[Reprint from Alienist and Neurologist, St. Louis, July, 1890.] 
An Unusual Case of Atrophy of the Skin. 
By A. H, Ohmann-Dumesnil, 
Professor of dermatology, 8t. Louis College of Physicians and Surgeons 
r more or less remote influence of the nervous 
system, as well as its direct effects upon processes 
occurring in the skin, have made this part of dermatology 
highly interesting. The anatomical investigations made in 
direct reference to this subject have tended to show a 
far reaching influence on the part of the nerves; and 
while results entirely different from each other are seen, 
there can be no doubt as to this origin in at least a large 
number of cases. Not only have these conclusions been 
reached by means of anatomical and pathological investi- 
gations, but confirmatory proof has been added in the 
form of experiments, in which the conditions were arti- 
ficially produced and were followed by the expected 
results, or rather by manifestations which had been fore- 
told, and thus a demonstration of the truth of the original 
proposition was furnished. There is a large class of 
diseases of the skin in which we find quite a number of 
representatives of those forms due to some organic or 
functional change in the nerves. The class in which we 
find so many manifestations of the potent effects of nerve 
influence, is that which includes the atrophic forms of 
disease, in which either the entire skin is involved or 
merely certain anatomical portions of it. While it is true 
that these neurotic changes or disturbances are not always 
its primary or remote causes, investigation will show that 
they are directly interested in the production of certain 
atrophic processes. The case which I propose to outline 
is one in which the neurotic origin of the process 
observed admits of no doubt, no more than the presence 
of the atrophic condition. This very fact is one which 
renders it interesting, as also the probable remote cause 
1 2 
A. H. Ohtnann-Dutnesnil. 
which was also determined with certainty almost. The 
case, in brief, is as follows: 
Case;—Grace B , when she presented herself at the 
clinic, was seven and a half years old. From the mother 
it was learned that five years previously she sustained a 
severe burn on the anterior aspect of the right wrist, 
towards the radial side and a little above the proximal 
extremity of the metacarpal bone of the thumb. The 
burn which was sustained was estimated to be of the size 
of a silver twenty-five cent piece. _ This was probably an 
exaggeration. Following this injury there was slight 
anaesthesia of the forearm. The mother further stated that 
the arms were of the same size, so far as she could 
determine, at the time of the accident. 
When examined by me in March, 1889, I found that 
hyperaesthesia existed to a limited degree, both in the 
forearm and upper arm, and this was more marked in the 
region supplied by the brachial and radial nerves. That 
is, hyperaesthesia was found on the inner and anterior 
aspect of the upper arm and on the anterior and outer 
aspect of the forearm. At the site where the burn had 
occurred a small ovalish scar existed, having the dimen- 
sions of a silver dime. 
The child appeared fairly well nourished, although 
inclined to be anaemic. She was rather small for her age. 
The teeth were good, and the skin normal, the hair growth 
being about the average. There were no indications of 
any syphilitic taint nor any marks to denote a strumous 
habit. 
The right arm presented atrophic rectilinear areas 
about three-eighths of an inch in width, and varying in 
length from three-quarters to two inches, situated upon the 
anterior surface of the arm and forearm, and apparently 
following or lying directly over the brachial and the radial 
nerves. These areas were five in number, the larger ones 
being situated upon the forearm. They were distinctly 
depressed, although this was more apparent to the sight 
than to the touch. The color was paler than that of the 
normal skin, but the presence of heat caused them to 
assume a higher color than that of the normal integu- 
ment. Fine blood vessels could be traced in these areas. 
Upon taking up the atrophied skin, its thinness in com- 
parison with that of the normal could be easily made out 
The right arm was also affected in another way Atrophy of the Skin. 
3 
There existed a certain amount of atrophy in the mus- 
cles, not only of the upper- arm and forearm but also of 
the thumb, the fingers being normal. This atrophy was 
sufficiently marked to be perceptible upon inspection. In 
order to determine the exact amount of atrophy which 
existed the following measurements were made, whereby 
a comparison might be established: 
Circumference 
of wrist 
Right. 
33 in- 
Left. Difference. 
4l in- £ in. 
U 
middle of forearm 
4i “ 
Si " 
3 “ 
<< 
elbow - 
5 “ 
6 “ 
i “ 
H 
biceps 
4i “ 
5i “ 
i “ 
a 
thumb 
if " 
2 “ 
f “ 
When we compare the amount of loss with the meas- 
urements of the normal arm, it will be readily seen that 
the atrophy was one of a marked character. It was on 
account of this marked difference that relief was sought. 
While dynamometric measurements were not made, rough 
experiments readily demonstrated a perceptible loss of 
muscular power. 
