J Case of Cinca Cricopbijtina alnpium. 
LOUIS A. DU II HI NO, M.D., 
PROFESSOR OF SKIN DISEASES IN THE UNIVERSITY OF PENNSYLVANIA, DERMATOLOGIST 
TO THE PHILADELPHIA HOSPITAL, ETC\_ 
READ BEFORE THE PHILADELPHIA COUNTY MEDICAL SOcjctY, APRIL *2d. 
[Reprinted from the Medical and Surgical Uepuktkp. oi .iprj i.Ui. \t>7' 
The case which I have the honor of showing 
the Society this evening is one exhibiting a 
quite rare form of nail disease, designated tinea 
tricophytina unguium or onychomyc >sis tricho- 
phytina. The condition may be briefly defined 
as an invasion of the nail by the vegetable 
growth known as the tricophyton. Not only 
the surface but the entire substance of the nail 
is thus affected, causing opacity and yellowish 
discoloration, together with increase in bulk, 
more or leas Assuring, fracture, and ultimately 
crumbling of the nail. The notes of the case 
are us follows : 
treatment, it slowly disappeared, so that by the 
end of the year from the commencement these 
two nails wore again perfectly healthy. 
Ab >ot four months after the two nails just 
referred to wore invaded, “ ringworms,” as 
she terms them, made their appearance on the 
tinkers of the diseased nails. They gradually 
crept up the fingers, over the back of the hand 
and wrist, and later appeared upon the arms 
and upon the general surface. She states that 
she has had these lesions (and there is, from 
her description of them, every reason to believe 
that they were truly patches of tinea circinata), 
off and on, quite constantly, for the last five and 
a half years. They have occurred chiefly about 
the wrists and knees. They would very 
frequently completely encircle the wrists, and 
were always of a more aggravated type on the 
left than on the right wrist. They were particu- 
larly prone to occur in the flexures of the knees. 
They wore also of very frequent occurrence 
about the back of the neck and around the 
waist. The face never manifested any signs of 
the disease. The lesions of tinea circinata over 
the general surface were of all sizes, from a 
split pea to a silver half-dollar, beginning 
usually as irregularly rounded, split-pea sized 
patches, and in time forming smaller or larger 
rings. Often they would coalesce, constituting 
variously sized, irregularly shaped, more or less 
indistinctly defined patches. Thr-y lasted a 
The patient, J. D., is a single woman, of 
medium size, but of spare frame, twenty-five 
years of ago. She has light brown hair. Her 
occupation is that of a weaver, which she has 
followed for a number of years. She looks 
weakly and frail, but according to her state- 
ment she has until lately always enjoyed aver- 
age general health. Her father and sister 
died of consumption. 
The nail disease manifested itself about six 
years ago, two nails, the thumb and index 
linger of left hand, being attacked at the same 
time. Those were involved to about the same 
degree that wo now see the index linger nail of 
the right hand. The disease first showed itself 
around the free border of the nails. It gradu- 
ally, in the course of six months, took possession 
of the whole of both nails, after which, without 2 
variable time, from a few weeks to as many 
months. She states that she has often counted 
upon her a dozen or more distinct lesions, and 
that since the commencement she has certainly 
had hundreds of them. They were never very 
red nor inflammatory, but were very itchy. 
to the <|tiick. There in, moreover, marked thick- 
ening here, together with a mass of dense, soft, 
broken-down nail substance, of a dirty groonish- 
yellow color. 
The color of the body of the nails is pale- 
yellowish, with hero and there opaque, whitish, 
ill-defined specks, the size of small and largo 
pin-heads. Strim of a greenish-grayish color, 
caused by extraneous matter collecting about 
the fissures, are also present. Hero and there 
the nail substance is formed into irregular 
ridges, or a fragment of nail has become de- 
tached, leaving an irregularly-shaped cavity, or 
a shreddy surface. The nails are in some places 
soft, and can bo readily scraped away, while at 
other points they are still quite hard, and can 
only bo removed by paring them. 
As stated, two finger nails were attacked four 
months before any disease of the skin ap- 
peared. About one year later the other nails 
began to be affected in the same manner as the 
first two nails, so that within a year and a 
half all the nails which are now involved had 
been attacked. The thumb-nail of the right 
hand, which was one of the two nails first in- 
vaded, was very badly diseased, even more so 
than any at the present time. The thumb was, 
for some time, very much swollen, so that she 
was unable to wear a glove. It will be remem- 
bered that this nail recovered within a year 
from the date at which it began, without treat- 
ment. All of the diseased nails have been 
better and worse from time to time, but none of 
them within the last five years have shown 
any disposition to return to health. They have 
never been the seat of any subjective symptoms. 
They grow, after cutting, quite as rapidly as 
the healthy nails. 
They are manifestly involved throughout 
their entire substance, from their external sur- 
face to their beds, for the yellowish infiltration 
is seen to lie deeply imbedded. Moreover, by 
scraping and cutting it is seen that the disease 
penetrates deeply. The infiltration of the fun- 
gus exists more extensively at some points than 
at others, as shown by the presence of the 
whitish and yellowish specks referred to, repre- 
senting foci of disease. All the nails, more- 
over, arc invaded throughout their whole surface, 
from their borders to their roots, and from side 
to side. 
