Extracted from the 
TRANSACTIONS OF THE COLLEGE OF PHYSICIANS OF 
PHILADELPHIA. 
THIRD SERIES, VOLUME V. REPORT OF A CASE OF DIABETES MELLITUS IN 
WHICH DOUBLE CATARACT EXISTED: 
DEATH OCCURRING THREE DAYS SUBSEQUENT TO AN OPERATION 
OF EXTRACTION. 
By 
J. EWING MEARS, M.D., 
SURGEON TO ST. MARY'S HOSPITAL, ETC. 
[Read May 5, 1880.] 
Whilst on a professional visit to Bedford Springs, 
Penna., in the month of April, 1879, in consultation 
with Dr. Griffith, I was asked by Dr. Gump of that 
place to see with him a young man who was suffering 
from diabetes mellitus. The following brief history 
relating to his attack was obtained :- 
J. Z. B., single, aged 30 years, had been a clerk in a dry goods 
store for sixteen years. In November, 1874, he had an attack 
of pneumonia, from which he recovered well. Whilst suffer- 
ing from great mental anxiety and worry, caused by a "cross 
in love," he had what was described as a very " light" con- 
vulsion on October 4, 1876. From this time until July 18, 
1877, he was in fairly good health, although still suffering 
from mental distress. At this latter date he had a succession 
of violent convulsions, lasting for four or five hours, and fol- 
lowing this attack he was quite ill for three weeks. The 
exact nature of these convulsive seizures could not be ascer- 
tained, though they were thought to have been epileptiform 
in character. About the middle of the month of December, 
following, the patient complained of excessive micturition. 
On submitting the urine to examination, it was found to 68 
MEARS, 
contain a small quantity of sugar, which increased in amount 
rapidly, so that by January 25, 1878, it was reported to con- 
tain a very large quantity, and the daily secretion of urine 
was three gallons. The treatment which was adopted afforded 
some relief, but the patient declined to continue it for a 
longer period than a month. 
According to the statement of his attending physician, the 
patient gradually lost flesh and strength, so that I found him, 
at the time of my visit, fifteen months later, much emaciated 
and anaemic. His pulse was feeble but not very rapid-86 to 
90 per minute; his tongue was moist, red, and free from coat- 
ing; skin dry and harsh; bowels in quite good condition. 
He did not complain of excessive thirst or dryness of the 
mouth. He appeared much distressed on account of increas- 
ing loss of vision, which was found to be due to double cata- 
ract-complete lenticular opacity being present in the right 
eye, with partial and progressive change in the left lens. As 
he had not been under the immediate care of his physician 
for some time, the changes in the lenses had not been observed, 
and no information could be obtained with regard to the time 
at which the degeneration began, other than the statement 
of the patient to the effect that he had noted failure of vision 
during the past few months. 
He was very anxious that something should be done to 
relieve the approaching blindness, which he feared would 
soon render him helpless. I advised against any operative 
procedures at that time, owing to his enfeebled condition, 
stating, however, that, if he improved under treatment and 
would come to the city, I would consider the propriety of an 
operation for his relief. I suggested that he should be treated 
by the administration of ten grains of iodide of potassium 
three times daily, and that his diet should be restricted to 
skimmed milk, a pint being given every three hours; if 
needed, beef-tea and eggs were to be added to his diet, but no 
starchy food was to be allowed. Under this plan of treatment 
he improved decidedly and rapidly; the daily secretion of 
urine decreased from twenty-four pints to six pints, and its DIABETES MELLITUS AND CATARACT. 
69 
saccharine condition was also notably changed, the quantity 
of sugar being markedly diminished. This improvement 
occurred in the interval from the time I had seen him in 
April, to June 4, when he came to the city, a period of less 
than two months. Feeling so much improved, he had come 
to the city for the purpose of having the operation of extrac- 
tion performed, and was very earnest in his entreaties that 
it should be done. 
After consultation with Dr. Schell, whose report of the 
operation and the subsequent condition of the patient I ap- 
pend, I decided to perform extraction upon the right eye. 
