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III. To modify accommodative states. - Exercise with prisms, base out, may be used to stimulate a subnormal accomodation, and exercise with prisms, base in, to relieve a spasm of accommodation. These exercises, particularly the latter, constitute, I believe, a very useful application of prisms.

THE PATHOLOGIC RESULTS OF DEXTROCULARITY AND SINISTROCULARITY.

BY GEORGE M. GOULD, M.D., PHILADELPHIA, PENN.

A little observation and a few tests will show with some exceptions, to be noted later, the right-handed or dextromanual person is also right-eyed, or dextrocular, and the left-handed is left-eyed. That is to say, there is, in the dextromanual, the same habitual and unconscious choice of the image of the right eye for the more expert and important tasks, just as the right hand is chosen for those functions in skilled work. A dextromantial hunter places his gun against the right shoulder because he can sight it with the right better than the left eye. The right-handed person, in playing the violin, violoncello, etc., is forced to use the left hand for the more expert task, because he thus sees the fingers and the neck of the instrument without foreshortening and better than he could if the fingering were done with the right hand. All actions, in fact, are determined by the fundamental necessity that accurate vision shall precede all action, and vision is more accurate with the habitually exercised eye just as manual function is more expert and reliable with the hand most exercised in a special kind of work. A little closer observation soon demonstrates that not only is the dextromanual also dextrocular but that he is likewise rightfooted, and usually right-eared; he is dextropedal, and dextroaural. This is equivalenf to saying that a person is either dextral, generally, as to ear, eye, hand, and foot, or else he is sinistral. There must manifestly be a unity in the coordinations of all acts,

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307;

and such cobrdinations would evidently be better if there was a habitual one-sided similarity of execution running through all kinds of action, so that there would be no indecision in rapid and dangerous acts. The unity and the resultant promptness and accuracy of all motions is thus enhanced by a synchronous dextrality or sinistrality. The mixed type, illustrated by the socalled ambidextrous, would place the organism at a wretched disadvantage in the struggle for existence, and in the social struggle of the highest types of human life. The underlying and long forerunning cause, however, of the co6rdination of dextral acts, or of sinistral ones, lies in the necessity of the localization of the organ of speech in one or in the other side of the cerebrum. As it is a single and not a dual function its organ can be only in one place. Pathology has proved what physiology pointed out, that in the dextral the speech-center is in the left side of the brain, and in the sinistral it is on the right side. Moreover, the intellectual act of writing develops the speech center on the side opposite to the writing hand. The history of cases with tumors and paralyses has settled this question beyond controversy. The speech center may be looked upon as the organ through which intellectual judgment and decision issues in determination and act. The spoken and written word is the most intimate act of the mind, its irrevocable and immediate exponent. Prior to all judgment and decision vision must give the data. Intellect is in fact the product of vision, and all mental symbols, the letters of the alphabet themselves, are but modified visual images. The thing seen is thus worked into judgment, and by the third component of human action, motion, is wrought into completed function. Vision, judgment, act, are thus the unexceptional conditions of human activity and validity. It is at once plain that if the centers wvhich intermediate these three functions are upon one side of the brain, in contiguity, and closely united by many intercentral fibres, the resultant act will be more accurate and rapid than if one or two of the centers are in the opposite side of the brain. The commissural fibers between the two cerebral hemispheres would be

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fewer and longer, and the coordination less clear, sharp, and certain. This is the neurologic basis for a common dextrality, or a common sinistrality, of function in one individual, and it completely demolishes the foolish contention of those who would vainly educate the two per cent. of left-handed children to be ambidextrous. There never was an ambidextrous person, but there has been produced much misery by the foolish attempt to create ambidexterity. A paper on the general subject of dextrality and sinistrality will soon appear in the Poputlar Science

