THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES. FEBRUARY, 1892. EXPERIENCE IN THE TREATMENT OF CHRONIC RINGWORM IN AN INSTITUTION.1 BY LOUIS A. DUHRING, M.D., PROFESSOR OF SKIN DISEASES IN THE UNIVERSITY OF PENNSYLVANIA. For the purpose of this communication it is not necessary to mention the name of the institution in which the experience about to be recorded was obtained. Suffice it to state that it was one of the largest and most favorably known in the country. I was requested by the board of trustees to take charge of the affected boys, and if possible to free the institution of the disease, which had long held sway there and was increasing rather than decreasing. Upon consultation with the attending physician, it was learned that ringworm had been prevalent for some years, and that lately it had been spreading in spite of care and attention on the part of physician and nurses. After an examination of all the suspected cases, among which were found a few cases of seborrhoea and eczema, it was found that there were forty-eight subjects affected with ringworm of the scalp, as demonstrated by the microscope, occurring in boys whose age ranged from eight to twelve, the average being ten. The disease in almost all instances was chronic, having existed in most cases from six months to three years, the average duration being about a year. All of the boys were inmates of the infirmary; were isolated, and had been under local, general and hygienic treatment at the hands of the attending physician. The institution was clean, and the hygiene, food, and the care of the patients was satisfactory, the attendants being faithful to their duties, so that there were no apparent defects 1 Read before the American Dermatological Association, at Washington, Sept. 23, 1891. VOL. 103, No. 2.-FEBRUARY, 1892. in the management to which the prevalence of the disease, and more particularly its spread, could be traced. There is nothing special to be said as to the general condition of the patients, for while some were puny, with defective nutrition, others were up to the average, and a few seemed to be even robust. The majority, however, it must be said, inclined to be lean and scrawny, and were without much stamina. Out of the forty-eight cases thirty-two might properly be designated as "bad cases," all of these showing the disease extensively developed and in a chronic state. Some of these had been considered as cured at one time or another during the previous year, but sooner or later, after their dismissal from the infirmary, were returned with a recurrence of the disease. It is not necessary that the symptoms and the several forms of ringworm encountered should be dwelt upon here, interesting as the subject. might be. It may, however, be briefly stated that many of the cases illustrated the worst possible features of the disease in its chronic stage, characterized by numerous discrete or aggravated erythematous, papular, follicular, chronically inflamed lesions, invading the scalp in the form of small and large areas. In some instances the whole scalp was more or less involved. The hairs were for the most part broken off close to the scalp, giving rise to light or dark puncta, the disease manifestly having its seat mainly in the deeper portions of the follicles. In other cases follicular scurfiness, with or without badly damaged or broken-off hairs, constituted the most striking feature. Follicular inflammatory papules, subacute or chronic in type, were also common," but a goose-flesh appearance of the scalp, and pustules, were of infrequent occurrence. As everyone knows who is familiar with the disease in its chronic state, the manifestations appear in varied forms and are difficult to describe. The lesions so characteristic of recently formed ringworm were altogether wanting, in place of which there existed a condition having its seat mainly in the deeper portions of the follicles, with comparatively little epidermic involvement of the surface. No cases of alopecia areata, or of any condition even suggestive of that disease, were encountered. It is my intention to confine the paper to the subject of therapeutics, and more especially with the view of giving the results of the year's work with the several local remedies prescribed. Notes of each case were, in the first place, separately recorded, including the previous history as to duration, relapses, and the remedies employed; the character of the lesions and the amount of disease present; the tendency or not to inflammatory action; the nutrition of the skin, its behavior under treatment, and other peculiarities. Subsequently, with each examination, memoranda were made of the progress of the case and of the action of the remedies, together with the formulæ prescribed. These records were kept up throughout the course of the treatment, and constitute the data from which this summary is prepared. The hair, as a rule, was clipped short about once a week, but in some cases the scalp was regularly shaved every few days. In either case the applications were brought into the closest possible contact with the follicles, chiefly by friction with oils and ointments. A few remarks may be made here as to depilation. The theory of this procedure in the treatment of ringworm is good, and should be put into practice, as far as practicable, in all cases. Where