The Itch Scabies Errol Craig Full Chapter
The Itch Scabies Errol Craig Full Chapter
The Itch Scabies Errol Craig Full Chapter
E R R O L C R A IG , M D, Ph D
Clinical Dermatologist, The Permanente Medical Group, Inc.
Walnut Creek, California, USA
1
3
Great Clarendon Street, Oxford, OX2 6DP,
United Kingdom
Oxford University Press is a department of the University of Oxford.
It furthers the University’s objective of excellence in research, scholarship,
and education by publishing worldwide. Oxford is a registered trade mark of
Oxford University Press in the UK and in certain other countries
Names of patients have been changed and clinical details may have been modi-
fied to protect patient privacy.
All attempts have been made to ensure accuracy of information, and any errors
that may exist are solely my own.
Contents
1. Introduction 1
2. Transmissibility 5
3. The Rash 23
4. The Mite 55
5. Epidemiology 73
6. History 93
7. Early Pioneers 121
8. Therapy 135
9. Conclusion 161
References 163
Index 173
It may be objected that considerable ink has been wasted in retelling
such an oft old tale as scabies. But while trite and commonplace, dull
and sordid, it nevertheless assumes commanding importance, when
unidentified and uncontrolled.
—William Cunningham MD, 1915. (105)
1
Introduction
As a newly minted doctor at the ripe age of 35, I found myself sitting in a nook
of the dermatology clinic with my white coat on, feeling vaguely puzzled. I was
in the midst of my dermatology residency training, and had arrived at clinic a
few minutes prior, having spent the morning in lectures elsewhere. To my left
and right were patient exam rooms. Around me were chairs for dermatology
residents, medical students, and the more senior doctors to sit and discuss
cases. At our disposal were several computers, as well as a wall full of serious
dermatological tomes, some running more than a thousand pages in length.
While waiting for my first patient to be roomed, I noticed something unusual
about the nearest exam room. The door was not only shut, but additionally
blocked off by a flimsy criss-cross of blue masking tape running from corner to
corner of the door frame. Where the strands crossed each other in the middle
was affixed a small yellow sticky note with the words ‘HOUSEKEEPING’ scrib-
bled on it, all in capitals. What could possibly be going on?
It appears that while I had been out for the morning, a case of scabies had
befallen the clinic, with repercussions now lasting into the afternoon. And just
what exactly had taken an exam room out of commission? Scabies is an itchy
contagious skin disease caused by the scabies mite, which resides in the skin
and can only just barely be detected by the naked eye, provided one has excep-
tional eyesight (7). The intensely itchy rash that it causes, can be at times tricky
to diagnose, but with a little bit of luck, and patience, it is actually possible with
a fine blade to extract the mite out of the skin and examine it under the micro-
scope. Here one can see the human itch mite Sarcoptes scabiei in its full glory—
fat and pudgy, with weird spikes and long running spines. It has been likened to
a tortoise, but to my eye, it looks more like a comically obese blob.
To those who have never been afflicted or perhaps have never even heard of
scabies, it might seem but a medical curiosity. Who would believe that a tiny
male mite would exist that seeks out and impregnates a similarly tiny female
mite that then proceeds to lay eggs which hatch and form baby mites, all in
your skin? And that this could lead to a skin disease and an intense itch? At
first, it may be perceived only subtly, or in fact not at all.1 With time it leads to
2 Introduction
had scabies, even the thought of it can cause hair on the back of the neck to
stand up. I suspect for you this book will represent a spooky and somewhat ob-
sessive read.
In these pages, I shall strive to assimilate the historical writings and more
modern investigations on scabies while weaving in anecdotes from my own
clinical career. My goal is to demystify scabies and explore what we do and
do not know about this arthropod, parasite, and general pest. My experiences
have taught me to respect scabies as a disease and not to underestimate it, but
also not to fear it. And if nothing else, I hope to reassure that it is far less con-
tagious than, at least, was conveyed to me when I was starting my training.
And this I have learned through my readings but also confirmed from personal
experience.
Note
1. James (VI) King of Scotland, and later England, was reported to have said that ‘None but
kings and princes should have The Itch for the sensation of scratching was so delightful’
(127). In my experience, few sufferers of scabies would agree with this description.
2
Transmissibility
Gertrude
your waist while we gently slide you to the wheelchair.’ She grasped my hands
but quickly balked. ‘No I can’t, please help me.’ Gertrude was in full-out panic
mode, weak and seemingly stuck in a taxi, while Jan and I went through various
possibilities on how to extract her safely.
After several minutes of this and an even further exasperated taxi driver
hovering in the background, our clinic manager showed up with a piece of
professional transport equipment resembling a toddler chair swing with mul-
tiple straps attached to a winch-like apparatus. Within a few minutes we had
Gertrude strapped in and hoisted out of the cab, transferred to the wheelchair,
and whisked into the clinic.
Once in the exam room, she calmed down a little and apologized for the
trouble she had caused. By all means it was the start of an unusual clinic visit.
