bmj military health · mentorum, like the p. pubis, also almost invariably .attacbes its eggs to...

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ClinicOrl' a':nd other Notes

(5)" When the fomentatioDsare omit~e~heusoi or sl).Une soaksm~y be used, bu~ , if there is a; return of.'colour ,and odour, treatmept by fomentati~ns 'must ,be res~med:", 'I ',,' , , '

(6) A bacteriological examination of the pus shquld be made every two or three:,,' days as a guide to treatment; Cases in which the clinical signs of the 'infection ~re ' absent ,brit, the orgaJilism is .fohud on bacteriological exaininati~n are probably

, harmless;, but it is wise in these case,s to continue toe eusol fomentations, for a, long period. '- " ,

" .'

PY'ODERMIA' OF ,PARASITIC OBJGIN.l

'f By CAPTAINS H, C. ,.SEMON AND, H. W. BARBER. RoyalAr~y Medical COrp8.

IT is impossible to ~ork for~uyl~ngth oftime~t ,a ~ilit!J,ry ,hospital Jor, diseases of the skin without beingimpressedby the large preponder~nceof cases

,of pyogenill iilfectio:Q; T,hus, out of a total number ,0£669 patients admitted, , under our personal care between Aprltl and May W 1917, 631, Le., 94'3 per cent. ' were cases of this' natu.re. ' ," "j' , -. "." , .\ '

:Among soldiers"pyoderinia of ,the scalp;faceahd ,neck, fs usually associated :with' thesebcirrhooic diathesis ,(Darier:s "kerose"), whereas, when it occurs ori the trunk and, limbs it is,' in: ou:r opinion" aHn()st invariably the ,result of a.'

'conc()mitant 'or preceding para~itic infec'tion, yiz., scabies or pediculosis. it is the object of this pape~ to, establish the parasiti6 e~1010gyof I pyodermia.

; of. the _ trunk and limps, to emphasiz~ the striking.differences in the clinical pictures produced by the acar'Q.!'I and the louse, arid to .describe _ briefly ~he thera-

~ peutic measures which, iq ourhatids"have~ieldedthe, best results. , " , ' , . There is seldom .any difficulty' in recognizing. ,pyodermia due to scabies,

, even ,though ther~ l;>e '~o-acth:e' lesions present.' rr:he distr'ibutioIlof ~heeruption, ',~\or of what rem~ins of it when, the cas~ comes under observation; is highly

chara/cteristic; , . ",' , .' ' " . As it is of paralllount importance in the differential diagnosis 9f the 'various '

,types of pyodermia, we may be, pardoned for briefly recalling the main features" ot~he scabietic eruption. For descriptive purposes we propose to copsider :.-:. '

, (1) A case ?fearlysc~bies; , , ", i

(2) One in'which, secondary pyogeni~ infection has occurred.., " -, ') I (3) One in, which ,the' affection _"manifests itself in a subject with the

eborrhq3ic diathesis. ' ',~ ,

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" (1) 'To meet with cases' of early" and~l1ncomplicat8d scabie's in troops fresh I trom the trenches is exceptional, as pyogenic infectio'n is' a rapid ,and 'almost_

,constanlisequel. . 'In sqcb, burrows ,al1d vesi~les, it pr~sent, can mpst easily , be demonstrated on the .hards, espec~agy along 'their ulnar bprdets;and between' , the fingers, on the flexor aspect' of the wrists, on the pr~puce and glans, penis, and-, ,on the anklesanil qorsum of the foot. ", " "

, '1 F6rthe ,pu~pose ~f this article it is proposed:t6'u~e 'the, 'word "pyodermia" to include the various. types of' lesions denoted by the terms impetigo" furunculosis and ecthyma. ,

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" ./ Cl~nical" and ,oth~r 'Notes \~ ;389 ' ,.

