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count of the very slender anastomosis between the vessels of the two halves - tongue, scarcely any bleeding occurs when the organ is split in the median

cording to Poirier, the collecting trunks which arise from the lymph net

in the mucous membrane and muscular substance of the tongue may be ed into four groups :-(1) Apical trunks which open partly into the submental s and partly into a gland of the medial deep cervical group lying immediately the anterior belly of the omo-hyoid muscle. (2) Marginal trunks which pass, ateral to the sublingual gland and through the mylo-hyoid muscle, to join the anterior of the submaxillary lymph glands; others pass medial to the sub1 gland, in front of and behind the hyoglossus muscle, to join the glands of the 1 deep cervical group. The more anterior their lingual origin the lower in the is the gland to which they pass. (3) The basal trunks, from the posterior of the tongue, pass from before backwards towards the inferior extremity of nsils, where they pierce the superior and middle constrictors of the pharynx, fter surrounding the lingual artery, open into a gland placed on the internal r vein immediately below the posterior belly of the digastric. (4) The central , which descend in the middle line between the genio-glossi

, pass beneath the ssus and mylo-hyoid muscles into the submaxillary space, and thence in of the hyoid bone (having embraced the tendon of the digastric) to join the

of the medial deep cervical group. tween the tongue and the lingual surface of the gums is the alveolo-glossal crossed in the median plane by the frenulum linguæ, which passes upwards to ferior surface of the tongue (Fig. 1084). Immediately on either side of the part of the frenulum is the orifice of the submaxillary duct. A little external frenulum the profunda veins are seen lying immediately under the thin mucous rane; to the lateral side of the veins are the profunda arteries and the lingual , both of which lie deeper than the veins, and are therefore not visible. e mucous membrane at the anterior part of the floor of each alveolo-glossal

is thrown into a slight elevation, which overlies, and is caused by, the ponding sublingual salivary gland. The duct of the submaxillary gland and gual nerve lie beneath and to the medial side of the sublingual gland. dividing a shortened frenulum for “tongue-tie" the deep lingual vessels and the of the submaxillary ducts must be avoided. Behind the frenulum linguæ are the r borders of the genio-glossi, which descend to the superior genial tubercles. In ons necessitating the removal of the region of the symphysis of the mandible, or the ion of the origins of the genio-glossi, the tongue must be kept forward, otherwise tient will be suffocated by the organ falling backwards over the entrance to the

In removing a small salivary calculus from the floor of the mouth the calculus be fixed with the finger against the lingual surface of the mandible before cutting

pon it.

hen the teeth are clenched the vestibule of the mouth communicates behind #t molars with the oral cavity proper through an opening which barely admits ium-sized catheter. Hence, when the jaws cannot be separated it is generally ary to feed the patient through a tube passed along the floor of the nose. hen the mouth is opened widely and a deep inspiration is taken, the soft

is elevated, and the glosso-palatine and pharyngo-palatine arches are red prominent. The glosso - palatine arches spring from the anterior

of the soft palate, close to the base of the uvula, and arch downand laterally, in front of the palatine tonsils, to end at the posterior end - side of the tongue. The pharyngo-palatine arches are really the continuaf the lower free border of the soft palate downwards behind the palatine s to become attached to, and lost upon, the side wall of the pharynx. her with the lower edge of the soft palate and the base of the tongue they

a hemispherical opening (pharyngo-nasal isthmus), through which the mucous rane covering the posterior wall of the nasal portion of the pharynx is visible. e palatine tonsils (Fig. 1085) lie one on each side of the isthmus, between the ne arches; they are situated opposite the angle of the mandible, but they cannot

[graphic]

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greater palatine
in front of the lia
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be felt from the outside. Each tonsil is covered, on its free surface, by mucous during the greate membrane upon which are seen the orifices of the tonsillar crypts; the lateral or palate, close to it deep surface is covered by a layer of fibrous tissue which forms an imperfect ophy)

, in order
capsule to the organ. According to Merkel, the internal carotid artery is situated Disions should
1:5 cm. behind the lateral margin of the tonsil, which is separated from the superior
constrictor by a quantity of loose cellular tissue and fat, so that the gland can be
grasped with a volsellum and pulled forwards without dragging the vessel with it.
The tonsil receives its blood-supply mainly from a small vessel derived from the
anterior palatine artery; when this branch is larger than usual and adherent todel of the soft
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greater palatine foramina, run forwards in shallow grooves in the hard to its alveolar margin. In the operation for cleft palate (staphylororder to secure nourishment for the muco-periosteal flaps, the lateral ould be made lateral to those vessels. ry hæmorrhage after the operation for cleft palate is treated by plugging the latine foramen, which lies a little medial to the last molar tooth about } in. the hamular process, which can be felt at the superior extremity of the fold of embrane containing the pterygo-maxillary ligament. In the closure of a wide e soft palate the tension of the tensor veli palatini muscle is got rid of by ff the hamulus with a small chisel introduced at the posterior extremity of the ef incisions. | Part of the Pharynx.—To explore the superior or nasal part of the the finger should be hooked upwards behind the soft palate. Anteriorly, er readily detects the sharp posterior border of the vomer, the choanae, posterior extremity of the middle and inferior conchæ. The roof of the formed by the basilar part of the occipital bone, while upon the posterior

transverse bony ridge caused by the projection of the anterior arch of the Upon the side walls of the nasal part of the pharynx are the openings auditory tubes, situated } in. behind the posterior extremities of the conchæ. The orifices, bounded superiorly and posteriorly by a prominent are directed downwards and forwards, and, therefore, in a direction favourthe passage of the Eustachian catheter. Behind the prominent posterior

of the orifice is the recess of the pharynx (O.T. fossa of Rosenmüller), ch the point of the Eustachian catheter is apt to become engaged. Upon of and posterior wall of the pharynx, down to the level of the anterior f the atlas, and extending laterally as far as the orifices of the auditory tubes, llection of adenoid tissue, the pharyngeal tonsil. Hypertrophy of this tissue tutes the condition known as “adenoids," the harmful effects of which are due eir interference with nasal respiration. Upon the centre of the pharyngeal I is an orifice leading into a small recess into which numerous mucous glands

