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N. Seruk, MD

Co-Director, University of Illinois at Urbana-Champaign Carle Illinois College of Medicine

Because ticks may harbor highly infectious agents, the clinician should use appropriate infection-control precautions. Unless the tick is removed, quadriplegia and respiratory paralysis may ensue; the case fatality rate without tick removal approaches 10%. Preventive measures used in tick-infested areas include wearing protective clothing that fits snugly about the ankles, wrists, waist, and neck so that ticks cannot gain access to the skin. People and pets should be inspected for ticks after visits to tick-infested areas. It should be noted that upon removal of the tick, the mouthparts often remain imbedded in the skin. Removal of the mouthparts is not critical; they will either be walled off as a foreign body or be worked out in the process of scratching. This is characterized by an ascending flaccid paralysis, fever, and general intoxication, which may lead to respiratory compromise and death. The paralysis is due to toxic substances released in the saliva of the tick and may be reversed by tick removal. Tick paralysis is observed more commonly in young children and when tick attachment is in opposition to the central nervous system. Ticks are also involved in the transmission of infections such as Lyme disease, Rocky Mountain spotted fever, ehrlichiosis, Colorado tick fever, relapsing fever, tularemia, Q fever, and babesiosis (Clinical Case 78-2; see also Table 78-2). The reader is referred to the appropriate sections of this book for discussion of the clinical and microbiological aspects of these infections. Insects include mosquitoes, flies, fleas, lice, roaches, bees, wasps, beetles, and moths, to name just a few. The insect body is divided into three parts-head, thorax, and abdomen-and is equipped with one pair of antennae, three pairs of appendages, and one or two pairs of wings or no wings at all. The medical significance of any insect is related to its way of life, particularly its mouthparts and feeding habits. Insects may serve as vectors for a number of bacterial, viral, protozoan, and metazoan pathogens. Certain insects may serve merely as mechanical vectors for the transmission of pathogens, whereas in other insects, the pathogens undergo multiplication or cyclic development within the insect host. Insects can also be pathogens themselves by causing mechanical injury through bites, chemical injury through the injection of toxins, and allergic reactions to materials transmitted by bites or stings. There are more than 30 orders of insects, but only those of major medical importance are discussed in this section. Diagnosis the diagnosis of tick bites and tick-borne diseases usually rests on the finding of a tick or a history of exposure to tickinfested areas. The identification of an organism as an adult tick is usually straightforward and based on the observations of an organism that is dorsoventrally flattened and possesses four pairs of legs and no visible segmentation (see Figures 78-6 and 78-7). An entomologist or parasitologist should be consulted if further identification is desired. The diagnosis of specific tick-borne infectious diseases is covered in the respective sections of this book. All dipterans have a single pair of functional membranous wings and various modifications of the mouthparts, which have been adapted for piercing the skin and sucking blood or tissue juices. Their most important feature is their role as mechanical or biological vectors of a number of infectious diseases, including leishmaniasis, trypanosomiasis, malaria, filariasis, onchocerciasis, tularemia, bartonellosis, and the viral encephalitides (see Table 78-2). The bloodsucking flies include mosquitoes, sandflies, and blackflies, all of which are capable of transmitting diseases to humans. Other dipterans, such as horseflies and stableflies, are capable of inflicting painful bites but are not known to transmit human pathogens. Although the common housefly does not bite, it certainly is capable of mechanical transmission of a number of viral, bacterial, and protozoan infections to human hosts. The infectious diseases transmitted by bloodsucking flies are well covered in other chapters of this book. The following section deals only with injury resulting from the bite of these insects and the effects Treatment, Prevention, and Control Early removal of attached ticks is of primary importance and may be accomplished by steady traction on the tick body, grasped with forceps as close to the skin as possible.

