Myiasis.

Under the name of myiasis we designate the complex symptoms which parasitic dipterous larvæ give rise to in man (Braun), and we conceive under the term myiasis externa (dermatosa s. cutanea) all lesions of the human integument caused by fly larvæ and of the cavities covered with mucosa therewith connected, such as the external auditory meatus, the oro-nasal cavity, the urethra and vagina. The occurrence of dipterous larvæ in the digestive tract is named myiasis intestinalia or interna.

Myiasis externa.

The larvæ of a species of fly belonging to the Muscidæ, Lucilia macellaria,1075 are found in relative frequency in the nose, especially in America and India.1076 Riley1077 has stated that the screw-worm of Central America and of the United States is nothing else than the larva of Lucilia macellaria, and also that the Brazilian fly named “berna” may be no other than Lucilia macellaria. Their offspring may set up inflammatory disturbances in the soft tissues of man. This fly has a wide distribution, from the Argentine Republic to Canada, also in the British portions of the East Indies, where the disease is named “peenash.” This word is derived from the Sanskrit, and is said to be a collective name for all diseases of the nose. Lahory1078 states that within a period of nine years ninety-one cases of “peenash” occurred in Allyghar, two of these ending fatally. Lucilia macellaria is not at all timid but bold, like the house-flies and blue-bottles, its relatives. It not only lives at no great distance from human dwellings, and forces its way into villas and country houses, but even attacks its victims without awaking them from their sleep. Although this species shows a certain preference for nasal cavities affected with catarrh or pus (v. Frantzius1079), and also the external auditory meatus, as well as ulcerated or wounded parts of the body, and even badly ulcerated skin carcinoma (Lutz1080), it is not a rare thing for it to penetrate into one of the above-mentioned cavities rapidly to deposit its eggs, without these parts having been previously affected. The report also of Conil,1081 in which these flies bear the name of Calliphora anthropophaga1082 is an interesting one. Probably it was the same species of Muscid in the cases of myiasis nasi observed by von Tengemann, Delasiauve,1083 Weber,1084 Mankiewicz,1085 and Kirschmann.1086 In the case recorded by Prima,1087 and in that recorded by Britton,1088 the issue was a fatal one; in the latter the larvæ escaped through the pharynx and nose; the hyoid bone and the soft parts of the palate were destroyed, the speech and power of swallowing were hindered. At the post-mortem extensive destruction of the internal nose was found, so that the nasal bones could only be kept in their position by the aid of the external skin. Even during life 227 larvæ escaped. Similar destructive processes were found in the case communicated by Richardson.1089 In two cases reported by Schmidt1090 300 and 350 larvæ were respectively removed from the nose, and the patients recovered. Wolinz1091 found his patient had lost consciousness, and that in the pus filling up the entrances to the nose numerous larvæ were moving; recovery followed. In the case communicated by Adler,1092 more than 150 larvæ escaped from the nose of an old man. Curran1093 states that people suffering from “peenash” frequently die from meningitis. The cases reported by Pierre1094 related to the forms of severe myiasis frequently to be observed in Guiana. In a patient who was suffering from typhus (? typhoid), Douglas1095 found the conjunctival sacs full of larvæ; in two other individuals the nasal cavities were attacked.

The case observed by Summa1096 was that of a man, aged 28, who suffered from nasal obstruction, fœtor, epistaxis and pain in the nose. Out of seven of the cases occurring at Fort Clark, U.S.A., and in its neighbourhood, six ended fatally; in all these cases Kimball1097 diagnosed ozæna; attracted by the strong odour the flies forced their way into the noses of the patients when asleep and there deposited their ova. In a case reported by Carrière1098 an abscess of the nasal septum was produced by the larvæ of flies; Chiodi1099 reports seven cases of myiasis due to Lucilia macellaria; among these was a case of rhinitis myiatica, in which a cerebral abscess leading to a fatal termination developed, being produced by the migration of a larva into the brain. Among the three cases of Lesbini1100 was that of a girl, aged 16, with 250 larvæ in the diseased nasal cavity. Quintano1101 observed larvæ beneath the eyelids in one case. It is possible that the cases of Cesare1102 and Calamida1103 were those of myiasis nasi due to Lucilia macellaria. The larvæ are also found in the nasal accessory sinuses, as is seen from the cases reported by De Saulle1104 (frontal sinus), Delasiauve1105 (frontal sinus), MacGregor1106 (antrum of Highmore), and Bordenave1107 (antrum of Highmore).

