Postgrad Med J: first published as 10.1136/pgmj.24.271.264 on 1 May 1948. Downloaded from 264 POST GRADUATE MEDICAL JOURNAL May 1946 portant that the physiotherapist should supervise Mrs. G. F., aged 53, housewife. The right and the movements and make sure that the metacarpal left bones were excised in November, I945 (Fig. I). is again moved through a full active range at the She is now very satisfied and has no pain, but new joint. states that her hands are not quite so strong for This treatment is continued until the patient turning taps as previously. The radiographs can return to light work, which is usually a matter taken in January, 1948, show a satisfactory result of four to six weeks. Some patients complain of on 'the right, but on the left a fragment of the pain for longer than this, but others are surpris- trapezium remains in situ (Fig. 5). It is interest- ingly pain free; one started milking cows within ing to note how this fragment has increased in a month of operation. size since the film taken one year after operation (Fig. 6). Results and Case Reports Miss E. W., aged 46, sempstress. Four years of All the patients have been very satisfied with the pain and difficulty in carrying out her work. The results of the operation, and have reported im- right trapezium was excised in April, 1944. She proved function and little or no pain. Removal has been working full time since with no pain. of the trapezium leaves the thumb a little weaker Miss N., aged 58. Symptoms following an in- than the normal, but a full range of movement of jury nine months before. Pain on using. left the metacarpal is regained with no obvious thumb and a marked cystic swelling over the deformity. trapezio-metacarpal joint (Fig. 3). The trapezium Mr. E. B., aged 48, farm worker. Pain and swel- was excised in April, i944. In 1948 she reported ling at the base of the right thumb which he dated that her thumb was quite satisfactory and she from an injury two years before. The right was very pleased that she had undergone the trapezium was excised in April, 1944. He worked operation. full time after this, but attended again in I947, Mr. Q. W., aged 62, retired, is an example of ihe complaining of pain in the left thumb (Fig. 2). results in older patients. He gave a history of in The left trapezium was excised February, 1947. pain over a period of five years. with unsuccessfulby copyright. He was able to do full work inside two months and treatment by physiotherapy. The right trapezium has been doing full farm work since. He states was excised in February, 1947. He now amuses there is no pain and he can do anything. On himself sawing up logs. examination in January, I948, there was a full and painless range of movement with good power in BIBLIOGRAPHY GERVIS, W. H. ('947), Proc. Roy. Soc. Med., 40; 492. both thumbs, but slight crepitus on movement on RAY, M. B. (I933), Proc. Roy. Soc. Med., 27, I93. the right side (Fig. 4). FORESTIER, J. (1927), La Presse Medicale. http://pmj.bmj.com/

MEDIAN COMPRESSION IN THE on September 23, 2021 by guest. Protected By P. H. NEWMAN, D.S.O., M.C., F.R.C.S. Assistant Orthopa dic Surgeon, The Middlesex Hospital, A4sista at Surgeon, Thv Royal National Orthopaedic Hospital-

