Chapter XXXVI: Introduction (5)

The only one of the leeches that comes under consideration from the clinical point of view is _Limnatis nilotica_ (_Hæmopsis sanguisuga_), which obtains access to the mouth with drinking water, and becomes lodged, even in the case of man, in the pharynx, larynx, trachea, œsophagus and nose.

Amongst the causes of severe hæmorrhage from the pharynx Jurasz[982] mentions the occurrence of leeches in that region: in Northern Europe this must be accounted one of the greatest of rarities, whilst at all times in southern countries, such as South Italy, Spain, Greece, Algiers, Tunis and Egypt, it appears to have been more frequent. Even the physicians of antiquity had much to say about it. Upon the occurrence of blood-stained expectoration, Hippocrates recommends the oral cavity to be examined to see whether a leech is not present in it. Galen speaks of hæmatemesis due to the presence of leeches in the pharynx and stomach. Similar mention is found in the writings of Celsus, Asclepiades, Scribonius Largus, Dioscorides, Aëtius, Oribasius, Paulus Aegineta and others. In recent times, Cortial[983] has published observations relating to this subject which he had the opportunity of making in Constantine. Palazzolo[984] also in Sicily found leeches in two cases in the pharynx, in one case on the posterior wall, in the other in the crypt over the left tonsil. According to Roset,[985] leeches adhere by preference behind the uvula, simulating hæmatemesis and hæmoptysis, and the persistent hæmorrhages they give rise to may lead to severe anæmia. Leeches are found in still greater frequency in the larynx than in the pharyngeal cavity. Huber[986] records several observations of this kind in his historical and therapeutical study. In the case of a man, aged 64, Ramon de la Sota y Lastra[987] observed a leech on the nodulus epiglottidis; this was removed with the forceps. In the case recorded by Photiades,[988] a leech had remained adherent to the vocal cord for more than twenty-two days. Maissurianz[989] records two such cases: in one the leech had remained in the sinus morgagni for three weeks, in the other in the same place for ten days. The case recorded by Schmolitschew[990] is an interesting one; it was that of a woman who for four days had suffered from violent hæmoptysis, the cause of which was a leech that was fixed on the laryngeal wall of the epiglottis close above the vocal cords. In his case (that of a soldier), Godet[991] was forced to perform thyrotomy to remove the leech from the larynx. Ficano[992] removed a live leech with the forceps from the lower laryngeal cavity in a man, aged 30. Massei[993] reports a similar case. The case reported by Winternitz and Karbinski[994] was that of a peasant girl, aged 16, who suffered from coughing, hoarseness, and blood-stained expectoration; a leech had lodged on the root of the epiglottis. Aubert[995] removed a leech from the larynx of a woman after the performance of tracheotomy. Seifert[996] reports three cases: in the first the leech had become fixed to the left vocal cord, in the second it was found in the lower laryngeal cavity, and in the third on the border of the left ligamentum aryepiglotticum. Leone[997] has published the case of a leech in the larynx, Martin[998] two cases with the leech lodged in the lower laryngeal cavity, Berthoud[999] a similar case, Palazzolo[1000] two such cases, Panzat[1001] one case (lower laryngeal cavity). Moucharinski[1002] reports a case in which the leech had stayed more than twenty days in the larynx. Martin[1003] easily removed a leech from the posterior portion of the vocal cord with the forceps. Vieus and Nepeon[1004] record a case of a leech in the larynx. It is quite exceptional for leeches to gain access to the trachea; cases of this kind have been recorded by Aubert,[1005] Vicano,[1006] Ridola[1007] and Tapin[1008] (the leech was firmly fixed to the bifurcation and caused coughing, hæmoptysis and attacks of asphyxia; it was easily removed by the aid of a tracheal tube). Now and then leeches are found in the nose.

[982] Jurasz, Heymann’s “Handb. d. Laryng. u. Rhinol.,” 1899, ii.

[983] Cortial, _Union méd._, 1886.

[984] Palazzolo, _Bull. del. mal. dell’ orecchio, etc._, 1895.

[985] Roset, _Rev. d. Cienc. méd. de Barcelona_, 1907, ii.

[986] Huber, _Deutsch: Arch. f. klin. Med._, xlvii.

[987] Ramon de la Sota y Lastra, _Rev. méd. de Sevilla_, 1883.

[988] Photiades, _Int. Zentralbl. f. Laryng._, 1884.

[989] Maissurianz, _St. Petersb. med. Wochenschr._, 1883.

[990] Schmolitschew, _Wratsch_, 1884.

[991] Godet, _Arch. de Méd. et Pharm. milit._, 1887.

[992] Ficano, _Rev. de Laryng._, 1890.

[993] Massei, _Int. Journ. of Laryng._, 1890.

[994] Winternitz and Karbinski, _Prag. med. Wochenschr._, 1890.

[995] Aubert, _Echo méd._, 1891.

[996] Seifert, _Rev. de Laryng._, 1893.

[997] Leone, _Boll. del. mal. dell’ orecchio, etc._, 1892.

[998] Martin, _Arch. de Méd. et Pharm. milit._, 1891.

[999] Berthoud, _ibid._, 1893.

[1000] Palazzolo, _Boll. del. mal. dell’ orecchio_, 1895.

[1001] Panzat, _Arch. de Méd. et Pharm. milit._, 1896.

[1002] Moucharinski, _Wratsch_, 1896.

[1003] Martin, _Rev. barcelon de enf. de oido_, 1906.

[1004] Vieus and Nepeon, _Monatsschr. f. Ohrenheilk._, 1884.

[1005] Aubert, _Echo méd._, October 12, 1891.

[1006] Vicano, _Boll. del. mal. dell’ orecchio, etc._, 1892, ix.

