 Global war carried our fighting men to far-flung beaches. They faced not only guns, but insects and disease. At a critical stage of the Sicilian invasion, many were knocked out, not by enemy fire, but by the bite of an insect they didn't even see. It put them out of action, making them victims of sand fly fever, one of the sand fly-borne diseases. Very few American medical men or entomologists ever had firsthand experience with either the disease or the phlebotomous sand fly that carries it. These sand flies were encountered by most Americans for the first time in World War II. Phlebotomous is an obnoxious blood-sucking pest about one-third the size of a mosquito. Just as with mosquitoes, it is only the female that sucks blood. The genus Phlebotomous should not be confused with the genus Culecoides, also called sand flies, and common along the South Atlantic coast and elsewhere. Only Phlebotomous is concerned in the sand fly-borne diseases. The characteristic position of the wings raised to form a bee distinguishes it from almost every other fly. It breathes in loose soil and debris, usually under stone, or in masonry cracks, where it is dark and moist, but never wet. At this typical breeding place, the sand fly pauses and begins an unhurried gradual entrance. Unlike many gnats and midges, it never circles about, but advances in short, huffing flights. The female lays a batch of 40 to 75 eggs, which hatch in 7 to 10 days. The sluggish larvae are worm-like. They feed on debris, feces, insect bodies, and decaying vegetation. There are four larval stages. Hibernation, if it occurs at all, is in the fourth stage. Larval development takes 3 to 6 weeks. In pupation, the larval skin is pushed back like a sleeve, becoming a wrinkled mass at the posterior end of the motionless pupa. At this stage, transformation takes place. The pupa case splits, and the winged adult emerges. The pupil stage takes 10 days. The total life history is slow, compared with such insects as flies and mosquitoes. It takes at least 2 to 3 months. The study of sand flies started in the Mediterranean, where they are very abundant and carry several of the most serious sand fly-borne diseases. They occur in many places in Africa and in the Middle East. The sand fly belt includes the tropics and extends into the temperate zones. In the Orient, there are several notorious sand fly regions. In the New World, Central and South America harbor a wealth of sand fly species. Fortunately, phlebotomus is scarce in the United States, although it does occur in some of the southern states. Phlebotomus transmits 3 serious diseases. One of them is sand fly fever, caused by a filterable virus. It is transmitted from person to person by the sand fly's bite. The disease is also known as papatachi fever, phlebotomus fever, and 3-day fever. It occurs throughout the Mediterranean area, the Balkans, Middle East, and parts of the Orient. Most people in endemic countries have had the disease and are immune, but troops who enter such areas for the first time may come down with the disease within 3 or 4 days. Sand fly fever strikes suddenly, disabling the victim at once. Diagnosis may be difficult, except during epidemics. Symptoms such as severe frontal headache and backache are consistent with those of other diseases, such as dengue fever or influenza. The face is flushed. The eyeballs are tender to the touch. The conjunctivy are congested. Usually, there is no true skin rash, as in dengue. Frequently, the patient is depressed and apathetic. Fever rises rapidly. The incubation period is very short, usually 3 or 4 days. The temperature reaches its peak between 102 and 104 degrees on the first or second day of fever. It usually lasts from 2 to 4 days, with 3 days so common as to give it the name 3-day fever. After the fever subsides, some patients feel fit at once, most convalesce in 7 to 10 days. Although the disease is never fatal, its military importance is great, and the large part of a command may be knocked out at one time. There is no treatment or inoculation against the disease. The only way to avoid it is to guard against the sand fly's bite. A second group of serious diseases transmitted by the sand flies are those caused by protozoan flagellates of the genus leishmania, known collectively as leishmaniasis. Leishmania is easily grown in artificial culture. This is the form as seen in culture. All species of leishmania are morphologically identical. The body, spindle, or cigar shape moves by means of a long flagellum at one end. When stained, the essential structures of the flagellate are the rounded reddish nucleus, the more deeply stained rod or dot-like parabasal body at one end, and the long whip-like flagellum, which arises from it. This form, the motile flagellate, is the one assumed by the parasite whenever it is found growing outside the human body, either in culture or in the intestine and mouth parts of the sand fly. Inside the human body, as this stained smear of spleen tissue shows, the parasite is somewhat different. It is now oval in shape and has lost its flagellum. This tissue form is the leishman-donovan body, or LD body. In all cases, it develops within the cells of the reticuloendophilio system, in