Desiring to place the patient in a favorable condition for the 
operation, I withdrew medication and placed him upon a 
highly nutritious diet. Whilst this plan of preparation was 
being carried out, he was, unfortunately, subjected to great 
mental anxiety by the behavior of his attendant, upon whom 
he was entirely dependent. Knowing the great importance 
of having him free from all depressing influences, I stated 
that I would decline to operate unless I received assurances 
that all causes of trouble were removed, and that he was en- 
tirely free from anxiety. Receiving these assurances, I con- 
tinued the preparatory treatment, and on June 9 performed 
extraction upon the right eye, the report of the operation 
being given by Dr. Schell, as follows:- 
" By the request of Dr. Mears I visited Mr. B. in consulta- 
tion with him on June 7. The patient, though not well 
nourished, in consequence of an attack of diabetes from which 
he had suffered for some time, was otherwise in fair condition. 
His skin was soft and moist, and his pulse 78 per minute, 
soft and elastic. In both eyes the crystalline lens was found 
to be cataractous; on the right side the cataract was fully 
formed, soft, and ripe; on the left side it was not quite ma- 
ture, there still being a small quantity of transparent cortical 
matter at the equator of the lens. Vision was limited to 
light perception in both eyes, with entire absence of retinal 
reflex; otherwise the eyes appeared to be quite healthy. The 70 
MEARS, 
cornese were clear, the irides mobile, tension normal, and 
projection of light excellent. As the patient was very anxious 
to have his sight restored and to return to his home, it was 
decided to operate, on at least the right eye, at once. 
" In pursuance of this conclusion, two days later, i. e. on 
the 9th of June, the patient was anaesthetized by means of 
sulphuric ether, and succumbed to its influence readily. Dr. 
Mears performed the operation by making a peripheral inci- 
sion upwards in the cornea, lacerating the capsule with the 
point of the knife during its passage through the anterior 
chamber, and readily expressing the soft lens with the spoon 
without iridectomy. After the instillation of atropia the eye 
was bandaged in the usual manner, and healed in two days 
without inflammatory action. The pupil appeared round, 
clear, and black under lateral illumination, and the patient 
expressed himself as delighted with the fact that he was able 
to see when the bandage was removed in the interval of the 
dressings. As far as the eye was concerned, the operation 
may be considered to have been a perfect success." 
Noting the condition of the patient after the operation 
somewhat more in detail, it may be stated that he came out 
of the state of anaesthesia quietly and calmly; the operation 
did not produce shock, and no nausea was present. In the 
evening of the day of the operation, he took nourishment, 
was free from pain, and during the night slept very well. 
The day following, June 10, his condition was in every way 
excellent; he was cheerful and contented to remain quietly 
in bed. The quantity of urine had not increased, and his 
desire for liquids was not abnormal. The pulse was increased 
in frequency, which condition had been noted to exist since 
the operation. The next day, on removing the bandage, he 
appeared much pleased-at the fact of his being able to see 
out of the eye upon which the operation had been performed. 
His condition was regarded as so favorable that arrangements 
were made to permit him to sit up on the next day. On 
visiting him, however, in the middle of the afternoon, a very DIABETES MELLITUS AND CATARACT. 
71 
perceptible change in his condition was noted to have oc- 
curred. He was very much depressed in spirits, and mani- 
fested great restlessness; his respirations were markedly- 
increased in frequency, being thirty to the minute, and his 
pulse was quite rapid, 98 to 100 per minute. There was no 
febrile movement, nor any evidence of inflammatory action 
present. Learning that some trouble had occurred between 
his attendant and himself, I attributed the changed condition 
as largely due to excitement, and spoke to him of the neces- 
sity of avoiding it in his present condition, and cautioned 
the attendant against any action on his part which would 
provoke it. 