[1007] Ridola, _Arch. ital. di Laryng._, 1894, ii.

[1008] Tapin, _Siglo med._, March 16, 1907.

Lusitanus[1009] relates the case of a man who suffered from severe headaches. A medical man ordered the application of a leech to the anterior portion of the nostril. Owing to the carelessness of the surgeon the leech crawled right into the nose; it was impossible to extract the leech or to kill it, and it produced a severe hæmorrhage which led to the death of the patient within two days. In a case recorded by Sinclair,[1010] a leech, _Hæmopsis sanguisuga_, gained access to the nose of a boy, aged 3; it remained there a fortnight; it caused frequent attacks of epistaxis and in the end it was removed by means of forceps. Condorelli-Francaviglia[1011] records a case in which severe epistaxis was caused by a leech which had probably entered the anterior portion of the left nostril by way of the pharynx and become tightly fixed there. It was seen by posterior rhinoscopy, and was removed from in front by means of slightly curved forceps. Sota y Lastra[1012] mentions the occurrence of leeches in the nose, and Keng[1013] reports the case of nasal obstruction from a leech. The removal of leeches is effected by means of injections or by the direct sprinkling of salt or acid solutions on their bodies, which brings about their detachment. When possible a previous attempt should be made to seize them with forceps so as to make their immediate extraction possible. The species of Hæmadipsa (Looss[1014]) live in tropical regions in moist places on the ground or in the jungle. They climb bushes and even trees with astonishing rapidity upon the approach of larger animals and also of man (whom they clearly recognize from the vibration of the ground caused by footsteps). From thence they let themselves fall on their victims to suck their blood. Their bites are generally painless, and of themselves not dangerous, but if they are unusually numerous they rapidly accumulate on the body in large numbers and give rise to marked debility and, if the wound become infected, to severe complications and even death. On the other hand, under careful treatment the wounds heal easily and fairly rapidly.

[1009] Lusitanus, _see_ Seifert in Heymann’s “Handb.,” p. 599.

[1010] Sinclair, _Brit. Med. Journ._, June 20, 1885, i.

[1011] Condorelli-Francaviglia, Spallangini, 1892.

[1012] Sota y Lastra, _Rév. méd. de Sevilla_, 1887.

[1013] Keng, _Scot. Med. and Surg. Journ._, October, 1899.

[1014] Looss, “Handb. d. Tropenkrankh.,” v. Mense, i, p. 194.

Firm leather and firmly adhering clothes afford no certain protection against the attacks of these leeches, as they know how to force themselves with extraordinary rapidity through the narrowest interstices between the clothes and thus gain access to the skin. When they have sucked their fill--and this may take several hours to accomplish--they fall off of themselves. To effect an earlier removal drops of irritative or corrosive fluids are employed (salt solutions, acids, etc.). Tearing away the leech by force should be avoided, as in this way portions of the leech’s body may be left behind in the wound and inflammation be set up.

ARTHROPODA.

*Leptus autumnalis* (Grass, Harvest, or Gooseberry Mite[1015]).

In the hot season of the year, that is, during the months of July and August, it is noticed that those people who stray amongst syringa bushes or who pick gooseberries or kidney beans are attacked by the _Leptus autumnalis_. On the uncovered parts of the body there appear numerous red spots and papules, which itch and burn smartly. The itching does not commence diffusely, as in the case of scabies (MacLennars[1016]), but is limited to the particular points where the parasite is situated. There are especial outbreaks of itching in the morning, arising perhaps from the hatching of ova in the host after lying in the warmth of the bed.[1017] Leptus frequently provokes general erythema, eczematization or severe feverish urticaria, which in France is known by the name of fièvre de grain (Mégnieu, Besnier[1018]). If the individual efflorescences be carefully examined, there will be noticed almost without exception a minute boss towards the centre, noticeable by its yellowish-red colour. If an attempt is made to remove it with the point of a needle or to scrape it off the surface, one can often perceive, even with the naked eye, a small reddish creature moving actively about. The treatment of these very troublesome symptoms consists in warm baths with soapy lavages, also lavages with alcohol, spirit salmiac (G. P.), 5 per cent. carbol or creolin solution, diluted vinegar, benzine, emulsions of balsam of Peru, rubbing in sulphur ointment (Sandwith[1019]); ointments of creosote or eucalyptus are recommended. Other grass and grain mites also occasionally penetrate the skin of man and produce transitory but sometimes very severe eruptions, urticaria and eczema papulosum, as Geber[1020] and subsequent to him Josai[1021] have reported of the barley mite. In sensitive individuals the skin becomes bright red, to a greater or less extent their temperature is raised and frequently slight febrile affections are present. If the inflammatory skin symptoms have reached their culminating point after three or four days and no fresh complications arise, they only remain for a short while, the effects of scratching and pigment spots being left.

[1015] There is no reason for calling this the gooseberry mite. It is rarely found on this fruit. The gooseberry mite is _Bryolia pretiosa_.

[1016] MacLennars, _Lancet_, 1905.

[1017] [This cannot be the case, as _Leptus autumnalis_ is the larval form of _Trombidium holosericeum_.--F. V. T.]

[1018] Sack, “Handb. d. Hautkrankh.,” v. Mraček, 1907.

[1019] Sandwith, _Lancet_, 1905.

[1020] Geber, “Handbuch d. Hautkrankh.,” in v. Ziemssen’s “Handbuch d. spez. Pathol. u. Therap.,” 1884, xiv.

[1021] Josai.

*Kedani, Akaneesch* (The Japanese River or Inundation Disease).

