REPRINTED FROM

Che Boston Medical and Surgical JournalFEBRUARY 14. 1889.

ON THE INCREASING PREVALENCE OFSCABIES,

With Remarks upon Treatment.

BY

JAMES C. WHITE,*M.D.;Professor ofDermatology in Harvard Udiversity.

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ON THE INCREASING PREVALENCE OFSCABIES,

WITH REMARKS UPON TREATMENT. 1

BY JAMES C. WHITE, M.D.,

Professor of Dermatology in Harvard University .

The great increase in the prevalence of scabiesin and about Boston during the last four or fiveyears leads me to ask your brief attention to thesubject. The disease has exhibited marked fluctua-tions in frequency of occurrence in this communitysince my student days. During that period ofthree years passed in the Tremont Medical School,and the lecture seasons of the University, 1853-1856, I do not remember to have seen a case ; sothat I might have entered practice after receivingthe degree of doctor of medicine without beingable to recognize the disease. In the immediatecontinuation of my study in Europe, where thedisease was almost a normal condition of life amongthe lower classes, and where, in the vast standingarmies, soldiers were treated for the affection bythe regiment at a time, abundant opportunityoffered to become familiar with it in all its possiblemanifestations. On my return I found that it didoccur more frequently than it was recognizedamongst us, although rarely. But with the break-ing out of the war of the Rebellion, three years sub-sequently, it became after a time very prevalentamong the soldiers, probably through the enlist-

1 Read before the Boston Society for Medical Improvement, .Tan.28, 1889.

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merit of recent immigrants and the favoring condi-tions of camp life, and later was established as ageneral epidemic in our armies over their vast fieldof operations. But so little were army and volun-teer surgeons acquainted with the disease and itsmanagement that they regarded it as an unknownaffection “ defying nomenclatureand classification.’'"In replying in an editorial article to this opinion,thus expressed in various communications from thearmy at that time, I was taken to task for thestatement that “ I have examined a great manycases of ‘ army itch ’ in returned soldiers and theirfamilies, and do not hesitate to express the opinionthat it is simply scabies, that it is always causedby the itch insect, and that it readily yields toproper external treatment.” The soldiers broughtit home with them on furlough and after dischargefrom service, and thus it became a wide-spread epi-demic, affecting all classes of society.

At that time, 1864,1 was led to make an extendedcommunication on its recognition and treatment tothis society.

Gradually, however, under our cleanly ways offamily life, so unfavorable to its development andjspread, the disease disappeared again almost wholly,from this portion of our country at least. It wouldrevive to a noticeable extent at times when immi-gration became most active, getting a temporarylodgment in this or that factory town throughnewly arrived operatives, or in acity family througha recently imported nursery girl, or a school-fellow,but nowhere a persistent or endemic existence. Thestock or material for clinical teaching was mainlydependent upon a renewed supply from Europeansources, and for several years was kept up princi-pally by returned cattle-drovers. As will be seen

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by the following figures, there have been yearsrecently' when the class graduating from our medi-cal school had little better clinical means of study-ing the disease than I had in my pupilage. I givethe number of cases treated yearly in the out-patient department for skin diseases of the Massa-chusetts General Hospital since its establishmenttwenty years hgo :—

In 1809 50 cases1870 22 “ ■1871 30 “

1872 20 “

1873 24 “

1874 17 “

1875 8 “

1876 35 “

1877 2 “

1878 11 “

In 1879 15 cases1880 9 “

1881 9 “

1882 25 “

1883. .department closed.1884 08 cases.1885 98 “

1880 105 “

1887 123 “

1888 105 “

It must be observed that this last number, 165,by no means indicates the real number of caseswhich might be included in the returns, for in themajority of instances the patient applying forrelief was only one of several members of a familywho were also treated for the same affection.Generally it is only one child out of several whichis brought for treatment,— the one most seriouslyaffected. These patients reside only in part inBoston ; they come also from towns within a radiusof fifteen or twenty miles distant. They are notonly the poor and dirty,but are in considerable pro-portion from the fairly well-to-do classes, and ofcleanly habits.2

There has been also a proportionate increase inthe number of cases occurring in my private prac-tice. Whereas it has been previously rare totreat more than one or two patients with the disease

2 Dr. Greenough in 1887 called attention to a similar increase inthe frequency of the disease at the Skin Departmentof the BostonDispensary.

