The greatest advantage, however, which this method possesses over that with a larger opening including section of a rib, consists in withdrawing the gas as well as the matter from the cavity of the pleura. The integrity of the ribs being preserved, the chest-wall can better resist the tendency to collapse into the vacuum created, into which the lung is thus forced to descend, at the same time freeing itself from adhesions and assuring a better preservation of the original capacity of the pleural space. When convalescence is complete after this treatment we believe that there is not so apt to be curving of the body to one side, that the local deformity will not be so marked, and that the function of the lung will be less impaired.

A few cases treated in this way, though very tedious, have made most satisfactory recoveries.

CORNEAL ABSCISSION-A REPORT OF FORTY

ONE OPERATIONS.

By J. M. CRAWFORD, M.D., ATLANTA.

The object of this paper is to bring before you a subject with which the majority of you are more or less familiar, in print at least. I do not promise to throw any new light on the subject, but simply to give my personal experience, with the hope thereof of influencing some among you to lay aside prejudice and give to your patients the great benefit to be derived from this old and simple operation.

I say "old operation," since we find it spoken of more than one hundred and fifty years ago. Its revival was accomplished some thirty-five years ago by Critchett, of London, and later was modified by Knapp, of New York.

OPERATIVE PROCEDURE.

The operation, as you are aware, consists of the removal of the front portion of the ball together with the ciliary bodies and crystalline lens. The patient should be given chloroform or ether, as a local anesthetic is not sufficient. Personally, as I have stated on former occasions, I prefer the administration of chloroform because the psychic shock is much less and the after-effects better.

The primary operation of this kind was made by simply cutting off the anterior portion of the ball, leaving a stump formed by the sclera with the muscles attached. No stitches were taken to prevent the escape of the vit

reous humor, and, strange though it may seem, this method was found to be better, in many instances, than enucleation.

CRITCHETT'S OPERATION.

George Critchett later improved on this method by inserting three or four curved needles threaded with silk through the ball from above downward, a little behind the ciliary bodies, after which he cut off the anterior portion of the ball in front of his needles, leaving a small margin of sclera through which he drew his needles. The scleral edges were brought together by means of these silk sutures, which were tied. The sutures were allowed to remain for six or eight days and were then removed.

KNAPP'S OPERATION.

Knapp modified this operation by eliminating the curved needles and thread, closing the wound by external sutures, thus changing a very tedious operation into a simple one.

With the help of this cut I will endeavor to point out to you the successive steps in the operative procedure as I have practiced it. From the upper end of the vertical meridian (c), about four millimeters temporally, a curved needle is passed through the conjunctiva and the outer layers of the sclerotic, drawn out and introduced below the cornea at this point (d), passing through the conjunctiva and outer layers of the sclerotic in the same way as above the cornea, only in the opposite directionnasally instead of temporally-and reappearing at the lower portion of the vertical meridian. The needle is removed and you have a loop (e) and the two ends of the thread resting on the temple. This process is repeated on the nasal side. The sutures being placed, you proceed to cut away that portion of the ball lying in front of them (a b), care being taken not to cut the threads and thereby

delay the operation. The first steps after the abscission is to let the ends out and tie the sutures. The ends of the temporal thread are drawn toward the nose, making of the loop a straight line and thus drawing the upper and lower edges of the temporal side of the wound together. The process is repeated on the nasal side, and when the sutures are tied, the wound has a puckered appearance similar to a pouch. The eye is then bandaged and the patient kept in bed until the wound heals, which it does speedily.

EVIDENCE.

As I have intimated in the beginning of this article, there is some prejudice in regard to this operation. The

objection has been urged that the operation is frequently followed by sympathetic ophthalmia. I will say just here that I have within the last ten years made forty-one of these operations with entirely satisfactory results, except in one instance, when a case of cyclitis developed. You may judge for yourselves, from the appearance of these few patients whom I present to you, what the cosmetic effect is of such an operation where a natural stump is left on which to operate an artificial eye. You will see how easily and naturally the artificial eye moves in unison with the natural eye.

Having in mind the prejudice of some of my honored colleagues and the specific objection (sympathetic ophthalmia), I wrote to some of the leading oculists of this country asking them to answer certain questions, to which I received speedy and courteous replies. The questions were as follows:

Do you ever resort to Critchett's operation?

Has the operation pleased you in its results?

What, if any, bad results have you had to follow the operation?

Have you seen or known of a case of sympathetic ophthalmia resulting from the operation?

Do you make the Mules' operation instead?

Why?

Do you prefer enucleation to the Mules' or the Critchett?

The answers to these interrogations I have endeavored to condense into tabular form, as follows: