THE-TREATMENT OF THE EARLIER

STAGES OF SENILE CATARACT.*

By HENRY SMITH, V.H.S.,

Lieutenant-Colonel, i.ji.s. ,

Civil Surgeon, Amritsar.

Tiie earlier stages of cataract we may divide

roughly into two :?(l) The stage we can treat

without operation, and (2) the stage in which operation is necessary.

(1) The diagnosis of the earliest stage of

cataract does not appear to have received the

amount of attention it deserves, if we are to

measure such attention, by what has been written on the subject; partly, I suppose, because the

ordinary patient pays little or no heed to

deteriorating distant vision, so long as his vision is efficient for near objects; perhaps a larger proportion of this class of case comes to us

earlier in the Punjab than to you in Europe. Cataract being so prevalent, and appearing in

the prime of life; so most of my patients are

quite aware of the possibility of the onset of

cataract and fear it, I have been devoting a good deal of attention to this subject for the last few

years. Among other patients, I have a large sec- tion of railway, whose officials I have to examine once a year for vision ; when their vision falls

below ??? they are no longer fit for duty; such

patients remain under my observation of necessity. The first symptom the patient complains of, especially railway officials and sportsmen, is that

their distant vision is failing, no complaint being made of their near vision. A man's vision will

be reduced to T%- or even before he complains severely of near vision, at yW or better he seldom

complains of vision for near purposes (I am

assuming throughout that his vision formerly was normal). This is the characteristic symptom of

the earliest stage of cataract?a symptom which should cause the general practitioner to send the patient to a specialist.

For our present purpose, let us carefully exclude cases with any fundus or vitreous trouble oi'

any retrobulbar condition. The vision not

having fallen below we seldom observe any opacities in the lens?at ̂ we may find sand-like

opacities or striae central or peripheral, above

TeTr we nearly always find these conditions. The

cases in which the vision has been reduced to

* Head at the Oxford Ophthalmological Congress, July 1914. i

Nov., 1914.] HENRY SMITH ON SENILE CATARACT. 431

f, f or -j%- without any opacity in the lens show loss of transparency merely. With an acetylene light, for example, you examine a healthy eye at the same time with one of these, and you observe that while the former is absolutely clear, the

fundus of the latter appears as if you were ex-

amining it with a poor light. If we could put the difference of the clearness of the fundus of

these two eyes in some formula we could

estimate for scientific purposes the degree of loss

of transparency. For the present we have to be content with the test card for this purpose. In

diagnosing these cases for treatment, for

statistical purposes, we have to be very careful

to exclude all other diseased conditions which

would interfere with vision. The treatment

which I adopt would influence many conditions of the cornea, of the fundus and retrobulbar

conditions, favourably, though combined with a

corresponding stage of cataract, and would thus, consequently, vitiate statistics sometimes unduly favourably, sometimes unduly unfavourably.

Given a case which is sound apart from this

stage of cataract, with distant vision reduced to

? or 25 minims of a 1 in 4,000, 5,000, or 6,000 solution of cyanide of mercury, according to the age of the patient (the younger the patient, the stronger the solution required to produce a standard reaction), injected sub-conjunctivally, the patient being under the influence of

cocaine locally and having had a hypodermic of

morphia up to half a grain an hour previously, will, in my observation, within a month of

the injection bring this patient's vision back

to f- or even %, and at the end of three months

he will be one better on the test card. The

railway officials under my care, having to appear before me once a year, seldom fall below until

they come under treatment. I give them a

month's leave and an injection of cyanide of mer- cury, and by the end of the month they go back to duty with the full amount of vision required ; that is, patients who have fallen to f, f or iV I have a number of these men under observation for more than a year and so far the results appear to be enduring. I have an officer in the Indian

Army, whom an invaliding board declared to be

unfit for any further service on account of his eye-

sight. He was blind in one eye, and the other

was in the early stage of cataract without opacities. He came to me; I asked the authorities to give him a grace of three months, at the end of this time he appeared before the same board with vision equal to -? and was passed for duty and is

now either first or second in command of his

regiment. He was treated about three years ago so the result may be considered as enduring. I

have a number of sportsmen and others with

similar results. I am sorry that I have not got records with me, as I came home on very short

leave intending to do nothing. Your worthy

secretary insisted on my contributing something to your proceedings, and I can thus only give you generalities and odd cases from memory.

