2000 year history of scabies: from humoral beliefs to contagion to modern understanding, October 24, 2013

- [Russell Currier] Well thanks Donna for that kind introduction and I wouldn't say this is the biggest disease in the world, but if you have it it is, I'll tell ya. It's very annoying. And I always told people that when I worked for the state health department, I was the Rodney Dangerfield of the agency because I got no respect. So when something came along that they didn't know what to do with, they'd say give it to Russ Currier, like school asbestos. I handled that program for a long time, head lice in schools. I took care of that, and then scabies in nursing homes, I took care of that. So I went out and was really kind of a quack practicing medicine if you will in my career and always tell people I for the most part worked on just two diseases in my career, and that doesn't sound like many. But I said they were the two most, they were two of the foremost important diseases 'cause they were incurable. And the incurables are rabies, babies, scabies and tabies, tabies being tertiary syphilis. But I didn't work on thatfortunately. But it was quite a run. We'll start here with a quote by King James VI of Scotland and the first of England. He had two titles. And scabies is from the Latin word, to scratch and is a condition of both man and animals. I'd like to mention that in deep time, if we go back to proto humans and humans, the sarcoptes scabiei was basically adapted to that species and that species only. And what happened 15 to 20,000 years ago, man domesticated dog or maybe it was the other way around. I'm not sure, but eventually mites colonized dogs. And then livestock species were domesticated more recently, and they became infected. Occasionally they would escape. And now we have just everything from giraffes to camels to you name it, with scabies. But it's not a separate species. It's sarcoptes scabiei variant suis canis and so forth. So it's kind of a peculiar thing in that sense. And there's scores of species of animals that have those. Well anyway, here's a micron micrograph of the scabies, and one of the things you see here, these are actually part of the jaws but they're mistakenly seen under the microscope and called the head. And they have a couple sucker-like appendages on the end of their limbs which enables them to burrow. And the adults have four pair of legs. The larval mites in the developmental stages have three pair. We see here just kind of an assimilation here of the life cycle. The female, fertilized female in this case, lays two to three eggs per day. And larval mites emerge in about a week, and a week to 10 days, and then they go through other stages. In about three weeks or a little longer they become adults. And the average patient, and we'll have a lot more to say about this, has really a single digit number of mites. We're talking adult female mites. That's how it's determined. At the other end of the spectrum, a typical case will have thousands, for sure hundreds, and we'll get a little more into that when we get into it. Let's get into some of the history here. This is kind of a who's who of people that did work on scabies. There at 605 is a Chinese gentleman, Zau-yun-fang, noted the mite, "Could be removed from the watery "contents of the vesical by means of the point "of a needle." At-Tabari in 790 repeated this. Avenzoar in 1165 said, "It, the mite, lies "under the skin and if the skin is scratched "in certain spots, a tiny animal comes out "which is hardly visible to the naked eye." I think they had a good idea what scabies was but I'm not sure in any case if we can believe all of that. But let me just say that Saint Hildegard here is credited with really being the first person in her writings, Physica, to make that connection. But the, and this is extremely important, the dogma of Galen in the humorless was just so intense that people discounted it. They would say well, it's coincidental type thing. And they didn't see the cause and effect if you will. And then it was just literally forgotten about. We'll come back to more of these people in some of the next slides. So one of the people who have published so much, and I've got one of his books here, Reuben Friedman wrote the story of scabies. He was a dermatologist at Temple University and he divides history into three phases, the pre-acarian, the acarian and the post acarian. In the pre-acarian of course ends in about the year, it goes through the biblical era, and Aristotle and Galen in the first 500 years and then the middle ages we have the acarian where people like Hildegard are seeing this mite, or claiming to see it, with maybe the keenest of vision you could and so forth. The overwhelming problem was this character here, Galen, who spent many years, he was a Greek citizen and went to Rome to make his living and wrote a great deal. I mean he was the foundation of medicine for 1500 years. It's hard to believe. And it was both good and bad because he did have, I mean he was extremely competent on the one hand, but excuse me, his ideas persisted just too long. And the Romans wrote about this, especially scab or scabies in sheep and the treatment again with sulfur and tar. Avenzoar I think I mentioned him, he distinguished scabies as different from prurigo or eczema-like conditions, and Saint Hildegard again. If we get into the Medieval period or the acarian period, there are a number of people who make the issue that these mites do exist and so forth. The important thing