Wet sand creeping eruption at the largest American army station

318 TRANSACTIONS OFTHE ROYALSOCIETY OI~ TROPICAL MEDICINE AND HYGIENE. Vol. XXIV. No. 3. November, 1930.

W E T SAND C R E E P I N G E R U P T I O N AT T H E L A R G E S T A M E R I C A N ARMY S T A T I O N . BY

EDGAR ERSKINE HUME, M.D., DR. P.H., LL.D., D.T.M., F.A.C.P., Medical Inspector, Fort Benning, Georgia.

Creeping eruption is a skin disease characterized by a linear, tortuous and serpiginous eruption, accompanied by intense itching, which day by day extends at one end, fading at the other : it is of common occurrence at Fort Benning. During the writer's service here as Medical Inspector (Medical Officer of Health) since 1926, many cases have come under his observation, all of which have been of the wet sand type. Fort Benning, with a population of 8,000, including civilians, is the largest military post in the part of the country in which this form of creeping eruption occurs, and is one of the largest stations of the United States Army. The reservation, nearly 100,000 acres in extent, is located in a subtropical zone (32 ° N. latitude, 84 ° W. longitude), about ten miles from Columbus, Georgia (population 43,000), and approximately 200 miles north of the Gulf of Mexico. The land was acquired by the War Department for a training site in 1918, and after the Armistice was retained as a temporary camp. In 1922 it was made a permanent station, and the construction of brick and other durable buildings began, which work is progressing as fast as funds become available, but at present about half of the buildings are still of a temporary character (of pine wood). The nature of the old buildings and the extensive construction of new ones now in progress have a bearing on the incidence of creeping eruption, as is shown below. Not all of the inhabitants live in the military post proper, for about 200 families, chiefly small farmers, many of whom are negroes, are included. They are the former tenants of the plantation lands which the army acquired by purchase, and who have been allowed to continue their occupancy until the land is needed or until there is some other reason for their removal. This history of the land is not unimportant in its relation to the occurrence of creeping eruption and of hookworm disease.

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HISTORY OF CREEPING ERUPTION. The term creeping eruption is used to connote a syndrome produced by two distinct varieties of parasites, which normally follow the percutaneous route in their mode of entry. The infection of man is an accident. The normal migration of the infecting larvm from the skin to the internal organs, in which the adult stage (in'nematodes) or larval stage (in gastrophilus) of the parasites is usually passed in the appropriate host, is usually hindered in man. Thus in human beings the disease is a purely cutaneous infestation, characterized by the migration of the infecting larva~. Possibly other larvm than those already incriminated may play this r61e. Creeping eruption is a term first applied by LEE (1874) in England to a dermatosis apparently due to a migrating parasite, though he was unable to demonstrate the parasite itself. CROCKER(1893) saw a similar case, also in England, and, suspecting an insect larva as the cause, proposed the term larva migrans. Both terms are now in common use in the literature. Synonyms are hyponomoderma (KAPOSI, 1898) dermamyiasis linearis mstroas (KUMBERG,1898) larbisch, walossjatik (Russian), Hautmaulwurf (German). The diagnosis of creeping eruption has also been loosely used to describe other skin diseases. 8AMSON-HIMMELSTJERNE (1895), in Russia, recovered a fly larva from a skin lesion in a case of creeping eruption, and thought it to be the larva of the horse bot or gadfly (Gastrophilus.) This 8OKOLOW (1895), also in Russia, demonstrated in the same year. The condition was first described in the United States by VAN HARTLINGEN (1902), and shortly afterwards by 8TELWAGEN (1904), HAMBURGER (1904) and 8HELMIRE (1905). These and a number of later writers described in every instance creeping eruption due to the horse bot or other insect larva (gnathostomissis). KIRBY-SMITH, DOVE and WHITE (1926), who have very kindly supplied me with full information regarding their extensive work on this condition in tile United States, announced that they had shown that the creeping eruption commonly found in the south-eastern states was not due to a fly larva at all, but due to the larval stage of a nematode. They succeeded in obtaining the parasite from the advancing end of a visible lesion and by serial sections of material removed at biopsy, demonstrated that the parasite is a third-stage larva, which, pending the discovery of the adult worm, they called Agamonematodum migrans. This nematode was later recognized morphologically as Ancylostoma braziliense, a hookworm parasitic in dogs, cats and other animals. Experimentally, cultures of A. caninum were found to produce dermal lesions quite similar in character. It was therefore reasoned that A. caninum may in nature be the cause of this condition as well as in experiment. They have suggested that the term creeping eruption be used only for the type produced by the larval nematode, and having a linear, tortuous, and serpiginous outline. It has been uniformly considered very difficult to recover the parasite from