If a survey is made of the literature of the cases described of myiasis nasi produced by Lucilia macellaria1108 the following information is forthcoming: In Europe this form of the disease is of very rare occurrence, whilst in America and India1109 it is frequent. Persons suffering from ozæna are rendered the most liable to danger as the penetrating odour entices the flies in tropical countries with intense frequency, so much so that v. Frantzius does not consider this myiasis as an independent disease, but as a complication of ozæna of frequent occurrence in warm countries. The infection is so far of interest in its nature, in that it only takes place during the day. The fly is on the wing only by day when the sun is shining, and consequently only deposits its eggs at this time. Therefore persons suffering from ozæna are principally exposed to the danger of being pursued by the flies when they succumb to sleep during the mid-day hours in the open or in dwellings that are not closed up.

Headache is the symptom which most troubles the patients. It extends over the whole cranium and persists uninterruptedly, with more or less severe periods. Violent headaches in the frontal and buccal regions are almost always present in this complaint; they are experienced either only on one side or on both simultaneously; sometimes the pain is extended to the lower jaw and region of the neck, following the whole extent of the trigeminal nerve. The inflammation of the nasal mucosa produced by the penetration into it of the larvæ extends right into the frontal sinus and antrum. Simultaneously the patients, at the height of their trouble, suffer from persistent sleeplessness and severe vertigo, so that they reel and cannot walk straight; excessive sneezing always sets in at the commencement. The larvæ immediately spread over the nasal mucosa to seek a place suitable to feed, and irritate the nasal mucous membrane by the tickling sensation they produce. Later the patients frequently sneeze when the maggots move to and fro.

One very characteristic symptom consists in the peculiar swelling of the face, which is extended either over the whole or only one half of it, and may alternate with attacks of erysipelas (Brokaw1110).

The discharge from the nose is of special diagnostic value. It consists of a blood-stained serous matter or blood-stained fluid, which is perpetually trickling from one or both nostrils. The larvæ especially choose the anterior portions of the nasal cavity, where they can be seen lying in groups together at the base of the choanæ. The consequence of this is that the soft palate becomes intensely swollen, and this in turn makes swallowing very difficult; speech is impeded, and the voice acquires a nasal intonation. Symptoms of fever become more or less pronounced according to the number of larvæ present, and according to the nature and constitution of the individual. The appetite is in abeyance throughout the whole duration of the illness, and sometimes there is the onset of slight attacks of diarrhœa.

If the larvæ are not removed in good time there follows excessive destruction of the interior of the nose and of the turbinals; and the whole nasal framework undergoes disintegration, frequently, too, the velum palati, so that the larvæ come into sight in the oral cavity. Individuals thus severely attacked succumb through exhaustion, symptoms of meningitis (cerebral abscess) or septicæmia (Prima1111). Twenty-one out of thirty-eight cases recorded (collected) by Maillard1112 died.

The method of prophylaxis is self-evident from what has been stated. On bright summer days neither the healthy nor those suffering from diseases of the nose should sleep during the day-time in the open or in public habitations; sufferers from nasal diseases should pay special attention to this.

Treatment consists in the removal of the larvæ; this, however, is not always easy.

