Cataract extraction : being a series of papers with discussion and comments read before the Ophthalmological section of the New York academy of medicine, 1907-1908

Front matter

K :;N a.V'OR ;; ':VRS, M.D. m)(LA]l -. V'i'.OMRGv, M.D.

IB)WAAD :l COM . ■;•!, m.Dp "I. II; MtX)j;wAR:r:; m.D.

I/MBCY RiMLBi\)]3 J£RG3 M.D, ]'.■ HBRBjGB: DMpQRNg, M.D: A.. Eji DAVIS, M.J).

Introduction

The editor, during his incumbency of the office of president of the Section of Ophthalmology, New York Academy of Medicine, 1907, instituted a symposium on cataract extraction. A different surgeon was selected to read a paper on each occasion, and that paper and the discussion which followed it constituted the main feature of the evening. It was attempted to select each essayist with a view to his peculiar aptness to present the part of the subject which, by reason of experience or training, he was best fitted to handle, and the sequence of the papers was arranged as far as possible in the order in which a surgeon would perform the operation.

After the chapter on the technic of the operation, the editor has taken the liberty of interpolating the description of a specially constructed lance-shaped keratome with which he has recently extracted cataract successfully.

It was deemed pertinent to the subject to introduce papers on artificial maturation of cataract, the extraction of artificially-matured lenses in highly myopic eyes, and the after-results, immediate and remote, of extraction.

The following pages are the result of that plan.

The majority of the surgeons have to a great extent presented their subjects from a personal stand-point, except in the chapters on the technic of the combined and simple extraction, and on discission of the postoperative capsule, in which the essayists at the request of the editor have treated their themes in a more didactic way.

VI INTRODUCTION.

It has been the aim of the editor to have the subject so presented that it may be regarded as an expression of modern thought and practice in cataract extraction. He has made comments at the end of the discussion which follows each paper for the purpose of emphasizing certain views of the essayists, to add something which may have been omitted or to take sides on vexed questions of judgment or technic. The various steps of the operation and the elements of the technic in it are so interdependent and interwoven that it is not surprising to find one essayist occasionally encroaching on the ground of another. So far from this repetition being undesirable, it appears to the editor to be a distinct advantage, since by multiplying counsel, wisdom is more certainly attained.

The editor desires to express his thanks and appreciation to the gentlemen who by their able cooperation have rendered this achievement possible.

The papers of Drs. Weeks, Pooley, Claiborne and Marple were printed antecedently in the New York Medical Journal; that of Dr. Woodward in the Vermont Medical Monthly; that of Dr. Coburn in the New York Medical Record, and Dr. Fridenberg's in the American Journal of Ophthalmology.

The editor acknowledges his indebtedness to the editors of these journals for the privilege they have accorded him of incorporating these papers in this book.

23 West 36 Street, New York City.

July 15, 1908,

Chapter I

What Stage in the Development of Cataract, Particularly Senile Cataract, is the Most Suitable for its Removal by Extraction? Page i.

BY

JOHN ELMER WEEKS, M. D.

Professor of Ophthalmology, University and Bellevue Hospital Medical College; Surgeon New York Eye and Ear Infirmary.

Chapter II

The Preparation of the Patient and the Antiseptic Precautions to be Employed Preceding the Extraction of Cataract. Page 12.

BY

EDGAR S. THOMSON, M. D.

Surgeon and Pathologist, Manhattan Eye and Ear Hospital; Instructor in Ophthalmology, Manhattan Eye and Ear Hospital Post-graduate School.

Chapter III

Simple Extraction versus Combined Extraction. Page 25.

BY

EDWARD B. COBURN, M. D.

Surgeon and Pathologist New Amsterdam Eye and Ear Hospital; Assistant

Surgeon Department of Ophthalmology, Cornell University

Medical College.

Chapter IV

Combined Extraction versus Simple Extraction. Page 32.

BY

J. H. WOODWARD, M. D.

Formerly Professor of Ophthalmology, Vermont Medical College.

vii

Vlll CONTEXTS.

Chapter V

The Technic of the Simple and of the Combined Operation for the Extraction of Mature Senile Cataract. Page 45.

BY

PERCY FRIDEXBERG, M. D.

Assistant Adjunct Surgeon, Ophthalmic and Aural Department, ilt. Sinn, Hospital; Junior Surgeon, New York Eye and Ear Infirmary.