is the bottom thing is that Jansen invents the microscope. But that was improved on certainly by Von Leeuwenhoek, who's really the father of building microscopes. Which he was an interesting fella because he he had no advanced formal education. He was a part-time janitor at the equivalent of city hall where he lived. And he run a dry goods place, but in his spare time he made microscopes, a number of them. I think about 180. And he didn't publish anything, and he just amused himself with what he saw in rain water and blood and what have you. And that certainly enabled the subsequent work by people like Mouffet there who was an Englishman who gave the first accurate description of the mite. And there were others like Hauptman. And then finally one of the biggies equivalent to Hildegard's work was Bonomo's letter to Redi, which I'll get to here in a minute. But again in the 1700s, just a lot of setbacks. I mean mostly because of this dominant anti-contagionous thinking that we had in the field of medicine. And Lineas, without even seeing a mite, gave it the name acris humanus subcutaneous, so I mean there was some progress. But the real, one of the big seminal developments if you will was this letter by Bonomo who was an Italian naval doctor. And Cestoni was I believe a pharmacist. I'm just gonna narrate the first, I think these were the first two paragraphs of this letter, or two of the key paragraphs. He states, "Having frequently observed that the poor women "when their children are troubled with the itch "do with the point of a pin pull out of the scabby skin "little bladders of water and crack them like fleas "upon their nails, and that the scabby slaves "and the beguiled at Leghorn do often practice "this mutual kindness upon one another. "It came into my mind to examine what these bladders "might really be. "I quickly found an itchy person and asking him "where he felt the greatest and most acute itching, "he pointed to a great many little papules "not yet scabbed over, of which picking out one "with a very fine needle and squeezing from it "a thin water, I took out the very small white globule "scarcely discernible. "Observing this with a microscope, "I found it to be a very minute living creature "in shape resembling a tortoise." And that's what they do look like. I can vouch for that. "Of whitish color, a little dark upon the back "with some thin and long hairs "of nimble motion with six feet." So that was a larval stage. "A sharp head with two little horns at the end "of the snout as represented in figure one three." Well I don't have that. But that was a major, anyone who writes about scabies, writes about Bonomo's letter to, and what happened after that? Everyone discounted it or forget it. Well here's an interesting thing here. You've all heard of Samuel Johnson's dictionary I hope. He was the first lexicographer, at least for the English language, and here was his definition of itch, "A cutaneous disease extremely contagious "which overspreads the body with small pustules "filled with a thin serum and raised as microscopes "have discovered by a small animal. "It is cured by sulfur." I mean he was way ahead of his time. Anyway, he was a very, very interesting person, and there's a great biography by James Boswell. It's a classic biography, and he had all kinds of health problems. How he could do that as well as social and so forth. He had tuberculosis scrofula, probably from drinking raw milk contaminated with microbacterium bovis. He had gout, testicular cancer. He had what turned out to be Tourette's syndrome. He had odd effects where he made grunting sounds and one head was over to the side. And of course he was a hunchback besides. At any rate he would almost offend people by his appearance and his presence. But he had a lot of close friends. He had a contract for three years, but it took him nine years to get that dictionary done, which is a classic. And I just had to include that because he was right on the money. He was right on the money. And finally a Swede by the name of De Geer provided the first representations. So very often you see sarcoptes scabiei parentheses De Geer. So his name is linked with that. And finally medical authorities were just debating, especially in France, kind of the intellectual center of Europe at that time, whether the mites were kind of a coincidental contaminant or something of that nature, or were they really the cause of the disease. And a fellow by the name of Alibert challenged a senior medical student. He might have been a pharmacist, but I've kind of seen both, by the name Gales who, and that name or that term in french means itch, and he says he wasn't sure what he should do his thesis on as a senior. And he says well why don't you do it on the itch, because that's your name, you know so he did do that. But it was later shown to be kind of free living mites. And a naturalist by the name of Respel in 1829 refuted that. And it was a flour mite or cheese mite, I'm just not sure, 'cause I've seen both. So this whole issue of contagion versus humoral causes of disease continued to rage on. And there is, where gonna get to Renucci in a minute, but there is a very good drawing of mites. And the bottom two here are what Galle had mistook for the itch mite. So that kind of set things back. And I thought as long as I was at it, another hoax. This is in the literature here by Bonanni in 1691. Well what is that, people? That's a pubic louse. But he rendered the drawing of the scabies mite just like that. So it was just