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Col. Franklin H. Grauer, MC, Samuel T. Helms, M.D., and Theodore H. Ingalls, M.D.
Part I. Fungus Infections
The story of the control of fungus infections in World War II is a series of paradoxes. Although these infections, in themselves, seldom produce serious consequences, they were responsible, in all theaters of war including the Zone of Interior, for a heavy loss of days from duty. They also required an undue amount of medical attention in outpatient clinics as well as in hospitals, where they required an undue bed occupancy. Their prevention and control were a rather hopeless task. To begin with, medical officers were confronted with a varying amount of infection, both active and latent. All the circumstances were favorable to the development of recurrence, reinfection, and relapse. Fresh infections in new hosts also required treatment.
Even in civilian life, the prevention and control of fungus infections are difficult. In the circumstances of warfare, the task was close to impossible for the reason that the best methods of prevention are based on personal hygiene, and personal hygiene in time of war is always difficult and frequently entirely impractical.
The Medical Corps, from its peacetime experience, was fully aware of the nature of the problem which it would encounter in wartime. In 1941, U.S. Army statistics indicated that skin diseases, including the mycoses, were responsible for 8.2 percent of all admissions and for 7.2 percent of all days lost from disease; the figures relate to hospitals and quarters and not to hospitals only. Since most dermatological patients are ambulatory and are managed in outpatient dispensaries rather than in hospitals and quarters, the chances are that the statistics just cited do not give a true picture of the real incidence of dermatological disease.
In the Manual of Dermatology, which was published in 1942, Maj. Gen. James C. Magee, The Surgeon General, called attention to the importance of dermatological disease in military life in his foreword to this volume. Diseases of the skin, he pointed out, are of greater importance. in military service
than they are in civilian life. Although they cause few fatalities, they result in a considerable loss of effective manpower and in the partial incapacity of a significant number of personnel of many commands.
Although ground troops, because of the particularly unfavorable conditions under which they operated, had more dermatophytosis than any other component of the Army, skin diseases were also a problem in the Army Air Forces, in both flying and nonflying personnel. These diseases were less of a problem in the Navy because personal hygiene was reasonably simple to maintain on shipboard; showers and frequent changes of clothing were usually possible. On submarines, especially when they were operating in tropical waters, high temperatures and intense humidity produced less favorable conditions.
Coccidioidomycosis.-During World War II, the only deep fungus infection of military significance was coccidioidomycosis, which affected only troops stationed in the southwestern part of the United States, particularly the San Joaquin Valley in California and certain portions of Arizona and Texas.
These areas, in which the disease was endemic, were ideal for flying because of their almost continuously clear weather. They also served admirably for the desert training of armored troops. Areas which were known to be heavily infected were avoided, as far as possible, but military necessities sometimes dictated their extensive use. Since infection is usually acquired by the inhalation of spores present in the dust in dry and sandy regions, the troops stationed in these areas were unavoidably exposed. The infectiousness of some areas was discovered only when the disease appeared in the troops stationed there or when positive reactions to the coccidioidin test occurred in troops previously stationed or bivouacked there.
Coccidioidomycosis, like other deep fungus infections, is not primarily a dermatologic problem since the involvement of the lungs, of other viscera, and of the lymphatic system is more important than involvement of the skin. The entire subject is discussed in another volume of the history of the Medical Department in World War II and therefore needs no further consideration here.1
EARLY CONCEPT OF THE CONTROL OF FUNGUS INFECTIONS
The opinions of The
Surgeon General concerning the prophylaxis of fungus infections of the skin
before the United States
entered World War II were contained in three
publications: (1) War Department Circular No. 47, dated
Field Manual 8-40, Field Sanitation, 1940. In substance, these publications contained the following material:
The spread of the causal agents of ringworm infection is by person-toperson contact. Tinea cruris is also transmitted by clothing, towels, bathroom floors, and toilet seats. Ringworm of the extremities is spread by contact of the bare feet with floors, mats, benches, and chairs in bathrooms, gymnasiums, clubs, and swimming pools. It is also spread by towels and by slippers, shoes, and other articles of clothing worn next to the skin. The fungi may persist for a long time in and on these various objects.
Control measures for all forms of ringworm infection are based on the same general principle; namely, to prevent the bare skin of noninfected persons from coming into contact with objects which may have been contaminated by infected persons.
Daily baths and the use of a drying powder in the axillary regions and on the perineum after the bath are essential measures of prevention of tinea cruris. Equal parts of boric acid, zinc oxide, and starch make a satisfactory powder.
The feet should be carefully inspected at the regular monthly inspection and at all other foot inspections. All cases of trichophytosis and of tinea cruris should be promptly reported. Even slight cases should be thoroughly treated to eliminate the sources of infection. Acute cases of tinea cruris require hospitalization in order to prevent spread. If an unusual number of cases of ringworm or tinea cruris appear, sanitary precautions should be investigated to make sure that they are being rigidly enforced.
To prevent ringworm of the extremities, the feet should be kept dry, and the areas between the toes should be given particular attention after the bath. If there is a tendency to perspiration, issue foot powder should be applied twice daily. Formaldehyde and other drying solutions should be used only on the advice of a medical officer.
If ringworm of the extremities is prevalent in a command, special precautions are required.
Disinfection is considered the most effective control measure. Bathhouse floors and equipment, including mats, benches, and chairs, are to be scrubbed daily, first with soap and water and afterward with some disinfectant, such as the solution of calcium hypochlorite used for footbaths or 2 percent cresol. Shower baths should be provided with removable duckboards, which are scrubbed and exposed to sunlight, for several hours each day.
Bathhouses should be equipped with footbaths located at the entrance of the showers and sufficiently large to insure that it would be impossible not to step into them before and after the shower. When possible, different tubs should be provided for use before and after the bath. The tubs should be constructed of concrete or rubber, since solutions of calcium hypochlorite
are affected by metal and wood, and should be at least 6 inches deep. The reasons for the use of the tubs should be carefully explained.
The exchange or common use of towels, gymnasium suits, and similar articles is to be avoided unless they have been thoroughly disinfected by boiling or in some other manner. Leather and rubber goods can be disinfected with cresol solution. Shoes can be disinfected by pouring 1-percent thymol solution in gasoline or alcohol into them and allowing it to evaporate. Individual rubber slippers were recommended to prevent contact of the bare feet with infected surfaces.
Regulations for the use of swimming pools include restriction on the number of bathers allowed in them at any one time and between intervals of cleaning and draining; a preliminary, thorough soap-and-water bath; a preliminary footbath in calcium hypochlorite solution; exclusion from the pool of all ill persons; and continuous disinfection of the water, preferably with a chlorine solution.
Prewar instructions for the prevention of ringworm were based on the use of chlorine, certain salts of which were thought to have potent fungistatic and fungicidal properties. Sodium thiosulfate had originally been used for footbaths but had not been proved efficient. In the Panama Canal Department, in fact, the commanding general had asked permission to discontinue its use.
Sodium thiosulfate was replaced by grade A calcium hypochlorite, which was used in solutions of 1 ounce of the dry chemical to each gallon of water, to yield 0.5 percent of available chlorine. The solutions were to be changed daily.
Early in 1942, when it became evident that high-test calcium hypochlorite was likely to become a critical material, The Quartermaster General inquired of The Surgeon General whether sodium hypochlorite could be substituted for it in the footbaths used to prevent fungus infections. Maj. (later Col.) William S. Stone, MC, Chief, Sanitation and Hygiene Branch and Laboratory Branch, Preventive Medicine Division, Office of the Surgeon General, replied that it could be substituted if the Quartermaster was prepared to handle a liquid product and if it was used in strengths sufficient to achieve and maintain a satisfactory concentration of chlorine. On 23 June 1942, with the publication of War Department Circular No. 261, the use of high-test calcium hypochlorite was restricted to water purification. On 27 July 1942, The Surgeon General informed the Commanding General, Army Ground Forces, that arrangements had been made with The Quartermaster General to supply sodium hypochlorite and standard bleach for disinfection of footbaths; both agents, it was stated, were satisfactory when they were used in sufficient concentration to produce not less than 50 p.p.m. of residual chlorine.
On 27 July 1943, Maj. Charles H. Miller, Jr., MC, Sanitation Branch, Preventive Medicine Division, Professional Services, Office of the Surgeon General, noted that, since the use of high-test calcium hypochlorite had been restricted, no definite policy had been laid down by the Preventive Medicine Division concerning a stock solution for footbaths. Major Miller suggested to Lt. Col. (later Col.) Arthur P. Long, MC, Acting Chief of the Sanitation Branch, that chlorinated lime be standardized for this purpose, since it was not a critical item, was easy to produce and ship, and was fairly stable.
On 17 August 1943, The Surgeon General recommended to the Commandant, Medical Field Service School, Carlisle Barracks, Pa., that solutions in footbaths be maintained at from 50 to 100 p.p.m. available chlorine, about one-fiftieth of the strength advised in FM 21-10, Military Sanitation and First Aid, and FM 8-40, Field Sanitation, which were then being revised. In the same letter, it was suggested that practical tests be carried out at the School to determine how frequently solutions in footbaths would have to be changed to maintain efficient concentration. It was further suggested that a routine of prevention be devised which would not be unduly burdensome.
The tests, which were carried out in the Department of Military Sanitation at the Medical Field Service School, were reported on 19 November 1943, by Maj. (later Lt. Col.) Cecil H. Connell, SnC, as follows:
1. Hypochlorite solutions require replenishment after 48 to 72 hours if the footbaths stand in the ordinary shower room without use.
2. Solutions which originally contain only 100 p.p.m. available chlorine must be replaced within an hour after they have been used by from 10 to 15 men. This requirement implies such close supervision as to make solutions in this strength impractical.
3. Even at an initial concentration of 1,000 p.p.m. available chlorine, no more than 40 to 50 men should use a footbath in a 24-hour period without replenishment of the solution.
4. Solutions must not be exposed either to direct sunlight or to bright diffuse sunlight.
5. Solutions of 1,000 p.p.m. available chlorine prepared from chloride of lime or sodium hypochlorite in water originally containing only 200 p.p.m. bicarbonate alkalinity are more stable than equivalent solutions prepared from grade A calcium hypochlorite. There is very little difference in the stability of solutions similarly prepared to provide 100 p.p.m. available chlorine. The use of higher concentrations, however, will raise the pH of the solutions to such a level that their fungicidal value will be affected.
Further studies directed toward the buffering of solutions were recommended. These studies were not carried out. On 4 January 1944, in reply to a request from the Office of the Surgeon General for a comment on this proposal, Dr. J. Gardner Hopkins (p. 90) stated that he did not consider the investigation warranted for the following reasons:
1. Latent infections were already so widespread among the troops that the value of attempting to prevent the transfer of infection from man to
man was highly questionable. Supposedly new infections were for the most part probably exacerbations of old latent infections.
