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A Study on Superficial Ringworm Infections

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A STUDY ON SUPERFICIAL RINGWORM INFECTIONS
P.K .
Fraser.
M .B..
Ch.B.
ProQuest Number: 13905568
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The m a t e r i a l
for th is
N a v y d u r i n g t h e y e a r s 1 9 3 5 _ 1 939>
D irector
t h e s i s was c o l l e c t e d
an*3- 1 a™ i n d e b t e d t o t h e M e d i c a l
G eneral f o r p e rm is sio n to use i t
i n t h i s w a y.
G r a t e f u l acknow ledgem ents a r e due to
T h a t c h e r a n d S u r g e o n Commander R.A.W.
Ford,
S u r g e o n C a p t a i n C.M.R .
f o r m e r l y o f H .M .S .
fo r p e rm issio n to use the f ig u r e s of th a t s h ip ;
Commander J . J .
Cussack,
i n t h e Royal
f o r m e r l y o f H .M .S .
also
to
D orsetshire,
h i s m e d i c a l r e c o r d s a t my d i s p o s a l w h i l e h i s
Hood,
Surgeon
fo r placing
s h i p was a t
Shanghai
i n 1936.
The P a t h o l o g i c a l D e p a r t m e n t ,
D is e a s e s o f th e Skin,L ondon,
to i l l u s t r a t e
St.
J o h n 's H o sp ital fo r
very k in d ly l e n t
th e c l i n i c a l photograph
C h a p t e r 3> a n d m o s t o f t h e m a t e r i a l i n t h e m i c r o p h o t o :
: g r a p h s came f r o m t h e
same s o u r c e .
The a c t u a l m i c r o p h o t o g r a p h y was
d o n e b y t h e W ell com e B u r e a u o f S c i e n t i f i c
In v estig atio n ,
a n d I am
i n d e b t e d to them f o r t h e i r u n f a i l i n g h e l p f u l n e s s .
P l a t e s 1 and 2 a r e from th e
Shanghai,
and i n f e c t e d
photography.
& C o.,
c o l l e c t i o n o f D r.
s c a l e s were s u p p l i e d fro m h i s
F. R e i s s o f
clin ic
for
Th ey w e r e p h o t o g r a p h e d t h r o u g h t h e c o u r t e s y o f S c h m i d t
of S hanghai.
A ccess to
r e f e r e n c e s was g r e a t l y
: i n g c o - o p e r a t i o n o f Mr.
L ib rarian .
T .J.
S hields,
f a c i l i t a t e d by th e ungrudg
B r i t i s h M edical A s s o c i a t i o n
W ith o u t h i s h e l p t h i s t h e s i s w ould have b e en i m p o s s i b le .
I am g r a t e f u l t o h i m f o r a l l t h e a s s i s t a n c e h e h a s s o e f f i c i e n t l y
rendered.
School,
I am a l s o
in d e b te d to
and t h e L e s t e r
In stitu te
At v a r i o u s p e r i o d s t h e
p u b lis h e d elsew here,
kindness of:
th e l i b r a r i a n s o f t h e L eeds M edical
f o r M edical R e s e a rc h ,
chapters in t h i s
Shanghai.
t h e s i s have been
and c o p y r i g h t s h a v e b e e n r e t u r n e d t h r o u g h t h e
The B r i t i s h M e d i c a l J o u r n a l ;
The J o u r n a l o f T r o p i c a l
M edicine and H ygiene;
a n d The J o u r n a l o f t h e R o y a l N a v a l M e d i c a l
S ervice.
To t h e f o r e i g n
s t u d e n t s o f London U n i v e r s i t y
w ith the
tra n s la tio n of referen ces
m aterial
re w a r d and p ro m p te d o n l y by f r i e n d l i n e s s t o w a r d s a f e l l o w -
student,
th e y gave f r e e l y o f t h e i r
t o them ,
an in c o m p r e h e n s ib le
L astly,
I e x p r e s s my t h a n k s .
who h e l p e d
tim e,
W ithout
i n what must h a v e a p p ea re d
in v estig atio n .
I w ish to a p o lo g is e to
t h o s e o f my c a s e s t o whom
I p r o m i s e d u n d y i n g fa m e i n t h e a n n a l s o f m e d i c i n e i n e x c h a n g e f o r
th eir
feet.
of fig u res.
tru st
I doubt i f
However,
th ey w i l l re c o g n is e th e m se lv e s in th e groups
t h e i r c o - o p e r a t i o n was e s s e n t i a l ,
I am f o r g i v e n t h i s m i l d d e c e i t .
and I
Page
C h a p t e r 1 .............
Intro d u ctio n
Page
2
C h a p t e r 2 .............
The H i s t o r y o f
S u p e r f i c i a l Ri ngworm
In fectio n s
Page
6
D iagnosis o f S u p e r f ic ia l
R ing w orm I n f e c t i o n s
Page
H
C h a p t e r 4 .............
T rlchophytin in D iag n o sis
Page
29
C h a p t e r 5 .............
Incidence of S u p e rf ic ia l
Ringworm I n f e c t i o n s
Page
37
V i a b i l i t y o f t h e Common
P a t h o g e n i c -^Ungi
Page
48
C h a p t e r 7 .............
T rea tm e n t and P r o p h y l a x i s
Page
65
C h a p t e r 8 .............
G e n e r a l C o m m e n tar y
Page
.7 8
C h a p t e r 3 .............
C h a p t e r 6 .............
Page .
.
CHAPTER ONE
In tro d u ctio n .
There a re
numerous f u n g i p a t h o g e n i c
m ost o f them o f t r o p i c a l
proposed in t h i s
for su p e rfic ia l
the f e e t .
t o man,
or s u b t r o p i c a l o c c u r re n c e ,
t h e s i s to d e a l o n ly w ith t h e
i n f e c t i o n s o f the
skin,
The c a u s a t i v e o r g a n i s m s ,
v arieties
i n most c a s e s ,
and t h e c o m p a r a ti v e ly i n f r e q u e n t y e a s t
w ith in the
scope o f t h i s
is
is rare
in th is
i s obvious t h a t the
showing an a l a r m i n g upw ard t r e n d .
of a f f a i r s
r e v e a l s two f a c t o r s o f e r r o r :
in d ia g n o sis.
i n c r e a s e a p p e a r s to be a c t u a l ,
' H e a l t h o f t h e N av y'
sp e c ie s of
R in g w o rm o f t h e
more f r e q u e n t r e c o g n i t i o n o f s u p e r f i c i a l l e s i o n s ,
th e
to
co n trib u tio n .
in cid en ce o f th ese co n d itio n s
en th u siastic a ttitu d e
responsible
i n f e c t i o n s do n o t come
From r e p o r t s o n m y c o t i c d e r m a t o s e s i t
A nalysis o f t h i s s ta te
is
reference
are
and i t
country to o b ta in c u l t u r e s o u ts id e th e se g e n era.
scalp,
and i t
w ith s p e c ia l
th e g e n e r a t r i c h o p h y t o n and e p id e r m o p h y to n ,
fo rtu n ately
D espite
and a too
th e s e how ever,
and t h e f o l l o w i n g t a b l e
pub licatio n s bears th is
the
c o m p ile d from
o u t:-
Table 1
1930
19 31
1932
72
65
101
110
142
238
311
Fresh
cases
38031
42798
39284
41852
38652
37963
40278
T otal
strength
888 4 0
87075
83285
83125
83 2 4 0
86345
92245
Tinea
(various
form s)
1933
193A
193H
1936
Page . 1 ..
I t w i l l b e s e e n t h a t t h e f i g u r e s commence i n 193°>
b ein g the
f i r s t y e a r i n w h ic h m y c o tic i n f e c t i o n s were s e p a r a t e d from
the b u lk o f s k in d is e a s e s ,
service
:ly th is
that
a n d so f a r ,
to have c a r r i e d out t h i s
t h e Navy i s
statistic a l
t a b l e c o n t a i n s some u n a v o i d a b l e
th e only f ig h t in g
refinem ent.
fallacies.
U nfortunate
To b e g i n w i t h ,
most ringw orm l e s i o n s i n t h e a d u l t do n o t r e q u i r e h o s p i t a l i s a t i o n ,
an d c a s e s t r e a t e d on th e a t t e n d i n g l i s t
( v a r io u s form s)
o r f r e s h c a s e s colum ns.
are not
In a d d itio n ,
on e o r two c a s e s o f t i n e a t o n s u r a n s f r o m t h e
tra in in g establishm ents.
Were t h e
in c lu d e d in the t i n e a
f ig u r e s to
t h e r e may be
c a d e t's college or boys1
Include a l l
c a s e s o f s u p e r f i c i a l ringworm r e p o r t i n g f o r t r e a t m e n t ,
f r o m y e a r t o y e a r w o u l d b e v e r y much h i g h e r .
th e se
in fectio n s
the in c id e n ce
So t r o u b l e s o m e a r e
i n h o t c o u n t r i e s t h a t i n 1 9 3 & a com m ittee of
s u r g e o n s from t h e M e d i t e r r a n e a n F l e e t was a p p o i n t e d to
q u e s t i o n o f p r o p h y l a x i s a n d t r e a t m e n t on t h a t
Over a p e r i o d o f s i x t e e n y e a r s C . J .
the fo llo w in g fr e s h
Year
1910
1911
1912
1913
1914
1915
1916
1917
fresh
statio n
W hite
c o n sid e r the
(MacEwan 1 9 3 8 ) .
(1927) re p o rte d
cases seen in h is p r iv a te p r a c tic e ,
Fresh cases
of
tin ea.
3
5
11
14
20
17
21
25
Year
Fresh cases
o f tin ea.
1918
1919
1920
19 2 1
19 2 2
1923
1924
1925
a n d W i l l i a m s ( 1 9 3 6 ) s ho w e d a n u p w a r d t r e n d i n
31
19
87
131
118
148
156
147
s u p e r f i c i a l mycoses
Page A . .
i n B o s t o n f r o m 1 9 2 6 t o 1933*
cases of
other
R e iss in Shanghai
(1 9 3 8 ) had 72 f r e s h
t i n e a p e d i s i n 1 9 3 4 a n d 273 i n 1 9 3 & a n d t h e i n c i d e n c e o f
s u p e r f i c i a l m ycotic i n f e c t i o n s
marked te n d e n c y ;
W itton F ly n n ,
showed an upw ard t h o u g h l e s s
w h ile from A u s t r a l i a ,
re p o rts in d icate
( M a k in ;
1935) t h a t t i n e a p e d i s and c r u r i s a r e becom ing i n c r e a s :
: i n g l y common.
As we u n d e r s t a n d t h e m ,
th ese in fe c tio n s
d isfig u rin g or d isab lin g diseases,
s e r v i c e s and h y g i e n i c
stand ards are
b u t i n c o u n t r i e s whose s o c i a l
s o m e w h a t b e h i n d o u r own, g r o s s
a n d c r i p p l i n g d e f o r m i t i e s may r e s u l t .
below a r e from th e
illu stra te
are not u su ally
The two p l a t e s r e p r o d u c e d
c o l l e c t i o n o f D r. F. R e i s s o f S h a h g h a i ,
and
th e r e l a t i o n s h i p betw een c h r o n i c t i n e a p e d is and
recurrent e ry sip ela s-lik e
m an ifestatio n s -
P late 1
P late
2
C h ro n ic lymphoedema
Many do n o t a g r e e w i t h A l l a n ' s s u g g e s t i o n ( 1 9 3 4 ) t h a t t h i s
£
!
Page
. 5. .
c o n d itio n i s an a l l e r g i c m a n i f e s t a t i o n o f fu n g u s i n f e c t i o n ,
h a s been p o in te d out
(R eiss,
1 9 3 8 ) t h a t a c h r o n i c p e d a l l e s i o n may-
w ell serv e as a p o r t a l o f e n try
tim e,
for
s e c o n d a r y o r g a n i s m s w h i c h may,
l e a d to a c h r o n i c lymphoedema.
even a m ild degree o f
may r e n d e r a man u n f i t
From a s e r v i c e p o i n t
fo r duty,
to
in t.
M ed.,
54»606.
MacEwan, E.
( 1938) P e r s o n a l com m unication.
M a k in ,
F.H.
(1935) B r i t .
R eiss,
F.
(1938) Jo u r.
W hite, C .J .
W illiam s,
(1936)
W itton F lynn, J . J .
Med. J o u r . ,
C l i n . M ed.,
( 1927) A rch.
J.W.
o f view
say n o th in g o f p e rs o n a l d is c o m fo rt
R eferences.
(1934) A rch .
in
secondary i n f e c t i o n from a sm all m y c o tic fo c u s
and p a i n .
A l l a n , E.
but i t
Derm.
ib id .
(1935) B r i t .
2,693.
Shanghai,
3 ,13.
S y p h ., C hicago,
15, 387*
33,335*
Med. J o u r . ,
2 , 693.
Page . . . .
CHAPTER TWO.
The H i s t o r y o f S u p e r f i c i a l Ri ng w or m I n f e c t i o n s .
The s t u d y o f f u n g i i s a s o l d a s t h a t o f b o t a n y ,
was n o t u n t i l th e n i n e t e e n t h c e n t u r y
became r e c o g n i z e d ,
although th e re are
but it
in France th a t c l i n i c a l
mycology
s e v e r a l m entions o f p a r a s i t i c
moulds b e f o r e t h a t t i m e .
The r o y a l b o t a n i s t ,
Hooke ( E d . ,
1934),
i n 1677 n o te d a
p a r a s i t i c f u n g u s w h ic h c a u s e d d i s c o l o u r a t i o n on r o s e l e a v e s ,
s h o r t l y a f te r w a r d s M alp ig h i w rote of v e g e ta b le p a r a s i t e s w h ic h grow on o t h e r p l a n t s "
- a s he c a l l e d them .
M icheli d e sc rib e d th e genus a s p e r g i l l u s ,
b o tan ist,
L innaeus,
in h is
t a b u l a t e d a l l t h e a v a i l a b l e know ledge o f t h e
I t was n o t t i l l
the f i r s t p a r a s i t i c
T h e n i n 1729
the
c o l l e c t e d a nd
fungi.
1839, how ever, t h a t Langenbeck d is c o v e r e d
f u n g u s o f man, t h a t o f t h r u s h ,
year Schonlein d isco v e re d favus.
It
is in te re stin g
y e a r s p r e v i o u s l y Remak h a d n o t i c e d m y c e l i a l
r e g a r d e d them a s s e c o n d a r y i m p l a n t a t i o n s .
d i s c o v e r y o f ringw orm i n 1844 by Gruby.
c o n fu s io n by h i s
a n d i n t h e same
t o n o t e t h a t two
filam en ts in favus but
The n e x t
s t e p was t h e
He d e s c r i b e d t h r e e r i n g w o r m
f u n g i a s s o c i a t e d w i t h a s many t y p e s o f l e s i o n .
caused con sid erab le
"plants
and 23 y e a r s l a t e r
'8 p e c ie s P lantarum '
a nd
U n f o r t u n a t e l y , he
c l i n i c a l d e s c r i p t i o n s i n which
he m is ta k e n ly in c lu d e d t y p i c a l exam ples of a l o p e c i a a r e a t a as cases
of tin ea.
N aturally,
and h i s work f e l l
o th e r o b se rv e rs f a i l e d to fin d fungi in a lo p ec ia
in to
d isrep u te.
Sabouraud l a t e r co n firm e d h is
f i n d i n g s and acknow ledged th e p r i o r i t y o f h i s
a f t e r G ru b y 's p u b l i c a t i o n ,
discovery.
Four y e a r s
M alm ste in found a fu n g u s i n ringworm
Page . . . .
w hich he c a l l e d a t r i c h o p h y t o n ,
g iven to
the c o n d itio n i t
So f a r t h e
and b e a r d r e g i o n s ,
a n d t h e name t r i c h o p h y t o s i s was
caused.
s tu d y o f ringw orm had b e e n l i m i t e d to
the s c a lp
a n d t h e f i r s t d e p a r t u r e w a s made b y D e "v e rg ie i n
1857> when h e d e s c r i b e d e c z e m a m a r g i n a t u m a s a f o r m o f h e r p e s c i r c i n e .
H ebra i n i 860 g a v e a c l a s s i c a l d e s c r i p t i o n o f th e
what i s
extrem ely i n t e r e s t i n g
m entioned i t s
condition,
a nd
i n view o f modern A m erican s t a t i s t i c s ,
in f r e q u e n t d is s e m in a tio n to th e
ex trem ities.
The
c a u s a l f a c t o r w a s f o u n d f o u r y e a r s l a t e r b y K o b n e r , when h e i s o l a t e d
f u n g a l e l e m e n t s fr o m eczem a m a r g i n a tu m and p r o v e d t h e i r
sp ecificity
by r e p r o d u c i n g th e d i s e a s e e x p e r i m e n t a l l y .
The f i r s t
m e n tio n o f ringw orm o f th e
f e e t as a separate
en tity
w a s made b y M o u k t a r i n 1 8 9 2 , when h e f o u n d f u n g i i n d e r m a t i t i s
o f the
so les.
He f o l l o w e d R e m a k ' s e r r o r ,
f ila m e n ts a s secondary contam inants,
o b serv atio n s passed unnoticed.
Zlngale
how ever,
w ith the
and re g a rd e d th e
re s u lt th a t his
Some t i m e b e f o r e t h i s ,
i n 1888,
( 1 9 2 3 ) c la i m s t h a t P e l l i z a r i d e s c r i b e d ringworm a s p r o d u c in g
eczema o f t h e f e e t .
T h ereafter,
advance o f b a c te r io l o g y ,
Id en tificatio n ,
and th e
mycology f e l l
w ith th e r a p i d and s p e c t a c u l a r
more e x a c t m e t h o d s o f c u l t u r e a n d
somewhat i n t o
d isrep u te.
The n e x t a d v a n c e d i d n o t f o l l o w t i l l
1 9 0 8 , when W h i t f i e l d
( 1 9 0 8 ) fou n d f u n g i i n s i x c a s e s o f v e s i c u l a r and s c a l y eczema
betw een t h e t o e s .
T h i s was t h e
exam ination of a l l
such c ase s in h is p r a c t i c e .
S a b o u r a u d ( 1 9 IO)
r e s u l t o f r o u tin e m icroscopic
Two y e a r s l a t e r
showed e p i d e r m o p h y . t o n i n g u i n a l e by c u l t u r e
and f o o t l e s i o n s and i n 1 9 H ,
i n hand
a t a m eeting o f th e R oyal S o c ie ty o f
M e d i c i n e , h e a nd W h i t f i e l d p r e s e n t e d p a p e r s o n r i n g w o r m o f t h e f e e t
which drew u n i v e r s a l a t t e n t i o n t o t h e c o n d i t i o n .
P a g e . .Q.
From t h a t
tim e an i n c r e a s i n g amount o f c o n f i r m a t o r y
evidence has been fo rth co m in g ,
a l t h o u g h many i m p o r t a n t m o d i f i c a t i o n s
have tak en p la c e .
I n h i s o r i g i n a l w r i t i n g s S a b o u r a u d l a i d down t h a t : (a) A given fungus alw ays p ro d u c e s a c o n s ta n t c l i n i c a l p i c t u r e .
(b ) Eczema m a r g in a tu m i s a lw a y s due t o e p i d e r m o p h y t o n i n g u i n a l e ,
a s a r e most f o o t l e s i o n s .
( c ) A g i v e n f u n g u s g r o w n o n h i s p r o o f med ium w o u l d a l w a y s a p p e a r
t h e s am e.
Ormsby a n d M i t c h e l l
shown t h a t
(1 9 1 6 ) and Rosenbaum ( 1 9 2 3 ) h a v e s i n c e
t h e same f u n g u s may c a u s e a v a r i e t y o f l e s i o n s ,
v a r i o u s f u n g i may c a u s e i d e n t i c a l l e s i o n s .
Weidman ( 1 9 2 2 ,
K u r o t c h k i n and Chen ( 1 9 3 1 ) , h a v e p r a c t i c a l l y
w ith r e g a r d to t h e
a lo t
incidence o f e .in g u in a le
seems to d e p en d on l o c a l i t y .
and
1927),
and
re v e rse d the p o s itio n
in foot cases,
although
K u ro tch k in th in k s e . i n g u i n a l e the
c om mo n est c a u s e o f t i n e a p e d i s i n E u r o p e w h i l e R e i s s o f S h a n g h a i
f i n d s a t r i c h o p h y t o n th e most f r e q u e n t o f f e n d e r i n h i s p r a c t i c e .
Table
9
c lin ically
chapter
5 shows t h e v a r i e t y o f f u n g i i s o l a t e d from
i d e n t i c a l cases in 1938.
The t h i r d p o s t u l a t e
s t i l l h o l d s good and fo r m s t h e b a s i s
fo r i d e n t i f i c a t i o n o f pathogenic
fungi to -d a y .
medium S a b o u r a u d u s e d c r u d e m a l t o s e ( C h a n u t ) ,
In h is o rig in al
b u t the f a c to r y
for
i t s m a n u f a c t u r e w a s c l o s e d i n 1 8 9 6 ( S a b o u r a u d q u o t e d Weidman a n d
M cM illan,
1921),
a l t h o u g h s m a l l q u a n t i t i e s c o n t i n u e d t o a p p e a r on
th e m arket lo n g a f t e r
acco rd in g ly used,
occurred.
th is
(M itchell,
w ith the r e s u l t
1922).
S u b s t i t u t e m e d i a w e re
th a t the w id est c u l t u r a l v a r i a t i o n s
T h e p o s i t i o n h a s now b e e n u n i v e r s a l l y c l e a r e d b y t h e
s t a n d a r d i s a t i o n o f g ro w th on l o c a l
media a g a i n s t o r i g i n a l c u l t u r e s
.
Page . . . ?
o b ta in e d c h i e f l y from Sabouraud.
So p r e v a l e n t h a s f o o t r i n g w o r m b e c o m e i n A m e r i c a ,
193° i t
was r a n k e d by t h e d e r m a t o l o g i s t s o f t h a t c o u n t r y
193° ) a s t h e commonest s k i n d i s e a s e ,
riv al.
It
retu rn in g
is
far o u tstrip p in g
s a id to have been b ro u g h t to
s o l d i e r s a f t e r t h e G r e a t War.
its
th a t in
(L ancet,
nearest
t h e U n i t e d S t a t e s by
Gray (1926) c o n s i d e r s i t
was i n t r o d u c e d t o B r i t a i n by r e t u r n i n g A n g l o - I n d i a n s .
Page 19.
R eferences.
D evergie,
M . G . A . ( 1 8 5 7 ) M a l a d i e s de l a P e a u ,
E d ito rial,
(1934) J o u r .T r o p .M e d .
G r a y , A.M.H.
H ebra, F.
T .J.
a n d Ch en,
a n d Sy ph.
F . K . ( 193l )
C hicago,
27, 607.
N a t. M ed .Jo u r. o f C hina, 17,521.
(193°) 2,421.
M itch ell,
Ormsby,
( 1 9 2 6 ) P r o c e e d . A m e r . D e r m . A s s n . , May.
H . E . (1 9 3 3 ) Arch.Derm,
K urotchkin,
M ouktar,
37,377*
( i 8 6 0 ) Handbuch d e r S p e c l a l l e n P a t h o l o g i e und T h e r a p l e .
K ittred g e,
L ancet,
and Hyg.,
p p . 273*
J . H . ( 1 9 2 2 ) A r c h . Derra. a n d S y p h . ,
C hicago,
5,174*
D . ( l 8 9 2 ) A n n . d e Derm, e t S y p h , 3» B8 5 .