‘No problem, Gertrude. I’m sorry you had to go through all that. So let’s see
what brings you in. . . .’ She related that she was extremely itchy. She extended
her arms out and showed me her hands, which revealed dozens of small zig-zag
white and flaky patterned lines most prominently where the base of her thumb
and index finger met the skin of her palm. In a way it looked like a bizarre pat-
tern of peeling, or perhaps even air blisters. Yet I knew immediately here were
burrows, the cavernous tracks of scabies and its tell-tale sign. At times one of
the most difficult diagnoses to make, and at times one of the easiest, this was
a slam dunk case of scabies, straight out of the textbook. I told her she had
scabies, and could not help but catching site of her caregiver Jan glaring at me
with mouth open. My medical assistant also peered at me, though a bit less
conspicuously. The contagious nature of the disease had them worried, and the
tension in the air was palpable. ‘Well let me take a scraping to look at under
the microscope’, I added almost out of routine. Seeing is believing, and is of
great utility in less straightforward cases; here I had no doubt. Yet I faithfully
donned my purple nitrile gloves and took her hand. In my other hand was my
dermatoscope, a small magnifying optical apparatus with a powerful polarized
light source, and a filter to subtract out scattered or incident light. I localized
the end of a burrow and peering through the dermatoscope saw a minute tri-
angular structure corresponding to the pigmented mouth parts and front legs
of the scabies mite. With a very sharp blade, I surgically plucked an ever so
small piece of skin including this fragment, transferred it to a glass slide, and
headed over to the microscope. There as expected, I saw the pudgy oval body of
the scabies mite with its stubby legs terminating in long spines.
When I came back to inform Gertrude, it dawned on me that but 20 min-
utes earlier I had my arms fully around her, holding her at first by her arms
and then by her hands, trying to assist her out of the taxi. Would this be the
Mellanby 7
Mellanby
Scabies has a long and intriguing history, dating back to antiquity. At the risk
of presenting a jumbled chronology, however, let us first jump to the middle
of the twentieth century to discuss the life and work of Mellanby. Mellanby
Figure 2.1 Kenneth Mellanby, exact date unknown, likely just prior to or at the
very beginning years of his pioneering scabies investigations.
Courtesy of Alex Mellanby.
8 Transmissibility
Figure 2.2 Kenneth Mellanby (1908–1993) (L) standing next to Bjørn Heilesen
(1913–2000) (R) on the roof of London School of Hygiene and Tropical Medicine,
1947. This photo was taken several years after Mellanby’s ground-breaking studies
of scabies.
Courtesy of Simon Heilesen.
I must make it clear that at the outset the problem which appeared to me of
paramount importance was that of transmission, that is to say, just how and
where did the uninfected person pick up the scabies mite and so ‘catch’ the
disease. I believed, with most others, that infection usually took place through
the medium of inanimate objects, i.e. mites that were to be found lurking in
dirty blankets waiting to infect the unfortunate individual who used them
next. I was even prepared to believe that the scabies epidemic which was
apparent in these early days of the war was mainly due to the military, for
soldiers were, I thought, being infected by the bedding which was not being
frequently enough disinfested, and so they were then taking home the disease
to infect their wives and children when on leave. (19)
Studying how scabies is transmitted had been, and still is, fraught with lo-
gistical and ethical difficulties. Mellanby fortuitously benefitted from wartime
circumstances. He found himself in a climate where there existed a willing and
eager group of experimental subjects amongst conscientious objectors to the
war. In 1939, the British Parliament had passed the National Service (Armed
Forces) Act, which mandated widespread military conscription, but made pro-
visions for conscientious objectors. Such objectors could avoid conscription, in
return for performing noncombatant jobs. Yet the truly principled objector did
not want to engage in noncombatant military projects. However, they might be
willing to make a contribution, even at some discomfort to themselves, should
their participation provide broader benefits for humanity, including allowing
themselves to be subject to medical experimentation. Mellanby wrote:
Mellanby 11
The idea of using conscientious objectors had been growing in my mind for
some time, and I knew that at this time there were many individuals who felt
they could not take part in the war as combatants and who at the same time
wished to serve humanity. In the summer of 1940, the number of outlets for
such service was small, and many pacifists appeared to think that the duties
which they were performing, or to which they had been directed, were very
unimportant. (19)
Figure 2.3 Fairholmes, the Victorian villa in Sheffield, England, where Kenneth
Mellanby conducted his studies on scabies during World War II.
Courtesy of John Broom.
I had assumed that as a result of the type of exposure . . . within a few days
of using the bedding or clothing normal clinical scabies would be apparent
in the majority of the volunteers. Therefore no one was more surprised than
I when weeks and months, covered by a very large number of different experi-
ments of this kind, went by, and not one of my volunteers had developed sca-
bies. It seemed obvious that the current views on transmission were somehow
at fault, and it was necessary entirely to change the whole plan of the experi-
ments. The reactions of the volunteers at this time were interesting. At the
outset they were all naturally a bit nervous about what was going to happen to
them. They had volunteered to have scabies, and were all perfectly willing to
go through with it but it was going to be an unpleasant experience. But now
that they had been doing the work of volunteers for what seemed a very long
period, and no one had developed the disease or had anything unpleasant to
report—they began to feel a bit fraudulent and all became exceedingly keen
to develop and suffer from the disease.
Mellanby 13
Mellanby did not have to resort to such measures, and eventually was
able to demonstrate the transmission of scabies from one individual to an-
other. However it wound up being much more difficult than he had origin-
ally thought. Simply sleeping in a bed previously used by a known scabies
sufferer was not sufficient to spread the disease—of 19 volunteers who did so,
none contracted scabies. The first cases of transmission were only detected
when volunteers donned the well-worn underwear of scabies sufferers while
still warm—and of the 32 volunteers who obliged, only 2 contracted scabies.
Moreover, it took a long time for scabies to develop in his volunteer subjects.
