THE 
TREATMENT OF ACNE. 
(Read before the Ohio State Medical Society, at Columbus, 
June 12, 1888.) 
By B. MERRILL RICKETTS, M.D., 
CINCINNATI, OHIO. 
REPRINTED FROM 
THE MEDICAL REGISTER: 
PHIEADEEPHIA. THE TREATMENT OF ACNE. 
(Read before the Ohio State Medical Society, at Columbus, June 12, 1888.) 
By B. MERRILL RICKETTS, M.D., 
CINCINNATI, OHIO. 
Mr. PRESIDENT AND GENTLEMEN: My 
object in coming before you to-day is to pre- 
sent a subject for consideration which, I fear, has 
been neglected in the extreme by you, as by practi- 
tioners in general. 
I do not know that we have a cutaneous disease of 
such supposed chronicity which is more amenable to 
both surgical and medicinal treatment than acne. 
Surely there are none more worthy of our consid- 
eration when we know that it is not a respecter of 
persons. It may maim and disfigure the most beau- 
tiful face, thereby making the victim an object of 
sympathy. 
Who of you have not listened to the pleadings of 
a young boy or girl, or a mother for her son or 
daughter, to have the disease checked in its course. 
Since it is so often found on the face, beauty conse- 
quently being at stake, it is natural that it is a much 
dreaded disease, and persistent efforts made to cure 
it. There are few if any diseases whose nosology 
begins earlier or that are so equally distributed over 
the intervening period than acne. It was Cilsus, 
during the First Century a.d., who made first mention 
of it. Galen also speaks of it, 150 a.d., about a 
century later. Among others, we find Actius, 500-600 
a.d.; Avicenna, 1037 a.d.; Johannes Actuarius, in 
the Thirteenth Century; Gio di Vigo, 1525 a.d.; 
Paracelsus, 1573 a.d., and Limuas, 1763 a.d. 
The gentlemen have written very discouragingly 2 
as to any successful course of treatment. This, per- 
haps, has been due to their inability to recognize the 
cause. Even now, we are many times at a loss as to 
the exact cause, but with the unlimited resources we 
now have as to treatment, together with our knowl- 
edge of pathology and the cause of disease, we are 
better able to render beneficial services in these cases 
than ever before. 
I did not come here to discuss the pathology of 
acne, for you can readily get that. Neither do I 
come to report a list of cases, for you have all had 
them; but I do come to enter into an active discus- 
sion upon the subject, and to tell you the results of 
my own experience in the treatment of this special 
trouble, at the same time to give you that which I 
have gleaned from the writings of other members of 
my profession. The time of this Society would not 
be profitably spent if I were to enter into detail, 
bringing about the different varieties of the disease 
and treatment in this connection. However, that we 
may talk intelligently and understandingly upon the 
subject, and that we may bring out prominently the 
three or four great underlying principles which gov- 
ern the successful termination of the disease, it will 
be necessary to abandon a voluminous classification 
and adopt one more simple: i. Acne due to faulty 
secretion or excretion of sebaceous matter. 2. Acne 
due to congestion and inflammation of sebaceous 
gland, with involvement of the surrounding tissue. 
In the first class we find frequently that mechani- 
cal cause is the main factor, as the closing or partial 
closing of the ducts by foreign matter, or by some 
nervous influence, which cause them to be lessened 3 
in calibre, thereby not allowing the free exit of gland- 
ular secretion. This is the case in the two forms of 
" acne punctata." 
In one of these two forms (acne punctata nigra- 
comedo) we find the mass composed of sebaceous 
and foreign matter ; the deepest portion of the mass 
is much larger than the superficial portion. In the 
other (acne punctata albada-milium) the mass is 
purely sebaceous, and perfectly enclosed within a sack, 
the mouth of the duct having been entirely obliterated. 
Here we have a deposit of white, cheesy matter just 
beneath the cuticle, which, when cut, escapes in a 
somewhat hardened form. 