really, really humorous how much variation there was in those mites. And I want to just give you two slides on lice because I appeared at a meeting in Sweden with the author of this paper, David Reed. Actually he was in absentia because his wife had back surgery. But he published a paper, Pair of lice lost or parasites regained. You can see the Milton implications in there. But he showed that, looked at all the various lice of higher primates including man, and you can see that we have both, the head and body louse are essentially pediculus humanus. They've evolved a little differently. But they're the same genus and species. And then we have this crazy pthirus pubis thing which is really a take off from the gorilla louse. And what happened in evolutionary terms, when man split off from chimps, we took our lice with us and they of course eventually evolved as we did into their own distinctive species. But that was six, six and a half million years ago. And then three to four million years ago, the gorilla, and how this happened is anyone's guess, but it jumped species to humans and somehow adapted and we've had that disgusting parasite ever since. Back to scabies here. At last on August 13th, 1834, Alibert was again goin crazy and he, there was debates raging as to the cause of scabies in the Hopital Saint Louis. And I'll quote from a statement by Reuben Friedman from The Story of Scabies published in Medical Life. "On August 13th, 1834, Professor Alibert's clinic "at the Hospital Saint Louis in Paris, "Simon Francois Renucci, a senior medical student "discovered the acarias scabei. "This was actually a rediscovery. "He was from the Island of Corsica "and observed peasant women who removed mites "with needles and demonstrated this "to Alibert on a young female patient. "This date should be recognized as the beginning "of the present era of medicine, namely that "of etiologic diagnosis. "It may truly be designated as the day "on which was finally and completely put to an end "a thousand and one fanciful and archaic theories "previously entertained by man since the beginning "of time concerning the cause of disease." So I think that states it with a great deal of confidence for sure. My veterinary colleagues at the time were not just sitting on their hands either. Of course our first veterinary school didn't even get going til about 252 years ago in Lyon, France. But prior to that we had just basically one medicine. And they had collected mites and Weidal demonstrated the acris and the cat. Let's see, Kirkstein 1789 in the horse, Waltz in the sheep in 1809, Gohier in 1812 in the ox and the dog. In the meantime, Whiteman, who had transmitted the itch mite of the horse to man in 1791. Again that might have not gone to sexual maturity because of the specificity from a parasitic standpoint. Why Professor Alibert, I gather did not take a carriage ride over to the other side of Paris to talk to these people, I don't know. But he was influenced. I did see where one writer was influenced. Well, we're now in the post acarian era now. - Tradition. - Ambition. - Exploration. - Inspiration. - [Narrator] You feel it when you step on campus at the University of Iowa. - The energy and pride of students inspired by our history. - And excited about our future. - When you join the Hawkeye family, you're a part of it all. - Be a part of it. - Be a part of it. - Be a part of it. - Be a Hawkeye. - [Sports Announcer] The Hawkeyes are rising. After at trip to the NIT championship game last season, the Iowa's men's basketball team will be heating things up on the court once again. And you can help get Carter rocking. [Stadium Announcer]showtime! Order your season tickets today. Don't miss a minute of the action. Call 1 800 IAHAWKS or visit hawkeyesports.com. - [Narrator] We have a certain way of doing things. You'll see it in the determination of our students in the classroom and on our fields. In the collaboration among our faculty that lead to great innovation and change. In the vision of our writers, artists and doctors. Bringing the world to Iowa and Iowa to the world. It's the Hawkeye way. - [Russell Currier] After this incident, the rediscovery if you will in Paris. And one of the big 32 cylinder dermatologists at the time was Ferdinand von Hebra and he was the first scientific dermatologist. And he was an interesting guy. You know back in those days it was hard to find dissection material when you were studying anatomy. So he was out quietly removing a corpse from a grave and was caught and arrested. And he went to trial and the judge recognizing this newly needed physicians bed, even in Vienna at that time, and said his sentence would be wearing a small rope in the shape of a hangman's noose as a necklace the rest of his life. Which he did wear. But he was a brilliant dermatologist, a brilliant dermatologist. And I've got a reprint if anyone cares to look at it of his work. He also, he treated over 40,000 patients with scabies if you can believe that. He also was a supporter of Semmelweis on the childbed or purpural fever, that big strep infection that killed like 18% of women that delivered back in those days. So he was definitely a good guy and knew good things. And my friend Reuben Friedman, I've got many of his publications, wrote detailed histories on scabies. But both Hebra and Friedman really felt that full mites in inanimate objects really contributed to this problem, its persistence in its transmission, admitting that close personal contact was probably still the best way. And then