1395

The Harvest MiteTHE harvest mite or berry bug is generally regarded

as insignificant-one of life’s minor horrors, and

uninteresting medically because it does not cause

serious disease. Yet this mite-Trombicula autumnalis-is very widespread; and discomfort occasioned byinfestation with it can be intense. Its common names

suggest that it is a nuisance only of the countryside;but in towns and semirural areas many cases of trombi-culosis may be misdiagnosed as heat spots, urticaria,erythema, or dermatitis.The larva of T. autumnalis hatches in summer in the

earth. It is six-legged, red, active, and only 0-2 mm. insize-that is to say, smaller than Acarus scabiei and

hardly visible to the naked eye. Only this larval stagefeeds on warm-blooded hosts; the adult mite lives inthe ground throughout the winter, and the eggs arelaid in the spring. The normal hosts of the larvx arerabbits, smaller mammals such as rats and mice, anddomestic animals. The larvse are most numerous in

dry summers, especially towards the autumn. Theyare most liable to be picked up in moist weedy places,on river banks, and in open fields and under and aboutfruit bushes and trees.1 They are found also on lawns,in parks, and on golf-courses.The free-moving larva; make their way through gaps

in clothing at ankles, wrists, or collar to the skin of thelimbs and body. As they can travel surprisingly fast(at two feet a minute) over the skin,2 they soon reachareas distant from the point of entry. The sites mostcommonly attacked are the ankles (mainly behind themalleoli), behind the knees, the groins, the intercruraland gluteal folds, the insides of the thighs, the waistlinewhere clothing presses, the axillae, the neck, and theshoulders-places where the skin is soft, thin, and moist.The larvae feed by attaching themselves to the skin,injecting an irritant lytic fluid into the skin, and suckingthe liquefied cell products. Larvse are not easily foundon the skin. because. havine fed. thev dron off and

disappear. The lesion is at first a small weal, intenselyitchy, which soon becomes a small papule. The itchinessoften persists for days or even weeks with remissions;a papule which has become quiescent may be reactivatedby being scratched or rubbed. Persons exposed to

attack vary widely in their susceptibility to infestationand in their reaction to the toxic substance injected bythe larva. Some people seem to be completely immune,while others are severely affected.3 Allergy may partlydetermine the severity of the reaction, and repeatedinfestation may lead to hypersensitivity, which may passoff in time. Since the intense irritation induces the

patient to scratch or rub the lesion, secondary infectionmay follow. Especially in children, a severe attack mayproduce constitutional symptoms.

In countries where trombulicid mites transmitserious disease, preventive measures have included

clearing away surplus vegetation and treatment of thesurface of the soil with powdered sulphur or with1. Jones, M. B. Parasitology, 1950, 40, 1.2. Jenkins, D. W. Amer. J. Hyg. 1948, 48, 22, 36.3. Allington, H. V., Allington, R. R. J. Amer. med. Ass. 1954, 155, 240.

acaricides.4 But much can be done by individuals toprevent access of the larvae to the body surface. Appli-cation of dimethyl phthalate or dibutyl phthalate toankles, wrists, and neck, and also perhaps to boot-tops,trouser turn-ups, sleeves, cuffs, and neckband, may befound effective if repeated every day or so. Benzylbenzoate, similarly applied, has also proved effective.More lasting prevention can be achieved by impreg-nating clothing with repellants. In the treatment of thelesions themselves, small dabs of an anti-histaminecream may relieve the itching.

Annotations

TORQUAYDECISIONS about the Royal Commission’s report having

been taken at last month’s special meeting,5 the repre-sentative body of the British Medical Association mayhave been looking forward to an easy time at its annualmeeting in Torquay last week. But there is an applicationof Parkinson’s law to gatherings of this kind, and repre-sentatives soon found plenty to argue about, thoughthey did not always have brand-new topics to stimulatethem.

