Cataract In The Medical Casebook

 

“Sherlock examines the cataract knife.”

© Alex Holt

 

This Week

For our penultimate blog page, we are going to have a look at cataracts. As we will see, eye disease was a particular area of interest for Sir Arthur Conan Doyle.

  

The Illustrator

Alex Holt is an artist specialising in original ink illustrations. He has a special interest in Comic Art, single image illustrations and covers. Alex is a student of the Edinburgh Atelier of Fine Art. He works in private commissions and commercial projects. More of his work can be found in Instagram @alexholtart.

 

Cataract

Cataract + Sherlock 

Cataracts get three references in the Sherlock Holmes canon.

Firstly we head to “A Study In Scarlet”, the first Sherlock Holmes story.

Number 3, Lauriston Gardens wore an ill-omened and minatory look. It was one of four which stood back some little way from the street, two being occupied and two empty. The latter looked out with three tiers of vacant melancholy windows, which were blank and dreary, save that here and there a “To Let” card had developed like a cataract upon the bleared panes.

Here the term is being used a simile. The notices are obscuring the windows in the same way that a cataract obscures vision through the lens of the eye. It is an interesting choice of allusion, and, as we shall see, likely reflects Conan Doyle’s developing interest in eye disease when the story was written.

We will revisit Lauriston Gardens in our Typhoid Fever chapter. 

In “The Adventure Of The Empty House”, the condition itself makes an appearance.

The Honourable Ronald Adair was the second son of the Earl of Maynooth, at that time governor of one of the Australian colonies. Adair’s mother had returned from Australia to undergo the operation for cataract, and she, her son Ronald, and her daughter Hilda were living together at 427 Park Lane.

Clearly at the time Conan Doyle wrote the story, the Australian health service was fairly basic, if development of a cataract necessitated a long trip back to London for surgery.

This story needs mention as it is the one where Sherlock Holmes makes a dramatic reappearance after his supposed death in a tussle with Professor Moriarty at the Reichenbach Falls. It is also a particularly fine tale – Ronald Adair is murdered in his bedroom, but the door is locked from the inside, there is no murder weapon, no sign of a struggle, and a 20 foot drop from the bedroom window to an undisturbed flowerbed.

In “Silver Blaze”, we encounter a surgical implement used for cataract surgery.

We all filed into the front room and sat round the central table while the Inspector unlocked a square tin box and laid a small heap of things before us. There was a box of vestas, two inches of tallow candle, an A D P brier-root pipe, a pouch of sealskin with half an ounce of long-cut Cavendish, a silver watch with a gold chain, five sovereigns in gold, an aluminium pencil-case, a few papers, and an ivory-handled knife with a very delicate, inflexible blade marked Weiss + Co, London.

“This is a very singular knife”, said Holmes, lifting it up and examining it minutely. “I presume, as I see blood-stains upon it, that it is the one which was found in the dead man’s grasp. Watson, this knife is surely in your line?”

“It is what is called a cataract knife,” said I.

“I thought so. A very delicate knife devised for very delicate work.”

We will discover how the cataract knife was used in our chapter on rheumatism.

I love the level of information provided in some of Conan Doyle’s writing – the list of the contents of the tin box is so detailed. Whilst working as a GP in Portsmouth, he became interested in the medicine of the eye [ophthalmology]. In 1890, he abandoned general practice to retrain as an ophthalmologist. He moved to Vienna to study, though moved on to London after a few months, setting up practice in Montague Place, behind the British Museum. In the 1891 census he describes himself as an “ophthalmic surgeon”. Thus he would likely be familiar with a cataract knife, and could provide the level of detail as to the manufacturer of the knife. John Weiss and Co were a real company, founded in 1787, and rather wonderfully, they still exist, and they still specialise in surgical instruments for ophthalmic surgery.

 

Cataract In Victorian Times 

What is Cataract? Cataract is an opacity of the lens. How is it that so many aged persons suffer from cataract? Well, I suppose we must look upon cataract in aged persons as one of the natural phenomena of life – the culminating point in the process of hardening, shrinking, and degeneration which the lens undergoes in common with other tissues as we grow older, and which seems natural to us all. When, for example, an average individual attains the age of forty and upwards, he requires glasses. Why is this? Simply because the lens has become too hard to fulfil its usual function in the process of accommodation for near objects. As time passes on, this – shall I call it natural sclerosis? – increases, until in certain cases the normal relationship of the lens fibres is so changed that it becomes opaque; the patient cannot see, and the surgeon cannot illuminate the fundus of the eyeball: that is cataract. The lens has become opaque, and, so far from assisting vision, constitutes an actual obstruction to the passage of the rays of light. [14] 

Which is much the same as my simple modern GP understanding of a cataract.

Would it be possible to restore the transparency of the lens? What a momentous question! As well ask, would it be possible to restore youth? [14]

The obstruction must be removed, and this can only be done by operation. What operation shall we perform? Will any surgical procedure short of actual removal of the lens from the organism – that is extraction, as it is called – suffice? I fear not. [14]

It is clear, therefore, gentlemen, that our only resource is extraction. What is the best method of performing extraction? In order that you may appreciate this question it will be necessary to glance at the history of the operation, which may be said to have commenced in 1752 … when Daviel presented his classic memoir to the French Academy. Daviel operated whilst seated himself and facing the patient, who also occupied a chair on a lower level. He used a lance-shaped knife, and incised the lower half of the circumference of the cornea, delivering the lens through the natural pupil. When successful, the flap operation, as it is called, left nothing to be desired; but fifteen eyes in a hundred were irrevocably lost, and twenty more so damaged that it is a matter for special wonder that no serious attempt at improvement was made until 1860. [14]

I visited Graefe’s, Pagenstecher’s, and Mooren’s cliniques at this time in order to study their various methods of operating, and, after careful investigation of the whole subject, arrived at the conclusion that Shefte’s incision in the corneal margin was the best, and that it needed but to be slightly enlarged in order to enable us to extract the lens without the objectionable scoop or the use of any traction instrument whatever. [14]

This is essentially the same incision that is used in modern surgery to remove cataracts. Modern surgery has two main differences, however. Removal of the lens is aided by a process called phacoemulsification, which breaks the lens into small pieces. Then, following removal, an artificial intraocular lens is inserted to replace the damaged one.

Cataract surgery is fantastic surgery. It is done more than any other surgical procedure, is cheap, almost always successful, and can hugely improve the patient’s quality of life. These days almost all NHS cataract surgery is farmed off to private providers, which is what happens with simple surgical procedures in the modern NHS [private medicine, of course, wants little to do with the complex stuff].

I have tried unsuccessfully to determine if Conan Doyle carried out cataract surgery. One might assume he performed eye surgery if he set himself up as an ophthalmic surgeon, but I suspect he specialised in eye refraction, which is provision of glasses, as an optometrist would be the expert in today. There is documentary evidence that Conan Doyle learnt this skill at the Portsmouth Eye and Ear Infirmary.

He didn’t stay in this career for long, however, as the move to London coincided with his moving into short stories [he sent the first such story, “A Scandal In Bohemia”, to his publisher, four days after his move to London]. It appears that a mere 2 months later he gave up medical practice to become a full-time writer.

 

The Book

The Medical Casebook of Sherlock Holmes and Dr John Watson is available from all good bookstores including Amazon USA, Barnes and Noble, Amazon UK and additional formats like Kindle.

 

Next Week

Next week, we’ll have our final blog page. We are going to conclude with a look at tuberculosis. This is a fascinating subject – TB was a huge public health issue in Victorian times, and Conan Doyle’s first wife, Louise, died of the disease.