The Human Face; 
Its Modifications in Health and Disease, 
and its Value as a Guide 
in Diagnosis. 
BY 
AMBROSE L. RANNEY, M. D. 
REPRINT FROM 
2Tl)e 'Ncin Yotft fHciural Journal. 
December, 1880. This Paper is reprinted from The New York Medical Journal 
for December, 1880. 
The contents of that number are as follows: 
©tiginal ffiommunications. 
PAG* 
The Human Face: its Modifications in Health 
and Disease, and its Value as a Guide in 
Diagnosis. By Ambrose L. Ranney, 
M.D., etc 561 
On the Management of the Second Stage of 
Natural Labor. By William T. Lusk, 
M. D., etc 595 
An Analysis of One Hundred and Forty Cases 
of Excision of Cancer of the Rectum. By 
Charles B. Kelsey, M. D., etc 608 
Visual Purple. By W. C. Ayres, M. D 619 
A Case of Abscess of the Abdominal Wall, in 
a Patient with Subclavian Aneurism. By 
T. It. Chambers, M. D 623 
3E tutorials. 
The Brooklyn Debate on Puerperal Convul- 
sions 627 
The Index-Catalogue 629 
Enlargement of the “Journal.” 680 
3&ebictos anti 3Uterarg Wotcs. 
Balfour’s Comparative Embryology 630 
PAG* 
Patzel on Functional Nervous Diseases 635 
Bastian on the Brain as an Organ of Mind— 63T 
Books and Pamphlets received 638 
Reports on tpe progress of ittehfcfne. 
Quarterly Report on General Medicine. By 
W. H. Katzenbach, M. D., etc 640 
Quarterly Report on Materia Medica, Thera- 
peutics, and Toxicology. By Gaspar 
Griswold, M. D 648 
Quarterly Report on Venereal and Genito-Uri- 
nary Diseases. By Edward B. Bron- 
son, M. D., etc 65ft 
jf&iscellans. 
Hansen on Pernicious Progressive Anaemia... 668 
Hansen on the Bacillus of Leprosy 66ft 
Bokkenheuser on Salicylic Acid in Acute Ar- 
ticular Rheumatism 669, 
The International Medical Congress of 1881... 669 
Army Intelligence 671] 
The New York Medical Journal is published monthly, and 
contains 112 closely printed octavo pages. It is devoted to the general 
practice of medicine, and aims to meet the wants of the general 
practitioner. 
EDITED BY 
FRANK P. FOSTER, M. D., 
PHYSICIAN FOB DISEASES OF "WOMEN TO THE OUT-PATIENT DEPARTMENT OF THE NEW 
YORK HOSPITAL. 
New York: D. APPLETON & CO., Publishers, 
1, 3, & 5 BOND STREET. 
Single Number, 40 Cents. Yearly Subscription, $4.00. THE HUMAN FACE; ITS MODIFICATIONS IN 
HEALTH AND DISEASE, AND ITS YALUE AS 
A GUIDE IN DIAGNOSIS. A / 
By AMBROSE L. RANNEY, M. D., 
ADJUNCT PROFESSOR OF ANATOMY IN THE MEDICAL DEPARTMENT OF THE UNIVERSITY 
OF THE CITY OF NEW YORK. 
The extent to which the anatomy of the head, as studied 
from the standpoint of physiognomy, may suggest points of 
practical value to the physician or surgeon, has not, in my 
opinion, received sufficient consideration in the popular text- 
books of the day. From the “ British and Foreign Medical 
Review ” of 1841 I quote the following sentence : “ Medical 
physiognomy is, in many instances, a source of diagnosis 
which seldom fails the practitioner who is himself well versed 
in it; and we believe that much of the exquisite tact in dis- 
crimination of disease, which distinguishes some practitioners 
and which others can never attain, depends upon the vivid 
perception of an eye and ear habitually familiar with the 
lineaments, the tone, and the gestures of disease.” Among 
the earlier authors, who were ignorant of many of the present 
methods of determining the condition, size, and position of 
organs, since the art of auscultation and percussion is a growth 4 
of later date, the study of the human countenance formed a 
very important part of the preparatory drill. The followers 
of Hippocrates and Galen were rendered perfect in their per- 
ceptive faculties. The former gave to us, in his masterly 
work, descriptions of the symptoms of disease which are still 
considered classic, while the latter, in his essays on the “ Tem- 
peraments,” * is equally careful to note the most trivial altera- 
tion either of the face or of the posture. 
There seems to be a growing tendency of late to regard 
the rational symptoms of disease as subordinate to the results 
of a physical examination, and as of but little value in them- 
selves, except as confirmatory evidence. Authors frequently 
render the description of the symptoms of disease so terse and 
indefinite, that but few of the readers of the later medical or 
surgical works could precisely picture to themselves the ap- 
pearance of a sufferer from any of the maladies, with the pathol- 
ogy and physical symptoms of which they may be thoroughly 
familiar. It is not infrequently the experience of the most eru- 
dite of the profession to be amazed at the gift, which is pos- 
sessed by some less scholarly brother, of making a diagnosis, 
which seldom errs, without the aid of the thermometer or the 
stethoscope; and many an old nurse, long accustomed to 
spend weary nights in watching the sick, can often render a 
prognosis which seems little short of inspiration when her 
utter ignorance of all medical knowledge is considered. 
Despite the fact that some of our best authors have de- 
nounced the attempts of De Salle, Jadelot, and Seibert to 
establish certain facial lines and wrinkles as of positive value 
in diagnosis, and have pronounced all such statements as a 
mere fantasy, still no one of large experience can deny that 
the face may at times afford most positive and valuable in- 
formation. 
In 1806, Lavaterf published his work upon this subject, 
in which he discusses at great length the diagnostic value of 
general physiognomy. Subsequently, Sir Charles Bell wrote 
upon the subject from a purely anatomical point of view, and, 
in 1824, published his “ Essays upon Expression.” Baum- 
* Kuhn’s edition. 
+ “L’Art de connaitre les Hommes par Physiognomie.” Paris, 1806-’7. 5 
gaertner* added his contribution to the subject in 1839, and 
Laycock,j* in 1862, published his course of lectures, with illus- 
trations, which were designed to show the various types of 
diathesis and their bearing upon the general development. 
Corfe, in 1867, published a series of contributions in the 
“Medical Times and Gazette,” in which the subject was 
studied from a clinical point of view, and in which not only 
the entire held of facial expression, but also that of general 
physiognomy, was pointed out to the student, so far as the 
cases under consideration illustrated any points of special in- 
terest. 
Darwin’s great work upon the expression of the emotions 
in animals and the contributions of Connelly upon the typi- 
cal shades of expression peculiar to the insane may well be 
read by those who question the utility of this much-neglected 
department of science. The careful study of the expressions 
of the face and the modifications which age produces in it is 
at least very advantageous in furnishing a normal standard by 
which deviations in disease may be studied. I quote from 
the most excellent treatise of Blandin § the following sen- 
tence : “ Those who neglect or seek to ridicule this mode 
of investigation prove only one thing, that they study pathol- 
ogy without a proper knowledge of anatomy and physiology, 
upon which the former is founded. The morbid expressions of 
the face are an extremely useful and often the only guide of 
the medical practitioner in the case of a very young child, 
that can tell nothing in regard to its sufferings.” 
It is with a view to systematize and arrange the collected 
investigations of the authors previously named, and to bring 
within the compass of a single article such practical informa- 
tion as the anatomy of the face may afford the practitioner, 
that I am led to draw professional attention to this subject 
once more. \ 
The physiognomy of the sick presents innumerable shades 
of expression. It may assume the various conditions expres- 
sive of sadness, dejection, attentiveness, indifference, uneasi- 
ness, or terror; it may, at times, be smiling; occasionally 
* “Atlas,” 1839. t “Med. Times and Gaz.,” 1862, vol. i. 
X “ Med. Times and Gaz.,” 1862. § “ Anatomie Topographique.” 6 
menacing or wandering; and may sometimes show a series 
of changes in rapid succession. 
These various conditions of the countenance may not only 
be the direct result of the influence of the ever-varying pas- 
sions upon the muscles of the face, as is the case in health, but 
they may also be classed as morbid phenomena, each of which 
possesses some special significance. Chomel lays great stress 
upon these variations of countenance, and endeavors to point 
out the special diagnostic value of each. 
Facial Lines and Wrinkles.—The theories of De Salle, 
Jadelot, and Seibert * as to the diagnostic value of facial lines 
and wrinkles have had their share of support from time to 
time ; while they have also been considered by some authors 
as speculative and destitute of any value. The existence of 
these marks may be attributable to one of two conditions, viz., 
a disappearance of the fat from the subcutaneous tissues of the 
Fig. 1.—The Transverse Kugse. 
face, or the abnormal contraction of certain facial muscles, 
dependent upon some apparent irritation of the motor nerves 
supplying the affected muscles. It is important, in using these 
lines and wrinkles as guides in diagnosis, that the discrimina- 
* Williams, “ Principles of Medicine.” 7 
tion be made between those lines which are natural to the 
face of the sufferer and those which are developed as a result 
of the disease. For the reason that the face of the adult is 
always more or less marked by lines,* it must be evident that 
these lines are a more reliable guide in the infant than in later 
life, if their diagnostic value remains unquestioned. Without 
entering into a discussion as to the merits of the question, I 
give the theories advanced for whatever interest and value 
they may possess to the reader. The wrinkles of the face may 
be classified into six groups as follows : 
(1.) The Transverse Rugae.—These are situated upon the 
forehead, and are formed by the action of the occipito-fron- 
talis muscle. They are thought to be expressive of an extreme 
amount of pain, arising from causes outside of the cavities of 
the body. 
Fig. 2.—The Oculo-frontal Rug®. 
(2). The Oculo-frontal Rugae.—These extend vertically from 
the forehead to the root of the nose, and are formed by the 
* Blandin, op. cit. 8 
corrugator supercilii muscles. They are thought to express- 
distress, anxiety, anguish, and excessive pain from some inter- 
nal cause. It is said that they furthermore indicate an im- 
perfect or false crisis; and that, in attacks of acute diseases, 
an impending efflorescence and sometimes a fatal termination 
may be indicated by their occurrence. In those types of head- 
ache where the pain is very excessive, these rugae may exist 
simultaneously with the ones previously described. It is stated 
that when the former rugae meet the latter abruptly, during 
the course of an acute disease, some serious lesion of the brain,, 
or its coverings, is developing. 
Fig. 3.—The Line of Jadelot. 
(3.) The Linea Oculo-zygomatica.—This line (the line of 
Jadelot) extends from the inner angle of the eye downward and 
outward, passing across the face below the malar bone. It is 9 
said to indicate, in children, a cerebral or nervous affection • * 
and, in adult life, some disease of the genital organs, mastur- 
bation, or venereal excess. 
(4.) The Linea Nasalis (Line of De Salle).—This line ex- 
tends from the upper border of the ala nasi downward, in a 
direction more or less curved, to the outer edge of the orbicu- 
laris muscle. This line is said to be strongly marked in 
phthisis and in atrophy. Its upper half (the linea nasalis 
proper) is thought to be a reliable indication of intestinal dis- 
ease, if extensively developed and prominent; the lower half 
(the linea buecalis) is supposed to indicate the existence of 
some disease affecting the stomach. It is claimed by Peiper 
that, when this line appears conjointly with the line of Jade- 
lot, it may be regarded as a positive indication of worms in 
children, if a peculiar fixed condition of the eye exists and a 
pallor of the face is present. 
Fig. 4.—The Line of De Salle. 
(5.) The Linea labialis.—This line extends downward 
from the angle of the mouth till it becomes lost in the lower 
* Vogel, “ On Diseases of Children.” New York : D. Appleton & Co. 10 
portion of the face. It is usually developed in connection 
with those diseases which render breathing laborious or pain- 
ful, and is more common in children than in the adult as a 
sign of diagnostic value. 
Fig. 5.—The Linea Collateralis Nasi. 
(6.) The Linea Collaterals Nasi.—This line extends from 
the nose downward to the chin, in a semicircular direction. 
It lies outside of the linea buccalis, the linea nasalis, and the 
linea labialis. It is thought to be a reliable guide to diseases 
of the thoracic and abdominal viscera.* 
Color of the Face.—The color of the face is subject to 
variations which to the eye of the medical adviser afford un- 
questioned aid in diagnosis. Flushing of the face, as evidenced 
by a diffused redness which is of a transient character, is very 
* Corfe, “ Med. Times and Gaz.,” 1867. 11 
common in women suffering from irregularity of the men- 
strual periods and during the menopause. In plethora, espe- 
cially after exertion or excitement, an unnatural redness of the 
face may occur, associated with symptoms indicative of cere- 
bral hypersemia. Pressure of tumors, either of the neck or of 
the thorax, upon the sympathetic nerve may create an abnor- 
mal dilatation of the capillaries, thus resulting in a redness of 
the skin, with an increase of the temperature of the affected 
region; while section of the sympathetic nerve, although a 
rare form of accident, w’ould result in a like condition.* Red 
patches occur on the cheek during an attack of croupous 
pneumonia. In wasting affections of a chronic character, es- 
pecially of the lungs, such as phthisis, cancer, etc., a circum- 
scribed redness over the malar bones, known as the “ hectic 
flush,” is usually present. It may occasionally affect only one 
cheek,f where only one lung is diseased. Pallor of the face 
is the rule during convalescence from any severe disease, and 
in patients long deprived of sunlight.:]; A waxy pallor exists 
in chronic Bright’s disease, which renders the skin almost 
transparent. In the chill of fevers and malarial attacks, a 
dusky paleness is usually perceived ; while in cases of haemor- 
rhage, where the loss of blood has been sufficient to produce 
constitutional effects, the pallor of the face assumes a peculiar 
leaden color. § A greenish tint is present in profound attacks 
of anaemia and during chlorosis, fl giving to the face an appear- 
ance similar to that of imperfectly bleached wax. 
Malaria and cancer are often manifested by a light straw 
rotor of the face, although it may occasionally result in the 
deep yellow of In the early stages of jaundice, 
the sclerotic coat of the eye and the corners of the mouth first 
show the yellow color, although the discoloration soon tends to 
become diffused over the entire face. A blue tinge exists in those 
cases where the venous return to the right heart is obstructed, 
or where, from any cause, the oxygenation of the blood is im- 
* M. Foster. \ Stille. \ Williams, op. cit. 
§ Sir Charles Bell, “ Treatise on Surgery.” 
| Niemeyer, “Text-Book of Practical Medicine.” New York: D. Appleton 
& Co. 
