THE FACE.8. The approaches to the organs of the senses, their ever-varying expression, their numerous muscles, and their rich profusion of vessels and nerves, give the face great anatomical importance, which has a most valuable bearing, not only on the practice of surgery, but on the physiognomy of health, and in the diagnosis of disease.9.Foramina for branches of fifth nerve.—As a surgeon may be called upon to divide any one of the three chief branches of the fifth nerve upon the face, he looks with interest to the precise situations where they leave their bony foramina with their corresponding arteries. The supraorbital notch or foramen can be felt about the junction of the inner with the middle third of the supraorbital margin. From this point a perpendicular line drawn with a slight inclination outwards, so as to cross the interval between the two bicuspid teeth in both jaws, passes over the infraorbital and the mental foramina. The direction of these two lower foramina looks towards the angle of the nose.10.Pulley for superior oblique muscle.—By pressing the thumb beneath the internal angular process of the frontal bone, the cartilaginous pulley for the tendon of the superior oblique muscle can be distinctly felt. We should be careful not to interfere with this pulley in any operation about the orbit.11.Lower jaw.—The working of the condyle of the jaw vertically and from side to side can be distinctly felt in front of the ear. When the mouth is opened wide, the condyle advances out of the glenoid cavity on to the eminentia articularis, and returns into its socket when the mouth is shut. The muscle which causes this advance is the externalpterygoid; and it gives the jaw a greater freedom of grinding motion.The posterior margin of the ramus of the lower jaw corresponds with a line drawn from the condyle to the angle. In opening abscesses in the parotid region, the knife should not be introduced behind this line for fear of wounding the external carotid artery. Punctures to any depth may be safely made in front of it. They are often necessary where inflammation of the parotid gland ensues after eruptive fevers, and runs on to suppuration. The swelling, tension, and pain are most distressing. Owing to the fibrous framework of the gland, the matter is not circumscribed, but diffused. One puncture is not enough. Three or more may be requisite. The blade of the knife should be held horizontally, so as to be less likely to injure the branches of the facial nerve. We are not to be disappointed if no matter flows. The punctures give relief, and matter will probably exude the next day.12.Parotid duct.—A line drawn from the bottom of the lobe of the ear to midway between the nose and the mouth gives the course of the parotid duct. Opposite the second upper molar, the duct opens by a papilla into the mouth. The branch of the facial nerve which supplies the buccinator runs with the duct.13.Temporal and facial arteries.—The pulsation of the trunk of the temporal artery can be felt, between the root of the zygoma and the ear. This should be well known to and used by chloroformists. It is also a convenient pulse to feel in a sleeping patient. The facial artery can be distinctly felt as it passes over the body of the jaw at the anterior edge of the masseter; again near the corner of the mouth close to the mucous membrane: and, lastly, by the side of the ala nasi, up to the inner side of the tendo oculi. By holding the lips between the finger and thumb the coronary arteries are felt under the mucous membrane. The facial vein does not accompany the tortuous artery, but runs a straight course from the inner angle of the eye to the front border of the masseter, just behind the artery.14.Eyelids and eyes.—The opening between the eyelids varies in size in different persons; hence more of the eyeball is seen in some than in others, and the eye appears larger. Although human eyes do vary a little in size, yet the actual difference is by no means so great as is generally supposed. The size of the fissure has much to do with the apparent size of the eye. Contrast the narrow fissure of the Chinese and Mongolian races, and the apparent smallness of their eyes with those of Europeans. As a rule the external angle of the lid is higher than the internal. When not exaggerated, it gives the face an arch and pleasing expression.Evert the lids to see the Meibomian glands; observe their perpendicular arrangement, in the substance of the tarsal cartilages.The free borders of the lids are not bevelled, as described by J. L. Petit and most anatomists, ‘so as to form with the globe of the closed eye a triangular canal for the flow of the tears.’ On the contrary, it is easily seen that the lid margins, when closed, come into accurate contact. Their plane is not exactly horizontal, but slightly inclined upwards.Every time the eye is shut, the ball turns upwards and inwards, so that the cornea is completely covered by the upper lid. This may be well seen by raising the lid of a sleeping infant; also in cases of low fever when the lid is not completely closed. This up-turning of the eye obviously clears the cornea, and protects it from the light.A careful examination of the motion of the lower lid in the act of shutting the eye proves that it is a double motion. The lid is not only slightly raised, but drawn inwards about 1/12 of an inch. This second movement sweeps any particles of dust as well as moisture towards the inner canthus.15.Puncta lachrymalia.—The puncta lachrymalia are distinctly visible at the inner angles of the lids. The lower punctum is larger and a little more external than the upper, so that they are not exactly opposite. The direction, too, of the puncta deserves notice. Their open mouths look a little backwards, ready to imbibe the tears. When their properbearing is lost, as in facial paralysis or by a cicatrix near the lid, the tears overflow the cheek. The length of the lachrymal canals is from three to four lines. The lower is a little shorter and wider than the upper. As each makes a little angle in its course, about a line from its orifice, the lid should be drawn outwards to straighten the canal when we introduce a probe.16.Lachrymal sac.—To find the lachrymal sac, draw outwards the eyelids to tighten the tendo oculi, which crosses the sac a little above its middle. A knife introduced just below the tendon close to the edge of the orbit would enter the sac. The angular artery and vein would be on the inner side of the incision. A probe directed in a line with the inner edge of the orbit,i.e.downwards, outwards, and backwards, would pass down the nasal duct, and appear in the inferior meatus of the nose.The tendo oculi serves many purposes besides giving attachment to the cartilages and muscles of the lids. One purpose is said to be to pump the tears into the lachrymal sac. Place a finger on the tendon, and feel that it tightens every time the lids are closed. The tendon, being intimately connected to the sac, draws, as it tightens, the sac wall outwards and forwards, and in this way it may pump along the lachrymal canals any fluid collected at the angle of the eye.17.Nasal duct.—The nasal duct is from six to eight lines long, and narrowest in the middle of its course. Its termination in the inferior meatus lies under the inferior spongy bone, about a quarter of an inch behind the bony edge of the nostril. The appearance of the orifice in the dry bone conveys no idea of its size and shape in life; for it is diminished by a valve-like fold of mucous membrane, so that it becomes, in most cases, a mere slit, not exceeding a line in diameter.The facility with which instruments can be introduced into the nasal opening of the duct depends upon its position as well as its size. This position varies in different instances. Sometimes it opens directly into the roof of the inferior meatus, in which case the hole is large and round, so that tears readilyrun into the nose. In other instances the opening is situated on the outer wall of the meatus, and is then always such a narrow fissure as to be hardly discernible. The practical conclusion then is, that a probe can be easily introduced when the opening is in the roof of the meatus, but not without difficulty and laceration of the mucous membrane when on the outer wall. This difficulty indeed may be increased by the narrowness of the meatus, arising from an unusual curvature of the spongy bone.18.Nose and nasal cavities.—The line where the cartilages of the nose are attached to the nasal and superior maxillary bones can be traced with precision. The close connection of the skin to the cartilages admits of no stretching; hence the acute pain felt in erysipelas and boils on the nose. The external aperture of the nose is always placed a little lower than the floor of the nostril, so that the nose must be pulled up before we can inspect its cavities.Looking into the nostrils, we find that the left is, in the majority of cases, narrower than the right, owing to an inclination of the septum towards the left. A communication sometimes exists between them, through a hole in the septum, as in the case of the celebrated anatomist Hildebrandt. By stretching open the anterior nares we can get a view of the end of the inferior spongy bone. The middle spongy bone cannot be seen: its attachment to the ethmoid is high up, nearly opposite the tendo oculi. The cavities are so much narrowed transversely by the spongy bones, that in the extraction of polypi it is better to dilate the blades of the forceps perpendicularly, and near the septum.19.Mouth.