Ringworm : its diagnosis and treatment

Front matter

MOO 1

; ITS ,\

lGNOSIS & TREATMENT

CHAPTER I. Introductory Remarks

PAGE

Result of treatment often unsatisfactory — contagious nature of ringworm — essential cause of symptoms is the growth of a parasite — proofs — tinea tonsurans, and tinea circinata — trichophyton tonsurans — the exact nature of the fungus — the essential point in treatment — special general conditions favouring parasitic growth 1

CHAPTER H.

The Different Varieties, and the Diagnosis of Ringworm of the Head.

The usual mistakes in diagnosis— detailed description of chronic, disseminated, and recent cases — microscopical appearances — in chronic — in recent ringworm — description of recent typical patches — rarer varieties — when ringworm is to be considered well —atrophied stumps — oil globules mistaken for conidia — the diagnostic value of the hair coming out easily from a suspicious place — the common error of looking for spores on ordinary hairs — diagnosis from alopecia areata and tinea decalvans — parasitic or non-parasitic nature of tinea decalvans — description of tinea decalvans — diagnosis of it from ringworm — local scurfiness — its diagnosis — diagnosis of squamous eczema, psoriasis, and favus — per centage of ringworm cases among boys 6

VI

CONTENTS.

CHAPTER III. Ringworm op the Body — Tinea Circinata

PAGE

Description of tinea circinata — diagnosis from squamous eczema, seborrhcea, pityriasis, and psoriasis — microscopic appearances — treatment of — Goa powder — eczema marginatum, and its treatment — tinea tonsurans of the finger nails — tinea sycosis, its diagnosis and treatment 25

CHAPTER IV. The Treatment of Recent Ringworm of the Head

The proper application of remedies — the question of shaving the head — carbolic glycerine treatment — epilation— proper for* ceps for — treatment when the places get very sore — caps — precautions — special ointment of carbolic acid, citrine and sulphur ointments — Goa powder — chrysophanic acid — Coster's paste — other remedies 33

CHAPTER V. The Treatment of Chronic Ringworm

First, where a Large Extent of Surface is Diseased.

The reason why chronic ringworm is so difiicult to cure — treatment by oleate of mercury 46

CONTENTS.

vii

CHAPTER VI. The Artificial Production op Kerion

The Treatment of Chronic Ringworm, where the Disease does not Extend over a Large Extent of Surface.

PAGE

Kerion — sometimes happens accidentally — may occur spontaneously — nature's method of effecting a cure — when kerion ought to be produced artificially — croton oil — directions for using croton oil — precautions to be observed — the great aim of this treatment — treatment after kerion has been produced — treatment of the bald patches — the oil getting on to the pillow-case — small places or isolated stumps reappearing — the special ointment, etc , may cause kerion unexpectedly — treatment — the friends ought to be previously prepared for this result — kerion resembles the formation of an abscess — croton oil sometimes often applied without producing kerion — treatment if a pustular rash only is produced — very rarely slight slougbing — tartar emetic ointment — distinct bald patch never left — exact description of kerion — not an abscess — a deep pustular rash alone is often caused by croton oil — will often cure — but certainly not all inveterate cases — list of most suitable cases in which to produce kerion. . . 50

CHAPTER VII. The Treatment op Disseminated Ringworm

Forceps and glass used — method of procedure in disseminated cases — treatment with terchloride of antimony — inveterate and incurable cases — treatment of. 63 viii

CONTENTS.

CHAPTER VIII. Genekal and Constitutional Treatment

PAGE

Disinfection — isolation — internal treatment — iron, etc. — fat — scurf after ringworm — its usual cause and treatment —hints on diagnosis — proof of a place being absolutely well ... 69

CHAPTER IX. Ringworm in Schools

Including the Questions of "Certificates" and "Isolation."

Question of certificates — examinations — isolation — when cases are to be admitted into public schools— general rules for use in schools to avoid the risk of contagion —domestic examinations — washing — hair- cutting — rules to be observed when ringworm breaks out in a school or family — what to do if it spreads — nurses — isolation — dietary — cubic space and ventilation — when may a child mix again with the healthy — concluding remarks 73

EINGWOEM :

ITS

DIAGNOSIS AND TREATMENT.

