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Chapter XX

Communicable Diseases, Table of Contents

CHAPTER XX

DISEASES OF THE SKIN

Diseases of the skin, exclusive of dermatological manifestations of venereal disease, though ordinarily considered to be of minor importance in so far as danger to life is concerned, are of great importance to an 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 Civil War, for example, 74,182 cases of skin disease were reported,1 divided as follows: Itch, 35,236; "skin diseases," 38,946. As to the true nature of the condition termed itch, there was considerable doubt, though many observers declared that the only difference to be observed between the reported cases of itch and scabies was one of degree; that is to say, the soldiers neglected to apply for treatment until after they had been completely covered with the eruption.

That the incidence of skin diseases in our Army during the World War was considerable also is shown by the following tabulation.

TABLE 97.-Diseases of the skin and cellular tissue. Primary admissions, officers and enlisted men, United States Army, April 1, 1917, to December 31, 1919. Absolute numbers

 


United States

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 diseases were concurrent with other diseases for which admission to hospital was made, in the 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



Total

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 scabies among 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 United States. This is doubtless due to the fact that not only were skin diseases affecting inducted men charged to the United States rates, but also skin diseases acquired by members of the American Expeditionary Forces and discovered after the return of these forces to the United States. It is very unfortunate that the tabulations can not reveal the true state of ectoparasitism and its relationship with secondary infections of the skin. In so far as pediculosis is concerned estimates only can be made of its prevalence, for men who were lice infested were not admitted to sick report for purposes of disinfestation, but disinfestation was practiced as a routine, particularly among our field forces. As an instance of the extent of pediculosis among our forces, it may be said that at about the time the armistice began it was estimated that among our combat divisions at the front the lice infestation rate was fully 90 per cent.2

In the Army in both the United States and France dermatology was combined with urology. Thus, in the Surgeon General's Office there was a section of the division of infectious diseases and laboratories devoted to urology and dermatology. Specialists in these subjects were assigned to each camp and large hospital. In the American Expeditionary Forces also these specialties were combined. In the division of urology and diseases of the skin there were a senior consultant, a consultant in urology, and two consultants in dermatology; a consultant in urology for the base sections; a urologist for each combat division, for each base section and hospital center.

In the United States, wards occasionally were set aside solely for the treatment of skin diseases. Thus a distinct dermatological service was established at the base hospital, Camp Pike, Ark., in the summer of 1918.3 Also a special ward was established at the embarkation hospital, Newport News, Va., for the treatment of infectious skin conditions.4 On the whole, however, patients with skin diseases were treated either in the general wards or in the venereal-disease wards. In the American Expeditionary Forces also the rule was to treat patients with diseases of the skin in either general or venereal wards. There were exceptions to the rule. During the spring and summer of 1918 it was possible for some of the field hospitals attached to combat divisions to operate as skin hospitals. The 42d Division, for example, operated such a hospital while in the Baccarat sector, from the latter part of April to the latter part of June.5 Such hospitals, however, could be temporary expedients only, and were perforce discontinued when open warfare was begun in the latter part of the summer.

In the district of Paris, American Red Cross Military Hospital No. 9 was utilized largely for the treatment of skin diseases.6 It was originally a Russian bath establishment containing 60 bathtubs, and had accommodations for approximately 100 patients with skin diseases in addition to those in the genitourinary department. This was the only permanent military hospital in the American Expeditionary Forces that was utilized almost solely for the treatment of skin diseases, and base hospitals cared for such conditions in 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 all the skin diseases, the Army was most concerned with scabies and pediculosis; also that though there was considerable pediculosis among the troops, more especially the American Expeditionary Forces, there was a relatively small amount of secondary skin infection attributable to pediculi.

SCABIES

In view of the fact that scabies was so well known prior to the war, the question may well be asked why this disease is controlled with such difficulty in the Army. The answer is principally in the matter of diagnosis. In civil practice when the date of a single known exposure can be obtained, several weeks usually elapse before the patient notices any marked itching, or seeks medical advice. Under army conditions, particularly when men are forced to go without change of clothing for prolonged periods, as under conditions at the front, the incubation period is doubtless shorter than in civil life.

In Chart LII, which shows the rate per thousand strength of scabies, both for white and colored enlisted men in the Army in the United States, some idea may be obtained as to the amount of scabies to be anticipated among inducted men. Prior to the World War, the incidence of scabies in the Army was 1.50 per thousand per annum. In the fall of 1917, however, after the mobilization of the new army had begun, the rate increased to an average of 3 per thousand per annum. During the greater part of the following year this rate varied between 3 and 4 per thousand per annum for white enlisted men, and for colored 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 men from scabies in our cantonments in the United States during 1917 and the greater part of 1918, or until the time when overseas men began to return to this country there is some question. It is not believed that the colored person enjoys any proportionately greater freedom from infestation by the itch mite than the white man; doubtless, being less hyperesthetic than the white man, he experiences less itching. Thus, there are less scratching and, consequently, less secondary infections of the skin. It is possible in this way to account for relatively fewer colored men seeking medical advice as to scabies; furthermore, many cases of scabies among the colored men are missed through difficulty in recognizing the condition.

