[2004 April 25] Aha! A BBC production in November 2003 mentions this story and the author, Broughton Coburn. I'll try to contact him ASAP. Not surprisingly, he is now a writer by trade, concentrating on Nepal. From reviews, I think the following or a refinement is in a collection, so there may be significant copyright issues. However, I'll keep this up until asked otherwise. Not very many people find their way here anyway.
[2005 April 9]I never did hear back from Broughton Coburn, so keeping this up until asked otherwise may be for quite a while. If you do copy text from here, please keep the attribution. His, not mine!
An article in a Hong Kong medical journal made it into the popular press which resulted in 100 accesses yesterday from people using search engines, references in hiking forums in NH and the northwest, etc. The previous maximum was 7. This account is much, much better than the news article. I'm satisfied that the following is true, but cases are not common enough for most physicians to be familiar with the syndrome.
[2009 November 12] Today is the tenth anniversary of this web page, and the story is still great.
[2010 February 27] Broughton Coburn sent an Email, largely to say hello. I think that means I can keep this up. Hurrah!
[2010 April 18] A research article about the syndrome (with yucky photos) caught the attention of the BBC and various netizens, and that produced a flurry of accesses here. The article is nowhere as entertaining as this one, but the photographs are a useful addition if you want physical imagery.
Anxious and distracted, I gripped the table leg where I sat in a tea stall pigeonholed in Kathmandu's noisy and crowded central bazaar. I tried to concentrate. A boy wearing rags patched on rags stepped from behind the counter and, balancing a trayload of tumblers of milk tea, set a glass at an adjacent table. Then, he looked at me. It was there. Something was crawling out of my nose.
The boy froze as if electrically shocked. Dropping the tray, he ran from the teashop, fleeing as from the curse of the Hindu demoness Kali, Shiva's wrathful manifestation, whose gaze alone can mortify armies.
So, it was real, after all. Reflexively, I leaped up and over the spilled and broken glasses, and found the boy half-crouched and trembling against the wall of a nearby building, burying his head into his folded arms.
"What did you see? What did you see?" I asked him intently in Nepali, wanting to grab him and shake out an answer, or sympathy, perhaps. I felt as frightened as he. Shielding his eyes from mine, he ran from my voice, head down, arms pumping, through the alley and across the next street.
My thoughts raced, trying to piece together the chain of events. I prayed that the ordeal that began eighteen days earlier in the American Peace Corps office in Kathmandu might at last be nearing an end.
Recently graduated from college, I was a Peace Corps volunteer posted in Nepal, monsoon season, 1975. As I relaxed on the couch in the office lounge, reading my mail, a drop of blood splashed onto an aerogram from home. I looked up, unable to see where it came from. More drips appeared, from my nose, bloodying my fingers. Not again, I thought -- not an early symptom of yet another exotic Asian disorder.
I had recently returned from a trek to Mt. Everest base camp. In my mind I reviewed the trip -- the 18,000 foot altitude, the thin, crystalline air, the simple meals of well-cooked, bullet-resistant buckwheat pancakes, and the cold, refreshing mountain spring water. At lower elevations, to drink untreated water, even if clear, would risk infection with hepatitis, typhoid fever, giardia, amoebae, and other parasites. But I disliked the taste of iodine pills, and a vigorous thirst could overcome my caution if the water looked as if it originated in a mountain spring. I had come to accept that, in Nepal, disease was an occupational hazard, and doctors, if available, often prescribed a shotgun treatment of broad-spectrum drugs. Risky place, this corner of Asia, I pondered while standing in the hallway, staring blankly at an outdated notice on the bulletin board.
Barney, the office doctor, stepped into the hallway. I said hello, but did not mention the brief nose bleed, afraid it might arouse too many questions. Barney was a pediatrician. Nepal, and tropical medicine, were new assignments for him. Each case he saw seemed to set off an imaginary beeper, allowing him to escape, scratching his head, to a medical text in his study. Generally, he would select an overweight volume, heft it onto the examining table, then read and re-read passages aloud to his patients, becoming more indecisive with each rendition. The volunteers referred to him by the nickname of "Ke Garne" ("What To Do?") Barney.
