NECK. 



583 



ascends here ; and since, from the angle of the 

 jaw to the base of the skull, it lies beside the 

 pharynx, covered by the lateral parts of that 

 cylinder, it is liable to be involved in a punc- 

 tured wound from the mouth ; and this unfor- 

 tunate accident has not unfrequently occurred 

 in operations on the tonsil, which organ in its 

 swollen state is so closely applied to the in- 

 ternal carotid artery, that if it were transfixed 

 by a bistoury in an outward direction, the 

 vessel could hardly escape. Hence the im- 

 portance of care, in relieving tonsillary ab- 

 scesses, to direct the point of the instrument, 

 as much as possible, towards the median line, 

 and to select for incision that part of the cyst 

 which most nearly adjoins the palate. The 

 jugular vein emerges behind the artery and 

 runs downwardly along its outer side : of the 

 three divisions of the eighth nerve, which leave 

 the cranium in front of the vein, the glosso- 

 pharyngeal is applied to the outer, the vagus 

 and spinal accessary to the inner part of its 

 circumference. The muscular branch of the 

 latter winds from within behind the vein, and 

 obliquely descends to the sterno-mastoid : the 

 vagus continues to descend vertically along its 

 inner side, but both the glosso-pharyngeal and 

 hypo-glossal nerves obliquely cross between it 

 and the artery, and subsequently arch over the 

 latter in their passage to the tongue. From its 

 relations to the vertebrae in this space, the pha- 

 lynx may participate in their diseased condi- 

 tions, and give vent to abscesses, dependent on 

 caries of the cervical spine. The surgeon may 

 sometimes assist his diagnosis of complaints so 

 situated, by introducing his ringer into the 

 pharynx.* 



8. Lastly, I proceed to recapitulate, briefly 

 and in connexion, the practical relations of the 

 sterno-cleido-rnastoideus in regard of the spaces 

 which have been described. Its clavicular 

 origin is in the inferior division of the posterior 

 triangle, covers the subclavian artery in the first 

 and second portions of its course, and in many 

 instances extends this origin so far outwardly 

 as to hide the vessel during a considerable part 

 of its third stage ; it likewise, of course, covers 

 many parts lying between it and the artery, 

 the jugular and subclavian veins, the vagus and 

 phrenic nerves, the scalenus anticus and omo- 

 hyoid muscles, and the origin and divergence 

 of many arterial branches: these fibres obviously 

 require division, varying according to circum- 

 stances, when the subclavian artery is to be 

 exposed. The interval between its origins cor- 

 responds to the sterno-clavicular joint, and, on 

 the right side, to the bifurcation of the arteria 

 innominata : along the cellular line, prolonged 

 from this interval, (which answers to the dia- 

 gonal dividing the two great triangles,) M. Se- 

 dillot proposes to penetrate, without section of 



* A case has lately occurred to the writer illus- 

 trating; this fact. It was one of neuralgia; the pain 

 was of extreme severity and obstinacy ; it affected 

 the occipital region, and was referred to the great 

 occipital nerve. An examination through the 

 pharynx succeeded in detecting, as its prohahle 

 cause, a firm (apparently bony ) tumour, connected 

 with the transverse processes, between which that 

 nerve emerges. 



muscular fibre, in order to reach the common 

 carotid artery. The sternal head of the muscle, 

 directing itself backward, obliquely crosses, in 

 the inferior segment of the great anterior trian- 

 gle, the sheath of the vessels, from which the 

 sub-hyoid muscles partly divide it. In order 

 to reach the common carotid artery these fibres 

 are accordingly cut asunder, except where the 

 operator prefers the anatomical finesse of M. Se- 

 dillot's plan. Tracing the muscle in the middle 

 of the neck, we find it a most serviceable guide 

 in operations on the common carotid, and on 

 its primary or secondary branches. A vertical 

 incision directed to the point of its intersection 

 with the omo-hyoid muscle (nearly opposite the 

 cricoid cartilage) enables the surgeon conve- 

 niently to draw these muscles aside, and to 

 expose, according as the wound is higher or 

 lower, the external and internal carotids, or the 

 trunk from which they originate, and, in close 

 connexion with the anterior layer of their sheath, 

 the descending branch of the hypo-glossal. 

 Finally, about and above the level of the hyoid 

 bone, the anterior edge of ihe sterno-mastoid, 

 with the posterior belly of the digastric, and 

 the cornu of the os hyoides, furnish definite 

 marks for discovering the superior thyroid, the 

 lingual, the facial or the continued external 

 carotid artery; since, in the space so bounded, 

 the last named vessel vertically ascends, the 

 first almost horizontally advances, and the other 

 two pass to their destinations with intermediate 

 obliquity. 



IV. ADDITIONAL PRACTICAL OBSERVATIONS. 



It yet remains, in conclusion, briefly to 

 review some circumstances in the anatomy of 

 the neck, which particularly bear on its dis- 

 eases and on the operations undertaken for 

 their cure. 1. In endeavouring to form a 

 diagnosis of tumours in this region, the surgeon 

 will, in the first place, remember their extreme 

 liability to deceptive pulsation, and will neg- 

 lect no precaution for ascertaining their rela- 

 tion to the large arterial trunks. The glands, 

 which lie about the common and external ca- 

 rotid arteries, in the anterior triangle of the 

 neck, and those which are situated in the 

 supra-clavicular space, are particularly subject, 

 when enlarged, to derive pulsation from the 

 vessels to which they are respectively conti- 

 guous. The history of the case, the signs 

 afforded by auscultation, the manner in which 

 a non-aneurismal tumour may frequently be 

 moved away from the artery that communi- 

 cates an impulse to it, the marked difference 

 even to the unpractised hand, between the 

 mere jerk of elevation in the one case, and the 

 thrilling diastole in the other, are materials for 

 distinction, to which it is here enough to allude. 

 Nor must it be forgotten, that, from the near- 

 ness of the aortic arch to the root of the neck, 

 its aneurisms, as they grow upwards and clear 

 the strait of the thorax, may simulate the cha- 

 racters of a like disease in the carotid or sub- 

 clavian artery. Cases constantly occur, (and 

 may be found abundantly quoted in systematic 

 surgical works,) in which tumours of this kind, 