the skin, bone marrow, spleen, liver, and other organs. Although all the species of leishmania look alike, they act differently and produce different diseases. One species, leishmania tropica, causes ulcers of the skin, known as cutaneous leishmaniasis, or oriental sore. In the old world, oriental sore extends from the Mediterranean through the Middle East into India. In many places where practically every person has the sore or bears its scar, it has acquired local names such as Bagdad Boyle, Aleppo Button, Jericho Rose, the Seal of Cambay, Deli Boyle. In South and Central America is found a new world variety of oriental sore, distributed through such diverse regions as the Highlands of Karoo, and the Chickle Forests of Yucatan. The disease begins as a firm red papule, weeks or even months after the bite of the infected sand fly. It grows slowly and steadily, but is not painful. There is no fever or other symptom. Sooner or later, an ulcer is formed with firm raised margins. There is always secondary bacterial infection. There may be a crust or an open, purulent oozing sore. Usually the ulcer reaches the size of a half dollar or larger. There may be just one lesion or many. They are located on parts exposed to the bite of the sand fly, principally the face, ears, forearms, legs. This case has multiple lesions on face and arms. The ulcers go on for about a year or even two, but finally heal spontaneously. Leaving disfiguring scars, the stamp of the disease. Cutaneous leishmaniasis can be treated. The initial papule should not be allowed to go on to ulceration or the ulcers to extensive scarring. They should be stopped by treatment with various drugs containing antimony. This case and the one following are healing under treatment or have already healed with only small scars. Treated in time, scarring could have been prevented. In South America, chiefly in jungles, another species, leishmania brasiliensis, attacks not only the skin, but the mucosa of the nose and mouth. For that reason it is called mucocutaneous leishmaniasis, known locally as espundia. The lesions are horribly destructive and go on for years, eating away the center of the face. Espundia can be treated effectively with antimony compounds, but the process is often difficult and long drawn out. The most serious disease caused by leishmania is visceral leishmaniasis or kala azar. The parasites, leishmania donovani, produce a generalized infection of the whole body. In India, epidemics of kala azar have killed tens of thousands. In villages of Assam province and the Ganges Valley and in cities like Calcutta. It also occurs in North China, in the Mediterranean area, and more recently has been found in South American jungles. The incubation period of kala azar is long and may last from two or three months to over a year. The onset may be sudden, although in many cases it is extremely insidious. The symptoms vary and often simulate those of other diseases such as malaria or typhoid. The fever is usually irregular. In this case, the temperature has dropped in response to treatment. One of the most characteristic and constant features of kala azar is the progressive enlargement of the spleen. In endemic areas it is common to find that the spleen has already reached the level of the umbilicus or even lower, before cases are brought for medical treatment. In this case, now in about the third month of the disease, the spleen is nearly three inches below the costal margin. In kala azar the liver also is usually somewhat enlarged. The white cell count is down. There is always some degree of anemia. Diagnosis may be confirmed by finding the parasites in tissue obtained by puncture of bone or spleen. Untreated, kala azar may have a fatality rate as high as 90 to 95%. However, the intravenous administration of various drugs containing antimony reverses these figures and makes it possible to save 90 to 95%. Nevertheless, kala azar remains a serious public health problem in many parts of the world. In certain mountain valleys of Peru, Ecuador and Colombia, there is a curious sand fly-borne disease not found anywhere else in the world. Bartonellosis, also known as Carrion's disease, Viruga peruana, a Roya fever, and caused by a minute bacillus, Bartonella bacilliformis. Bartonella is a very minute gram-negative rod-like or cacoid organism of about the same size as rickettsia. It grows readily in special culture media and may be cultivated from the blood at any stage of the disease. In culture it characteristically forms compact clumps or colonies which are difficult to break up. This famed smear shows both isolated organisms and dense clumps. The commonest form of Bartonellosis is characterized by a generalized eruption of nodules on the pace and extremities. These nodules give the disease its common name, Viruga, which is Spanish for wart. After an incubation period of about two weeks, the disease begins with irregular fever, headache, malaise, and pains in bones and joints. Usually the patient is not very sick, although some are incapacitated. The symptoms may last several weeks, followed by a period without symptoms. Finally, with or without a renewal of fever and joint pains, the eruption appears. The nodules are