Anyway, my nose had stopped bleeding. But when I bicycled through the bazaar to my apartment, it began leaking blood again, continuously, for 20 minutes. The next afternoon, I went to a tree farm to request seedlings for the village where I taught school. There, my nose dribbled again. Not knowing what to do, I held a handkerchief to my face like a shy, about-to-be-married Hindu woman hiding the terror and shame that she pictured awaiting her. The following day, still bleeding, I saw Ke Garne Barney. He examined my nose with his nasoscope, and speculated that my nasal membranes might be weak, perhaps aggravated by the dryness and cold of high altitude. He gave me a bottle of neo-synephrine, a thumbs up, a good handshake, and a return appointment.
I gave the neo-synephrine a full trial, for three days, though from the first application my nose only seemed to bleed more. Each day, it bled in painless, erratic spells. It dripped in the evenings, but not while I slept or, unaccountably, until ten in the morning. I remained in Kathmandu, reluctant to return to the village where I was posted. Even without nose problems, to most villagers I was a strange enough apparition. I knew what they'd do with me: direct me to the shaman, who would likely deduce from a diagnostic trance that I had been infected by the hex of a witch with reversed feet, requiring that I shave my head and sacrifice a water buffalo to Narayan, an incarnation of Vishnu. Fine, but on my Peace Corps allowance I couldn't afford a water buffalo.
"Well, I might have to cauterize your nose," Barney suggested on the fourth day. "I can't think of what else to do." The neo-synephrine hadn't worked, and he could see no irritant.
"I'd like to wait," I told him, adding that I had heard that noses didn't smell as effectively after cauterizing.
"Well, yeah, I've heard the same thing," he shrugged in agreement.
Eight days of chronic bleeding. Rumors surfaced that Barney had misdiagnosed some patients, the positive side of which was that they got medically evacuated to Bangkok, a great place for overcoming homesickness. I needed another opinion, but during the monsoon Barney was the only Western-trained doctor in town. Perhaps Warren, a scholar friend who lived downstairs, would have an idea. Warren's guru was a Buddhist priest of the Newar ethnic group, and the man practiced traditional Asian medicine.
On our Chinese one-speed bicycles, Warren and I threaded through the bazaar to the pharmacy and clinic of Dr. Mana Bajra Bajracharya. Descended from a 700-year lineage of Royal Physicians, "Mana" practiced Ayurvedic medicine, an empirical science described in the Vedas. It works by treating fundamental imbalances, rather than symptoms, by realigning the body's complementary elements of nerve, mucous and bile. Mana had earned a thick volume of testimonial letters from around the world -- thirty-two years' worth -- extolling his cures for diabetes, hepatitis, arthritis, multiple sclerosis, sexual dysfunction, and cancer.
Sitting in the waiting room, Warren assured me that Mana would have a safe and ready treatment. Aging but animated, the doctor appeared in the vine-framed doorway. He summoned me into his examining room. Dr. Mana performed a thorough Ayurvedic exam, which included reading my pulse and turning my eyelids inside out, presumably to search for clues in the sound and pattern of blood vessels. Mana's diagnosis was similar to Barney's, but he was puzzled by the duration of the bleeding. He prescribed aloe, an herbal astringent. That didn't work, either.
Fourteen days. The total loss of blood was not serious, but I began to question whether I would ever be normal again, as victims of chronic hiccoughs must feel, longing for rest. I wondered if I should have my nose cauterized, after all, or be evacuated to Bangkok or Atlanta's Center for Disease Control. Perhaps the village shaman should be sent for. I couldn't concentrate, saw fewer friends, stammered slightly, and experienced jarring flashbacks of college psychology case studies of deviants, and of cautions from the U.S. Government shrink who screened me in the U.S. Long periods of isolation from that which was familiar, they all said, could induce hallucinations, or worse.
On the eighteenth day after the first nose bleed, I bicycled down a cluttered, medieval side street of the central market. Thankfully, my nose hadn't dripped in several hours. But from the corner of my eye I thought I saw something emerge from my right nostril. I reached for my nose, which felt normal. I continued pedaling, presuming it to be a piece of coagulated blood.
There it is again. Then gone. Yes, something is in there, and it's working its way out. A panic flushed over me. My nose grew large in my field of view, and the world beyond my face diminished.
