THE FACE, MOUTH AND PHARYNX 187 



involved, i.e. not only the proximal glands but also the whole 

 chain of the deep cervical lymph glands. 



On this account Butlin advocated the complete dissection of 

 the anterior triangle as a routine measure. The area is exposed 

 by two incisions, one along the whole length of the anterior 

 border of the sterno-mastoid and the other extending from the 

 symphysis menti to meet the first at the level of the upper 

 border of the thyreoid cartilage. The two skin flaps are retracted 

 and the exposed platysma is removed, since it is traversed by 

 lymph vessels which connect the deep and superficial cervical 

 lymph glands. For the same reason the investing layer of the 

 deep fascia and the pretracheal fascia are both removed, as well 

 as the stylo-mandibular ligament. All the anterior deep cervical 

 lymph glands are taken away, and the lower part of the parotid 

 salivary gland is removed in order to give access to the uppermost 

 members of the group. In order to make certain that none of 

 the submaxillary lymph glands are overlooked, the submaxillary 

 salivary gland is also excised. Finally, after the removal of the 

 submental lymph glands, the median raphe of the mylo-hyoids 

 is cut through, and a search is made between the two genio-hyoid 

 muscles. 



When this operation is carried out as a preliminary step to 

 removal of the tongue, and where there is extensive glandular 

 infection, the external carotid artery and internal jugular vein 

 may be resected. 



On account of its rich network of lymphatics, and the presence 

 in its substance of a quantity of loose connective tissue, the 

 tongue may, in acute glossitis, suddenly become so enormously 

 swollen as to fill up the mouth and protrude from it. Relief 

 may be obtained by free incisions, which are made parallel to 

 the course of the profunda linguae (ranine) artery (i.e. from 

 behind forwards). In the event of injury to the vessel, which 

 lies on a deep plane, the haemorrhage may be controlled by 

 introducing the finger into the mouth and hooking the base of 

 the tongue forwards against the mandible. 



The position of lingual dermoids is described on p. 152. 



Removal of One Half of the Tongue for malignant disease 

 may be performed entirely through the mouth. The mucous 

 membrane is cut through from the frenulum linguae to the 

 glosso-palatine arch (anterior pillar of the fauces), along the 

 line of its reflection from the gum. A second incision is made, 

 commencing at the frenulum, passing over the under surface of 