Chapter VI

Extraction of Cataract with a Lance-shaped Keratome. Page 80.

BY

J. HERBERT CLAIBORXE, M. D.

Instructor in Ophthalmology, Cornell University Medical College; Surgeon New Amsterdam Eye and Ear Hospital.

CHAPTER Vn.

The After-treatment. Page 91.

BY

A. E. DAMS, M. D.

Professor of Ophthalmology, New York Post-graduate College; OphtJialmic Surgeon, New York Post-graduate Hospital.

Chapter VIII

Discission after Cataract Extraction: Its Indications and Technic Page 106.

BY

RUDOLPH C. DEXIG, M. D.

Ophthalmic Surgeon to the German Hospital and Dispensary.

CHAPTER LX.

Extraction of Cataract in the Capsule. Page 117.

BY

WILBUR B. MARPLE, M. D.

Formerly Professor of Ophthalmology, New York Polyclinic; Surgeon, New York Eye and Ear Infirmary.

CONTENTS. IX

Chapter X

The Operations for the Artificial Maturation of Cataract. Page 129.

BY

THOS. R. POOLEY, M. D.

Formerly Professor 0} Ophthalmology, New York Polyclinic; Executive Surgeon New Amsterdam Eye and Ear Hospital.

CHAPTER XL

A New Procedure and Instrument for the Artificial Maturation of Cataract. Page 134.

BY

J. HERBERT CLAIBORNE, M. D.

Instructor in Ophthalmology, Cornell University Medical College; Surgeon New Amsterdam Eye and Ear Hospital.

Chapter XII

The Extraction of the Artificially Cataractous Lens in High Myopia. Page 146.

BY

WALTER EYRE LAMBERT, M. D.

Formerly Professor of Ophthalmology, New York Polyclinic; Surgeon, New York Eye and Ear Infirmary.

Chapter XIII

Final Results of Cataract Extraction. Page 158.

BY

HERBERT W. WOOTON, M. D.

Assistant Surgeon Manhattan Eye and Ear Hospital; Instructor in Ophthalmology, Manhattan Eye and Ear Hospital Post-graduate School.

CATAEACT EXTRACTION.

Chapter I

WHAT STAGE IN THE DEVELOPMENT OF CATARACT, PAR- TICULARLY SENILE CATARACT, IS THE MOST SUITABLE FOR ITS REMOVAL BY EXTRACTION ?

John Elmer Weeks, M. D.,

In considering this question I infer that we are agreed that the effort of the surgeon should always be in the best interest of the patient. In many cases extraction of cataract may be delayed until the surgeon is satisfied that the most favorable time for the operation has arrived. In many other cases the extraction is necessary for economic reasons at the earliest time possible compatible with good results.

I think that all ophthalmic surgeons agree that the most propitious time for the extraction of cataract is when the lens substance is readily detachable from the lens capsule. When the cataract has reached this stage it is really mature in an operative sense. The terms "mature cataract" and "complete opacification of the lens" are thought by many to be synonymous. This idea is erroneous so far as it applies to the most favorable time for the removal of cataract, as there are many exceptions.

In this connection it may be well to refer to and to briefly describe the types of senile cataract most frequently met with. These are:

Z CATARACT EXTRACTION.

1. Equatorial (cortical) cataract: (a) imbibition cataract; (b) cataract, always smaller than the normal lens.

2. Cortical (choroidal) cataract, anterior or posterior or both.

3. Nuclear cataract.

The equatorial cataract, the form most frequently met with, begins by the formation of opaque striae near the equator of the lens. The shrinkage of the nuclear portion of the lens in this form plays an important part. The cortical lamellae, as has been pointed out by Becker, do not shrink as rapidly as the nuclear lamellae; as a consequence a process of cleavage between peripheral and nuclear lamellae is set up. The fissures thus formed are filled with fluid, granular detritus, Morgagnian globules (myelin globules) and fat globules, the whole of which forms the liquor Morgagni. These spaces, filled as they are, produce white opaque striae. This process is most marked in the equatorial region of the lens, probably because the traction of the suspensory ligament prevents the lens fibres from following the nucleus as readily as do those at the anterior and posterior poles of the lens.

As the process advances the lens fibres, among which the fissures form, take on a granular and fatty degeneration and become more or less disintegrated and broken. Morgagnian globules and albuminoid masses appear.