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(2) :w.hen,secoJ?,daty infootion has occurred,'pap_ulesand~ superficial pU!;ltules' " , and boils~p1aketheirt1ppearan'ce, ilot only in'th'e 'above, situations, but ,also on the

extensor s'tirfacesofthe el!:>ows, the anteri9r axillaryfolds(wh~rethey are some-" ,times associated with-burrows); round the ,nipples, and very commonly aroundtlie • 'umbilicus, and on~the ioW-er ,half of ,the buttocks. On the lower extremities ,the

'eruption is most ~vident ,onthe posterior arid'internal aspects of th~ thigh~, the ~npedor asp~ct of. ,the knees, the popliteal space'; ,and behind the malleoli. It ,is 'a1sQ wort~yofremark,that long after, all evidence of active .infection has subsided; chron~c p~urigi~ouspap':llestend tb ,persist in certain situations,/particularlythe ' wrists, the inner surfaces' of the' thighs, the buttoc,ks, and on the, scrotum and' penis. A f~a:ture of the scabietie<e;ru ptiontliat has helped usin: doubtful caSes. of,

.pruritisaq.d,pyodermia"-and one,the importanc(l ,of which we partic,uhi.rly desire to emph~J'jze~i~ the' peculia'rgoose-like itppearance' of the' affected cutis in',~ genera1. On,B'xamination with a lens, this appeadncelsfound to be due to the erection' 'of the pilo-sebaceous fol~icles,and 'in ,6ur e~perience it is an almost constaIlt,tlioughluiexplained pheJ;lo~enon in scabies. ,,','

, (3) Where the exudative seborrhmicdiathesis exists; infection witli scabies is usually as~ociated ~itha severe and widespread eruptIon:' The acarus is one' of, the' IJ10st ,p~t~pt \ageJ;lts, ill- prqvokirrg 'andlight'ing up an acut,eseborrhooic de:r111atitis';in persons thus \ predisposed, which, is not infrequently mistaken for thederniatitis 'excited by the injud,icioususe 6£sulp11ur." '"" '

" , (~.B.--'-On the ot4er hand, seborrhreic 'subj ects are particularly liable to, suffer ft;om sulphur der'matitis.) ",,', "", " "

Toe e~uption'begins' asa discrete papule, 'fomcular ec~ema~on:fined to the" .erect'ed pilo-sebaceous follicles: already,descrihed. Later, confluence takes pJace

, by the ecz6lnatization of th~interv,eI\ing skin,and.this, giscrete follicular ljLppear~ ance is lost~a~d diffuse ,patc~es of' eczeJ;lla, which may later ,coa'l~sce, to form 'la~geplaques; make their appearance. -~\ ' ", .",',,'

, Tllese ,characteristic lesions may be generalized, but tend" to be 'most severe and persistent on the f9r~3irms, the in,nersurface of the upper arInS andaxillro., betwee~ ,the 'scapu:lai,on the,lower~ abdom,en, on the' inner, surface of, the thighs, and, in the popliteal spaces. In this type of case seb~mhooiceczema of the-face and, scalp of~eri ~o-exists, lliud is apt to prove a trap to those' ~ ho have hitherto believed thatfacialeruptioIls ptecludeadiagriosis of scabies.

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,T}:lecondition~unQ,er which ~,ur, tro,?ps ,h,a;e, beEm fighting a,re respon~ibl~ for /, the 'occurrence/of .cases of pediculosis far more severe and extensive than are, com~only seen in civil hospital practice.; There is no doubt wh~tever thati:ri. this connexion the Pediculusvestiinentorumor corp~ris is the chief offender.' , It i~rare.to find P. pubis! while P.ca~itis is still more uncommon. We, will, ,therefore, confine our remarks to ,the P. vestimentorum. Thefollowillgdescription of ~hemain external characteristics ,of the, parasite is .taken with ackn9wledgments ~",

, ft'om that excellent nion()graph, ~' The Louse (problem at the Western Front," by , Lance~Serjt. A. D. 'Peacock, R.A.M.C.,T.~~, .M.Sc. (Dunelni). ' "

" The female is ab(;mt ,four millimetres, In, length; the male about three Illilli- r

• rpeties. The head bears one pair ,ofantennre, and ,the ,black eyes, The three thOracic segments: ar/! fused and present but )ittledeinarcation." ,There are three

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390 Clinical and othe,' Notes

pairs of strong legs attached to the thorax, each of which terminates in a short powerful spine. There are eight abdominal segments, the two terminal being fused. Posteriorly, the male is pointed a.nd the penis may sometimes be seen extruded , wherea.s, in the fe male, the posterior end is hilobed, a.nd bea.rs a pair of ventral copulatory DI"gans. It is well known that t he female deposits ber eggs in clothing of all sorts and in blanke~s , and most of the prophylachc measures again st " lousiness" have been directed to the sterilizatio n of the soldiers' kits.