we get into a sub form of scabies which happened in Norway of all places in leprosy patients. And Danielssen and Boeck co-authored a great publication on it. But they documented crusted scabies. It was usually a co-infection and in fact, von Hebra visited them four years after their publication in 1852 and he later published something and named this condition Scabies Norvegica of Boeckii. Well and then they named the organism, was it sarcoptes or acoris I can't remember, crustosa. And in other words, it was a separate species when in fact it was the same species. And they finally did studies, Hebra himself, to demonstrate on human transmission that it caused the ordinary scabies. Well the University of Iowa here was not immune from that and there was a male Down Syndrome patient here treated at the hospital. Is Dr. Caplan here? Oh yeah, here ya are, I'm sorry. Anyway I honor him with this great paper because this Air Force officer I think was doing a residency here or something. Anyway, he got infected himself from treating this patient so it was quite the deal. But that would be crusted or keratotic scabies. And then finally, I mean there's some other little tidbits that are of interest. One thing that Reuben wrote about was Napoleon. And he published a small book that actually was a lecture, called The Emperor's Itch. And I quote from a book review. "It is said that 40,000 books have been written "on the life of Napoleon but the present "interesting monograph by Friedman is the first "which discusses an annoying disease of the skin "from which he suffered for many years. "This phase of Napoleon's life has been overlooked "or been misunderstood by previous biographers." So Dr. Friedman came to the conclusion that he suffered from reactivated latent malaria and tuberculosis. There was the dermatologic diagnosis and said basically came to the conclusion that it was a myth and so forth. One thing I haven't talked about is military scabies 'cause this is a big problem in military operations and it was during the Civil War. And in the centennial of war's end about what, 35 years ago, these two physicians from Virginia, Richmond, took a look at camp itch and tried to, many northern authorities and physicians felt that it was just scabies because these guys would take off their clothes at the end of the day and just tear themselves apart. But the distribution of the areas of pruritus didn't match scabies which would be on the right torso. So their conclusions were, "Insufficient evidence "remains to determine the exact nature of camp itch "and may have been scabies as many northern observers "maintain. "However as true southerners, we must stand "with Guild and Clayboard and conclude "that camp itch was a distinct non-contagious "pruriginous dermatitis resulting in some way "from the vicissitudes of combat and leading "to disability of great numbers of troops "during the Civil War." So that's just a little aside. And then in all my studies, I came across this paper and I just gotta tell you about it with this quote, is a divertimento again, Scabies Among the Well To Do, and this was published in JAMA, February 29th. And I think the editor must have been on a long winter vacation because it just snuck in there. It so hilariously funny. This is the first handful of sentences. "My office file contains 53 cases of scabies "among the better feathered, the silver spooned, "and the intellectual and professional elect. "Of the 53, 37 had seen one or more physicians "without relief. "Eight of them had seen grade A dermatologists. "In five of the eight there had been diagnostic errors. "To those I myself contributed one. "A correct total of 10 correct diagnoses had been made "by 49 physicians who saw 37 of the patients. "To one of them his family physician made the remark, 'I "would have called it scabies myself if it hadn't been. "I thought that was a disease no nice people ever had.'" And it was people coming back from cruises and so forth. We won't go into how it was transmitted. Well there were kinda three pivotal events. We talked about Hildegard. We talked about Bonomo's letter to Redi. And in terms of paradigm shift, it was the World War II era, and a gentleman by the name of Kenneth Mellanby in the UK ushered in our modern understanding of scabies, that one, he demonstrated that there's very few mites on people. They usually number in the single digits. About half of them have five or fewer. And number two, that the incubation period, which was heretofore thought to be up to this time to be two-to-three days probably. Well it turned out to be more like 30 to 45 days. And the incubation period represents the development of sensitization, hypersensitization, which then results in itching. And then he himself beginning these studies, thought that full mites too were important. And when he set up these studies with a group of people euphemistically called volunteers, they were conscientious objectors, but he got a dozen of 'em and set up these things and had disinfected a lot of things. In Britain this was very costly and it actually affected military operations as well. And soldiers were picking it up on short times being home on leave and that sort of thing. And there was so much crowding, sometimes two families to a house and what have you. So scabies was epidemic. But he basically ushered in all this modern understanding that we now see. And he published a book on this, and I have a copy. I hope I'm not wired so I can do a little show and tell here. I have it here, it's called