(a) In some cataracts, particularly in those forming rather early in life, an imbibition of intraocular fluids takes place, and the lens becomes considerably swollen, pushing the iris forward and causing a narrowing of the anterior chamber. The opacification of the lens progresses as the swelling increases, and the lens becomes almost opaque when the swelling has reached its maximum. The white soft cataract is the extreme example of this process. After having reached the maximum swelling, the lens gradually loses in volume, and the anterior chamber becomes deeper until the lens becomes smaller than the normal transparent lens at the same period of life.

(b) In some cataracts which develop by the formation of fissures in the cortex a period of swelling, as pointed out by Priestly Smith, does not develop, the lens always remaining smaller than the normal lens of the same age.

Before maturity is reached these two forms of cataract present glistening or lustrous sectors, the so-called asbestos stripes. This appearance is produced by the granular contents of fissures and laminae of lens fibres undergoing granular and fatty degeneration and shining through transparent lens tissue and capsule, the liquor Morgagni not yet having found its way between capsule and cortical lamella of lens fibres. When the liquor Morgagni has found its way between capsule and cotical lamella, even in a very thin layer, the asbestos appearance is almost, if not entirely, lost although when the layer of liquor Morgagni is very thin the structure of the lens may be visible to some extent.

Cataracts which develop in the manner described can be readily removed when the development of liquor Morgagni between the lens capsule and the cortical lamina of lens fibres, in however thin a layer, has taken place. In not a few cases this occurs before the anterior chamber is fully restored to its normal depth. If extraction is attempted before this period the lens cortex will adhere more or less firmly to the capsule and some soft lens substance will remain in the capsule. If this form of cataract is permitted to become hypermature the capsule may become thickened by hyperplasia of the epithelial cells, the intracapsular fluid escapes, calcareous and cholestrin deposits form, the degenerated lens fibres become attached to the anterior capsule, and difficulty in extraction is experienced.

Another form of cleavage cataract met with not very infrequently is the purely cortical cataract, sometimes referred to as chorioidal cataract. This is frequently preceded or accompanied in its early stage by a very mild uveitis or anterior chorioiditis. The process of cleavage begins in the posterior lamellae of the lens, very near the capsule of the lens, sometimes near the equator, often at the posterior pole. It interferes very greatly with vision, advances very slowly, and may become almost, if not quite, stationary. Both eyes are usually involved, but it may be monocular. There may be vitreous opacities in some cases; in others the vitreous may be perfectly clear and the function of the retina may be unimpaired. The lens in these cases is, as a rule, smaller than the normal lens, but a stage in which the lens substance is readily separable from the capsule is reached, if ever, only after many years have elapsed. Reduction in the size of the lens by the process of sclerosis may continue until the lens becomes very thin (disciform).

The third form, which is second in frequency to the first form described, is that in which the opacification appears at the centre of the lens. The process is essentially one of sclerosis. In some cases numerous minute fissures are found between lamella? in the nuclear portion of the lens, due to a process of cleavage, the process but slightly affecting the cortical part of the lens. In other cases of this type no cleavage can be seen. The substance of the lens becomes sclerosed, the nuclear portion taking on a deep amber color and becoming hazy. In these cases the lens is always smaller than the normal lens at a corresponding age; it tends to grow thinner (disciform) and smaller in its equatorial diameter. Such a lens when the opacification has advanced sufficiently far to interfere with vision to an annoying degree, is not very closely adherent to its capsule. When extraction is attempted the cortical lamellae are more adherent to the nuclear portion than to the capsule, and are removed almost completely with the nuclear portion even when the cortex is transparent to a considerable extent.

There is a fourth type of cataract which we are called upon to extract from time to time, namely, the zonular cataract, when the cataractous portion becomes so dense and is so large that vision is reduced below the point which enables the patient to follow the ordinary vocations of life; also there are cases in which calcareous deposits render dissipation of the cataract by needling imprudent or impossible.

Extraction of cataract in the types described, if done when most propitious for the welfare of the patient should be performed in the first type as soon as liquor Morgagni appears between the lens capsule and the lens substance; in the second type, at the convenience of the patient after vision is reduced below that necessary for the ordinary vocations of life ; in the third type, when useful vision has been abolished and the lens is appreciably shrunken; in the fourth type, at the convenience of the patient after vision is reduced below that necessary for ordinary uses.