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A An absolnLely .cblloracteri stic picture uf pedioulosis. Kote the localization a.nd the appCRortlollCC

of the lesions. 1. An early pustnle, i.e. , infected bite, wiLh Its ccntro.l yellow \'cliicle. H. The central vesiclo ha.s become a. small crust covering a. sma.lI underlying u lcer. Ill. Infection is sprc!Codiug pel·iphera.lly a long the lymphatics and t he circu lar ulcer is th us being produced. IV. Tbe circular encrusted ulcer.

It Joes nOli appoar, however, to have been generally realized that the P. vest·imentorum, like the P. pubis, also almost invariably .attacbes its eggs to the pubic and perineal hairs, and less commonly to those of the axillre, and other covered hairy region s. In no available text· books or monographs to which we have bad access is this fact referred to, although its importance is at once obvious and far reaching. I

Some months ago, one of us (H.S.), in examining seven consecutive cases of ecthyma. and furunculosis of the lower extremities, .happenea to notice in each of

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Oii1iical and other Notes 391

B 'I'be pediculons boil in an cllrly stage. Note (1) The central small dark crust cllpping tb e

elevated, dusky, cone Rhaped and puckered focus of infection; (2, cdorual to It a. fine collarette of white sca.les; a.nd (3) a. surround ing ha.lo of hypermmia,

..

C Pediculous boil on the tmtcrior surface of the thigh. A ctlltcrilorm ulcer is in progress of

being formed. The chara.cteristic circula.r crusted lesion would ultimat.oly result.




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392 Olinical and otheT Notes

them the presence of " nits" on · the pubic bairs, and from this time forward wc have made a. point of carefully examining the pubic and axillary hairs in every patient that has come beforo us.

The l'esulta of our obsen,ations may be summarized as follows:-(1) In almost every case presenting any or all of the lesions we have learnt

to associate with pediculosis, "nits" were found either in the pubio, axillary or perineal hair.

(2) In cases of pediculosis in whioh new lesions developed while the patients were actually under treatment in hospita.l, careful search of the above-mentioned bairy regioD3 almost invariably reven.led the presence of jj nits" which had

D Two early boils which our experience nas ta.ught DS to recognize as oC pediculous origin. They

werc situated on the fore and upper ann of a. paticnt with marked e,·idence of "lousiness" on the rest of his body.

escaped the attention of the orderly in charge of the case. Removal of these, . the application of paraffin or 1/40 cf11'bolic lotion, and a complete change of kit

were always successful in preventing the further appeara.nce of frcsh pustules. It may here Be said that until we realized the importance of tbe pubic aud axillary hair as breeding places for lice, our cases of pediculosis were constantly develop. illg new furuncl~s (i.e., infected bi tes); now tha.t wc insist on the pubic and axillary hair being cropped and all nits removed with paraffin , thi s no longer occurs. The cases a.re consequently cured in a very much shorter time,

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Clinical and other Notes 393

(3) Although P. pubis is occasionally met with, and when p eesent is u sua.l1y found both on th~ pubis and in tbe axilhe, in the vast majority of our ca.ses the eggs fouod iu these regions were those of the P. vestimentorum. Vile were first led to tbis conclusion owing to the frequency witb wbicb live specimens of P. vestimentorum were found crawling a.mong the egg.lu.den hairs, particularly on tbe pubis, aUhough P. pubis wero absent. 11713 ' have s1:nce succeeded in hatohing ant young P_1Je,~ti1nenlor1/"1n f rom halTs ,'emoved f)'om the pubis, and lcept

E The pediculou!' lesions arc here displayed in severa.l stagsR. Abovo the risht iliac crest (and

somewha·t out of focus), is a.lilte stage of the 8uperfioia.l oiroular ulcer (4) in text. On the right buttock a.nd in closo proximity to the centre of tbo natnl cleft is an abortive exa.mple of the type described under (5) iu text. The remainder partako or t he characters described in detail und~r the bell,diug of supcrficinl pustules and boils.

at body temperature /01" severed days. This experiment conclusively proves that tbe P. 'liestimentorum hR.bitually lays its eggs on huma.n ha-ir, and this fact should always be carefully considered in undertaking prophylactic measures against louse infection.

We ma.y now consider the differeot lesioDs met with in a.ssociation with pediculosis. Of these there are three main types;

(1) Tbe actual' bite of tbe parasite. (2) Superficial uoinfected scratch marks. (3) Superficial pustules and biiils,

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G'linical and other'N otes . \ . ".\

. '( 4). C~rcular encrusted lesions of. varying . depth. . (5).V~ry charaqt~~isticline!l:l' leflions,pr'esumably a sequel to (~) and (4) ...