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the lesions of creeping eruption. AUSTMANN(1926), by clearing the skin with machine oil and using Lombard's well-known method of observing the capillaries in the intact skin, was able by means of a biocular dissecting microscope (magnification about twenty diametres) to see the livng larva in situ. It was located at about one and a half centimetres from the end of the red line and to one side. The larva was removed with the point of a needle and identified as Gastrophilus intestinalis. This extraction was performed without injury to the blood vessels. Previously RUDELL (1913) and CATES ( 1 9 1 4 ) h a d been able to remove parasites without local injury. Despite frequent attempts, in only one instance has the parasite been mechanically removed from the lesion at Fort Benning. In that case the larva was found to be A. braziliense. The trouble is occasioned by the appearance of the physical signs of the larva only after it has " crept " farther along, and the tortuous course and irregular rate of progress add to the difficulty. It is well nigh impossible to calculate the area to be excised to include the offender. In Lagos, SMITH and ELMES (1928) have likewise demonstrated the parasite in material taken at biopsy from a patient. The parasite was in the deepest part of the Malpigian layer of the epidermis, the contents of the burrow exerting pressure on the surrounding cells which were considerably flattened. In Durban, Natal, CAWSTON (1929) removed a portion of skin in a case of the disease, contracted in an adult whilst gardening. The parasite on microscopic examination was seen as a narrow coiled up larva in a burrow through the epidermis. Experimental infection of human beings has been several times recorded. FULLEBORN (1927) infected himself and a volunteer with larva of Uncinaria stenocephala of the dog, and produced creeping eruption. He then had an area of skin, 2 cm. by 1 cm., excised, and by serial sections showed the worm. The borrows were superficial, lying close to the horny layer of the epithelium. KIRBY-SMITH, DOVE and WHITE (1926) succeeded experimentally in producing creeping eruption by infecting the human skin with cultures obtained from the f~eces of dogs infested with A. braziliense. Autopsies on such dogs showed the presence of both this parasite and A. caninum. Later, WHITE and Dove (1927) were able to produce a dermatitis by experimental infestation with the larvae of A. caninum. The latter hookworm produced a skin disease similar in many respects to that caused by A. braziliense, except that the papules were not followed by linear lesions. Observations thus far indicate that caninura dermatitis at times occurs clinically in a mixed infection with creeping eruption. Owing to the extensive distribution of ./i. caninum, it seems likely that infections of the skin with this species may occur in widely different localities. WHITE (1927) has described an ingenious method for obtaining infective nematode tarvm from cultures. " The method makes use of the fact, often observed, that the larvm of a number of parasitic nematodes as they approach

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WkT SAND CREEPING ERUPTION.

the third larval stage and the close of the free-living period, tend to migrate trom the medium in which they are growing. The apparatus traps many of the migrating worms." INCIDENCE. KIRBY-SMITH and his co-workers, by submitting a questionnaire to dermatologists throughout the eastern and southern parts of the United States, found that creeping eruption is confined at present to the coastal plains from New Jersey south and west to Texas, inclusive. Naturally the distribution of the disease is that of A. brazilieme, and on account of the wide occurrence of that parasite, it is probable that many unrecognized cases exist. The disease has, so far, been rare in inland States. Fort Benning is almost in the centre of the zone just described. On the other hand, the genus of flies (Gastrophilus) responsible for the form of creeping eruption due to insect larva has never been reported from that section of the country. The condition has been found only during the warm season. The hotter and more humid the weather, the more common the cases of creeping eruption. It has not been seen at all in the winter months, and but rarely in the early spring, but the incidence extends well into the autumn. Moisture and warmth favour the development of the infective larvae of A. braziliense, and consequently increase the infestation of dogs and cats by these parasites. In turn the soil becomes more widely polluted and creeping eruption results to a greater extent in human beings. Drying readily destroys the eggs and larvae of the worms, but the infective larvae remain alive for a long time in damp environment. At Fort Benning the warm weather begins early, and lasts late. During the height of the summer the temperature and humidity are those of the tropics. The soil is sandy, and has proved an excellent medium for the growth of A. brazillense. The spring of 1929 was marked by heavy rains which completely saturated the soil. The condition was ideal for creeping eruption, and an increased incidence was early predicted, which later came about. On the other hand, 1930 has been uncommonly dry, and the sandy soil has contained very little moisture. The first case ot creeping eruption of the year was seen only on 20th July, following a short period of heavy rains. These observations are in keeping with those of others, that the greatest number of cases is during the rainy part of the hot months. The moist soil is, moreover, highly favourable to the life of Necator americanus, so that hookworm in human beings is apt to be associated with creeping eruption. (Nearly 20 per cent. of recruits from this locality harbour N. americanus). Children are undoubtedly more susceptible than adults. This may be due to the texture and thinness of the skin, for it is also noted that persons of fair complexion and thin skin are more apt to become infected than those with thick or pigmented skin. While the condition is found in negroes, it has been quite rare, and only seen in young children. Such also has been the observation