This disease is only known in Japan, and is limited to the neighbourhood of some great rivers on the west coast. The people mostly attacked are those who cut the hemp harvest in the infected localities, occasionally those who transport it or come into contact with it (Looss[1022]). The disease is frequently manifested in the form of indefinite disturbances of the general condition; it commences generally on the sixth day after the presumed infection with rigors, headaches, feeling of weakness, swelling of the lymphatic glands in the loin or in the arm-pits; in the periphery a black dry scab is formed. In addition there is an intense conjunctivitis, and added to symptoms of fever an exanthema resembling measles that lasts from four to seven days. There is frequent delirium and difficulty of hearing which persist for a long while. Obstinate constipation is a striking symptom. At the end of a fortnight, earlier in slighter cases, the fever commences to abate and a rapid convalescence sets in. In pregnant women abortion with fatal issue is frequent. With regard to prophylaxis, Baelz[1023] recommends as rapid a cultivation of the soil as possible, which has led to a speedy disappearance of the disease in districts where it was once dreaded. Treatment is symptomatic. Japanese do not tolerate antipyretic drugs as well as Europeans.

[1022] Looss, “Handbuch d. Tropenkrankh.,” v. Mense, p. 195.

[1023] Baelz, _Virchow’s Archiv_, lxxviii.

Dermanyssus gallinæ (avium).

During the day the resort of bird mites is in the droppings and in the woodwork, etc., of cages in which canaries, crossbills and parrots are kept; in the crevices of doors, in the chinks between the board planks of bedsteads, so that at night they may seek some domestic animal to suck the blood and so satisfy their hunger. It is by no means rare for young animals, chickens and unfledged pigeons, etc., to perish in consequence of the great loss of blood. This nocturnal habit of life explains why no mites can be found during the day in spite of the most careful examination of the human body, to which they may be transmitted. On the uncovered parts of the body they not only cause severe irritation, but also severe diffuse itching erythema and eczema. Thorough disinfection of the cages by hot solution of caustic potash, in addition, sprinkling over with tar, red carbolic acid or petroleum, thoroughly powdering over the birds with flores pyrethræ, washing with water containing oleum anisi, washing the walls, doors and bedsteads with soap, disinfection of the mattresses, linen and clothes, will protect against further infection. In the case of man the disease needs no special treatment, as the eruptions generally disappear after some days. Heinecke[1024] recommends lavages with 1 per cent. carbolic acid solution. [_Vide_ also p. 492 in body of this work.--F. V. T.]

[1024] Heinecke, _Münch. med. Wochenschr._, 1901.

[_Dermanyssus hirundinis_, Hermann, is identical with this species. By far the best treatment is with paraffin or kerosene oil applied to the places where they pass the day.--F. V. T.]

Ixodes reduvius (ricinus).

The female is occasionally transmitted to the human skin, and bores its proboscis deep into it and sucks itself full of blood. At sensitive points of the cutaneous surface--for example over the skin of the penis--a feeling of severe pain is produced. Buy’s[1025] observations as to the geographical distribution of the _Ixodinæ_ show that in all lands in which cattle, horses, sheep and dogs exist, _Ixodinæ_ are to be found. Recent observations show that the _Ixodinæ_ play an important part in the transmission of Hæmosporidia (_vide_ body of work, pp. 493, 494). Sprinkling with oil, vaseline, benzine, ether, petroleum, naphtha, turpentine (Jelgenum[1026]), will easily lead to the removal of the parasite; if the body is torn away with violence and the proboscis is left sticking in the skin, the presence of the latter will give rise to inflammation and suppuration.

[1025] Buy, “Histoire naturelle et médicale des Ixodes,” “Thèse de Lyon,” 1906.

[1026] Jelgenum, _Med. Weekblad v. Noord- en Zuid-Nederland_, 1901, i, No. 24.

*Sarcoptes scabiei* (Scabies).

The disease produced by _Sarcoptes scabiei_ shows itself in polymorphous areas, such as accompany eczema, and are produced on the one hand by the Sarcoptes alone and on the other hand by the scratching with the nails. The localization of both kinds of efflorescences is different from those which are produced by the Sarcoptes; they occur as papules, vesicles, pustules and mite-tracks, and their usual situation is between the fingers, on the ulnar border of the hand, on the wrist, on the palm of the hand, on the anterior border of the axilla, on the penis and at the base of the thorax. The excoriations are situated on the forearm, over the thigh, over the abdomen, and may be distributed in greater or less degree over the whole body; the back and the face only remain free. The symptoms consist in violent itching, the onset of which specially takes place at night.

The mite-tracks are fine curving lines, curved like *a*, *u*, *c*, or *s*, which appear as if they had been scratched with a fine needle. Upon closer examination with the magnifying glass one sees in their course small openings. These openings, in persons who keep themselves clean, are scarcely coloured; but in patients whose occupations necessitate their being associated with coloured or dirty substances, they are dark. The length of the tracks varies from some millimetres to 1-1/2 to 2 cm. They are at the one end, where the Sarcoptes is embedded in the epidermis, widened like a funnel and slightly exfoliated. The track at this point is sharply defined; the mite shows through the epidermis as a yellowish round point. In the course of the track there develop papulæ, vesicles or pustules, which raise the level of the track. The intensity of these inflammatory appearances depends upon the susceptibility of the human individual and upon the capability of the reaction of the skin. There are people in whom scarcely any inflammatory symptoms make their appearance; on the other hand there are some, especially children and lymphatic individuals, in whom severe impetiginous ecthymatous pustules, together with their sequelæ, are set up.

The results produced by scratching consist in papules, which usually bear a small scab of blood, and are arranged in the form of striæ, in eczematous surfaces, weeping or sanguineous scabs, vesicles, pustules, etc. The complications that set in are frequently urticaria and even furuncles, lymphangitis and inflammation of the glands, which now and then is followed by the formation of abscesses in the glands.

