Medical Home Remedies:
As Recommended by 19th and 20th century Doctors!
Courtesy of


The biggy of the late 1800's. Clearly shows the massive inroads in medical science and the treatment of disease.

ALCOHOL AND THE HUMAN BODY In fact alcohol was known to be a poison, and considered quite dangerous. Something modern medicine now agrees with. This was known circa 1907. A very impressive scientific book on the subject.

DISEASES OF THE SKIN is a massive book on skin diseases from 1914. Don't be feint hearted though, it's loaded with photos that I found disturbing.




and please share with your online friends.


Synonyms.—Tinea sycosis; Tinea barbæ; Tinea trichophytina barbæ; Tricho-
phytosis barbæ; Sycosis parasitica; Sycosis parasitaria; Sycosis contagiosa; Sycosis
hyphomycotica; Herpes tonsurans barbæ; Mentagra parasitica; Ringworm of the beard;
Barber’s itch; Parasitic sycosis; Parasitic mentagra; Hyphogenous sycosis; Fr., Sycosis
parasitaire; Sycosis trichophytique; Trichophytie sycosique; Trichophytie de la barbe;
Ger., Parastäre Bartfinne; Parasitische Bartfinne.

Symptoms.—Ringworm of the bearded region, or tinea sycosis,
as it is commonly termed, is met with infrequently as compared to
the disease on the scalp or general surface. There are two distinct

Fig. 280.—-Ringworm (tinea sycosis, superficial type) somewhat suggestive of a spread­
ing circinate syphiloderm (fungus demonstrated).

types observed, one which remains superficial, and the other a deep-
seated or nodular form. As a rule, it begins in the same manner as
ringworm on non-hairy parts, as one or more rounded, slightly scaly,

1120                                 PARASITIC AFFECTIONS

hyperemic patches, with, in some or all, the tendency in their earliest
formation to be more pronounced peripherally.

In the superficial variety it so continues, the areas enlarging and
clearing up somewhat centrally, the border being usually quite distinctly
elevated. Several near-by patches may coalesce and give rise to a
large, irregular area. There may or may not be slight or moderate
itchiness. The hairs and follicles are involved to a slight or decided
extent, and show similar changes to those observed in the scalp disease;
never, however, to so pronounced a degree. They are, in most parts,
readily extracted, with but little traction; in fact, in some cases some

Fig. 281.—Ringworm (tinea sycosis) in a hostler, of ten days’ duration. Patches
are of the deep-seated, kerion-like, or pustulo-inflammatory type, the hairs loosening
and falling out; one side of the upper lip also partly involved.

of them drop out spontaneously. On the other hand, not infrequently
they, or the most of them, remain firmly implanted, the disease limiting
itself to the epidermis proper. The malady may thus continue, often
after a time remaining stationary, or even showing a tendency to disappear
without treatment. There is in this form rarely any disposition to pus-
tulation. In other instances the process involves the tissue somewhat
more deeply, giving rise to some thickening and infiltration, exhibiting
a midway condition between the superficial variety and the deep-seated
form, into the latter of which it may finally develop.

Sabouraud describes a superficial form (trichophytie sèche, à forme
d’ichtyose pilaire) of the malady in which the skin itself remains un-



involved, the hairs and upper part of the follicles suffering; the hairs
are broken off a little distance from the skin, and the base is surrounded
by dry epidermic scales or débris.

The deep-seated variety begins, as a rule, in the same manner as
described, and after remaining superficial a variable time, shows a de­
cided, and often rapid, tendency to extend down into the follicles and
tissues; occasionally it begins somewhat similarly to sycosis vulgaris.
As a result of such deep involvement more or less subcutaneous swelling
ensues, and the affected parts assume a distinctly lumpy and nodular
condition, often suggestive, when extensively developed, of crowded,

Fig. 282.—Ringworm (tinea sycosis) of the deep-seated, kerion-like, and nodular
type. The whole neck and chin are invaded, the hairs loosening and falling out.
Three months’ duration.

sluggish, somewhat flattened, furuncles or cutaneous abscesses, and at
times having a carbuncular aspect. The overlying skin is usually con­
siderably reddened, often presenting a glossy appearance, and studded
with few or numerous follicular pustules. The nodules ordinarily, after
a time, tend to soften and break down and discharge at one or more of
the follicular openings, a glairy, glutinous, mucopurulent or purulent
material, which may dry to thick, adherent crusts. In some instances,
instead of fairly well-defined lumpiness or nodulation, it presents as
patchy, diffused, sometimes circumscribed, firm, later boggy, infiltra­
tions. In others the features are closely similar to those of kerion on
the scalp, with which, in fact, the process is in many respects analogous.

1122                                  PARASITIC AFFECTIONS

The hairs themselves may or may not be conspicuously implicated, but,
as a rule, as soon as the tumor-like swellings are at all developed they fall
out; sometimes, indeed, earlier in the disease. The extent of the involve­
ment varies; it may take in the whole bearded region, being especially
well marked just on the chin and under the jaw, producing a good deal
of disfigurement; in other cases it may remain more or less limited to the
chin, and exceptionally there is but one patch of carbuncular-looking
aspect. The upper lip is seldom involved, probably never independently,
but along with extensive invasion of the other parts. The process shows
but little disposition to spontaneous disappearance, usually continuing,

Fig. 283.—Ringworm (tinea sycosis) of the deep-seated, kerion-like, and nodular
type, of a month’s duration, consisting in this instance—comparatively rare—of but one
area made up of several confluent, deep-seated, suppurating nodules, with loosening and
falling out of the hair. Such cases are occasionally mistaken for carbuncles and

in an irregular, sluggish manner, more or less indefinitely, unless relieved
by treatment. As to subjective symptoms, there may be, especially in
the earlier stages, slight itching; later possibly burning, and variable sore­
ness and tenderness.

Diagnosis.—The superficial type of ringworm of the bearded
region is, as a rule, readily recognized by its ring-like configuration,
its method of beginning and extension, and quite usually also by evi­
dences of hair involvement. It might possibly, if consisting of but few
ring patches, be mistaken for the circinate tubercular syphiloderm. In
this latter the border is more infiltrated, is of darker color, and the part

RINGWORM                                         1123

traversed frequently shows atrophy or pigmentation, or both; if ulcera-
tion or scarring is present, as often noted, it would furnish conclusive
proof of its syphilitic character, as these are not seen in the superficial
form of ringworm. Moreover, in ringworm the hairs quite commonly
exhibit the effects of the fungus invasion, and in doubtful cases can be
subjected to microscopic examination. The ring-like characters of the
patches and the hair involvement, as well as the history and course, will
serve to distinguish it from eczema and seborrhea. These features and
the absence of any special tendency to follicular pustules suffice to ex­
clude sycosis vulgaris.

The deep-seated, nodular form, if at all developed, can scarcely
be confounded with other maladies—the peculiar lumpiness of the parts,
the involvement of the hair and hair loss, the history, and finally, in
doubtful cases, microscopic examination, furnishing conclusive differ-

Fig. 284.                                                         Fig. 285.

Figs. 284, 285.—Cultures of the Microsporon Audouini on maltose proof medium—
at fifteen and twenty days. Appears first as a white feathery disk, with a minute
central acuminated point, and shows later three or four furrows, and later still these
become more marked, between which develop shorter furrows; the surface, at first white
and feathery, becomes grayish or grayish white, appearing not unlike a short-nap
woolen cloth (courtesy of Dr. R. Sabouraud; from his work Les Teignes).

ential points. Sycosis vulgaris is relatively superficial, with no con­
spicuous infiltration or lumpiness, and the pustules usually small and
pierced by a hair; and unless the suppurative action is marked, there
is but little tendency for the hairs to fall out. There could scarcely be
confusion with the tuberculogummatous syphiloderm, as the superficial
or deep ulceration, the greenish, purulent, and commonly offensive dis­
charge, as well as the bulky crusts often observed in syphilis, are not to
be found in tinea sycosis. In fact, in the latter, although its characters
are frequently suggestive of possible destructive action, most cases
after recovery show but little marking, often not any at all; in others
several or more small insignificant scars. Special care should be exer­
cised not to mistake the single circumscribed tumor-like formation to
which exceptionally ringworm limits itself for a carbuncle; a sluggish
formation of this kind on the chin region, showing generally much less
inflammatory activity than carbuncle, with relatively slighter swelling
and pain, should always be, first of all, considered as probably of ringworm

1124                           PARASITIC AFFECTIONS

fungus origin, and the hairs accordingly examined. Three or four in­
stances have come to my notice in which the growth was opened by
surgeons under the impression that it was carbuncular or of the nature
of an abscess.

