Communicable Diseases, Table of Contents
CHAPTER XX
DISEASES OF THE SKIN
Diseases of the skin, exclusive of dermatologicalmanifestations of venereal disease, though ordinarily considered to be of minorimportance in so far as danger to life is concerned, are of great importance toan army operating in the field, by reason of the noneffectiveness they cause.This was true of past wars and equally so of the World War. During the CivilWar, for example, 74,182 cases of skin disease were reported,1divided as follows: Itch, 35,236; "skin diseases," 38,946. As tothe true nature of the condition termed itch, there was considerable doubt,though many observers declared that the only difference to be observed betweenthe reported cases of itch and scabies was one of degree; that is to say, thesoldiers neglected to apply for treatment until after they had been completelycovered with the eruption.
That the incidence of skin diseases in our Army during theWorld War was considerable also is shown by the following tabulation.
|
| Europe | Total |
| United States | Europe | Total |
Carbuncle | 1,515 | 815 | 2,330 | Impetigo | 1,456 | 1,279 | 2,735 |
Furuncle | 15,806 | 4,152 | 19,958 | Lichen | 76 | 13 | 89 |
Abscess | 11,868 | 4,461 | 16,329 | Pityriasis | 471 | 108 | 579 |
Cellulitis | 9,278 | 3,546 | 12,824 | Psoriasis | 903 | 603 | 1,506 |
Trichophytosis | 2,299 | 514 | 2,813 | Scabies | 12,099 | 22,035 | 34,134 |
Ectoporasitism | 1,703 | 1,566 | 3,269 | Skin and cellular tissue, other diseases of | 13,277 | 6,993 | 20,270 |
Dermatitis | 707 | 151 | 858 |
| 77,885 | 48,480 | 126,365 |
Eczema | 2,898 | 1,137 | 4,035 | ||||
Erythema | 1,173 | 322 | 1,495 | ||||
Herpes | 2,356 | 785 | 3,141 |
In addition to the occurrence of skin diseases, as shown above, such diseaseswere concurrent with other diseases for which admission to hospital was made, inthe following numbers:
Carbuncle | 158 | Impetigo | 328 |
Furuncle | 1,763 | Lichen | 19 |
Abscess | 3,681 | Pityriasis | 238 |
Cellulitis | 1,718 | Psoriasis | 356 |
Trichophytosis | 411 | Scabies | 2,926 |
Ectoparasitism | 741 | Skin and cellular tissue, other diseases of | 4,911 |
Dermatitis | 150 |
| 18,007 |
Eczema | 663 | ||
Erythema | 352 | ||
Herpes | 572 |
aUnless otherwise stated, all figures for the World War period are derived from sick and wounded reports sent to the Surgeon General.-Ed.
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An analysis of the above tabulations shows the relative importance of scabiesamong the skin infections. It also shows that, with the exception of scabies,there was a preponderance of diseases of the skin among our forces in the UnitedStates. This is doubtless due to the fact that not only were skin diseasesaffecting inducted men charged to the United States rates, but also skindiseases acquired by members of the American Expeditionary Forces and discoveredafter the return of these forces to the United States. It is very unfortunatethat the tabulations can not reveal the true state of ectoparasitism and itsrelationship with secondary infections of the skin. In so far as pediculosis isconcerned estimates only can be made of its prevalence, for men who were liceinfested were not admitted to sick report for purposes of disinfestation, butdisinfestation was practiced as a routine, particularly among our field forces.As an instance of the extent of pediculosis among our forces, it may be saidthat at about the time the armistice began it was estimated that among ourcombat divisions at the front the lice infestation rate was fully 90 per cent.2
In the Army in both the United States and France dermatologywas combined with urology. Thus, in the Surgeon General's Office there was asection of the division of infectious diseases and laboratories devoted tourology and dermatology. Specialists in these subjects were assigned to eachcamp and large hospital. In the American Expeditionary Forces also thesespecialties were combined. In the division of urology and diseases of the skinthere were a senior consultant, a consultant in urology, and two consultants indermatology; a consultant in urology for the base sections; a urologist for eachcombat division, for each base section and hospital center.