The duration of the disease is unlimited; when untreated it leads to a form of rare occurrence, that of scabies norvegica[1027]; in this the collection of crusts and scales, in which a quantity of dead mites, larvæ and ova are present, may become colossal.

[1027] [This is produced by a distinct species, _vide_ pp. 519–20.--F. V. T.]

The symptoms of scabies abate in the presence of intercurrent acute diseases and reappear after the malady is over. The fact has for long contributed to the idea of scabies being regarded as a disease capable of being “driven in” upon the internal organs and forming metastases.

The diagnosis is rendered certain upon the discovery of a track. Traces of scratching on the extremities and on the abdomen, papular or pustular efflorescences between the fingers, toes, in the neighbourhood of the wrist, of the elbow, on the anterior border of the arm-pit, on the tuber ischii, in the girdle region, and especially the presence of disintegrated tracts over the penis (prepuce and glans), will allow of the diagnosis being made. Certain occupational eczemas (grocers, lime-workers, maltsters, bakers and others), also prurigo, must be borne in mind when diagnosing this disease.

The prognosis is always a favourable one. Even after such a long duration and after such severe symptoms the disease may completely clear up. There are, however, frequently left behind post-scabious inflammatous and pruriginous conditions which only yield after protracted treatment. Scabiophilia, which persists in certain patients for a long time after the scabies has been cured, must here be mentioned.

In the treatment of scabies four points must be kept in view. (1) The mites and the ova must be killed by the treatment; (2) the treatment must have regard to the intensity of the inflammatory symptoms; (3) the clothes (body-linen) of the patients must be disinfected; the bed-linen, the beds and the bedsteads must be cleansed; (4) when a person suffers from scabies his entourage must be examined, and all diseased conditions treated in the same way as under (3).

The treatment (1) should be preceded by a bath with thorough soap ablution, and when the inflammatory symptoms are not too severe, with green soap. After the bath the skin is dried and the scabies remedy proper applied in warmth. Sulphur preparations receive first consideration; among such Vlemingkz’s mixture occupies a prominent position; this is rubbed in for half an hour by means of a strong camel-hair brush, to be followed by another bath and powder applications after drying. Repeat this method for three days one after the other, or for two days, and a third time eight days later. The latter method is worthy of recommendation as the ova, which perhaps resist the parasiticide action, have by this time developed into larvæ, and the latter can then be destroyed with certainty. The remaining sulphur preparations, which are specially employed in the form of ointments, are more complex, as the ointment should remain on the skin. Helmerisch’s and Wilkinson’s ointments are the kinds specially employed. Nagelschmidt[1028] recommends thiopinol as a very suitable sulphur preparation in the form of baths or as a 10 or 5 per cent. ointment in the following way: Upon his reception the patient is given a thiopinol bath, in which he remains for thirty minutes. Immediately afterwards 30 to 40 grm. 10 per cent. thiopinol vaseline is carefully rubbed in. The rubbing is repeated daily, and the treatment is concluded on the second to fourth day with a second thiopinol bath. Thiopinol produces no more irritation than the ordinary sulphur ointments; it is, however, much more penetrative and more capable of absorption.

[1028] Nagelschmidt, _Med. Klin._, 1907, xxxv.

We frequently make use of Kaposi’s naphthol ointment, as it renders the skin supple, causes proportionately little irritation, and has but little smell. Treatment with balsam of Peru is certainly expensive, but in the slighter attacks it is relatively the simplest. We give the patient a bath, have him thoroughly dried and rub in 30 to 40 to 50 grm. balsam of Peru carefully and evenly all over, wrap him in a covering of wool, and make him rest in bed for twelve to fifteen hours, to be followed by a bath with careful cleansing with soap; this treatment need rarely be repeated. The balsam of Peru can be applied undiluted for the rubbings or mixed with ung. glycerini, or resorbin or glycerine in equal parts. [Norman Walker uses balsam of Peru 1/2 oz. dissolved in rectified spirit; to be painted on with a brush.]--J. P. S. The manufacturers name the undiluted product of the active constituent of balsam of Peru, benzoic acid benzyl-ester, Peruscabin. For the treatment of scabies it is recommended by Sachs[1029] that it should only be administered when mixed with ricinus oil, under the name of Peru oil, in applications repeated three times within thirty-six hours.

[1029] Sachs, _Deutsch. med. Wochenschr._, 1900.

Sack[1030] also considers Peru oil a non-irritant, effectual, pleasant, inodorous and non-staining drug. But he only allows the applications to be used every twelve hours for three to four consecutive days (altogether 200 to 300 grm. of Peru oil are requisite), and after the sixth or seventh rubbing a bath should be taken with the use of Dutch soap. Juliusberg[1031] considers this treatment specially suited for private practice. Another modern drug is epicarin ([Beta]-oxy-naphthyl-ortho-oxy-meta-tolyol acid); this is applied in 10 to 20 per cent. ointments (Pfeiffenberger[1032]), epicarin 7·0 grm., cretæ alb. 2·0 grm., vasel. flavi 30·0 grm., lanolin 15·0 grm., axungia poric. 45·0 grm. (Rille[1033]); epicarin 15·0 grm., sapon. virid. 5·0 grm., axung. poric. 100·0 grm., cretæ alb. 10·0 grm. (Kraus[1034]); for children, epicarin 5·0 grm., lanolin 90·0 grm., ol. olivar. 10·0 grm. (Kaposi[1035]). Siebert[1036] lays stress upon the odourlessness and colourlessness of epicarin ointment as a strong reason for its use, and points out that it is a harmless drug, the action of which is certain. Endermol (salicylic acid ointment) has a destructive action on the mites even in a 0·1 per cent. ointment (Wolters,[1037] Demitsch[1038]); it is, however, very expensive and not wholly free from danger; and the same applies to nicotiana soap (Taenzer,[1039] Schumann[1040]).

