ON THE 
PROMINENCE OF THE EYEBALL, 
WITH 
SINKING OF THE CARUNCLE AND SEMILUNAR 
FOLD FOLLOWING THE ORDINARY 
OPERATION FOR STRABISMUS. 
WITH AN 
ACCOUNT OF A PAIR OF SCISSORS FOR PERFORMING THE 
S CB-CON.JUNCTIYAL OPERATION. 
BY 
ADDINELL HEWSON, M.D., 
OXK OF THE SURGEON'S OF WILLS HOSPITAL, PHILADELPHIA. 
PHI LADELPHIA: 
J. B. LIPPINOOTT AND CO., 
22 & 24 NORTH FOURTH STREET. 
1858. ON THE 
PROMINENCE OF THE EYEBALL, 
WITH 
SINKING OF THE CARUNCLE AND SEMILUNAR 
FOLD FOLLOWING THE ORDINARY 
OPERATION FOR STRABISMUS. 
WITH AN 
ACCOUNT OF A PAIR OF SCISSORS FOR PERFORMING THE 
SUB-CONJUNCTIVAL OPERATION. 
BY 
ADDINELL IIEWSON, M.D., 
ONE OF THE SURGEONS WILLS HOSPITAL, PHILADELPHIA. 
PHILADELPHIA: 
J. B. LIPPINCOTT AND CO., 
22 & 24 NORTH FOURTH STREET. 
1858. [Republished from the North American Medico-Cliirurgical Review for March, 1858.] 
ON THE 
PROMINENCE OF THE EYEBALL. 
Eighteen years have now elapsed since the operation of tenotomy was 
first successfully performed by Dieffenbach, of Berlin, for the cure of stra- 
bismus ; and the thousands of cases which were subjected to this mode Or 
cure, immediately on the announcement of his success, by surgeons of un- 
doubted skill, as well as by the hosts of squint-cutters who sprung up like 
mushrooms everywhere, should have early determined, it might naturally 
be supposed, beyond all doubt, the real value of the operation. Yet this, 
it would seem, is really far from being the case; for although no one can 
deny tjiat squint in any direction can be rectified by division of the muscles 
which give rise to the distortion, and that the operation is recommended 
by most surgeons, there are many of much experience and sound judgment, 
at the present day, who declare that, in a large majority of the cases sub- 
jected to it, the operation, especially when performed on only one eye, is 
far from being satisfactory in its results, as it is followed by a peculiar 
vacant staring expression by no means agreeable to a beholder. This effect 
has alone deterred many afflicted with obliquity from submitting to the 
operation, and influenced many surgeons in declining to resort to it. 
This objection was raised against the operation early in its history, for 
Chevalier d’Ammon mentions it in a letter to Dieffenbach* as a constant 
result, even in the most satisfactory cases. And Calder, whose brochure 
on the operation was written in 1841, says he considers “this peculiar 
staring appearance, or seeming largeness of the eye after the operation, as 
one of its greatest drawbacks.”! Then DuffmJ has well remarked, that “the 
original obliquity of vision, it is true, may be removed” (by the operation;) 
“but if in its stead there be substituted a staring, vacant, projecting eye of 
apparently disproportionate size or a disagreeable leer, or if a mere altera- 
tion only in the nature of the obliquity be effected, it is very questionable 
how far the expression of the eye is bettered by the change.” 
A reviewer of Mackenzie’s essay on the operation, writing in the Medical 
Gazette, in 1841,§ states, “that in a walk along the streets one may now 
* Arch. General, for 1841, p. 260. f Calder on Strabismus, London, 1841. 
J London Medical Gazette for 1839-40, p. 941. \ Vol. ii. p. 948. 4 
Hewson on Strabismus. 
recognize almost as many who hare been cut as there were two years ago 
obviously squinting.” 
This effect of the operation has also been admitted by Lawrence, Mac- 
kenzie, Walton, Nelaton, and most who have written anything of late on 
the subject. Mackenzie, especially, admits that “ the eye which has had its 
adductor divided, presents a greater gap between the cornea and caruncle 
than natural: the caruncle is more sunk, the lids more open, the eye more 
prominent and convex at the nasal angle.” “If both eyes,” he further 
remarks, “ have been operated on, both are rendered more prominent than 
natural; but being equally so, the circumstance attracts less notice. Where 
only one eye projects, and the projection is great, the physiognomy is very 
remarkably and disagreeably affected.”* Then Mr. Critchett, who has 
written very recently on the subject,f is still more positive in the expression 
of his opinion, and all who are at all familiar with his valuable contributions 
to ophthalmic surgery, will receive his statements with the greatest confidence 
as to their accuracy. He says, “ the first point that strikes every close 
observer, even in the most favorable specimens of the operation, where the 
eye has assumed a perfectly normal position and moves freely, is a certain 
sinking in and loss of the caruncle, so that the inner part of the globe 
seems more exposed than that of the opposite eye, and a fossa exists in the 
place of the caruncle ; this, so far,” he says, “ as my experience goes, is an 
invariable result of the operation, and explains the circumstance that has 
often been remarked, that those cases are the most successful in which it 
has been necessary to operate on both eyes,” etc. And for my own part, I 
must candidly confess, although a warm advocate of the operation, that I 
have yet to see a case which had been subjected to it—and I have sought 
diligently for such—in which I could not recognize the fact, often at a 
glance, and always by close inspection. Finally, such has been the effects 
of this operation, that a person of no less practical skill and judgment than 
Mr. Bransby B. Cooper, has “ questioned the propriety of operating alto- 
gether. ”| 
It will thus be seen that it is very generally admitted that a disagreeable 
expression of the eye is a frequent, if not constant sequent of the operation 
as originally proposed for the cure of strabismus. This peculiar expression 
is due, as has already been intimated, to increased prominence of the eye- 
ball, and depression or retraction of the semilunar fold and caruncle,—the 
latter, as Dr. Dix,§ of Boston, long ago observed, giving to the eye “ the 
appearance of a globe lying in the orbit, but detached from it.” 
* Mackenzie on the Eye, American edition, 1855, p. 381. 
t Practical Remarks on Strabismus, published in the London Lancet for 1855, vol. i. p. 479. 
$ Proceedings of the Royal Medical and Cliirurgical Society of London, reported in the Lancet for 1846, 
vol. i. p. 159. 
J American edition of Cooper’s Dictionary: Article “ Strabismus.” Hewson on Strabismus. 