Cases with sand-like opacities, if the pupillary area is clear of opacity, respond equally well to

sub-conjunctival injections of cyanide of mer-

cury. I have not so much hope of the perma- nence of the result in these cases. With vision down to -j'V, the pupillary area being fairly deal', great improvement follows, but these cases rapidly relapse. (Throughout I am speaking of the light of the tropics.) The number of patients in Europe (where cata-

ract matures so much more slowly than with us) who suffer from the early stage of cataract, and who go to their graves before it has reached what we call immaturity, must be considerable. I

would like to impress on those who may be dis- posed to devote attention to this line of treatment that as regards statistics they should be very care-

ful in the diagnosis that they are selecting cases

appropriate and uncomplicated by any fundus or retrobulbar condition. The dream of both patients and ophthalmologists has been to discover some method of dispersing (as the patient calls it) cataract, or preventing its development, or both. I think we are on the track ; I have little doubt of it myself. I do not, for a moment, think that

cyanide of mercury has any more potent action than other agents which would give a similar amount of reaction.

What is the cause of ordinary senile cataract ? Can we argue backwards from the above facts to- wards a solution ? Nutrition by osmosis never appealed to me. Is senile cataract due to starva- tion through a condition of the nutrient channels

corresponding to atheroma of the arteries, or is it due to a bio-cliemical poison ? Is the nutrient fluid of the lens manufactured by a special mechan- ism ? and, if so, is that mechanism some of the

gland-like cells of the ciliary region ? If so, we

could understand these cells assuming a patholo- gical function and recovering therefrom under

treatment. After all, this could only be the prox- imate cause; not the more remote one. The

more remote cause of senile cataract in the Punjab seems to be connected with the dietary. The

area of prevalence of stone in the bladder covers

roughly the same area as cataract, and in all these areas the staple food is wheat, not rice. But on

this matter I am not dogmatic; I have no theory, nor has any theory yet been advanced which will harmonize with the facts.

2. The early stage of Cataract in 'which opera- tion is necessary.?By this we mean a condition of the lens in which there are definite opacities sufficient to deprive the patient of useful vision, but in which there are varying degrees of transparent or living lens matter?a condition commonly known as immature cataract. The previous class

432 THE 1 .INDIAN MEDICAL GAZETTE. [Nov., 1914,

merges into this one by imperceptible degrees* From the patients point of view this class de-

mands urgent consideration on account of the

depressing influence that waiting involves, and the financial ruin that awaits them at the end of the

waiting period. Those in extensive practice in the treatment of cataract will, I am sure, realize

this fact. I have frequently been told by lawyers, for example, with mature cataract, that five years previously they could have paid any fee and

would have paid any fee for relief, but that now

they are practically paupers. So much for the

waiting period. My long distance patients are almost all of

this class, and they come to me because their own

surgeon refuses to operate, and tells them that

they must wait the maturing of the lens. I think

I may take for granted that the capsulotomy operation is not satisfactory for the treatment of

these cases, and that the different procedures adopted for hastening the maturing processes are not satisfactory; I certainly would not get so many of these cases if other competent men found the direct capsulotomy operation of the maturing procedures satisfactory. The direct capsulotomy operation for these cases is very disappointing, owing to the difficulty, I might say impossibility, of removing the living lens matter from the

capsule; its consequent proliferation; and the formation of a dense after-cataract, to which the iris is frequently tied down and which is very difficult to deal with. The latest ripening proce- dure is, I think, American, it consists in the deliberate production of a traumatic cataract, and the extraction of it within a few days of its production. This ripening procedure is, in my opinion, the worst of the lot. It implies among other things the liberation of lens matter into the aqueous chamber and as a consequent certain

iritis, and the extraction of the lens under these conditions?'the most difficult of all cataracts to deal with together with the fact that it courts serious complications.