Instead of manifesting in hours or days, as he had assumed, Mellanby found
that that it took roughly 6 weeks for volunteers to develop The Itch. Mellanby
described similar results based on experiments he performed on himself:
My own experience was typical. I allowed a mite to burrow into my own wrist,
and observed it—almost like a pet—for two months. Each day the tunnel was
enlarged, eggs were located in the burrow, but I have no skin reaction. It was
only in the fifth week that a redness was observed around the mite, and that
skin irritation became obvious. (2)
severe itch, often significant enough to cause sleep disruption. Mellanby wrote
about his subject’s experiences:
The experiment was very unpleasant for the participants. They had, many of
them, in the first experiments been infected for a few weeks only and they
felt rather that the symptoms of ‘intolerable irritation’ and other unpleasant
experiences attributed in the literature to clinical scabies tended to be ex-
aggerated. They soon changed their minds. After being infected for about a
hundred days they mostly agreed that what they had previously experienced
was negligible. Some kept rough brushes to rub over the skin to relieve irri-
tation. On cold nights some would rise from a sleepless bed and walk naked
through the house, as when the skin was chilled the itching temporarily sub-
sided and sometimes, if sufficiently tired, it was possible to fall asleep before
the skin got warm and the irritation returned. Certain volunteers were re-
duced to sleeping naked as they scratched so vigorously in their sleep that
their pyjamas were torn to shreds. (19)5
The procedure is as follows: The patient lies naked on a couch in a good light
in a warm room and the surface of the body is inspected, using a watchmaker’s
eyeglass; the mites are extracted with a mounted needle. With a little experi-
ence it is possible to detect the mites in the skin before removal. Each patient
is carefully examined at least two, and often more, times, and the accuracy of
the results has been ensured by keeping some patients from whom the mites
have been removed in this way under observation for periods of weeks, to en-
sure that none has been missed. (76)
Following this protocol, Mellanby was able to compile a listing of how many
female mites could be found on each and every individual examined, which he
referred to as the ‘parasite rate’ (76).9
In all, Mellanby removed 9978 female mites from a total of 886 male pa-
tients, an average of 11 female mites per patient. Far from teeming with them,
the average infested individual harboured less than a dozen scabies mites! This
statistic helps one understand how a doctor may easily miss the diagnosis of
scabies after only a quick or cursory examination.
Based on his surprising findings of low mite burden and limited transmissi-
bility, Mellanby suggested that the average scabies-infested individual was far
less contagious than many had assumed. He indirectly observed this fact by
noting that for most of the course of his experiments, no staff or visitors acci-
dentally contracted scabies. Only later, when several of his subjects harboured
mites in the hundreds, did accidental infection occur.10 Mellanby thus pro-
posed that only the small subset of patients with a very high mite burden were
likely to be contagious through casual contact. But because the great majority
of patients bear very few mites, he concluded that overall scabies is not a highly
contagious disease. Thus, with Mellanby’s data in the back of my mind, I wasn’t
particularly worried that I would catch scabies from Gertrude.
16 Transmissibility
Figure 2.4 Kenneth Mellanby, exact date unknown, being served tea after
appearing to have blood drawn. Toward the end of his scabies investigations,
Mellanby participated in a series of vitamin-depravation experiments, which
would have entailed testing of various body fluids, including blood. Thus this
photo likely dates to 1944 or 1945.
Courtesy of Alex Mellanby.
18 Transmissibility
wound up lasting several years, involved the strict measurement and ana-
lysis of all dietary intake as well as output including excrement. This work was
undertaken with colleagues from Sheffield, including the famous biochemist
Sir Hans Krebs.12 Subsequent experiments on vitamin C deprivation were
performed during the late war years at the Sorby Institute, though not under
Mellanby’s auspices. As the years rolled on, vitamin deprivation experiments
came to require all of the institute’s resources, and scabies experiments were
phased out (41).
Mellanby’s research with volunteer subjects was performed during extraor-
dinary times:
I did not know quite what I was letting my volunteers in for when I origin-
ally asked them to submit to infection with scabies. I knew the disease could
be very unpleasant and had heard patients saying that the intolerable itching
had prevented them from sleeping for weeks, but it seemed unlikely that any
permanent harm would be done to any of the volunteers. Nevertheless, at the
outset I imagined that it would be a necessary safeguard for each man to sign
some sort of detailed contract, setting forth his duties and the risks he was
taking. . . . (19)
Figure 2.5 Kenneth Mellanby, Officer of the Order of the British Empire, in his
more mature years.
Courtesy of the Archives of the University of Sheffield.
Notes
1. As Mellanby would later write, ‘It was evident that any initiative would have to come
from me’ (108).
2. Mellanby wrote:
Among the mass of writing about scabies there were to be found lucid accounts of
first-class work, but unless one had made a particular study of the subject it was
almost impossible to sift these from a mass of indifferent and inaccurate papers.
Thus the great Viennese dermatologist Hebra discovered almost all the main facts
about scabies a hundred years ago, and if proper reliance had been placed on his
results, instead of their being practically forgotten and displaced by inaccurate
information based often on the study of unrelated parasites attacking animals and
not man, a great deal of human suffering would have been avoided.
3. British soldiers disabled by scabies and its complications were a significant problem in
World War I with the average hospital stay due secondary infections being over 1 month.
4. Mellanby wrote that he, ‘was not too sanguine that it would appear practicable to the
[Health] Ministry or Treasury’, yet his proposal was approved with only mild bureau-
cratic delay. ‘I do not think that “red tape” was allowed to cause any real delay’, he wrote,
20 Transmissibility
‘. . . as these discussions were being carried out when the Ministry and most people in
London were greatly preoccupied by German air raids’ (19).
