Trophoneurosis of the Skin CAUSED BY INJURY TO THE MEDIAN NERVE. AT THE TENTH ANNUAL MEETING OF THE AMERICAN DERMATO- LOGICAL ASSOCIATION. BY G. H. TILDEN, M.D. [Reprinted from Journal of Cutaneous and Venereal Diseases, Vol. IV., October, 1886.] NEW YORK: WM. WOOD & CO., PUBLISHERS, 56 & 58 LAFAYETTE PLACE. 1886. Trophoneurosis of the Skin CAUSED BY INJURY TO THE MEDIAN NERVE. READ AT THE TENTH ANNUAL MEETING OF THE AMERICAN DERMATO- LOGICAL ASSOCIATION. BY G. H. TILDEN, M.D. [Reprinted from Journal of Cutaneous and Venereal Diseases, Vol. IV., October, 1886.] NEW YORK: WM. WOOD & CO., PUBLISHERS, 56 & 58 LAFAYETTE PLACE. 1886. TROPHONEUROSIS OF THE SKIN CAUSED BY INJURY TO THE MEDIAN NERVE. EF., 55 years of age, a carpenter by trade, was wounded in the wrist by a circular saw on November 10, that is, exactly four months before coming under observation. The linear cicatrix resulting from this wound is about two and one-quarter inches in length, and its direction parallel to the long axis of the arm. It is situated on the flexor surface of the right wrist at about the middle line, and being slightly curved, its convexity is directed toward the ball of the thumb. The wound was sewed up immediately after the accident, and union took place in about ten days, at the end of which time the stitches were re- moved. Three or four days after the infliction of the injury, the patient began to be conscious of a loss of tactile sense and feeling of numbness in the last two phalanges of the fore and middle fingers, which disturb- ance of sensation has continued and steadily increased in severity ever since. There was also evident, at first, a similar feeling of numbness in the thumb, but to a less degree, which has been gradually diminishing, and is now no longer experienced. About three weeks after the accident, there appeared for the first time a bulla, situated upon the terminal phalanx of the index finger, and since then similar lesions have developed from time to time upon the last two1 phalanges of the fore and middle fingers. These bullae are about the size of a pea, their epidermal covering is tense, and they are filled with a clear serous fluid. They make their appearance every two or three weeks, are unaccompanied by any subjective sensation, being rapidly de- veloped, generally during the night, and do not increase in size after having once been formed. The region of the skin upon which they are situated is reddened to a slight degree before they make their appearance. Removal of their epidermal covering discloses a superficial excoriation which heals in a week or ten days. When several of these lesions have been developed successively in the same spot, there is finally produced a condition of thickening and accumulation of epidermis, a true tylosis, such as is shown on the side of the forefinger in the portrait, and it has been the custom of the patient to pare down these accumulations of epi- dermis with a razor. About two weeks before I first saw him, the largest 4 Tilden, Trophoneurosis of the Skin. bulla which had yet appeared was developed, giving rise to the ulcer situ- ated on the inner side of the tip of the forefinger. The skin in general over the last two phalanges of the affected fingers, more particularly on their dorsal surfaces, is tense, of a white color and glossy texture, while these fingers upon palpation offer a sense of solidity, of greater resistance and less elasticity of tissue than is furnished by the other fingers. The growth of the nails is unaffected. The region of the cicatrix in the wrist is somewhat sensitive to pressure, and there is entire loss of sensation in the last two phalanges of the fore and middle fingers. Dr. W. N. Bullard kindly examined the patient for me with reference to a more exact determination of the condition of the hand as regards loss of sensation, motive power, and reaction to electric stimulus. In the portion of the hand designated by light shading there was par- tial anaesthesia, the patient being able to distinguish between the point and head of a pin. In the last two phalanges of the fore and middle fingers, the region indicated by dark shading, there was total anaesthesia and analgesia, inability to make distinction between two points and one, and absence of the temperature sense. Tested by the dynamometer, the right hand was capable of exerting but one-half the force of the left. The reaction of all the muscles in the anaesthetic region was diminished to the faradic current, while the galvanic current excited the so-called degeneration reaction in the first and second interossei muscles. Six weeks' treatment, in the shape of the application of the faradic current to the hand and forearm, caused decided improvement in all the symptoms, both subjective and objective. The power of motion and muscular force increased, the sensation of numbness in the fingers became much