5 
The fact once admitted that such effects follow the operation, it becomes 
a matter of great importance to determine their cause—or causes, if more 
than one,—and to determine whether they must necessarily follow the divi- 
sion of the rectus or not, and how they can be avoided. 
The opinion early set forth by Herbert Mayo, in regard to the increased 
prominence, is the one advocated by Mr. Critchett and most other writers. 
It is, that it is due to the loss of the balance of power between the recti and 
obliqui muscles—the latter acting, as Mr. Critchett says,* with undue 
power when one of the recti is divided. If such is the case, the defect is 
an unavoidable consequence of the operation, and must invariably follow 
the division of one of the straight muscles, no matter how this division may 
be accomplished. Is, however, this opinion a mere hypothesis, or is it 
based on facts ? It is said to be based on the facts, that the recti, when 
acting together, have the power to retract, and the two obliqui, by a similar 
unity of action, to protrude the eyeball. But are these facts ? In the first 
place, does the eye, in its normal state, undergo either retraction or protru- 
sion ? It certainly does, to a very limited extent. This is shown every 
time the eyelids are opened or shut—as was pointed out by Sir C. Bell.f 
Then protrusion, or increased prominence of the ball, is apparent in the 
staring of amazement. And the retraction has been observed, it is said, 
during operations on the eye,—as that for cataract. Admitting, then, that 
such movements can take place in the ball, is it by the action of the straight 
and oblique muscles that they are produced ? 
The recti arise, in general terms, from the ligament of Zinn, at the apex 
of the orbit; and passing forward on either side, are said to embrace a 
large segment of the eyeball, on which they have their insertion, near 
the margin of the cornea. If there is nothing to interfere with their 
action, these muscles must, under such circumstances, have a tendency, 
whenever they contract, of compressing the eyeball, as well as causing it to 
retract in the orbit. One of these effects must as necessarily follow as the 
other, and the contents of the ball must, of a consequence, be disturbed 
in their relations by every movement given to the eye by these muscles. 
But it is well-known to every one that such effects do not attend the 
action of the recti muscles. They are prevented from exerting such in- 
fluences on the eyeball by the deep ocular fascia, first demonstrated fifty 
years ago by Tenon, and more recently described by Farrell, Helie, 
Richet, and others. This fascia, to which Mr. Farrell has given the name 
of the tunica vaginalis oculi,\ is a fibrous tunic, of a yellowish white 
color, connected in front with the margin of the orbit, and extending 
inward and backward to the entrance of the optic nerve into the sclerotic, 
where it becomes continuous with the dense envelope of that nerve. It 
* Op. Cit. f Nervous System of the Human Body, by Sir C. Bell: Edinburgh, 1836, p. 153. 
J Dublin Journal, vol. xix. Old Series for 1841, p. 337. 6 
Hewson on Strabismus. 
forms a covering to the adipose tissue in the bottom of the orbital cavity, 
and serves as a socket for the eye to roll in. It has six openings, through 
which the tendons of the muscles escape to reach the sclerotic coat. “ These 
tendons are loosely connected to the edges of these apertures by fine cellular 
tissue,*” which forms an envelope for them, but** in no way interferes with 
their motions through these openings. Farrell’s mode of demonstrating 
this fascia does not give a correct idea of its relations to the ball, and 
especially of the position of these openings for the recti muscles. By split- 
ting the lids in a vertical direction, stretching each of the flaps thus formed 
forcibly away from the eye, and fixing them firmly in these positions, the 
tissues beneath the conjunctiva are all very much distorted in their relations. 
By this stretching, the sub-conjunctival layer of the ocular fascia is found 
drawn away from the ball, when the conjunctiva is dissected off, and 
appears blended with the deeper layer, and the two seem like one dense 
membrane extending from the cartilages of the lids to the optic nerve 
behind the ball; and the openings, or places of exit of the recti muscles, 
seem at some distance from the ball. A horizontal or vertical section of an 
eye frozen in the orbit, with all its appendages in their natural position, 
gives a very different view of the relations of these structures. 
Fig. l.f 
Figure 1, drawn by Mr. Daniels with great care and accuracy, from a 
* Farrell. 
f Figure 1 represents a transverse section of the right eye, with all the reflections of the occular fascia, 
and its relations to the eyeball, muscles, and lids, faithfully delineated from a dissection made by the 
author, and still in his possession. The distance between the anterior or sub-conjunctival, and the poste- 
rior or deep ocular fascia, is somewhat greater in the drawing than is natural, in consequence of the 
traction made on these two layers to show the character of the dense cellular tissue which fills up the 
space between them. Hewson on Strabismus. 
7 
horizontal section prepared in this way, shows the true relations of these 
orifices for the tendons of the recti. These orifices, if they may be so called, 
are here seen at the points where the ocular fascia divides into two leaflets, 
(tracing it from behind forward,) the one to pass outward—speaking of 
the eyeball as a centre—to the edge of the orbit, the other forward, over 
the anterior segment of the ball. Of the further reflections and attach- 
ments of this fascia we shall have to speak hereafter. 
Each one of the recti, just before passing through the orifices in the 
fascia, divides, as Tenon pointed out, into two tendinous bands. The 
smaller of these two bands is directed toward the edge of the orbit, and 
passing behind the tunica vaginalis, or deep ocular fascia, becomes at- 
tached to the tissue covering the orbit, by a small flat tendon. The other 
passes through the tunica, and being directed inward, is inserted into the 
sclerotica. The smaller portion Tenon calls the orbital tendon, the other 
the ocular. Of all the orbital portions, that “ of the internal rectus is 
relatively the largest.”* 
The influence of these orbital tendons can be readily perceived. Placed 
as they are behind the deep fascia, they are admirably arranged to prevent 
the recti from compressing the ball and causing it to recede in the orbit. 
These tendons, aided perhaps by the fascia, have the effect of making the 
action of the recti on the ball similar to what it would be if these muscles 
had their origin from the sides of the orbit, while they possess a rapidity 
and facility of motion greater than could in that case belong to them. 
These anatomical details certainly do not seem to me to favor the posses- 
sion of a power by the recti of retracting the eyeball. 
But vivisections have been resorted to for the purpose of determining 
this action of the recti, and Mr. B. B. Cooper’s experiment is cited to prove 
the possession of this retracting power by these muscles. He succeeded in 
producing permanent retraction of the globe within the orbit in a rabbit, 
by dividing the two oblique muscles. But is it not verily begging the 
question, to say that the recti produce this retraction ? The experiment 
proves nothing whatever in regard to the action of the recti muscles. 