The degree of vision necessary to the individual in order that he may not be incapacitated differs with the vocation. It may be put at twenty fortieths to twenty two-hundredths.

In the foregoing pages we have considered the most propitious time for the removal of cataract. In the process of development of all forms of cataract there is a stage between the loss of useful vision and the condition in which the detachment of the lens fibres from the lens capsule is most easy; this may extend over a few months or a few years. This stage is distressing to the patient and in not a few instances entails hardships on himself and his family.

During a long experience in the removal of the non-cataracous lenses in the dead house, conducted for self-instruction as well as for the instruction of students in the operative surgery of the eye, the writer has studied the behavior of the transparent lens. It was observed that in the lenses which were twenty-five or thirty years old, the nuclear portion was fairly firm, about two-thirds of the mass of the lens coming away with the nucleus. It was further observed that much of the detached cortex could be made to follow the nuclear portion. The firm "nuclear" portion becomes larger as the age of the lens increases. On the strength of these observations, in spite of the dictum "hands off" in reference to operations on immature cataract, I began to remove the cataractous lens soon after it had reached a degree of opaqueness sufficient to interfere with useful vision, whatever the form of the cataract might be, in all cases in which such removal was particularly urgent, those cases being excepted in which the lens was much swollen. If the lens is much swollen, the narrow anterior chamber makes the extraction much more difficult; it is much better then to wait until the lens has shrunken to some degree before attempting the operation.

Before this plan was followed, the operation of ripening advocated by Forster was tried in a number of cases. The lenses became rapidly opaque, but it was found that removal six weeks or two years later was complicated by adhesion of cortical substance to the capsule to probably the same extent as would have been the case had the extraction been performed at the time of the Forster operation. This experience was sufficient to cause the writer to abandon all ripening operations as not of sufficient value to compensate for the extra liability to accidents and inflammatory changes consequent on them.

In almost all cases of the extraction of immature cataract some soft lens substance remains even after very careful irrigation of the anterior chamber. All that can be removed without too severe manipulation should be removed, but if a little cortex remains it is not a serious matter. Cortical lens substance which may remain in the eye after the removal of immature cataract does not give rise to serious inflammatory trouble.

Substances capable of producing irritation, such as tabular crystals of cholesterin or minute deposits of lime, do not exist in the cortex of the immature cataractous lens, but do appear in greater or less quantities in the cortex and deeper parts of the hypermature cataract, and their escape from the lens capsule and retention in the anterior or posterior chamber is not infrequently accompanied or followed by irritation to the eye of greater or less severity. The cortex of the immature cataract absorbs slowly if it lies in a capsule which has been opened near its periphery and in which the opening is small. If the capsule has been opened freely, absorption of the cortical substance advances more rapidly.

After the remaining cortical substance is absorbed the capsule of the lens may be dealt with as may be indicated by its condition. It may not be necessary to do anything with it.

At a meeting of the American Medical Association, held in Baltimore in 1895, the writer reported the results of twenty-five successive cases of immature and zonular cataract for the removal of which he had operated by extraction. There were no losses. The combined extraction was done in six cases; simple extraction in nineteen cases. One prolapse

S CATARACT EXTRACTION.

of iris occurred. Discission was done in twenty cases. Uliimate vision was 20 20 or better in thirteen cases {52 per cent.). The lowest vision in any case was 20/70.

Since 1S95 I have operated in many similar cases, proportionately more combined than simple operations being done. The visual results have not been less favorable than those reported in 1895.

I do not wish it understood that I operate for the removal of cataract by preference before the time of selection is reached. The difficulty of extracting immature cataract is greater than the difficulty of extracting mature cataract. When it is done, it should be done by expert operators. When so done the visual results are not much, if any, below those obtained after the removal of mature cataract.

Discussiox.

In the discussion on Dr. Weeks 's paper, Dr. E. Gruexixg stated that many cataracts were sufficiently transparent to allow of serviceable distant vision, but not sufficiently transparent to permit the person to do useful near work, and that in many of these cases the lens was sclerosed and extraction could be safely performed. He did not operate in cataract that was really immature. If there was a large and transparent cortex, it was, as a rule, better to wait, but if the patient insisted upon operation it was usually better to perform a preliminary iridectomy. At times, however, the surgeon was compelled to perform extraction at one sitting, for sometimes the patient would not submit to a double operation. In zonular cataract, extraction could be performed without waiting for complete ripening of the lens. This could be preferably done by removing the nucleus and as much soft cortex as possible at one sitting, leaving the rest of the cortex to be absorbed. Removal of a cataract in its capsule was, of course, the ideal operation, but on the average the results were less favorable than by the ordinary methods, for the loss of vitreous which might result was sometimes the cause of subsequent detachments of the retina and hemorrhage at the time of operation.

