DIABETIC CATARACT, 
IRITIS, ETC., 
A CLINICAL LECTURE 
DELIVERED AT THE 
MICHIGAN COLLEGE op MEDICINE 
. " V 
C. J. LUNDY. M. 1)., 
Professor of Clinical Diseases of the Eye and Diseases 
of the Ear and Throat. , •*. 
(Reported by A. Thuener, M. D., Assistant fiurgeon to the 
Michigan Free Eye and Ear Infirmary.) 
RE-PRINTED FROM MICHIGAN MEDICAL NEWS. 
June 10th, 1880. Diabetic Cataract, Iritis, Etc. 
A Clinical Lecture Delivered at the Michigan College of 
Medicine by C. J. Lundy, M. D., Prof, of Clinical 
Diseases of the Eye, and of Diseases of the Ear 
and Throat. 
Ladies and Gentlemen :—The first patient 
whom I present to you is Mrs. H., aet. 51, who 
comes to consult me from the southern part of 
the State. She has cataract in both eyes, and her 
case presents many points which should greatly 
interest you, not so much on account of the cata- 
ract, as on account of the condition of the system 
which has caused the cataract. By the term “ cata- 
ract” is understood an opaque condition of the 
crystalline lens, which prevents, to a greater or 
lesser extent, the passage of rays of light to the 
fundus of the eye. 
There are several forms of cataract, and based 
upon some condition peculiar to each form, we have 
a variety of names for the affection, although the 
chief element in all cases is a loss of transpar- 
ency in the lens substance. The cataract may be 
hard or soft, and this depends on its consistency. 
Soft cataract is found in young people while hard 
cataract occurs in old people, on which account it 
is also termed senile cataract. The form of cata- 
ract which exists in our patient is essentially the 
same as the senile cataract, although it depends 
upon a condition of the system which in young 
people is a cause of soft cataract. 
Cataract may be general or partial—general if the 
whole lens is involved, and partial if the opacity is 4 
limited to a portion of the lens. In our patient it 
is general for the opacity involves more or less com- 
pletely the whole lens. Cataract may be congenital 
or acquired, and the traumatic cataract belongs to 
the latter class. In the case before you it is 
acquired. Cataract may be either primary or 
secondary—primary, if it occurs independently of 
disease in other portions of the eye, and secondary 
if it depends on some intraocular disease. In the 
case under consideration, the cataract is primary, 
although it is secondary to the systemic disease. 
Then there is a lare number of special forms of cata- 
ract, so to speak, such as nuclear, cortical, lamellar, 
polar, etc., etc., which I shall not take the time to 
describe, for this is not a lecture on cataract and 
besides they have no particular bearing upon the 
case under consideration. 
The history of this case is as follows : Till nine 
years ago this patient enjoyed good health. About 
that time she was delivered of a living healthy 
child, but did not recover from the effects of labor 
as quickly as usual. She was thirsty all the time 
and drank large quantities of water. She does not 
remember whether she passed an unusual amount of 
urine, but I have no doubt she did. One year after 
that time she was voiding the enormous quantity of 
twenty-four quarts of urine daily, or about one 
quart every hour. The urine wTas found to contain 
sugar, and it has contained sugar constantly since 
that time. 
During these eight years she has lost eighty 
pounds in weight, and as you see she is now very 
feeble. For the past couple of months her condi- 
tion has been worse than'usual, although she is now 
voiding only about eight or ten quarts of urine daily. 
Her appetite is still good although she frequently 
suffers from disturbances of the stomach, and com- 
plains of a peculiar “fluttering” sensation in that 
region, which is attended with a feeling of faintness. 
The heart’s action is very feeble, and there is a 5 
cardiac murmur which, in my opinion, is due to 
anaemia, and the pulse is irregular and intermitting. 
The skin is dry and harsh as is usual in such cases. 
Although I have determined the presence of glucose 
in the urine by means of the sulphate of copper and 
the liquor potassa test, no quantitative analysis 
has been made. I shall request Prof. Clark, whom 
I see present, to make this quantitative analysis 
for you and explain to you its chemistry. [Prof. 