Hence the flesh of an animal killed by a venomed dart or a snake bite (should be considered as fatal as the poison itself and) should not be taken immediately after its death. The flesh of such an animal, however, may be eaten after a period of its forty eight minutes (Muhurta) from death after the 17. Symptoms Of taking poison internally -Whoever passes a black sooty stool with loud 5 flatus, or sheds hot tears and drops down with agony. The heart of such a man poisoning) cannot be burnt since the poison from its very nature lies extended in the i8. On the other hand, a snake bitten person, into whose body an incision is unattended with bleeding, or on whose body the strokes of lashes leave no marks, nor * In the Charaka Samhiti also we come across in the identical ex- pressions of opinion as to the seat of poison dead body of an animal or man, dying from poison from a poisoned dart or snake-bite or from poison administered internally. A is case of snake-bite in which the tongue of the victim found to be coated white and whose hair the falls off (on the slightest pull), bridge of whose nose beis comes bent and the voice hoarse, where there jaw about the hopeless. The case in which thick, long lumps of mucus are exboth the of the body with pectorated accompanied by bleeding from orifices all upward and the downward distinct impression of the fangs on the bitten part, 23. A case of snake-bite like that marked by the symptoms of of a an insane state panied drunkard and accom- by severe distressing symptoms (Upadrava), as well as loss of voice of the circulation of blood* and complexion and an absence and by other fatal symptoms and no action need be taken should be abandoned therein. O Susruta, to enter of their bites as a discourse on the treatment they are beyond the 2-A. Classification - I shall, however, describe in due order, the classification of the terrestrial snakes whose poison lies in their fangs wherewith they bite the human beings number, * (and other animals). Darvi-kara (hooded), Mandali (hoodless and painted with circular patches or rings of their skin), Rsiijiinsta varied colours on (hoodless and striped), Nirvisha (non-venomous or slightly venomous) and Vaikaranja (hybrid species). The last named is also, in its turn, divided into three sub-divisions only, (hooded), the Mandali (hoodless and the Rdjimdn (striped ones). Snakes born of Vaikaranja parents are of variegated colours (Chitra) and are of seven different species (three of these being Mandali (marked with rings) and 3. Classification snake trampled under or anywise terrified or of snake-bites;- fit foot, or in a of anger or hunger, attacked, or out of its innate bites malicious nature, will bite a man or an animal. The of these snakes highly enraged as they are, are grouped under three heads by men conversant with their nature, viz. Their specific considerable depth are Symptoms found;- the bite in which one, two or more marks (punctures) of fangs of on the affected part attended with a slight bleeding as well as those which are extremely slender and owe their origin to the turning aside and lowering of its mouth (head) immediately after the bite and are attended with swelling and the charac- Chap. A (superficial) puncture (or made by the fangs of a snake and the affected whitish or bite, part being attended with reddish, bluish, is yellowish lines or stripes is called the Radita which characterised by the presence of a very small quantity is of A Nirvisha (nonmarked by the presence of one or more venomous) fang marks, an absence of swelling and the presence of slightly vitiated blood at the spot and is not attended venom in the punctured wound. The contact of a snake with the body of a naturally timid person vation of his bodily part. The poison of a snake inoperative (the in a country resorted to by the celestial Garuda king of birds), or by the gods, Yakshas, in Siddhas and Brahmarshis, as well as one 5. Those which are large and slow and marked with parti-coloured * It should be noted here that coming in contact nails, etc. Features of the different Castes among^St snakes - the snakes whose skin is; lustrous like a pearl or silver, like gold is coloured yellow and looks and emits a sweet smell, should be regarded as belonging to the Brsflimaiia species of snakes. Those the which are glossy, extremely irritable in their nature and marked with spots on discs of the sun shell their skin resembling and moon, or of the shape of a conch- (Ambuja) or an umbrella, should be regarded as belonging to the Kshatriya species. The colour snakes which resemble a buffalo or a leopard in and lustre or are rough-skinned or are possessed of a should be consi7. The poison (circular of all hooded snakes (Phani) deranges aggravates the Pitta, while and aggravates the bodily Ydyu, that of the Mandali spotted) species that of the Rdjimin (striped) class aggravates the bodily Kapha. The poison origin aggravates the of a snake of hybrid (Vaikaranja) two particular Doshas of the body which fact its parents would have separately aggravated to - its which helps us to ascertain the species 8. Particular habits of different kinds of snakes;- Now hear me describe the special Chap. A snake of the Rdjimdn last species, is found abroad night, the in the fourth or the quarter of the Mandali snakes are (in found to be out in the three preceding watches, while quest the Darvi-kara snakes are found to be abroad of prey) only in the day time. A as Darvi-kara snake of tender age, a middle-aged Rdjimin snake and an old Mandali snake are as fatal personified death. A snake of extremely tender as well as age, the one roughly handled as by a as mungoose, or oppressed with water, extremely old and emaciated one, well an is or one which its extremely frightened or has recently cast off should be considered as mild-venomed.