CHAPTER I. Introductory Remarks

It is surprising that the results of the treatment of ringworm of the head should generally be so very unsatisfactory, but such is the fact; and, though many cases of the disease are quickly cured, yet a large proportion are allowed, through inefficient treatment, or no treatment at all, to lapse into the chronic form before the disease is well taken in hand.

It must always be remembered that we have to destroy a fungus that is rapidly insinuating itself into the deeper parts of the epidermic strata of the follicles, and between the fibres of the hairs, and therefore fast getting out of the reach of remedies simply applied to the surface of the scalp.

Ringworm is essentially a contagious disease,

B

EINGWORM : THE DIAGNOSIS.

yet we must not deny the possibility of the transmission of the conidia through the air, as the late Dr. Tilbury Fox found the fungous elements in abundance in the dust deposited from the air of a ward in which ringworm cases were located. The contagious nature of the affection has been fully demonstrated by experiments, as well as by clinical observation.

As to the nature of ringworm Dr. Fox says : — " The arguments in favour of the assertion that the growth of the parasite is the essential cause of the inflammatory symptoms and the disorganised state of the hairs in ringworm are unanswerable. I will mention but one or two. No such textural alteration as is present in the hairs in ringworm is ever produced except by the attack of the fungus upon them ; with the destruction of the fungus the disease at once ceases ; parasiticides, if they reach the fungus, speedily cure the disease ; and lastly, the fungus can be shown to be a vegetable structure by artificial cultivation, which is impossible in the case of degenerate animal structure; and by chemical manipulation."*

Ringworm may attack, any part of the body, though it is much more difficult to eradicate when

* Lectures on Ringworm, Dr. Tilbury Fox.

INTRODUCTORY REMARKS.

it exists on the head. Ringworm of the body, as it is generally seen in England, is readily cured by almost any parasiticide, because the mischief lies close at hand, and can easily be dealt with. Ringworm of the head rarely occurs after the age of puberty j but cases have sometimes been seen in the adult. Ringworm of the body may develope at any age, though it is much more common among children ; and, if seen in adults, is generally observed on the hands or arms of those attending children afflicted with the complaint. Very rarely, it may attack the hairs of the beard, producing parasitic, or tinea sycosis.

Tinea tonsurans and tinea circinata, differ only as regards their locality. The former often infects the body and produces patches of tinea circinata. The fungus in both is the trichophyton tonsurans.

The question of the exact nature of the fungus is a very difficult and intricate one to answer, and I shall not attempt to pursue the subject here, but refer any reader who desires to follow it up, to Hebra's work on skin diseases,* but I quote the following :

" It will be seen that, in spite of the numerous observations on record of attempts at cultivation,

* Hebra on Diseases of the Skin, vol. v., pp. 114 to 138. New Sydenham Society, 1880.

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EINGWOEM : THE DIAGNOSIS.

we are far from being able to determine the proper relationship of the fungi met with in well established parasitic dermatoses to one another, or to the mould fungi. If, therefore, some pathologists hold the opinion expressed by Hebra of the identity of favus and tinea tonsurans to be true, and even include pityriasis versicolor also, it is important that it should be understood that they are not at all supported by scientific mycology at the present time — " It follows necessarily, that we must, for the present, regard the fungi met with in the dermatomycoses as specific individuals."

When the fungus first effects a lodgment on the surface of the skin it causes irritation, a certain amount of inflammation with redness, and often minute vesiculation, followed by desquamation. Then it attacks the hairs, rendering them dry and brittle, splitting them up, and disorganising them.

As regards the treatment, although general and constitutional remedies are most beneficial in the chronic forms of the disease, yet the essential point to remember, is, the fact that the fungus must be destroyed by local apjjlications, general treatment alone being absolutely useless.

Ringworm affecting parts of the body not hav-

INTRODUCTORY REMARKS.

ing deep-rooted hair, is, generally, easily eradicated ; as well as ringworm on very young children, and recent cases of scalp disease ; but, now and then, although the very best treatment is adopted, the ringworm will spread in spite of ordinary remedies, the skin of some individuals seeming to afford a soil more particularly favourable to the growth of the fungus.