Returning at ten o'clock at nio-ht, I found his condition 
worse; respirations 40 per minute, and very shallow; pulse 
small and rapid, 110-114 per minute; temperature normal; 
slight delirium present. By an effort he could be made to 
answer questions. Bromide of potassium in twenty grain 
doses had been given every two hours since the visit in the 
afternoon, without producing any effect. Tincture of aconite 
was ordered in doses of three drops, combined with the bro- 
mide of potassium. The remedies failed to afford any relief, 
and at three o'clock in the morning of the day following, 
death occurred. Towards the end, the delirium was more 
marked, the respirations were very rapid, pulse 120-124, and 
convulsive movements were present, as manifested by twitch- 
ings of the upper and lower extremities. Permission was 
obtained to examine the brain, and the examination was 
made two hours and a half after death by Dr. Morris Long- 
streth, whose report I present herewith. 
" Post-mortem Record of Mr. B.-June 12,1879. Duration 
1| hours; 2J hours after death, Rigor mortis slightly de- 
veloped. Surface of body pale. Face emaciated. Head only 
examined. The deeper parts of the scalp and the pericra- 
nium were much congested. The skullcap was very much 
thinned in places, and the same condition was found on the 
parts of the temporal and occipital bone attached to the base 
of the skull. 72 
MEARS, 
"The dura mater was very bloody and its vessels un- 
usually prominent; the membrane was tensely spanned over 
the brain; in places it was very tightly adherent to the 
bone, both over the convexity and at the base ; the adhesion 
was not general, but was confined to small spots and areas. 
At these places, as traced by slight tearings of the mem- 
brane or by shreds of its tissue left in contact with the bone, 
the dura was found thickened and rough. The cerebral sur- 
face of the membrane at these places presented a mammil- 
lated appearance, and around them the membrane was in- 
jected. The summits of several of these growths felt harsh 
and were apparently calcareous, probably due to changes in the 
bone beneath. The number of places affected in this manner 
was about twenty. The character of the growth was that 
of small fibroid nodules. 
"The arachnoid was entirely opaque and whitish in very 
many places, especially along the sulci of the cerebrum and also 
at points opposed to the dura mater growths, as was accurately 
traced in several instances. Although the dura was removed 
with care, it is not known that it was adherent to the arach- 
noid at these places, except at one place where the union of 
the growth to the arachnoid was found to be very intimate. 
Along the longitudinal sinus the union of these two mem- 
branes was very close, there being a large amount of fibrous 
and lymphoid structure; it was especially marked at the 
vertex where the large veins empty into the sinus. Beneath 
the arachnoid there was a very large amount of clear serum, 
which in many places caused an upward bulging of the mem- 
brane, and also a slight separation of the convolutions. The 
convolutions, except at these places, were slightly flattened. 
"The vessels of the pia mater were very full of blood, and 
over nearly the whole surface of the cerebrum the smaller 
vessels were found very markedly injected. 
" At the base of the brain, the vessels of the circle of Willis 
presented nearly normal appearances; at a few places athe- 
romatous changes were visible, especially at the termination 
of the carotids, and at one or two places on the basilar artery. DIABETES MELL1TUS AND CATARACT. 
73 
The membrane in the interpeduncular space was thickened 
and opaque. The nerve trunks appeared normal, except the 
right optic nerve, which was less consistent than its tel low, 
and was somewhat flattened; no change was found in the 
commissure or in either optic tract. A considerable amount 
of serum escaped on division of the infundibulum, and con- 
tinued to ooze afterwards on handling the brain. 
" On opening the lateral ventricles there was still present a 
considerable amount of serum, and the cavity of the ventri- 
cles was evidently stretched, especially the posterior horns. 
The foramen of Monro was widely opened. The choroid 
plexus was very full of blood, and its surface was slightly 
granular, as well as that of the ependyma of the lateral ven- 
tricles. The septum lucidum was firm. The vessels of the 
velum interposition were very full of blood. (Careful search 
was made later for any cause of obstruction to these vessels, 
but none was found.) The third and fourth ventricles were 
also stretched, especially the latter; their interior structures 
were normal except the middle commissure of the third, 
which was softer than normal (apparently from stretching). 