Etiology.—Ringworm is due, as stated in the preliminary remarks
(q. v.) on the disease and its fungi, to the invasion of the epidermic tissue
by fungus elements. The disease is contagious. It may be conveyed
directly by contact or through the medium of toilet articles and wearing
apparel. It is particularly common in children’s schools and institutions
where there are so many opportunities, direct and indirect, for commu­
nication. Day nurseries, “homes,” and like charitable havens for in­
fants and children are often quite active centers for its spread. Barber­
shops and hair-dressing establishments, “complexion or beauty parlors,”
laundries, etc, are likewise common sources of the disease. It is also

Fig. 286.                                                         Fig. 287.

Figs. 286, 287.—Cultures of the Microsporon lanosum on maltose proof medium—
at fifteen and thirty days; surface downy, with a smooth, powdery central area, around
about which develops a ring of projecting white wooly down; this results in a relative
depression or umbilication centrally; thread-like lines of a grayish tint radiate from the
outer border of the ring (courtesy of Dr. R. Sabouraud; from his work Les Teignes).

quite frequently transmitted from the lower animals, especially the
cat, dog, horses, cows, rabbits, etc1 The wearing of underwear brought
from the laundry in a damp condition, subsequently having a moldy
odor, has, according to my observations, apparently been of etiologic

1 Examples of contagion from the dog, cat, and horse are found quite numerously
referred to in literature, and are not uncommon in the experience of those with large
clinical opportunities. Eddowes, Brit. Jour. Derm., 1898, p. 149, gives an instance in
a girl of fifteen of its contraction from a pet hedgehog, the fungus being found in the
scrapings from the patient, and also in the prickles of the animal; Busch, “On Ring­
worm Infection in Man and Animals,” Brit. Med. Jour., Feb. 9. 1901, records several
examples of animal contagion, among which one from a pet canary; in these instances
the observations were confirmed by examination of the animals; Kessler, Jour. Amer.
Med. Assoc.,
Oct. 25, 1902, finds that in stock-raising districts the most frequent source
of contagion is from cattle and especially from yearling calves; the farmers call the dis­
ease “barn-itch"; and Mewborn, “A Case of Ringworm of the Face and Two of the Scalp
Contracted from a Microsporon of the Cat; with Some Observations on the Identifica­
tion of the Sources of Infection in Ringworm Cases by Means of Cultures,” New York
Med. Jour.,
Nov. 15, 1902 (with illustrations).

Plate XXX.

Figs, i and 2 (x about 300).—Microsporon Audouini in the hair; Fig. 1 shows
mosaic of spores and also mycelium, the latter seldom seen in these cases ; Fig. 2 is a
stained specimen.

Fig. 3 ( x about 400).—-Trichophyton of the endothrix variety—stained specimen.
(Courtesy of Dr. Charles J. White.)

Figs. 4 and 5 (x about 400).—Trichophyton of the variety ectothrix ; hairs from a
case of ringworm of the bearded region involving also the upper lip—hairs from the

latter region. Fig.4 shows fungus on surface of hair, and Fig. 5 Fungus in the hair.

(Courtesy of Dr. M. B. Hartzell.)

RINGWORM                                              1125

bearing in some cases of body ringworm. Both sexes are liable, and in
about equal proportion; and age in a general way, except in certain
situations, exercises but little influence, although the malady is seldom
seen in those past fifty. Those of fair complexion and whose general
nutrition is impaired are thought to be more susceptible, especially as

Fig. 288.                                                         Fig. 289.

Figs. 288, 289.—Cultures of the Trichophyton crateriforme on maltose proof medium
—at twenty and thirty-five days; central crater-like or cup-shaped cavity, with a but­
ton-like projection in the middle; surface is velvety in appearance, the central part
being yellowish in color, with a white periphery, becoming later cream colored (courtesy
of Dr. R. Sabouraud; from his work Les Teignes).

regards the scalp affection, but while seemingly so in many instances,
Aldersmith, Crocker, and many others hold the contrary. My own ob­
servations indicate that the most stubborn types are more commonly
met with in those of relatively poor general health, but as to the in-

Fig. 290.                                                         Fig. 291.

Figs. 290, 291.—Cultures of the Trichophyton acuminatum on maltose proof me­
dium—at twenty and thirty-five days; powdery surface and cream colored, becoming
brownish later, with, in some instances, a violet tinge; center rather sharply acumi­
nated, the furrows sometimes opening later and showing small holes (courtesy of Dr. R.
Sabouraud; from his work Les Teignes).

fluence of complexion, I have encountered the malady in all its situa­
tions, but especially on the scalp, quite frequently in negro children,
probably as often relatively as in whites. The disease prevails to a
somewhat greater extent in some countries than in others, although it is
common enough everywhere. Sabouraud’s experimental investigations

1126                                 PARASITIC AFFECTIONS

indicate that susceptibility may measurably depend upon the acidity or
alkalinity of the sweat secretion, the latter condition largely increasing
the proportion of successful inoculations.

Ringworm of the general surface may occur at any age, but is much
more frequent in children and young adults; less so in the middle period

Fig. 292.                                                         Fig. 293.

Figs. 292, 293.—Cultures of the Trichophyton violaceum on glucose proof medium
—the left at sixty days; the right shows an old, thirty-day culture, having been more
than a year in the laboratory and taken on a spongy form. Is somewhat rounded in
shape, with slightly projecting swellings, and with small button-like projections cen­
trally; has a shining surface with often five or six or more radiations; and is of a beau­
tiful violet color (courtesy of Dr. R. Sabouraud; from his work Les Teignes).

of life, and rather unusual in advancing years. As typically encountered,
it is due to the large-spored fungus, commonly the ectothrix variety.
This is also etiologic in the markedly inflammatory and deep-seated
types. The superficial furfuraceous macular spots or patches seen,

Fig. 294.                                                         Fig, 295.

Figs. 294, 295.—Cultures of the Trichophyton cerebriforme on maltose proof me­
dium—at twenty-five and sixty days; surface, which is powdery and at first white, later
cream yellow, is suggestive of the cerebral convolutions; at the central part a break
finally occurs, forming a cavity with irregular periphery (courtesy of Dr. R. Sabouraud;
from his work Les Teignes).

with sometimes but little tendency to clearing centrally, and of but
slightly hyperemic character, are sometimes due to the small-spored
fungus, or to one of the endothrix varieties of the large-spored fungus;
and those transitory forms of lenticular rosy macules, often scarcely
perceptibly reddened, are also caused, for the most part at least, by the

RINGWORM                                    1127

endothrix variety of the large-spored fungus, although this latter some­
times, as well as also occasionally the microsporon, are productive of
typical examples of the malady. Tinea cruris, as well as some of the
eczematoid, vesicular, and vesicobullous eruptions about the hands and
feet, are, as previously stated, due to a special fungus—Epidermophyton

Ringworm of the scalp is a common affection, but it is one which
may be said to be limited to children, seldom presenting or persisting
after the fourteenth or fifteenth year, and with rare exceptions never
occurring in the adult. I have met with but one such instance in a
woman aged thirty. Professor Duhring1 has “never seen it in persons
over sixteen or seventeen years of age.” Hyde and Montgomery2
state that “ringworm in the scalp of the adult and the aged is, indeed,

Fig. 296.                                                    Fig. 297.

Figs. 296, 297.—Cultures of the Trichophyton asteroides on maltose proof medium
—at twenty and thirty days; central prominence—which later shows tendency to um-
bilication—with numerous fine star-like radiations; the radiations are usually more dis­
tinct and pronounced in cultures on glucose proof medium; the color is a pure white,
and the surface powdery like plaster of Paris—representing the so-called “gypsum”
type culture (courtesy of Dr. R. Sabouraud; from his work Les Teignes).

among the rarest of cutaneous accidents.” Crocker3 has observed it
beginning in the adult, in 3 instances, one at the age of thirty-four, one
at fifty­ three, and another at fifty-five; Jamieson4 in 2 women, one a
nursemaid, the other aged thirty-eight; Aldersmith,5 with his large ex­
perience, has seen it in but 5 cases in twenty years. Cases have been
reported recently by Colcott Fox,6 Anderson,7 and Abraham.8 These

1 Duhring, Diseases of the Skin, third ed., p. 615.

2 Hyde and Montgomery, Diseases of the Skin.

3 Crocker, Diseases of the Skin, third ed., p. 1293.

4 Jamieson, Diseases of the Skin.

5 Aldersmith, Ringworm and Alopecia Areata; also an additional case (male, aged
twenty-three), reported recently, Brit. Jour. Derm., 1898, p. 5.

