

THE NECK 117 



ensure a successful result, and this proceeding cannot be carried 

 out by the subcutaneous method. At the present time an open 

 operation is performed through an oblique incision across the 

 lower part of the muscle. The deep fascia is freely incised, and 

 the muscle is divided along with the fascia on its deep surface. 

 It may even be necessary to open the carotid sheath to obtain 

 sufficient relaxation. 



The Internal Jugular Vein is a direct downward con- 

 tinuation of the transverse (lateral) sinus, and it emerges from the 

 skull at the posterior part of the jugular foramen. In its upper- 

 most part it is rarely seen by the surgeon, since it lies deeply, 

 under cover of the styloid process and the parotid gland. It 

 descends in the carotid sheath, the relations of which are 

 described on p. 115, and it is covered by the sterno-mastoid 

 muscle. In the sheath the vein lies on the lateral side of the 

 common carotid artery and its terminal branches, but it overlaps 

 them anteriorly. When an opening is made in the carotid 

 sheath, the vein bulges through and it is easily recognised by 

 its blue-grey colour. If the venous return to the heart is ob- 

 structed in any way, the internal jugular vein shares in the general 

 engorgement and becomes greatly distended. In the lower part 

 of the neck the vein crosses in front of the first part of the 

 subclavian artery, and it terminates behind the sternal end of 

 the clavicle by uniting with the subclavian to form the in- 

 nominate vein. 



Malignant and tuberculous lymph glands frequently become 

 adherent to the internal jugular vein, and it is not uncommon 

 for the surgeon to resect a portion of the vessel in order to facilitate 

 their removal. The vein is first isolated inferiorly, and it is 

 then divided between ligatures as low down as necessary. The 

 vein is then dissected upwards a procedure which is easier 

 than the reverse method, because numerous tributaries join the 

 vein in its upper part and render its isolation extremely difficult. 

 The portion most commonly resected receives the common facial 

 vein, which must also be ligatured and divided. The rise in 

 pressure in the internal jugular vein during vomiting is so great 

 that lateral ligatures may be forced off. Consequently, if the 

 vein is wounded during an operation, it is much safer to divide 

 it completely and ligature both the cut ends. 



The Common Facial Vein is the most important tributary 

 of the internal jugular, and it serves as a useful landmark in 

 removal of the tonsillar and the upper anterior group of the 