[1030] Sack, “Handb. d. Hautkrankh.,” v. Mraček.

[1031] Juliusberg, _Therap. Monatsh._, 1901.

[1032] Pfeiffenberger, _Klin. therap. Wochenschr._, 1900.

[1033] Rille, “Die Heilkunde,” 1900.

[1034] Kraus, _Allg. wien. med. Zeit._, 1900.

[1035] Kaposi, _Wien. med. Wochenschr._, 1900.

[1036] Siebert, _Münch. med. Wochenschr._, 1900.

[1037] Wolters, _Therap. Monatsh._, 1898.

[1038] Demitsch, _Wratsch_, 1905, iv.

[1039] Taenzer, _Monatsh. f. prakt. Derm._, xxi.

[1040] Schumann, _Allg. med. Central-Zeitg._, 1901.

To give an account in detail of the drugs and methods--old and new--used in the treatment of scabies would far outrun the limits of this work.

Demodex folliculorum.

It is not yet certain whether the _Demodex folliculorum_ is capable of developing pathological conditions in man. Veiel[1041] assumes that the hair follicle mite has no connection either with the formation of comedones or even with sebaceous gland disease. Kaposi[1042] considers that they cause no disease in man and cannot be regarded as a cause of acne. Saalfeld[1043] clearly adheres to the same standpoint, similarly so Jessner,[1044] who, when discussing comedones, makes no mention of acne of hair follicle mites. Weyl[1045] and Geber[1046] adhere to the opinion that the presence of a Demodex in man in contradistinction to its presence in animals possesses absolutely no pathogenic influence. On the other hand de Amicis,[1047] Majochi,[1048] and Dubreuilh[1049] report single cases of pronounced circumscribed clear brown pigmentations which they attribute to _Demodex folliculorum_. In all these cases, moreover, as regards localization the affection had a certain resemblance to pityriasis versicolor; nevertheless, in the scales separated off with the scalpel no fungi were found, but on the other hand Demodices in moderate quantity. In his earlier cases Majochi has seen the Demodex in the secretion from meibomian glands and had claimed it to be the excitant of chalazion and, as Mibelli[1050] did, considered it to be the cause of some diseases of the eyelids. Ivers[1051] found the parasite in 69 per cent. of normal borders of the eyelids, and attributes a pathological signification to it. Hünsche[1052] and Mulder[1053] arrive at the same conclusions; in the light of their investigations the Demodex is found as a constant accessory--certainly not in the meibomian glands, as it is limited only to the internal part of the hair follicle. Lewandowsky[1054] considers that it can hardly be demonstrated at present that the same parasite which in individual specimens causes no symptoms is capable of producing pathological conditions when markedly increased in numbers.

[1041] Veiel, v. Ziemssen’s “Handb. d. spez. Path. u. Therap.,” 1884, xiv.

[1042] Kaposi, “Path. u. Therap. d. Hautkrankh.,” 1899.

[1043] Saalfeld, Lesser’s “Encyclop. d. Haut- u. Geschlechtskrankh.,” 1900.

[1044] Jessner, “Kompend. d. Hautkrankh.,” 1906, 3rd ed.

[1045] Weyl and Geber, v. Ziemssen’s “Handb. d. spez. Path. u. Therap.,” 1884, xiv.

[1046] Weyl and Geber, v. Ziemssen’s “Handb. d. spez. Path. u. Therap.,” 1884, xiv.

[1047] de Amicis, quoted by Lewandowsky.

[1048] Majochi, _Centralbl. f. Bakt._, xxv.

[1049] Dubreuilh, _La Prat. Derm._, Paris, 1901.

[1050] Mibelli, quoted by Lewandowsky.

[1051] Ivers, _ibid._

[1052] Hünsche, _Münch. med. Wochenschr._, 1900, xlv.

[1053] Mulder, _Weekbl. v. het Nederl. Tijdschr. v. Geneesk._, 1889.

[1054] Lewandowsky, _Deutsch. med. Wochenschr._, 1907, xx.

Treatment is by the removal of the comedones, above all, by their mechanical removal by pressure with a watch-key and with the various comedo-compressors, and by subsequent cleansing of the skin with ether, benzine or spirit. If the eyelids should be affected with blepharitis due to the presence of Demodex in large numbers, epilation and administration of a parasiticide is recommended.

Demodex folliculorum canis.

Transmission from dog to man is in any case very rare, and by many its occurrence is generally doubted. Nevertheless Gruby[1055] and Remak[1056] claim that it is transmissible--an opinion which has also been shared by Neumann[1057] and Zürn.[1058] The latter saw in the case of a married couple who had the care of mangy dogs the onset of diseased areas on their hands and feet, which were like those on the dogs and contained the same parasites.

[1055] Gruby, quoted by Lewandowsky.

[1056] Remak, _ibid._

[1057] Neumann, _ibid._

[1058] Zürn, _ibid._

A. Babes[1059] also reports several observations which go to show that persons who, to some extent, have been shown to have been in contact with mange-stricken dogs have been attacked by a scabies-like eruption localized over the thorax, abdomen, back and extremities; large numbers of Demodices were found in the follicular pustules. Lewandowsky[1060] reports one case--that of an Italian workman, who suffered from an outbreak on the face, like impetigo; there was crust formation and at the edge of the crusts the epidermis appeared like a narrow row or border of vesicles. A small portion of the covering of the row of vesicles was lifted off, and after slight warming examined in 40 per cent. liquor potassæ. In this a large number of animal parasites of the Demodex group were found, and without doubt _Demodex folliculorum canis_ alone. Hünsche[1061] assumes that _Demodex folliculorum_ penetrates into the tissues and produces abscesses.