6 Colcott Fox, ibid., 1898, p. 253 (in a man aged forty-two).

7 Anderson, ibid., p. 156 (resembling alopecia areata).

8 Abraham, ibid., p. 163 (4 cases since 1885).

1128                                  PARASITIC AFFECTIONS

adult scalp cases—those noted by the last four observers named and also
the last one of Crocker’s cases—were due to the large-spored fungus, all
except Anderson’s to the endothrix variety; Anderson’s to the ectothrix.
In the others the variety of fungus was not known or not stated.

Ringworm of the scalp, however, as observed in children, is pre­
ponderantly due to the small-spored fungus (usually the microsporon
Audouini), although in a fair proportion the endothrix (mostly to the
trichophyton crateriforme and trichophyton acuminatum1) of the large-
spored fungus is etiologic, and the ectothrix is also occasionally causa­
tive—the last being commonly responsible for the inflammatory pustular
types. In hospital and dispensary practice C. J. White’s investigations
show the microsporon causative in Boston in 88 per cent, of the cases;
Corlett,2 90 per cent, in Cleveland; G. W. Wende (cited by Corlett), in
89 out of 90 cases in Buffalo; Colcott Fox and Blaxall give 80 to 90
per cent, in London, where Adamson’s observations give a still higher
proportion—178 out of 183 cases, and Scott (at London Hospital—700

Fig. 298.                                                        Fig. 299.

Figs. 298, 299.—Cultures of the trichophyton rosaceum on maltose proof medium—
at eighteen and forty-five days; at first it presents a round button-like appearance with
a central knob-like prominence; later five or six large rounded, somewhat deep, radiating
furrows develop; the surface is velvety; at first snow-white, it soon changes to its char­
acteristic rose color (courtesy of Dr. R. Sabouraud; from his work Les Teignes).

cases) 89.8 per cent., the other cases (10.2 per cent.) being due to the
endothrix; and, according to Aldersmith, 78 per cent, in private prac­
tice; Sabouraud, 60 per cent, in Paris; in Scotland, according to Norman
Walker,3 the enormous bulk of the cases, and in 18 out of 20 of Jamieson’s4
cases. On the other hand, in Italy, Mibelli5 has not met with the small-
spored fungus in a single instance, the malady being due to the large-
spored variety. The trained eye can in many instances usually recog­
nize, by the clinical appearances in a given case, which variety of fungus

1 In a large number of cases of trichophytosis capitis Colcott Fox found 38 per cent,
due to the trichophyton crateriforme, 26 per cent, to trichophyton acuminatum, 21
per cent, to trichophyton sulfureum, and 15 per cent, to trichophyton violaceum; in
211 Paris cases Sabouraud found 53 per cent, due to trichophyton crateriforme, 22 per
cent, to trichophyton acuminatum, 16 per cent, to trichophyton violaceum, and only 9
per cent, to all the other species of trichophyton.

2 Corlett, “Recent Researches in Ringworm,” Jour. Amer. Med. Assoc, March 18,

3 Norman Walker, An Introduction to Dermatology.

4 Jamieson, Brit. Med. Jour., 1893, ii, p. 470.

5 Mibelli, “Sur la pluralité des trichophytons,” Annales, 1895, p. 733.

RINGWORM                                               1129

is likely to be found, but this knowledge is a matter of no import in the
practical management of the case.1

Pathology.—The pathogenic role of the parasitic vegetable organ­
ism in provoking the conditions described is at the present day unques­
tioned. The plurality of the causative fungi is also generally conceded,
although such careful observers as Leslie Roberts and a few others are in­
clined to believe that the variations, or many of them at least, may be
due to the cultural methods and to the quality of the “sou,” etc2 The-
fungus invades the epidermis and hair, and in occasional instances the
nails (see Onychomycosis), and the phenomena observed are due to its

Fig. 300.                                                        Fig. 301.

Figs. 300, 301.—Cultures of the epidermophyton inguinale on maltose proof
medium—at eighteen and thirty days; dry and powdery, downy in appearance, with
wrinkle-like radiating furrows and slightly elevated folds, and a small central depression;
is greenish yellow in color (courtesy of Dr. R. Sabouraud; from his work Les

mechanical, irritative, and destructive action. In some instances, more
especially in the markedly inflammatory types of the malady, fungus ele­
ments are found deep in the follicles, in the perifollicular tissue, as well

1 Those cases of ringworm of the scalp presenting the well-defined rounded patch,
with follicular prominences, or goose-flesh appearance, and with light or dirty-grayish
colored branny or lamellated scales, and showing a powdery sheath or sheath-like cover­
ing (so-called circumpilar collarette) surrounding the whitish or grayish stumps and hairs
just within and above the follicular outlet are due to the microsporon. The hairs are
grayish, lusterless, and readily broken, and as most have been broken off, the patch has
a nibbled appearance. Only rarely is it responsible for the pustular or other inflamma­
tory forms. In that due to the trichophyton of the endothrix variety (in both sub-
species, resistant and fragile) the areas are smoother than those due to the microsporon,
and sometimes the surface is quite clean looking, lacking the grayish, frosted look, and
only exhibiting broken hairs and hair-stumps, and these usually without the circumpilar
collarettes. There may be one or more areas. Sometimes in these cases, especially due
to the “resistant” subspecies, there may be present some sebaceous scaliness, suggesting
seborrhea. Disseminated ringworm and the “black-dot“ ringworm are sometimes due
to this latter subvariety, although the “fragile” subspecies is more commonly respon­
sible for these forms, and also for many of the cases of “bald ringworm.” When due to
the endothrix, more especially the resistant variety, there may be seen very often one or
two large areas, with outlying or scattered small patches. It is especially ringworm
of the scalp caused by the endothrix that often has associated with it well-marked
patches of tinea circinata. Kerion and other markedly inflammatory and pustular
types are usually due to the ectothrix variety; Sabouraud says always, but Aldersmith,
Colcott Fox and Blaxall, Adamson, Malcolm Morris, and others have found the kerion
type occasionally produced by the small-spored fungus. The ectothrix fungus is
also held responsible for the cases of ringworm of the bearded region observed in the
male adult, and contracted, either directly or indirectly, from animal sources, the pus-
producing variety from the horse. It is, therefore, much more common in hostlers and
those who have to do with these animals and cattle. For further information on these
points see preliminary remarks on this disease.

2 See a valuable and suggestive publication by Leslie Roberts, An Introduction to
the Study of the Mould Fungi Parasitic on Man,
1893—a good critical review of the
same by Norman Walker in Brit. Jour. Derm., 1893, p. 375.

1130                                 PARASITIC AFFECTIONS

as in the derma proper (Robinson, Pellizari, Campana, Rosenbach,
Hartzell). The parasite finds, however, its most suitable habitat and
flourishes most luxuriantly in keratinized epithelial structures. The
exact botanical position of the microsporon and the trichophyton are
still involved in some doubt. Sabouraud contends that the microsporon
is distinct from the trichophytons, but is not able as yet to attach it to
any particular family; the trichophyton, owing to the tendency to form
masses of spores, he is inclined to place among the mucedinous mold
fungi, varieties of the family botrytis, or the sporotricha. Other in­
vestigators, among whom are Aldersmith and Colcott Fox and Blaxall,
believe they are nearly related members of the same family, and that
fructification is developed practically on precisely the same plan. The
source of the fungi is also as yet not definitely settled. Sabouraud be­
lieves that the microsporon is essentially a human parasite. Malcolm
Morris states the matter thus: “The origin of the fungi is uncertain.
Sabouraud thinks it probable that the trichophytes, or some of them,
may exist independently as saprophytes, and this suggests the possi­
bility of direct contagion from moldy vegetable substances. Ectothrix
is believed to be exclusively of animal origin (Colcott Fox)—more par­
ticularly the horse and cat. Some trichophytes also infest birds. The
small-spored fungus is likewise believed to be occasionally derived from
the horse, cat, or dog.”

