Landmarks Medical and Surgical

by Luther Holden; James Shuter

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 forefinger behind 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.’

THE NECK.

23. Subcutaneous veins.—Notice first the direction of the subcutaneous veins. The chief subcutaneous vein is the external jugular. Its course corresponds with a line drawn from the angle of the jaw to the middle of the clavicle, where it joins the subclavian. It is made more prominent by putting the sterno-mastoid into action, or by gentle pressure on the lower end of the vein. It is exceptionally joined by a branch which runs over the clavicle, and is termed ‘jugulo-cephalic.’ The anterior jugular generally runs along the front border of the sterno-mastoid.

24. Parts in central line. Os-hyoides.—Immediately below and nearly on a level with the lower jaw we feel the body of the os-hyoides, and can trace backwards on each side the whole length of the cornua. They might easily be broken by the grasp of a garotter. Below the body of the os-hyoides is the gap above the thyroid cartilage. This gap corresponds with the anterior thyro-hyoid ligament and the apex of the epiglottis; so that in cases of cut throat in this situation, nearly the whole of the epiglottis lies above the wound.