184 
Hirudineci in Palestine 
when the leech is in the pharynx or larynx, it is ‘hawked up’ almost 
continuously. As a rule, and of course in all laryngeal cases, there is 
considerable irritation about the larynx resulting in a short irritating 
cough, dyspnoea, varying in intensity from time to time, and sometimes 
considerable cyanosis from impeded respiration. The patient’s expres¬ 
sion is one of considerable distress, a great contrast to that following 
upon the instant relief afforded by the removal of the parasite. In 
laryngeal cases there is often complete loss of voice, the patient only 
speaking in a whisper and then with difficulty. On examination with a 
tongue depressor the leech is sometimes revealed, lying at the back of 
the pharynx ; in such a situation it cannot be mistaken as its black, 
rounded, annulated, shiny outline at once catches the eye. More 
commonly it is necessary to use the laryngoscope, and in a considerable 
proportion of cases the leech will be found attached close to one of the 
vocal cords. Its head attachment is sometimes just inside or just outside 
the cord, and it flops in and out of the aperture with the respiration. 
In such cases the wonder is not that the patient suffers from dyspnoea, 
but that he can breath at all. The upper larynx and the pharynx are 
largely bespattered with fresh blood and in the process of examination 
the patient usually coughs out a good deal of it. Why it is that a leech, 
which outside the body takes its fill and then drops off or is easily 
removed, continues when inside the mouth and throat to keep its hold, 
though apparently attacking different spots—leaving the old points to 
bleed—is a question I must leave to zoologists, but it is certainly the case, 
and in my experience in such a situation it seldom voluntarily quits its 
hold. According to the System of Medicine quoted above this species of 
Hirudinea is Limnatis nilotica. 
As regards the treatment, the natives of Palestine are accustomed if 
the worm is within their reach to transfix it with a sharp thorn from the 
Sidr tree : I have seen muleteers use a packing needle to extract a leech 
from a mule’s mouth. When the parasite is beyond reach of this 
process they use what they call es salata, that is the thick deposit 
which collects in their tobacco pipes. This they smear on the end of a 
fragment of wood and they say that if this touches the leech it is 
poisoned and leaves its hold. The cases which came to the European 
practitioner are almost always those where the skill of the amateur has 
failed and for these such simple means are useless. In my experience too 
the 1 spraying with salt solution ’ mentioned in Allbutt and Rolleston’s 
System has proved of little use. The two means I have found most 
successful are either mechanically seizing the worm by means of suitable 
forceps or paralysing it with cocaine. 
