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diff --git a/.gitattributes b/.gitattributes new file mode 100644 index 0000000..d7b82bc --- /dev/null +++ b/.gitattributes @@ -0,0 +1,4 @@ +*.txt text eol=lf +*.htm text eol=lf +*.html text eol=lf +*.md text eol=lf diff --git a/LICENSE.txt b/LICENSE.txt new file mode 100644 index 0000000..6312041 --- /dev/null +++ b/LICENSE.txt @@ -0,0 +1,11 @@ +This eBook, including all associated images, markup, improvements, +metadata, and any other content or labor, has been confirmed to be +in the PUBLIC DOMAIN IN THE UNITED STATES. + +Procedures for determining public domain status are described in +the "Copyright How-To" at https://www.gutenberg.org. + +No investigation has been made concerning possible copyrights in +jurisdictions other than the United States. Anyone seeking to utilize +this eBook outside of the United States should confirm copyright +status under the laws that apply to them. diff --git a/README.md b/README.md new file mode 100644 index 0000000..c82b00a --- /dev/null +++ b/README.md @@ -0,0 +1,2 @@ +Project Gutenberg (https://www.gutenberg.org) public repository for +eBook #69927 (https://www.gutenberg.org/ebooks/69927) diff --git a/old/69927-0.txt b/old/69927-0.txt deleted file mode 100644 index 5e827b2..0000000 --- a/old/69927-0.txt +++ /dev/null @@ -1,1438 +0,0 @@ -The Project Gutenberg eBook of Case of Filaria loa, by D. Argyll -Robertson - -This eBook is for the use of anyone anywhere in the United States and -most other parts of the world at no cost and with almost no restrictions -whatsoever. You may copy it, give it away or re-use it under the terms -of the Project Gutenberg License included with this eBook or online at -www.gutenberg.org. If you are not located in the United States, you -will have to check the laws of the country where you are located before -using this eBook. - -Title: Case of Filaria loa - -Author: D. Argyll Robertson - -Release Date: February 1, 2023 [eBook #69927] - -Language: English - -Produced by: deaurider and the Online Distributed Proofreading Team at - https://www.pgdp.net (This file was produced from images - generously made available by The Internet Archive) - -*** START OF THE PROJECT GUTENBERG EBOOK CASE OF FILARIA LOA *** - - - - - - - CASE OF FILARIA LOA. - - BY - D. ARGYLL ROBERTSON, M.D., F.R.C.S.ED., - OCULIST TO H.M. THE QUEEN IN SCOTLAND; PRESIDENT OF THE - OPHTHALMOLOGICAL SOCIETY OF THE UNITED KINGDOM; LECTURER ON - DISEASES OF THE EYE IN THE UNIVERSITY OF EDINBURGH, ETC. - - _Reprinted from the ‘Transactions of the Ophthalmological Society.’_ - - LONDON: - PRINTED BY ADLARD AND SON, - BARTHOLOMEW CLOSE, E.C., AND 20, HANOVER SQUARE, W. - 1895. - - - - -[Illustration: PLATE VI - -Illustrates Dr. Argyll Robertson’s paper on Filaria loa. - -MALE FILARIA LOA. - -FIG. 1.—The whole worm. Portions of the testicles and alimentary canal -protruding through a rupture of the wall of the parasite. - -FIG. 2.—The head of the worm. - -FIG. 3.—The curved tail of the worm with its papillæ. - -FIG. 4.—The ruptured part of the worm with protruding alimentary canal -and testes.] - - - - -Communication read at the Meeting of the Ophthalmological Society on -October 18th, 1894. - -_Case of_ Filaria loa, _in which the parasite was removed from under the -conjunctiva._ - -By D. ARGYLL ROBERTSON. - -(With Plate VI.) - - -On the 29th of June last I was consulted by Miss J. H⸺ on account of what -she termed the presence of a worm in her eye. - -She is a slightly anæmic, prematurely grey-haired, but otherwise -healthy-looking lady, thirty-two years of age. She has resided at Old -Calabar on the West Coast of Africa at intervals, for nearly eight years -altogether. She twice had to return home on account of debility following -severe intermittent fever. During her last visit to Old Calabar, which -extended to about eighteen months, she suffered almost the whole time -from chronic dysentery followed by severe remittent fever, which -necessitated her return to this country last January in a very weak state -of health. - -She stated that the worm was first observed by her in February of this -year, immediately after her return home. It frequented both eyes, but -showed a preference for the left one, sometimes coursing over the surface -of the eye under the conjunctiva, sometimes wriggling under the skin -of the eyelids—causing a tickling, irritating sensation, but not real -pain. It had latterly restricted its visits entirely to the left eye. -On account of the remittent fever from which she was still suffering, -her bedroom, when she first came home, was kept well heated, and until -she recovered from the fever she noticed that the worm was particularly -lively, occasionally causing the eye to become bloodshot, and the eyelids -to swell and blacken slightly. As long as she was confined to warm rooms -the worm was almost constantly moving about in the neighbourhood of the -eye, causing such irritation as to prevent reading or work of any kind. -This irritation with accompanying injection always passed off in the -course of the day, and never resulted in severe inflammation. - -She thus found that the worm was sensitive to cold, coming to the surface -when the temperature was high, and disappearing to deeper parts when she -was exposed to cold. As soon as she had recovered strength so far as -to be able to go out of doors the visits of the worm to the eye became -fewer, perhaps a week or longer occurring between them. It usually put -in an appearance when she was near a cosy fire or in bed. Its last -disappearance was for two months, during July and August, and as she at -that time passed a worm _per rectum_ she thought she had thus got rid of -it. During these two months she was mostly in the open air, but as soon -as, in September, the rooms began to be heated, it again came to the -surface. - -When I first saw Miss H—, in June, I very thoroughly examined the eye, -but failed to observe any trace of the parasite, unless perhaps the -appearance of a minute bluish vesicle at the extreme outer angle of -the conjunctival cul-de-sac corresponded to one of the extremities of -the worm, but the vesicle, though watched for a time, did not alter in -position or appearance. I gave her strict injunctions to return at any -time whenever she felt the worm on the move. - -I saw her twice at the eye wards of the Royal Infirmary about the -beginning of July, but on these occasions careful inspection was again -negative in its results. - -On the 12th of September, however, she again came to the Infirmary, -stating that she had felt the worm moving about in the left eye that -forenoon, and to prevent it leaving the surface she had kept the eye -well covered with a warm cloth till she made her way to the Infirmary. -On this occasion, after examining the eye for a minute or two, I observed -the worm moving in a tortuous, wriggling manner under the conjunctiva, -the surface of which became slightly elevated as it moved along. - -It passed with a pretty quick movement over the surface of the sclerotic -at the distance of about 5 mm. from the outer margin of the cornea. It -glided from the upper outer towards the lower outer part of the globe. -There was increased lachrymation and slightly increased injection of the -conjunctiva,—just such an appearance as would result from a particle of -dust in the eye. - -I at once placed my finger on the surface of the globe in such a manner -as to prevent the parasite passing backwards until the conjunctiva was -pretty well anæsthetised by the application of cocaine. I then got -my friend Dr. Maddox, who was present, to apply his finger while the -necessary preparations were hastily made for an operation. - -She was placed on a couch and the speculum applied, when the pressure -of the finger having been removed the wriggling movements of the worm -were resumed, as briskly as before the application of the cocaine. I now -grasped with a pair of toothed fixing forceps a good fold of conjunctiva -over the centre of the wriggling worm, taking care to include in the fold -all structures superficial to the sclerotic. I next made with a pair of -scissors an incision through the conjunctiva a little nearer the cornea, -in such a manner as to lift up a small flap of conjunctiva, and after a -little careful separation of the tissues found one extremity of the worm, -which I seized with a pair of iris forceps. On now relaxing the fixing -forceps the parasite came away readily. No irritation or inflammation -followed the operation. - -The worm presented the appearance of a piece of fishing-gut, being -round, firm, transparent, and colourless. It wriggled slightly for a few -minutes after removal while held in the forceps, but on being placed -in a solution of boracic acid, so as to prevent it becoming dry, it -seemed completely to lose its vitality. It measured 25 mm. in length and -barely half a millimetre in breadth. It terminated rather abruptly at -one extremity, scarcely tapering at all, but at the other it gradually -tapered to a pretty sharply curved fine point. Twisted round the worm, -and apparently attached to it near its centre, was a much finer, less -firm, transparent filamentous body, which I at first thought might -possibly prove to be a second young filaria, or even the male filaria, -but which on further careful microscopical examination appears to be -the alimentary canal of the worm protruded through an opening in its -musculo-cutaneous wall, caused by the forcible grasping of the parasite -with the forceps. - -The worm after removal was, on the suggestion of Dr. Muir, Pathologist -to the Infirmary, placed in a mixture of equal parts of glycerine and -methylated spirits, but the cork of the bottle in which the mixture was -put had retained some of the blue colouring matter (methyl violet) of -a solution previously in the bottle, and thus the preservative mixture -became faintly blue-tinted. The parasite absorbed the colouring matter -slightly, but the filamentous body projecting from it absorbed it more -freely, becoming markedly blue-tinted. After remaining in the solution -between three and four weeks the parasite was carefully mounted as a -microscopic preparation in glycerine jelly by Mr. Simpson, assistant -keeper of the University Anatomical Museum. - -It is not my intention to attempt an account of the natural history -of the parasite, as I propose to submit the specimen to some special -authority in that department. - -I have had some sketches of it made by a competent artist, and these, as -well as the preparation itself under the microscope, I have pleasure in -exhibiting to you. - -It appears to me not improbable that this specimen may be found to supply -what has hitherto been a missing link, namely, the male animal. - -Since writing this I have had the opportunity of submitting the specimen -to Dr. Munson, who at once recognised it as the male worm, and has -undertaken to make a careful microscopical examination and description of -it. - - “_Report by DR. MANSON on the structure of the_ Filaria loa, - _from an examination of the specimen removed in the foregoing - case, as well as of the specimen of the same parasite exhibited - at a meeting of the Society on January 31st, 1895. The latter - filaria was removed from the eyelid of a patient by Dr. J. R. - Logan, Liverpool._— - - [Illustration: FIG. 1. - - Male. Nat. size.] - - [Illustration: FIG. 2. - - Male. × 6.] - - [Illustration: FIG. 3. - - Head of male.] - - [Illustration: FIG. 4. - - Tail of male. Dr. Logan’s.] - - [Illustration: FIG. 5. - - Tail of male. Dr. A. Robertson’s.] - - _Filaria loa: male._—Body filiform, cylindrical, measuring - from 25 mm. to 30 mm. in length, by 0·30 mm. in breadth, of - uniform thickness, except where it tapers at the head and - tail. The cephalic end tapers somewhat abruptly to the simple - mouth, which is destitute of papillæ and armature. There is - no distinctly marked neck, but there is a sort of shoulder - about 0·15 mm. behind the mouth, where a number of strong - muscular longitudinal bands originate to pass down the body. - In one of the specimens the extreme head end is retracted and - abruptly truncated, measuring at the free end 0·1 mm. across; - in the other worm this part is more conical, and in it a short - pharynx can be seen, which opens out somewhat posteriorly. - At 0·1 mm. from the mouth the diameter of the worms is 0·15 - mm.; further back, at 0·6 mm. from the month, it is 0·25 mm. - The tail end is sharply incurvated and, perhaps, excavated - ventrally; it is not spirally twisted. The tail is provided - with well-marked lateral alæ, which can be traced forwards to - a point 0·3 mm. from the tip of the tail. At the base of the - anterior papilla the tail is 0·08 mm. in diameter. There are - five well-marked papillæ on each side of the ventral surface - of the tail. The three anterior papillæ are præanal and very - large, the most anterior being the largest. The papillæ are - closely approximated, stout, and bulbous at the free end; they - measure 0·04 mm. in length by 0·022 mm. in breadth. The fourth - papilla appears to be adanal or post-anal, and is rather more - separated from the third than the three anterior papillæ are - from each other, and is distinctly nearer the middle line; it - is also considerably smaller, 0·03 mm. by 0·01 mm. The fifth - and most posterior papilla is very much smaller than the others - and differently shaped, being conical and sharp-pointed. It - measures 0·014 mm. in length by 0·005 mm. in breadth at this - base. There are two slender and unequal spicules projecting - from one of the specimens. The cuticle is not obviously - striated, but is dotted over with a number of widely scattered, - nearly hemispherical, smooth bosses, springing abruptly from - the surface. There appears to be no definite arrangement of - these bosses; at all events, if they are arranged after a - pattern this could not be discerned. The larger bosses are - found towards the middle of the parasite; at the head and tail - they are considerably smaller, and in these situations they are - more sparingly distributed. The larger measure at the base 0·12 - mm., and rise about 0·004 mm. above the general surface. The - extreme ends of the parasite are not provided with bosses, the - first met with being about 1·5 mm. from the mouth and tail-tip - respectively. - - “Owing to the opacity of the specimens the details of the - internal structure cannot be made out. In one worm, as - mentioned, a short pharynx can be seen, but its continuation - into the œsophagus cannot be traced. The prolapsed testicular - and alimentary tubes in one of the specimens are collapsed and - ribbon-like; they are about 0·09 mm. in breadth. - - “The following diagram roughly indicates what I conceive to - be the arrangement of the details of the under surface of the - tail.” - - [Illustration: FIG. 6. - - Diagrammatic.] - -In endeavouring to ascertain how the parasite entered the system I -inquired as to the water and food supply at Old Calabar, and my patient -informed me that at Iköröfiön, the mission station at which she resided, -the entire water-supply during the dry season was obtained from a spring -that bubbled up out of the ground close to the river. During the rains, -however, this spring might occasionally be covered by the swollen river, -but at that season the water-supply was derived from a tank in which the -rain was collected. The water used for drinking was always boiled, and -twice filtered. In washing her face she was specially careful to keep -her eyes well closed, and if at any time her eyes were sore she bathed -them with the drinking-water. These precautions she took, as it was a -popular belief among the natives that the worm gets access to the eyes -through the water with which the eyes are bathed. She further informed -me that the occurrence of this kind of worm in the eye is well known to -natives of Old Calabar, and they use a solution of salt and water as a -wash to scare them away. Mosquitos abounded at the station, and any water -left standing in a dish soon swarmed with their eggs. The fruit supply -consisted of mangos, Avocado pears, bananas, pineapples, oranges, and -custard-apples. No uncooked vegetables were used as food. - -She herself had seen a number of instances of the worm in the eyes of -natives, and thus knew the nature of the affection when she had it -herself. It is said in Calabar that they are very difficult to