O .S.
and M i t c h e l l ,
J . H . ( 1 9 1 6 ) J o u r . A m e r . M e d . A s s n . , 67,711*
Rosenbaum, E . ( 1 9 2 3 ) D e rm .W c h n s c h r., 7 6 , 5 0 .
S a b o u r a u d , R . J . A . ( 1 9 I O ) A n n . d e Derm, e t S y p h . , 1 , 2 8 9 .
............................ Q u o t e d b y Weidman a n d M c M i l l a n ( 1 9 2 1 ) A r c h . D e r m , and
Syph.,
Weidman, F . D . ( 1 9 2 2 ) A r c h . D e r m . a n d S y p h . , C h i c a g o ,
............................ ( 1 9 2 7 )
ibid.
W h i t f i e l d , A . ( 1 9 O8 ) L a n c e t ,
Zingale,
15,415.
2,237.
M .( 1 9 2 3 ) G i o r . I t a l . d . m a l . V e n . , 6 4 , 9 2 9 .
C h i c a g o , 4 ,4 5 1
5,325*
Page
CHAPTER THREE
The D i a g n o s i s o f
S u p e r f i c i a l Ri ng w or m I n f e c t i o n s .
The m e d i c a l p r o f e s s i o n ,
p e r h a p s mo re s o t h a n a n y o t h e r ,
i s s u s c e p t i b l e to c h a n g e s i n f a s h i o n ;
and t h e grow ing aw are n e ss
among t h e p u b l i c o f s u p e r f i c i a l
ringworm i n f e c t i o n s ,
t h a t v a r i e t y known p o p u l a r l y a s
'a th l e te 's fo o t',
responsible
fo r the
in c re a s e in the
especially
may b e i n p a r t
incidence of th ese c o n d itio n s.
I n 1934 Gray (1 9 3 4 ) drew a t t e n t i o n t o th e p r o b l e m p r e s e n t e d by t h e s e
pedal le s io n s ,
a n d l a t e r Wise a n d W olf (1 9 3& ) d e p r e c a t e d t h e i r t o o
casual diagnosis.
The m a i n d i f f i c u l t y
in fectio n s
i n th e r e c o g n i t i o n of m ycotic
i s th e f r e q u e n t and e a r l y
sp o n tan eo u s d is a p p e a ra n c e of
fu n g a l m y c e lla from t h e i n f e c t e d a r e a ,
and i n l a t e
c a s e s t h e r e may
be n o th in g to d i s t i n g u i s h th e c o n d i t i o n from d e r m a t i t i s from o th e r
causes (W hitfield,
19°8, 1911).
The r e a s o n f o r t h i s d i s a p p e a r a n c e
i s h a r d to u n d e r s ta n d i n view o f th e v i a b i l i t y
fungi
(F arley,
K adisch,
1921;
Weidman, 1 9 2 7 ;
B ruhns, A lexander,
1929), b u t th e seco n d ary b a c t e r i a l
(F alchi, 1934).
a nd
c o n t a m i n a t i o n which
s o m e t i m e s o c c u r s may i n some way e x e r t a l e t h a l
m oulds,
o f the pathogenic
i n f l u e n c e on t h e
In t h i s connexion th e o b s e r v a t i o n s of
Weidman ( 1 9 2 6 ) on a c a s e o f p e d a l r i n g w o r m sown w i t h y e a s t s a r e o f
im portance.
seen,
J.H .
Th us i t
w o u l d a p p e a r t h a t many c a s e s o f t i n e a ,
w i l l n o t show t h e c a u s a l a g e n t ,
M i t c h e l l (1 9 2 2 ) and C . J . W h i t e
although such a u t h o r i t i e s as
(1919, 1927) c o u n te n a n c e a
d i a g n o s i s on c l i n i c a l grounds a lo n e i n th e
type.
when
T h i s may b e a d m i s s i b l e u n d e r c e r t a i n
ch ro n ic k e r a to tic pedal
circum stances,
but the
Page . V ; .
d e m o n s tr a tio n o f the
diag n o sis,
sp ec ific facto r
s t i l l rem ains a 's i n e
qua non’ in
a n d t h e f o l l o w i n g s t a t e m e n t b y R a m s b o t t o m ( 1 9 3 1 ) may be
ta k e n a s an e x p r e s s io n of g e n e r a l o p in io n :
"There i s ,
t e n d e n c y o n t h e p a r t o f some i n v e s t i g a t o r s t o
however,
a
assume a f u n g a l
o r i g i n o f a d i s e a s e on i n s u f f i c i e n t e v i d e n c e .
It is
n o t enough
to p o s t u l a t e the p a r a s i t i c n a tu re o f a d is e a s e
a nd t h e n ,
bacteria,
protozoa,
and o t h e r p a r a s i t e s b e in g e l i m i n a t e d ,
to d e s c r i b e i t
m ycotic;
th e e v i d e n c e must be a s c l e a r a s t h a t f o r any o t h e r
as
p a r a s i t i c g r o u p . 11
In a d d itio n
:d ig ital
i t must be remembered t h a t a l l c a s e s o f i n t e r :
s c a l i n g and m a c e ra tio n a r e n o t m y c o tic ,
G raffenried
(1 9 1 8 ) and C a ta n e i
form a s u i t a b l e n i d u s .
a l t h o u g h von
( 1 9 3 2 ) h a v e sh own t h a t
D i r t s e e m s t o b e a r no r e l a t i o n
such le s io n s
to
Infectio n ,
a s the h ig h e s t In c id e n c e i s
t o b e f o u n d among t h e w e a l t h y a n d more
l e i s u r e d c l a s s e s (B eintem a,
1931)*
N om enclature.
The o u t l o o k on m y c o t i c i n f e c t i o n s h a s b e e n f u r t h e r c o n f u s e d
by t h e v a r i e t y o f t e r m s u s e d t o d e s i g n a t e
sim ila r conditions.
By
s u p e r f i c i a l ringworm i s g e n e r a l l y u n d e r s t o o d a l e s i o n o f t h e s k in
caused by a v e g e ta b le p a r a s i t e ;
arrangem ent i s a b s e n t,
country.
and,
alth o u g h a t tim es the c ir c in a te
t h e name h a s s t o o d t h e
t e s t o f tim e i n t h i s
T r i c o p h y t o s i s and e p id e rm o p h y to s is a r e d e s c r i p t i v e
term s,
and i n d i c a t e th e g enus o f th e i n f e c t i n g f u n g u s , b u t w it h o u t
reco g n itio n in c u ltu re ,
d ifferen tiatio n is
Im possible.
so m ew ha t e l e g a n t s o u n d h a s l e d t o c o n s i d e r a b l e m i s u s e ,
the f a c t th a t in th e
Their
and d e s p i t e
m i n d s o f many t h e y s t a n d f o r a p a r a s i t i c s k i n
Page
c o n d itio n of the e x tr e m itie s ,
ap preciated.
.
th e u n d e rly in g cause i s n o t f u lly
I n c i d e n t a l l y t h e p r e d o m i n a t i n g g enus seems to depend
on g e o g r a p h i c a l s i t u a t i o n ,
f l o r a b y Weidman ( 1 9 2 7 )
and t h e t a b l e o f t h e world* s m y c o l o g i c a l
is of considerable
in te re st
in t h i s
connection.
R e c e n tly th e Am erican D e r m a t o l o g i c a l A s s o c i a t i o n h a s
la b e l le d in fe c tio n s of the e x tre m itie s - derm atophytosis,
Infections,
else w h e re - derm atom ycosis.
em bracing,
and g e n e r a l
These d e s c r i p t i o n s a re a l l -
b u t t h e y c a n n o t b e recommended f o r g e n e r a l u s e u n t i l a
more s c i e n t i f i c a t t i t u d e
tow ards m y co lo g ic al derm atology i s ad opted.
The t e r m t i n e a s t i l l h a s a m e a s u r e o f u s e f u l n e s s ,
a d d itio n of the s i t e
l o c a l i z e s the d is e a s e ,
cru ris,
etc.
tin e a barbs,
toe r o t ,
mango t o e ,
l e f t to
th e laym an.
e.g .
tin e a p ed is,
a th le te 's fo ot,
n o t o r i o u s l y vague a n d h a p h a z a r d .
a n d many o t h e r s ,
In s t a t i s t i c a l
v a r io u s ly d e s ig n a te d m ycotic I n f e c t i o n s ,
w ith the r e s u l t
Im possible.
tin ea
C o l l o q u i a l i s m s s u c h a s - Hong Kong f o o t ,
s h o u ld be
The S e r v i c e n o m e n c l a t u r e o f t h e s e c o n d i t i o n s i s
and t i n e a ,
and th e
still
r e t u r n s they are
trich o p h y to sis,
th a t accu rate s t a t i s t i c a l
U n i v e r s a l u s e o f t i n e a w o u l d do much t o
pompholyx,
deductions are
c l e a r up t h i s
confusion.
C lin ic a l D iagnosis.
S u p e r f i c i a l ringworm i s
cau sed by i n f e c t i o n o f the upper
l a y e r o f t h e e p i d e r m i s by f u n g i o f t h e g e n e r a t r i c h o p h y t o n an d
epiderm ophyton.
O t h e r me mbers o f t h e f a m i l y g y m n o a s e a c e a ( S t i t t )
may be i m p l i c a t e d , b u t t h e y a r e r a r e b y c o m p a r i s o n .
t h e p a r a s i t e s ho ws a p r e d i l e c t i o n f o r c e r t a i n a r e a s ;
:d ig ital
spaces,
and the c r u r a l and a x i l l a r y f o ld s .
C lin ically
the
in ter:
Is o la te d patches
P a g e \A . .
o f t e n o c c u r on e x p o s e d s i t e s fro m d i r e c t i n f e c t i o n ,
anim al s o u rc e s .
Su c h a n i m a l r i n g w o r m s u s u a l l y
p u s t u l a r elem ent.
A p a rt from t h e f e e t ,
m a c e r a t i o n may m o d i f y t h e p i c t u r e ,
by s h a r p l y d e m arcated ,
a healin g centre.
In ten sely
f r e q u e n t l y from
show a c o n s i d e r a b l e
w h ere m o i s t u r e and
the l e s i o n s a re c h a r a c te r iz e d
itch in g ,
in flam m ato ry a r e a s w ith
M inute v e s i c l e s w i l l be fo und a t th e p e r i p h e r y
where t h e in f l a m m a t i o n i s most m arked ( f i g . l ) ,
and t h e p a th o g e n
can be r e c o g n i z e d m i c r o s c o p i c a l l y i n s c r a p i n g s from t h e
spreading
edge.
F i g . 2 shows an a r e a on t h e b a c k o f t h e n eck which
probably in v o lv e s the
h air.
H air i n f e c t i o n s a re a ls o
b e a r d r e g i o n , b u t t h e y a r e e x t r e m e l y uncommon i n t h e
s e e n i n the
S ervices.
They
c a n b e d i a g n o s e d f r o m t h e mo re common s y c o s i s b a r b a e b y t h e p r e s e n c e
o f m ycelia,
w h i c h may b e s c a n t y ,
a nd by t h e f a c t t h a t i n t i n e a
barbae t h e r e
i s alw ay s a n o d u la r elem ent p r e s e n t .
It
should be
n o te d t h a t th e epiderm ophyton n e v e r a f f e c t s th e h a i r ,
ringworm o f th e s c a l p
ad u lts.
is a derm atologlcal c u r io s ity
I n the A s i a t i c a d u lt a c t i v e
spore v a r i e t y
and t h a t
in European
tin e a to n su ran s of th e larg e
i s a common o c c u r r e n c e .
F i g . 3 i l l u s t r a t e s a t y p i c a l p a t c h o f t i n e a a t a somewhat
l a t e r s ta g e b u t the
F ig . 4 is
c a r d i n a l f e a t u r e s can s t i l l b e made o u t .
a g o o d e x a m p l e o f t h e common c r u r a l i n f e c t i o n so
f r e q u e n t l y s e e n on t r o p i c a l s e r v i c e .
type of l e s i o n i s
The s p r e a d i n g e d g e o f t h i s
alw ays lo a d e d w ith f u n g i,
: i o n can be p i c k e d o f f w ith f i n e
ty p ic a l v e s ic u la r elem ent i s v ery
forceps.
and s c a l e s f o r exam inat:
S t r a n g e l y enough th e
seldom p r e s e n t i n t h i s l o c a t i o n .
D i f f e r e n t i a t i o n m u s t b e made f r o m i n t e r t r i g o
s t r e p t o c o c c i and y e a s t s ,
due to
th e f l e x u r a l form s o f seborrhoe i c
Page 2-5. .
d e r m a t i t i s and p s o r i a s i s ,
and e r y t h r a s m a .
S treptococcal in te r tr ig o
and th e
c h a r a c te ris tic v esicle
o f the le s i o n .
e d g e c a n b e made o u t a t t h e m a r g i n
M onilia in f e c tio n s
c e r t a i n t y by c u l t u r e ,
i s an im p etig o of the f l e x u r e s ,
can o n ly be d i f f e r e n t i a t e d w ith
as the p a r a s ite
o c c a s io n a lly a d o p ts a chain
f o r m a t i o n which shows a s a m ycelium m i c r o s c o p i c a l l y
(We idm an, 1 9 2 2 ) .
The f l e x u r a l f o r m s
I n f e c t i o n on a r m .
2
P a t c h on h a n d a n d nec:
d e r m a t i t i s and p s o r i a s i s a r e u s u a l l y a c c o m p a n i e d b y t h e more t y p i c a l
m a n ife s ta tio n s elsew here.
E ry th rasm a i s a r a r e i n f e c t i o n o f the sk in
o f th e u p p e r and i n n e r a s p e c t o f th e t h i g h s w i t h th e fu n g u s
M icrosporon m inutissim um .
It
i s a chronic d is e a s e
causing l i t t l e
P a g e .1.6..
itch in g ,
i n marked c o n t r a d i s t i n c t i o n
the h e a lin g
centre
to t i n e a ,
a n d d o e s n o t show
s o t y p i c a l o f t h e common r i n g w o r m s .
of erythrasm a i s extrem ely sm all,
o b j e c t i v e o f the m icroscope f o r
and r e q u i r e s the o i l
its
reco g n itio n .
m e n t i o n m u s t b e made o f t i n e a v e r s i c o l o r ,
The p a t h o g e n
im m ersion
In p assin g ,
a c o n d itio n o f the chest
a n d b a c k w h e r e a l m o s t p u r e c u l t u r e s o f t h e f u n g u s M. f u r f u r g r o w i n
a c o n d i t i o n o f low g r a d e p a r a s i t i s m .
Fig.
3
P atch of tin e a ,
l a t e r stage.
tnea c r u r i s .
In g en eral,
i t may b e s a i d t h a t a n y s h a r p l y d e f i n e d p a t c h
o f eczema s h o u ld be v ie w ed w i t h s u s p i c i o n u n t i l e x o n e r a t e d micro:
: scopically.
Page . .17.
Pedal In fectio n s.
P e d a l I n f e c t i o n may t a k e
the to e s ,
o r a t y p i c a l p a tc h on th e
r e ta in e d m oisture the o u tlin e
under the
t h e form o f m a c e r a t i o n betw een
i n s t e p o r dorsum.
i s often lo s t,
Owing t o
and the fu n g u s burrow s
s k i n which p e e l s o f f i n l a r g e f l a k e s
( f i g . 5 ).
A c c o rd in g to C . J . W hite
are ten c lin ic a l
(1927) th e re
v a r i e t i e s of foot
F ig .5
Tinea p e d is
Infected n a ils
in fe c tio n ,
b u t they a re too d e t a i l e d f o r normal p u rp o s e s ,
and t h e
18
Page . . . .
t h r e e c l a s s i f i c a t i o n s o f W illia m s (1922) sh o u ld be u sed .
(l)
H y p e rk erato sis w ith sc a lin g ;
(2) m a c e ra tio n o f the
They a r e :
s k in betw een
the to e s ;
and ( 3 ) a v e s i c u l a r form u s u a l l y
seen on th e i n s t e p .
W hitfield
(1934) i s o f th e o p i n i o n t h a t a l l
c a s e s commence a s a
v e s i c u l a r o r b u l l o u s e r u p t i o n , b u t G ra y ( 1 9 3 4 )
a g re e m e n t w i t h him,
is not in e n tire
and i n t h i s he f o l l o w s W hite
(1927) in
p o s t u l a t i n g a prim ary i n t e r t r i g i n o u s type.
O ver t h e l a s t few y e a r s a l l c a s e s w i t h a n a c u t e i n f e c t i o n ,
seen p e rs o n a lly ,
were v e s i c u l a r
in o rig in .
The r e m a i n s o f a
v e s i c u l a r edge b e tw e e n t h e t o e s can so m etim es be fou n d w i t h a hand
l e n s even a t an advanced s ta g e ,
b u t i t must be remembered t h a t ,
common w i t h m o s t s k i n d i s e a s e s ,
a com bination o f ty p e s w i l l be th e
most l i k e l y
in
finding.
D y s id ro tlc ide
L ichenoid ide
D ysidrotlc E ru p tio n s.
The e x a c t n a t u r e o f t h e v e s i c u l a r l e s i o n s ,
so f r e q u e n t l y
s e e n on t h e h a n d s a n d f e e t ,
h a s b e e n r a t h e r o b s c u r e d by t h e e m p h a s is
o f t h e F r e n c h s c h o o l on t h e m y c o tic f a c t o r .
D iscussing v e s ic u lo -
b u l l o u s and squamous e r u p t i o n s o f t h e e x t r e m i t i e s ,
red t h a t d y s i d r o s i s o r pompholyx i s
syndrome;
D arier
not a d i s t i n c t e n t i t y , b u t a
a n d , when n o t o c c u p a t i o n a l o r m e d i c a m e n t a l ,
due to f u n g i .
L a t e r he s t a t e d
c e n t o f c a s e s o f pompholyx.
of d y s id ro tlc eruptions,
in fe c tio n s
(1919) s t a t
( 1 9 2 8 ) t h a t he
i s probably
f o u n d f u n g i i n 80 p e r
R a g a b ( 1 9 3 4 ) f o u n d f u n g i i n 52 p e r c e n t
b u t m ost o f h i s c a s e s were o r d i n a r y rlngv/orm
( M c L a c h l a n a n d Brown,
1934)*
I n a c o m p r e h e n s iv e s u r v e y o f th e mechanism o f c h eiro p o m :
rpholyx,
M c L a c h l a n a n d Brown ( 1 9 3 4 ) f o u n d t h a t
resp o n sib le;
in la b ellin g
many f a c t o r s w e re
a n d W ise a n d W olf (193&) u r g e d t h e n e e d f o r c a u t i o n
d y s i d r o t i c c o n d itio n s of the e x t r e m i t i e s m ycotic.
True d y s i d r o s i s o r b l o c k i n g of t h e s w e a t p o r e s i s o f t e n
s e e n on t h e l a t e r a l
a s p e c t s o f th e f i n g e r s i n h o t hum id c o u n t r i e s ,
in the absence o f m ycotic f o c i elsew h ere.
N all I n f e c t i o n s .
N a i l i n f e c t i o n s a r e now r e g a r d e d a s much more common t h a n
form erly,
and t h e r e
i s a grow ing w eig h t o f o p i n i o n t h a t i n f e c t e d
n a i l s may show l i t t l e
o r no c l i n i c a l a b n o r m a l i t y ( W i l l i a m s , 1928;
W illiam s and B a r th e l,
1929;
O nych^om ycosls i s u s u a l l y
G r a y , 19341
W is e a n d W o l f , 1 9 3 ^ ) .
secondary to i n f e c t i o n else w h e re,
and th e
i n f e c t i v e agent g a i n s e n tra n c e under the f r e e
m argin o f th e n a i l .
A c c o r d i n g t o K u r o t c h k i n a nd C h e n ( 1 9 3 1 ) t h e r e
a r e two c l i n i c a l
v arieties:
( 1 ) t h e c om mo ne st f o r m ,
c h a r a c t e r i z e d b y b r i t t l e n e s s a nd
Page ??. .
t h i c k n e s s o f t h e n a i l s w i t h r i d g i n g and d e f o r m i t y
form i n w h ic h th e n a i l s a p p e a r no rm a l b u t l o s e
( f i g . 6 ) and ( 2 ) a
th e ir lu stre.
The
d i a g n o s i s i s made o n t h e a p o e a r a n c e o f t h e l e s i o n s a nd t h e p r e s e n c e
o f ringworm e ls e w h e r e .
M icro sco p ical exam ination w ill,
o f course,
be c a r r i e d out a s a r o u ti n e .
D i f f e r e n t i a t i o n w i l l h a v e t o b e made f r o m p s o r i a s i s ,
eczema,
and s y p h i l i s .
or gross defo rm ities,
I n p s o r i a s i s t h e n a i l s may show m i n u t e p i t s
and t h e p r e s e n c e o f t y p i c a l l e s i o n s
w i l l c lin c h the d ia g n o s is .
elsew here
The o t h e r two d i s e a s e s a r e r a r e l y met
w ith in S e rv ice p a t i e n t s .
D istal E ruptions.
In 1912 J a d a s s o h n drew a t t e n t i o n to
w hich o c c u r r e d i n s e v e r a l
spiny lic h e n o id p a p u le s
cases of kerion under h is care,
and th e s e
d i s t a l e r u p t i o n s a r e now f u l l y r e c o g n i z e d u n d e r t h e name o f " i d e s " ,
th is being a sh o rt t i t l e
a r e due to
t h e hae m a t o g e n o u s s p r e a d o f t o x i n s ,
them selves,
from a d i s t a l
tu b ercu lid es.
sen sitized ,
allerg y .
fo r epiderm ophytide or t r i c h o p h y t i d e .
focus o f in f e c tio n ,
o r more r a r e l y
fungi
and a r e a n a l o g o u s to
To p r o d u c e a n i d e t h e s k i n o f t h e
a s t h e phenomenon i s
They
s u b j e c t must be
a m a n ife s ta tio n of cutaneous
Fungi a r e v ery r a r e l y re c o v e r e d from th e id e .
I t i s g e n e r a l l y i n s i s t e d t h a t th e p rim a ry l e s i o n be deep
seated
(W illiam s,
1927; Dowling,
have been o b serv ed i n s u p e r f i c i a l
A nderson,
1934).
As t h e s k i n i s
sh o u ld r e a c t to th e
19 3 5 )»
although d i s t a l
in fectio n s
( P e c k , 1 9 3 ° '< A y r e s a n d
s e n s i t i z e d to
fungus p r o d u c ts i t
in traderm al in je c tio n of tric h o p h y tin .
The i d e e r u p t i o n may m a n i f e s t I t s e l f
t h e t h r e e c o m m o n e s t,
eruptions
a c c o r d i n g to Bloch ( 1 9 2 1 ) ,
i n s e v e r a l ways, b u t
sim ulate - ( l)
a
Page .
lichen
eruption,
: forme.
( 2 ) e r y t h e m a n o d o s u m , and ( 3 ) e r y t h e m a s c a r l a t i n l :
By f a r t h e
co m m one st t y p e s e e n t o - d a y
which i s w e ll i l l u s t r a t e d
e ruption
is a v esicu lar lesio n
i n f i g . 7 , and a f t e r t h a t a s m a l l l i c h e n o i d
( f i g . 8 ) (W illiam s, 1921).
I t must be remembered, how ever,
t h a t th e p e rc e n ta g e o f m ycotic c a s e s d e v elo p in g a l l e r g i c
i s v e r y s m a l l ( M u e n d e , 1 9 3 O).
