THE MOST COMMON EYE DISEASES IN THE NORTH-WEST PROVINCES AND OUDH, ETIOLOGY AND THEIR TREATMENT, TOGETHER WITH NOTES ON CATARACT, LINEAR EXTRACTION AND OTHER METHODS USED FOR OPERATING, ILLUSTRATED BY 1,000 CASES. By 'Surgeon-Captain G. H.

Civil Surgeon of Bijno

Fink, I.M.S.,

/

District.

I will not weary the reader with a description of the anatomy of the eye, but take" it for granted that the knowledge of that subject, as a student in the dissecting and lecture-rooms, still has that fascination over him which the eye of all subjects seems to have with most surgeons in India, particularly those in civil employ, who have greater advantages and opportunities than I must at their confreres iu the sister service. the outset of my paper apologise for the omission, since it would take up a very great deal of time and space, and ask him to refer to text-books on the subject of the eye, if he finds it necessary to do so, which I do not feel will be the case, siuce I am about to treat of the commonest eye complaints which the native of the North-West Provinces and Oudh is subject to, aud not diseases of a complex nature. Nature has provided us with the wonderful organs of vision known as the eyes, which serve various purposes in our lives, and without them any individual is seriously handicapped in the battle aud struggle for existence. The natives of India have an idea that we have one eye for good and the other for evil; but avoid the man with one eye; look upon him with suspicion, for he has lost his good eye and the one he sees with is the evil one. To the savage the eye is useful for purposes of hunting, for his food or for his enemy, and he

cultivates that keen sight for distance and discrimination ; also for colours, form and velocity of movement; in short, he has clear and accurate vision like the falcon which soars aloft, circles round and round, and at last darts down on the poor pigeon : to the civilized being, the man of culture aud letters, to enable him to carry on his particular study or vocation in life, whether it be a profession or a trade, an art or a science, vision, as perfect as can be, is very necessary. The higher you rise in the scale of civilization and learning, the more you notice optical defects in the eyes of individuals, brought about by strain in accommodation of the eyes for vision, through the muscles of the eye-ball and the iris, and in time the normal eye-ball becomes altered in varioui ways; hence, by hereditary transmission through several generations, myopia, hypermetropia, and various forms of astigmatism arise. We must recoguise the habits of an individual in his profession or occupation to obtain some clue to the defect which he suffers from, as acquired, otherwise heredity comes in as a cause. Besides the above optical defects which are noticed in various individuals, there is a form of vision known as presbyopia, which we are one aud all advancing towards in the natural course of decay aud degeneration which our whole body is subject to. The elasticity of youth is fast passing into the rigidity of advanced life, and so it is with the eye-ball aud its media,?they must share iu this general change, and the refracting media must fail to perform their duties with such precision and nicety as they used to do iu youth and adolescence. We have read a great deal of late in the British Medical Journal of Miner's Nystagmus and its causes, which illustrates the powerful effects of certain occupations and habits in life. The normal eye is spherical, aud the of light from the object looked at, passing rays through the refracting media are focussed or Any deviation or converge upon the retina. normal the from form of spherical eyechange ball to the elongated, flat, or wavy eye-ball; or any alteration in the refracting media or the must necessarily alter power of accommodation the point of focus or convergence of the rays of light, hence we have such optical defects as myopia, hypermetropia, aud astigmatism. This last form of vision has a great many types and varieties. The lower we go in the scale of civilization, we see diseases of the eye, due to bad sanitary surroundings, living under bad hygienic conditions such as dirty habits,?both personal tyid domestic?bad nourishment and poverty. The diseases of the eye among the lower orders are chiefly due to dirt and filth aud utter neglect of cleauliness,?most of these diseases start as ophthalmia in one form or another going on to granular lids and trichiasis or,

June

1894.]

FINK ON EYE DISEASES IN N. W. P.

panuus, nebula, leucoma, ulcers iritis, prolapse of the iris, anterior posterior synechia, glaucoma and glaucoma-

entropium, of coirneae, or

tous cataract, amaurosis.