Monthly. If by ocular disease, ametropia, accident, etc., the dextromanual are compelled to sinistrocular, the pathologic results which may flow from this interference, or reversal, of the natural order becomes of exceptional interest to the ophthalmologist. That these pathologic results exist I have no doubt, and have repeatedly demonstrated in the persons of actual patients. I suspect that they exist in at least ten per cent. of all patients, and no case whatever can be treated wholly irrespective of the fact of dextrocular, or sinistrocular, function. For purposes of naming and clarifying the ideas to be presented, let us call the right eye of right-handed persons and the left eye of left-handed persons the dominant eye. The caution must be emphasized that the hand which does the writing unconsciously or preferentially dictates the location of the speechcenter, and the true condition of dextromanuality or sinistromanuality. It hardly needs the saying that the accidents of ocular diseases, keratitis, fundus lesions, cataract, high ametropia, heterophoria, amblyopia, etc., may put out of function, or threaten to do so, the primary, that is, the naturally, logically, and neurologically, dominant eye, and thus the eye of the other side must be used as a makeshift and educated to become the secondarily dominant one. The older the age at which this occurs the greater the difficulty, the more of a tragedy will it be to the patient. There arise a hundred problems. I shall here allude, and most briefly, to but a few of these:

GOULD: Dextrocularity and Sinistrocularity.

309

i. In all operative procedures there should be an exceptional striving to save the dominant eye. I do not believe in operations for this purpose, but if only one eye can be straightened and made functional in strabismus, by all odds let it be the dominant one. The strabismus of a naturally dominant eye will be more easily cured than that of the non-dominant one. In double convergent squint the dominant eye should be the one first chosen to save. 2. In inflammatory diseases there should be the same solicitude, when choice, as frequently, is possible, to preserve the best function in the dominant eye. 3. The supreme value of the dominant eye makes it highly important that ametropia shall be corrected at the earliest day and vear possible. Every month that amblyopia, heterophoria, or strabismus increases in that eye makes the life history and struggle of that child a different and a more difficult one. Dextromanuality, or its opposite, is pronounced in children of less than a vear, and the location of the speech center is being fixed rapidly, and often unchangeably at two and three years of age. 4. If saving of the naturally dominant eye is impossible in the young child, and its fellow must be secondarily educated into dominancy, it becomes a question if the child should not also be taught to write, eat, etc., with the corresponding hand. 5. In the adult the dominant eye, I have found, will preserve its dominancy despite a considerably higher degree of amblyopia, ametropia, etc., than that of its fellow. But it is evident that there must be a limit. I doubt if the naturally dominant eye would retain its dominancy if it had, say, an acuteness of only 20/50, while the vision of the other was normal. This fact arouses a number of queries in the mind of the refractionist. One of these would refer to the inadvisability of giving the nondominant eye a greatly superior acuteness of vision by means of glasses. In an adult such a sudden change, even reversal, in the habits of a lifetime might be brought about that the spectacles would not be tolerated, and failures of varied kinds ensue. The
OPH.- 21

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GOULD: Dextrocularity and Sinistrocularity.

patient would then have a life handicap that would greatly lessen his personal validity and happiness. 6. An axis of astigmatism in the dominant eye from IO to 200 to either side of 900 or i800, while the axis in the fellow eye remains normal or unsymmetric, produces head-tilting; symmetric axes produce no,head-tilting. In the few months after I discovered this law I found in the ordinary run of office practice over thirty cases of head-tilting. The stupid error I had made all my life was to allow these patients to cant the head during the refraction testing. In this way I had failed to find how large is the number of right-handed patients who have the axis of astigmatism of the right eye from IO to 200 to one side of go' or i8o0. And never before this had I thought of the necessity of inquiring as to dextromanuality in patients having these slightlyunsymmetric axes of astigmatism. It is evident that an axis in the dominant eye only 50 to one side of go or i8o0 would hardly produce a noticeable tilt of the head, or might possibly be compensated for by the rotation of the eyeball itself. It is. possible that some types of heterophoria, and especially cyclophoria, may be explained as arising from this compensation ofthe ocular structures instead of producing the tilt or. cant of the head. It also seems to me possible that this compensatory twist of the eyeball in the orbit may possibly cause a compensatory twist of the optic nerve, and perhaps certain other diseases of the papilla and retina. After prescription of proper correcting glasses it would be natural to find before long a secondary change of axis resulting from the rectification of the abnormal head-tilt,. or ocular twist. Such patients must be kept under continuous and repeated observation. If the axis of astigmatism of the dominant eye is about 75 or I650, it is evident that, if the non-dominant eye is unsymmetric, the head must be tilted to the right in order to bring the false axis into line with the vertical lines of print, trees, houses, wall paper, doors, etc. If the axis of astigmatism of the dominant eye is about 1050 or I50, compensatory tilt of the head must be to the left. Greater

GOULD: Dextrocularity and Sinistrocularity.