The carpal tunnel is a very confined space. It and the hook of the hamate, and on the lateral has been designed as a trough with a hard floor side, of the tubercle of the scaphoid and the ridge and rigid bony walls in order to protect the im- on the trapezium, have stretched across between portant structures within its confines. But for their peaks a fibrous sheet forming a roof known this anatomical arrangement, it is unlikely that the as the transverse carpal ligament. This is a tough flexor tendons with their delicate sheaths and the structure giving additional protection and acting could withstand the trauma of re- as a bar to forward prolapse of the structures when current falls on the outstretched hand. The walls, the wrist is in fiexion. which consist on the the medial side of the pisiform The tendons and nerve pass from the loose en- Postgrad Med J: first published as 10.1136/pgmj.24.271.264 on 1 May 1948. Downloaded from May 1948 NEWMAN: Median Nerve Compression in the Carpal Tunnel 265 vironment of the soft tissues ofthe forearm through a directly traumatic nature. Briefly speaking the this bottleneck into the comparative freedom of the changes in order of severity are: palm. As the price of protection from exposure to I. Oedema of nerve without loss of conductivity. danger at this point, they forfeit as it were their 2. Transient paralysis with spontaneous liberty of expansion and freedom of movement recovery. other than that which is essential for the function 3. More severe loss of function with slow of the hand and fingers. There is no place for an recovery after release of pressure. abnormal body or for any hypertrophic process 4. Complete loss of conductivity without the within this tunnel. possibility of recovery, due to total nerve Acute compression of the median nerve at this degeneration. level occurs from forward dislocation of the lunate Recently Brain, Wright and Wilkinson (I947) bone (Fig. i), and may occasionally occur in other have described symptoms of carpal tunnel com- injuries of the carpus with displacement. In a pression of the median nerve arising spontaneously comminuted Colles' fracture a fine spicule of bone in six patients. In no case was there any obvious may project forwards between the flexor tendons encroachment upon the space of the tunnel. The and impinge directly on the median nerve. A patients were all women in the second half of life more insiduous onset of symptoms due to com- and five were occupied in household duties. pression may occur as a result of hypertrophic Experimentally a tambour was placed in the arthritis of the wrist as from an old fracture of the carpal tunnel of a cadaver and it was found that scaphoid (Fig. 2), or even from a malunited Colles' the tension was three times greater when the wrist fracture. In these cases there is some process was extended to a right angle than when flexed to which takes up space within the tunnel and undue the same degree. They point out that the duties pressure falls upon the normal contents. The of a housewife necessitates much work with the tendons derive some protection from their sheaths wrist in the extended position and they consider and do not register symptoms of lateral com- that this, combined with some degeneration in

pression unless it be severe. The nerve has no the artery of the nerve, is responsible for the com- by copyright. such sheath, is anchored laterally and is sus- mencement of a vicious circle of oedema and in- ceptible to alteration in pressure. creasing tension. Denny-Brown and Brenner (I944) in two articles have given the results of experiments in which Clinical Types different degrees of pressure were applied to peri- Clinically three types of compression of the pheral . They found that the effect on con- median nerve in the carpal tunnel are found. ductivity of the nerve varies considerably according Firstly, an acute traumatic type associated with to the degree of pressure and the length of time injuries such as anterior dislocation of the lunate

during which it is applied. The pressure plate bone; the symptoms recover with replacement of http://pmj.bmj.com/ was i i mm. in length. In one series of experi- bone, provided that this is not delayed too long. ments, if a light pressure of 5 to 7 gm. was applied Secondly, slow compression of the nerve of continuously there was no interference of con- spontaneous onset. Thirdly, slow compression duction, but narrowing of the nerve occurred at secondary to malunion or arthritis in the region. the site of pressure with swelling above and below the site of pressure. An increased pressure of 9 Symptoms and Signs of Slow to io gm. was attended with impairment of motor Compression function within six days and progressed to com- The symptoms are generally those of weakness of on September 23, 2021 by guest. Protected plete paralysis shortly afterwards. If, however, the hand and loss of the power to grip, especially the pressure was continued, the nerve overcame with the thumb. There may be a history of drop- this critical stage and function returned slowly. ping such articles as a cup of tea or saucepan. At the site of pressure, ischaemic and degenerative Tingling or pins and needles are felt over the changes took place, but there was no nerve or median nerve distribution. Pain is common and muscle degeneration distal to this area. extends from the thumb or index finger below, to Continued pressure for several days of 44 gm. the forearm, upper arm or even to the neck above; was followed by complete loss of all conductivity it is worse at night and aggravated by carrying and degeneration of the nerve both distally and for heavy objects. It is sometimes relieved by working some distance proximally. Release of pressure was the fingers and wrist backwards and forwards. not followed by return of function. Compression The following signs may be found in cases of by much greater pressure, e.g. 430 gm., for only this sort: two hours, was followed by recovery in about two i. Wasting of the , especially weeks. They came to the conclusion that all the the outer half. changes found were of an ischaemic rather than of 2. Sensory loss in the median area. DI Postgrad Med J: first published as 10.1136/pgmj.24.271.264 on 1 May 1948. Downloaded from 266 POST GRADUATE MEDICAL JOURNAZL Ma)Y94

. - i ''vffl - ...... -..*. .