[1059] Babes, _ibid._

[1060] Lewandowsky, _Deutsch. med. Wochenschr._, 1907, xx.

[1061] Hünsche, _Münch. med. Wochenschr._, 1900, xlv.

Treatment first consisted in dusting with zinc amyl powder, but after four days there was no change. After the regular use of xeroform as a powder application, the affection cleared up within fourteen days.

INSECTA.

*Pediculus capitis* (Pediculus capitis) (Head Louse).

We find _Pediculus capitis_ in very young children and in others more grown up to be the incessant and frequent cause of impetiginous crust-forming eczemas. It is more frequent in girls than in boys. In families it is endemic, in schools epidemic, but it also occurs in fair frequency in female adults (servant maids, waitresses) who may pay little attention to bodily cleanliness. The puncture of the parasites sets up a severe irritation, which leads to violent scratching. The consequences of this are the formation of nodules and pustules, crusts and “weeping” patches; the hairs become felted and the final clinical picture is that of plica polonica. The conditions of irritation which are produced by these parasites and then by the scratchings of the impetiginous, and frequently the very severe suppurative processes of the hair-bed, lead to swellings in the neck and sometimes even to glandular suppurations. The eczematous processes not infrequently extend over the face, the neck and the thorax. Blepharitis and conjunctivitis may be due to _Pediculus capitis_.

The means of infection are often very remarkable. Transmission from one individual to another certainly often occurs, but infection may take place in railway carriages and in other ways. A case under the observation of a colleague in Frankfort is a most remarkable one: he diagnosed pediculosis as the cause of a head eczema occurring among the children of one of the best families there. The infection took place through dolls adorned with human hair, in which the presence of nits could be demonstrated.

The diagnosis of _Pediculus capitis_ is not difficult to make when the hairs and hairy scalp are carefully examined for nits and living parasites. In better families it is a good plan to point out the _corpora delicti_ to their possessors and to make them aware of the possible sources of infection.

As regards treatment, lotions of sabadill vinegar are recommended; in slighter cases these are quite sufficient. In severe cases cure will not result unless dressings of petroleum, naphthol ointment (5 to 10 per cent.) and balsam of Peru be applied. In the case of plica polonica, the hair must be cut quite short (even in adults) so as to control matting of the hair. To get rid of nits from hair that is not matted, careful combing and washing with strongly alkaline fluids or with hot vinegar is suitable.

*Pediculus vestimenti* (Clothes Louse).

The clothes louse attacks adults by preference, and with especial frequency old and emaciated persons. It lives in the clothes, but derives its nourishment from the body. At the moment at which the clothes louse inserts its proboscis into the skin the person experiences a slight sting, which, however, at once ceases to hurt. If the body of the louse is sucked full of blood it falls off and the individual has rest from it for a time. A wheal develops around the hæmorrhagic area of the bitten spot and itches severely. The itching goes on until the eruption is scratched all over. This is followed by crust formation. When many parasites are present the itching reflexes become more severe, and the patients scratch themselves considerably and make long marks at those places where the Pediculi have been. The localization of the scratching effects is characteristic, corresponding with folds between portions of clothing (regions between the shoulder-blades, wrist and neck). If the condition lasts for a month, the scratching effects extend over the whole body, and secondary efflorescences become associated with it, such as pustules, ulcers and eczemas. Intermediate between this we find cicatrices and pigmentation, the latter under certain circumstances extending over the whole body. Sulla, Herod, Cardinal Dupet, Philip II, and others are said to have died from louse disease. That even at present many human beings are exposed to the danger of being devoured by lice is a fact that we have had the opportunity of observing on several occasions. Only to record one instance, a man, aged 65, was received into our clinic some time ago in an absolutely neglected condition (he had been staying for some weeks in a stable, lying on a wretched bed). The whole of the surface of his body was covered with countless furuncles, of greater and less size, which had partly become changed into undermined ulcers. Over the ulcers and beneath their undermined edges Pediculi were swarming.

*Phthirius inguinalis* (_Pediculus pubis_) (Crab Louse).

The transmission of these parasites generally takes place during coitus, and therefore they especially occur in the pubes. It is possible also that transmission is effected through dirty clothes and bed-linen and privy seats.[1062] Starting from the pubes the animals crawl out over the other parts of the body provided with hairs to the abdominal wall and the thorax (so far as these parts are furnished with thick hair) to the arm-pits, the beard, the eyebrows; not, however, to the hair of the head, or rarely so; among our numerous cases we have never met with an example of the crab louse attacking the hair of the head.

[1062] [A case of infection through a dirty station privy in Switzerland came to my knowledge in 1899, and numbers of pediculi were found there.--F. V. T.]

The irritation produced by the crab louse is extraordinarily severe, especially during the night, as the warmth of the bed incites the lice to active sucking. In consequence of the violent scratching indulged in, eczemas are set up at the points attacked, and these often spread to the neighbouring parts not covered with hair.