Then, palsy of these muscles, constituting a form of what is called Luscitas, 
uncomplicated by any other lesion, also proves that they have nothing to do 
with the protrusion or retraction of the eye, for in this disease (which is 
sometimes confounded with strabismus) we have no increased prominence 
as we should have if the recti, in their normal state, prevented protrusion 
of the ball. 
But does not the deep-seated position of many squinting eyes furnish 
pathological evidence of the retracting power of the recti ? By no 
means; for true squint, it is now well known, is due to a want of co-ordi- 
* IUchet, Traite Pratique d’Anat. Med. Chirurg., p. 307. 8 
Hewson on Strabismus. 
nating power, or consentaneous action of the two eyes, rather than to a 
rigidity or shortening of a rectus of one of them. In ail cases of the dis- 
ease, by closing the straight eye and then desiring the patient to look 
directly at you with the affected one, he will do so without any difficulty; 
the eye will move with the utmost promptness in obedience to his will, in 
every direction. This the patient certainly ought not to be able to do, if 
the deformity were owing to rigidity or shortening of one of the straight 
muscles, or paralysis of its antagonist. 
Having adduced, as I believe, sufficient evidence that the recti have not 
the power to effect retraction of the eyeball or prevent its protrusion, we 
have next to inquire whether the united action of the oblique, when un- 
opposed, can cause its protusion. The anatomical relations of these muscles 
do undoubtedly favor the idea that they can give rise to such an effect. 
The superior oblique, or obliquus major, is placed at the upper and inner 
part of the orbit, and arises about a line from the optic foramen, at the upper 
and inner part. From thence this long slender muscle proceeds toward the 
internal angular process, and terminates in a round tendon, which passes 
through a fibro-cartilaginous ring or pulley, (trochlea,) formed in the edge 
of the deep ocular fascia, and “ attached to a depression on the frontal bone 
at the inner margin of the orbit.” Thus the tendon escapes at this point 
from behind the ocular fascia. It is then “ reflected outward and back- 
ward, and passing between the globe and the superior rectus is inserted 
into the sclerotica, midway between the superior and external recti muscles, 
nearly equidistant from the cornea and the entrance of the optic,”* and 
consequently behind the vertical axis of the eye. 
The inferior oblique arises from a minute depression on the orbital process 
of the superior maxillary bone, just within the inferior margin of the orbit, 
and close by the external border of the lachrymal groove. ”f It is sur- 
rounded at its origin by the deep fascia, so that it may be said to be 
entirely in front of that structure. “ The muscle then inclines outward and 
backward between the inferior rectus and the floor of the orbit, and ends in 
a tendinous expansibn, which passes between the external rectus and the 
globe to be inserted into the sclerotica at its external and posterior aspect. 
As to the action of the muscle, the superior oblique may be regarded 
as arising from the trochlea, a point vertically opposite the origin of the 
inferior oblique. With such points of attachment, the combined action ot 
the two must be to draw the ball forward and inward; or if the inward 
tendency be opposed by the external rectus, they must thrust the ball for- 
ward only, or forward and a little outward; but in all instances the move- 
ment forward will be decided. Their united action must, therefore, be 
* Sharpey and Quain, p. 318, vol. i., American Edition. 
+ Ibid. Hewson on Strabismus. 
9 
capable of preventing retraction in an opposite direction. This capability 
was proved by Bransby B. Cooper’s experiment, before alluded to, for in that 
experiment it will be remembered retraction occurred on the division of 
these two muscles. 
If it is admitted, then, that the oblique muscles can, by their united ac- 
tion, protrude the ball in a manner more or less forward, and that the recti 
have no power by united action to move it in an opposite direction, what 
means, it may be asked, are there of opposing this tendency of the oblique, 
and causing the eyeball to recede as much as the deep-seated structures of 
the orbit will allow ? 
To this question I would answer, that in the eyelids are to be found the 
chief resistance to this tendency of the oblique muscles, and the power of 
forcing the eye backward. 
These structures, as is well known, consist, beneath the common tegu- 
mentary covering and connective tissue, of a sphincter muscle, attached 
most firmly at the inner angle,—two cartilages connected by dense fibrous 
tissue (part of the ocular fascia) to the orbit, and a reflection of the con- 
junctiva from the ball of the eye. The two lids differ, however, very much 
in size, and also in the extent and character of their motion. The upper is 
much the larger and deeper of the two. Its cartilage is semi-elliptical, 
and has a depth of six lines at the centre.* This lid descends, in the 
closing of the eye, below the lower border of the cornea,f and fairly em- 
braces a large portion of the anterior segment of the ball. The inferior lid 
has a long, narrow, and nearly straight cartilage of about a uniform width 
of two lines.! Its position is horizontal. rather than vertical, and it as- 
cends and descends but little in the closing and opening of the eye. The 
points of juncture of the two lids, constituting the inner and outer angles, 
are not on the same plane, either vertically or horizontally,—the inner 
being a little above and in front of the outer. They are both much behind 
the anterior surface of the eyeball. The whole structure of the lids is more 
firmly attached at the nose than toward the temple. 
The muscle of the lid consists of a broad stratum of elliptical fibres, de- 
riving their origin chiefly from the tendo oculi at the inner angle. “ The 
only points of fixed attachment (to bone) which its fibres possess, are at 
the inner margin of the orbit; they are free in the rest of their extent, 
except along the eyebrow, where they are blended with the occipito 
frontalis and corrugator supercilii.§ ' 
The fibres of the orbicularis, curving around the outer angle, have no 
direct connection with the edge of the orbit at this point; the cartilages, 
however, have, by a layer of dense fibrous tissue called the external angular 
ligaments. 
* Harrison. 
f Soemmering. 
I Harrison. 
% Sharpey and Quain, p. 335. 10 
Hewson on Strabismus. 
All these circumstances seem to me to favor the idea that the lids play 
an important part in retaining the eyeball in position against the action of 
the oblique. 
Any one, by closely watching the position of the outer commissure of the 
lids during the acts of shutting and opening the eye, may convince himself 
that this point (the outer commissure) glides inward, forward, and a little 
downward, and that the ball recedes somewhat as the eye is closed, and 
the reverse occurs as the eye is opened. 
