THE FACE. lla brag) 
In dividing a shortened frenum for “ tongue-tie” the ranine vessels and the orifices of 
Wharton’s ducts must be avoided. Behind the frenum.lingue are the anterior borders of 
the genio-hyo-glossi, which descend to the upper genial tubercles. In operations necessitat- 
ing the removal of the region of the symphysis of the jaw, or the separation of the origins 
of the genio-hyo-glossi, the tongue must be kept forward, otherwise the patient will be 
suffocated by the « organ falling backwards over the entrance to the lar ynux. In removing 
a small salivary calculus from the floor of the mouth the calculus should be fixed with the 
finger against the inner surface of the jaw before cutting down upon it. 
When the teeth are clenched the vestibule of the mouth communicates behind 
the last molars with the oral cavity proper through an opening which barely 
admits a medium-sized catheter. Hence, when the jaws cannot be separated it is 
generally necessary to feed the patient through a tube passed along the floor of the. 
nose. 
By opening the mouth widely and taking a deep inspiration, the soft palate is 
elev oe and the anterior and posterior pillars of the fauces are rendered prominent 
(Fig. 658). The anterior pillars are seen to spring from the anterior surface of the 
soft palate, close to the base of the uvula, and to arch downwards and outwards in 
front of the tonsils to end at the posterior extremity of the lateral border of the 
tongue. The posterior pillars are really the continuation of the lower free border of 
the soft palate downwards behind the tonsils to become attached to, and lost upon, 
the postero-lateral wall of the pharynx. Together with the lower edge of the soft 
palate and the base of the tongue they bound a hemispherical opening (isthmus 
faucium), through which is v isible the oral portion of the mucous membrane cover- 
ing the posterior wall of the pharynx. 
The faucial tonsils lie one on each side of the isthmus, between the anterior and 
posterior pillars of the fauces; they are situated opposite the angle of the jaw, 
but they cannot be felt from the outside. Each tonsil is covered on its free 
surface by mucous membrane upon which are seen the orifices of the tonsillar 
crypts; the outer or deep surface is covered by a layer of fibrous tissue which forms 
an imperfect capsule to the organ. According to Merkel, the internal carotid 
artery is situated 1:5 em. behind the outer 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 forward 
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 to the capsule of the tonsil the 
bleeding which attends the operation of removal of the tonsils may be consider- 
able. The hemorrhage can be arrested by pressing the bleeding point outwards 
against the internal ptery ygoid and the ramus of the jaw. If the bleeding be from 
a spurting vessel of larger size, its source, according to Merkel, is probably the 
facial artery, which has “heen wounded as it arches upwards beneath the digastric 
and stylo-hyoid muscles to within a short distance from the outer surface of the 
tonsil. In children and adolescents the tonsils are frequently hypertrophied ; the 
enlargement may be either general, more towards the middle line, downwards along 
the pharynx, or upwards behind the soft palate; to expose and thoroughly remove 
the last-mentioned variety of enlargement the upper part of the anterior pillar of 
the fauces must be divided. 
The mucous membrane and the periosteum of the hard palate are so closely 
united as to form practically one membrane. The posterior palatine arteries, after 
leaving the posterior palatine foramina, run forward in shallow grooves in the 
hard palate, close to its alveolar margin. In the operation for cleft palate 
(staphylorraphy), in order to secure nourishment for the muco-periosteal flaps, the 
lateral incisions should be made eaternal to these vessels. 
| Secondary hemorrhage after the operation for cleft palate is treated by plugging the 
posterior palatine foramen, which lies a little internal to the last molar tooth about 
4 in. in front of the hamular process, which can be felt at the upper extremity of the fold 
of mucous membrane containing the pterygo-maxillary ligament. In the closure of 
a wide cleft of the soft palate the tension of the tensor palati muscle is got rid of 
