War Surgery and Medicine
CHAPTER 21 — Skin Diseases
THE code of instructions to the civilian medical boards examining recruits in 1939 was not very specific regarding the question of skin disease. It directed that men with mild cases of psoriasis could be placed in grades otherwise suited to their physical fitness, but severe cases were to be placed in Grade III (fit for sedentary occupations). The revised code in 1942 was more specific by stating that men suffering from chronic or recurring skin diseases affecting areas of the body liable to aggravation by climate or conditions of military service were not to be placed in Grade I. This implied a knowledge by the board members of the effect of military service and particular climates.
Under the later ruling there were approximately 0–62 per cent of recruits examined who were rejected from Grade I on account of skin disease.
Reboarding in New Zealand Camps
In camps in New Zealand the number of those who were downgraded for skin disease seems to have approximated 1 per cent of the total who were reboarded. In an analysis made in 1943 it was found that nearly two-thirds of these cases had skin trouble before enlistment, but no note had been made on the boarding form by the civilian board. The chief troubles were eczema, acne, psoriasis, and recurring tinea, with the older age group predominating.
Middle East Experience
In 1943 it was calculated that cases of skin disease accounted for 10 per cent of the total hospital admissions for the whole of the Middle East Forces. The 2 NZEF had its share of skin complaints along with other Allied forces. Some of the conditions proved difficult to clear up in the tropical climate, and resulted in numbers of men being invalided back to New Zealand. Common causes of invaliding were ‘sweat dermatitis’ and seborrhoeic eczema. page 689 By February 1942, 55 men with skin disease had been returned to New Zealand and the number had increased to 326 by the end of the war. Of the complete total, there were 165 cases of eczema and 70 of dermatitis.
Statistics for hospital admissions in 2 NZEF, MEF and CMF, from July 1941 to December 1945 show the commoner diagnoses to be: dermatitis 494, dermatitis seborrhoeica 380, dermatitis chemical allergic 81, eczema 415, impetigo contagiosa 542, tinea 319, urticaria 200, herpes zoster 194, ecthyma 162, psoriasis 138. Inflammation of the areolar tissue, boils and abscesses, cellulitis, etc., were more numerous but are not dealt with as skin infections. (See Appendix.)
The common skin diseases which affected troops in the Middle East were predominantly the same as those occurring in New Zealand, but their course and severity were often influenced by climate, and generally accepted principles of treatment sometimes required modification. Excessive sweating in hot weather predisposed some men to certain skin troubles. Mechanical irritation by sand in desert areas aggravated many skin diseases. The large number of flies increased the risk of spread of infection, hence most skin lesions were best kept covered. Heat and relative humidity influenced treatment. In a hot, dry climate lotions and paints can rarely be used for long periods; rapid drying causes cracking of the surface, with exudation of serum, which readily becomes infected. Pastes are usually the best media for applying medicaments to moist or weeping lesions, even in the acute stages.
Some of these points were found out by experience in dealing with desert sores in 1940. This diagnosis was often loosely applied to any localised septic lesion of the skin, occurring under desert conditions. It was thought to be a disease peculiar to the Middle East, but proved to be a staphylococcal impetigo modified by the local conditions. Streptococci were also found in the sores and were, some thought, largely responsible for the infection.
The lesions favoured the parts of the limbs exposed to dust and sand, and under conditions of poor resistance sometimes spread into the deeper layers of the skin, where they ulcerated and formed ecthyma. In almost every theatre of war in hot climates, ecthymatous sores were a constant trouble and caused marked discomfort, a serious loss of efficiency (especially among armoured vehicle personnel), and some sick-wastage.
When the First Echelon was at Baggush in September 1940 desert sores became prevalent. These septic sores were infrequent page 690 at Gerawla, where there was little dust and much sea bathing. At Baggush there was much dust and the troops were farther from the sea. The passage of motor transport in the coastal area of the Western Desert raised a fine, flour-like dust which pervaded everywhere and infected cuts, abrasions, and insect bites. It easily penetrated through the meshes of an ordinary gauze bandage and dressing, and in addition to being a means of reinfection it mechanically irritated exposed tissues. Acting on these facts, some of the New Zealand medical officers found dressings of an occlusive nature most successful. Where ordinary eusol and flavine dressings were found ineffective, dressings of saline or sodium sulphate covered with elastoplast for several days promoted healing. Such treatments became standard. Two important principles were to avoid doing anything mechanically or by the use of chemical agents which would damage the islets of epithelium on which healing so much depended, and to avoid maceration of the skin surrounding the sore as this led to extension. In Palestine an AAMC committee reached similar conclusions regarding the sores, and developed a similar treatment. Knowledge of effective methods of treatment limited the number of evacuations from the Division to base hospitals.
