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obliterated, so that the nerve occu¬ carpal grooves. There is also well-
pies a comparatively superficial po¬ marked atrophy along the ulnar
sition. It is about two and a half side of the hypothenar eminence and
times the thickness of the normal of the adductor pollicis. The wast¬
nerve, and this spindle-like enlarge¬ ing is also very apparent on the
ment may be palpated an inch above palmar aspect of the hand. She can.
and below the internal condyle. extend, fairly well, the distal and.
Pressure on the nerve at this point middle phalanges of the right hand,
produces a tingling sensation in the but is unable to separate or approxi¬
ulnar distribution. mate the little or ring fingers, or
The urine is normal; the Was¬ flex the basal phalanges. There is
sermann reaction is negative, and slight power of contraction in the
roentgenoscopy of the neck region abductor minimi digiti. Adduction
reveals an absence of cervical ribs. of the thumb is lost, as is also the
Comment.—This case is of inter¬ function of the palmaris brevis.
est because of the exceedingly long There is good ulnar flexion of the
interval of thirty-six years which wrist.
had elapsed between the injury to Sensory examination shows a
the joint and the onset of the first loss of epicritic sensibility to light
symptoms of ulnar neuritis. This tactile impressions, in the digital
fact, taken in conjunction with the distribution of the ulnar nerve. The
very slight disturbances of sensi¬ sensations of deep pain and ex¬
bility, and the gradual progressive tremes of temperature are. normal.
atrophy of the hand muscles, had There are no trophic or secretory
given rise to serious doubts in the disturbances.
minds of a number of neurologists Electric Examination : There is no
as to the real nature of the muscular Fig. 1 (Case 1).—Fracture of the external con¬ muscle response to galvanic or
atrophy, so that medical history re¬ dyle and valgus deformity of elbow. faradic stimulation of the ulnar
peats itself and the same doubts nerve at the elbow, except ulnar
which Duchenne had experienced regarding this type of case flexion of the wrist. The intrinsic muscles of the hand sup¬
finds its counterpart even in these days of neurologic plied by the ulnar do not react to strong faradic currents,
enlightenment. while strong galvanic currents produce vermicular response
The deformity of the elbow joint is of the type most com¬ with reversal of the poles (reactions of degeneration).
monly associated with the late paralysis, namely, an ancient Roentgen Examination (Dr. A. H. Busby) : Any evidences
fracture of the external condyle with resulting valgus of early bone injury to the right elbow joint are confused
deformity and alteration of the configuration of the ulnar by the changes of osteo-arthritis which are present. There
groove. No definite exciting cause could be found to explain is considerable hypertrophied bone in the region of the
the late onset of the neuritis. It appeared mysteriously and internal condyle and head of the radius (Fig. 2). The left
progressed insidiously without apparent reason, as is the elbow joint shows old fracture of the external condyle, with
usual history of these cases. moderate amount of callus formation. There are evidences
Case 2.—A saleswoman, aged 65, fractured right elbozv at of hypertrophie osteo-arthritis on the internal condyle and
the age of 16; fair recovery with insufficient power of flexion. head of the radius. Slight evidences of osteo-arthritb are
At the age of 55, that is, thirty-nine years after the injury, also present on some of the bones of the wrist and hand.
symptoms of ulnar neuritis appeared and progressed gradu¬ The general neurologic examination is negative. Pupils
ally, namely, weakness, atrophy and disturbance of epicritic react normally and the tendon and skin reflexes are normal.
sensibility limited to the ulnar distribution of the hand. Save for the atrophy of the right ulnar distribution, the
There is cubitus valgus, the ulnar groove is shallow and musculature is well developed and of good power. No fibril-
deformed, and the nerve is thickened. lary twitchings are noted at any time. The urine is free
History.—The patient is a saleswoman, aged 65, who was from albumin and sugar.
referred to me with involution melancholia of ten months' Comment.—This case presents the characteristic history
duration. Except for the occasional presence of rheumatoid and course of the tardy ulnar palsy. Unusual is the
SYMPTOMATOLOGY
ankylosed in semiflexion and the ulnar groove almost
obliterated. In a similar case described by Sherren,7
The late neuritis of the ulnar nerve does not differ old arthritis had followed measles terminating in
in symptomatology from other forms of progressive marked valgus deformity. It is -»¡ery evident in the
neuritis. As is usual in compression, the motor nerves arthritic cases, as in fractures, dislocations and epi-
are more vulnerable than the sensory fibers, motor
physeal separations, that deformity of the ulnar groove
symptoms dominating the clinical picture and often and cubitus valgus play the important rôle.
preceding any evidence of sensory involvement. Usu¬ THE ULNAR NERVE
ally there is an atrophie paralysis of gradual develop¬ the
ment with changes in the electrical excitability corre¬ Usually nerve is free and movable in
perfectly
sponding to the degree and duration of the muscle its shallow or partially bony groove, and is
obliterated
degeneration. The sensory symptoms, both subjective the seat of a fusiform swelling. This spindle-shaped
and objective, may be very slight, and when present tumefaction of the nerve is from 2 to 3 inches long,
are typically neural in distribution. Even in advanced its centra] portion corresponding in a general way to
cases, the anesthesia is of the epicritic type, the proto- the tip of the olecranon.