This is especially seen in children of a strumous or lymphatic diathesis ; and it is often observed that all the children in a family of this description, if they become infected, will suffer either slightly or severely, evidently showing that there is some general condition present favouring the parasitic growth.

Ringworm does not exercise any noticeable influence on the general organism or constitution.

RINGWORM : THE DIAGNOSIS.

Chapter II

The Different Varieties, and the Diagnosis of Ringworm of the Head.

I do not propose to give a general description of ringworm, as the ordinary characteristics of the complaint are familiar to all medical men, but will pass on to make a few practical remarks, for the most part suggested by my own actual observation and experience.

In the first place, I cannot help observing that very few medical men, either in consultation or private practice, are aware how extremely difficult some cases of ringworm are to cure ; and the majority consider a case well, even when it has assumed a decidedly chronic state. Many boys are presented for admission to Christ's Hospital who, while bringing certificates from medical men of the highest professional standing that they are cured from ringworm, are still suffering from a severe form of the disease. I have often found, on inquiry, that an opinion has been formed, and a certificate given, without any special examination of the scalp, and certainly without

RINGWORM OF THE HEAD.

the help of a lens or microscope. Most practitioners imagine that a ringworm is cured when the hair is again growing freely and firmly on the part affected. This is a great mistake, as some of the most chronic cases are those in which the hair has grown again on the patches, but, on close inspection with a lens, some scurfiness, and many broken hairs or stum,ps may be seen scattered among the healthy hairs.

Speaking from experience, after the examination of a very large number of children, I have found that in the majority of cases where a boy or girl has had ringworm on the head within a year or two of my seeing them, the disease has not been really cured. As a rule, the treatment has been continued until some new hair has made its appearance, after which it has been discontinued, although many diseased stumps remained.

Besides the usual cases mentioned above, that is where there are numerous broken hairs to be seen on old patches, I sometimes find that the stumps have been rubbed down by friction, or partially removed by attempted epilation, before the examination. Under these circumstances, we see numerous follicles, with no hairs growing from them — a most suspicious sign, — and also some black dots. These blade dots are the orifices

RINGWORM : THE DIAGNOSIS.

of diseased follicles, in which the stumps have broken off on a level with the surface of the scalp by friction, or are the apertures, filled with dirt, left by the retraction of the broken and shortened stump into the follicle after attempted epilation.

Especially would I call attention to a variety I call disseminated ringworm — one rarely diagnosed, and the most chronic and difficult to cure. The hair is growing freely and firmly all over the head ; there are no patches to be seen now, although probably they have existed at an earlier stage of the disease; the skin appears generally healthy, and perhaps almost free from scurf: but numerous isolated stumps, or groups of stumps, are seen here and there, often scattered all over the scalp. This variety is almost always overlooked, and can only be detected by very careful examination.

The stumps in old chronic cases are very brittle, and almost always break on attempted epilation, showing under the microscope, after soaking some little time in liquor potassse, a most extensive implication with fungus, even down to the bulb of the hair. Rows upon rows of conidia, like strings of beads, are seen running parallel to the filaments, splitting the substance of the hair, and causing it to appear almost double the ordinary

CHRONIC RINGWORM.

size. Where the disease has continued for a year or longer, the whole thickness of the hair seems to be filled with these rows of conidia, which gives it the appearance of a solid mass resembling fish-

Fig. 2.

A stump, very full of fungus, taken from a case of chronic ringworm, of nearly three years duration, showing the rows of conidia, even down to the bulb, and the appearance of the stump where it has been broken off, frayed out, and some oil-globules.

RINGWORM ; THE DIAGNOSIS.

roe. Now and then a hair may be seen to be distended and ruptured along its shaft, the filaments with conidia protruding at these points, and in some cases the fungous elements so abundant as to completely disintegrate the hair. The free end of the broken stump possesses a jagged, stubble-like, frayed-out extremity. Between the filaments of the faggot-like end many conidia are seen. {Vide Fig. 2).

Cases like this have certainly existed for many months, or, more likely, for a year or two, and may have given the disease to many other members of a family, while all the time they have been overlooked, or thought to be well.