capture. -She has never heard of the parasite piercing the skin or conjunctiva. - -The ordinary guinea-worm (_Filaria medinesis_) under the skin is unknown -in Old Calabar. Miss H⸺ acted as dispenser for about a year during -the missionary’s absence, and never saw a case of it, nor heard of it -occurring during the whole of her residence there. - -As a result of inquiry I found that other members of the Old Calabar -Mission had been affected with _Filaria loa_. - -1. A lady, Mrs. M⸺, who for a time had resided with my patient at -Iköröfiön. She was in this country this year, but has returned to Old -Calabar. While in Scotland the worm was seen in her eye by my patient -Miss H⸺ and her sister, who is at present engaged in the study of -medicine. The latter saw the worm pass from the one eye to the other, -crossing the bridge of the nose under the skin. - -2. Mrs. H⸺, the widow of a medical missionary to Old Calabar. I had the -opportunity of seeing this lady, and eliciting the following particulars. - -She was three years in Old Calabar, from 1860 to 1863, at Old Town -Station. Here the water-supply was obtained from a spring which emerged -from the ground at a little distance from the river. Before use for -drinking the water was filtered through a porous stone basin, but it was -not boiled. The water for washing was not boiled or filtered, nor were -any precautions taken to prevent it coming in contact with the eyes. -During part of the time she was at Old Calabar she suffered from worm -in the eye, sometimes one, sometimes the other was affected, but never -both at the same time. She occasionally had a feeling as if the worm were -making its way under the skin at the root of the nose, in the eyelids, -or on the temple. The left eye was the one chiefly affected. She was -invalided home on account of intermittent fever. She did not suffer from -dysentery. The worms troubled her occasionally after her return home, -but they never came to the surface at a convenient time for removal till -in 1875, when her husband, Dr. H⸺, succeeded in removing a worm from her -left eye. She could not now recall the steps of the operation. About a -year later another worm was similarly removed by her husband—she thinks -from the same eye, and since then she has not experienced any symptoms of -filaria. These worms were preserved in spirits, but she fears were, after -some years, thrown away. - -As in the case of my patient, Mrs. H⸺ noticed that the worms scarcely -troubled her at all during winter. It was only in warm weather they -were lively. Both ladies occasionally noticed that the worm lay for a -short time coiled up and motionless under the conjunctiva. When the -worm appeared on the surface Mrs. H⸺ experienced a “biting, nibbling -sensation” at the part where the worm was, and the eye became tender and -watery, so that she had to keep it closed, but it never produced any -severe inflammation. When not under the conjunctiva or skin she was not -aware of its presence. - -3. The Rev. J. L⸺ went to Calabar in October, 1868, and returned in July, -1872. He often suffered from intermittent fever, on account of which he -was invalided, and by medical advice did not return. His recollection of -the time and circumstances of the appearance of the worm is now somewhat -faint, but he thinks it appeared during the latter part of his residence -in Old Calabar, and certainly troubled him after his return home. As far -as he remembers, one eye only, and he thinks the right, was affected, -but he cannot say with certainty. It only caused slight irritation, and -no severe inflammation. It affected the eyelids, he thinks, more than -the eye. He recalls one time in particular when, after preaching at -Musselburgh, he felt it wriggling under the skin of the upper lid, and -directed the attention of some friends to it, and they saw the movement -of the worm. The intervals at which it appeared were irregular, but -generally pretty long. He never felt the worm in any other part of the -body. As far as he can remember, the visits of the worm to the eye or -lids did not generally last long—at most two days. No attempt was made -to extract it, nor did any doctor see it. He has seen or felt nothing of -the worm for the last eight or nine years, at any rate. He did not notice -that the worm was influenced in its visits by the external temperature. - -In addition to these cases among members of the Old Calabar Mission, -I may refer to the experience of Dr. Thompstone, who was for eighteen -months stationed at Opobo, on the delta of the Niger, and who is in this -country at present. He informs me that while he was at Opobo he saw two -cases of _Filaria loa_. In the one negro the parasite was situated in -the lower eyelid at the inner canthus close to the lachrymal sac—the -swelling in that region giving the appearance of dacryocystitis. He tried -to press out what he considered the contents of the distended sac, when -he observed the coiled-up worm to wriggle away into the orbit, and the -swelling disappeared. - -In the other negro he observed the worm moving about under the -conjunctiva when he depressed the lower lid. The patient was affected -with slight conjunctivitis. Dr. Thompstone wished to undertake the -extraction of the parasite, but the patient declined operative -interference. While at Opobo he neither saw nor heard of other cases of -the affection. The water-supply for the native population there was very -polluted. - -The literature on this subject is very scanty. As far as I have been -able to ascertain there have hitherto not been more than twenty cases -recorded, and in most of them the accounts given have been bald and short -in the extreme. I may, therefore, be permitted to give a short _résumé_ -of what has been written regarding this filaria. - -The first case recorded appears to be that observed by M. Bajon,[1] a -French surgeon, who for twelve years practised his profession in the -island of Cayenne and in Guiana. He reports that in July, 1768, the -captain of a ship from Guadalupe brought to him a young negress about -six or seven years of age, and asked him to examine one of her eyes, in -which a small worm, about the thickness of a fine sewing thread, could -be distinctly seen. It was about two inches in length. It cruised round -about the eyeball in the cellular tissue between the conjunctiva and -sclerotic. It moved in a tortuous oblique manner. The colour of the eye -was not changed, and the young negress said she felt no pain with the -movements of the worm, but she had an almost continual watering of the -eye. - -On reflecting on the means he should employ to draw it out, he concluded -that if he made a minute aperture in the conjunctiva close to the head of -the small animal, and then stimulated it to move, it would emerge through -the opening. In carrying out this manœuvre, however, he found that in -place of escaping through the incision he had made, it passed by the side -of it, and went to the opposite surface of the eye. As this proceeding -did not succeed with him, he had recourse to the device of seizing the -worm by the middle with small forceps, along with the conjunctiva, then -making a small deep opening with a lancet by the side of its body, and -then introducing an ordinary needle, whereby he succeeded in drawing it -out doubled in two. - -Again, in 1771, another young negress, a little older than the last, -was brought to M. Bajon suffering from painful inflammation of the -conjunctiva. On examination he observed a worm a little longer than in -the previous case, and which, like it, moved round about the eye between -the conjunctiva and sclerotic. He proposed to employ the same procedure -that succeeded in the other case, but the patient would not consent. - -He considered that the worm was a dracunculus (dragonneau) similar to -those removed from other parts of the body in negroes, only finer and -shorter. - -The next case recorded is one by M. Mongin, a surgeon at St. Domingo, in -the ‘Journal de Médecine’ for 1770, occurring in a negress who had for -twenty-four hours complained of severe pain in the eye with scarcely any -inflammation. - -At first glance he saw a worm, which appeared to him to wriggle over the -globe, but on trying to seize it with forceps he found it to be between -the conjunctiva and sclerotic. - -To remove it he incised the conjunctiva, and it emerged through the -opening. It was one and a half inches long, and the thickness of a violin -string, and of an ashy colour. It was larger at one end than at the -other, and very pointed at the two extremities. He was inclined to view -it as a worm of the blood (_ver sanguin_), as it did not appear to him -possible for it otherwise to get into that position without giving rise -to pain and inflammation at the part. - -We have next several cases that were carefully observed and recorded by -M. Guyot, a French surgeon,[2] who had made many voyages to the Angola -coast of West Africa. The first case in which he discovered the filaria -was that of a negress in whom, after several examinations, he noticed a -ridge of the conjunctiva resembling a varicose vein, which induced him -to make minute openings over it to empty it. On pricking the elevated -conjunctiva with the point of a lancet he was surprised to observe the -projection disappear. The patient at the same time stated that she -felt something move in her eye, and that the movement was deep-seated. -He suspected that this could be nothing else than a roving worm (_ver -ambulant_), which sometimes appeared under the conjunctiva, sometimes -dived into the posterior parts of the eye. From inquiry he found that a -worm in the eye was common enough among natives of that land, and that -it was called a “loa,” and he consequently applied the term filaria loa -to the affection. He saw the worm on many occasions in the eye of the -negress, but whenever he touched the spot where it was it retreated to -the posterior parts of the orbit. On that voyage he saw several negroes -with this affection, for which he employed various collyria without -effect. - -In 1777 he made another voyage to the coast of Angola. Having many -negroes on board the ship he renewed his researches, and found several -individuals affected with the disease. As no benefit had been derived -from the applications he had previously used he proposed to extract the -worm through a small opening in the conjunctiva. To effect this it was -necessary to fix the worm, to which end he employed dissecting forceps, -without, however, being able to seize it. - -On another occasion he employed a ligature needle of medium size, with -which he pierced the conjunctiva by the side of the worm, and passed it -between the worm and the sclerotic, making it emerge at the opposite -side. By this manœuvre he was able to raise the fold of conjunctiva along -with the worm on the concavity of the needle. This fold he divided, and -drew out the worm without mutilation. The operation required to be done -very quickly, otherwise the worm escaped and disappeared, sometimes -for a very long time. Of five negroes upon whom he thus operated he -was only able to remove the worm twice. The worms were about fifteen -lines in length, and a little less thick than a violin string. He did -not think the worms were a species of dracunculus, for they were quite -white, firmer, and less long in proportion. He never saw the worm make an -opening for itself. In the seven voyages he had made to the Angola coast -he had never seen a negro affected with dracunculus. Other surgeons who -had sailed on these coasts assured him they also had seen no cases, which -made him conclude that the negroes of that country are not subject to -dracunculus. The cases on which he operated were healed in twenty-four -hours. - -We next find M. Clot at a meeting of the Académie Royale des Sciences -in December, 1832, referring to the case of a negress, who suffered -from a dracunculus under the conjunctiva of the eye. It appeared now -and then gliding between the conjunctiva and sclerotic, lifting up the -conjunctiva. This case appears to be one that was seen by Dr. Roulin at -Monpox in America. - -Another case is mentioned by Dr. Sigaud in his work on the ‘Climate and -Diseases of Brazil.’ He states he was witness in 1833 of the extraction, -by M. dos Santos, of a filaria situated in the orbit on the surface of -the sclerotic of a negress. - -In 1838 Dr. Guyon made an interesting communication to the French Academy -of Sciences, in which he narrated the case of a young negress affected -with two filariæ, one in the right and the other in the left eye, but -occasionally both appeared in the same eye; the passage of the worm -from the one eye to the other occurring with great rapidity through the -cellular tissue under the skin at the root of the nose. The filariæ were -in different eyes when the operator (Dr. Blot of Martinique) extracted -the filaria from the left. Some hours after, when he returned to extract -the other worm, he found that it had passed to the left eye, from which -he extracted it by a fresh incision. - -The first cases reported by an English surgeon were by Dr. Loney, a naval -surgeon, occurring in two Kroomen, whom he saw while cruising on the West -Coast of Africa during 1841-2. In both he succeeded in extracting the -parasite.[3] - -Another case was observed by Dr. Mitchell at Trinidad in the person of a -young negress, in whom the worm appeared at long and uncertain intervals -for four or five years before he had the opportunity of seeing it. At -length in 1845 Dr. Mitchell saw the worm twisted like the letter S lying -motionless under the conjunctiva, midway between the edge of the cornea -and the inner canthus. Extraction of the worm was deferred to enable six -or seven of his medical brethren to observe so unusual an appearance, -with the result that when they assembled the following morning the -parasite had removed itself to deeper parts.[4] - -A case is also recorded by Gervais and van Beneden,[5] in which M. -Lestrille succeeded in 1854 in extracting a filaria from a negress, and -Dr. Guyon once more, at a meeting of the French Academy of Sciences in -1864, exhibited another filaria, which had been removed by a French -naval surgeon from a negro of the Gaboon. The filaria was of unusual -size, measuring fifteen centimetres. Its length was such that the whole -of it could not be seen at one time below the conjunctiva, part always -remaining embedded in the deeper parts of the orbit.