In extemporaneous examination for fungus, if in ringworm of the
general surface, scrapings are taken from the border of the patch and
immediately contiguous skin, and put in some liquor potassæ on a glass
slide, with the cover-glass lightly placed over it; this is permitted to soak
for five or ten minutes or more, and then the cover-glass pressed down
and the material flattened out. If in ringworm of the scalp or bearded
region, an affected hair-stump or broken hair, preferably the former,
is carefully removed or picked out of the follicle, and similarly treated,
but, as a rule, a much longer soaking is required, and in stiff, thick,
and dark hairs a stronger solution. After a variable time the cover-
glass is firmly pressed down. Occasionally it is preferable to soak the
hair in a shallow vessel containing the potash solution. The specimen
can then be examined, for which a power of 300 diameters or more is
required. Jamieson heats the potash solution containing the specimen
somewhat by holding the slide over a spirit-lamp for a few seconds, and
subsequently washes the alkaline solution out, and examines the
specimens in glycerin. They can be mounted in this latter, although
after some time they become rather thin, washed-out-looking, and too

1 Malcolm Morris strongly advises the adoption of staining methods for the careful
morphologic study of the specimens. His plan, as modified by Norman Walker, is as
follows: “The hairs and scales are put on a slide and a drop of anilin-gentian violet or
alum-gentian violet 1 to 5: 100 added. Here it must remain at least five minutes. It
is then treated with Gram’s solution for three minutes or longer, and then dried with
blotting-paper. Then a drop of anilin oil with enough iodin in it to make a dark cherry
color is added; and after a little washing to and fro it is examined under a low power.
In most cases this is enough, but if the specimen is to be preserved, it must be washed
in pure anilin and then in xylol before mounting.” The small-spored fungi, according
to Morris, stains much more quickly than the large spored. The permanent mounting
can be made in Canada balsam.



The characters of the fungi vary somewhat. The spores of the
microsporon Audouini are usually rounded, occasionally somewhat
oval, and, as the result of pressure, sometimes polyhedral. They are
often double-contoured, contain granules and liquid, and are from 2
to 2.5 µ in diameter. The mycelium consists of sharply contoured,
transparent, pale-grayish, branching threads or tubes, showing frequently
slight bulging at irregular intervals, and often terminating in mycelial
spores. They are jointed here and there with real dissepiments, the
septa containing granules and cells. Cultures of this fungus show slight
differences in some instances, indicating possible variations in the plant,
although for the most part they are practically identical. These dif­
ferences are slight compared to those observed with cultures of the varie­
ties of the trichophyton. Some trifling variations are noted also in cul­
tures of the various species as found in different countries. The tricho-
phyton, or large-spored fungus, has spores and mycelium larger than those
of the microsporon; the spores are from 3 to 6 µ in diameter, and are ar­
ranged in a ladder-like or bead-like manner, forming band-like mycelium.
The mycelium does not branch so much as that of the small-spored fungus.
The mycelial filaments, whether sporulated or not, always divide dichot-
omously (Morris). The mycelium of the ectothrix is large and very
abundant in ringworm of the body, and the septa are long—much
longer than the septa of either the endothrix and the microsporon.
In Sabouraud’s microid class of the ectothrix the spores are small, and
doubtless often taken for those of the microsporons. Culture is the
only certain method of differentiating. The epidermophyton1 forms
mycelial network exactly like a trichophyton (Sabouraud). According to
the variety of fungus, its position, arrangement, and manner of the hair
invasion are to a variable extent somewhat different,2 although, according

1 Whitfield Brit. Jour. Derm., 1911, p. 380, (hand and foot cases) advises, when ex­
amination for the fungus is to be made in potash solution, “to peel off the scale from
the most suggestive undermined part of the eruption, and to lay the scale with its deep
surface upward on the slide; by attention to this detail it is commonly easy to see the
fungus immediately, whereas if the scale is laid with the deep side downward one may
have to wait an hour or more before one can see sufficiently clearly to identify the fun­

2 In the microsporon ringworm the fungus lies around the hair, forming the grayish
sheath or collarette described by Sabouraud. This observer and Malcolm Morris state
that the cuticle of the hair is first attacked and eaten away; the edges thus frayed and
the interior of the shaft invaded and in a downward direction, toward the root. Adam-
son and Colcott Fox, on the contrary, hold that the epidermis is first attacked. The
spores are often arranged in a mosaic-like manner around the hair, with little tendency
to form bands, but about the junction of the shaft with the bulbous portion is a terminal
fringe of long, plain, narrow, delicate, sometimes branched, mycelial threads, which
Colcott Fox regards as quite characteristic. The hair is finally often completely in­
vaded, and the broken ends found swarming with conidia.

With the large-spored fungus, endothrix variety, the hair-root first suffers, and the
action extends upward, the spores being arranged in chains, intermingled with short,
irregularly jointed mycelium. There is no visible circumpilary sheath, the spores lying
sometimes inside and sometimes outside of the hair. The mycelia run up the shaft
parallel to its long axis. This variety can usually be recognized microscopically by the
large spores and the bead- or ladder-like characters of the chains of spores, and espe­
cially by their intrapilar position (Aldersmith). In the resistant variety, in the earliest
stage, strings of jointed, ladder-like mycelium are seen outside of the hair and also
entering its substance; in the latter first only a few threads, later the hair is more or
less infiltrated with it. Finally all parts show fungus invasion—hair-shaft, its exterior,
especially between the hair and the root-sheath, and the bulb. There is seen dichoto-



to Colcott Fox and Blaxall, Malcolm Morris, Ravogli, and others, the
finer distinctions in the appearances and site of invasion insisted upon by
Sabouraud are not to be taken too strictly.

For cultures Sabouraud advises the general use of maltose and glu­
cose proof media so as to have a uniform standard; as his work and cul­
ture illustrations are practically based upon such, and are necessarily
the accepted standard of comparison, one or the other of these media
should always be employed. Other media usually produce consider­
able deviation, often an entirely different picture, and would result in
more or less confusion. His formula for the maltose proof medium is:
water, 1000 grams; crude maltose (Chanut), 40 grams; granulated pep­
tone (Chassaing), 10 grams; gelose, 18 grams. His formula for the glucose
proof medium is the same, with the maltose replaced by glucose (Chahut)
in the same quantity. The flask or test-tube—of which several should
be inoculated with the material from the case under investigation—
should be corked with non-absorbent cotton; 300 C. (86° F.) is found to
be the most favorable temperature; development is noticeable in about
eight or nine days, and becomes quite characteristic in a few weeks.
Ordinarily, clinical appearances in ringworm are diagnostic; in doubt­
ful cases microscopic examination can be resorted to and will usually
clear up the matter, but in rare and obscure cases, and in epidemics
where it is interesting and of some import to know the exact etiologic
fungus, cultures should be made.

The question of immunity and vaccine has recently come to the fore
in this disease as in others. It would seem, according to the observations
and experiments of Plato,1 Truffi, Bloch and Massini, Bruhns and Alex-

mously branched mycelium with transverse septa in the root-shaft, extending down­
ward toward the bulb. There may be finally a slight circumpilary sheath resulting from
the surrounding groups and chains of spores. In the fragile endothrix the conditions
found are somewhat similar, but the bands are not so long and continuous, and instead
of being ladder-like, have more the appearance of strings of beads or “chaplets,” the
hair substance sometimes so crowded that, as Sabouraud suggests, it looks like “fish-
roe” or a “bag of nuts.”