Tf Reynolds, “ System of Medicine.” 12 
perfectly performed. It occurs therefore in cyanosis, asphyxia, 
the fevers, certain diseases of the pulmonary organs which in- 
terfere with the circulation, and in diseases of the heart which 
render its action weak or imperfect. In cases of poisoning 
from the nitrate of silver, the skin assumes a still deeper blue 
tint than in those cases above mentioned, and the staining is 
permanent. In Addison’s disease of the supra renal capsules 
a dark-brown color of the skin results, which may be either 
uniform or in isolated spots, and which may, in severe cases, 
almost rival the pigmentation of the negro. The redness of 
erysipelas is usually accompanied by an oedema which renders 
the face tense and shining, and which often causes a markedly 
altered expression of the countenance. 
The face is the seat of many of the eruptions, some of 
which are confined almost exclusively to it, while others are 
usually found in that region before they appear elsewhere. It 
would exceed the limits of this article to enter into the descrip- 
tion of the characters which stamp each of the various erup- 
tions, since they can be easily learned by reference to any ot 
the special treatises. 
Oorfe suggests as a guide to the student in physiognomy 
the following table, which designates the prevailing changes in 
the complexion of the face in the course of the more common 
disorders. While it is not possible to construct any table 
which shall give all the information desired upon so important 
a subject, still this one may prove of some value as a means of 
aiding the memory : 
In cerebral disease the countenance is lethargic. 
In emphysema “ “ livid. 
In pulmonary oedema “ “ dusky and distressed. 
In pneumonia “ “ dusky and flushed. 
In pleurisy “ “ pale and anxious. 
In phthisis “ “ pale and thin. 
In malignant disease “ “ sallow and thin. 
In icterus “ “ yellow and thin. 
In renal disease “ “ thin, puffy, and anaemic. 
In peritonitis .. “ “ anxious and dragged. 
In uterine disease “ “ sallow and haggard. 
Marshall Hall* thus describes a countenance which ho 
* “ On Diagnosis.” London, 1817. 13 
considers typical of the acute form of dyspepsia: “This affec- 
tion is accompanied by some paleness or sallowness, and a 
daVk hue about the eye. The lips are slightly pale and livid. 
The cutaneous vessels exude a little oily perspiration, and the 
muscles of the face, and especially of the chin and lips, are af- 
fected with a degree of tremor, particularly on any hurry or 
surprise, or on speaking.” 
The Nose.—The nostrils are of some practical interest from 
a medical point of view. They dilate forcibly and rapidly in 
difficult respiration, when produced by disease ; * and itching 
of the nostril is regarded by many authors as a valuable diag- 
nostic sign of intestinal worms.f The nose seldom points di- 
rectly forward, being, as a rule, slightly inclined toward the 
right side. This fact is explained by Beclard as the result of 
the habit of wiping the nose with the right hand, since, in left- 
handed people, the opposite deflection exists. The nose of a 
face perfect in its outline should be one third of the length of 
the distance from the root of the hair to the chin; but, in 
certain races, the variation from this rule affords a special 
physiognomy. The integument which covers the nose is very 
firmly attached to the muscles underneath it by a cellulo- 
fatty layer. Blandin lays great stress upon this fact as ex- 
plaining the infrequency of oedema of this region, and as an 
effort on the part of Nature to preserve the uniformity of 
contour of the nose, which would be seriously impaired by any 
local swelling of the face, were the skin over the nose loosely 
attached. The nose is extremely vascular; hence the custom 
of surgeons to replace severed portions of the organ, even if 
completely detached, with a hope of obtaining union. Among 
the ancients, amputation of the nose was practiced upon the 
criminal classes, and the operation of rhinoplasty was first sug- 
gested as a means of relief for those so disfigured. 
The redness of the nose after an attack of crying indicates 
a connection between the sympathetic supply of the capillary 
vessels of the nose and that of the capillaries of the lachrymal 
apparatus; hence any form of irritation of either of these lo- 
calities is liable to be accompanied by symptoms referable to 
* Sir Charles Bell. 
f Peiper. 
£ Op. cit. 14 
the other.* Injury to the nose, resulting in fracture, often 
leaves a permanent facial deformity, and, even when no evi- 
dences of serious injury can be ascertained by external exami- 
nation, cerebral symptoms are liable to follow, as fracture of 
the base of the skull may result, from a transmission of the force 
through the perpendicular plate of the ethmoid bone.f Yas- 
cular tumors of the region of the nose are not uncommon, 
while a prominence of the capillary vessels of the nose is met 
with in the aged as the result of a defect in the contractile 
power of their coats.:}: 
Marked elevation of the nostril is regarded by some au- 
thorities § as an indicator of pain within the cavity of the 
thorax. 
The Eye.—“ It may appear to many a superfluous task to 
attempt to judge of the character of an individual by a glance 
at his face, but, whatever may be thought of the possibility of 
laying down strict rules for such judgment, it is a fact of 
every-day occurrence that we are, almost without reflection 
on our part, impressed favorably or unfavorably with the 
temper and talents of others by the expression of their coun- 
tenance. The face acquires its expression also from bodily 
habits and from intellectual or sensual pursuits, so that we 
may pass from the lofty and expanded forehead, with the 
small, well-formed mouth, of the philosopher, down to the shal- 
low front and protruded muzzle of the negro, whose habits 
are more bestial than those of the animals he chases for the 
support of his life.” || 
The intimate communications between the fifth, the sev- 
enth, and the sympathetic nerves, through the media of the 
ciliary, optic, and Meckel’s ganglia, would lead us to expect 
that the eye should exhibit, in its altered appearance, the de- 
rangement of internal structures. “ When a glance of this 
organ is caught, what a field of mute expression is open to the 
mind! This silent and instructive index of the whole man 
may be bright or dull, heavy or clear, half shut or unnaturally 
open, sunken or protruded, fixed or oscillating, straight or dis- 
torted, staring or twinkling, fiery or lethargic, anxious or dis- 
* Blandin, op. cit. Holden, “Human Osteology.” London, 1855. 
% Beclard. § Marshall Hall, op. cit. | Corfe, op. cit.. 15 
tressed; again, it may be watery or dry, of a pale blue, or its 
white turned to yellow.” * 
The pupils may be contracted or widely dilated, insensible 
to or intolerant of light, oscillating or otherwise, unequal in 
size, or changed from their natural clearness of outline. The 
noble arch of the brow speaks its varied language in every face 
of suffering humanity. It may be overhanging or corrugated, 
raised or depressed ; while the lid of the eye, an important part 
of this vault, exhibits alternations of puffiness or hollowness, of 
smoothness or unevenness, of darkness or paleness, of sallow- 
ness or brown discoloration, of white or purple. Lines inter- 
sect this region, and the varied tints are perpetually giving 
new color, new feature, new expression, by their shadows. If 
the frontal muscle acts in connection with the corrugator su- 
percilii, an acute deflection upward is given to the inner part 
of the eyebrow, very different from the general action of the 
muscle, and decidedly expressive of debilitating pain, or of 
discontent, according to the prevailing cast of the rest of 
the countenance. An irregularity of the pupils of the two 
eyes indicates, as a rule, pressure upon nerve centers or 
upon the optic nerve itself, f In adynamic fevers the eyes are 
heavy and extremely sluggish, and are, as a rule, partially 
covered by the drooping eyelid; while in certain forms of 
mania they are seldom This latter peculiarity 
is also often noticed in idiocy. 
In the so-called “ Bell’s paralysis,” due to failure of the 
facial nerve, the eyelids stand wide open and can not be volun- 
tarily closed, since the orbicularis palpebrarum muscle is 
paralyzed. This condition may be further recognized, if 
unilateral, by a smoothness of the affected side, since the 
antagonistic muscles tend to draw the face toward the side 
opposite to the one in which the muscular movement is im- 
paired ; an inability to place the mouth in the position of 
whistling, since for this act the two sides of the face must act 
in unison; loss of control of saliva, which dribbles from the 
* CORFE, Cp. tit. 
f Ferrier, “The Localization of Cerebral Disease.” New York: G. P. Put- 
nam’s Sons, 1879. 
\ Connelly, “Med Times and Gaz.,” 1861-’2. 16 
corner of the mouth; and a tendency to accumulation ot food 
in the cheek, since the buccinator muscle no longer acts. 
Fig. 6.—“ Bell’s Paralysis.” (Modified from Corfe.) 
When the third pair of nerves are affected upon either side, 
the upper eyelid can not be voluntarily raised, for the levator 
palpebrge muscle fails to act; and the eye is caused to diverge 
outward, since the external rectus muscle, not being supplied 
by the third pair, and having no counterbalancing muscle, 
draws the eye from its line of parallelism with its fellow. In 
photophobia, attempts to open the eye create resistance on the 
part of the patient, since the entrance of light causes pain; 
while, as death approaches, or in the state of coma (save in a 17 
tew exceptions), the eves are usually open. In cardiac hyper, 
trophy an unusual brilliancy of the eye is perceived,* since 
the arterial system is overfilled from the additional power of 
the heart. A peculiar glistening stare exists during the course 
of scarlet fever, which is in marked contrast with the liquid, 
tender and watery eye of measles.f Many diseases of the eye 
itself tend to greatly alter the normal expression of the face. 
Prominently among these may be mentioned cataract, glau- 
coma, cancer, staphyloma, exophthalmus, iritis, conjunctivitis, 
amaurosis, etc., but the special peculiarities of each need not 
be here described. 
Abnormalities of the pupils may afford the practitioner 
material aid in diagnosis. The pupils are found to be dilated 
during attacks of dyspnoea and after excessive muscular exer- 
in the latter stages of anaesthesia, and in cases of poison- 
ing from belladonna and other drugs of similar action. A 
contracted state of the pupils exists during alcoholic excite- 
ment, in the early stages of anaesthesia from chloroform, and 
in poisoning by morphia and other preparations of opium, 
physostigmin, chloral, and some other drugs. Paralysis of the 
third cranial nerve creates a dilated condition of the pupil of 
the same side, since that nerve controls the circular fibers of 
the iris. 
Growths within the deeper portions of the orbit tend to 
create a displacement of the eye forward, and thus to cause 
an apparent increase of that organ in size. A similar condition 
may also result from abscesses or the growth of tumors within 
the cavity of the antrum. In the so-called Basedow’s dis- 
ease,§ an abnormal prominence of the eyes accompanies a 
simultaneous enlargement of the thyroid gland. The eye- 
lashes, if abnormal, not only in themselves create deformity, 
* Loomis, “Lectures on Diseases of the Respiratory Organs, Heart, and 
Kidneys.” New York : William Wood & Co., 1874. 
f J. Duggan, quoted by Haviland Hall: “ Differential Diagnosis.” Philadel- 
phia, 1879. 
\ M. Foster, “Text-Book of Physiology,” 3d ed. London: Macmillan & Co., 
1879. 
§ F. ton Niemeyer, “Text-Book of Practical Medicine.” Translated by 
Hackley and Humphrey. New York : D. Appleton & Co., 1869. 18 
but also, by causing irritation of the conjunctiva, produce an 
alteration in the normal expression of the eye. 
The Cheek.—The cheek is capable of a great variety of 
movement. During the reception of liquid or solid food into 
the mouth, it is of the greatest assistance, since by its move- 
ments the two acts are greatly facilitated; during mastication, 
the buccinator muscle helps to force the food between the 
jaws, which are brought into apposition and rubbed together; 
and, finally, the cheek can act as an important factor in pro- 
ducing that peculiar type of countenance which is so strongly 
indicative of the desire of taking nourishment. The respira- 
tory motions of the cheek are manifested in the acts of gaping 
and blowing, and in the exhibition of intense passion, in which 
the malar region is markedly in sympathy with a general 
excitation of the whole respiratory apparatus. 
The cheek may become the mirror of the soul. When the 
feelings are gay, it is drawn outward and upward; but, when 
the mind is depressed or saddened, it is drawn obliquely down- 
ward. If these movements be carefully noted, it will be 
perceived that the movable point of the cheek is situated in 
the immediate vicinity of the naso-labial groove ;* since the 
attachments of several of the small facial muscles at about this 
point tend to draw the anterior part of the cheek outward from 
the line of this groove. It may be noticed, as a matter of 
interest, that, when the mental impressions are slight and 
trivial, no traces of their effect upon the face are left upon the 
cheek ; but, when they are of a serious or prolonged character, 
deep and permanent grooves are formed, which are of interest 
to the physiognomist as an indication of the temperament, and 
to the medical adviser as often of positive value in diagnosis. 
In the young child, the cheek, which is at nearly the same 
instant alternately moistaned with a tear or decked with a 
smile, preserves in the healthy state the roundness which 
marks that happy age; but in the adult, the cheek, on the 
contrary, presents numerous lines and wrinkles, and this ap- 
pearance becomes still more apparent as old age approaches. 
There are, however, lines in the cheek of the aged which 
* Blandin, op. cit. 19 
tshould not be mistaken for evidences either of the temperament 
•or of disease, since they are produced simply by the approxi- 
mation of the jaws. Lavater,* in his work upon physiognomy, 
locates most of the sentiment of the face in the cheek, and 
draws comparisons between the base and jealous face and that 
which is generous and noble, as a support to his theory. 
The color of the cheek varies much, both as a direct result 
of the passions and from special diseased conditions, which 
have been mentioned previously in this article. In fear and 
envy, the cheek is usually pale and colorless, while in love, 
embarrassment, or anger it is often uncommonly red. To the 
physiologist, these changes are a beautiful exhibition of the 
sympathy which exists between the mind and the circulatory 
and respiratory systems, which are seldom influenced except 
simultaneously. The changes in the cheek which affect ex- 
pression, like the respiratory motions, depend chiefly upon the 
influence of the facial nerve ; and thus it is that children and 
females, in whom the nervous system is generally more sus- 
ceptible to impressions, also present, to the greatest degree, 
more or less transient modifications of the cheek. The cheek 
suffers a diminution in its fat as age advances, and when the 
teeth have been lost the approximation of the jaws forces the 
redundant cheek outward; and its flaceidity, from the loss of 
fatty tissue, throws it into folds, which are not present in the 
face of the infant. 
The cheek approaches a triangular form in the infant, but 
it becomes quadrilateral when the teeth are developed ; and 
in the old man, as the teeth are lost, it again returns to the 
triangular form as in infancy. The fact that the maxillary 
sinus is very imperfectly developed in the child, and gradually 
increases as age advances, explains to a great extent why the 
triangular form tends to become quadrilateral; and the fre- 
quency of abnormal protrusions of this region is explained by 
growths or the accumulation of fluid within this cavity. The 
changes in the cheek produced by advancing years are also 
illustrated in its color. In the child, the bright rose tint, 
which accompanies exertion and frequently the hours of sleep, 
* Op. cit., Hunter’s'edition. 20 
bespeaks health and general activity; but in adult age this 
coloring tends to disappear, and in old age the cheek often 
assumes a striated redness, which is due to an abnormal dilata- 
tion of the capillary vessels, especially the veins. The vas- 
cularity of the cheek renders the occurrence of erectile tumors 
common in this region ; and the elasticity of the tissues affords 
an anatomical explanation of the little disfigurement which 
follows the removal of large portions of the cheek, in case sur- 
gical interference is demanded from any cause. 