At the present time the general surface of the 
body is entirely clear of disease,.and she states, 
has been so for at least a year. She has not 
noticed any patches of tinea circinata during 
this period. 
Upon cutting into the more diseased nails, or 
even upon scraping them with a blunt instru- 
ment, the nail substance is found to be soft, 
and to break down or to split into lamina) 
or fragments, varying in size and shape. The 
free borders are much more brittle and friable 
than the central portion of the nails; still, the 
whole nail substance is noted to bo the seat of 
more or loss disease. 
Five nails are affected ; the nails of the thumb 
and little finger of left hand, and the index, mid- 
dle and little fingers of the right hand. The 
other nails are perfectly healthy, and are in all 
respects well shapen and symmetrically formed. 
The toe nails appear to be sound. 
As they are all very similarly involved, the 
same description will apply to all of them. 
They are firmly seated on their beds, showing 
no tendency to become detached. They are 
markedly thickened, in some places treble the 
normal thickness, two of them being consider- 
ably raised up, and in the form of the exterior 
of an oyster shell, while the others are oven 
flatter than normal. Their surfaces arc uneven, 
rough and rugged, depressions and eminences 
existing hero and there quite conspicuously, 
Furrows are also present, running both trans- 
versely and longitudinally. Several of the nails 
are split up their entire length ; others arc not 
at all fissured. The free borders are in all in- 
stances broken, ragged, and more or less split 
Under the microscope both the scrapings and 
parings show the tricophyton fungus in abund- 
ance. It should bo stated that the specimens, 
previous to examination, wore first soaked for 
five minutes in liquor potassuo, to break up the 
adherent colls of the nail, after which they 
wore washed in distilled water, and examined 
in a saturated solution of acetate of potassium. 
The liquor potassiu plays an important part in 
destroying a certain amount of nail substance, 
thus rendering the fungus more clearly visible. 
It is in all cases an indispensable agent in the 
examination of the several vegetable parasites of 
the skin, whether attacking the epidermis, hair, 
or nail. Although, as has boon stated, the 3 
growth is present in quantity, it will not be 
found in every fragment of nail substance that 
may bo submitted to the microscope. In many 
small pieces, and also in some specimens of 
nail dust or tilings, it may not be found, or in 
such small quantity, and so broken, as to be 
scarcely recognizable. In the examination of 
the vegetable parasites of the skin, it is well 
known to those accustomed to study these struc- 
tures that it is often quite impossible to pro- 
nounce positively upon one or two spores, or a 
fragment of mycelium. Various formations 
and bodies common to microscopic fields may 
readily bo mistaken for vegetable organisms. 
Indeed, whore the growth is scanty, it is not 
very uncommon for even skilled microscopists 
to bo mistaken, in their interpretation of certain 
structures. 
knife, to cut and scrape the nail substance 
away as much as possible without causing 
pain, followed by the application of strong 
potash soap and water, with a brush, and after- 
ward by an alcoholic solution of corrosive 
sublimate, three grains to the ounce. As will 
be seen, the nails have been considerably 
changed by this treatment. Internally she 
has been taking preparations of iron, and small 
tonic doses of arsenic, which I regard as im- 
portant therapeutic aids in such long continued 
and obstinate cases of parasitic disease as the 
present. As a parasiticide, the hyposulphite 
of sodium in solution (3j ad, sj) may be favor- 
ably mentioned. It should be applied with a 
cloth tied on the nail, and repeated often. 
Within the last month the patient has com- 
plained of a new symptom, in no way con- 
nected with the nail disease, but which may 
nevertheless be mentioned. She has, on some 
four or five occasions, at irregular intervals of 
a few days or several weeks, suffered from 
sudden and painless hemorrhages from the 
bowel. They have in each instance been 
sudden, the discharge taking place without 
previous warning to the patient, and unaccom- 
panied with pain or other like symptom. In 
no instance has the hemorrhage been the result 
of undue exertion. The quantity of fluid lost 
varied on different occasions, from a cupful to, 
she thinks, several pints. It appeared to her 
ns being quite pure blood, of a bright red color. 
It did not ooze, but gushed forth in volume. 
Only when it occurred copiously was it fol- 
lowed by weakness and prostration. She has 
never experienced any symptom of the kind 
before; nor has she suffered at any time from 
haemoptysis or from epistaxis. Menstruation 
has always been perfectly normal os to time, 
quantity, and duration. It has taken place 
normally during the past three months, and has 
not been influenced in any way by the hemor- 
rhage from the bowels. The bowels have 
always been somewhat constipated, and are so 
at the present time. 