less marked, while the tenderness upon pressure over the cicatrix in the wrist, disappeared entirely. But one bulla was developed during the time of treatment, and the ulcer on the forefinger nearly healed. Tilden, Trophoneurosis of the Skin. 5 The patient then gave up treatment and resumed work, using his right hand to manipulate a hammer. No particular change in the im- proved condition of the hand was noticed until the end of about three weeks, when quite suddenly all the subjective symptoms reappeared, the fingers became stiff and their power diminished, the feeling of numbness in them returned, while the sensitiveness to pressure upon the cicatrix in the wrist became again manifest. I saw him at this time, and a freshly formed bulla had developed upon the back of the second phalanx of the middle finger. The ulcer which had formerly existed on the inner side of the forefinger was transformed into a crater-like callus, the thickened epidermis being arranged in concentric rings around the cen- tre, which presented a small blood crust covering an excoriation. The whole skin of the end of the forefinger was extremely thickened and in- durated, doubtless on account of the friction caused by the use of the hammer, these changes in the epidermis being apparently much greater than could have been occasioned by the same amount of friction applied to normally innervated skin. The hand was in fully as useless a condition as when he was first seen, all that had been gained by treatment having been lost. It was proposed to the patient that an incision be made in th e region of the cicatrix, with the intention of finding out the exact condition of things, and if possible to remedy them. This was the last time I saw him, although he promised to return after having made up his mind as to the operation. The evidence that there are nerves which control in some way the nutrition, the growth and repair of tissue, is a matter of inductive rea- 6 Tilden, Trophoneurosis of the Skin. soning rather than of anatomical demonstration. Whether these nerves exist as individual and special nerve fibres, or whether the motor and sen- sory nerves are the ones by which the nutrition of tissues is governed, is unknown. The latter seems to me to be the more rational view, namely, that the so-called trophic influence is transmitted from the nerve centres and ganglia to the tissues by the motor and sensory nerve fibres, and that interference with the conducting power of these nerves, by disease or in- jury affecting them at some part of their course-as well as disease of the ganglia and central nervous system-may disturb, not only motor power and sensation, but also the nutrition of tissues. That it always does so is by no means the case, but why trophic changes should take place in one instance and not in another is not clear. Leaving out of consideration instances of trophic changes in the skin due to disease of the nervous system, the most notable examples of which are furnished by zoster, perforating ulcer of the foot, some forms of leprosy, and so-called symmetrical gangrene, cases of similar changes in the skin caused by injury to the nerves are not uncommon, a number of instances being given by Mitchell and by Leloir. Such changes are more apt to follow partial injury to a nerve than complete section thereof, and there very commonly exists in these cases a condition of chronic irritation of the injured nerve fibres, occasioned by pressure, constriction, or inflammatory processes. A noteworthy example of this is furnished in a case reported by Paget, in which the median nerve was compressed by a large callus, resulting from fracture of the lower end of the radius. "The thumb and first and second fingers ulcerated; and the ulcers resisted all treatment until the wrist was kept bent in such a way as to relieve the nerve from pressure. The ulcers re- turned whenever the hand was allowed to resume its former position." The changes in the skin commonly seen in these cases are the condi- tion of so-called glossy skin and vesicular and bullous eruptions, followed by superficial ulcerations, which, as a rule, readily heal. Tylotic changes may occur as in the present instance. The treatment in these cases con- sists in the application of electricity to the injured nerve, and of blisters over the seat of injury. A last resource is to cut down upon the affected nerve, and endeavor to relieve by surgical means any constriction of or pressure upon the nerve which may be found to exist. If no such con- dition of things can be detected, resection of a portion of the nerve might be advisable, since complete section of a nerve is not likely to be fol- lowed by spontaneous trophic changes, and since, according to Leloir, it has been found by Brown-Sequard and Verneuil that resection of portion of the affected nerve is sometimes followed by the arrest of trophic changes.