firm, smooth, and pink or red in color and vary in size from two or three millimeters to the size of a hazelnut. There is no connection between the nodules and the location of the actual bite. In their histopathology, the nodules resemble hemangiomas. They are very vascular and bleed easily. They are not painful. Older nodules become covered with a crust. The nodules may be very numerous, or there may be only an occasional nodule. The eruption usually disappears within two or three months. The nodules heal without scarring or other sign. Occasionally, as in this case, the nodules are subcutaneous. Practically every child in endemic regions gets the disease in the first year or two of life. Childhood cases are usually very mild. The more severe infections occur in adult nonimmunes. These purely eruptive benign cases include the vast majority of all infections. However, there is another clinical form of bartonellosis known as auroria fever. Many of the red cells become infected with the coccoid, rod, and filamentous forms of bartonella. There is a profound, rapidly developing anemia. The red count drops to as low as one million. Fifty to seventy percent of the anemic cases die. Those who survive convalesce slowly. And finally, after weeks or months, they go through the typical eruptive phase of bartonellosis. This case passed the anemic phase five months before and now shows extremely heavy eruption. There is no treatment, although penicillin in preliminary trials has shown promise. A study of the insect breathing places and habits is essential to the control of sand fly-borne diseases. Unlike mosquitoes, sand flies never breed in water, but in loose soil and organic debris, usually under stones associated with open soil and vegetation. They occur over wide areas and in many types of terrain, in open country with stone walls, in the heart of a Mediterranean city with its parks, masonry buildings, ancient ruins. There are many cracks, crevices, and loose stones forming ideal resting and breathing places. In rocky hillside villages with buildings of stone or in special cases, even in a salt desert as around the Dead Sea, they are found in mountainous regions such as the Andes and in deep jungles. Any spot which is dark and free of air currents may shelter sand flies. They hide by day and become active only at night. These old masonry walls provide many hiding places. In any of the varied types of sand fly shelters, we may find them, catch them, identify them, and attack them. A deep recess in a masonry ruin is an ideal place to look. Tobacco smoke makes the sand flies come out of the cracks and crevices. It also confuses them and makes them easy to catch. They can be caught in a suction apparatus or any small tube or vial. In these special tubes, sand flies can be kept alive several days. Loose stone walls are both breathing and resting places. Bomb rubble aggravates an existing sand fly situation or may create a new one. Caves yield good samples of both males and females of local species. In some desert areas, sand flies breed in rodent burrows. The rodents are the principal hosts with man only an incidental victim. In jungles, favorite hiding places are in buttresses of trees, under leaves, in animal burrows, and in hollow trees. Indoors, sand flies can be found in huts, houses, and barracks. They enter at night and rest during the day. The tighter and darker the building, the more sand flies remain. Most of them won't stay in tents, cane huts, houses that are open under the eaves or walled with sheet metal. They may rest near beds or make their way to darker corners, usually toward the ceiling. They are often in plain sight on smooth white walls. They may hide in crevices, in cupboards, or behind objects. The technique of search indoors or outdoors is the same. The time of danger indoors and outdoors is the same too. Sand flies bite from sunset to sunrise. There are several protective measures which form a first line of defense. One of them is insect repellent. While the army insect repellent was originally developed against mosquitoes, it is even more effective against sand flies. But there is a right and a wrong way to apply it. Use both hands, put the bottle down. In the field it will be easier to find it in the dark if it is always put against the foot. With both hands rub the repellent on the back of the head, behind the ears and inside the ears. Avoid getting it in the eyes and lips. Pat an excess on the cheeks, on the forehead, and on the chin. Then work it with the fingertips over the bridge of the nose, the lower eyelids, the upper eyelids, and toward the lip, rub it down the neck since sand flies crawl underneath clothing. Roll up the sleeves to rub it on wrists and forearms. Don't forget the ankles. It is important to put repellent on the ankles both on the bare skin and on the socks. If boots or leggings are worn, the trousers should be tucked in. Repellent applied to all exposed skin gives protection for three or four hours. After that it must be put on all over again. Since sand flies cannot bite through clothing, keep everything buttoned. Another temporary protective measure is the Freon aerosol insecticide dispenser, or aerosol bomb. The aerosol