—What can be seen and felt through the mouth? The upper surface of the tongue, ‘speculum primarum viarum,’ is a study in itself. We notice, on its under surface, a median furrow, on each side of which stands out the ranine vein, lying upon the prominent fibres of the lingualis. In the middle line of the floor of the mouth is the ‘frenum linguæ,’ with the orifice of the duct of the submaxillary gland on each side of it. The gland itself can be detected immediately beneath the mucous membraneby feeling further back near the angle of the jaw, at the same time pressing the gland upwards from below.The long ridge of mucous membrane on each side of the floor contains the sublingual glands.We can feel the attachment of the ‘genio-hyo-glossi’ behind the symphysis of the jaw. The division of this attachment would enable a surgeon to draw the tongue more freely out of the mouth in any attempt to remove carcinoma extending far back into its root.There is great difference in the shape of the hard palate; this difference depends upon the depth of the alveolar processes. In some it forms a broad arch; in others it is narrow, and rises almost to a point like a Gothic arch, and materially impairs the tone of the voice.Throat.—To examine the throat well, the nose should be held so as to compel breathing through the mouth. Thus the soft palate will be raised, the palatine arches widened, and the tonsils and the back of the pharynx fairly exposed. Pressing the tongue downwards, provided it be done very gently, is also of advantage. Rude treatment the tongue at once resists. The forefinger can be passed into the throat, beyond the epiglottis, as low as the bottom of the cricoid cartilage, and thus search the pharynx down to the top of the œsophagus, and the hyoid space (on each side) where foreign bodies are so apt to lodge. The greater cornu of the hyoid bone can be felt as a distinct projection on either side. In introducing a tube into the œsophagus the finger should keep the instrument well against the back of the pharynx so as to prevent its slipping into the larynx.Pass the finger between the teeth and the cheek and feel the anterior border of the coronoid process of the jaw. On the inner side of this process, between it and the tuberosity of the upper jaw, is a recess, where a deeply-seated temporal abscess might burst, or might be opened. Behind the last molar on the inner side of the upper jaw we can distinctly feel the hamular process of the sphenoid bone; also the lower part of the pterygoid fossa, and the internal pterygoid plate. Behind, and on the outer side of the last molar, can be feltpart of the back of the antrum and of the lower part of the external pterygoid plate.On the roof of the mouth we can feel the pulsation of the posterior palatine artery. Hæmorrhage from this vessel can be arrested by plugging the orifice of the canal, which lies (not far from the surface) on the inner side of the last molar, about 1/3 of an inch in front of the hamular process.When the mouth is wide open, the pterygo-maxillary ligament forms a prominent fold readily seen and felt beneath the mucous membrane, behind the last molar teeth. A little below the attachment of this ligament to the lower jaw we can easily feel the gustatory nerve, as it runs close to the bone below the last molar tooth. The exact position of the nerve can be ascertained in one’s own person by the acute pain on pressure. A division of the nerve, easily effected by a small incision, gives much temporary relief in cases of advanced carcinoma of the tongue.To feed a patient in spasmodic closure of the jaw, it is well to know that there is behind the last molar teeth a space sufficient for the passage of a small tube into the mouth.Antrum.—Lift up the upper lip and examine the front wall of the antrum. The proper place in which to tap it is above the second bicuspid tooth, about one inch above the margin of the gum.20.Posterior nares.—A surgeon’s finger should be familiar with the feel of the posterior nares, and of all that is within reach behind the soft palate. This is important in relation to the attachment of polypi, to plugging the nostrils, and to the proper size of the plug. In the examination of this part of the back of the throat it is necessary to throw the head well back, because, in this position, nearly all the pharynx in front of the basilar process comes down below the level of the hard palate, and can be seen as well as felt. But when the skull is horizontal,i.e.at a right angle with the spine, the hard palate is on a level with the margin of the foramen magnum, and the parts covering the basilar process are concealed from view.The head then being well back, introduce the forefingerbehind the soft palate, and turn it up towards the base of the skull. You feel the strong grip of the superior constrictor. Hooking the finger well forwards, you can feel the contour of the posterior nares. Their size depends upon the anterior, but rarely exceeds a small inch in the vertical diameter, and a small half-inch in the transverse. The plug for the posterior nares should not be larger than this. Their plane is not perpendicular, but slopes a little forwards. You can feel the septum formed by the vomer, and also the posterior end of the inferior spongy bone in each nostril.21.Tonsils.