But apart from these varieties, some of which are exceedingly difficult to diagnose, I have had children sent to me, certified as cured, when there were typical patches existing as large as a fiveshilling piece, itching, and covered with very short, broken, dry, opaque, and twisted hairs, looking as if they had been nibbled- oft', frequently of the usual yellow or ash-grey colour, and with fine opaque branny scales or scurf, evidently showing that some medical men have no idea what ringworm is like; and even when these appearances are pointed out to them, they affirm that the disease is dried up and cared, and that the child is quite Jit to mix with other children.

RECENT RINGWORM OP THE HEAD. 11

The occurrence of the short nibbled-off stumps is most characteristic, and with ordinary precautions no mistake ought to be made. Broken hairs, or stumps, for microscopical examination should be carefully removed with a pair of fine pointed forceps, and placed in a drop of liquor potassaa on the centre of a glass slide. The cover-glass should be applied, and the specimen left, if possible, for a few hours, in order to make it more transparent. The thin glass should then be slightly pressed down, so as to compress the stump, and spread out the mass of conidia.

The shaft, (Vide frontispiece), will then be seen to be covered in parts with thick masses of conidia, but not to be split up so much in its substance, as is the case after the disease has existed some time. (Vide Fig. 2). The hair appears opaque at first, and often of a reddish brown colour. The shaft is seen to be invaded by the conidia, and even mycelium threads may be observed on the surface, and penetrating the substance of the hair ; but the broken end, though swarming with conidia, does not appear quite so frayed out as it does in the previous specimen, taken from a case of much longer standing. Many conidia, in groups or strings, are seen floating about the field, together with oil globules, epithelial cells,

RINGWORM : THE DIAGNOSIS.

and debris. The little masses of regular sized, and circular conidia are very characteristic, and show the specimen to be fungus, and not simply fat globules. Sometimes, in cases not under treatment, masses of fungous elements are often removed that require teasing out with a pair of needles, before the conidia can be distinctly seen.

If the fine epidermic scales are examined, the mycelium filaments will, as a rule, be seen, as well as conidia, penetrating between them.

The conidia, or spores, measure about the tgoo to the jnro of an inch in diameter.

The fungous elements do not penetrate beyond the epidermic strata, and are found in the hairs and the inner root-sheath. The hair papillae are never invaded.*

It is a great mistake to think that ringworm of the scalp usually presents itself to the medical practitioner as a red, rough, or scaly spot of a ring-like form, almost destitute of hairs; the appearance of ordinary ringworm of the skin (described further on,) is not often seen on the head. At an early stage of the disease, there may be only a very small scurfy spot or two, containing hairs more brittle than usual j but as a rule the

* For further information on tbis subject vide Hebra's work on Skin Diseases, 1880.

RECENT RINGWORM OP THE HEAD. 13

doctor does not see the case until one or more of the hairs are broken off short.

If ringworm of the head is observed at its commencement, a small ring of minute, pin-head sized vesicles, on a red base, may sometimes be seen. These quickly terminate in desquamation or furfuraceous scales, and the places rapidly spread, and soon put on their characteristic appearance.

Recent typical patches vary in size, are more or less circular in shape, and of a greyish or slaty colour ; they are covered with fine opaque branny scales or scurf, and are more or less bald, with numerous broken hairs or stumps. The scalp is slightly raised, and the follicles are too prominent, the skin having the appearance of cutis anserina. The surface is covered with dry lamellated scales, and, here and there, slight crusts may be observed. Small, asbestos, sheath-like coverings, of a dull white colour, and composed of epidermic scales mingled with fungous elements, more or less surround the base of the stumps. This gives rise to a white frost-like looking surface.

Most of the hairs have become broken off ; and those remaining can usually be easily pulled away whole, or else they break off on the slightest

EINGWOEM : THE DIAGNOSIS.

traction. The hairs are lustreless, and look as if covered with fine dust ; and most of them being broken off short, as if they had been nibbled, give the part a stubble-like appearance. The stumps are thickened, dull, dry, opaque, brittle, and usually break on attempted epilation. Some of the hairs are twisted, and bent at an angle, after emerging from the follicles.

There is generally some itching of the surface, and this may be one of the first symptoms of ringworm.

At other times actual stumps are not seen, but shortened irregular twisted-looking hairs, sometimes lying quite flat on the scalp, and of a lighter colour, which, on attempted epilation, break off and show the usual fungus.