,
F ig .9 In te rc e llu la r spaces
F i g . 10
C ontam inations
X 125.
eruptions
Page
The D i a g n o s i s o f S u p e r f i c i a l Ringw orm I n f e c t i o n s
F i e . 11
Low p o w e r o f f u n g u s
Pig.L ' d
High power of fungus.
.
Page .2.3 .
F i g . 13
High pow er o f fu n g u s
F i g . 14.
Mosaic
X 4 00
P ag e .2 4 .
M icroscopical D iag n o sis.
In m ic ro sc o p ic a l i n v e s t ig a ti o n s the
w i t h a No. 4 e y e p i e c e
p rep aratio n ,
is
tw o -th ird s o b jectiv e
s u f f i c i e n t f o r a* g e n e r a l s e a r c h o f t h e
and th e o n e - s i x t h o b j e c t i v e f o r c o n f i r m a t i o n and d e t a i l s .
I n d i r e c t l i g h t i s b e s t a s . i t m akes t h e hyphae
th read s.
A p l a n e m i r r o r can be u s e d w ith t h e low pow er,
m a te ria l i s not too
essen tial.
thick,
but otherw ise c o n ce n tra te d l i g h t i s
and i f very t h i n ,
d i r e c t l y w ith o u t m ounting.
as in tin e a c ru ris ,
can be examined
Most s p e c i m e n s , h o w e v e r, w i l l h a v e t o be
a n d t h e a g e n t m o s t commonly u s e d i s l i q u o r p o t a s s a e .
fe w d r o p s o f t h e l i q u o r s h o u l d b e a d d e d t o t h e
slid e,
when t h e
The s c r a p i n g s s h o u l d b e t a k e n f r o m t h e a c t i v e e d g e o f
the p a tc h ,
cleared,
stand out as r e f r a c t i l e
and th e whole a llo w e d to
d rying o u t.
A
s c a l e s on a m icroscope
s t a n d f r o m o ne h o u r u p w a r d s w i t h o u t
G e n tle h e a t i n g o v e r a flam e f o r a few s e c o n d s w i l l
a s s i s t th e 'p r o c e s s .
T hereafter,
a co v ersllp
s h o u l d be a p p l i e d and
the p r e p a ra tio n p re s se d out i n to a th in film .
Many m e t h o d s h a v e b e e n d e v i s e d t o d i f f e r e n t i a t e
fungus
i n the film , bu t in p r a c t i c e th e p o ta sh s o l u t i o n is the s im p le s t.
The s c o r c h m e th o d o f Bachman ( 1 9 2 0 ) n e v e r s e e m s t o w o r k ,
dyes advocated,
such a s c re s y l v i o l e t ,
and o r a n g e G (Bachman, 1 9 2 0 ) ,
to p re v e n t flo o d in g the f i e l d .
require
and t h e
a cid u late d gentian v io le t
c o n sid e ra b le d e lic a c y of touch
A c o m b i n e d c l e a r i n g a nd s t a i n i n g a g e n t
is lactophenol co tto n b lu e :L actic acid
Phenol c r y s ta ls
G lycerine
A q.dest.
C otton blu e
a nd i f
the
....
....
....
....
....
1
1
2
1
5
c.c.
grm.
c .c.
c.c.
Pe r c e n t .
s c a l e s a r e t h i c k th e y can be t r e a t e d w ith h y d ro x id e ,
P a g e .25 .
w ashed i n w a t e r and m ounted i n L .C .B .
(S w artz and Conat,
1936).
Fungi must n e v e r b e c o n f u s e d w ith t h e i n t e r c e l l u l a r
which f r e q u e n t l y s t a n d o u t a s f i n e r e f r a c t i l e
lin es
( f i g . 9 )-
spaces
°n
h ig h pow er e x a m in a tio n they w i l l be see n t o be c o n tin u o u s w ith t h e
cell o u tlin e.
refractile
A nother cause o f e r r o r i s th e p re se n c e of h ig h ly
v e g e t a b l e and anim al
from swabs u s e d to
all
f i b r e s d e r i v e d from so c k s ,
clean the a re a before scraping.
They may assume
s h a p e s and o f t e n have a ra g g e d edge ( f i g . 1 0 ).
The a c t u a l p a t h o g e n i s
filam ent,
it
and
a long se ld o m -b ra n c h in g r e f r a c t i l e
a n d p r o l o n g e d s e a r c h o f t h e f i e l d may be r e q u i r e d t o f i n d
( H o p k in s , 1937)*
The p a r a s i t e
c r o s s e s t h e e p i d e r m a l c e l l s a nd
sh o w s no t e n d e n c y t o f o l l o w t h e i r o u t l i n e .
power a p p e a r a n c e o f a mycelium ,
o f t h e same p r e p a r a t i o n .
th e f i e l d
F i g . 1 1 sh o w s t h e low
a n d f i g . 12 t h e h i g h p o w e r a p p e a r a n c e
The l o s s o f r e f r a c t i l l t y
i s du e t o t h e f o c u s o f t h e c a m e r a .
i n some p a r t s o f
F ig .1 3 i s a h i g h power
p h o to g ra p h from a d i f f e r e n t c a s e .
M osaics.
A strange
"m osaic"
a p a r a s i t i c mycelium i s
( f i g . 1 4 ) o f what a t f i r s t a p p e a r s to be
som etim es se e n ,
and d o u b t i s f r e e l y
e x p re ssed as to th e n a tu re o f t h i s o r g a n iz a tio n .
r e g a r d e d a s an a r t e f a c t due t o
some i n t e r a c t i o n b e t w e e n t h e
e p id e rm a l c e l l s and t h e l i q u o r p o ta sse e
u se d i n m ounting,
view i s g a i n i n g g ro u n d I n A m e ric a (Greenwood,
G regory, 1935;
how ever,
still
S w a rtz and C o n at, 1 9 3 6 ) .
regard i t
In England I t i s
1935 D a v iso n and
D ow din g a nd O r r ( 1 9 3 6 ) ,
as a d iso rg a n ize d fungus,
found th e norm al fu n g u s fo rm in g p a r t of a m o saic.
and th e y have
In t h i s connection
t h e o b s e r v a t i o n s o f C r a w f o r d - J o n e s ( 1 9 3 5 ) on t h e f r a g i l i t y
are of i n t e r e s t .
and t h i s
of fungi
I n a p e r s o n a l I n v e s t i g a t i o n on t i n e a p e d i s
Page
m entioned l a t e r ,
m osaic;
..
on e c a s e was s e e n w h e r e t h e m y c e l i u m e n d e d i n a
a n d t h e f i n d i n g o f t h i s p a t t e r n i n t h e f i l m i s now t a k e n
a s an i n d i c a t i o n f o r
a f u r t h e r sea rc h of the p re p a r a tio n ,
i n some
cases w ith su ccess.
N ails.
I n exam ining i n f e c t e d n a i l s ,
a razor blade,
and t h e y s h o u l d i n c l u d e m a t e r i a l
s u rfa c e of th e f r e e
w ith g la s s ,
s h a v i n g s s h o u l d b e made w i t h
e d g e down t o
but th e y a re a p t to
th e quick.
from t h e
under
S c r a p i n g s c a n b e made
le a d to a r t e f a c t s in th e f i e l d ,
du e
to o v e rla p p in g of th e frag m e n ts w ith the fo rm a tio n o f ten o u s
refractile
lin es.
The s p e c i m e n s h o u l d b e b o i l e d f o r
f iv e m inutes i n liq u o r
p o ta s s e e , and t r a n s f e r r e d t o a s l i d e w i t h a p l a t i n u m l o o p .
It
can
t h e n b e s p r e a d b y p r e s s u r e on t h e c o v e r s l l p .
Commentary.
As t h e f u n g u s i s f r e q u e n t l y d i f f i c u l t t o d e t e c t ,
the
s c r a p i n g s sh o u ld be r e p r e s e n t a t i v e o f a l l th e a c t i v e p a r t of th e
lesio n ,
and n o t one s m a ll a r e a .
n egative m icroscopical fin d in g s,
In c l i n i c a l l y p o s itiv e
c a se s w ith
Weidman ( 1 9 2 7 ) a d v i s e s d r e s s i n g
t h e p a r t f o r a few d a y s w i t h 4 P e r c e n t d e x t r o s e t o e n c o u r a g e t h e
grow th o f f u n g i.
I h a v e u s e d t h i s method s e v e r a l t i m e s , b u t th e
re s u lts d id not ju s tify
the m easure.
C onclusion.
The f a c t t h a t t h e r e
not ju s tif y
m a c e ra tio n betw een th e t o e s does
a d ia g n o s i s o f t i n e a p e d i s In t h e absence of m icroscop:
: le a l confirm ation.
experience,
is
Only i n e x p e r t h a n d s w i t h y e a r s o f c l i n i c a l
backed by m ic ro s c o p ic a l c o r r e l a t i o n ,
is
t h i s perm issible.
The c a s u a l o b s e r v e r n e e d o n l y b e r e m i n d e d t h a t t h e a p p o s i t i o n o f
Page .? 7 .
a n y two s k i n s u r f a c e s f o r a s u f f i c i e n t l e n g t h , o f t i m e w i l l l e a d t o
m a c e ra tio n and d e r m a t i t i s .
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J.,
A yres,
J r . , a n d A n d erso n , N . P . (1934) A rc h .D e r m .S y p h ., C hicago,
29,537.
S .,
Bachman,
R.W.
B e i n t e m a , K.
a nd G o r n y , ¥ . ( 1 9 3 5 ) D e r m a t . W c h n s c h r . , 1 0 1 , I O 3 4 .
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1 0 , 7 .5 .
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H o p k i n s , J.G-. ( 1 9 3 7 ) . A r c h . D e r m . S y p h . , C h i c a g o ,
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5 ,1 4 7 *
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S . M . ( 1 9 3 O ). A r c h . D e r m . S y p h . , C h i c a g o ,
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ib id .,
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Ibid,
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15,415*
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Ib id ,
4,353*
5,163-
Idem.
(1927).
I b id , 15,451.
Idem.
(1928).
I b i d , 18,73°*
F .,
supra).
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Idem .(1 9 2 2 ).
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2,237*
(1911) B r i t . J o u r . D e r m . S y p h . , 2 3 , 3 5 .
W h itfie ld , A .(1934).
W illiam s,
37,5°!*
A rc h .D e rm .S y p h ., Chicago, 1 5 , 3 8 7.
W h i t f i e l d , A . ( 1 9 O8 ) .
W illiam s,
33,291.
5,325-
W hite,
..................
22,40.
C.M ., and B a r t h e l , E . A . (1 9 2 9 ) .J .A m e r .M e d .A s s o c ., 9 3 ,9°7*
and W olf, J . ( 1 9 3 6 ) A r c h .D e r m .S y p h .,
34,
1.
Page
.
CHAPTER FOUR
T rlchophytin
In D ia g n o s is .
P re v io u s I n v e s t i g a t i o n s w ith M ycotic E x t r a c t s .
The u s e o f m y c o t i c e x t r a c t s
of r e a c t i v i t y
d iag n o sis of s u p e rfic ia l
tin ea
i n f e r s an a l t e r e d
state
ex ists
fact,
a n d f o r many y e a r s m y c o l o g i s t s h a v e e n d e a v o u r e d t o
:o llary
state
in the
in the body.
in c e r ta in b a c te r ia l d isea ses i s
That t h i s
a w ell-estab lish ed
fin d a cor:
i n ringworm i n f e c t i o n s .
The p o s i t i o n w i t h r e g a r d t o d e e p r i n g w o r m h a s p r a c t i c a l l y
been c l e a r e d ,
:ficlal
but the
occurrence of g en eral
t y p e h a s c a u s e d much c o n t r o v e r s y .
spontaneous cure in deep t i n e a
changes in th e
The t e n d e n c y
(Sabouraud;
in fectio n
and th e r a r i t y
i n a d u l t s h a s been c i t e d a s an example o f
a c q u ir e d h e r d im m unity.
S u p p o r t in g th e d e v e lo p m e n t o f im m unity
Greenbaum ( 1 9 2 4 ) and S c h o lz (1 9 3 4 )
showed t h a t b y i n o c u l a t i n g
g u i n e a - p i g s c u t a n e o u s l y w ith ringw orm th e y r e n d e r e d th e
immune t o
fu rth e r in o cu latio n ,
not use the
m oulds.
same a n i m a l t w i c e
Greenbaum a l s o
and t h a t th e
site
anim als
a n d S a b o u r a u d f o u n d t h a t he c o u l d
in te s tin g
f o r the p a th o g e n i c ity of
showed t h a t by i n o c u l a t i n g
human w i t h t r i c h o p h y t o n g y p s e u m s p o n t a n e o u s h e a l i n g
weeks,
tow ards
G-reenbaum, 1 9 2 4 ) h a s b e e n
e x p l a i n e d by t h e d e v e lo p m e n t o f a g e n e r a l im m u n ity ,
of s c a lp
super:
the
skin o f a
occu rred in four
of th e l e s i o n could not be r e i n f e c t e d
lo n g a s t h r e e m onths a f t e r w a r d s .
F urther,
as
he c la i m e d t h a t th e
im m unity t h u s p r o d u c e d was g r o u p - s p e c i f i c a g a i n s t t h e o t h e r r i n g w o r m s ,
and s a i d t h a t
"sc
sharply d efin ed is
:u la tio n of a p rev io u sly healed s ite
th is lo cal
im m unity t h a t r e l n o c :
only shows a ta k e
a t the
exact
AP. .
Page
edge o f t h e p r e v i o u s l e s i o n " .
as a p p lie d to
in f e c t the
su p erficial
first
D isproving t h i s
in fectio n ,
in terd ig ital
c u tan eo u s im m unization
Weidman ( 1 9 2 7 ) was a b l e t o
c l e f t o f h i s f o o t on two o c c a s i o n s w i t h
t r i c h o p h y t o n c r u r i s a f t e r a l a p s e o f two y e a r s ,
ap p ears t o have been unduly lo n g .
practice
to
p atien t,
desp ite
unusual.
I t is also
alth o u g h the i n t e r v a l
n o t uncommon i n t r o p i c a l
s e e m ore t h a n one a t t a c k o f t i n e a c r u r i s i n t h e
t h e f a c t t h a t Gray (1934) t h i n k s t h i s
same
is rath er
M cC re a ( 1 9 3 1 ) r e p o r t s r e p e a t e d r e i n f e c t i o n s o f t h e same
a r e a s on g u i n e a - p i g s w i t h t h e
common p a t h o g e n s .
The o c c a s i o n a l d e v e l o p m e n t o f d i s t a l p h y t i d e r u p t i o n s i n
su p erficial
(1929),
I n f e c t i o n s h a s b e en e s t a b l i s h e d by J a d a s s o h n and Peck
S u l z b e r g e r and K e r r ( 1 9 3 0 ), Peck ( 1 9 3 ° ) and A y r e s and
A n derson (1934)>
w h i l e a fu n g u s h a s been r e c o v e r e d from th e c i r c u l a t :
: i n g b l o o d i n some c a s e s ( S u l z b e r g e r , 1 9 2 8 ; P e c k , 1 9 3 ° ;
a l.,
1 9 3 2 ).
I t i s o f i n t e r e s t to n o te the
ringworm c u l t u r e s o f
S trick ler et
i n h i b i t o r y e f f e c t on
serum from c a s e s w ith p h y t i d e r u p t i o n s ( P e r and
B r a u d e , 1 9 2 8 ; A y r e s a n d A n d e r s o n , 19 3 4 )* R a v a u t a nd R a b e a u ( 1 9 3 2 ) e v e n
claim g e n e r a l changes in s u p e r f i c i a l y e a s t i n f e c t i o n s ,
used an e x t r a c t o f y e a s t c u l t u r e s ,
" le v u rin ," as a d iagnostic te s t.
From t h e f o r e g o i n g e v i d e n c e i t
is lo g ical
s u p e r f i c i a l ringw orm can som etim es cause l o c a l
i s r e a s o n to b e l i e v e
l i m i t e d to
the s i t e
and th e y have
th a t the p ro d u c ts of the
to c o n clu d e t h a t
im m unity,
and t h e r e
cau sal fu n g u s a re not
of in fe c tio n .
The d i a g n o s t i c s k i n t e s t s h a v e g i v e n v e r y v a r i a b l e
in the hands of d i f f e r e n t i n v e s t i g a t o r s .
as C astellani
(1934) p la c e s l i t t l e
publishes f u l l d e ta i ls
T aran telli
resu lts
Such an e m in e n t m y c o lo g is t
relian ce
o n t h e m , a l t h o u g h he
fo r the p r e p a r a t io n of the e x t r a c t ;
( 1 9 2 6 ) and G a r z e l l a ( 1 9 2 6 ) i n s i s t
w hile
t h a t to produce a
Page 21. .
positiv e
r e s u l t th e J e s i o n should be d e e p - s e a te d .
using l i n e a r s c a r i f i c a t i o n ,
p atien ts;
Amberg ( 1 9 1 0 ) ,
h a d t h i r t e e n p o s i t i v e s f r o m 131 c a s u a l
f o u r o f t h e t h i r t e e n h a d no p r e v i o u s h i s t o r y o f r i n g w o r m .
R epeating t h i s i n v e s t i g a t i o n ,
Rosen, Peck,
and Sobel
(1931)
i n t r a d e r m a l l y t e s t e d 102 d e r m a t o l o g i c a l p a t i e n t s - s e v e n ty - tw o o f
th e m w i t h some p e d a l
six ty -sev en .
series,
s k i n l e s i o n - and f o u n d a p o s i t i v e r e a c t i o n i n
T h ere were n i n e p ro v e d c a s e s o f t i n e a p e d i s i n t h i s
and e i g h t o f them r e a c t e d s t r o n g l y .
( 1 9 3 3 ) e n c o u r a g i n g l y r e p o r t 72 p e r c e n t ,
cases of
su p erficial
per cen t,
tin ea,
M u s k a tb lit and D i r e c t o r
p o s i t i v e r e s u l t s i n 30 0
w h i l e R u e t e a n d S c h o l z ( 1 9 3 4 ) c l a i m 100
su cc e ss in proved c a se s.
In a d d itio n ,
the last-nam ed
o b s e r v e r s c o n ten d t h a t th e e x t r a c t used w i l l o n ly r e a c t a g a i n s t the
fu n g u s fro m which i t
is prepared,
S u l z b e r g e r and K e r r ( 1 9 3 ° ) gen erally ,
a l t h o u g h t h i s i s d i s p r o v e d by
These group r e a c t i o n s a re a c c e p te d
and a r e t o be e x p e c t e d i n view o f t h e c l o s e b i o l o g i c a l
r e l a t i o n s h i p o f th e p a th o g e n ic moulds.
T ra u b and Tolmach (1935)
s k in t e s t e d 135 c a s e s d ia g n o se d c l i n i c a l l y
83 c u l t u r a l
confirm ations.
a s d e rm a to p h y to s is w ith
1 6 o f t h e 83 c a s e s w e re n e g a t i v e .
L o m h o l t ( I 9 3 4 ) a n d Muende ( 1 9 3 4 )
re g a rd derm al t e s t s as b ein g of
e s p e c i a l v a lu e i n th e d i f f e r e n t i a t i o n o f m ycotic from d y s i d r o t i c
eczema - a m a t t e r o f i m p o r ta n c e i n t h i s
in s i g n i f i c a n c e of the
c o u n t r y on a c c o u n t o f t h e
m ycotic f a c t o r i n th e l a t t e r ty p e o f l e s i o n
( M c L a c h l a n a nd B ro w n, 1 9 3 4 ) *
The P r e s e n t I n v e s t i g a t i o n .
T h i s i n v e s t i g a t i o n w a s c a r r i e d o u t o n 159 c a s e s ,
th e m w i t h s u p e r f i c i a l p e d a l t i n e a ;
p a tie n ts used as c o n tro ls .
the i n t e r d i g i t a l
53 o f
th e r e m a i n i n g 106 were c a s u a l
I n e v e r y c a s e a c a r e f u l e x a m i n a t i o n of
c r u r a l and a x i l l a r y
f o l d s was made,
and any s k in
s u r f a c e showing m a c e r a t i o n o r d e s q u a m a tio n was e xam ined m i c r o s c o p i c :
Page
rally for
fungus,
.
w h i l e t h e p r e v i o u s d e r m a t o l o g i c a l h i s t o r y was
asse ssed as to th e p o s s i b i l i t y
of a fungus i n f e c t i o n .
P o lyvalent
t r i c h o p h y t i n ( H o e s c h t ) was u s e d t h r o u g h o u t i n a d i l u t i o n o f 1 i n 5 0 ,
and t h e d i l u e n t was em ployed a s a c o n t r o l .
1 i n 800 were a l s o
D i l u t i o n s o f 1 i n 25O and
used a t the beginning of th e i n v e s t i g a t i o n ,
were so o n d i s p e n s e d w i t h a s u n n e c e s s a r y .
The s o l u t i o n s w e r e r e n e w e d
a t m onthly I n t e r v a l s to e n su re a g a i n s t d e t e r i o r a t i o n .
trial
o f the l i n e a r
s c a r a nd p a t c h m e t h o d s t h e
was c h o s e n a s b e i n g t h e m o s t r e l i a b l e ,
w ith a f i n e
needle
but
A fter a
intraderm al route
The t r i c h o p h y t i n w a s i n j e c t e d
i n t o th e f l e x o r s u r f a c e of the r i g h t arm and th e
c o n t r o l was i n j e c t e d
in a sim ila r s ite
i n t h e o t h e r arm,
care being
t a k e n t h a t t h e s y r i n g e s a nd n e e d l e s u s e d w e r e d r y a n d f r e e
from
tr a c e s o f chem icals.
F o u r t y p e s o f r e a c t i o n w e re met w i t h :
tran sien t
u rticarial
reaction;
Types 1 ,
2,
(4 ) l a t e
(3)
eczem atoid
a n d 4 c o r r e s p o n d t o t h o s e d e s c r i b e d by
S u l z b e r g e r a n d W ise ( 1 9 3 2 ) ,
its
i m m e d i a t e and
( 2 ) inflam m atory r e a c t i o n ;
inflam m ato ry r e a c t i o n w ith v e s i c l e fo rm atio n ;
reactio n .
(l)
a n d Type 3 h a s b e e n a d d e d o n a c c o u n t o f
f r e q u e n t o c c u r re n c e in th e s t r o n g l y p o s i t i v e group.
o c c a s io n a ll y seen in th e n e g a tiv e group, and,
1 8 d u e t o t i s s u e da m ag e a t t h e s i t e
Type 1 was
a c c o rd in g t o Bray,
of i n j e c t i o n .
A Type 1 r e a c t i o n
a s d e s c r i b e d b y M a r c u s s e n ( 1 9 3 7 ) was met w i t h o n c e i n t h i s s e r i e s .
The p a t i e n t was n e g a t i v e c l i n i c a l l y ,
history.
but gave a s tr o n g ly s u g g estiv e
Ten m i n u t e s a f t e r i n j e c t i o n ,
the t e s t
s i t e had sw ollen to
t h e s i z e o f a d u c k ' s e g g , w h i l e t h e c o n t r o l was n e g a t i v e .
There
were no a c c o m p a n y i n g g e n e r a l sy mp tom s a nd t h e c o n d i t i o n s u b s i d e d
c o m p l e t e l y i n two h o u r s ,
reaction.
to be fo llo w e d l a t e r by th e u s u a l ty p e o f
Page .3 3 .
