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Scabies—A golden opportunity
PUBLIC HEALTH SCABIES--A G O L D E N O P P O R T U N I T Y
OCTOBER
self completely in man's skin in two and a-half minutes; she holds to the skin by the suckers of the front legs, and elevates her body into a nearly vertical position by using the long terminal bristles of the hind legs. This is generally done on some part of the human body of which the skin is thin. Once the mite is beneath the skin it rests if the man is in a cold place and only continues to excavate its burrow when the skin becomes warm, as in a warm room or in bed; it is, only when the mite is advancing through the epidermis that the itching is felt. It is assumed that the mites feed on the liquid that is available from the epidermal cells which they crush. A part of the life history may be observed by opening burrows or by dissecting them from the underlying tissues and mounting them whole. It can then be seen that the first egg is laid within twenty-four hours of the female's becoming mature. The egg may hatch in about sixty-five hours, but the period varies, probably with the temperature of the surface of the skin,, and the stage may last as long as 100 hours. Gerlach states that it may even extend to ten days, but this certainly requires verification. The egg produces an active hexapod larva which moults into an octopod nymph; at the next moult this produces either an adult male or an immature female, which has to moult once again to produce an adult female. The duration of the successive stages is as follows: egg, 2½ days or more; larva, 1½ to 3 days; nymph, 1½ to 2½ days; immature female, 2 to 4 days: At the shortest, therefore, the period from deposition of egg to emergence of adult female might be less than eight days. Life History of Parasite THE LARVA Scabies is caused by the various stages of the life The larva quits the" burrow of its parent in which cycle of the mite Sarcoptes scabiei var. hominis. The mite is very closely similar to the variants affecting the it hatched from the egg and makes its own burrow, horse and other domestic animals, producing sarcoptic which may sometimes be distinguished by a minute mange. There is actually some considerable doubt as vesicle beneath its floor; it appears that it may enter to whether there are any anatomical differences between the skin by way of a hair follicle. Whether the the acari infecting man and those infecting animals. nymphs, males, and immature females wander and There is, however, definitely a high degree of biological make their own burrows, or whether all the early stages specificity for different animals to the extent that there are gone through in that made by the larva, is not are biological races associated with different hosts. known. But it appears to be well established that the I will not describe the detailed anatomy of the mite adult female does not normally move, though she can as it is only of academic interest. For the description start a fresh burrow if she is forcibly removed from of the life cycle I am indebted to Prof. Buxton of the the skin. London School of Hygiene and Tropical Medicine The larvae, and probably all stages, are sensitive to and the account is taken direct from the script of a dryness, and one may suppose that there is a high textbook of entomology as yet unpublished, which has mortality among those which are wandering over the been revised up to 1938.* Most of the information is, host's skin or clothes. Even if humidity is high it: is similar to that given by Munro in 1919, and I believe thought that no stage of the mite is able to survive that the research work of Dr. Kenneth Mellanby,~ unfed for longer than a few days, though further innow being undertaken at Sheffield, may show a number formation would be welcome; according to Munro the isolated larva lives not longer than 30 hours even if of points to be incorrect. The life history of Sarcoptes scabiei is difficult to kept moist. It is said that the infestation spreads to follow for the mites are very small and delicate and those with whom tho patient sleeps because the early much of the cycle is passed beneath the skin of the stages of the mite normally wander when the patient host. The adult female, removed from her burrow in is warm, but they are so small--the larva is only 0"15 the skin, her normal home, is capable of burying her- ram. long--that they have seldom been observed. The pairing of Sarcaptes scabiei has not been * This has recently formed the basis of an article in the observed. The once accepted view was that the male pairs with the immature female, which is fertilised for British Medical Journal of September 20th, 1941. life, so that the adult female does not pair. It is now ~" See British Medical Journal, September 20th, 1941. By C. W. DixoN, M.D., B.S., D.L.O., D.CH., O.P.H., Medical O~cer of Health, East Elloe and Spalding R.D.C. " I n the past, typhus and typhoid played fearful havoc in the field and camp; these diseases medical science has curbed, a triumph amply recognised. The scourge of scabies survives, however, to the present time." This was written by MacCormac in 1917, but it seems to be extremely apt just now. The acaris, the adult mite, was discovered by de Geer in 1788, and a fair contribution to the knowledge of the biology was made by various dermatologists between the years 1850 and 1900. The only work since then was that done by J. W. Munro during the last war and published in 1919. In this a number of suggestions of earlier workers were confirmed. The writers of orthodox medical textbooks, however, seem to go on copying incorrect information from one book to another, so that the original source has been lost.. Advance in our knowledge of scabies in the last twenty years is practically nil, and in the last forty years slight. I~ seems, therefore, that with the apparent increase of scabies under war conditions, a golden opportunity is at hand to make this good. To refresh the minds of those who may be in charge of the control of scabies but may not have personally seen or treated cases of scabies for a number of years, I will go over the principal features of the" biology as known at present, together with the symptoms and points of diagnosis.
10
1941
PUBLIC HEALTH
thought probable that it is the adult female that does pair. The life of an individual female has never been followed through, but it seems probable that she lays rather more than two eggs daily to a maximum of about forty to fifty. THE BURROW
The burrow is made in the deeper part of the horny layer of the epidermis, rarely reaching so, deep as the granular layer. In sections it may be seen that the epidermis round the mouth of the burrow is oedematous. The layers of epidermis below the burrow are also frequently oedematous with dilated lymphatics. A vesicle may also be present beneath the burrow, perhaps when the burrow is that of a larval mite. In the papillary layer the blood capillaries are dilated and surrounded by inflammatory exudate. The burrow is tortuous and may reach a length of 5--15 mm. Itching, which is a common symptom, is not caused by the presence of the mite on the skin but by its activity in extending its burrow; it is therefore most troublesome when the patient is in bed or in a warm room. From personal observation, the burrows of.the adult female appear rather superficial with a relative absence of reaction in the skin. The burrows of the immature forms would appear to go deeper and often produce hyperaemic reaction under them. It seems that the vesicles on the floor of the runs, usually ascribed to the presence of immature forms, may also partly depend upon the type of reaction of the host.