Drugs for Private Patients has always been a popularbanner at representative meetings, and it was againgreeted affectionately, seemingly in the confident hopethat it was being paraded for the last time, The supplyof drugs for private patients through the National HealthService was " a debt of honour owed by the ConservativeParty ", announced one standard-bearer. Surprisingly,however, there seemed to have been some backslidinghere: last year the representative body threw up onlyone vote against N.H.S. drugs for private patients; thisyear no less than eleven dissented, and eleven thereremained despite a recount and a rescrutiny, perhaps todispel a suspicion that the Lancet cricket team had some-how got into the hall.

The meeting was unanimously indignant about thehospital building programme. The Government’s pro-posed expenditure over the next five years was regardedas " totally inadequate "; and the squalid and outdatedstate of large provincial hospitals must be remedied by areplacement policy of greater vigour and efficacy. Mr.H. H. Langston, chairman of the Central Consultants andSpecialists Committee, referring to a Times suggestion 11that there was a real danger of overbuilding hospitals,maintained that they had not demanded more beds,simply more up-to-date hospitals. To those who knewthe hospitals it was clear that big gaps had to be remedied.Members of the National Federation of Spiritual

Healers should not, the meeting pronounced firmly, beallowed to conduct their practice in National HealthService wards. 7 The spiritualists were condemned as

self-styled healers with no justification for the title.

They had nothing in common with ministers of religionand their views and methods were entirely different.Of course, Mr. Langston added, the hospital patient hadthe right to ask whoever he liked to visit him, but should4. Baker, E. W., Evans, T. N., Gould, D. J., Hull, W. B., Kegan, H. L.

A Manual of Parasitic Mites of Medical or Economic Importance.National Pest Control Society, Inc., New York, 1954.

5. See Lancet, May 28, 1960, p. 1178.6. Times, June 16, 1960, p. 13.7. See Lancet, May 28, 1960, p. 1177.

1396

he wish to receive treatment from a spiritual healer itshould be made plain beyond all doubt that he was thepatient of a doctor of the hospital while he was in hospital,and no treatment of any sort could be allowed which wasnot directed and authorised by the doctor under whosecare the patient was.The inquiries of the Public Health Laboratory Ser-

vice’s committee 8 on the sewage contamination of

bathing beaches in England and Wales had suggestedthat " with the possible exception of a few aestheticallyrevolting beaches ... the risk to health of bathing insewage-contaminated sea-water can, for all practicalpurposes, be ignored ". Representatives pronouncedthemselves flabbergasted at the committee’s complacency,and they sympathised with Dr. W. H. N. Angus whenhe said that the public was not going to be hoodwinkedby medical statistics and pathological techniques whenthey waded into this fxcal flotsam. The pollution of theSolent " sewer " was said to be equivalent to three gallonsof sewage in a small swimming-pool, and the meeting wasobviously more impressed by this comparison than byassurances that the committee’s findings were reasonable.On Monday a helicopter brought the Duke of Edin-

burgh, the retiring president of the B.M.A., to join themeeting, and he inducted Sir Arthur Porritt as presidentfor 1960-61.

SYPHILIS AND THE PUBLIC HEALTH

THE decline of infectious syphilis in Western countriessince the 1939-45 war is rightly claimed as highly satis-factory. There can be little doubt that much of thissuccess has been due to penicillin, which has proved athoroughly effective and comparatively safe remedy.Effective treatment, however, does not completely solvethe problem of venereal infections-a fact of which theincrease in gonorrhoea in the past few years has forciblyreminded us. In this country the number of patientswith infectious syphilis has continued to decline, and hasnow reached a lower level than any previously recorded.The total number of patients with acquired syphilis of

, less than a year’s duration attending the clinics in 1946 9-the year of highest incidence after the late war-was17,675, but by 1958 the total had fallen to 704.10 Probablyfew cases are treated elsewhere than at the clinics andtherefore this low figure does not greatly underestimatethe prevalence.The chief medical officer of the Ministry of Health, in

his report for 1957,11 remarked that it was hard to under-stand why the number of new cases of early infectioussyphilis continued to fall despite the continuing rise inincidence of gonorrhoea. He suggested that higherdosage of penicillin, now often given in a slow-releasemedium for the treatment of gonorrhoea, might in somecases be responsible for aborting incubating early syphilis.Yet early syphilis is beginning to increase in some countrieswhere the same factors may be presumed to operate.The Expert Committee on Venereal Infections and