In the summer of 1941, when the New Zealand Division was in the Western Desert again, desert sores again proved troublesome. When RMOs were circularised with details of a new occlusive treatment found effective in 7 Armoured Division, admissions to medical units decreased. The treatment involved the use of an ointment made by crushing a tablet of sulphapyridine in 2 oz. of paraffin molle flavine and the covering of the sore with elastoplast or sticking plaster for three to five days.
In September 1942, after the Division had been fighting continuously in the Desert for two and a half months, there was an increase in septic skin conditions entailing admissions to hospital. In the belief that if the undue dryness of the skin caused by sun, wind, and dust could be relieved the incidence of desert sores would drop, the British authorities made a move to issue a cold cream to the troops as a prophylactic agent. But the Battle of Alamein led to such a fast advance that the cold cream never reached the units where it was most needed. In Italy in the cooler climate these septic skin conditions were much reduced in incidence. The introduction of sulphonamides, and later of penicillin, helped to obviate in the Middle East the enormous sick-wastage which had occurred in the war of 1914–18, though injudicious use of local sulphonamide treatment not infrequently led to sensitisation and the development of an eczema.page 691
Eczema and Dermatitis
Climatic dermatitis was always present in New Zealand general hospitals, especially in Egypt. Most common was a chronic sweat dermatitis, in which a patient seemed to develop a hypersensitivity to his own sweat. Also common in 2 NZEF were seborrhoeic infections, and when these became eczematised they formed another large group of incapacitating skin eruptions. There were also miscellaneous other dermatoses of lower incidence in which heat was an aggravating factor. Under military conditions in the Middle East the feet were the commonest sites affected by skin diseases. Many men were incapacitated in the summer by sweat dermatitis of the feet alone.
Heat-sensitive cases responded well to hospital treatment, and could be cleared up rapidly with X-rays, but no treatment would prevent relapses on return to the former environment. Cases of sweat dermatitis were benefited by the frequent removal of perspiration by showers and baths, but the more severe cases were best protected from soap and water. This could be prevented by anointing these areas with soft paraffin before a shower.
Some of the victims of dermatitis could possibly have been recognised before they were sent to a tropical climate—for instance, a man with a mild patch or two of scaly dermatitis on the feet, which has always been worse in hot weather; the man who gets sweat intertrigo in his flexures every summer; the man with chronic severe dandruff and recurrent eruptions on the ears. Such soldiers should not be posted to tropical localities.
Skin Disorders of the Feet
The commonest disturbances of the skin of the feet were, in order of frequency: first, hyperidrosis; second, eczema; third, pyogenic infections; and a bad fourth, tinea.
Hyperidrosis (Excessive Sweating)
Causes: In most cases the patient was a ‘seborrhoeic’ subject. It will be helpful to explain exactly what is meant by this term, which is a bad one, since only a minority of these people have oily skins. The seborrhoeic diathesis is an inborn constitution in which the skin is deficient in several respects. Its resistance to infection is low, resulting in furunculosis, sycosis barbae, chronic blepharitis, styes, dandruff, seborrhoeic dermatitis, acne, and intertrigo. It tends to become hypersensitive, resulting in eczema, especially ‘seborrhoeic’ and ‘dysidrotic’ eczema. And its secretions are apt to be excessive, resulting in hyperidrosis, and in a few cases, seborrhoea.page 692
The mucous membranes are often similarly defective, particularly in the respiratory tract (causing chronic rhinitis, sinusitis, tonsillitis, and bronchitis) and the alimentary tract (causing chronic gastritis and other dyspepsias). These foci of sepsis aggravate the skin condition, and in some cases of hyperidrosis and eczema removal of them will give relief.
Seborrhoeic subjects are frequently of a psychoneurotic temperament, and since the sweat glands of the hands and feet are under direct nervous control, this makes matters worse. Hyperidrosis is also common in those with flat feet.