3II

variations of the axis than 200 would hardly be compensated for by head-tilting, but would either produce amblvopia, a transfer of dominancy to the other eye, or else some other pathologic consequence equlally harmful to action and life. The axis of the largest number of head-tilters is 750 in the right eye, and thus the majority tilt the head to the right. 7. Among the thirty or more head-tilters I have found, in the few months mentioned, about a dozen with resultant scoliosis. The fact was usually unsuspected by the patient, the parent, and the attending general physician. I sometimes had difficulty in getting consent that an expert orthopedic surgeon should verify the diagnosis. A report of these cases, the nature of the compensatory spinal curvature, and the cure by glasses alone, or by glasses and orthopedic help, will be published later. It is needless to add that the method of production of scoliosis resulting from an enforced and habitual abnormal position of the head is well understood by orthopedic surgeons. Habitual carrying forward, for instance, of the hearing ear in case of unilateral deafness will result in scoliosis. There are undoubtedly thousands of scoliotic children in the United States whose spinal malcurvation is due to a slightly aberrant axis of astigmatism. 8. An ametropia in the non-dominant eye which tends to throw it out of function is much more likely to result in malfunction, non-function, and disease of that eye, than would be the case in the dominant eye. Many practical suggestions and rules result from this fact, both in refraction work and in the management of inflammatory diseases. In amblyopiatrics, for instance, it is perhaps as well not to strive to give the non-dominant eye an exceptional or even an equal acuteness of vision. Nature will not respond to the attempt so willingly as in a similar attempt with the dominant eye. 9. The failure to diagnose the unsymmetric variation of axis of the dominant eye will of course result in the non-cire of the reflexes, which are caused by eye-strain. This is so well established that it may serve as a reason for re-examination of the cases in which in the past there has not been perfect relief of

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patients with general ill-health, migraine, dyspepsia, headache, neurasthenia, insomnia, melancholy, etc., probablv due to eyestrain. Not seldom the change of axis, found to exist when the refraction test is made with the head accurately erect, will at once bring astonishing and brilliant relief of many forms of inveterate systemic functional disease.*
POSTSCRIPT.

After the foregoing paper had been read at Atlantic City Dr. Peter N. Callan said to me that the suggestion of righteyedness had also come to him, and he had asked the question in the Medical Record of April 2, I88I. Confirmation of the fact had been found in the examination of the records of more than i,ooo of the private patients of Dr. H. D. Noyes, in whom each eye had been carefully examined and the vision and refraction noted. The general results were that when myopia existedthere was a higher degree in the right than in the left eye, andwhen hyperopia was present there was a less degree in the right than in the left. In the hyperopic- cases the vision was more acute in the right than in the left, and in the myopic the vision was almost the same in each eye, taking all degrees into consideration. Dr. Callan drew the conclusion " that with binocular vision we use one eye more than its fellow -that one being generally the right eye." This quick confirmation of the theory of dextrocularity was unexpected, and suggests a number of valuable and practical rules in refraction-work, in the case of the eyes of school children, students, etc. There are indirectly further proofs of the theory to be found in the ingenious and instructive paper of Dr. Wheelock Rider on
* A corollary of the discovery of the cause of so many cases of tilted heads is suggested. Besides the thousand vertical and horizontal objects that demand relief of astigmatism, or its placing at axes go' or I8o', the predominant cause in civilization is the shape of the letters of the printed page. As a rule these are made up chiefly of lines at axis go' supplemented by a few at I8o', and a less number of curves and of oblique axes, at about 6o' or 7o0% or, conversely, at 120' or I10'. It is these last which should be eliminated when it is possible, and in all but a few letters this is possible, the exceptions, (K, V, X, Z) being relatively unimportant. The lower case of small letters could be modified in shape to correspond to these. The lesson as to vertical and slanted handwriting at school is equally plain.

Discussion.

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" Unilateral Winking," published in Transactionis of the Anwericatn OphthaInmological Society, I898, to which my attention was kindly directed by the author in the discussion of my paper, and which had also escaped my notice.
DISCUSSION.