With regard to the methods which have proved to be effectual in the destruction of living larvæ and their expulsion from the nose, strongly smelling and easily diluted fluids come first, such as alcohol, eau-de-Cologne, and ether, which should kill the creatures when injected into the nostrils. The earlier physicians, such as Salzmann,1113 Honold,1114 and Henkel,1115 have seen good results from the use of these methods, whilst Mankiewicz1116 and Goldstein1117 obtained no results whatever. Kimball’s1118 careful investigations have shown that a decoction of bitter herbs recommended by Behrends1119 (tansy, wormwood) have just as little effect as the tobacco decoction employed by Boerhave1120 and Kilgour.1121 The sternutatories employed by the older physicians are entirely neglected. Delasiauve1122 experienced good results from the inhalation of the smoke of paper cigarettes, which were soaked with a solution of 2·0 pot. arsenic in 30·0 distilled water. Whilst, according to Kimball, balsam of Peru had no effect on the larvæ, Mankiewicz succeeded in removing the larvæ from the nose with the help of that drug. Turpentine steam or mixtures of turpentine employed by Indian physicians have not been very effectual according to Moore,1123 Kimball and Goldstein. Success has been attained in some cases by the use of insufflations of calomel (Roura,1124 Cerna,1125 Schmidt1126) or of iodoform (Pascal1127). Joseph1128 recommends concentrated alum solution being sniffed up into the nose as very effectual. Sublimate and carbol solutions do not appear to be very successful (Kimball, Moore, Goldstein), whilst benzine inhalations (Pierre1129) have shown better results. Scheppegrell1130 strongly recommends injections of oil which kill the larvæ, while it is perfectly harmless to the nasal mucosa. Cesare1131 employed nasal lavages with solutions of salicylate of soda with good results, and Calamida1132 lavages with physiological saline solution. Bresgen1133 recommends the nose being cocainized and the larvæ being removed with a pincette. Roorda-Smit1134 cocainized the nose, then insufflated calomel and plugged the nose with a gauze tampon dusted with calomel. After two hours fifty-six larvæ crawled out along the plug. Continuation of the treatment resulted in a complete cure.

Injections of chloroform water (Jourdran1135) or chloroform inhalations, or injections of pure chloroform into the nose, have proved the most effectual (Goldstein,1136 Osborn,1137 Jourdran, Durham,1138 Jennings,1139 Kimball,1140 Mackenzie,1141 Oatmann,1142 Zarniko,1143 Antony,1144 Folkes1145). Camphorated carbolic solutions are very well spoken of: Grayson1146 states that these kill the larvæ immediately. Some authors have removed the larvæ with forceps (Goldstein1147), others with pincettes; thus Brokaw extracted 200 fragments with the forceps, Pascal eighty fragments with the pincettes, and Wolinz1148 also appears to have removed the larvæ with forceps.

Greater operative measures than these do not appear to have been undertaken in latter days; yet Morgagni1149 states that the army surgeon, Cæsar Mogatus, at Bologna, first trephined the frontal sinus and then extracted a “worm” from it.

Larvæ of other Muscidæ have come under observation much more rarely (Cheval1150 [larvæ of Galleria mellonella1151], Bond,1152 Dumesnil1153 [larvæ of Piophila casei]). Species of the genus Scolopendra (Myriapoda), which all shun the light and seek their food during the night—which consists of animal and vegetable substances—frequently make their way into the nasal cavities of people when asleep. They are found not only in the nose, but in the accessory cavities. In the chapter on the “Parasites of the Nose”1154 we have collected striking instances, but we have omitted to mention the observation made by Bertrand1155 (Scolopendra in sinus maxillaris) and that made by Bergmann1156 (Scolopendra in sinus frontalis). In the same chapter some remarks are made as to the occurrence in the nose of earwigs, caterpillars, scorpions and termites, as well as of animals which have not been identified.

The larvæ that develop in the auditory meatus penetrate the membrana tympani, destroy the middle ear and may produce meningitis and intracranial suppurations. In one case Vesescu1157 extracted seven living larvæ from the ear with the aid of a thin pair of pincettes. Köhler1158 recommends the infusion of drops of ol. terebinth. to destroy the larvæ, Quintano1159 the insufflation of the following powder: Oxid. hydrarg. rubr., sulfur., āā 1·0 grm., pulv. gi. arab. 8·0 grm.; Lesbini1160 recommends tincture of iodine. In the case reported by Henneberg1161 the larvæ were those of Lucilia cæsar.

Eye affections due to Lucilia macellaria are very uncommon; the literature relating to the lesions of the eye produced by the larvæ of flies has been collected in Kayser’s1162 work. In the cases under the observation of Schultz-Zeyden1163 both the eyes of a female tramp were destroyed, and quantities of larvæ were also found in the nasal fossæ and in the ears.