In the United States, wards occasionally were set asidesolely for the treatment of skin diseases. Thus a distinct dermatologicalservice was established at the base hospital, Camp Pike, Ark., in the summer of1918.3 Also a special ward was established atthe embarkation hospital, Newport News, Va., for the treatment of infectiousskin conditions.4 On the whole,however, patients with skin diseases were treated either in the general wards orin the venereal-disease wards. In the American Expeditionary Forces also therule was to treat patients with diseases of the skin in either general orvenereal wards. There were exceptions to the rule. During the spring and summerof 1918 it was possible for some of the field hospitals attached to combatdivisions to operate as skin hospitals. The 42d Division, for example, operatedsuch a hospital while in the Baccarat sector, from the latter part of April tothe latter part of June.5 Suchhospitals, however, could be temporary expedients only, and were perforcediscontinued when open warfare was begun in the latter part of the summer.
In the district of Paris, American Red Cross MilitaryHospital No. 9 was utilized largely for the treatment of skin diseases.6It was originally a Russian bath establishment containing 60 bathtubs, andhad accommodations for approximately 100 patients with skin diseases in additionto those in the genitourinary department. This was the only permanent militaryhospital in the American Expeditionary Forces that was utilized almost solelyfor the treatment of skin diseases, and base hospitals cared for such conditionsin much the same manner as was done in hospitals in the United States.
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From what has been considered above it is seen that, of allthe skin diseases, the Army was most concerned with scabies and pediculosis;also that though there was considerable pediculosis among the troops, moreespecially the American Expeditionary Forces, there was a relatively smallamount of secondary skin infection attributable to pediculi.
SCABIES
In view of the fact that scabies was so well known prior to thewar, the question may well be asked why this disease is controlled with suchdifficulty in the Army. The answer is principally in the matter of diagnosis. Incivil practice when the date of a single known exposure can be obtained, severalweeks usually elapse before the patient notices any marked itching, or seeksmedical advice. Under army conditions, particularly when men are forced to gowithout change of clothing for prolonged periods, as under conditions at thefront, the incubation period is doubtless shorter than in civil life.
In Chart LII, which shows the rate per thousand strength ofscabies, both for white and colored enlisted men in the Army in the UnitedStates, some idea may be obtained as to the amount of scabies to be anticipatedamong inducted men. Prior to the World War, the incidence of scabies in the Armywas 1.50 per thousand per annum. In the fall of 1917, however, after themobilization of the new army had begun, the rate increased to an average of 3per thousand per annum. During the greater part of the following year this ratevaried between 3 and 4 per thousand per annum for white enlisted men, and forcolored enlisted men it was below 2 per thousand except during the month of May,1918. As to the reason for the comparative freedom of the colored enlisted menfrom scabies in our cantonments in the United States during 1917 and the greaterpart of 1918, or until the time when overseas men began to return to thiscountry there is some question. It is not believed that the colored personenjoys any proportionately greater freedom from infestation by the itch mitethan the white man; doubtless, being less hyperesthetic than the white man, heexperiences less itching. Thus, there are less scratching and, consequently,less secondary infections of the skin. It is possible in this way to account forrelatively fewer colored men seeking medical advice as to scabies; furthermore,many cases of scabies among the colored men are missed through difficulty inrecognizing the condition.
Chart LIII shows the cumulative effect of front-line serviceon the existence of scabies; that is, as more and more of our combat divisionsentered the front line the rate for white enlisted men, who mostly wereconcerned, rose from 7.67 per thousand per annum in March, 1918, to 14.23 inAugust. For September, October, and November following, the rates apparentlydecreased. This decrease was more apparent than real, however, for it was duringthese months that our troops were most actively engaged in battle; there werefewer opportunities for physical inspection of the men than ordinarily was thecase; furthermore, many men with scabies, thinking themselves lice infested,failed to seek medical advice on their own initiative. On the other hand, thetrue situation as regards scabies among the combat troops is reflected in therates for this
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disease during the month of December, 1918, and in 1919. Itwas possible now to examine physically all members of the overseas forces. Infact, intensive efforts were made to eliminate all ectoparasites. Thus, in theconduct of the physical examination an essential part of the disinfestationprocess, it became possible to recognize a measurably greater number of cases ofscabies.
As to the mode of spread of scabies, it has been observed thatthe incidence of scabies greatly increases in the civil population during wars.Though in civil life scabies is usually contracted by sleeping with an infestedperson, in military life the use of infested blankets is doubtless a common modeof transmission. Other articles of wearing apparel, not ordinarily suspected,may become infested and may transmit scabies. Munro,7of the British Army, showed that gloves which aviators used in commoncould easily transmit the disease.