5. Norman Proctor was a baker prior to the war and volunteered for service with Mellanby
at the Sorby research institute. He recalled:
It was extremely itchy. At night the men would get out of bed and walk around
naked in the cold to stop the itching. The cure in the early days was awful. Another
volunteer held you down in a very hot bath, then they rubbed you with sulphur
ointment. It caused impetigo and other skin troubles. Later Dr Mellanby treated
us with Benzyl Benzoate. My five mites had multiplied to 59 before they were
cleared off. They were all over my body. (41)
6. This process is similar to how today exposure to tuberculosis is tested for in many
medical settings. Mycobacterial tuberculosis antigens, in the form of purified protein
derivative, are injected into dermis of a patient’s forearm, and the injection site is subse-
quently monitored for the development of a wheal.
7. This process is known as delayed type hypersensitivity, and is one of the mechanisms
that our immune system utilizes to defend our bodies from pathogens and external
agents.
8. Mellanby wrote:
On six occasions batches of eggs numbering from three to twenty were removed
from the burrows on cases of scabies and placed on the skin of uninfected volun-
teers. The eggs were kept in position by a small ring of vulcanite and protected by
a bandage until they hatched. In none of these cases was an infection produced.
Numbers of larvae were also transferred on seven occasions, and in no case was
an infection established . . . Adult female parasites were removed from patients
and placed on the body of the volunteer. In every case where this was done to an
individual who had never before been infected with the disease provided that no
treatment was given, then typical clinical scabies developed eventually. (58)
9. Mellanby wrote, ‘With experience it is possible to discover-and to remove-every bur-
rowing adult female mite on a patient’ (2). Of note Mellanby was only detecting mites
present in burrows, which are strictly female mites. Male mites tend to localize in or
around hair follicles and roam the surface of the skin freely and are thus not readily de-
tected by this technique.
10. Here, Mellanby clearly demonstrated that occasional individuals can be highly
contagious.
For a period of 18 months, when as a rule more than half of a total household of
twenty persons was infected, with most individuals showing parasitic infections
higher than the average but not higher than 50, no infection of ‘controls’ or of vis-
itors who mixed freely with the infected volunteers, took place. Later when two
volunteers showed for a month rates of well over 200, two cases of infection arose
in the control population. (58)
Only 3.9% of Mellanby’s patients harboured over 50 mites, with the most heavily in-
fested subject harbouring 511 mites. There are a variety of reasons why patients could
have a high mite burden, which will be further discussed. When the mite burden is
extraordinarily high, a variant presentation has been described, called crusted or
Norwegian scabies. Often such patients harbour tens or even hundreds of thousands of
mites and are highly contagious.
11. The unwashed group, however, was understandably more likely to develop infections in
their scratched-up skin.
Mellanby 21
Cherene
backpedalled. ‘Uh, please come in, I would like to examine you’, I entreated.
Sure enough he had burrows and identifiable mites; he had wound up con-
tracting scabies after all. I sheepishly sent a prescription for scabies medication
to the pharmacy with a mumbled mea culpa: ‘I probably should have treated
you the first time around.’ Arthur was gracious, and I sought atonement by
writing a new prescription for his wife, who had no symptoms now, so that
they’d both have medication with which they could treat concurrently. I also
inquired if there was anyone else in the household that needed to be considered
(there wasn’t). I had experienced first-hand, one of the prime reasons for failure
to control the spread of scabies—treating the patient as if they lived in a bubble.
Close contacts should always be simultaneously treated, regardless of whether
they are itchy and whether they are officially your patient or not (181).1
So let’s put on our dermatologist hats for a minute and review the clinical
aspects of scabies. Scabies is an ectoparasite, that is to say an organism that
lives, at the expense of humans, on its host’s external surface. The pregnant fe-
male mite burrows into the uppermost layer of the skin, the epidermis, where
it obtains nutrients and lays its eggs, without providing anything in return to its
host. It is an infectious disease of the skin, and the skin alone. It does not and
cannot invade any other part of the human body. In its quintessential form, it
is not hard to recognize. Patients and their family members present with severe
itch, often worse at night, with burrows predominantly on the hands, wrists,
and often genitals (Figures 3.1 and 3.2).
There is no other skin disease quite like it in this regard. Dermatologist and
nondermatologist alike, as well as medical student or other medical profes-
sional, can often quickly recognize scabies. Even the lay public can diagnose
scabies when the presentation is classic. However, when all the clues are not in
place or there is contradictory or misleading information, the picture can be
much more confusing. Dr John Stokes, the Director of the Institute of Venereal
Disease Control at the University of Pennsylvania and early American derma-
tologist and venereologist, in 1936, summarized this elegantly with his state-
ment that scabies was ‘at once the easiest and the most difficult diagnosis in
dermatology’. This still holds true today.
On clinical examination, the finding of burrows is, in medical parlance,
‘pathognomonic’ for scabies—that is to say a smoking gun, indisputable evi-
dence. As the proverb goes, seeing is believing. Proof of scabies infestation is
Figure 3.1 Greyish-white meandering lines representing two scabies burrows
on palmar skin. These tell-tale lesions of scabies can be easily missed if one does
not know what to look for. On the palm, the burrow disrupts the orderly pattern
of skin ridges. At the leading edge a triangular speck can be seen by those with
excellent eyesight. The thin arrows indicate the location of the burrow, and thick
arrows indicate the mite at end of burrow.
Courtesy of Marc Silverstein.
Figure 3.2 Additional burrows. The mite (thick arrows) can be just barely
visualized at the leading edge and appears as a triangular dot.
Courtesy of Marc Silverstein.
