The stools were black and tarry from the first, evidently from old blood clots. The early appearance of tarry stools indicates that hemorrhage had occurred in the alimentary tract before birth. No evidence of hemorrhage elsewhere was noted.

The temperature was subnormal, but the pulse was very weak, and the collapse severe. The abdomen was rather rigid, but no especially tender point was found.

A diagnosis of ulcer of the stomach was made. The treatment was: Bicarbonate of soda in half grain doses every hour, with bismuth. Soda was also given in the drinking water and lime water in the milk. This treatment was instituted within a few hours after birth of the child. Doses of 1/10 minim of the onethousandth solution of adrenalin chloride were given every 15 minutes upon the occurrence of bleeding. There was no hemorrhage after the sixth day, and the baby has followed an entirely normal course since and at present is plump and well and in every respect a normal and healthy baby.

We have abundant support from the pathological side, for such a diagnosis, since many cases have been reported of ulcer found in babies less than a week old or even in those still-born. We know of no other condition which could produce the clinical picture here given, with recovery in such a manner.

Hematemesis could scarcely occur in a baby from cancer, hepatic cirrhosis, varices in the esophagus, aneurism, or the other causes occasionally noted in the adult. It appears to us that the case should not be classed as one of morbus maculosus neonatorum, since the bleeding was confined to the stomach to the best of our knowledge, and was accompanied by the marked gastric irritability, and hyperacidity so well known in connection with ulcer. In Townsend's cases the temperature was often elevated, while in this case it was depressed. "The general and not local nature of the affection, its self-limited character, the presence of fever, and the greater prevalence of the disease in hospitals, suggests an infectious origin" (for morbus maculous neonatorum) (Townsend). Says Dreschfeld: "The temperature (in ulcer) is normal, or even subnormal if the nutrition suffers much." The absence of jaundice and the recovery would also favor the probability of our proposed diagnosis, for but 19 out of 50 of Townsend's cases recovered.

Kundrat states that small ulcers are quite frequently found in children even only a few days old, but states that he has never known chronic ulcer to develop from these little ulcerations, probably because acid catarrh is rare in children. Henoch speaks of the occurrence of ulcer in the new-born, while Widerhofer denies its presence in childhood.

Dreschfeld states that "Before the age of puberty gastric ulcer is of very rare occurrence; yet it has been observed in infants, and occasionally soon after birth. The melena of the newly-born, though often due to erosions and small multiple ulcerations, has in some cases been found to be due to simple ulcers of the stomach with regular well-defined borders, varying in diameter from one to three centimeters, and situated in the stomach or duodenum. In other cases of melena neonatorum no lesion has been found in either the stomach or intestines."

Some of the American authors agree with the former authorities. The positive evidence is of much more value than the negative, here as elsewhere. The absence of history of pain and tenderness in so young a child, bearing in mind the difficulty of eliciting exact symptoms in a baby already nearly collapsed with frequent vomiting and loss of blood, could count but little in view of the presence of the severe vomiting, the hematemesis, and the corrosive action of the regurgitated fluids.

The prognosis seems to be better in children than in adults. Correction of the hyperacidity is looked upon as of great importance by most writers. We know of nothing promising better results than the adrenalin so far as the danger from hemorrhage is concerned. In cases of perforation attempt at operation might be justifiable, although the mortality would probably be excessive at this age.

INFECTION WITH FLY LARVAE.*

WM. C. MITCHELL, M.D.

When the female fly deposits its eggs in living tissue and the eggs develop into larvae, the diseased condition is known as myasis.

A study of the literature of this somewhat obscure subject shows that the condition is by no means so rare as one might sup

*Read before the Denver Academy of Medicine, April, 1905.

pose. The eggs may be deposited on the mucous membrane of the eye, on the mucous membrane of the ear, on the mucous membrane of the nose, or in open wounds, myiasis conjunctivae, myiasis aurium, myiasis narium and myiasis vulnerum.

It is a matter of common observation on the farm or on sheep ranches that at times wounds on cattle, horses or sheep may become the breeding places of maggots, so that the wound may teem with these pests. Such observations are also frequently met with by surgeons in open or exposed wounds.

In studying the natural history of the family Muscidiae, which embraces both the house flies and the blow flies, it develops that the mature house fly deposits her eggs chiefly in excrement, that of the horse being preferred, and after about 24 hours the eggs develop into larvae. The insects remain in this, the larval state, for about six or seven days. They then go into the pupal state and after from three to four days emerge as young flies. The blue bottle or blow fly prefers dead animal matter as a depository for its eggs, although in emergency it deposits them elsewhere, many cases being on record of the deposition of these eggs and their subsequent development on living animals. Lydekker in his chapter on diptera mentions that toads seem to be a particular object of attack by blow flies. In one instance nearly a whole colony of toads were exterminated by the larvae of these flies which chiefly infected the nostrils. As testifying to the most extraordinary vitality of these larvae may be mentioned the case of a lizard that dined on gravid blow flies. The eggs of these flies hatched out in the stomach of the lizard and promptly attacking the internal organs, killed the lizard. Other instances are also on record of the digestive tract of these animals being destroyed by fly larvae taken in as food.

