RINGWORM IN GENERAL SURVEY IN LITERATURE
In daily life we find ringworm a difficult disorder to cure: a few cases yield to almost any sensible treatment, but the bulk of them offer a stubborn resistance. And yet we often find the therapeutics of ringworm in the text-books confined to a very few lines. One author of no mean standing tells us that the soft- soap treatment generally suffices! However, some authors do not hesitate to speak out plainly on the subject. And I notice that the more the authors know of ringworm, the more they have studied it, the less therapeutically positive do they become. Willan (1817) confessed that it is “hard to cure.”
Gruby (1844) made the discovery that a fungus was present in the broken-off hairs and in their root sheaths. This parasite was fully described by Malmsten, in Stockholm, in 1845, and it was named by him the Trichophyton tonsurans. Cazenave’s name, Herpes tonsurans, is most commonly met with in many works. Its other names are legion.
Alder Smith, M.B. Lond., F.R.C.S. (“Ringworm: Its Diagnosis and Treatment,” London 1885), has very usefully spent many years in studying ringworm, and in the work just named shows himself a thorough master of the subject, has position as Resident Medical Officer at Christ’s Hospital, London, affording him incomparable opportunities for such studies. I shall take this author as the representative of the latest views of science on the subject of ringworm.
Alder Smith thus defines ringworm:-
“Ringworm is a disease of the skin caused by a microscopic vegetable parasite; and the characteristic lesions are due to this minute fungus invading the epithelial layers of the skin, the hair follicles, and the hairs. The growth which causes this very troublesome affection belongs to the lowest order of plant life, the fungi or moulds; the same fungus is found both in ringworm of the head and the body, and the two affections are essentially one. This disease, which is a very common one, is liable to attack all classes-the rich as well as the poor-and is highly contagious, but it is almost entirely confined to children.” And then says:-
“The history of ringworm is complicated, as certain varieties of form of the disease have received a number of designations from the older authors.” *”Viz.- Porrigo scutullata, Willan; herpes tonsurans, herpes squamosus, Cazenave; herpes circinatus, Bateman; porrigo ton soria, dartre furfuracee arrondie, Alibert; tinea tondens, squarus tondens, Mahon; phyto- alopecia, Malmstem; rhizophyto-alopecia, trichophytie, Gruby; dermatomycosis tonsurans, Kobner; tinea trichophytina, tinea circinata, Anderson; trichonosis furfuracea; porrigo furfurans; lichen herpetiformis, Devergie; lichen circumscriptus, figuratus, gyratus, impetigo figerata, etc.; Germ., scherende flechte; Fr., herpes tonsurant; teigne tondante; teigne tonsurante.”
As to the life-history of the fungus I will refer my readers to Alder Smith’s work, which is beyond compare the best epitome of the subject with which I am acquainted, almost all the other works on ringworm are antiquated and only of historic value. But I must quote what Alder Smith says of the host of the Trichophyton tonsurans.
“All children are not equally susceptible to ringworm. A certain unknown condition of the skin is necessary for the growth of the fungus, as some children never take ringworm though constantly liable to become infected For it is evident that when one child in a family has ringworm, and is not under any treatment, the others must be exposed to the action of the fungus; yet, at times, the disease does not spread.
“This fact is often used as an argument by parents, to prove that their children are not suffering from any contagious form of disease, and that they are in a fit condition to enter a school.
“On some the fungus takes but slight hold, and is easily destroyed. Others are extremely susceptible; the disease quickly attacks the follicles and the hairs, and spreads with great rapidity although under treatment. Sometimes treatment even accelerates the already rapid spread of the disease, by producing impetiginous eczema with crusts; and, by means of the pus, the fungus is carried to more distant and healthy parts. This variety is most difficult to manage. “The difference in these cases must depend on some peculiar nutritive condition of the soil or material in which the fungus develops, or upon some special state of the general health or constitution. In fact the state of the soil is a most important condition; and the rapidity with which a small spot of ringworm will spread before it comes under efficient treatment depends chiefly upon this peculiar condition of the soil or nidus. We generally find that ringworm specially occurs, and spreads most rapidly among poorly nourished children of a strumous or lymphatic diathesis. *”Mr. M. Morris states- and I fully agree with him- ‘that children with very light brown, golden, or colourless hair, with light grey or blue eyes, and with fine skin with thin epidermis, take ringworm easily and usually have it severely. The Lancet, Jan. 29th, 1881. And it is often observed that all the children in a family of this description, if they become infected, will suffer severely; evidently showing that there is some general condition present favouring the parasitic growth.