Dr. T. R. Poolet stated that in immature cataract he was opposed to operation as a general practice. Of course, when both eyes were about equally affected a patient was reduced to serious straits on account of the double k vision and the operation might be rendered necessaiy, but these cases were not very common. Nuclear cataract and sclerosed lenses could be removed before completely ripe without much danger. Zonular cataract was very difficult to deal with, for one could not be sure of removal of all the soft lens substance and, in these cases, a preliminary iridectomv was a good thing. In anv case of cataract extraction, when it was known that the eye was highly myopic, a preliminary iridectomy ought to be performed.

Dr. E. S. Thomson made it a rule to operate as soon as the lack of vision in the better eye incapacitated the patient, except when the lens was much swollen or when much soft lens matter existed. How to distinguish clinically when these conditions are present is very difficult. When the lens is sclerosed the state of affairs is evident, but in the ordinary cases with stria? from the equator it is very hard to tell. He never performed extraction in the capsule unless he was compelled to. When there was much soft lens matter he preferred the simple operation and did not like to operate in two stages. The position he took upon the time to operate in cataract depended principally upon how far he could determine the presence or absence of soft lens matter.

Dr. H. Kxapp stated that removal of the lens in the capsule was not difficult if the section was made below. He does not like to operate on immature cataract, for some particles of soft lens matter are sure to be left behind. When much cortex was left behind, he irrigated with a special syringe. This syringe resembles an ordinary hypodermic with a short angular tip. It is made of glass, the piston working very tightly, and the whole syringe could be disinfected by boiling. He also used the syringe to inject salt solution when much vitreous had been lost, and also to syringe out the anterior chamber when it contained much blood.

Dr. E. B. Coburn did not believe in inflicting much trauma in order to remove soft lens matter, and believed that too long a time should not elapse between the primary operation and the discission of the capsule, if this should be necessary, for a connective-tissue formation took place which made discission, with the increasing lapse of time, correspondingly difficult. With a swollen lens and a shallow anterior chamber, we should not operate, but if we found much sticky cortex during the operation we should carefully extract the soft lens matter without undue trauma.

Dr. J. E. Weeks, in closing, stated that, while the extraction of immature cataract was attended by many difficulties, the hardships often inflicted by waiting rendered early extraction in some cases perfectly justifiable.

[Within the last twelve months I have removed a perfectly clear lens from an eye in which there appeared to be a posterior cortical central cataract. This opacity interfered with the vision to such an extent that I concluded to attempt combined extraction. Artificial maturation was contraindicated by the existence of an old iritis and an indefinite history of choroiditis. A large incision was made, a T-shaped cystotomy was done, and the lens was delivered entire with ease. Inspection of the lens showed that it was clear throughout; there was no opacity of the fibres even at the posterior pole. The opacity seen before the operation must, therefore, have been a posterior capsular one. I made a demonstration of the clearness and magnifying power of the lens by reading print through it. The eye healed quickly, but the patient unhappily injured her eye twice on the fourth night after the operation by striking at mosquitoes. The wound was opened, and a prolapse of one of the pillars of the coloboma was caused. Two weeks later she was again accidentally struck in the eye by her little grandson, and a more extensive opening of the wound, together with prolapse of the choroid, was produced. The visual result, of course, was bad, and an interesting feature of the case lay in a rolling up of the entire capsule into a scroll-shaped mass, which was finally attached to the site of the wound.

There were, apparently, no cortical remnants; perhaps the freedom with which the capsule separated from the lens, was due to the preceding iritis and choroidal disease.

This case, however, proves that a perfectly clear lens may be delivered without the capsule. Nevertheless, it is not a wise procedure to extract such lenses, and it should not be attempted except for stringent economic reasons.

If it is imperative to operate at once, the combined extraction or a preliminary iridectomy should be done.