The Lucilia is found relatively seldom on the cutaneous surface. Henneberg’s1164 case was that of a neglected girl, aged 20, in whom countless larvæ (L. cæsar) were found in a plica polonica; after the plica polonica had been removed the scalp was found to be covered with a large quantity of ulcers which swarmed with larvæ, large and small. The skin of the trunk was also much macerated and covered with larvæ. Death resulted from sepsis; Westenhöffer1165 remarks on this case that a lesion of the head from which the patient had suffered previously and the perpetual state of intoxication in which she was had probably given rise to the lodgment of the fly larvæ. Whether the communications made by Munk1166 of maggots in the mouth relate to Lucilia I do not know. Vesescu,1167 in one case with extensive ulceration and deep fistulæ in the skin, removed 176 larvæ with the pincette. In Roorda-Smit’s1168 case there were two ulcers in the neck of a girl, aged 17, and larvæ appeared at their base. After dusting with calomel and the application of a bandage the next day fifty-two dead or half-dead larvæ came to light. Recovery took place. Lesbini,1169 in the case of an old lady, saw numerous larvæ in an ulcer of the leg she was suffering from. Hector’s1170 case appears to have been one of myiasis cutanea provoked by Lucilia.

The first exact observations of myiasis cutanea from Sarcophaga magnifica are due to Wohlfahrt,1171 in whose honour Portschinsky1172 named this species of fly S. wohlfahrti. Portschinsky ascertained that S. wohlfahrti was not confined to man as its sole host, but that several of our domestic animals, such as cattle, horses, pigs, dogs and geese, were visited. In these animals small wounds serve to entice the flies and to supply them with a suitable site for the deposition of their eggs. The oral armature of the young larvæ renders it easy for them to penetrate not only the mucosa and cutaneous surface but also intact places in the submucous connective tissue. In many localities more than half the herds have proved to be infected by the flies. The fly only frequents open spaces and never enters human dwellings, and is so timid that it approaches man only during sleep; infection, therefore, takes place only out of doors, in summer, in clear, warm weather, and only in such individuals as sleep in the open air. Individuals are most exposed to risk who suffer from catarrhs or inflammations, combined with purulent secretions of the nasal cavity (ozæna), or otorrhœa, or ulcers in any parts of the body accessible to the female fly.

The frequency and intensity of the infection will be in inverse proportion to the advance in civilization of the inhabitants, their idea of cleanliness, their having timely medical aid and the chances of their being rapidly attended to. On that account the majority of cases of myiasis (Sarcophaga) are reported from Russia. The literature of this kind of myiasis nasalis is not very extensive; in addition to Wohlfahrt, Portschinsky and Joseph,1173 there is a communication by Gerstäcker,1174 who found fifteen adult larvæ of S. wohlfahrti in the nasal cavity of one man. The larvæ transmitted from Ordruf by Dr. Thomas to Löw,1175 in Vienna, which were discharged from the nose of a woman, aged 71, suffering from ozæna, were recognized by the well-known dipterologist Braun as belonging to S. wohlfahrti. Among the cases reported by Joseph, one only affected the nose; it was that of a peasant girl, aged 11, who had suffered from ozæna; she had travelled on the open road and had there gone to sleep. Severe symptoms set in and death followed under delirium. In making the post-mortem it was found that the interior of the nose was extensively destroyed by larvæ of S. wohlfahrti. Powell found Sarcophaga larvæ in two persons who had slept in the open air; the larvæ were killed by injections of chloroform and sublimate. Destruction of the eyes by S. wohlfahrti has only been observed in a few cases; it is reported by Cloquet1176 that, in the case of a ragman who had lain some time in the fields, both eyes were pierced by larvæ. On the outer skin the larvæ of S. wohlfahrti have been found more than once in inflammatory or festering areas. Freund1177 demonstrated that from a five year old child, which had suffered for some time from an impetiginous eczema of the skin of the head, from two suppurating abscess cavities which extended to the periosteum, which was already affected, twenty-one living larvæ were taken; rapid healing took place under antiseptic bandaging.

The small treatise by Balzer and Schimpff1178 contains two new observations on myiasis externa; in the one case an ulcer on a man’s foot was full of larvæ, in the other case the head of a woman showed numerous larvæ without the skin of the head being destroyed. Brandt’s1179 observation is interesting, for he found such larvæ in the gums of a sick person.