In the ectothrix variety, usually observed in ringworm of the bearded region, the
fungus is found principally in the intrafollicular portion, consisting of large long bands
with segments at irregular, usually long, distances, and often dividing dichotomously.
They run along outside of the hair, slightly invading the cuticular portion, sometimes
markedly (endo-ectothrix), although this latter is rarely eroded, as in the small-spored
variety. The spores vary considerably in size, from 3 to 12 µ in diameter, and are
situated around the hairs arranged in chains. Sabouraud states that the hair is not in­
vaded, the fungus remaining outside, but according to Aldersmith, Colcott Fox and
Blaxall, the shaft is sometimes, probably always (Fox and Blaxall), implicated to some
extent. Ravogli’s (“Notes on Ringworm,” New York Med. Jour., June 29, 1901)
studies showed that both the endothrix and ectothrix could be found vegetating inside
of the hair and in the epidermis. In hairs from cases of tinea sycosis, due to the ecto-
thrix, I have often seen the shaft more or less crowded with mycelium, as also shown in
accompanying cut by Hartzell. Fox and Blaxall have noted in several instances that
the fungus scarcely exceeded that of the microsporon in size. These represent Sabou-
raud’s later microid variety of the ectothrix. There is a sheath of fungus around the
hair at the follicle mouth, but it fits less closely than that observed with the micro-

1 Plato, Archiv, 1902, lx, p. 63 (posthumous paper edited by Neisser); Truffi,
Revue pratique, 1903, H. 10, Clinica Medica, 1904—abs. in Monatshefte, 1904, xxxix, p.
679; Bloch and Massini, Zeitschr. f. Hyg. u. Infektionskr., 1909, p. 69—abs. in Monat-
1909, lxix, p. 419; Bruhns and Alexander, Dermatolog. Zeitschr., 1910, xvii, p.
695; Amberg, Jour. Exper. Med., July, 1910, xii, p. 435.



ander, Amberg, Sabouraud, and others, that trichophytosis of an acute,
but more especially of a deep-seated character, may measurably influence
the general organism, sufficiently so as to confer a variable immunity—
according to Sabouraud the greater the reaction, the greater the immu­
nity. Jadassohn (cited by Bruhns and Alexander) has made a similar
observation “that a patient never suffers from a second infection after
an attack of deep-seated ringworm.” It has also been found, as first
shown by Plato and confirmed by Truffi, Amberg, and others, that the
vaccination or injection with “trichophytin”1 gives rise to a reaction
even after the disease had long disappeared—a general and local reaction
not unlike that of Von Pirquet’s test for tuberculosis. The superficial
varieties of ringworm, unlike the deep-seated types, rarely protect or
react; Bruhns and Alexander suggest as an explanation that when the
lesions penetrate deeply antibodies are thrown out in much greater
quantity than when there is a mere superficial lesion. The few
attempts to influence the disease by its use have, however, been of
doubtful effect.

Prognosis.—Ringworm is a curable malady, varying consider­
ably in rebelliousness in the several regions involved, and also in the
same regions in different individuals. The variety of the fungi that
may be etiologic in a given case has in a measure also a bearing, but
for practical purposes this can usually be ignored. Ringworm of the
general surface is, as a rule, readily manageable, in average cases of but
a few patches of the mildly hyperemic and scaly type, from several days
to a few weeks’ treatment generally sufficing to remove the disease.
Exceptionally, however, the patches, especially of the moderately and
markedly developed type, are slow in yielding, and new areas continue
to spring up irregularly from time to time. The deep-seated variety
is the most rebellious, and occasionally, when apparently cured, a re­
crudescence gradually presents in the same situation after treatment
has been discontinued. Such exceptional examples may require a few
months’ use of somewhat strong remedial applications before permanent
freedom is secured.

In the genitocrural parts (tinea cruris, eczema marginatum), as like­
wise in its analogue in the axillary region, it is usually, even in its milder
varieties, more or less obstinate, not less than several weeks to a few
months being required; and if the malady has been of long duration, is
extensive and shows considerable infiltration, it is quite refractory,
although always finally yielding to persistent measures.

Ringworm of the scalp, while often troublesome, eventually gets
well, a regrowth of hair taking place, so that there remains no disfigure­
ment. When limited to one or two areas and of short duration, with
prompt, energetic management it can, in the majority of cases at least,
and especially in private practice, be readily cured, requiring on the aver­
age a few months’ treatment. The same may be said of a small minority
of patients when the disease has been of longer duration. On the other

1 Plato made cultures from lesions of deep-seated nodular ringworm of the bearded
region; this culture was sterilized, filtered and diluted with 0.25 per cent, carbolic acid
—to this he gave the name “trichophytin.”

1134                              PARASITIC AFFECTIONS

hand, in some cases it is extremely rebellious, continued and energetic
treatment from six months to a year being necessary to bring about a
result; and in not a few instances it is particularly obstinate, and without
methodic and persistent measures such cases last almost indefinitely,
or until nature begins to look after the cure as the child verges into pu­
berty, it disappearing spontaneously approaching or shortly after this
period. For this reason in those instances in which the malady begins
in advanced childhood, if properly treated, it responds, as a rule, rapidly.
In very young children also the fungus does not seem to get so firm a
hold. It is generally conceded that the small-spored fungus is the
parasitic agent in most of the refractory cases. While in those instances
due to the large-spored fungus the disease yields, as a rule, much more
rapidly, still there are occasional cases which also prove persistently
obstinate. As a general thing the markedly inflammatory types, and
especially the kerion type, usually due to the ectothrix variety of the
large-spored fungus, respond somewhat readily. It may be pretty
positively stated, however, that many of the alleged cures of established
ringworm of the scalp in a period of less than a few months, whatever
the type of the disease, are merely errors of observation, for not infre­
quently the practitioner pronounces it cured when the hair has begun
to fill in in the affected area or areas, whereas the malady in reality may
still persist in a less conspicuous but chronic state, and the case remain
an active center of contagion for other children. X-ray treatment
cautiously applied by a trained expert, usually in a single dose suffi­
cient to bring about epilation, materially shortens the period of

Ringworm of the bearded region, although often presenting active
and repulsive symptoms, is usually rapidly amenable to proper treat­
ment. All cases are curable, and only in the worst type and in long-
neglected instances is there any significant permanent hair loss or other
disfigurement. A period of several weeks in the beginning and mild
cases, to several months in the severe forms, is required to bring about
a cure.

Treatment.—The management of ringworm varies slightly on
different parts, not so much as to the remedies themselves, but as regards
the strength of applications, although some applications are found more
satisfactory in certain situations than in others. While, from the nature
of the malady, recourse is had to practically external applications alone,
and constitutional treatment usually considered of no avail, yet, in
chronic cases, especially of the scalp, occurring in hospital, dispensary,
and other patients of impaired nutrition, it has seemed to me that the
administration of cod-liver oil and iron, especially the former, has an
influence for good directly upon the general health, and indirectly upon
the cutaneous disease, in rendering the “soil” a less desirable one for
fungus vegetation, and in this manner lending some aid, although doubt­
less slight, toward the final cure. It is not unlikely, moreover, that sul­
phur internally administered in small doses, by its exhalation through
the skin, makes this structure a less desirable habitat for the organism,
and thus be of contributory value.



Treatment of Ringworm of the General Surface.—The patches are
to be kept free from scaliness by soap-and-water washings, using sapo
viridis in sluggish and obstinate cases. If temporary disfigurement is
not objected to, an excellent plan of treatment consists in painting the
patch or patches daily for three or four days with tincture of iodin;
in young children the tincture is to be diluted with from ½ to 1 part
of alcohol. A solution of sodium hyposulphite, 1 dram (4.) to the
ounce (32.); fresh sulphurous acid; a lotion of carbolic acid, from 10 to
20 grains (0.65-1.33) to the ounce (32.); a mercuric chlorid lotion, from
1 to 3 grains (0.065-0.2) to the ounce (32.), are all, as a rule, quickly
efficacious. The same may be said of sulphur, white precipitate, and
tar ointments, weakened somewhat, or in full strength in obstinate
cases. In the latter also I have frequently employed tincture of iodin
containing 1 to 3 grains (0.065-0.2) of biniodid of mercury to the ounce
(32.); and also the plan of painting with a saturated solution of chrys-
arobin in chloroform, and covering with a coating of collodion. In the
rather rare cases of eczematoid eruption of the hands and feet Sabouraud
and Whitfield have employed with success a 1 to 3 per cent, chrysarobin
ointment. Whitfeld also commends using cautiously and not too long
an ointment containing 3 per cent, of salicylic acid and 5 per cent, of
benzoic acid, and stronger in obstinate cases when necessary and not
irritating. Strong remedies must, of course, be used with care.