Then the protrusion of the ball which attends palsy of the orbicularis, as 
occurred in cases reported by Sir C. Bell,* proves negatively, at least, that 
the lids prevent protrusion. And a case recorded by Mr. Holthousef proves 
the fact in the most positive and conclusive manner. The patient was one 
“ suffering from paralysis of the third pair of nerves. The symptoms were 
ptosis, external strabismus, dilated pupil, and a total inability to move the 
eyeball from the position in which it was drawn by the external rectus. 
“ Raising the upper lid gently with my thumb,” he says, “ I told the patient 
to close her eye, and in her efforts to do so the orbicularis visibly depressed 
the globe toward the bottom of the orbit, and at the same time moved the 
cornea somewhat inward, so that it was made to occupy a situation midway 
between the external and internal canthi of the eyelids.” 
And again, Mackenzie, in his work on “ Diseases of the Eye,” in alluding 
to a case of luscitas, states a fact singularly conclusive as to the views here 
advocated. He states that the luscitas had been preceded by exophthalmos 
and palsy of the side of the face, but that these symptoms had subsided. 
Here we have the protrusion subsiding with the disappearance of the 
paralysis of the orbicularis. 
These views of the effect of the recti and orbicularis on the protrusion of 
the ball are not new. They have been urged before, and, among others, 
by Mr. Holthouse; yet this gentleman, after declaring that the recti have 
no power to produce retraction, but that this motion of the ball is caused 
by the orbicularis, appears to have forgotten what he had said, for he subse- 
quently speaks of an antagonism between the obliqui and recti being de- 
stroyed, and retraction or protrusion occurring as the consequence of either 
set of muscles being weakened or strengthened; and remarks that “this 
has an important bearing on the operation for strabismus, for the division 
of one of the recti, by weakening the retractive force, relatively increases 
that of the opposing one; so that some degree of protrusion, under these 
circumstances, must always be looked for.”J How well might Mr. Lucas 
retort on him for this, in his own words; for in speaking, in a subsequent 
part of his book, of Mr. Lucas’s report of the results following the division 
of the oblique, he says:—“ The report of these operations by Mr. Lucas 
* Op. Cit., Appendix. f Holthouae’s Lectures on Strabismus, London, 1854, p. 8. J Ibid. p. 1L IIewson on Strabismus. 
11 
not only bears out the views advanced in this paper, but is remarkable as 
showing the little faith which anatomists place in their own accounts of 
the action of these muscles. Thus, Mr. Lucas having informed us that the 
action of the inferior oblique is to direct the eye upward and inward, and 
that of the superior oblique downward and slightly outward, does not hesi- 
tate to divide the last-named muscle in order to rectify a convergent squint.” 
But, to return to the subject, it will be exceedingly difficult for any one, 
adopting the opinion that the recti have no power to retract the eyeball or 
prevent its protrusion, to understand why the simple division of the rectus 
internus should cause increased prominence or protrusion of the ball. In- 
deed, if the arguments I have adduced in regard to what I am disposed to 
believe are the chief retaining and protruding powers of the eye, have any 
truth in them, the simple division of one of the recti must not, necessarily, 
be followed by such protrusion; and yet I have stated and proved, on the 
testimony of the most reliable witnesses, that such an effect always follows 
the operation performed in the ordinary way. Yes; but in the operation 
are not other parts divided besides the muscle ? and may not the division 
of these be the source of the deformity ? 
To determine this, let us first inquire what is the character of the wound 
made in the operations, which have been followed by this defect. 
Dieffenbach, in his earliest operations, after making the conjuctiva tense 
by means of two hooks at the inner canthus, “ proceeded to incise the con- 
junctiva in this part, (the internal canthus,) by the side of the globe, sepe- 
rated it still deeper from the latter, and then divided the internal rectus 
thus exposed, with a pair of fine scissors, near to its insertion.”* 
Of the effect of this mode of operating, I have already given the testi- 
mony of Ammon, furnished in his letter to the great Berlin surgeon. 
Then Mr. Lucasf (who was the first to publish on the subject in our 
language) uses a sharp hook to draw the eye out and fix it. This he in- 
serts into the tunica conjunctiva, about two lines, or, two and a half lines 
distant from the cornea, and on a line corresponding to its transverse axis. 
He then gently draws forward the conjunctiva, and makes a semicircular 
incision of this membrane by means of the sharp-pointed scissors, from below 
upward upon the outer side of the hook, to an extent varying from four to 
six lines; and, he says, it may sometimes be desirable to make the incision 
longer.! Through this opening he passes a blunt hook from below up- 
ward between the tendon of the muscle and the sclerotic, and having thus 
brought the tendon into view, he divides it with the scissors as close to its 
insertion as is compatible with the safety of the sclerotic. 
* Dieffenbach’s Letter to Dr. Lomas, Lond. Med. Gaz. for 1839-40, p. 109. 
f A Practical Treatise on the Cure of Strabismus or Squint, by Operation. By P. Bennett Lucas, Lon- 
don, 1840. I Ibid. p. 70 12 
Hewson on Strabismus. 
This mode of operating, adopted by Mr. Lucas, although different in its 
details from that resorted to by Dieffenbach, is essentially the same, it may 
be said, as regards the direction and character of the incision in the parts 
covering the muscle, although, it is true, he divides the conjunctiva and 
subjacent parts nearer to the cornea. Of the effects following this opera- 
tion we have the testimony, already quoted, of Mr. Duffin, who adopted 
the method.* 
Following close on. the publication of Dieffenbach’s and Lucas’s modes 
of operating, we find a host of different methods proposed by various indi- 
viduals. Indeed, it is quite curious, as well as amusing, to see the warfare 
which was carried on in the journals, in the early history of the operation, 
as to who was the first to resort to one mode of operating or another; as 
to the relative value of hooks and elevators, scissors and knives, in the 
operation; as to who was the first to propose the use of the one or the 
other; as to who did the operation first in this place or that, etc. Still, 
amid all these trifling discussions, many useful hints reached the light, and 
the details of the operation were varied in many ways. With perhaps the 
exception of the methods proposed by Guerin, Amussat, and Boyer, they 
are all alike as regards the character and direction of the incision made to 
expose the tendon of the muscle, and the remarks made in reference to 
Dieflfenbach’s and Lucas’s may be applied to them all. They all recom- 
mend a free division of the parts in a vertical direction, not only for the 
purpose, in all instances, of exposing the muscle, but often of freely dividing 
every band of tissue which it was supposed might be binding the eye down 
in its distorted position; and even of dividing the oblique—one or both— 
to rectify the deformity. 