[6] - -Dr. Morton[7] reports a case occurring in a negress residing at Gaboon -in West Africa, in which a native woman succeeded in extracting the -parasite. The worm, preserved in gin, had been sent to him by a -missionary, the Rev. Dr. Nassau, in the district, who informed him that -although he had been very many years in that country, and had often heard -of the parasite, this was the first specimen he had been able to secure. -The missionary himself appeared to be also affected with filaria, which, -however, did not appear on the eye, but could, he said, occasionally be -felt under the skin of the fingers, and once in the skin of the lower -eyelid, from which position he attempted himself to remove it with -scalpel and forceps, but he did not succeed, the worm wriggling away -across his cheek. The worm that was sent to Dr. Morton measured 16 mm., -but was in too badly preserved a state to permit of accurate examination. - -Lastly, in Dr. Davidson’s work on hygiene and diseases of warm climates -(p. 962) Dr. Manson, who writes the article on filaria, reports the case -of a negro who had been affected with _Filaria loa_, and in whose blood -he afterwards found the _Filaria diurna_, and raises the question whether -the _Filaria loa_ may not turn out to be the female parental form of the -_Filaria diurna_. - -I am afraid we must confess that we are as yet very ignorant of many -points connected with the life history of the _Filaria loa_. With the -adult female parasite we have a limited acquaintance, but till now we -are ignorant of the appearance of the male worm. The larvæ have been -observed in the interior of the adult, but what their further course is, -what transmigration may occur, ere they reappear as fully formed filariæ -under the conjunctiva has yet to be discovered. The only observation that -bears at all upon this question is that made by Dr. Manson and reported -in Dr. Davidson’s work, that in one case of _Filaria loa_, the _Filaria -diurna_ was afterwards found in the blood. With the view of ascertaining -whether the _Filaria diurna_ was present in the blood of my patient -Miss H⸺, and also with the view of getting a report as to her general -medical condition, I got my friend Dr. Alexander Bruce to undertake the -examination. - -It must, however, be borne in mind that in her case the filaria removed -proves to be a male, and, unless she were affected with the female -parasite as well, no embryos could be expected in the blood. - - _Report by Dr. Alexander Bruce, October 16th, 1894._—“Miss H⸺, - missionary to Old Calabar, went there at the age of twenty-two, - has been out there ten years altogether; first was out for two - years, then furloughed for one year on account of an attack - of intermittent fever which turned her hair grey, but was not - otherwise very severe in type. Then she was out for four years - and home for one year on furlough. Then was out for seventeen - months, invalided home in January, 1894, for remittent fever, - gastritis, and a form of dysentery and great anæmia. The - remittent fever began in December, 1893, with delirium at - beginning, and fever which rose daily to 102° and 103° F. - She was sent to sea in ten days, and on the way home the - temperature on one occasion rose to 107°; this was reduced by - ice-pack. Improvement was slow, being retarded by the gastritis - and dysentery, and the tendency to pyrexia did not abate till - the end of June. The gastritis was indicated by intense pain - (agony, she called it) in swallowing anything, whether solid or - fluid. The bowels now move only once daily or less frequently, - and the motions are accompanied by small flakes of mucus - (formerly by blood). There was always great mental depression - during the attacks of dysentery. - - “The arms became, since June, stiff and swollen, especially on - awakening from sleep (whether at night or during the day), and - the hands felt ‘numb,’ ‘dead,’ ‘as if asleep,’ or ‘as if they - didn’t belong to her.’ - - “She was so weak that she had to remain in bed till the - beginning of April. Since then, after a visit to Crieff, she - has improved rapidly, and can now walk two or three miles - easily. She now has a fairly good colour, has good appetite, - and no pain in the stomach. Examination of the circulatory - system shows absolutely nothing abnormal, no dilatation of - the ventricles, no arterial, valvular, or venous bruits. The - respiratory murmurs and the percussion note of the lungs are - normal. The liver is not, and the spleen is, just appreciably - enlarged. The blood flows readily from a prick in the finger; - it is rich red in colour. The red corpuscles are well-coloured, - well-formed, and form rouleaux readily. There is a slight - increase in the white corpuscles. Specimens of the blood drawn - at 9 a.m., 8 p.m., 9 p.m., 1 p.m., and dried on the slide - showed no evidence of filaria of any kind. - - “The forearms presented, on the anterior and posterior aspects, - slight flattened doughy swellings, which had no definite - boundary and were not painful to pressure. There was no - alteration in the colour of the skin over them.” - -We are still at a loss to account for the entrance of the worm into -the body. There are, I think, two different channels by which it might -possibly find access. First, by the passage of the embryo filariæ -directly through the conjunctiva, being brought in contact with the eye -in water used for washing the face or bathing the eye. This I think an -unlikely means of entrance, as in my patient special pains were taken to -avoid such a possibility, and yet she became affected with the disease, -and the power of the worm to penetrate skin or mucous membrane has never -been demonstrated. Second, by the swallowing of the embryo filariæ along -with articles of food or drink. Although in the case of my patient -excellent measures were taken to secure the purity of the water-supply, -and although the nature of the food was such as not readily to lend -itself to the conveyance of impurities, still I think recent researches, -made more particularly by Dr. Manson with regard to the development of -the _Filaria sanguinis_, render it probable that the ova of the _Filaria -loa_ are, as suggested by Dr. Manson, taken into the circulation of the -patient affected by the mature female parasite. That then some insect of -predatory habits, drawing its food-supply from this polluted stream, -becomes, in its turn, the host which supplies the necessary elements for -the further development of the parasite. This insect, in its turn dying, -deposits the embryo filariæ in water, which, being used for drinking -purposes, permits the parasite once more to affect man. Which the insect -is that probably plays the part of intermediate host is as yet unknown. -This view is purely hypothetical, but I think, reasoning from analogy, -the most probable one of the development of the _Filaria loa_. - -The geographical distribution of this parasite appears to be a very -limited one, as almost all, if not all, of the persons affected, whose -cases have been reported, have either been natives of or been long -resident on a limited area of the West Coast of Africa, including -Congoland and Old Calabar. If Dr. Manson’s view as to the mode of -development of the worm be substantiated, then naturally the area of -the disease must necessarily be limited to the regions in which the -intermediate insect host is to be found. - -The fully grown worm may, judging by some of the cases recorded, infest -the human subject for a good many years, and may yet not give rise to -any very serious symptoms. It possesses very considerable locomotive -powers. It is capable of wandering at will from one eye to the other, to -disappear into the deeper parts of the orbit, to wander under the skin of -the eyelids, and even to make excursions in the temporal region. These -seem to be the limits of its excursions. No doubt the Rev. Dr. Nassau -(the missionary at the Gaboon) had sometimes sensations of a filaria -under the skin of the fingers as well as under the skin of the eyelid, -but it is doubtful if this was a true case of _Filaria loa_, and even -then if the worm had made its way from the fingers to the eyelid. At the -same time it must be borne in mind that there are few regions of the body -in which the skin is so thin as in the eyelids, whereby the presence of -a small filamentous body can easily be discerned. The parasite might -readily move about under the coarser cutis of other parts and yet escape -detection. - -The sensitiveness of the parasite to cold appears to be fully established -by the experience of my patient and Mrs. H⸺, and it is possible that a -prolonged residence in a cool climate may eventually prove fatal to the -worm, as seems to have occurred in the case of the Rev. J. L⸺. All the -cases previously recorded have occurred in negroes, but those I have -brought forward prove that Europeans are also susceptible to the attacks -of this worm. - -I think I am warranted in saying that the disease is not very rare in -the district favoured by the parasite, as, although the number of cases -reported is small, the irregular intervals at which the worm comes to -the surface, and the slight irritation or annoyance its presence causes, -often prevent those affected seeking surgical advice; while it must be -admitted that medical assistance is not very readily procured in large -parts of the district where cases occur. - -The interest connected with the elucidation of the obscure points in -the natural history of the worm will, I trust, stimulate those of our -profession residing on the West Coast of Africa to undertake the further -necessary investigations. - - * * * * * - -Remarks by Dr. PATRICK MANSON.—I have no hesitation in saying that I -consider the communication to which we have just listened from the -President to be one of the most important on the subject of filaria -loa that has been made for many years. Two or three years ago I had -an opportunity of examining the blood of a number of negroes from Old -Calabar in a missionary establishment and elsewhere, and I made the -interesting discovery that in 50 per cent. the blood contained the -embryos of a species of filaria—_Filaria perstans_—which were quite -different in their zoological characters from the filaria of the blood, -with which every one must now be familiar. While examining one of these -patients whose blood contained this new species of filaria I found -another species of bloodworm, whose anatomical features were similar -to those of the ordinary _Filaria sanguinis_, but which presented a -very great difference physiologically, inasmuch as contrary to what is -observed with the ordinary filaria, this one disappears at night and can -only be found in the blood during the daytime. This second new bloodworm -I therefore called _Filaria diurna_. Some time later, in a communication -which I had from Professor Leuckart, he told me he had been enabled to -examine the embryos in the uterus of an adult _Filaria loa_, and he sent -me a sketch of these embryos. On comparing this sketch with the _Filaria -diurna_, I came to the conclusion that they were practically identical, -and therefore that the filaria I had found in the blood of the negroes -might possibly be the embryos of _Filaria loa_. This opinion appeared to -me to be strengthened by the fact that this patient had previously had -a loa under the conjunctiva. I have very little doubt that the embryo -of _Filaria loa_ finds its way into the blood. Clinically, there is no -evidence of its attempting to find its way to the surface of the body, -and it is evident that there must be some arrangement by which it can -get out of the body, and so propagate its species by passing from one -person to another. From this and other considerations I consider that -it must be by way of the blood that the necessary escape is effected. -With the ordinary filaria it is now well known that the mosquito removes -it from the blood and acts the part of intermediate host, and I suppose -that a similar arrangement must exist in respect of the _Filaria loa_. On -inquiring of the Old Calabar negroes as to the blood-sucking insects of -the district, I learned that there was a particular fly which exists in -great numbers about the creeks, and was very annoying on account of its -pertinacity. I think this insect, which is also diurnal in its habits, -is probably the intermediate host for the _Filaria loa_, us the mosquito -is for the ordinary filaria. I do not believe that this individual worm -was the only _Filaria loa_ in the body of the patient whose history -we have just listened to. It became visible simply because it wandered -to a spot where it could be seen; elsewhere in the connective tissue -I opine there are others. The patient was first seen in February, and -whether sufficient time has intervened for the maturation of these -parasites and the evolution of their embryos I cannot say. None, it is -true, were found in the blood, but the specimen was a male, and from this -it is impossible to say what the degree of maturity the embryos of any -females present may be. I think the blood should be examined again, and -I would suggest that if possible a similar examination should be made -of the other members of the mission, and of the patients the President -referred to. The locomotive habits and sensibility to cold of this -parasite are particularly interesting in respect of the way in which -they subserve its interests, on which they certainly have a bearing. -The measurements of the _Filaria loa_ usually given, as ascertained -by looking over the literature of the subject, are from 17 mm. to 70 -mm. The smaller measurements are explained by the author’s case; they -apply presumably to the male parasite, which in the filaridæ is almost -invariably smaller than the female. One measurement given, 15 cm., is -so enormous that I question the accuracy of the observation, or, if the -measurement were exact, it must have referred to some other parasite -than _Filaria loa_. With respect to the nature of the protrusions from -the body of the parasite under the microscope, one of them is certainly -the alimentary canal; the other is probably the testis ruptured in two. -One must be careful in coming to a conclusion about these and similar -connective-tissue parasites. There are four or five whose young inhabit -the human blood; and there are others whose young appear to have a -different history. Especially in West Africa do we find such parasites. -There is the guinea-worm, said, however, not to be found in Old Calabar; -it certainly is found in the neighbourhood; its name signifies an African -origin. There is the _Filaria perstans_, the _Filaria nocturna_, and -also a very minute bloodworm, _Filaria demarquayi_, the parental form -of which, as of _F. perstans_, has not yet been found. There is the -_Filaria volvulus_, which resembles the _Filaria loa_, in that it lives -in the subcutaneous cellular tissue. Not long ago Professor Magalhães, -of Rio Janeiro, described a species of filaria which he found in the -left ventricle of the heart, which is also probably a new species. It -follows, therefore, that before venturing on the diagnosis from specimens -of parasites found in the blood or connective tissues, usually more or -less mutilated, one requires to be very careful. One singular fact about -the _Filaria loa_ is that it will not live in the West Indies. It has -been introduced many times, but does not spread. It has been removed -from the eye there from imported negro slaves, but it has not become -acclimatised. In this respect it resembles very closely the _Filaria -medinensis_ (guinea-worm), which was introduced times without number -during the days of slave importation into the West Indies, yet it has -died out altogether except in one or two places, the island Curaçao and -a limited district in Brazil. This undoubtedly is in consequence of one -of two things; either the habits of the people, or the absence of the -proper intermediate host. In respect of the guinea-worm the intermediate -host is a fresh-water cyclops. I recently had a case in the Seamen’s -Hospital from which I was enabled to procure the embryos. This enabled -me to carry out some experiments which I would urge upon those who have -the opportunity to repeat. When the guinea-worm arrives at maturity a -little vesicle or bulla is formed on the ankle or foot. The vesicle -ruptures, and on careful examination you will see a small orifice in -the centre in which sometimes the head of the worm may be seen, but not -always. If you take a sponge and drop some cold water, not on, but in the -neighbourhood of this orifice, you will see the hole become filled with -a white grumous material, which under the microscope, and on adding a -little water, is seen to be a wriggling, writhing mass of embryos. The -application of water to the leg after an interval may lead to further -extrusion of embryos. This is a striking illustration of the curious way -nature has adapted the habits of the guinea-worm to its requirements. -The young guinea-worm lives in water, and probably for this reason the -mature worm descends to the feet or ankles, the parts of the human body -in tropical countries most often within reach of water. Having procured -in this way a supply of embryos, I tried to repeat the experiment -described by the Russian naturalist, Fedschenko, on the metamorphosis -of the embryos of the guinea-worm in its intermediate host. I obtained -some fresh-water cyclops and placed them in water with the embryos. After -five or six hours I took one of the cyclops and placed it under the -microscope, and I found the body-cavity to contain twenty or thirty of -the living and moving embryos. The next day, however, the cyclops were -all dead, but the contained embryos were all lively. Having still one or -two of the cyclops left I repeated the experiment, but, proceeding more -cautiously, placed only a few of the embryos in the water along with the -cyclops. After a few hours I removed the cyclops, and found that each -of them had two or three guinea-worm embryos coiled up or moving about -in their insides. Two of the cyclops I kept alive; one lived sixteen -days and the other five weeks, and during this time the embryos could -be seen moving and developing. At the end of five weeks I killed the -cyclops, and I found the guinea-worm embryos