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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.

LONDON: PRINTED BY ADLARD AND SON, BARTHOLOMEW CLOSE, E.C., AND 20, HANOVER SQUARE, W. 1895.

Communication read at the Meeting of the Ophthalmological Society on October 18th, 1894.

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 anaemic, 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.

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 anaesthetised 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 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.

"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 oesophagus 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 diagtam roughly indicates what I conceive to be the arrangement of the details of the under surface of the tail."

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 Ik?r?fi?n, 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 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.

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.

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 first case recorded appears to be that observed by M. Bajon, 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 manoeuvre, 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 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 M?decine' 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 , 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, 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 , 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.

We next find M. Clot at a meeting of the Acad?mie 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 filariae, 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 filariae were in different eyes when the operator 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.

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.

A case is also recorded by Gervais and van Beneden, 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.

Dr. Morton 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.

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.

"The arms became, since June, stiff and swollen, especially on awakening from sleep , 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."

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 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.

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