anomalies and curiosities of medicine-第208部分

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　manipulate　his　tongue；　accompanied　by　hideous　hisses；　as　viciously　as　a　serpent。〃

Under　the　name　of　dermatitis　exfoliativa　neonatorum；　Ritter　has　described　an　eruption　which　he　observed　in　the　foundling　asylum　at　Prague；　where　nearly　300　cases　occurred　in　ten　years。　According　to　Crocker　it　begins　in　the　second　or　third　week　of　life；　and　occasionally　as　late　as　the　fifth　week；　with　diffuse　and　universal　scaling；　which　may　be　branny　or　in　laminae　like　pityriasis　rubra；　and　either　dry　or　with　suffusion　beneath　the　epidermis。　Sometimes　it　presents　flaccid　bullae　like　pemphigus　foliaceus；　and　then　there　are　crusts　as　well　as　scales；　with　rhagades　on　the　mouth；　anus；　etc。；　there　is　a　total　absence　of　fever　or　other　general　symptoms。　About　50　per　cent　die　of　marasmus　and　loss　of　heat；　with　or　without　diarrhea。　In　those　who　recover　the　surface　gradually　becomes　pale　and　the　desquamation　ceases。　Opinions　differ　regarding　it；　some　considering　it　of　septic　origin；　while　others　believe　it　to　be　nothing　but　pemphigus　foliaceus。　Kaposi　regards　it　as　an　aggravation　of　the　physiologic　exfoliation　of　the　new…born。　Elliott　of　New　York　reports　two　cases　with　a　review　of　the　subject；　but　none　have　been　reported　in　England。　Cases　on　the　Continent　have　been　described　by　Billard；　von　Baer；　Caspary；　those　already　mentioned；　and　others。

The　name　epidemic　exfoliative　dermatitis　has　been　given　to　an　epidemic　skin…disease　which　made　its　appearance　in　1891　in　England；　425　cases　were　collected　in　six　institutions；　besides　sporadic　cases　in　private　houses。

In　1895；　in　London；　some　photographs　and　sketches　were　exhibited　that　were　taken　from　several　of　the　163　cases　which　occurred　in　the　Paddington　Infirmary　and　Workhouse；　under　the　care　of　Dr。　Savill；　from　whose　negatives　they　were　prepared。　They　were　arranged　in　order　to　illustrate　the　successive　stages　of　the　disorder。　The　eruption　starts　usually　with　discrete　papules；　often　in　stellate　groups；　and　generally　arranged　symmetrically　when　on　the　limbs。　These　become　fused　into　crimson；　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　shoulder；　attended　with　decided　itching　but　not　with　pain。　The　latter　symptom　did　not　come　on　until　three　years　later。　In　the　course　of　a　year　or　two　the　lesions　increased　in　number；　so　that　in　four　years　the　shoulder　and　arm　were　thickly　studded　with　them。　During　the　next　five　years　no　particular　changes　occurred　either　in　lesions　or　in　the　degree　of　pain。　The　region　affected　simply　looked　like　a　solid　sheet　of　variously…sized；　closely…packed；　confluent　tubercles；　hard　and　dense。　The　tubercles　were　at　all　times　painful　to　the　touch；　and　even　the　contact　of　air　was　sufficient　to　cause　great　suffering。　During　the　paroxysms；　which　occurred　usually　at　several　short　intervals　every　day；　the　skin　changed　color　frequently　and　rapidly；　passing　through　various　reddish　and　violet　tints；　at　times　becoming　purplish。

As　a　paroxysm　came　on　the　man　was　in　the　habit　of　gently　pressing　and　holding　the　arm　closely　to　his　body。　At　one　time　he　endured　the　attack　in　a　standing　posture；　walking　the　floor；　but　usually　he　seated　hims