the lesions, however, are widely disseminated, occupying the greater part or almost the whole scalp, and, moreover, where the hairs are brittle and broken off close to or even below the surface of the scalp, it becomes almost an impossibility. Add to this the time consumed in the operation, and that even skilled operators can show but meagre results for an hour's work upon such a scalp, it will be found that the application of the proceeding is limited and adapted only to suitable cases. In some of the more chronic and worst cases it was abandoned as being impracticable. Early in the treatment it became manifest that many of the cases represented the most rebellious types of the affection, and that perseverance, powerful parasiticides, and time would be required to cure the disease, which was literally firmly rooted. In the selection of remedies and the formulæ, due regard was given to the age, development, complexion, and general nutrition of the patient. Those of dark complexion, as was to be expected, tolerated much stronger formula than those with light hair. From time to time active treatment had to be suspended in order to note what progress had been made upon the disease, and to allow the inflammatory symptoms due to the remedies to subside. The more important remedies and the formulæ prescribed, including the combinations and the strength of several drugs used, may now be referred to. If the list seem a long one, it should be borne in mind that not only was the number of patients large, but that owing to the obstinacy of the disease and the long period most of the cases were under observation, there was ample opportunity for experimentation. Moreover, it was noted that a change of remedy was sometimes followed by good results. I do not wish, however, to convey the idea that frequent change of treatment is to be recommended; on the contrary, having once selected a remedy of recognized worth, it is best to persevere with it until positive results, favorable or unfavorable, have been obtained. From time to time during the treatment it became necessary to use cleansing agents, with the view of clearing the surface of scale, crust, and débris, the result either of the disease itself or of the remedies applied. For this purpose a mixture of soft-soap and sulphur was generally used, preceded by inunctions with carbolized oil; in other cases, where the crusting was excessive, adherent, or painful, a flaxseed meal poultice was applied for a short period. This latter was sometimes found to be especially beneficial, not only in loosening the crusts, but also in subduing inflammation. Occasionally the irritation and inflammatory action set up by the stronger remedies was such that for a few days bland or soothing applications were demanded. Of these, ointments composed of a half-drachm of precipitated sulphur to the ounce of oxide of zinc ointment, and equal parts of oxide of zinc ointment and petrolatum, proved beneficial. A salicylic acid paste (of starch and petrolatum), ten or twelve grains to the ounce, and weak ointments of calomel and of white precipitate, were also prescribed with benefit. Lotions, more especially such as contained sulphurous acid and hyposulphite of sodium, were found useful where kerion had developed. Lotions, however, are not to be commended in other forms of the disease. Reference may now be made to the parasiticides, and in order to present the subject as clearly as possible, and to avoid repetition, the several drugs will be taken up under separate headings. Carbolic acid: This was used extensively in the form of an ointment and as a mixture with olive oil and with glycerin, in strength varying from a half-drachm to two drachms to the ounce. It was ordered in a large number of cases in the earlier period of the treatment. In some cases entire dependence was placed upon its virtue as a parasiticide, while in others it was prescribed in combination, as follows: Carbolic acid, 3j-3ij; ointment of nitrate of mercury, zij-ziv; sulphur ointment, ziij-zv. In a few cases tar ointment was substituted for the mercurial. As a parasiticide in this disease, the experience in this series of cases would lead me to give carbolic acid a comparatively low rank. It did not prove, either alone or in the combinations quoted, so curative as some other drugs. It was surprising to note the strength in which it could be applied without provoking much cutaneous disturbance, this latter taking the form chiefly of more or less extensive desquamation in the shape of large areas of raised, blistered epidermis. Tar was prescribed mainly with carbolic acid, or with sulphur or ointment of nitrate of mercury, as already noted, but nothing favorable can be said of it, even for the purpose of allaying inflammatory irritation or scurfiness. Iodine was prescribed as a tincture, in the officinal and in double that strength, and also in the mixture known as Coster's paste, consisting of two drachms of iodine to one ounce of oil of tar. This was employed at one period freely, but the results were disappointing. While the mixture is efficacious in recent or mild cases, where the fungus is not deeply lodged, it fails in chronic cases, I believe, because it does not remain in constant contact with the epidermis; and, further, for the reason that, from the nature of the application, it cannot penetrate |