DR. WALTER L. PYLE. - I feel somewhat embarrassed to steal Dr. Gould's thunder, but I have been in conference on this subject with him many months, and think that many points should be brought out that he has omitted in his paper. It is marvelous the way these examples can be multiplied. Carrying the gun to the right shoulder and playing the violin are most striking, but there are many others; the engineer, who sits so that he can use his right eye for watching, with his weaker left hand on the throttle, for instance. In gross work the difficult part is done with the left hand; in chopping, for instance, the right hand simply guides the blow. As to the inconvenience of ambidexterity I know of a naturally left-handed man who was compelled to use his right hand by his early teachers and who complains of being unable to think when he writes, so that he has to do all his literary work by dictation. As to head-tilting, Dr. Gould's first case was very striking. He spoke to me of a girl several months ago, who came into his office with wry-neck and evident spinal curvature, whom he refracted. She was sent to a physical culturist, and taught to stand erect. On her return, notwithstanding her improved health, she said, " when I stand straight, Doctor, I can not see through my glasses." Immediately after the proper oblique axis of the cylinder was prescribed vision with the head erect was perfect. We make a mistake if we allow patients to cant the head in testing the eyes. I recently sent for a half-dozen cases that in my earlier days I had failed to correct satisfactorily, and these I refracted again. In three the oblique axis was 75, where I had put it at 90 with the head tilted. The association of ocular deformity with spinal curvature is not new, but it has usually been attributed to muscular anomaly, no attention being paid to the axis of the astigmatism as a factor. The treatment advised was tenotomy, or prisms, and these nearly always failed to give relief. In regard to the pernicious effect of small amounts of hypermetropia brought out today, it is mv opinion they are not of such consequence in producing asthenopia as are similar amounts of astigmatism, particularly when at oblique axes.

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Discussioi.

DR. W. E. LAMBERT. -I wish to disagree decidedly with the illustrations brought out and applied by Dr. Gould: saying that because a man takes his. gun up to the right shoulder he must be dextrocular. It is because he uses his right hand to pull the trigger. And, as to the violin playing, it is more important to have the right hand manipulate the bow than the strings of the instrument. As to passing to the right on the road, it is only in this country that it is done; in Europe they pass to the left. I do not think the illustrations are at all good. DR. PERCY FRIDENBERG. - The idea of Dr. Gould's is interesting, if true. Some ethnologists tell us that the original favoring
of the right side is due entirely to the position of the heart. The greatest vascular supply is to the left side, and there is early development of the brain on that side, while the development of the right side was due to the importance in early times of protecting the heart with the shield on the left arm and using the right arm for fighting. I think the objection Dr. Lambert has just stated may be applied to other examples. The violinist does not look with the right eye at the strings, good players look away from the instrument when they play. The 'cellist holds the instrument about an equal distance from both maculae. I think the idea of associating dominance of one eye in this manner is certainly open to objection. If the normal being has equal vision in both eyes I can hardly see how such dominance can be established. The fact of the case is that the majority are unable to distinguish which eye is concerned in vision, and many tests of simulation are based upon that fact. One eye is only dominant when the other is defective. To carry this theory further and say that we should avoid straightening a non-dominant eye it seems to me would be a mistake.

DR. P. A. CALLAN. - I am fully in accord with Dr. Gould as to the question of a dominant eye, but presume the doctor knows it is not original with him, but that the idea is a generation old. I think La Compte, in the International Scientific Series, thirty years ago, published a book on vision, giving a good many of these examples. As to ambidexterity, I think every surgeon should educate his left hand to use the knife and scissors. It is a great handicap for a young man to be able to use only one hand in surgical work, and if he starts out early he can accomplish a great deal by using his left hand. In that respect I think the deductions of Dr. Gould are

Discussion.

3IS

wrong. I use my influence at every opportunity to persuade young men to develop the use of the left hand so that they can use the Graefe knife, or the scissors, in that hand if necessary.

DR. LucIEN HowE.-I think we would all be interested in this summary which Dr. Gould makes, to have at least a digest of the data from which the conclusions are drawn. The latter are very interesting, but are based upon observations which we must look for elsewhere. We would like to hear the data, and have the figures a little more exactly. I wish to say that the subject is gone into thoroughly by Grant Allen, in a chapter on right and left handedness. It is in a little book entitled " Falling in Love, and Other Essays on the More Exact Sciences." The subject of ambidextrousness interests us, though we have all seen surgeons who were ambisinistrous. DR. C. H. WILLIAMS. -I would like to mention one case in this connection: A friend of mine, a distinguished surgeon, is right-handed, and is also a very enthusiastic sportsman. For many years he could not understand why he missed so many of his birds when shooting. He finally found that he was putting his gun to his right shoulder and sighting with his left eye. He was right-handed, but left-eyed.