Treatment of Ringworm of the Genitocrural Region.—Any of the
several applications already named will often be found useful in ring­
worm in this location. In some cases, however, the eczematous aspect
of the disease is quite marked, and at first only the milder remedies
are tolerated. For such types the calamin-zinc-oxid lotion with saturated
solution of boric acid as the base, and containing 2 to 10 grains (0.133-
0.65) of resorcin and 5 to 10 grains (0.333-0.65) of carbolic acid to the
ounce (32.), materially benefits and sometimes cures. The salicylated
paste, containing 30 to 60 grains (2.-4.) of sulphur or 5 to 20 grains
(0.33-1.33) of resorcin to the ounce (32.), also acts satisfactorily in some
cases. As a rule, however, even in seemingly irritable cases the stronger
applications may be made use of. It is well to begin with the lotion of
sodium hyposulphite already referred to, dabbing it on freely twice daily.
If the parts become somewhat dry and harsh from its use, which fre­
quently occurs, after the solution dries on, a small quantity of vaselin,
cold cream, or a weak sulphur salve, from 20 to 60 grains (1.33-4.) to the
ounce (32.), may be gently smeared over. If this fails to cure, a lotion
of resorcin, from 5 to 15 grains (0.33-1.) to the ounce (32.), is to be tried.
If still persistent, a lotion of mercuric chlorid, from 1 to 3 grains (0.065-
0.2) to the ounce (32.), is to be applied twice daily, with or without the
supplementary application of a plain unguent or the cautious use of a
white precipitate ointment, 20 to 60 grains (1.33-4.) to the ounce (32.).
In sluggish forms the mercuric chlorid may be applied in tincture of
benzoin or myrrh, from 2 to 4 grains (0.13-0.265) to the ounce (32.),
as advised by R. W. Taylor. In particularly rebellious cases occasional
shampooing of the parts with sapo viridis and hot water is to precede the
remedial application. A valuable remedy in obstinate thickened and



sluggish types of the disease is an ointment of chrysarobin, from 20 to
60 grains (1.3-4.) to the ounce (32.), used cautiously and intermittently
for only two or three days at a time; or this drug may be applied as a
paint, as employed in psoriasis. Paintings, once daily or every other day,
with the tincture of iodin, full strength or weakened if the skin is irritable,
is also valuable, and applied well at the borders and slightly beyond, will
sometimes stop the extension of the disease as well as prove curative;
in sluggish cases the biniodid of mercury, 1 to 3 grains (0.065-0.2) to
the ounce (32.), can be added. After the disease is seemingly cured,
occasional remedial applications are to be advised for a few weeks in
order to guard against a relapse. The same plans of treatment are to be
pursued when the disease is situated in and about the axilla.

Treatment of Ringworm of the Scalp.1—The hair around the patch
or patches should be cut close or even shaved; that of the surround­
ing scalp is to be kept short, so as to permit of easy inspection, thus
facilitating the discovery of any new foci of disease. If there are more
than several patches, it is advisable that the hair of the entire scalp
should be closely cropped or shaved from time to time. If the area of
disease is small, the hair on the patch and that immediately surrounding
should be carefully extracted with the depilating forceps. It is not,
however, feasible in cases of any extent, and often in limited areas it is
difficult to have it properly followed out; and in some instances, too, the
broken hairs and hair-stumps are so fragile and break so easily that they
cannot be readily extracted. For these reasons in late years, except in
selected cases, I have made use (Brayton) of a depilatory for ridding the
patch of the hair and hair-stumps; owing to the nascent sulphureted
hydrogen evolved, the depilatory has also some direct remedial value.
One consisting of 3 drams (12.) of barium sulphid and drams (10.)
each of zinc oxid and powdered starch can be employed. At the time
of application enough water is added to a sufficient portion to make a
paste, and this is spread in a thick layer on the area or areas, slightly
overlapping the edges. It is to remain on from several to ten minutes,
according to the character of the hair, the sensitiveness of the skin, as
well as to the efficiency of the depilatory; as soon as heat of the skin or a
burning sensation is felt it is washed off thoroughly, and, if it has acted as
it should, the hairs, including the stumps, will have been destroyed deep
into the follicles, and sometimes possibly to the full depth of the latter.
Should there be accidentally much resulting irritation, a soothing oint­
ment can be applied for a few hours or so; as a rule, this is not necessary.
The depilatory should be used every five to ten days, depending upon
the rapidity of regrowth. It should never be applied to an actively in­
flammatory patch.

Before taking up the consideration of the remedial applications
certain adjuvant measures should be referred to. The spread of the
disease to other parts of the scalp and to other children should be pre­
vented, as far as this is possible, by certain routine measures, and these
can, as a rule, be carried out even when the active remedies are being
used upon the patches. With this object in view the scalp is to be washed
1 The x-ray treatment will be referred to later.



every second or third day with a medicated sapo viridis such as the

R. Sulphur, præcip.,                                     3j (4.);

ß-naphthol,                                             gr. xx-xl (1.33-1.65);

Saponis viridis,                                        3j (32-)-

The lather should be permitted to remain on for five to fifteen min­
utes, as it has in itself an inhibitory or destructive influence upon the
fungus.1 If there is risk of taking cold, the parts may be enveloped
with some covering. The lather is subsequently thoroughly rinsed off,
the scalp rubbed dry, and then a general parasiticide application made.
For this purpose either an ointment consisting of 1 dram (4.) of pre­
cipitated sulphur, 30 grains (2.) of ß-naphthol, and an ounce (32.) of
petrolatum; or a lotion of 2 drams (8.) carbolic acid, resorcin 1 dram (4.),
and saturated solution of boric acid 1 pint (500.) can be used. Such a
general application should be made once daily. It is possible that the
salve is more effectual in preventing the dissemination of the spores,
although it is not so agreeable as the lotion. As an additional measure
in preventing the spread of the disease, paper or any other material which
permits of daily destruction or washing should be constantly worn as the
hat lining. Whatever remedial method is adopted, it should be thor­
oughly carried out; if a wash is used, it is to be first gently rubbed in for
a minute or two, and then dabbed on for five or six minutes; if an oint­
ment, it should be well worked in by gentle but somewhat firm rubbing
for five to ten minutes. Many remedies have been brought forward
from time to time for the rapid cure of ringworm of this region, but
those of large experience in its treatment soon learn that it is not so
much the remedy selected as it is the thoroughness of its application and
the perseverance in its use that bring success. For recent patches the
white precipitate ointment, sulphur ointment weakened with 1 or 2
parts of lard, tar ointment weakened or of official strength, paintings
with tincture of iodin, sulphurous acid, pure or diluted, resorcin in lotion
or ointment from 5 to 10 per cent, in strength, an ointment of calomel
from 30 to 60 grains (2.-4.) to the ounce (32.), carbolic acid in lotion or
ointment, from 20 to 60 grains (1.3-4.) to the ounce (32.), will all be found
valuable and frequently curative after several weeks’ or a few months’
use. An old method of treatment consists in the use of Coster‘s paint
(iodin, 3ij (8.); oil of tar, 3vj (24.)), one or two coats daily for two days,
allowing the crust that forms partly to detach itself, and then gently
pulling it off. The application is repeated several times and will be
.found satisfactory, especially in the treatment of recent patches; it
should not be used in children under three or four years of age unless
the proportion of iodin is lessened. In many of the chronic cases, how­
ever, stronger applications will be found necessary. Among the latter
may be mentioned mercury oleate, strong sulphur ointment, and a
paint or ointment of chrysarobin. Strong carbolic acid ointments, from

1 See interesting papers bearing upon this point and the influence of other sub­
tances upon the vitality of the fungus by Thin, Brit. Med. Jour., 1889, i, p. 397, and
Schwengers, Monatshefte, 1890, vol. xi, p. 155.




1 to 2 drams (2.-8.) to the ounce (32.), will also prove useful. Mercury
oleate in the form of an ointment, from 10 to 25 per cent, strength, is
often in itself a valuable remedy. Mercuric chlorid in solution is also a
valuable and frequently used remedy, applied in solution in the strength
of 1 to 4 grains (0.065-0.265) to the ounce (32.), preferably of equal
parts of water and alcohol; it should not be applied to the entire scalp
in its stronger proportion for fear of absorption.

While I have employed most of the remedies of older reputation and
the new ones introduced in recent years with success, the management
of these cases has in recent years in my own practice narrowed itself down
to the use of sulphur, ß-naphthol, iodin, chrysarobin, and croton oil,
conjointly with the adjuvant measures already referred to. Sulphur
and naphthol are most valuable and appropriate for those cases in­
volving a greater part of the scalp; chrysarobin and iodin for circum­
scribed areas, and croton oil for those patches which have persistently
failed to yield to the other remedies. Sulphur and naphthol are pre­
scribed together in ointment, 2 drams (8.) of the former and 30 to 60
grains (2.-4.) of the latter, with enough benzoated lard or lard and
petrolatum to make the ounce (32.), and will prove valuable in recent
cases and especially in young subjects. Occasionally this amount of
naphthol, in those of extremely sensitive skin, gives rise to a feeling of
considerable burning, and in such instances this ingredient can be reduced
in quantity. Exceptionally, also, the quantity of sulphur must be less­
ened in young children. This ointment can also be satisfactorily em­
ployed as the beginning treatment in extensive cases, the more recently
affected parts usually soon yielding, leaving the chronic areas for the
stronger remedies to be mentioned.