The r e s u l t s w e r e r e a d a t i n t e r v a l s o f o n e , t w o ,
seven d a y s ,
and were c l a s s i f i e d
C lassificatio n
Day o f F i r s t
four,
according to th e fo llo w in g ta b le :
Maximum
V esicles
Desquam:
S t r o ng
l s t - 2 nd
2 0 - 4 0 mm..
f
Medium
lst-^ rd
1 0 - 2 0 mm.
-
+
Weak
2n d - 3 rd
10 mm.
-
-
-
-
N egative
a nd
-
-
f
*
The t r i c h o p h y t i n when f r e s h a p p e a r s t o b e r e m a r k a b l y
resistan t
to h e a t,
a s t e n p o s i t i v e a nd t e n n e g a t i v e c a s e s r e t e s t e d
a f te r a u to clav in g the
e x t r a c t g a v e t h e same r e s u l t s .
This s t a b i l i t y
h a s b e e n c o m m e n t e d o n b y Goodman a n d Marks ( 1 9 3 5 ) *
A summary o f t h e i n v e s t i g a t i o n i s
s e t o u t i n t a b u l a r form
below:
Weak
N egative
Strong
Medium
R e a c tio n R ea c tio n R eaction R eactio n
T y p e o f C as e
No. o f
Cases
(A) M i c r o s c o p i c a l l y
proved tin e a
53
28
9
9
7
(B) C o n t r o l w i t h p r e :
:v io u s h is to r y of
tin ea
38
8
10
12
8
68
2
15
14
37
( c) C o n t r o l w i t h
negative h isto ry
Owing t o
th re e groups i t
a nd n o t
the d iffe re n c e
i s proposed to s c r u t i n i z e
in term s of p e rc e n ta g e s .
are d is a p p o in tin g ,
m icroscopically.
i n the num bers o f c a s e s i n the
the ta b le as i t
stands
The s e v e n n e g a t i v e s i n G ro up A
b u t f o u r o f t h o s e c a s e s showed "m osaic" fu n g i
A c c o r d i n g t o Weidman ( 1 9 3 ^ )
such "m o saics" a re
e i t h e r a s t a g e i n t h e d e v e l o p m e n t o f f u n g u s o r a r e due t o
some
Page
fungoid a c t i o n on th e s u p e r f i c i a l l a y e r s of th e d erm is,
W hitfield
w hile
(1 9 3 5 ) r e g a r d s them a s a r t e f a c t s due t o I n t e r a c t i o n
i
i
b etw een t h e e p i d e r m a l s c a l e s and t h e c a u s t i c p o t a s h u s e d in
p r e p a r a t i o n o f th e m i c r o s c o p i c a l specim en.
culture
R epeated a tte m p ts to
s c a l e s s h o w i n g s u c h " m o s a i c s " w e r e made u n d e r i d e a l c o n d i t i o n s
in R am sbottom ' 8 m y c o lo g ic a l l a b o r a t o r y w ith o u t s u c c e s s .
T heir exact
nature,
th erefo re,
of in te r e s t
to note
t h e i r f r e q u e n t a s s o c i a t i o n w ith th e a c c e p te d type of fu ng u s.
The r e s u l t s
m ust be a m a t t e r f o r d o u b t,
i n Group B a r e g r a t i f y i n g ,
but i t
is
b u t th e unavoidable p e rs o n a l
e r r o r i n a s s e s s i n g t h e h i s t o r y ma kes i t d i f f i c u l t t o d r a w a d e f i n i t e
conclusion;
a n d t h i s b e c o m e s e s p e c i a l l y n o t i c e a b l e i n G ro up C.
Many p a t i e n t s may h a v e h a d a p a t c h o f s u p e r f i c i a l t i n e a n o t
diagnosed a s such,
com pletely.
o r a n I n t e r d i g i t a l t y p e may h a v e e s c a p e d n o t i c e
The f r e q u e n c y o f s u c h p r e v i o u s i n f e c t i o n s h a s b e e n
reg ard ed a s n e g a tiv in g the v alue of a p o s itiv e r e a c tio n
W ol f, 1 9 3 6 ) ,
a nd t h i s
w o u l d s eem t o i n c r e a s e
( W is e a nd
c o n s id e r a b ly th e value
of a negative re a c tio n .
C onclusions.
From t h i s s m a l l s e r i e s a nd f r o m o b s e r v a t i o n o f t h e s k i n
tests
in
reactio n
h isto ry
o th e r hands,
it
in a c l i n i c a l l y
is perm issible to s ta te
th a t a stro n g
su g g estiv e case w ith a n e g ativ e p rev io u s
le n d s a b i a s tow ards a d ia g n o s is o f t i n e a ,
w hile a n e g a tiv e
r e a c tio n i n a s i m i l a r case p re c lu d e s a p o s i t i v e d ia g n o sis com pletely.
An i n t e r e s t i n g
hy two n e g a t i v e r e a c t o r s
o u t c o m e o f t h e i n v e s t i g a t i o n was p r o v i d e d
i n G r o u p C.
Some t i m e a f t e r t e s t i n g t h e y
d e v e l o p e d m i c r o s c o p i c a l l y p r o v e d t i n e a p e d i s - on e w i t h an a s s o c i a t e d
t i n e a c r u r i s - a n d when r e t e s t e d t h r e e w e e k s a n d t w e l v e m o n t h s
a f t e r i n f e c t i o n gave a s tr o n g ly p o s i t i v e r e s u l t .
Page 35.
Summary.
The c a s e f o r d i a g n o s t i c
ex tracts i s
set fo rth
dermal t e s t s w ith fu n g u s
a n d t h e r e s u l t s o f some p r e v i o u s i n v e s t i g a t i o n s
are g iven.
An i n v e s t i g a t i o n i s d e s c r i b e d a n d t h e r e s u l t s g i v e n i n
tab u lar
form.
The l i m i t a t i o n s o f a p o s i t i v e r e s u l t a r e n o t e d ,
and th e
value of a n e g a t i v e r e s u l t i n th e d i f f e r e n t i a l d ia g n o s i s o f p e d al
skin l e s i o n s
is
stressed .
R eferences.
Amberg,
A yres,
S . ( 1 9 1 0 ) J o u r . E x p e r . M e d . , 1 2 ,4 3 5 *
S .Jr.,
C astellan i,
G arzella,
a n d A n d e r s o n , N . P . (1934) A r c h .D e r m .S y p h ., C h ic a g o , 29, 537.
A ( 1 9 3 4 ) J o u r . T r o p . M e d . H y g . , 37>3^ 3 -
N .(1926)
G. I t a l , Derm. S y p h . , 6 7 , 2 8 0 .
Goodman, H . , a n d M a r k s ,
J .( 1 9 3 p ) A rch.D erm .S yph., Chicago, 31, 819.
G r a y , A . M . H . ( 1 9 3 4 ) B r i t . M e d . J o u r . , 2, 5 4 1 *
Greenbaum,
S . S . ( 1 9 2 4 ) A r c h . D e r m . S y p h . , C h ic a g o , 10,279*
Jadassohn,
W., a n d P e c k , S . M . ( 1 9 2 9 ) A r c h . D e r m . S y p h . , B e r l i n ,
Lom holt,
158, 16.
S . ( 1 9 3 4 ) U g e s k r . L a e g . , 96,655*
McCrea, A . ( 1 9 3 l ) J o u r . T r o p . M e d . H y g . , 3 4 ,2 0 4 *
M cLachlan, A .D .,
M arcussen,
Muende,
a n d Brow n, W . H . ( 1 9 3 4 ) B r i t . J . D e r m . S y p h . , 4 6 , 4 5 7 *
P.V. ( 1 9 3 7 ) A rch.D erm . S y p h . , C h ic a g o ,
36,494*
1 . ( 1934) B r it.J o u r .D e r m .S y p h ., 46,479.
M u s k a t b l l t , E . , And D i r e c t o r , W . ( 1 9 3 3 ) A r c h . D e r m . S y p h . , C h i c a g o 2 7 , 7 3 9 .
Peck,
S.M. ( 1 9 3 0 )
P e r, M .L.,
ib id .,
22, 40.
and B raude, R . (1928) A cta D erm .V en ero l., 9, 1.
Page
.
R eferences (C o n td .)
R avaut,
Rosen,
P .,
I.,
a n d R a b e a u , H .( 1 9 3 2 ) P r e s s e Med., 4 °,192 5*
Peck,
R uete, A .E .,
Scholz,
S.M ., and So b el,N (1 9 3 l) A rch .D erm .S y p h .,
C hicago, 23, 1 04 1.
and S c h o l t z ,
68,241.
U .( 1 9 3 4 ) D erm .W schr., 99,1342.
S trick ler,
A. e t a l . ( l 9 3 2 )
S ulzberger,
M .B.(1 9 2 8 )
...............
and K err,
...............
a n d W ise F. ( 1 9 3 2 )
T aran telli,
Traub,
U. ( 1 9 3 4 ) Derm. Z t s c h r . ,
A rch .D erm .S y p h ., Chicago,
ib id .
P . S . ( 1 9 3 O)
J.
25,1028.
18. 891.
A llergy,
2, 11.
J o u r.A m e r.M e d .A s sn ., 99, 1759.
E .(1 9 2 6 ) G .Ita l.D e rm .S y p h ., 67,108.
E . F . , a n d T o lm a c h ,J .A .(1935) A rch.D erm .S yph., Chicago, 32,4 1 3 .
Weidman,
F . D . ( 1 9 2 7 ) A r c h . D e r m . S y p h . , C h i c a g o , 15,41-5.
( 1 9 3 6 ) P e r s o n a l Communication.
W h i t f i e l d , A . ( 1 9 3 6 ) P e r s o n a l Communication.
W ise ,
F .,
and W olf, J . ( 1 9 3 6 ) A rc h .D e r m .S y p h ., C hicago, 3 4 ,1 .
Page 77
CHAPTER FIVE
The I n c i d e n c e o f S u p e r f i c i a l Ringworm I n f e c t i o n s .
I n 1 9 2 4 B u t l e r and h i s c o - w o r k e r s e x a m i n e d 5OO i n d i v i d u a l s
in th e U .S.N avy.
p atien ts,
T h i s group embraced o f f i c e r s ,
and m e d ic a l o r d e r l i e s ,
d e d u c t i o n s do n o t
of m ycotic i n f e c t i o n
p o sitiv e
the g e n e ra l r e s u l t s are
1 8 0 c a s e s ( 3 0f°) w e r e f o u n d w i t h a h i s t o r y
and 16 c a s e s were d i s c o v e r e d w i t h a c t i v e l e s i o n s
on t h e h a n d s o r f e e t .
t h e 16 c a s e s .
a n d a l t h o u g h some o f t h e p e r c e n t a g e
stand s t a t i s t i c a l an aly sis,
of considerable in te r e s t .
m arines, h o s p i ta l
F u n g i w e r e r e c o v e r e d m i c r o s c o p i c a l l y i n 11 o f
A l t h o u g h n o t a l l o f t h e 11 p o s i t i v e
cu ltu res,
it
c a s e s would g i v e
i s r e a s o n a b l e to assume t h a t a t l e a s t h a l f t h a t
num be r h a r b o u r e d l i v i n g p a t h o g e n i c f u n g i .
W ilso n i n 1 9 3 2 examined th e
f e e t o f 4 6 4 U. S.Ar my R e s e r v e men a nd f o u n d o n l y 3 - 4 5 u n a f f e c t e d .
did not
He
c o n f i r m h i s d i a g n o s i s m i c r o s c o p i c a l l y a nd many o f h i s
po sitiv e
c a s e s were u n d o u b te d ly i n t e r d i g i t a l
ringworm.
m aceration and not
A s i m i l a r e r r o r i s obvious in a la y
s t a t e m e n t i n t h e U .S.
Army a n d Navy R e g i s t e r ( 1 9 3 8 ) w h i c h s a y s t h a t 95$ o f t h e Navy s u f f e r
fr o m m y c o t i c i n f e c t i o n s o f t h e f e e t .
I n a s t u d e n t i n v e s t i g a t i o n H u lsey and J o rd a n ( 1 9 2 5 ) found
67 c l i n i c a l l y p o s i t i v e
c a s e s i n 100 i n d i v i d u a l s .
They t o o k s c r a p i n g s
fr om b e t w e e n t h e t o e s o f 77 a n d f o u n d f u n g i m i c r o s c o p i c a l l y i n 49 o f
them.
T h i s h i g h p o s i t i v e r a t i o was n o t b o r n e o u t c u l t u r a l l y ,
had o n ly 5 g r o w th s from 49 c u l t u r e s .
However,
t h i s me an s t h a t
a s th ey
5
s t u d e n t s i n t h e 100 exam ined were a c t i n g a s p o t e n t i a l r e s e r v o i r s o f
infection.
On a m o r e a m b i t i o u s s c a l e , L e g g e e t a l . ( l 9 2 9 )
examined
3,100 f r e s h e n t r a n t s t o th e U n i v e r s i t y o f C a l i f o r n i a f o r th e s e s s i o n
Page .3 8 ..
1928-1929.
On e n t r y
5 3 . 3# o f t h e men a nd 1 5 * 3 $ ° f t h e women showed
c l i n i c a l m a n i f e s t a t i o n s betw een th e to e s .
A f t e r th e s p r in g term ,
of
1 , 0 0 0 men a n d 9 9 7 women o f t h i s g r o u p who h a d b e e n d o i n g g y m n a s t i c s ,
7 8 . 6$ o f t h e
f o r m e r a n d 1 7 - 3$ o f t h e l a t t e r h a d I n t e r d i g i t a l l e s i o n s .
The 2 5 . 3$ i n c r e a s e
i n t h e c a s e o f t h e men w a s a t t r i b u t e d t o a n o l d
and u n s a n i t a r y g y m n a s i u m .
I should lik e to p o in t out t h a t h e re a g a in
the d i a g n o s i s was a c l i n i c a l on e .
A n o t h e r s t u d e n t i n v e s t i g a t i o n by
G il m a n ( 1 9 3 3 ) a t t h e U n i v e r s i t y o f P h i l a d e l p h i a showe d a n i n c i d e n c e
o f 60$ t i n e a p e d i s among 7 3 5 s t u d e n t s .
Fr om a s o c i o l o g i c a l
a s p e c t , A n d r e w s a nd B i r k m a n ( 1 9 3 1 )
e x a m i n e d ^20 m a l e s t u d e n t s i n t h e s e c o n d d e c a d e a t a New Y o r k t r a d e
s c h o o l a n d f o u n d t h a t 65 (1 2 . 5$ )
infectio n .
showed c l i n i c a l s i g n s o f p e d a l
The s t u d e n t s came f r o m a c o m p a r a t i v e l y p o o r s o c i a l c l a s s
a nd t h e l a c k o f h y g i e n e i n many c a s e s was o b v i o u s , y e t t h e i n c i d e n c e
was much l o w e r t h a n i n o t h e r g r o u p i n v e s t i g a t i o n s .
r i n g c o m p a r a t i v e s t u d y was made b y M u s k a t b l i t
122 i n d i v i d u a l s ,
A nother i n t e r e s t ,
( 1 9 3 3 ) on a g r o u P o f
made u p o f 1 0 0 p a t i e n t s f r o m t h e B e l l v u e H o s p i t a l
Skin C l i n i c and 112 m e d ic a l s t u d e n t s .
and 1 0 3 s t u d e n t s w e r e p o s i t i v e ,
"A lthough p e r f e c t l y
w o uld b e i m p r o p e r t o
C l i n i c a l l y 85 o f t h e p a t i e n t s
b u t a s the i n v e s t i g a t o r says
normal s k in o c c u rs r a r e l y
i n t h e t o e webs,
c o n s id e r toe-ringw orm a 'u n i v e r s a l '
d isea se as
many o t h e r c a u s e s b e s i d e s f u n g i may c a u s e s i m i l a r c h a n g e s . "
on t o s a y
it
He g o e s
" t h e e x a c t d i a g n o s i s o f a m y c o t i c p r o c e s s i n t h e t o e webs
r e q u i r e s m i c r o s c o p i c a l e x a m i n a tio n and c u l t u r e s . M ic r o s c o p ic a l
exam ination o f t h i s
s e r i e s s h o w e d 27 p o s i t i v e s among t h e d i s p e n s a r y
p a t i e n t s a n d 32 i n t h e
s tu d e n t group.
The r e l a t i o n o f t h e i n c i d e n c e o f s u p e r f i c i a l t i n e a t o
o t h e r s k i n d i s e a s e s h a s shown a r e m a r k a b l e c h a n g e w i t h i n f a i r l y
Page . 3 ? . .
re c en t tim es.
I n 1 9 2 9 Goodman c l a s s i f i e d t h e
in c id e n c e of skin
d i s e a s e s r e p o r t e d from v a r i o u s s o u r c e s d u r i n g th e y e a r s 1913 t o 1927,
a nd t i n e a w a s a b o u t e i g h t h o n t h e l i s t .
(Goodman,
i n 19 31 > h e r e p o r t e d
1 9 3 1 ) " th a t i n h i s own p r a c t i c e a t t h e New Y o r k S k i n and
Cancer H o s p i t a l ,
t i n e a had r i s e n t o second p l a c e d u r i n g 1928 and 1929.
In stu d en t h e a lth serv ices i t
of the
L ater,
s k i n (G ilm an,
i s r e g a r d e d a s t h e co m m on e st d i s e a s e
1934>’ A l d e r s o n and R e i c h ,
1937)*
Page
4? . . .
Personal In v e stig atio n s.
The f o l l o w i n g i n v e s t i g a t i o n s w e r e c a r r i e d o u t on b o a r d
H.M.
s h i p s o f w a r a n d t h e c a s e s a r e made up o f o f f i c e r s and men o f
t h e R o y a l N a v y , R o y a l M a r i n e s , a n d M e r c h a n t N a vy.
These i n d i v i d u a l s ,
fo r p u rp o s e s o f com parison w ith stu d en t i n v e s t i g a t i o n s ab ro ad ,
live
u n d e r much t h e same c o n d i t i o n s a s t h e u n d e r g r a d u a t e body i n a ny
u n iv ersity .
The common b a t h r o o m a n d w a s h p l a c e i s a n e s t a b l i s h e d
i n s t i t u t i o n an d t h e r e i s c o n s i d e r a b l e c o n g e s t i o n i n c h a n g in g and
dry in g rooms.
atten tio n
A p a r t from s p r i n t e r s and d i s t a n c e r u n n e r s , l i t t l e
i s p a id to
fo o t hygiene,
a s o ile d b a th flo o r before drying.
a n d b a t h e r s f r e q u e n t l y w a l k on
Und er s u c h c o n d i t i o n s i t wou ld
a p p e a r t h a t a u n i v e r s a l p e d a l I n f e c t i o n i s i n e v i t a b l e and t h e h i g h
f i g u r e s fr o m A m e ric a w ould seem t o u p h o ld t h i s c o n c l u s i o n .
i n H.M. S.
Hood i n 1 9 3 4 w i t h a n a v e r a g e c o m p l e m e n t o f 1 . 1 2 0 i n d i v i d u a l s ,
t h e r e w e r e o n l y 18 c a s e s o f m y c o t i c i n f e c t i o n .
y e a r were d ia g n o s e d c l i n i c a l l y .
in ten siv e
H ow ev e r,
The c a s e s d u r i n g t h a t
I n t h e f o l l o w i n g y e a r when an
s t u d y o f r i n g w o r m l e s i o n s was i n s t i t u t e d b y m y s e l f ,
25 c a s e s
o f s u p e r f i c i a l t i n e a p r e s e n t e d t h e m s e l v e s f o r t r e a t m e n t f r o m an
e n l a r g e d a v e r a g e com plem ent o f 1,285*
A triv ial
The f o l l o w i n g t a b l e s w i l l f a c i l i t a t e
resu lts
increase of 7 cases.
s c ru tin y of the
Ta b l e 1 .
H .M .S . Hood. 1 9 3 4 *
A v e r a g e c o m p l e m e n t ............................................................
F r e s h c a s e s ..............................................................................
F r e s h c a s e s o f t i n e s .......................................................
N o . o f t i n e a c a s e s h o s p i t a l i s e d ...............................
D a y s s i c k n e s s f r o m t i n e a .............................................
1
5
i
P a g e .41. . .
Table 2
H.M. S. Hood, 1 9 5 5 .
A v e r a g e c o m p l e m e n t ..................................................... 1285
F r e s h c a s e s .........................................................! ! . ] 116 27
F r e s h c a s e s o f t i n e a ...............................................
25
N o . o f t i n e a c a s e s h o s p i t a l i s e d .......................
2
D a y s s i c k n e s s f r o m t i n e a ...................................
39
The c a s e s o f t i n e a h a d no r e l a t i o n
t o t h e n um be r o f t o t a l
f r e s h c a s e s p r e s e n t i n g t h e m s e l v e s fr o m m on th t o m o n th , o r t o t h e
t i m e o f t h e y e a r a s on e w o u l d e x p e c t .
Table 3 .
Month
m £ ________________________________________1 22i
Fresh
Cases of
Month
Fresh
Cases of
cases
tin ea.
cases
tin ea.
Jan.
Fe b.
Mar.
A pril
May
June
July
Aug.
Sept.
Oct.
Nov.
Dec.
152
19 1
124
40
94
16 9
93
50
158
16 1
94
80
2
1
1
1
2
2
2
2
2
2
1
0
Over th e
ringworm i n f e c t i o n
Tinea
11
"
"
11
Jan.
Feb.
Mar.
A pril
May
June
July
Aug.
Sept.
Oct.
Nov.
Dec.
107
107
168
29
145
129
134
I2
1 89
192
198
15 7
0
0
2
2
3
1
4
0
6
4
1
2
two y e a r p e r i o d t h e r e w e r e 43 c a s e s o f s u p e r f i c i a l
composed o f t h e f o l l o w i n g v a r i e t i e s : -
Table 4 p e d i s ( i n t e r d i g i t a l t y p e ) . . . 25 c a s e s
11
( v e s i c u l a r t y p e ) .................
2
m a n i s .........................................................
1
c r u r i s ...................................................... 12
'
c o r p o r i s ................................................
3
An a s s o c i a t e d t i n e a p e d i s a n d c r u r i s s o commonly d e s c r i b e d b y many
w r i t e r s was n o t s e e n i n t h i s s e r i e s .
The r e l a t i o n o f t i n e a t o o t h e r d i s e a s e s o f t h e s k i n i s
in terestin g ,
and i t h e a d s th e l i s t w ith eczema u n p la c e d .
Page 4 ? . . .
Table
S.
T i n e a .......................................
43 c a s e s
S c a b ie s and p e d i c u l i . .
7R
»
I m p e t i g o .................................
ti
11
O t h e r d i s e a s e s o f s k i n ............... 1 2 2
I t m u s t b e p o i n t e d o u t t h a t .H.M. S. Hood was i n home w a t e r s
during most o f t h i s
tropical
:iBon,
country,
tim e,
and a p a r t from a s h o r t s t a y i n a su b ­
t h e c l i m a t e was t e m p e r a t e t h r o u g h o u t .
For compar:
I h a v e c o m p i l e d some f i g u r e s f r o m t h e r e c o r d s o f H.M. S.
D o rse tsh ire fo r the
t w e l v e m o n t h s A p r i l 1 9 3 5 - A p r i l 1 9 3 6 on t h e C h i n a
statio n .
Table 6 .
H.M. S. D o r s e t s h i r e .
A v e r a g e c o m p l e m e n t .......................
T o t a l f r e s h c a s e s .........................
F r e s h c a s e s o f t i n e a ..................
D a y s s i c k n e s s due t o t i n e a .