DR. WHEELOCK RIDER. - Dr. Gould's paper is along lines that have occupied my time and attention for many years. Some of the results of this study may be found in the transactions of this society for I898, and I have since collected a much larger number of observations for further investigation. An English ophthalmic surgeon, whose paper I have never seen, called attention, I believe, some years ago, to the subject of the " master " eye, and it is not only easily demonstrated but highly important to remember that in most individuals the right or left is the " dominant " or "-fixing " eye, and that much that passes for binocular vision is in reality monocular vision. The " winking-test" roughly determines, among other things, which is the better eye - the one probably dominating over its fellow in binocular vision, so called. The influence of dexterity in the selection of this eye, when even slight visual conditions alone have not already determined the matter, is, I believe, much less than the reader of the paper assumes. Right-handed persons are surely not, ipse facto, right-eyed. In many hundreds of

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3Discussion.

persons examined on this point not much more than IO per cent. seem to be influenced by their right-handedness. With regard to the violin, the manner of holding which the reader instanced as an example of the right-eyed tendency, I feel somewhat competent to speak from long personal experience with its use, my practice beginning in my seventh year. The violin, like all instruments of the viol class, is a right-handed instrument. In the early forms the fingering (executed with the left hand) was very simple, especially as the fingerboard was frequently fretted. The strings were struck with the fingers of the more skilled right hand, or with a plectrum held by them. The guitar of today well represents this archaic form. Today the training of the right fingers, right wrist, and right elbow -the bowing -makes the violinist. No violinist is better than his

right wrist. The gun is likewise a right-handed implement-the pistol surely, and just as surely the older forms of the musket, mechanically supported at the end of the barrel. The right index and middle finger are under better and quicker control, and the better trained right arm and shoulder bear the brunt of aiming and firing. Men very commonly shoot right-handed with a defective right eye, which would otherwise never be employed for sighting, but when the defect is marked they are forcedI to reverse the position. Having determined that the unconsciously-acquired and very fixed habits of lid closure are chiefly due to differences of visual acuity (or effort) we are prepared to investigate other unconsciously-acquired muscular habits, such as clasping the hands, washing the hands, folding the hands and arms, chopping, spading, and shoveling, turning the head to look over the shotulder, kicking, jumping, sliding on ice, even smiling, and many others. Most of these habits are formed in early life, and are so fixed and numerous that they might serve as the foundation of a svstem of identification, just as do anatomical peculiarities. They are by no means the same in all right-handed persons, but are 'fotund in different individuals in all possible combinations and probablv will be shown to be, while partly correlated, chiefly dependent upon general functional and anatomical peculiarities of the parts, as is lid closure, and not upon the particular functional peculiarity of right-handedness. Carrying owls to Athens -suggesting terminology to a lexicographer - I would propose in place of the Latin terms " dextrocularity " and " sinistrocularity " that, for the sake of

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obvious uniformity, the Greek equivalents be substituted: "dexiopia " and " aristeropia."

DR. MYLES STANDISH. -Some ten or twelve years ago two gentlemen, writing in collaboration, published a paper in the Ophthalmic Reziew, or the RoYal Ophthainological Hospital Reports on this subject, right or left oculation. I found the subject interesting, and fromi that on to the present time all of my refraction cases have been tested as to whether they were right or left eyed. I am positive that the relation is real. I have tested people a number of times, and they have always selected the same eye. As to the theories of right and left handedness I will not speak. Every man regulates his following eye by the fixing one,. if it is possible. If he has an error of refraction, which he can correct in the following eye, he corrects it through the standard of his fixing eve. If that fact is borne in mind many faults in glasses will be easily discovered; you must remember that the man is looking with one eye and trying to accommodate the other eye to it. Another thing: if any of you ever order prisms to correct a difficulty, in glasses that are habitually used, if you put the greater part of your correction before the following eye and the minor portion before the fixing eye you will find them much more readily used and longer worn with comfort than if you split it and put half before each eye; or in some cases if you put all your prism correction before the following eye you will do better still. I have not taken the matter up as a fad, but have followed it ten years habitually in every single case and have kept records of all my private cases. It is not a subject to be laughed out of
court.