2. The hypothesis that dermatophytosis is contracted in shower baths remained to be proved. The necessity of disinfecting the feet after the shower therefore was highly questionable.
3. The effectiveness of a footbath of satisfactory chlorine content at the proper hydrogen ion concentration was also unproved. Furthermore, it was completely impractical to suppose that soldiers would fulfill the necessary requirements for such baths, even if the method were effective.
4. While hypochlorite was highly effective in vitro against suspensions of fungus spores, it was apparently very ineffective clinically.
Dr. Hopkins suggested that, if such an experiment should be undertaken, the strongest and most potent disinfectant available be used for the studies. If it were found to reduce the incidence of dermatophytosis, a search could be conducted later for a cheaper substitute. He also suggested, realistically, that it might be well, since footbaths were apparently to be continued, to devise an inexpensive method of insuring that they contained more active chlorine.
The Manual of Dermatology, prepared under the auspices of the Division of Medical Sciences, National Research Council, and published in 1942, which represented the consensus of dermatological opinion at the time, gave the first indication that the former theories of transmission and the former reliance upon disinfection of the feet were no longer fully acceptable.
Predisposing causes of dermatophytosis of the feet were listed as excessive sweating, circulatory instability or vascular disease of the extremities, long marches, the use of heavy shoes, prolonged wearing of shoes, and prolonged immersion of the feet. Both the incidence and the severity of the condition were stated to be greater in hot, moist climates.
Instructions for prophylaxis were substantially those already outlined, with the following three additional instructions:
1. Prophylaxis for the purpose of preventing transmission of fresh fungus infections was highly overrated. The crucial factor was individual susceptibility to infection. Some persons would acquire ringworm, no matter what the efforts to avoid it, and others would not acquire it despite repeated exposure.
2. The use of sodium hypochlorite or sodium thiosulfate footbaths near shower rooms was not always practical and was of doubtful value in preventing infections.
3. Sterilization of shoes by placing them in a closed container with a sponge soaked in formalin was of doubtful value and should be employed only if there was evidence of actual spread of contagion from man to man or if shoes which had been worn were reissued.
War Department Technical Manual, Guides to Therapy for Medical Officers, on the care of the feet, which was published on 20 March 1942, recommended disinfectant footbaths and formalin fumigation of presumably infected shoes. As late as May 1944, the same policies were still in effect.
In November 1944, the policy concerning the use of disinfectant footbaths began to change. In a note published in the Bulletin of the U.S. Army Medical Department, it was pointed out that hypochlorite footbaths had been adopted by the Medical Department, on the basis of early reports of their value, in 1931. Studies by Major Connell at the Medical Field Service School (p. 87) and by Dr. Hopkins and his associates at Fort Benning, Ga. (pp. 91-92) indicated that this method of disinfection was unlikely to be effective because of (1) the variable rates of decrease in concentration of effective fungicidal solutions, a property common to all solutions used in footbaths, and (2) the limitation of range of effective concentrations, a property common to chlorine solutions.
The note in the Bulletin also pointed out that-
1. Even if solutions used in footbaths killed all free spores present, a certain proportion would escape because they are encased in the keratin of epidermal scales.
2. Any solution which would dissolve keratin rapidly enough to kill the encased spores would also dissolve the horny layer of the sole and produce a severe dermatitis.
3. The keratin-encased spores are tracked onto floors adjacent to footbaths, subsequently become freed from the scales, sporulate, and, finally, serve as the main source of reinfection.
In view of these facts, it was suggested that the emphasis in prevention of dermatophytosis be transferred to mechanical methods of cleaning shower rooms and barracks floors by using water under pressure, scrubbing with brushes and detergents, and exposing duckboards and flooring, whenever practical, to direct, unfiltered sunlight.
In November 1944, in a revised memorandum issued by the Department of Military Sanitation, Medical Field Service School, and dealing with the control of athlete's foot, the article from the Bulletin which has just been cited was used as a reference. In this revision, as in the article in the Bulletin, the emphasis was placed upon mechanical methods of cleaning. Duckboards were not recommended unless floors were dirty or in poor repair; then alternate sets were to be used daily. Detailed directions were given for personal hygiene, cleanliness of clothing, disinfection of shoes by formalin, use of wooden sandals in barracks and shower rooms, use of issue foot powder, early medical treatment of abrasions and fissures, and frequent, careful foot inspections.
War Department Circular No. 146, issued 17 May 1945, directed that the use of footbaths be discontinued and placed the responsibility for the
prevention of athlete's foot upon careful personal hygiene and mechanical cleansing measures.
By July 1942, the importance of dermatophytosis in the expanding U.S. Army was so fully realized that a special research project on its prevention and treatment was undertaken by the Committee on Medical Research, Office of Scientific Research and Development, National Research Council.2 This project was conducted under an Army contract with the College of Physicians and Surgeons, Columbia University. The principal investigator, Dr. Hopkins, Professor of Dermatology, had had a wide experience in clinical investigation, particularly in the fields of mycology and bacteriology. The use of Army personnel for the investigation was authorized at the Station Hospital, Fort Benning, Ga., by the Commanding General, Army Service Forces.
In the statement of the problem on 10 July 1942, it was pointed out that, although the various dermatoses of the feet which had come to be known as athlete's foot had existed in World War I, they had not been serious. They had also, sometimes in association with tinea cruris, been sources of considerable discomfort and disability in Panama and the Philippines, even before the war, and were likely to become major problems in the fighting in the Far East.
The subjects proposed for investigation were (1) the incidence of dermatoses of the feet, (2) the etiology of these dermatoses, especially the types of fungi and bacteria concerned, and (3) the development and testing of methods of treatment of these dermatoses as well as of fungus infections of the groin and trunk.3 At this time, although considerable data were available on the new fungicides and antiseptics recommended for the prevention and treatment of these conditions, few reliable data were available on the results accomplished by these agents. It was thought that the studies would be most significant if they could be carried out on infantrymen on active duty in a hot climate, and, for that reason, Fort Benning was selected as a promising location for the investigation.
In his annual report for 1942-43 to the Committee on Medical Research, Office of Scientific Research and Development, National Research Council,
Dr. Hopkins summarized the concepts of prophylaxis current when the investigation was begun, as follows:
1. Prevention of infection is difficult to study in groups of men since most of them, including, probably, the most susceptible, are already infected. It may be an impractical aim in any group. If, however, prevention of infection is possible, it seems more hopeful to attack the parasite where its presence is known (that is, on the feet), rather than on floors and other objects which may or may not be contaminated. The efficacy of prophylactic footbaths has not yet been established, though heavy growths of nonpathogenic molds and bacteria have been recovered from hypochlorite footbaths after a few hours' use. Methods of sterilizing shoes, from which dermatophytes have been recovered, as well as floors must also be investigated.
2. Prevention of activation of latent cases seems, on present evidence, more practical than the prevention of infection. Hygienic measures include daily washing of the feet; careful drying, especially between the toes; removal of shoes and socks during rest periods, with elevation of the feet; and the use of wooden sandals or other open footgear in barracks, although no real evidence exists that there is danger in going barefoot.
The progress of the investigation is best described by summarizing the various progress reports made by Dr. Hopkins and his associates.
Report, 1 September 1943
In this report, data were presented derived from observations made on various techniques of prophylaxis.
Materials and methods.-Three companies (E, F, and G) of an infantry regiment were studied. A platoon of Company G served as the control group. The men of Companies E and F were examined once a month, though, for various reasons, chiefly training activities, furloughs, and transfers, it was never possible to examine an entire company or to follow the same group of men over the 4-month period of the investigation. From 65 to 148 men, or a mean of 101, from each company were available at each examination, and the percentages recorded were based on the actual number of men included at each examination.
Symptoms and signs were recorded. Any complaint of burning was classified as pain. Redness and desquamation of the toes varied only slightly from company to company and from month to month, as might be expected in a group of infantrymen observed under the same circumstances. Slides from toe webs and other suspected areas were examined for fungi.
Footbaths.-Footbaths of high-test, calcium hypochlorite, in concentration to provide 50 p.p.m. of available chlorine, were used in the study of Company F. This company had shown a fairly uniform incidence of dermatophytosis in the 3 months preceding the study. During the period of study, there was no significant diminution in the number of men complaining of pain or itching or showing signs of intertrigo, and the proportion of fungi demonstrable in scrapings increased from 34 percent to 55 percent. The control company in the same battalion, which did not use footbaths, showed no significant change in the rate of dermatophytosis.
The absence of effect may have been due to failure of the men to follow instructions, but more probably, it was due to the following facts:
1. Disinfectant baths after showers would be unlikely to exert a notable effect in a group of men of whom 40 percent were already infected.
2. Hypochlorite deteriorates so rapidly that it is unlikely to be an effective disinfectant. Profuse growths of saprophytic fungi and bacteria were cultured from these baths after they had been in use a few hours.
Powder.-A powder containing 3 percent benzoic acid, 10 percent tannic acid, and 0.25 percent aerosol in talc was issued to all the men of Company E who were present at the first examination, whether or not they showed signs of mycosis. The objective was to treat incipient cases. This powder had been somewhat effective in relieving complaints and in causing the disappearance of fungi from scrapings when it was issued to men attending sick call. It had neither effect in this investigation, and it was concluded that it had not been used systematically.
Ointments and powders.-Company G was divided into four groups, one of which served as a control group while the other three were used to test the effects of treatment agents applied as ointment and powder. The objective was to treat carriers effectively and thus reduce the incidence of infection in the group as a whole. The attempt did not succeed, perhaps because infection was already so widespread, though another factor also had to be taken into consideration, that most of the men probably did not persist in treatment after their acute symptoms were relieved. Pain and itching were significantly reduced in the treated group, and some men became fungi-negative, but there was no lasting reduction in the percentage of infections, even in the treated group.
There were two conclusions from these initial studies:
1. The prophylactic effect of the treatment of carriers could be studied only if persistence of treatment could be enforced by military discipline.
2. Even if it could be enforced, it was doubtful that further spread of the infection could be prevented in groups which were already heavily infected.
Report, 18 January 1944
A memorandum to the
Director, Infantry Board, Fort Benning, Ga.,
dated 18 January 1944, reported the results of the study on foot powders
The powders tested included benzoic acid powder in various formulas, undecylenic acid powder in various formulas, and 10 percent sodium propionate powder.4 Two platoons used Government-issue powder, two talc
powder, and two no powder at all. All of the powders contributed to the comfort of some of the men, but none was superior to the Government-issue powder.
