576 



NECK. 



goitres by the knife have been almost super- 

 seded by the discovery, that iodine exerts a 

 marked controul over many enlargements of 

 the thyroid body ; and it would evince other 

 boldness than that of knowledge, lightly to 

 undertake the excision of a tumour so impor- 

 tantly connected. The jugular vein, the caro- 

 tid artery, the pneumogastric nerve, which on 

 each side the diseased body would overlap, 

 the trachea and oesophagus, which it would 

 almost encircle, might indeed be avoided in an 

 attempt at its removal ; but the enormous ve- 

 nous as well as arterial haemorrhage that must 

 occur, and the extreme likelihood of dividing 

 the recurrent nerves, would involve a not small 

 possibility of accelerating the fatal result, and 

 deter every prudent surgeon from attempting 

 an operation of such extraordinary risk, except 

 under circumstances that might justify the most 

 favourable remote prognosis. The ligature of 

 its nutrient arteries has been advocated as a 

 cure for bronchocele ; but, although this mode 

 of procedure presents fewer anatomical difficul- 

 ties than that last mentioned, yet, from surgical 

 considerations of its extreme uncertainty and 

 unsafe protraction, it seems little entitled to 

 preference. 



On the left side, the (esophagus, inclining 

 from the median line, presents itself in the 

 antero-inferior triangle. It only half emerges 

 from behind the trachea (which still covers its 

 right portion), and closely lies on the vertebrae : 

 it continues the canal of the pharynx, from a 

 line of abrupt distinction opposite the lower 

 edge of the cricoid cartilage, downward. It is 

 at its commencement that this tube most fre- 

 quently interests the surgeon, by becoming the 

 seat of stricture, or by arresting and fixing 

 foreign bodies. To this space the operation of 

 cesophagotomy belongs ; and the left side is, 

 for obvious reasons of convenience, chosen for 

 its performance. In Mr. Arnott's instructive 

 paper on the subject the following directions 

 occur, which may serve to illustrate the ana- 

 tomy of the region in regard of the operation in 

 question : " The situation of the external in- 

 cision will, in some measure, depend upon 

 that of the body to be removed, but as the 

 pharynx, tapering gradually in its descent, ter- 

 minates in the oesophagus immediately under 

 the larynx, it is here that a bulky substance is 

 most apt to be detained. In reaching the 

 oesophagus at this place, taking as a centre a 

 spot corresponding to the level of the lower 

 margin of the cricoid cartilage and the first 

 ring of the trachea, the only parts of conse- 

 quence, whose injury is to be dreaded, are the 

 inferior thyroideal artery and recurrent nerve, 

 (the superior thyroideal artery being too high 

 to run any risk ;) but these will not be wound- 

 ed, if the same plan is adopted as that in the 

 case related, of separating the deeper-seated 

 parts by the handle of the scalpel and the 

 finger instead of by the knife. Here they were 

 not seen during the operation, in fact they 

 were not within the sphere of the wound, for, 

 on examining the parts after death, the artery 

 and nerve were found below and on the inner 

 side of it. Still I am satisfied by trials on the 



dead body, that the artery is likely to be di- 

 vided if the operation is completed by the 

 knife, and hence the expediency of proceed- 

 ing deliberately, cutting but little at a time, 

 sponging carefully, so as to see and avoid the 

 artery, if possible, or to tie it immediately 

 when cut. The recurrent nerve runs less risk 

 as it reaches the side of the trachea, to which 

 it is attached in its ascent, lower down. I do 

 not allude to the carotid artery as being ex- 

 posed to any peril. 1 think, with Mr. Allan 

 Burns, that he must be wanton indeed in the 

 use of his knife, who hurts this vessel. In 

 making the incision into the oesophagus, it is 

 to be remembered that the recurrent nerve runs 

 in the angle between this tube and the trachea, 

 and therefore the incision is to be made a 

 little behind this angle." * 



3. Antero- superior triangle. This pretty 

 nearly corresponds to the depression which in 

 lean subjects is seen at the side of the neck 

 beneath the jaw and in front of the sterno- 

 cleido-mastoid muscle. It is bounded behind 

 by the diagonal line to which we have so often 

 referred ; the posterior belly of the digastric 

 and the superior belly of the omo-hyoid con- 

 stitute, respectively, its upper and lower bor- 

 ders, and their convergence to the hyoid bone 

 anteriorly forms its apex. The fascia super- 

 ficialis, enclosing the platysma myoides, ex- 

 tends uninterruptedly over its borders; and the 

 cervical aponeurosis splitting at each, extends 

 singly over the area which they enclose : the 

 transverse processes of the vertebrae, covered 

 by muscular attachment and by the pre-verte- 

 bral aponeurosis, form its floor. The common 

 carotid artery enters it below, and, at about the 

 level of the lower border of the third vertebra, 

 divides into the internal carotid, which con- 

 tinues to the cranium the direction of the trunk, .- 

 and the external, w.hich runs and ramifies in 

 more superficial parts; the sympathetic, as in 

 other regions of the neck, lies between the 

 posterior layer of the sheath of the vessels and 

 the pre-vertebral fascia ; the superior laryngeal 

 nerve lies in the same interval, obliquely bend- 

 ing from above to the posterior part of the 

 thyro-hyoid membrane behind the vessels : it 

 is on the confines of this triangle and the di- 

 gastric space that the posterior belly of that 

 muscle, accompanied by the stylo-hyoid mus- 

 cle above and the lingual nerve below, arches 

 across the external and internal carotids, and at 

 about this level the stylo-glossus and stylo-pha- 

 ryngeus with the glosso-pharyngeal nerve in- 

 tervene between those large arteries. It is only 

 below this crossing that the vessels fall under 

 our present consideration, and their study may 

 be facilitated by extending an arbitrary line of 

 division from the os hyoides ( t the apex of the 

 space) transversely backward. Such a line 

 would have below it the trunk, bifurcation and 

 continuing branches of the common carotid, 

 and the origin from the external of the supe- 

 rior thyroid artery alone ; while, above the level 

 referred to, the continued secondary trunks 

 would be seen, and many of the branches 



* Medko-Chirurgical Transactions, vol. xviii. 