26 The Rash
made by scraping the contents of the burrow onto a glass slide and observing
mites, eggs, or faecal pellets (scybala) under the microscope (Figures 3.3–3.5).
When in doubt as to whether burrows are truly present, one can perform the
ink test, whereby a felt tipped marker is rubbed over the presumed burrow and
then immediately wiped clean with rubbing alcohol. A positive test outlines
the burrow with ink that has sunk in and cannot be wiped away. More modern
tools used by dermatologists to recognize burrows, include the dermatoscope,
a palm-sized handheld surface microscope (Figure 3.6).
Using a dermatoscope, one can even identify a mite at the leading edge of
the burrow based on the presence of a small brown triangle, which has been
described as the delta-winged jet sign (66) (Figure 3.7).
This corresponds to the pigment present in the mite’s head and front legs.
The brown pigment at the head of a white burrow has additionally been de-
scribed as a ‘jetliner with its trail’ (95), as if it were an airplane soaring high in
the sky, with the remainder of the burrow likened to its plume.
Figure 3.5 Skin scrapings can be difficult to interpret, particularly when the skin
is thick. An immature (six-legged) mite lies hidden amongst the scale in between
the air bubbles.
28 The Rash
Figure 3.6 View of a burrow through a dermatoscope. The mite can be detected
as a minute brown speck at the edge of the burrow (arrow). Ova and faecal pellets
(scybala), however, cannot be visualized using dermoscopy.
Figure 3.7 Dermoscopy of a burrow, enlarged. At the leading edge of the burrow
the mite can be identified by the triangular pigmentation corresponding to its
head and legs. Experienced dermoscopists can make a positive diagnosis of
scabies based on dermoscopic findings alone. The brown areas of the mite may be
harder to detect in darker skinned patients.
Courtesy of Marc Silverstein.
Dermatology 101: Scabies 29
Figure 3.8 Typical distribution of the rash of scabies. Interestingly this does not
strictly correspond to the sites where the mite is likely to burrow.
Reproduced from Mellanby, Kenneth. (1972). Scabies, 2nd Edition. EW Classey Ltd: Faringdon.
does human activity, and as external stimuli and distractions diminish, all sorts
of cutaneous sensations, itch included, have the potential to become magni-
fied. And on the flip side, itching more at night-time is not mandatory for a
case to be scabies. Some scabies cases itch equally day and night, and it is not
unheard of to see cases that itch more during the daytime. Mellanby’s volun-
teers characterized the itch of scabies as being of three different types: (i) the
intermittent itching of almost a biting character which sets in suddenly, (ii)
localized skin bump itching, and (iii) diffuse itch sensation in areas where there
is little or no sign of inflammation or infestation (8). This last point is particu-
larly worth noting. Such patients having been sensitized to the mite, are often
indiscriminately itchy. In less than straightforward cases of scabies, the key to
Dermatology 101: Scabies 31
Figure 3.9 The rash of scabies likely represents a hypersensitivity reaction and can
be urticarial or hive-like in nature.
making the diagnosis is always to keep it in mind as a possibility. Any and all
itchy disorders should at least briefly be considered as possible scabies, whether
obvious rash is present or not.
There are several corollaries to Mellanby’s observation that sensitization
occurs with scabies. For starters, interacting with a known scabies patient
does not cause one to develop the immediate sensation of itch. Any display
of scratching, discomfort, or anxiety after being around someone with scabies
is nothing but the mind playing tricks on itself. Even in the unlikely scenario
that one contracted scabies from a patient, itch would not be experienced for
many weeks. Second, and clinically more significant, those who don’t itch are
not necessarily uninfected. Thus at the risk of sounding redundant, it should be
reiterated that close contacts of infested patients, whether they are itchy or not,
must also be treated. If they aren’t, and are infested with scabies in the process
of being sensitized, they can serve as a reservoir for the mite and pass it back
to the original host—so-called ping-pong transmission. Thus it might come
as a surprise that among doctors, including dermatologists, treatment of close
contacts is frequently overlooked or conveniently ignored. Last, not unlike in
a mosquito bite, the itch of scabies can persist long after the parasite is killed or
removed. Such itch can persist up to 6 weeks and can be exceedingly frustrating
for patient and physician alike, but is not necessarily a sign of treatment failure.
32 The Rash
should be qualified. It holds for locations with dry weather and a temperate cli-
mate, such as Europe and North America.8 In such settings, scabies is a lot more
fragile than most people suspect. After being diagnosed and treated, heroic
cleaning and decontamination procedures are unnecessary. Simple washing
of sheets and towels is a reasonable measure. There is no need to throw away
clothing and call an exterminator. In temperate climates, sealing recently worn
articles in a plastic bag for 72 hours will suffice to dry up any mites and render
them harmless.9 Other decontamination measures that have been shown to in-
activate fomites include freezing at ˗10 °C for 5 hours, heating at 50 °C for 10
minutes. Scabies contracted in tropical and humid climates, however, behave
considerably differently, and here fomites have greater durability and thus are
more important in spreading the disease. Recent research suggests that under
these circumstances, articles of clothing and bedding need to be isolated for at
least 8 days to no longer be infective (158).10
In nontropical climates, there is one major exception to the finding that fo-
mites are very unlikely to be responsible for disease transmission. This occurs
in the case of crusted or Norwegian scabies (named in tribute to the Norwegian
dermatologists Danielssen and Boeck, who first described the condition). In
cases of crusted scabies, the mite burden is several orders of magnitude higher
than usual. Such patients can harbour hundreds of thousands or even millions
of mites. Often immunodeficiency is responsible for this extreme prolifer-
ation, and crusted scabies can be seen in cases of HIV, leukaemia, or organ
transplantation. Additionally, crusted scabies can occur in those with impaired
itch reflexes, such as the demented, the developmentally disabled, those with
neurological diseases, as well as the extreme elderly. These cases of Norwegian
or crusted scabies are often atypical in their clinical appearance and elude easy
diagnosis (Figure 3.10) (204).