Clinical Features: The appearance of the hyperidrotic foot is characteristic. Constantly moist with sweat, the skin becomes macerated. It takes on a sodden, dead-white appearance, for which the maximum sites are the pressure areas—across the anterior arch, especially the ball of the big toe, and on the heels; and the parts of greatest sweat stagnation—between the toes. It is this whitish colour that leads to this condition being called ‘tinea’, and in the fifth toe cleft the appearances may be identical. Some cases show in addition a hyperkeratosis of the pressure areas, which may be very marked.
Treatment and Disposal: As a routine method the following was the most satisfactory:
Twice a day wash the feet in soap and water, and then soak for fifteen minutes in 1 in 4000 potassium permanganate solution (if possible warm). Allow this to dry thoroughly. Then dust liberally with powder—e.g., Acid. Salicyl. 3 per cent Talc (French chalk) or Acid. Boric. Put on clean socks containing some of this powder.
If there is no improvement try acid. Tannic 10 per cent in spirit, applied as a paint, instead of the permanganate soaks.
It is only where there is added hyperkeratosis that Whitfield's ointment should be used (or better, an ointment containing salicylic acid alone 3–6 per cent). This can be applied each night until the keratosis is reduced.
It was felt that men whose condition could not be controlled by the above methods should be forwarded to Base, where more constant attention was possible, for consideration of regrading.
Causes: The seborrhoeic constitution was again the commonest factor underlying cases of eczema. A characteristic variety was the chronic sweat dermatitis, or ‘dysidrotic eczema’, which affects seborrhoeics especially. It was uncommon for an eczema to have its origin in a fungous infection.page 693
Clinical Features: In a dysidrotic eczema the eruption runs closely parallel to the amount of sweating which occurs. The milder cases clear up entirely in the winter, only to recur when the hot weather comes round again.
There are the following three sites of predilection:
The dorsum of the toes and of the foot in their neighbourhood. This is greatest in the region of the big toe. This distribution distinguishes it from tinea, which affects the under surface of the toes and is greatest in the region of the little toe.
The hollow of the ankle behind the malleoli, more on the inner, and often continuous with the lesions on the instep.
The lesions of eczema are papules, vesicles, and scales. These may become confluent, giving rise to raw, weeping areas and large, red scaly patches. Itching is generally severe.
Treatment: As a routine the milder cases may be treated with calamine or lead and calamine lotion. Severer cases should be dressed daily with Lassar's Paste. In the chronic stages the best routine dressing is coal-tar paste—3 per cent of prepared coal tar in Lassar's Paste.
In dysidrotic cases the feet should be washed frequently to remove sweat, but in all eczemas the actual affected areas should first be protected from soap and water by the application of vaseline. A bland dusting powder should be used in the socks.
The prognosis in cases of dysidrotic eczema severe enough to be incapacitating was poor. Hospital treatment and X-ray therapy cleared them up, but they rapidly recurred when the soldier returned to duty in hot weather. It was best for them to be regraded.
This was usually a complication of hyperidrosis or eczema. When severe, or with inguinal adenitis or fever, they were treated in bed. The milder cases, such as a few pustules in an area of eczema, did well with dressings of Pasta Flava—Hyd. Ox. Flav. 2 per cent (or Acriflavine –1 per cent) in Lassar's Paste.
Severe cases with suppurating ulcerated areas were best treated with four-hourly dressings of tulle gras, covered with compresses of eusol or saline, and cotton wool.
Compared with eczematous conditions, tinea was uncommon. It accounted for a minority of foot eruptions, and was much less common in the groin than non-specific intertrigo. The important practical point is that these conditions are aggravated by fungicidal page 694 applications, whereas the soothing treatment for eczemas does not irritate tinea, and indeed usually benefits it by helping the natural resistance of the skin to overcome the infection. Where microscopic examination does not show fungus, or where microscopes are not at hand, it is safer to treat foot outbreaks, for instance, with soaks of 1:5000 potassium permanganate than to use Whitfield's ointment. In the groin these remarks are especially applicable since tinea cruris is easily confirmed microscopically and the skin in this region is easily irritated.
A possible exception to the above is Castellani's fuchsin paint, a fungicidal preparation which is much milder than one would judge from its formula. It is highly effective as a fungus-killer, and even in non-fungous intertrigos is a valuable measure for the first ten to fourteen days of treatment.