A person treated with eighteen series (three hun- dred and twenty-four in number) of such Sneha-vastis and Niruha-vastis in the above mentioned way and rules of diet observing the prescribed and conduct live is enabled to develop a muscular strength in no inferior to life way his that of an elephant, in and full to a sinless a thousand years, faculties, 25. An excessive application of only one kind of Vasti, either of a Sneha-vasti, or of a Niruha vasti, should be avoided, since an excess of the first (Sneha-vasti) tends to Chap. I Hence an application of the Sneha-vasti should ^ be followed by one of the Niruha-vasti and vice vers a in order to avoid all apprehension of an aggravation of Daily applications of a Sneha- r Pitta, Kapha and Vayu. Distresses from we (an abuse or excess distressing of) Sneha-vasti which are found - Now of shall describe the distresses to attend a Sneha vasti. Various kinds symptoms vasti of a are produced by the application in the of a Sneha mild or weak potency is case of a patient whose stomach would be, filled with the aggravated Doshas so that the Snehi cannot flow back, being over- whelmed, as in the it by the aggravated Doshas. Water- brash, a sweet taste in the mouth, heaviness of the limbs, vomiting, difficult breathing, catarrhal fever (^ita-Jvara) and an aversion to food are the indications due to the retention of the injected Sneha in the bowels overpowered by the action of the deranged Kapha. In these (Sneha) Vastis and such other cases, applications of remedial measures as are soothing to the Dosha or rise to the retention Doshas (giving of the Sneha in the bowels) should be adopted with due regard to the nature and intensity of each. Cramps (Am^saya), tion (Sula) and heaviness of in the stomach affec- suppression the in Vdyu the (flatus), of the heart, a bad taste fits, mouth, difficult respiration, epileptic vertigo and an aversion retention to food are the the Sneh symptoms which attend a of in the bowels owing to the pressure of food into the matter carried be remedied measures. Such a case should a case of Ati-pidita (overpressure on the bladder of the) enema and 32. Uttara-vastiS mode to; - Now we shall describe the the of applying an Uttara-vasti (injection into patient^. It (in should be shaped like the stem of a Mdlati flower girth) at its and provided with an aperture a admitting the passage of authori ies mustard (of the in is seed. Several hold that the leng h of the pipe should be equal to that largest dose of a of the penis patient). The Sneha to be used Uttara-vasti) connection with an urethral injection only one Kun- cha Pa I a); and this should be determined with discretion the in respect of patients below twenty-five years of age. Mudga- pulse to pass through In the case of a vaginal douche or injection (Vasti), the pipe of the Uttara-vasti should be introduced to the extent of four fingers only into the vaginal canal. The Vasti of the of (bladder of the enema) should be or, made of the bladder of a hog, lamb, skin of 2l a goat, or in bird, its absence, leg the neck of a for or of the a Driti leathern bag 40. He should then be ^nade to putake of a gruel (Vavdgu) mixed with milk and clarified butter according to his digestive capacity. He should be made to sit on his a cushion placed on even ground and as high as 624 knee-joints. The pipe should be most gently pressed in the case of a girl before - menstruation. For the purpose of purifying the the uterus (Garbh^saya), of double ordinary (one Prasrita) quantity Sneha should be injected into the vaginal canal (by means of a Vasti) with a pipe having it. In case the injected fluid does not the prescribed time), a fresh come back (within Vasti (enema) should be * Milk, Yusha and meat-soup should be prescribed in cases of the predominance of Kapha, Pitta and Vayu respectively. A cold decoction of Yashti-madhu saturated with the) honey and sugart or a decoction of the (bark of milk-exuding trees (Kshiri-Vriksha or cold milk, should again be injected into the bladder, in the event of there being a burning sensation Diseases such as in that organ. Symptoms which mark, or dangers which attend, a judicious or an injudicious application of an Uttara-vasti are respect- ively identical with those which characterise or attend those of a Sneha-vasti, Thus ends 45-46. Now we as shall discourse on the mode of applying well as on the treatment with a Nirudha-vasti (Nirudhopakrama-Chlkltsitam). The mode of preparing a Vasti;- the application of an Anuvasana-vasti (enema) should of one of the Asthdpana class. The clyster (Vasti) should be applied at ber, noon in a well-cleansed cham- devoid of any gust of wind, and the patient should left be laid on his side on a spacious bed little not furnished his with any pillows, but a buttocks would at rest, raised up there where be and there should patient his left attendants in a. The with should thigh right continue held in cheerful mood an out- stretched posture and the one flexed, and is should refrain from speaking to any body. One half of the mouth of the it Vasti should be kept con- tracted left by pressing with the small and ring finger of his be stretched hand and the (other) half should with the aid of his thumb, index and middle fingers, and thus the medicinal solution should be poured into the bladder (Vasti). The neck of the pipe should be previously lubricated with clarified butter, and gently introduced into the rectum of the patient up to its Karnikd (protuberance) along the line of spinal column and with its mouth up-turned. Metrical Text;- the hold the its physician left should then enema (Vasti) with his hand and press medi- bladder with his right.

For these patients, the lowest intensity level at which Wave V can be visualized and repeated is considered the threshold. For better definition across the frequency range, frequency-specific stimuli, such as tone pips, are used. Because tonal signals have a slower rise-fall time than clicks, the wave morphology may be degraded, making threshold identification more difficult. Normative values from research centers for gender and age are available; however, to be accurate, each clinic should establish its own equipment-specific normative values. The active electrode can be placed in the ear canal, on the tympanic membrane, or through the tympanic membrane; the reference electrode can be placed on the vertex or the contralateral earlobe or mastoid. Most commonly, only the summating potential and the compound action potential are of interest. The amplitude of the summating potential (reflecting activity of the hair cells) is compared with that of the compound action potential (reflecting whole nerve activity). The configuration of the hearing loss may also contribute to variability in the latencies. These may include the absence of waves, prolonged absolute or relative latencies (2 or 3 standard deviations beyond the mean), or prolonged interaural latencies. Emissions are recorded from a small microphone placed in the ear canal via a soft probe. In response to these two tones, a normal cochlea will generate tones, called distortion products, at frequencies that are related to F1 and F2. Although the results do show a relationship with the audiometric configuration, the relationship is not precise. More research is needed to determine the specific recording parameters and criteria for predicting peripheral hearing loss. It also is used in confirming pure-tone test results obtained from young children, in patients for whom a functional hearing loss is suspected, for audiometric configuration confirmation, for ototoxic drug monitoring, and in hearing aid candidacy. Audiometric predictions using stimulus-frequency otoacoustic emissions and middle ear measurements. As the traveling wave progresses through the cochlea, the basal (high frequency) turn of the cochlea is first to be stimulated by the click and responds earliest, followed by the more middle- and low-frequency (apical) portions, thus allowing the response to be analyzed in both the frequency and time domain. Meniere disease causes recurrent vertigo attacks that can last between 20 minutes and 24 hours. An isolated attack of vertigo that lasts more than 24 hours is suggestive of vestibular neuronitis. Autonomic symptoms such as nausea, vomiting, and sweating are common presenting symptoms. Generally, the more intense symptoms a patient has, the more likely it is that the vertigo is caused by a peripheral lesion. The first task for a neurotologist in evaluating a patient with a balance disorder is to allow the patient to describe what he or she senses, using his own descriptions. However, the clinician may help the patient in choosing the correct terms to describe his complaints. Most often, lightheadedness occurs with nonvestibular causes such as cardiac or vasovagal reflex. It should be distinguished from dizziness, which describes any kind of altered sense of orientation. A history of vertigo is of great value in identifying the presence of vestibular pathology but not in localizing its origin. Vertigo results from impaired tonic symmetry in the inputs of the vestibular nuclei.