Climate and climatic diseases, with infection contagion, of course, must be considered as accountable for a certain percentage of eye Macnamara and others have told us diseases. how the eyes out in India have to be protected from the reflected rays of the sun which, if long continued, seem to effect the retina, which swells and creates headache, herice the necessity of dark neutral-tinted glasses to keep off the glare of the sun, which in the North-West Provinces and Oudh, the Punjab and Sindh seems worse than anywhere else, owing to the sandy soil and extremes of temperature and hot winds. In fact, I am not quite sure whether many of the cases we see, of what is termed sunstroke, are not a form of fever produced by the sun's rays affecting the retina and carried through the opticnerves to the optic commissure and track, and so to the brain generally, causing a turgescence of the whole chain of nervous communication. Such cases might benefit more rapidly aud recovery set in if (he fever is treated through topical applications to the eye and a dark-room, together with sedatives to the nervous system. Contagion and infection, doubtless, do play their part in affecting the eyes. The ravages of small-pox in by-gone days produced many blind persons, but happily vaccination and sanitation have greatly lessened the numbers we now see in modern times. Local causes and influences must doubtless play a part also, and a very large part too, I fancy, in the production of eye diseases; The sand and dust, the myriads of flies and various iusects, and the soil must account for many of the cases of ophthalmia or purulent diseases of the eye which are witnessed among children. It behoves the ophthalmic surgeon, therefore, to be very circumspect, observant and contemplative before he forms his diagnosis of the patient's condition; for after all it is not the disease, but the patient that he has to treat. The habits, the family history and the surroundings of your patient will often offer a clue to the objective and subjective symptoms and signs, to enable you to base your diagnosis on sound premises and so to arrive at a logical conclusion. We do, however, from time to time, witness exceptions of a startling nature in old age, where there is perfect vision without the aid of glasses. There is a habit among Eastern people of pencilling the eyelids with what is called soorma, which is black oxide of antimony, which the native of India firmly believes as cooling and clearing the vision. We know how the people of higher altitudes and among the snows have various methods of preventing enow blindness, which Arctic explorers, or

207

like the great Dr. Nansen who is now away in search of the North Pole by acting in unison with the polar currents and drifting with the ice, has mentioned in his "First Crossing of Greenland." Soorma has probably the power of absorbing redundant rays of light and creating a flow of tears which wash the eyes and keep the ducts aud cauals open channels., It is not with these rare exceptions or optical defect that I wish to deal, but with the commonest diseases of the eye generally in the North-West Proviuces and Oudli, and more particularly with cataract aud linear extraction and other methods which commend themselves to the ophthalmic surgeon. The eye has a great fascination for surgeons in this country owing to the numerous cases which pour in no sooner the news is heralded that the eye is the surgeou's hobby. European surgeons and surgery have achieved such wonders and perfection in modern times that the surgeon is the second god in the eyes of the native public. The wonders of cocain have travelled far and wide as a local anresthetic, aud every surgeon in his particular district where cocain was first brought into use is associated in the minds of the ignorant public as being the discoverer, because his predecessor used chloroform, regarding which there is a certain amount of dread owing to accidents. Let us hope, however, that the more confidence will be established when successes of the Hyderabad Commission, due to the efforts of Lawrie, Bomford and others, will soon drive the accidental effects of chloroform iuto deep oblivion in a few years. I must not travel iuto the Nizam's Dominions lest the fascination seize me of lingering on respiration and leaving circulation to take care of itself, which by this time ought to be au established fact, after the effects on the vagus nerve have been disclosed. Now, come with me into the dominions of the North-West Provinces and Oudh during my camping-tour in search of the vaccinator's results with the needle and vaccine lymph on the and I am prepared to young infants and children, show you in the course of a few weeks what you have not noticed for yourself, perhaps, for years, in the shape of eye diseases of ali kinds, curable and incurable: It is?undoubtedly a move in the right direction now that Civil Surgeons are made Health Officers of their districts, for they are able to appreciate more fully the real requirements of their districts from a sanitary and medical point of view, and to make practical suggestions for the relief of human suffering with which tbey come into daily contact in the discharge of their duties. The squalling infants are a sight to witness as the vaccinator extends his parental arms for your close inspection of The first thing which strikes your the child. eye is the scantiness of clothing which the inNature's garments and the warmth of fant has.