The impression which one obtains of the active movement of larvæ on wounds is a strange and at the same time uncanny one. One finds that the larvæ to obtain protection against the drying of the surface of the abscess almost incessantly burrow with their heads, first contracting and then expanding the body, which rises and falls, and keeping the tail upwards. Owing to these movements producing irritation, increase of inflammation may ultimately arise, causing erysipelas and cellulitis.

The treatment of myiasis nasalis caused by Sarcophaga is the same as in myiasis caused by Lucilia, and in the other places where found it is merely a question of the removal of the larvæ and the subsequent proper treatment of the surface of the abscess. In Northern Nigeria Lelean1180 found Auchmeromyia depressa to be the cause of myiasis externa.1181

The occurrence of Oestrid larvæ in a human being is very rare, at least up till now myiasis oestrosa has been very seldom observed in man in Europe. Whilst the hosts of the Muscidæ comprise a considerable number of warm-blooded animals, on which the larvæ develop, each species of the Oestridæ appears, on the other hand, to have a definite host or some definite hosts of the class Mammalia. No species of Oestrid is peculiar to man. Although in America, as well as in Europe, Oestrus hominis was spoken of up to the middle of the last century, no such species exists.

But in both hemispheres, in America much more often than in Europe, Oestrid larvæ have been found in man. In Florida, Mexico, New Granada, Argentina, Brazil, Costa Rica and other districts, and especially where large herds of cattle are kept, myiasis oestrosa has been observed in shepherds, huntsmen and amongst the rural population. The larvæ of Hypoderma bovis, according to the observations of Goudot,1182 occur as a parasite in man. Poilroux1183 found larvæ of cavicolous Oestridæ in the nose of a man, aged 55. Amongst the species of warble flies, whose larvæ are parasites in domestic animals and game in Europe, reliable observers have found larvæ of two kinds, Hypoderma bovis and Hypoderma diana, also in man.1184

The larvæ of H. bovis have very seldom been observed in the nose. The case quoted by Kirschmann,1185 which was that of a peasant woman, aged 50, who was suffering from ozæna, and in which violent attacks of sneezing, epistaxis, pain in the forehead, and swelling of the face were observed, is, according to Löw1186 and Joseph,1187 not an Oestrid; Muscid larvæ were evidently the cause. By the injection of diluted iron chloride solution seventy-nine larvæ were removed from the nose. In the case reported by Razoux1188 the species of larva is not definitely known—at least, v. Frantzius1189 did not consider them Oestrid larvæ. Joseph does not definitely say that Oestrid larvæ were the cause of a case which he quotes. He was sent a number of uninjured larvæ of Oestrus ovis ready to pupate, which were said to have been expelled, during violent sneezing, from the nose of a peasant woman who had suffered for six months from continuous frontal headache and chronic nasal catarrh.

The Oestrides prefer to use the surfaces of wounds on the skin of man to lay their eggs, which develop into larvæ; but they often use their ovipositors1190 to make a fresh wound. In this case there arise in the skin, and particularly in the subcutaneous connective tissue of the neck, in the region of the shoulder, as well as in other parts of the body painful, furuncle-like inflammations which are known under the name of gad-fly boils. These boils may become the size of pigeons’ eggs; if several are together, they appear to form a connected tumour. Each tumour is elastic and somewhat movable, and has an orifice through which the larva breathes and discharges its excreta. At times these turn to festers and gangrenous disintegrations, which may even cause the loss of a limb. Wilms1191 had the opportunity a few years ago of observing a case of myiasis dermatosa oestrosa in Leipzig. The fistula which led to the larva was slit open and the larva extracted. As a notable characteristic of myiasis oestrosa Joseph states that the larvæ grow very slowly. The flight time of the Oestridæ is the hot summer months.

Adams1192 observed on the Isthmus of Panama a number of cases of a skin disease which is caused by the larvæ of Dermatobia noxialis (Gusano-peludo-Muche). The larvæ penetrate not only the skin but also the mucous membrane of the pharynx and larynx, and from there proceed through the tissue to the subcutaneous cellular tissue. The infection seems to result from bathing.

The study of “thimni,” a human myiasis caused by Oestrus ovis, by Ed. and Et. Sergent,1193 deals more with the zoology and with the geographical distribution of this insect in North Africa than with the clinical appearances of myiasis. [This paper deals with matters of great interest, with important facts.—F. V. T.]