The Lips.—Certain deformities of the face are common 
in the region of the lips and mouth. Among these may be 
mentioned the condition of deficient closure, which is the nor- 
mal condition of the hare, and to which the term “ hare-lip ” 
is applied. This deformity may he associated with that of 
fissure of the hard palate, and often with imperfect develop- 
ment of the soft palate; and thus not only is the countenance 
impaired, hut the power of sucking, natural to the infant, is 
destroyed, and the articulation of words is subsequently ren- 
dered imperfect. The vascularity of the lips renders the de- 
velopment of erectile tumors of this region not infrequent; 
while hypertrophy of the tissues forming the lips may occur 
as one of the types of facial deformity. 
The lips of the young child are very much longer in pro- 
portion to the face than those of the adult, aifd their increased 
length renders the act of sucking easier to the infant than if 
the teeth were present, since the lips can be made almost to 
cross each other and thus closely embrace the nipple. When 
the teeth are formed, the excessive length of the lips dimin- 
ishes, and the expression of the face is thus greatly altered ; 
while, in the old man, as the teeth are lost, the lips again be- 
come very long, which accounts for their projection forward 
when the mouth is closed, and which gives to the face of those 
advanced in years the peculiar pouting expression so often 
seen.* The excessive length of the lips in the aged further- 
more acts as a hindrance to mastication, and often renders the 
articulation of words extremely indistinct. 
In sickness, if the angle of the mouth be depressed, pain 
* Bt.andin, op. til. 21 
and languor may be read ; and, when the eorrugator supercilii 
muscle cooperates with the depressor muscles of the mouth, 
acute suffering is proclaimed.* 
Extreme pallor of the lips is observed in excessive haemor- 
rhage, in purpura, in chlorosis, etc.; deep lividity denotes a 
defective oxygenation of the blood, and occurs chiefly in dis- 
eases of the lungs, heart, and larynx; while pale lividity oc- 
curs in cases where the circulation of the surface is languid or 
imperfect, f In painful affections of the abdominal organs, 
the upper lip is usually raised and stretched over the gums or 
teeth, so as to give a diagnostic expression to the countenance, 
which is considered by some as of great value. In anasarca 
of the face, the lips, eyes, and cheeks are most affected, since 
the subcutaneous cellular tissue in these regions admits of dis- 
tention more readily than in those regions where it is not so 
loose. 
Deformities of tiie Face.—Among the extraordinary de- 
formities of the orbital region, may be casually mentioned 
those rare cases of absence of the eyes, and the union of the 
two orbits, as reported by Tenon and Bartholine. The eyelids 
may also be found deticient or united at birth; and occasion- 
ally turned in or out, when the skin and the conjunctiva are 
of unequal length. The last type of deformity is most fre- 
quently the result of cicatrization of the tissues of the face, 
following an injury; while adhesions of the eyelids to the 
globe of the eye may be either a congenital defect or the re- 
sult of inflammatory processes. The pupils may be absent at 
birth, or mav be partially while deformities of 
this aperture may also be acquired as the result of adhesions 
between the iris and the cornea or the crystalline lens, or as 
the result of an operation in which portions of the iris are ex- 
cised for the relief of glaucoma. 
The entire absence of the face at the time of birth has been 
recorded by Lecart, Curtius, and Beclard; while in numerous 
instances the median portions of the face have been absent, or 
the existence of deep central fissures in the face has been de- 
tected. Cases are on record where all evidences of the ex- 
* CORFE. 
f Marshall Hall, op. tit. 
X Blandin, op. tit 22 
istence of tlie nostrils are absent, termed “ anarina ” ; those- 
where the mouth has been found absent, termed “astomia” 
and those where a double nose has existed, as recorded by Be- 
dard. In these abnormalities, as in those where the cranium 
has been partially or totally wanting, an arrest of the process, 
of development at an early stage of foetal life must have oc- 
curred, the date of which in pregnancy may be roughly esti- 
mated by the extent and situation of the deformity. In cases 
of senile atrophy of the forehead, the bones are sometimes 
completely absorbed, and hernia of the encephalon may thus 
spontaneously be produced. 
Tumors of the face always create a deformity, which is 
confined to the anatomical region affected ; some of which 
have already been referred to in this article in the treatment 
of certain of the special features. Many conditions of the 
face, which may properly be spoken of as deformities, are de- 
pendent upon disease. Some of those which affect the eye and 
its appendages, and others which are due to injury of nerves 
or to disease of nerve centers, will be described later on, among 
the special types of physiognomy which are of interest in their 
bearing upon general diagnosis. Severe types of ulceration, 
as it occurs in lupus and carcinoma, often create so extensive 
a destruction of tissue as to give rise to hideous deformities, 
but they have no special bearing upon the diagnosis of the ex- 
isting disease. 
Special Types of Face.—Many of the specific forms of 
disease have their special physiognomy. As examples of this 
fact, scrofulous children inherit either a velvety skin, dark- 
brown complexion, dark hair, dark brilliant eyes, and long 
lashes, with the lineaments of a face finely drawn and expres- 
sive ; or a fair complexion, thick and swollen nose, broad chin,, 
teeth irregular and developed late, inflammation of the Mei- 
bomian glands, scrofulous ophthalmia, eruptions of the head, 
nose, and lips, and enlarged cervical glands.* 
Hippocrates f describes a characteristic expression, which 
has been called from him the “ facies Hippocratiea,” in which 
the eyebrows are knitted, the eyes are hollow and sunken, the^ 
* Williams, op. cit. 
f “ Prognostics ” (Adams’s translation)- 23 
nose is very sharp, the ears are cold, thin, and contracted, with 
marked shriveling of the lobules; the face is pale and of a 
greenish, livid, or leaden hue; and the skin about the fore- 
head is tense, dry, and hard. This type of countenance is a 
most frequent indicator of impending death from chronic dis 
ease, or in an acute form of disease which has been unusually 
prolonged. 
The “ facies stupida ” is distinguished by a dullness of ex- 
pression, which is its chief characteristic. A peculiarity exists 
as regards the eyes, which are extremely dull, and resemble 
those seen in alcoholic stupor. This type of countenance is 
identical with the so-called “ typhoid face,” since it is most 
frequently met with either in connection with typhoid fever 
or with the typhoid condition associated with some other dis- 
ease.* 
Another type of countenance to which attention is fre- 
quently drawn is called the “pinched countenance.” It can 
be produced artificially by exposure to cold, and is character- 
ized by an apparent decrease in the size of the face, with a 
contracted and drawn expression of the features, and pallor 
or livid color of the skin. It is said to exist most frequently 
in the course of acute peritoneal inflammation. 