—Before taking leave of the throat, look well at the position of the tonsils between the anterior and posterior half arches of the palate. In a healthy state they should not project beyond the level of these arches. In all operations upon the tonsils, we should remember the close proximity of the internal carotid artery to their outer side. Nothing intervenes but the pharyngeal aponeurosis, and the superior constrictor of the pharynx. Hence the rule in operating on the tonsils, always to keep the point of the knife inwards.In troublesome hæmorrhage from the tonsils, after an incision or removal, it is well to know that they are accessible to pressure if necessary by means of a padded stick, or even a finger.22.Features.—A word or two on the lines of the face as indicative of expression. Everyone pays unconscious homage to the study of physiognomy when, scanning the features of a stranger, he draws conclusions concerning his intelligence, disposition, and character. Without discussing how much physiognomy is really worth, there can be no doubt that it is a mistake to place it in the same category as phrenology, since the latter lacks that sound basis of physiology which no one can deny to the former.A person fond of observing cannot fail to have arrived at the conclusion that a man’s daily calling moulds his features. Place a soldier, a sailor, a compositor, and a clergyman side by side, and who will not immediately detect a marked difference in their physiognomies?The muscles of the features are generally described as arising from the bony fabric of the face, and as inserted into the nose, the corners of the mouth, and the lips. But this description gives a very inadequate idea of their true insertion. They drop fibres into the skin all along their course, so that there is hardly a point of the face which has not its little fibre to move it. The habitual recurrence of good or evil thoughts, the indulgence in particular modes of life, call into play corresponding sets of muscles which, by producing folds and wrinkles, give a permanent cast to the features, and speak a language which all can understand, and which rarely misleads. Schiller puts this well when he says that ‘it is an admirable proof of infinite wisdom that what is noble and benevolent beautifies the human countenance; what is base and hateful imprints upon it a revolting expression.’
8. The approaches to the organs of the senses, their ever-varying expression, their numerous muscles, and their rich profusion of vessels and nerves, give the face great anatomical importance, which has a most valuable bearing, not only on the practice of surgery, but on the physiognomy of health, and in the diagnosis of disease.
9.Foramina for branches of fifth nerve.—As a surgeon may be called upon to divide any one of the three chief branches of the fifth nerve upon the face, he looks with interest to the precise situations where they leave their bony foramina with their corresponding arteries. The supraorbital notch or foramen can be felt about the junction of the inner with the middle third of the supraorbital margin. From this point a perpendicular line drawn with a slight inclination outwards, so as to cross the interval between the two bicuspid teeth in both jaws, passes over the infraorbital and the mental foramina. The direction of these two lower foramina looks towards the angle of the nose.
10.Pulley for superior oblique muscle.—By pressing the thumb beneath the internal angular process of the frontal bone, the cartilaginous pulley for the tendon of the superior oblique muscle can be distinctly felt. We should be careful not to interfere with this pulley in any operation about the orbit.
11.Lower jaw.—The working of the condyle of the jaw vertically and from side to side can be distinctly felt in front of the ear. When the mouth is opened wide, the condyle advances out of the glenoid cavity on to the eminentia articularis, and returns into its socket when the mouth is shut. The muscle which causes this advance is the externalpterygoid; and it gives the jaw a greater freedom of grinding motion.
The posterior margin of the ramus of the lower jaw corresponds with a line drawn from the condyle to the angle. In opening abscesses in the parotid region, the knife should not be introduced behind this line for fear of wounding the external carotid artery. Punctures to any depth may be safely made in front of it. They are often necessary where inflammation of the parotid gland ensues after eruptive fevers, and runs on to suppuration. The swelling, tension, and pain are most distressing. Owing to the fibrous framework of the gland, the matter is not circumscribed, but diffused. One puncture is not enough. Three or more may be requisite. The blade of the knife should be held horizontally, so as to be less likely to injure the branches of the facial nerve. We are not to be disappointed if no matter flows. The punctures give relief, and matter will probably exude the next day.
