Chapter XXXVII: Introduction (6)

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 Mankiewicz[1116] and Goldstein[1117] obtained no results whatever. Kimball’s[1118] careful investigations have shown that a decoction of bitter herbs recommended by Behrends[1119] (tansy, wormwood) have just as little effect as the tobacco decoction employed by Boerhave[1120] and Kilgour.[1121] The sternutatories employed by the older physicians are entirely neglected. Delasiauve[1122] 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] Schmidt[1126]) or of iodoform (Pascal[1127]). Joseph[1128] 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 (Pierre[1129]) have shown better results. Scheppegrell[1130] strongly recommends injections of oil which kill the larvæ, while it is perfectly harmless to the nasal mucosa. Cesare[1131] employed nasal lavages with solutions of salicylate of soda with good results, and Calamida[1132] lavages with physiological saline solution. Bresgen[1133] recommends the nose being cocainized and the larvæ being removed with a pincette. Roorda-Smit[1134] 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.

[1113] Salzmann, _see_ Tiedemann, Mannheim, 1844.

[1114] Honold, _ibid._

[1115] Henkel, _ibid._

[1116] Mankiewicz, _Virchow’s Archiv_, 1868, xliv.

[1117] Goldstein, _New York Med. Journ._, 1892.

[1118] Kimball, _ibid._, 1893.

[1119] Behrends, _see_ Tiedemann.

[1120] Boerhave, _ibid._

[1121] Kilgour, _ibid._

[1122] Delasiauve, _loc. cit._

[1123] Moore, _Chicago Med. Times_, 1893.

[1124] Roura, _Gaz. di San. milit._, 1884.

[1125] Cerna, _New York Med. Journ._, 1893.

[1126] Schmidt, _Texas Courier_, 1884.

[1127] Pascal, _Arch. d. Méd. milit._, 1895.

[1128] Joseph, _Deutsch. med. Zeitg._, 1885.

[1129] Pierre, “Thèse de Paris,” 1888.

[1130] Scheppegrell, _New York Med. Journ._, 1898.

[1131] Cesare, _loc. cit._

[1132] Calamida, _loc. cit._

[1133] Bresgen, Eulenburg’s “Real. Encyclopädie,” third edition.

[1134] Roorda-Smit, _Deutsch. med. Wochenschr._, 1906.

Injections of chloroform water (Jourdran[1135]) 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] Folkes[1145]). Camphorated carbolic solutions are very well spoken of: Grayson[1146] states that these kill the larvæ immediately. Some authors have removed the larvæ with forceps (Goldstein[1147]), others with pincettes; thus Brokaw extracted 200 fragments with the forceps, Pascal eighty fragments with the pincettes, and Wolinz[1148] also appears to have removed the larvæ with forceps.

[1135] Jourdran, _Arch. de Méd. nav._, 1895.

[1136] Goldstein, _New York Med. Journ._, 1892.

[1137] Osborn, _Daniel’s Med. Journ._, 1891.

[1138] Durham, _Chicago Med. Times_, 1893.

[1139] Jennings, _Kansas City Med. Index_, 1890.

[1140] Kimball, _New York Med. Journ._, 1893.

[1141] Mackenzie, “Diseases of the Nose and Throat.”

[1142] Oatmann, _Med. Mirror_, February, 1894.

[1143] Zarniko, “Lehrb. d. Krankh. d. Nase.”

[1144] Antony, _Bull. Soc. méd. des Hôp. de Paris_, 1903.

[1145] Folkes, _New York Med. Record_, 1907.

[1146] Grayson, _St. Louis Med. and Surg. Journ._, 1891.

[1147] Goldstein, _New York Med. Journ._, 1892.

[1148] Wolinz, _Wratsch_, 1884.

Greater operative measures than these do not appear to have been undertaken in latter days; yet Morgagni[1149] states that the army surgeon, Cæsar Mogatus, at Bologna, first trephined the frontal sinus and then extracted a “worm” from it.

[1149] Morgagni, _see_ Tiedemann.