Sources of Infection Scabies can be contracted by the transfer of either eggs, larval stages, or mature acari to the skin of the new host. The host may become theoretically infected in as short a time as two and a-half minutes if an adult female is transferred, or in about eight days if eggs are transferred and have to be hatched. It is obvious that, as the eggs are on the surface of the skin and no burrowing takes place until the nymph hatches out, peace and quiet without washing is required for their development. Therefore adequate bathing with hot water weekly should go a long way to prevent infection by this means. On the other hand, infection by the adult female is so rapid that contact, particularly between people in the same bed, will cause infection. The view once held that scabies was a venereal disease is most probably based on observations on shortexposure infections in this manner. These can undoubtedly occur, but I don't think anyone to-day suggests that this is the most frequent source of spread. Obviously it is the stage when multiple runs are present and when nymphs and adult acari are on the skin that there is the greatest chance of transfer to new hosts. The habit of the mite in being particularly active when the skin is warm means that chance contact, such as, for instance, shaking hands, etc., is unlikely to result in infection, as acari in burrows in exposed parts of the body are unlikely to appear out of these burrows except when these parts are warm. I feel that transmission in schools is not common, but this point requires investigation. Most probably infection occurs among children mostly during out-ofschool time, particularly in communal sleeping quarters, shelters, etc., and during rough-and-tumble games.
CLOTHING AND BLANKETS
In the Services great importance is attached to the disinfection of blankets, and this idea seems to be behind recent suggestions that local authorities should do likewise. This is a problem of some economic importance. In 1868 Hebra, who treated some thousands of cases, stated that he found disinfection of clothing and blankets unnecessary and implies that scabies is rarely spread by these means. Many other workers after this date expressed similar views, but in 1917 MacCormac stated that all evidence pointed to blankets as being the source of infection and the cause of spread in the Army. What evidence these views were based upon I do not know, but the Army-sponsored experiments of Munro, in my opinion, gave no support at all to MacCormac's views, particularly as in reading Munro's account of his work one gets the impression that he expected infection to be extremely likely from this source. This view of MacCormac seems to have been accepted by the medical profession without question, in spite of there being no reliable information to back it up. Furthermore, it was contrary to opinion expressed by a number of very able and observant dermatologists of the past. It seems that with the louse problem in the Army at the time, which was being dealt with by disinfection of bedding and clothing, th~ obvious thing to do to make appearance of preventing spread was the disinfection of blankets. From this, we now have in every textbook, pamphlet, Ministry of Health Circular, etc., instructions about disinfection of bedding. I am convinced it is quite unnecessary to disinfect blankets or bedding and my experience is in keeping with this view, and I hope that the time is now ripe for some systematic experiments in this direction on a large scale. Infection from clothing, however, particularly when taken at once from a patient, gave positive results in almost all of Munro's experiments, particularly with garments such as vests, pants, gloves, etc., where there is intimate contact with the sites of election of the parasite. Munro, however, has to admit that egginfected clothing is capable of remaining infected only for two to three days, and mite-infected clothing obviously less. A certain amount of moisture is absolutely essential for the life of the mites and in the ova. It must be remembered that the ova are not nearly so hardy as those other parasites of man. Chance infection does not seem very common. I have never seen a case among nurses treating scabies, and Munro, in experiments upon himself, came to the conclusion that ordinary cleanliness is quite enough to prevent chance contagion obtaining a hold. Details of the life history of the mite show why this should be so. SCABIES IN THE ARMY
One hears civilian authorities blame the presence of military personnel in their area for the increase and spread. The military authorities blame the civilians as the source of their scabies. Both are probably true in that the mass movement of persons will increase the risk of any infectious disease. From my own observations of a number of military units which had equal facilities for weekly bathing the incidence of scabies 11
PUBLIC HEALTH seems to depend on the type of soldier and whether they have any wish to be clean when facilities are provided. This was most noticeable by its absence in the case of units consisting mostly of Welsh miners or Lancashire cotton workers. A unit which was mostly composed o~ Londoners made good use of the facilities and consequently there was an absence of scabies. There is a considerable difference in the cleanliness in the different types of men even when using the same facilities for ablution. The second important point is the ability and particularly the energy shown by the unit medical officer in keeping his men under constant observation so that the earliest case can be removed and treated.
Points in Diagnosis The diagnosis of scabies is a point which the medical profession at large seems to be extremely vague about. This is a pity, as accurate and early diagnosis is the most important factor in the control of the disease. It is popularly called the "itch," and unfortunately many doctors think that any condition which itches must. be scabies, particularly in a district where they have suddenly become "scabies-conscious," or that where there is no itching the skin condition cannot be scabies. Often in the first case they are dumbfounded because, after what appears to be and what probably is a satisfactory course of treatment, the patient will turn up still complaining of irritation. The doctor then panics, gets the case admitted to hospital, and it is found that the irritation is due to over-treatment, or he may repeat the treatment again, giving the patient a sulphur dermatitis or even a generalised eczema. I wish to emphasise that irritation in itself is of extremely little value in the diagnosis of scabies. This point is particularly important, because one sees in the literature reports of miraculous cures for scabies; the cases, however, have only presented irritation as a diagnostic criterion. There is only one infallible criterion and that is recovery of the mite from the patient. I find that I can find it in most cases of simple scabies, although, when well-marked burrows are present, I usually do not bother. MacCormac, on the other hand, during the last war stated that the acaris is extraordinarily difficult to find even in well-marked, untreated cases. I have recently received a letter from Dr. Kenneth Mellanby in which he states that with practice recovery of the mite is exceedingly easy, and he now refuses to diagnose scabies as such without discovery of the mite. However, from the purely dermatological point of view scabies can be diagnosed with certainty without the recovery of the mite. The presence of definite runs is satisfactory evidence. In complicated cases where, particularly in children, there is generalised impetigo, .the distribution is very typical and is easily differentiated from a general impetigo secondary to some other cause. Burrows are most easily found on the flexor aspect of the wrist, between the fingers, the ante-cubital fossa, anterior axillary folds, fronts of the ankles, and on the penis. Scratch marks are most commonly present on the fronts of the forearms and the front and inner aspect of the thighs, but scratch marks in these positions are 12
OCTOBER not diagnostic of scabies. Secondary impetigo is particularly common in service cases on the buttocks and on the anterior aspect of the thighs. In children the infection is more general, particularly in those who have their underclothes sewn on, and runs may be seen in almost any part of the body, including even the neck, but acari apparently never burrow on the face or scalp. In cases that have been partly treated or where secondary impetigo or acute eczema has supervened a very careful examination is necessary from head to foot and in daylight. I look at doubtful runs with a magnifying glass. The diagnosis or scabies is really a simple matter once you know what to look for and where, and in these times many general practitioners and public health medical officers require a demonstration with cases to show them the salient points of diagnosis. It must be remembered, particularly in those adults who maintain a fair standard of hygiene, that infection may persist for months or even years without producing many lesions and are therefore not noticed. If occurring in a middle-aged woman it is probably being treated as a menopausal pruritus, and if "spots" are present it is called a dermatitis and treated with calomine. I feel sure that there is a large reservoir of infection, especially among the adult population, solely due to imperfections in the diagnostic ability of the medical profession.