The structures felt in the post-nasal space may be rendered visible by cting the light upon a small mirror placed immediately behind and below the palate (posterior rhinoscopy). The inferior part of the inferior concha is ured from view by the bulging of the superior surface of the soft palate. In plugging the posterior nares, it is important to remember that those openings sure nearly one inch in the vertical and half an inch in the transverse direction. the child, owing to the small size of the face, the vertical diameter of the nasoarynx is relatively much smaller than in the adult. The lymph vessels from the nasal cavities and pharynx, including the palatine d pharyngeal tonsils, join the sub-parotid and superior deep cervical glands, one

which lies medial to the carotid vessels between the recess of the pharynx d the prevertebral fascia. In children suppuration originating in this gland is e commonest cause of a retro-pharyngeal abscess.

In the adult the four upper cervical vertebræ can be explored from the mouth, hile in the child the finger can also reach as far down as the sixth vertebra and the ack of the cricoid cartilage.

THE NECK.

The general envelope of deep cervical fascia, along with the processes and partitions which proceed from its deep surface, subdivides the neck into compartments which limit and determine the spread of pus. The most important compartment is the central or visceral compartment, bounded anteriorly by the pretracheal fascia, posteriorly by the prevertebral fascia, and laterally by the fascia forming the vascular compartment. Posteriorly, this compartment extends from the base of the skull downwards into the posterior mediastinum; anteriorly, it extends from the hyoid bone into the anterior part of the superior mediastinum. Abscesses in the visceral compartment are either secondary to disease of the lymph glands or organs it

[graphic]

contains, or the result of a primary suppurative cellulitis. A tubercular abscess with the carotid originating in one of the retropharyngeal lymph glands (Fig. 1085) lies in fronting the trunk of of the prevertebral fascia, and points towards the posterior wall of the pharynx,

avtid sheath & abscesses secondary to disease of the cervical vertebræ lie behind the prevertebral interval between fascia, and spread laterally behind the vascular compartment; they point behind pland, which is the sterno-mastoid, and should be opened through an incision at the posterior

A glandular border of the muscle, the surgeon keeping to the anterior aspect of the transverse udhesions being processes in order to avoid the structures in the vascular compartment (Chiene).

In front of the visceral compartment is a small muscular compartment containing this compart the infra-hyoid muscles; anterior to it again, in the region of the supra-sternal ether the media notch, is the small supra-sternal compartment, containing the lower part of the

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arotid sheath and its contents, being pulled well forwards. In approachrunk of the inferior thyreoid artery from the front the sterno-mastoid and neath are retracted and the dissection is continued through the cellular between the carotid sheath and the sheath (outer capsule) of the thyreoid nich is formed by the splitting of the pretracheal fascia. indular abscess in this compartment usually points upon the surface, 3 being formed, first, between the gland and the fascia, and, subsequently, the latter and the cutaneous structures. In diffuse suppurative cellulitis ompartment the pus burrows towards the root of the neck, and may reach e mediastinum or the axilla. ian Line of the Neck. The body of the hyoid bone divides the median plane ck into supra- and infra-hyoid portions. Above the hyoid bone is the subriangle, with its apex at the inferior border of the symphysis menti and its

[graphic]

Anterior belly of digastric

Mylo-hyoid

Submaxillary gland

Submaxillary gland

Omo-hyoid Thyreo-hyoid membrane

Sterno-hyoid

Internal jugular vein
Thyreoid cartilage

Superior thyreoid vein
Superior thyreoid artery

Common carotid artery
Crico-thyreoid ligament

Sterno-mastoid
Cricoid cartilage

Crico-thyreoid muscle
Lobe of thyreoid gland

Lobe of thyreoid gland
Common carotid

Isthmus of thyreoid
Phrenic nerve

Scalenus anterior
Inferior thyreoid
Transverse cervical

Scalenus medius
Vertebral artery

Subclavian artery
Subclavian artery
Transverse scapular artery
Common carotid artery

First rib
Internal mammary artery

Trachea
Innominate artery

Inferior thyreoid vein 087. — DISSECTION OF THE FRONT OF THE NECK. The lower portions of the sterno-mastoid muscles have been removed, and the lower part of the right common carotid artery cut away to show the deeper parts. (From Cunningham. )

formed by the anterior bellies of the digastrics. In the floor of the triangle the anterior portions of the mylo-hyoid muscles, separated by the median e (Fig. 1087). The most important structures in the triangle are the submental h glands, which can usually be felt a little above the body of the hyoid • In children they are a frequent seat of abscess secondary to impetigo of the er lip and chin. About 1 in. below the hyoid bone is the pomum Adami, more minent in the male than in the female. On either side of the pomum Adami the laminæ of the thyreoid cartilage, while between the latter and the hyoid bone he thyreo-hyoid membrane. In the operation of sub-hyoid pharyngotomy the lottis and the superior opening of the larynx are reached by passing through anterior wall of the pharynx at the level of the thyreo-hyoid membrane.

structures divided from without inwards are: the integuments, the sternoid, omo-hyoid, and thyreo-hyoid muscles, the median portion of the thyreo-hyoid mbrane, along with a layer of fat between it and the lower part of the glottis

, and, finally, the glosso - epiglottic ligament and fold of mucous mbrane. The incision must not be extended too far on either side of the

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