Treponematoses of the World Health Organisation 12stated that in the U.S.A. infectious cases of syphilisincreased by 15% in 1959 over the preceding year; the8. See ibid. Jan. 9, 1960, p. 100.9. Report of the Ministry of Health for the Year 1957: part II; appendix C,

table B; p. 281. H.M. Stationery Office, 1958.10. Report ofthe Ministry of Health for the Year 1958: part II; appendix C,

table B, p. 253. H.M. Stationery Office, 1959.11. Report of the Ministry of Health for the Year 1957: part II, p. 70.

H.M. Stationery Office, 1958.12. W.H.O. document WHO/VDT/257, Oct. 30, 1959; p. 27.

disease has, in fact, been on the increase since 1954, andsyphilis in all its stages ranks fourth among notifiablediseases in the U.S.A. In recent years increases have been

reported also from Finland, France, Italy, and variousareas in Africa.

The remarkable outbreak of infectious syphilis in Mary-land, described in last week’s issue, in which recogni-tion of a single case of syphilis led to the detection of 44other previously untreated cases, shows that this conditioncan spread among the promiscuous with epidemic force.One striking feature of this group of cases was the youthof the patients. All but 4 were under 25 years of age and25 were under 20, a girl of 13 being the youngest. A jointstatement from the U.S.A. by the Association of Stateand Territorial Health Officers, the American VenerealDisease Association, and the American Social HealthAssociation, 13 declares that venereal disease is increasingamong teenagers and children. From 1957 to 1958 thenumber of reported cases of infected children aged 10-14increased from 2443 to 2793 (14-3%) and of those aged15-19 from 44,864 to 49,909 (11.4%). Full details for1959 are not yet known; but 29 States and 21 cities havealready reported increases in early syphilis in youngpeople aged 15-19, and 25 States and 43 cities have

reported increases in gonorrhcea in the same age-group.There have also been reports of an increase of bothdiseases among children aged 10-14.

In a symposium at this year’s Health Congress of theRoyal Society of Health 14 it was stated that evidencecollected from 147 clinics for venereal disease in England,Scotland, and Wales showed that new cases of gonor-rhcea had increased by 13-8% in 1958 over the total for1957. By far the biggest increase was in young peopleaged 18-19. We must be vigilant and continue to

strengthen our measures for prevention and control ofvenereal infections. There is, perhaps, one particularlesson to be learnt from the Maryland experience andfrom methods in the U.S.A. generally: the more assiduousthe efforts to trace contacts, the larger the number ofinfected persons brought under treatment. Neverthelessthe techniques of contact tracing must conform to theoutlook of the society in which they are applied; and it isdoubtful whether the method of " cluster-testing ", inwhich not only sex contacts of patients but many otherfriends and acquaintances who might conceivably havebeen exposed are investigated, would be acceptable here.

ANGOR ANIMI AFTER AQUEOUS PROCAINEPENICILLIN

IN 1951 Batchelor et a1.15 described 8 cases in whichintramuscular injection of aqueous procaine penicillinwas followed by an immediate reaction of which themost striking symptom was anxiety with a conviction ofimpending death. Bjornberg and Selstram 16 have nowrecorded similar reactions in 33 patients. A constantfeature was a conviction of impending death or severeanxiety; and sensory disturbances, such as par2esthesiTand tactile, visual, and auditory hallucinations, were

common, with various degrees of mental confusion. Theacute episode lasted for from minutes to an hour, withexhaustion and anxiety persisting for a few days or

13. Today’s V.D. Control Problem: joint statement by Association of Stateand Territorial Health Officers. American Venereal Disease Associa-tion, and American Social Health Association, February, 1960, p. 16.

14 Med. Offr, 1960, 103, 251.15. Batchelor, R. C. L., Horne, G. O., Rogerson, H. L. Lancet, 1951, ii, 195.16. Björnberg, A., Selstram, J. Acta psychiat. Kbh. 1960, 35, 129.