Treatment I am going to say very little about treatment, as in the light of our present knowledge a discussion on treatment is rather a case of putting the cart before the horse. Moreover, the gullibility and ignorance of the medical profession has enabled the pharmaceutical chemist to do good business in preparing more and more magical remedies. This is particularly easy, as unless accurate diagnostic criteria are adhered to all statistical results of treatment are valueless. In 1905 Neumann gave a list of twenty-four substances which were acaricides and this list can be extended, but no one has yet shown if or how any of these substances get into a tortuous burrow 5 to 15 mm. in length and about a quarter of a millimetre in width situated at varying depths in the cornified layers of the skin. Obviously the essence of the treatment must be the laying open of the burrows to expose mites and eggs. The way to do this is with hot water, soap, and a scrubbing brush. Surely, therefore, from our knowledge of the relative frailty of both mites and eggs, mechanical treatment in opening up the burrows will very probably deal with them without the use of any acaricide. Any material that tends to soften the upper horny layers of the skin will make eradication of the burrows easier. In my opinion sulphur ointment has become popular for this reason and not so much because of the power of the sulphur in this form. I see no reason~ why scabies should not be cured with frequent baths and liberal use of the scrubbing brush, although it may be found that limited use of an acaricide will assist. Prophylaxis is obviously the same. It must be remembered that all acancldes that have been used are irritants and can produce considerable reaction in the skin, and a great deal of hospitalisation I
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1941 (especially, I believe, in the last war) was due to excessive use of these substances. Following on this question of treatment, I feel that some of the problems of the spread of scabies are not unconnected with the lack ol~ interest shown by members of medical and nursing staffs. I do not doubt but that there are many sick bays, Public Assistance Institutions, etc., which are admitting cases of scabies where on admission "routine " treatment is carried out without the case being seen by a medical officer. He probably orders treatment over the telephone, and the case may be discharged likewise on the o p i n i o n of the nurse in charge. I may be wrong and such a state may not be common, but I feel that investigation in this direction is required. Under such conditions, of course, figures relating to admissions, return cases, or treatment are valueless. Personal Observations My personal experiences are, I a m afraid, rather limited, but they lend support to my previous suggestions. During the winter of 1939-1940 I treated in a sick bay some 130 cases of scabies in evacuee children, a number of cases that were sent in as scabies that were not, and a number of return cases of scabies, I have analysed the results, and although the figures are statistically small they may point to useful fields for further investigation. Of the cases admitted as scabies 10"9 per cent. were not due to scabies. Of the cases admitted as return cases 53 per cent. were not due to scabies. This is interesting in view of considerable numbers of apparent return cases in some areas. Seven cases, or roughly 5 per cent., were admitted a second time suffering from scabies. Six of these were admitted over three months after the date of discharge from hospital. I therefore suggest that these were reinfected from their original source or from some other source. The other case was returned after two weeks, together with a child with whom he was previously billeted and who had apparently had scabies at the time of the original case but had not been sent in for treatment. I therefore think that none of my seven cases were relapses but that they were reinfections from some source. Three of these cases came from a district where I have reason to doubt the ability of the practitioner to recognise scabies. In one case a grandfather in the house was reported to have spots and was under treatment by his doctor. The long period of time is probably accounted for by personal contact being less intimate, and there is the possibility of some delay in the diagnosis. One case was returned three months after discharge, and in this instance inquiries from the child elicited that the foster parent had been treated by her own doctor for a skin complaint of some duration. It was suggested to the doctor, in view of the child being a definite case of scabies, that the foster-parent might be also; he agreed at once, treated the woman, and when the child returned no further infection occurred. Of these seven reinfected cases only one, the case just referred to, where there was evidence of direct infection, was from my own district, in which no disinfection of blankets or bedding is carried out although, in all, 45 cases were admitted. Four of the reinfected cases were from a district where steam disinfection of blankets and bedding was carried out and
PUBLIC HEALTH two cases were from a district where fumigation of the room and its contents was performed. From these two districts together 84 cases had been admitted. In spite of the small figures I feel that the evidence is in support of my contention that the disinfection of blankets and bedding is entirely superfluous. During the last nine months I have treated about 55 cases of scabies in Service patients. Most were complicated by impetigo and in the majority the m e n could very well have also been labelled "hygiene deficiency " - - n o relapses have come to my notice. A case of scabies occurred in a regiment which for four months had had no scabies. It was found that the man's wife and child had moved into a village near the unit just previously and both were infected with scabies. The man was admitted and treated, the wife and child attended twice daily for baths for a week, which was until all the runs had gone. Sulphur ointment was used for three days, nothing was done to the bedding, blankets, or clothing of the woman or child, but no relapse has occurred. All the cases during the winter 1939-1940 were treated with sulphur ointment, usually for three to five days. Baths were taken daily, particular attention being paid to scrubbing the hands. Severe sulphur reaction occurred in five cases, and I feel that the treatment with ointment was much too prolonged. This did not affect their stay in hospital,r as the vast majority of the children had severe impetigo, which took some time to get completely healed; as they were evacuees no attempt was made to get them back to their billets until they were completely clean. All cases had runs present, and no case without runs was treated as scabies. A further point that has interested me is the variation in the liability to become infected under seemingly optimal conditions. It is common knowledge that certain persons seem particularly susceptible to be attacked by fleas, lice, and other vermin, whereas others seem relatively immune. This phenomenon, which ] can describe only as the " palatability" of the host to the parasite, has not, I believe, been described in scabies. Two small girls were admitted as cases of scabies; they were sisters, slept together, and their standard of hygiene appeared equal. Although one showed well-marked scabies with many runs and was probably of at least a month's duration, the other showed no signs of any runs at all, although they were carefully searched for. Possibly some persons may be particularly palatable, and this child was presumably unpalatable. This may tend to explain the fact that, although a reasonable standard of personal cleanliness will prevent chance infection taking a hold, most dermatologists have had from time to time cases of scabies in duchesses and other such persons whose standard of personal hygiene would, one imagine, prevent them from remaining infected. Further observations are required. Coneluslon In conclusion I would like to emphasise the following p o i n t s : 1. Our knowledge of the biolo~:y is none too accurate, but it is hoped that Dr. Mellanby will be able to rectify this.
