172 Whitfield : Points in the Pathology of Acne

THE fundamental error in acne is seborrhcea. Theretis at present a lack of knowledge as to the causation of seborrhoea, but it is known that it is common in adolescence, in disorders of the alimentary tract, and is apparently an inborn peculiarity in some individuals. The symptoms of acne vulgaris are, as we may say, built up on seborrhoea as a basis, and comprise, first, the production of a .horny plug in the pilo-sebaceous follicle, the so-called blackhead or comedo; secondly, suppuration around the comedo; and, thirdly, the production of persistent granulomatous nodes, or, in some cases, of cyst-abscesses. The bacteriology of the condition has been studied for many years by several investigators, and the views held by the various workers are divergent. Unna and Hodara found a small bacillus present, which they did not cuiltivate, and came to the conclusion that it was the cause of the suppuration. Sabouraud also found the same bacillus and cultivated it, and believed that it was the cause of the seborrhcea and the comedo, but not the cause of the suppuration, which he considered was due to the pyogenic staphylococci. Gilchrist believed that the bacillus was the cause of the symptoms of acne, and named the bacillus the Bacillus acnes. Some years ago I investigated the question and came to the conclusion that the seborrheea was not bacterial in origin, that the comedo was caused by the small bacillus, which, following Sabouraud, I shall refer to as the microbacillus, and that the suppuration was caused by Staphylococcus pyogenes albus. Recently Fleming worked at the subject and came to the conclusion that the suppuration was in most cases caused by the microbacillus, and urged in proof of his contention its invariable presence in the lesions, its power when rubbed into the arm of producing suppuration in some people, the variable opsonic index in acne patients, and the beneficial effect of inoculation. The appearance of Fleming's work stimulated me to renew my investigations, especially because of the very considerable proportion of acne pustules in which he was unable to demonstrate staphylococci. I therefore examined pus from unopened pustules in my next twenty cases, and in nineteen of these I