FIG. i.-Forward dislocation of the lunate bone as- FIG. 2.-Radio-carpal arthritis secondary to old fracture sociated with median nerve palsy. of the right scaphoid (Patient C). by copyright.

3. A localized swelling proximal to the trans- The latter is a synergist with the Extensor Pollici3 verse ligament. Longus. 4. - Loss of power of extension in the outer Treatment three digits. For cases of slow onset, whether secondary to a 5. Impaired movement of the wrist and radio- space-occupying lesion process or of apparently logical changes, only in the secondary spontaneous origin, incision of the transverse liga-

type of slow compression. ment is a rational procedure. A vertical midline http://pmj.bmj.com/ Wasting of the thenar eminence occurs typically incision is made, extending no further than the in the Abductor Pollicis Brevis and Opponens. It proximal boundary of the transverse ligament to may occur in the Flexor Pollicis Brevis, as the avoid placing the scar on the important pressure nerve supply of this muscle varies. Highet (1943), area in front of the carpus. As soon as the in- studying war wounds of the median nerve, found cision is made the median nerve is generally at that the Flexor Brevis is supplied four times in once obvious, grossly swollen and prolapsed, ventrally to lie immediately beneath the deep five by the . The two lateral lum- on September 23, 2021 by guest. Protected bricals are also affected, but this paresis is very fascia. The 'distal end of the skin incision is difficult to detect clinically. lifted up and the transverse ligament incised Sensory impairment can often be detected over subcutaneously in a vertical direction. The' the distal phalanges and includes light touch and nerve beneath the ligament is compressed, In' discrimination, temperature and pain. More marked contrast with the swollen proximal extensive sensory loss may occur. segment. The swelling proximal to the transverse ligament Differential Diagnosis is sometimes very obvious and may resemble a The conditions which may give rise to confusion compound palmar ganglion. It is, however, more do so because they cause pain, wasting, or local localized and has no fluid thrill. The swelling in swelling. The fact- that the primary type of com- the palm is negligible. pression occurs as a bilateral condition in middle Loss of extension of the thumb, index or middle. aged women doing heavy housework- helps- to fingers has been reported in some cases. This eliminate some of these condition. The secondary may be explained by the paralysis of the lateral type shows radiological signs of old injury or two lumbricals or of the Flexor Pollicis Brevis. arthritic 'changes and is generally unilateral. Postgrad Med J: first published as 10.1136/pgmj.24.271.264 on 1 May 1948. Downloaded from May 1948 NEWMAN: Median Nerve Comnpression in the Carpal Tunnel 267

K . rs ...... IG3Ths:-i0¶anso1Ptenh 1hoig0^

S.- ~~~~~I -Iz,- :

FIG. 3.-The hands of Padent B. showing grosspn wtasting of the thenar eminences. hea w by copyright.

i~~~-, *.010 ll....