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PUBLIC HEALTH 2. The standard of knowledge among the medical profession, particularly over diagnostic signs, is low, and is the principal cause for the continuation of the disease. Early and accurate diagnosis is essential. 3. Treatment is haphazard, and in institutions both medical and nursing staff are disinterested. A false impression is being gained of return-cases, and cases are probably being discharged while still infectious. 4. Disinfection of bedding and blankets is unnecessary. Disinfection of clothing, even underclothing, is not essential; washing will suffice, and probably airing out of doors for three to four days would be suffÉcient. Scabies is essentially a disease of personal contact. 5. Normal standards of cleanliness will prevent chance infection taking a hold. Adequate bathing facilities for civilians and service personnel would go a long way in preventing scabies. There must be education and the desire to be clean; obviously this should start in schools. Unfortunately many, especially in rural areas, have no satisfactory washing facilities. 6. Treatment must be centred on the mechanical opening of the burrows.
WELFARE IN PUBLIC SHELTERS* By M. A. CRESWICK ATKINSON,
Regional Welfare Adviser, London Civil De[ence Region In considering the organisation of welfare work in public shelters it is important to bear the policy of dispersal continually in mind. If this is not done, and if too much attention is paid to entertainment of various kinds, public shelters may be made so attractive that people who have hitherto been content to use the individual types of domestic shelter may be drawn to the use of the public ones; and it must be remembered that there are health risks inherent in the use of such shelters which are non-existent in the domestic type. Nevertheless, although many more people are making use of all forms of domestic shelter, a regular population may still be found in the public shelters, and some organised effort is necessary to relieve the tedium of the hours spent there at night, more particularly duriiqg the autumn and winter months. Steps must be taken toward the solution of special problems concerned with women, children, and adolescents. It is necessary, therefore, to steer a middle course, and, in doing so, not to neglect the possibility of the provision of some type of welfare in the communal as well as the public shelters. The organisation of interests and occupations for public shelter users has a very definite value in improving behaviour and maintaining order, besides promoting better health conditions and morale. The word "welfare " can cover a very wide field of activity. In order to narrow the meaning of the term the word can be defined as embracing all those amenities, facilities, and activities not included in the responsibilities of local authorities towards public shelters. * Slightly abridged version of a paper read at a meetin~ of the Metropolitan Branch of the Society of Medical Officers of Health. 14
OCTOBER Welfare Organisation at London Region Headquarters That the Commissioners for the London Region are alive to the importance of welfare arrangements for the occupants of shelters used for dormitory purposes is proved by the fact that local authorities have been asked to take an active interest in this aspect of shelter life, and to make arrangements by which self-help activities and occupational interests are encouraged in all types of public shelter. In addition a welfare advisory committee has been set up under the chairmanship of the Commissioner, Alderman C. W. Key, to discuss welfare matters and to consider current problems in relation to women, children and adolescents; a regional welfare adviser has been appointed, and local authorities ma35 with the approval of the Commissioners, appoint either a full-time or part-time shelter welfare officer if the local shelter needs warrant such an appointment being made.
Planning of Welfare for Publio Shelters Shelter welfare may be planned in three w a y s : - (a) by making use of existing arrangements and taking full advantage of opportunities offered through official sources; (b) by introducing new schemes and ideas; (c) by making individual welfare possible. In a number of areas work of this nature has already been carried out to some extent, but it has frequently been found that, whilst some shelters are given almost a surfeit of attention, others, smaller and more difficult to arrange for, are left out in the cold; and it must be remembered that it is in the least attractive shelters that welfare is most important. New schemes can be introduced by ascertaining what types of specialised assistance are available from official sources, such as the London County Council Evening Institutes, and from local voluntary organisations. Individualised welfare can be made possible by bringing together the persons needing help and advice and the means by which such assistance may be given.