12.Parotid duct.—A line drawn from the bottom of the lobe of the ear to midway between the nose and the mouth gives the course of the parotid duct. Opposite the second upper molar, the duct opens by a papilla into the mouth. The branch of the facial nerve which supplies the buccinator runs with the duct.
13.Temporal and facial arteries.—The pulsation of the trunk of the temporal artery can be felt, between the root of the zygoma and the ear. This should be well known to and used by chloroformists. It is also a convenient pulse to feel in a sleeping patient. The facial artery can be distinctly felt as it passes over the body of the jaw at the anterior edge of the masseter; again near the corner of the mouth close to the mucous membrane: and, lastly, by the side of the ala nasi, up to the inner side of the tendo oculi. By holding the lips between the finger and thumb the coronary arteries are felt under the mucous membrane. The facial vein does not accompany the tortuous artery, but runs a straight course from the inner angle of the eye to the front border of the masseter, just behind the artery.
14.Eyelids and eyes.—The opening between the eyelids varies in size in different persons; hence more of the eyeball is seen in some than in others, and the eye appears larger. Although human eyes do vary a little in size, yet the actual difference is by no means so great as is generally supposed. The size of the fissure has much to do with the apparent size of the eye. Contrast the narrow fissure of the Chinese and Mongolian races, and the apparent smallness of their eyes with those of Europeans. As a rule the external angle of the lid is higher than the internal. When not exaggerated, it gives the face an arch and pleasing expression.
Evert the lids to see the Meibomian glands; observe their perpendicular arrangement, in the substance of the tarsal cartilages.
The free borders of the lids are not bevelled, as described by J. L. Petit and most anatomists, ‘so as to form with the globe of the closed eye a triangular canal for the flow of the tears.’ On the contrary, it is easily seen that the lid margins, when closed, come into accurate contact. Their plane is not exactly horizontal, but slightly inclined upwards.
Every time the eye is shut, the ball turns upwards and inwards, so that the cornea is completely covered by the upper lid. This may be well seen by raising the lid of a sleeping infant; also in cases of low fever when the lid is not completely closed. This up-turning of the eye obviously clears the cornea, and protects it from the light.
A careful examination of the motion of the lower lid in the act of shutting the eye proves that it is a double motion. The lid is not only slightly raised, but drawn inwards about 1/12 of an inch. This second movement sweeps any particles of dust as well as moisture towards the inner canthus.
15.Puncta lachrymalia.—The puncta lachrymalia are distinctly visible at the inner angles of the lids. The lower punctum is larger and a little more external than the upper, so that they are not exactly opposite. The direction, too, of the puncta deserves notice. Their open mouths look a little backwards, ready to imbibe the tears. When their properbearing is lost, as in facial paralysis or by a cicatrix near the lid, the tears overflow the cheek. The length of the lachrymal canals is from three to four lines. The lower is a little shorter and wider than the upper. As each makes a little angle in its course, about a line from its orifice, the lid should be drawn outwards to straighten the canal when we introduce a probe.
16.Lachrymal sac.—To find the lachrymal sac, draw outwards the eyelids to tighten the tendo oculi, which crosses the sac a little above its middle. A knife introduced just below the tendon close to the edge of the orbit would enter the sac. The angular artery and vein would be on the inner side of the incision. A probe directed in a line with the inner edge of the orbit,i.e.downwards, outwards, and backwards, would pass down the nasal duct, and appear in the inferior meatus of the nose.
The tendo oculi serves many purposes besides giving attachment to the cartilages and muscles of the lids. One purpose is said to be to pump the tears into the lachrymal sac. Place a finger on the tendon, and feel that it tightens every time the lids are closed. The tendon, being intimately connected to the sac, draws, as it tightens, the sac wall outwards and forwards, and in this way it may pump along the lachrymal canals any fluid collected at the angle of the eye.