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a year, I have seen at my office in 1885eleven cases,in 1886 fourteen cases, in 1887 eight cases, and in1888 eighteen cases.

It is impossible to find a satisfactory explanationof this great increase in the prevalence of scabiesin this vicinity. Immigration has not been especi-ally large in the.past few years, nor has there beenany noticeable change in the ways of living, or moreintimate intercourse between various classes ofsociety, which might possibly account for it. InEuropean countries it is the close relations ofbarrack life in the vast standing armies, the corre-sponding possibilities of bodily contact connectedwith apprentice life, and the general disregard forpersonal cleanliness, which afford such facilities forthe spread and continuance of the disease, condi-tions which fortunately do hot exist in the UnitedStates. It is not impossible that the crowding ofgreat numbers of operatives of both sexes in thelarge working establishments of our cities, and themultiplication of commercial travellers, traversingall parts of our country, new features in our sociallife, may present more favoring chances for the developnient of the disease than formerly existed. Thedirect channels of communication from individualto individual most commonly recognized are betweenschoolmates, nurse and child, bed-fellows, artisans,operatives, shop-girls, and through family inter-course, and impure sexual contact.

Treatment. — 1 wish to add a few words aboutthe choice and use of remedies. The old methodsof cure employed in my student days in foreignhospitals may still be relied upon, but they havebeen superseded in most part by others more gentlein action and as effective. Helmerich’s salve, more

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or less modified, was chiefly used in France. Theoriginal formula was: flowers of sulphur, two parts ;

subcarbonate of potash, one part; lard, eight parts.Prof. Hardy used lard, threehundredparts; sulphur,fifty parts; subcarbonate of potash, twenty-fiveparts. In his “ quick cure ” at the Saint LouisHospital the patient was rubbed all over with softsoap for half an hour; he was then kept in a hotbath for half an hour; and during the third half-hour he was rubbed everywhere with this ointment.He was then dismissed. Bazin used Helmerich’ssalve unchanged, and two frictions instead of one.Relapses after these quick cures were frequent.

In Germany Wilkinson’s ointment was for a longtime used. As modified by Prof. Hebra its formulawas: fy. Sulph. venal., ol. fagi, aa fvi, sapon.viridis, adipis, aa libram, cretse, §iv. M. An equalquantity of alcohol was sometimes substituted forthe lard. They were employed as follows : Thepatient was put into a warm bath, where he re-mained for half an hour. Then a piece of coarseblanket was smeared with sapo viridis, and withit every portion of the skin was .thoroughly rubbed.This was washed off in the bath, the skin was dried,and then rubbed with the ointment or tincture.This process was repeated on the following andeach successive day until the itching ceased. LaterYlemingkx’ solution (made by boiling two partsof flowers of sulphur and one part of caustic limein twenty parts of water until twelve parts remain,and then filtering) was wholly employed by Hebra.This was rubbed with a woollen cloth into thewhole surface of the body for half an hour. Thepatient then was kept in a warm bath for an hour,subsequently sponged off with pure water, anddismissed. This is a very effective remedy, but

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if used incautiously it is sure to aggravate theeczematous inflammation which always accom-panies the disease. Three or four days is, however,a much safer period to keep the patient under ob-servation and treatment.

Iii 1864 Barensprung demonstrated in tlie Berlinhospitals the value of Peruvian balsam as a parasiti-cide in this disease, and in the following year styraxwas employed there for the same purpose. Theiressential and active principles are identical, viz.,cinnamin and cinnamic acid. The former containsthem in larger proportion, but the latter is cheaper.In the Peruvian balsam the itch insect dies intwenty to thirty minutes, whereas in styrax it maylive from two to five hours. The method thenemployed was to rub the balsam, or the styrax soft-ened with olive oil, four parts of the former to oneof the latter, over- the whole surface at night. Forgreater certainty of effect this process was gener-ally repeated after some days. The application ofthese substances to the skin produces no irritation.

Kaplithol was introduced into the therapeuticsof scabies by Kaposi in 1881. He employed thefollowing formula: /3-naphthol, fifteen parts;green soap, fifty parts, powdered chalk, ten parts;lard, one hundred parts. This preparation wasrubbed into all affected parts twice in the period oftwenty-four hours. He demonstrated the fact thatthe disease could be cured in this way with cer-tainty and safety.