The fact that senile immature cataract can be extracted in capsule as easily as mature cataract, and with as uniformly good results, is one of the strongest claims in favour of intracapsular extraction of cataract. The normal senile lens is just as easily dislocated as the mature senile cataractous lens. We come across cases of

slowly ripening senile cataract, associated with disease of the thoroid which is probably to

a large extent dependant on that disease. This is the type of immature cataract which we find not infrequently very difficult to dislocate. It is a type which I would advise the novice not to tackle with a light heart. We succeed in partially dislocating the lens adjacent to the wound. It refuses to move aity further. We need to be ready without delay to slip a spatula behind it and to cause it to slide up the spatula by pressure from

outside the cornea ; taking care not to wipe it between the instruments. To do this neatly is what I consider the last accomplishment of a

highly accomplished operator. The normal senile immature cataract is one of the simplest of all cataracts to extract by the intracapsular method. In favour of intracapsular extraction we have the almost'entire absence of iritis; we have no other cataract to deal with ; and we can operate on

cataract at any stage. It has been frequently laid down in both Europe and America that the

eye of the white man is different from that of his Aryan brother. I have now done many cataracts on pure Europeans; many more in

different degrees of dilution of European blood ; and I can see no difference. A difference which

probably does exist between the European and the Punjabi is, that in the Punjab we get cataract much earlier than you do in Europe or America; and that we probably thus operate on a higher proportion of people with a sound fundus, in

which case the average resulting vision could be

better. I have a number of men between 40 and

55 years of age in the Indian Army doing full duty including long range rifle shooting, wearing cata-

ract spectacles. Another objection raised to the intracapsular

operation is that we cannot do without an iridec-

tomy. This is not the case. The operation is

as easily done without an iridectomy as with one ;

I have frequently done it through an opium pupil without difficulty. The same principle holds as

regards an iridectomy in this operation as in the

capsulotomy operation. It has also been objected that we do not obtain the key-liole pupil often observed after the capsulotomy operation. This

is strictly correct; we get a U-shaped pupil. The explanation of the difference is that our iris

is free, whereas the pillars of the coloboma

following the capsulotomy operation are tied down to the after cataract; hence it is key-hole. I have

frequently extracted the after cataract following the capsulotomy operation in cases with a beauti- ful key-hole coloboma. It was interesting to see that the key-hole disappeared and that a U-

sliaped pupil was the result. If you consider the

matter from a mechanical standpoint, this reason-

ing and result will be evident. If you atropinize or homatropinize any eye with this key-hole pupil you will observe why it is key-hole.

I would like to draw your attention to the pro-

gress)* n racapsular extraction in India. When

I first began the teaching men intracapsular extraction, there were about 5,000 cataracts

done yearly in the Punjab Province. In 1912

the number had increased to about 15,000, and in 1913 I understand that it is between 16 and

17,000 in the same area. These are practically all intracapsular; at least 90 per cent, of them

are. In other Provinces where intracapsular extraction is becoming the operation of election,

Nov., 1914.1 WANTED A POSTGRADUATE OPHTHALMIC SCHOOL. 433

pimilar progress is being made. I think I can

see the day not far distant when intracapsular extraction will be the operation throughout the Indian Empire, and when GO.000 cataracts a

year will be done in that Empire. I feel that this is rather a disjointed discourse,

simply touching on the outskirts of a big subject, but the interest is more in the discussion to follow

than in this paper. I shall be delighted to answer any questions or give any details connect- ed with the subject as far as I can, and I think it is better to leave more time for discussion than to read a longer paper.

It is my hope that in the near future some gener- ous people associated with a generous Government will found a postgraduate school of ophthal- mology in the Punjab?that area of the world in which diseases of the eye are most prevalent? and that it will be hampered neither by finance nor by spheres of influence. That this school will be manned by clinical and research workers sufficiently to utilize the enormous amount of material available for teaching. The Indian

Empire requires such a school for the training of its own staff and for the doing of research work in ophthalmology?a matter which so vitally concerns the peoples of our huge Indian Empire. It should not be forgotten that it is the surgeon who commanded the confidence of the people of India for Western medicine and that it is he who still continues to command their confidence, and that without him there would be little respect to-day from the people of India for medicine or sanita- tion. Single handed and unofficially I have been doing what I could in the teaching of men (both Indian and European) in addition to my ordinary duties. This of necessity is confined to the clini- cal side and to a limited number. To cover

the whole ground, and to do my official work would be, of course, absolutely be}Tond the physi- cal capacity of one man. A school thus establish- ed would be in a position to give as fine a train- ing in pathological work as any in the world. The fields open in research work are unlimited and seductive. In the clinical and operative side we should be able to give the finest course of training in the world 011 account of the vast- ness of our material. So I hope we will be able to welcome you to our Indian school of oph- thalmology in the not distant future.