In recent years preparations of higher fatty acids have come into prominence as non-irritating fungicides. These were not developed in time for use in the recent war, but it is certain they will fill a place in tropical dermatology in the future.
Most chronic skin diseases in the army were due to a lowering of resistance to infection, so that the common saprophytes of the skin became pathogenic. This was especially true in hot climates, and in an investigation of 200 patients admitted to 1 NZ General Hospital Lieutenant-Colonel R. G. Park, in 1944, pointed out the commonest causes to be—other infective processes, psychoneurosis, a large number of sources of external irritation, and inborn susceptibility.
It is an accepted fact that one infective disease will predispose to others. Either acute intercurrent infections or chronic foci of sepsis were found in about 20 per cent of the cases examined. Usually when the infection subsided the skin cleared up, but sometimes it did not seem to be able to recover its resistance, particularly where there was a long period of post-infective debility. In the Middle East such cases were common after infective hepatitis.
Approximately 25 per cent of the cases investigated had some underlying mental stress, and these cases fared relatively poorly in the Middle East. Many men gave the history that their skin trouble began only after their nervous symptoms, and that any exacerbation of the latter seemed to make their skins worse. This suggested page 695 that the decline in mental wellbeing played a part in lowering the resistance to infection, rather than being merely an accompaniment or a result of it.
Friction was a common local precipitating factor in many chronic infective conditions. Examples were the persistent beard eruptions which were particularly stubborn under the customary military shaving conditions of cold water and blunt blades; army boots were the chief factor in many seborrhoeic eczemas of the feet; seborrhoeic dermatitis was on occasions due to woollen underclothes, and heavy socks gave rise to a particularly obstinate eruption around the ankles; watch straps and tightly fitting garments were trouble-some in hot weather as a cause of active seborrhoeic eruptions; adhesive strapping was a common irritant and was not favoured as a dermatological dressing; dust and dirt were such potent allies of the skin organisms that even previously normal men became susceptible to boils and desert sores in the Western Desert, especially when water was limited and sea bathing not possible.
The Constitutional Factor
By no means every soldier, however, who had been subjected to the conditions already mentioned became afflicted with skin disorders. It was necessary for the victim to have some natural inborn susceptibility as well. This was a varying factor in every case, and the chief and only factor in a few people—those who are born with inferior skins and have them all their lives. In chronic cases admitted to 1 General Hospital a previous history of civilian skin infection was elicited in 30 per cent.
The recognition of this constitutional type could have eliminated some men who were sent overseas. Its main features were:
A long history of the above varieties of chronic skin infections in civilian life, particularly if they have been worse in the hot weather.
A similar poor resistance to general infective diseases and to infections of the mucous membranes of the nose, throat, ears, etc.
A number of associated non-infective disorders, of which the chief is hyperidrosis (especially of the hands and feet).
A family history of any of the above.
The Middle East environment owed its deleterious effects to a combination of heat, dry atmosphere, dust, sand, dirt, and lack of water, together with the cutaneous, internal, and psychological stresses of military service away from home in a trying part of the world. In the environment many skin conditions were slow to heal page 696 and prone to recur, entailing much hospitalisation. The more serious cases were evacuated to New Zealand, and it was felt at times that a more liberal policy of invaliding might well have been adopted so that men could have been returned to New Zealand where they would probably have given efficient service in a different climate.
In Italy the skin diseases proved to be similar in kind and incidence to those encountered in the Middle East. They were largely related to field conditions. Chronic ulcers were common, and in the summer there were lesions which closely resembled desert sores. Furunculosis was one of the most common infections.
Late in 1944 a new development was the local use of penicillin for infective conditions. It was specific against staphylococcal and streptococcal conditions such as impetigo and boils, but did not affect the many varieties of seborrhoeic dermatitis. In this respect it was similar in effect to the sulphonamides.
Sensitisation to Sulphonamides and Penicillin
As with the sulphonamides, cases of contact dermatitis followed the local application of penicillin. After incubation periods of five to seven days some patients developed dermatitis, which cleared when the penicillin application was stopped. Reapplication of penicillin caused an immediate recurrence. Penicillin, therefore, presented a similar allergic problem as did the sulphonamides—namely, that the local application of a life-saving chemotherapeutic agent for trivial skin conditions can set up sensitisation which hinders its subsequent use for serious infections. With penicillin, however, the sensitivity of such cases to injections appeared to be lower than was the case with sulphonamides. The contra-indications to its local use were therefore less obvious, but the occurrence of these sensitivities indicated that the drug should not be applied to the skin for periods longer than three to four days at a time.