This is the simplest and most easily managed of 
any form of the disease. However, in either of the 
two varieties (comedo or milium) the sebaceous 
matter should be removed with as little injury to the 
surrounding parts as possible. 
The easiest and most harmless way of extracting 
the comedoes is by pressure between the two index 
fingers, over which is tightly stretched some thin, 
soft fabric. Steady pressure is made with great care, 
so that the finger will not slip ; then by removing the 
cuticle and causing an injury which may require 
several days to repair itself. 
The masses serve as foreign bodies, and if allowed 
to remain, will sooner or later cause irritation, fol- 
lowed by congestion, inflammation, and the subse- 
quent formation of pus. 
Just as often as the sac is emptied it will each time 
become smaller and smaller, and have a more uniform 
calibre. The inflamed condition is not as likely to 
take place with the milium as the comedo, and will 4 
not require treatment other than that of the knife, 
which will give free exit, the same duct seldom fill- 
ing up more than once. 
The local treatment of the comedo form is quite 
different, as something else is required besides free 
exit. It will be found necessary to apply some stim- 
ulating lotion or paste, such as naphthol and sulphur 
in combination with green soap. This form of paste 
I have found to answer the purpose better than any 
other that I have used, in that by the application of 
towels saturated in hot water, the cuticle will exfo- 
liate freely, leaving the ducts freely open and the con- 
tents to escape spontaneously for at least a few hours. 
I will not consider the other form due to faulty se- 
cretion or excretion of sebaceous matter, known as 
acne sebaceo, or seborrhcea, as that is other than what I 
intended to deal with upon this occasion; therefore, I 
shall now take up the two varieties of the second 
class, known as acne indurata and acne simplex. 
These are the most troublesome to treat, and *the 
results arising (if they are left to run their course)' 
are much more serious than are the results of the first 
class, for many times there is marked permanent dis- 
figurement, especially when the disease has been ex- 
tensive upon the face. 
There is a class of cases found among both boys 
and girls from fourteen to twenty years of age which 
are exceedingly obstinate, tubercular predisposition 
seeming to predominate. In fact, many of them suc- 
cumb to tuberculosis before the age of twenty-five. 
Such cases, as a rule, are greatly benefited by the 
use of iodide of arsenic and potassium, together with 
a generous diet of the most digestible food and fresh 5 
air. Any indigestion or derangement of the alimen- 
tary tract seems to aggravate or excite acne in this 
class of cases more than any other; while, on the other 
hand, those having no tubercular history are not so 
susceptible to these changes, and are more difficult to 
manage, the treatment being altogether different in 
the two classes. In the latter, the ingestion of cer- 
tain kinds of food, as beets, radishes, or pork, the 
use of tea, coffee, alcoholic or malt stimulants to ex- 
cess will produce it, The majority of cases, I think, 
are either due to or excited by the use of improper 
food and to neglect of diet. 
Then, again, there are many cases which seem to 
be due to some nervous derangement produced by 
causes other than indigestion, but are not understood. 
These, I might say, are the most obstinate to treat, 
seeming at all times to resist all kinds of treatment. 
In all cases, whether a cause can be assigned or 
not, the pus in each individual acne should be given 
free exit with a small knife, such as is used in cata- 
ract operations. A spray of rhigolene for a few min- 
utes, say two or three, will anesthetize the skin to 
such an extent that the operation will be painless. 
Immediately after these pus cups are opened the hot 
water should be applied in the manner before stated. 
I have found nothing so serviceable in either of the 
two forms as arsenous acid in the form of the Asiatic 
pill, having given as much as one-half grain daily 
for this disease. When given in combination with 
kali iod. for two or three weeks, the disease seems to 
be aggravated, and the patient feels very much dis- 
couraged, thinking that the remedy will have no 
effect except to increase the severity of the symptoms. 6 
This, however, is not the case, as the pustules become 
fewer, less elevated and congested after a ten days' or 
ten weeks' treatment. This course, however, will 
avail nothing unless the patient abstains from the use 
of all stimulants and indigestible food. 
