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much, voluntarily, gets mixed up, and often can't recall names of things; 4, alexia almost complete; cannot read except the shortest words by slowly spelling them out; 5, marked agraphia; cannot write spontaneously, to dictation or to copy; 6, imperfectly recalls names of objects presented to him; grip R. 58, L. 60.
Diagnosis, embolism of terminal branches of Sylvian artery, producing lesion of left angular gyrus. While a portion of the first temporal might be affected, it seems to me more probable that the slight degree of amnesic aphasia and paraphasia depended on the lesion of the visual area. The patient was highly educated and had always been a student.
The treatment of aphasia is not mentioned in many of our text-books, and is regarded as absolutely hopeless by others, But it will not do to class all cases of aphasia together and let them alone. A case is reported by Kuchler of a man who became a hemiplegic and total aphasic at twenty-seven. For nine years he was let alone, and his condition remained unchanged. Then an attempt was made to educate the right hemisphere, and, after six weeks of diligent work, the man could say a hundred words and several invaluable short sentences. Gutzman in '94, reported three cases successfully treated by practice in writing with the left hand. It is maintained by German authorities that if children were taught to write equally well with both hands the danger of aphasia would be avoided. When we
consider the remarkable results which have been achieved within a few years with deaf mute children in teaching articulate speech, it is reasonable to believe that the same methods and training would have results in a fair proportion of cases in aphasics. The difficulty has been in the failure to realize the conditions of the patient and the conditions of suc
The aphasic is apt to be emotional, irritable and childish. He is in fact a child in some ways, and the same patience and tact and perseverance is needed to accomplish anything as with a child. If the patient has shown signs of mental decay previous to the attack, it is useless to trouble him by any effort to educate fresh areas. If on the other hand there is a history of mental vigor up to the catastrophy, it is right to make the attempt. Such was the case with No. II., who reports very satisfactory progress in the recovery of his lost powers under the guidance of a competent instructor. Ordinarily the physician cannot undertake this work. If it can be afforded, it is better to hire a good teacher. Then if there is brought to the work the same industry, patience and enthusiasm that there is in acquiring a new language, much can be done with an intelligent patient.
THE TREATMENT OF ACNE.
R. A. McDONNELL, M.D., CLINICAL Assistant in DERMATOLOGY, MEDICAL DEPARTMENT, Yale UNIVERSITY.
This mooted subject merits the close attention of all practitioners, because the disease, on the one hand, is so very common and disfiguring, and, on the other hand, is generally so amenable to well directed treatment. But in just this point of well directed treatment comes the difficulty, for there are many recognized factors which may produce acne, and in order to cure the disease we must get at the cause. It is no longer fair to the patient to simply write for one of the many combinations which have been recommended as “good for acne," but each case should be studied individually, with a view to finding out what is at the bottom of it. The problem before us may be fairly stated thus -(a) How shall we remove the eruption which is present? and (b) how shall we prevent its recurrence?
The lesion of acne consists of an inflammation in a sebaceous gland and the tissues in its immediate vicinity, due to one or more of the three primary factors mentioned in the following scheme. This scheme includes, I think, all the causes of acne, but they are sufficient to furnish food for thought.
a. Natural tendency
Anaemia 1. To the skin
b. Poor Nutrition Chlorosis
itself 1. To overproduc
Struma tion of sebum,
c. Hypernutrition (puberty) due
a. From genito urinary organs. 2. To reflex action 6. From digestive Constipation
Toxines c. From nose (rhinitis) d. From brain (mental troubles)
Wind 1. Occlusion of duct from hyperaemia Heat 2. To impediments 2. Cosmetics
Cold to exit of sebum
| Drugs eliminated
Attacking, then, the first half of our problem-how to remove the existing eruption—we must differentiate between acutely inflamed and torpid cases, between those characterized by great nodules containing pus and those presenting only inflamed papules. If pus has formed, it is unquestionably the best policy to give it exit, because first, it is rarely absorbed and must eventually be discharged through an opening which will be indefinitely large and liable to leave a scar; second, every abscess, however small, is painful until opened; third, by opening and using antiseptics, one can prevent these glandular abscesses from becoming foci for the distribution of inoculable pus to new glands. Taking, then, a case where large nodules predominate, it is good practice to make a deep incision with a fine lancet over the center of each lump, to gently express the pus, and then to encourage bleeding by laving with tepid water. Free bleeding is beneficial, relieving the tenderness by relaxing the congestion, and helping the prevention of stains which so often follow the deposition of blood pigments in the part. After the incised nodule has bled profusely it should be well sponged with an antiseptic solution, e. g. one-thousandth bichloride of mercury. Then Aristol may be blown into it with a powder blower.