It must also be admitted that even the methods most in vogue at the 
present day resemble each other in the vertical direction of the incision. 
It is true that most surgeons now avoid any very extensive dissection of 
the globe, or unnecessary disturbance of the ocular fascia, being satisfied 
with the division of the superjacent tissues, near the insertion of the tendon. 
Yet, even when all this has been done, it is admitted that “ protrusion of 
the globe, in some degree, occurs in nearly every instance. ”f 
Having detailed just so much of the operation as is sufficient to show 
the character and extent of the division of the superjacent tissues resorted 
to, I have now to show how such a division of these parts can give rise to 
increased prominence of the eyeball and sinking of the semilunar fold and 
caruncle. But, as I have taken the ground that the tendency to protrusion 
in the normal state of the eye is opposed by the orbicularis, I have really 
now to prove that the division of the superjacent tissues of the ball disturbs 
* Lond. Med. Gaz. for 1840-41, p. 61. 
t Walton, p. 269, Amer. Edit. IIewson on Strabismus. 
13 
the action or weakens the power of the orbicularis, and thus causes the 
protrusion of the eye; for I have denied that the division of the rectus has 
anything to do with this protrusion. 
This, I believe, can be done by a careful consideration of the close con- 
nection of the superjacent tissues of the rectus with the orbicularis, and 
especially the connection of the ocular fascia with the latter muscle. 
For this purpose I will consider the ocular fascia more in detail than I 
have yet done. I shall, of course, to do this, be compelled to go over much 
of the ground I have already been over, and although I may even trace it 
in the same direction as I have done, the repetition, I hope, will not prove 
irksome in connection with the new importance attached to its relations. 
Tracing this ocular fascia, as Tenon* has done, from the optic nerve for- 
ward, we find it forming a complete cup for the ball, and sending off on 
each side a kind of ligamentous wing, as Tenon calls it, to attach the globe 
to the orbit. “ These ligamentous wings are formed by the juxta-position 
(Vadossement) of the portions of this tunic, which pass, the one from the 
front and the other from the back of the globe. ”f The anterior leaflet of 
these “ wings” corresponds to what is usually spoken of as the sub-conjunctival 
fascia, the posterior to the deep-seated ocular fascia. (See Fig. 1, p. 269.) 
These two (the sub-conjunctival and the deep-seated ocular fascia) are, how- 
ever, but separate layers of a continuous structure; for the fascia, traced from 
the optic nerve, is found, when it reaches where the ocular tendon pierces it, to 
become much thicker, and divided into two leaflets,—the posterior, and 
much the stronger, passing off in front of the orbital tendons to the margin 
of the orbit, acquires a firm attachment to this border, and becomes 
continuous with the posterior margin of the tarsal cartilages for their 
whole length, and thus forms the ligaments (suspensary ligaments as they 
are called) of the lids. The other leaflet of the ocular fascia continues 
forward, and forms a covering to the anterior segment of the sclerotic as 
well as to the tendons of the straight muscles; and when this leaflet 
reaches to within about one-twelfth of an inch of the circumference of the 
cornea it is doubled on itself, and being reflected under the conjunctiva, it 
forms the sub-conjunctival fascia. (Fig. 2y) Some anatomists have de- 
scribed this layer of fascia as extending close up to the cornea, but I have 
never been able to detect it nearer than I have described, and I have the 
authority of Harrison and Jamain that it does not extend close to the 
cornea. Tracing this layer (the sub-conjunctival) from the ball to the in- 
ner angle, we find it passing somewhat obliquely backward, immediately 
under the conjuntiva, to meet the deeper layer. The two layers, although 
intimately connected by dense cellular tissue which fills up the space be- 
* Recherches sur Anat., Paris, 1806. 
f Op. Cit. p. 201. 14 
Hewson on Strabismus. 
tween them near the ball, become closely blended together in the neigh- 
borhood of the semilunar fold and caruncle, to which they have a firm 
attachment, as can be proved by traction on them. (See Fig 1, p. 269.) Then 
their united structures become blended with the layer of tissue covering the 
tensor tarsi, and with “ that strong and very tense aponeurosis derived from 
Fig. 2 * 
« 
the margins of the tendo oculi which extends over the lachrymal sac,”f 
and which is described by most anatomists as the posterior tendon of the 
orbicularis, from the firm support it affords the muscle through its true 
tendon. From this point we find the fascia connected with the tendon, and 
diffusing itself beneath the conjunctiva of both lids. This is all shown 
in Fig. 1, p. 269. 
* An anterior view of the sub-conjunctival portion of the ocular fascia, showing its relations to 
various structures of the eye. The conjunctiva has all been removed except a small portion around the 
edge of the cornea, which, however, has been carefully dissected up to that edge. The fascia is left in 
situ on the outer segment of the ball, showing how close it extends to the edge of the cornea, and its 
manner of reflection from the ball to the margins of the orbit to be diffused over the surface of the lids 
beneath the conjunctiva. On the upper, lower, and inner segments it has been partly detached from the 
globe. The portion from the inner segment has been put upon the stretch in a vertical direction, and the 
ball located so as to bring into view the tendon of the internal rectus at its insertion, and to show the 
portion of the deeper layer interposed between the tendon and the sclerotic, forming the posterior border 
of the opening in this deep layer for the transmission of the ocular tendon of the muscle. The 
connection of the sub-conjunctival layer with the caruncle can readily be seen in this picture. An in- 
cision like that in the ordinary operation has been made through both layers of the fascia, to expose the 
belly of the muscle, 
f Harrison. Hewson on Strabismus. 
15 
On the outside, as well as above and below, these two layers of fascia 
pass in the same way from the ball, to meet and become blended near the 
edge of the orbit, and thence connect with the lids. In the lids, at the 
temporal angle, they form the external angular ligaments of Winslow. 
It may be thus seen that this fascia is blended with more than one struc- 
ture at the angles of the orbit; but that it is especially connected with the 
semilunar fold and caruncle any one can satisfy himself by making a dis- 
section of the eye from behind, and removing all the adipose tissue and 
other intervening structures until nothing is left but the fascia, and then 
drawing it backward, he will readily perceive that he causes these parts to 
recede. Then, again, by dividing this fascia, with the conjunctiva, in a 
vertical direction, as in the ordinary operation for strabismus, I have found 
that I could by traction on both lids draw the outer end of the tendon some 
little forward, much more so than I was able to do before dividing these parts. 
