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slightly raised maculae； which in severe cases become further fused into red thickened patches； in which the papules can still be felt and sometimes seen。 Vesicles form； and exudation occurs in only about one…third of the cases。 Desquamation of the epidermis is the invariable feature of all cases； and it usually commences between the fourth and eighth days。 In severe cases successive layers of the epidermis are shed； in larger or smaller scales； throughout the whole course of the malady。 One…half of the epidermis shed from the hand of a patient is exhibited in this collection。
Of sphaceloderma； or gangrene of the skin； probably the most interesting is Raynaud's disease of symmetric gangrene； a vascular disorder； which is seen in three grades of intensity： there is local syncope； producing the condition known as dead…fingers or dead…toes； and analogous to that produced by intense cold； and local asphyxia； which usually follows local syncope； or may develop independently。 Chilblains are the mildest manifestation of this condition。 The fingers； toes； and ears； are the parts usually affected。 In the most extreme degree the parts are swollen； stiff； and livid； and the capillary circulation is almost stagnant； this is local or symmetric gangrene； the mildest form of which follows asphyxia。 Small areas of necrosis appear on the pads of the fingers and of the toes； also at the edges of the ears and tip of the nose。 Occasional symmetric patches appear on the limbs and trunk； and in extensive cases terminate in gangrene。 Raynaud suggested that the local syncope was produced by contraction of the vessels； the asphyxia is probably caused by a dilatation of the capillaries and venules； with persistence of the spasm of the arterioles。 According to Osler two forms of congestion occur； which may be seen in adjacent fingers； one of which may be swollen； intensely red； and extremely hot； the other swollen； cyanotic； and intensely cold。 Sometimes all four extremities are involved； as in Southey's case； in a girl of two and a half in whom the process began on the calves； after a slight feverish attack； and then numerous patches rapidly becoming gangrenous appeared on the backs of the legs； thighs； buttocks； and upper arms； worse where there was pressure； the child died thirty…two hours after the onset。 The whole phenomenon may be unilateral； as in Smith's case； quoted by Crocker；in a girl of three years in whom the left hand was cold and livid； while on the right there was lividity； progressing to gangrene of the fingers and of the thumb up to the first knuckles； where complete separation occurred。
A considerable number of cases of apparently spontaneous gangrene of the skin have been recorded in medical literature as occurring generally in hysteric young women。 Crocker remarks that they are generally classified as erythema gangraenosum； and are always to be regarded with grave suspicion of being self…induced。 Ehrl records an interesting case of this nature with an accompanying illustration。 The patient was a girl of eighteen whose face； left breast； anus； legs； and feet became affected every autumn since her sixth year； after an attack of measles。 At first the skin became red； then water…blisters formed； the size of a grain of corn； and in three days reaching the size of a hazel…nut； these burst and healed； leaving no scars。 The menses appeared at the fifteenth year； lasted eight days； with great loss of blood； but there was no subsequent menstruation； and no vicarious hemorrhage。 Afterward the right half of the face became red for three or four weeks； with a disturbance of the sensibility of this part； including the right half of the mucosa of the mouth and the conjunctive of the right eye。 At the seventeenth year the patient began to have a left…sided headache and increased sweating of the right half of the body。 In 1892 the periodically…appearing skin…affection became worse。 Instead of healing； the broken vessels became blackish and healed slowly； leaving ulcers； granulations； and scars； and the gangrenous tendency of the skin increased。 Disturbance of the sight shortly intervened； associated with aphonia。 The sensibility of the whole body； with the exception of the face； was greatly impaired； and there was true gangrene of the corium。 A younger sister of the patient was similarly affected with symptoms of hysteria； hemianesthesia； etc。
Neuroses of the skin consist in augmentation of sensibility or hyperesthesia and diminution of sensibility or anesthesia。 There are some curious old cases of loss of sensation。 Ferdinandus mentions a case of a young man of twenty…four who； after having been seized with insensibility of the whole body with the exception of the head； was cured by purgatives and other remedies。 Bartholinus cites the case of a young man who lost the senses of taste and feeling； and also the case of a young girl who could permit the skin of her forehead to be pricked and the skin of her neck to be burned without experiencing any pain。 In his 〃Surgery〃 Lamothe mentions a case of insensibility of the hands and feet in consequence of a horse…kick in the head without the infliction of any external wound。 In the 〃Memoires de l'Academie des Sciences〃 for the year 1743； we read an account of a soldier who； after having accidentally lost all sensation in his left arm； continued to go through the whole of the manual exercise with the same facility as ever。 It was also known that La Condamine was able to use his hands for many years after they had lost their sensation。 Rayer gives a case of paralysis of the skin of the left side of the trunk without any affection of the muscles； in a man of forty…three of apoplectic constitution。 The paralysis extended from the left mammary region to the haunch； and from the vertebrae to the linea alba。 Throughout this whole extent the skin was insensible and could be pinched or even punctured without the patient being aware that he was even touched。 The parts did not present any perceptible alteration in texture or in color。 The patient was free from fever and made no complaint except a slight headache。 Rayer quotes another case in a man of sixty who had been bitten three years previously by a dog that was not mad。 He was greatly frightened by the accident and every time he saw a dog he trembled violently； and on one occasion he suffered a convulsive attack for one and a half hours。 The convulsions increased in number and frequency； he lost his memory； and exhibited other signs of incipient dementia。 He was admitted to the hospital with two small wounds upon the head； one above the left eyebrow and the other on the scalp； occasioned by a fall on his entrance into the hospital。 For several days a great degree of insensibility of the skin of the whole body was observed without any implication of the power of voluntary motion。 He was entirely cured in eighteen days。
Duhring reports a very rare form of disease of the skin； which may be designated neuroma cutis dolorosum； or painful neuroma of the skin。 The patient was a boiler…maker of seventy who had no family history bearing on the disease。 Ten years previously a few cutaneous tubercles the size and shape of a split…pea were noticed on the left shoul