EDGAR ERSKINE HUME,

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of SMITH and ELMES (1928) in Lagos in Africa. As far as observations at Fort Benning are concerned, there has been no difference in incidence between boys and girls, but men are more apt to have the disease than women, probably on account of greater exposure. Adults who have come in contact with the soil during camps, when fishing, etc., are frequently infected. Cases in children are common in the summer months on account, in part, of the practice of going about barefooted. Wading in shallow streams and playing along their sandy banks also favour infestation. At Fort Benning appropriate warnings against these practices have been issued, and all concerned notified that the human hookworm is common in this vicinity, and t h a t " ground itch " may result from allowing children to go without shoes. Such warnings further explain t h a t " ground itch " may mean either the first stage of hookworm infestation or the common creeping eruption. In Natal, CAWSTON (1930) reports infection to be common among children who are allowed to sit during play in the moist soil of gardens frequented by domestic pets. Children at Fort Benning have frequently been infected by playing in sandy soil, either in its natural site or when transported to playgrounds and used in sandpiles. On this account the practice of building sandpiles of this material for children's play has been discontinued. At Fort Benning there are approximately 2,000 children, and many more living in the town of Columbus who are entitled to treatment by medical officers of the army, so that there is good opportunity to judge of the incidence of the disease by age groups. Moreover, the experience of civil practitioners in the nearby towns confirms that of the Fort Benning medical staff. While occupation is a factor in the incidence of creeping eruption, as shown by several observers, at a military post this has not been so evident. Workmen in perspiration-soaked clothing have frequently been affected as have also those who have worked under buildings in which pet animals have been kept. Men employed in the construction of new buildings have fairly commonly become infected. The soil may be contaminated with the larvae through the deposition of f~ecal material by dogs, cats and other animals, or by means of polluted water. The sudden rains quickly cover parts of the ground surface with water, and larwe floating in this medium may easily be carried from place to place. One common medium of infection is the sand carried from creek banks for building purposes. In the United States the parasites are thought to occur in a number of wild and domestic animals, but so far reports have included only the dog and cat. In other parts of the world many animals had been reported as hosts, including the wild dog, wolf, hyena, peccary, leopard, civet cat, genet, lion, tiger, sloth bear, cat bear, and squirrel. Nearly all of the cases reported at Fort Benning have been traced to soil polluted by the droppings of dogs and cats : as at nearly all army posts, there are a fairly large number of pet dogs, and not a few pet cats. Besides these, there are a number of domestic cats

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W E T SAND CREEPING E R U P T I O N .

