OPENING OF THE UrTTCRAL POUCHES. 75 



opening thus formed there is seen the stylo-maxillaris 

 muscle, sm, Plate XIV, lying against the median side of 

 the parotid gland covered only by the aponeurosis of the 

 mastoido-humeralis muscle. With the handle of the scalpel 

 inclined toward the wing of the atlas penetrate in the 

 direction parallel to the long axis of their fibers the aponeu- 

 rotic expansion of the mastoido-humeralis, and the stylo- 

 maxillaris muscle. The puncture is thus located between 

 the ninth and tenth nerves on one side and the internal 

 carotid artery on the other. Since the wall of the guttural 

 pouch rests against the median side of the digastricus 

 or sterno-maxillaris 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 into the penetrant wound and 

 by forcibly parting these, dilates it. The abnormal contents 

 are then removed by means of forceps, curetting and irriga- 

 tion. In order to prevent adhesion of the wound lips in 

 the firmly stretched stylo-maxillaris muscle, introduce a 

 strong drainage tube into the pouch and fix it to the external 

 borders of the wound by a suture. 



III. Dieterich' s method. This operation is effected at a 

 point between I and II, the opening of the pouch being 

 made immediately behind the stylo-maxillaris muscle. In 

 order to accomplish this the cutaneous wound over the wing 

 of the atlas must be prolonged below it. After detaching 

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

 in the vascular angle and push a sharp scalpel along its 

 dorsal side to the pouch which here becomes opened on its 

 posterior lateral surface. 