had undergone a certain -degree of development. The outer cuticle of the embryo had separated a -good deal from the body—ecdysis, and there were certain changes in the -alimentary canal. I have no doubt that had the cyclops been in a normal -condition as regards exposure to light and sun, the metamorphosis of the -guinea-worm inside the cyclops would have been completed. This shows -that it would be possible to introduce the guinea-worm into England if -we did not wear boots or shoes, and if we were in the habit of wading -about in pools and marshes as do the natives of West Africa. There would -be a discharge of the embryos into the water, and if less care were -taken about the purity of the water-supply, and supposing there to be no -adverse climatic influences, the worm would become common. This little -story about guinea-worms shows how these and similar parasites pass from -one man to another; and it shows how slight differences of habit, absence -of intermediate host, and so on, govern the distribution of a parasite -like _Filaria loa_. If you examine this _Filaria loa_ exhibited by the -President under the microscope, you will see that all over the skin there -are minute but regular bosses or protuberances. This occurs in certain -filariæ, but in no other human species so far as I am aware. These -protuberances, I have no doubt, have a bearing on the locomotive habits -of this particular parasite. I pass round a reproduction by Blanchard -from a book which carries us back a century further in the history of the -_Filaria loa_ than that given by Dr. Robertson. This book was written -by Pigafetta,[8] and it contains a picture showing a man drawing a -guinea-worm out of his leg, and a woman having a worm removed from the -eye, doubtless a _Filaria loa_. - - -FOOTNOTES - -[1] Bajon’s ‘Mémoire pour servir à l’histoire de Cayenne et de la -Guyane,’ t. 1er, p. 325, 1777. - -[2] Arrachart, ‘Mémoires, dissertations de Chirurgie, et observations de -Chirurgie,’ 1805, p. 228. - -[3] ‘Lancet,’ vol. i, 1844, p. 309. - -[4] Ibid., Nov. 26th, 1859. - -[5] ‘Zoologie médicale,’ 1859, vol. ii, p. 143. - -[6] ‘Annales d’Oculistique,’ 1864, p. 241. - -[7] ‘American Journal of the Med. Sciences,’ 1877, vol. lxxiv, p. 113. - -[8] ‘Vera descriptio regni africani, quod tam ab incolis quam Lusitanis -Congus appellatur,’ Frankfort, 1598. - - - - -[Illustration: PLATE VII - -Illustrates Dr. Argyll Robertson’s paper on Filaria loa. - -FEMALE FILARIA LOA. - -FIG. 1.—The whole worm. Portions of alimentary canal and uterine tube -protruding through an opening in the wall of the parasite. - -FIG. 2.—A portion of uterine tube, highly magnified, showing embryo -filariæ in interior. - -FIG. 3.—Head of worm, with rounded projection of wall of worm at one -point, due to injury. - -FIG. 4.—Part of worm where rupture of wall occurred. _a._ Alimentary -canal. _b._ Uterine tube with embryo filariæ.] - - - - -FURTHER NOTE OF CASE OF FILARIA LOA. - -_Read at the Meeting of the Ophthalmological Society on March 14th, 1895._ - -By D. ARGYLL ROBERTSON. - -(With Plate VII.) - - -At a meeting of this Society on the 18th of October last I narrated the -case of a patient, Miss H⸺, affected with _Filaria loa_, and I exhibited -a male worm which I had removed from under the conjunctiva of her left -eye. I purpose now to give a short account of the further history of that -patient, and a description of a female _Filaria loa_ which I succeeded in -removing from her right upper eyelid. - -After the removal of the filaria from under the conjunctiva, Miss H⸺ -was not troubled with the sensations she associates with the presence -of a worm for a period of about six weeks, when again she experienced -a burrowing sensation at the back of her left eye. It affected her at -intervals, and especially when she was occupying a hot room. - -On the 3rd of February she distinctly felt a worm moving about in her -left upper eyelid, and came at once to me, but before she arrived this -feeling had gone, and I failed to discover any signs of the parasite. She -returned on the 6th of February with the statement that not only had she -felt the worm moving about in the left lower lid, but that it had also -been distinctly seen wriggling under the skin. I saw her three different -times that day, but failed to observe anything that might indicate with -certainty the presence of a parasite, although she sat in front of a -hot fire and had a succession of hot poultices applied, so as to tempt -the worm to the surface. On the third visit, as she felt the wriggling -of the worm, and as there seemed to be a little fulness at one point in -the left lower lid, I decided to cut down at that point and search for -the parasite. This I did with Dr. Mackay’s assistance, having first of -all applied clamp-forceps so as to prevent the worm escaping if it were -there. I failed to find any parasite, although I made a careful search, -and the patient showed great nerve and steadiness under operation, but I -noticed a distinct narrow channel or burrow parallel to the edge of the -lid, and crossing about the middle of it, which gave me the impression of -being a burrow by which the worm had moved across the lid. - -Two days later Miss H⸺ came complaining of a swelling in the right -temporal region. This swelling seemed pretty deeply situated, and firm -palpation failed to reveal any corded feeling such as might indicate the -presence of a worm. - -On the 13th of February she felt the worm wriggling across the right -upper eyelid, and then it appeared to her to remain coiled up under the -skin. She bound the eye carefully up and came at once to the infirmary. -I examined the lid and noticed a fulness at the upper inner part, which -might be a coiled-up worm. By pressure of the fingers I attempted to -force the swelling towards the edge of the lid, but I could neither -see nor feel any movement such as might be expected from the presence -of a worm. As, however, the patient’s sensations were very distinct, I -determined to make an exploratory incision. I applied the clamp-forceps -and made a free incision over the region of the swelling, but found -the chief cause of the fulness to be a small deposit of fat, which I -cut away, and then proceeded to explore the neighbourhood carefully. -After some dissection I found a very fine transparent filamentous -body. On drawing upon it with forceps it came away with a snap. It -was much smaller in calibre and shorter than the usual _Filaria loa_, -and I concluded that it was only a portion of a filaria—the main part -being caught between the blades of the clamp-forceps. The forceps -being removed, further exploration was made, in which I was assisted -by Dr. Mackay, and after some dissection a well-marked _Filaria loa_ -was discovered deeply embedded in the muscular tissue and removed with -forceps. The edges of the incision were brought together by a couple of -fine sutures, and healing occurred by first intention. - -The worm thus removed measured about 30 mm. in length and nearly 1 -mm. in thickness. It was firm and transparent like a small piece of -fishing-gut. It tapered at either extremity to a blunt point, the tail -being rather sharper-pointed than the head. At the distance of about 9 -mm. from the caudal end an opening existed in the wall of the parasite, -through which protruded a filamentous coil, which subsequent microscopic -examination revealed to be the uterine tubes filled with ova in all -stages of development up to embryo filariæ. Notwithstanding the amount -protruded, the interior of the parasite was yet to a great extent -occupied by oviduct, the alimentary canal being apparently comparatively -small in size. The wall seemed to be chiefly composed of muscular fibre, -the transverse striæ of which were readily visible at all parts. The -semicircular projecting tubercles, which Dr. Manson is inclined to -view as serving to facilitate the gliding movements of the parasite by -enabling it to get a purchase on surrounding parts, were very numerous -towards the caudal end, fewer in number at the centre, and very sparsely -distributed at the head extremity. Near the oral end of the worm a small -general projection of the wall existed on one side, probably due to a -partial rupture produced by injury. - -The small piece of the worm I first removed in the course of the -operation proved on microscopic examination to be part of the oviduct -containing embryo filariæ. - -I will submit my specimen for more careful and thorough examination and -report to Dr. Manson, who is entitled to speak with such authority on -this subject. - -During the last six months I have at intervals examined blood drawn from -Miss H⸺ at various periods of day and night, but have never been able to -discover the presence of any filariæ. - -My patient has several times directed my attention to ill-defined -swellings under the skin of the forearms a little above the wrists, over -the dorsal surface of the radius, more marked generally in the right arm. -The surface of the swellings was not quite uniform, but did not give one -the idea of being produced by a coiled-up worm. The swellings measured -about half an inch in diameter. They were not painful, but occasioned a -feeling of stiffness when the arms were used. The swellings occurred at -irregular intervals, and were generally most marked in the mornings. Cold -had no influence in dispelling them; on the contrary, the application of -cold water on one or two occasions seemed to bring the swellings forward. - -My patient informs me that natives of Calabar, and others resident for a -time there, are subject to such swellings in the forearms and wrists, to -which the natives apply the term “Ndi töt,” or swelling. These swellings -she has only suffered from since her return home. - -I have further a correction to make in the history of my patient I -previously submitted. It would appear that while she was most careful -with regard to the purification of her drinking-water by boiling -and filtering, she was for ten days prior to leaving Old Calabar so -completely prostrated as to be unable to attend to any household matters, -and the person who undertook her duties was unacquainted with the -procedure employed for purifying the water. It might thus readily happen -that she at that time partook of impure water containing embryo filariæ. -As she had no symptoms of filaria till after her return home, this -_might_ explain their entrance into her system. - -It is easy to understand how the embryo filariæ may enter the system, -although their presence in impure water has not yet been demonstrated. -And it is easy to conceive that, having entered the system from the -alimentary canal, they may breed and bring forth a large crop of embryo -parasites. But the chief difficulty consists in determining how these -embryo filariæ escape from the bodies of those affected with the disease, -and get deposited in the impure water and thus propagate the disease. - -In the case of the _Filaria sanguinis_ this is accomplished by the -mosquito which constitutes the intermediate host; but as in the case of -my patient, as well as in the case reported by Dr. Logan of Liverpool, -careful examination of the blood failed to reveal the presence of embryo -filariæ, some other system of propagation than that by blood-sucking -insects must be looked for. Possibly the embryo parasites may be -discharged along with some of the excreta from the body, and from faulty -sanitary arrangements find their way into drinking-water. Whether this be -so or not, future investigation will probably show. - - * * * * * - -_Report on the structure of the female parasite_ (by Dr. MANSON).—Female -_Filaria loa_: length, 3·25 cm.; breadth, 0·5 mm.; ova at morula stage, -0·03 by 0·02 mm.; length of outstretched embryos in uterus, 0·25 mm. - -As regards her general appearance, the female _Filaria loa_ resembles the -male parasite, only she is considerably larger and her tail is straight, -tapers to a diameter of about 0·1 mm., and is then abruptly truncated. -The mouth, the head, the stout muscular ring just posterior to the mouth, -the stout longitudinal muscular bands, and the bosses on the integument -resemble exactly those of the male worm. In consequence of the mutilation -of the specimen it is impossible to say where the vagina opens, or where -the anus is placed. The uterine tubes are stuffed with embryos at all -stages of development. The more mature embryos resemble in size and shape -those of _F. nocturna_ and _F. diurna_, but in consequence of the method -of mounting it is impossible to say if they are possessed of a sheath -or not. If they are possessed of a sheath, I should say that they are -practically indistinguishable from the parasites mentioned. - - - PRINTED BY ADLARD AND SON, - BARTHOLOMEW CLOSE, E.C., AND 20, HANOVER SQUARE, W. - -*** END OF THE PROJECT GUTENBERG EBOOK CASE OF FILARIA LOA *** - -Updated editions will replace the previous one--the old editions will -be renamed. - -Creating the works from print editions not protected by U.S. copyright -law means that no one owns a United States copyright in these works, -so the Foundation (and you!) can copy and distribute it in the -United States without permission and without paying copyright -royalties. 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Argyll Robertson</p> -<div style='display:block; margin:1em 0'> -This eBook is for the use of anyone anywhere in the United States and -most other parts of the world at no cost and with almost no restrictions -whatsoever. You may copy it, give it away or re-use it under the terms -of the Project Gutenberg License included with this eBook or online -at <a href="https://www.gutenberg.org">www.gutenberg.org</a>. If you -are not located in the United States, you will have to check the laws of the -country where you are located before using this eBook. -</div> - -<p style='display:block; margin-top:1em; margin-bottom:1em; margin-left:2em; text-indent:-2em'>Title: Case of Filaria loa</p> -<p style='display:block; margin-top:1em; margin-bottom:0; margin-left:2em; text-indent:-2em'>Author: D. Argyll Robertson</p> -<p style='display:block; text-indent:0; margin:1em 0'>Release Date: February 1, 2023 [eBook #69927]</p> -<p style='display:block; text-indent:0; margin:1em 0'>Language: English</p> - <p style='display:block; margin-top:1em; margin-bottom:0; margin-left:2em; text-indent:-2em; text-align:left'>Produced by: deaurider and the Online Distributed Proofreading Team at https://www.pgdp.net (This file was produced from images generously made available by The Internet Archive)</p> -<div style='margin-top:2em; margin-bottom:4em'>*** START OF THE PROJECT GUTENBERG EBOOK CASE OF FILARIA LOA ***</div> - -<p><span class="pagenum"><a id="Page_1"></a>[1]</span></p> - -<h1>CASE OF FILARIA LOA.</h1> - -<p class="titlepage larger"><span class="smaller">BY</span><br> -<span class="smcap">D. ARGYLL ROBERTSON, M.D., F.R.C.S.Ed.</span>,<br> -<span class="smaller">OCULIST TO H.M. THE QUEEN IN SCOTLAND; PRESIDENT OF THE<br> -OPHTHALMOLOGICAL SOCIETY OF THE UNITED KINGDOM; LECTURER ON<br> -DISEASES OF THE EYE IN THE UNIVERSITY OF EDINBURGH, ETC.</span></p> - -<p class="titlepage"><i>Reprinted from the ‘Transactions of the Ophthalmological Society.’</i></p> - -<p class="titlepage"><span class="smaller">LONDON:</span><br> -<span class="larger">PRINTED BY ADLARD AND SON,</span><br> -<span class="smcap">BARTHOLOMEW CLOSE, E.C., and 20, HANOVER SQUARE, W.</span><br> -1895.</p> - -<hr class="chap x-ebookmaker-drop"> - -<div class="figcenter illowp50" id="plate6" style="max-width: 93.75em;"> - <p class="caption">PLATE VI</p> - <p class="caption">Illustrates Dr. Argyll Robertson’s paper on Filaria loa.</p> - <img class="w100" src="images/plate6.jpg" alt=""> - <p class="caption"><span class="smcap">Male Filaria Loa.</span></p> - <p class="caption2"><span class="smcap">Fig. 1.</span>—The whole worm. - Portions of the testicles and alimentary canal protruding through a - rupture of the wall of the parasite.</p> - <p class="caption2"><span class="smcap">Fig. 2.</span>—The head of the worm.</p> - <p class="caption2"><span class="smcap">Fig. 3.</span>—The curved tail of - the worm with its papillæ.</p> - <p class="caption2"><span class="smcap">Fig. 4.</span>—The ruptured part of - the worm with protruding alimentary canal and testes.</p> -</div> - -<hr class="chap x-ebookmaker-drop"> - -<div class="chapter"> - -<h2 class="nobreak">Communication read at the Meeting of the Ophthalmological -Society on October 18th, 1894.