17.Nasal duct.—The nasal duct is from six to eight lines long, and narrowest in the middle of its course. Its termination in the inferior meatus lies under the inferior spongy bone, about a quarter of an inch behind the bony edge of the nostril. The appearance of the orifice in the dry bone conveys no idea of its size and shape in life; for it is diminished by a valve-like fold of mucous membrane, so that it becomes, in most cases, a mere slit, not exceeding a line in diameter.
The facility with which instruments can be introduced into the nasal opening of the duct depends upon its position as well as its size. This position varies in different instances. Sometimes it opens directly into the roof of the inferior meatus, in which case the hole is large and round, so that tears readilyrun into the nose. In other instances the opening is situated on the outer wall of the meatus, and is then always such a narrow fissure as to be hardly discernible. The practical conclusion then is, that a probe can be easily introduced when the opening is in the roof of the meatus, but not without difficulty and laceration of the mucous membrane when on the outer wall. This difficulty indeed may be increased by the narrowness of the meatus, arising from an unusual curvature of the spongy bone.
18.Nose and nasal cavities.—The line where the cartilages of the nose are attached to the nasal and superior maxillary bones can be traced with precision. The close connection of the skin to the cartilages admits of no stretching; hence the acute pain felt in erysipelas and boils on the nose. The external aperture of the nose is always placed a little lower than the floor of the nostril, so that the nose must be pulled up before we can inspect its cavities.
Looking into the nostrils, we find that the left is, in the majority of cases, narrower than the right, owing to an inclination of the septum towards the left. A communication sometimes exists between them, through a hole in the septum, as in the case of the celebrated anatomist Hildebrandt. By stretching open the anterior nares we can get a view of the end of the inferior spongy bone. The middle spongy bone cannot be seen: its attachment to the ethmoid is high up, nearly opposite the tendo oculi. The cavities are so much narrowed transversely by the spongy bones, that in the extraction of polypi it is better to dilate the blades of the forceps perpendicularly, and near the septum.
19.Mouth.—What can be seen and felt through the mouth? The upper surface of the tongue, ‘speculum primarum viarum,’ is a study in itself. We notice, on its under surface, a median furrow, on each side of which stands out the ranine vein, lying upon the prominent fibres of the lingualis. In the middle line of the floor of the mouth is the ‘frenum linguæ,’ with the orifice of the duct of the submaxillary gland on each side of it. The gland itself can be detected immediately beneath the mucous membraneby feeling further back near the angle of the jaw, at the same time pressing the gland upwards from below.
The long ridge of mucous membrane on each side of the floor contains the sublingual glands.
We can feel the attachment of the ‘genio-hyo-glossi’ behind the symphysis of the jaw. The division of this attachment would enable a surgeon to draw the tongue more freely out of the mouth in any attempt to remove carcinoma extending far back into its root.
There is great difference in the shape of the hard palate; this difference depends upon the depth of the alveolar processes. In some it forms a broad arch; in others it is narrow, and rises almost to a point like a Gothic arch, and materially impairs the tone of the voice.
Throat.—To examine the throat well, the nose should be held so as to compel breathing through the mouth. Thus the soft palate will be raised, the palatine arches widened, and the tonsils and the back of the pharynx fairly exposed. Pressing the tongue downwards, provided it be done very gently, is also of advantage. Rude treatment the tongue at once resists. The forefinger can be passed into the throat, beyond the epiglottis, as low as the bottom of the cricoid cartilage, and thus search the pharynx down to the top of the œsophagus, and the hyoid space (on each side) where foreign bodies are so apt to lodge. The greater cornu of the hyoid bone can be felt as a distinct projection on either side. In introducing a tube into the œsophagus the finger should keep the instrument well against the back of the pharynx so as to prevent its slipping into the larynx.
Pass the finger between the teeth and the cheek and feel the anterior border of the coronoid process of the jaw. On the inner side of this process, between it and the tuberosity of the upper jaw, is a recess, where a deeply-seated temporal abscess might burst, or might be opened. Behind the last molar on the inner side of the upper jaw we can distinctly feel the hamular process of the sphenoid bone; also the lower part of the pterygoid fossa, and the internal pterygoid plate. Behind, and on the outer side of the last molar, can be feltpart of the back of the antrum and of the lower part of the external pterygoid plate.
