576 
goitres by the knife have been almost super- 
seded hy 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 , the pneumogastric nerve, which on 
each side the diseased body would overt 
—the trachea and esophagus, which it would 
almost encircle, might indeed be avoided in an 
attempt at its removal; but the enormous ve- 
nous as well as arterial hemorrhage that must 
occur, and the extreme likelihood of dividing 
the recurrent nerves, would involve a not small 
ssibility of accelerating the fatal result, and 
sae every prudent surgeon from attempting 
an operation of such extraordinary risk, except 
under circumstances that might justify the most 
favourable remote prognosis. e 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 vertebra : 
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 esophagus immediately under 
the larynx, it is here that a bulky substance is 
most apt to be detained. In reaching the 
cesophagus 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 a 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 
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 
NECK. 
py. 
dead body, that the artery is likely to be: 
vided if the operation is completed by | 
knife, and hence the expediency of procee 
ing deliberately, cutting but little at a tim 
sponging carefully, so as to see and avoid 
artery, if possible, or to tie it immediat 
when cut. The recurrent nerve runs 
as it reaches the side of the trachea, to 
it is attached in its ascent, lower down. IT 
not allude to the carotid artery as being 
pened to any peril. 1 think, with Mr. A 
urns, that he must be wanton indeed in 
use of his knife, who hurts this vessel. 
making the incision into the cesophag 
to be remembered that the recurrent nerve 
in the angle between this tube and the trac 
and therefore the incision is to be ma 
little behind this angle.” * . 
3. Antero- superior triangle.— This pr 
nearly corresponds to the depression whi 
lean subjects is seen at the side of the 
beneath the jaw and in front of the ste 
cleido-mastoid muscle. It is bounded be 
by the diagonal line to which we have so ¢ 
referred ; the posterior belly of the dig; 
and the superior belly of the omo-hyoid 
stitute, respectively, its upper and le 
ders, and their convergence to the h 
anteriorly forms its apex. The fascia 
ficialis, enclosing the platysma myoides 
tends uninterruptedly over its borders; al 
cervical aponeurosis splitting at each, 3 
singly over the area which they enclose 
transverse processes of the vertebra, ¢ 
by muscular attachment and by the pre-t 
bral aponeurosis, form its floor. The cor 
carotid artery enters it below, and, at ab 
level of the lower border of the third ver 
divides into the internal carotid, which 
tinues to the cranium the direction of thet 
and the external, which runs and rami 
more superficial parts; the sympathetic, 
other regions of the neck, lies betwe 
posterior layer of the sheath of the ves: 
the pre-vertebral fascia ; the superior lar 
nerve lies in the same interval, oblique 
ing from above to the posterior part 
thyro-hyoid membrane behind the 
is on the confines of this triangle and 
gastric space that the posterior belly 
muscle, accompanied by the stylo-hyoi 
cle above and the lingual nerve belos 
across the external and internal carotid: 
about this level the stylo-glossus and st 
ryngeus with the glosso- nt 
tervene between those large arteries. It 
below this crossing that the vessels fal 
our present consideration, and their stu 
be facilitated by extending an arbitrary 
division from the os hyoides ( t the ape 
space) transversely backward. 
would have below it the trunk, bifurea 
continuing branches of the common 
and the origin from the external of th 
rior thyroid artery alone; while, above th 
referred to, the continued ; 
would be seen, and many of 
tt 5 
——s 
seconc 7 
, =o 
t 
a 
* Medico-Chirurgical Transactions, 