I also found that my ability to draw this point forward was in direct ratio 
with the extent of the vertical division of the superjacent parts and the 
nearness of the incision to the caruncle. 
Finally, a careful examination of an eye which has been operated on for 
strabismus in the ordinary way, will show that this very change has taken 
place in the position of the tendon. This may be seen in Fig. 3, copied 
from a photograph taken recently of a patient operated on by me some four 
Fig. 3. 
years since. Only one eye, the right, was operated on, and the contrast 
in the position of the tendons of the two orbicularies is very remarkable. 
It might be supposed that this appearance of the position of this tendon of 
the eye operated on was due to the increased depth of the fossa at the inner 
angle ; that the change of the position of the tendon was more apparent 
than real. Viewing the two tendons, however, from a position in which the 
fossa cannot have any effect on the impression produced of the situation of 
the tendons, or when the eyes are both closed, it will be recognized that there 16 
Hewson on Strabismus. 
is a real difference; that the outer end of the tendon of the right eye does 
really jut forward a little. But, admitting this change in the position of the 
tendon, is it not, it may be urged, due to the protrusion of the eyeball, which, 
putting the orbicularis on the stretch, drags the end of the tendon forward ? 
Is the tendon, however, capable of being moved in this way by the orbicularis ? 
If it was it should come forward every time the muscle is forcibly con- 
tracted ; but that such does not occur any one can satisfy himself by placing 
his finger firmly on the tendon, and then forcibly closing the eye. He will 
then perceive that the tendon remains fixed in its original position, although 
the fibres of the muscle may be so puckered up as to overlap it. I have 
not been able to discover that this effect of the operation on the position 
of this tendon has ever been pointed out before ; but since my attention has 
been called to it, during the past year, I have noticed it as an invariable 
result; and whenever I have attracted the attention of others to it they 
have expressed surprise that they had not observed it before, it was so 
patent. 
This disturbance of the tendo oculi—the only fixed point of attachment 
of the sphincter muscle of the lids—must have an important influence on 
the action of that muscle; it must weaken its power to prevent protrusion 
of the ball, for the nearer this insertion of the muscle is brought to the 
plane of the anterior surface of the globe of the eye, the less must be its 
ability to press that globe back. The sinking of the caruncle may be in 
part only apparent from this position of the tendon. The internal angle 
of the lids coming forward might give the effect of this little body being 
more depressed than it really is. Still I am of opinion, from careful ob- 
servation, that its position is somewhat affected by the operation. It seems 
to me to be flattened or stretched out, and by pulling on the inner end of 
either the upper or lower lid of an eye which has been operated on for 
squint, I have noticed that I could move this body more sensibly than in the 
natural eye. Of the real change of the position of the semilunar fold there 
can be no doubt. Both the caruncle and fold, I am satisfied, are disturbed 
by the division of the conjunctiva and ocular fascia. It was supposed that 
the disturbance of these parts (the semilunar fold and caruncle) were due 
only to the nearness of the incision to them. The incision was, therefore, 
made close to the cornea, and although much more satisfactory results were 
obtained by this, still the evils of the operation were not entirely prevented, 
they were only lessened. It is a well-known fact that Mr. Haynes Wal- 
ton* has advocated operating in this way by a very small vertical incision 
directly over the insertion of the tendon of the rectus, and just extensive 
enough to reach and draw out the tendon with the blunt hook. This, how- 
• Op. Cit. p. 260. Hewson on Strabismus. 
17 
ever, he does not seem to have found sufficient, for more recently we learn of 
his closely stitching up the wound after the division of the muscle. Then 
Helie,* Amussat, and Lucien Boyerf resorted to a horizontal cut in the 
conjunctiva and fascia, along the border of the muscle, to prevent the 
effects of the operation on the eyeball, semilunar fold, and caruncle; and 
for the same purpose Jules Guerin proposed his sub-conjunctival method. J 
This sub-conjunctival division of the tendon of the rectus has been strongly 
advocated by Mr. Brooke in a paper read before the Royal Medical and 
Chirurgical Society of London,§ and recently by Mr. Norman in a com- 
munication to the North London Medical Society, at its meeting, Dec. 14, 
1856 ;|| and it has also met with warm support during some years from Mr. 
Critchett and his colleagues, at the Royal London Ophthalmic Hospital, 
Moorfields.^f 
From such testimony there can be but little, if any, hesitation in believ- 
ing that the evil effects of the ordinary procedure of Dieffenbach and 
others are greatly diminished by the sub-conjunctival division of the 
muscle. And from the same sources for my evidence, as well as from per- 
sonal observations, I am led to the conviction that the diminution of these 
effects is in an inverse ratio with the extent to which the fascia is disturbed. 
Thus, en resume, I have, at least, attempted to prove the following pro- 
positions in reference to the prominence of the eyeball—sinking of the 
semilunar fold and caruncle—following the ordinary operation for strabismus. 
1. That these effects are not due to a disturbance of the balance of 
power between the recti and obliqui muscles, for the simple reason that no 
such balance of power exists between those muscles. 
2. That the recti have no power to retract or prevent protrusion of the 
eyeball. 
3. That the obliqui can protrude the ball. 
4. That the action of the obliqui is opposed by the orbicularis. 
5. That the power of the orbicularis to oppose the obliqui is weakened 
by the extensive vertical division of the conjunctiva and ocular fascia, which, 
especially the latter, play an important part in sustaining it in its action. 
6. That in the ordinary operation these structures are so disturbed as to 
cause the evils spoken of. 
As corollaries to the foregoing propositions I would urge— 
o. That these evils are not an unavoidable consequence of the division 
of the rectus. 
* These sur l’Operation du Strabisme. Paris, 1841. 
f Iteciierches sur l’Operation du Strabisme, 1842-44, 1 vol. 8vo., avec 12 planches. 
| Memoir sur la Myotomie Oculaire, par la Methode sous Conjunctival; Gazette Medicale, 1842. 
J Proceedings reported in the Lancet for 1846, vol. i. p. 159. | Lancet for 1857, vol. i. p. 67. 
f London Lancet for 1855, vol. i. p. 479. 18 
Hewson on Strabismus. 
b. That they can be prevented by a sub-conjunctival division of the 
muscle. 