The treatment consists in the removal of the larvæ (from the nose); in Brazil it is the custom to drop tobacco juice into the boil in order to kill the larvæ (Strauch1194).

One is only justified in speaking of myiasis intestinalis when there is no doubt that living fly maggots or flies themselves can be proved to have been found in the fresh contents of the stomach or intestine (Schlesinger and Weichselbaum1195). In the discussion of myiasis intestinalis we give the evidence of Schlesinger and Weichselbaum, as well as that of Wirsing,1196 to which must be added a number of other investigations.

In a great number of acute cases apparently only the stomach was affected, there being no signs in the intestine. In these cases sudden illness is noticed, colic, sometimes unbearable pains in the region of the stomach, pyrosis, vomiting or continuous intense inclination to vomit, occasionally even with the mixture of blood. Frequently a general feeling of malaise, twinges of pain in the muscles, and attacks of giddiness were notified, very rarely fever. Generally all the symptoms disappeared in a short time when the larvæ had been removed by an act of vomiting or by washing out the stomach.

It is well to note that in the history of many cases the pains preceding the expulsion of the larvæ are stated to be extremely violent.

Acute myiasis of the intestinal canal frequently runs a course without special symptoms and is only an accidental condition; one has, however, in such cases to guard against errors. The fæces may be deposited in vessels or places where fly larvæ are in great numbers, or a subsequent infection of the fæces with the eggs or larvæ of flies may have taken place. Only when the inspection of the excrement immediately following defæcation proves the presence of living larvæ, and when there were certainly no fly larvæ in the vessel previously, can one speak of the passing of fly larvæ from the intestine. More frequent than the cases showing no special symptoms are those with pronounced disturbances in the intestinal passage, obstruction or diarrhœa (also constipation and diarrhœa alternately), violent and sometimes agonizing abdominal pains (Pottiez1197), which preceded the evacuation of the larvæ and subsided after their removal. General symptoms, like weakness, languor, transitory vague pains, loss of appetite, sickness, rarely fever, giddiness, attacks of faintness, epileptic attacks (Krause1198) are observed. In a few cases blood and pus have been noticed in the evacuation of the bowels.

In the cases of chronic myiasis of the intestine the aspect of the disease is dominated by the complex symptom of colitis mucosa.

The following features are noticeable, namely, the intermittent passing of blood, the influence over the expulsion of the larvæ of mechanical procedure (massaging of the abdomen), the duration of the process for several years, the sometimes enormous number of insects contained in the dejecta. Another clinically important factor is the passing of the larvæ in batches. While for some time no larvæ may appear in the stools, they may suddenly be ejected in great numbers, either because the conditions of feeding are not suitable, or because medicaments remove them from the intestine. The hæmorrhage is ascribed by Schlesinger and Weichselbaum directly to lesions of the mucous membrane caused by the larvæ; in the case reported by these writers there were found shreds of tissue as well as pus in the stool. The pains occurring spontaneously in the abdomen are at times influenced by position and attitude of the body, often they were more violent after rest and after evacuation of the bowels; often they were continuous, but in that case less intense; pressure on the abdomen is generally little felt. The condition of the blood was in two cases (Pasquale1199 and Schlesinger and Weichselbaum) a marked chlorotic one. The state of nutrition seems almost always to suffer with prolongation of the disease, but in Peiper’s1200 cases this was not so. The condition of the appetite was in some instances good, in others very bad. A frequent symptom is headache of a migraine-like character and neuralgic pains in different parts.

Schlesinger and Weichselbaum’s case shows that there are forms of myiasis intestinalis which, after prolonged sickness, lead to death, and that in consequence of the formation of intestinal abscesses stricture of the intestine may arise from the subsequent formation of a scar.

