. A text-book of medicine for students and practitioners . rs of the wristand fingers, and onlylater the supinators,flexors, etc. In theupper arm the deltoidalmost always atro-phies first, and thenthe biceps, while thetriceps may remainintact somewhat long-er. There are alsocases in which theatrophy begins in the 1deltoid and the mus-cles of the upper arm,while the small mus-cles of the hands andfingers are not affect-ed until later. Themuscles of tbe trunkare usually added tothe list quite late—the muscles that ex-tend Ibe bead andkeep it erect, so tbat tlie liead sinks forward—Ibc trapezii,
. A text-book of medicine for students and practitioners . rs of the wristand fingers, and onlylater the supinators,flexors, etc. In theupper arm the deltoidalmost always atro-phies first, and thenthe biceps, while thetriceps may remainintact somewhat long-er. There are alsocases in which theatrophy begins in the 1deltoid and the mus-cles of the upper arm,while the small mus-cles of the hands andfingers are not affect-ed until later. Themuscles of tbe trunkare usually added tothe list quite late—the muscles that ex-tend Ibe bead andkeep it erect, so tbat tlie liead sinks forward—Ibc trapezii, tbe infraspinatiand supraspinati, tlie rbomboidei, tbe latissimi dorsi, tbe pectorals, etc.(see Figs. 171 and 17-5). Tbe disturbance of function caused by tbeatrophy of all tbese musck>s is readily a])i)arent rroin wbat was said inthe chapter on the different forms of |)aialysis. In advanced cases thearms hang down bixly l)y tbe sides of Ibc Irunk. Oidy with the greatestdifficulty, if at all, can tbe ])ati(Mit (b) anylbing witb tbem—dress or un-. FiG. 174. Fig. 175. 174 and 175.—Spinal progressive muscular atrophy.(Personal observation.) 378 DISEASES OF THE NERVOUS SYSTEM dress himself; but he sometimes learns to help himself, at least in somedegree, by throwing movements, by motions of the trunk, by using hismouth in taking liold of things, etc. Quite rarely the atropliy finally attacksthe muscles of the neck. The severest respiratory disturbances, and lliiallya fatal termination, may be brought about liv an implication of the (liaj)hragmand other muscles of respiration. The time which elapses before the gradual appearance of the more markeddisturbances of function is almost always very long. Years may elapse be-fore the atrophy extends from the small muscles of the hand to the othermuscles of tlie arm. In the muscles of the legs the first signs of atropliyalmost always develop very late, if at all. The arms are often perfectly use-less when the patient can s
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