Human Guinea Pigs. And here's a book by Reuben Friedman as well. At any rate, I heard him speak at the University of Minnesota, Milton Orkin, a dermatologist who published a great deal on lice and scabies in the early 1970s and even after organized that meeting. And he got Ken Mellanby over there. So I actually got to meet him. Let me quote from one of his publications. "A more exhaustive study of the literature showed "that Hebra and others had previously suggested "that personal contact including sexual intercourse, "was more likely to cause transmission "than full mites. "We got as far as discussing the importation "of an infected woman and asking our volunteers "to commit adultery in the interest of medical research. "In the end this proved unnecessary. "Of 38 volunteers, two had worn patient's underclothing." And that was for a week on a scabietic soldier, and then it went on the CO for a week. They got, two out of the 38 got scabies. Two out of the 38 got scabies. "Symptoms were detected more than a month "after their presumed date of infection. "This was the first suggestion "that the disease might have a long incubation period." Well in December, 1993, Dr. Mellanby passed away. And he was an entomologist. He wasn't a physician, and he was sensitive to that fact. But he did an incredible job. And he had the ability, better than anyone in the history as far as I could tell, to picking out a mite with a needle. And he did experiments on himself. He would drop them down the back of his shirt, a mite, and within two hours it'd be burrowing into his wrist, the flexor surface of his wrist. He did a lot of that kind of stuff. But he was just an incredible person with 20 XIs for sure. And I have a copy of this obit. But anyway, he was a gem. And then here's another great quote. "But if there are individuals going about "with very high parasite rates, "they may occasionally leave a mite in the most "unlikely places causing embarrassment "to the surprised victim. "However I do not think that the following verse is "unduly libelous to the profession concerned. "Here's the poem. "Reckon thy research on sarcoptes has revealed "an infection began at home with your wives "and your children or when your living in sin "except in the case of the clergy "who accomplish remarkable feats, "and catch scabies and crabs from doorhandles and cabs "and from blankets and lavatory seats." I think some of those poems are actually developed by the conscientious objectors, 'cause they were just bored out of their minds. And they were pretty well educated successful people. Well anyway, since we're in the UK, you probably all remember the Falkland Island war. Well one of the things that really affected the enthusiasm of the Argentinean soldiers was scabies right there, and they lost their will to fight really fast. And I think in any stressful population with refugees, soldiers, crowding, it really takes on a life all its own. There's also a secular cycle every 15 years. I'm not giving you all those details 'cause I kinda want to work with the historical thing. At any rate, just to give you a little briefing on scabies, those are the people that we see the most, children, mothers of infants, sexual partners, would be the ordinary scabies with few mites. Institutionalized person, much heavier mite burden, and immunocompromised, AIDs patients, male Down Syndrome and some of those. One of the things you hear a lot about is called the burrow. It's like a mole in your backyard. And right here is a burrow. And that's the best burrow I've ever seen. This is a borrowed slide from a dermatologist in Cincinnati who sent it to me. And if you were to scrape that or go at that with a needle, the top of that white part there, you can see how much coffee I've had to drink, would be the place where you would wanna go. I never did work, I tried once, twice, but I really couldn't make it work. So I just did scraping. I scraped this youngster's foot. This is the grandson of an index patient, a retired nurse with diabetes who was just loaded with mites, oh my goodness. She just, and infected half the people in the hospital at Sheridan, Iowa 30 years ago. But any rate, what you see is kind of a macular thing. It's very, very difficult, and of course it can mimic other conditions. So and scabies itself is an imitator. It can even manifest itself in a variety of things. So this statement is really true. It's once the easiest and most difficult diagnosis in medicine. And I think Mellanby said in Minnesota back then, the people who scrape probably don't need to, and the doctors who don't scrape are the ones that should. You make a clinical diagnosis, give em a little of this or that and run em out the door. It's a time-consuming process. It's a time-consuming process, and what it is, is you put a little oil. The standard references call for mineral oil. I use microscopic type B immersion oil. It has a higher viscosity. It adheres to the blade, tap it off, scrape off the rest with a cover slip and drop it on, and put it under a microscope and that's what you see. Here's our nice adult, well-developed female. This Idaho baked potato is an egg. And then just above there, you see these orange-gold nuggets. Those are fecal pellets from the mite. And any of those three would be diagnostic in that case. Here's a case of crusted or keratotic or Norwegian scabies. I quit using that term. I had a cute letter from Mellanby who said yeah, I know what that's like. The Russian cockroach in Germany is known as the German cockroach and