THE NECK 135 



the artery have to be sacrificed. When ligatures are being 

 applied, prior to resection, care must be taken not to include 

 the vagus nerve. Should the common facial vein be wounded 

 near its termination, the haemorrhage may be so great, owing 

 to its proximity to the internal jugular, as to suggest injury of 

 the larger vessel. In ligation of the common facial, the ligatures 

 must be placed so as to control its numerous tributaries (superior 

 thyreoid, etc., p. 119). 



The accessory nerve is found in the upper part of its 

 course by dissecting the deep fascia off the anterior border 

 of the sterno - mastoid, i J inches below the tip of the 

 mastoid process. It pierces this fascia to reach the muscle. 

 The branch from the occipital artery to the sterno-mastoid 

 (p. 122) serves as a convenient guide, and, after the nerve has 

 been found in this situation, it is traced upwards and forwards 

 through the glands till it disappears under cover of the posterior 

 belly of the digastric (p. 122). Improved access to the highest 

 group of lymph glands, which lie under cover of the parotid 

 gland and the mastoid process, may be obtained by dividing 

 the anterior part of the insertion of the sterno-mastoid trans- 

 versely. These lymph glands lie superficial to, and slightly 

 lower than, the occipital artery. 



The position of the accessory nerve in the posterior triangle 

 of the neck is described on p. 125. When the lymph glands of 

 the posterior triangle are involved, the nerve must be exposed 

 before they are attacked, as it is the most important structure 

 in the region. If a little dissection amongst the enlarged glands 

 at the middle of the posterior border of the sterno-mastoid 

 fails to expose the nerve, it must be sought for at the point where 

 it disappears under cover of the trapezius (p. 125), and then 

 traced upwards through the mass. The enlarged glands are apt 

 to alter the course of the nerve, and it runs grave risk of injury 

 if a prolonged search for it is made amongst them. 



When the lower groups are involved, good exposure is obtained 

 by a long oblique incision extending from the junction of the 

 middle and lower thirds of the anterior border of the trapezius 

 almost to the jugular (suprasternal) notch. The terminal part 

 of the external jugular vein and the accessory nerve are exposed, 

 the latter as it disappears under cover of the trapezius in the 

 posterior part of the wound. In removing the glands, the 

 surgeon does not require to cut through the prevertebral fascia, 

 and, as a result, the nerves of supply to the levator scapulae 



96 