Such patients can present with extensive scaling or crusting, and appear to
have an extremely uncared for or unwashed appearance.
Their scaly skin, however, teems with scabies organisms, and the flakes of
affected individuals can literally harbour thousands of mites (Figures 3.11
and 3.12).
In essence, Norwegian or crusted scabies represents the human analogue of
animal mange. Often the multiple and serious medical issues that these pa-
tients suffer from make their crusted skin seem like the least of their problems.
These cases are clearly much more infectious than others, and can carry a high
mortality rate. Because of the huge mite burden, fomites are of greater concern
than in garden variety scabies cases, and need to be taken seriously. Careful
attention should be paid to cleaning of the immediate environment. Bedding
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gestemd en zeide „mi góedoe pikíen mass’ra, san’ doe joe agen”. 183 „Mi
de síki, néne” 184 was dan het antwoord. Op verzoek van mijn moeder
zou néne mij wat afleiding bezorgen, door mij een anansi-tori te
vertellen. Eerst maakte zij eenige gebaren, haalde diep adem en toen
begon zij:
Nu, een moeder had drie dochters; en de vader van die meisjes was
een haan, die in de struiken nabij het huis woonde. Wanneer Moeder
voeder had voor Vader, zong ze driemaal:
Op zekeren dag zou Mama inkoopen gaan doen in de stad. Het oudste
der meisjes, Mina geheeten, zou dien [324]dag voor Vader zorgen. Het
jongste kind werd naar school gezonden, en de twee anderen gingen
lekkernijen koopen met het geld, dat de moeder had gegeven, om eten
voor Vader te koopen.
Kakkadoedel, kakkadoedel!
Iffi joe biérti, kom mi da!
Toen was Moeder gerust. Ze kreeg haar aandeel van de soep, maar
kon toch niet eten. Het was alsof ze een voorgevoel had, dat het Vaders
vleesch was.
Het jongste dochtertje had evenwel verklaard, dat toen ze thuis kwam,
Mina en Jet bezig waren veêren te begraven in een kuil achter de
keuken.
Moeder vatte toen argwaan. Ze vroeg Mina of hetgeen ze haar als maal
had voorgezet Vaders vleesch niet was. Mina antwoordde natuurlijk
ontkennend. [325]
Moeder liep haar na, maar zij kon haar kind nog slechts bij het haar
grijpen. Leisah verdronk en Moeder behield eenige strepen in de palm
harer hand.
Arme Leisah!
Sedert dien tijd hebben alle menschen strepen in de palm van de hand.
Er wordt verhaald, dat in zeker dorp twee echtelieden woonden, die dol
waren op kinderen, maar er zelf geen hadden.
We moeten trachten, op welke wijze dan ook, aan een kind te komen,
zeiden zij.
Eens kwam een oude vrouw bij hen aan huis, vroeg de vrouw naar haar
welstand en naar dien van haren echtgenoot. De vrouw des huizes
antwoordde met droevige stem:
De vrouw des huizes deelde hare grieven mede, waarna de oude vrouw
haar een wees van acht dagen in handen gaf.
Het kind behoorde tot de vrouwelijke kunne en kreeg den naam van
Jacoba. Zij werd opgevoed als kind des huizes. [326]Toen zij twaalf jaar
was, moest ze voor huishoudelijke bezigheden beginnen te zorgen,
hetgeen zij met vlijt deed.
Van dat alles vermoeid, zong zij het navolgende, waaruit haar
voornemen bleek:
Haar pleegmoeder liep haar na als een pijl uit den boog, maar kon haar
niet inhalen.
Er wordt verhaald, dat in een dorp een moeder met hare dochter
woonde en dat zij tot buren een moeder en dochter hadden, die zeer
wangunstig waren.
Het eerste meisje was allemansvriend; zij werd door iedereen bemind
en heette Akoeba 190 (Jacoba).
Akoeba nam haar buurmeisje Afi 191 tot vriendin aan, maar deze
benijdde haar in alles.
Eens kwam een oude vrouw bij Akoeba en gaf haar een kalebas ten
geschenke, zeggende:
„Ik ben een arm mensch; ik bezit niets op aarde, dat waarde heeft om
het U als geschenk aan te bieden; daarom hoop ik, dat ge deze
kleinigheid aan zult nemen, alsof het een kostbaar geschenk van een
rijk man was. Maar, mijn kind, deze kalebas moet gewasschen worden
in het land van ’Ma Soemba, opdat hij U gehoorzame.
Dat land is niet ver van hier, maar de wegen, die daarheen leiden, zijn
schier onbekend, daar er geen andere menschen wonen, dan ’Ma
Soemba zelve, die den sleutel aller tooverformulieren in handen heeft.
Het is niet gemakkelijk, ’Ma Soemba te naderen, als men niet vooraf is
ingelicht door betrouwbare personen.
Ge gaat van hieruit rechtdoor, tot daar, waar de weg zich in tweeën
splitst: de eene kant is schoon, de andere vuil.
Beloop den vuilen weg; aan het einde zult gij ’Ma Soemba vinden. Zij
zal U spreken en indien zij U iets vraagt, moet ge gehoorzamen, dan zal
ze Uwe kalebas wasschen, hoor, jonge dame!