Children In planning shelter welfare the needs of all sections of the shelter population must be Considered. One of the first problems to present itself is that of children using public shelters for dormitory purposes. Of course they should not be in these shelters at all. Despite the most careful arrangements and adequate medical aid post provision, they are bound to be exposed to the risk of .infection, and to other dangers. The finest public shelter ever designed cannot, by reason of the very factors which make it secure, be a satisfactory sleeping place for any child. Children should, instead, be sleeping with open windows, in a country area to which they have been evacuated. Nevertheless the fact remains that children are still to be found in public shelters of all kinds, and it has therefore become necessary to consider this problem, and to find a means by which their needs are catered for, without attracting yet more parents to bring their children to them. It is usually possible to arrange supervised play centres or play groups in most shelters; even in the tubes the "under-fives " can be gathered
OCTOBER
self completely in man's skin in two and a-half minutes; she holds to the skin by the suckers of the front legs, and elevates her body into a nearly vertical position by using the long terminal bristles of the hind legs. This is generally done on some part of the human body of which the skin is thin. Once the mite is beneath the skin it rests if the man is in a cold place and only continues to excavate its burrow when the skin becomes warm, as in a warm room or in bed; it is, only when the mite is advancing through the epidermis that the itching is felt. It is assumed that the mites feed on the liquid that is available from the epidermal cells which they crush. A part of the life history may be observed by opening burrows or by dissecting them from the underlying tissues and mounting them whole. It can then be seen that the first egg is laid within twenty-four hours of the female's becoming mature. The egg may hatch in about sixty-five hours, but the period varies, probably with the temperature of the surface of the skin,, and the stage may last as long as 100 hours. Gerlach states that it may even extend to ten days, but this certainly requires verification. The egg produces an active hexapod larva which moults into an octopod nymph; at the next moult this produces either an adult male or an immature female, which has to moult once again to produce an adult female. The duration of the successive stages is as follows: egg, 2½ days or more; larva, 1½ to 3 days; nymph, 1½ to 2½ days; immature female, 2 to 4 days: At the shortest, therefore, the period from deposition of egg to emergence of adult female might be less than eight days. Life History of Parasite THE LARVA Scabies is caused by the various stages of the life The larva quits the" burrow of its parent in which cycle of the mite Sarcoptes scabiei var. hominis. The mite is very closely similar to the variants affecting the it hatched from the egg and makes its own burrow, horse and other domestic animals, producing sarcoptic which may sometimes be distinguished by a minute mange. There is actually some considerable doubt as vesicle beneath its floor; it appears that it may enter to whether there are any anatomical differences between the skin by way of a hair follicle. Whether the the acari infecting man and those infecting animals. nymphs, males, and immature females wander and There is, however, definitely a high degree of biological make their own burrows, or whether all the early stages specificity for different animals to the extent that there are gone through in that made by the larva, is not are biological races associated with different hosts. known. But it appears to be well established that the I will not describe the detailed anatomy of the mite adult female does not normally move, though she can as it is only of academic interest. For the description start a fresh burrow if she is forcibly removed from of the life cycle I am indebted to Prof. Buxton of the the skin. London School of Hygiene and Tropical Medicine The larvae, and probably all stages, are sensitive to and the account is taken direct from the script of a dryness, and one may suppose that there is a high textbook of entomology as yet unpublished, which has mortality among those which are wandering over the been revised up to 1938.* Most of the information is, host's skin or clothes. Even if humidity is high it: is similar to that given by Munro in 1919, and I believe thought that no stage of the mite is able to survive that the research work of Dr. Kenneth Mellanby,~ unfed for longer than a few days, though further innow being undertaken at Sheffield, may show a number formation would be welcome; according to Munro the isolated larva lives not longer than 30 hours even if of points to be incorrect. The life history of Sarcoptes scabiei is difficult to kept moist. It is said that the infestation spreads to follow for the mites are very small and delicate and those with whom tho patient sleeps because the early much of the cycle is passed beneath the skin of the stages of the mite normally wander when the patient host. The adult female, removed from her burrow in is warm, but they are so small--the larva is only 0"15 the skin, her normal home, is capable of burying her- ram. long--that they have seldom been observed. The pairing of Sarcaptes scabiei has not been * This has recently formed the basis of an article in the observed. The once accepted view was that the male pairs with the immature female, which is fertilised for British Medical Journal of September 20th, 1941. life, so that the adult female does not pair. It is now ~" See British Medical Journal, September 20th, 1941. By C. W. DixoN, M.D., B.S., D.L.O., D.CH., O.P.H., Medical O~cer of Health, East Elloe and Spalding R.D.C. " I n the past, typhus and typhoid played fearful havoc in the field and camp; these diseases medical science has curbed, a triumph amply recognised. The scourge of scabies survives, however, to the present time." This was written by MacCormac in 1917, but it seems to be extremely apt just now. The acaris, the adult mite, was discovered by de Geer in 1788, and a fair contribution to the knowledge of the biology was made by various dermatologists between the years 1850 and 1900. The only work since then was that done by J. W. Munro during the last war and published in 1919. In this a number of suggestions of earlier workers were confirmed. The writers of orthodox medical textbooks, however, seem to go on copying incorrect information from one book to another, so that the original source has been lost.. Advance in our knowledge of scabies in the last twenty years is practically nil, and in the last forty years slight. I~ seems, therefore, that with the apparent increase of scabies under war conditions, a golden opportunity is at hand to make this good. To refresh the minds of those who may be in charge of the control of scabies but may not have personally seen or treated cases of scabies for a number of years, I will go over the principal features of the" biology as known at present, together with the symptoms and points of diagnosis.
10
1941
PUBLIC HEALTH
thought probable that it is the adult female that does pair. The life of an individual female has never been followed through, but it seems probable that she lays rather more than two eggs daily to a maximum of about forty to fifty. THE BURROW
The burrow is made in the deeper part of the horny layer of the epidermis, rarely reaching so, deep as the granular layer. In sections it may be seen that the epidermis round the mouth of the burrow is oedematous. The layers of epidermis below the burrow are also frequently oedematous with dilated lymphatics. A vesicle may also be present beneath the burrow, perhaps when the burrow is that of a larval mite. In the papillary layer the blood capillaries are dilated and surrounded by inflammatory exudate. The burrow is tortuous and may reach a length of 5--15 mm. Itching, which is a common symptom, is not caused by the presence of the mite on the skin but by its activity in extending its burrow; it is therefore most troublesome when the patient is in bed or in a warm room. From personal observation, the burrows of.the adult female appear rather superficial with a relative absence of reaction in the skin. The burrows of the immature forms would appear to go deeper and often produce hyperaemic reaction under them. It seems that the vesicles on the floor of the runs, usually ascribed to the presence of immature forms, may also partly depend upon the type of reaction of the host.
