The Emperor's Itch.

Abstract

Standing with his right hand tucked inside his waistcoat, Napoleon I of France looks off in deep thought, in Jacques-Louis David’s 1812 painting Napoleon in His Study. Though this stance appears regal, there are speculations that this iconic pose was merely a facade for his scratching convenience. At a time when scabies ran rampant, it is no surprise that some believe that Napoleon probably had “the itch.” We now know “the itch” is attributed to scabies, which came from the Latin term scabere—“to scratch.” This condition manifests as pruritic rashes in the human host following colonization of the mite Sarcoptes scabiei in the skin as a result of skin-to-skin contact with an infected host. This infestation is classically seen as papules or burrows, which are thread-like tunnels under the skin f i l led with egg cases and mite fecal pellets. When these burrows are not concealed by papular or vesicular lesions, the parasite itself can be seen at the end of the tunnel as a black dot. Giovan Cosimo Bonomo first described the mite in 1687. However, the causal relationship between the mite and the itching symptoms was not elucidated until 1834 when Simon Francois Renucci, a Corsican medical student, used a needle probe to remove a mite from a young female patient with “the itch.” The key component of his procedure was based on the needle technique of Corsican market women: excavating near the vesicle’s center. Our understanding of the disease was furthered by entomologist Kenneth Mellanby, who noted the small mite burden in the scabietic soldiers he studied and established the person-to-person body contact mode of disease transmission. Today, scabies continues to be a problem in impoverished communities and in sexually active, immunosuppressed, or elderly individuals. But was Napoleon’s pose truly attributed to scabies? Reuben Friedman, an American physician, debunked this theory in 1940. He presented some evidence: Napoleon took many sulfur baths, and Empress Josephine was not known to have scabies. What he actually suffered from, Friedman argued, was dermatitis herpetiformis, which is now clearly linked with celiac disease. Blistering rashes accompanied by intense itching and burning are its hallmarks. Was Napoleon’s stance a consequence of his urge to scratch? No one knows for sure. Whether it was scabies or dermatitis herpetiformis, the Emperor’s affliction is a reality for many patients today. Both conditions can be masked by common features of papules, vesicles, and erosions, prompting misdiagnoses. Fortunately, thanks to histological examination, the Emperor’s itch is now an unraveled mystery and treatable affliction.