In 1945 cases were still seen from time to time in 2 NZEF of sensitisation dermatitis produced by local application of sulphonamide. In the British forces its use for these purposes was prohibited, but it seemed that some of the newer New Zealand RMOs were still unaware of this state of affairs. By this time the knowledge of the local use of sulphonamides on the skin had advanced. It was found possible to apply them to cutaneous lesions without danger of sensitisation, so long as a small dose was given simultaneously by mouth.page 697
Scabies and Pediculosis
Throughout the time 2 NZEF was in the Middle East and Italy there were cases of scabies and pediculosis (as there was in any other force, the Army in New Zealand included), but the incidence was not high until in the latter stages in Italy. In the winter of 1944 the incidence in the Division increased, but the highest figures were reached in the months of May to October 1945. This was in spite of the showering and disinfestation facilities available. It must be ascribed to free mingling with the local population and lack of discipline. When the remnants of the Division were in the Florence area in October 1945 these infestations reached their peak incidence of 131 cases of scabies and 165 of lice for the month. At this stage units were widely dispersed and had independent showering arrangements. Patients were admitted to hospital who had not bathed for some time. It was necessary for HQ 2 NZEF to issue a directive to all unit commanders to ensure better discipline in the matter of personal hygiene. The resulting action led to a prompt reduction in the incidence of both scabies and pediculosis, there being only sporadic cases more in keeping with the good record of 2 NZEF as regards personal hygiene, and relative freedom from infestation and skin troubles attributable to a lack of personal cleanliness. In this connection considerable assistance was rendered through the facilities acquired and developed by 4 Field Hygiene Company in regard to showering and disinfestation. Equipment for such purposes should be freely available in any military force.
It was common in military practice to find cases of dermatitis mistaken for scabies and made worse by anti-scabietic therapy. This was a type of disseminated papular dermatitis commonly seen in hot weather, particularly related to sweating. The chief point in diagnosis is that the lesions do not involve the areas of predilection to scabies.
Experience of Pacific Force
In the Pacific Islands skin diseases were proportionately a greater medical problem than they were in the Middle East. The incidence steadily increased as 3 NZ Division moved northwards towards the Equator. Skin disease in the Solomon Islands was the chief cause of attendance at the RAPs, and formed the greater part of the medical work of the Field Ambulances. Only the more chronic and more severe cases were evacuated to 2 NZ CCS, and yet these amounted to 449 in eight months. In one period of five months (March–August 1943) there were 202 cases, including 40 outpatients, treated at 4 NZ General Hospital at the Base in New Caledonia. The majority of cases were of eczema and dermatitis, page 698 with a fair proportion of ecthyma, and a lesser number of cases of tinea, acne vulgaris, and other infections. The more serious cases admitted to the General Hospital were treated as inpatients for an average period of approximately one month. Even then patients who were not down-graded had to be thoroughly tried out before allowing them to return to full duty. Many lesions tended to break out again when the soldier started to work and sweat in the hot sun. In the case of dermatitis of the foot, for example, the patient had to be given a trial of work while wearing heavy boots and socks.
Early in January 1944 the high incidence of skin disease in 3 NZ Division began to cause concern and brief surveys of conditions in the Vella Lavella and Treasury Islands were made by a skin specialist. It was found that the percentage of unit strength attending RAPs daily on account of skin disease during the month of December 1943 was as follows: Treasury Islands, 6–20 per cent; Vella Lavella, 6–10 per cent; Guadalcanal 1–6 per cent. These percentages do not refer only to new cases, but to all cases requiring treatment at each sick parade.
The causes of skin disease were found to be, in descending order of importance: sweat, trauma and infection, lack of washing facilities, infestation by larval mites, fungoid infection, standing in sea-water, sodden clothing, and sensitisation. Exposure to sunlight and diet did not appear to be factors. The incidence of skin disease was highest during the early periods of camp construction. As jungle undergrowth was cleared away and proper camps and tracks were established the situation improved.