In an attempt to discuss the question of the etiology 
of this case, one point must not be lost sight of, viz., that 
there are two forms of linear'atrophy, one being due to 
nervous influence of a direct or remote character, and the 
other, to mechanical causes. We may have the absorption 
of certain elements taking place through long-continued 
pressure, or we may have apparent atrophy through a 
stretching of the skin, as observed in the cases of obese 
persons and of pregnant women. In this last class we> 
have as much to deal with a displacement as with an 
atrophic process, and in the case which I have reported, 
almost every cause but direct nervous influence can be 
easily eliminated. 
A condition somewhat similar to the one reported is 
that known as “glossy skin,” which is of distinctly neu- 
rotic origin, occurs upon the extremities, and is accom- 
panied by a burning pain. Duhring* states that “similar 
changes occur in progressive muscular atrophy, due to 
disturbance of nutrition of the affected parts.” 
• L. A. Duhring. “Treatise on Diseases of the Skin." 1881. 4 
A. //. Ohmann-bnmesnii. 
Mitchell* has shown that nerve injuries will cause 
wasting of the muscles, atrophy or the skin and disap- 
pearance of the subcutaneous connective tissue. “ Glossy 
skin” is said by Robinsonf to follow wounds, besides the 
other causes mentioned by writers in general. 
McCall mentions a case of atrophy of the 
skin in which that portion supplied by the supraorbital 
nerve was affected. He also states that unilateral atrophy 
of the face is supposed to be due to permanent irritation 
of the cervical sympathetic. Brunner§ mentions a case 
of atrophy of the left side of the face in an epileptic 
woman. The atrophy involved not only the skin, but the 
muscles as well. 
I have quoted these few examples to show the trend 
of opinion in respect to certain forms of atrophy, which 
resemble the one I have reported. A question which 
suggests itself in regard to my case is the following: 
Was the atrophy of the skin consecutive upon that of 
the muscles, or vice versa; or were both processes simul- 
taneous? This, of course, cannot be answered, as the 
time which elapsed from the first period—that of the 
burn—to the period of examination, was too long. More- 
over, the first observer was untrained and not capable of 
making any observations that would bear any weight. 
One fact noted by the mother, however, is reliable—that 
the atrophy of the skin and that of the muscles were 
progressive in character, the former increasing in extent 
and the latter becoming more marked ; or, to express it 
more clearly, the atrophied .portions of the skin increased 
in area and the arm became more shrunken. 
Crocker || has devoted some considerable attention to 
the various forms of atrophy of the skin, and in his clas- 
sification of them he gives the following : 
•Weir Mitchell. “ Injuries of the Nerves and Their Consequences.” 1872. 
t A. R. Robinson. " A Manual;of Dermatology.” 1884. 
J McCall Anderson. "Treatise on Diseases of the Skin.” 1887. 
§In A. Eulenberg and P. Guttmann. “Physiology and Pathology of the 
Sympathetic System of Nerves.” 1879. 
|1H. Radoliffe Crocker. " Diseases of the Skin.” 1888. Atrophy of the Skin. 
5 
Atrophoderma 
Neuroticum 
(glossy skin.) 
Traumaticum. 
Non-traumaticum. 
This would include “ glossy skin ” as the type and, 
of course, variations would necessarily exist, perhaps 
totally distinct, as much so as is morphcea from scleroderma, 
which are held by many to be different phases of the 
same disease. 
While it is true that there is a tendency nowadays 
to eschew traumatism as a factor in the causation of 
pathological processes, we cannot but accept it in many 
instances, if for no other reason than that a better 
explanation cannot be furnished. In the case reported it 
seems plausible to me to assume that the atrophy of the 
skin and of the muscles were simultaneous. Not only 
this, but that the remote cause was the burn which 
affected the radial nerve and, through it, the brachial, in 
such a manner as to produce functional disturbance, if 
not actual organic disintegration of a more or less limited 
character. It would be a very difficult matter, on the 
other hand, to determine whether the sympathetic nerves 
were not also implicated to a greater or less extent, 
especially in view of the history of the case and of the 
narrow anatomical ties which bind these members of the 
nervous system to the others. 
That general neurotic trouble caused the local changes 
is out of the question, as it did not exist, and would, no 
doubt, have produced entirely different manifestations. 
It is to be regretted that more detailed work has not 
been done in investigating the dermatoses of neurotic 
origin. The neurologist gives the skin but a passing 
glance, while the dermatologist devotes but little attention 
to the nervous system, so that in the recorded cases 
which we find of atrophy of the skin the history is 
invariably meager in one respect, as are also the clinical 
description and pathological investigation.