.... R'...... http://pmj.bmj.com/

...'...... on September 23, 2021 by guest. Protected

FIG.- 4. h enare meia nev seen' at opra

FIG.(Pten4.elreThe middlrereenracto popera- to the nenrve. Note the thenar wasting. Postgrad Med J: first published as 10.1136/pgmj.24.271.264 on 1 May 1948. Downloaded from 268 POST GRADUATE MEDICAL JOURNAL May 1948 (i) The pain may be simulated in the cervical Examination showed wasting of the Abductor rib syndrome. Usually such pain radiates down Pollicis Brevis, Opponens Pollicis and, possibly, the inner border of the forearm, wasting may occur a part of the Flexor Brevis on both sides, but more in muscles supplied by the ulnar nerve, and marked on the right. There was a noticeable vascular phenomena may be present. Sometimes, swelling proximal to each transverse ligament, of a however, paraesthesiae and lateral forearm pain doughy character and extending for two to three with thenar wasting occur and give rise to con- inches. There was impairment of light touch, siderable confusion. There is no local swelling pain and temperature sensation over the terminal and no radiological changes are seen at the wrist. phalanges of the lateral three and a half digits. For a more detailed differentiation the reader is This sensory loss was bilateral and the remaining referred to the article previously mentioned by one and a half digits were normal. The X-ray Brain, Wright and Wilkinson (I947). showed no abnormality. In lesions of the 6-7 cervical disc which involve At operation the transverse carpal ligament was the seventh cervical root, lateral arm pain and incised on both sides. A large swollen nerve was paraesthesiae occur and sensory changes in the found lying immediately deep to the deep fascia; thumb index and middle fingers are common. under the ligament iteself it was constricted. Thenar wasting, however, is not present. Six months after operation the tingling had Stenosing tendo-vaginitis of the sheath of the gone, she was no longer kept awake at night and Flexor Longus Pollicis over the head of the first power was slowly recovering. On examination metacarpal often causes pain over the thenar there was still considerable wasting in the outer eminence and up the flexor aspect of the forearm. half of each thenar eminence. If the condition advances to a snapping thumb Patient B was a man aged 59, a leather worker the diagnosis is clear. Otherwise the only local occupied in hand-stitching. He had noticed loss signs may be slight nodularity and tenderness in of power in the right thumb for four years and in the line of the tendon at the level of the basal the left for six months. Recently he had had pins on flexion of in in cold crease of the thumb, with pain the and needles his fingers, especially wetby copyright. thumb against resistance. weather. Pain in the fingers and arms kept him (2) Thenar wasting may be simulated by lower awake at night. motor neurone lesions such as anterior polio- Examination showed gross wasting of the outer myelitis. Such wasting, however, extends beyond half of the right thenar eminence and to a slightly the outer half of the thenar eminence and there is less degree on the left (Fig. 3). There was no sensory loss. blunting of light touch and pain sensation over (3) A local swelling may be produced by lesions the terminal phalanges of the lateral three and a such as the common ganglion arising from a half digits. The X-rays showed no abnormality.

carpal joint; degenerative changes along the At operation a grossly swollen nerve was found http://pmj.bmj.com/ sheath of a deep tendon such as the Flexor on the right side and a slight degree of swelling on Pollicis Longus; compound palmar ganglion, and the left. The carpal ligament was incised on both rare local conditions such as a parosteal lipoma or sides. Three months after operation there was small haemangioma. It is most unusual, however, no recovery of muscle power or wasting on either for any of these conditions to be associated with side, but the tingling and night pain had gone. thenar wasting, though some median sensory Patient C was a man aged 42. Twenty years changes may occur as a pressure effect. ago he sustained a fracture of the scaphoid. Sub- sequently the proximal fragment showed aseptic on September 23, 2021 by guest. Protected Case Reports necrosis and secondary arthritis developed in the Three patients with slow compression of the wrist. The proximal fragment was excised some nerve have come under my care. Two cases were time later. For the past six months he had noticed of the spontaneous type and the third was pain in the other palm and fingers of the right secondary to an old fracture of the scaphoid. hand. The pain was worse at night and radiated Patient A was a woman aged 66, occupied with up the forearm. He complained of some loss of house duties. Six months previously she had power in the thumb, but the pain was his major noticed pins and needles while knitting, in the concern. palms and tips of the fingers. Pain came on later There was severe limitation of movement at the and kept her awake at night; it was relieved by wrist joint. There was some wasting of the outer flexing and extending the fingers. She had part of the thenar eminence. Movements of the frequently dropped things and had noticed loss fingers were normal. No obvious loss of sensa.- of power, particularly in the thumbs. There had tion was detected in the fingers. The X-rays been a dull ache in the arm and neck and she had showed marked arthritic changes in the wrist simultaneous headache. joint (Fig. 2). Postgrad Med J: first published as 10.1136/pgmj.24.271.264 on 1 May 1948. Downloaded from May i948 STEVENSON: Multiple Myelomatosis 269 At operation the median nerve was found BIBLIOGRAPHY swollen above and constricted beneath the trans- BRAIN, W. R., WRIGHT, A. D., WILKINSON, M. (I947), verse ligament (Fig. 4). The ligament was in- Lancet, I, 277 (see correspondence following, p. 387). DENNY-BROWN, D., BRENNER, C. (0944a), Arch. Neurol. cised. Three months after operation there were no Psychiat., 5I, I, and 52, I. pins and needles and no pain. Power had improved ELLIOTT, F. A., and KREMER, M. (1945), Lancet, I, 4. little but the patient was entirely satisfied. HIGHET, W. B. (1943), Lancet, i, 227.