Zij liep door en zag twee voeten vechten. Ze verzocht en kreeg verlof,
door te gaan, onder het zingen van haar lied.
Iets verder trof Akoeba twee mátta’s* vechtende aan. Zij vroeg om door
te mogen gaan, hetgeen haar werd toegestaan, toen ze met haar lied
een aanvang maakte.
Eindelijk kwam zij aan het punt, waar de weg zich in tweeën splitste; de
eene zijweg was schoon, de andere vuil en onbegaanbaar.
Zij betrad den weg, die haar was aangewezen en zag vóór een huis een
vrouw, ’Ma Soemba, vol wonden en schurft zitten.
„Wat kom je hier doen!” vroeg zij aan het meisje. „Wees zoo goed en
wasch mij mijn rug af; er is water achter het huis”.
Akoeba waschte haar rug schoon, waardoor zij hare handen vol bloed
kreeg van de vele open wonden.
Of haar onderweg, bij het naar huis gaan, iets overkwam, wordt niet
verteld. [329]
Haar moeder wachtte haar met ongeduld en vroeg, of zij succes had
gehad.
Na eenige dagen kwam Afi haar vriendin bezoeken, terwijl deze juist
bezig was, haar kalebas te probeeren, waaruit zij tot hare groote
verbazing tal van gouden, zilveren en andere waardevolle voorwerpen
zag te voorschijn komen.
… waaruit zij tot hare groote verbazing tal van gouden, zilveren
en andere waardevolle voorwerpen zag te voorschijn komen.—
Zie blz. 329.
Akoeba vertelde hare vriendin alles en leerde haar ook het lied.
Den volgenden dag, reeds vóór zonsopgang, ondernam Afi den tocht.
Zij bereikte de splitsing van den weg en daar begon zij hare vriendin op
de onbehoorlijkste wijze uit te schelden.
„Zij dacht mij wat op de mouw te spelden, maar ik ben wijzer, dan ze
denkt. Het is uit wangunst, dat ze mij heeft gezegd, dien vuilen weg te
loopen. Zij wil niet, dat ik in haar geluk zal deelen. Ja! Zoo zijn de
menschen!—Maar ik neem dien schoonen weg.”
Op het einde gekomen, trof zij ’Ma Soemba aan, bezig obia 194 te koken.
„Geef me Uwe kalebas, dan zal ik haar uitwasschen; vrees niets”, zei de
vrouw. [330]
Doch juffer Afi bedankte haar niet eens, doch zei slechts: „Geef mij mijn
kalebas terug, want je maakt haar weêr vuil met jou handen”.
Vol blijdschap kwam zij weêr thuis bij moeder, die haar dadelijk vroeg, of
alles in orde was.
„Zeker, Mama, onze buurvrouw wilde mij misleiden, maar ik ben wijzer
dan ze denkt.
Ik ben klaar gekomen en zal haar bewijzen, dat niet alleen zij in ’t bezit
is van een wonderkalebas”.
Toen zij nog denzelfden dag het voorwerp raadpleegde, weigerde het;
het gaf geen resultaat. Haar vriendin ried haar toen aan, de kalebas
slechts in geval van nood te gebruiken. Doch Afi antwoordde, dat ze
geld noodig had en begon andermaal haar kalebas te raadplegen. Toen
kwam er allerlei ongedierte uit te voorschijn, dat haar doodde.
Er was eens een koning, die een zoon had, dien hij naar Holland had
gezonden, om te gaan leeren.
Den volgenden dag vertrok de jongen, en toen hij achter in den tuin
kwam, zag hij daar een dorren vijgeboom, die hem vroeg:
„Mijnheer, is het waar, dat ondank ’s werelds loon is?”
„Ja, het is waar, dat ondank ’s werelds loon is, want zie, ik heb aan uw
vader vruchten gegeven; hij heeft [331]mijne vruchten op brandewijn
gezet en ze gestoofd. En nu ben ik oud geworden; ik kan niet meer
bloeien en nu wil hij mij tot brandhout maken”.
„Van daag”, riep de jongen uit, „zie ik toch, dat ondank ’s werelds loon
is, want, kijk, ik heb u uit het vuur genomen en nu wilt ge mij dooden”.
Doch daar kwam juist een awari* voorbij, die dezelfde vraag tot den
jongen richtte, waarop deze antwoordde:
„Ja, het is waar, ondank is ’s werelds loon, want zie, ik heb de slang uit
het vuur genomen en nu wil ze mij dooden”.
„Ga mij wijzen”, hervatte Awari, „hoe gij de slang uit het vuur hebt
weggenomen”.
De slang kronkelde zich weêr om den stok en Awari gooide hem in het
vuur.
Daarop vervolgde Awari tegen den jongen:
„Goed, doch dan moet gij met mij meê naar huis gaan; want ik wil mijn
vader en moeder wijzen, wie mij van den dood gered heeft”.
„Neen, dat doe ik niet, ik ben geen mensch; ik ben maar een dier”. [332]
Thuis gekomen bij zijn vader en moeder, sprak de jongen tot Awari:
„Niets wil ik hebben, maar als gij mij elken morgen een kip wilt geven,
dan ben ik tevreden”.
De koning zeide:
„Het is goed; kijk, hier heb ik een hok vol kippen; elken morgen kunt ge
er een komen halen”.
Maar dat beviel de koningin in het geheel niet; zij riep haar kokkin en
sprak tot haar:
Er was eens in een dorp een vrouw, die drie zoons had, waarvan de
oudste Mininimi heette, de tweede Krimintaria en de jongste Kopro
Kanon.