In evaluating this report, it was pointed out, the following three facts should be taken into consideration:
1. The tests were made in winter, when the incidence of dermatophytosis does not normally increase.
2. Precise scoring of the indefinite signs and symptoms of dermatophytosis is not possible.
3. A single microscopic examination for fungi is not conclusive, the error being at least 20 percent.
Publication, June 1944
Dr. Hopkins and his associates published the results of their studies at Fort Benning in the June 1944 issue of the Bulletin of the U.S. Army Medical Department. This paper contained a detailed discussion of the possibility that any fresh outbreak of dermatophytosis might mean either a new infection or a recrudescence of a latent infection. At this time, there was serious doubt that exogenous infection was an etiological factor of significance. Clinical evidence suggested that the incidence of dermatophytosis in troops was in the neighborhood of 80 percent. Surveys of various infantry organizations had shown incidences ranging from 52 to 78 percent. Microscopic evidence, which is notoriously unreliable on single examinations, had shown an incidence of 30 to 50 percent. The high carrier rate diminished the probability of success by any practical means of prevention of infection. The corollary was the prevention of activation; that is, the treatment of incipient and latent cases before they became active.
The following plan was proposed:
1. At monthly inspections, men should stand with their backs to the examining officer and raise each foot, so as to expose the sole and the toe webs.
2. Every man showing evidence of dermatophytosis should be given preparations for self-treatment, such as benzoic acid paint, salicylic acid and Merthiolate paint, or ISB (tincture iodine 7 percent, 15 cc.; salicylic acid 3 gm.; benzoic acid 6 gm.; camphor 10 gm.; and alcohol q.s. ad. 100 cc.) paint.
3. Each infected soldier should be required to report for reinspection until his feet were perfectly clear. Then he should be instructed to use one of the preparations just mentioned on his feet every week throughout the warm season, to prevent relapse. All the evidence favored the view that the patient's own feet are the source of infection, which flares up under the stress of hot weather, heavy shoes, and violent exercise.
4. Since infection from floors, baths, and laundries, and reinfection from shoes, socks, and similar sources of infection, had not yet been definitely excluded, disinfection of floors and showers, protection of the feet by wooden
sandals, and the application of one of the fungicides just listed was recommended, especially among recruits.
Earlier, Dr. Hopkins had reported that the powder issued through supply channels did not seem to be extensively used. Both medical and line officers were apparently under the impression that it should be used only in active cases, in which it seemed to have little value. Important principles of prevention were (1) to make the diagnosis of dermatophytosis at inspection rather than sick call; (2) to differentiate dermatophytosis from other dermatoses of the feet; (3) to begin treatment promptly and to persist in it without interruption as long as there was evidence of infection and for a considerable time thereafter, especially during warm weather; (4) to use weak, nonirritating agents, for their fungistatic rather than fungicidal effect, and to keep the skin continuously under their influence; (5) to individualize the treatment of severe, recalcitrant cases; and (6) to utilize all possible hygienic measures. The adherence to these principles was more important than the use of any single agent.
Report, 15 July 1944
In a report dated 15 July 1944, Dr. Hopkins pointed out again that efforts to prevent contagion had not proved effective in the tests carried out at Fort Benning and that efforts to prevent activation by systematic treatment of latent or incipient cases had also met with no demonstrable success, probably because of lack of cooperation by the soldiers involved in the experiment.
The high incidence of dermatophytosis was considered to be caused by damage of the stratum corneum by violent exercise in hot weather in heavy shoes. The application of various substances, especially lecithin and carnauba wax, apparently hardens the skin surface and increases its water repellency, and efforts in this direction were being continued, though no clear-cut prophylactic effects had yet been accomplished. Improvement of foot hygiene was believed to hold the most promise.
It was recommended that ineffectual attempts to prevent contagion should be abandoned and that efforts be directed toward improved foot hygiene and persistent treatment of latent and incipient cases, since the prevention of contagion was apparently entirely impractical. At a conference on fungus infections of the skin held by the Division of Medical Sciences, National Research Council, acting for the Committee on Medical Research, Office of Scientific Research and Development, 20 June 1944, Dr. Hopkins had made a report on the investigation at Fort Benning, and the conference had concluded that footbaths were neither effective nor necessary and had recommended that their use be discontinued.
Report, 31 December 1945
In his report of 31 December 1945, Dr. Hopkins reiterated the importance of latent or subclinical dermatophytoses; the ineffectiveness of footbaths; the
failure of attempts to free the feet of fungi by prolonged treatment after signs and symptoms had disappeared; and the fact that there were only two hopeful methods of prophylaxis, the constant use of suppressive measures and the improvement of the physiologic condition of the skin.
Powders were regarded as the most practical agents for suppressive treatment because of their safety in packing and their ease of application. None of the agents tested showed any advantage over the Government-issue powder already in use. On the other hand, most of the undecylenic acid powders used in the tests contained only 2 percent zinc undecylenate. A small group of patients treated with an undecylenic acid powder with a 10 percent content showed a slightly reduced incidence of mycoses. Attention was called to the report by Sulzberger and his associates (pp. 96-97) which showed that powders containing 18 percent zinc undecylenate and 2 percent undecylenic acid were definitely effective.
Report of Council on Pharmacy and Chemistry, American Medical Association
In a report of the Council on Pharmacy and Chemistry, American Medical Association, issued in July 1945 and participated in by Dr. Hopkins, the following conclusions had been reached:
1. Evidence from the laboratory does not settle the question of recurrence versus reinfection. Some observers have cultured fungi from apparently normal feet, while others have failed. All dermatologists are agreed that fungi can remain for long periods within diseased nails without provoking an inflammatory reaction. The nails thus constitute an innocent-looking reservoir of infection. Fungi are known to have lived as long as 433 days in dry scales, which suggest that at least some attacks are to be explained by reinfection.
2. Because fungi have been isolated from shoes, clothing, floors, and similar objects, the role of reinfection cannot be disregarded.
3. Some observers believe that the solution of the problem lies in the species of fungus concerned. Epidermophyton inguinale infections are readily cured; a second attack must be a reinfection. Trichophyton purpureum infections are extremely resistant to treatment; a second attack is likely to be a recurrence. Succeeding attacks of Trichophyton interdigitale infection may be either a reinfection or a recurrence. The corollary of these observations is that prophylaxis should have two objectives, to destroy the fungi on the skin completely and to destroy them in shoes and other environmental locations.
4. Footbaths are of no value. Good results reported from their use probably fail to take into account the increased attention to foot hygiene which follows attention to the subject.
U.S. NAVY STUDIES
Two studies conducted under the auspices of the Research Division, Bureau of Medicine and Surgery, U.S. Navy, on the effectiveness of certain preparations in the prophylaxis and treatment of fungus infections of the feet and groin are pertinent in this connection.
The first of these studies, which was conducted between September and December 1944, involved a total of 808 prisoner volunteers at the U.S. Naval Disciplinary Barracks, Hart's Island, N.Y. The circumstances of the test were highly favorable because the subjects could be kept under precise and uninterrupted observation.
Each foot of each subject was regarded as a separate test object, and it was thus possible to make a direct comparison of the effect of two measures employed in the same individual without regard to such variable factors as differences in individual susceptibility to infection, intensity of exposure, reaction to infection, and tendency to spontaneous recovery. Powdered preparations were used exclusively because they were easy and safe to carry about and store, they were stable, and they were convenient to use and apply. A powder also has the additional advantage of absorbing moisture from the skin surfaces of the areas in which fungi usually thrive.
Active fungus infections developed in personnel tested as follows: In 23 (8.85 percent) of 260 men who had no treatment at all; in 7 (8.33 percent) of 84 men who wore an impregnated sock on one foot; in 28 (11.16 percent) of 251 men who used a boric acid-salicylic acid powder on one foot; in 8 (3.10 percent) of 258 men who used propionate powder on one foot; and in 3 (1.07 percent) of 281 men who used undecylenic acid-undecylenate powder on one foot.
These observations suggested that the use of both propionate powder and undecylenic acid powder afforded some degree of protection against fungus infections, with the latter agent somewhat more effective. The results, perhaps inconclusive in themselves, were supported by the results of therapeutic studies which indicated corresponding trends for each of the agents studied. Essentially the same results were apparent when tests were carried out with these agents during the continuous wearing of shoes over a 7-day period.
The second Navy study was an investigation of the feet under field conditions in Florida, from March 1945, the beginning of the hot season, until the latter part of August. The study was conducted by the paired-foot technique and with test ointments as well as powders. The results were as follows:
Of 4,720 unselected men examined at the beginning of the study, 1,124 (23.8 percent) had clinical evidence of fungus infection of the feet, and 201 (4.26 percent) had clinical evidence of fungus infection of the groin.
Of 4,194 men free from infection at the beginning of the investigation, active fungus infections of the feet were acquired during the 8-week period of training by (1) 387 (28.0 percent) of 1,384 men who formed a control
group and received no treatment, (2) 20 (14.8 percent) of 135 men who used sodium propionate powder, (3) 64 (7.9 percent) of 814 men who used calcium-zinc propionate powder, (4) 98 (15.1 percent) of 648 men who used boric acid-salicylic acid powder, (5) 48 (4.0 percent) of 1,213 men who used undecylenic acid powder.
In the study of prophylactic measures in infections of the groin, of 4,785 men free of infection at the beginning of the study, active infections were acquired during the training period by (1) 164 (10.3 percent) of 1,598 men who formed a control group and received no treatment, (2) 24 (2.9 percent) of 815 men who used calcium-zinc propionate powder, (3) 31 (4.2 percent) of 731 men who used boric acid-salicylic acid powder, (4) 10 (0.7 percent) of 1,450 men who used undecylenic acid powder.
In both of these tests, undecylenic acid powder showed significant superiority to all other fungistatic agents tested.5 From the therapeutic standpoint, all agents showed effectiveness, with undecylenic acid powder significantly superior. In the treatment of the more severe infections of the groin and feet, undecylenic acid ointment was significantly superior to propionic acid ointment.
Studies on prophylaxis of dermatophytosis which were concerned with footgear had two objectives, the sterilization of presumably infected footgear and the use of special types.
Sterilization of Footgear
Formaldehyde (formalin) had been recommended for sterilization of shoes in the prewar instructions for the prevention of dermatophytosis (p. 89). The authors of the Manual of Dermatology (Drs. Pillsbury, Sulzberger, and Livingood) questioned the usefulness of this method (p. 88).
At a conference on dermatophytosis held by the Division of Medical Sciences, National Research Council, acting for the Committee on Medical Research, Office of Scientific Research and Development, on 8 November 1943, considerable attention was devoted to this subject. In a report on methods of sterilization of shoes being repaired for reissue, it was stated that the use of neither chlorine nor formaldehyde gas had proved satisfactory for this purpose. Tests then in progress showed that formaldehyde in solution, while
it did not insure complete destruction of pathogens, was somewhat more satisfactory. A search was under way for an antiseptic or germicide with which shoe leather could be impregnated to inhibit and, preferably, to kill pathogens during the life of the shoe.