In sulphur, styrax or peruvian balsam, and naph-thol we have three effective, sufficient parasiticides.The action of the other substances employed sogenerally in combination with them, as above men-tioned, the alkalies, tars, gritty powders, etc., issimply auxiliary, and addressed to the solvent or

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mechanical removal of the epidermal coverings, orcrusts, which protect the animals and eggs in theburrows and pits against the active agents, or forthe relief or prevention of the inflammatory pro-cesses, which always accompany the disease, ormay be provoked by the injudicious use of theremedies employed in its cure. It may be saidthat it is in a proper knowledge of these latter,most essential, points of treatment that the success-ful management of scabies chiefly consists. Itshould never be forgotten that every case of ad-vanced scabies is mainly an eczema, developed, inextent of surface affected and intensity of lesions,bv individual peculiarity of the cutaneous tissuesunder the influence of scratching, and that thechanges in the skin due to the direct action of theparasite are always but a small practical part ofthe same. The mere destruction of the animal inall its phases may be, therefore, but a part onlyof treatment, although always the first and essen-tial step. It is important therefore, firstly, that inthe choice or combination of remedies we selectthose which shall destroy the animal with certaintyand quickness, and yet shall not aggravate theexisting inflammatory changes in the skin; andsecondly, that we do not use them too long.

I generally employ in dispensary practice thefollowing method, and may say in advance that itis applicable in every case, however extensive orsevere may be the accompanying inflammatoryprocesses. I prefer a mixture of the threeactive agents (a scattering shot), and combinethem in this way. Sulph. flor. 3ii, /3-naphthol3i, balsam Peruv., vaseline, aa §i. M. Thisquantity is generally sufficient for the cure of asingle case. The patient is directed to rub a third of

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this mixture into the whole surface of the body,from the neck downwards, at bedtime. He is espe-cially told to rub it between the lingers and uponthe penis, and that it must be applied to the backby some other person. He is to sleep in old gar-ments, that the bedclothes may not be soiled. Inthe morning the skin is to be thoroughly washedwith soap and water. The use of the bath in thisclass of patients is of course out of the question,nor is it essential. The ointment is to be used inthis way for three consecutive nights. Generallythe itching ceases almost wholly on the first appli-cation. The patient is also told not to use it afterthe third night, unless, after waiting two morenights, there should be a decided return of thepruritus here or there, in which case the salve is tobe rubbed into such parts only, and only for twonights running. For very young children I omitthe naphthol in prescribing the ointment, on accountof its occasional irritating properties.

In cases where the accompanying eczema issevere, it is well to require an inspection of thepatient again on the sixth or seventh day. when itwill sometimes be found necessary to direct acourse of treatment addressed to this residuarycondition. A very frequent mistake on the partof the physician or patient at this stage is the con-clusion that the appearances, or accompanying itch-ing, are signs of the continued activity of the orig-inal affection, and the consequent renewal of theuse of the stimulating parasiticide, which only ag-gravates the existing process. I have often seencases of post-scabietic eczema in dispensary andprivate practice, which have been kept going formonths by such errors of judgment. It mustalso be remembered that in prolonged cases of itch

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the cutaneous nerves have acquired, as it were, thehabit of demanding to be scratched, and seem torequire it for a long time after every visible signof the disease has disappeared, and these cases ofsurviving pruritus are often mistaken for remain-ing evidence of the original affection, and mis-treated accordinglv.

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Directions are always given that on the firstnight of the treatment all the clothes which havebeen worn next to the skin, — shirts, drawers, andsocks, and the sheets and pillowcases last slept in, —

shallbe thoroughly boiled before being used again.Gloves should be baked or destroyed. It is to beassumed that every bed-fellow has the disease also,and requires treatment as much as the patient.Every member of the family should also be in-spected and treated in the same way, howeverslight in character or extent may be the indicationsof the affection. I have seen the disease keep upa continued and alternating existence in a largefamily for a year, during which period nearly allits members underwent treatment one or moretimes, simply because they were not treated simul-taneously. I have recently directed live membersof a private family to be thus generally treated,although only two of the household at that timepresented any positive indications of the presenceof the disease.

As to the more general control of the affection inits well-nigh epidemic state of prevalence, it isonly by drawing the attention of the profession tothis activity, and to the best methods of destroyingit in individual instances, that we may hope toaccomplish anything, and it is for this purpose thatI offer this brief contribution to your notice.

CUPPLES & HURD, THE ALGONQUIN PRESS, BOSTON.

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