have acne. Gilchrist states that he obtains from firm acne papules, which show no macroscopic evidence of suppuration, pure cultures of a bacillus, which he designates bacillus-acnes. Unna also describes a bacillus, which is considered by him the cause of acne. The form of this bacillus is different from that described by Gilchrist. The bacilli must have a favorable soil for their growth. In many cases no defect in the general health can be discovered, but the lesions of these cases are usually limited in their area, and must be ascribed either to some local irritant, or to the plugging of the glands with dust improperly removed. Certain times of life seem to favor infection. The disease is frequently observed to begin at the age of puberty and it is rare after the thirty-fifth year. A large number of the cases present some digestive disturbance, usually caused by faulty and irregular diet and poor hygiene. Many show circulatory weakness, cold hands and feet. In females, menstrual disorders seem to play an important part, the eruption being very much worse, either just before, just after, or during menstruation. The use of iodides and bromides, long continued, sometimes produces an extremely intractable form of acne. Sedentary living, alcoholic excess, anæmia, rapid growth in the young and diabetes, produce a favorable field for acne infection.

Pathology. Acne is an inflammation of the sebaceous glands. and of the follicles of the lanugo hairs, situated within, or immediately adjacent thereto. There is a blacking of the glandular outlet which Unna ascribes to a hyperkeratosis, resulting in comedo formation; this creates the soil for infection by the micro-organism described under etiology. There is inflammation in and around the gland. There is inflammatory infiltration, either completely surrounding the gland, or around the gland outlet. The infiltration around several glands may coalesce, thereby making a large lesion. Breaking down and suppuration usually, but not always, ensues. There may be a small dermic abscess formed by the breaking down of the epithelial lining of the glands. A large dermic abscess results from an abundant suppuration of several glands, the pus burrowing deeply from the bottom of the follicle into the connective tissue. In the large lesions the contents show sebaceous matter, tissue débris and even parts of the hair follicles, mixed with sero

purulent fluid. In this fluid are also found diplococci and the bacillus-acne. The exact form of bacillus is differently described by different observers and at times staphylococci, although Unna states that these are not necessary for suppuration.

Prognosis. The prognosis is favorable, the majority of cases being cured in a few months. Some cases, especially those that have continued for a long time with a large number of scars and deep-seated lesions, which are rebellious and obstinate, tend to wear out the patience of the practitioner and patient as well. Many cases, especially those occurring at the time of puberty, make a complete recovery unaided after several years.

Treatment. As we have seen above, acne is dependent on two causes, the local usually the same, the general or constitutional cause rarely the same. Our first efforts must be directed to a correct diagnosis of these causes. The mode of living, the amount of fresh air and sleep and the diet, must in their turn receive proper consideration and correction, if needed. Constitutional defects. must be remedied as much as possible by appropriate medication, bathing and hygiene. Along with the constitutional treatment we must continue local treatment, and as the eruption is due to an infection, we must with great care go over the infected area and remove the comedoes. There is no surer or speedier way than mechanically, but great care must be used that the entire retained mass is expelled, as little good results from removing the mass. partially. On this account the instrument, which is no doubt familiar to you, devised by Prof. E. B. Bronson, of New York, effects their removal most completely. All pustules should be carefully opened and cleaned and for this purpose a broad needle seems. the best. After the removal of the comedoes, opening of the pustules, the application of an alcoholic solution of bichloride of mercury as strong as can be borne without too much irritating effect, from one-half to two and one-half grains to the ounce. This serves two purposes, first its antiseptic action, and secondly its tendency to produce an exfoliation, keeps the orifices of the glands. open and allows drainage. High frequency electricity should now be applied on the area covered by the eruption for its stimulating effect on the vaso-motor system. The length of this treatment

should be about five minutes. The best form of high frequency currents for the ordinary cases is the helicoidal shunt of D'Arsonval, but should more stimulation be desired in a sluggish case, the current form, an Oudin Resonator is much more beneficial. The patient should be instructed in most cases to apply hot fomentations to the infected area at night to prepare for the reception of local medication. This medication should vary as follows. If the corneous layer of the skin be thickened, an ointment containing precip-sulph., 3 ss to 3 iss to the ounce, should be applied every night until it is properly reduced. If it is a case where the skin is extremely oily, the following should be applied:

In superficial cases, without deep lesions, the common lotio-alba is of great service when properly made. The best proportion is as follows:

Cases which are sluggish are well stimulated and benefited by an ointment containing ichthyol, green soap, and sulphur. If there is dryness of the skin, an ointment containing from three to ten per cent. of ammoniated mercury can be rubbed in at night. In cases where there are a large number of deep-seated lesions, nothing acts as well as the application of the Roentgen-ray. We must, however, realize that the Roentgen-ray is a great power for good or for evil and is not justified unless other means fail. The tube

should be a low one, placed ten inches from the lesion and the dose carefully regulated. A weak current for four minutes should be used at first, and gradually the time, but not the strength, should be increased. The eye-brows, mouth, and hair should, of course, be carefully protected. It is not desirable to produce a dermatitis, and it is rare when this treatment fails in the most obstinate case.