An evaluation of various disinfectants for this purpose, conducted by the Office of the Quartermaster General, showed that pieces of leather could be effectively sterilized with formaldehyde vapor, though the effectiveness of the agent was influenced by the amount of moisture in the atmosphere. The gas was also slow to penetrate cracks and crevices in shoes. Formaldehyde solution had proved consistently effective on dirty shoes inoculated with a medium containing a suspension of spores incubated to establish growth. The use of the solution was followed by the application of a solution of sodium bisulfite, to neutralize all free formaldehyde, and then by a bath in a solution of 0.5 percent pentachlorophenol in oil and water. This method, which had the approval of The Surgeon General, was to be instituted at two shoe-rebuilding plants within the next few weeks.
It was agreed that these studies should be continued, since investigation of penitentiary personnel had showed that the use of chemically treated shoes had reduced the incidence of infection materially. At the conference on fungus infections held on 20 June 1944, it was also concluded that shoe sterilization was desirable until further information was available concerning factory-rebuilt shoes. Shoes turned in for exchange, which did not require repair, were not to be sterilized, since available evidence did not indicate that footgear in this condition transmitted fungus infections. In an article in the Journal of the American Medical Association for 14 July 1945, techniques of disinfecting previously worn shoes with formaldehyde were described for both small lots and large numbers.
Special Types of Footgear
Clogs.-Clogs were employed in a number of installations, but never officially. In July 1943, a representative of The Surgeon General stated that reports from whole units provided with clogs for use in shower rooms had been very favorable. In the March 1945 issue of the Bulletin of the U.S. Army Medical Department, details were given for their construction from salvaged material available at any camp.
Sandals.-There is no doubt that aeration is essential in the hygiene of the feet and that the heavy, impermeable footgear of the infantryman, particularly when it is worn in hot climates, influences the incidence of mycoses. A preliminary study of the use of open-toed sandals at Eglin Field, Fla., in May 1944, produced such good results in the 20 subjects of the test that the Air Surgeon requested the Army Air Forces Proving Ground Command to conduct a similar test on a larger scale. The request was prompted by the fact that 30 percent of the patients treated in the Eglin Field dispensary between May and October the previous year had come because of foot infections.
A well-controlled test was therefore carried out for a 2-month period on 900 control personnel and 1,200 experimental personnel. The experimental group wore sandals which had leather soles and uppers and rubber heels, usually without socks. The control group wore the regular Army footgear.
Of the 2,100 men examined during the week ending 15 May 1944, at the beginning of the study, only 19 percent showed no visible evidence of infection, and 23 percent had infections severe enough to be of medical concern. At the end of the 2-month period of testing, only 3.5 percent of the men who wore sandals had evident infections, and in most of them the disease was of no great medical concern. The men, for the most part, liked the sandals. Only one instance of trauma which might have been prevented by wearing service shoes occurred during the test.
Among the group wearing regular-issue shoes, 28 percent had severe infections. Sixteen men from the control group had to be hospitalized for infections of the feet during the test period, as against only one man from the experimental group; 208 days of hospitalization were charged to the 900 men in the control group, as against only 13 days to the 1,200 men wearing sandals. Many men whose feet had improved while they were wearing sandals had serious infections again when they resumed wearing Army shoes.
The results of this experiment suggested that it would be quite feasible to eliminate dermatophytoses completely from an organization by the use of sandals, the exercise of foot hygiene, and a certain amount of medical treatment.
How practical the general use of sandals would be was, of course, another matter. They are not practical for combat troops, for marching, or in terrain infested either by mosquitoes or by hookworm larvae.6
As a result of the experiment at the Army Air Forces Proving Ground at Eglin Field, a recommendation was sent to The Quartermaster General on 24 April 1945 by Brig. Gen. Charles R. Glenn, Deputy Air Surgeon, that a satisfactory type of sandal be developed for issue to troops under certain specified conditions. The Eglin Field experiment and Dr. Hopkins' evaluation of it were cited in support of this recommendation. The recommendation was endorsed by Brig. Gen. James S. Simmons, MC, Director, Preventive Medicine Service, Office of the Surgeon General, on 4 May 1945, but the sandal suggested had not yet been developed when the war in the Pacific ended 3 months later.
Studies on the use of sandals in the Pacific theater are described under that heading (p. 104).
Jungle boots.-In June and July 1944, at the request of Maj. (later Lt. Col.) John C. Brinsmead, Infantry Board, Fort Benning, Dr. Hopkins and
his associates participated in a test with fabric-top jungle boots, to determine the effects of aeration of the feet. Three types of boots were used: Type A, with leather sole and canvas vamp and upper; type B, with leather sole and canvas upper; and type C, regulation jungle boot. Four groups, each consisting of 20 men, participated in the test. Twenty men wore type A boot, 20 men type B, and 20 men type C. The fourth group wore type A boot on one foot and type B boot on the other. The test groups, carrying full field equipment, marched through swamps for several hours each day, their feet being dry only when their shoes were removed at night. The feet were examined when the shoes were issued and at 5-day intervals during the 30 days of the test.
The test did not prove conclusive, one reason being that no control group wore regular-issue combat shoes. No outstanding prophylactic or curative effects followed the use of any type of boot worn, and none of the changes in the feet could be attributed solely to the footgear used. Any curative or prophylactic effect due to aeration was masked by the constant immersion, which, curiously, seemed to have some beneficial effect, although it provided the very conditions usually considered favorable for the growth of fungi. The effect of jungle boots on dermatophytosis under dry conditions was not determined.
A similar study conducted by the Navy during field training at Camp LeJeune, N.C., was reported in October 1944. The test, which was designed to evaluate a special tropical boot with nylon uppers, was carried out on 200 men, half of whom wore these boots while the other half wore the standard Marine Corps field shoes and leggings. Each man went through a rigorous 6-week training period, which included marching and amphibious landings. The feet were examined weekly. At the end of the field trials, the feet of the men who wore the experimental boots were in better condition, with much less maceration and scaling, than the feet of the men who wore the standard Marine Corps boots. The experimental boots were also in better condition than the standard boots.
FUNGUS INFECTIONS IN
In the Canal Zone, where the heat is constant and the humidity is high, dermatophytosis, as might have been expected, was the outstanding dermatological problem among both military and civilian dispensary patients. During the year ending on 30 June 1944, 28 percent of the new patients seen in the dermatology clinic at the Gorgas Hospital, Canal Zone, had tinea infection as the basis of their chief complaints, and 34 percent of the dermatological patients admitted to the hospital had dermatophytosis. The percentages would have been even more impressive if they had been calculated on the total number of clinic visits and the total number of hospital-stay days. It
was just as important in the Canal Zone that all medical officers, regardless of their special field, be familiar with the clinical appearance and practical management of fungus infections as it was that medical officers in the Pacific be aware of malaria.
Preventive measures, which applied to the whole Caribbean Defense Command, began with the provision of hot running water at all barracks at permanent posts, camps, and bases. Adequate supplies of fresh water were maintained at all outlying installations and positions except at Salinas, Ecuador, and Seymour Island, Galapagos Islands, where salt-water showers were provided. Two sets of duckboards were provided for each shower; they were used on alternate days, so that the set not in use could be sunned. Disinfectant footbaths proved as unsatisfactory in the tropics as elsewhere in the prevention of fungus infections of the feet.
The most important preventive measure was careful personal hygiene. All personnel were thoroughly instructed in such matters as daily baths, with careful drying, with a clean towel, especially of the interdigital spaces, the armpits, and the groin; frequent changes of underclothing; and boiling of clothing worn next to the body. The care of his clothing was a responsibility of the soldier himself; many cases of epidermophytosis had been traced to the wearing of soiled, perspiration-soggy clothing, especially fatigue uniforms.
Special attention was given to the feet. Instructions were to wash them twice daily, with soap and warm water, then to apply powder freely, especially between the toes. Ordinary borated talcum powder was extremely satisfactory, but the kind of powder used was not as important as its frequent, regular application. The use of an astringent on the feet, such as rubbing alcohol, was also thought to be a useful preventive measure.
Cotton socks were preferable to woolen socks. Instructions were to change them daily and, if the feet perspired excessively, twice daily. It was recommended that, whenever practical, perforated shoes and open sandals, which permit free ventilation, should be used.
European Theater of Operations
As early as 3 April 1943, the question of fungus infections of the feet was discussed in the European Theater of Operations. On that date, Lt. Col. (later Col.) Donald M. Pillsbury, MC, Senior Consultant in Dermatology, Office of the Chief Surgeon, ETOUSA (European Theater of Operations), expressed the opinion that footbaths in shower rooms were unnecessary because (1) their effectiveness was in question, (2) soldiers would avoid using them whenever they could, (3) the incidence of fungus infections of the feet was low, and (4) proper foot hygiene and the use of foot powder would be sufficient to prevent such infections.
On 10 June 1943, Colonel Pillsbury visited Depot G-25 with Maj. (later Col.) Ralph R. Cleland, SnC, to study the incidence of ringworm infection in this service installation. The men on this post were doing exceptionally
heavy work in depots, machine shops, and on construction jobs, and the proportion doing sedentary work was low. The men wore regular-issue shoes, many of which had rubber soles, with very heavy British-issue socks. Recommendations were made for frequent changes of socks; regular use of issue foot powder; bathing the feet daily during warm weather and drying them well; regular, careful cleaning of showers; sterilization of Red Cross hospital slippers with formalin vapor or methyl bromide; and regular inspections of the feet. It was also recommended that an investigation be made to determine whether or not the use of rubber-soled shoes was increasing the incidence of fungus infection and that the situation be checked at intervals from the Office of the Chief Surgeon, Headquarters, ETOUSA.
On 27 July 1943, Colonel Pillsbury reported to the Chief Surgeon that a study of 2,257 men in Eastern, Western, and Southern Base Sections showed that only 20 percent had entirely normal feet. Forty percent had slight inflammatory changes, which for the most part could not be classified as true ringworm, and 30 percent had moderate to severe fungus infections. The latter group served as definite potential sources of infectiveness. British-issue socks and rubber-soled shoes were thought to be responsible for a fair number of these cases. Not more than a quarter of the men questioned used foot powder regularly, because of individual laxity, failure of noncommissioned officers to emphasize the importance of foot hygiene, and occasional inadequate supplies. Hypochlorite footbaths had been of no apparent value in preventing fungus infections.7
Recommendations to improve this situation included discontinuance of footbaths, increased emphasis on foot hygiene, discarding of British-issue socks by men who showed any signs of inflammatory skin changes, and mechanical cleaning of shower rooms. Attention was called to Medical Bulletin 9, September 1943, Office of the Chief Surgeon, Headquarters, ETOUSA, which described the types of socks available in the theater and directed that medical officers familiarize themselves with them and recommend the use of the proper socks for special types of work and weather.
On 6 March 1944, Circular Letter No. 34, Office of the Chief Surgeon, Headquarters, ETOUSA, stated that too many patients with complications of simple skin diseases were being hospitalized and that the load of admissions must be decreased. Fungus infections of the feet, it was pointed out, could be prevented by frequent washing, careful drying, regular use of foot powder, the use of proper socks, frequent changes of socks, immediate attention to superficial lesions, and careful examination of the feet at inspections. Overtreatment, it was stated, was responsible for more disability than any single skin disease.