INDIAN MEDICAL GAZETTE.

208

the mother's affections, together with the tail of her chuddar, are enough for the babe, which struggles against the vaccinator's efforts as the cold strikes its naked body. The next thing which strikes the eye are its eyes, closed up and glued together with dried discharges of a yellowy-white which plaster the eyelashes and If you try to open the flow over the lower lids. lids by gently drawing them apart, the child struggles violently, cries, and buries its head in the mother's breast; or if suspended in those of the vaccinator, it probably micturates over him, unless he cautiously keeps his charge as far distant from him as the ejaculator urinre has

povfer

to aot.

If you succeed in parting the lids, you will observe a gush of hot tears or the flow of purulent discharge. The tender mother in the distant village, far from proper medical aid, waits until business calls her or the father to the Sadr Station, and then brings her infant blind or with prolapse of the iris or suppuration of the eye-ball. If this be not the course of events, then the satiah gets hold of the child, and when his nostrums fail, he recommends the Civil Surgeon as able to do the rest; and woe be to the Civil Surgeon who attempts to do anything after the satiah has once worked mischief, particularly to give any hope of vision after the satiaWs hand has once touched the child, for if he does not produce a miraculous cure, the whole village will accuse him of being the cause of the entire mischief and not the satiah. If the satiah has fled from the village, which wise satiahs always do, then Fate has been against the child and blindness has resulted. No satiah stays long enough to get discredit for the mischief d?ne by him to scores of eyes. More about this gentleman later on. When matha-devi and other devis are among them, is it a wonder that more cases ol blindness are not common ? Negligence and carelessness almost amounting to crime, under the cloak of ignorance,is permitted to exist, when simple cleansing of the eyes with warm water and a little alum would have probably saved the little mite the life-long misery and wretchedness which Fate is responsible for. Poverty is 110 excuse where water and a few sticks for a fire are abundant. It is cruel and heart-rending to witness a young infant, suffered to become blind from the ?day of its birth,and the cold,chilly air of the cold weather playing over its naked body. Truly the survival of the fittest rules severely in such cases. Consider your life without vision, how dark, cheerless and purposeless it would be, if to-night you were told that to-morrow's sun will bring with it total darkness as th# light streams through to You hear your bedchamber. your window in the music and the songs of birds, but you tniM

their You

[June

colouring

and the

scent

perfume

1894.

landscape around you* of the flowers in your garden, but you miss the thoughtful pansy, the modest daisy and the peeping violet. You listen to your friend's voice, but you miss the bright smile and the twinkling merry laughter round liis eyes. You are blind amid the joy and the mirth of your own home and its comfortable hearth, hopelessly blind, blind to the whole of the scenes of by-gone happy hours when the be pictured with all its outer world could warmth of colour and meaning : "

the

in trees, books in the running brooks. Sermons in stones, and good in everything."

Tongues

A great medical philosopher has told us how no head injury, however trivial, is to be considered too trifling to treat, lest complications, erysipelas chiefly, should set in and destroy life. We know the gravity of this complication of head or face injuries, and so it is with the eye, no matter how trifling the ailment or defect might be,?those organs of vision are so delicate in their anatomy that the loss of a few hours might mean loss to sight or eveu to life perhaps. See the mischief which an inverted eyelash creates if it be suffered to remain for years. See what such foreign bodies as a speck of lime in the eye creates. I once had the misfortune to have a piece of lime mixed with sulphate of copper, which is used for colour-washing Indian houses inside, fall into my eye while I was asleep in bed. A dry piece must have fallen into the inner canthus, and on awakening dropt into the eye ; but in the course of a few hours my I could not account eye was a sight to behold. for the mischief at all and supposed it must be due to a dirty towel used in the dispensary ; but no, for all my towels are soaked in mercury lotion first and then given to me after drying. Some time after, as I was going to bed, my eye being so swollen, painful and throbbing, I discovered a larger fragment of lime and copper so the cause was dison the bedsheets, and the covered, remedy rapidly applied, and the eye saved. Let us now see what are tho most common eye diseases which we come across in the NorthWest Provinces and Oudh. Diseases

of the Eyelids.

