The operation is divided into three parts, and is performed under cocaine: (1) tenotomy of both external recti muscles and stretching of conjunctiva and Tenon's capsule; (2) making the elliptical opening either on one eye or both; (3) suturing this opening.

The details of the operation are carried out as follows:

1. Tenotomy of both external recti muscles, making an opening through the conjunctiva, over the insertion of the tendons. I then stretch Tenon's capsule until the cornea is well into the inner canthus; this is done on both eyes. Panas's method is to insert the hook under the muscle and apply pronounced traction, at the same

under the external or internal muscle, prevents rotation of the eyeball.

2. With the retractor-forceps I grasp the conjunctiva vertically, midway between the cornea and caruncle and directly over the internal muscle, and draw upward the conjunctiva and as much of Tenon's capsule as I can. I raise the forceps two or three times to take up as much of the redundant tissue as my judgment dictates, and by this means one apparently is always successful in separating conjunctiva and overlying tissue from the muscle, if it be still present; then with curved scissors I cut, with one long sweep, the upraised conjunctiva and capsule close to the eyeball, making an elliptical opening, exposing, at

time burying the cornea in the outer or inner canthus. The stretching of Tenon's capsule is an important part of the operation. My method is as follows: The strabismus-hook, which is a large one, flat on its side, is inserted in the opened conjunctiva and Tenon's capsule, and with considerable traction all the tissues are stretched inward until the cornea is buried in the inner canthus. The stretching of the upper tissue has, as can be readily understood, a tendency to rotate the eyeball to a certain degree and leave the conjunctiva and Tenon's capsule intact. below; to equalize the stretching, the point of the hook is reversed, and the lower conjunctiva and capsule stretched. In Panas's method the hook, being placed

times, the attenuated muscle, and, if no muscle be present, then the clear sclerotic. (Figs. 9 and 10.)

This opening now extends in a vertical direction, beginning below the lower level. of the cornea to a point above the same; its width over the muscle is about one full centimeter at its greatest diameter. The conjunctiva is then separated around this elliptical wound from its subconjunctival tissues at all points, even around the cornea, if possible.

3. The elliptical opening is brought together with four sutures; the upper su ture is inserted through conjunctiva and Tenon's capsule, and across under conjunctiva and Tenon's capsule midway between the insertion of the superior rectus

muscle and the margin of the cornea; a similar suture is passed through the lower margin of the conjunctiva and brought out midway between the insertion of the inferior muscle and the margin of the cornea; this thread is then tied, and in like manner the upper thread; two more sutures are passed through the margin of the lips of the wound and united. (Fig. 11.)

This constitutes the details of the operation. The object of the operator should be to produce one to four millimeters of convergence, which disappears during cicatrization. When the defect is not more than two or three millimeters I have performed an external tenotomy on both and stretched Tenon's capsule, with excellent results, without taking out the elliptical section, especially in those cases where the eyes could be held by the patient at fixed convergence at ten inches.

While this operation is similar in many details to that of De-Wecker, Knapp, Snellen, Gruening, and Grandelement, yet I am sure its simplicity has much to commend it, and the results obtained in my hands make it preferable to any one of the abovementioned methods. (Figs. 12, 12a, 13, and 13a.)

PTOSIS (5 OPERATIONS).

Panas's method was followed in two operations and a simple removal of an elliptical section of the upper eyelid in three cases.

In cases where the drooping of one or both eyelids accompanying paralysis of the third nerve or nerves, it is not advisable to seek operative measures until all internal medication has failed. This treatment, with electricity, may be kept up for one or two years. In congenital defects operative measures may be applied at any age (but not under five years).

Panas's Method.1-A horizontal incision is made two centimeters long down to the periosteum, just below the margin of the 'Archives d'Ophtalmology, 1886, page 1.

orbit, and another three centimeters long just above the eyebrow. A bridge of skin is dissected off between these two incisions; a flap of skin is then formed on the lid. This part of the operation is simplified by inserting a horn spatula underneath the upper eyelid, keeping it taut; two vertical incisions, one curved toward the outer and the second toward the inner canthus; this flap is dissected off, and four stitches are passed under the bridge, over the brow, and attached to the upper edge of the upper incision and the divided fibers of the occipito-frontalis muscle. Two additional lateral sutures aid in preventing the lid from drooping.

The simple operation is: First, an incision is made five millimeters from the margin of the lid from the inner to the outer canthus, while a second is carried in a curved line from one end of the first incision to the other end. The apex of the curve being well up to the orbital ridge, the skin is well drawn out and dissected off without interfering with the fibers of the orbicularis muscle. The margins of the gap are drawn together with fine silk sutures, which may be removed at the end of the fifth or sixth day.

TATTOOING (25 OPERATIONS).

These operations were simply performed for cosmetic purposes, and the results desired were obtained.

The ink is procured from China, and is made of sepia and compressed into sticks. In preparing it for use a few drops of clear water are placed in a porcelain dish, and the ink is rubbed down until a thick paste is made, and this is pricked into the cornea. De-Wecker, of Paris, I believe, was the first to introduce it into ophthalmic surgery.

There are several styles of needles used. The original needle was broad, shaped somewhat like a spear, with a groove running along the back. Into this groove the fluid ink was placed, and as the pricks were made the point was fed. The second, and,