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; ':,,',' t' .' {2Y, SORATCH,MARKS.'; . .'" .', ",

. These ar~ ~6st commonly sit\latedon the·,'should6r~>'chest,· butto'ck~'a~d 'sacral ~egion ,Uppy~ partsonhighs, li6th intern~l,'~ an te~ior!an,a,yxte.rl)al surfaces;

~ and lOP thetegs.' ',The excoriatioris correspond in. their differennsituations to the. 'lines along which the patient' can_m.ost· easily \ scratch hilpself ,(CC grattage 'instinctif "--r;:-Dubre~ilh). Thus on the b~ttockst~eyten,d to, radiate upward~

· and outward~ ,fiomthe anus. On itne"o:uter \iurfac'esof;tbethi'ghsthey' r'l+n vedica,llyupwatds, on, tfieinnet surfaces upwards ,and outwards\and siqliJarly~ on

· thesacrpm. I ; '. , • \. •••• .• • , • '. ,"'" •••

~' At this. stage it is interesting 'to ~oil!pa;re the' scratch m,a'rks~\t I~cabie(> w~th those caused by the pediculus. ,-We hav,e already r,eferred,tdthe 'er,ectio'nof the

· pilo~sebaceoU:s, follicl/ils in: !1cabies,. a~d, in this di'sease'the,scr~tch rparksappear as. \ · m~nutePinpoint blood crusts:at' theapices/of tlie e'rec,~edfoniCles, whereas, An .'. I pediculosis, in: which, no such foIlieular- erecpion is seen,the seratchn'iltrks are .' merely line:),r excoriations of. the otherwise normal epidermis. . I, .. . ' I' ~ p, • .:' ' . / .. ', " "', ", I . '.: '. I \" " _ ' /, \ (

, . . (3) l'USTUL:ES($UPERll'WIAL): BOiLS (DEEP).· ,... ,

.' ~Apa~t-frd~ (l)a.iJ'a (2) o~r observati~ns 'w,?uld'lead Us to believe I~h~~ra sup~r-' \ ,'flCiaI or deep 'pU:~ttil~is the>i'nitiatory st,age of the ,other lesion'Smetwith in

pediculosis. The sequence/Of events is':aS'fol1ows :--",: /: " " . ,. I. \ i' , I 1',""" ,. '. . .' \._

..... (a) A:n ir:lduratedjl,"dtable, bright ,red haloari~es, !).roynd the odginal Dite: In ,the centre. of 'tqis a minute yellowish-white [ vesicle rapIdly drying tq form' ~ crust, .

. \. ,makes -its appearance. , When. pressure is appli.ed t'o ~; superficial 'lesion~t this stage a,'s,mall. quantity of jJUs is exuded from the centraI~esiQle or crust. In the deep va.ri~ty' (~r " l1~ir") which is; often elevated and 'sur;rounded by ajvi\:le area

" of .induration, similar/treatment res,uIts in the f6~cibleprojection ofa eonsiqerabIe

.I.

· qurantity6f sapguinebuli> P?S,'f~o~:ryhat is: evi,den'tly a, bott1e-shaped~ca;itl In'

both types .of lesion 'the is~perficial,opeiJ.ing ()r mouth' is very minute and of d!lfinitely circular outline, a fa9t that' supports b,il,r view that these pustules are originally formed ro;urid pu~ctur!'lsmade by th~ parasit,e. If these~pustules ,are ;dealt ~ith ihthis early st!1ge bJordinary antisepticapplic,ations(e.g., binet.iod.) theyus:ual,lyinyol~tewithout;pr!Jgressil?g ~urther:,but if not interfered with, the,

Aesions ,t~buIated under (4) are aptto,result .. ',' . . -',/ ',' .-, ",; \ " ',', '

, . (4)/ Ci~CUL4R'ENCRUfi!~ L.ESIONS.OE VARY~NG D~fTH." .' • ..,.

It is, not difficult to trace: theprogz:essive 'ae~elop:t;rient. of ulcers of v~rying .dept!:J. and extent (as may be, s~enby a 'ref~rence to.the accompan~ing photo-igraphs), from the pustules above deseribed~· . f .