The Manual of Therapy published in the European theater in May 1944, just before the invasion of the Continent, outlined the care of acute infections
of the feet and recommended, in the chronic phase, the personal measures of foot hygiene which have already been described.8
On 19 June 1944, in response to a request from the Division of Medical Sciences, National Research Council, for a statement on fungus infections of the skin which could be read at a forthcoming conference (p. 97), Colonel Pillsbury wrote as follows:
1. Fungus infections of the feet had not proved as great a problem in the European theater as in the Zone of Interior or in tropical theaters, probably because of the cooler environment. Local outbreaks could usually be traced to improper footgear or poor foot hygiene.
2. Fungus infections of the groin were common but were seldom disabling unless they had been complicated by overtreatment or by chronic follicular infections.
3. All inflammatory eruptions of the hands and feet were likely to be diagnosed originally as fungus infections. Actually, only about 50 percent of these eruptions were of fungus origin, while in some cases the underlying fungus infection was obscured by pyoderma, reactions to treatment, or a contact dermatitis.
4. Prophylactic measures were entirely practical. They included personal cleanliness, careful drying of the feet, and regular use of foot powder. Footbaths were of no value, and soldiers did not use them unless they were forced to.
5. Almost all acute attacks were caused by increased growth of the fungi which were old and respected members of the individual's own skin flora. A patient who had sustained two or three acute attacks of a fungus infection was never again the same, dermatologically speaking, especially if there had been a pyogenic complication.
After outlining the methods of management used in fungus infections, Colonel Pillsbury concluded with the statement that fungicides then available hardly deserved the name. The solution of the problem as it then existed, he said, was (1) to disseminate knowledge concerning the intelligent use of well-tested compounds which did as little harm as possible and (2) to lend every encouragement to studies which would yield basic information. He did not consider the comparison of the effects of various preparations as yielding the desired information.
Additional memorandums and circular letters issued in the theater and personal instruction all reiterated that the prevention of fungus infections depended upon careful foot hygiene and that footbaths should not be used in the hope of preventing them.
Several observers in the European theater believed that there was a correlation between the presence of fungus infections and the development of trenchfoot, but this was not a generally accepted theory.
Southwest Pacific Area
As late as July 1945, Brig. Gen. (later Maj. Gen.) Guy B. Denit, Chief Surgeon, U.S. Army Forces, Pacific, stated that dermatoses remained one of the greatest single problems of hospital admissions and evacuations in the Pacific. In one evacuation hospital, skin conditions constituted 54.8 percent
of the evacuations for general medical causes; they were chiefly chronic eczematoid lesions superimposed on epidermophytoses and trichophytoses.
In September 1944, Dr. Hopkins, acting as Technical Observer, Office of Field Service, Office of Scientific Research and Development, began an extensive tour of the medical installations in the SWPA (Southwest Pacific Area) to study dermatoses, particularly dermatoses of fungus origin. His tour extended from Brisbane, Australia, to Leyte, Philippine Islands, and included general and station hospitals, outpatient dispensaries, and battalion aid stations. Time did not permit microscopic or cultural studies, and statistical evidence concerning the incidence of dermatoses could not be secured because of lack of knowledge of the numbers of troops from which hospitalized patients were derived.
Dr. Hopkins' report to General Denit, dated 13 March 1945, contained the following observations:
Dermatophytosis of the feet was the cause of much discomfort, but in rear areas it was seldom disabling. In base and station hospitals well removed from the front, the incidence of intertrigo of the toes on dermatological ward was lower than would be found in a group of healthy soldiers on active duty. In base dispensaries, fungus infections of the feet were more frequent, but no more frequent than in military dispensaries in the Zone of Interior. In battalion and regimental aid stations for troops actually in combat and in clearing companies directly to the rear, these infections were frequent and were often severe. The shoes could not be removed for days at a time in the frontline, and there was little opportunity to care for the feet, with the result that there was apparently a significant amount of complete disability.
In most of the cases diagnosed as epidermophytoses, no fungi could be demonstrated. In only a few cases did it seem reasonable to assume that the eruptions had originally been of fungus origin and then had become secondarily infected, though the possibility, of course, could not be positively excluded in many cases.
As in the Zone of Interior, few attacks seemed to be caused by external infection or reinfection from shoes or clothing. Most of the patients brought their infections with them in latent form, and they flared up under the difficult climatic conditions. The routine use of a mild fungicide, such as the Government-issue foot powder, was a more effective prophylactic measure than hypochlorite baths or disinfection of shoes, socks, and shower-room floors. Powder was more convenient to use than ointments.
Dr. Hopkins considered that the wearing of sandals would be an excellent preventive measure. He suggested that sandals might be issued and permission given to wear them during hours and in areas defined by the surgeon of each organization. They should have thick soles and toe guards, so that their use would not interfere with the programs for the control of malaria and hookworm.
The incidence of tinea cruris was high, especially among troops in active training or in combat. It was conceivable that the disease handicapped the men in the performance of their duties, though only occasionally did it cause complete disability or require hospitalization.
Tinea corporis was frequent and often involved the arms and legs also. It was sometimes severe enough to require hospitalization. In almost every hospital visited, there were 3 or 4 patients with generalized ringworm among every 100 or 200 dermatological patients. These infections were no more severe, and probably no more numerous, than those encountered at Fort Benning in August and September, but in the Pacific they were perennial. The etiological factor was unevaporated sweat, which was due, in turn, to the wearing of clothing in hot, humid weather. In U.S. troops, the eruption was often encountered in a band about the belt and over the buttocks, where the clothing was thickest. Like tinea cruris, tinea corporis was often refractory to treatment.
An interesting experiment had been conducted in the Pacific by the 43d Infantry Division while it was in a rest area. Three hundred men with unclassified skin diseases, a large number of whom presumably had fungus infections, were kept on the beach for 4 hours daily without either clothing or shoes. They were free to bathe, lie in the sun, or exercise as they chose. In 80 to 90 percent of these cases, the skin conditions cleared up with no other treatment. The obvious curative factor was evaporation of perspiration and the keeping of the skin as dry as possible. Direct exposure to the sun possibly had an added sterilizing or tonic effect. Dr. Hopkins recommended that permission for the men to go naked to the waist during the sunny hours of the day might be a good preventive practice, which would not militate against the antimalarial program. A change in the fabric of the Army shirt and the use of some more loosely woven fabric, such as was used in the Australian Army shirt, was another possibility.
Observations in the SWPA suggested a possible individual immunity to dermatophytosis. In any platoon or company, perhaps 10 percent of the men would never have any indication of the disease although they mingled freely with infected men and usually employed no prophylactic measures. The cause of this apparent immunity was unknown, and it was Dr. Hopkins' opinion that a study of it might be rewarding.
An interesting part of Dr. Hopkins' report concerned the group of men who, after the Leyte landings, stood, marched, and slept for long periods in flooded rice paddies without removing their shoes. A significant amount of temporary total disability developed, and many of the men had to be carried out when evacuation became possible. This episode was reported to Dr. Hopkins by Maj. James R. Webster, MC, at the 54th General Hospital near Humboldt Bay, Dutch New Guinea, which received many of these casualties. During the acute stage, Major Webster stated, no fungi could be found in the
lesions, which suggested that the condition was essentially bacterial. The fact that in many instances fungi could be demonstrated after acute symptoms had subsided suggested that, in at least some of these cases, the bacterial infection was secondary to a fungus infection and that the essential pathogenic factor was maceration of the stratum corneum by prolonged immersion. Dr. Hopkins agreed with Major Webster that it was unfortunate that some of these patients had been evacuated with the diagnosis of immersion foot.9
On the ground that greasing the feet had proved a useful preventive measure in the trench warfare in Europe in 1918, an experiment was set up, under the direction of Maj. (later Lt. Col.) John J. Mohrman, MC, Surgeon, 43d Infantry Division, before the Luzon landings. One group of men greased their feet with petrolatum, another with liquid petrolatum, and still another with a fatty acid ointment.
Since the Luzon landings were made on dry terrain, the chief purpose of the experiment was defeated, but a few useful facts were determined. Sixteen enlisted personnel of the 56th Portable Surgical Hospital, who applied foot powder to one foot and liquid petrolatum to the other, had no pronounced discomfort and no visible damage to the skin during the landings, although the heat was extreme. Similar results were evident in another group of 16 men from the same installation who applied foot powder to one foot and undecylenic acid ointment to the other. Most of the men in both groups preferred the powder, but a few thought that oiling had kept them more comfortable. These observations were regarded as sufficient to show that it would be entirely safe to oil the feet prophylactically in future landings on terrain expected to be flooded, in the expectation that the number and severity of the skin infections and other conditions encountered after the Leyte landings might be diminished.
Since much of the fighting in World War II, as well as much of the training, took place in warm or tropical climates, the dermatophytoses became extremely important, and research in this field received additional emphasis. As a result of practical experience and research studies, concepts changed. The role of bacteria assumed greater importance in the etiology of the infectious intertrigoes once considered to be caused entirely by fungi. Opinion regarding repeated attacks of dermatophytosis swung away from the older
concept of reinfection to the newer one of relapse brought about by violent exercise, the wearing of impervious shoes, unevaporated sweat, and maceration of the skin.10
The acceptance of these theories meant that many of the measures of prevention which were commonly used before the war and in the first years of fighting were not only ineffective but were also potentially harmful. Footbaths in the prophylaxis of dermatophytosis fell into disrepute. Emphasis was placed upon strict attention to foot hygiene, with measures to keep the feet clean and dry. These measures included the use of perforated shoes or sandals, when practical; the use of socks capable of absorbing moisture; and the regular use of a drying, mildly fungistatic foot powder. Undecylenic acid and zinc undecylenate, which were developed during the course of the war, proved more effective fungistatic agents than any previously available and had the additional advantage of not causing irritation.
FRANKLIN H. GRAUER,
Part II. Impetigo
The situation relating to impetigo at the beginning of World War II differed little from that in World War I, and the actual experience with the disease did not differ materially from that in civilian medical practice, with the exception of experience in the tropics and advances in treatment with antibiotic drugs. The question of its epidemiology is still unsettled. There is no proof as to whether Staphylococcus aureus or Streptococcus hemolyticus is the primary or causative organism, and when cultures have been made of impetiginous lesions the results have only served to becloud the issue. Preventive measures are still considered to be personal hygiene, cleanliness, sanitation, and education. The disease was never a serious military problem. The occurrence varied from theater to theater, being somewhat more frequent and important in the tropics.
Military reports and publications deal with old, or widely accepted, knowledge. The only new scientific facts or discoveries have to do with the use of sulfanilamide and other sulfa derivatives, locally or orally, and with penicillin preparations, locally or parenterally.