Hordeolum or stye.?Generally the reBult of poverty of blood, errors in diet or general loss of tone of the system, occurs in children as well as adults, and liable to recurrence as long as the patient's general state of health is indifferent or bad. Treatment..?If seen early, remove the eye lash which grows out of the centre and which can be made clearly visible by means of a magnifying glass, and lightly touch the cavity in which the lash was held with a fine pencil of caustic.

June

FINK ON EYE DISEASES IN N.-W. P.

1894:]

209

Iii course of time the lashes might disappear and leave a reddish, pink appearance to the lids showing the margin of the conjunctival surface. This occurs through a slight aversion of the lid, and of the loss the through eyelashes there is an accumulationof dust and dirt which irritates and still further inflames the edges of the eyelids and makes the eye present a staring and ugly appearance. Treatment.?Free ablution with soap and water with a certain amount of friction of the edges of the lids with a stiff camel-hair brush. Mercury lotion to wash the eyelids freely twice or thrice a day, and the topical application of a little dilutw white precipitate or citrine ointment with a stiff camel-hair brush to the edges of the lids. Trichiasis.?Inversion of the lashes which touch the eve-ball, and by constant contact set up irritation of the conjunctiva, followed by pannus and corneal affections, such as nebula, leucoma and ulcer of the cornea. Trichiasis is liable to follow attacks of Tonic ; Ferri et quiuia) citratis gr. iii to v. and chronic ophthalmia with granular blepharitis 3i. Aqua The eyelashes vary in the number which lids. Thrice a day after meals. as well as the situation which is are affected Chalazion (tarsal tumour), due to some ac- attacked. Sometimes you see the inner or outer cidental circumstances, negligence to wash the or canthus of the extremity eyelid affected,?at eyes properly, or some general condition of ill- other times the centre ; but whatever part is health, which causes a blocking up of the duct the seat of the mischief there are various modes of one of the Meibomian glands and gradually of treatment. Some surgeons treat the case by filling up of the walls of the gland by the secretion withdrawal of the inverted lashes, but this is from them, which expands the walls and casetedious; it has to be repeated over and over ation of the liquid secretion takes place in a is painful and less effectual than other glairy substance like the contents of a ganglion, again, and the native patient will not submit methods, or even pus is occasionally found through in- to and over again brought under over being flammatory changes and suppuration taking place. treatment extending over weeks and months. They are found to point either above the Treatment.?If only a few lashes are affected upper lid, under the skin of the eyelid, or under the " snaring" operation seems useful, and the the conjunctiva, beneath the lid on its inner following is the mode in which it is performed : surface, like a shot or pea let into the skin or Wash the eyelids and lashes with warm mercury conjunctiva, and if pressed between the fingers lotion 1 in 5000, place the patient on the table to present a distinct shotty feel. in front of a good light, aud by means of a Treatment.?Evert the lid, transfix the cyst glass closely inspect the inverted magnifying with the blade of a cataract knife previously lashes. Then with a very fine curved needle, oiled, and spoon out the contents with a spud or as depicted in the diagram A, whose point is scoop, and with a good pair of forceps, with fine, in carbolic oil, pass the point carefully dipped strong and well-uniting points, tear out the sac at the root of the lashes bringing the point out of the cyst as is recommended for sebaceous through the skin of the eyelid ; thread the eye cysts. Check hajmorrhag'e with a piece of cotton- of the needle with the ends of a long human wool dipped in chloroform and just gently touch needle the draw and through the skin j the cavity with it, after which wash out with hair, out the lash use a good pair of which must hold the lash at its root, cilia-forceps, and traction must be firmly and steadily made in the long axis of the lash, and it will easily come away and afford immediate relief; otherwise if you tug at it and the lash breaks off short at the root, it gives rise to very great pain and further inflammation and swelling. If not seen in the early stage, very often the simple and efficient application of flexible collodiurn all round the stye at the lower margin of the lid will cause a subsidence. The collodium acts like a splint and gives rest to the eyelid. Calcium sulphide gr. ^ t. s. in pill. It not a succession of hot linseed meal and poppy head poultices will give great relief ; and when the stye points to a head, either draw out the lash f rom the centre, which will now come away more easily, or make a small incision across the stye by transfixion from side to side with a Von Graafe's cataract knife.