665
.2 5 6 1
.44
.122
I t w i l l be s e e n t h a t d u r in g 1935 th e c a s e s o f t i n e a f o r th e
D o r s e t s h i r e a r e a l m o s t d o u b l e t h o s e f o r t h e Hood w h i c h h a d p r a c t i c a l l y
tw ice th e
com plem ent,
w h i l e t h e d a y s s i c k n e s s i s much g r e a t e r ,
d o u b t l e s s t o t h e h e a t a nd h u m i d i t y o f t h e C h i n a s t a t i o n .
fact th a t a l l
tro p ical
due
It is a
s k i n i n f e c t i o n s a r e n o to r i o u s ly d i f f i c u l t to t r e a t in
co u n tries.
So f a r t h e s e f i g u r e s h a v e d e a l t w i t h o v e r t i n f e c t i o n s
aP P l y i n g f o r t r e a t m e n t ,
and i n 1 9 3 5 I t was d e c i d e d t o e x a m i n e a
r e p r e s e n t a t i v e c r o s s s e c t i o n o f t h e p e r s o n n e l t o d e t e r m i n e t h e n um be r
°f la te n t
cases.
T h i s was do n e a t G i b r a l t a r a n d i n C h i n a d u r i n g t h e
y e a r s 1 9 3 5 - 1 9 3 7 - T h e men w e r e d r a w n a t r a n d o m f r o m t h e v a r i o u s
b r a n c h e s i n t h e N a vy a n d w e r e n o t c o m p l a i n i n g o f s k i n d i s e a s e .
A
ease was r e g a r d e d a s c l i n i c a l l y p o s i t i v e o n l y i f t h e r e was p r e s e n t
a defin ite
v e s i c u l a r l e s i o n on t h e f o o t .
In cid en tally ,
these fig u re s
P a g e .4-3
apply t o
fo o t c a se s only,
§
a s no l e s i o n s w e r e d i s c o v e r e d e l s e w h e r e
In t h e s e r i e s .
T able 7 .
No.
exam ined
428
C lin ic ally positiv e
7 1 (1 6 .6 * )
M icro-positive
33(7-7*)
I n t h e 71 c l i n i c a l l y p o s i t i v e c a s e s t h e r e w e re 34 i n t h e
4th d e c a d e ;
32 i n th e 3 r d - d e c a d e ;
and 5 i n t h e 2 nd d e c a d e .
209
i n d i v i d u a l s w e r e o f t h e e n g i n e e r b r a n c h a n d t h e y h a d o n l y 29
p o s i t i v e s w ith 12 m ic ro s c o p ic a l c o n firm a tio n s .
As a b r a n c h ,
they
work u n d e r c o n d i t i o n s o f h e a t a nd m o i s t u r e w i t h f r e q u e n t w a s h i n g
i n crowded b a t h s p a c e s ,
propagation,
a l l o f w h i c h would s eem i d e a l f o r f u n g u s
yet th e ir nositiv e
in th e i n v e s t i g a t i o n .
r a t e was l o w e r t h a n a ny o t h e r b r a n c h
The more f r e q u e n t b a t h i n g r e q u i r e d b y t h e
e n g i n e e r s may o f f s e t t h e c o n d i t i o n s i n w h i c h t h e y w ork .
A n o t h e r f o o t s u r v e y o n a more e x t e n s i v e s c a l e was c a r r i e d
o u t d u r i n g t h e a u t u m n a n d w i n t e r o f 1938 i n s m a l l s h i p s a t t a c h e d t o
t h e Home s t a t i o n .
A c a r e f u l h i s t o r y was t a k e n f r o m e a c h i n d i v i d u a l
w i t h r e g a r d t o t h e p o s s i b i l i t y o f a p r e v i o u s m y c o t i c i n f e c t i o n and
any c a s e w i t h m a c e r a t i o n o r d e s q u a m a t i o n b e t w e e n t h e t o e s ,
how s l i g h t ,
was r e g a r d e d a s
' a b n o r m a l 1.
no m a t t e r
C l i n i c a l e x a m i n a t i o n was
made i n t h e m o r n i n g a n d t h e s c a l e s w e re e x a m i n e d m i c r o s c o p i c a l l y i n
i h e a f t e r n o o n a f t e r s o a k i n g i n 1 0 * l i q u o r p o t a s s a e f o r a t l e a s t two
hours.
In o r d e r to l e s s e n th e ch an ces o f m is s in g fungus i n s c a l e s ,
t h e f i r s t 1 5 0 s c r a p i n g s w e re r e - e x a m i n e d a f t e r
2A h o u r s , b u t i n no
c a s e d i d a p r e v i o u s l y n e g a t i v e s l i d e become p o s i t i v e .
The p a t n o g e n
was n e v e r r e c o v e r e d i n t h e m a c e r a t e d t y p e o f l e s i o n b u t was f r e q u e n t l y
found i n f e e t s h o w i n g o n l y a t i n y a r e a o f h y p e r k e r a t o s i s i n t h e
fourth i n t e r s p a c e .
In o t h e r w ords, u n le s s th e
in terd ig ital
skin is
P a g e .44 . .
absolutely
I n t a c t t h e r e I s a lw a y s t h e p o s s i b i l i t y o f a ringworm
in fectio n .
I am I n c l i n e d t o t h i n k t h a t t h e f i n d i n g o f p a t h o g e n i c
mo u ld s I n c l i n i c a l l y
n e g a t i v e f e e t I s du e t o o v e r l o o k i n g s u c h a
h y p erk erato tic le sio n .
The f o l l o w i n g r e s u l t s w e r e o b t a i n e d f r o m t h i s I n v e s t i g a t i o n :
Table 8 .
Number o f I n d i v i d u a l s e x a m i n e d ................................. 622
I n d i v i d u a l s w i t h p e d a l l e s i o n s ................................... 3 1 9 ( 5 1 . 3%)
M i c r o s c o p i c a l l y p o s i t i v e ..................................................
33(5.3$)
I n d i v i d u a l s w i t h p r e v i o u s m y c o t i c h i s t o r y , . . . 1 8 8 ( 3 0 . 2$)
C a s e s o f p r e v i o u s h i s t o r y w i t h a b n o r m a l i t y . . . 1 34
Of t h e 31 9 a b n o r m a l c a s e s , o n l y 23 sho wed no l e s i o n i n t h e
4th i n t e r s p a c e .
due t o
A p a r t f r o m e c z e m a t o i d a r e a s on t h e d o r s u m ,
a m a l f o r m a t i o n of th e f o o t c a u s in g cram p in g o f t h e middle t o e s
w ith a n u n d u ly open 4 t h i n t e r s p a c e .
(319)
t h i s was
7 2 . 7$ o f t h e ' a b n o r m a l '
cases
showed a c l o s e d o r cramped type o f f o o t and a s i m i l a r c o n d i t i o n
was p r e s e n t
i n o n l y 3 4 *7$ o f t h e n o r m a l c a s e s
( 3° 3 ^*
1 regard th is
a s s t r o n g p r o o f t h a t a p p o s i t i o n o f t h e s k i n s u r f a c e s i s one o f t h e
main f a c t o r s i n p r o d u c i n g i n t e r d i g i t a l l e s i o n s .
’abnorm al'
T h e r e w e r e 141
c a s e s i n t h e 4 t h d e c a d e ; 153 i n t h e 3 r d d e c a d e ;
a n d 21 i n
t h e 2n d d e c a d e ,
and t h i s a g r e e s w ith W h ite 's f i n d i n g s in h i s p r i v a t e
cases (T able
ch ap .l).
2,
The g r o u p i n t h e 5 t h d e c a d e was t o o s m a l l
t o be o f a n y s t a t i s t i c a l u s e .
O nce a g a i n t h e e n g i n e e r s v i n d i c a t e d t h e i r p r o f e s s i o n a s
t h e y h a d a n a b n o r m a l i t y r a t e o f 5 2 . 4$ f r o m a t o t a l o f 2 7 3 , w h i l e t h e
e x e c u t i v e b r a n c h s h o w e d a r a t e o f 5 4 * 2 $ f r o m a t o t a l o f 251*
these i n v e s t i g a t i o n s ,
one i s
working s u r r o u n d i n g s ,
in th e case o f the e n g in e e r s , h as l i t t l e
From
f o r c e d to t h e c o n c l u s i o n t h a t immediate
I n f l u e n c e o n' t h e i n c i d e n c e o f p e d a l i n f e c t i o n s a nd i t may be t h a t
t h e common d e n o m i n a t o r i s t h e b a t h r o o m .
Page . .45 .
C ultural
In v estig atio n s.
I n c o l l a b o r a t i o n w i t h M lrs F.L.
Museum o f N a t u r a l H i s t o r y ,
flo ra of the p o s itiv e
Stephens o f th e B r i t i s h
I t was d e c i d e d to
I n v e s t i g a t e th e mycotic
c a s e s In th e l a s t I n v e s t i g a t i o n .
A ccordingly
s i x t e e n o f t h e m o s t h e a v i l y i n f e c t e d were s e l e c t e d a n d t h e s c a l e s
sent f o r c u l t u r e .
sealed i n s t e r i l e
In a l l
B e f o r e d e s p a t c h t h e y w e re d e f a t t e d w i t h e t h e r and
b la c k p h o to g rap h ic paper envelooes.
c a s e s p l a n t s w e r e made on S a b o u r a u d * s medium and
o r d i n a r y a g a r m e d i a a d j u s t e d t o a n e u t r a l pH.
room t e m p e r a t u r e a n d 3 7 D e g . C .
I n c u b a t i o n was a t
In p r a c t i c a l l y every c ase re p e a te d
s u b - c u l t u r e s h a d t o b e made o n a c c o u n t o f s a p r o D h y t l c o v e r g r o w t h s ,
despite
the
f a c t t h a t i n t h e l a b o r a t o r y e v e r y b a t c h o f s c a l e s was
t r e a t e d w i t h some a n t i s e p t i c .
The c l a s s i f i c a t i o n was a c c o r d i n g t o
D o d g e ' s M e d i c a l M y c o l o g y ( 1 9 3 6 ) w i t h some p e r s o n a l m o d i f i c a t i o n s t o
comply w i t h r e c e n t m y c o l o g l c a l o p i n i o n .
On t h e k i n d a d v i c e o f S i r
Aldo C a s t e l l a n i t r i c h o p h y t o n p u r p u r e u m was r e n a m e d t r i c h o p h y t o n
rubrum.
The f o l l o w i n g p a t h o g e n s w e re r e c o v e r e d ; T a b le 9.
P a t h o g e n i c moulds
case 1
"
2
" 3
:'Ii
"
"
4
9
T r i c h o p h y t o n rubrum
T r i c h o p h y t o n rubrum
Trichophyton in t e r d i g i t a l e
C o re th ro p s is hom inis (V u ill)
N il.
N il.
T r i c h o p h y t o n rubrum
E p i d e rm o p h y to n f lo c c o s u m and
A sp erg illu s.
T richophyton i n t e r d i g i t a l e
B acteria
Yeast
N il.
S taphylococci
11
11
U nidentif:
: ied
n
it
11
N il.
n
It
11
tt
11
11
U nidentif:
: ied.
n
Page .4£ ..
Table 9 ( C o n td .)
P a t h o g e n i c moulds
Case
11
11
II
11
10
11
12
13
14
16
bacteria
E p i d e r m o p h y t o n f l o c c o s u m and
^ T r i c h o p h y t o n gypseum
E p iderm ophyton floccosum
T richO D hyton
T richoohyton
T richoohyton
T richophyton
T richophyton
least
N il.
S taphylococci
it
11
11
n
11
rubrum
rubrum
rubrum
rubrum
rubrum
Case 4 p r e s e n t e d a most unusual p a r a s i t e ,
(1936) q u o t e s G l u i g a n i a s r e c o v e r i n g i t
N il.
U nidenti f :
: ied
N il.
11
11
11
11
a l t h o u g h Brumpt
from a n i n t e r d i g i t a l l e s i o n .
Case 8 p r e s e n t e d w h a t was a t f i r s t t h o u g h t t o be a n a c h o r l o n .
Special
a t t e n t i o n was d i r e c t e d to w ard s t h i s fungus but a p u re c u l t u r e
f i n a l l y p ro v ed to
be an epiderm ophyton.
In an i n t e r e s t i n g paper,
Lewis, R o s e n f e l d ,
a n d Hopoer (1937)> c o l l e c t e d th e r e p o r t e d c a s e s o f
achorion I n f e c t i o n o f the g la u b ro u s shin.
In cidence of N all In f e c tio n s .
C o n s id e r a b l e d i f f e r e n c e of o p in io n e x i s t s as to the
freq u e n cy o f ringw orm I n f e c t i o n o f the n a i l s ,
survey o f th e l i t e r a t u r e
In 1933*
on t h e
a nd a c o m p r e h e n s i v e
s u b j e c t was p u b l i s h e d by K i t t r e d g e
My own r e s u l t s h a v e b e e n c o n s i s t e n t l y n e g a t i v e , b u t t h i s
may h a v e b e e n d u e t o a n u n f o r t u n a t e c h o i c e o f m a t e r i a l .
suspect n a i l s i t
n ail,
is
c lin ically
In exam ining
e s s e n t i a l t o t a k e s h a v in g s from e v e ry p a r t o f
n e g a tiv e a s w ell a s p o s i t i v e ,
a s t h e pathogen
®ay be l o c a l i s e d i n o n e s m a l l a r e a .
Summary.
R e p o r t s on s u p e r f i c i a l ringworm i n f e c t i o n s ,
c h i e f l y from
at)r o a d , h a v e b e e n e x a m i n e d , a nd t h e e r r o r s i n d i a g n o s i s p o i n t e d o u t .
Page . 47..
The r e s u l t s o f some p e r s o n a l I n v e s t i g a t i o n s h a v e b e e n
given.
R eferences.
A lderson,
H . E . , a n d R e i c h , A . ( 1 9 3 7 ) A rch.D erm .Syph., Chicago, 36, 57.
A n d r e w s , G . C . , a n d B i r k m a n , F . W . ( 1 9 3 1 ) New Y o r k S t . J o u r . M e d . , 3 1 , 1 0 2 9 B r u m p t , E . ( 1 9 3 6 ) P r e c i s de P a r a s l t o l o g i e , M a s s o n e t C i e , P a r i s ,
2,1802.
B u t l e r , C. S . , H o u g h t o n , J . E . , a n d C o o p e r , G. F. ( 1 9 2 4 ) B u l l . U . S .N av y.M ed .
Serv. 21,615.
G ilm an,R.L. ( 1 9 3 3 ) J .A .M .A ., 100,1 7 5 .
--------------------( 1 9 3 4 ) Am er . J o u r . M e d . S c i . , 1 8 8 , 2 6 8 .
G o o d m a n ,H .( 1 9 2 9 ) A r c h . D e r m . S y p h . , C h i c a g o ,
--------------------( 3.933.)
ibid.
20, 186.
23, 872.
H u l s e y , S. H . , a n d J o r d a n , F . M . ( 1 9 2 5 ) Amer . J o u r . Med. S c i . , 1 6 9 , 2 6 7 .
H i t t r e d g e , H . E . ( 1 9 3 3 ) A rc h .D erm .S y p h ., Chicago,
27, 607.
L e g g e , R . T . , B o n a r , L . , a n d Temp le t o n , H . J . ( 1 9 2 9 ) J . A . M . A . , 9 3 , 1 7 ° .
L e w i s , G . M . , R o s e n f e l d , H . , a n d H o p u e r , M . E . ( 1 9 3 7 ) M e d .R e c o r d , N e w York,
14 5 ,lo 9 .
M u s k a t b l l t , E . ( 1 9 3 3 ) New Y o r k S t . J o u r . M e d . , 3 3 * 6 3 2 .
U.S.Army a n d Navy R e g i s - e r , ( 1 9 3 8 ) W a s h i n g t o n ,
W i l s o n , D . J . ( 1 9 3 4 ) A r c h .D e r m .S y p h ., C hicago,
59,3*
30, 841.
Page 4®..
CHAPTER SIX
—V i a b i l i t y o f t h e Common P a t h o g e n i c F u n g i .
A know ledge o f th e v i a b i l i t y o f th e c a u s a tiv e fu n g i i n
the I n f e c t e d a r e a ;
i n d e t a c h e d s c a l e s , and a l s o I n r e l a t i o n t o such
facto rs as h e a t and co ld ;
m o i s t u r e a n d pH;
and c h e m i c a l a g e n t s I s e s s e n t i a l ,
X- a n d u l t r a - v i o l e t r a y s
I n o rd e r su b sequ en tly to e x h ib it
lo g i c a l p r o p h y l a c t i c and t h e r a p e u t i c measures.
seem t o p l a c e
scien tific
the
t r e a t m e n t o f s u p e r f i c i a l m yootlc I n f e c t i o n s on a
and s a t i s f a c t o r y b a s i s ,
m ycologists,
a n d y e t , a c c o r d i n g t o most
t h e r e s u l t s a r e d i s a p p o i n t i n g ( W h i t f i e l d , 1934)» w h ile
do u b t h a s b e e n e x p r e s s e d I f
1937).
Such a s t u d y would
t in e a pedis i s ever cured (S ulzberger,
Many f a c t o r s h a v e b e e n b l a m e d f o r t h i s ;
t h e m o u ld i n
c h ie fly su rv iv al of
s p o r e f o r m i n t h e I n f e c t e d a r e a a n d r e i n f e o t l o n from
diseased n a i l s
(Semon, 1922;
W illia m s , 1928;
B eintem a, 1 9 3 1 ).
D o u b t l e s s i n many c a s e s t h e i n f e c t i v e a g e n t i s d i f f i c u l t t o e r a d i c a t e ,
but l e s i o n s o f th e
long a f t e r t h e
s k i n s u r f a c e d u e t o m e c h a n i c a l c a u s e s may p e r s i s t
sp ecific
f a c t o r has been d e a lt w ith .
V i a b i l i t y i n t h e I n f e c t e d Are a.
T rea tm e n t o f a m ycotic l e s i o n w i l l cause an e a r ly
disappearance o f m y c ella .
contribute,
The d e v e l o p m e n t o f i m m u n i t y may a l s o
a l t h o u g h t h i s i s a so mewhat c o n t r o v e r s i a l p o i n t .
d if f ic u lt to account fot
I t is
th e s u rv iv a l o f spores In the le s i o n ,
as
Sohramek ( 1 9 1 6 ) a n d S t r i c k l e r a n d McKeever ( 1 9 3 4 ) h a v e shown t h a t
fungl b u r r o w s u p e r f i c i a l l y ,
and th ey have re c o v e re d fu n g a l elem ents
fle v e r a l i n c h e s f r o m t h e l e s i o n i n some c a s e s .
however, a i m a t
M ost f o r m s o f t r e a t m e n t
some f o r m o f p e n e t r a t i o n a n d d e c o r t i c a t i o n ,
and the
P a g e .4 ? . .
m e di c am e nt I n v a r i a b l y co m es I n c o n t a c t w i t h a n a r e a w e l l b e y o n d t h e
lesion.
It
Is
I n t e r e s t i n g t o n o t e t h a t p a t h o g e n i c m o u ld s do n o t
u s u a l l y o c c u r a s s a p r o p h y t e s on h e a l t h y s k i n .
In a series of cultures
from t h e I n t e r s p a c e s o f t h e f e e t o f 100 c l i n i c a l l y n e g a t i v e p a t i e n t s
Burgess ( 1 9 2 5 ) ,
h a d no p o s i t i v e r e s u l t s ,
and M u s k a t b l l t (1933)
could
not f i n d f u n g i m i c r o s c o p i c a l l y o r c u l t u r a l l y i n th e c l i n i c a l l y h e a l t h y
fe e t o f 212 c a s u a l
su b jects.
On t h e o t h e r h a n d , C o r n b l e e t ( 1 9 2 6 )
o b ta in e d t h r e e p a t h o g e n s from t h e i n t e r s p a c e s a s th e r e s u l t o f
c u l t u r e s from 100 c a r e f u l l y
history.
s e le c te d cases w ith a n eg ativ e p rev io u s
On t h e l i n e s o f C o r n b l e e t ' s I n v e s t i g a t i o n K u r o t c h k l n a nd
Chen ( 1 9 3 0 ) , r e c o v e r e d f i v e p a t h o g e n s f r o m 150 n o r m a l c a s e s ,
Downing a n d h i s c o l l a b o r a t o r s
and
( 1 9 3 7 ) h a d two p o s i t i v e r e s u l t s i n a
s e r i e s o f 3 0 0 c u l t u r e s o f s c r a p i n g s from t h e s k i n o f 100 c l i n i c a l l y
negative c a s e s .
T h e s e r e s u l t s r a t h e r t e n d t o show t h a t t h e p o s i t i v e s were
c a r r i e r s w i t h o u t s h o w i n g s i g n s o f I n f e c t i o n , b u t t h e y may h a v e b e e n
a c c id e n tl y c o n t a m i n a t e d from i n f e c t e d c a s e s , and th e h ig h in c id e n c e
of th e d is e a s e
I n A m erica and C hina le n d s
s u p p o r t to t h i s view.
P a t h o g e n i c m o u l d s do n o t n o r m a l l y o c c u r a s s a p r o p h y t e s u n d e r n a t u r a l
conditions,
a l t h o u g h Muende a n d Webb ( 1 9 3 7 ) h a v e r e c e n t l y r e p o r t e d a
case w i t h T r i c h o p h y t o n G y p s e u m - a s t e r o i d e s .
As t h e r e s u l t o f p e r s o n a l
exam ination m i c r o s c o p i c a l l y - w ith c u l t u r a l c o n f ir m a tio n In s u s p ic io u s
c a s e s - o f s c r a p i n g s f r o m b e t w e e n t h e t o e s o f o v e r $00 c l i n i c a l l y
Negative c a s e s ,
o n l y o n e c a s e wa6 f o u n d h a r b o u r i n g f u n g i —
EP l d e r m o p h y t o n I n g u i n a l e - a n d h e g a v e a h i s t o r y o f d e r m a t i t i s o f t h e
f e e t some y e a r s p r e v i o u s t o e x a m i n a t i o n .
'
P a g e . 5 P ..
V i a b i l i t y I n D etached S c a l e s .
The w i d e s t v a r i a t i o n s o f o p i n i o n e x i s t a s t o t h e maximum
tim e fu n g i I n I n f e c t e d s c a le s can rem ain v ia b le
o u tsid e
th e body.
D ixon ( 1924) r e p o r t e d a c a s e o f t i n e a p e d i s where he r e c o v e r e d th e
o rg a n is m from t h e s h o e s m onths a f t e r t h e p a t i e n t h a d c e a s e d t o w ear
th e m , a n d J a m i e s o n a n d McCrea (1937)
f o o t w e a r o f 52 p o s i t i v e c a s e s ,
had been d is c a rd e d .
o b t a i n e d 16 p a t h o g e n s fr o m t h e
i n some i n s t a n c e s m o n t h s a f t e r t h e
In c u l t u r a l
in v estig atio n s,
a n d K a d is c h ( 1 9 2 9 ) r e c o v e r e d f u n g i m onths a f t e r
leath er,
and Bonar and D reyer
(1932)
B ruhns, A lexander
s p r e a d i n g them on
found t h a t T ric h o p h y to n l n t e r -
d i g i t a l e grew w e l l on a v a r i e t y o f n a t u r a l m edia and r e s i s t e d
fo r a consid erab le
tim e.
F arley
shoes
(1921) k e p t I n f e c t e d
drying
scales in paper
e n v e lo p e s a n d c u l t u r e d them a t i n t e r v a l s w i t h t h e f o l l o w i n g r e s u l t s : -
Type o f c a s e .