" The brain tissue was apparently normal; there was no ab- 
normal coloration and no softening found at any part. Ex- 
cept near the surface of convolutions, the puncta vasculosa 
were not unduly prominent (considering that the skull was 
opened and examined first), but at these parts, in places, the 
vascularity showed more distinctly than usual. 
" The base of the skull (interiorly) was very uneven, the fur- 
rows and crests, for the accommodation of the convolutions, 
were very marked, and several of the crests, especially in the 
middle fossae but also at other parts, were elevated more than 
a half inch. The condition was more than an exaggeration 
of a normal condition, for several of these cristce were thickened 
at their summits and roughened, the surfaces presenting a 
spongy appearance. 
"In the examination of the tentorium (while searching for 
an obstruction in or around its straight sinus), a growth, 
similar to those occurring at other parts of the dura, was 74 
MEARS, 
found on its under surface in close connection with the right 
fifth (trigeminal) nerve. The nerve was examined, but no 
change could be distinctly pointed out in its substance; its 
trunk, however, had been cut in removing the brain directly 
at the point where the growth occurred on the membrane. 
" The calvaria showed moderately marked depressions for 
the Pacchionian bodies, but at four or five places, especially 
a marked one on the left frontal bone, the internal plate was 
completely eroded, and the diploe was opened. None of 
these places were larger than a pea, and their surfaces were 
rough and spongy. The crests and furrows on this portion 
of the skull were less marked than on the base. The petrous 
bones on both sides were not removed for examination, but 
neither the dura mater covering them nor the bone tissue, 
examined after the removal of the dura, showed any evi- 
dence of inflammatory disease of the parts having its origin 
in the external or middle ear. 
"Remarks.-The changes found in the bone tissue within 
the cranial cavity, as well as the alteration in the membranes 
and the intracranial circulation, all point to the conclusion 
that the commencement of the patient's troubles dated back 
to a period some considerable time previous to his death. 
Of the character and nature of the changes found there seems 
to be little that can be said with certainty. The minute 
growths on the dura mater were clearly of a fibrous character, 
and therein resembled the fibroid tumors which not unfre- 
quently have their seat on this membrane. The cause of the 
little growths found in this case is equally obscure as that 
of the larger masses spoken of. 
" On the relationship or connection of the diabetes mellitus 
and the cataractous change in the crystalline lens, and on 
the occurrence of either of these pathological phenomena, the 
autopsy throws no absolute light; nevertheless there are one 
or two points to which it may be well to call attention, and 
to broach the question of the relationship of the marked 
alterations of intra-cranial circulation to diabetes, on the one DIABETES MELLITES AND CATARACT. 
75 
hand, and of the growth near the fifth nerve and the disease 
of the lens, on the other hand. It is well proved that patho- 
logical changes within the cavity or in the floor of the fourth 
ventricle or of the parts immediately beneath, in the medulla 
oblongata, are followed by or are the cause of a diabetes. 
While nothing was found in this case indicative of any 
organic change in the tissues of the medulla oblongata, there 
was much to show that for some considerable time a condi- 
tion of the cranial circulation had been maintained which 
must have produced a distension of the cerebral ventricles, 
the fourth ventricle along with the others, and that thus the 
floor of the ventricle must have been pressed up in an abnormal 
manner. (The construction of the basilar portion of the occi- 
pital bone and of the foramen magnum were such as to favor 
and exaggerate the effects of such a distension of the fourth 
ventricle in pressing the tissues of the medulla.) This pres- 
sure, varying with the condition of the cerebral circulation, 
would produce a corresponding variation in the symptoms, 
viz., the diabetes. 
"The simultaneous occurrence of diabetes mellitus and a 
cataractous condition of the crystalline lens, whether related 
as cause and effect or not, and the untoward results of opera- 
tive measures-at least so far as the eye itself is concerned- 
for the removal of the cataract, are well known. Whether 
the cataract in this case had any connection with previous 
existing diabetes, as before remarked, the autopsy gives no 
answer. From the condition of the eye operated on, the 
answer can be made that this organ did not follow the gene- 
ral rule ; it did not suppurate or degenerate as it usually does 
following cataract operations in diabetic patients. 