Sometimes the head may become partially covered with crusts, with the stumps to be seen underneath them. Chronic ringworm may also occur in the form of pustular spots, with a stump in the centre. This appears to be nature's effort to get rid of the stump, and can be successfully imitated by treatment. A very chronic form is also often observed, in which there are one or more large irregular patches, often extending nearly all over the scalp. The surface is very scurfy, and very many of the long hairs remain, together

WHEN IS RINGWORM TO BE PRONOUNCED WELL? 15

with numerous stumps. This variety is sometimes mistaken for seborrhcea or eczema, but can always be diagnosed by the stumps. Cases are even found where the entire scalp is affected.

When is ringworm to be pronounced well?

Medical men should not consider a case cured, or certify a child free from ringworm, unless they have most carefully examined the whole scalp in a good light, and scrutinised any suspicious spot with a lens, and are certain that there is not to be seen a single stump (or even the black dots before mentioned,) giving evidence of the fungus under the microscope. Sometimes it is extremely difficult to detect the stumps when only a few exist ; and often the attention is directed to the short hairs round a treated patch (caused by the hair having been cut,) instead of to the diseased stumps, which are frequently concealed by the healthy hairs, and only protrude about a sixteenth part of an inch. Stumps are often of a lighter colour than the rest of the hair ; and as long as any remain — and they may exist for years — the disease is not cured, and may continue stationary, or spread again, and moreover give the malady to other children.

16 KINGWOKM : THE DIAGNOSIS.

If all the bulbs could be extracted together with the stumps, the disease might be considered cured; but almost always one or more will break off, allowing the root part, which of course contains the fungus in an active state, to remain behind in the follicle, out of which it will not protrude again for a week or two. It constantly happens that a doctor removes, as he thinks, all the stumps from a patch, and certifies the case to be well. But if the place is watched a few weeks, the stumps will probably appear again ; in fact, I consider it extremely difficult to certify that a child who has had ringworm is absolutely well. Time after time stumps will crop up here and there, breaking off when an attempt is made to extract them ; and they may continue to re-appear for months after the case in other respects seems well. Even specialists will be deceived, and after putting a strong caustic on a single patch, and thus getting a bald place apparently quite free from stumps, they will certify the case to be well ; but after a week or two, up come the stumps again, and prove the incorrectness of the certificate. A bald patch should therefore, never be considered well until the new downy hair is growing freely, without a single stump, or black dot, among it.

Atrophied stumps. Sometimes, when ringworm

ATROPHIED STUMPS.

is cured, especially after the head has been shaved, there are a few atrophied stumps seen. These easily come away entire when extracted. They have small atrophied roots, and show no fungus under the microscope, the ends being sharp cut (from shaving) or blunt, and often pigmented; the shaft being of the normal, or less than the normal thickness.

In old chronic cases the diseased stumps undergo some fatty degeneration, and thus many small oil-globules are seen in and about them, as well as conidia; but small oil-globules on a normal hair or atrophied stump must not be mistaken for conidia. To a practised eye there is no difficulty in diagnosing between atrophied and diseased stumps. The regular, equal-sized, and bead-like arrangement of the bright and circular conidia, with their double contoured outline and nuclear contents, on or in the substance of the hair, cannot be mistaken when once seen. Ether will also distinguish oil-globules from conidia, by dissolving the former ; although the fractured, faggot-like appearance of the broken end of a diseased stump is most characteristic.

Diagnosis.

In diagnosis I place but very little reliance on

c

RINGWORM : THE DIAGNOSIS.

the fact that the hairs come out easily round a suspicious spot, as they may do so with equal facility all over the head in children where ringworm is not present, and be very firm in obstinate forms of the disease. A very common error is to take a long hair, or one short, from previous cutting or shaving, growing close to or even on a patch of ringworm, and, finding no conidia on it under the microscope, to conclude the disease is cured. It is useless, as a rule, to look for conidia on the long hairs taken from or around a treated patch. The whole attention for diagnosis and prognosis must be paid to the short stumps.

T have seen a bald patch on a boy's head, purposely made by pulling out the hair, very much resemble ringworm, as it happened to be on a scurfy place, but of course it contained no stumps.