No. o f
cases.
No.
giving
p o sitiv e
resu lts.
R em arks.
Tinea c r u r i s
E. i n g u i n a l e v i a b l e
a f t e r 1 4 5, 174 an d 433
days.
T in e a unguium
U n in d e n tif ie d fungus
v i a b l e a f t e r 418 days
Jfoile i n a s i m i l a r I n v e s t i g a t i o n
resu lts
quoting M itch ell
(1922) ,
W eldm an's
( 1927) w ere a s f o l l o w s : -
In fectio n .
Toe r i n g w o r m
Toe r i n g w o r m
O rganism .
E. c r u r i s
Tr. i n te r d ig it a lf
O bservers. C ases,
Weidman
Weldman
M itchell
M itchell
Drying o f t h e s c a l e s b e f o r e s t o r a g e i s
1
1
2
1
C ultures
No. o f
secured, days v ia b le .
1
0
1
18 0
1 8 0 -3 0 0
300
n e c e s sa ry to p re v e n t overgrow th.
The a b o v e i n v e s t i g a t i o n s p l a c e
t h e maximum p e r i o d o f
survival of fungi in s c a le s a t over a y ear.
P re v io u s to th ese
P a g e . 51.
rep o rts,
D old (1920) k e p t I n f e c t e d s c a l e s I n s t e r i l e
e n v e lo p e s , and
f o u n d t h a t t h e r e w a s no g r o w t h o n c u l t u r e a f t e r t h i r t y
w orth s t r e s s i n g
t h a t the p a th o g e n ic ity o f th e
not in v e stig ate d ,
and the
days.
It
is
s e c o n d a r y g r o w t h s was
f o l l o w i n g p e r s o n a l c a s e s w ould t e n d to
in d ic a te th a t t h i s undergoes m o d ific a tio n o u ts id e
th e body.
(1 ) A y o u n g man r e p o r t e d w i t h a n a r e a o f w e e p i n g e c z e m a i n t h e
fo u rth in te rsp ac e ,
e x ten d in g to
c o n d itio n had been p re se n t
h a d l a s t e d two w e e k s .
fo r an i n d e f i n i t e
On e x a m i n a t i o n ,
toesw as re d and m acerated ,
fo rm atio n .
th e dorsum o f th e r i g h t f o o t .
the
The
tim e and th e a c u te
stage
s k in betw een th e a f f e c t e d
a n d i n some p l a c e s t h e r e
was c r u s t
Sm all v e s i c l e s w ere p r e s e n t a t th e p e r i p h e r y o f t h e l e s i o n .
S c r a p i n g s from t h e c e n t r e and from t h e c r u s t s w ere n e g a t i v e , b u t t h e
v e s ic le s and m arginal s c a le s
m icro sco p ically .
S c a l e s an d v e s i c l e s w ere rem oved, an d a f t e r
tre a tm e n t w ith e th e r ,
w ere d e s p a tc h e d f o r c u l t u r e .
o f E. i n g u i n a l e r e s u l t e d .
(K eller,
21 M e s s m a t e s ,
showed 12 c a s e s o f i n t e r d l g i t a l
s u c h a s I s common I n y o u n g a t h l e t i c
1926);
A heavy grow th
E xam ination of th e p a t i e n t ' s
who s h a r e d t h e s am e b a t h r o o m ,
m aceration,
showed a b u n d a n t f u n g a l m y c e l ia
t h e r e m a in d e r were n e g a t i v e .
men i n h o t w e a t h e r
A ll the m acerated
c a s e s were s c r a p e d and exam ined m i c r o s c o p i c a l l y w i t h a n e g a t i v e
resu lt.
T h e y w e r e e x a m i n e d f o r t n i g h t l y o n tw o o c c a s i o n s , b u t no
f r e s h c a s e s a p p e a r e d and none d e v e lo p e d s u b s e q u e n t l y .
The c o n t a c t s
t o o k no p r e c a u t i o n s a n d t h e b a t h r o o m f l o o r was n o t s t e r i l i z e d
i n any
way.
(2)
An o f f i c e r p r e s e n t e d h i m s e l f w i t h a n e x t e n s i v e t i n e a c r u r i s
of t h r e e w eeks'
du ratio n .
and t h e f e e t w e r e c l e a r .
T h e r e h a d b e e n no l e s i o n b e f o r e t h a t t i m e
M y c e lia w ere s e e n i n ab u n d an ce
Page.5.2.
m icro sco p ically ,
and a heav y g ro w th r e s u l t e d on c u l t u r e .
th e h a b i t o f u s in g a group o f th r e e l a v a t o r i e s ,
b y 30 o f f i c e r s ,
and proved m ic ro s c o p ic a lly ,
He w a s i n
u s e d on an a v e r a g e
a n d y e t no f r e s h c a s e s r e s u l t e d .
m u s t h a v e b e e n p i c k e d up b y o t h e r s ,
.
In fected
scales
a s t h e y were e a s i l y r e c o v e r e d ,
from t h e c r u r a l seam o f t h e p a t i e n t ' s
u n d erclo th es.
(3)
A s a i l o r r e p o r t e d w ith a v e s i c u l a r eczema o v e r th e d o r s a
a sp e c t o f the l e f t
f o o t e x te n d in g betw een th e i n t e r d l g i t a l
The c o n d i t i o n h a d b e e n p r e s e n t t h r e e w e e k s ;
form ,
spaces.
two w e e k s i n a m i l d
an d a week i n a w e e p in g e c z e m a t i z e d fo rm .
He h a d b e e n e x a m i n e d
a s h o r t tim e b e f o r e In th e r o u t i n e c l i n i c a l and m ic ro sc o p ic a l
exam ination fo r i n t e r d l g i t a l
i n f e c t i o n and p ronounced n e g a ti v e .
A bundant f u n g i were r e c o v e r e d m i c r o s c o p i c a l l y fro m t h e l e s i o n ,
showed p r a c t i c a l l y
no s e c o n d a r y I n f e c t i o n .
w hich
The p a t i e n t h a d b e e n
u s i n g a t i l e d w a s h - p l a c e s h a r e d b y 38 o t h e r s ,
and c l i n i c a l and
m ic r o s c o p i c e x a m i n a t io n s o f s c r a p i n g s from b e tw e e n t h e t o e s o f t h e s e
men w e r e n e g a t i v e .
E xam ination o f th e In s id e o f th e l e f t
p r o d u c e d a few s c a l e s w h ic h showed m y c e l i a .
sock
The b a t h r o o m f l o o r w a s
s c r u b b e d w i t h s o a p a n d w a t e r a n d no a n t i s e p t i c
was u s e d .
No f r e s h
cases appeared.
I n view o f th e a l l e g e d v i a b i l i t y o f t h e p a th o g e n ic fu n g i
and th e i d e a l c o n d itio n s f o r im p la n ta tio n o f i n f e c t i o n ,
m aceration,
In a d d i t i o n ,
and m o istu re,
all
It
seems s t r a n g e
c r u r i s d u e t o E.
t h a t no f r e s h c a s e s r e s u l t e d .
th ree occurred in a su b tro p ic al
M e r c e r a n d F a r b e r (1935)
warm th,
sum me r.
I n v e s t i g a t e d an epidem ic o f t i n e a
I n g u i n a l e on a l i n e r ,
a n d came t o
the c o n c lu s io n
t h a t c r o s s i n f e c t i o n was t a k i n g p l a c e c h i e f l y b y t o w e l s a n d a r t i c l e s
o'3)
Pa g e .-; -;
of clo th in g ,
w h i l e G J e s s l n g a n d M o sslg e (1937)
rep o rted a fa m ilia l
o u t b r e a k w h e r e t h e i n f e c t i o n w a s d u e t o t h e u s e o f common t o w e l s .
The o l d t h e o r y ,
t h a t I n f e c tio n of the f e e t i s
due c h i e f l y to c o n t a c t
w i t h sw im m ing-bath f l o o r s ,
e tc .,
S u l z b e r g e r (1937)>
th at at le a s t in cases of re in fe c tio n ,
local
states,
skin r e s is ta n c e
is
is ra th e r lo sin g favour,
o f param ount im p o rta n c e .
and
the
Some t i m e a g o a n
i n v e s t i g a t i o n on t h e m y c o t i c f l o r a o f f l o o r s was c a r r i e d o u t i n t h e
d e p a rtm e n t o f d e rm a to lo g y o f th e N a tio n a l M edical C o lle g e o f S h an g h ai.
Many o f t h e p a t i e n t s
n o t wear s h o e s ,
in th is
departm ent are o f th e c o o lie c l a s s
y e t t h e r e s u l t s were c o m p l e t e l y n e g a t i v e
a n d do
(R eiss,
1938).
H eat and C o ld .
It
i s w e l l known t h a t p e d a l I n f e c t i o n s r e a c h t h e i r p e a k o f
i n c i d e n c e i n t h e h o t summer m o n t h s , b u t t h i s
asso ciated fa c to rs :
i s p ro b a b ly due to
I n c re a s e d sw eatin g , m a c e ra tio n o f the
more f r e q u e n t e x p o s u r e , r a t h e r t h a n t o t h e a c t u a l i n c r e a s e
surrounding te m p e ratu re.
R ecen tly i t
the
skin,
and
in the
has been suggested th a t c e r ta in
types o f ru b b e r footw ear p re d is p o se d to
in fectio n ,
but th is
c a n be
e x p lain ed by th e delay ed e v a p o ra tio n and subsequent m a ceratio n o f the
s k i n w h i c h i s b o u n d t o t a k e p l a c e w he n t h e f e e t a r e h e r m e t i c a l l y
sealed.
The maximum l e t h a l
tem perature fo r p ath o g en ic fungi in
c u l t u r e h a s b e e n d e t e r m i n e d b y Weldman ( 1 9 2 7 ) a t b e t w e e n 4 8 a n d
51°C., and t h i s h a s b e e n c o n f i r m e d b y T a te
(1929) ,
although
C .J. W hite (1927) b e l i e v e s t h a t f u n g i a r e n o t d e s t r o y e d by b o i l i n g ,
and M i t c h e l l
after b o ilin g
however,
(1922)
c la i m e d t o have r e c o v e r e d E.
In g u in a le by c u ltu r e
i n 15 p e r c e n t , p o t a s s i u m h y d r o x i d e .
su rv iv e a high tem p eratu re,
r e s u l t s o b t a i n e d b y Weldman,
Few p a t h o g e n s ,
and i n view o f th e c o n s t a n t
t h e l e t h a l t e m p e r a t u r e may b e r e g a r d e d
P ag e .54.
as fa irly
to
co n stan t.
How f a r t h i s
h o ld s good In v iv o
Is d i f f i c u l t
s a y , h u t t r e a t m e n t a lo n g th e r m a l l i n e s w ould n o t be d i f f i c u l t w ith
in d u ced c u r r e n t s .
The e f f e c t o f c o l d o n c u l t u r e s h a s n o t r e c e i v e d much
atten tio n ,
a lth o u g h T aylor
(1930)
advocates sp ray in g th e a f f e c te d
p a r t w ith e th y l c h lo rid e a s a c u ra tiv e
m easure.
S i m i l a r l y Freeman
( 1 9 2 5 ) a d v i s e d s t r o k i n g t h e a r e a w i t h c a r b o n d i o x i d e snow.
The
r e s u l t i n g e x t e n s i v e d e s q u a m a t i o n w h i c h f o l l o w s s u c h t r e a t m e n t may b e
t h e m ain f a c t o r In r e s o l u t i o n .
Fr om a b a c t e r i a l a n a l o g y t h e m o r e
r e s i s t a n t m oulds w ould b e l i k e l y to
in sp o re form ,
su rv iv e a c e r t a i n degree o f co ld
a n d t h i s may b e t h e e x p l a n a t i o n o f t h e r e m i s s i o n s ,
th e course of n y c o tic in f e c tio n s ,
in
so f r e q u e n t l y s e e n I n c o l d w e a t h e r .
M o is tu r e a n d pH.
M o is tu r e I s e s s e n t i a l f o r th e gro w th o f m oulds, b u t u n d e r
c e r t a i n c o n d itio n s they are a b le to
su rv iv e drying out in c u ltu r e
on a c c o u n t o f s p o r e f o r m a t i o n (D ix o n ,
Bonar and D re y e r,
1932).
M oisture
producing m aceratio n o f th e
sk in ,
o m ittin g to dry th e I n t e r d l g i t a l
The r e s u l t i n g c o n d i t i o n ,
m aceration,
1924;
Is also
B ruhns e t a l , ,
1929;
th e m ain f a c t o r I n
and t h i s can be d e m o n s tra te d by
spaces a f te r bath in g
how ever, i s
f o r a week.
m e re ly one o f I n t e r d l g i t a l
and a superadded I n f e c tio n w ith a p ath o g en ic fungus Is
e s s e n t i a l to com plete th e p i c t u r e o f t i n e a p e d i s .
S o u t e r (1937)
re g a rd s th e h ig h in c id e n c e o f i n f e c t i o n in the l e i s u r e d c l a s s e s as
due t o c a r e l e s s n e s s a f t e r b a t h i n g ,
soil
for in fe c tio n .
a nd Novy ( 1 9 3 4 )
w ith subsequent p re p a ra tio n o f th e
As t h e r e s u l t o f t h e i r i n v e s t i g a t i o n s ,
N orton
showed t h a t t h e d e g r e e o f m o i s t u r e p r e s e n t h a s a
d i r e c t e f f e c t on th e b a c t e r i a l
f l o r a o f the s k in ,
and C o rn b le e t (1932)
d e m o n stra te d t h a t th e s e l f - s t e r i l i z i n g power o f th e n a t u r a l
fo ld s of
Page. .55 .
th e body i s low er th a n t h a t o f th e
surrounding s k in .
Personal
a t t e m p t s t o i n o c u l a t e d r y s c a r i f i e d h um a n s k i n w i t h p r o v e d p a t h o g e n i c
fu n g i have been in v a r ia b ly u n s u c c e s s fu l.
Indeed i t
is d iffic u lt
to
r e p r o d u c e ringw orm i n f e c t i o n s e x p e r i m e n t a l l y u n d e r any c o n d i t i o n s .
The h i g h I n c i d e n c e o f i n f e c t i o n i n t h e
h a s l e d many i n v e s t i g a t o r s
lo catio n .
(1927),
fo u rth in tersp ace
to seek an a l t e r e d sw eat r e a c tio n i n t h i s
In th e a cc e p ted absence o f a lk a lin e
and L e v in and S i l v e r s
(1932 ) a t t r i b u t e
a p o c r i n e g l a n d s Gray
t h e h i g h pH o f t h e
sw eat in th e I n te r s p a c e
t o d e c o m p o s i t i o n i n t h e warm t u n n e l f o r m e d
by th e f o u r t h and f i f t h
to es.
M oreover,
the l a t t e r
showed t h a t t h e s u r f a c e r e a c t i o n o f t h e
ev ap o ratio n i s prevented.
s k in becomes a l k a l i n e
Some t i m e a g o ,
squeeze in to
s h o e s w i t h c o n s t a n t a p p o s i t i o n o f t h e tw o o u t s i d e
in te rs p a c e w ith the
in c o n clu siv e .
the
tig h t-fittin g
toes,
the au th o r
in c id e n ce of m a ceratio n i n the
s i z e o f sh o e worn.
when
o n t h e a s s u m p t i o n t h a t men
w i t h l a r g e , f e e t w o u ld b e more l i k e l y t o
attem p ted to c o r r e la te
in v estig ato rs
The r e s u l t s ,
fo u rth
how ever,
were
I n a n I n g e n i o u s i n v e s t i g a t i o n a s t o t h e pH o f t h e a r e a
i n q u e s t i o n , W eldman ( 1 9 2 7 ) a t t e m p t e d t o i d e n t i f y m o r p h o l o g i c a l
rem n an ts o f a s e c o n d a ry sex g la n d found i n c e r t a i n ru m in a n ts by
serial
s e c t i o n o f a number
evidence o f s p e c i a l g la n d s
p r o p e r t i e s o f th e m oulds,
o f human f e e t .
He was u n a b l e t o f i n d
i n t h e r e g i o n . W orking on t h e f e r m e n t a t i v e
T ate
(1929) ,
p o s tu l a t e d t h a t the p a th o g en ic
f u n g i c o n t a i n a n en zyme w h i c h i s a c t i v e o n l y i n a n a l k a l i n e m e di um .
X- a n d U n t r a - V l o l e t R a y s .
A s u f f i c i e n t l y lo n g exposure to X -rays w ill undoubtedly
k i l l fungi in c u ltu r e ,
but
r e s u l t i n p e r m a n e n t da m ag e
glands,
sca r form ation,
a f u n g ic id a l dose to
in the
form o f
and t e l a n g i e c t a s i s .
the
skin w ill
a tro p h y of the s u p e r f i c i a l
Thus X -ra y s a r e n e v e r
P a g e .? ?
used to d e stro y fungi in th e
s k in (G ray,
1935)>
alth o u g h sm all doses
may h e u s e f u l i n r e s o l v i n g t h e e c z e m a t o i d c o n d i t i o n a f t e r d e s t r u c t i o n
o f the pathogen.
G l a s s o n (1920)
u sed X -rays a s an a d ju v a n t to
c h ry s a ro b in and re p o r te d good r e s u l t s ,
and Ingram (1935)
states
th at
f r a c t i o n a l e x p o s u r e s may b e u s e f u l i n c l e a r i n g u p a c h r o n i c r e s i s t a n t
case.
It
is
o b v io u s t h a t a h e a v ie r ex p o su re can be g iv e n to an a r e a
n atu rally k e ra to tlc
and d e v o id o f s u p e r f i c i a l g l a n d s .
X - r a y s i n a n a c u t e c a s e may e v e n h a v e a s l i g h t l y
on t h e c a u s a t i v e mould ( C h a v a r r i a a n d C l a r k ,
X -rays a re co m p arativ ely r a r e l y used,
stim u latin g e ffe c t
1924) .
and B u t l e r ,
The u s e o f
In t h i s country
H oughton, and
C ooper (1924)
c o n s i d e r t h e i r employment i n s u p e r f i c i a l i n f e c t i o n s
unnecessary.
T h e ir use i s
eru p tio n s
(W illiam s,
fr e q u e n tly follow ed by d i s t a l
"lde"
1927).
The s u p e r s o f t o r l o n g w a v e - l e n g t h G r e n z r a y s h a v e b e e n
em ployed on a c c o u n t o f t h e i r l a c k o f p e n e t r a t i o n
(M u sk a tb lit and
O u s p e n s k y , 1 9 3 3 ) > an<^ r e p o r t s i n d i c a t e t h a t t h e y do l i t t l e
the
s k i n (Bucky, 1927;
Dorne a n d W h ite , 1 9 3 1 ) .
be r e g a r d e d a s f u n g i c i d a l ,
in f e c tio n s of the
w ell.
They c a n n o t ,
a n d B uschke (1931) r e p o r t s
how ever,
fo u r m icrosporon
scalp tr e a te d u n su cc e ssfu lly w ithout e p ila tio n .
S i m i l a r l y Dorne a n d W hite
f u n g i were l i t t l e
damage t o
(1931)
affected,
On t h e o t h e r h a n d ,
derm atophyto s i s , r e s i s t a n t
f o u n d t h a t t h e common p a t h o g e n i c
a lth o u g h y e a s t le s i o n s responded f a i r l y
S choltz
(1932) r e p o r t s
fiv e cases of
to o in tm e n ts and X -ra y s , w hich c l e a r e d
up w i t h G r e n z r a y s .
A word o f w a rn in g :
X -ra y s c a n c a u s e g r e a t damage, a n d th e y
should be u sed o n ly by th e e x p e r t .
Exposure o f b a c t e r i a
leth al e ffe c t,
to u l t r a - v i o l e t l i g h t h a s a r a p i d l y
and th e method h a s b e e n a p p l i e d c o m m e rc ia lly to
P a g e .5 7 ..
d r in k i n g and b a t h i n g w a te r p l a n t s .
(Gomez-Vega, 1 9 3 6 ) ,
F u n g i a r e more r e s i s t a n t
and S c o t t a n d M cK inley (1930)
e s t i m a t e d t h a t an
e x p o s u r e o f f r o m f i v e t o t w e n t y - f i v e m i n u t e s a t a d i s t a n c e o f on e
foot is
necessary fo r d e stru c tio n .
In an I n t e r e s t i n g i n v e s t i g a t i o n ,
C h a v a rr ia and C la rk ( 1924) found t h a t fu n g i c o u ld be s e n s i t i z e d to
v isib le
(1936).
lig h t by eo sin ,
The l a t t e r
a n d t h i s h a s b e e n c o n f i r m e d b y Gomez-Vega
i n v e s t i g a t o r f o u n d t h a t m e r c u r o c h r o m e was
p a rtic u la rly effectiv e
w he n u s e d i n t h i s w ay .
Chemical Agents.
The f u n g i c i d a l a g e n t s i n common u s e i n t h i s
io d in e and s a l i c y l i c a c i d ,
and the form er i s g e n e r a ll y a c c e p te d as
b e in g one o f th e most p o w e r f u l,
enough,
salicy lic
in terd lg ltale
even i n h ig h d i l u t i o n s .
S tran g ely
a c i d h a s b een found to be a p o o r f u n g ic id e I n v i t r o .
S c h am b erg , Brown a n d H a r k i n s
E.
country are
in cu ltu re
exposure o f f i f t e e n m inutes,
(1931)
found t h a t io d in e k i l l s
in a d i l u t i o n o f 1 :8 5 ,0 0 0 a f t e r an
and i t
retain s i t s
p r o p e r t i e s i n the
p r e s e n c e o f b l o o d a n d v e s i c l e s e r u m ( K l n g e r y , W i l l i a m s & Wood ward 1 9 3 5 ) As
the r e s u l t o f In v i t r o
e x p e r im e n ts G ould and C a r t e r ( 1 9 3 0 ) ,
t h a t th e a d d itio n o f benzoic to
power o f t h e l a t t e r ,
salicy lic
and S t r l c k l e r
(1933)
acid r a is e s
state
the f u n g ic id a l
h a 8 su g g este d the
p o te n tia tio n o f io d in e by th e a d d itio n o f p o tassiu m io d id e .
Sm yth a n d Smyth J n r .
pine o i l s and s t a t e
o il,
(1932)
recommend,
100 p e r c e n t ,
t h a t on a c c o u n t o f t h e low v a p o u r p r e s s u r e o f t h e
c o n ta c t w ith th e s k in i s m ain tain ed f o r a c o n s id e ra b le tim e.
A queo us a n d a l c o h o l i c
s o lu tio n s of e s s e n t i a l o i l s have been c r e d i t e d
w ith s t r o n g f u n g i c i d a l p o w ers,
and t h e i r u se has b een fa v o u ra b ly
r e p o r t e d on by M yers and T h l e n e s ( 1 9 2 5 ) ,
and A d k i s s o n ( 1 9 2 8 ) .
M itchell
( 1927, and K ingery
L e g g e , B o n ar and T e m p le to n (1934)
a d v ise the
P ag e. 5>§..
a d d i t i o n o f thym ol 1*4 p e r c e n t . ,
t h a t the th e ra p e u tic
p er cen t.
successes
to W h itf ie ld 's o in tm e n t,
Jump f r o m 4 7 * 9 p e r c e n t ,
a l c o h o l and a c e to n e and m ercury a c e t a t e
(Scham berg e t a l . ,
1931)*
It
fuch sin is a d e f in ite
to note th a t a c id
(Gomez-Vega, 1 9 3 6 ) ,
(Scham berg and K olm er, 1922)
a c tiv ity o f vario u s th erap eu tic
shows
a g e n ts :-
H ighest f u n g i s t a t i c d ilu tio n s
f o r T. r o s a c e u m
M edicam ent
Iodine
...