Clark, after making some remarks on diabetic 
urine, examined the specimen of the patient’s urine 
and found its specific gravity to be 1040, and that it 
showed abundance of sugar according to Fehling’s 
test. The quantitative analysis was not made during 
the lecture—Reporter.] Now what is this strange 
disease ? It is diabetes mellitus, and the cataracts 
are the kind commonly called, in such cases, diabe- 
tic cataract. Her vision began to fail between three 
and four years ago, and for a year and a half she has 
been unable to read. At the present time vision is 
very poor, and she can scarcely count fingers at a 
distance of one foot. 
As you examine her eyes you will observe that the 
back of the pupil is occupied by a grayish mass, 
and that the pupil does not present that black 
appearance which it does in the normal eye. The 
crystalline lens, which was once so transparent that 
almost all the rays of light falling upon it passed 
through unobstructed, has now become opaque and 
reflects back most of these rays, and hence you will 
see it as a grayish body occupying the back of the 
pupil. This opacity of the lens is cataractous, and is 
doubtless the result of disturbed nutrition within 
the lens, and in such cases sugar has been found not 
only in the urine but also in the lens substance as 
well as in every fluid and tissue of the body. To 
determine the presence of cataract it is advisable to 
examine the suspected eye by oblique or focal illu- 
mination, and also with the ophthalmoscope. 
Having made your diagnosis what will be your 6 
prognosis in such cases as this ? As regards the 
general course of the disease (diabetes) it cannot be 
favorable, and especially is this true of young sub- 
jects. As regards the eye and the prospects of 
the successful extraction of the cataract, much will 
depend upon the general health and condition of 
the patient. If his general health is still good, and 
if by a proper diet you can diminish the quantity of 
sugar and urine excreted, an extraction of cataract 
may be made with a certain degree of safety. 
Indeed, Wecker, of Paris, maintains that the 
diabetic condition need not be taken into considera- 
tion before extraction of cataract, and he cites two 
cases in support of his argument. But in the cases 
upon which Wecker operated there was no impair- 
ment of the general health, and one of them was in 
good health ten years after the operation, while the 
other asserted that he never felt better than at the 
time of the operation. 
In the case of our patient, I do not deem it advisa- 
ble to perform an operation for the extraction of 
cataract at the present time. There is an irritable 
condition of the eye and a hypersensitive condition 
of the retina, for notwithstanding that the cataracts 
obstruct most of the light she cannot look at a lamp, 
gas jet, or other bright light even for a momen 
without distress. However, I do not think there is 
any retinitis, for the field of vision is good in all 
directions for each eye as tested with the candle in 
the dark room. In making the examination with 
the opthalmoscope and by means of oblique illumi- 
nation, I caused much pain in the eyes, which pain 
extended to the cervical portion of the spine, and 
the patient was well nigh exhaustad although the 
examination occupied but a few minutes. 
At present her general health is poorer than it has 
been for a long time. Then she is extremely feeble, 
and is not in a fit condition to undergo an operation 
of any kind. Cataract operations in such subjects 
are liable to be followed by suppuration of the cor- 7 
neal wound and this process may involve the whole 
cornea. We know that in diabetic patients there is 
a tendency to inflammatory troubles, and, in the 
case of our patient, this point is well worthy of 
consideration. My advice, then, would be to 
improve if possible the general condition and 
strength of the patient and check this enormous 
elimination of sugar from the system. If these can 
be accomplished I would first perform an iridectomy, 
that is, remove a portion of the iris, as is done for 
artifical pupil when made upwards, or as in the first 
step in cataract operation, and in the course of 
some weeks or months afterwards, I would, if all 
things were favorable, extract the opaque lens. By 
thus dividing the operation, as it were, you lessen 
the liability to inflammation, and enhance the prob- 
ability of success, 
ACUTE IRITIS. 