</h2> - -<p class="center larger"><i>Case of <span class="antiqua">Filaria loa</span>, in which the parasite was removed -from under the conjunctiva.</i></p> - -<p class="center larger">By <span class="smcap">D. Argyll Robertson</span>.</p> - -<p class="center larger">(With <a href="#plate6">Plate VI</a>.)</p> - -</div> - -<p>On the 29th of June last I was consulted by Miss -J. H⸺ on account of what she termed the presence of a -worm in her eye.</p> - -<p>She is a slightly anæmic, prematurely grey-haired, but -otherwise healthy-looking lady, thirty-two years of age. -She has resided at Old Calabar on the West Coast of -Africa at intervals, for nearly eight years altogether. She -twice had to return home on account of debility following -severe intermittent fever. During her last visit to Old -Calabar, which extended to about eighteen months, she -suffered almost the whole time from chronic dysentery -followed by severe remittent fever, which necessitated her -return to this country last January in a very weak state -of health.</p> - -<p>She stated that the worm was first observed by her in -February of this year, immediately after her return home. -It frequented both eyes, but showed a preference for the -left one, sometimes coursing over the surface of the eye -under the conjunctiva, sometimes wriggling under the -skin of the eyelids—causing a tickling, irritating sensation, -but not real pain. It had latterly restricted its -visits entirely to the left eye. On account of the remittent -fever from which she was still suffering, her bedroom, -when she first came home, was kept well heated, and until<span class="pagenum"><a id="Page_2"></a>[2]</span> -she recovered from the fever she noticed that the worm -was particularly lively, occasionally causing the eye to -become bloodshot, and the eyelids to swell and blacken -slightly. As long as she was confined to warm rooms the -worm was almost constantly moving about in the neighbourhood -of the eye, causing such irritation as to prevent -reading or work of any kind. This irritation with -accompanying injection always passed off in the course of -the day, and never resulted in severe inflammation.</p> - -<p>She thus found that the worm was sensitive to cold, -coming to the surface when the temperature was high, and -disappearing to deeper parts when she was exposed to cold. -As soon as she had recovered strength so far as to be able -to go out of doors the visits of the worm to the eye became -fewer, perhaps a week or longer occurring between -them. It usually put in an appearance when she was -near a cosy fire or in bed. Its last disappearance was -for two months, during July and August, and as she at -that time passed a worm <i>per rectum</i> she thought she had -thus got rid of it. During these two months she was -mostly in the open air, but as soon as, in September, the -rooms began to be heated, it again came to the surface.</p> - -<p>When I first saw Miss H—, in June, I very thoroughly -examined the eye, but failed to observe any trace of the -parasite, unless perhaps the appearance of a minute -bluish vesicle at the extreme outer angle of the conjunctival -cul-de-sac corresponded to one of the extremities of -the worm, but the vesicle, though watched for a time, did -not alter in position or appearance. I gave her strict -injunctions to return at any time whenever she felt the -worm on the move.</p> - -<p>I saw her twice at the eye wards of the Royal -Infirmary about the beginning of July, but on these occasions -careful inspection was again negative in its results.</p> - -<p>On the 12th of September, however, she again came -to the Infirmary, stating that she had felt the worm -moving about in the left eye that forenoon, and to -prevent it leaving the surface she had kept the eye well<span class="pagenum"><a id="Page_3"></a>[3]</span> -covered with a warm cloth till she made her way to the -Infirmary. On this occasion, after examining the eye for -a minute or two, I observed the worm moving in a tortuous, -wriggling manner under the conjunctiva, the surface -of which became slightly elevated as it moved along.</p> - -<p>It passed with a pretty quick movement over the -surface of the sclerotic at the distance of about 5 mm. -from the outer margin of the cornea. It glided from the -upper outer towards the lower outer part of the globe. -There was increased lachrymation and slightly increased -injection of the conjunctiva,—just such an appearance as -would result from a particle of dust in the eye.</p> - -<p>I at once placed my finger on the surface of the globe -in such a manner as to prevent the parasite passing -backwards until the conjunctiva was pretty well anæsthetised -by the application of cocaine. I then got my -friend Dr. Maddox, who was present, to apply his finger -while the necessary preparations were hastily made for -an operation.</p> - -<p>She was placed on a couch and the speculum applied, -when the pressure of the finger having been removed the -wriggling movements of the worm were resumed, as -briskly as before the application of the cocaine. I now -grasped with a pair of toothed fixing forceps a good fold -of conjunctiva over the centre of the wriggling worm, -taking care to include in the fold all structures superficial -to the sclerotic. I next made with a pair of -scissors an incision through the conjunctiva a little nearer -the cornea, in such a manner as to lift up a small flap of -conjunctiva, and after a little careful separation of the -tissues found one extremity of the worm, which I seized -with a pair of iris forceps. On now relaxing the fixing -forceps the parasite came away readily. No irritation or -inflammation followed the operation.</p> - -<p>The worm presented the appearance of a piece of -fishing-gut, being round, firm, transparent, and colourless. -It wriggled slightly for a few minutes after removal -while held in the forceps, but on being placed in a<span class="pagenum"><a id="Page_4"></a>[4]</span> -solution of boracic acid, so as to prevent it becoming dry, -it seemed completely to lose its vitality. It measured -25 mm. in length and barely half a millimetre in breadth. -It terminated rather abruptly at one extremity, scarcely -tapering at all, but at the other it gradually tapered to a -pretty sharply curved fine point. Twisted round the -worm, and apparently attached to it near its centre, was a -much finer, less firm, transparent filamentous body, which -I at first thought might possibly prove to be a second -young filaria, or even the male filaria, but which on -further careful microscopical examination appears to be -the alimentary canal of the worm protruded through an -opening in its musculo-cutaneous wall, caused by the -forcible grasping of the parasite with the forceps.</p> - -<p>The worm after removal was, on the suggestion of -Dr. Muir, Pathologist to the Infirmary, placed in a -mixture of equal parts of glycerine and methylated spirits, -but the cork of the bottle in which the mixture was put -had retained some of the blue colouring matter (methyl -violet) of a solution previously in the bottle, and thus the -preservative mixture became faintly blue-tinted. The -parasite absorbed the colouring matter slightly, but the -filamentous body projecting from it absorbed it more -freely, becoming markedly blue-tinted. After remaining -in the solution between three and four weeks the parasite -was carefully mounted as a microscopic preparation in -glycerine jelly by Mr. Simpson, assistant keeper of the -University Anatomical Museum.</p> - -<p>It is not my intention to attempt an account of the -natural history of the parasite, as I propose to submit the -specimen to some special authority in that department.</p> - -<p>I have had some sketches of it made by a competent -artist, and these, as well as the preparation itself under the -microscope, I have pleasure in exhibiting to you.</p> - -<p>It appears to me not improbable that this specimen -may be found to supply what has hitherto been a missing -link, namely, the male animal.</p> - -<p>Since writing this I have had the opportunity of submitting<span class="pagenum"><a id="Page_5"></a>[5]</span> -the specimen to Dr. Munson, who at once recognised -it as the male worm, and has undertaken to make -a careful microscopical examination and description of it.</p> - -<div class="blockquote"> - -<p>“<i>Report by <span class="smcap">Dr. Manson</span> on the structure of the <span class="antiqua">Filaria -loa</span>, from an examination of the specimen removed in the -foregoing case, as well as of the specimen of the same -parasite exhibited at a meeting of the Society on January -31st, 1895. The latter filaria was removed from the -eyelid of a patient by Dr. J. R. Logan, Liverpool.</i>—</p> - -<div class="figcenter illowp66" id="figure1" style="max-width: 12.5em;"> - <p class="caption"><span class="smcap">Fig. 1.</span></p> - <img class="w100" src="images/figure1.jpg" alt=""> - <p class="caption">Male. Nat. size.</p> -</div> - -<div class="figcenter illowp100" id="figure2" style="max-width: 31.25em;"> - <p class="caption"><span class="smcap">Fig. 2.</span></p> - <img class="w100" src="images/figure2.jpg" alt=""> - <p class="caption">Male. × 6.</p> -</div> - -<div class="figcenter illowp50" id="figure3" style="max-width: 15.625em;"> - <p class="caption"><span class="smcap">Fig. 3.</span></p> - <img class="w100" src="images/figure3.jpg" alt=""> - <p class="caption">Head of male.</p> -</div> - -<div class="figcenter illowp69" id="figure4" style="max-width: 18.75em;"> - <p class="caption"><span class="smcap">Fig. 4.</span></p> - <img class="w100" src="images/figure4.jpg" alt=""> - <p class="caption">Tail of male. Dr. Logan’s.</p> -</div> - -<div class="figcenter illowp87" id="figure5" style="max-width: 21.875em;"> - <p class="caption"><span class="smcap">Fig. 5.</span></p> - <img class="w100" src="images/figure5.jpg" alt=""> - <p class="caption">Tail of male. Dr. A. Robertson’s.</p> -</div> - -<p><i>Filaria loa: male.</i>—Body filiform, cylindrical, measuring -from 25 mm. to 30 mm. in length, by 0·30 mm. in -breadth, of uniform thickness, except where it tapers at -the head and tail. The cephalic end tapers somewhat -abruptly to the simple mouth, which is destitute of -papillæ and armature. There is no distinctly marked<span class="pagenum"><a id="Page_6"></a>[6]</span> -neck, but there is a sort of shoulder about 0·15 mm. -behind the mouth, where a number of strong muscular -longitudinal bands originate to pass down the body. In -one of the specimens the extreme head end is retracted -and abruptly truncated, measuring at the free end 0·1 mm. -across; in the other worm this part is more conical, and -in it a short pharynx can be seen, which opens out -somewhat posteriorly. At 0·1 mm. from the mouth the -diameter of the worms is 0·15 mm.; further back, at -0·6 mm. from the month, it is 0·25 mm. The tail end is -sharply incurvated and, perhaps, excavated ventrally; it<span class="pagenum"><a id="Page_7"></a>[7]</span> -is not spirally twisted. The tail is provided with well-marked -lateral alæ, which can be traced forwards to a point -0·3 mm. from the tip of the tail. At the base of the -anterior papilla the tail is 0·08 mm. in diameter. There -are five well-marked papillæ on each side of the -ventral surface of the tail. The three anterior papillæ -are præanal and very large, the most anterior being -the largest. The papillæ are closely approximated, -stout, and bulbous at the free end; they measure -0·04 mm. in length by 0·022 mm. in breadth. The -fourth papilla appears to be adanal or post-anal, and is -rather more separated from the third than the three -anterior papillæ are from each other, and is distinctly -nearer the middle line; it is also considerably smaller, -0·03 mm. by 0·01 mm. The fifth and most posterior -papilla is very much smaller than the others and differently -shaped, being conical and sharp-pointed. It measures -0·014 mm. in length by 0·005 mm. in breadth at this base. -There are two slender and unequal spicules projecting -from one of the specimens. The cuticle is not obviously -striated, but is dotted over with a number of widely scattered, -nearly hemispherical, smooth bosses, springing -abruptly from the surface. There appears to be no definite -arrangement of these bosses; at all events, if they are -arranged after a pattern this could not be discerned. -The larger bosses are found towards the middle of the -parasite; at the head and tail they are considerably -smaller, and in these situations they are more sparingly -distributed. The larger measure at the base 0·12 mm., and -rise about 0·004 mm. above the general surface. The -extreme ends of the parasite are not provided with -bosses, the first met with being about 1·5 mm. from the -mouth and tail-tip respectively.</p> - -<p>“Owing to the opacity of the specimens the details of -the internal structure cannot be made out. In one worm, as -mentioned, a short pharynx can be seen, but its continuation -into the œsophagus cannot be traced. The prolapsed -testicular and alimentary tubes in one of the specimens<span class="pagenum"><a id="Page_8"></a>[8]</span> -are collapsed and ribbon-like; they are about 0·09 mm. in -breadth.</p> - -<p>“The following diagram roughly indicates what I conceive -to be the arrangement of the details of the under -surface of the tail.”</p> - -<div class="figcenter illowp37" id="figure6" style="max-width: 12.5em;"> - <p class="caption"><span class="smcap">Fig. 6.</span></p> - <img class="w100" src="images/figure6.jpg" alt=""> - <p class="caption">Diagrammatic.</p> -</div> - -</div> - -<p>In endeavouring to ascertain how the parasite entered -the system I inquired as to the water and food supply at -Old Calabar, and my patient informed me that at Iköröfiön, -the mission station at which she resided, the entire water-supply -during the dry season was obtained from a spring -that bubbled up out of the ground close to the river. -During the rains, however, this spring might occasionally -be covered by the swollen river, but at that season -the water-supply was derived from a tank in which -the rain was collected. The water used for drinking -was always boiled, and twice filtered. In washing her -face she was specially careful to keep her eyes well -closed, and if at any time her eyes were sore she bathed<span class="pagenum"><a id="Page_9"></a>[9]</span> -them with the drinking-water. These precautions she -took, as it was a popular belief among the natives that the -worm gets access to the eyes through the water with -which the eyes are bathed. She further informed me -that the occurrence of this kind of worm in the eye is well -known to natives of Old Calabar, and they use a solution -of salt and water as a wash to scare them away. -Mosquitos abounded at the station, and any water left -standing in a dish soon swarmed with their eggs. The -fruit supply consisted of mangos, Avocado pears, bananas, -pineapples, oranges, and custard-apples. No uncooked -vegetables were used as food.</p> - -<p>She herself had seen a number of instances of the -worm in the eyes of natives, and thus knew the nature of -the affection when she had it herself. It is said in -Calabar that they are very difficult to capture. She has -never heard of the parasite piercing the skin or conjunctiva.</p> - -<p>The ordinary guinea-worm (<i>Filaria medinesis</i>) under -the skin is unknown in Old Calabar. Miss H⸺ acted as -dispenser for about a year during the missionary’s absence, -and never saw a case of it, nor heard of it occurring during -the whole of her residence there.</p> - -<p>As a result of inquiry I found that other members of -the Old Calabar Mission had been affected with <i>Filaria loa</i>.</p> - -<p>1. A lady, Mrs. M⸺, who for a time had resided with -my patient at Iköröfiön. She was in this country this -year, but has returned to Old Calabar. While in Scotland -the worm was seen in her eye by my patient Miss H⸺ and -her sister, who is at present engaged in the study of -medicine. The latter saw the worm pass from the one eye -to the other, crossing the bridge of the nose under the skin.</p> - -<p>2. Mrs. H⸺, the widow of a medical missionary to Old -Calabar. I had the opportunity of seeing this lady, and -eliciting the following particulars.