...
B r i l l i a n t green
M ercuric c h lo rid e
B naphthol
.....................
Phenol
C ry stal v io le t
I o d o f o r m ..................
Amraoniated m e rc u ry
Re s o r e i n ...................
M ethylene b lu e . .
G entian v i o l e t ..
F u c h s i n .....................
S a lic y lic a c id ..
B enzoic a c id
...
Sodium t h l o s u l p h a t e
C hrysarobin
This t a b l e ,
although
fu n g icid e.
The f o l l o w i n g t a b l e
fu n g istatic
s o lu tio n w ith
f u c h s i n h a v e b e e n recommended
in terestin g
f u c h s in s t i m u l a t e s grow th i n c u l t u r e
th e
to 64*4
V arious dyes have been found to have h ig h l e t h a l p r o p e r tie s
a n d m e r c u r y a c e t a t e c r y s t a l v i o l e t i n 25 p e r c e n t ,
b asic
and say
1 : 1 0 0 ,0 0 0
1: 16,000
1 : 4 ,0 0 0
1 : 3 ,2 0 0
l : l , 600
1:500
1:400
1 :2 0 0
1 :2 0 0
1 :2 0 0
1 :2 0 0
1 :2 0 0
1:50
1:40
Not i n 1:20
Not i n 1 :1 0
f r o m t h e same s o u r c e ,
shows t h e f u n g i c i d a l
A c t i v i t y o f some o f t h e m e d i c a m e n t s i n common u s e : -
Page 3 ) . . .
Fungicidal A c tiv ity
.. , ,
.
M edicament
Exposure
15 m lns.
1 hr.
B r i l l i a n t green
1:25
C ry stal v io le t
1:25
G entian v i o l e t
Not I n 1 : 2 5
...................
1 :5 ,0 0 0
Io d in e
Phenol
...................
1:25
M ercuric c h lo rid e 1:1 0 ,0 0 0
B naphthol
...
1:25
1:80
1:50
1:25
1 :5 ,0 0 0
1:25
1:1 0 ,0 0 0
1:25
I t w i l l be n o tic e d t h a t
d e s tr u c tio n o f th e fungus,
o f grow th.
3 hrs.
24 h r s .
1:200
1:50
1:50
1 :7 .5 0 0
1:50
1 :1 0 ,0 0 0
1:50
1:200
1:200
1:50
1 :10,000
1:150
1:1 5 ,0 0 0
1:100
"fun g icid al"
and " f u n g is ta s l s "
is
(O sborne and H itc h c o c k , 1931>
1933;
( 1933) found t h a t
S h a f f e r and C arey , 1933;
to denote i n h i b i t i o n
(A yres J n r . ,
O s b o rn e , Putm an and
Emmons, 1 9 3 3 ) .
Form aldehyde has b een u sed
A nderson and Y oungblood, 1931.
and I t has been found e f f e c t i v e
¥.
in bath in g e stab lish m e n ts,
H enderson,
1932),
i n d e s tr o y in g fungus i n fo o tw e a r.
Sodium t h i o s u l p h a t e h a s b e e n recommended (G o u ld ,
but its
r e p o r t e d on (O sborne and H itc h c o c k ,
lo ses i t s
and Spring
fungus i n s c a l e s c o u ld be k i l l e d by im m ersion i n
c h l o r i n a t e d s w i m m in g w a t e r f o r tw o h o u r s .
and i t
used to denote
C h l o r i n e h a s b e e n r e c o m m e n d e d b y some w o r k e r s a s c h e a p
and e f f e c t i v e
R ick lo ff,
f o r T. r o s a o e u m .
1931)
as a fu ngicide
a c tio n has been unfavourably
1931;
K ingery e t a l . ,
1935).
f u n g i c i d a l p r o p e r t i e s on c o n t a c t w ith c h l o r i n a t e d
swimming w a t e r .
Three com m ercial f u n g ic i d e s have been u se d t h e r a p e u t i c a l l y :
abraclde,
m ycocten,
and p a r a n itr o p h e n o l.
A braclde i s
the p r o p r ie ta r y
Dame f o r a m i x t u r e o f tw o h y d r o x y - m e t h y l - b u t y l b e n z i n e s ,
and i t
u sed t o p r e v e n t t h e g r o w th o f moulds i n p a i n t s a n d e n a m e ls .
It
is
is
e x tre m e ly p o p u l a r i n th e army, and h a s b e e n c r e d i t e d w i t h a h i g h
therapeutic e ffic ie n c y
(C raw ford-Jones,
1935) .
M ycocten i s
an e s t e r
P a g e . .6 9 .
o f oxy-benzolc a c id ,
in fo o d stu ffs.
and i t
is
u s e d to p r e v e n t t h e g ro w th o f m oulds
Success has follow ed i t s
c lin ic a l a p p lic a tio n in
s o l u t i o n and o in tm e n t form (N o e l-G o ld s m lth , 1 9 3 6 ).
i s used in the l e a t h e r tra d e
to s t e r i l i z e
1935).
and good r e s u l t s have fo llo w e d i t s
1934;
M arriot,
1935).
It
P aran itro p h en o l
u n tre a te d h id es (R obertson,
t h e r a p e u t i c u s e (Semon,
h a s b e e n u s e d b y m y s e l f f o r some y e a r s ,
a n d t h e r e h a v e b e e n no c a s e s o f f a i l u r e
p r e s e r v a tiv e s have been p re s s e d in to
so f a r .
serv ice,
E v e n wood
a n d W i e d e r ( 1 9 3 5 ) Has
r e p o r t e d f a v o u r a b l y on t h e f u n g i s t a t i c pow er i n v i t r o ,
o f tw o p h e n o l s
u s e d t o p r e s e r v e wooden p o s t s .
Com m entary.
W hile i t
v iab le
a d m itte d t h a t p a th o g e n ic fu n g i can rem ain
fo r long p e rio d s in e ffe c te d
they can r e t a i n
facto r,
is
scales,
th ere
com bined w i t h t h e s e n s i t i v i t y o f t h e p a r a s i t e
make i t
p ro p o rtio n of th erap eu tic
the p a r a s i t e
is
no p r o o f t h a t
th e ir p ath o g en icity fo r a sim ila r perio d .
t h e common f u n g i c i d e s ,
d ifficu lt
failu res
not d if f ic u lt
e x p l a i n i n view o f th e
in foot cases.
i s h a rd to
s u p e r f i c i a l h a b i t a t o f the i n f e c t i v e
a tte n tio n has been p aid to
the
it
is
a g en t and
effect.
o b v i o u s t h a t t o o much
"seed" and n o t enough to th e
treatm ent of tin e a pedis i t
fungus i n t h a t l e s i o n ;
to most o f
The t h e o r y t h a t
to k i l l b u t to g e t a t ,
To a s t u d e n t o f t h e r a p e u t i c s ,
This
to a c c o u n t f o r th e h ig h
th e f a c t t h a t most t r e a t m e n t s have a p e n e t r a t i v e
In the
is
"so il".
i s n o t enough to e r a d i c a t e
the
a t t e n t i o n must be p a i d t o l o c a l h y g ie n e , and
m e a s u r e s t o e n s u r e v e n t i l a t i o n o f t h e f e e t a n d make t h e l o c a t i o n
u n s u i t a b l e f o r f u n g i must be i n s t i t u t e d .
Page.6 1 ..
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P ractitio n er,
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710.
33.
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Ib id .,
xx x l, 452.
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xxvl,
B o n ar, L. a n d T em p leto n , H . J . (1934)*
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Id.
462.
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S .T .
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cxxxv, 479.
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225.
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K lngery, L .B ., W illiam s, R .J .
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x x il,
59*
P ractitio n er,
and A d k isso n ,
K urotchkin, T .J .
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lx x x ix , 421.
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M ed.,
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Page
$ 5. .
CHAPTER SEVEN
T reatm ent and P r o p h y la x i s .
A t some t i m e o r o t h e r s i n c e t h e
le sio n s,
cure.
a ll,
p ractically
d is c o v e ry o f m ycotic s k in
every a n t i s e p t i c has been lau d ed a s a s p e c i f i c
T his a t f i r s t
glance te n d s to dem onstrate th e ln e f f lc a c y
on th e o t h e r han d ,
it
may a l s o
show t h a t a n y l o g i c a l
i n c a r e f u l and e x p e r i e n c e d h an d s w i l l be s u c c e s s f u l .
p ractitio n ers
a state
r e g a r d t h e common p a t h o g e n i c
of a ffa irs
It
Is also
in the
is
same p a t i e n t .
Too many
the l a b o r a to r y ,
ev id en t in the c a su a ln e ss of t h e i r
n o t uncommon t o f i n d i l l o g i c a l
This i s bad p o lic y ,
It
p ro v id e d the d is e a s e
skin in fe c tio n .
In fected area;
p o ssib le,
latter
It
treatm en t.
a n d i s u n d o u b t e d l y one
As i n a l l
i s much b e t t e r t o a d h e r e , t o a f e w p r o v e d
re m e d ie s th a n to ru s h b l i n d l y
S u p erficial
and t h i s
com binations o f tre a tm e n t
o f th e b e s t m ethods o f p r o d u c in g d e r m a t i t i s v e n e n a ta .
b ran ch es of m edicine,
treatm ent
fungo a s I n d e s t r u c t i b l e ,
which i s n o t b o rn e o u t i n
d esp airin g a ttitu d e
of
f r o m on e new d i s c o v e r y t o
ringworm i n f e c t i o n s
another.
can be p e rm a n e n tly cu re d ,
i s r e g a r d e d a s a whole a n d n o t a s a l o c a l i s e d
i s n ot enough to e r a d i c a t e
the p a r a s ite
i n f e c t e d c l o t h e s must a l s o be d e a l t w i t h ,
the source o f in f e c tio n tra c e d .
i n the
and i f
The d i f f i c u l t i e s
in the
m e t h o d o f a p p r o a c h w e r e p o i n t e d o u t b y Weidman ( 1 9 3 4 ) when h e
said " Th e h y g i e n e o f t h e p r o b l e m i s
w hether th e d i f f i c u l t y
sterilise
so c o m p l i c a t e d t h a t I d o u b t
can be met by t h a t r o u t e .
a l l the w earing a p p a re l o f the p a t i e n t ;
would s t i l l
It
is
im p ossible
even so,
re m a in t h e f l o o r c o v e r i n g s i n o u r homes, h o t e l s ,
there
shower
to
Page
bath s,
etc.
It
s e e m s t o me t h a t t h e
i n t h e way o f t r e a t m e n t
i s to
.
r e a l approach to th e
estab lish
m illenium
c o n d itio n s in the
in ter:
: t r i g i n o u s l o c a t i o n s i n which t h e f u n g i work and m o b i l i s e ,
make t h e s e l o c a t i o n s u n d e s i r a b l e
I n some c a s e s i t
clo th es,
d irect
but it
is
t o t h e f u n g u s . 11
w i l l be im p o s s ib le
essen tial
to
erad icate
c o n ta c t w ith th e in fe c te d a re a .
in fe ctio n s,
i t w ill be n ecessary ,
acid ify
in terd lg ital
th e
w hich w i l l
to s t e r i l i s e
a l l the
th e fungus i n garm ents in
In the case o f pedal
subsequent to
treatm en t,
to
spaces as a p ro p h y la c tic a g a in s t re in fe c tio n .
Common T h e r a p e u t i c A g e n t s .
Io d in e.
Of t h e v a r i o u s m e d i c a m e n t s i n common u s e i o d i n e h o l d s
pride
v itro .
as the
of p lace,
It
and i t s
e f f i c a c y h a s b e e n p r o v e d i n v i v o and i n
is esp ecially
useful
s tr o n g or weak t i n c t u r e
a s s u g g e s t e d by S t r i c k l e r
so lu tio n s
of io d in e,
i n t i n e a c r u r i s and can be a p p l i e d
o r p o t e n t i a t e d w ith p o ta ssiu m io d id e
(1933)*
Tlie F r e n c h u s e i n t r a v e n o u s .
a n d t h e y re c om m en d t h e m i n t h i s way f o r t i n e a
b a rb a e and o th e r deep s e a te d I n f e c t i o n s
Iodine c r y s ta ls
P o tas. iod id e
Aq. d e s t i l
ad
Commence w i t h l c c .
u n til
5cc.
in
5c c .
2
3
10 0
d istilled
region,
and i f
d e r m a t i t i s may b e s e t u p .
any fo rm ,
w ater.
S w a rtz (1935)
from e t h y l i o d i d e i n h a l a t i o n s .
T h e r e i s u s u a l l y some i r r i t a t i o n
th e c r u r a l
1937)*
d i s t i l l e d w a t e r a n d i n c r e a s e by l c c d a i l y
are in je c te d in 15cc.
r e p o r t s good r e s u l t s
(Roxburgh,
th is
is
when i o d i n e
is
a p p lie d to
not c a r e f u l l y w atched an I r r i t a n t
I have a p e rs o n a l a v e r s io n to
a nd I h a v e s e e n a g r e a t many b a d r e s u l t s
iodine
in
from o v e r tre a tm e it.
S alicy lic acid T his a c id
Is u n i v e r s a l l y used in m ycotic i n f e c t i o n s ,
and i t
Page 6 7 ..
i s u su ally
com bined w i t h b e n z o ic a c i d a s i n W h i t f i e l d ' s o in t m e n t A c .sa llc y l.
A c. b e n z o i c .
P araf.m o l.
01. cocois. n u cis.
The o i n t m e n t i s e x t r e m e l y f l u i d
p ara.ffin
i n h o t w e a th e r and g r s . 1 5 o f h a r d
can be a d d ed a s a s t i f f e n i n g
: i n g w he n u s e d n e a r t h e
it
ad
g rs.1 5
g rs.2 5
drs. 2
oz. 1
scrotum ,
agent.
It
and W h i t f i e l d
Is
somewhat i r r i t a t :
(1 9 3 4 ) recommends t h a t
sh ou ld be used f o r f iv e day s a t a tim e w ith r e s t p e r i o d s o f t h r e e
days.
It
has the ad v an tag e of b e in g c o l o u r l e s s .
I f a p a in t is
p r e f e r r e d the fo llo w in g i s u s e fu l
A c.salicy l.
A c.b en zo ic.
A cetone
S p . v i n i m eth. ad
d r.l
o z .l,l/2
o z .l
o z.4
The a b o v e c o m b i n a t i o n s o f s a l i c y l i c a c i d
resu lts,
and W h i t f i e l d s a y s t h a t
u se fu ln e ss are ex trav ag an t.
som etim es y i e l d d i s a p p o i n t i n g
some o f t h e c l a i m s a s t o
I a l w a y s add 1 . 4 $ thym ol t o W h i t f i e l d ' s
o in tm e n t a s s u g g e s te d by Legge e t a l . ( l 9 3 4 ) »
its
use round th e an u s.
o in tm e n t and p a i n t
th eir
Parke,
D a v i s & Co.
u n d e r t h e name o f
This of co u rse p r e c lu d e s
m arket a s a l i c y l i c
'M y c o z o l'.
An i o d i d e s a l i c y l i c
a c i d p a i n t h a s been a d v o c a te d by S t r i c k l e r Iodine c r y s t a l s
P o tas.io d id e
A c .sa lic y l
A c.b o ric
A l c o h o l 50$
ad
and th e o r i g i n a t o r
1 .3
1 .9
1 .9
3 .8
59.1
c l a i m s a v e r y low p e r c e n t a g e o f i r r i t a n t
reactio n s.
The u s e o f m a c e r a t i n g o i n t m e n t s i n i n t e r d i g i t a l p e d a l
in fe c tio n s n e c e s sita te s frequent cu rettag e,
be d o n e p e r s o n a l l y .
exposes th e
;ly.
The r e s u l t s
sh o u ld alw ays
Such a p r o c e d u r e re m o v e s d e a d s k i n a n d t h o r o u g h l y
in fected area.
ro u tin e i s adapted,
and t h i s
It
is
also d e s ira b le ,
to su p erv ise every step
no m a t t e r w h a t
in the treatm en t p erso n al:
f r o m s u c h p e r s o n a l t r e a t m e n t a r e much more
i
Page £ ? ..
satisfacto ry .
In the
somewhat r a r e m y c o tic p r u r i t i s
an i,
C astellan !
( 1 9 2 4 ) recommends a co m b in ed s a l i c y l i c o i n t m e n t a s o r i g i n a t e d by
Deek A c .sa lic y l.
Bism uth s u b n l t .
M ercury s a l i c y l .
01. eu caly p ti.
P a ra f.liq .
Adeps l a n l
4 p arts
10 "
4 n
10 "
aa
100
F r om a s i n g l e p e r s o n a l e x p e r i e n c e I c a n b e s t d e s c r i b e
as
'v e ry
th is p rep aratio n
s tim u la tin g '.
C h rvsarobln.
I n t h e c o u r s e o f y e a r s c h r y s a r o b i n h a s b e e n f o u n d t o be
alm ost a s p e c i f i c
Indeed i t
first
in the
tr e a tm e n t o f s u p e r f i c i a l m ycotic
was f o r t h e t r e a t m e n t o f t h e s e c o n d i t i o n s t h a t i t
intro d u ced
(N o r m a n W a l k e r ,
C hrysarobin
Adeps l a n l
P araf.m u l. aa
it
is
sp ecific
1932).
E x h i b ite d a s an o in tm en t -
d rs.4
I n u n c tio n should be c a r r i e d out
seven days,
according to
the r e a c t i o n o f th e
p atien t.
Some w i l l
c o m p la in o f s l i g h t b u r n i n g from t h i s
but i t
s u r p r i s i n g how f e w s i d e e f f e c t s a r e p r o d u c e d .
fo llo w e d by a s o o th in g l o t i o n ,
h a l f a drachm o f l i q u o r p l c i s
A sy n th etic
by B ay er,
it
such a s l o t i o
calam inae,
treatm en t,
It
sh o u ld be
t o which
c a r b o n i s o r 3$ i c h t h y o l c a n b e a d d e d .
d e riv a tiv e of chrysarobin - c ig n o lin ,
i s extrem ely u s e fu l in tin e a p e d is.
C ignolin
Adeps l a n i
P a r a f mol.
was
g r s .2 0
for tin e a c ru ris.
once a day f o r f o u r to
is
in fectio n s.
prepared
In o i n t m e n t form -
g rs.1 0 .
aa.d rs.
4
s h o u ld be ru b b e d i n to t h e i n f e c t e d a r e a once d a i l y ,
ta k in g care
Page .6.9.
t h a t the
in te rd ig ital
spaces are also
treated .
be e x h ib ite d to c a s e s o f v e s ic u la r tin e a ,
it
to the
T h is t r e a t m e n t can
and I have even a p p l i e d
w eeping e c z e m a to ld ty p e w ith s u c c e s s .
days of d a lly a p o lic a tio n s w ill e ffe c t a cure.
p arts
sh o u ld be w rapped in gau ze,
fittin g
shoes or san d a ls.
in the l a t e r
crural
from t h i s
and th e p a t i e n t
treatm en t.
but th ere
in unction
the
sh o u ld wear lo o s e
to p u t him to b e d
is u su a lly co n sid erab le
discom fort
m easure.
e f f e c t on th e e y e s s h o u ld be rem em bered,
"turn
fo urteen
C i g n o l i n can be a p p l i e d to t h e
When u s i n g c h r y s a r o b i n a n d i t s
to
A fter
I t may e v e n b e n e c e s s a r y
s ta g e s of the
type o f t i n e a ,
Seven to
fine lin e n
in to purple
d eriv ativ es,
the
irrita n t
in a d d itio n to th e ir a b i l i t y
raim ent".
B u r g e s s ( 1 9 3 8 ) recom mends a c h r y s a r o b i n o i n t m e n t w i t h
s a l i c y l i c a c i d (D reu w 's o in tm e n t) A c .sa lic y l.
C hrysarobin
O l.ru sci
L in sap .m o l.
P araf.m al.
6
12
12
15
60
C h r y s a r o b i n a n d c i g n o l i n do n o t a c t w e l l i n p a i n t f o r m .
Dy e s .
Fuchsin i s
and i t
is
C astellan !
u n d o u b te d ly one o f th e b e s t a n t i - m y c o t i c d y es
m o s t com monly e m p l o y e d i n t h e p a i n t
f o r m o r i g i n a t e d by
(1929).
S a t.a lc o h o lic so ln .b a sic -fu c h sin
5$ a q . c a r b o l i c a c i d s o l n .
F i l t e r and add
B oric a c id
A f t e r t w o h o u r s add
A cetone
Two h o u r s l a t e r a d d
R esorcin
S tore in a dark co lo u red b o t t l e .
lO cc.
lOOcc.
lgrm .
5 CClO grm s.
Page .7 9 .
It
is
a n o n - i r r i t a n t p r e p a r a t i o n and i s
and c o r p o r is .
The o n l y d r a w b a c k s a r e i t s
p ro p erties.
for tin e a c ru ris
c o l o u r and s t a i n i n g
D a ily a p p l i c a t i o n f o r 7 - 1 4 d a y s w i l l e f f e c t a c u re and
t h e m ethod i s o f Im p o r ta n c e
i n women.
and i t
sp ecific
When a p p l i e d t o
in th e tre a tm e n t of m ycotic I n f e c tio n s
the f e e t
i s may c a u s e d r y i n g a n d f i s s u r i n g
may h a v e t o b e a l t e r n a t e d w i t h a n o i n t m e n t .
pedal tin e a are
in
somewhat d i s a p p o i n t i n g .
2$ m a l a c h i t e g r e e n i n
I t h a s much t h e
The r e s u l t s
sp irit is
another u sefu l p re p a ra tio n .
sam e p r o p e r t i e s a s f u c h s i n p a i n t a n d i s
used in th e
same way f o r s i m i l a r c o n d i t i o n s .
In d u strial
fu n g icid es.
A b ra c ld e i n th e form o f an e m u ls io n w ith soap i s
p o p u l a r i n some q u a r t e r s .
It
is
u s u a l l y em ployed a s a l/lO O b a t h .
I n d i l u t i o n s above t h i s
the
flo ats
In a s e r i e s o f t e s t s
to
the
surface.
extrem ely
a b r a c l d e co m es o u t o f s o l u t i o n a n d
conducted by m yself i t
was fo und t h a t w ith t h e l/lO O s o l u t i o n t h e r e
was c o n s i d e r a b l e
Irritatio n ,
th e i r r i t a t i o n
and t h a t
i n s t r e n g t h s below t h i s
was
c o n fin e d to t.ie j u n c t i o n o f th e p a r t under tr e a tm e n t w ith th e
o f the lo tio n .
but th is
is
A l/lO O b a th h a s been ad v ocated a s a p r o p h y la c tic ,
uneconom ic and d a n g e ro u s .
P a ra n itro p h e n o l as used i n the l e a t h e r tr a d e
n o n -irritatin g .
a week,
it
surface
Used i n a ^
is of value
i s com pletely
a q u e o u s s o l u t i o n 20 m i n u t e s d a l l y f o r
in t i n e a p e d is and m an is.
The o b j e c t i o n a b l e
yellow
c o l o u r can be o b v i a t e d by a d d in g a few d r o p s o f h y d r o c h l o r i c
acid .
