somewhat better than in right. For the palmar flexors the same condition holds good. Grip on the left side is good, on the right subnormal. In the legs there is no apparent wasting, the right leg seems a little weaker than the left. Reflexes.—Plantar not obtained on either side. Abdominal not obtained. Cremaster obtained on both sides; they are equal. Patel- lar reflexes are active on both sides, on the right exaggerated. Tendo Achillis reflex present on both sides, plus on the right. There is the most exquisite ankle-clonqs on the right side, none on the left. Triceps : reflex well marked on the left, not obtained on the right. Periosteal reflex at wrist better marked on the left side. Mechanical stimulation.—About the same on both sides Electrical Examination. Faradic. Nervus ulnaris 28 28 Nervus radialis 22-28 22-28 ■Nervus medianus 22 .' 17-22 M. Biceps 17-22 13 “ Triceps 22-28 22-28 “ Deltoideus 22 22-28 “ Extensor communis- 22 ~,.28 “ Extensor radialis 17-22 28 “ Extensor ulnaris 17 22 “ Extensor pollicis et indicis 22-28 28 “ Extensor minimi digiti 28 “ Supinator longus 22-28 22-28 “ Flexor profundus 17-22 28-34 . “ Flexor ulnaris 28 28 “ Flexor sublimus 28 28-34 “ Pronator rad. ter 28 28-34 “ Adductor pollicis 28 44-49 “ Opponens pollicis .28-34 22-28 “ Thenar 28 28-34 “ Interossei 28 .34 “ Flexor minimi digiti 22 “ Adductor minimi digiti 28 LEFT. EIGHT. 13 As there was really no difference between the two sides as regards the strength of the current which produced the smallest contraction, we concluded to stimulate all the muscles with a fairly strong faradic current, and note the difference in the strength of the contractions, which in some of the muscles was quite apparent. The result was as follows : With a current of 49, bicipites react equally. The reac- tion of the ulnar nerve is less strong and less quick and less tetanic on the right side; extensor communis less active on right side; supinatores almost equal; extensores radial, equal; extensores ulnares almost equal; pronatores equal; flexor, profund., flexor, carpi ra- dial., flexor, sublim. equal on both sides ; flexor carpi ulnaris perhaps a little more sluggish on the right side; the triceps more sluggish and less tetanic on right side; pectoralis less on right side; opponens and adductor pollicis decidedly less on right side. Galvanic Current. Left Arm.— Ulnar nerve, 24 M. A., K. C. C. < 6 M. A., A. C. C., A. 0. C., 8. Radial nerve, 2 M. A., K. C. C. < 34 M. A., A. 0. C., A. C. C., + 8. Median nerve, 1J M. A., K. C. C. <3 M. A., A. O. C., A. C. C., 8. M. Deltoid, ant. part, 4 M. A., K. C. C. > 34 M. A., A. C. C. -| mid. part, 54 M. A., K. C. C. > 5 M. A., A. C. C. !■ quick, post, part, 6 M. A., K. C. C. > 54 M. A., A. C. C. 3 “ Triceps, 2f M. A., K. C. C. <5 M. A., A. C. C. “ Biceps, UM. A., K. C. C. 34 M. A., A. C. C. “ Flexor carpi ulnaris, 24 M. A., K. C. C. <5 M. A., A. C. G, “ Flexor profundus, 24 M. A., K. C. C. <34 M. A., A. C. C. “ Flexor sublimis (u, in), 2M. A., K. C. C. <5 M. A., A. C. C. “ Flexor sublimis (ind. and little), 2 M. A., K. C. C. <5 M. A., A. C. C. “ Adductor pollicis, 2M. A., K. C. C. <6 M. A., A. C. C. “ Opponens, 3 M. A., K. C. C. <6 M. A., A. C. C. “ Flexor carpi radialis, 3M. A., K. C. C. <5 M. A., A. C. C. All the contractions are quick, not sluggish. 14 Right Arm.— Ulnar nerve, 11 M. A., K. C. C. < 5 M. A., A. C. C. Radial nerve, 2J M. A., K. C. C. < 41 M. A., A. C. C. Median nerve, 2J M. A., K. C. C. < 2| M. A., A. O. C., 8J M. A., A. C. C. M. Extensor radialis, 3J M. A., K. C. C. < M. A., A. C. C. “ Supinator, 3M. A., K. C. C. —3 M. A., A. C. C. “ Extensor ulnaris, 2M. A., K. C. C. < 5 M. A., A. C. C. “ Extensor communis, 3M. A., K. C. C. —3 M. A., A. C. C. “ Extensor indicis, 2J M. A., K. C. C. <4J M. A., A. C. C. “ Extensor pollicis, 21 M. A., K. C. C. <4J M. A., A. C. C. « Deltoideus, 2-31 M. A., K. C. C. < 4J-6 M. A., A. C. C. “ Flexor ulnar, 21 M. A., K. C. C.