THE TONSILS 1351 



being opposite to the last molar tooth. (Roser, Letievant.) In cancer of the tongue pain is 

 often referred up the auriculo-temporal nerve to the ear and side of head. 



Behind the last molar tooth can be felt the coronoid process, and higher up, 

 just behind and medial to the tooth, the pterygoid hamulus of the sphenoid. 

 This process is a landmark to the site of the greater palatine foramen, which lies 

 just in front of it, and which transmits the greater palatine branch of the descend- 

 ing palatine artery, together with the anterior palatine nerve. The vessel and 

 nerve run forward in grooves on the lower surface of the palatine process of the 

 maxilla, giving off anastomosing branches toward the middle line, and join at 

 the incisive foramen with the nasopalatine artery. 



Their position must be remembered in raising the flaps during the operation for closure of 

 a cleft in the hard palate. To ensure the vitality of the flaps the incisions must be made lateral 

 to the vascular arch, close to and parallel with the upper alveolus, and should not extend be- 

 yond a point opposite to and just medial to the last molar tooth, for fear of encroaching upon 

 the posterior palatine canal. 



When the teeth are clenched, there is still a space, communicating between the 

 mouth and pharynx behind the molar teeth, which admits a medium-sized 

 catheter. When a patient breathes deeply through the mouth and the head is 

 thrown back, the soft palate is raised, the pillars (arches) separated; the uvula and 

 fauces, with the anterior and posterior pillars, with their attachments, the tonsils, 

 and the back of the pharynx are exposed. 



This portion of the pharyngeal mucous membrane would lie over the lower part of the 

 second and the upper part of the third cervical vertebrae, the anterior arch of the atlas corre- 

 sponding to the level of the posterior nares, and the body of the epistropheus (axis) to the level 

 of the soft palate (fig. 1097). If a finger be introduced past the soft palate to this part of the 

 spine and turned upward and downward, it is possible, with the aid of an anaesthetic, to examine 

 the upper four or five and, in children, sLx vertebrae, as far as the anterior surfaces of their 

 bodies. 'The part of the column which is accessible to a straight instrument introduced through 

 the mouth is very limited, extending, in the adult, from the lower border of the axis to the middle 

 or lower part of the fourth cervical vertebra; in the child, owing to the small size of the face, it 

 comprises the bodies of the axis and of the third cervical vertebra.' (Thane and Godlee, from 

 Chipault.) The distance from the incisor teeth to the commencement of the oesophagus at 

 the cricoid cartilage is 15 cm. (6 in.) in the adult, and the distance from the teeth to the cardiac 

 orifice of the stomach is 48 to 50 cm. (16 or 17 in.). 



The lymphatic drainage of the face, mouth, and tongue is given on pp. 712 

 and 715. 



Tonsils. — The relations of the tonsils should be carefully examined. Thus, 

 they are separated externally by the superior constrictor and pharyngeal aponeuro- 

 sis from the oscending pharyngeal and internal carotid arteries . The latter vessel 

 lies about 2.5 cm. (1 in.) behind and to the lateral side of the tonsil. When 

 serious haemorrhage follows operations here, it usually comes from one of the 

 numerous tonsillar branches (fig. 448). The extent to which the tonsil is covered 

 by the anterior pillar, how far it projects upward beneath the soft palate or 

 downward into the pharynx, have all important bearings on the mode of removal. 

 Its position corresponds to a point a little above and in front of the angle of the 

 jaw. The lateral surface, enclosed by an imperfect capsule and separated from 

 the superior constrictor by connective tissue, explains how an enlarged tonsil 

 can be dragged medialward by a vulsellum, and enucleated after an incision in the 

 mucous membrane around. It is in this connective tissue that severe infective 

 inflammation, e. g., after scarlet fever or an imbedded pipe-stem, maj^ set up 

 haemorrhage or spreading cellulitis, retro-pharyngeal or otherwise. 



The finger introduced downward at the back of the mouth, especially if the parts are ren- 

 dered in sensitive by local anaesthetics, feels the vallate papillae, the lingual and laryngeal surf aces 

 of the epiglottis, the arytaeno-epiglottidean folds, with the cuneiform and corniculate cartilages. 

 If the finger be moved upward behind the soft palate and turned upward to the base of the skull, 

 and then forward, it will feel the choanae (posterior nares), separated by the vomer. The other 

 boundaries of these are, laterally, the medial pterygoid plate and palate bones; above, the basi- 

 sphenoid; and below, the horizontal plate of the palate bone and the inferior nasal spine. 

 Within each nostril would be felt the posterior ends of the two lower nasal conchae (turbinate 

 bones); above and behind is felt the basilar process of the skull, the vault of the pharynx, 

 and the bodies of the upper cervical vertebrae (fig. 1097). 



The size of the choanae, in the bony skull 2.5 cm. (l.in.) vertically by 1.2 cm. (^ in.), and the 

 presence of any adenoids, are especially to be noted. The richness of the naso-pharynx in 

 glandular structures, its proneness to inflammation, and of this inflammation to spread to other 

 parts, — e. g., the tympanum, — are well known. The finger should be familiar wdth the feel of 