"In regard to another explanation of the cataractous change 
in the lens, it may be worth while to call attention to the small 
growth found on the tentorium, closely related to the right 
fifth nerve. There are several cases on record of growths on 
or about this nerve producing cataractous or other ocular 
changes in the corresponding eye,as well as, of course, in other 
parts supplied by the same nerve. Whether it is possible that 76 
MEARS, 
a very limited lesion of this nerve trunk-so small a change 
as not to be visible to the unaided eye-can produce limited 
lesions in a peripheral part, e. g., the lens, of course the 
autopsy of this case does not determine ; it is a question that 
the further study of this nerve and its morbid changes only 
can answer." 
As the interest in the above case relates especially 
to the condition of cataract and the results following 
operative procedures, I desire to invite attention more 
particularly to these points. The history of the case, 
as well as the pathological conditions revealed post- 
mortem, clearly establish the cause of the disease to 
have been located in the nervous system, taking ori- 
gin in the mental emotion-" perturbation of the 
brain"-to which the patient was subjected and which 
continued to act for a long period, changing its form 
as the disease advanced, but still exercising its influ- 
ence upon the patient until his death. 
The occurrence of cataract in diabetes mellitus 
and their pathological relations have long been known 
and studied. Various explanations have been offered 
to account for the production of the lenticular opa- 
city. That which proposed to account for the change 
upon the theory of osmosis (B.W. Richardson, Journal 
de la Physiologic, etc. [Brown-Sequard], t. iii.)-"the 
passage of the fluids of the lens by exosmosis to the 
unnaturally dense blood without" (the density being 
due to the presence of the sugar), causing a "precipi- 
tation within the lens of calcareous and other matters" 
and thus opacity, has not received the approval of 
more recent observers. Later observations have 
seemed to show that the degenerative change which 
occurs in the lens is one of the class " known to be DIABETES MELLITUS AND CATARACT. 
77 
correlated in the way of nutrition or rather of mal- 
nutrition with the diabetic state." (Brit. and For. 
Medico-Chirurg. Review, vol. xxx., 1862.) 
It would be interesting to determine by an exami- 
nation of cases in which lenticular opacity has been 
reported as having been present, whether the causes 
in these cases were, as in this case, of nervous origin. 
In a small number of cases which I have examined, 
this observation was made. Should the examination 
of a larger number of cases prove this observation 
correct, the conclusion might be drawn that the cata- 
ractous lens occurred only in those cases in which 
the cause of the disease was due to some morbid con- 
dition existing in the nervous system. 
With regard to the performance of operations for 
the relief of cataract in diabetic patients, Dr. Dick- 
inson (Diseases of the Kidney) makes the following 
statement: "Surgery in such cases is attended with 
unusual danger: first, from consequent suppuration 
to which diabetic subjects are especially prone; and 
secondly, from the likelihood that even if the wound 
heal well, the patient may be dangerously depressed 
by the successive action of apprehension before the 
operation and darkness and restraint after it." He 
alludes to a case, in his own experience, in which the 
patient died after an operation which, locally, was 
perfectly successful. He further states, however, that 
cases are reported in which the operation has been 
followed by satisfactory results, "though the perils 
which environ it are such as to justify its perform- 
ance only in exceptional circumstances." 
Profoundly impressed with the dangers which sur- 
rounded operative procedures in such circumstances, 78 
MEARS, DIABETES MELLITUS AND CATARACT. 
I performed the operation in the above case in re- 
sponse to the patient's earnest wish for surgical relief, 
and with the hope of removing an obstacle to im- 
provement of his general health, by reason of its in- 
terference with his exercise in the open air, and the 
depression of spirits which the condition of almost 
total blindness produced. With regard to the method 
of operation in removing the cataractous lens in these 
cases, the linear is to be selected in preference to the 
flap operation, as by this method the wound is much 
smaller and the danger of suppuration is greatly 
lessened.