Operative surgery . se thegland from behind forward, and receive a communicating branch from thegreat auricular in its substance. Immediately beneath the floor of the spacelie the internal carotid artery and internal jugular vein, along with the spi-nal accessory, glosso-pharyngeal, and pneumogastric nerves. Lymphaticglands lie over the parotid and are present within it, and their enlargementmay be mistaken for that of the gland itself. 1106 OPERATIVE SURGERY. llie Contrai7idicatio7is to Extivpatwji.—Iininobility of tlie tumor anda malignant growth implicating the structure of the gland may be
Operative surgery . se thegland from behind forward, and receive a communicating branch from thegreat auricular in its substance. Immediately beneath the floor of the spacelie the internal carotid artery and internal jugular vein, along with the spi-nal accessory, glosso-pharyngeal, and pneumogastric nerves. Lymphaticglands lie over the parotid and are present within it, and their enlargementmay be mistaken for that of the gland itself. 1106 OPERATIVE SURGERY. llie Contrai7idicatio7is to Extivpatwji.—Iininobility of tlie tumor anda malignant growth implicating the structure of the gland may be regardedas strong contraindications to operation. The Operation.—Place the patient upon a suitable table in a good light,with the shoulders elevated and the head turned to the opposite side. Makean incision from the zygoma downward along the central line of the tumorto its lower border. If necessary, this one can be supplemented by one ormore extending from it at right angles. The integumentary flaps are freely. Fig. 1298.—The surgical anatomy of the thyroid gland. reflected to expose the growth. The tumor should be raised from belowupward, and held by a volsella. This will raise the external carotid from itsbed, when it should be isolated, tied between two ligatures, and vessels that enter or escape from the tumor at this point should betreated in the same manner (Fig. 1298). The tumor can now be raisedupward, and its separation from the deeper tissues continued by means ofthe fingers or handle of the scalpel; the former are the better. The vessels,as they appear in the course of the dissection, are isolated and cut betweentwo ligatures. The separation of the growth from the floor of the space must be donegently and with great caution on account of the contiguity of the internaljugular vein and the other important vessels, and the nerves located there,which, if the growth be a large one, will be pressed upon by it, and may havebecome adherent to it. It is sc
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