The growth in the present case is unquestion- 
ably the trioophyton, the commonest fungus 
that invades the integument of man, being 
found as the cause of tinea circinata, tinea 
tonsurans, tinea sycosis and tinea tricophytina 
unguium, j Specimens were hero exhibited un- 
der the microscope.] It is characterized by 
mycelium and spores, both elements being, as a 
rule, in every possible state of development. In 
the case before us wo observe that the mycelium 
largely predominates, there being, indeed, but 
few spores present in the majority of specimens 
examined. This occurrence is usually the case, 
the growth as found in the nail appearing very 
much in the manner as in tinea circinata. The 
mycelium is of all sizes and of all shapes. In 
some specimens it is luxuriantly developed, 
long, branching, and of great calibre, while in 
others it is small, narrow, and manifestly 
stunted. It varies in form and quantity with 
the nail upon which it exists, and with external 
conditions. As a rule it grows most rapidly 
and luxuriantly whore heat and moisture are 
abundantly provided, whether naturally or 
artificially. Beyond the presence of the fungus 
there is nothing worthy of special note to be 
referred to. As in all oases of parasitic disease 
of tbo nail, whether of tinea favosa or of tinea 
tricophytina, the colls of the nail substance are 
more or loss dry, shrunken and degenerated, 
showing hero and there variously sized granules. 
Upon examination of the great too nail of the 
left foot, to which the patient has lately called 
my attention, I find it to be opaque, and of a 
bright, pale-yellow color. This condition has 
appeared within the lost month. No other 
nail is so affected. The form of the nail is 
natural, and the surface smooth and polished, 
the cloudiness and yellowish color being the 
only symptoms of disease; and wore one not 
The notes describing the appearance of the 
disease, which 1 have read, were made previous 
to the patient having been placed upon external 
treatment, about two months since. The reme- 
dies directed consisted in the daily use of the 4 
looking for parasitic disease the true nature of 
the condition would, in all probability, be over- 
looked. 
Anderson, of Glasgow, in his analysis of 
11,000 consecutive cases of skin disease (Lon- 
don, 1H72), does not appear to have mot with 
the affection. Tinea trioophytina, according to 
his statement, was encountered one hundred 
and seventy-eight times, occurring on the gen- 
eral surface, and board. There is no 
mention of it having in any of the cases involved 
the nails. 
Within the week my attention has also been 
directed to several small split-pea sized, irregu- 
larly rounded, pale-reddish, slightly scaly le- 
sions on the left forearm and shoulder, which 
have recently made their appearance. They 
are found to be the earliest manifestations of 
tinea circinata, the scales of which, under the 
microscope, show the tricophyton plainly. 
Thus, after an interval of more than a year 
these lesions again manifest themselves, and 
probably will continue to do so for some time, 
unless treated promptly and vigorously. [Pa- 
tient exhibited.] 
White, of Boston (Jioslon Medical and Surgi- 
cal Journal, 1870), in an analysis of 6000 cases 
of skin disease, reports one hundred and eighty 
cases of tinea trioophytina as occurring upon 
the scalp, general surface and beard, but does 
not speak of the disease as having in any case 
shown itself in the nail. 
Disease of the nail due to the presence of the 
tricophyton is of rare occurrence. Kobner 
( Virchotr's Archiv, vol. xxii, 1861) reports 
that out of one hundred cases of tinea tri- 
cophytina he encountered but two examples 
where the disease attacked the nails. These 
occurred in two sisters, children of eight and 
ten years, who were suffering with tinea tonsu- 
rans. Two finger nails and two .thumb nails 
were involved in one case, and the two thumb 
nails only in the other cose. 
In my own experience the affection is de- 
cidedly a rare one. It has certainly boon 
several years since 1 have mot with a case. At 
the same time the condition doubtless occurs 
more frequently than would be inferred from 
these statistics, being either not brought to the 
notice of the physician by the patient, or, as L 
think is more likely the case, passes unrecog- 
nized as to the true nature of the disease. 
The case that 1 have described is particularly 
interesting in the fact that the disease of the 
nail preceded the affection of the skin. In the 
majority of cases the nail disease follows the 
tinea circinata. The occurrence of the disease 
in the toe nail is also a rarity, some authors, as 
Dr. Fox [Epitome of Skin Diseases, London, p. 
69), even making the statement that it is never 
found here. The long duration and the per- 
sistency of the tinea circinata is also worthy of 
remark. The facts, that two of the finger-nails 
that wore severely attacked recovered within a 
year, without treatment, and that the tinea cir- 
cinata recurred after a year’s absence, are points 
that go to show that the disease, under certain 
conditions, oven in the nail, inclines to perish 
of itself, and that where the soil is favorable it 
may recur, oven at long intervals, for an indefi- 
nite period. 
Purser (Dublin Quarterly Journal of Medical 
Science, November, 1865) also gives the notes 
of two cases, one a young lady, the other a 
middle-aged man. In the case of the young 
lady there was a previous history of tinea 
circinata of the finger, but no such disease 
existed at the time the case came under obser- 
vation. With the other case there was no his- 
tory of any previous tinea circinata, nor was 
there any disease of the skin existing at the time. 
One“ffnger nail and two toe nails wore attacked. 
Fag'ge, of London {Transaction* of the Clini- 
cal Society of London, 1868; and Guy's Hos- 
pital Ileports, vol. xv, 1869) reports four exam- 
ples. The same observer exhibited two other 
cases before the London Pathological Society in 
1870 (Lancet, February sth, 1870).