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./ '\' (Q)LINEAR< IMPETlGo. i;,',' ('

Sup~rfici~I)inea~e~c~~~ted lesions r~sul)t from the exuda~ion of 'serum along -. the lines of- ex'corilition duetoscfatcbin'g; they may occur.iri. any. prurig~~ou(>

. cOD)plairi~,'and are in~no~aye~E/ilcially chariwteristic' of pediculosis. l ,On the. J' \'" ,

. 'lM~jorMacC~llnacilDd Captajn~mall haverecently\dr~wnattent!on to the fapt t~at .' ;,'1 superficial," lineariiDpetigo" may: be'a ,nianif€~tatJon (If, w,hat they aptly term a'" wa~'

n~uro~i~.". It is frEquently asscciatedwithanlllstliesili of ·the paJate, altered cutaneous' .seIisfpi1ity,-and other stigmata of the psychopathic state. ~ . . . .'

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Olinical and other Notes 395

otber~ band, the variety which is pathognom~njc of louse infection is a guttershaped ulcer covered by a urownish crust, and of considerable depth. Its outline varies with the stage of its development, wbich, in DUI' opinion, proceeds from the longitudinal uigital excava.tion of one of Lilt! circular ulcers a bove described ; a.nd in fact in a severe case of pediculo!;is nIl the intenT18d ia.tc stages between the

F 'I'bis photograph of the loins demonstrates a case of "linear impetigo," a. very favou rite

feeding ground of the pcdiculu8: lesioDB in thi s region when of 0. pyodermiu character are Htlmost invariably the result of louse infection.

circular and the rectangular gutter-shaped ulcer so called 11 impetigo lintlaris" ca.n easily be demonstrated (vide photograpbs). These. circula.r and linear les ions when healed a.re invariably replaced hy bluish stains a.nd brown pigmenta.tion which persist a long time, or if suiIwiently deep, by the forma.tion of actua.l scar tissue. The chief points in tbe differential diagnosis of tbe eruptions due to -scabies and pediculosis may now be presented in a tabula.r fOfm.




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396 Olinical and other Notes

SC.o\.BIES. r.lJ:DlCUI,O!:)I8. Localization.

Ha.nds, wrists, elbowiI, nllLcrio[ nxil- Posterior axiUu.ry folds. !lhouldcrs. IMY folds, umbilicllR a.nd abdomen, lower sncml region and upper pa.ri; of the but· tria.ngular arCl\ on the bu ttooks. t acks, g roins,'t.highs, and the skin between

Penis and scrotum; knees and ankles. :B1 ront of kueel';, :-mkles and feeL

Type of Lesion. Burrowg, vesicles, slllall Ruperficia.l

crustR, papules, pustules 1\114 a Rpt'!cific f!J'ouLiull of the pilo.sebar.oous follicles with 106condary eczema.tiy,utiou, especia.lly in seborrhooic 0. ..... .:;0$.

Scrawh marks 'are rcpresclltl.x1 by minute blood tSru~t8 at the apices of the Iweoted follicles.

Superficia.l and de~p pustules, with a surrounding red anci induro.t.cd lmIo. Cir culn.r cncru~ t.cu u lcers of "i.'aryinR d epth flnu size. but on the wh ole WIry much hHger t han tho:;e met in :;cubies_

" Linear impetigo."

It is obvious t hat since infcc~ion with bot·h the pll.raf>ite1:l iR quite commoll, t.he two clinical p ictures m :\.y be superimposed.

•

G A pediculous hoil (rom 'oyLich the crust has been romoved and the PU t;; exprcssed . It demon-6trates very clearly the commencemcnt of an ulcer which l(l~cr assumes an ecth)'ma.~ous type _




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Clinical and othe .. Notes 397

J . H

The wel1.defined I' collarette" wil l be noted in both the above lesions. I t would seem to be a common feature in boils due to lice.

I Miorophotograpb o[ young Pediculus 1Jestimel~lor1tm, artificially h a.tched from ovum OD

a pubic hai r.




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, . . . . P1;(PPHYLAXH; OF,PE~)ldPLOsIs. ,i .. ' .

. It is beyond. the' scope 'of this, paper' to . ~up:ple~ent by i other suggesti~nl:!the, trlElasures for the disinfection, of blankets 'andcfothing at preselltin'use at all general J:iospitais'and, milit.ary cleansing 'aepotsinFran9e.~ . We wOuld,'how~vef~ ~mp~~si~et~~ ,extreme importance: ~f' sitllulta~eousl~ eradiGatfrig :the res~rv~ir,s " and ,breEldingiplaces on the human~ Dody/itself (as is donein scabies), fotwhich .