The other class of suppurating cases, where small pustules are present, and usually in great numbers, would be tedious to treat were it necessary to open each individual lesion separately; so for such the following procedure is recommended. Some preparation which will produce desquamation, the following being as good as any:
is spread thickly over the affected surface and allowed to remain there for about three-quarters of an hour (the time varying somewhat with the texture of the patient's skin), and then wiped, not washed, off. This is repeated once a day, best in the evening, every day for five days. The surface soon begins to turn red, and then brown, going through all the familiar phases of sunburn. Finally the whole surface desquamates, frequently in large thin epidermal scales; to the under surface of these may often be seen adhering numerous comedones which have formerly plugged up the orifices of the sebaceous ducts. Thus at one stroke we have opened all superficial abscesses, and removed
most of the comedones. After the fifth night, a soothing paste is applied each evening and allowed to remain all night, so that the dermatitis which has been excited by the shelling process may be curbed. Lassar's salicylic paste is excellent for this purpose, its formula being:
50.0 M M
The whole process of desquamation is usually complete in about ten days. These are the methods of dealing with suppurating glands, and when any suppurating glands are present, they are always in order. Indeed, they will probably have to be repeated several different times as occasion arises.
But there is another class of lesions where the impediment to the exit of the gland's contents is formed by local swelling caused by hyperaemia from cold, heat or wind. These are the cases where numerous small, fiery red papules abound. It would be folly either to open these and risk a scar, or to subject the patient to the desquamating process, because the application of some bland salve like Lassar's salicylic paste mentioned above will relieve the hyperaemia, and very frequently, unaided, cure the disease.
The preceding measures, it will be at once remarked, are, although absolutely essential and indispensable preliminaries, only preparatory to the really curative treatment, which must deal with the source of supply, the overproduction of sebum itself. And thus we come to the second half of our problemhow to prevent the recurrence of the eruption. As we have seen, new lesions may be produced by either local or internal causes, usually both. And so it is logical to use both local and internal remedies. If we have already cleared the way for action by removing comedones and pustules according to the methods above described, we must see to it that the ducts of the sebaceous glands are kept clear, and to this end we prescribe soaps, ethereal and alcoholic lotions to dissolve the fatty plugs as formed, friction with coarse towels to mechanically dislodge such plugs, or, if there is closure of the ducts from hyperaemic swelling, we protect the parts from exposure as much as possible, and make use of soothing applications like Lassar's paste.
One agent niay be specially mentioned in this connection, namely, a medicated soap, containing five per cent resorcin. This is directed to be
used after the ordinary fashion about three times a day, the resorcin reinforcing the cleansing action of the soap by its reducing properties, and limiting by direct action the amount of sebum secreted. Having guarded in this way against the re-accumulation of plugs in the sebaceous ducts, we can hope to accomplish but two things more by external treatment-first, by using astringent remedies, to limit by direct action the amount of sebum produced, and second, by employing antiseptics, to prevent the lodgment in the glands of pus-exciting micro-organisms. In the first class. are the various preparations of sulphur, resorcin, B naphthol, ichthyol, zinc, and similar remedies, which have been advised and which are all unquestionably useful if employed at the right time-i. e., after emptying the glands and opening the ducts. In the second class are the mercurial preparations. These are valuable in all cases, as is every attempt at cleanliness.
To sum up, the objects of external treatment are (1) to remove existing lesions, (2) to keep the sebaceous ducts patent, (3) to maintain comparative antisepsis, and (4) to aid internal treatment in limiting the amount of sebum produced.
We now come to the internal measures in the treatment of acne, and observe, first of all, that there is no unanimity of opinion on this subject among dermatologists. A German author of renown says that there are no internal remedies known which will bring about a cure of acne (Innerliche Medicamente, welche eine Heilung der Acne herbeiführen, kennen wir nicht."'). American and French authors, on the other hand, dwell on the special importance of internal treatment. A reference to the list of causes of acne will show that there are several of them which may be most satisfactorily reached by internal medication. If the skin and the mucous membranes are pale, the heartbeats rapid, and the breathing much accelerated on slight exertion, is not this good reason for giving iron and manganese? I have been sure of the good results of one-grain tablets of Per-manganate of Potash after meals in these cases.
But not by any means all cases of acne occur in anaemic individuals. here are the lively boys and girls about the age of puberty whose excess of vitality must manifest itself in some direction, and if they are kept shut up at their studies or piano practice too constantly and not allowed to let off surplus steam by sufficient and agreeable out-of-door exercise, they are bound to suffer for it. The treatment here should be hygienic rather than internal.
Then there are cases undoubtedly due largely to reflexes from the genito-urinary organs-masturbation, with resulting vesicu-