Skin trauma could be prevented to a certain extent by suitable clothing, viz., shirt with long sleeves, trousers tucked into battle-dress anklets, boots and socks, and this was the order of dress during jungle manoeuvres. To combat sweat reactions, men were encouraged to wash frequently in fresh water whenever it was obtainable, and to apply dusting powder before dressing. They were also taught to report even a minor skin abrasion as soon as possible. Medical orderlies were taught to use aseptic technique when dressing these septic cases, for streptococcal infection was readily spread from one case to another.
In the Treasury Islands the incidence was much higher on Stirling than on Mono Island, and larval mites appeared to be the chief cause of skin lesions on the lower limbs. The presence of the larval mite on Stirling Island was apparently known to the natives, who avoided living there. Mosquito repellent (No. 612) applied to the exposed skin was found to be a successful prophylactic against these mites.page 699
Both in New Caledonia and the Solomon Islands there were numerous species of ‘poisonous’ trees and plants, which produced dermatitis on first contact with the skin. The foliage and wood-sap were highly irritant, and produced erythema and oedema followed by vesiculation and exudation. Other cases of eczema and dermatitis were the result of (a) sweat, (b) products of bacterial or fungoid infection, (c) chemical substances used in skin treatment, such as sulphanilamide, iodine, sulphur, acriflavine.
Ecthyma, a streptococcal and often staphylococcal infection involving the whole thickness of the skin, was exceedingly common in the tropics, both amongst natives and whites. As the ‘desert sore’ it was common in the Middle East, and as the ‘tropical ulcer’ it was even more common in New Caledonia and the Solomon Islands, where the hot, humid climate favoured bacterial growth. In the early spreading stage a haemolytic streptococcus was often isolated in pure culture, but in the chronic ulcer stage staphylococci, diphtheroids, and non-haemolytic streptococci were found in addition. In a number of cases virulent Klebs-Loeffler bacilli were isolated from the ulcer and sometimes from the patient's throat as well. No complications were observed amongst these latter cases in 2 NZ CCS, though peripheral neuritis was reported by Allied medical officers.
In the RNZAF in the Pacific more men were unfit and more time was lost from skin diseases than from any other type of disease. Twenty-eight per cent of the medical admissions in the area were on account of skin diseases—somewhat more than a quarter of the total illness.
On the whole, skin cases were off duty for longer than those suffering from other types of illness. More than a third—34 per cent of those unfit for more than three weeks—were hospitalised because of skin diseases.
Skin diseases also accounted for a large number of medical repatriations—125 out of 967 repatriations, or 13 per cent.
To give figures showing the widespread incidence of skin disease: in the first eight months of 1945 there were 1000 cases of skin disease in the force of 7800. Nearly a hundred of these cases were in hospital for more than three weeks before returning to duty, and a further 79 had to be repatriated. On the other hand, during the same period there were only 49 cases of malaria—of these there were only 4 cases who were in hospital for more than three weeks, and a further 6 who had to be repatriated.page 700
The incidence of skin disease was therefore twenty times greater than the incidence of malaria in 1945. Skin diseases represented the major problem for military personnel serving in the tropical Pacific.
Forty-nine per cent of the admissions for skin diseases were on account of infected wounds, ulcers, cellulitis, etc.; dermatitis, impetigo, eczema, etc., accounted for 27 per cent; boils and carbuncles for 12 per cent; tineal conditions for 6 per cent; paronychia for 3 per cent; and other conditions for 3 per cent of admissions.
Nearly half the hospitalisation for skin conditions was due therefore to infected wounds, ulcers, and cellulitis. These cases were also slower in responding to treatment than dermatitis, eczematous conditions, etc., and accounted for nearly 60 per cent of the ‘skins’ requiring more than three weeks in hospital.
On the other hand, nearly all cases of infected wounds and ulcers cleared up satisfactorily without having to be repatriated. During the whole period the RNZAF forces were in the Pacific only 13 men had to be sent back to New Zealand on account of ulcers and infected wounds, whereas 112 men had to be sent back with other skin conditions. From the point of view of permanent loss of manpower, dysidrotic and tineal conditions were much more serious than infected wounds.