It must, of course, be for others to determine whether I have been suc- 
cessful in sustaining the truthfulness of these propositions or not; but their 
admission or denial will not necessarily affect the character of the state- 
ments contained in the corollaries, for these statements may be in accord- 
ance with the truth, though they are not legitimately deduced or founded 
upon true premises. They may be sustained by observation and experience, 
the great touchstones, after all, in our science; for no matter how specious 
our arguments may be, or how plausible our deductions, if they are not 
sustained by these they are worth nothing. I have some such testimony to 
bring forward in support of these statements; but before offering it I 
will describe the means by which I have divided the tendon of the rectus 
without disturbing the fascia, and my manner of performing the operation. 
For the sub-conjunctival operation I use a pair of scissors, which I de- 
vised some time since, and which were made by Mr. Kolbe, from a model I 
had furnished him. They are represented of full size in Fig. 5, and are 
Fig. 4. 
Fig. 5. 
peculiar in their appearance. They consist of a male and female blade, con- 
nected together by a compound sliding joint. These blades have a curve 
of a circle of three-fourths of an inch radius, and are sharpened on opposite 
sides for the distance of a little over half an inch from their points. The 
point of the male blade is blunt—that of the female quite sharp. The 
latter blade slides over the former on two flat-headed screws, which fit accu- 
rately in the grooves of this blade, and are capable of being tightened so 
as to prevent all irregularity of motion. The rings on the handles are 
arranged for convenience of using the instrument. When the handles 
are widely separated, as in Fig. 6, the point of the female blade is buried 
on the side of the male, and as they are closed this point of the female 
blade comes up in front of the cutting edge of the male, until there is a Hewson on Strabismus. 
19 
space of a line in width between the point and this edge, (see Fig. 4.) 
This point then ascends, preserving always the space of a line between its 
edge and the cutting edge of the male blade, until the two points are on a 
level. Then the female blade slides toward the male, and their edges 
cross, and the whole of the female blade is buried on the side of the 
Fig. 6. 
male. The whole of this complicated movement is effected by simply 
pressing the handles together as in closing an ordinary pair of scissors. 
When well made, the scissors will always close with the utmost regu- 
larity and facility; but from the nature of the motion between their two 
blades, they cannot be readily opened while held by one hand, nor is this 
at all necessary, for they are to be taken in the hand ready for use, with the 
handles widely separated, so that the male blade can be used like a blunt 
hook, and passed beneath the tendon. This is to be accomplished through 
a small horizontal slit, made close to the inner and lower segment of the 
circumference of the cornea, and on a line with the lowest point of that 
structure. A cut of a quarter of an inch in the conjunctiva, in this position, 
has enabled me to pass the point of the scissors directly between the 
sclerotica and its cup-like envelope of the ocular fascia, and reach the ten- 
don of the internal rectus without much disturbing the fascia. It will be 
remembered that this ocular envelope does not, according to Harrison and 
Jarnain, extend close up to the circumference of the cornea, before it is re- 
flected under the conjunctiva, to form the sub-conjunctival fascia; and my 
own experience leads me to the belief, as l>efore stated, that it does not ap- 
proach within a line, if it always reaches so near to the cornea. My 
purpose, therefore, in making the slit in the conjunctiva, as described above, 
is to get between the edge of the fascia and the cornea. It does not 
materially affect the results of the operation if this horizontal cut should 20 
Hewson on Strabismus. 
involve the edge of the fascia, as I have more than once made it do ; but 
it is desirable, I think, to avoid any unnecessary cutting in the operation. 
To make this incision I pinch up the conjunctiva, at the point indicated, 
with a toothed forceps, and divide it with a pair of sharp-pointed scissors. 
The opening made, I still retain my hold of the conjunctiva with the 
forceps, and introduce the male blade of the squint scissors through the 
slit, and insinuating this carefully between the sclerotica and the fascia, I 
pass its point back to a depth of nearly half an inch; then sweeping it up, 
and making it hug close to the ball, I slide the blade without difficulty 
beneath the muscle, and bring its point above the upper border. This done, 
and there is no difficulty in effecting it, I complete the operation by 
simply bringing the handles of the instrument together, taking care, as I 
do so, that the point of the female blade does not catch in the edge of the 
wound in the conjunctiva. Of this I find there is no danger, if the instru- 
ment is laid flat on the sclerotic. The two blades completely divide all the 
tendon embraced between them, and if I have taken care to carry the point 
of the male blade above the upper border of the tendon, and to draw the 
instrument toward me, so as to make the tendon tense before closing the 
handles, I find I can divide the whole of this insertion of the muscle by a 
single stroke of the scissors. 
These scissors, in the estimation of all who have seen me use them in 
private and hospital practice, are thought to render the sub-conjunctival 
method a very simple and certain procedure. Against the operation, as 
thus performed, there cannot be urged the objections made to Guerin’s, of 
its being either uncertain or hazardous.* The male blade can be passed 
as readily and as certainly as a blunt hook beneath the tendon, for it is 
nothing more nor less, as regards its point and curvature, than the blunt 
hook employed in the ordinary operation; and there is no danger, or even 
possibility, of this entering the eye. There is no risk of any very ex- 
tensive division of tissues being caused by the scissors. They divide, 
at one time, only what is embraced in the space of a line broad by half an 
inch long; and if they are properly used—that is, laid flat to the sclerotica— 
and care is taken to get the point of the female blade beneath the fascia, 
they will divide nothing but the tendon. Of this I have again and again 
satisfied myself by experiment on the dead subject. 
Then, again, with these scissors there is not the same difficulty or uncer- 
tainty in dividing the insertion of the muscle as there is in the plan pro- 
posed by Mr. Critchett, and which is already known to the readers of this 
journal, as the whole of his paper published in the Lancet, in 1855, was 
recently stolen by one of his countrymen, and published as an original 
article, in the North American Medico-Chirurgical Review for March, 1857. 
* Liston’s Lectures, American Edition, 1846, p. 107. Hewson on Strabismus. 
21 
Mr. Critchett’s mode of operating, it will be remembered, consists in 
passing a blunt hook beneath the tendon through a small horizontal cut 
in the conjunctiva and fascia, at the lower border of the muscle. “ The 
blades of the scissors must then be passed in through the opening, and, by 
a succession of small cuts, the tendon may be readily divided between the 
hook and the insertion into the sclerotic, and close to the latter.” He 
remarks, however, that “ some little difficulty in making a complete division 
is experienced, when the insertion of the tendon is rather broad, in reaching 
its upper edge ; and, when that is the case, I make a small counter-opening,” 
he says, “in the conjunctiva, corresponding to the upper border of the 
muscle, I introduce the hook from above, and, having passed it beneath 
the remaining slip of tendon, divide it with the scissors in the same direc- 
tion.”* The length of the blades, and their curve, in my scissors, are 
sufficient to avoid the necessity of resorting to any such expedient as that 
described above by Mr. Critchett, to completely divide the tendon when it 
has a broad insertion. And in this respect, at least, the operation with 
them possesses an advantage over that proposed by Mr. Critchett. 