The conclusion that impetigo contagiosa was not frequently encountered and that the incidence was so low that the disease never seriously threatened or disturbed the effectiveness of command may justifiably be drawn.
The average number of days lost per admission for the years 1942, 1943, and 1945 was 12. The noneffective rate for the 4 years 1942 to 1945, inclusive, was 0.04 per 1,000 average strength.
Incidence data were available for the years 1944 and 1945 only. These figures are for both primary and secondary diagnosis. There was a total of 29,611 cases for the 2 years, of which 5,935 were in the continental United States and 23,676 outside continental United States. The average rate per annum, per 1,000 average strength, was 1.93 for all theaters and areas; 0.86 for continental United States; 2.80 for oversea areas; 1.41 for the European theater; 2.69 for the Mediterranean theater; 1.64 for the Middle East; 4.29 for CBI (China-Burma-India theater); 6.64 for SWPA; 3.14 for the Central and South Pacific Area; 0.51 for North America; and 0.89 for Latin America.
Pacific areas.-From the figures in table 9, it is clearly seen that impetigo presented a more serious problem in tropical than in temperate climates. A report from the South Pacific Base Command, dated 15 April 1945, indicates that impetigo and similar diseases were more frequent, of greater severity, and more difficult to control under tropical conditions, especially in combat troops.11 Reporting to the Office of Scientific Research and Development in March 1945, Dr. Hopkins remarked that impetigo was encountered in the Southwest Pacific Area, particularly under battle conditions. The disease responded to treatment by penicillin ointment, but, if inadequately treated, it persisted longer in the tropics than in temperate zones. Impetigo was common in the following areas: New Guinea, Guam, the British Solomons, Nauru, the Fiji Islands, Samoa, the Wallis and Horn Islands, the Marquesas, and the Hawaiian archipelago.12 During 1945, many cases of impetigo were reported by the 224th Quartermaster Battalion as occurring over preexisting heat rash.
In 1944, impetigo contagiosa was reported 16 times in a total of 232 cases of dermatitis in SWPA, and for the same year, the 119th Station Hospital, New Guinea, reported 5 cases in a series of 284 skin cases.13
European Theater of Operations.-Of 2,697 admissions to hospitals for diseases of the skin and cellular tissue reported in the European theater in November 1943, 78 were for impetigo.14 This constituted an annual admission rate of 0.88 per 1,000 strength out of a total of 30.43 for all skin diseases.
On 6 March 1944, the Chief Surgeon, ETOUSA, called attention to the fact that too many patients with complications of simple skin diseases were being admitted to hospitals in the European theater and warned that delay in treatment led to chronicity.15 Unit commanders were advised that cleanliness of clothing and body were necessary preventive measures.
1Includes North Africa.
Mediterranean Theater of Operations.-Capt. (later Maj.) Emory Ladany, MC, discussing dermatology in an Army station hospital in Italy, stated that the majority of cases of pyodermia in Italy were of a most superficial type and that many of the impetigo contagiosa cases could be traced to local barber shops. Another report from the 61st Station Hospital at Foggia, Italy, listed pyodermia as the third most common dermatological condition encountered at that hospital.16
However, on the basis of an analysis of 3,000 consecutive cases from a military dermatological practice in which he found 131 cases of impetigo and ecthyma, (4.4 percent), Lt. Col. Harry W. Woolhandler, MC, concluded that these diseases hardly warranted consideration as contagious diseases.17
The treatment of impetigo is discussed in detail in the Manual of Dermatology, prepared in 1942 for use in the Army at the instigation of the National Research Council.18
The introduction of the sulfonamide drugs contributed to the successful treatment of impetigo and thus indirectly to the prevention of its spread. In May 1943, Bigger and Hodgson of the Royal Army Medical Corps reported on a study of the bacteriology of impetigo contagiosa.19 They made cultures from lesions of 130 patients from service personnel who had the disease and concluded that it is rarely, if ever, caused by streptococci of any type but is caused in most cases by Staph. aureus. The great majority of cases were cured by local treatment with sulfonamides within 10 days. Sulfonamides applied locally also helped to prevent or cure secondary infections.
Dr. Alex J. Steigman, in January 1942,20 wrote that the increase in the incidence of scabies and impetigo had created an important medical and economic problem in industry and in the Armed Forces. This motivated him to report on an improved method of therapy which reduced the length of time required for treatment. Regarding the bacteriology of impetigo as an unsolved problem, he found that sulfathiazole, locally applied, was the most successful agent because it was effective against both Staph. aureus and Str. hemolyticus. This method reduced by half the time of treatment of 51 cases in a London hospital.
Carslaw and Swenarton21 reported in August 1941 that 20 months' experience had shown impetigo and scabies to be the most common and troublesome skin disease in the British Navy. They shortened treatment of impetigo by use of sulfanilamide ointment and cleansing emulsions, having previously treated scabies with benzyl benzoate. Other published articles recount similar successful treatment with these drugs.22
When penicillin became generally available, it was found to be more effective and to expedite the time of cure.23 Treatment of impetigo, ecthyma, impetiginized eczema, and so forth, is discussed in the Bulletin of the U.S. Army Medical Department of September 1945.24 The use of sulfonamide
ointment is advised against, and penicillin locally and parenterally is advocated.
The dangers of sulfonamides25 and of penicillin sensitization are not to be dismissed lightly. Neither of these drugs can always be depended upon as certain and safe cures. It should also be remembered that many drugs which are used safely in the Untied States are not tolerated in the tropics. Therapy should be mild. Phenol, mercury, sulfer, and keratolytic agents should be avoided in the tropics.
SAMUEL T. HELMS, M.D.
PART III. Scabies
General experience, 1942-45.During the years 1942 through 1945, the incidence of scabies measurably increased in most theaters of military operations (table 10), and generally progressively higher rises in rates of infection were recorded in the U.S. Army. The problem was especially acute after the invasions of north Africa and Europe; in those areas, rates were highest. Exceptions to the general trend were observed only in the Middle East, where numbers of cases (237 during the 4-year period) were inconsequential, and in the SWPA (Australia), where the rate was highest in the first year of war; with this one exception, rates for scabies in the Pacific were so low as to constitute more of a routine problem in diagnosis and therapy than one of prevention. Indeed, by 1943, these rates had fallen below those of continental United States, and a report from the SWPA for May 194426specifically noted that cases of scabies, pediculosis corporis, or pediculosis pubis had been seen rarely and that only 22 cases had been diagnosed as scabies among 14,038 hospital admissions, 977 of which had been for skin conditions.
Incidence was lowest in the Pacific, CBI, and North America; yet, a field medical bulletin from the CBI (China-Burma-India theater) in 1943 indicated that scabies was ever present but that its incidence was held down to an inappreciable amount by monthly physical examinations and isolation practices. The data of table 10 substantiate the first, if not the last, part of the assertion. As far away from the pressure of refugees, crowding, and shortages as the Caribbean area, one survey of 5,000 troops made in 194427 revealed that 7 percent of military personnel were infected with scabies and that there was a tendency for scabies in the tropics to be limited to the genitalia and surrounding skin areas. That tendency was observed in all years of the war and in all theaters. Its epidemiological significance is unquestionably in relation to scabies as a venereal infection. This and other aspects of epidemiology and problems of treatment and control are most clearly illus‑
trated by the data and experience of the Mediterranean and European theaters.
1Includes North Africa.
Prewar incidence in Europe.-The behavior of scabies as it involved the U.S. Army in Europe and in the Mediterranean areas is best given against a prewar and early war background, civilian as well as military. As the condition was not a notifiable disease, it is impossible to obtain data denoting incidence for the period from 1930 to 1938. Mellanby,28 however, showed that a rough index of prevalence could be obtained by determining the frequency of scabies in patients admitted to hospitals for infectious disease in five English cities and presented hospital data in three large suburban boroughs with more than half a million inhabitants and in two smaller, quasi-rural boroughs. When patients were admitted to those hospitals, the presence of scabies was recorded in addition to the disease for which they were admitted. Thus, for all practical purposes, such data are in the nature of a survey and, although the selection of patients is undoubtedly biased, nonetheless it confirms clinical impressions of an increasing prevalence of the condition as Great Britain moved to mobilization and declaration of war. Further reasons for the increase in scabies before the actual outbreak of hostilities are speculative, but propagation of the infection afterward, during a period of great disruption of normal family life, with the aggregation of people in air-raid shelters and the like, is readily understandable.
By 1942, scabies was frequent among both civilians and troops in the United Kingdom. It is hardly surprising that rates among British soldiers in their own homeland remained consistently higher than rates among U.S.
troops (chart 1). Nor is it surprising that, in 1943, rates among Americans in the European theater (England) rose; indeed, they reached the highest incidence observed in any theater until 1945 (table 10). A pronounced seasonal exacerbation in the winter months of 1942 and 1943 is observed in chart 1. Table 11 reveals a similar seasonal rise in rates in the European and Mediterranean theaters during the coldest months of 1944. That the influence of season is less important than the influence of social factors consequent to winter crowding and slowing of battle activity was demonstrated by later experience and by the sharp rise in incidence for the year 1945 when high rates were observed in the summer months that followed V-E Day.
1Includes Alaska and Iceland.
A rising trend in the prevalence of scabies among civilians during the early war years occurred in France much as in England. At l'Hôpital de Saint-Louis, Paris, which specializes in skin diseases, a sharp rise in the number of cases of scabies treated was noted immediately following the influx of refugees during the summer of 1940; the hospital treated 9,859 cases in 1939 and 24,559 cases in 1940.29 In 1941, 65,875 cases of scabies, and in 1942, 102,645 cases, were treated in the hospital; this was a tenfold increase in the course of only 3 years. Similar rises assuredly occurred in other countries of Europe, north Africa, and the Middle East. No data are at hand concerning the incidence of scabies among Arabs in Morocco, but the contacts between U.S. troops and the indigenes of north Africa were distinctly limited in 1943 as compared with those that existed in 1944 with the civilian population in Italy. The admission rates for scabies in the Mediterranean theater during these 2 years were 2.56 and 5.37 per 1,000 average strength, respectively.
European and Mediterranean Theaters of Operations.-Although throughout the whole war the greatest number of cases (56,499) were diagnosed in the continental United States, the most pressing problems in terms of numbers, rates, and urgency-for example, among replacement troops about to go into the line-occurred in Europe, especially in Italy, the United Kingdom, France, and Germany. In those countries, U.S. troops were situated among civilian populations that had been longest at war and had consequently experienced a high prevalence of scabies. In the U.S. Army overseas, spread of scabies gained momentum in 1943 and initial rates of 1942 had almost tripled by 1945. That most of the cases were contracted overseas was demonstrated by surveys of recently arrived troops which consistently showed relative, if not absolute, freedom from this skin disease.30 The good condition of new arrivals was assuredly due in large part to the successful screening and processing at points of embarkation. Although not outstandingly high, the rates of admissions for scabies in the United States were high enough to have increased the incidence of scabies in Europe, had the disease gone undetected and untreated. Rates for scabies in the Mediterranean and European theaters stayed consistently above those of other theaters and of the continental United States. The difference in rates in favor of the United States is far greater than is apparent in the data of table 10, because a significant percentage of cases contracted overseas were credited to continental United States after arrival home and because many more patients went unreported in the war zone than in the Zone of Interior.