Case 2. The next patient is Thomas L., set. 25. 
One week ago, after exposure to cold from a draft 
of air blowing over him at night, his right eye 
became sensitive to light and the tears began to flow 
quite freely and vision was blurred. This photo- 
phobia and lachrymation were soon followed by pain 
which became so severe as to prevent sleep for four 
or five nights. He presented himself at the infir- 
mary yesterday, where some of you saw him, when 
the case was diagnosed as acute plastic iritis. By 
iritis you will understand that there is an inflam- 
mation of the iris. On account of certain patholog- 
ical differences, pathologists describe the acute 
idiopathic inflammations of the iris under three 
heads, viz. ■: serous iritis, which is rare ; plastic iritis, 
which is most common; and purulent or parenchym 
atous iritis. Although it will not always be an 
easy matter to follow this classification clinically, 
yet it answers well enough. As you examine this 
patient you will observe a general congestion of the 
eye, and especially a zone of congested ciliary 8 
vessels behind the corneo-scleral junction. By 
oblique illumination you will see that the iris is 
discolored, and the pupil is irregular and immovable, 
and that in the lower and inner quadrant of the 
pupil there is a deposit of plastic lymph, or what 
Alt would denominate as “fibrinous coagulum.” 
He tells us that .the vision of this inflamed eye is 
poor, and you will observe there is great intolerance 
of light, and that exposure to light causes a copious 
flow of tears. Although his pain is not so great as 
it was yesterday, yet it is tolerably severe. It is n'ot 
confined to the eye, but extends over the brow and 
side of the head and down the side of the nose—in 
a word it follows the distribution of the first divis- 
ion of the fifth nerve. The patient is a robust, 
healthy, temperate man, and he never has had either 
syphilis or rheumatism. This is his first attack of 
inflammation of the eye. There can be but little 
doubt that the exposure to cold was the exciting 
cause of this attack of iritis. Notwithstanding that 
a four grain solution of sulphate of atropia has been 
used five or six times in his eye within twenty-four 
hours, there is scarcely any dilatation of the pupil. 
This is due in part to the inflamed condition of the 
iris, but more particularly to the results of the 
e. to posterior synechia. By posterior 
synechia I mean an attachment of the iris to the 
capsule of the lens. This posterior synechia is one 
of the most frequent of the bad results of iritis, and 
one that should be prevented if possible. Its occur- 
rence often leads to serious trouble and occasionally 
to loss o? the eye. Now how shall we treat such 
cases ? First, the eye must be placed at rest. Rest 
is important in the management of all inflamed 
organs, and to this the eye forms no exception 
Rest can be secured by paralyzing the muscle of 
accommodation and by shading the eye from the 
light. The pupil should, if possible, be quickly 
dilated, and for this purpose you may use a four 
grain solution of sulphate of atropia or a two grain 9 
solution of sulphate of duboisia. Of either of these 
solutions you may put a few drops in the eye every 
two or three hours. If the pupil dilates the blood 
vessels must of necessity contract, and the severity 
of the inflammation will be modified. The dilatation 
of the pupil also prevents adhesion of the iris to the 
capsule of the lens. Even if adhesion has taken 
place you can frequently break it up by the vigor- 
ous use of mydriatics, as will be illustrated in the 
next case. Aside from the therapeutic value, 
atropia and duboisia are valuable anodynes and wflll 
greatly relieve the pain in such cases. Two or 
three leeches may be applied to the temple with 
advantage in such cases, and their use is indicated 
if the pain is violent and the course of the inflamma- 
tion is severe. The internal administration of 
mercury may be resorted to with advantage in all 
forms of iritis, but if the exciting cause is syphilis 
the mercurial should be given freeely. Other con- 
stitutional taints should receive appropriate 
treatment. If the posterior synechia becomes com- 
plete the performance of an iridectomy would be 
indicated after the severity of the inflammation has 
subsided. 
SIMPLE IRITIS WITH CORNEAL ULCER. 