running about in a semi-wild state, despite efforts to destroy them. Such animals doubtless serve as hosts of A. braziliense. The " bay lynx " or " bob cat " (Lynx rufus), sometimes erroneously known as the wild-cat, of which there are a fair number at Fort Benning, may also serve as a host. These animals have the habit of going into the roadways, particularly the bridges, to def~ecate, so that the chance of their being a factor in soil pollution is comparatively great. It is thought, also, that the parasite may be present in the wild-living domestic hog, of which there are many on the Fort Benning reservation, the progeriy of domestic pigs that were not captured by their owners when the reservation was acquired. For more than twelve years they have been living wild. Cultures of the faces of these animals have been made repeatedly, but with uniformly negative results. The report by GmLIOLI (1929) that the wild pig or peccary (Dicotyles peccari) of British Guiana is a common host is significant in this connection. The parasite ./1. braziliense has also been known as .4. ceylanicum and A. gibsoni, and has been reported from many parts of the world, especially tropical and subtropical countries. Besides the areas within the United States, as outlined, it has been identified in Brazil, British Guiana, Dutch Guiana, Argentina and Panama in the New World; Sierra Leone, Belgian Congo, Accra (Gold Coast), Durban (Natal), and the Transvaal in Africa ; and Bengal, Madras, China, the Malay Peninsula, Persia, Siam, Sumatra, Ceylon, Java, and the Philippines in Asia. CLINICAL COURSE. This disease, while not fatal, is the source of great discomfort. It is characterized by intense itching which in small children may lead, in untreated cases, to nervous complications. In some cases a differential diagnosis from other dermatoses is not easy. The invasion of the skin is marked by an urticarial papule not unlike that following the bite of a mosquito or the invasion by the " red bug " o r " chigger " (as the larval stage of the harvest mite, Trombidium, is known locally). It is less like the burrows of Acarus scabiei which the Gastrophilus form has been said to resemble (HAMBURGER). It also resembles " ground itch " sensations as was above stated. In their experiments in self infection with the larvae of A. caninum, DOVE and WHITE describe a slight pin-pricking sensation of a few seconds duration, indicating the ingress of the larvae. In one instance this occurred about twenty minutes after the inoculation (which was carried out merely by placing the cultures on the forearm), and the other in about an hour. Minute red circular macules indicating points of entry of larva~ were noted in two of the forearm lesions. The parasite seems to remain at the point of ingress for a while, causing an itching somewhat resembling ordinary urticaria. Three or four days after

FIG. Larva

of

A.

braziliense

FIG. Infestation

To face

page

318.

1.

of

in

epidermis.

2.

Gastrophilus

larvae.

FIG. 3. Creeping eruption of leg ; Gastrophilus infestation.

FIG. 4. Wet sand creeping eruption in a child. Infestation was acquired in a sandpile at Fort Benning.

Fic. 5. Extensive infestation with tlncylostoma braziliense.

(KIRBY-SMITH'S case.)

EDGAR ERSKINE HUME,

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the entry of the parasite, it begins to " creep," though in some instances this is delayed. There is considerable variation in the rate of migration as well as in its extent. At times little if any migration is noted, and such cases are apt to be mistaken for other forms of skin disease. The distance travelled by the parasite in twenty-four hours is rarely more than an inch, and often not over half that extent. The accounts of migrations of five or six inches per day have upon investigation been found to be mythical. The lesion remains papular in appearance for several days, but soon a narrow erythematous line may be discovered by touch, which marks the path of the burrow. It has aptly been likened to the burrow of the meadow mole. The oedema fluid and cellular exudate in the channel through which the worm has passed so distend the burrow that it may be felt. This is seen also in photomicrographs. Along the lines of these burrows small vesicles may be seen. There is a tendency for these vesicles to become infected from scratching or otherwise, so that there may result an infected dermatitis varying from simple vesicular irritation to actual abscess formation. In the more severe and extensive infections, sometimes seen in adults, there are secondary symptoms varying in gravity. Naturally such severe conditions are not so common in patients under military supervision, as in those in the more remote rural districts where medical attention is less easily obtained. One child at Fort Benning, aged eighteen months, was heavily infected about the buttocks and legs from sitting in infected soil, and the lesions when scratched open became infected from the stools. The cases here have usually come in early for treatment, so that the more severe conditions such as have been described by KIRBY-SMITH have not been observed. However, the writer has seen them in the charity clinic of the nearby town. The presence of vesicles is characteristic of the nematode infestation, while the absence of vesicles, i.e., a papular line, strongly suggests Gastrophilus infestation (AuSTMANN,1926). There seems to be but one clinical type of Ancylostoma infestation. On the other hand, LAPIN (1924) distinguishes a superficial and a deep type of lesion in the bot fly creeping eruption. He finds that lesions due to G. hcemorrhoidalis tend to occur more frequently on the face and buttocks, while those due to G. equi (intestinalis) occur more frequently on the extremities. These are ot the superficial type. Lesions of the wet sand creeping eruption have been found in every part of the skin except the scalp, and in the same individual many parts of the body may harbour the parasites. The eruption in the lower extremities, however, is far more common than in other parts of the body. In more than two-thirds of the series of 300 cases reported by KIRBY-SMITH, the lesions were in the lower extremity. The next most common site of infestation is the arms and hands, while lesions of the trunk are uncommon. Here, again, the experience at Fort Benning has been the same as in KIRBY-SMITH'S series. The condition is more or less self-limited, for even in untreated cases, unless complicated by secondary infections, it usually ends within a few weeks

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WET SAND CREEPING ERUPTION.