In the long list of diseases which tend to shut off the sup- 
ply of air to the lungs more or less suddenly, and in those ac- 
cidents, such as choking, strangulation, smothering, drowning, 
etc., where the same effect is accomplished, the symptoms of 
apnoea are manifested in the face by flushing and turgidity, at 
first, and, later on, by a livid and purplish color. The veins 
of the neck become markedly swollen, and the eyes seem to 
protrude from their sockets. A loss of consciousness, and pos- 
sibly convulsions, precedes death.f 
The countenance of extreme anaemia is seen in those cases 
where, from sudden or gradual haemorrhage, the prognosis 
is rendered alarming. The phenomena which attend this 
mode of dying are pallor of the face, with a peculiar leaden 
or clay-like hue, cold sweats, dimness of vision, dilated pupils, 
* Finlayson, “ Clinical Diagnosis.” Philadelphia : II. C. Lea, 1878. 
f Watson, “Practice of Physic” (Condie’s edition). 
\ Sir Charles Bell, op. cit. 24 
a slow, weak, irregular pulse, and speedy insensibility. With 
these symptoms are frequently conjoined nausea, restlessness 
and tossing of the limbs, transient delirium; a breathing 
which is irregular, sighing, and, at last, gasping ; and con- 
vulsions before the scene closes. 
Fig. 7.—Face after Haemorrhage. (Modified from Corfe.) 
The expression of the countenance is typically marked in 
certain of the inflammatory diseases of the eye.* In stru- 
mous ophthalmia, the child’s brow is knit and contracted, 
while the ala nasi and the upper lip are drawn upward. Those 
muscles which tend to exclude the light from the inflamed or- 
gan, without shutting out the perception of external objects, 
are called into action; thus producing a peculiar and distinc- 
tive grin. In severe cases, the child will snlk all day in dark 
corners, or, if compelled to stay in bed, will bury the face in 
the pillow, since the exclusion of all light tends greatly to di- 
* Haynes Walton, “ Operative Ophthalmic Surgery.” Philadelphia, 1853. 25 
minish the suffering. If brought to the window, the eyes are 
shaded with the hands or the arms ; and, if the eye be opened, 
a profusion of hot, scalding tears will enter the nose and give 
rise to sneezing, or flow over the face and cause excoriation of 
the adjoining parts. This special intolerance of light seems 
to be a chief characteristic of this type of trouble, since it is 
•often greatly out of proportion to the redness which indicates 
the extent of the inflammation present. In catarrhal ophthal- 
mia, the inflammation seems to be confined to the conjunctiva 
and the Meibomian follicles. The eyelids are glued together 
by the lashes, which are bathed in the excessive secretion of 
the conjunctiva or of the inflamed follicles; and a redness of 
the surface of the eye, with some pain and uneasiness, is the 
only other symptom of special diagnostic value. 
The deformity of iritis is characterized by a redness of the 
sclerotic ; a change in the color of the iris, and in its general 
appearance, as compared with the healthy eye ; an irregularity 
in the pupil, produced by adhesion of the iris to the adjacent 
structures; possibly immobility of the pupil, as the result of 
such adhesions; and a visible deposit of eoagulable lymph. 
The pupil, in acute iritis, seldom dilates in the dark, on ac- 
count of the intense congestion which exists;* and it is usu- 
ally smaller than that of the unaffected eye. Some pain and 
excessive photophobia are usually also present in attacks of 
acute iritis. There is something very peculiar in the expres- 
sion of the countenance of a person suffering from amaurosis, 
by which alone the physician may almost recognize the dis- 
ease. Such a patient enters a room with an air of great un- 
certainty as to movement; the eyes are not directed toward 
surrounding objects ; the eyelids are wide open ; and the pa- 
tient seems gazing into vacancy. This unmeaning stare of the 
face is due, in great measure, to an absence of that harmony 
of movement and expression which results largely from the in- 
formation obtained by the exercise of vision.f This seeming 
stare at nothing is not observed in patients who are blind in 
consequence of opacity of the crystalline lens or of its capsule, 
* See tlie experiments of Mosso, quoted by Michael Foster, 
f Watson, op. cit. 26 
i. e., in consequence of cataract. They, on the contrary, while 
they can not see, still seem to look about them, as if they were 
conscious that the power of sight remained in the retina, al- 
though the perception of objects was shut out from it. Pa- 
tients, afflicted with cataract, who can not detect the existence 
of a gas jet or a candle in a dark room, are not fit subjects for 
operation, as the existence of trouble behind the lens may safely 
be surmised; since the periphery of the lens seldom becomes, 
opaque to such an extent as to prevent the perception of light 
by the retina, even if the outline of objects can not be per- 
ceived. 
The countenance of chronic hydrocephalus is perhaps the 
most typical of any of the conditions to which the attention of 
the physician or surgeon is directed. In it, the frontal bone 
is tilted forward, so that the forehead, instead of slanting a 
little backward, rises perpendicularly, or even juts out at its 
upper part, and overhangs the brow. The parietal bones 
bulge, above, toward the sides; the occiput is pushed back- 
ward ; and the head becomes long, broad, and deep, but flat- 
tened on the top. This, at least, is the most ordinary result. 
In some instances, however, the skull rises up in a conical 
form, like a sugar-loaf. Not unfrequently the whole head is 
irregularly deformed, the two sides being unsymmetrical. 
Some of these rarer varieties of form are fixed and connate; 
others are owing, probably, to the kind of external pressure 
to which the head has been subjected. While the skull may 
be rapidly enlarging, the bones of the face grow no faster than 
usual, perhaps not even so fast; and the disproportion that 
results gives an odd and peculiar physiognomy to the unhappy 
subjects of this calamity. They have not the usual round or 
oval face of childhood. The forehead is broad, and the out- 
line of the features tapers toward the chin. The visage is- 
triangular. The great disproportion in size between the head 
and the face is diagnostic of the disease, and would serve to 
distinguish the skull of the hydrocephalic child from that of a 
giant. In acute cerebral diseases, the countenance is either 
wild and excited, or lethargic and expressionless.* 
* Sir Charles Bell, op. cit. 27 
Thoracic affections are all accompanied by more or less 
change in the color of the face; whereas the alteration in the 
natural hue of the features is so slight in abdominal diseases,, 
that both the intellect and the complexion remain unaltered 
up to the ffnal struggle, though the pinched and dragged fea- 
tures express the acute sufferings of the patient. In pneumo- 
nia, the countenance is inanimate; the cheek, of a dusky hue, 
with a tinge of red; the eyelid droops over the globe; the 
brow is overhanging; the lips are dry, herpetic, and of a faint 
claret color; the chest is comparatively motionless, but the 
abdomen exhibits evidences of activity; the skin is hot; and 
the respiratory acts are usually about double the normal num- 
ber, while the pulse is markedly accelerated. In cases where 
the dyspnoea is extreme, the patient, entirely regardless of 
what is going on about him, seems wholly occupied in respir- 
ing; is unable to lie down, and can scarcely speak; and the 
face becomes expressive of the greatest anxiety, while the ex- 
panded nostrils and their incessant movement indicate pul- 
monary distress. 
In emphysema, the face is not only dusky but anaemic; 
the eyes are wide open, as the patient gazes at you ; the dusky 
redness of the lips bespeaks the lack of proper oxygenation of 
the blood; the neck is thrown backward, and the mouth is 
slightly7 open, while the cheek is puffed out during the expira- 
tory act; the distended nostril and the elevated brow stamp 
the case as one of dyspnoea ; while the coldness of the skin 
shows that no acute inflammatory condition is present. If we 
see, in addition to these facial evidences of disease, the de- 
formity of the chest which has been termed the “ barrel- 
shaped ” thorax, the shrugged shoulders, and the absence of 
that expansive movement so well marked in normal respira- 
tion, auscultation and percussion can hardly make the diag- 
nosis more positive. 