</p> - -<p>She was three years in Old Calabar, from 1860 to 1863, at -Old Town Station. Here the water-supply was obtained -from a spring which emerged from the ground at a little<span class="pagenum"><a id="Page_10"></a>[10]</span> -distance from the river. Before use for drinking the -water was filtered through a porous stone basin, but it -was not boiled. The water for washing was not boiled -or filtered, nor were any precautions taken to prevent it -coming in contact with the eyes. During part of the -time she was at Old Calabar she suffered from worm in -the eye, sometimes one, sometimes the other was -affected, but never both at the same time. She occasionally -had a feeling as if the worm were making its -way under the skin at the root of the nose, in the eyelids, -or on the temple. The left eye was the one chiefly -affected. She was invalided home on account of intermittent -fever. She did not suffer from dysentery. The -worms troubled her occasionally after her return home, -but they never came to the surface at a convenient time -for removal till in 1875, when her husband, Dr. H⸺, succeeded -in removing a worm from her left eye. She could -not now recall the steps of the operation. About a year -later another worm was similarly removed by her husband—she -thinks from the same eye, and since then she has not -experienced any symptoms of filaria. These worms were -preserved in spirits, but she fears were, after some years, -thrown away.</p> - -<p>As in the case of my patient, Mrs. H⸺ noticed that -the worms scarcely troubled her at all during winter. -It was only in warm weather they were lively. Both -ladies occasionally noticed that the worm lay for a short -time coiled up and motionless under the conjunctiva. When -the worm appeared on the surface Mrs. H⸺ experienced a -“biting, nibbling sensation” at the part where the worm -was, and the eye became tender and watery, so that she -had to keep it closed, but it never produced any severe -inflammation. When not under the conjunctiva or skin -she was not aware of its presence.</p> - -<p>3. The Rev. J. L⸺ went to Calabar in October, 1868, -and returned in July, 1872. He often suffered from -intermittent fever, on account of which he was invalided, -and by medical advice did not return. His recollection<span class="pagenum"><a id="Page_11"></a>[11]</span> -of the time and circumstances of the appearance of the -worm is now somewhat faint, but he thinks it appeared -during the latter part of his residence in Old Calabar, and -certainly troubled him after his return home. As far as -he remembers, one eye only, and he thinks the right, was -affected, but he cannot say with certainty. It only -caused slight irritation, and no severe inflammation. It -affected the eyelids, he thinks, more than the eye. He -recalls one time in particular when, after preaching at -Musselburgh, he felt it wriggling under the skin of the -upper lid, and directed the attention of some friends to -it, and they saw the movement of the worm. The -intervals at which it appeared were irregular, but generally -pretty long. He never felt the worm in any other -part of the body. As far as he can remember, the visits -of the worm to the eye or lids did not generally last long—at -most two days. No attempt was made to extract it, -nor did any doctor see it. He has seen or felt nothing -of the worm for the last eight or nine years, at any rate. -He did not notice that the worm was influenced in its -visits by the external temperature.</p> - -<p>In addition to these cases among members of the Old -Calabar Mission, I may refer to the experience of Dr. -Thompstone, who was for eighteen months stationed at -Opobo, on the delta of the Niger, and who is in this -country at present. He informs me that while he was at -Opobo he saw two cases of <i>Filaria loa</i>. In the one -negro the parasite was situated in the lower eyelid at the -inner canthus close to the lachrymal sac—the swelling in -that region giving the appearance of dacryocystitis. He -tried to press out what he considered the contents of the -distended sac, when he observed the coiled-up worm to -wriggle away into the orbit, and the swelling disappeared.</p> - -<p>In the other negro he observed the worm moving -about under the conjunctiva when he depressed the lower -lid. The patient was affected with slight conjunctivitis. -Dr. Thompstone wished to undertake the extraction of -the parasite, but the patient declined operative interference.<span class="pagenum"><a id="Page_12"></a>[12]</span> -While at Opobo he neither saw nor heard of -other cases of the affection. The water-supply for the -native population there was very polluted.</p> - -<p>The literature on this subject is very scanty. As far -as I have been able to ascertain there have hitherto not -been more than twenty cases recorded, and in most of -them the accounts given have been bald and short in the -extreme. I may, therefore, be permitted to give a short -<i>résumé</i> of what has been written regarding this filaria.</p> - -<p>The first case recorded appears to be that observed by -M. Bajon,<a id="FNanchor_1" href="#Footnote_1" class="fnanchor">[1]</a> a French surgeon, who for twelve years -practised his profession in the island of Cayenne and in -Guiana. He reports that in July, 1768, the captain of a -ship from Guadalupe brought to him a young negress -about six or seven years of age, and asked him to -examine one of her eyes, in which a small worm, about -the thickness of a fine sewing thread, could be distinctly -seen. It was about two inches in length. It cruised -round about the eyeball in the cellular tissue between the -conjunctiva and sclerotic. It moved in a tortuous oblique -manner. The colour of the eye was not changed, and the -young negress said she felt no pain with the movements -of the worm, but she had an almost continual watering of -the eye.</p> - -<p>On reflecting on the means he should employ to draw -it out, he concluded that if he made a minute aperture in -the conjunctiva close to the head of the small animal, and -then stimulated it to move, it would emerge through the -opening. In carrying out this manœuvre, however, he -found that in place of escaping through the incision he -had made, it passed by the side of it, and went to the -opposite surface of the eye. As this proceeding did not -succeed with him, he had recourse to the device of -seizing the worm by the middle with small forceps, along -with the conjunctiva, then making a small deep opening -with a lancet by the side of its body, and then introducing<span class="pagenum"><a id="Page_13"></a>[13]</span> -an ordinary needle, whereby he succeeded in drawing it -out doubled in two.</p> - -<p>Again, in 1771, another young negress, a little older -than the last, was brought to M. Bajon suffering from -painful inflammation of the conjunctiva. On examination -he observed a worm a little longer than in the previous -case, and which, like it, moved round about the eye -between the conjunctiva and sclerotic. He proposed to -employ the same procedure that succeeded in the other -case, but the patient would not consent.</p> - -<p>He considered that the worm was a dracunculus -(dragonneau) similar to those removed from other parts -of the body in negroes, only finer and shorter.</p> - -<p>The next case recorded is one by M. Mongin, a -surgeon at St. Domingo, in the ‘Journal de Médecine’ -for 1770, occurring in a negress who had for twenty-four -hours complained of severe pain in the eye with scarcely -any inflammation.</p> - -<p>At first glance he saw a worm, which appeared to him -to wriggle over the globe, but on trying to seize it with -forceps he found it to be between the conjunctiva and -sclerotic.</p> - -<p>To remove it he incised the conjunctiva, and it emerged -through the opening. It was one and a half inches long, -and the thickness of a violin string, and of an ashy -colour. It was larger at one end than at the other, and -very pointed at the two extremities. He was inclined to -view it as a worm of the blood (<i>ver sanguin</i>), as it did not -appear to him possible for it otherwise to get into that -position without giving rise to pain and inflammation at -the part.</p> - -<p>We have next several cases that were carefully observed -and recorded by M. Guyot, a French surgeon,<a id="FNanchor_2" href="#Footnote_2" class="fnanchor">[2]</a> who had -made many voyages to the Angola coast of West Africa. -The first case in which he discovered the filaria was that -of a negress in whom, after several examinations, he<span class="pagenum"><a id="Page_14"></a>[14]</span> -noticed a ridge of the conjunctiva resembling a varicose -vein, which induced him to make minute openings over it -to empty it. On pricking the elevated conjunctiva with -the point of a lancet he was surprised to observe the -projection disappear. The patient at the same time -stated that she felt something move in her eye, and that -the movement was deep-seated. He suspected that this -could be nothing else than a roving worm (<i>ver ambulant</i>), -which sometimes appeared under the conjunctiva, -sometimes dived into the posterior parts of the eye. -From inquiry he found that a worm in the eye was -common enough among natives of that land, and that it -was called a “loa,” and he consequently applied the term -filaria loa to the affection. He saw the worm on many -occasions in the eye of the negress, but whenever he -touched the spot where it was it retreated to the posterior -parts of the orbit. On that voyage he saw several -negroes with this affection, for which he employed various -collyria without effect.</p> - -<p>In 1777 he made another voyage to the coast of -Angola. Having many negroes on board the ship he -renewed his researches, and found several individuals -affected with the disease. As no benefit had been -derived from the applications he had previously used he -proposed to extract the worm through a small opening in -the conjunctiva. To effect this it was necessary to fix -the worm, to which end he employed dissecting forceps, -without, however, being able to seize it.</p> - -<p>On another occasion he employed a ligature needle of -medium size, with which he pierced the conjunctiva by -the side of the worm, and passed it between the worm -and the sclerotic, making it emerge at the opposite side. -By this manœuvre he was able to raise the fold of -conjunctiva along with the worm on the concavity of the -needle. This fold he divided, and drew out the worm -without mutilation. The operation required to be done -very quickly, otherwise the worm escaped and disappeared, -sometimes for a very long time. Of five negroes upon<span class="pagenum"><a id="Page_15"></a>[15]</span> -whom he thus operated he was only able to remove the -worm twice. The worms were about fifteen lines in -length, and a little less thick than a violin string. He -did not think the worms were a species of dracunculus, -for they were quite white, firmer, and less long in proportion. -He never saw the worm make an opening for -itself. In the seven voyages he had made to the Angola -coast he had never seen a negro affected with dracunculus. -Other surgeons who had sailed on these coasts assured -him they also had seen no cases, which made him conclude -that the negroes of that country are not subject to -dracunculus. The cases on which he operated were -healed in twenty-four hours.</p> - -<p>We next find M. Clot at a meeting of the Académie -Royale des Sciences in December, 1832, referring to the -case of a negress, who suffered from a dracunculus under -the conjunctiva of the eye. It appeared now and then -gliding between the conjunctiva and sclerotic, lifting up -the conjunctiva. This case appears to be one that was -seen by Dr. Roulin at Monpox in America.</p> - -<p>Another case is mentioned by Dr. Sigaud in his work -on the ‘Climate and Diseases of Brazil.’ He states he was -witness in 1833 of the extraction, by M. dos Santos, of a -filaria situated in the orbit on the surface of the sclerotic -of a negress.</p> - -<p>In 1838 Dr. Guyon made an interesting communication -to the French Academy of Sciences, in which he narrated -the case of a young negress affected with two filariæ, one -in the right and the other in the left eye, but occasionally -both appeared in the same eye; the passage of the -worm from the one eye to the other occurring with great -rapidity through the cellular tissue under the skin at the -root of the nose. The filariæ were in different eyes -when the operator (Dr. Blot of Martinique) extracted the -filaria from the left. Some hours after, when he returned -to extract the other worm, he found that it had passed to -the left eye, from which he extracted it by a fresh -incision.</p> - -<p><span class="pagenum"><a id="Page_16"></a>[16]</span></p> - -<p>The first cases reported by an English surgeon were -by Dr. Loney, a naval surgeon, occurring in two -Kroomen, whom he saw while cruising on the West Coast -of Africa during 1841-2. In both he succeeded in -extracting the parasite.<a id="FNanchor_3" href="#Footnote_3" class="fnanchor">[3]</a></p> - -<p>Another case was observed by Dr. Mitchell at Trinidad -in the person of a young negress, in whom the worm -appeared at long and uncertain intervals for four or five -years before he had the opportunity of seeing it. At -length in 1845 Dr. Mitchell saw the worm twisted like the -letter <span class="sans">S</span> lying motionless under the conjunctiva, midway -between the edge of the cornea and the inner canthus. -Extraction of the worm was deferred to enable six or -seven of his medical brethren to observe so unusual an -appearance, with the result that when they assembled the -following morning the parasite had removed itself to -deeper parts.<a id="FNanchor_4" href="#Footnote_4" class="fnanchor">[4]</a></p> - -<p>A case is also recorded by Gervais and van Beneden,<a id="FNanchor_5" href="#Footnote_5" class="fnanchor">[5]</a> -in which M. Lestrille succeeded in 1854 in extracting a -filaria from a negress, and Dr. Guyon once more, at a -meeting of the French Academy of Sciences in 1864, -exhibited another filaria, which had been removed by a -French naval surgeon from a negro of the Gaboon. -The filaria was of unusual size, measuring fifteen -centimetres. Its length was such that the whole of -it could not be seen at one time below the conjunctiva, -part always remaining embedded in the deeper parts of -the orbit.<a id="FNanchor_6" href="#Footnote_6" class="fnanchor">[6]</a></p> - -<p>Dr. Morton<a id="FNanchor_7" href="#Footnote_7" class="fnanchor">[7]</a> reports a case occurring in a negress -residing at Gaboon in West Africa, in which a native -woman succeeded in extracting the parasite. The worm, -preserved in gin, had been sent to him by a missionary, -the Rev. Dr. Nassau, in the district, who informed<span class="pagenum"><a id="Page_17"></a>[17]</span> -him that although he had been very many years in that -country, and had often heard of the parasite, this was the -first specimen he had been able to secure. The missionary -himself appeared to be also affected with filaria, -which, however, did not appear on the eye, but could, he -said, occasionally be felt under the skin of the fingers, -and once in the skin of the lower eyelid, from which -position he attempted himself to remove it with scalpel -and forceps, but he did not succeed, the worm wriggling -away across his cheek. The worm that was sent to Dr. -Morton measured 16 mm., but was in too badly preserved -a state to permit of accurate examination.</p> - -<p>Lastly, in Dr. Davidson’s work on hygiene and diseases -of warm climates (p. 962) Dr. Manson, who writes the -article on filaria, reports the case of a negro who had -been affected with <i>Filaria loa</i>, and in whose blood he afterwards -found the <i>Filaria diurna</i>, and raises the question -whether the <i>Filaria loa</i> may not turn out to be the female -parental form of the <i>Filaria diurna</i>.</p> - -<p>I am afraid we must confess that we are as yet very -ignorant of many points connected with the life history -of the <i>Filaria loa</i>. With the adult female parasite we -have a limited acquaintance, but till now we are ignorant -of the appearance of the male worm. The larvæ have -been observed in the interior of the adult, but what their -further course is, what transmigration may occur, ere they -reappear as fully formed filariæ under the conjunctiva -has yet to be discovered. The only observation that -bears at all upon this question is that made by -Dr. Manson and reported in Dr. Davidson’s work, that in -one case of <i>Filaria loa</i>, the <i>Filaria diurna</i> was afterwards -found in the blood. With the view of ascertaining -whether the <i>Filaria diurna</i> was present in the blood of -my patient Miss H⸺, and also with the view of getting -a report as to her general medical condition, I got my -friend Dr. Alexander Bruce to undertake the examination.