DR. ALLEMAN. - I have been in the habit of testing for the dominant eye for some time, and of being guided in operating by my findings in that respect. I have an example in a patient upon whom I operated some time ago for cataract. I operated on one eye, and he had normal vision with his correction, but when looking at anything quickly he looked with the bad eye, which had been the dominant one, and could not see. If he had time to select the corrected eye he could see all right, but was subject to all sorts of annoyance by using quickly the dominant eye. DR. VERHOEFF. -.I think the first one to bring out this conception of the dominant eye, or, as he called it, the directing eye, was Javal, who used it in his theory of stereoscopic vision. I think

3I8

Discussion.

it can be easily shown that in true bionocular vision, that is, in stereoscopic vision, where both eyes are being used, that one eye has not a predominance over the other. The question of a directing eye comes up only under certain conditions, where one eye is selected and the image in the other suppressed, that is, where we revert to monocular vision. Here, in my experience, where there is any great difference between the eyes, it has always been the poorer eye which gives way, as would be expected. Where the difference between the eyes is comparatively slight, the person is right-eyed or left-eyed accordingly as he is righthanded or left-handed, as would also be expected. I think the problem is a little different from what it is generally regarded. It is usually thought that the directing eye does about all the work, and that the other does almost nothing. It is easy to show that this is not the case, but that each eye does its full share. It is only when both eyes can not be used that one is selected, as in using the microscope. DR. GOULD.- A word in reference to the thought that has been expressed as regards the first publication or notice of the idea of a dominant eye. I myself have never seen any, and I have looked through the literature pretty thoroughly. I shall be glad if any member will point otut to me any reference to the matter. One gentleman has vaguely referred to such publication, but I wish he could give it more definitely, as I should have given credit to the proper authority had I been able to find it. It was certainly original with me, but I shall be glad to know if any one has preceded me. In reference to the proof of which eye is the dominant one, there is a very simple test. I left out all the detail which has been discussed because it is to appear in the Popular Science Monthly for August. Ask a patient, touching anything, to go up and sight across a table or anything of that kind and see with which eye he sights. Or, ask a patient to take up a stick and sight with it: if he closes the left eye he is right-eyed, if he takes -it up in this manner I know he is left-eyed. As to violin-playing, I think the gentlemen are mistaken. They fail to recognize that the instrument could have been strung the other way had it not been for the fact- that it was recognized that this would not allow the learner to watch the fingers manipulate the strings, because there would be poor vision because of foreshortening. The piano of course is a right-handed instrument,
_

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319

because the right hand plays the more difficult part, while with the violin it is the left hand that does the more expert work. I wish to enter a protest against the misreporting of what a man says. I never said, nor implied, that the non-dominant eye should be let alone, or not surgically treated. I never even implied it. One of the miost striking examples is a patient of mine in Camden, who is left-handed for everything, but who shoots the gun from his right shoulder, but he gets highly curved gunstocks, and sights with the left eye, depressing the right below the level of the barrel. Another patient of mine in Philadelphia does the same thing. The instance Dr. Williams has given us is also a demonstration of this kind. I did not know Le Conte had ever spoken of this theory, or of anything like it. You will find that there is a great deal 6f truth, most practical truth, in this idea. I beg you not to think that it is merely a theoretical fad.

THE MUSCLE OF HORNER AND ITS RELATION TO THE RETRACTION OF THE CARUNCLE AFTER TENOTOMY OF THE INTERNAL RECTUS.
BY LUCIEN HOWE, M.D.,
BUFFALO, N. Y.

It is usuallv supposed that this muscle was described first by .an eminent Swiss ophthalmologist of that name. But such is not the case. It was discovered by Prof. W. E. Horner, adjunct professor in the University of Pennsylvania, and described by him in a quaint chapter in the Philadelphia Journal of the Medi.cal and Physical Sciences, I824, page 70. In order to demonstrate its position, he made an elliptical incision following the fibers of the orbicularis muscle around the upper and lower lids near the margin of the orbit except toward the inner canthus, and then deepening this incision until it passed entirely through lids, cartilage, and conjunctiva, he reflected the lid over the nose. In this way, when the dissection is completed, it is possible to see the faint outline of a muscle,which, commencing