Tinea decalvans, alopecia areata, or circumscripta. There is little fear of alopecia areata being mistaken for ringworm, when it extends over a considerable portion of the scalp ; but, what is called, tinea decalvans, or small patches of alopecia, may simulate it.

Dr. Liveing, in his work on the diagnosis of skin diseases, says : — " Tinea tonsurans occasionally produces perfectly smooth, bald, shining patches of skin, bearing a close resemblance to

TINEA (?) DECALVANS.

alopecia areata : — it is the occasional development of these temporary, smooth, bald patches in common ringworm which has given rise to the erroneous belief that there is a parasitic disease called tinea decalvans, distinct on the one hand from tinea tonsurans, and on the other from alopecia areata ; no such disease really exists."

Against this opinion I quote the following from Dr. Tilbury Fox's woz-k on skin diseases : — "At the present time there is a ' dead set' made by almost every writer on diseases of the skin against the parasitic nature of tinea decalvans, and I believe I stand alone in my opinion of its parasitic nature : — now I am quite ready to admit that this parasitic disease is not common — far from it, aud that the majority of cases of circumscribed baldness observed in the head are not parasitic at all. But I cannot but state that I have found fungus elements without doubt."

Dr. Liveing's view offers a possible explanation of the facts recorded by Dr. Tilbury Fox, who himself admits the rarity of the parasitic affection.

A remarkable outbreak of tinea decalvans, at Hanwell School, is reported by Dr. Hillier,* who also believed in the parasitic and contagious nature of this disease.

* Handbook of Skin Diseases, Dr. Hillier, p. 286.

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EINGWOEM : THE DIAGNOSIS.

My own experience is certainly in favour of the non-parasitic nature of alopecia areata or circumscripta. I have never been able to discover the fungus on the club-shaped stumps, nor have I ever seen a bald patch where I could not decide, whether it was tinea tonsurans, or alopecia areata.

With regard to the practical question of admitting a case of circumscribed alopecia into a school, I may say that I do not fear its spreading, and therefore would not reject it.

At any rate, whether parasitic or not, tinea (?) decalvans, or alopecia areata ought to be distinguished from tinea tonsurans. In the former affection we see one or more, generally circular, bald spots. The places are perfectly smooth and shining, instead of being scurfy; there is no change of colour in the skin, nor is it raised ; and no ordinary stumps are to be observed, although a few club-shaped short hairs, or stumps, are generally to be found at the circamference of the patch.

These club-shaped stumps have atrophied roots ; are easily extracted on the slightest traction, instead of breaking of : and, very rarely — according to some authorities — some minute fungus is to be discovered under the microscope, but never the appearance seen in Figs. 1 or 2. The

LOCAL SCURFINESS.

bulb will be found to be tapering, and reduced in size ; while the free club-shaped end is thickened, and more opaque, exhibiting at times, clusters of fibres radiating outwards in a brush-like form.

There is another kind of baldness sometimes mistaken for ringworm, viz. a bald, or partially bald, patch on the occiput of a young child, that has been caused simply by the head being bored in the pillow at night.

Local scurfiness, without stumps, does not necessarily imply ringworm ; but such spots, especially in light-haired children, or if the disease exists in another part of the head, are very suspicious, and must be carefully examined with a lens, and the scurf placed under the microscope. Often a single stump alone will be discovered. General scurfiness or seborrhcea, however, must not be mistaken for ringworm.

There is a variety of local scurfiness of the head which sometimes very closely simulates ringworm. Patches are seen, where the hair has partially fallen off, having the usual scurfy appearance of chronic ringworm ; even scabs may exist from slight eczema ; and what is more likely to mislead, a false appearance of stumps, caused by the white epidermic scales running up a short distance on

RINGWORM : THE DIAGNOSIS.

the shafts of healthy hairs, as an asbestos-like sheath, and thus very much resembling ordinary stumps. With a lens there is no difficulty in the diagnosis, as no broken hairs are present.

Squamous eczema and psoriasis of the scalp, must also be diagnosed from ringworm. Many points of difference are given in the text books, but the only one of ■practical importance is the absence in these diseases of any characteristic stumps on the scurfy patches.