58 OPENING OF THE GUTTURAL POUCHES. 



scalpel inclined toward the wing of the atlas penetrate in the 

 direction of their fibers the aponenrotic expansion of the 

 mastoido-humeralis muscle and the sterno maxillaris muscle. 

 The puncture is thus located between the ninth and tenth 

 nerves on one side and the internal carotid on the other. 

 Since the wall of the guttural pouch rests against the median 

 side of the digastricus muscle it is opened by this incision. 

 The operator inserts an index finger along the blade of the 

 knife at first and then withdrawing the instrument passes 

 the other index finger also in the penetrant wound and by 

 forcibly parting these dilates it. The abnormal contents are 

 then removed by means of forceps, curetting and irrigation. 

 In order to prevent adhesion of the wound lips in the firmly 

 stretched stylo-maxillaris muscle, introduce a strong drain- 

 age tube into the pouch and fix it to the external borders of 

 the wound by a suture. 



III. Dieterich' 1 s method. This combines the operations 

 under I and II, with the difference that the superior opening 

 of the pouch is made immediately behind the stylo-maxillaris. 

 In order to accomplish this the cutaneous wound over the 

 wing of the atlas must be prolonged below it. After detach- 

 ing the posterior border of the parotid gland the operator 

 searches in the loose areolar tissue with the index finger of 

 the left hand for the vascular angle which is formed by the 

 occipital, internal carotid and external carotid arteries which 

 may be detected by pulsation the same is located at a depth 

 of somewhere from 8 to 10 cm. Place the volar surface of 

 the finger in the vascular angle and push a sharp scalpel 

 along the dorsal surface of the finger to the pouch which 

 here becomes opened on its posterior lateral surface. 



This method has the advantage over Chabert's that for 

 the removal of hard contents (chondroid) the opening can 

 be readily dilated, even to such an extent that the entire 

 hand can be passed into the air sac and the opening of the 

 Kustachian tube be explored. 