Larvæ of other _Muscidæ_ have come under observation much more rarely (Cheval[1150] [larvæ of _Galleria mellonella_[1151]], Bond,[1152] Dumesnil[1153] [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 Bertrand[1155] (Scolopendra in sinus maxillaris) and that made by Bergmann[1156] (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.

[1150] Cheval, _Journ. de Méd. et de Chir._, 1893.

[1151] [This is the larva of a moth.--F. V. T.]

[1152] Bond, _Int. Zentralbl. f. Laryng._, 1896.

[1153] Dumesnil, _see_ Friedreich, “Die Krankh. d. Nase,” 1858.

[1154] Seifert, _see_ Heymann’s “Handb.”

[1155] Bertrand, _Soc. méd. de Bologne_, 1839.

[1156] Bergmann, _Korrespondenzbl. d. deutsch. Ges. f. Psych._, Neuwied, 1859.

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 Vesescu[1157] extracted seven living larvæ from the ear with the aid of a thin pair of pincettes. Köhler[1158] recommends the infusion of drops of ol. terebinth. to destroy the larvæ, Quintano[1159] the insufflation of the following powder: Oxid. hydrarg. rubr., sulfur., āā 1·0 grm., pulv. gi. arab. 8·0 grm.; Lesbini[1160] recommends tincture of iodine. In the case reported by Henneberg[1161] the larvæ were those of _Lucilia cæsar_.

[1157] Vesescu, _Riv. stiintelor med._, February, 1906.

[1158] Köhler, _Monatsschr. f. Ohrenheilk._, 1885.

[1159] Quintano, _see_ Seifert, _loc. cit._

[1160] Lesbini, _La Argent. Med._, 1905.

[1161] Henneberg, _Berl. med. Ges._, February 18, 1903.

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’s[1162] work. In the cases under the observation of Schultz-Zeyden[1163] both the eyes of a female tramp were destroyed, and quantities of larvæ were also found in the nasal fossæ and in the ears.

[1162] Kayser, _Klin. Monatsbl. f. Augenheilk._, 1905.

[1163] Schultz-Zeyden, _Berl. klin. Wochenschr._, 1906.

The Lucilia is found relatively seldom on the cutaneous surface. Henneberg’s[1164] 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; Westenhöffer[1165] 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 Munk[1166] 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’s[1168] 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’s[1170] case appears to have been one of myiasis cutanea provoked by Lucilia.

[1164] Henneberg, _Berl. med. Ges._, February 18, 1903.

[1165] Westenhöffer, _Verein f. innere Med._, Berlin, May 7, 1906.

[1166] Munk, _Wien. med. Presse_, xxi.

[1167] Vesescu, _loc. cit._

[1168] Roorda-Smit, _Deutsch. med. Wochenschr._, 1906.

[1169] Lesbini, _loc. cit._

[1170] Hector, _Lancet_, 1902.

The first exact observations of myiasis cutanea from _Sarcophaga magnifica_ are due to Wohlfahrt,[1171] in whose honour Portschinsky[1172] 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.

[1171] Wohlfahrt, “De vermibus per nares excretis,” Norimbergae, 1770.

[1172] Portschinsky, “Norae Soc. entomolog. Rossicae,” 1875.

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 Cloquet[1176] 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. Freund[1177] 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.

[1173] Joseph, _Deutsch. med. Zeitg._, 1885.

[1174] Gerstäcker, “Sitzungsberichte d. Ges. f. naturf. Freunde in Berlin,” 1875.

[1175] Löw, _Wien. med. Wochenschr._, 1883, xxxi.

[1176] Cloquet, _see_ Schultz-Zehden, _loc. cit._

[1177] Freund, _Ges. f. innere Med. in Wien_, December 5, 1901; and _Wien. med. Wochenschr._, 1910, li.

The small treatise by Balzer and Schimpff[1178] 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’s[1179] observation is interesting, for he found such larvæ in the gums of a sick person.

[1178] Balzer and Schimpff, _Annal. de Derm. et de Syph._, 1902.

[1179] Brandt, _Wratsch_, 1888.

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 Lelean[1180] found _Auchmeromyia depressa_ to be the cause of myiasis externa.[1181]

[1180] Lelean, _Brit. Med. Journ._, 1904.