pathic sensibility being well preserved. In the absence In Murphy's8 case a small osteomalike growth was
of pain, this scarcely perceptible disturbance of tac¬ found beneath the nerve, and in Case 3 of my series,
tile sensibility may be overlooked and lead to the sus¬ a small cystic tumor. Such findings, however, are
rare and usually there is only the fusiform thickening
picion of progressive muscular atrophy, more espe¬ of the nerve in its shallow groove, associated with
cially as the wasting of the small muscles of the hand
is slowly progressive. valgus deformity of the joint.
Here, however, the absence of fibrillary twitchings In two of the recorded cases in which the diseased
and the strict limitation of atrophy to the ulnar nerve portion of the nerve had been excised during surgical
distribution, together with the disturbances of sensi¬ intervention (Sherren7), microscopic studies showed
bility, should be sufficient to remove all doubt and the presence of an interstitial neuritis with irregular
make the diagnosis clear. areas of sclerosis in the perineurium and endoneurium.
In the diagnostic differentiation, it may be well to In the sclerosed patches there was well-marked
recall the hypothenar type of neural hand atrophy atrophy of the nerve fibers.
from chronic pressure neuritis of the deep palmar
PERIOD OF LATENCY
branch of the ulnar nerve.4 This branch of the nerve
is purely motor, and the resulting atrophy is strictly The peculiar and unusual feature of this group of
cases is the long interval of time elapsing between
limited to the small muscles of the hand supplied by
the ulnar nerve. In this type, as in the tardy paraly¬ the original injury and the development of the first
sis, the course may be slowly progressive ; and with symptoms of ulnar neuritis. This may range all the
the absence of all sensory symptoms, both subjective way from six to thirty-five years. In one of my cases,
and objective, a clinical picture is produced which may thirty-nine years elapsed before the atrophy of the
hand muscles became apparent. The reasons for this
closely resemble an early stage of progressive muscular long delay are not definitely known.
atrophy. Attention, however, to the strictly neural It has, however, been pointed out that a similar
distribution of the atrophie paralysis and the absence
of fibrillary tremors will serve to make the diagnosis interval is usually present in cases of cervical rib,
clear. which, although a congenital deformity, usually gives
ETIOLOGY rise to no symptoms until adult life. It is not unlikely
that with the increase of connective tissue in later life,
The essential etiologic factor in these cases is the not only is there greater susceptibility to irritative
deformity and malposition of the elbow joint, usually
the result of fracture-dislocations in early life. The lesions, but also the nerve structures are themselves
less elastic and do not take so kindly to mild chronic
most frequent deformity is the cubitus valgus, which
in many cases is associated with evidences of old frac¬ irritative traumas, as in early life. The very vague¬
ness of these explanations only emphasizes our real
ture of the external condyle of the humérus. Moucher,5
in particular, has emphasized this combination of lack of knowledge as to the underlying factors. That
it is a mechanical and irritative reaction cannot be
lesions. doubted. So much is clear from the localization of the
In the cases with valgus deformity, there is also neuritic process and the corresponding joint changes.
some dislocation of the structures forming the ulnar
Elsewhere, I have described9 a neural type of thcnar
groove, the olecranon is often displaced inward, and atrophy from compression neuritis of the small thenar
the bony channel between it and the condyle is shal¬ branch of the median nerve, as it emerges from
lower than normal. As a result, there is produced an beneath the anterior annular ligament of the wrist.
alteration in the course and bony relationship of the
ulnar nerve in this region. 6. Webber: Zur Etiologie peripheralen Ulnaris und Medianus
L\l=a"\hmungen,Deutsch. Ztschr. f. Nervenh., 1899, xv, 18.
3. Huet: Neurites professionelles du nerf median et du nerf cubital 7. Sherren: Chronic Neuritis of the Ulnar Nerve Due to Deformity
chez un ouvrier menuisier porteur d'une ancienne fracture du coude, in the Region of the Elbow Joint, Edinburgh Med. Jour., 1908, xxiii, 500.
Arch. de Neurol., 1900, ix, Series 2, p. 531. 8. Murphy, J. B.: Neuroma of Ulnar Neuritis, the Result of Trauma
4. Hunt, Ramsay: The Thenar and Hypothenar Types of Neural Incident to Fracture at the Elbow Joint, Clinics, 1914, iii, No. 2.
Atrophy of the Hand, Am. Jour. Med. Sc., February, 1911. 9. Hunt, J. Ramsay: The Neural Atrophy of the Muscles of the
5. Mouchet: Paralysie tardive du nerf cubital a la suite des frac- Hand, Without Sensory Disturbances, Rev. Neurol. and Psych., 1914,
tures du condyle externe de l'hum\l=e'\rus,Jour. de chir., 1914, xii, 437. xii, 137.