OPENING OF the; GUTTURAL POUCHES 55 



stylo-maxillaris muscle, sm. Fig 17, 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 aponeurotic expansion of the mastoido-humeralis, 

 and the stylo-maxillaris muscles. 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 instru- 

 ment passes the other index finger also into the penetrant 

 wound and by forcibly parting these, dilates it. The ab- 

 normal contents are then removed by means of forceps, 

 curretting and irrigation. 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. 



13. THE ROARING OPERATION 

 FIGS. 18-22 



Instruments. Razor, hypodermic syringe, scalpels, tena- 

 culum, artery forceps, laryngeal speculum, two long 

 curved dressing forceps, hard rubber syringe with long 

 pipe, two soft rubber ventricular burrs, reflecting lamp, 

 razor-shaped scalpel, long angular scissors. 



The following technic has for its aim two fundamental 

 objects which are to be kept constantly in mind : 



I. It is aimed to bring about a prompt, firm, complete 

 and permanent adhesion of the arytenoid cartilage and vocal 

 cord against the inner face of the thyroid cartilage in the 