Case 8. The next patient is Herman W., set 40, 
cabinet maker. You see he is a pale, thin, anaemic 
individual, quite unlike the last patient. Although 
not strong or robust he has enjoyed fair health and 
has never had syphilis and is not rheumatic. He 
had an ulcer on the cornea four years ago which has 
left a small white scar or leucoma. Abut six days 
ago he took cold while at work in the Pullman 
car shops. He was working beside an open window 
through which a stiff breeze was blowing and to 
which the affected eye was exposed. In the course 
of a day or two the eye became irritable and painful, 
there was much dread of light and the tears flowed 
profusely. When he came under observation two 10 
days ago, a small point of infiltration wras noticed 
in the center of the cornea, there was well marked 
ciliary injection, both of the deep and superficial 
vessels, the iris was somewhat discolored, the pupil 
was inactive, and there was an attachment of the 
iris to the lens capsule at the upper and inner quad- 
rant of the pupil. Several of you saw him yester- 
day at the Michigan Free Eye and Ear Infirmary 
when the pupil was somewhat dilated but it still 
was adherent at a small point. The epithelial layer 
of the cornea had disappeared over the point of 
infiltation, and all the characteristics of a superficial 
ulcer of the cornea were present. To-day you will 
observe that the pupil is well dilated, that it is 
round and regular, and that I have succeeded in 
tearing loose the posterior synechia. The small 
corneal ulcer presents no observable change since 
yesterday. Iritis is sometimes secondary to corneal 
i nflammations, but in this case I think the corneal 
trouble would not be likely to cause it, for the ulcer 
is small and superficial. Internal treatment has 
consisted of one-sixteenth of a grain of bichloride of 
mercury and one drachm of the compound tinc- 
ture of cinchona thrice daily. Atropia sulphate 
has been used frequently, and in the course of a few 
days I shall dust a little calomel into the eye on 
account of the ulceration of the cornea, and in the 
mean time shall continue the atropia. 
Case 4. The next patient is J. W., set. 8. She is 
a scrofulous child, and although her corneal affection 
would make me suspect inherited syphilis, yet I 
cannot detect evidence of it, As you see the right 
cornea presents a diffuse cloudiness, although this 
is less dense than it was. You also notice the rosy 
zone of congested ciliary vessels behind the corneo- 
scleral junction, the manner in which she shrinks 
from the light and the copious flow of tears. There 
is also an adhesion of the iris to the capsule of the 
INTERSTITIAL KERATITIS WITH IRITIS. 11 
lens, which I think can be easily broken up for it is 
limited in extent, and the corneal trouble is getting 
oetter. I think the corneal inflammution was undoubt- 
edly the exciting cause of iritis in this case. The 
treatment should consist in the use of atropia to 
prevent complete posterior synechia and to tear loose 
synecha already formed, if any exist ; the adminis- 
tration of cod liver oil and tonics, and the use either of 
calomel or the ointment the yellow oxide of mercury 
(hydrarg. oxid. subflavse gr. vj, vaseline § ss) in the 
eye once daily. If iodide of potassium is adminis- 
tered internally it were better not to use mercurials 
in the eye. At best these cases are slow and 
tedious. 
Case 5. The patient is master Charles M.. set. 8, 
whom I operated upon before you some two weeks 
ago. I bring him before you to show you the perfect 
result of the operations. You remember that the 
squint was of high degree, and that it was neces- 
sary to sever the internal rectus of each eye. Now 
that the squint is fully corrected, he should be 
examined for spectacles and the hypermetropia, 
which was the prime cause of this squint, should be 
corrected by suitable convex glasses. 
Case 6. This little patient you have seen before. 
You remember that I severed the internal rectus of 
the right eye for convergent squint, and that I told 
you she would undoubtedly need an operation on 
the other eye. To-day the right eye is straight, but 
the other is not so; and in order to enable the visual 
axes to assume a correct position and thus avoid 
double images, the internal rectus of the left eye 
must be snipped. 
STRABISMUS CONVERGERS.