Of special interest is the onset of maculæ cæruleæ (tâches bleues) in some persons affected with crab lice (people disposed to sweating seem to be peculiarly liable to these). They consist in pale blue patches of various size and shape, varying from that of a hemp-seed to that of a lentil, and again to that of a nail in size and form. These are found over the cutaneous surface of the abdomen, thorax and thigh, and are often only seen by a good lateral illumination. Duguet[1063] considers that the condition is a toxic erythema, that it is set up, on the occasion of the bite of the parasite penetrating the skin, by the poisonous substance derived from it. Oppenheim[1064] considers that it is a colouring substance that is formed in the salivary glands of the parasites, and which penetrates the skin when the insects bite, and thus forms the maculæ cæruleæ. We have on several occasions emulated the experiment of Duguet (trituration in a mortar of crab lice freshly taken from the human body and inoculating the mass thus obtained beneath the skin), and have similarly been enabled to produce the maculæ cæruleæ experimentally, but we have certainly been unable to determine which of the hypotheses is the correct one, the toxic erythema or the colouring substance inhibition theory.

[1063] Duguet, _Annal. de Derm._, II Sér., i.

[1064] Oppenheim, “Handb. d. Hautkrankh.,” v. Mraček, 1907.

The diagnosis of phthirasis is very easy, for either the sexually mature parasites or the nits are found on the hairs.

As regards treatment, grey ointment is regarded as a generally useful application; it gives rise, however, to a slight eczema of the genitals, especially in males, when injudiciously used. Geber[1065] recommends petroleum or balsam of Peru, Oppenheim[1066] a 1 per cent. sublimate solution for lotions, or a mixture of equal parts of petroleum and benzine when the sublimate cannot be borne. The use of a 5 per cent. ointment with hydrarg. oxid. flavum is worth considering in treatment of pediculosis of the eyebrows and eyelashes. The simplest method of treatment, and one with a radical effect, is that by sulphuric ether recommended by Thomer.[1067] It certainly produces a sharp burning sensation, but the living parasites and nits are destroyed in one sitting. We prefer ether lotions as a rule, and we thoroughly rub the affected parts with a pad of wadding well soaked with the ether. The dead parasites and the nits fall on to what lies beneath when the rubbing is done thoroughly, and the burning sensation caused by the ether only lasts a few minutes.

[1065] Geber, _see_ Seifert, Lesser’s “Encyclop.,” p. 387.

[1066] Oppenheim, _loc. cit._

[1067] Thomer, _see_ Seifert, Lesser’s “Encyclop.,” p. 387.

*Cimex (Acanthia) lectularia*[1068] (_Cimex lectularius_) (Bed Bug).

[1068] _Vide_ genus Cimex, p. 534.

The puncture in the skin made by the bed bug gives rise to an extraordinary amount of severe itching and a burning sensation, and when the skin is sensitive wheals of remarkable size (_urticaria ex cimicibus_). These eruptions that cause such severe itching are scratched by those attacked, till very soon blood begins to flow, and this generally leads to the formation of a dried crust of blood at the point of eruption.

The diagnosis is not always easy, as urticaria arising in other ways frequently leads to similar vigorous scratching and formation of crusts of dried blood. Men who have some experience in this matter (for example, commercial travellers), when they are attacked by severe itching at night, are in the habit of striking a light and searching in their bed and body-linen for the bugs, in order to be able to hand over the _corpora delicti_ to the landlord if need be. The assumption that the bugs in the East play an actual part in the propagation of tuberculosis and bubonic plague has been proved by investigations made by Nuttall[1069] to be at least very exaggerated if not wholly without foundation. Further investigations may decide how far the bugs participate in the transmission of kala-azar, as is believed by Rogers to take place.

[1069] Nuttall, _see_ Sack “Handb.,” v. Mraček, p. 290.

The bed bugs must be exterminated by spraying the chinks and joints in the boards with petroleum and benzine, pulling up the carpets and cleansing the bedsteads. For the treatment of the bite itself the methods recommended as an antidote against insects’ stings in general are suitable: 2 per cent. carbol vaseline (Rosenbach[1070]), thymol dissolved in spirit (1 in 50[1071]), æthrol or deci-æthrol, form-æthrol (manufactured by Dr. Nordlinger, Flörsheim a. /M.), formol[1072] (formol 15 parts, xylol 5 parts, acetone 44 parts, Canada balsam 1 part), with the aid of a pad of wadding placed over the part bitten, lavages with vinegar, citron juice and spirit of salmiac.

[1070] Rosenbach, _Therap. Monatsh._, 1903.

[1071] _Leipzig. med. Monatsh._, 1907, vi.

[1072] _Chemist and Druggist_, August 25, 1906.

*Pulex irritans* (Human Flea).

The bite of the flea produces a slight discharge of blood about the size of a pin’s head, which rapidly becomes surrounded with a circular area similar to a patch of roseola. The redness fades away after a longer or shorter while (several hours), whilst the discharge of blood is to be seen for one or two days longer. In dirty people the whole body may be covered with such discharges of blood. Individuals with very delicate, sensitive skin, especially small children, show true wheal formation at the site of the bite. In certain cases there develops from one such single bite an urticaria that extends over a large part of the body. The manner by which an irritating substance is introduced into the skin upon biting by the bed bug and also by the flea is clear. The bite is followed by a feeling of itching, which is liable to rob nervous persons of their sleep. Sensitive individuals are upset even by the fleas moving over the surface of the skin during their rest at night.

Treatment consists in extreme cleanliness, capture of the parasites, sprinkling the body and bed-linen with insect powders. The fleas are difficult to remove from barracks, schools and hospitals.

*Dermatophilus* (*Sarcopsylla*) *penetrans* (Sand Flea).

The fertilized females penetrate into the skin with their heads, and here they swell, in consequence of the numerous and growing eggs and larvæ, to a white ball the size of a small pea, on which the head is recognizable only as a small brown point.