While it is true that scabies, like pediculosis and venereal disease, tended to flourish among troops and civilian populations when bathing facilities and soap were scarce, propagation of the disease was associated with, rather than
caused by, such shortages. In the continental United States, where such facilities were far superior to those of oversea stations, reported incidence and annual admissions for scabies, although generally lower than those in Europe, were, nonetheless, too high for mere cleanliness to have been the critical factor.
One principle that emerged clearly through the years 1942-45 is that the frequency of scabies in military personnel is dependent, among other factors, on the frequency of scabies among civilians and on opportunity for fraternization. For example, some 2,130 cases were reported to the Surgeon, MTOUSA (Mediterranean Theater of Operations), in April, May, and June 1945. The rates among combat troops for these 3 months were 22, 43, and 57 per 1,000 average strength, respectively, while the rates among service troops during the same 3 months were significantly higher; namely, 54, 56, and 77.31 An effect of fraternization is implicit. That transmission was for the most part by direct contact was shown in the early part of the war by Mellanby,32 who stated : "In 63 experiments using underclothing and blankets scabies was transmitted twice only, although everything was done to favour transmission. In none of the experiments (25 in all) using blankets alone, was infection transmitted, and * * * under normal conditions blankets can seldom be responsible for the transmission of the disease. On the other hand, a small number of the experiments have shown that transmission by comparatively slight personal contact may be readily accomplished." This view was confirmed by field experience in which conversations and clinical evidence indicated that infection was contracted in the same manner as was a venereal disease in more than one-half the cases.
Given a large enough primary focus of infection among close-knit troops, however, an undetermined but significant amount of indirect spread undoubtedly occurs. For example, one report from the Southwest Pacific Area revealed 5 cases of scabies among 59 enlisted men in a guard detachment.33 On investigation, it was found that members of the guard were using beds and bedding indiscriminately.
TREATMENT AND RESEARCH, 1941-45
Failure to cope adequately with the two most important facts-that scabies is essentially a contact disease and in large part a venereal disease-was assuredly the most significant deficiency of the military program which was developed to control scabies during World War II. Much of this deficiency arose from the situation of the moment. However, too much time and effort was given in the early years of the war to a search for a perfect scabicide and to disinfection of clothing, whereas basic remedies were already
satisfactory and commonsense hygiene and a simple clothing exchange would have sufficed in ordinary circumstances to combat indirect spread of infection. Not enough attention was given to the plight of civilians and, in particular, to civilian contacts of infected soldiers; to the indoctrination of the soldier about the disease; and to joint command responsibilities for control of the disease-especially among resting troops, replacement troops, and service troops.
Overemphasis on clinical aspects of scabies contributed to an oversimplified concept of the disease as being due to a single cause (Sarcoptes scabiei hominis) and, hence, amenable to a single solution. It followed that, if instructions were rigid and therapy meticulous, the disease should be controllable. Thus, the first North African directive on treatment of scabies, dated 27 November 1942,34 stated: "As soon as the medical officer has made the diagnosis the patient will be painted from neck to feet with benzyl benzoate emulsion or solution * * *." The directive gave 12 additional unequivocal instructions-most of them clear, incisive commands-even specifying that 2 fluid ounces were to be applied with a brush and that the patient was to shower and be rechecked once weekly for 6 weeks. The difficulty was not merely that benzyl benzoate was for all practical purposes unobtainable, but the directive implied that control of scabies was a matter of treatment; it made no allowance for the social characteristics of the human host and the dynamic contribution of his shifting social environment. Location of source of infection and treatment by focal attack is essential to control.
In the interest of an improved rationale for treatment, English research of 1940 and 1941 came to focus largely around the behavior, in vivo distributions, and in vitro survival of S. scabiei;35 effective ways to administer sulfur; and the penetration of oily and alcoholic vehicles developed for applying benzyl benzoate.36 The merits of sulfur, long since established, were fully confirmed, and benzyl benzoate was added to the dispensary list of therapeutics; it was seldom to be found on dispensary shelves during the North African and Mediterranean campaigns.
Productive as such research was-and it was undoubtedly the most productive on the subject throughout the war-it was concerned primarily with treatment and secondarily with the inadequacy of "stoving" measures directed against transfer by fomites; it hardly came to grips with prevention. A realistic appreciation of the complexity of supply aspects is more evident
in British directives than in U.S. Army directives of 1942; the former contain fewer orders and more homely but practical observations.
The procedures used in the control of scabies in the U.S. Army were, to a large extent, based on British research contributions of Mellanby, Johnson, Bartley, and others before the United States was a belligerent power. These investigators successively reviewed and extended knowledge of the life history, habits, survival, and transmission of the parasite and of the treatment of the infection. The work was important and basic, not so much for anything that was strikingly new as for the clear definition of biological facts and quantitative studies that were made. The work indicated, for example, that the average number of mites per man was approximately 10 to 15; that severe cases may have few parasites, whereas patients with few symptoms may have large mite populations; and that indirect contact is of far less importance than direct contact in transmission.
Relative to the necessity for disinfestation of clothing and bedding of patients, the evidence from Great Britain during the early part of the war showed that to give meticulous attention to fomites was to dissipate time, effort, and money, and to underemphasize the major importance of direct contact in transmission of the infection. One study showed that, among 2,100 patients treated without disinfestation of personal belongings, there were 99 relapses explainable by reinfection and an additional 47 (2.2 percent) in which reinfection from human sources did not appear to have been likely. Further investigation was made of an unstated number of patients from 3,700 families in which care had been taken to disinfest personal effects of patients but little or no effort had been made to bring all members of the household group under observation or treatment; 22 percent of these families required re-treatment. Of 793 families containing an unstated number of patients in whom efforts were made to include for observation every member of the household, while the fomites received little attention, members from only 6 families relapsed. The implication is that it is much more important to take into account the family itself than to consider the family possessions.
The conclusion that an extensive disinfestation program was unjustified by no means contraindicated the simple ordinary measures of personal hygiene in relation to scabies-bathing and a change to clean clothing, if possible. The practical result of research was to demonstrate that both sulfur and benzyl benzoate were effective agents with which to cure scabies and that preliminary washing and scrubbing of the skin facilitated the scabicidal action of the drugs tested. Even the manner and place of bathing was the subject of thorough discussion, and the records of a meeting of some 25 experts of the British Ministry of Health in March 1942 state "* * * the merits of shower v. slipper baths were discussed and it was decided that a slipper bath was much more satisfactory but where this was impossible a shower bath would suffice." It was asserted that one advantage in favor of the slipper baths was that the nurse could supervise the patient more closely
than when a shower was used. Showers, however, could be arranged to deliver the water at about shoulder level rather than directly over the patient's head in order to avoid wetting women's hair. Some discussion took place at the meeting on the length of time which should be spent in a bath or under a shower, and it was agreed that soaking in a bath for 10 minutes or washing under a shower for 5 minutes might be adopted as a working rule. The use of a scrubbing brush was deprecated, and it was agreed that a flannel washcloth might well be substituted. It was the consensus that, in view of the shortage of soft soap, hard soap would be quite satisfactory.
As the war progressed, it became evident that the most important factor in prevention of lost time and disability from scabies was early recognition and treatment in the dispensary. That this goal was far from consistently attained in the Mediterranean theater is implicit in the stated opinion of dermatologists who convened in 1945 to discuss major dermatological problems of the theater. They were in agreement that scabies accounted for the great bulk of absenteeism caused by parasitic disease. Prolonged absenteeism primarily due to scabies all too frequently resulted from secondary infection, scratch dermatitis, overtreatment, or sensitization of the skin. Sulfur was preferred in cases complicated by secondary infection. The average stay of patients admitted to station and general hospitals with complications or secondary infections was found to be about 2 weeks, and it was actually necessary to evacuate to the Zone of Interior an undetermined number with chronic dermatitis due to scabies with superimposed infection and underlying skin allergies. It was found necessary to devote considerable effort to training ancillary personnel in the details of treatment. Nor did it suffice to supply the soldier-patient with antiscabies medication together with verbal directions for using an ointment. It was better to supply the patient with a printed sheet setting forth in simple, detailed language the treatment routine, the reasons for it, and the necessity for complete compliance with directions in order to assure relief. Failure to comply meant risk of reinfection if the source was venereal, of exacerbation otherwise, and of secondary infection in either event.
Reasonable and satisfactory as were the therapeutic procedures evolved in 1941 and 1942, they had serious limitations when put into effect in field dispensaries away from urban and general hospitals during the invasions of Morocco, Algiers, Italy, France, and Germany. Then benzyl benzoate was more often than not in short supply. More important, the source of much of the disease was the civilians, a condition which went largely unnoticed and unchecked.
One of the first to solve this problem for a civilian population deprived of petrolatum and lanolin with which to manufacture ointment was a French physician of Casablanca, Dr. E. Lépinay, chief of dermatology at l'Hôpital
Jules Columbo. He conceived the idea of using a U.S. Army quartermaster item, agricultural spray-a finely emulsified alkaline oil used in spraying orange trees and available through Allied Military Government in ample quantities-as a vehicle for the suspension and application of sulfur. Pilot experiments, first with the unmixed oil (huile blanche) and then with sulfur added, revealed a completely satisfactory medicament, and, during the years 1943-44, hundreds of civilians in the vicinity of Casablanca were successfully treated and cured of scabies. Since the cooperation of infected civilians was seldom difficult to obtain when the situation was explained by their own physicians or by U.S. soldiers involved, the way was open for attacking sources through which Army personnel were being infected. As a principle, however, this or a similar plan designed to prevent rather than cure scabies by controlling civilian reservoirs of infection was never developed to the extent that would have been feasible.
When both sulfur ointments and benzyl benzoate were unobtainable, the writer and others had occasion to confirm many times the efficacy of sulfur in agricultural spray. Only once was more than minor irritation of the skin encountered; this occurred in the late winter of 1945 among soldiers freshly treated with sulfurated oil and gathered around a field stove to warm themselves. Unquestionably, the unusual amount of heat to which the skin was subjected in this instance contributed to a sulfur dermatitis that was observed later.
Scabies as a clinical problem was much the same in every theater, but the mass problem was continuously changing. Scabies in the 1st Armored and 1st Infantry Divisions during the winter defensive of 1942-43 in Morocco and Algiers was not the same problem as scabies a year later among service troops in the vicinity of Naples or the disease encountered on Saipan in 1944, or at redistribution points in Bremerhaven after the war in Europe was over. The following history illustrates the point-scabies arising in epidemic proportions against a particular military and civilian background and scabies in troops coming from replacement units in the vicinity of Rome to Arno Valley depots and thence into the line during the winter months of 1944-45.