When the disease has assumed the indurated form, 
and is situated upon the back, it will be necessary to 
put the point of the knife deep into the tissue, as the 
skin is so much thicker in this locality than upon the 
face; however, in many cases of the face the sac of 
pus will lie beneath the integument in the subcellular 
tissue-especially is this so when the induration is 
extensive, or when two pockets have connected or are 
inclined to do so. When this state of affairs exists, 
the centre of the induration will be found in quite a 
number of instances to be gelatinous, requiring the 
use of a small scoop to remove it. Here is when the 
use of cocaine is indicated, and if properly used sub- 
cutaneously, will permit of painless surgical inter- 
ference. 
It is surprising to know how little disfigurement 
follows such an operation, kike all wounds of the 
face, repair is rapid. It is these painful procedures 
that enable the attendant to see his patient fre- 
quently, thus bringing about speedy recovery. 
Frequent and free incisions, followed by the appli- 
cation of water as hot as can be borne, will do more 
towards leading these cases to a favorable termina- 
tion than any other procedure. That the incision 
should be made early and frequently, is shown in 
those neglected cases where pus has burrowed, re- 
quiring two or more incisions to liberate the whole 
contents of the sac. Pus can always be found where 7 
there is induration accompanied by redness and ten- 
derness. The amount may not exceed three or four 
drops, but when removed will give instant relief from 
the sharp pain produced by the pressure of the pus 
upon the peripheral nerves supplying the integument. 
Incision seems to answer the purposes, viz.: to give 
exit to the pus, and to relieve congestion. 
Within the past two years I have had these patients 
resort to massage night and morning, kneading the 
skin involved with the fingers to see if a better cir- 
culation could not be had, thereby hastening the 
process of waste and repair and lessening indura- 
tion. I think that the results have been better, and 
there is less tendency of a recurrence. General mas- 
sage is also beneficial, and I will say a most satisfac- 
tory treatment in connection with digestible food, 
pure air, and bright sunshine, there being but few, if 
any, cases that will not show an improvement at the 
end of four or five weeks under such conditions. 
This is the least likely of the two forms to return 
when it has once been cured. 
Acne simplex is found upon the face of persons 
as young as ten and not over twenty years of age, 
but occurs later in life with males than with females. 
The papules or pustules are very small, are elevated 
and tender, and are more or less inflamed. Its course 
is shorter than that of acne indurata, and seldom 
extends over a period of three weeks, leaving no 
scars, unless uncared for. It is sometimes very obsti- 
nate to treat, which is no doubt due to the inability 
to recognize the cause. This difficulty, along with 
the difficulty of differential diagnosis, is the cause of 
the greatest trouble. 8 
These patients, as a rule, suffer from debility of 
some kind, having a poor appetite and a general list- 
lessness. The treatment is both internal and external, 
and if carried out energetically, will give satisfactory 
results. The bowels should be kept relaxed with 
Hauthorn, Hunyadi, or some other such water taken 
upon retiring or just before breakfast. 
Turkish baths, given with general massage two or 
three times each week, will many times be attended 
by good results, especially the abdominal massage. 
When given for constipation, fluid ext. ergot, in half- 
drachm doses after each meal, is supposed to be bene- 
ficial in these cases. The cutaneous bloodvessels are 
contracted thereby, lessening the amount of blood, 
consequently lessening congestion. Tonics, such as 
iron, arsenic, strychnine, etc., are also serviceable. 
One-eighth grain of arsenous acid, given with the 
elixir gentian, com. tr. ferri cliloridi, with a few drops 
of hydrochloric acid, after each meal, gradually in- 
creased until one-half or three-quarters of a grain of 
the arsenious acid is taken daily, is by far the best I 
have given. 
The external treatment consists in thorough re- 
moval of sebaceous matter after applying hot water 
for fifteen or twenty minutes. At the end of this 
time a stimulating paste of ichthyol and mollin, or 
lanolin, should be applied once or twice daily. Re- 
sorcin, with sub. nit. bismuth, zinc ox., and mollin 
or lanolin, is also very good. 
93 Rast Fourth Street.