In

drawing

???

...

mercury lotion.

Blepharitis (Tinea Tarsi)chiefly occurs among castes and those who are dirty and negligent of (lie eyes, and do not consider washing them a necessitv, a luxury seldom indulged in. Po verty of blood and ill-nourishment, and the lower

as a sequel to attacks of fever and eczema, might give rise to it as well. lhe eyelids present an ugly, scraggy look, through loss of lashes, or a glueing together of eventually two or more lashes

with

A the needle i9 unthreaded nncl with-

yellowish gummy drawn, and the appearance of the human hair is secretion at their roots, followed by a fine branny as given in the diagram 13. You then with a disquumafion. fine pair of iris forceps pass the inverted lash a

33

INDIAN MEDICAL GAZETTE.

210

hair ami draw the the lid which at the s:ime time draws the lash out with it, and it is allowed to remain in its transplanted position as in C. You repeat the operation with the other

through the loop of human loop out through the skin of

Human hair

ensnaring the lash.

trans Lash trans-

plutetj. plated.

eyelashes until .ill are transplanted one by one? If desired cocain might be injected hypodermically to save pain; but there is very little pain experienced in the operation. Entropium or entropion is the condition where the upper or lower eyelids are curved inwards at their edges, carrying the lashes inwards at the same time and causing great disfigurement of the eyes, or by constant contact with the cornea and eye-ball, setting up pannus, leucoma, epiphora or even ulceration of the cornea in At any rate it is a great discomsome cases. fort and inconvenience to the patient and demands an operation. You see a great many such cases in the North-West Provinces and Oudh, and they are usually due to chronic ophthalmia and granular lids, as will he observed by everting the lid and carefully examining the palpebral conjunctiva which presents an angry red appearance, which, by looking at through

magnifying glass, presents an appearpile. Treatment.?Numerous operations have been devised for this conditiou of things; but the one 1 usually adopt is known as Burow's operation, although at times one has to adopt others to ance

a

like velvet

suit the circumstances of your

Streatfield's, Dianoux's, Van

patient, viz.,

Millingen,

or

Spencer Watson's. Burow's operation is performed in a somewhat modified manner by myself, and I have found the results very satisfactory. First, wash the eyelids and conjunctiva thoroughly with mercury lotion 1 in 5C00, inject a few drops of 4 per cent, cocain solution hypodermically into the skin, and also a few drops (one or two) into the eye itself to keep the patient steady on the operalion-table before a good light. It is well to inform the patient that he will experience some pain; but to hold tlie table firmly with the bauds on each side and clench the teeth if he does, and,

[June

1894.