[1181] [Numerous instances of attacks by Auchmeromyia are known and referred to under that genus, pp. 593–4. The species referred to here is not _depressa_, Walker.--F. V. T.]

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. Poilroux[1183] 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]

[1182] Goudot, _Annal. d. Sci. nat._, 1845.

[1183] Poilroux, _Journ de Méd., Chir._, etc., 1809.

[1184] [_Hypoderma linearis_ is frequently confused with _H. bovis_.--F. V. T.]

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 Löw[1186] 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 Razoux[1188] the species of larva is not definitely known--at least, v. Frantzius[1189] 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.

[1185] Kirschmann, _Wien. med. Wochenschr._, 1881.

[1186] Löw, _Wien. med. Wochenschr._, 1882.

[1187] Joseph, _Deutsch. med. Zeitg._, 1885.

[1188] Razoux, _Journ. de Méd., Chir._, etc., 1758.

[1189] v. Frantzius, _Virchow’s Archiv_, 1868, xliii.

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 ovipositors[1190] 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. Wilms[1191] 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.

[1190] [The Oestrides appear to lay their ova on the hair of animals. They do not puncture the skin.--F. V. T.]

[1191] Wilms, _Deutsch. med. Wochenschr._, 1897.

Adams[1192] 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.

[1192] Adams, _Journ. Amer. Med. Assoc._, 1904.

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.]

[1193] Ed. and Et. Sergent, _Annal. de l’Inst. Pasteur_, 1907.

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 (Strauch[1194]).

[1194] Strauch, _Journ. of Cut. Dis._, 1906.

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 Weichselbaum[1195]). 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.

[1195] Schlesinger and Weichselbaum, _Wien. klin. Wochenschr._, 1902, i.

[1196] Wirsing, _Zeitschr. f. klin. Med._, 1906, lx.

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 (Pottiez[1197]), 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 (Krause[1198]) are observed. In a few cases blood and pus have been noticed in the evacuation of the bowels.

[1197] Pottiez, _Bull. de l’Acad. royale de Méd. de Belgique_, xv.

[1198] Krause, _Deutsch. med. Wochenschr._, 1886, xvii.

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 (Pasquale[1199] 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’s[1200] 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.

[1199] Pasquale, _Centralbl. f. Bakt._, 1891.

[1200] Peiper, “Fliegenlarv. als gelegentl. Parasiten d. Menschen,” Berlin, 1900.

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. Salzmann[1202] 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. Salzmann[1202] reports a case where the maggots of _Anthomyia_[1203] _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.

[1201] Csokor, _Wien. klin. Wochenschr._, 1901, p. 129.

[1202] Salzmann, _Württemberg. med. Korrespondenzbl._ 1883, liii.

[1203] [This is presumably _Homalomyia_ (_Fannia_) _scalaris_.--F. V. T.]

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 vomitoria_[1205] are especially observed.

[1204] [This fly, common in houses, is known as _Homalomyia canicularis_, and the next belongs to the same genus.--F. V. T.]

[1205] [This fly belongs to the genus _Calliphora_, not _Musca_.--F. V. T.]

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] Staniek[1207]) 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.

[1206] Joseph, _Deutsch. med. Zeitg._, 1885 and 1887.

[1207] Staniek, _see_ Schlesinger and Weichselbaum, p. 47.

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 (Peiper[1208]), infus. of Persian insect powder (5 in 200), mineral waters, Carlsbad water, seem to have had good results.

[1208] Peiper, “Fliegenlarv. als gelegentl. Parasiten d. Menschen,” Berlin, 1900.

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. Lee[1209] 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 Duckworth[1210] 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. Crocker[1211] 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.

[1209] R. J. Lee, _Journ. Clin. Soc. Lond._, November 27, 1874.

[1210] Dickinson, Fox and Duckworth, _ibid._, 1875.

[1211] Crocker, “Diseases of the Skin,” 1893; “Atlas of the Diseases of the Skin.”