Sources of Infection Scabies can be contracted by the transfer of either eggs, larval stages, or mature acari to the skin of the new host. The host may become theoretically infected in as short a time as two and a-half minutes if an adult female is transferred, or in about eight days if eggs are transferred and have to be hatched. It is obvious that, as the eggs are on the surface of the skin and no burrowing takes place until the nymph hatches out, peace and quiet without washing is required for their development. Therefore adequate bathing with hot water weekly should go a long way to prevent infection by this means. On the other hand, infection by the adult female is so rapid that contact, particularly between people in the same bed, will cause infection. The view once held that scabies was a venereal disease is most probably based on observations on shortexposure infections in this manner. These can undoubtedly occur, but I don't think anyone to-day suggests that this is the most frequent source of spread. Obviously it is the stage when multiple runs are present and when nymphs and adult acari are on the skin that there is the greatest chance of transfer to new hosts. The habit of the mite in being particularly active when the skin is warm means that chance contact, such as, for instance, shaking hands, etc., is unlikely to result in infection, as acari in burrows in exposed parts of the body are unlikely to appear out of these burrows except when these parts are warm. I feel that transmission in schools is not common, but this point requires investigation. Most probably infection occurs among children mostly during out-ofschool time, particularly in communal sleeping quarters, shelters, etc., and during rough-and-tumble games.
CLOTHING AND BLANKETS
In the Services great importance is attached to the disinfection of blankets, and this idea seems to be behind recent suggestions that local authorities should do likewise. This is a problem of some economic importance. In 1868 Hebra, who treated some thousands of cases, stated that he found disinfection of clothing and blankets unnecessary and implies that scabies is rarely spread by these means. Many other workers after this date expressed similar views, but in 1917 MacCormac stated that all evidence pointed to blankets as being the source of infection and the cause of spread in the Army. What evidence these views were based upon I do not know, but the Army-sponsored experiments of Munro, in my opinion, gave no support at all to MacCormac's views, particularly as in reading Munro's account of his work one gets the impression that he expected infection to be extremely likely from this source. This view of MacCormac seems to have been accepted by the medical profession without question, in spite of there being no reliable information to back it up. Furthermore, it was contrary to opinion expressed by a number of very able and observant dermatologists of the past. It seems that with the louse problem in the Army at the time, which was being dealt with by disinfection of bedding and clothing, th~ obvious thing to do to make appearance of preventing spread was the disinfection of blankets. From this, we now have in every textbook, pamphlet, Ministry of Health Circular, etc., instructions about disinfection of bedding. I am convinced it is quite unnecessary to disinfect blankets or bedding and my experience is in keeping with this view, and I hope that the time is now ripe for some systematic experiments in this direction on a large scale. Infection from clothing, however, particularly when taken at once from a patient, gave positive results in almost all of Munro's experiments, particularly with garments such as vests, pants, gloves, etc., where there is intimate contact with the sites of election of the parasite. Munro, however, has to admit that egginfected clothing is capable of remaining infected only for two to three days, and mite-infected clothing obviously less. A certain amount of moisture is absolutely essential for the life of the mites and in the ova. It must be remembered that the ova are not nearly so hardy as those other parasites of man. Chance infection does not seem very common. I have never seen a case among nurses treating scabies, and Munro, in experiments upon himself, came to the conclusion that ordinary cleanliness is quite enough to prevent chance contagion obtaining a hold. Details of the life history of the mite show why this should be so. SCABIES IN THE ARMY
One hears civilian authorities blame the presence of military personnel in their area for the increase and spread. The military authorities blame the civilians as the source of their scabies. Both are probably true in that the mass movement of persons will increase the risk of any infectious disease. From my own observations of a number of military units which had equal facilities for weekly bathing the incidence of scabies 11
PUBLIC HEALTH seems to depend on the type of soldier and whether they have any wish to be clean when facilities are provided. This was most noticeable by its absence in the case of units consisting mostly of Welsh miners or Lancashire cotton workers. A unit which was mostly composed o~ Londoners made good use of the facilities and consequently there was an absence of scabies. There is a considerable difference in the cleanliness in the different types of men even when using the same facilities for ablution. The second important point is the ability and particularly the energy shown by the unit medical officer in keeping his men under constant observation so that the earliest case can be removed and treated.
Points in Diagnosis The diagnosis of scabies is a point which the medical profession at large seems to be extremely vague about. This is a pity, as accurate and early diagnosis is the most important factor in the control of the disease. It is popularly called the "itch," and unfortunately many doctors think that any condition which itches must. be scabies, particularly in a district where they have suddenly become "scabies-conscious," or that where there is no itching the skin condition cannot be scabies. Often in the first case they are dumbfounded because, after what appears to be and what probably is a satisfactory course of treatment, the patient will turn up still complaining of irritation. The doctor then panics, gets the case admitted to hospital, and it is found that the irritation is due to over-treatment, or he may repeat the treatment again, giving the patient a sulphur dermatitis or even a generalised eczema. I wish to emphasise that irritation in itself is of extremely little value in the diagnosis of scabies. This point is particularly important, because one sees in the literature reports of miraculous cures for scabies; the cases, however, have only presented irritation as a diagnostic criterion. There is only one infallible criterion and that is recovery of the mite from the patient. I find that I can find it in most cases of simple scabies, although, when well-marked burrows are present, I usually do not bother. MacCormac, on the other hand, during the last war stated that the acaris is extraordinarily difficult to find even in well-marked, untreated cases. I have recently received a letter from Dr. Kenneth Mellanby in which he states that with practice recovery of the mite is exceedingly easy, and he now refuses to diagnose scabies as such without discovery of the mite. However, from the purely dermatological point of view scabies can be diagnosed with certainty without the recovery of the mite. The presence of definite runs is satisfactory evidence. In complicated cases where, particularly in children, there is generalised impetigo, .the distribution is very typical and is easily differentiated from a general impetigo secondary to some other cause. Burrows are most easily found on the flexor aspect of the wrist, between the fingers, the ante-cubital fossa, anterior axillary folds, fronts of the ankles, and on the penis. Scratch marks are most commonly present on the fronts of the forearms and the front and inner aspect of the thighs, but scratch marks in these positions are 12
OCTOBER not diagnostic of scabies. Secondary impetigo is particularly common in service cases on the buttocks and on the anterior aspect of the thighs. In children the infection is more general, particularly in those who have their underclothes sewn on, and runs may be seen in almost any part of the body, including even the neck, but acari apparently never burrow on the face or scalp. In cases that have been partly treated or where secondary impetigo or acute eczema has supervened a very careful examination is necessary from head to foot and in daylight. I look at doubtful runs with a magnifying glass. The diagnosis or scabies is really a simple matter once you know what to look for and where, and in these times many general practitioners and public health medical officers require a demonstration with cases to show them the salient points of diagnosis. It must be remembered, particularly in those adults who maintain a fair standard of hygiene, that infection may persist for months or even years without producing many lesions and are therefore not noticed. If occurring in a middle-aged woman it is probably being treated as a menopausal pruritus, and if "spots" are present it is called a dermatitis and treated with calomine. I feel sure that there is a large reservoir of infection, especially among the adult population, solely due to imperfections in the diagnostic ability of the medical profession.