all that sort of stuff. But anyway that's a challenge to treat. Because you do need to get at the keratolytic things too to break down those heavy crusts. That was the nursing home patient. I guess I could go back to that. I did three scrapings of areas the size of a postage stamp and removed 27 mites from this gal's back in a nursing home in Des Moines. So in a sense what we have is ordinary scabies with a few mites, we have crusted scabies with tons of mites. And if we come in between, we have atypical crusted or Iowa nursing home scabies. And here's our treatment things. That top treatment is the 2000-year-old treatment, Crotanitron, Lindane and Permethrin are more later basically insecticidal type things. And then the new kid on the block is ivermectin, which is used, given as an oral thing. And it's great for use in nursing home. It's off-label use but it's extremely, extremely safe. And the one thing that's used in the United Kingdom is 25% benzyl benzoate solution. I don't want to go over my time here, but from Kenneth Mellanby's book, he did treat the initial cases with sulfur. And then he got into the benzyl benzoate. And then here's a couple more verses from him or his conscientious objectors or volunteers. "The treatment most in vogue of late concerns "the benzyl benzoate. "Made up in water, it's applied all over "every patient's hide. "It cures a very high proportion when used "with care and skill and caution." And then here's another verse. "Darus yields rotenone, which some will cure alone "without a bath or scrubbers soap. "This surely is the soldier's hope. "This treatment seldom has a failure, "but whoa be tied the genitalia." It's very irritating to the male scrotum, so that was, and then it's the final one. "But if you want to be safe and sure, "use the old fashioned cure. "Cover the victim with soft soap, "then in hot water let them soak. "A scrubbing next is his appointment "and finish off with sulfur ointment." But anyway, suffice it say that ivermectin, as my mother used to say when she was disappointed in me, when I was a kid of course, you never send a boy when you got a man. And that would be the treatment of my first treatment of choice if you have an extensive problem in an institution. - [Narrator] There are over 24,000 bridges in Iowa. But only one connects University of Iowa hospitals and clinics to Iowa River Landing. From pediatrics and women's health, to cardiology and routine exams, world class medical care can be found at a new convenient location in Coralville. Iowa River Landing is here. And it's designed just for you. For an appointment, call 319 467- 2000. - [Coach Bluder] Hi, this is Coach Bluder. And I'm here to tell you it's game on. The Hawkeyes are ready for this season. And we hope you're ready to join us. Order your Iowans basketball season tickets today. Call 1 800 IAHAWKS or visit hawkeyesports.com. - [Narrator] Show your Iowa pride. The Iowa Hawk Shop, where Iowa shops. The ultimate collection of Iowa Hawkeye merchandise, gifts and apparel. Help support the University of Iowa. All proceeds benefit men's and women's athletic teams and student programs. The Iowa Hawk Shop, where Iowa shops. Show your Iowa pride. Call 1 800 HAWKSHOP or visit www.hawkshop.com. - [Russell Currier] The trademark name is Stromectol, and Merck has never gone to licensing this for lice and scabies. So it's always got to be off label use. But it's extremely safe. And it's also Merck gives truckloads of this stuff to Africa and South America for filarid diseases like onchocerciasis or river blindness and elephantitis as you see here. And just like in swine it kills everything else there well. I mean it's a wonder drug, and toddlers pass their hookworms, school boys with schistosomiasis stop urinating blood, which they thought was a male form of menstruation. And adults see their lice and scabies fall off. "So people feel a lot better, Dr. Richards said. "Mectizan is sometimes called the poor man's Viagra. "People stop itching, they feel great and voila. "I've heard of babies named Mectizan." Well being a veterinarian, I got to give you just a little bit on the animal side. This is demodectic mange, a different mite, demodex folliculorum. Occasionally it causes a problem in humans but in dogs it's almost always puppies, puppy mange or red mange. Not a lot of scratching but alopecia and hair loss for sure and it can be treated like other things. Then there's true sarcoptic mange. You don't have a lot hair loss, but a lot of itching around the margin of the ears, the underside, and around the tail head. And there's a whole variety of treatment options for them. This has been a livestock thing. You've heard of sheep scab. Part of ordinary swine husbandry was treating these crazy critters with a scabicide. Otherwise they just wouldn't do well. Now that we have ivermectin, it takes care of the scabies. So that's no longer an issue, and all pigs are treated with this. Merck has made so much money on this in countries like New Zealand they're embarrassed 'cause they can only take out so much money out of the country, and they don't know what to do. It also causes some interesting problems. In the manure, of cattle manure in Australia, it killed the dung beetles, which actually rendered the manure into a smaller volume. So it was causing an ecologic crisis there. It was isolated from the soil from a Japanese golf course. Just an amazing drug. And there's a little bit about swine scabies, where you would see it in the ears. And it's essentially been