A very different life-history is given by the bot flies of horses, of cattle and of sheep which form an entirely different family, the oestridiae. The larvae of these flies are forced from the very first to lead a parasitic existence in the bodies of their respective hosts. The horse fly deposits its eggs on the hide of the horse and when these eggs develop into larvae they irritate the skin. The horse licks the irritated part and swallows the maggots which promptly fasten to its mucous membrane. Here they live for about a year, when they pass out with the excrement, burrow into the ground

and go into the pupal state. They remain as pupae for about six weeks and emerge as flies. The cattle flies lay their eggs on the hide of cattle, and the maggots as they develop burrow beneath the skin and form tumors with an opening externally. The larvae remain here for about eleven months and then, falling to the ground, go into the pupal state to emerge as flies after about one month. Sheep flies lay their eggs in the nostrils of sheep and the larvae migrating into the frontal sinuses remain here for about nine months, after which they drop to the ground and go into the pupal state, later to emerge as flies.

About August, 1900, Dr. E. P. IIershey brought me the larvae of a fly which he had taken from a boil on a child's neck. Child was one year old and had several boils on the right arm and neck. From this crop of boils Dr. Hershey obtained six maggots, four dead and two alive. Only one maggot was found in each boil. The child lived within half a block of the park at Twenty-eighth avenue and Gilpin street, where it was frequently taken for an airing. The child wore short sleeves and low-neck dresses. At my suggestion, as Dr. Hershey had met with failure in attempting to cultivate the larvae of another case to be described later, an attempt was made to cultivate this maggot by placing it in wet horse manure. When the larva was placed in this mixture, it moved in and out and was very lively like it had found a long-lost home. I can give no accurate description of this larva any more than to say that it presented the general appearance of fly maggots with which all are familiar. We had great hopes of raising a fly from this particular larva for the purpose of studying it, beliving that it would be much easier for inexperienced entymologists like ourselves to classify a fly than a larva. The janitor of the building, however, saved us all further trouble, as he threw the entire mass away after the larva had been developed nicely for two days.

Dr. Hershey informed me that ten years prior to the present case, he attended a child in the same neighborhood, afflicted with boils on the neck and back of the head, and that eight living maggots in all were taken from these boils. He attempted to cultivate the biggest of these on a piece of meat but the experiment was a failure. In February, 1905, Dr. Thos. H. Hawkins brought me the larva of some insect taken from a patient ten years old, with the

following history: Patient lives at Lamar, Colo., and was referred to Dr. Hawkins by Dr. Fewkes. The boy would complain of intense rheumatic pains, and a greenish-black spot varying in size from a nickel to a dollar would appear. Spots were seen on the legs, the arm, the thigh and the back. From three of these a living worm was extruded. One of these was sent to Dr. Hawkins preserved in alcohol, and this specimen, which I now present to you, was turned over to me. Following up to the greenish area from which this worm was extruded was a line about eight inches long extending in a tortuous path from one scapula to the other. This line was greenish black at first and gradually faded to a white line about oneeighth of an inch thick. With the extrusion of the worm in every case, the pain ceased and no further trouble was experienced. The boy lives on a farm and works around the horses, pigs, etc. There are no sheep on the place. No history of having been stung by any insect could be obtained.

The remarkable features about all three of these infections is first, their occurrence in this temperate climate, and, secondly, in the eggs of these flies being deposited in what was apparently the healthy unbroken skin and their developing to larvae. For it is by no means uncommon to have a development of maggots in an open wound or sore to which flies may have access to lay their eggs. Such boil-like infections as Dr. Hershey's two cases are apparently of frequent occurrence in tropical countries, due either to the blow of blue bottle fly, the dermatobia, the cayor fly or some similar species. Dr. Hawkins' case is a remarkable one, in view of the extraordinary length which the larva traveled under the skin, the distance as estimated by Dr. Hawkins being eight inches in route from one scalpula to the other.

As to the identification of the larvae of these two cases, in my opinion, they were the larvae of the blow flies.

This opinion may be entirely wrong. It is founded on what knowledge I could glean from a study of all the literature at my disposal in the city. Consultation with several local entomologists showed that they were as much in doubt as I was about the matter. I believe that the only other larva with which they could be confounded is the larvae of the sheep flies, and these larvae do not resemble the two specimens which were sent to me.