I needed to have this sighting confirmed by someone, by an earthling not yet infected. But if this thing was part of a generalized, insidious infection, I feared, people might not tell me the truth. I pulled over to a teashop, ordered a glass of tea, and waited. Again I saw a blurred form, but felt nothing. That's when the boy in the teashop saw it, too, and at terrifyingly close range.
Dumbfounded, I stood in the alley beside the teashop, watching the boy run off. I paid the startled shopkeeper for my tea, and the spilled tea, and biked back to my apartment. In the bedroom mirror there was only a nose, a normal one. I drew up a chair and positioned myself squarely in front of the mirror, hands cupped on my knees, resolving to watch my nose until I saw it, the thing. For a quarter hour, self-conscious but purposeful, I focused, a hunter stalking himself.
Then, as if trying to catch me unaware, a long, brown, eel-like creature slid out, silently, offering no physical sensation at all. Guardedly, it scanned the air and retracted, leaving no trace. The probing tentacle of a monster. Kali. An hallucination, a mirage. I momentarily felt non-human, an alien sent to earth on reconnaissance to test the spiritual or intestinal fortitude of those who dared look at me. I would not last long in this incarnation. I would be captured for dissection by the world's scientific community. "War-ren," I called haltingly. Warren ran up the stairs, perceiving from my voice a turning point. We met in the bathroom, where his initial skepticism turned to dread.
"Eee . . . Yaah!" Warren exclaimed in unique, guttural sounds, appropriate for what we were beholding. He held his hands up, preparing to fend off the worm-like organism should it escape from me and head in his direction.
Experimenting, I found that, somehow, handfuls of water splashed up my nose drew out the animal a finger's length, weaving and searching. I tried to grab it, but was unable to touch it before it withdrew. Warren tried, his face distorted in trepidation and disgust, betraying his stoic military school training.
We couldn't even touch it. Our index fingers and thumbs were poised closely at my right nostril, but the slippery form retreated before either of us could pinch closed on it. Sensing any threat, the thing disappeared. We were horrified -- Warren more than I; my hormones of self-preservation had overtaken the hormones of fear. So this was why I had found it strangely easier to inhale than to exhale through that nostril: the thing had formed a kind of a valve in there.
It was Sunday. Barney's day off. The American medical clinic was closed except for emergencies, which were discouraged.
"Let's go see Mana again, now," Warren proposed. He was confident that Dr. Mana, though he missed the diagnosis, would at least recognize the thing itself.
We bicycled through a bazaar teeming with busy, unconcerned mortals. Like a Tibetan chanting his mantra, Warren rhythmically intoned "I don't believe it, I don't believe it," synchronizing the don'ts to each pedal stroke. I repeated the familiar Buddhist mantra, Om Mane Padme Hum, but it came out sounding more like "Oh Mommy Take Me Home."
Mana motioned us into his study, an extension of his examining room. Demonic, cryptic charts peered from the tops of cabinets overflowing with unbound ancient texts. Glass cases lining one wall were filled with odd-sized, murky bottles of tonics with Sanskrit names. I thought I saw my name on one of the bottles. Mana said a few words in his tribal language to the gnomish compounder, who was wearing a smock caked with herbal and mineral -- and what looked like animal -- residue. He then turned to serve tea, assuming we had come to discuss a publishing project Warren had been helping him with. Warren stated that this meeting was of much greater urgency, then explained my situation. The thing was hiding. Perhaps it would burrow into my brain, or lay eggs. Ungraciously, Warren let out a spacious laugh.
"None of this is possible!" Mana interjected with customary confidence. "Thirty-two years I am a physician in Nepal, and I have never seen a worm in a patient's nose!"
I hadn't, either. "Watch this," I rejoined, equally confidently, though my voice was breaking. I asked Dr. Mana to call for some water, and we stepped into his courtyard, a square of buildings that housed his herb stores, compounding laboratory, and apartments of his extended family. His grandnephews and nieces ran about in carefree play until the compounder arrived with a glass. I squatted down. Mana and Warren followed. The children stopped playing. I poured water into my hand and tossed it toward my nose. The thing came out on cue. Startling us, Mana jumped up, hands and fingers writhing, eyesrolling, face contorted.