Ordinarily, however, the best application for the patches in young
patients and in recent areas in other cases is iodin tincture, containing
a small quantity of mercuric iodid, as in the following:

R. Hydrarg. biniodid.,                                     gr. j-iij (0.033-0.2);

Tinct. iodini,                                               3j (32.).

This is painted on twice daily, two or three coatings at each time, until
the areas become somewhat tender or until the film thus formed cracks
or begins to loosen. The parts are then anointed with a mild salve,
and as soon as the film is detachable it is picked or pulled off. If there
is active underlying irritation, which is not usually observed, the same
ointment may be applied for a day or so, and the paintings resumed.
If the iodin applications seem to be slow in bringing about complete
cure, another plan is to be instituted.

Chrysarobin is by far the most valuable application in most of the
cases, but this drug as made by various manufacturing chemists differs
considerably in quality; naturally, an efficient preparation is an essential
for success. It is also highly indorsed by Duhring, Malcolm Morris,
Hutchinson, Unna, Allen, Corlett, and many others.1 It may be used

1 See papers by Duhring, “Experience in the Treatment of Chronic Ringworm in an
Institution,” Amer. Jour. Med. Sci., vol. ciii, 1892, i, p. 109; by Allen, “Treatment of
Ringworm of the Scalp in Institutions,” Pediatrics, 1896, vol. ii, p. 169.



in all cases, but more especially in those of somewhat limited extent; it
must be employed with greater care in patients under the age of three
years; in fact, in most of the younger patients the sulphur-naphthol
salve or the iodin paintings will suffice to bring about a cure, and are to
be preferred. Chrysarobin is most satisfactorily applied as a saturated
solution in chloroform, and in the manner described in psoriasis. The
areas are painted over with this until well coated with a film of chrysaro-
bin, the chloroform rapidly evaporating. Over this are then painted
three or four layers of good collodion. No further application is to be
made until the film so formed begins to crack or to detach itself. As
soon as it becomes detachable it is gently pulled off, and if there is any
active irritation beneath, a mild ointment may be used for a few hours
or a day until this is subdued and the paintings resumed. In some (but
if employed with care not in many) instances chrysarobin gives rise to
a mild or moderately severe dermatitis of the surrounding skin, and under
these circumstances it becomes necessary to suspend its use temporarily.
In rare instances this tendency to dermatitis may repeat itself, the skin
of the patient being intolerant of this remedy, and it must be then set
aside and give place to another plan.

In some patients these several methods will fail to bring about a
cure; or more frequently will cure most of the areas, but fail to make suffi­
cient impression upon a few patches. It is just in such instances especially
that croton oil, so strongly advised by Aldersmith, has its particular
field of usefulness. In those cases, too, in which, for various reasons, a
rapid cure is desired, recourse may be had to this application. It is a
severe remedy, and the parts are made actively inflammatory; its care­
less use, and the pushing of the inflammatory action beyond a reasonable
limit, would, of course, result in considerable follicular destruction. It
must always be used with caution, and it is never to be employed in young
children, nor applied to an area at any one time larger than an inch in
diameter; larger areas can be treated in sections. The application
should be made by the physician himself or by a trained attendant.
With this plan of treatment the use of the depilatory, except as a be­
ginning measure, is to be omitted.

At first it is desirable to have the oil weakened with 2 or 3 parts
of almond oil, and if it is found that no active inflammation arises,
it should be applied stronger. In most cases, especially in older children,
the pure oil is required. It should be scantily used, as it seems to have a
distinct tendency to spread beyond the part; a little vaselin at the border
of the area will circumscribe its action. It is to be applied two or three
times daily, and to bring about the desired amount of inflammatory
reaction ordinarily requires two to six days. When it is possible to have
poultices repeatedly applied afterward the oil applications may be dis­
continued as soon as slight swelling and minute pustulation present; the
subsequent poulticing will bring about sufficiently pronounced inflam­

Cases of disseminated ringworm can be treated by active methods—
iodin or chrysarobin paintings. If the spots are numerous, the number
may be usually brought down by the use of the sulphur-naphthol oint-



ment and then the remaining obstinate spots can be treated with iodin
or chrysarobin; if necessary for final cure, the oil can be employed. In
such cases many of the areas yield readily with any good treatment,
leaving behind several or more obstinate spots. In those instances
in which the disease is so extensive as practically to involve the greater
part of the scalp, presenting large and irregular areas or confluent sheets,
it is advisable to use the stronger sulphur-naphthol ointment until it is
reduced in extent. Or this can be applied to the parts generally, and small
portions treated with the iodin or chrysarobin paintings. Croton oil, if
used at all, should be left until the disease is reduced to several circum­
scribed areas; it is never to be employed in the beginning of treatment in
these confluent cases. For the markedly inflammatory types, and
particularly kerion, the application of boric acid ointment, or an oint­
ment of sulphur, 30 to 60 grains (2.-4.) to the ounce (32.), or one of
white precipitate, 20 to 40 grains (1.33-2.65) to the ounce (32.), is to be
advised. After the active inflammatory signs have subsided the same
can be continued, or stronger treatment instituted. Ordinarily in
kerion the inflammatory process itself is destructive to the fungus, or
casts it off and brings about a cure.

Among other remedies and plans which are variously indorsed may be
mentioned a 10 to 25 per cent, ointment of oleate of copper (Shoemaker,
Crocker); covering the diseased area nightly with a compress wet with a
4 to 5 per cent, solution of calcium chlorid, and enveloping with rubber
tissue, followed the next morning by washing with soap and water and
the application of diachylon plaster, with twice weekly a painting with
tincture of iodin (Sabouraud); applications of formaldehyd in the strength
of formalin (40 per cent.) or weakened (Pottevin, Salter, Vidal, Solares,
Hutchins, Allen); the application and penetration of corrosive sublimate
solution by cataphorešis (Ambrosi, Reynolds, Ravogli, Wessinger);
and the Harrison method, consisting of the use of two solutions: No. 1,
of ½ dram (2.) of potassium iodid and 4 drams (16.) each of liquor potassæ
and spirits of wine; No. 2, of 4 grains (0.265) of mercuric chlorid and 4
drams (16.) each of spirits of wine and water, applying No. 1 at first
and following with No. 2; it is a severe method, exciting considerable in­
flammation and occasionally resulting in scars, and has been condemned
by some and commended by others.

Jackson1 gets success in most cases with an ointment made of about
1 dram (4.) of iodin crystals and 1 ounce (32.) of goose grease; it is to
be applied twice daily until it produces a reaction, which is shown by a
slight swelling of the patch, and then once daily; in two to three weeks the
hair falls out, which usually presages the cure, the hair finally regrowing
and showing no evidence of disease.

X-ray treatment, which was introduced by Sabouraud and Noiré,2

1 Jackson, Med. Review, Feb. 1, 1902, and April 11, 1903.

2 Sabouraud and Noiré, La presse médicale, 1904, p. 825, and Annales, 1904, p. 80;
account also by Bunch, Brit. Jour. Derm., 1904, p. 265, and Lancet, Feb. 18, 1905, and
in editorials in Brit. Jour. Derm., Feb., 1905, and Jour. Cutan. Dis., April, 1905; and
abstract translation of Sabouraud and Noiré’s paper by W. S. Fox, in Brit. Jour. Derm.,
Feb., 1905, p. 67; Macleod, Brit. Med. Jour., Sept., 1905; Adamson, “A Simplified
Method of x-ray Application for the Cure of Ringworm of the Scalp (Kienböck’s



is a remedy that is promptly curative in ringworm of the scalp, and whose
favorable experience has been repeated by others. Their method is
based upon one measured application of this agent sufficient to produce
depilation, this latter ensuing two to three weeks after exposure, and

Fig. 302.—The Sabouraud method of x-ray treatment (from Sabouraud’s Les Teignes).

without, at the most, the production of more than the mildest x-ray
erythema.1 Others have used the x-ray treatment cautiously, at inter-
Method),” Lancet, 1909, p. 1379; Dore, “The Present Position of the x-ray Treatment
in Ringworm,” Lancet, 1911, clxxx, p. 432. In a recent article (“Radiotherapie des
teignes,” Annales, 1909, p. 452) Sabouraud goes over the ground again, as above de­
tailed, replying to criticisms, citing the possible accidents and the measures to avoid