</p> - -<p>It must, however, be borne in mind that in her case<span class="pagenum"><a id="Page_18"></a>[18]</span> -the filaria removed proves to be a male, and, unless she -were affected with the female parasite as well, no embryos -could be expected in the blood.</p> - -<div class="blockquote"> - -<p><i>Report by Dr. Alexander Bruce, October 16th, 1894.</i>—“Miss -H⸺, missionary to Old Calabar, went there at the -age of twenty-two, has been out there ten years altogether; -first was out for two years, then furloughed for one -year on account of an attack of intermittent fever which -turned her hair grey, but was not otherwise very severe in -type. Then she was out for four years and home for one -year on furlough. Then was out for seventeen months, -invalided home in January, 1894, for remittent fever, -gastritis, and a form of dysentery and great anæmia. -The remittent fever began in December, 1893, with -delirium at beginning, and fever which rose daily to 102° -and 103° F. She was sent to sea in ten days, and on -the way home the temperature on one occasion rose to -107°; this was reduced by ice-pack. Improvement was -slow, being retarded by the gastritis and dysentery, and -the tendency to pyrexia did not abate till the end of -June. The gastritis was indicated by intense pain (agony, -she called it) in swallowing anything, whether solid or -fluid. The bowels now move only once daily or less frequently, -and the motions are accompanied by small flakes -of mucus (formerly by blood). There was always great -mental depression during the attacks of dysentery.</p> - -<p>“The arms became, since June, stiff and swollen, -especially on awakening from sleep (whether at night or -during the day), and the hands felt ‘numb,’ ‘dead,’ -‘as if asleep,’ or ‘as if they didn’t belong to her.’</p> - -<p>“She was so weak that she had to remain in bed till the -beginning of April. Since then, after a visit to Crieff, -she has improved rapidly, and can now walk two or three -miles easily. She now has a fairly good colour, has good -appetite, and no pain in the stomach. Examination of -the circulatory system shows absolutely nothing abnormal, -no dilatation of the ventricles, no arterial, valvular, or<span class="pagenum"><a id="Page_19"></a>[19]</span> -venous bruits. The respiratory murmurs and the percussion -note of the lungs are normal. The liver is not, and -the spleen is, just appreciably enlarged. The blood flows -readily from a prick in the finger; it is rich red in colour. -The red corpuscles are well-coloured, well-formed, and -form rouleaux readily. There is a slight increase in the -white corpuscles. Specimens of the blood drawn at -9 a.m., 8 p.m., 9 p.m., 1 p.m., and dried on the slide -showed no evidence of filaria of any kind.</p> - -<p>“The forearms presented, on the anterior and posterior -aspects, slight flattened doughy swellings, which had no -definite boundary and were not painful to pressure. -There was no alteration in the colour of the skin over -them.”</p> - -</div> - -<p>We are still at a loss to account for the entrance of -the worm into the body. There are, I think, two -different channels by which it might possibly find access. -First, by the passage of the embryo filariæ directly -through the conjunctiva, being brought in contact with -the eye in water used for washing the face or bathing the -eye. This I think an unlikely means of entrance, as in -my patient special pains were taken to avoid such a -possibility, and yet she became affected with the disease, -and the power of the worm to penetrate skin or mucous -membrane has never been demonstrated. Second, by the -swallowing of the embryo filariæ along with articles of -food or drink. Although in the case of my patient -excellent measures were taken to secure the purity of the -water-supply, and although the nature of the food was -such as not readily to lend itself to the conveyance of -impurities, still I think recent researches, made more -particularly by Dr. Manson with regard to the development -of the <i>Filaria sanguinis</i>, render it probable that the -ova of the <i>Filaria loa</i> are, as suggested by Dr. Manson, -taken into the circulation of the patient affected by the -mature female parasite. That then some insect of predatory -habits, drawing its food-supply from this polluted<span class="pagenum"><a id="Page_20"></a>[20]</span> -stream, becomes, in its turn, the host which supplies the -necessary elements for the further development of the -parasite. This insect, in its turn dying, deposits the -embryo filariæ in water, which, being used for drinking -purposes, permits the parasite once more to affect man. -Which the insect is that probably plays the part of intermediate -host is as yet unknown. This view is purely -hypothetical, but I think, reasoning from analogy, the -most probable one of the development of the <i>Filaria -loa</i>.</p> - -<p>The geographical distribution of this parasite appears -to be a very limited one, as almost all, if not all, of the -persons affected, whose cases have been reported, have -either been natives of or been long resident on a limited -area of the West Coast of Africa, including Congoland -and Old Calabar. If Dr. Manson’s view as to the mode -of development of the worm be substantiated, then -naturally the area of the disease must necessarily be -limited to the regions in which the intermediate insect -host is to be found.</p> - -<p>The fully grown worm may, judging by some of the -cases recorded, infest the human subject for a good many -years, and may yet not give rise to any very serious -symptoms. It possesses very considerable locomotive -powers. It is capable of wandering at will from one eye -to the other, to disappear into the deeper parts of the -orbit, to wander under the skin of the eyelids, and even -to make excursions in the temporal region. These seem -to be the limits of its excursions. No doubt the -Rev. Dr. Nassau (the missionary at the Gaboon) had -sometimes sensations of a filaria under the skin of the -fingers as well as under the skin of the eyelid, but it is -doubtful if this was a true case of <i>Filaria loa</i>, and even -then if the worm had made its way from the fingers to -the eyelid. At the same time it must be borne in mind -that there are few regions of the body in which the skin -is so thin as in the eyelids, whereby the presence of a -small filamentous body can easily be discerned. The<span class="pagenum"><a id="Page_21"></a>[21]</span> -parasite might readily move about under the coarser -cutis of other parts and yet escape detection.</p> - -<p>The sensitiveness of the parasite to cold appears to be -fully established by the experience of my patient and -Mrs. H⸺, and it is possible that a prolonged residence -in a cool climate may eventually prove fatal to the worm, -as seems to have occurred in the case of the Rev. J. L⸺. -All the cases previously recorded have occurred in negroes, -but those I have brought forward prove that Europeans -are also susceptible to the attacks of this worm.</p> - -<p>I think I am warranted in saying that the disease is -not very rare in the district favoured by the parasite, as, -although the number of cases reported is small, the -irregular intervals at which the worm comes to the surface, -and the slight irritation or annoyance its presence -causes, often prevent those affected seeking surgical advice; -while it must be admitted that medical assistance is -not very readily procured in large parts of the district -where cases occur.</p> - -<p>The interest connected with the elucidation of the -obscure points in the natural history of the worm will, I -trust, stimulate those of our profession residing on the -West Coast of Africa to undertake the further necessary -investigations.</p> - -<hr class="tb"> - -<p>Remarks by Dr. <span class="smcap">Patrick Manson</span>.—I have no hesitation -in saying that I consider the communication to which we -have just listened from the President to be one of the most -important on the subject of filaria loa that has been made -for many years. Two or three years ago I had an opportunity -of examining the blood of a number of negroes -from Old Calabar in a missionary establishment and elsewhere, -and I made the interesting discovery that in 50 -per cent. the blood contained the embryos of a species of -filaria—<i>Filaria perstans</i>—which were quite different in -their zoological characters from the filaria of the blood, -with which every one must now be familiar. While examining -one of these patients whose blood contained this<span class="pagenum"><a id="Page_22"></a>[22]</span> -new species of filaria I found another species of bloodworm, -whose anatomical features were similar to those of -the ordinary <i>Filaria sanguinis</i>, but which presented a -very great difference physiologically, inasmuch as contrary -to what is observed with the ordinary filaria, this one -disappears at night and can only be found in the blood -during the daytime. This second new bloodworm I -therefore called <i>Filaria diurna</i>. Some time later, in a -communication which I had from Professor Leuckart, he -told me he had been enabled to examine the embryos in the -uterus of an adult <i>Filaria loa</i>, and he sent me a sketch of -these embryos. On comparing this sketch with the <i>Filaria -diurna</i>, I came to the conclusion that they were -practically identical, and therefore that the filaria I had -found in the blood of the negroes might possibly be the -embryos of <i>Filaria loa</i>. This opinion appeared to me -to be strengthened by the fact that this patient had previously -had a loa under the conjunctiva. I have very -little doubt that the embryo of <i>Filaria loa</i> finds its -way into the blood. Clinically, there is no evidence of -its attempting to find its way to the surface of the body, -and it is evident that there must be some arrangement by -which it can get out of the body, and so propagate its -species by passing from one person to another. From -this and other considerations I consider that it must be -by way of the blood that the necessary escape is effected. -With the ordinary filaria it is now well known that the -mosquito removes it from the blood and acts the part of -intermediate host, and I suppose that a similar arrangement -must exist in respect of the <i>Filaria loa</i>. On inquiring of -the Old Calabar negroes as to the blood-sucking insects -of the district, I learned that there was a particular fly -which exists in great numbers about the creeks, and was -very annoying on account of its pertinacity. I think this -insect, which is also diurnal in its habits, is probably the -intermediate host for the <i>Filaria loa</i>, us the mosquito is -for the ordinary filaria. I do not believe that this individual -worm was the only <i>Filaria loa</i> in the body of the<span class="pagenum"><a id="Page_23"></a>[23]</span> -patient whose history we have just listened to. It became -visible simply because it wandered to a spot where -it could be seen; elsewhere in the connective tissue I opine -there are others. The patient was first seen in February, -and whether sufficient time has intervened for the maturation -of these parasites and the evolution of their embryos -I cannot say. None, it is true, were found in the -blood, but the specimen was a male, and from this it is -impossible to say what the degree of maturity the embryos -of any females present may be. I think the blood -should be examined again, and I would suggest that if -possible a similar examination should be made of the other -members of the mission, and of the patients the President -referred to. The locomotive habits and sensibility to -cold of this parasite are particularly interesting in respect -of the way in which they subserve its interests, on which -they certainly have a bearing. The measurements of the -<i>Filaria loa</i> usually given, as ascertained by looking over -the literature of the subject, are from 17 mm. to 70 mm. -The smaller measurements are explained by the author’s -case; they apply presumably to the male parasite, which -in the filaridæ is almost invariably smaller than the -female. One measurement given, 15 cm., is so enormous -that I question the accuracy of the observation, or, if the -measurement were exact, it must have referred to some -other parasite than <i>Filaria loa</i>. With respect to the -nature of the protrusions from the body of the parasite -under the microscope, one of them is certainly the -alimentary canal; the other is probably the testis ruptured -in two. One must be careful in coming to a conclusion -about these and similar connective-tissue parasites. -There are four or five whose young inhabit the human -blood; and there are others whose young appear to have -a different history. Especially in West Africa do we find -such parasites. There is the guinea-worm, said, however, -not to be found in Old Calabar; it certainly is found in -the neighbourhood; its name signifies an African origin. -There is the <i>Filaria perstans</i>, the <i>Filaria nocturna</i>, and<span class="pagenum"><a id="Page_24"></a>[24]</span> -also a very minute bloodworm, <i>Filaria demarquayi</i>, the -parental form of which, as of <i>F. perstans</i>, has not yet been -found. There is the <i>Filaria volvulus</i>, which resembles the -<i>Filaria loa</i>, in that it lives in the subcutaneous cellular -tissue. Not long ago Professor Magalhães, of Rio -Janeiro, described a species of filaria which he found in -the left ventricle of the heart, which is also probably -a new species. It follows, therefore, that before venturing -on the diagnosis from specimens of parasites found -in the blood or connective tissues, usually more or less -mutilated, one requires to be very careful. One singular -fact about the <i>Filaria loa</i> is that it will not live in the -West Indies. It has been introduced many times, but -does not spread. It has been removed from the eye there -from imported negro slaves, but it has not become -acclimatised. In this respect it resembles very closely -the <i>Filaria medinensis</i> (guinea-worm), which was introduced -times without number during the days of slave -importation into the West Indies, yet it has died out altogether -except in one or two places, the island Curaçao and -a limited district in Brazil. This undoubtedly is in consequence -of one of two things; either the habits of the people, -or the absence of the proper intermediate host. In respect -of the guinea-worm the intermediate host is a fresh-water -cyclops. I recently had a case in the Seamen’s Hospital -from which I was enabled to procure the embryos. -This enabled me to carry out some experiments which I -would urge upon those who have the opportunity to -repeat. When the guinea-worm arrives at maturity a -little vesicle or bulla is formed on the ankle or foot. -The vesicle ruptures, and on careful examination you -will see a small orifice in the centre in which sometimes -the head of the worm may be seen, but not always. If -you take a sponge and drop some cold water, not on, but -in the neighbourhood of this orifice, you will see the hole -become filled with a white grumous material, which -under the microscope, and on adding a little water, is -seen to be a wriggling, writhing mass of embryos. The<span class="pagenum"><a id="Page_25"></a>[25]</span> -application of water to the leg after an interval may -lead to further extrusion of embryos. This is a -striking illustration of the curious way nature has -adapted the habits of the guinea-worm to its requirements. -The young guinea-worm lives in water, and -probably for this reason the mature worm descends to -the feet or ankles, the parts of the human body in -tropical countries most often within reach of water. -Having procured in this way a supply of embryos, I tried -to repeat the experiment described by the Russian -naturalist, Fedschenko, on the metamorphosis of the -embryos of the guinea-worm in its intermediate host. I -obtained some fresh-water cyclops and placed them in -water with the embryos. After five or six hours I took -one of the cyclops and placed it under the microscope, -and