A Case of Painful Subcutaneous 
Neuroma (Neuro-Fibroma). 
BY 
J. ABBOTT CANTRELL, M.D., 
OF PHILADELPHIA. 
Read in the Section of Dermatology and Syphilographv, at the Forti- 
eth Annual Meeting of the American Medical Association, 
June, 1889. 
Reprinted from “ The Journal of the American Medical 
Association,” April 12, 1890. 
CHICAGO : 
Printed at the Office of the Association. 
1890. A Case of Painful Subcutaneous 
Neuroma (Neuro-Fibroma). 
J. ABBOTT CANTRE IjE'/m.I)., 
OF PHILADELPHIA. 
Read in the Section of Dermatology and Syphilography, at the Forti- 
eth Annual Meeting of the American Medical Association, 
June, 1889. 
Reprinted from “ The Journal of the American Medical 
Association,” April 12, 1890. 
CHICAGO: 
Printed at the Office of the Association. 
1890. A CASE OF PAINFUL SUBCUTANEOUS 
NEUROMA (NEURO-FIBROMA). 
Jack C., 29 years of age, was born, and has al- 
ways lived, in New Jersey. He is a farmer by 
occupation, although obliged to retire temporarily 
at times, on account of the distress in the arms. 
His previous health was always excellent, and 
with the exception of a sister, his family have 
never presented a similar disease. 
He noticed, for the first time, about fourteen 
years ago, a small round nodule on the left arm, 
accompanied with intolerable itching, but with- 
out pain. This nodule increased in size, slowly 
but steadily, reaching its present dimensions in 
about four years, by which time there four new 
and smaller lesions in the same vicinity. In eight 
years after the appearance of the first nodule a 
solitary lesion was noticed on the right arm cor- 
respondingly, which in four years was accompa- 
nied by five others. The man does not know ex- 
actly when the pain first began, but believes it 
was between four and five years after the appear- 
ance of the first tubercle. 
This man presented himself for treatment at 
the clinic in April, 1889, showing the lesions on 
both arms about midway between the tip of the 
shoulder and a point corresponding to the inser- 
tion of the deltoid muscle, being grouped on each 
arm, those on the left arm being five in number, 
the larger occupying the centre of the group, 4 
and being the size of a pea, while the others sur- 
rounding it were about the size of a pin’s head. 
Those on the right arm were similar in size, 
but there were five surrounding the central figure. 
The lesions are separated, one from the other, by 
about 5 or 6 lines. They are firmly situated in 
the skin and movable only with it. They cer- 
tainly must run down into the subcutaneous tis- 
sue. They are elevated between 2 and 5 lines 
above the surrounding skin; the skin covering 
them is tightly drawn, being very smooth and 
shining brightly. The epithelium seems intact. 
The skin over the top of the larger lesions is of 
a yellowish pink, while at the base it is almost a 
purple; the smaller lesions are normal at the base 
but yellowish at the summit. All the lesions are 
perfectly round, the larger one looking as if a pea 
had been placed under the cuticle and was holding 
it out beyond che surrounding skin. 
Surrounding the lesions the skin looked entire- 
ly healthy, there not being a single dilated capil- 
lary visible, as might have been expected. 
At the appearance, and during the continuance 
of the pains, there was no change of color, al- 
though the part became warmer than usual, re- 
maining so for a short time after its subsidence. 
Cold and heat, from what I could learn, did not 
affect him in the least, but if slightly touched a 
great amount of pain was experienced. There is 
surely a deep connection with a branch of the 
brachial plexus. 
The pains, for which trouble he applied for 
treatment, were of a paroxysmal nature, and con- 
stituted the whole distress. They began by ap- 
pearing slowly about four years after the appear- 
ance of the first tubercle and got worse as the 
disease progressed. I did not see him in any of 
the paroxysms, but from what he says I could 5 
readily imagine the greatest torture. The pains 
at times resembled an aching tooth, beginning 
with a throbbing sensation, and getting gradually 
worse, at last giving several great jumps almost 
causing him to fall to the floor. These pains lasted 
from fifteen minutes to one-half hour, but were 
quite frequent during the day, and always worse at 
night, which only happened once or twice a week. 