An outbreak having its source around Rome was identified quite by chance in the vicinity of Florence simply because both benzyl benzoate and ointment bases were in short supply and because centralization of cases for treatment brought centralization of vital statistics that made appreciation of the situation possible and indicated the source of the outbreak 200 miles further down in Italy around Rome. No headway could be made against the development of an ever-increasing stream of new cases until attention was transferred to the problems of the replacement and training command in Rome.
Detachment C of the 50th Station Hospital had been set up at Ponte a Evola, 40 miles south of Florence, in December 1944 and January 1945, in
order to care for a depot of some 10,000 replacement troops (fig. 11). New units arrived from Rome as others moved forward into the Po and Arno Valleys. The overall medical problem was to supplement medical care being handled on a dispensary basis by four battalion surgeons, with each sick call averaging between 60 and 120 patients and with the nearest general hospital in Florence, 40 miles to the north approachable only over bumpy roads in midwinter. The hospital detachment had been started with the expectation that it would be a consultation clinic; as it was coming to completion, military authorities decided that the unit would exercise a complete station hospital function, but with half the staff of the conventional station hospital. This meant that each physician allotted by the table of organization exercised a dual role; the commanding officer, for example, was also roentgenologist, and the chief of the medical service was also dermatologist.
When the detachment first began to operate in January 1945, no less than 95 of the first 221 medical consultations were for the diagnosis and treatment of scabies; yet neither benzyl benzoate nor ointment bases were to be had, and reliance had been placed on 1-ounce tubes of sulfur ointment, self-applied. In fact, no benzyl benzoate had been available through supply channels since the opening of the depot in September 1944. Hence, the centralized treatment of all patients with scabies was undertaken with 10 percent sulfur in agricultural spray. Beginning on the 8th of February, soldiers were treated on an ambulatory status, arrangements being made for clothing exchange after treatment. Nearly one-half were cured with two applications of the sulfurized spray, applied with a paintbrush in the morning and again in the evening; the rest required a second and third course, at weekly intervals.
Despite the improved therapy, rates for scabies continued to mount, from 30 in the 8th Replacement Depot, for example, in December 1944 to 35 and 170 per 1,000 average strength per annum in January and February 1945, respectively. Analysis of 50 cases revealed that 5 weeks was the average duration of symptoms before treatment. Both history and distribution of the papules indicated that the disease was of venereal origin in perhaps one-half of the cases and that the source of a mounting epidemic was at the large replacement center at Rome, with transmission occurring before troops arrived in the encampment at Ponte a Evola. This conclusion was brought to the attention of Col. William S. Stone, Chief, Preventive Medicine Division, Allied Forces Headquarters, who at the same time was being acquainted with mounting scabies problems elsewhere in the theater, notably in the 6th Port Battalion at Pisa and in Stockade No. 1 at Aversa. The situation was considered serious enough for formation temporarily of a three-man scabies commission, with Maj. Robert Buchanan, Jr., MC, and Capt. Lewis Capland coping with general problems in northern Italy. The author was assigned to the Office of the Surgeon, Headquarters, Replacement and Training Command, MTOUSA, to devote a month's attention to the situation developing at Rome, where personally conducted surveys of 1,304 men revealed more than 2 percent to be infected with scabies.37
To set up a scabies detection program on a larger scale meant merely to increase the objective of "short arm" inspection. Despite the drudgery of lining up and inspecting a naked company, this is a most profitable method for the prevention of lost time and disability due to numerous medical causes. Detection of venereal disease is only part of the gain. Rashes, fungus infections, dots denoting crab lice, nits of body lice, scabies, chiggers, mites, and various other entomologic and microbiologic bedfellows may be detected at a glance and as a tangible reward for the most dreary assignment that befalls the lot of the battalion surgeon. If the men then sit down in a line with their feet out and with the little toes held apart, because of the predilection of athlete's foot for the interface between 4th and 5th toes, then trichophytosis, with and without infection, and plantar warts, a most important cause of chronic disability, may be detected on the way back.
Most cases having been identified, attention was given to improved therapy, even to the sterilization of clothing by means of steam. The practice of dispensing 1-ounce tubes of sulfur ointment was discontinued. To remedy supply deficiencies, both benzyl benzoate and emulsion base were obtained from a nearby hospital, and soldiers were treated on a duty status with supervised application of the scabicide. Treatment was prescribed so that the soldier would remain covered with ointment for at least 12 hours, and then treatment was repeated in a week in order to kill off newly hatched, second-generation mites. A check was stipulated at the end of 2 weeks. Finally, to facilitate coordination of command and medical action, mimeo‑
graphed information and instructions were prepared for distribution to company and unit commanders as well as patients. This step was as important as any of the others. The information and instructions are reproduced in appendix A.
Because emulsion base seemed an excellent vehicle for the application of both sulfur and benzyl benzoate, patients at one dispensary during the month of April were treated with 30 percent benzyl benzoate in this base. Those at at another dispensary were treated with ointment containing 20 percent sulfur, 10 percent sodium carbonate, and 70 percent emulsion base. Results are given in table 12. Two applications, a week apart, of either ointment appeared to give definitely better results than a single treatment. This was interpreted to mean that a second generation of mites had hatched after the ointment was first applied. On the other hand, objective scientific evaluation of these data is not possible because it is not known to what extent reinfection entered into failures, and the criterion of cure or failure was necessarily subjective and perhaps biased in favor of benzyl benzoate. It did not seem necessary to add an ovicide to these ointments of known efficacy, and re-treatment at least once seemed a reasonable measure of insurance in the light of the social setting.
In order to extend action beyond treatment and toward prevention, attention was next given to the civilian problem through the cooperation of Lt. Col. Gordon M. Frizelle, RAMC, Chief, Allied Commission Public Health Department in Rome, and Professor Tarantelli, Chief, Dermatology Department, University of Rome. Both were highly interested in the possibility of being able to replace unobtainable petrolatum and lanolin ointments with a cheap, effective scabicide manufactured from sulfur and agricultural spray. A drum of spray was procured with which to mix sulfur which had always been plentiful. Thus, an ointment equivalent was made available for civilians, and large-scale treatment was carried out for the first time in many months. The full effect of the overall program is not subject to statistical demonstration, but it is known to be good, and in May 1945 troops with a high incidence of skin infections were no longer being forwarded for replacement directly into combat.
A last report of increased incidence of scabies as the war ended demonstrated again the multiple causes of localized outbreaks-a specific locale, a particular season, a given period of hostilities-all were critical factors in determining whether the disease became epidemic or stayed endemic in a specified unit.
Data from 12 of 15 redistribution stations in operation at the cessation of hostilities show an annual incidence rate of 12.9 per 1,000 average strength for 1945, as compared with a rate of 6.9 during the same year for the four service commands in which the 12 stations were located, pointing to a higher incidence among troops returning on rotation. This increase in scabies was widespread, however, as is indicated by the fact that the First, Sixth, and Seventh Service Commands, containing no redistribution centers, reported rates of 11.4, 14.6, and 12.1 per 1,000 per annum, respectively. There is no reason to doubt that the high rates of 1945 (table 10) reflected increased mingling with an infected civilian population after V-E Day, nor to doubt that they can be regarded as of contact (mostly venereal) origin.
A noteworthy fact in the U.S. Army of World War II, with respect to scabies, was the establishment of a rate for the 4 years 1942 to 1945, inclusive, of 4.02 per 1,000 average strength per annum in oversea troops. This compares with an incidence of 42.71 in the trench warfare experience of British Expeditionary Forces, 1914-18, and an oversea admission rate of 11.90 per 1,000 average strength per year in the U.S. Army in World War I. Obviously, one significant factor was the difference between a war of movement and a war of attrition. Indirect transfer of mites in trench dugouts presumably played a much more important role in transmission than did indirect contact in tanks, on trucks, and in planes; and, presumably, the preventive effect of both hygiene and therapy was stronger in World War II. In fact, from 1941 to 1945, experience for the whole Army with respect to the control of scabies was so good that it became possible to demonstrate the interweaving of a particular civilian situation with a military epidemic. Scabies emerged as more of a problem among resting, replacement, and service troops than among troops in the line.
In retrospect, it is evident that sulfur in some sort of mildly alkaline oil emulsion similar to agricultural spray could have been made widely available for the use of civilian populations at extremely low cost and cargo space and to military advantage. Now that aerosol apparatus has been perfected for brushless shaving creams, it is also evident that this kind of device and emulsified base would have been ideally suited as a dispensing container and vehicle for sulfur or benzyl benzoate. Each of these two excellent and time-tested agents constitutes a satisfactory scabicide, benzyl benzoate holding the esthetic advantage. Although a new and perfect agent on the dispensary shelves would always be welcome, needed research today
would appear to be along other lines. It is highly desirable to determine whether a second application of the two most satisfactory ointments already available, about a week after the first, is necessary to take care of mites that have hatched from eggs of first-generation females; to investigate epidemiologically civilian-military relationships and possibilities of true prevention; and to establish desirable frequencies for screening (by cursory inspection) soldiers at risk.
It is curious that in World War II, during times of epidemic, the tendency was to look for the source of difficulty in the therapeutic agent being used, whereas more effort should have been directed toward compilation of statistical and conversational data leading toward contacts and specific and general civilian problems, as is done for syphilis and gonorrhea. The civilian problem could have been attacked more vigorously than it was, through existing agencies of military government and public health. When failures of therapy occurred, the possibilities should have been investigated that the exacerbation was due to reinfection, as well as therapeutic failure, or that the failure was due to the hatching of eggs already present in the skin during initial therapy. Neither benzyl benzoate nor sulfur is reputed to be ovicidal, but the necessity for adding benzocaine as an ovicide has been questioned because of the greater likelihood of dermatitis from "shotgun therapy."
Experience during World War II showed that, with rates of less than 5 per 1,000 average strength per annum in any sizable unit, the problem therapeutically and prophylactically was minor; when rates rose above 10, the implications were that scabies was of endemic significance in the civilian population; and when the incidence among U.S. troops began to soar toward 50 or 100, the indications usually were clear that the disease was epidemic among civilians as well. Under these circumstances, the problems of civilian therapy, fraternization, and command responsibility assumed critical importance in the reduction of case rates among Army personnel. Early diagnosis as well as carefully administered therapy of patient, contacts, and infected members of a contact's family, rather than mere cure, were basic to prevention and control. While it was not found necessary to disinfect fomites regularly, there were occasions when such procedures were indicated; and the principle did not negate a change to clean clothes after therapy, the washing of regularly worn uniforms, and a blanket exchange. More emphasis should have been given to supplying hospitals and clinics in occupied areas with cheap, mildly alkaline oil emulsions for civilian use as vehicles for the application of sulfur.
THEODORE H. INGALLS, M.D.