" purpose batbs." m~dicatedor otherwis~, are not sufficient, . \If these.~~e overlboked'N. , it ;is. obvious thanh~re is' Bverjjiilrelih~oa!ofarapid re~i~fectiono( t~e steriliz.ed:') ga.rm~nt<jwithin a~hort time of .their re~iss.ue; Wepaye found: the cropping of .

. the pubic qair and th,El repeateliap'plication: o£.pap:af'tin', or 1/40 carbolic .lotion to the'· , 'pubis" perineum, and axillrequiteeffective-althoughthere is, nO'uoubt that if it

. , " cQuldbe supplied, pe~rol (which is useaforthispUrposeinthe'FTench'~rmy)' would be the most powerful agent" as it,llot only kills the'~dult parasite'instantly, ....

.':~ut'also penetr'ates the chitinO'us envelope ofth\'l>ovum,anddet~ches Jtfro.l;n the ", h~ir~ '~" ,,~' c, . / .'" " . I, "~/! -/ ~ .\ /'" ~ (',' ,,' .,' ~:,. ~ ~ " ;.

A~ • improvement of petw~'i is ,the solution .o.f ~aphth~lene' one perce~t, ~nd sulphtj.rone per cent inbepzolor petrol, recorilmendedas'ofproved'effi.ciency l;>y C!tptain J.A. Gunn':R.A:M.O. (T.),M.:p.: D)Sc;, in t~e 'British Med,ical J'qurnal, '~~y5,191T: I, ~/'\~I ~..,~' '. ,',.", ' ,', j •• ,~.,

.This solution is not only.prophylactic to,garments, mom.en'tarily steeped in it; i;' over several months, (nit)is, as 'wear~in£<:>rIlled, and have/otirs'elves1proted,

, i:p.stantaneously l.ethalto both p,api.sites and their eggs. '" r Treatment.;:-In so.1diers the;routineJreatment of scabieshasalreiLdy been :exh~ustively. dealt. with .intne. current number of . The :British jOlUrnal·", Qf [Jerinatol9gy. ,J)y . Major H. '. M'acOorn1ac,R.A.M,d.~1:.), ,M.D.;' RR.O;P. ; ~ it is,

'"thereiore,unnecessary, to discuss ithe~e~ " .: , ., ' .• ' . The roost important point to.' be observed in, the tre~tmentofpedJcul0fi!is is

the discovery andeHmination: of the parasite and its eggs. ' . . . ,The, methods found efficient by us .have 'already bee? described. It now

-remains: to. mention briefly ou.r Inethods of. treating the secondary lesions .. ,' .. (1) Treatmeniof theF:rimary .PUstul~.~Ir ofsmalI or:moderat,e~size,e4pressioi:iofl't~~ ; co-utttihed: pus, and' painting the surrounding skin. with ,iodin,e, ,is almost. !1lwB;yssufficieut t~eJ;!sure resolutiop. f, '. .' '. <", '. " ',(~) :whe~ uhleratiol), and 9rus~inghaveoccurred,th~reis;notqirig, whichinou~

~han:ds has yield~d better tes~lts t~an ,an' ointrbentonhe/followi~gcom'position :0- ',. . \ A~id.salicy!.. }. " . ' ,~ '"

I Sulpho preolp. .. . ,.. ,.' a~i'gt;. x /:1

Ung. hyd. ox. fhiv.,. ad Si \ Thlsis'kept applied day and !?igJ;i~on ,lipen or Hut, and in'frorq' fO~l1 da,ys!to c'a,'

" we~kthel';Juperficial ulcers will be loil1idin, the mltjority 6f cases to. ha,ve healed., completely'. . r)aep Ulc,ers of,' an ,ecthymatoTIstypel!,lso:d.o well uI;lder it,:espeCially . if the.patient is kept .in bed with hislegsraisep.it:is' onlyoceasiopaHytbatwe, ' fueet '\yith thedeep\y eroded indolent variety. Tflese have to be treated ,on getjeral

" principles with the patient in bed,and~iiLtax thetherape'\l~ic resource~ and skill of the physician, to .the,u't.~ost. ' .' . ,.... / ' ';'' . ., ., .... , ." ,.