will kill all the sand flies in a room. During sleep a sand fly net, which is much finer than mosquito netting, gives protection. When not in use it should be kept folded up. The net should be suspended from its supports, not draped over them. Holes or rips should be repaired with adhesive tape or properly sewn. At night it is important that the bottom edge of the net should be tucked in so as to close every possible opening. If any part hangs loose, sand flies can find their way in. The net should be tucked in all around, well under the blankets or mattress. There should be an opening left to crawl through, which must then be tucked in from the inside, thus closing the net completely and securely. The net should be inspected closely with a flashlight to make certain there are no sand flies or mosquitoes inside. While sleeping no part of the body should rest against the net because insects can bite right through it. Repellent applied to the netting itself gives added protection. The effectiveness of these measures, repellent, aerosol bomb, bed net, depends on the user. All of them are important and must not be neglected. But at best they are temporary. The next night and every night the same procedure must be followed. The sand fly has not been controlled, it has only been warded off. For a long time these defensive measures were the only protection. The advent of DDT however opened up new horizons. For the first time a weapon appeared which gives not merely short term protection, but long term control. With DDT we pass to the offensive. Applied as a residual spray, it makes surfaces poisonous to many insects. The peculiar flight habits of sand flies make them particularly vulnerable to it. For instance, on reaching a building in search of a blood meal, sand flies don't fly directly through doors or windows, but stop to rest on the wall outside. By short flights that look like hops they make their way toward an opening. At any point they may pause from a few moments to as long as 15 to 20 minutes Ordinary screening offers no protection. They go right through it. Even after they are inside they take their time making short hops along the wall. This leisurely flight may take minutes or may take half the night. The important point is that sand flies spend a great deal of time resting on walls before they ever get to their victims. So far the sand flies have been resting on untreated walls. Let's see what happens when they alight on a surface coated with DDT. The spray evaporates leaving crystals of DDT which remain for weeks or months. It is well known that mosquitoes, flies and bed bugs are killed by DDT residual spray. Sand flies are even more sensitive. DDT gets in through the feet and passes up the legs into the body where it acts as a nerve poison. A toxic effect shown by great agitation follows only two or three minutes contact with DDT. The sand flies fall but may get up only to fall again. 15 to 30 minutes contact gives a lethal dose. On sprayed walls the sand flies peculiar flight habits make them especially vulnerable. Their long frequent causes ensure lethal contact with DDT. Few sand flies ever reach their victims when the DDT residual spray is applied to the inner walls and ceilings of sleeping and living quarters. It gives almost total protection to people in barracks, houses, huts and even tents. House spraying is already a standard practice in malaria work. It is also the most effective single measure against sand flies. Sand fly control can be made a part of any malaria program. It is also advisable to spray the outside of doors, windows and other openings together with a little of the surrounding wall. This alone creates a barrier which most sand flies do not pass. One spraying is good for about two months. This is individual house control. In outdoor control the same principle making surfaces lethal can be applied. Several of the sand flies weak points can be exploited. Its flight habits, its dependence on daytime shelters which are easily attacked, its limited flight range, a hundred yards or so, and the long life cycle making its replacement rate low. These stone walls contain the breeding and resting places on which sand flies are completely dependent. DDT makes them death traps. These are the surfaces on which sand flies must alight. DDT makes them lethal barriers. In one camp the spraying of buildings and strategic outdoor objects gave not only house control but area control as well. Every region has its own particular problems but the same principles hold throughout. It is necessary to understand the sand fly and for area control to take advantage of the terrain and the habits of local species. The various protective and control measures should be applied as conditions warrant. As a first line of defense under field or temporary conditions use the insect repellent, the aerosol bomb, the sand fly net. For control in permanent installations use the DDT residual spray. For house control spray inside and outside around the openings. For area control apply the spray so as to destroy the sand flies at their breeding and resting places and to create lethal barriers. With DDT the sand fly can be controlled and the diseases which it transmits prevented.