Dr. Weeks's results are remarkable, in view of the fact that of twenty-five cases, simple extraction was performed in nineteen, and the combined operation in six. The results, however, in this small series of cases, should not form the basis of a rule of action. J. h. c]

Chapter II. The Preparation Of The Patient And The Antiseptic

PRECAUTIONS TO BE EMPLOYED PRECEDING THE

EXTRACTION OF CATARACT.

Edgar S. Thomson, M. D.

The important points to be considered in preparing for the operation of extraction of senile cataract are included under the following general headings: I. The general preparation of the patient. II. The preparation of the field of operation.

III. The preparation of the operator and of the instruments to be used.

These questions have in the past led to great diversity of opinion, especially in regard to the methods used. It would be neither profitable nor interesting to attempt a statistical paper in this connection, and so I have simply set down what I believe to be the best usages and opinions of the leading American writers upon the subject, colored, of course, by my own preferences.

I. THE PREPARATION OF THE PATIENT.

It may be said in general that any patient undergoing an operation for cataract should be in his normal state of health, if circumstances permit, in order that we may secure resistance to bacterial invasion, prompt healing and the least possible post-operative inflammation. The following should be especially considered:

(a) The cardio-vascular system.

(b) The kidneys, particularly with reference to diabetes.

(c) The respiratory apparatus.

(d) The nervous system.

(e) Toxic influences, especially syphilis and alcohol.

(f) *The digestive tract.

Assuming that the operation is performed under proper aseptic conditions, the state of the heart and vessels concerns us most, on account of the dreaded complication, choroidal hemorrhage, which destroys vision. Unless this follows some accident, as post-operative vomiting, loss of vitreous, compression of the eyeball by forcible attempts to close the lids, etc., it is hardly conceivable that the rupture of a choroidal vessel should occur unless some degree of degeneration of the vessel wall is present; therefore the evidences of arterio-sclerosis should be carefully noted, together with the degree of vascular tension present. The most reliable symptoms are, accentuation of the second sound of the heart, the persistent elimination of large amounts of urine poor in solids (of low specific gravity) and rigidity of the radials or other vessels. It is a well-known fact that vascular changes are not always symmetrical, and therefore it is not sufficient to feel the radials, but the brachials, facials, and all other accessible arteries, if suspicion arises. The history of the patient may lead us to suspect arterio-sclerosis, and the presence of an old chronic nephritis should cause us to look for it very carefully. The vascular tension may be judged by the degree of resistance to compression of the pulse at the wrist, by the heart sounds, or, best of all, by the sphygmomanometer. I believe we may almost always be forewarned, though we may not always be able to prevent the catastrophe of choroidal hemorrhage.

Where the arterial tension is high, especially if vascular degeneration is present in marked degree, hemorrhage is more apt to occur, and the patient should be on careful diet and regimen for some days before the operation. Drugs to lower the arterial tension — veratrum viride, aconite or nitroglycerin — have been advised and are, in my opinion, indicated, though my personal experience with these remedies in this connection, fortunately, has been small. In such cases the circulatory system should be depleted by free catharsis, preferably with salines, before the operation; and, finally, the vessels should be subjected to no strain that can possibly be avoided after the first incision. It is better to operate on these patients in the bed in which they are to remain than to take them to the operating-room.

Urinalysis, which should always be done before cataract extraction, may give us important information. The presence of an acute or subacute nephritis would, of course, be an absolute contra-indication to the operation, for reasons which are obvious. Such patients should receive appropriate diet and treatment until a period more favorable for the extraction.

The respiratory system interests us chiefly on account of the risk of hemorrhage, or reopening of the wound, with its attendant dangers, in an attack of coughing during the first three or four days of convalescence. In acute bronchitis it is, of course, best to wait; but chronic bronchitis may be treated with codein or -^-grain doses of heroin every two or three hours for a day or two before the operation, giving sufficient to control the cough. Acute coryza with tendency to sneeze is, of course, an indication for the postponement of the operation. Asthma requires the same plan of treatment as chronic bronchitis, i. e., sedatives for two days or more before the operation to control the paroxysms.

The preparation of the nervous system is a difficult matter and one much less under our control than those previously mentioned. Patients who fret or worry may be given bromids so as to sleep well for several nights before the operation. The remainder is a matter of personal encouragement, but even under favorable conditions nervous reaction, like delirium, is not always to be foreseen and must be treated according to the indications as they arise. I do not administer morphine in these cases, as I fear the stimulation in some instances and the nausea in others, but prefer to control a nervous patient largely by encouragement and moral suasion.