eliminated. So in summary, this is a skin parasite that goes back for as far as written history there is. And it's still a problem in third world settings. I went down on a medical exercise in Honduras when I was in the Army Reserve, and we went out and treated, and kids all had scabies and that sort of thing, and probably a lot of head lice too. So it's not anything that's gonna leave us, that's for sure. And then occasionally it does come in and recognizing and maintaining that index of suspicion. In other words, if I was the director of nursing for a nursing home, and they say, well we got to bring in Mrs. So and So or Mr. So and So from Chicago because their family's moving, and they're gonna now be in this nursing home, but he's got some skin problems. So I'd say hey look, he doesn't even come in here until he sees a dermatologist and rules out scabies. Because boy, once they come in it's your problem. And they had very heavy mite burdens, and the rest is history. Well the final take home message is this is Rudolph Virchow, kind of the father of pathology as we know it. And he made the quote, "Between animal "and human medicine, there is no dividing line, "nor should there be. "The object is different but the experience "obtained constitutes the basis of all medicine." And I submit that my small efforts at scabies were kind of some evidence to that effect. Incidentally, let me tell you an aside about him. He was really pushing for public health reform in Germany, and the chancellor loathe him. And finally he challenged him to a duel. And he said well I'll tell ya, since he was the challengee, he got the option to choose the weapon. And he said well there'll be two sausages, one with trichinosis and one without. And that was the end of that challenge. I did publish a review paper in the Annals of New York Academy of Science, and if anyone wants a review paper that's heavily weighted to history, with two Australian colleagues, no less. And Shelly Walton is an entomologist and Shelly, one of the things she did with the co-author here, Bart Curry, a physician was looking at Aborigines, like our American Indians if you will, maybe some other ethnic groups. They have a lot of dogs, everywhere. And they have scabies. And so the question come up, should we do something about scabies in the Aborigines. And everyone says well unless we do the dogs, no because they're just gonna get them again. So she went and did mitochondrial DNA studies going back and showed where that division occurred a long, long time ago and basically there's no meaningful transmission. You might get a mite or two on ya. They might exist a day or two, but they're not gonna go to sexual maturity and cause an infestation. That was very, very valuable because then public health authorities in Australia went right to work on dealing with the problem in them. So that would be the summary of my formal remarks, and I'd welcome a question or comment or something. Yes, Dr. Caplan. - [Dr. Caplan] Thank you for answering something that's been troubling into the dermatologic world for a long time. The phrase, Norwegian scabies was a puzzle, and it's become very important in the time of political correctness, not to call it Norwegian. It seems offensive, to the Norwegians at least. It's crusted scabies. - [Russell Currier] Right. - [Dr. Caplan] Butwhere did that name come from in the first place. - [Russell Currier] Yeah. - [Dr. Caplan] Answer there about Heber's visit to Danielssen and Boeck. - [Russell Currier] Quite important, exactly. - [Dr. Caplan] Danielssen was head of the Leprosy Hospital in Bergen, Norway. His son-in-law was Armauer Hansen, who replaced him for who now know used the name Hansen. You've heard the Hansen. Danielssen and his son-in-law were in much disagreement because Danielssen with all his work with the leprosy patients, thought that the problem was due to miasma, something just in the environment, mysterious or bad air or something. - [Russell Currier] Is very dominant. - [Dr. Caplan] And Hansen of course was crucial in that first identification and claimed that the leper bacillus was the cause. - [Russell Currier] Cause of the problem. - And so the two of them were at odds for a long time before Hansen's work was finally accepted. But another part of that problem is puzzle of about why institutionalized people, or what is that population. Sometimes it's older sick people in nursing homes and maybe in a place for instance, like our state hospital in Woodward. I don't know about this as a problem, but I think that kind of an institution for a long time the problem was thought to have to do with mental deficiency. People who were mentally retarded. Well it perhaps was simply due to there were places where those folks were gathered together in an institution. This patient that was the index patient for our local epidemic... - [Russell Currier] Yeah, right. - [Dr. Caplan] He Definitely was mentally retarded in a fairly serious way. It was never clear that this was before chromosomal identification of Down Syndrome. We sort of thought he had some of the features that suggested he had Down Syndrome, but we never knew for sure what his problem was. But at any rate he was the index case with this problem that we thought was a very expensive exfoliated dermatitis and ultimately we found the organisms and made a definite diagnosis. In the meantime we had that little local epidemic among other patients and the staff, including that resident, Dr. Hayden. The man was not very cooperative. - [Russell Currier] Had