Fig. 7. 
The success attending the use of these scissors has thus far been in strict 
confirmation of the views I have advanced as to the defects following the 
ordinary operation. It is now a year since they were devised, and I have 
in that time had the opportunities of employing them nine times ; and in 
none of the cases in which I have employed them have I been able to detect 
any sinking of the semilunar fold or caruncle, or any increased fullness of 
the eye—and for these defects I have made diligent search. I have care- 
fully noted the amount of separation of the lids, and the relations of the 
semilunar fold and caruncle, before and after the operations; so that, as 
far as they go, these cases furnish reliable testimony of the results. But 
* Lancet for 1855, vol. i. p. 507. 22 
Hewson on Strabismus. 
I have as yet had only a single case—such cases are rare—in which the 
division of one of the internal recti was found sufficient to relieve the squint. 
This was an outdoor patient of the Wills Hospital; and as no memoranda 
are taken at that institution of the addresses of such patients, I am not now 
able to obtain a photograph of her; and, in lieu of her picture, which would 
furnish such a very positive evidence of the success of the operation, I offer 
a picture of one of the other cases, (Fig. 7,) as from it, at least, some idea 
may be formed of the success I have met with. In this case, as well as in 
the others, the amount of separation of the eyelids, and the position of the 
semilunar fold and caruncle, were carefully noted before and after the 
operation, as the only positive means of determining, when both eyes are 
subjected to it, that no change has been produced in these respects by it 
In all these respects the eye is the same as it was before the operation. 
Those who are in the habit of following the advice of Lucas, Duffin, and 
others, to freely divide the fascia in the event of the division of the internal 
rectus not proving sufficient to immediately remove the deformity, may 
urge the necessity of dividing that structure as an argument against the 
method here recommended. But if the existence or persistence of squint 
is due in any degree to the contraction or binding down of the fascia, how 
could a patient straighten the eye and move it at will in all directions, as 
he can do on closing the apparently sound eye. The truth is that, in a 
very great majority of cases, the disease is one mutually affecting the 
internal recti of both eyes, although it appears to be confined to one only; 
and Mr. Elliott, of Carlisle, England,* long since laid it down as a rule to 
divide the second adductor in cases where “ parallelism is not perfectly re- 
stored by division of the first.” This rule has been endorsed by Mackenzie and 
others, who do not advocate or (as far as my knowledge goes) perform the 
sub-conjunctival operation; and I cannot better conclude this paper, which 
has already extended far beyond the limits it was originally intended to 
possess, than by quoting the remarks of the eminent physiologist, Dr. Car- 
penter, on this point. He says, “that he is well convinced, from repeated 
observations, that those surgeons are in the right who have maintained 
that, in a large majority of cases, strabismus is caused by an affection of 
both sets of muscles or nerves, and not of one only; and that it then re- 
quires, for its perfect cure, the division of the corresponding muscles on 
both sides. Cases will be frequently met with in which this is evident—the 
two eyes being employed to nearly the same extent, and the patient giving 
to both a slight inward direction, when desired to look straight forward. 
In general, however, one eye usually looks straight forward, while the other 
is greatly inverted ; and the sight of the inverted eye is frequently affected 
to a considerable degree by disuse; so that, when the patient voluntarily 
* Edinburgh Medical and Surgical Journal, vol. lv. for 1841, p. 370. Hewson on Strabismus. 
23 
rotates it into its proper axis, his vision with it is far from being distinct. 
Some surgeons,” he further remarks, “have maintained that the inverted 
eye is usually the only one at fault, and consider that the division of the 
tendon of its internal rectus is sufficient for the cure. They would even 
divide its other tendons, if the parallelism be not restored, rather than 
touch the other eye. The author is himself satisfied, however, that the 
restriction of the abnormal state of the single eye is the exception, and not 
the rule, in all but very slight cases of strabismus; and to this opinion he 
is led both by the consideration of the mode in which strabismus first takes 
place, and by the results of the operation which have come under his notice. 
If the eyes of an infant affected with cerebral disease be watched, there will 
frequently be observed in them very irregular movements—the axes of the 
two being sometimes extremely convergent, and then very divergent. This 
irregularity is rarely or never seen to be confined to one eye. Now, in a 
large proportion of cases of strabismus, the malady is a consequence of 
some cerebral affection during infancy or childhood, which we can scarcely 
suppose to have affected one eye only. Again, in other instances, we find 
the strabismus to have resulted from the constant direction of the eyes to 
very near objects, as in short-sighted persons; and here, too, the cause 
manifestly affects both. Now it is easy to understand why one of the 
patient’s eyes should appear to be in its natural position, while the other 
is greatly inverted. The cause of strabismus usually affects the two eyes 
somewhat unequally, so that one is much more inverted than the other. 
We will call the least inverted eye A, and the other B. In the ordinary 
acts of vision, the patient will make most use of the least inverted eye, A, 
because he can most readily look straight forward or outward with it; but, 
to bring it into the axis, or to rotate it outward, necessitates a still more 
decided inversion of B. This remains the position of things: the patient 
usually looking straight forward with A, which is the eye constantly em- 
ployed for the purposes of vision, and frequently almost burying under the 
inner canthus the other eye, B, the vision in which is of very little use to 
him. When, therefore, the tendon of the internal rectus of B is divided, 
the relative position of the two is not entirely rectified. Sometimes it ap- 
pears to be so for a time; but the strabismus then begins to return, and it 
can only be checked by division of the tendon of the other eye, A; after 
which the cure is generally complete and permanent.”* 
Note.—Since the greater part of this article was written, I have learned from 
my friend, Dr. Emil Fischer, that Professor Graefe, of Berlin, has expressed the 
same or similar views in regard to the action of the orbicularis and recti, in a 
recent article published by him in his Arch, of Ophthalmology, for October, 
* American edition of Carpenter’s Principles of Human Physiology. 24 
Of this fact I cannot certify of my own knowledge, as I possess no 
quaintance whatever of the German language. But, if such is the cat 
it will be no little gratification to me that the views I have attempted to 
develop should be advocated by so very eminent an authority as Professor 
Graefe. 
Hewson on Strabismus.