The parasite always dies in the skin, and there is no record of any intestinal infestation in human beings from A. braziliense. It is not impossible that the violent and deep scratching caused by the " creeping " may in some cases cause actual removal of the larva. Wet sand creeping eruption is to be suspected in any erythematous, urticaria-like, papular lesion, causing intense itching, when the patient gives a history of contact with damp soil during the warm season of the year in a locality within the geographical area of this disease. At Fort Benning it is always considered in any diagnosis of dermatitis. Conditions which may resemble this creeping eruption include, for example, chemical dermatitis complicated by infection, but here the itching linear lesions of the periphery of the affected area are wanting ; dermatophytosis may offer difficulties, particularly as that condition is coenmon within the same geographical areas, during the same season, and characterized by intense itching. However, the burrowlike extensions of creeping eruption are not seen in dermatophytosis. Cases of the simultaneous presence of the two conditions have been observed. The uncinarial dermatitis, the initial lesion produced by N. americanus, has been confused with creeping eruption, partly through the use of the term " ground itch " for both conditions. Both itch intensely and in appearance are macular and papular. The invasion by N. americanus lacks, however, the advancing linear lesion of creeping eruption, and, moreover, usually lasts only about a fortnight, while the duration of creeping eruption is longer. CORRIGAN (1925) found that by painting two parallel lines with iodine on either side of the lesion it was possible successfully to force the larva to proceed virtually in a straight line between the parallel areas. This ingenious experiment was attempted at Port Benning, but with no success whatever. The larva appeared to cross the iodine lines quite as readily as to go between them. CORRIGAN was working with the larva of Gastropkilus, which may differ in this respect from that of Ancylostoma. TREATMENT. The ounce of prevention is assuredly worth the pound of cure in this condition. By means of official and unofficial notices, parents are warned not to allow their children to go about barefooted in the localities in which creeping eruption occurs. This measure is worth while also as prophylaxis against hookworm disease (N. americanus). It is particularly important that children should avoid walking with uncovered feet where the soil is wet following rains. Wading in small streams and along their banks is to be avoided, especial|y where, as at Fort Benning, the banks may have been polluted by the droppings of lynxes and pigs, as weU as dogs. Workmen and others are cautioned against exposure of their bodies, particularly the arms and legs, to damp earth. Regulations at Fort Benning forbid the admission of dogs and cats to children's playgrounds, and the owners of sandpiles are warned to keep domestic pets away from them.

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In untreated cases recovery takes place in several weeks or months, or, as said, the patient's frantic scratching may actually tear out the worm. Such occurrences may explain not a few imperfectly understood clinical histories of terrible itching lasting for several months and then disappearing. Treatment depends, of course, on the destruction of the larva in the skin. This is often quite difficult as the physician at times cannot find the actual location of the worm. The parasite seems to travel in advance of the visible course of the lesion, and as the rate of travel varies and the path is exceedingly tortuous, the operator is put to it to know just where to apply the local treatment. The best means of locating the larva is to ask the patient to point out the spot where the itching is most intense. This has proved a successful practice at Fort Benning, it having been recommended by KIRBY-SMITH. In small children co-operation of this kind is often not obtainable, and a guess must be hazarded. Furthermore, most children brought in for treatment have already been treated at home by means of various chemical irritants, so that often a series of blisters and pustules mark the site. These must be carefully opened and treated. For this purpose we use a freshly prepared 2 per cent. solution of mercurochrome. The most satisfactory method of treatment depends on the killing of the larva by freezing. This is attained by the application of a spray of ethyl chloride. The spray is applied to the " most itching spot," or where it is thought that the larva is located. The part should remain frozen for two minutes. The refrigeration is carried forward in advance of the terminal portion of the lesions. Following the application of the ethyl chloride, the infected areas are kept covered with wet dressings steeped in boric acid and aluminum acetate. An ice pack is placed over the dressings to prevent any warming of the parts. Daily inspections must follow in order to check the presence of other active lesions, which, if found, are treated by the ethyl chloride spray as before. The treatments are continued until the patient reports that there is no more itching and no further active lesions can be detected on examination. Following the treatment there is desquamation of the skin, and until this is completed the parts are kept covered with a boric-salicylic acid ointment consisting of : Salicylic acid . . . . . . . . 20.0 grams. Boric acid . . . . . . . . . . 100.0 ,, Yellow wax . . . . . . . . . . 50.0 ,, Petrolatum jelly . . . . . . . . 850.0 ,, In cases of extensive secondary infections the use of Dakin's solution has been found very satisfactory, following the application of the ethyl chloride spray. At Fort Benning we have not seen cases of infestation of the palms of the hands or the soles of the feet, which obviously offer special difficulties as to treatment. KIRBY-SMITH has had fair success with the following treatment:

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WET SAND CREEPING E R U P T I O N .