\ ,The views which we hold on ,the great importatic$ of .the pediculus as a,. . ca.use of.disahiIit:tare strongly.siIpP9rted by. t~e :figur~s we submit below.' " ,',.' ; . •

. The results oCour anILlysis maybe tabulat,ed as follows :---, . ',' ".' .,".'... "'; ,- ' .. ; \ ",,'.

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Olinical and dther Notes , ,

, 'TOTAL N;;'MB~R OF O~SE1S ADru:ITTED BETWEEN APRIL l';AND MAY 9" 19~7',)69. 669' ,

, ; 'I' 'Scabies

,17i

;' 'i _--'--____ --'--1 ~-__c___,'_:~' -' -"~', (', " •

'Pyodermias Other diseases, e.g., " " '

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, 631 ' pSQriasis,' herpes, <, -"

I, , eczema, tinea,&c. '

I. ' Pediculosis ' " ,

(a) Inwhich '(b) In which' no lice or , lice or ova ova were fe:und, b:ut in

, were 'pre- whic;h there was pte-,se n ton sumptive - evidence' of p u b'i c 0 ~ pediculosis,~. g., me~ ,

,axill a ry 'lanodermia, s ctatc h ,hairs , ,marks on.shoulders etc.

, 190 . ' '67 ' , "

I ' Scabies

and ,pedicu

losis ' co-existi,ng

24

I Sebor": rhrea 112

, 'r, 38' .

, I Other eases ,67

, ,

" These' are the ~combined ies~lts of our ind?penderit, obser~~tions; theindi~ vidual figu.res ~ere~s follows,:,--c-' ,," '

'\',

Scabies Pediculo3is' 'Scabies and Sebor-(a) rbooa

, Otber cases ' "'Other , Total' (b) "pediculosis

'H. C. S. 101 ~,. 83 44 .11, 51 , of pyodermia' ,', cases

42'" 14';." 346 25" •• ',' 24r '323 .' Ho W.B. 70 107 ',23 ' 13 ' ... 61

, ' ':rhus,the va~ioust6tals ~orrespon:d fairly ciosely u~der"eacl;1 heading.,' , , It will be seen that out~ofa, total number of 631 cases ofpy6dermia,1452 were

associated with'para,sitic' i~feCtion,i.e., 71'6 per cent. Of thes~hi.tt~r, In, i.e;, ;:17'6 per': cent, , wet:e 90nsequent on scabies alone;' 257, i.~.; 56'9' per cent, were; apparently secon'aarytopediculo~is;' while in' 24" i.e.; 5'5 per cent,' the' two "

, infections were 'coincident. " '. , ', " , t4e prepo~~erating pe~c'entage\ofthe ':pediculou~ cases' i~ at 'once apparent.,

Of the remaining' non-parasiti~' cases' of pyo,dermia, seoorr.ncea-:-whioh is common, and of a severe type'among our troops-accounts for, the pIajority, whilst in only"

,'sixty-seven could no definite eause be assigned. ,'.,' , \ ' . ,",' (We are, thereforejustified in ass,uming that p~~asite~ arere~ponsibl~, to a .very

( con,siderable. degree 'for the, disapilityinducedhy s~in 4is~ases i~ :this! War.,',

~P:!:lCLUSI6NS.

( (1) The disabi1ity~roduced by p'a;asitic, inf~t~on is:;rery considerable. or '669 cases adjnitted in just ,pverfive_wee,ll:s: 442 were directly attributable'to scabies

:,and pediculosis/ ;.' ", .'.. .'.", .. '. (2)0£ 'these 442, 171 \vere 'due to scabies al~ne,' 24 to the cOplbined infections, and 257 to pediculI: / ' ' " .' ,,' , '\ . , ," (3) TheP. vestimen,torum is 6,apable, !Iond,in a(Jonsidera~le majority of cases.

- actually does lay its eggs in the hair of the pubis and perineum, and sometimes ' the axilla. ' . ' ' ' , ' , , -, , , ' , ~

'(4) fro,m this factther~ arises" the, important dedpctibn, that measures'directeq towards .. sterilization of the' clothes cannot be efficient unless the host himself is also disinfecte,d at the same ,time.' ,

, (5) ,We regard it as extremely probable that the Jesions of. pediculosis are initiated in suscepti~fe ,Individuals arou~d the actual bite of ,the louse.