Treatment I am going to say very little about treatment, as in the light of our present knowledge a discussion on treatment is rather a case of putting the cart before the horse. Moreover, the gullibility and ignorance of the medical profession has enabled the pharmaceutical chemist to do good business in preparing more and more magical remedies. This is particularly easy, as unless accurate diagnostic criteria are adhered to all statistical results of treatment are valueless. In 1905 Neumann gave a list of twenty-four substances which were acaricides and this list can be extended, but no one has yet shown if or how any of these substances get into a tortuous burrow 5 to 15 mm. in length and about a quarter of a millimetre in width situated at varying depths in the cornified layers of the skin. Obviously the essence of the treatment must be the laying open of the burrows to expose mites and eggs. The way to do this is with hot water, soap, and a scrubbing brush. Surely, therefore, from our knowledge of the relative frailty of both mites and eggs, mechanical treatment in opening up the burrows will very probably deal with them without the use of any acaricide. Any material that tends to soften the upper horny layers of the skin will make eradication of the burrows easier. In my opinion sulphur ointment has become popular for this reason and not so much because of the power of the sulphur in this form. I see no reason~ why scabies should not be cured with frequent baths and liberal use of the scrubbing brush, although it may be found that limited use of an acaricide will assist. Prophylaxis is obviously the same. It must be remembered that all acancldes that have been used are irritants and can produce considerable reaction in the skin, and a great deal of hospitalisation I
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1941 (especially, I believe, in the last war) was due to excessive use of these substances. Following on this question of treatment, I feel that some of the problems of the spread of scabies are not unconnected with the lack ol~ interest shown by members of medical and nursing staffs. I do not doubt but that there are many sick bays, Public Assistance Institutions, etc., which are admitting cases of scabies where on admission "routine " treatment is carried out without the case being seen by a medical officer. He probably orders treatment over the telephone, and the case may be discharged likewise on the o p i n i o n of the nurse in charge. I may be wrong and such a state may not be common, but I feel that investigation in this direction is required. Under such conditions, of course, figures relating to admissions, return cases, or treatment are valueless. Personal Observations My personal experiences are, I a m afraid, rather limited, but they lend support to my previous suggestions. During the winter of 1939-1940 I treated in a sick bay some 130 cases of scabies in evacuee children, a number of cases that were sent in as scabies that were not, and a number of return cases of scabies, I have analysed the results, and although the figures are statistically small they may point to useful fields for further investigation. Of the cases admitted as scabies 10"9 per cent. were not due to scabies. Of the cases admitted as return cases 53 per cent. were not due to scabies. This is interesting in view of considerable numbers of apparent return cases in some areas. Seven cases, or roughly 5 per cent., were admitted a second time suffering from scabies. Six of these were admitted over three months after the date of discharge from hospital. I therefore suggest that these were reinfected from their original source or from some other source. The other case was returned after two weeks, together with a child with whom he was previously billeted and who had apparently had scabies at the time of the original case but had not been sent in for treatment. I therefore think that none of my seven cases were relapses but that they were reinfections from some source. Three of these cases came from a district where I have reason to doubt the ability of the practitioner to recognise scabies. In one case a grandfather in the house was reported to have spots and was under treatment by his doctor. The long period of time is probably accounted for by personal contact being less intimate, and there is the possibility of some delay in the diagnosis. One case was returned three months after discharge, and in this instance inquiries from the child elicited that the foster parent had been treated by her own doctor for a skin complaint of some duration. It was suggested to the doctor, in view of the child being a definite case of scabies, that the foster-parent might be also; he agreed at once, treated the woman, and when the child returned no further infection occurred. Of these seven reinfected cases only one, the case just referred to, where there was evidence of direct infection, was from my own district, in which no disinfection of blankets or bedding is carried out although, in all, 45 cases were admitted. Four of the reinfected cases were from a district where steam disinfection of blankets and bedding was carried out and
PUBLIC HEALTH two cases were from a district where fumigation of the room and its contents was performed. From these two districts together 84 cases had been admitted. In spite of the small figures I feel that the evidence is in support of my contention that the disinfection of blankets and bedding is entirely superfluous. During the last nine months I have treated about 55 cases of scabies in Service patients. Most were complicated by impetigo and in the majority the m e n could very well have also been labelled "hygiene deficiency " - - n o relapses have come to my notice. A case of scabies occurred in a regiment which for four months had had no scabies. It was found that the man's wife and child had moved into a village near the unit just previously and both were infected with scabies. The man was admitted and treated, the wife and child attended twice daily for baths for a week, which was until all the runs had gone. Sulphur ointment was used for three days, nothing was done to the bedding, blankets, or clothing of the woman or child, but no relapse has occurred. All the cases during the winter 1939-1940 were treated with sulphur ointment, usually for three to five days. Baths were taken daily, particular attention being paid to scrubbing the hands. Severe sulphur reaction occurred in five cases, and I feel that the treatment with ointment was much too prolonged. This did not affect their stay in hospital,r as the vast majority of the children had severe impetigo, which took some time to get completely healed; as they were evacuees no attempt was made to get them back to their billets until they were completely clean. All cases had runs present, and no case without runs was treated as scabies. A further point that has interested me is the variation in the liability to become infected under seemingly optimal conditions. It is common knowledge that certain persons seem particularly susceptible to be attacked by fleas, lice, and other vermin, whereas others seem relatively immune. This phenomenon, which ] can describe only as the " palatability" of the host to the parasite, has not, I believe, been described in scabies. Two small girls were admitted as cases of scabies; they were sisters, slept together, and their standard of hygiene appeared equal. Although one showed well-marked scabies with many runs and was probably of at least a month's duration, the other showed no signs of any runs at all, although they were carefully searched for. Possibly some persons may be particularly palatable, and this child was presumably unpalatable. This may tend to explain the fact that, although a reasonable standard of personal cleanliness will prevent chance infection taking a hold, most dermatologists have had from time to time cases of scabies in duchesses and other such persons whose standard of personal hygiene would, one imagine, prevent them from remaining infected. Further observations are required. Coneluslon In conclusion I would like to emphasise the following p o i n t s : 1. Our knowledge of the biolo~:y is none too accurate, but it is hoped that Dr. Mellanby will be able to rectify this.