The friction of his wearing apparel kept up a 
continual pain throughout the day, and at night 
the bedclothes could not be borne on the arms. 
When suffering from the worst pains he is obliv- 
ious to what is transpiring around him. If per- 
chance the lesions be violently struck, or the arm 
be given a sudden jerk, the spot feels as if a sharp 
pointed instrument had been inserted, almost 
causing syncope, while the pain would last several 
hours; in fact, sometimes lasting all through the 
day—causing him to be constantly on the move 
and trying to forget it by the best possible means. 
If the lesions are handled slightly, as when exam- 
ined, there is considerable pain. 
He says he dislikes to go to bed on account of 
not being able to lie on either side, and fearing 
to lie on his back, lest in a moment of restlessness 
he may turn over on either arm, and be awakened 
suddenly as if he had been struck a sudden blow, 
so on account of this, when the pains were at their 
worst he occupied a large armchair and a footstool. 
The day preceding a storm he feels very restless 
and uncomfortable, but on the appearance of the 
storm he is no worse. He feels very comfortable 
in settled weather, be it warm or cold. 
In a careful search of the literature of the sub- 
ject, I was only able to find four cases that present 
any similarity to the case of to-day—those of Duh- 
ring, Kosinski, John Ashhurst, Jr. and Jonathan 
Hutchinson, Jr. Most of the other and previous 6 
cases I feel are examples of the ‘ ‘ painful subcu- 
taneous tubercle.” 
Duhring’s case, a man 70 years of age, first no- 
ticed the disease ten years previously; it occupied 
the left scapular region, shoulder, and the outer 
side of the left arm as far down as the elbow, com- 
pletely covering these parts. 
Kosinski observed it in a man 30 years of age, 
who noticed it for the first time when 16 years of 
age, when it occupied the posterior and outer side 
of the right thigh, as far down as the lower third, 
and a portion of the buttock. There were as many 
as a hundred lesions. 
In 1883 John Ashhurst, Jr., amputated the thigh 
between the middle and lower third. The flaps 
sloughing, a reamputation was necessary. With- 
in a year, a small lump, tender to the touch, ap- 
peared in the skin, posteriorly and a little to the 
outer side of the stump. 
Jonathan Hutchinson, Jr., reports a neuroma of 
the parotid in a girl 20 years of age. 
I had hoped to-day to show microscopical sec- 
tions of my case, but the man proving obstinate, 
would not allow me the privilege, so I will make 
the best of the bargain by giving the microscopi- 
cal reports of the other cases, and show by them 
the fibroid nature of all these cases. 
That of Duhring showed the “ corium to be in- 
filtrated with a new connective growth, which was 
firm in structure. The tissue, beneath and in the 
mass of the specimen, consisted of a solid, resist- 
ant-looking connective tissue, irregularly devel- 
oped and uneven in arrangement. The bulk of 
the tissue was old in appearance and fitted to- 
gether, the new cell elements being entirely want- 
ing, the connective tissue fibrils being closely 
packed in places, forming wave-like bands. There 
were also numerous free fibrils of elastic tissue 7 
scattered here and there, and there were no nerve 
trunks or branches found in the mass.” 
In Kosinski’s case, “the mass showed a con- 
sistence of gray nerve fibrils with a great quan- 
tity of a dense fibrous tissue, interspersed with 
some connective tissue.” 
Ashhurst found “interiorly in the tumor a 
somewhat elastic, rather dense-looking growth of 
whitish color, over which passed yellowish fibres, 
probably strands of the scaled nerve. Microscop- 
ically the interior showed an entire absence of 
nervous elements and a section exhibited fat cells, 
abundant fibrous tissue, some spindle cells and 
numerous free nuclei near the enlarged and di- 
lated blood-vessels.” 
Hutchinson came to the conclusion, after a very 
exhaustive examination, that his case was un- 
doubtedly of a fibroid nature, while it consisted 
of connective and a quantity of fibrous tissues. 
With a summary of these four cases, all of 
which showed in their microscopical examina- 
tions a structure consisting of fibrous and con- 
nective tissues, resembling those of the human 
body, also all sections of heretofore examined 
fibromatous tumors, I cannot but feel that to 
place them with the fibromata would certainly be 
to place them where they belong—calling them 
neuro-fibromata.