to kind of - [Dr. Caplan] Holding him down while we scraped and then it was about three weeks later Jack himself began, and we found the organism in him. - [Russell Currier] Yeah, well the other thing too about patients in some of these, they spend a lot of time in bed, and there's that warmth there. They also get a lot of hands on care. As an example, there were three, what do you call them, physical therapists or something, that worked the trap line of nursing homes. And they were itching. And I recovered a mite from one of those three on a scraping at the state health department. So they were carrying it. And now we have labor pools where two people call in sick and the director of nursing in a nursing home is going crazy. Well she calls an agency that sends over a nurse or nurse's aide or whatever they are. And so you, it's not super cohorted. And I think the bigger the facility, the more there is of that type of thing. And so the opportunities for contagion or introduction are fairly significant, fairly significant. So, oh one more question back there, yes. - [Audience Member]question from what you usually hear, but how does - [Russell Currier] How does what take? - [Audience Member] How doesof taking on germs and things like that. - [Audience Member] The immune system. - [Russell Currier] Oh the immune system, yeah. - [Audience Member]gigantic as amour as a mite. - [Russell Currier] Yeah, it really doesn't. You know you've all heard of the term seven year itch. You know, it's one of the incurable diseases so to speak, historically. And the term seven year itch, although it related to someone turning 40 and needed to have an affair to make his life interesting, which was used as a movie scenario a number of times 40 years ago, but the term seven year itch originally originated from scabies. So you could have this for years. And that's what the theory was on Napoleon that I talked about earlier. So your body just doesn't do a super good job. But probably like most parasites, after a long period, they just sort of die off or maybe they become to interbred or something, I don't know. But you might have a miraculous self cure. - [Audience Member] And why patients have more risk of a problem - [Russell Currier] Well I think just because itching itself reduces the burden of mites. And if your immunocompromised, you don't have that intense level of hypersensitivity. So your mite population increases, which we see in nursing homes. We see it in AIDs patients and male Down Syndrome and so forth. - [Audience Member] Do you mean immunocompromised patients can't feel as much or some other thing is going on that you can't feel it out from all the other problems. - [Russell Currier] Yeah, right, and that's where skin scraping or having that consciousness is so very important. Let Mellanby be an inspiration to you. He looked at I think over 800 soldiers with scabies and removed every mite. One had over 500, with a needle. He'd lay 'em on a couch stark naked and just spend hours there teasing out those mites. Busy doctors, you know it's hard for them to take more than 15 minutes. And that's the reason why Mellanby suggested this in Minnesota. Well, it's probably too difficult for you doctors. Train an office nurse in the techniques and let them do it. Because they can spend maybe even 30, 45 minutes, 60 minutes with a patient. One time I got a call from a couple. I'll just tell you this. He was a radio announcer for a country western radio station in Des Moines, and he said, you know my girlfriend and I are being treated for allergy to some detergent. You know this is a common history, but we think it might be scabies. Would you come out, and I was kind of reluctant. And I said well, you know, I was just curious. So I got there and the main person of interest was his girlfriend who was running late. And he was doing some scratching. So anyway, I said well let's start in on you, at least look at you while we're waiting. And I made about a half a dozen slides. And I found one mite at the Achilles tendon area skin of his heel. But that took me over a half hour to do. So you're talking about a major time commitment. But just remember what Mellanby said. The people who scrape probably don't have to, and the ones who don't are the very people who should scrape. So it's a very easy technique. And the more you do, and a nice patient to start in on is a nursing home patient. 'Cause they have a heavy mite burden. It's easy to recover mites and then your confidence ratchets up from there. And the rest is history. But give 'em steroid creams. That improves things, but then you get a heavier mite burden after that, and all kinds of problems with a, or sometimes with repeat treatments with scabicides can become an irritant and you can get iatrogenic scabies if you will. So that's a problem as well. So that's where the art of medicine comes in. Well anyway, you've been a delightful audience and a friendly audience. So and we've had a few laughs. I've got business cards so if anyone wants to contact me about some further reference or something, I'd be tickled to hear from you. - [Donna Hirst] The History of Medicine Society has a gift for you. I have a gift. - [Russell Currier] You gotta be kidding, oh wow. - [Donna Hirst] Third edition of Airs of Hypocrites, our catalog. - [Russell Currier] Oh how neat. - [Donna Hirst] A very nice book. - [Russell Currier] Yeah, oh for goodness sakes, yeah. Well this is something I'll treasure. - [Donna Hirst] Thank you - [Russell Currier] Yeah, thank you.