I found the body-cavity to contain twenty or thirty -of the living and moving embryos. The next day, however, -the cyclops were all dead, but the contained -embryos were all lively. Having still one or two of the -cyclops left I repeated the experiment, but, proceeding -more cautiously, placed only a few of the embryos in -the water along with the cyclops. After a few hours I -removed the cyclops, and found that each of them had -two or three guinea-worm embryos coiled up or moving -about in their insides. Two of the cyclops I kept alive; -one lived sixteen days and the other five weeks, and -during this time the embryos could be seen moving and -developing. At the end of five weeks I killed the cyclops, -and I found the guinea-worm embryos had undergone a -certain degree of development. The outer cuticle of the -embryo had separated a good deal from the body—ecdysis, -and there were certain changes in the alimentary canal. -I have no doubt that had the cyclops been in a normal -condition as regards exposure to light and sun, the metamorphosis -of the guinea-worm inside the cyclops would -have been completed. This shows that it would be possible -to introduce the guinea-worm into England if we -did not wear boots or shoes, and if we were in the habit of<span class="pagenum"><a id="Page_26"></a>[26]</span> -wading about in pools and marshes as do the natives of -West Africa. There would be a discharge of the embryos -into the water, and if less care were taken about the purity -of the water-supply, and supposing there to be no adverse -climatic influences, the worm would become common. This -little story about guinea-worms shows how these and -similar parasites pass from one man to another; and it -shows how slight differences of habit, absence of intermediate -host, and so on, govern the distribution of a -parasite like <i>Filaria loa</i>. If you examine this <i>Filaria loa</i> -exhibited by the President under the microscope, you will -see that all over the skin there are minute but regular -bosses or protuberances. This occurs in certain filariæ, -but in no other human species so far as I am aware. -These protuberances, I have no doubt, have a bearing on -the locomotive habits of this particular parasite. I pass -round a reproduction by Blanchard from a book which -carries us back a century further in the history of the -<i>Filaria loa</i> than that given by Dr. Robertson. This book -was written by Pigafetta,<a id="FNanchor_8" href="#Footnote_8" class="fnanchor">[8]</a> and it contains a picture -showing a man drawing a guinea-worm out of his leg, and -a woman having a worm removed from the eye, doubtless -a <i>Filaria loa</i>.</p> - -<div class="footnotes"> - -<h3>FOOTNOTES</h3> - -<div class="footnote"> - -<p><a id="Footnote_1" href="#FNanchor_1" class="label">[1]</a> Bajon’s ‘Mémoire pour servir à l’histoire de Cayenne et de la Guyane,’ -t. 1er, p. 325, 1777.</p> - -</div> - -<div class="footnote"> - -<p><a id="Footnote_2" href="#FNanchor_2" class="label">[2]</a> Arrachart, ‘Mémoires, dissertations de Chirurgie, et observations de Chirurgie,’ -1805, p. 228.</p> - -</div> - -<div class="footnote"> - -<p><a id="Footnote_3" href="#FNanchor_3" class="label">[3]</a> ‘Lancet,’ vol. i, 1844, p. 309.</p> - -</div> - -<div class="footnote"> - -<p><a id="Footnote_4" href="#FNanchor_4" class="label">[4]</a> Ibid., Nov. 26th, 1859.</p> - -</div> - -<div class="footnote"> - -<p><a id="Footnote_5" href="#FNanchor_5" class="label">[5]</a> ‘Zoologie médicale,’ 1859, vol. ii, p. 143.</p> - -</div> - -<div class="footnote"> - -<p><a id="Footnote_6" href="#FNanchor_6" class="label">[6]</a> ‘Annales d’Oculistique,’ 1864, p. 241.</p> - -</div> - -<div class="footnote"> - -<p><a id="Footnote_7" href="#FNanchor_7" class="label">[7]</a> ‘American Journal of the Med. Sciences,’ 1877, vol. lxxiv, p. 113.</p> - -</div> - -<div class="footnote"> - -<p><a id="Footnote_8" href="#FNanchor_8" class="label">[8]</a> ‘Vera descriptio regni africani, quod tam ab incolis quam Lusitanis -Congus appellatur,’ Frankfort, 1598.</p> - -</div> - -</div> - -<hr class="chap x-ebookmaker-drop"> - -<div class="figcenter illowp50" id="plate7" style="max-width: 93.75em;"> - <p class="caption">PLATE VII</p> - <p class="caption">Illustrates Dr. Argyll Robertson’s paper on Filaria loa.</p> - <img class="w100" src="images/plate7.jpg" alt=""> - <p class="caption"><span class="smcap">Female Filaria Loa.</span></p> - <p class="caption2"><span class="smcap">Fig. 1.</span>—The whole worm. Portions - of alimentary canal and uterine tube protruding through an opening in the - wall of the parasite.</p> - <p class="caption2"><span class="smcap">Fig. 2.</span>—A portion of uterine - tube, highly magnified, showing embryo filariæ in interior.</p> - <p class="caption2"><span class="smcap">Fig. 3.</span>—Head of worm, with - rounded projection of wall of worm at one point, due to injury.</p> - <p class="caption2"><span class="smcap">Fig. 4.</span>—Part of worm where - rupture of wall occurred. <i>a.</i> Alimentary canal. <i>b.</i> Uterine - tube with embryo filariæ.</p> -</div> - -<hr class="chap x-ebookmaker-drop"> - -<div class="chapter"> - -<p><span class="pagenum"><a id="Page_27"></a>[27]</span></p> - -<h2 class="nobreak"><span class="smcap">Further Note of Case of Filaria loa.</span></h2> - -<p class="center larger"><i>Read at the Meeting of the Ophthalmological Society on March 14th, 1895.</i></p> - -<p class="center larger">By <span class="smcap">D. Argyll Robertson</span>.</p> - -<p class="center larger">(With <a href="#plate7">Plate VII</a>.)</p> - -</div> - -<p>At a meeting of this Society on the 18th of October -last I narrated the case of a patient, Miss H⸺, affected -with <i>Filaria loa</i>, and I exhibited a male worm which I had -removed from under the conjunctiva of her left eye. I -purpose now to give a short account of the further history -of that patient, and a description of a female <i>Filaria loa</i> -which I succeeded in removing from her right upper -eyelid.</p> - -<p>After the removal of the filaria from under the conjunctiva, -Miss H⸺ was not troubled with the sensations -she associates with the presence of a worm for a period of -about six weeks, when again she experienced a burrowing -sensation at the back of her left eye. It affected her at intervals, -and especially when she was occupying a hot room.</p> - -<p>On the 3rd of February she distinctly felt a worm -moving about in her left upper eyelid, and came at once -to me, but before she arrived this feeling had gone, and -I failed to discover any signs of the parasite. She returned -on the 6th of February with the statement that -not only had she felt the worm moving about in the left -lower lid, but that it had also been distinctly seen wriggling -under the skin. I saw her three different times -that day, but failed to observe anything that might indicate -with certainty the presence of a parasite, although -she sat in front of a hot fire and had a succession of -hot poultices applied, so as to tempt the worm to the surface. -On the third visit, as she felt the wriggling of the -worm, and as there seemed to be a little fulness at one -point in the left lower lid, I decided to cut down at that -point and search for the parasite. This I did with Dr. -Mackay’s assistance, having first of all applied clamp-forceps -so as to prevent the worm escaping if it were there. -I failed to find any parasite, although I made a careful -search, and the patient showed great nerve and steadiness -under operation, but I noticed a distinct narrow channel or -burrow parallel to the edge of the lid, and crossing about -the middle of it, which gave me the impression of being -a burrow by which the worm had moved across the lid.</p> - -<p>Two days later Miss H⸺ came complaining of a swelling -in the right temporal region. This swelling seemed -pretty deeply situated, and firm palpation failed to reveal -any corded feeling such as might indicate the presence of -a worm.</p> - -<p>On the 13th of February she felt the worm wriggling<span class="pagenum"><a id="Page_28"></a>[28]</span> -across the right upper eyelid, and then it appeared to -her to remain coiled up under the skin. She bound the -eye carefully up and came at once to the infirmary. I -examined the lid and noticed a fulness at the upper inner -part, which might be a coiled-up worm. By pressure of -the fingers I attempted to force the swelling towards the -edge of the lid, but I could neither see nor feel any movement -such as might be expected from the presence of a -worm. As, however, the patient’s sensations were very -distinct, I determined to make an exploratory incision. -I applied the clamp-forceps and made a free incision over -the region of the swelling, but found the chief cause of -the fulness to be a small deposit of fat, which I cut away, -and then proceeded to explore the neighbourhood carefully. -After some dissection I found a very fine transparent -filamentous body. On drawing upon it with forceps it -came away with a snap. It was much smaller in calibre -and shorter than the usual <i>Filaria loa</i>, and I concluded -that it was only a portion of a filaria—the main part -being caught between the blades of the clamp-forceps. -The forceps being removed, further exploration was made, -in which I was assisted by Dr. Mackay, and after some -dissection a well-marked <i>Filaria loa</i> was discovered deeply -embedded in the muscular tissue and removed with forceps. -The edges of the incision were brought together by a couple -of fine sutures, and healing occurred by first intention.</p> - -<p>The worm thus removed measured about 30 mm. in -length and nearly 1 mm. in thickness. It was firm and -transparent like a small piece of fishing-gut. It tapered -at either extremity to a blunt point, the tail being rather -sharper-pointed than the head. At the distance of about -9 mm. from the caudal end an opening existed in the -wall of the parasite, through which protruded a filamentous -coil, which subsequent microscopic examination revealed -to be the uterine tubes filled with ova in all stages of -development up to embryo filariæ. Notwithstanding the -amount protruded, the interior of the parasite was yet to -a great extent occupied by oviduct, the alimentary canal<span class="pagenum"><a id="Page_29"></a>[29]</span> -being apparently comparatively small in size. The wall -seemed to be chiefly composed of muscular fibre, the -transverse striæ of which were readily visible at all parts. -The semicircular projecting tubercles, which Dr. Manson is -inclined to view as serving to facilitate the gliding movements -of the parasite by enabling it to get a purchase on -surrounding parts, were very numerous towards the caudal -end, fewer in number at the centre, and very sparsely distributed -at the head extremity. Near the oral end of -the worm a small general projection of the wall existed -on one side, probably due to a partial rupture produced -by injury.</p> - -<p>The small piece of the worm I first removed in the -course of the operation proved on microscopic examination -to be part of the oviduct containing embryo filariæ.</p> - -<p>I will submit my specimen for more careful and -thorough examination and report to Dr. Manson, who is -entitled to speak with such authority on this subject.</p> - -<p>During the last six months I have at intervals examined -blood drawn from Miss H⸺ at various periods of day and -night, but have never been able to discover the presence -of any filariæ.</p> - -<p>My patient has several times directed my attention to -ill-defined swellings under the skin of the forearms a -little above the wrists, over the dorsal surface of the -radius, more marked generally in the right arm. The -surface of the swellings was not quite uniform, but did -not give one the idea of being produced by a coiled-up -worm. The swellings measured about half an inch in -diameter. They were not painful, but occasioned a feeling -of stiffness when the arms were used. The swellings -occurred at irregular intervals, and were generally most -marked in the mornings. Cold had no influence in dispelling -them; on the contrary, the application of cold -water on one or two occasions seemed to bring the -swellings forward.</p> - -<p>My patient informs me that natives of Calabar, and -others resident for a time there, are subject to such<span class="pagenum"><a id="Page_30"></a>[30]</span> -swellings in the forearms and wrists, to which the natives -apply the term “Ndi töt,” or swelling. These swellings -she has only suffered from since her return home.</p> - -<p>I have further a correction to make in the history of -my patient I previously submitted. It would appear that -while she was most careful with regard to the purification -of her drinking-water by boiling and filtering, she was -for ten days prior to leaving Old Calabar so completely -prostrated as to be unable to attend to any household -matters, and the person who undertook her duties was -unacquainted with the procedure employed for purifying -the water. It might thus readily happen that she at that -time partook of impure water containing embryo filariæ. -As she had no symptoms of filaria till after her return -home, this <i>might</i> explain their entrance into her system.</p> - -<p>It is easy to understand how the embryo filariæ may -enter the system, although their presence in impure water -has not yet been demonstrated. And it is easy to conceive -that, having entered the system from the alimentary -canal, they may breed and bring forth a large crop of -embryo parasites. But the chief difficulty consists in -determining how these embryo filariæ escape from the -bodies of those affected with the disease, and get deposited -in the impure water and thus propagate the disease.</p> - -<p>In the case of the <i>Filaria sanguinis</i> this is accomplished -by the mosquito which constitutes the intermediate host; -but as in the case of my patient, as well as in the case -reported by Dr. Logan of Liverpool, careful examination -of the blood failed to reveal the presence of embryo filariæ, -some other system of propagation than that by blood-sucking -insects must be looked for. Possibly the embryo -parasites may be discharged along with some of the -excreta from the body, and from faulty sanitary arrangements -find their way into drinking-water. Whether this -be so or not, future investigation will probably show.</p> - -<hr class="tb"> - -<p><i>Report on the structure of the female parasite</i> (by Dr. -<span class="smcap">Manson</span>).—Female <i>Filaria loa</i>: -length, 3·25 cm.; breadth,<span class="pagenum"><a id="Page_31"></a>[31]</span> -0·5 mm.; ova at morula stage, 0·03 by 0·02 mm.; length -of outstretched embryos in uterus, 0·25 mm.</p> - -<p>As regards her general appearance, the female <i>Filaria -loa</i> resembles the male parasite, only she is considerably -larger and her tail is straight, tapers to a diameter of -about 0·1 mm., and is then abruptly truncated. The -mouth, the head, the stout muscular ring just posterior to -the mouth, the stout longitudinal muscular bands, and the -bosses on the integument resemble exactly those of the male -worm. In consequence of the mutilation of the specimen -it is impossible to say where the vagina opens, or where -the anus is placed. The uterine tubes are stuffed with -embryos at all stages of development. The more mature -embryos resemble in size and shape those of <i>F. nocturna</i> -and <i>F. diurna</i>, but in consequence of the method of mounting -it is impossible to say if they are possessed of a -sheath or not. If they are possessed of a sheath, I should -say that they are practically indistinguishable from the -parasites mentioned.</p> - -<p class="titlepage">PRINTED BY ADLARD AND SON,<br> -BARTHOLOMEW CLOSE, E.C., AND 20, HANOVER SQUARE, W.</p> - -<div style='display:block; margin-top:4em'>*** END OF THE PROJECT GUTENBERG EBOOK CASE OF FILARIA LOA ***</div> -<div style='text-align:left'> - -<div style='display:block; margin:1em 0'> -Updated editions will replace the previous one—the old editions will -be renamed. -</div> - -<div style='display:block; margin:1em 0'> -Creating the works from print editions not protected by U.S. copyright -law means that no one owns a United States copyright in these works, -so the Foundation (and you!) can copy and distribute it in the United -States without permission and without paying copyright -royalties. 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