136 An Introduction to Medical Mycology 



but the proper technic should be carried out to the letter. We do not advise 

 the evulsion of more than two or three fingernails. We almost never advise 

 the evulsion of toenails because reinfection nearly always takes place and 

 the procedure usually leaves the tissues so painful that the patient is kept 

 from walking. Complete evulsion should not be considered when infection 

 is due to M. albicans. 



After sterilization of the overlying and surrounding skin with tincture of 

 iodine, the paronychial tissue is infiltrated with procaine hydrochloride. 

 The free border of the nail is grasped with a pair of forceps, and by blunt 

 dissection the nail is progressively separated from its bed. Care should 

 be taken not to break up the friable nail or, when the lunula is reached, not 

 to destroy or injure the nail bed, since this would prevent or interfere with 

 the return of a normal nail. The last attachment of the nail should be sepa- 

 rated by tearing it gently across. Sterile gauze is applied with pressure 

 until all bleeding is arrested. This usually takes from 10 to 15 minutes. 

 The region is then painted with a 1 per cent aqueous solution of gentian 

 violet, and a loose dry gauze dressing is applied. Since exudation may be 

 expected, the dressing should be changed in two hours. After this a daily 

 change of dressings is usually sufficient. Gentian violet should be applied 

 each time the dressing is changed and daily for five or six days, after which 

 the dressing is usually omitted. We do not advise the use of an ointment 

 after the evulsion, particularly while exudation is still to be noted. 



(2) Roentgen therapy.— When indicated, unfiltered roentgen radiation 

 in fractional doses (90 roentgens) may be administered once weekly for 

 six weeks. Further treatment is only given if cure is imminent. 



(3) Mechanical removal of infected nail tissue.— A great deal of diseased 

 nail tissue may be removed by the physician or technician by successive 

 peeling with a Bard-Parker knife. (If care is used, a sharp blade will 

 do no harm and does save time.) It has become our practice to use this 

 method more often than formerly, repeating the procedure every two or 

 three weeks. We have become more confident of ultimate success and are 

 rarely disappointed, even in infections due to T. purpureum. As mentioned 

 previously, the use of a revolving burr is of value for the same purpose. How- 

 ever it is difficult to sterilize and the infective material is widely dis- 

 seminated. The patient should always be instructed to scrape the nail until 

 the part becomes sensitive before any application. He may use a file or a 

 piece of glass (the broken edge), and all removed nail should be collected 

 on paper and burned. 



(4) Useful applications.— 1. Chrysarobin is probably the best single 

 drug. It may be used in the strength of 20 per cent in collodion or 1 per 

 cent in chloroform. There are other ways of using the drug, but these 



