CREEPING ERUPTION, OR LARVA MIGRANS

BY G. O. BRINKLEY, M.D., SAVANNAH.

Creeping eruption is a condition caused by a migrating larva, supposed to be a depterous insect belonging to the family ostridae or botfly, genus gastrophilus, species hemorrhodolis; but as there are upwards of sixty species of the botfly, at least twenty-four of which are found in North America, the question of species is not definitely settled.

This rare cutaneous condition was first described by Robert J. Lee, of London, from two cases (1875 and 1884).

In 1902, Von Harlingen reported in the American Medical Journal of Science a series of cases (two or three in number) known as creeping larva in the human skin. This was the first to be recorded in this country, although he did not find the larva, which is as illusive as the treatment is deceptive.

Stelwagon reported his first case before the section of cutaneous medicine and surgery of the American Medical Association in 1903, and his second case before the same section in 1904. He also mentions two other cases in his recent book on Diseases of the Skin.

Homburger, of Baltimore, reported his only case in 1903, before the Medical and Chirurgical faculty of Maryland, in which he dwelt largely on its relation to the subject myiasis, as well as its special dermatological importance.

Shelmire reported his only case before the Texas Medical Association, April, 1905.

Hutchins, of Atlanta, reported two cases, with special reference to treatment, in the Journal Cutaneous Discases, June, 1906.

The above are all the American cases that I have been able to find reported. There have been several cases reported in England, Austria, Arabia, Bulgaria and Russia-the latter having furnished more cases than any other country, and the only country where the larva has actually been found in the human skin; hence, we have only the Russian authority as to the actual cause of this extremely interesting disease. However, the clinical manifestations are so analogous in the various cases reported, that it makes one feel morally certain that the etiological factor is some kind of migrating larva in or under the skin.

The larva found in Russia by Sokoloff and SamsonHimmelstjerna measures about one millimeter in length, spindle shape, segmented, better developed at the head end, has two hooklets and apparently supplied with two suckers.

The point of infection is usually on exposed surfaces, as hands, wrist, feet, legs, and buttocks.

The lesion produced is a narrow red line one-sixth to one-eighth inch broad, only just perceptibly raised. This line travels over the surface at the rate of one-half an inch daily, forming all kind of curves and gyrations, though sometimes it goes straight. The red line fades at the passing end in a few days, while the larva itself is about one-fourth-inch beyond the active end, where there is itching and burning by which some patients can locate the larva, as was the case with my first patient. Case 1.-Male, age twenty-four, white, American born.

Early in July of last year, while at Tybee Island, it began as an itchy pimple near the tip of the left ring finger, slightly erythematous. Extending up from this pimple was the beginning of a burrow-like unto a miniature groundmole track under the skin, this burrow extending up near the margin of the nail, crossing the dorsal aspect of the finger just above the nail, continuing around to the palmar surface, then traveling up to the middle one-third of the finger. After making many loops, curves and gyrations, this serpentine-like burrow extended nearly to the palm of the hand, traveling from one-half to three-quarters of an inch daily.

Just in advance of the growing end could be seen a small dark-brown bead-like spot by the use of a magnify-. ing glass. After the blood had been pressed out the parts with a glass spatula, this spot was located about one-quarter-inch beyond the apparent end of the growing

line.

During several days of careful observation, this small dark speck kept its distance beyond the growing end of the line. This line was from one-eighth to one-sixth of an inch wide, slightly elevated, surmounted with vesicles and occasionally a papule, irregular in character and of a pale reddish color. The passing end, within a few days, began to fade, leaving a slightly purplish brown pigmentation; over this laid a few delicate crusts and scales which were remnants of the former vesicular line.

After carefully watching the progress of this eruption for several days, during which time antiseptics were kept constantly applied, without results; and not being allowed to excise a piece of tissue at the active end of this peculiar eruption. In the meantime, the patient insisted on some other form of radical treatment.

I then injected a few drops of a cocaine solution, im

mediately followed with three drops of chloroform, the needle being pointed as near as possible to the small dark spot, which is supposed to be the larva. The chloroform caused but little pain, and tissue reaction very slightly, with the exception of some increased erythemia. It, however, had the desired effect, as it stopped the progress of the eruption, and within one week's time the patient was well, with the exception of the recovery of the fingernail, which was lost, owing to the burrow being in such close contact with the nail root in its early passage.

Case 2.-German, male, age thirty-eight, began early in October of last year while patient was having a day's outing in the country-as an itchy pimple on the erythematous base below ankle on the outer side of the right foot. Three days later, when I first saw the patient, there was a distinct ridge of a reddish color about two and a half inches long and one-sixth inch wide, irregular in character, composed principally of papules and vesicles slightly elevated. This ridge or line was very wavy and serpiginous.

Just beyond the active end could be seen a small grayish-brown bead-like spot, by the aid of a magnifying glass, after the parts had been rendered enemic by pressure with a glass spatula. For three days I watched this little organism play hide and seek around the external malleolus, leaving a mark behind it. The patient would not permit me to excise a piece of tissue, for fear it would leave a running "sore;" hence, I resorted to the injection of chloroform, not using cocaine; about four drops was injected in the skin, just over the external malleolus. This caused severe pain and necrosis of tissue at the point of injection, leaving a very sluggish ulcer about three-eighths by one-half-inch in size. This ulcer required much longer time to be cured than would

an excision. However, the injection had the desired effect, as the eruption stopped at once.

This method of chloroform treatment is not original with me, as Hutchins, of Atlanta, treated both of his cases in this manner. The first one was successful after the second injection. His other case had a multiple infection, and the injection seemed to scatter the larva in many directions. Necrosis of tissues resulted, and the

patient drifted out of his hands.

Case 3.—Male, white, Scotchman, age fifty. The latter part of September last, while landscape gardening, it began as a small water blister over an erythematous base,. about the middle third of the leg on the anterior surface, extending upward in a linear formation to upper third of leg. I first saw the patient about two months later, and the upper half of the leg had been pretty well traversed by the little organism. There were several signs of old and new burrow. The more recent would be only a red line slightly elevated, when a few hours older it would be papulo-vesicular, and within a few more hours it would be almost entirely vesicular, as the older or passing end would gradually dry up, leaving only a brownish, pigmented, scaly track, gradually fading into the normal surface. This was carefully watched for about ten days. The organism would, some days, travel as far as two and one-half inches, and other days it would move only the fraction of an inch. The parasite was rather hard to locate in this case, as it migrated over the same territory so often, which was pigmented. The scales and crust interfered with its location. It eventually, however, marched out in the open field, and I excised a small piece of tissue at the site of the suspected parasite, but was unable to find the larva. The patient came back to my