There are certain facial conditions, which so clearly tell, 
to the student of physiognomy, of the existence of that most, 
prominent sign of many pulmonary and cardiac diseases, 
dyspnoea, that it may be well to enumerate the alterations- 
from the normal countenance wdiich chiefly indicate this con- 
dition. In all cases where dyspnoea is present, the brows will 28 
usually be found to be raised; the eyes will be full, staring, 
and clear; the nostril will be dilated, and often it may be 
seen to move with each respiratory act;* the mouth will 
Fig. 8.—Countenance of Emphysema. (Modified from Corfe.) 
commonly stand partly open, while its angles will be drawn 
outward and upward ; the upper lip will be elevated, so as to 
show the margins of the teeth ; and the utterance of the patient 
will be monosyllabic, as the rapidity of breathing renders the 
utterance of long sentences a matter of extreme difficulty. 
When we add to these symptoms those of imperfect oxygena- 
tion of blood, as is met with in all conditions where the free 
entrance of air is in any way interfered with, we can better 
understand liowr the clear eye becomes stupid, as coma ap- 
* Layater, op. cit. ; Sir Charles Bell, “ Anatomy of Expression.” 29 
proaches, from the carbonic-acid poisoning, and the face cy- 
anotic from the venous tinge of the blood. It thus becomes 
possible for the student to picture to himself the countenance 
which must exist in such conditions as acute laryngitis, spas- 
modic and true croup, thoracic tumors which cause pressure 
upon the lungs or the trachea, and the various conditions of 
the lung itself, which impede the entrance of air to the organ, 
but which are not of inflammatory origin, and which have, for 
that reason, no distinctive physiognomy. 
Fig. 9.—Cardiac Dyspnoea. (Modified from Corfe.) 
In cases where renal dropsy has stamped its characteristic 
marks upon the countenance, we may perceive the signs ot 
dyspnoea, due to the accompanying oedema of the lungs, in 
the corrugated forehead, the raised eyebrow, the dilated and 
waving nostrils; the corners of the mouth will be found to be 
drawn downward and outward, expressive of some disease of 
the abdominal cavity; the eye will be full and anxious, in- 
dicative of suffering long continued and borne with patient 
calmness; the conjunctiva may present that pellucid and bleb- 
like condition, so often seen in this type of disease, and an 80 
oedema of the eyelid may greatly alter its appearance ; finally, 
the waxy pallor of the complexion and the pasty and bloated 
cheeks show the profound anaemia of the patient. 
Chronic diseases of the abdominal cavity are usually char 
acterized by a languor of the eye and by an absence of that 
flash of alarm so peculiar to the acute forms of abdominal 
trouble; * and, if attended with steadily increasing danger to 
life, the corrugated brow and eyelid, the retraction of the 
■cheek, the dragged and elongated nostrils, the depressed angles 
of the mouth, the protruded chin, and the parted lips, with 
the teeth firmly clinched behind them, still further proclaim 
the seat of the disease.f 
Fig. 10.—Face of a Patient with Obstruction at the Pyloric Orifice. 
The pale face, stamped with the signs of anxiety and dis- 
tress; the head raised upon two or three pillows, and the 
trunk similarly supported; the knitted brow, which bespeaks 
the cerebral disturbance; the nostrils, waving to and fro with 
each breath; and the jugulars which, as they lie exposed in 
* CORFE, Op. dt. 
f M. Louis, quoted by Marshall Hall, op. dt. 31 
the throat, show that the valves of the. heart are acting im- 
perfectly, by their pulsation or unusual distention ; all may 
Fig. 11.—Cancer of the Abdominal Cavity. (Modified from Corfe.) 
be found in endocardial or pericardial inflammations, or in 
conditions of the heart dependent upon chronic valvular dis- 
ease. * 
The countenance of continued fevers is liable to receive a 
modification from their complication with some morbid affec- 
tion of the head, the viscera of the thorax, or of the abdomen ; 
the dejection produced by the latter of which is among the 
most important objects in the clinical study of these diseases.f 
In scurvy, the dirty ashy hue of the skin and its characteristic 
dryness; the blue and bleeding gums; the emaciation and 
* Corvisart, “Diseases of the Heart,” Gates’s translation. Boston, 1812. 
f Marshall* Hall, op. cit. 32 
the frequent indurations of the inter-muscular tissue of the 
cheeks; the sunken eyes, surrounded by a blue ring; and the 
livid tinge of the lips, make the diagnosis positive at once. 
In Graves’s, or Basedow’s, disease, a peculiarity of the eye 
is produced, due to its partial protrusion from the orbit, prob- 
ably from an increase of the intra-orbital fat, which stamps 
the disease beyond a possibility of error in diagnosis. In many 
cases, the inability to approximate the lids, and an absence of 
powTer to move the eye, on account of the paralysis of the 
muscles from the stretching which they have undergone, fur- 
nish evidence also of disease of that organ which enhances the 
facial deformity. 
In Asiatic cholera, and in children during attacks of pro- 
fuse diarrhoea, the eyeballs sink into the orbit, a dark ecchy- 
mosis appears in the region of the eyes, the lower eyelid forms 
a prominent fold in the region of its attachment to the cheek, 
the nose is pointed and sharp, and the lips, normally ruddy 
and full, become thin and sharply outlined. These changes 
are chiefly dependent upon a rapid emaciation, which follows 
the withdrawal of a large proportion of the water from the 
tissues.* In chronic atrophy, the entire absence of the adipose 
tissue in the subcutaneous structures causes the skin to become 
loose and corrugated; while various muscles become promi- 
nent from contraction (chiefly the frontalis, the corrugator 
supercilii, and the levator labii superioris).f Thus the so- 
called “ senile face ” or “ Voltairean countenance ” is produced, 
which is seldom to be mistaken in the child4 
Among the diseases of the nervous system, there are certain 
types of physiognomy which are so characteristic as to be of 
the most positive value in diagnosis. Thus, in the attacks of 
epilepsy, the neck at first becomes twisted, the chin raised, 
and brought round by a series of jerks toward one shoulder. 
The features are greatly distorted. The brow is knit; the 
eyes are sometimes fixed and staring, at other times rolling 
about in the orbit, and again turned up beneath the eyelid, so 
that the cornea is covered and only the white sclerotic is to be 
seen; the mouth is twisted to one side and distorted; the 
* Vogel, op. cit. f Marshall Hall, op. cit. % Vogel, op. cit. 33 
tongue is thrust between the teeth, and, caught by the violent 
closure of the jaws, is bitten, often severely; and the foam 
which issues from the mouth is reddened with blood. The 
turgescence of the face indicates obstruction of the venous cir- 
culation ; the cheeks become purplish and livid, and the veins 
of the neck are visibly distended. 