" T h e areas involved are carefully studied, and the distal ends of all active lesions are frozen with ethyl chloride spray. T h e entire area is then painted with tincture of iodine. This is followed by an application of 10 per cent. ammoniated mercury ointment to which is added 10 per cent. salicylic acid. T h e ointment should be applied with a " canton flannel " cloth strapped to the area. This is removed the following day. T h e tincture of iodine and the mercury ointment must be used with extreme caution, because of the violent reaction occasioned by their combined use. This treatment, although it is a heroic one, requires a very short time, and is usually followed b y a p e r m a n e n t cure." T h e r e have been a n u m b e r of treatments for creeping eruption tried with varying success. Destruction of the larva by cold seems to be the most satisfactory, but attempts to produce cold by other agents than ethyl chloride, such, for example, as carbon dioxide snow, freezing mixtures of salt and crushed ice, etc., have not been found effective. Among other treatments that have been r e c o m m e n d e d may be mentioned the pricking of the lesions with hot needles, the use of the actual cautery, ultra violet light, injections of chloroform or cocaine, applications of ethyl acetate collodion (made by evaporating the ether from ordinary flexible collodion and redissolving the residue in ethyl acetate), and other irritating chemical compounds. AUERHANN (1914) reports success in destroying the larva by pinching with the fingers. CAWSTON (1929), in Natal, found that cases showed rapid i m p r o v e m e n t upon the administration of one or more intramuscular injections of colloidal antimony or an intravenous injection of tartar emetic. This treatment has not been tried at Fort Benning, though it would be considered if cases not yielding to the local use of ethyl chloride were to be treated. BIBLIOGRAPHY. (1921). Ein in Deutschland beobaehteter Fall yon Creeping Disease, Derm. Wochnschr., lxxiii, 1269. AUERI~ANN, W. (1914). Zwei FMle von Hyponomoderma (Creeping Disease), ibid. lviii, 673-676. AUSTMANN, K . J . (1926). Creeping Eruption ; Report of the First Case from Manitoba, Jl. Amer. IVied. Assoc., lxxxvii, 1196-1200. AUGUSTINE, D. L., and SMILLIE, W. G. (1926). Relation of Type of Soils of Alabama to Distribution of Hookworm Disease, Amer. J1. Hyg., Sup., vi, 36-62. BISHOPP, F. C., LAAKE,E. W., BRUNDRETT,H. M., and W~LLS, R . W . (1925 and 1926). The Cattle Grubbs or Ox-Warbles : their Biologies and Suggestions for Control, U.S. Dept. ofAgricult., Bul. No. 20, Nov., 1925 ; Bul. No. 1396, Apr., 1926. BOAS, J. E. V. (1907). " Larva Migrans," eine Gastrophiluslarve in der Haut eines Menschen in D~nmark, Monatschf. f. Prakt. Dermat., xliv, 505-513. BODI~T. (1918). Note sur quelques cas de Pseudomyiase Rampante ou Pseudo-Dracunculose observ6s h Tarmatave, Bul. Soc. Path. Exot., xi, 716. BocRow, S . L . (1922). Creeping Disease (Larva Migrans) Gastrophilus Cutis, Dermat. Wchnschr,, lxxiv, 519. CASAZZA, R. (1928). Sui Dermatoendozoi, a pr0posito di un nuovo parasita (Creeping Disease) e Pseudo-Scabbia da " Dermolecanum migrans," Boll. d. soc. med.-chir di Pavia, iii, 391-425. CATES, T . H . (1914). Creeping Disease (Eruption), Derm. Wchnschr., lviii, 417. CAWSTON, F . G . (1928). Creeping Eruption of Natal, Known as Sand Worm Disease, Jl. Trop. Med. ~.~ Hyg., xxxi, 201-202. AI,PEL, J.

EDGAR ERSKINE HUME•

CAWSTON,F . G .

3~

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