“Ringworm is also commonly seen amongst those who, while they are not decidedly strumous, are yet thin and pallid.
“Most children with chronic ringworm dislike fat; this avoidance of fat in the diet-according to Dr. Fox-‘has a most potent influence in leading to the development of a condition of nutrition which is favourable to the occurrence of obstinate ringworm.’
“But, on the other hand, we constantly see both recent and chronic ringworm in those who are neither strumous nor ill- nourished,-in fact upon decidedly healthy and robust children. This leads me still to hold the opinion, that the peculiar condition which is favourable to the development of the ringworm fungus is unknown.
“Ringworm does not exercise any noticeable influence on the general organism or constitution, or on the general nutrition of the body.”
I cannot agree with Dr. Fox’s view, just quoted, in regard to the avoidance of fat as a food; what I would say is this: These children dislike fat because they are in an ill condition; the ill condition pre-exists the avoidance of fat, and is not produced by want of it, other than secondarily. Alder Smith, as we see, holds the opinion that “we constantly see both recent and chronic ringworm in those who are neither strumous nor ill- nourished-in fact, upon decidedly healthy and robust children.”
This I deny; the ringworm mould cannot grow on really healthy children any more than fish can live out of water. They may look healthy, even very healthy; they may appear to be robust, jolly, rosy, fat, but they are not truly healthy, or their skin-surface would not get mouldy in ringwormy patches. Of course, my opportunities for observing ringworm are not by any means to be compared to those of Alder Smith’s, but I have examined a goodly number to test the point, and have never yet found a truly healthy child the subject of ringworm: they all have more or less indurated glands somewhere. From the curative results following the exhibition of Bacillinum I am led to believe that the mould of ringworm can only grow on those who are more or less strumous or tubercular, and that the degree of the disease gauges the degree of the constitutional morbidity.
Now Alder Smith is a reliable observer, a man of science and fact, and there is strong inherent evidence in his work on ringworm that he puts his facts fairly and squarely before his readers. This being so, it must follow that his facts should prove the constitutional nature of ringworm if such be the case.
Let us see.
ALDER SMITH’S FACTS VERSUS
ALDER SMITH’S VIEW THAT
“DECIDEDLY HEALTHY CHILDREN”
MAY BE SUBJECT TO
In the following quotations from Alder Smith’s work most of the italics are mine.
He says (pp. 29 et seq.):-
“Diagnosis of Ringworm which has Existed Some Time.
“Chronic Squamous Ringworm. “In the first place, I cannot help observing that very few medical men, either in consultation or private practice, are aware how extremely difficult some cases of ringworm are to cure; and the majority consider a case well, even when it has assumed a decidedly chronic state. I constantly have boys brought to me on their return to private schools, and very many also on their presentation for admission to Christ’s Hospital, who, while bringing certificates from medical men of the highest professional standing that they are cured of ringworm, and quite fit to mix with other children, are still suffering from a severe, contagious, and chronic form of the disease; and I have often found on inquiry, l that an opinion has been formed, and a certificate given without any special examination of the scalp, and certainly without the help of the lens or microscope. Many practitioners imagine that ringworm is cured when some of the hair is again growing freely and firmly on the part affected. This is a great mistake, as some of the most chronic and intractable cases are those in which the hair has partially grown again on the scurfy patches; but, on close inspection with a lens, some short broken-off hair or stumps may be seen scattered among the healthy hairs.
“It is impossible to speak too strongly on this point, as an outbreak of ringworm in a school is often due to the admission into it of an unrecognised case of the disease. As a rule, the trouble arises from a boy returning to school (after he has had an attack of ringworm on the head) with a certificate to the effect that he is cured, when in fact he is suffering from a chronic and contagious form of the complaint; or, from the entry into the school of an entirely unsuspected case; generally a boy, who has had a scurfy patch on his head for some time, but who is, in reality, suffering from chronic ringworm.
“Speaking from experience, after the examination of a very large number of children, both in private and for admission into Christ’s Hospital and other schools, I have found that in by far the majority of cases where a boy has had ringworm on the head within a year or two of my seeing him, the disease has not been really cured. As a rule, the treatment has been continued until some new hair has made its appearance on the patches, after which it has been discontinued, although many diseased stumps remained. When this stage has been reached, the case will often continue in the same chronic state-the patches remained about the same size, getting neither better nor worse-while the little patient, who may be certified as “perfectly well,” may be the constant and unsuspected cause of a succession of outbreaks of ringworm in a school.”