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PUBLIC HEALTH 2. The standard of knowledge among the medical profession, particularly over diagnostic signs, is low, and is the principal cause for the continuation of the disease. Early and accurate diagnosis is essential. 3. Treatment is haphazard, and in institutions both medical and nursing staff are disinterested. A false impression is being gained of return-cases, and cases are probably being discharged while still infectious. 4. Disinfection of bedding and blankets is unnecessary. Disinfection of clothing, even underclothing, is not essential; washing will suffice, and probably airing out of doors for three to four days would be suffÉcient. Scabies is essentially a disease of personal contact. 5. Normal standards of cleanliness will prevent chance infection taking a hold. Adequate bathing facilities for civilians and service personnel would go a long way in preventing scabies. There must be education and the desire to be clean; obviously this should start in schools. Unfortunately many, especially in rural areas, have no satisfactory washing facilities. 6. Treatment must be centred on the mechanical opening of the burrows.
WELFARE IN PUBLIC SHELTERS* By M. A. CRESWICK ATKINSON,
Regional Welfare Adviser, London Civil De[ence Region In considering the organisation of welfare work in public shelters it is important to bear the policy of dispersal continually in mind. If this is not done, and if too much attention is paid to entertainment of various kinds, public shelters may be made so attractive that people who have hitherto been content to use the individual types of domestic shelter may be drawn to the use of the public ones; and it must be remembered that there are health risks inherent in the use of such shelters which are non-existent in the domestic type. Nevertheless, although many more people are making use of all forms of domestic shelter, a regular population may still be found in the public shelters, and some organised effort is necessary to relieve the tedium of the hours spent there at night, more particularly duriiqg the autumn and winter months. Steps must be taken toward the solution of special problems concerned with women, children, and adolescents. It is necessary, therefore, to steer a middle course, and, in doing so, not to neglect the possibility of the provision of some type of welfare in the communal as well as the public shelters. The organisation of interests and occupations for public shelter users has a very definite value in improving behaviour and maintaining order, besides promoting better health conditions and morale. The word "welfare " can cover a very wide field of activity. In order to narrow the meaning of the term the word can be defined as embracing all those amenities, facilities, and activities not included in the responsibilities of local authorities towards public shelters. * Slightly abridged version of a paper read at a meetin~ of the Metropolitan Branch of the Society of Medical Officers of Health. 14
OCTOBER Welfare Organisation at London Region Headquarters That the Commissioners for the London Region are alive to the importance of welfare arrangements for the occupants of shelters used for dormitory purposes is proved by the fact that local authorities have been asked to take an active interest in this aspect of shelter life, and to make arrangements by which self-help activities and occupational interests are encouraged in all types of public shelter. In addition a welfare advisory committee has been set up under the chairmanship of the Commissioner, Alderman C. W. Key, to discuss welfare matters and to consider current problems in relation to women, children and adolescents; a regional welfare adviser has been appointed, and local authorities ma35 with the approval of the Commissioners, appoint either a full-time or part-time shelter welfare officer if the local shelter needs warrant such an appointment being made.
Planning of Welfare for Publio Shelters Shelter welfare may be planned in three w a y s : - (a) by making use of existing arrangements and taking full advantage of opportunities offered through official sources; (b) by introducing new schemes and ideas; (c) by making individual welfare possible. In a number of areas work of this nature has already been carried out to some extent, but it has frequently been found that, whilst some shelters are given almost a surfeit of attention, others, smaller and more difficult to arrange for, are left out in the cold; and it must be remembered that it is in the least attractive shelters that welfare is most important. New schemes can be introduced by ascertaining what types of specialised assistance are available from official sources, such as the London County Council Evening Institutes, and from local voluntary organisations. Individualised welfare can be made possible by bringing together the persons needing help and advice and the means by which such assistance may be given.
Children In planning shelter welfare the needs of all sections of the shelter population must be Considered. One of the first problems to present itself is that of children using public shelters for dormitory purposes. Of course they should not be in these shelters at all. Despite the most careful arrangements and adequate medical aid post provision, they are bound to be exposed to the risk of .infection, and to other dangers. The finest public shelter ever designed cannot, by reason of the very factors which make it secure, be a satisfactory sleeping place for any child. Children should, instead, be sleeping with open windows, in a country area to which they have been evacuated. Nevertheless the fact remains that children are still to be found in public shelters of all kinds, and it has therefore become necessary to consider this problem, and to find a means by which their needs are catered for, without attracting yet more parents to bring their children to them. It is usually possible to arrange supervised play centres or play groups in most shelters; even in the tubes the "under-fives " can be gathered