In this way a small brown tumour arises, over which, at the commencement, the skin is not reddened; after some days, however, it becomes inflamed; in the centre of it a small opening is seen. If the parasite is not extracted the skin that lies over it becomes destroyed by suppuration, and thus becomes removed. At the commencement the part affected itches, with increasing inflammation; the symptoms of irritation become more severe and may amount to actual pain. If the small suppurative processes be neglected, inflammation and gangrenous and septic processes may arise. The region of the body sought out by preference by the sand flea is the sole of the foot, the toes, under the free ends of the nails and the digito-plantoid folds--more rarely the scrotum, thigh and other parts are attacked (Scheube[1073]). The number of parasites found on one person may amount to several hundreds.

[1073] Scheube, “Die Krankh. d. warmer Länder,” 1896.

Treatment consists in the removal of the parasites from the skin with a needle or a small sharp knife and the application of a bandage. Rubbing the feet with copaiba or Peru balsam, sprinkling them with insect powder, or washing them with bay rum (Berger[1074]) acts as a prophylactic or removes the irritation of the skin produced by the parasites.

[1074] Berger, _Therap. Monatsh._, April, 1907.

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] Riley[1077] 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. Lahory[1078] 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. Frantzius[1079]), and also the external auditory meatus, as well as ulcerated or wounded parts of the body, and even badly ulcerated skin carcinoma (Lutz[1080]), 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 anthropophaga_[1082] 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 Schmidt[1090] 300 and 350 larvæ were respectively removed from the nose, and the patients recovered. Wolinz[1091] 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. Curran[1093] states that people suffering from “peenash” frequently die from meningitis. The cases reported by Pierre[1094] related to the forms of severe myiasis frequently to be observed in Guiana. In a patient who was suffering from typhus (? typhoid), Douglas[1095] found the conjunctival sacs full of larvæ; in two other individuals the nasal cavities were attacked.

[1075] [_Chrysomyia macellaria_, p. 587.--F. V. T.]

[1076] [_C. macellaria_, Fabricius, the screw-worm fly, is found in tropical America and the West Indies. The genus is restricted to America. The species from India is a Pycnosoma.--F. V. T.]

[1077] Riley, _American Naturalist_, 1883, xvii.

[1078] Lahory, _Edin. Med. Journ._, 1856.

[1079] v. Frantzius, _Virchow’s Archiv_, 1868, xliii.

[1080] Lutz, _see_ Joseph, _Deutsch. med. Zeitg._, 1885.

[1081] Conil, _Annal. de Science nat. zool._, 1878.

[1082] [This fly belongs to the genus Cordylobia, and is peculiar to Africa. _C. anthropophaga_, or the tumbri fly, is, when a larva, a subcutaneous parasite of man and animals.--F. V. T.]

[1083] Delasiauve, Gerhardt’s “Handb. d. Kinderkrankh.,” 1878, iii.

[1084] Weber, _Mexique Rec. d. Mém. de Méd. milit._, 1867.

[1085] Mankiewicz, _Virchow’s Archiv_, 1868, xliv.

[1086] Kirschmann, _Wien. med. Wochenschr._, 1881.

[1087] Prima, “Thèse de Paris,” 1881.

[1088] Britton, Cambridge, Massachusetts, 1883.

[1089] Richardson, _Medical Monthly_, 1883.

[1090] Schmidt, _Texas Med. Journ._, 1887.

[1091] Wolinz, _Wratsch_, 1884.

[1092] Adler, _Med. Record_, 1885.

[1093] Curran, _Med. Press and Circ._, 1887.

[1094] Pierre, “Thèse de Paris,” 1888.

[1095] Douglas, _Kansas City Med. Index_, 1890.

The case observed by Summa[1096] 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 Kimball[1097] 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 Carrière[1098] an abscess of the nasal septum was produced by the larvæ of flies; Chiodi[1099] 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 Lesbini[1100] was that of a girl, aged 16, with 250 larvæ in the diseased nasal cavity. Quintano[1101] observed larvæ beneath the eyelids in one case. It is possible that the cases of Cesare[1102] and Calamida[1103] 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 Saulle[1104] (frontal sinus), Delasiauve[1105] (frontal sinus), MacGregor[1106] (antrum of Highmore), and Bordenave[1107] (antrum of Highmore).

[1096] Summa, St. Louis, 1889.

[1097] Kimball, _New York Med. Journ._, 1893.

[1098] Carrière, _Gaz. hebd. de Méd. et de Chir._, 1898, xciv.

[1099] Chiodi, _La Argent. Med._, March 1, 1905.

[1100] Lesbini, _ibid._

[1101] Quintano, “Cronic oftalm. de Cadiz,” 1878.

[1102] Cesare, _Arch. ital. di Otol._, April, 1903.

[1103] Calamida, _Giorn. d. R. Accad. de Med. di Torino_, September, 1903.

[1104] De Saulle, _Gaz. des Hôp._, Paris, 1857.

[1105] Delasiauve, _Gaz. hebd. de Méd._, Paris, 1885.

[1106] MacGregor, _Arch. gén. de Med._, No. 1,031.

[1107] Bordenave, “Deuxième Mém. présenté à l’Acad. de Chir.,” v, p. 387.

If a survey is made of the literature of the cases described of myiasis nasi produced by _Lucilia macellaria_[1108] the following information is forthcoming: In Europe this form of the disease is of very rare occurrence, whilst in America and India[1109] 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.

[1108] [And the other species, of course, must be included here.--F. V. T.]

[1109] [Concerning Europe and India, _macellaria_ does not occur.--F. V. T.]

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 (Brokaw[1110]).

[1110] Brokaw, _see_ Seifert, in Heymann’s “Handb.,” p. 595.

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 (Prima[1111]). Twenty-one out of thirty-eight cases recorded (collected) by Maillard[1112] died.

[1111] Prima, “Thèse de Paris,” 1881.

[1112] Maillard, “Thèse de Montpellier,” 1870.

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.