We therefore see that in by far the majority of cases certified as cured the disease has not been cured at all, but still exists as Chronic Squamous Ringworm. Hence it follows that the ordinary statistics of the cure of ringworm by medical and surgical practitioners are worthless. The cures are not real, the treatment has merely got rid of the worst of the ringwormy mould in its more gross and evident form. Even one year, even two years, after;the cure the sufferers continue to be contagiously ringwormy notwithstanding the fact that the patches have been scoured clean and the hairs have grown again.
Our Author further says:-
“Especially would I call attention to a variety I call “disseminated ringworm”-one rarely diagnosed, and the most chronic and difficult to cure. The hair is found to be growing freely and firmly all over the head; there are, perhaps, no patches to be seen now, although probably they have existed at an earlier staged of the disease; the skin appears generally healthy, and perhaps almost free from scurf: but numerous isolated and generally thickened stumps, or groups of stumps, or black dots, are seen here and there, often scattered all over the scalp. This variety is almost always overlooked, and can only be detected by very careful examination.”
And again:__ “Diffuse Ringworm.
“A very chronic from,”diffuse ringworm,” is also sometimes seen, in which there are one or more large irregular patches, often extending nearly all over the scalp. The surface is very scurfy, and very many of the long hairs have grown again, but numerous stumps are to be seen in every direction. This variety is constantly overlooked, or mistaken for seborrhoea or chronic squamous eczema; but it can always be diagnosed by the stumps. Cases are even found where the entire scalp is affected. “Chronic Pustular Ringworm.
“Chronic ringworm may also occur in the form of Pustular spots, with a certain amount of redness and crusting around, and with a stump existing in the centre of each spot. This appears to be Nature’s effort to get rid of the stump, and can be successfully imitated by treatment.
“Sometimes chronic ringworm may exist, without apparent change, for months or even years, as a single spot, or in spots so small that they are not noticed, even by professional men, with numerous long hairs and only a few stumps. Often ten minutes or more has to be spent in examining a child’s head before any stumps can be detected. I have known an outbreak of ringworm in a school to be caused by a chronic spot not larger than a split pea, and where only a few stumps could be found on close examination with a lens.”
We see, then, that not only are most of the cases certified by eminent medical men as cured, not really cured, but that “Disseminated Ringworm,” “Diffuse Ringworm,” and “Small-Spot Ringworm” are “rarely diagnosed,” “constantly overlooked,” and “not noticed even by professional men.”
It must, therefore, be manifest that the germs of ringworm must be about in almost every gathering of children, at every party, in every school, in almost every church and chapel in the world; and when we further remember that Dr. Tilbury Fox found the conidia of trichophyton in abundance in the dust deposited from the air of a ward in which ringworm cases were located, it must be pretty clear that ringworm may be communicated through the air in a multitude of different places, and in almost all schools and other places where children do congregate, and that is practically everywhere. Alder Smith further affirms (p.5) that it may be caught from the heads or infected articles belonging to boys or girls, with chronic, and often unknown and untreated, varieties of the disease, which are every day mistaken for chronic scruf or dry eczema.
Therefore we may say that the germs of ringworm are practically everywhere. This is quite what we should expect from our knowledge of the moulds generally: given the right conditions for mouldiness and moulds, and there they are. Also, given the right soil and conditions for ringworm__and there it is.
The other known facts of the disease ringworm leads us to the same conclusion as just stated probable universal presence of the germs of ringworm,.
Keeping still to our Author, we read (p.44):__”I am positive that a ringworm on the head, the size of a sixpence, can develop in forty-eight hours, and increase to the size of a florin in another twenty-four hours, because I have actually seen ringworm grow at this rate. But this is certainly not the usual rate of progress. Ringworm generally develops much more slowly than this; yet there is no doubt that a moderate sized patch may appear in a few days.
“It cannot, on the other hand, be said how long it has not existed; for the place may spread very slowly, and remain almost in the same state for weeks, or even months.
“Cases like these (chronic ringworm) must have existed some time; probably for many months, or possibly for years.
“I remember one inveterate case that resisted all treatment for nine years, and though the patient was eighteen when I last saw him, he still had disseminated ringworm; and another disseminated case (lately under my care) had been treated by many medical men for a period of eight years without being cured.