Chart LIII shows the cumulative effect of front-line service on the existence of scabies; that is, as more and more of our combat divisions entered the front line the rate for white enlisted men, who mostly were concerned, rose from 7.67 per thousand per annum in March, 1918, to 14.23 in August. For September, October, and November following, the rates apparently decreased. This decrease was more apparent than real, however, for it was during these months that our troops were most actively engaged in battle; there were fewer opportunities for physical inspection of the men than ordinarily was the case; furthermore, many men with scabies, thinking themselves lice infested, failed to seek medical advice on their own initiative. On the other hand, the true situation as regards scabies among the combat troops is reflected in the rates for this


554

disease during the month of December, 1918, and in 1919. It was possible now to examine physically all members of the overseas forces. In fact, intensive efforts were made to eliminate all ectoparasites. Thus, in the conduct of the physical examination an essential part of the disinfestation process, it became possible to recognize a measurably greater number of cases of scabies.

CHART LII

As to the mode of spread of scabies, it has been observed that the incidence of scabies greatly increases in the civil population during wars. Though in civil life scabies is usually contracted by sleeping with an infested person, in military life the use of infested blankets is doubtless a common mode of transmission. Other articles of wearing apparel, not ordinarily suspected, may become infested and may transmit scabies. Munro,7 of the British Army, showed that gloves which aviators used in common could easily transmit the disease.


555

DIAGNOSIS

The scabies that occurred in the Army, particularly among our overseas forces, differed materially from the scabies of civil life. The burrows were not so characteristically located; itching at night was not commonly complained of; the condition frequently was veiled by pyodermias or the superimposition of lesions due to pediculosis. Burrows between the fingers and on the palms seldom were present; however, vesicles were common there, and on the penis, papules, vesicles, and crusts usually were present. Thus, because pediculi do not attack these regions, the presence of lesions there was of great diagnostic value. Impetiginous crusting of the skin over the elbows, knees, and buttocks being practically pathognomonic of scabies, also was of diagnostic value. Other favored sites for the excorited lesions were on the flexor surfaces of the wrists, the anterior folds of the axillæ, the abdomen, and the inner surfaces of the thighs.

CHART LIII


556

TREATMENT

The object of the treatment of uncomplicated cases of scabies was to expose the itch mites and their larvæ and then to subject them to an insecticide. Of the several insecticides of reputed value in the cure of scabies medical officers placed almost sole reliance on sulphur in ointment form.

Before the ointment was applied it was necessary for the patient 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. The length of time given to the bath varied from 20 to 30 minutes, usually the latter. The bathing was arranged as follows: The showers, arranged in batteries of heads, so that groups of 36 or more men could bathe at once, were turned on for five minutes. Each man then lathered himself thoroughly with green soap. The water was turned off, and the men so arranged themselves that each could scrub the back and buttocks of the man in front. A bath mit made of Turkish toweling was usually used for this purpose, though occasionally nailbrushes were used. Five minutes were devoted to this part of the scrubbing; then for 10 minutes each 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. After thoroughly drying themselves the men applied sulphur ointment to their bodies, from their necks to the tips of their toes and fingers. To facilitate the application of the ointment to their backs, the men formed a ring so that each could apply the ointment to the man in front, in much the same manner as the scrubbing with soap was accomplished. Five minutes were given up to this. For the next 15 minutes each man applied the ointment to the remainder of his own body.

The ointment was allowed to remain on the body until the following day, when the bath, as described above, was repeated. On the third day a cleansing shower was given but no ointment was applied.

In the American Red Cross Hospital No. 9, in Paris, the sulphur rub was repeated on three successive days. In a series of 300 cases treated there the relapses numbered 3, and there were but 3 cases of sulphur dermatitis.

In cases complicated by pyodermia it was necessary first to cure the complication before the severe method of treatment outlined above could be given. Meanwhile, the scabies could be kept in abeyance by the application of a 10 per cent sulphur ointment.

As regards the length of time required for treatment, we have seen that in uncomplicated cases this was from three to four days. In complicated cases, however, the average stay in hospital was a month.


557

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. The Military Surgeon, Washington, 1920, xlvii, No. 2, 129.

(3) Hutchins, M. B.: Skin diseases at an Army camp. Journal of Cutaneous Diseases, including Syphilis, Chicago, 1919, xxxvii, 456.

(4) Lane, C. G.: Scabies at the Embarkation Hospital, Camp Stuart, 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, Historical Division, S. G. O.

(6) Knowles, F. C.: War dermatology in France and the preventive measures taken. The Military Surgeon, Washington, 1919, xlv, 200, 285.

(7) Munro, J. W.: Report of Scabies Investigation. Journal of the Royal Army Medical Corps, London, 1919, xxxiii, 1.