The question of the mode of infection is interesting; in this mouth, nose and anus must be considered. The most frequent way is certainly by means of food on which flies have laid their eggs, or which is permeated with young maggots. This may be raw (especially grated) meat, cheese, fruit, salad, milk, cabbage, cold farinaceous foods, raspberries. When the stomach is affected, when the gastric juice has lost acidity and power of digestion, the larvæ will be able to stay and develop more easily. According to Csokor,1201 if the eggs get into the gastro-intestinal canal of man with the food, the delicate stages of the young larvæ would certainly not survive the action of the gastric juice. Salzmann1202 assumed that the invasion occasionally occurred through the rectum, the larvæ creeping into the anus while the person is asleep. Wirsing accepts this method of infection for two of his cases, where it was a question of the infection of an infant. Salzmann1202 reports a case where the maggots of Anthomyia1203 scalaris were passed in great numbers from the urethra of an old man. The patient had been catheterized on account of urethral stricture and was probably infected with eggs or larvæ at the same time.

The diagnosis of the affection is easy and sure, if living larvæ are found in the contents of the stomach or in the stools, and if contamination is out of the question.

The number of different species of flies whose larvæ are found in myiasis intestinalis is considerable. The larvæ of species of Anthomyia (A. canicularis,1204 A. scalaris, etc.), of Sarcophaga carnaria and S. magnifica and of Musca vomitoria1205 are especially observed.

The prognosis is certainly generally favourable, but must be made with some reserve in chronic cases, in view of the observations of Schlesinger and Weichselbaum (intestinal stenosis).

The treatment must aim at removing the larvæ as soon as possible from the digestive canal.

In cases of myiasis of the stomach, a thorough washing out of the stomach (Joseph,1206 Staniek1207) is to be preferred to emetics used with success in individual instances; perhaps it would be advisable to add menthol or thymol to the mixture.

In myiasis of the intestine internal remedies and local treatment of the intestine must be considered.

So far santonin seems to have proved to be the best remedy. In some cases extract. filicis maris, calomel, semina cucurbitæ, naphthalene 0·1 to 0·5 (Peiper1208), infus. of Persian insect powder (5 in 200), mineral waters, Carlsbad water, seem to have had good results.

For irrigation of the rectum, weak solutions of argentum nitricum, tannin, thymol, gelatine, ol. ricini, naphthalene may be used. Wirsing administered an aperient (Rurella compound liquorice powder) and a soap enema after the passing of the first larvæ.

The principal thing is the prophylaxis, which must include the careful protection of articles of food, on which flies may lay their eggs (protection by glass dishes, tulle or fine wire nets). Fruit should not be eaten before being washed or rubbed with a cloth.

Gastricolous Oestridæ (Creeping Disease).

Syn.: Creeping eruption; Larva migrans; Hautmaulwurf; Dermatomyiasis linearis migrans oestrosa; Hyponomoderma; Dermatitis linearis migrans; Linea migrans; Epidermiditis linearis migrans Wolossatik; Kriechkrankheit; Hautkratzschorf; Myiase hypodermique.

Under the name “creeping disease,” R. J. Lee1209 has recorded a peculiar affection of the skin in a three year old girl, which appeared first in the form of pale red, thread-like irregular protuberances, which seemed partly to become entwined on the right malleolus and had spread without causing special disturbances to the abdomen. Dickinson, Fox and Duckworth1210 reported, in connection with this, that they observed a growth of this red line of about 1 in. per diem. Since then a number of similar cases have been reported which, without doubt, were cases of larvæ creeping under the skin. Crocker1211 saw such a case in a two year old girl, the progress of the red line varying in one night between 4 and 7 1/2 in. In Europe the first case was observed in Vienna, by v. Neumann and Rille,1212 also in a two year old girl.

v. Samson-Himmelstjerna,1213 Sokoloff,1214 Rawnitzky1215 found larvæ at the end of the tract, which had been recorded as larvæ of Gastrophilus by Cholodowsky.1216 According to Blanchard (Arch. f. Par., 1901) the larvæ were those of Hypoderma bovis.

How these larvæ get into the skin has not yet been definitely ascertained; v. Samson is of the opinion that they usually obtain access to man as larvæ, Stelwagon1217 believes that the infection generally occurs in a seaside watering place; a patient of Ehrmann’s1218 fell ill when he returned from the manœuvres, where he had lain for some time on the ground. Here and there it is reported that the eruption was preceded for a longer or shorter time by lesions of the skin (incised wounds, furuncles, slight excoriations, v. Harlingen1219).