On a c c o u n t o f t h e d r y i n g e f f e c t i t
o intm ent.
s h o u l d be f o l l o w e d by an
Some w o r k e r s p r e f e r a 2 $ s o l u t i o n
M ycocten i s
in s p i r i t .
a f a v o u r i t e remedy i n Denmark,
and Lomholt
Page
( G o l d s m i t h 193&) a d v i s e s t h e
fo llo w in g com bination:
M ycocten
A c .sa lic y l.
P a ra f.liq .
U ng.plurabi ox ( D . P . )
It
is
..
aa. 3 p a rts
60
"
f r e q u e n t l y em ployed w ith a m ycocten p a i n t .
M etallic
fu n g icid es.
Copper s a l t s i n h i g h d i l u t i o n a r e l e t h a l t o
form s o f v e g e ta b le l i f e ,
In m ycotic derm atoses.
and t h e i r u se h a s b e en l o g i c a l l y
recommended
M o lo n e y ( 1 9 3 7 ) r e p o r t s g o o d r e s u l t s
20$ s o l u t i o n o f d e h y d r a t e d c o p p e r s u l p h a t e
s h o u ld be rubbed in to
th e low er
in pure g ly c e r in .
the l e s i o n d a l l y f o r f i f t e e n
so lu tio n s of silv e r n itr a te
are
also u sefu l
m inutes.
from a
It
Weak
i n th e w eeping eczem atoid
type.
M ycotic E x t r a c t s .
A c o n s i d e r a b l e amount o f work h a s b e e n done o n t h e u s e o f
m ycotic
e x t r a c t s i n ringw orm i n f e c t i o n s ,
u n iv e rsa lly d isap p o in tin g .
eru p tio n s
it
is
Even i n c a s e s w i t h m a n i f e s t a l l e r g i c
s u f f i c i e n t to
Tolmach and Traub (1 9 3 8 )
tre a t
th e prim ary l e s i o n .
R ecently
c a rrie d out a c a re fu lly c o n tro lle d se rie s
o f t e s t s w ith p oor r e s u l t s .
th ese p re p a ra tio n s
and the r e s u l t s have been
In the p re s e n t
s t a t e o f o u r knowledge
c a n n o t b e recommended f o r g e n e r a l t r e a t m e n t .
Pow ders.
Pow ders a r e
useful in
tre a tm e n t a s an a d ju v a n t to o in tm e n ts .
I n w eeping c a s e s th e y cau se d r y in g o f th e d i s c h a r g e ,
th ey a re a l l
that is
r e q u ir e d to
Boric acid
Venetian talc
Kaolin
S llan to x
e ffe c t a cure.
and f r e q u e n t l y
B u r g e s s recommends -
aa.l part
(am orphous s i l i c o n d i o x i d e ,
S i l i c a Gel L t d .)
is
another
Page
u s e f u l d u s t i n g p o w d e r ( M a r t i n Row 1 9 3 1 ) •
starch
It
I s b e s t to
fr o m a l l p o w d e r s to be u s e d on t h e f e e t .
m o i s t u r e a n d movement i t
As a r u l e
2$ s a l i c y l i c
exclude
In the p resen ce of
t e n d s t o c a k e a n d may a g g r a v a t e
acid is
7.2. .
Itch in g .
added to th e above p r e p a r a t i o n s .
S te rilis a tio n of clo th es.
W henever p o s s i b l e
a r e a s h o u l d be b o i l e d .
the
a l l garm ents in c o n ta c t w ith th e i n f e c te d
T his w i l l In c lu d e
case of b oots or le a t h e r g lo v e s,
w ith 50cc.
socks,
s in g le ts etc.
In
they sh o u ld be p l a c e d In a box
of fo r m a lin i n an open c o n ta i n e r an d l e f t
f o r 24 h o u r s .
To s a v e t i m e t h e i n s i d e s o f s h o e s c a n b e s w a b b e d w i t h f o r m a l i n a n d
le ft
to
air
rep laced ,
f o r two d a y s .
I n s o l e s s h o u ld be d e s t r o y e d ,
t h e y s h o u ld be s t e r i l i s e d f r e q u e n t l y .
It
and i f
may b e m e n t i o n e d
t h a t many o f t h e a g e n t s e m p l o y e d i n d r y c l e a n i n g a r e n o t f u n g i c i d a l .
K a d i s c h (1 9 3 1 ) a d v i s e s 1$ th y m o l I n s p i r i t
b u t t h e m ethod seems u n d u ly e x p e n s i v e .
p erfectly
for
sterilisin g
Steam s t e r i l i s a t i o n
clo th es
is
satisfacto ry .
Treatm ent o f T inea C r u r i s .
I f the a f f e c t e d
lo tio n ,
day.
or ic h th y o l
area is
in f la m e d o r w eeping,
calam ine l o t i o n ,
Some p r e f e r t o
calam ine
sh o u ld be a p p lie d t h r e e tim e s a
use ung.hydrarg.am m on.
a t th e s t a r t .
Under
g a r m e n t s s h o u l d b e s t e r i l i s e d a t t h e c o m m e nc e m e nt o f t r e a t m e n t a nd
reg u larly
th ereafter.
'When t h e
in flam m atio n h a s su b sid e d ,
t h e o i n t m e n t s o r p a i n t s s h o u ld t h e n be e x h i b i t e d d a i l y ,
d aily ,
or tw ice
a cc o rd in g to th e r e a c t i o n o f th e i n d i v i d u a l . L a t e r ,
cure has been e ffe c te d ,
on e o f
when a
th e a r e a should be d u s te d f r e q u e n t l y w ith a
s a l i c y l i c a c i d powder.
This ro u tin e
is
also
su fficien t for
tin ea a x illa ris .
Page ] } ..
T reatm ent o f T in ea P e d is .
It
i s essen tial
adequate v e n t i l a t i o n .
(B e rb e ria n 1933),
in a l l
cases of fo o t
in fectio n
to ensure
W oollen s o c k s s h o u ld be p r o h i b i t e d
and c o tto n or
Rubber sho es a re bad a s they
'c e llu la r'
s o c k s worn i n s t e a d .
in crease lo c a l
te m p e ra tu re and h u m id ity ,
and s a n d a l s o r sh o es w ith open u p p e rs sh o u ld be used.
In th e p re se n c e o f a superadded p u s tu la r in f e c tio n ,
p o ta s s iu m perm anganate s o l u t i o n ,
so lu tio n
should be u sed a s a b a th
be pow dered betw een t r e a t m e n t s .
cured,
o r I / 5OOO p e r c h l o r i d e
tw ice d a i l y ,
o f m ercury
f e e t should
When t h e e c z e m a t o l d e l e m e n t h a s b e e n
an o in tm en t should be rubbed i n .
day w i l l
and th e
I / 4 OOO
a g a in depend on th e i n d i v i d u a l
The n u m b e r o f i n u n c t i o n s p e r
reactio n .
C a s te lla n i's p a in t
h a s a j u s t l y d e s e r v e d r e p u t a t i o n i n e cz e m a to ld ringw orm s, b u t
u su ally
it
r e q u i r e s t o b e s u p p l e m e n t e d b y a n o i n t m e n t when t h e c a s e h a s
re a c h e d th e dry s t a g e .
V/it h s a l i c y l i c o i n t m e n t s i n t e r d i g i t a l
done once w eekly
s h o u ld be
and th e socks sh o u ld be b o i l e d f r e q u e n t l y .
h y p e rid ro sis i f p resen t,
found e f f e c t i v e :
and n i g h t ,
curettage
must be t r e a t e d ,
equal p a r ts
Pe da l,
and t h e f o l l o w i n g w i l l be
s p i r i t v i n i m eth.
a n d w a t e r morning
o r a f o o t b a t h o f 5$ f o r m a l i n o n c e d a i l y f o r t e n m i n u t e s .
Subsequent to cure,
d etailed la te r,
r e g u la r p ro p h y la c tic m easures,
as
should be c a r r i e d o u t.
T r e a t m e n t o f T i n e a Unguium.
As t h e
in thetreatm en t
prim ary fo cu s i s
in the n a i l bed,
the d i f f i c u l t i e s
o f n a i l i n f e c t i o n s c a n be a p p r e c i a t e d .
t h e b e s t method i s
to
U ndoubtedly
avulse th e n a i l under l o c a l or g e n e ra l
a n a e s t h e s i a and a p p l y a n t i - m y c o t i c a g e n t s t o
the bed.
I n most
Page
cases th is w ill su ffice,
destroy
but occasionally i t
the n a i l p erm an en tly .
w i l l be n e c e s s a ry
A more t e d i o u s method i s
l i q u o r p o t a s s a e a n d s c r a p e away t h e
softened la y e r.
W h itfield
come o f f
Infected p a rts d a ily .
i n a b o u t t h r e e weeks and a s a r u l e
req u ired .
F e h lin g 's
.
to
to apply
a d v i s e s a n o i n t m e n t o f 12$> b e n z o i c a c i d a n d 6$ s a l i c y l i c
should be stra p p ed over th e
74 .
(1934)
acid .
T his
The n a i l s w i l l
no f u r t h e r t r e a t m e n t i s
s o l u t i o n a s a d a i l y d r e s s i n g on l i n t
is u sefu l,
and e v a p o r a t i o n can be p r e v e n t e d by th e u se o f ru b b e r f i n g e r s t a l l s .
L o c a l a p p l i c a t i o n s a r e e x t r e m e l y p a i n f u l and. i t
necessary
may b e
to use s e d a t i v e d ru g s d u rin g t h e i r e x h i b i t i o n .
P ro p h y lax is.
P r o p h y la c tic m easures a re
tow ards th e
Of t h e s e
on th e
in d iv id u al,
th e form er i s
in d iv id u al.
are u n sa tisfa c to ry
o f two k i n d s ;
those d ire c te d
and th o s e d ir e c te d tow ards h is
surroundings.
to be p r e f e r r e d a s th e onus i s t h u s p la c e d
G eneral m easures such a s i n t e r c e p t o r b a th s ,
etc.
by t h e m s e l v e s .
P erso n al.
F irstly ,
asto n ish in g
th e
e d u c a t i o n on f o o t h y g i e n e i s e s s e n t i a l .
s p a c e s when b a t h i n g ,
n o t ' b o t h e r t o d ry them p r o p e r l y .
most p e d a l m ycoses.
m oisture p red isp o se
In h i s
a n d a n e q u a l l y l a r g e n u m b e r do
This,
I consid er,
The n a t u r a l w a r m t h o f t h e
to m a c e r a t i o n and t h e
so il
i s the b ases of
f o o t and r e t a i n e d
is tnus prepared
i n v e s t i g a t i o n on U . S . s o l d i e r s ,
for
W ilson (1934) fo u n d
t h a t the largest company h a d t h e l o w e s t i n c i d e n c e o f f o o t
due to
is
t h e n u m b e r o f o t h e r w i s e c l e a n l y p e o p l e who do n o t w a s h
in te rd ig ital
in fectio n .
It
complaints,
t,.e fact t h a t t h e comp any c om m a nd er t o o k a k e e n i n t e r e s t in
Page ? ? . .
t h e w e l f a r e o f h i s m e n . By f r e q u e n t p e r s o n a l
feet,
he p ro d u c e d a most s a l u t a r y
command.
The f e e t
' f o o t f i x a t i o n 1 com plex i n h i s
sh o u ld be k e p t from c o n t a c t w ith th e b a th -ro o m
f l o o r a s much a s p o s s i b l e ,
i n A m erica,
exam inations of t h e i r
and p a p e r s l i p p e r s ,
such a s a re used
are u s e fu l.
N o t i c e s s h o u ld be p l a c e d i n a l l w ash in g p l a c e s and sh o w ers.
To b e e f f e c t i v e ,
such n o t i c e s sh o u ld be c o n c is e ,
and th e
follow ing
i
is
suggested as a s a tis f a c to r y p o s te r :"YOUR FEET"
" C a r e le s s n e s s in w ashing and d r y in g the f e e t
w i l l l e a d to eczem a and ringw orm .
Wash c a r e f u l l y b e t w e e n y o u r t o e s a n d p o w d e r
them a f t e r d r y i n g .
R eport t o the d o c to r a t the f i r s t sig n of tr o u b l e " .
The f e e t a n d i n t e r d i g i t a l
soap and w a t e r a t l e a s t once a d a y ,
w a te r to
i n h i b i t sw eating.
an d pow dered w ith s a l i c y l i c
(B ellsario ).
Osborne
and f i n a l l y
They s h o u ld t h e n b e t h o r o u g h l y d r i e d
acid
talc,
so lu tio n ,
o f more s i m p l e m e a s u r e s .
o r r u b b e d w ith lem on J u i c e
but th is
tim es.
o f the
and n o t ,
to i l l - f i t t i n g
seems u n n e c e s s a r y
In hot c o u n trie s
s o c k s a n d s h o e s s h o u l d b e worn a t a l l
t o e s i s due t o
r in s e d w ith cold
( G o l d s m i t h 193&) a d v i s e s s w a b b i n g t h e t o e s
w i t h 1 cf s o d i u m h y p o c h l o r i t e
the fa c e
s p a c e s s h o u ld be washed w ith
shrunken socks,
in
'v e n tila te d '
F r e q u e n tly cram ping
a s i s u s u a l l y siipposed
shoes.
C r o s s i n f e c t i o n by t o w e l s can be p r e v e n t e d b y i m p r e s s i n g
on th e
in d iv id u al
the
n e c e s s i t y f o r u s i n g o n l y h i s own t o w e l .
humid c o u n t r i e s f a c i l i t i e s
In
f o r d ry in g to w e ls a f t e r b a th i n g should
be p ro v id e d .
G eneral.
As b a t h - r o o m f l o o r s a r e g e n e r a l l y
su sp ect,
th ey should be
Page .7 6 .
washed f r e q u e n t l y w ith
necessary
to ensure
cannot be p ro p e rly
tile s
soap and w a te r .
thorough d ry in g .
cleaned,
or p o lish e d concrete
they are
easily
cleaned.
a b o l i s h e d and d ry in g
shower c u b i c l e .
F o r c e d v e n t i l a t i o n may b e
Wooden f l o o r s a n d m a t s ,
w hich
should be d isp e n se d w ith and c lo s e ly s e t
su b stitu ted .
R ubber m ats a r e
useful as
B a th s t o o l s and b e n c h e s s h o u l d be
should be done w h ile s ta n d i n g i n t h e b a t h or
T raffic
i n th e b a th -ro o m sh o u ld be re d u c e d to a
minimum.
In the p resen ce of o v e rt In f e c tio n ,
w a l l s and f l o o r s s h o u l d
I
b e s w a b b e d a f t e r w a s h i n g w i t h 2Jc s o d i u m h y p o c h l o r i t e
Form alin i s u s e f u l,
afterw ard s.
b u t the
r o o m c a n n o t b e u s e d f o r some t i m e
A shallow rubber b a th
may b e p l a c e d a t t h e
p a ss through i t .
p aran itro p h en o l
so lu tio n .
e n tra n c e to
c o n t a i n i n g 1$ sodium h y p o c h l o r i t e
t h e w a s h - p l a c e a n d b a t h e r s made t o
The s o l u t i o n s h o u l d b e c h a n g e d d a i l y
so lu tio n is
efficacio u s,
washed b e f o r e d r y in g th e y e llo w
.
b u t u n le s s the
5$ a c i d u l a t e d
f e e t are
c o lo u r r e a p p e a r s on to w e ls .
So diu m
t h i o s u l p h a t e does n o t ap p ea r to be s a t i s f a c t o r y .
P e r h a p s th e b e s t and s i m p l e s t m ethod i s to
ch lo rin e
powder,
bath-room f lo o r .
such as i s used fo r w ater p u r i f i c a t i o n ,
on th e
T h is soon becomes c o n v e r te d i n t o an a d h e s iv e ,
stro n g ly a n tis e p tic ,
th e
sp rinkle
a n d t h o r o u g h l y o b j e c t i o n a b l e mush,
i n d i v i d u a l to wash and d ry h i s
feet carefu lly .
and f o r c e s
The s u b s e q u e n t
w ashing g r e a t l y l e s s e n s th e r i s k o f a ch em ical d e r m a t i t i s .
larg e dredgers of s a lic y lic
lab elled
"F oot Pow der".
acid t a l c
s h o u l d b e p r o v i d e d and
L astly ,
Page . 7 7 .
R eferences.
B elisario ,
J . 0 . ( 1 9 3 6 ) B r i t . M e d . J o u r . , 1,4°5*
B erberlan ,
D .A .(I9 3 8 ) A rch .D erm .S y p h ., C hicago,
B urgess,
J . F . ( 1 9 3 8 ) C anad.M ed.A ssn. J o u r . , 38,577*
C astellan i,
A .(1924) Jo u r.T ro p .M ed .H y g ., 27,3°4-
--------------------------- ( 1 9 2 9 )
G oldsm ith,
K adlsch,
38, 367.
ib id .
3 2 , 77-
N .(1 9 3 6 ) Recent Advances in D erm atology,
E .(l9 3 l)
D e rm a t. W schr.
M oloney, J . B . (1937)
Osborne,
S trlck ler,
Sw artz,
Tolm ach,
W alker,
U.S.Navy M e d . B u l l e t i n ,
N.
(vide
35*440*
supra).
Common S k i n D i s e a s e s ,
C hurch ill p p .142.
A . (1933) A rc h .D erm .S y p h ., C hicago,
J.H .
(1935)
2 9 ,521.
J o u r . R . A . M . C . , 57,449*
q u o t e d by G o l d s m i t h ,
Roxburgh, A .C .(1937)
p p .363*
37,1433*
Legge, R . T . , e t a l .( 1 9 3 4 ) A rch.D erm .S yph., C hicago,
M a r t i n Row, C . ( 1 9 3 l )
C h u rch ill,
ib id .,
28, 836.
32,551*
J .A .,a n d Traub, E .F .(1938)
ib id .,
38,925-
N .( 1932) I n t r o d u c t i o n to D erm atology,
W . G r e e n a n d S o n , p p . 243*
W eidm an,F .D ., q u o te d G ray , A .M .H .(1934) B r i t . M e d . J o u r . ,
W h i t f i e l d , A . ( 1 9 3 4 ) J o u r . T r o p . M e d . H y g . , 37,353*
W i l s o n , D . J . ( 19 3 4 ) A rc h .D e rm .S y p h ., C hicago,
30 , 841.
2,541*
P a g e . .7 ? .
CHAPTER EIGHT
G eneral
In th is
th esis,
Commentary.
a n a t t e m p t h a s b e e n made t o s t u d y t h e
p ro b le m o f s u p e r f i c i a l ringw orm i n f e c t i o n s a s t h e y
a ffe c t a large
g r o u p o f men i n t h e s e c o n d t o t h e f o u r t h d e c a d e s .
Such i n f e c t i o n s ,
although u s u a lly t r i v i a l ,
r e a c h epidem ic p r o p o r t i o n s
appar e n t,
is
can cause g r e a t d isc o m fo rt,
th e econom ic l o s s
th u s obvious.
through the p a t i e n t .
in fectio n ,
such d i f f i c u l t y
Why i s i t ,
th e problem o f
it,
a n d why i s
in repro d u cin g th e d ise a se ex p erim en tally ?
skin,
f o r th e grow th o f f u n g i,
In the
etc.,!:
t h a t o f f i f t e e n men
o n l y o n e man w i l l c o n t r a c t
o b v io u sly in the p a t i e n t 's
u n su itab le
schools,
a n d i n t h i s I am a t o n e w i t h my m ore
ex p erien ced c o lle a g u e s , that th e r e a l approach to
exposed to
is
Many I n g e n i o u s m e t h o d s h a v e b e e n d e v i s e d f o r m a s s
b u t I am c o n v i n c e d ,
prev en tio n is
they
from d i s a b i l i t y
The i m p o r t a n c e o f p r o p h y l a x i s i n i n s t i t u t i o n s ,
p ro tectio n ,
is
and i f
th ere
The a n s w e r
a n d i f we c a n r e n d e r t h a t
t h e n we h a v e s o l v e d t h e p r o b l e m .
i n t r o d u c t i o n I h a v e p o i n t e d o u t t h e w o r ld wide
i n c r e a s e i n th e in c id e n c e o f s u p e r f i c i a l ringw orm I n f e c t i o n s b u t I ta k e
e x c e p tio n to th e
in C hapter 5 .
in d iv id u als
fan tastic
f i g u r e s g i v e n b y some o f t h e i n v e s t i g a t o r s
To s a y t h a t 9 5 $ o f a n y l a r g e g r o u p o f h e a l t h y
suffer
from p e d a l m ycoses i s
the v e r i e s t nonsense,
n o t s u p p o r t e d b y my own, o r b y t h e s t a t i s t i c s
A m ycotic i n f e c t i o n i s
a state
a n d t o o many p r a c t i t i o n e r s
o f the
fro m t h e U .S.
skin not a s ta te
s u f f e r from what I c a l l
and is
Navy.
o f th e mind,
"epiderm ophytosis
o f the b ra in " .
In C h ap ter 3 I have endeavoured to s e t o u t the r o u ti n e
!
i
i
Page. 79. .
m ethods f o r d i a g n o s i s ,
a n d a n a t t e m p t s h o u l d b e made i n a l l
dem onstrate a fungus.
F requently a c l i n i c a l l y
n o t show f u n g i ,
in such c a s e s .
relied
suggestive case w ill
and th e t r l c h o p h y t i n i n v e s t i g a t i o n
u n d e r ta k e n w i t h a view t o
c ase s to
i n C h a p t e r 4 was
fin d in g an ad ju v an t d ia g n o s tic procedure
The r e s u l t s w e r e s o m e w h a t I n c o n c l u s i v e a n d c a n n o t b e
on b y t h e m s e l v e s .
In th is
c h a p te r I p u rp o se ly avoided e n te rin g
t h e d r e a r y f i e l d o f n o m e n c la tu re i n im m unobiology.
F r e q u e n t l y one
r e a d s o f f i x e d and c i r c u l a t i n g a n t i b o d i e s i n ringw orm i n f e c t i o n s ,
a s f a r a s I am a w a r e ,
an tib o d ies,
antibody p r e c ip ita tio n re a c tio n ,
lesio n s.
but
a s d e m o n s tra te d by th e a n t i g e n have n e v er b een found i n such
G o ld s m ith h a d a d m ir a b l y sum m arised m odern o p i n i o n on t h i s
s u b j e c t i n h i s R ecen t A dvances i n D erm atology.
A know ledge o f th e v i a b i l i t y
c l i n i c a l m ycology what p a th o l o g y I s t o
of th e p athogenic fungi i s
surgery.
W ithout a c l e a r
u n d e rs ta n d in g o f th e f a c t o r s I n f lu e n c in g the l i f e
p arasite,
th is
treatm en t i s p u re ly e m p iric a l.
to
and grow th o f th e
I have t r i e d
to d e a l w ith
f u l l y i n C h a p te r 6.
In the
fin al
t r e a t m e n t I s l a i d do w n,
c a r e f u l hands,
s e c t i o n no h a r d a n d f a s t r o u t i n e
for
a s I c o n s i d e r t h a t any l o g i c a l m ethod i n
and under p e rs o n a l s u p e rv is io n ,
I t m ust be rem em bered, h ow ever,
w ill be s u c c e s s fu l.
t h a t ringw orm i n f e c t i o n s a r e c a u s e d
by a d e l i c a t e v e g e t a b l e p a r a s i t e w hich c an re m a in v i a b l e f o r lo n g
p erio d s,
and I t
w ill be n ecessary to e ra d ic a te p o s s ib le so u rces of
r e i n f e c tio n In the p a t i e n t 's
be pronounced
'fu n g u s f r e e ' .
clo th es,
shoes,
e tc .,
b efo re a case can
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