The expressions of the countenance which are produced by 
paralysis of any of the special nerves of the face have striking- 
peculiarities which enable the skillful anatomist to easily de- 
tect the nerve affected. It is important to remember that, if 
paralysis of any nerve be the result of any form of external 
injury, a danger is presented in the form of tetanus, which 
should be guarded against by a quick comprehension of the 
existing malady and by all known precautions, applied with 
judgment based on the anatomical course and relations of the 
nerve affected. It is also well to bear in mind the fact, that 
any form of severe external violence about the face may, by 
causing a fracture of the bones through transmission of the 
force applied, cause injury to some special nerve whose course 
may lie far distant from the apparent seat of injury. It is 
not infrequent to find a fracture of the superior maxillary 
bone followed by symptoms indicative of a foreign body within 
the cavity of the antrum; and symptoms of irritation of the 
nasal mucous membrane, or of neuralgia of some of the 
principal nerve trunks distributed to the face, may likewise 
follow such an accident. Violence to the vault of the skull 
may produce not only cerebral lesions and their subsequent 
evidences in the face and body, but also types of local pa- 
ralysis,* produced by injury to some of the more important 
nerve trunks at their point of escape from the skull, in case 
the base of the skull has been injured. 
“A slight tremor of the lips; a hesitation of utterance; a 
partial loss of power over the lips and tongue, which seem to 
have lost their grip, as it were, over the consonants ; a charac- 
teristic stillness of all the muscles of expression ; and a slight 
disparity in the pupils are the predominant features of the 
early stage of development of the general paralysis of the 
* Holden, op. ext. 34 
nsane.” * In those rare cases where the facial nerve of both 
sides is impaired, symptoms similar to those mentioned above 
exist, except that the tongue has its normal capabilities ot 
movement, save in the perfect articulation of the labial conso- 
nants only, and that a complete absence of facial expression 
is present. An open mouth ; a loss of control over the saliva, 
which constantly dribbles ; an awkwardly moving or motion, 
less tongue ; and an indistinct articulation render the labio- 
glosso-laryngeal paralysis of Trousseau and Duchenne easy of 
detection, f In the so-called Bell’s paralysis, which has 
been described in previous pages of this article, the patient 
can not laugh, weep, or frown, or express any feeling or emo- 
tion with one side of the face; while the features of the other 
may be in full play. One half of the aspect is that of a 
sleeping or dead person ; while the other half is alive and 
merry. This incongruity would be ludicrously droll, were it 
not so frightful and distressing. 
During the fit of exacerbation, in an attack of tetanus, 
the aspect of the sufferer is sometimes frightful. The fore- 
head is corrugated and the brow knit, thus expressing the 
most severe type of bodily suffering; the orbicularis muscle 
of the eye is rigid, and the eye itself staring and motionless; 
the nostril is widely dilated, indicating the extreme dyspnoea; 
the corners of the mouth are drawn back, exposing the teeth, 
which are firmly clinched together; and the features, as a 
whole, have a fixed and ghastly grin—the so-called “ risus 
sardonicus.” During such paroxysms, as in those of epilepsy, 
the tongue is liable to become protruded between the teeth 
and to be severely bitten. 
In chorea, the facial muscles participate in the general ec- 
centricity of movement. Watson § thus describes the peculi- 
arities of this strange affection : “ The voluntary muscles are 
moved in that capricious and fantastic way in which we 
might fancy they would be moved, if some invisible mischiev- 
ous being, some Puck or Robin Goodfellow, were behind the 
patient and prompted the discordant gestures. With all this, 
* W. H. Gairdner, Article on “ Medical Physiognomy,” in Finlayson’s 
“ Clinical Diagnosis.” 
f Finlayson, op. cit. \ Sir Charles Bell, op. cit. § Op. cit. 35 
the articulation is impeded : there is the same perverse inter- 
ference with the muscles concerned in the utterance of the 
voice. Bv a strong figure of speech, the disorder might be 
called £ insanity of the muscles.’ ” 
In catalepsy, the patient lies often with eyes open and 
staring, yet without expression indicative of life ; more like a 
wax figure or a corpse than like a living subject. The fea- 
tures may be made to assume any expression, no matter how 
absurd, as the tissues have their normal pliability ; and they 
will remain so placed until again mechanically altered. This 
same peculiarity is also present in the muscles of the extremi- 
ties, and forms one of the distinguishing tests of the disease. 
The mental faculties are in abeyance, and all power of volun- 
tary motion is lost. The sensibility of the body seems also 
to be lost. 
The deformities of face and intellect which seem to be the 
result of residence in special atmospheric conditions, or of cer- 
tain well-defined localities, are illustrated in that race of peo- 
ple found in Yalais and the adjoining cantons of Switzerland, 
called “ cretins.” Many of these wretches are incapable of 
articulate speech ; some are blind, some are deaf, and some 
suffer from all of these privations. They are mostly dwarfish 
in stature, with large heads, wide vacant features, goggle eyes, 
short crooked limbs, and swollen bellies. The worst of them 
are insensible to the decencies of Nature, and in no class of 
mortals is the impress of humanity so pitiably defaced. They 
are usually the descendants of parents afflicted with goitre. 
In that long list of pathological conditions in which the 
brain may be subjected to more or less compression of its 
substance, there are certain signs of positive value in diagno- 
sis which may often assist the medical practitioner to locate 
the disease. Thus, in depressed fracture of the inner table 
of the skull, where the signs of external injury are absent; 
in abscess within the cranial cavity, during the course of me- 
ningeal inflammations; in apoplexy; in the development of 
intra-cranial tumors, etc., the eyelids will usually be closed 
and immovable; the pupils generally dilated or irregular, and 
always sluggish and less sensible to light than in health ; the 
breathing will be slow and stertorous if coma exists ; the spe- 36 
cial senses will be in abeyance ; and the temperature will be 
either normal or increased. The evidences of a paralyzed 
condition of certain of the cranial nerves may also exist, and 
thus afford an additional means of determining the exact seat 
of the disease. A rigidity of certain muscles, if present, de- 
notes some special irritation of the nerves which supply them, 
and it is, therefore, seldom present in cerebral softening, but 
frequently so in those cases where paralysis is produced by 
pressure upon nerve centers. In cases where the fifth cranial 
Fia. 12 -Partial Paralysis of the Facial Nerve froml Disease near the Pons Varolii. 
(Modified from Corfe.) 
nerve has been impaired by pressure, injury, or disease, the 
prominent symptoms are a redness of the conjunctiva on the 
side of the face supplied by the affected nerve; insensibility 
of the cornea, nostril, and tongue on the same side; a dull- 
ness of hearing; a partial or complete loss of smell, sight, and 37 
occasionally of taste also in the anterior two thirds of the 
lateral half of the tongue ; and a diseased state of the gums, 
similar to that observed in scurvy. 
While many typical varieties of countenance, which are 
of value to the diagnostician, have been omitted, since the 
limits of a single article have possibly been already over- 
stepped, still it is to be hoped that the facts mentioned, al- 
though they are but fragmentary jottings, may tend to kindle 
among the medical profession a renewed interest in a subject 
which is rapidly being lost sight of, and the value of which 
is often ignored. It is not to be expected that sight alone can 
guide the medical attendant to unerring diagnosis ; but that 
it may prove of the greatest value as an aid, can not, I think, 
be disputed. It is to be remembered, however, that a direct 
perceptive faculty, like that of touch, hearing, or smell, 
grows with use, and is capable of unlimited development. As 
with the musician, an instrument which at first produced dis- 
cords becomes, under skillful hands, one of melody; so the 
enlightened and accomplished practitioner may often see at a 
glance what, to one unaccustomed to note facial changes or to 
interpret their meaning, would escape detection, unless a 
special effort was made to note and record systematically the 
peculiarities of each particular feature and anatomical region 
of the face, and the records afterward studied, as the mariner 
studies his chart before he attempts to direct his vessel through 
channels with which he is not perfectly familiar.