On the roof of the mouth we can feel the pulsation of the posterior palatine artery. Hæmorrhage from this vessel can be arrested by plugging the orifice of the canal, which lies (not far from the surface) on the inner side of the last molar, about 1/3 of an inch in front of the hamular process.
When the mouth is wide open, the pterygo-maxillary ligament forms a prominent fold readily seen and felt beneath the mucous membrane, behind the last molar teeth. A little below the attachment of this ligament to the lower jaw we can easily feel the gustatory nerve, as it runs close to the bone below the last molar tooth. The exact position of the nerve can be ascertained in one’s own person by the acute pain on pressure. A division of the nerve, easily effected by a small incision, gives much temporary relief in cases of advanced carcinoma of the tongue.
To feed a patient in spasmodic closure of the jaw, it is well to know that there is behind the last molar teeth a space sufficient for the passage of a small tube into the mouth.
Antrum.—Lift up the upper lip and examine the front wall of the antrum. The proper place in which to tap it is above the second bicuspid tooth, about one inch above the margin of the gum.
20.Posterior nares.—A surgeon’s finger should be familiar with the feel of the posterior nares, and of all that is within reach behind the soft palate. This is important in relation to the attachment of polypi, to plugging the nostrils, and to the proper size of the plug. In the examination of this part of the back of the throat it is necessary to throw the head well back, because, in this position, nearly all the pharynx in front of the basilar process comes down below the level of the hard palate, and can be seen as well as felt. But when the skull is horizontal,i.e.at a right angle with the spine, the hard palate is on a level with the margin of the foramen magnum, and the parts covering the basilar process are concealed from view.
The head then being well back, introduce the forefingerbehind the soft palate, and turn it up towards the base of the skull. You feel the strong grip of the superior constrictor. Hooking the finger well forwards, you can feel the contour of the posterior nares. Their size depends upon the anterior, but rarely exceeds a small inch in the vertical diameter, and a small half-inch in the transverse. The plug for the posterior nares should not be larger than this. Their plane is not perpendicular, but slopes a little forwards. You can feel the septum formed by the vomer, and also the posterior end of the inferior spongy bone in each nostril.
21.Tonsils.—Before taking leave of the throat, look well at the position of the tonsils between the anterior and posterior half arches of the palate. In a healthy state they should not project beyond the level of these arches. In all operations upon the tonsils, we should remember the close proximity of the internal carotid artery to their outer side. Nothing intervenes but the pharyngeal aponeurosis, and the superior constrictor of the pharynx. Hence the rule in operating on the tonsils, always to keep the point of the knife inwards.
In troublesome hæmorrhage from the tonsils, after an incision or removal, it is well to know that they are accessible to pressure if necessary by means of a padded stick, or even a finger.
22.Features.—A word or two on the lines of the face as indicative of expression. Everyone pays unconscious homage to the study of physiognomy when, scanning the features of a stranger, he draws conclusions concerning his intelligence, disposition, and character. Without discussing how much physiognomy is really worth, there can be no doubt that it is a mistake to place it in the same category as phrenology, since the latter lacks that sound basis of physiology which no one can deny to the former.
A person fond of observing cannot fail to have arrived at the conclusion that a man’s daily calling moulds his features. Place a soldier, a sailor, a compositor, and a clergyman side by side, and who will not immediately detect a marked difference in their physiognomies?
The muscles of the features are generally described as arising from the bony fabric of the face, and as inserted into the nose, the corners of the mouth, and the lips. But this description gives a very inadequate idea of their true insertion. They drop fibres into the skin all along their course, so that there is hardly a point of the face which has not its little fibre to move it. The habitual recurrence of good or evil thoughts, the indulgence in particular modes of life, call into play corresponding sets of muscles which, by producing folds and wrinkles, give a permanent cast to the features, and speak a language which all can understand, and which rarely misleads. Schiller puts this well when he says that ‘it is an admirable proof of infinite wisdom that what is noble and benevolent beautifies the human countenance; what is base and hateful imprints upon it a revolting expression.’