GUIDE TO THE HEAD AND XECK 156^ 



GUIDE TO THE HEAD AND NECK. 



Back of the Scalp and Neck. — The landmarks having been studied, the skin 



is to be removed by making the following incisions : one is to be carried along 

 the median line from the level of the seventh cervical spinous process to the 

 vertex of the skull, and this incision may be prolonged to the root of the nose ; 

 a second is to be made from the upper part of the auricle, and a third from 

 the acromial region, both of these meeting the first incision. On reflecting the 

 flaps of skin thus marked out great care has to be exercised, as the skin and 

 superficial fascia are very closely adherent. The cutting edge of the knife 

 should be directed towards the sldn, so as to score it, and in doing so the roots 

 of the hairs will be severed. At the same time the dissector will note the 

 strong fibrous processes which bind the superficial fascia to the skin. 



The cutaneous nerves jire to be displayed at once, and followed to their 

 terminations. The great occipital nerve, with the occipital artery lyiag 

 external to it, will be met with piercing the complexus, and. it mav be, the 

 trapezius, about ^ inch from the median line, and the occipital venous plexus 

 is to be kept in view. The least, or third, occipital nerve, very minute, will 

 be found internal to the great occipital, and the small occipital nerve is to^ 

 be found along the posterior border of the stemo-cleido-mastoid muscle. 

 The great auricular nerve lies immediately below the small occipital, and 

 turns upwards and forwards over the upper part of the stemo-cleido-nicistoid 

 towards the lobule of the auricle, where its mastoid, auricular, and facial 

 branches are to be shown. The superficial or transverse cervical nerve can 

 cnly be shown initially. It appears immediately below the great auricular,, 

 and at once passes horizontally forwards over the stemo-cleido-mastoid, 

 where it must be left in the meantime. The spinal accessory nerve is to be 

 caught where it appears from beneath the posterior border of the stemo- 

 cleido-mastoid, about its centre and below the superficial cervical. It is to- 

 be followed downwards and outwards across the posterior triangle to the 

 anterior border of the trapezius, beneath which it disappears. Accompany- 

 ing it, and hnng on a lower level than it, an effort should be made to show 

 the two branches which the anterior primary divisions of the third and fourth 

 cervical nerves furnish to the trapezius. The descending superficial branches 

 of the cervical plexus will be met with at the posterior border of the stemo- 

 cleido-mastoid, immediately below the spinal accessory. If they appear as 

 one trunk they will soon divide into suprasternal, supraclavicular, and supra- 

 acromial ; but these nerves, in this position of the subject, can only be seen 

 at their commencement. 



The internal branches of the posterior primary divisions of the third, fourth, 

 and fifth cervical ner\-es are to be displayed as they pierce the trapezius close 

 to the median line, and they are to be followed outwards. 



Behind the auricle, over the mastoid process, the mastoid glands are to be 

 carefully looked for, and the occipital gland, or glands, will be met with over 

 the cranial insertion of the trapezius, or, it may be, the complexus. Along 

 the posterior border of the stemo-cleido-mastoid the glandulx concatenate 

 are to be looked for. 