Zij had Mininimi en Krimintaria lief, maar Kopro Kanon niet; daarom
werd hij verwaarloosd en zat hij vol schurft 196 en jaws*. Als het etenstijd
was, riep de moeder alleen de twee ouden, zingende: [333]
Arme Kopro Kanon was stokmager en stonk van vuil. Zijn moeder wilde
niets van hem weten. Ach! Arme Kopro Kanon!
Hij was juist op wacht, toen hij hoorde, op welke wijze de knapen
geroepen werden. Den volgenden dag kwam hij ter plaatse terug en
zong het lied met een heel grove stem.
„Gaat niet, want dat is de stem uwer moeder niet. Het komt mij voor, de
duivel te zijn”.
De duivel, die begreep, dat zijn zware stem de oorzaak was, dat de
jongens niet tot hem kwamen, ging toen bij een smid, om zijn tong te
laten vijlen.
De duivel … ging toen bij een smid om zijn tong te laten vijlen.—
Zie blz. 333.
De smid verbood zijn cliënt, bakoven* te eten, als zijn tong gevijld was,
daar zijn stem anders weêr grover zou worden.
Doch geen tien minuten van de smederij zijnde, ontmoette hij een
vrouw, die bakoven rondventte. De gulzigaard kon zijn lust niet
bedwingen en vroeg haar:
Satan ging toen weêr de wacht houden en zong het lied met
donderende stem. [334]
De verdelger der wereld ging terug naar den smid, zonder eenig succes
te hebben gehad. Zijn stem was veranderd, daar zijn tong door bakove
vergiftigd was. De smid zei hem:
„Als iemand onder behandeling van een dokter is, moet hij diens
voorschriften opvolgen; anders loopt hij gevaar. Denk niet, dat een
patiënt den dokter kan foppen, neen, hij fopt zich zelf!”
„Maar, waarom zijt gij zoo hatelijk tegen mij?” vroeg Satan.
De duivel zong.
Satan ging naar zijn bestemming en begon met een altstem te zingen,
waardoor de twee knapen zijn slachtoffer werden. Toen de moeder hun
riep, antwoordde Kopro Kanon met droevige stem:
Mininimi no de,
Krimintaria no de,
Kopro Kanon wawán de. 199
[335]
De moeder ging toen naar Kopro Kanon, voedde hem van toen af en
verzorgde hem goed. Zij kwam te sterven en Kopro Kanon begroef
haar.
Wie kinderen heeft, mag het eene niet boven het andere voortrekken,
maar moet van allen evenveel houden.
Men zegt, dat er menschen zijn, die de kunst verstaan, haar kam te
stelen, terwijl zij bezig is zich te kammen. Als de Watramama den dief
gevonden heeft, eischt zij haar kam terug en belooft in ruil een
aanzienlijke waarde aan geld. De dief echter paait haar met allerlei
beloften, en gebruikt haar om zoo te zeggen als een melkkoetje.
Telkens komt de Watramama terug en zij brengt steeds meer geld
mede, tot zij eindelijk het geluk heeft, haar kam terug te krijgen. Wil de
dief den kam niet teruggeven, [336]dan is hij verloren. Want de eerste
keer, dat hij over het water gaat, slaat zijn vaartuig om.
Er was eens iemand die, door een kreek varende, gekerm hoorde. Toen
hij voortparelde, bemerkte hij de Watramama, die in gevaar verkeerde
en hij verschafte haar hulp. De meermin zegende hem en beloofde hem
ten allen tijde haar bijstand. De man was visscher van beroep en deed
van toen af goede vangsten. Ook raadde zij hem aan, zijn pagala 202
open te laten, wanneer hij stadswaarts ging, en dagelijks vond hij er
geld in.
De man had vrouw en kinderen en toen de vrouw hem steeds met geld
thuis zag komen, vroeg zij naar de herkomst. Hij liet zich niet uit, doch
toen zij sterker aandrong en hij het, om de waarheid zeggen, niet meer
kon uithouden, vertelde hij haar alles en ook wat de gevolgen hiervan
zouden zijn.
Eens op een dag begaf de visscher zich naar een plantage, maar nog
eer hij op de plaats zijner bestemming was aangekomen, was hij
verdwenen.
Men zegt, dat het gevaarlijk is, de albino’s die nog al eens onder de
negers voorkomen, en Watramama-pikien 204 genoemd worden, veel
over het water te laten gaan, wanneer ze groot worden, daar de
Watramama ze dan wel eens tot zich neemt.
Zij had hem gewaarschuwd met niemand te spreken over hetgeen hij bij
haar hoorde of zag, maar Skroero-ki voldeed niet aan dat verzoek, en
toen hij weêr op den rivierbodem daalde, kwam hij niet meer aan de
oppervlakte terug.
Doch ze laten haar dan weêr gaan, daar ze anders gevaar zouden
loopen, om met boot en al in de diepte te verdwijnen!
No. 32. De Boa in de gedaante van een schoonen jongeling.
In zeer ouden tijd leefde een zeer mooi meisje. Haar schoonheid was
even beroemd, als haar trotschheid bekend was.
Maar het meisje hield staande, dat zij niet anders zou trouwen dan met
den man, dien zij lief had en dat zij er tot dusverre geen gezien had, die
hare liefde waardig was.
Nauwelijks hief zij hare oogen op hem of zij werd zoodanig bekoord
door zijn schoonheid, dat zij bijna [338]flauw viel. Zij riep: „Vader, moeder,
hier is de man, dien ik bemin; en met hem wil ik trouwen”.