"Aaahhh!" he cried, as if in anguish himself. "It's a leech!" A leech. A lurking, tenacious bloodsucker, evoking the quivering agony of Humphrey Bogart wading through a carnivorous, parasite-infested, uncharted African river -- an animal that had found its refuge, a human host, where it could develop, mature, lay eggs, and finally emerge as an evolved, aggressive, and no doubt hungry, life form.
Villagers had told me that leeches are inauspicious even by themselves, but by manifesting one in my nose I had been transfigured into an evil spirit of semi-human form. Even the children recognized it. Panic propelled them from the courtyard, running as if from a ravenous, multi-armed deity that subsists on small children. Women leaned from the courtyard's upper story windows and promptly latched the shutters, then climbed to the flat rooftops and called their neighbors to clamber over, across the roof -- not at ground level -- to see this from a safe distance. I felt a chill, and shivered uncontrollably.
Mana ordered tweezers, salt, and more water, figuring that the salt, a good leech repellent, might cause it to release. We squatted again. I splashed salt water into my nose. His tweezers could not touch the leech. He tried several times again. The salt water only caused it to retreat further inside.
"I don't know what to do," he confessed, frustrated that the case had seemed to defy his entire Ayurvedic medical tradition, and do so in front of his family. "I give up. Maybe your Western doctor has some kind of suction machine." Genial in defeat, Mana desired only that it be removed any way possible.
I called Barney at home from the phone in Mana's waiting room. Excitedly, I described the events, though perhaps not in the order they occurred. Yes, a leech stuck its head out of my nose when I splashed water up it, but it always disappeared before I could touch it. I asked Barney what he thought. There was no response.
"Are you there?" I asked into the telephone. It was not uncommon for phone calls in Kathmandu to be disconnected.
"Yeah, yeah, I'm here." Barney didn't like surprises.
"Well, what do you think?"
"This is difficult. I don't know what to say, exactly, except that I... I'd like to make an appointment for you to see the Embassy psychiatrist."
Ke Garne. I covered the receiver with my hand. Barney had decided that I was a drug- or culture-shocked deep end case -- another not uncommon feature of Kathmandu. I needed someone to corroborate my story, a respectable witness. Mana was busy calming his extended family, who were peeking over the rooftops, worried about contagion; Barney would probably figure Mana as a quack, anyway. Warren, a long-haired, unemployed U.S. Air Force Academy dropout, might not qualify, but he occasionally did construction work under contract to a branch of the United Nations.
"I have a U.N. contractor here, his name is Mr. Warren Smithson, and I'm going to put him on," I said resolutely to Barney.
Warren was low on patience with any kind of authoritarian figure, which for him included American-trained professionals. He tried to turn the case around on Barney, asking if maybe he was nuts, reminding him that this was reality, that I had better get some respect, and that he had better know what to do about this, and do it soon. I reached for the receiver, fearing Barney might have us both carted off to the psych unit.
"Okay, okay," Barney relented. "So, what do you want me to do about it?" What To Do. "I want you to take it out," I tried to say calmly, though my tone was of exasperation and pleading.
Barney knew of no precedent for a nose leech. Maybe his liability insurance wouldn't cover an untested leech removal procedure. I relayed Mana's suggestion about suction apparatus.
"I'll think about it on my way down to open up the clinic," Barney offered. "But I can't promise anything... I think the nurse should come, too, for this one," I could hear him add in an aside to himself.
Wearing the reluctant expressions of first year anatomy students just introduced to their cadaver, Barney and the nurse greeted me with simple nods in the driveway of the American medical compound. Barney mumbled about not having been taught anything about this in medical school, of vacation time, and of his chances for getting transferred to a post in Europe or the tropics. He kept glancing at his beeper hopefully.
The nurse and I helped him set up the naso-gastric suction pump, but the motor wouldn't operate: a burned fuse, with no replacement. Barney asked the two of us, for lack of specialists to confer with, if the pump would logically be the proper tool, and how he might use it if it did work. We had no idea.
I sat on the examining table. Barney inserted the nasoscope but saw nothing, hoping out loud that maybe the leech had fallen out while I was bicycling to the clinic. He flicked his head as if shaking off a dream, then brushed his hair back slowly and tightly with both hands, momentarily smoothing the set lines of his face. He fished out a pair of hemostats, resigned to having a go at grabbing it, just as Warren, Mana and I had tried.