MULTIPLE MYELOMATOSIS A Clinico-Pathological Review, with a Report of a Case of Myeloblastic Type By HARWOOD STEVENSON, M.D., M.R.C.P. Visiting Physician, Thc Royal National Orthopaedic Hospital, Stanmore

Bear this disease in mind when treating pains sternum and spine were found to be soft and of the limbs of an obscure and intractable brittle and the latter collapsed to such a degree character.' This was said by Thos. Blizard that the bodies of the lumbar vertebrae were Curling, F.R.S., Surgeon to the London Hospital, scarcely thicker than those of the cervical. Dal- to William Macintyre i00 years ago. The quota- rymple found the tumours which had so largely by copyright. tion is from the paper in which Macintyre pub- replaced the bones to contain ' oval cells with a lished at his leisure in i850 the clinical history of faint grey nucleus and a bright and distinct a case which had been noted to have ' urine of nucleolus.' He also described and illustrated with high density containing much animal matter, but wood-cuts cells with two, three or four such without dropsy or cerebral disturbance.' The nuclei. He commented that there was no new animal matter had been found to have unusual bone formation as in osteo-sarcoma. He differ- properties. The urine clouded on heating, cleared entiated these cells from pus cells by their power on boiling and coagulated on cooling again. of self-reproduction and described them as Furthermore, it did not coagulate with nitric acid ' nucleolated nuclear cells capable of reproducing http://pmj.bmj.com/ until it had stood for an hour or two. Then the their kind.' He thought the disease was truly coagulum cleared on boiling but solidified again malignant. on cooling. This strange behaviour had already These three papers all refer to earlier reports of been reported by Dr. Bence-Jones in i848. It is cases of MIVollities Ossium, a term which covered a of great interest to read the original papers in- considerable group of conditions. Macintyre's cluding the still earlier description of the morbid references show the difficulty of accurate differ- anatomy of the same case by Dalrymple in i845. ential diagnosis without biochemical aids. He on September 23, 2021 by guest. Protected The combined reports of the clinician Macintyre, refers to the term ' Medullary Gout' said to have the pathologist Dalrymple and the biochemist been used by Saillant of Paris in I792, which Bence-Jones made this the most completely re- suggests no more than pains in the bones with ported case at that time and have led to its hollow spacses. We are on firmer ground, however, designation as the first definite case, of multiple when we come to Howshipp (1826). myelomatosis. He described a woman of 35 whose history lasted for Macintyre tells the story of his patient with the six years with ' stooping rolling gait,' pain in the bones, humanity and feeling which at that period had not tenderness of the ribs, spontaneous fractures of both been banished from scientific papers. The account femora and massive albuminuria of undetermined type. is a model of accuracy and At necropsy the femora, pelvis, lower parts of the clarity from the moment tibiae, bodies of lumbar and dorsal vertebrae, ribs and when his patient while on holiday' vaulting out of sternum, could all be cut freely. The cortical bone was an underground cavern' falls to the ground with in many places reduced to egg-shell thickness and the great pain in the chest and severe dyspnoea-his bones contained cavities filled mostly with soft material first spontaneous varying in colour from dark blood to liver. The com- fracture-to the day when the bination of pain, fractures, the bones affected- their story is completed by the pathologist. The ribs, cavitation and the length of history make either hyper-