Twice it has been suggested that perhaps the parasites might come from vineyard snails (Crocker, Lenglet and Delaunay1220), and it is pointed out by v. Samson that in Russia the infection of peasants who work in the fields was specially frequent. It is noticeable how frequently the affection begins on uncovered parts of the body (face, hands, arms); but that fact, on the whole, is not in conflict with the statement (Kengsep1221) that the disease makes its first appearance over the nates, because children often sit on the ground and play with that part of their body uncovered. A case observed by us was that of an elderly lady who did not do this and was properly clothed, yet showed the typical lines of creeping disease on the nates, and asserted again and again that she had the feeling as if a worm were creeping under her skin.

The disease occurs in children as well as adults, so that age, sex and calling offer no determining point etiologically.

The clinical symptoms of the disease consist in the sudden appearance of itching and burning; if the cause is looked for one perceives a red line, raised but little above the surface of the skin, with irregular curves, never branched, but often entwined, broadening more or less rapidly at one end (1 to 15 cm. in twenty-four hours). The larva can be seen sometimes with a lens under pressure of the skin as a dark spot; formations of pus, such as other larvæ produce, are not noticed; now and again there is a formation of little vesicles (Hamburger,1222 v. Harlingen,1223 Bruno,1224 Ehrmann,1225 Brodier and Fouquet,1226 Rawnitzky1227). It may happen that the parasite burrows through a small region of the skin with many close curves for some time; on the other hand, observations exist where it covered large tracts in a short time. The itching and smarting cease in the place left by the larva, so that the patients even in the shortest tract can point out at which end the larva is, even if they have not watched the lengthening of the tract. Very rarely the larva invades the mucous membrane of the mouth, the nose, and the conjunctiva, proceeding from thence to the external cutaneous area.

The localization of the affection is very varied; the primary seat has been observed on the glutei muscles (Lee, Kengsep, Morris,1228 Rille, Seifert) and their surroundings (Stelwagon, Hamburger, Bruno), on the lower extremities (Stelwagon, Lenglet and Delaunay, Hutchins, Moorhead, Lee, Crocker, Schmid,1229 v. Harlingen), on the upper extremities (Samson, Meade and Freeman, Hutchins, Sokoloff, v. Harlingen, Brodier and Fouquet, Shelmire,1230 Stelwagon), on the face (Sokoloff, Moorhead, Kumberg,1231 Rawnitzky, Crocker, Boas1232), on the neck (Sokoloff), and on the body (Ehrmann, Brodier and Fouquet, Kaposi,1233 Topsent1234).

The duration of the affection varies very much; it varies between a few hours and some years1235; several times a spontaneous recovery has been reported.

The diagnosis of the disease is not at all difficult owing to its peculiar appearance.

The treatment can only consist in the removal or killing of the larvæ, since one cannot rely on spontaneous recovery, even if it has occurred in some cases. If one should succeed in locating the larva as a black spot at the end of the tract, its removal by means of a needle is the simplest method (Quortrup and Boas1236). In some instances a cure has been successfully accomplished by excision of the active end of the tract (v. Neumann and Rille, Schmid). In opposition to this method, which not all patients will allow, the method practised by Arab women (Rille and Riecke1237) of killing the worm with red hot needles is quite rational. Shelmire1238 used the electrolytic needle for the destruction of the maggots, Stelwagon1239 made use of cataphoresis, by means of which he applied a sublimate solution, afterwards cauterizing with a drop of nitric acid, as excision was refused. Crocker1240 and v. Harlingen1241 injected small quantities of carbolic acid; Moorhead1242 by a single freezing of the skin with ethyl chloride, attained a definite cessation of the attack at the active end. Hutchins1243 in one case made use of hypodermic injection of a few drops of solution of cocaine and afterwards of 1 to 2 drops of chloroform; in a second case of repeated applications of tincture of iodide, as Lenglet and Delaunay1244 did. v. Harlingen1245 allayed the affection in his first case by rubbing in sapo viridis and tar, in Kensep’s1246 case the cure seems to have been accomplished by an ointment containing resorcin, in Meade and Freeman’s1247 case by a 20 per cent. ichthyol paste. In our case we made exclusive use of Lassar’s paste; within four weeks a cure resulted, probably spontaneously, since one cannot ascribe any essential effect to this paste.