“It is impossible to say how long even a small spot of chronic ringworm may not have existed, as it may have remained in a latent state for month, or even years.
“The rate of growth and rapidity of reproduction are very different in individual cases. If the fungus spreads slowly, it indicates only a slightly favourable soil, and it can then-in its early stage-often be quickly eradicated; but if it grows rapidly, it is due to the general nutritive condition furnishing a favourable nidus: it is then most difficult, and sometimes impossible to arrest its course; the increase in the rate of growth of the fungus being greater than can be counterbalanced by rubbing in parasiticides.
“Dr. T. Fox says: ‘Ringworm is obstinate in proportion as this or that patient offers a favourable soil in his textures for the growth of the fungus or parasite.'”
I think the impartial will at once concede that Alder Smith the physician completely refutes Alder Smith the rubber-in of parasiticides, but that he should do it unbeknown to himself is distinctly curious.
Is Ringworm a Disease Due to Dirt?
No; not one of my cases of the past three or four years was due to dirt, all being members of the higher and upper middle classes, who tub and scrub, perhaps, even too much.
On this point Alder Smith says:
“It is a great mistake to think ringworm is due to dirt. Of course neglected children with dirty heads are more likely to be exposed to, and to take the disease; but it constantly occurs in children whose heads are kept perfectly clean, and where all proper care is taken. No matter what precautions are observed with regard to cleanliness, some of the other children in a school will commonly take ringworm if an untreated case is accidentally admitted into it, no matter from what class of society the pupils be obtained.” Note the some.
Our Author continues:- “Children under ten years of age seem more prone to take the disease than those who are older; and it is very rarely contracted after the age of thirteen, and hardly ever seen on the head in adults. Again, infants are not often infected.
“About puberty, ringworm is more manageable, and generally- even when it has existed for years it tends to get well spontaneously soon after this period.”
Now if the essence of the disease is the fungus, and the treatment is to be addressed to the killing of the fungi, why should the age of the individual host have anything to do with the parasite? And how is it that it gets well spontaneously after puberty?
Alder Smith devotes over a hundred pages to the treatment of ringworm-killing the fungi-and I will conclude this part of my subject with a few of his intercurrent remarks on the difficulties of the task. He says:-
“Nothing is easier to cure than a patch of ringworm situated on the body, but it is a very different matter when it exists on the hairy scalp. Then the treatment is, as a rule, most disappointing. Quick cures are very rare, and sure results are only to be obtained by thorough and long-continued employment of active remedies.
“It is necessary to keep in mind the important facts, that the fungus is the essential cause of the mischief; that it soon extends to the bottom of the hair-follicles; that its destruction is indispensable in order to cure the disease; that the great difficulty in curing ringworm is not to find parasiticides, but to get them to penetrate deeply into the hair-follicles, and thus come into contact with the fungus.
“Remedies act in two ways: first, by destroying the fungus- parasiticides, such as boracic acid, sulphurous acid, and the oleates of copper and mercury; others act by setting up inflammation, and even exudation about the follicles, and by this means cure the disease-as croton oil; but by far the majority combine both these properties, as acetic and carbolic acids, Goa powder, chrysarobin, nitrate of mercury, etc.
“It is very unwise to make a large sore place on the scalp, especially in recent ringworm, as the pustular variety may thus be set up; and strong preparations should never be used to young children.
“Selection of a Treatment.
“There are hundreds of different ways of treating ringworm of the head, and many ‘never-failing’ nostrums, which are warranted to cure the disease in a few days or weeks.
“The reason why so many things are said to cure ringworm is due to two causes: firstly, many cases are only ringworm of the body; secondly, numberless children are said to be well, when they still have ringworm in the most chronic form, and thus remedies are said to cure cases that have never been influenced for good by them. I have so often drawn attention to this fact that this may appear mere repetition, but considering the number of children constantly sent to me already certified as ‘cured, who have ringworm in a contagious form, it would appear that all that has been written on this subject has made but little impression on some medical men.
“The plain truth is that there is not a single plan (except the use of strong caustics which will form scars) which can be relied on with absolute certainty to cure ringworm of the head. The rapidity with which different cases, of apparently equal severity, yield to similar treatment varies greatly. Some go on unchecked for months, or even years, and may even spread under good treatment-while others rapidly get well.”