1 The essence of the method of Sabouraud and Noiré consists in giving one exposure
sufficiently long to produce depilation, and yet not long enough to be productive of any
ill-effects. This is done by employing some means of measuring the quantity of rays,
and by keeping the vacuum of the tube at a point equal to about a 3-inch spark gap. A
properly constructed milliampèremeter (in this instance the D'Arsonval meter) can be
inserted in the secondary circuit; and, most important of all, radiometer pastils of
Sabouraud and Noiré—i. e., circular wafers of paper coated with an emulsion of platino-
cyanid of barium in a collodion of amyl acetate—one of which is placed on a metal plate
(impermeable to the rays) at a distance of 3 inches from the anticathode. These
wafers have the property of changing color under the action of the x­rays in proportion
to the quantity of rays absorbed. Under similar conditions of current, tube, and
atmosphere (the rays act more rapidly when the air is dry) the time required to change
the color from its yellowish-green to a standard tint of fawn is that which is requisite to
produce complete depilation without dermatitis or danger of permanent alopecia.
In short: “To cure a patch of ringworm of the scalp by the x­ray, place the patch at a
distance of 15 centimeters from the center of the focus tube, and place at the same time
a disk of platinocyanid of barium paper 8 centimeters from the center of the tube.
When this disk has taken the color corresponding to the tint ‘B‘ of Sabouraud and
Noiré’s radiometer (and to 5 H of Holzknecht’s scale), the operation is terminated.”
There is a risk if this exposure is exceeded. If the exposures are made in daylight it is
necessary to place the pastil in black paper, and the examining must be done quickly,
as the pastil returns to its normal color rapidly when exposed to daylight.

In the course of a week after exposure a faint erythema is usually noted, which is
succeeded in a few days by a slight pigmentation; after about two weeks the hair begins



vals of a few days, till falling out of the hair results; this method, however,
is not to be commended, as there is danger of overdosage. Care should be
exercised that the slightest reaction is not exceeded, otherwise there is
risk of permanent baldness. It is not a method to be used by those in­

experienced in the use of the x-ray, and not, in my judgment, to be used
except in chronic and rebellious cases. It has its particular field in the

to fall out, which process is usually completed in a week. Should (from insufficient
dosage or idiosyncrasy) this not take place, after waiting two weeks more, another ex­
posure is made. Inasmuch as the fungus is not destroyed by the x-ray, in order to
prevent reinfection after exposure an ointment of oil of cade is rubbed in nightly, and
in the morning the scalp shampooed, and an alcoholic lotion containing tincture of iodin
applied to the entire scalp. If there is an impetiginous tendency, an ointment of sali­
cylic acid and sulphur or white precipitate is used instead of the tar ointment. After
thirty days a careful search is made to see that no diseased hairs have escaped; and every
fifteen days an examination is made until complete regrowth has taken place, which is
usually a matter of several months; about two months after exposure the hair is visible,
and normal growth complete three months later.

In preparing for the exposure the scalp is carefully examined, and if there are not
more than five patches, circles are drawn around each patch, going 1 cm. beyond the
diseased area; these areas are then painted with tincture of iodin, and the hair cropped
close. Each area is then exposed to the rays seriatum, all on the same day. If the dis­
ease is more extensive and scattered, the whole scalp is exposed successively in six sec­
tions, being careful not to expose any point twice. The parts not treated are, of course,
protected by tin or lead-foil; or the tube is enclosed with a projected opening adjusted to
treat only the part desired. According to Sabouraud and Noiré, only three months are
now required for a cure of cases (in l’école lailler, Hôpital St. Louis, Paris) that formerly
took two years.

RINGWORM                                  1143

treatment of epidemic institutional scalp ringworm. Until somewhat
recently the Sabouraud method of application had been that usually
employed, cylindric metallic or lead-foil localizers or protectors being
used. In extensive cases, however, in which the disease involves a large
or greater portion of the scalp and complete epilation of the entire
scalp is desirable, the Kienböck-Adamson1 method is rapidly growing in

In all cases of ringworm of the scalp treatment is to be discontinued
temporarily after several weeks or a few months, according to the grade
of the disease, for the purpose of noting the progress made. As long as
stumps are to be seen and a tendency to scaliness persists, especially
the former, a cure has not been effected. If there should be any doubt
upon this point several of the suspected hairs and also the new-growing
hairs should be subjected to microscopic examination. If it is shown that
there has not been any or much progress toward cure, a change of appli­
cation is to be instituted. If, however, considerable progress has been
made, it is advisable to adhere to the same line of treatment.

Ringworm of the Bearded Region.—Extraction of the hairs from
the affected areas is a measure that will aid considerably in promoting
a cure, and is, therefore, to be considered an essential part of the manage­
ment of the disease. The hair on other parts of the bearded region
should be kept sufficiently short or shaved to permit of easy inspection,
so that any new foci developing will be readily discovered and treated
before the fungus is firmly established. Almost any of the applications
mentioned in the treatment of the other varieties will, if perseveringly
used, prove efficacious in this form also. Experience teaches that the
best remedies, however, are the lotions of sodium hyposulphite and
mercuric chlorid, and ointments of white precipitate or calomel, of sul­
phur, and of oleate of mercury. The treatment in my own practice has
gravitated to two plans as being the most promising of rapid results—
one a sulphur treatment and the other a mercurial. Both are, doubtless,
in the aggregate of cases equally efficacious, but in some instances, when
progress is slow or unsatisfactory from one plan, a change to the other
is found to be of advantage. In the sulphur treatment a lotion of so­
dium hyposulphite, 1 dram (4.) to the ounce (32.), and an ointment of

1 By Adamson’s method only five exposures are necessary to depilate the entire
scalp, thereby reducing the time of irradiation to one and one-half hours. The scalp is
divided into five areas, with each of the marked points as a center; a sagittal line is
drawn—the hair having been previously clipped off short—from front to back, and
markings (A, B, C) made at three points—one (A) about 1 inch from the anterior
forehead hair border, one (C) about 1 inch above the posterior occipital hair border,
and the other (B) midway between these two. Another line is made extending through
the middle scalp point (B) across from ear to ear, marking points (D, D.’) about 1
inch above the ears. An exposure is made consecutively to each of the five points as
the centers, with a tube enclosed in a box-shield having an aperture of 3 inches in
diameter; the adjacent bare skin must be properly shielded. Each area is to have a
Sabouraud pastil dose. In this manner those sections of the scalp where overlapping
of the exposed areas occurs, the incidence of the rays is so oblique, and so much further
from their source, that the dose of x-rays impinging on these overlapping parts is not
excessive, but just sufficient to cause a defluvium of the hair. To the tube-shield are
attached three pegs made of soft wood, against which the scalp rests, so that the head
is retained throughout the exposure at a distance, at the central point, of 6½ inches
from the anticathode.



precipitated sulphur of from 10 to 20 per cent, strength, are conjointly
prescribed. The mercurial plan consists in the use of a corrosive sub­
limate lotion, from 1 to 3 grains (0.033-0.2.) to the ounce (32.), together `
with the employment of an ointment of 10 per cent, oleate of mercury,
2 or 3 drams (8.-12.) of the oleate with sufficient simple cerate, or simple
cerate and lard, to make up the ounce (32.); or, with a 10 to 20 per cent,
white precipitate or calomel ointment. The plan being selected, the
method of carrying it out is as follows: The lotion is applied freely, being
thoroughly dabbed over the affected areas and somewhat less liberally
over the whole bearded region—over the latter in order to prevent the
infection of new areas; after the wash has dried the ointment is to be
well rubbed in, usually over the diseased places only, but, if there is a
decided disposition toward spreading, the ointment as well as the lotion
should be applied, once daily at least, to the entire bearded part of the
face and neck. The applications should be made morning and evening,
and in urgent cases three or four times daily. Before the application,
or once or twice daily, the parts should be washed off with warm or hot
water and soap. Treatment should be continued vigorously until all
vestiges of the disease have disappeared; and then intermittently or
less actively for several weeks in order that the possibility of a relapse
may be guarded against. As in ringworm of the scalp, the x-ray can also
be employed in this form, but its use always requires caution, and most
cases can be as well managed without it.

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