Treatment in New Zealand of Ex-overseas Invalids
In most of the cases of skin disease returned to New Zealand the cause was the tendency of the lesions of the individuals concerned to become chronic under the climatic conditions. In New Zealand their condition was naturally much improved and subsequent treatment was more or less in line with civilian cases and general civilian practice.
Prognosis: From experience of pensions cases since the war it has been necessary to revise the optimistic prognosis, often given overseas, that eruptions would clear on return to New Zealand and removal from military conditions. It has turned out that in many of these cases military life has merely pulled the trigger, and that non-specific sensitivity has kept the disease going as a chronic disorder. The psychological stresses of rehabilitation, replacing those of active service, have undoubtedly contributed to this chronicity.
By 31 March 1951 the total of skin diseases recorded by the War Pensions Board had risen to 2890, the bulk of these being from overseas service, including service in the Pacific Islands and page 701 elsewhere. For diseases of the areolar tissue there were only 60 cases recorded.
Skin diseases are the most unsatisfactory of all the lesser ailments. This is due largely to the relative lack of knowledge of skin diseases in general and the obscurity of diagnosis. The only skin diseases that seem to have been finally disposed of by the Pensions Department are:
Tinea: These cases recurred for a year or two, and some cases were very persistent, attending hospital for twelve to eighteen months. Most of these cleared up with X-ray treatment.
Tropical Sores: From the Pacific theatre there were many cases but these cleared up rapidly on return to New Zealand.
Of the cases still on pension there are many which seem to have developed an allergic condition and tend to recur. Many cases, again, develop skin disease some time after their return to New Zealand, but are granted a pension if there is any history of skin disease overseas, though the conditions may not be at all similar.
In any future intake of recruits medical boards must be more particular in their inquiries into the skin condition of the recruit in civilian life. A follow-up is then necessary in camps to ensure that men are not sent overseas with skin diseases which are mild in New Zealand, but which would deteriorate in tropical or other conditions. The aid of a consultant skin specialist might well be made use of. In addition, each hospital unit in an overseas force should have a skin specialist on its staff.
The whole question of the boarding of recruits with mild degrees of skin pathology is of the greatest importance. These conditions are very common, especially in the adolescent, when they might almost be looked upon as a phase in development. If some skin abnormality is considered sufficient to make a man unfit for service in the Army, then there will be at once a great waste of manpower in men otherwise quite fit for service, and, in the adolescents, in men who will overcome their skin trouble naturally by the mere effluxion of time. Many of the diseases again cause little or no disability, and in times of stress could be disregarded by the man; and in possibly the majority of men in the Army the conditions are disregarded.
There is an inherent danger in specialisation in that the skin specialist, like his colleagues in other departments, is apt to pay too much attention to the minor disabilities, especially when they prove refractory and impossible to cure. If specialists had the page 702 care and boarding of every case there might be a grave danger of decimating the Army. On the other hand, their advice regarding treatment and the disposal of serious cases is, of course, invaluable.
It was forcibly brought out in statistics that skin diseases formed a high percentage of all illnesses in the Army. In such circumstances it is surprising that the most valuable dermatological weapon of all, X-ray therapy, should have been conspicuous by its absence. There was no therapy plant available in the 2 NZEF, and indeed in the whole of the Middle East Force there was only one. It is not claimed that radiotherapy will make men fit for the Army if they are unfit for it. But the cost of such apparatus in each General Hospital, and the provision of trained men to operate it, would have been paid for hundreds of times over in the saving of time spent by patients in hospital and off duty. Moreover, if many patients invalided home could have had the benefit of X-ray therapy early in the course of their disorders, instead of waiting until they were chronic, there would now be less money paid out in pensions.
|(1) Diseases of the Skin:|
|Herpes zoster (shingles)||194|
|Tinea unguium (nails)||2|
|Diseases of the nails||13|
|Diseases of the sebaceous glands||86|
|Diseases of the sweat glands and ducts||25|
|Diseases of the hair and follicles||36|
|Sycosis (hair and follicles)||52|
|Hypertrophy of nails||5|
|Tumours and cysts||397|
|(2) Diseases of the areolar tissue—general||31|
|Boils and abscesses||1568|
|Inflammation areolar tissue||3308|
|(Total treated, 202)|
|Type of Case||Number||Regraded|
|Type of Case||Number Admitted||Evacuated to Hospital|
R. G. Park New Zealand Medical Journal, April 1943 and June 1944.page 704