Take a pair of Snellin's forceps?the right pair for the right eye, aiul the left for the left?oil them with a 1 in 40 carbolic oil carefully, and gently pass the forceps with the right hand for the right, and the left hand for the left eye under the eyelid (upper eyelid). By means of a little gentle coaxing the forceps slides under the lid; if not, it is necessary to slit the outer canthus of the eye for about one?eight of an inch to give passage to the forceps. Having got the forceps under the lid, adjust it properly, fix the blades firmly by pressure with the index finger and thumb of one hand and screw home the disc top of the screw very gently but firmly so ns to prevent luemorrhage as much as possible. While screwing home, it is also necessary with the little finger of the hand, which is used for the screw, to draw up the skin of the upper lid towards the forehead so as to present a shiny, tense appearance of the lid when the forceps has been fixed firmly, otherwise the skin of the palpebral surface will pucker and render the operaThe upper lid tion somewhat more difficult. now looks tense and shiny, and also looks bluishpurple, owing to the incarceration of venous blood in the capillaries of the eyelid through the pressure of the blades of the forceps. For the left eye, you now take a Bell-Taylor's knife in the right hand, oil the blade first with a little carbolic oil 1 in 40 and enter the point gently about one millimetre from the edge of the lid at the nasal side of the skin of lid. Having punctured the skin, you now turn the cutting edge of the knife upwards and glide it along uuder the skin which it incises as if by a subcutaneous incision, rapidly and clean, following the curve of the lid all the while; venous oozing now occurs which must be checked by using ail astringent solution (alum gr. x to Ji) on a sponge, or touching with a fine dossil of lint dipped in a few minims of chloroform. Your first incision being over, you now begin again at the same point as before with your BellTaylor's knife, and a pair of fixation forceps is now required to hold the piece of semilunar skin which your knife excises by another rapid but gentle subcutaneous incision which follows the curve of Snellin's forceps. The extent of skin which is excised depends upon the degree of entropion present?a smaller and narrower semilune for a slight deformity, a medium for a medium, and a large for a pronounced one. liuo of subcutaneous excision of skin. Showing lino 1

as

rule, women bear the operation marvellously well, even without any anaesthetic. In the case of children you must give chloroform to over-

a

come

the

struggling

and

kicking.

Diagram

cutaneous

D shews the clotted line of sublinear excision, which is efFected

.Tone

1894/]

MAYNARD ON THE

CATARACT-PRICKING

rapidly by turning the knife's edge upwards ; no the point lias punctured the skin, 1, 2

sooner

and 3 shew the extent of skin necessary to excise in pronounced, iu medium, and in slight degrees of entropium, and after your subcutaneous incision has been made by running the knife along the curve which the eye must carefully follow as the edge cuts the skin clean and neat. By a few touches of the same knife, the included portion of skin is dissected away by holding one corner of skin with fixation forceps to euable you to dissect clean. With fixation forceps you now get hold of the edge of the upper lid, and evert it gently until the conjunctiva is visible. You then with a sharp and narrow scalpel cut through the tarsal cartilage, following the curve of the cartilage at a distance of about one millimetre from its edge. The operation now gives you a semilunar or eliptical piece of skin excised, and an eliptical piece of cartilage incised through, but still held together and lying loose iu its bed of sub-conjunctival tissue on its inner surface and the orbicularis palpebrarum fibres on the outer surface. The next step is to suture the edges of the wound on the upper lid whence the skin has been excised, with a fine curved needle and horse-hair sutures; the horse-hair suture must not be too stiff, but soft, and it would be well to soak it in a little mercury lotion for a while before using it. You suture the edges of the wound by a continuous suture as neatly and with as perfect coaptation as possible, leaving the end of the suture long, so as to draw the ends upwards after the operation, towards the forehead, which has the effect of everting the section of cartilage which has already beeu incised and so retaining it in this everted position. By using the right hand for the left eye and the left hand for the right, if you are ambidextrous, it is so much of an advantage in this operation, that you avoid injuring the point of your knife against the blades of the SneHiu's forceps in commencing your incisions from the nasal side instead of the temporal. At any rate I have found this a distinct advantage to myself, and so think fit to mention it. If you begin on the temporal side the blades of the Snellin's forceps are in the way and impede your knife in running along rapidly with its back towards the cartilage of the lid and the cutting edge upwards and forwards beneath the skin. A pad and compress with water-dressing is all that is now needed ; and if you find that the ends of the horse-hair suture have got loose from the situation of the forehead where they are fixed with resin plaster, all you have to do is to again get the ends and draw them upwards and forwards witen the cartilage will evert and ho fix again them once again to the^forchead with plaster. Remove the suture on fourth day. If there is entropion of the lower lids, Wharton Jones'

OP THE HINDUS.

a V-shaped incision gives results. As a rule, I have only seen a few of this affection in my hospital practice and not say much about it.

operation by

( To

be

continued.)

211

good cases can-