, (6) The seyerity,of the, lesJon.s produced, especially in the cas,eof sgabies, is;' veryconsiqerably aggr~v,atea by· the seborrhceicdiathesis.· . I'

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. (7). Rapid recovery inl'yodermia, a~sociated with either sc;abiesor pediculosis, IS' the rule, provided that, ,the respective· caus,e,s ar,!l re.cognized and :dealtwith in an efficient manner.1 . , '. ',' .

A QUICK ~~THOD OF DIAGNOSING THE TYPE ~ OF. '. MENINGOCOOCUS. IN OASES OF CEREBROSPINAI., FEVER.

/' . . . - ~ - ! ",-

By MAJOR A. S. GORDON BELL. R'oyalArmy Medi~al Corps.

Of, the Central Oerebrospinal Fever Laboratory. " ".', I" • I

. AND.

, ' , -c Miss I.M. HARMER.' . ' Of the Oentra.l Gerelirospinal FeverI:.aboratory.

, _ /. 'J , " \.

.- iN the E)ffective treatmentol cerebrospi~ai fever-early,recognition of' the ty~e" .~ .. _, of the infecting menirigoc'oc~tis: is of the utmos~ impo~tance ~n 'order that the corresponding specificcti~ative serum zp.ay be given as,sQon as possible~ , ' .. ' , "

.... Under thi:J mo'st, favourable circumstance's, fqity-eight hou~ must elapse before . the meningococc!ls call: b~ grown from the cere~rospinal fluid; or nasopharynx of the case and· its correct type diagnosed by _agglutinatioIl and not infrequently .•. se\;e:p.ty-two hours pass before the)nfectingmeningococcus is ~cla!!sed. ", ' .. ', , An at,temp~ was made int~~ firs~ 'place to shorten this period by~substitutin:g

..• ' a precipiti~ for the 'agghltination reaction; it fltiled aisrr1ally~ , F,inding t.~at in ~he'/ case of the four univalent agglutinating sera prepared from the rabbit and sent' out frok theCentrai Laboratory fo~ identifying types of the rr1eningococcus,the result.s· given. by ~ompltlm(mt fixation were pra~tica!1Y identical wit~ thpseobtained by agglutinat'iop" the write!s' next procee~ed to apply t~e complerpen~ fixation test. tq serum t~en from patients a:t an early st!ige of cerebrospinal fever, using the. four, standard ,type cocci as,a:p.tigens in eachinsta.nce. The results obtahled in six,teen successive cases of cerebrospinal fevt3r wer~ as ,fo~lows:- . .'

. rt will be, seeh that in each of these sixteen lcases ;except (b) the re§lults were not' clean cut,~ n~vertpeless the ind,icatioI'; 6btainedby thismetliod' was- proved ~right in all Of the cases in whi~hthe type of ,the coccus could subseq,u~ntly be

" 1 We have ,been asked t9 explain-'the fact that wherea~ about nlnety per dent of all tropps iD. the trenches<ar~ infected with·lic~,only a relatively smaltpro,Eortion (thEj exact figures cannot; of ,course, be· given) preElent the seccindaryles~(ms.we have described. It cai/ be,contended,that there is an individua~ susceptibility in some cases such as has\been pro~ed t<? exist in the case o£flea.bites (Boycott), and ~hose of mosquitoes an.d'other insects.'

In other cases the phenomellon of. !tnaphylaxis probably plays a par.t; .86 "that ,.the " susceptibility of the individual as evid~nced by the appe~ance of the lesions is "at :first latent, That some sPElci:fic toxin is injected by the lousejwhell . \feeding is' supported by the, fac~ that in ma~ked' cases' cif JillelanoderJ?ia; associated .with 'pediculosis,.even :th~, . > mucous membranes may become pigmented, as in Adp.iso~.~s disease (Thibierge and othe,rs).

\ Darier, moreover, pointB'outtl;t~t Hi is not l'll.re in such cases to firid a marked 'cachexia witp. very real asthenia-:-a fact whic.\l 'Ye have ourselyes observed on more .thanoneqccasion; , Another. factor' in~he productibn of the secondary lesio~ is, ill Qui opinion; the co-existence of the seJ)orrhreic diathesis' }vhich, 'as we have rureadypointe'd out, plays .s\1-ch an imporlant role}n the severe erulltions'" primarily due. td the Acarus, Ilcabiei. .

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