DISCUSSION.

Dr. Ralph A. McDonnell (New Haven): Mr. President and Gentlemen. It seems to me that in this paper altogether too much emphasis has been placed upon local treatment. There are three stages of acne that are commonly seen: (1) the mild cases, where an occasional papule or pustule is seen; (2) the cases of moderate severity, where a few papules or a few pustules are present all the time; and (3) the severer cases, where deep-seated tubercles are present and constantly replaced all of the time. These cases are all acne. From the mild cases, the moderate or medium cases develop, and from the medium cases, the severe ones come.

In the severe cases you will find a history of intestinal fermentation, excessive gas formation, headaches, dizzy spells, palpitation, and in many instances distress two hours or so after eating. In the bad cases you will always find a number of these symptoms. Now the bad cases develop from the medium cases, and the medium cases develop from the mild cases.

In my practice I lay a great deal more stress on the internal treatment of acne than on the external, and I don't think it is possible to cure the mild average case of acne without particular attention being paid to the diet and to the digestive tract. In a case with intestinal fermentation, you have got to cut off the things that are digested in the upper part of the small intestine, especially starches, such as breakfast cereals, potatoes, and new breads; you have got to cut off sweetmeats if you are going to get any good results, just as sure as can be. These cases are notoriously severe, even if the food is limited, and are absolutely incurable for years and years, unless you do pay attention to the diet, and that I know and am sure of from personal experience. I have treated a patient of 55 or so for acne vulgaris, and at the same time treated her daughter of twenty or so for acne vulgaris. It is not right to tell a young person that in a few years or a year or two the acne will subside without treatment. It does not subside; you have got to pay attention to it.

Internal treatment is rather important too, as it seems to me; you have got to regulate the bowels, because most of the cases are constipated; and you have got to use intestinal antiseptics: of these, I think the best is ichthyol.

I think external treatment is the least important of all, because many cases will get well without any external treatment if you regulate the diet and improve the digestion.

If there are lots of little papules and comedones, then a general application to cause peeling is proper. A green soap ointment will sometimes peel off the epidermis and liberate the contents of the follicles; this is proper treatment to start with. There are lots of ointments used containing sulphur, but I think that with the medicinal treatment you will get rid of most cases of acne.

The doctor said the prognosis is good, exceedingly good. In a great many of my cases the prognosis has not been so good. They have lasted for a long time. A few months do not suffice to cure bad cases of acne, but a good many months.

Speaking about the X-ray, I think that the X-ray is a very valuable means of treatment locally, but it can only cure those lesions that are already present. It cannot prevent the appearance of new lesions, neither can any external treatment. The X-ray treatment I give in a more concentrated form than the doctor does, to wit, exposures of from five to seven minutes at a distance of two or three inches with a soft tube, repeating it every five days, and get good results. I think it is desirable to produce a mild dermatitis, but not an X-ray burn.

I enjoyed the paper very much and I think the doctor is to be congratulated upon it.

Dr. Thomas M. Bull (Naugatuck): Mr. President and Gentlemen of the Society. I am very much pleased with this paper. I am always glad to hear a man give his own experience in regard to anything that we treat, because I think the experience of a man right here among us is worth more than that of a German or French professor who perhaps never saw an American patient, certainly not one from Connecticut. The conditions vary greatly in different parts of the world in regard to curing diseases, and the methods that he has spoken about, and Dr. McDonnell has spoken of as well, are most of them the same which I have adopted.

In addition to what they have given, I would say at first that I would lay a great deal more stress upon the diet and personal hygiene than almost any other factor. We are often asked if we can cure acne so it will stay cured, and I always tell patients asking this that, if they do the same things which produced the acne originally, they will probably have it again. But, after a certain time in life acne is very rare, that is, perhaps from the fourteenth to the 25th year acne is very common indeed; but after the 25th year it generally disappears. But that is during the time of life in which a person wants the best face they can possibly have, and the matter of acne is of considerable importance for that reason. I have sometimes seen boys who left home and went away simply because they were so tormented by their schoolmates and friends talking about their faces. They became so displeased about it that they left home.