I palmed water into my nose. I could tell that the leech appeared when Barney's body jerked. He hesitated, then bit his lower lip and approached, cautiously, as toward a dormant beast. Wait. Silently emerge. Clamp. Vanish. Wait. Emerge. Clamp. Missed again.
"Damn," Barney swore forcefully, as awed as the nurse and I by the lightning reactions of the primitive animal. Slowly, he backed away, as if trying to determine whether time was critical, or if he should stop right there and phone someone for advice, or maybe step out for a cigarette.
Sweating, his hand unsteady, he advanced again and tried clamping -- randomly -- below my nostril. After several minutes, he nabbed the end of the leech, the head, on its way out for air. He cinched down the hemostats' miniature grippers, and there the two of us paused, locked together in suspended animation. Then, with one palm on my forehead, he began to pull, slowly increasing the pressure. My focus narrowed as, cross-eyed, I watched the leech stretch outward. For the first time I could now feel the thing -- pulling vaguely from the interior of my head, indeed as if from the back of my head. It wouldn't let go.
"Let me know if it hurts -- otherwise, I'm . . . I'm just going to keep pulling until something happens," Barney stuttered, sounding unsure what that something might be, or whether he was doing the right thing at all. He now needed two hands on the hemostats. I braced one foot and a hand against the side wall of the examining room, while my other hand gripped the back of the cushioned table to keep from being pulled forward. The leech was stretched out nearly a foot; again we hesitated in this position, braced. I could see Barney soberly trying to reckon that under prolonged, static tension the leech might loosen and release, though his face was twisted in anticipation of a horrible accident.
My neck strained against the pull. I heard myself mouthing Warren's mantra. I don't believe it. I realized that I might never again experience this, nor again see such an expression on a doctor's face. I had been told to expect the unusual in this country, but this was more like some altered, metaphysical dream. I don't believe it.
Something snapped. Barney hit the wall directly behind him, while I fell over backward across the examining table. I couldn't see where the leech went, if in fact it came out, or if it had taken part of me with it. I wasn't sure Barney knew, either, until, with deliberation, he held up the trophy -- a fidgeting, clean, unattached leech, tightly seized in the clamps. Unstretched, it measured four inches long, as thick as a pencil, with a nickel-sized sucker on the host end. Barney's mouth hung open, grinning at the same time. As far as he could tell, he had done the right thing.
My nose dripped not a drop of blood. The leech, the hex, was gone. I said thanks and shook hands with Barney -- still speechless -- and stepped from the clinic to again join the world of benign, unencumbered humans. I slowed as I passed a neighborhood shrine. A gathering of devout Hindus were chanting, entranced, conducting a propitiatory ritual. I wondered if they had seen visions as gripping as my real one.
Two days later I went to see Mana. He caught sight of me before I crossed the threshold of his clinic.
"I know how we could have gotten it out!" he declared bouyantly from his waiting room. "If we had held a glass of water to your nose, and kept it there, it would have dropped off into the water on its own. Yak herders attract them from the nostrils of their yaks that way. Your leech had completed a stage of its life cycle -- it was done living in the host, which is usually livestock, and was waiting for a stream to drop into and float down, to reproduce and continue its cycle! Ha! You must have picked up the leech by drinking water from a stream the way a cow does!" He laughed loudly, unreservedly. I could feel the people sitting in the waiting room gawking at me with open, uneasy concern.
Then I remembered the mountain spring water. I had intentionally drunk on hands and knees, face in the stream, thinking it more sanitary. Of course. Villagers drink spring water from cupped hands, I now realized, to look for and avoid leeches. I returned to the American clinic to tell Barney. He was preparing a small shipping box for the creature, which was now safely restrained in a stoppered test tube. He was intrigued by Mana's explanation of the leech's life cycle, and said he would inquire about the removal technique in a cover letter to the Smithsonian Institution, where he was sending the specimen.
I expressed some apprehension. "But if our leech is lost in shipment, no one will believe the story."
"I don't think they'll believe it in any event," Barney responded as he carefully lettered a small label. I could see him grinning to himself, as if listening to his name being announced at a tropical medicine conference somewhere in Europe or the Caribbean. The label he prepared read simply, "Nose Leech. Nepal." I was grateful that my name, and I, were not attached to it.
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Page created 1999 November 12.