[1212] v. Neumann and Rille, _Wien. klin. Wochenschr._, 1895; _Dermatologenkongr._, Graz, 1895.

v. Samson-Himmelstjerna,[1213] Sokoloff,[1214] Rawnitzky[1215] 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_.

[1213] v. Samson-Himmelstjerna, _Wratsch_, 1895; _Arch. f. Derm. u. Syph._, 1897.

[1214] Sokoloff, _Wratsch_, 1896.

[1215] Rawnitzky, _Derm. Zeitschr._, v, p. 704.

[1216] Cholodowsky, _Wratsch_, 1896.

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, Stelwagon[1217] believes that the infection generally occurs in a seaside watering place; a patient of Ehrmann’s[1218] 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. Harlingen[1219]).

[1217] Stelwagon, _Journ. Cut. Dis._, xxii, 8.

[1218] Ehrmann, _Wien. derm. Ges._, November 17, 1897.

[1219] v. Harlingen, _Amer. Journ. of Med. Sci._, 1902.

Twice it has been suggested that perhaps the parasites might come from vineyard snails (Crocker, Lenglet and Delaunay[1220]), 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 (Kengsep[1221]) 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.

[1220] Lenglet and Delaunay, _Annal. de Derm. et de Syph._, 1904.

[1221] Kengsep, _Derm. Centralbl._, 1906, vii.

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] Rawnitzky[1227]). 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.

[1222] Hamburger, _Journ. of Cut. Dis._, 1904.

[1223] v. Harlingen, _loc. cit._

[1224] Bruno, v. Rille and Riecke, “Handb. d. Hautkrankh. v. Mraček.”

[1225] Ehrmann, _loc. cit._

[1226] Brodier and Fouquet, _Bull. de la Soc. franç. d. Derm._, 1904.

[1227] Rawnitzky, _loc. cit._

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, Boas[1232]), on the neck (Sokoloff), and on the body (Ehrmann, Brodier and Fouquet, Kaposi,[1233] Topsent[1234]).

[1228] Morris, _Brit. Journ. Derm._, 1896.

[1229] Schmid, _Verein der Aerzte in Steiermark_, February 12, 1900.

[1230] Shelmire, _Journ. Cut. Dis._, 1905.

[1231] Kumberg, _St. Petersb. med. Wochenschr._, 1898.

[1232] Boas, _Monatsh. f. prakt. Derm._, 1907, xliv.

[1233] Kaposi, _Wien. klin. Wochenschr._, 1898.

[1234] Topsent, _Arch. de Par._, 1901.

The duration of the affection varies very much; it varies between a few hours and some years[1235]; several times a spontaneous recovery has been reported.

[1235] [This is extremely unlikely, as the bots of Hypoderma only live for nine or ten months at the most!--F. V. T.]

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 Boas[1236]). 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 Riecke[1237]) of killing the worm with red hot needles is quite rational. Shelmire[1238] used the electrolytic needle for the destruction of the maggots, Stelwagon[1239] 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. Crocker[1240] and v. Harlingen[1241] injected small quantities of carbolic acid; Moorhead[1242] by a single freezing of the skin with ethyl chloride, attained a definite cessation of the attack at the active end. Hutchins[1243] 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 Delaunay[1244] did. v. Harlingen[1245] allayed the affection in his first case by rubbing in sapo viridis and tar, in Kensep’s[1246] case the cure seems to have been accomplished by an ointment containing resorcin, in Meade and Freeman’s[1247] 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.

[1236] Quortrup and Boas, _Hospitalstid._, 1907.

[1237] Rille and Riecke, “Handb. d. Hautkrankh.,” v. Mraček, 1907, iv.

[1238] Shelmire, _loc. cit._

[1239] Stelwagon, _loc. cit._

[1240] Crocker, _loc. cit._

[1241] v. Harlingen, _loc. cit._

[1242] Moorhead, _Texas Med. News_, 1906.

[1243] Hutchins, _Journ. Cut. Dis._, 1906.

[1244] Lenglet and Delaunay, _loc. cit._

[1245] v. Harlingen, _loc. cit._

[1246] Kensep, _loc. cit._

[1247] Meade and Freeman, _Brit. Journ. Derm._, October, 1906.