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DIAGNOSIS
The scabies that occurred in the Army, particularly among ouroverseas forces, differed materially from the scabies of civil life. The burrowswere not so characteristically located; itching at night was not commonlycomplained of; the condition frequently was veiled by pyodermias or thesuperimposition of lesions due to pediculosis. Burrows between the fingers andon the palms seldom were present; however, vesicles were common there, and onthe penis, papules, vesicles, and crusts usually were present. Thus, becausepediculi do not attack these regions, the presence of lesions there was of greatdiagnostic value. Impetiginous crusting of the skin over the elbows, knees, andbuttocks being practically pathognomonic of scabies, also was of diagnosticvalue. Other favored sites for the excorited lesions were on the flexor surfacesof the wrists, the anterior folds of the axill?, the abdomen, and the innersurfaces of the thighs.
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TREATMENT
The object of the treatment of uncomplicated cases of scabieswas to expose the itch mites and their larv? and then to subject them to aninsecticide. Of the several insecticides of reputed value in the cure of scabiesmedical officers placed almost sole reliance on sulphur in ointment form.
Before the ointment was applied it was necessary for thepatient to take a hot bath, using plenty of green soap applied with a bath mit.A tub bath was preferable, but since tub baths were rarely available,particularly in the American Expeditionary Forces, hot showers were used. Thelength of time given to the bath varied from 20 to 30 minutes, usually thelatter. The bathing was arranged as follows: The showers, arranged in batteriesof heads, so that groups of 36 or more men could bathe at once, were turned onfor five minutes. Each man then lathered himself thoroughly with green soap. Thewater was turned off, and the men so arranged themselves that each could scrubthe back and buttocks of the man in front. A bath mit made of Turkish towelingwas usually used for this purpose, though occasionally nailbrushes were used.Five minutes were devoted to this part of the scrubbing; then for 10 minuteseach man scrubbed the remainder of his own body. The showers were now turned on,and for 10 minutes the men stood beneath them and removed all soap. Afterthoroughly drying themselves the men applied sulphur ointment to their bodies,from their necks to the tips of their toes and fingers. To facilitate theapplication of the ointment to their backs, the men formed a ring so that eachcould apply the ointment to the man in front, in much the same manner as thescrubbing with soap was accomplished. Five minutes were given up to this. Forthe next 15 minutes each man applied the ointment to the remainder of his ownbody.
The ointment was allowed to remain on the body until thefollowing day, when the bath, as described above, was repeated. On the third daya cleansing shower was given but no ointment was applied.
In the American Red Cross Hospital No. 9, in Paris, thesulphur rub was repeated on three successive days. In a series of 300 casestreated there the relapses numbered 3, and there were but 3 cases of sulphurdermatitis.
In cases complicated by pyodermia it was necessary first tocure the complication before the severe method of treatment outlined above couldbe given. Meanwhile, the scabies could be kept in abeyance by the application ofa 10 per cent sulphur ointment.
As regards the length of time required for treatment, we haveseen that in uncomplicated cases this was from three to four days. Incomplicated cases, however, the average stay in hospital was a month.
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REFERENCES
(1) Medical and Surgical History of the War of the Rebellion,Medical Volume, Part Third, 886.
(2) Gilchrist, H. L.: Delousing the American Army in France. TheMilitary Surgeon, Washington, 1920, xlvii, No. 2, 129.
(3) Hutchins, M. B.: Skin diseases at an Army camp. Journalof Cutaneous Diseases, including Syphilis, Chicago, 1919, xxxvii, 456.
(4) Lane, C. G.: Scabies at the Embarkation Hospital, CampStuart, Newport News, Va. The Military Surgeon, Washington, 1919, xliv,No. 1, 65.
(5) Medical Department activities, 42d Division, undated.Prepared under the direction of the division surgeon. On file, HistoricalDivision, S. G. O.
(6) Knowles, F. C.: War dermatology in France and thepreventive measures taken. The Military Surgeon, Washington, 1919, xlv,200, 285.
(7) Munro, J. W.: Report of Scabies Investigation. Journalof the Royal Army Medical Corps, London, 1919, xxxiii, 1.
