r 66 SURGICAL APPLIED ANATOMY. [Chap. ix. 



The procedure is surrounded by considerable diffi- 

 culties. 



Dr. Bright and Dr. Ramskill have stated that 

 disease involving the vertebral artery just before it 

 enters the skull may lead to pain at the back of the 

 head. It is well known that the suboccipital nerve lies 

 in close connection with the artery over the posterior 

 arch of the atlas, and that it gives a branch to the 

 great occipital nerve which is distributed to the back 

 of the head. The close connection of artery and 

 nerve and this communicating branch may serve to 

 explain the symptom noted. In some of Dr. Ram- 

 skill's cases there was difficulty of articulation. This 

 he ascribes to pressure upon the hypoglossal nerve, 

 which is also in close relation with the vertebral 

 artery. The innominate artery has been temporarily 

 compressed through an incision made in the median 

 line near to the vessel. The posterior aspect of the 

 artery is exposed and compressed by the finger against 

 the sterno-clavicular articulation. 



In cases of bleeding from branches of the external 

 carotid it is better, when possible, to ligature the 

 trunk of that vessel in preference to securing the 

 common carotid. The latter procedure has a high 

 death rate (50 per cent.) due (1) to brain mischief, 

 following the lessened blood stream through the 

 internal carotid, and (2) to secondary haemorrhage, 

 due to the very free anastomosing channels. 



Air in veins. The veins of the neck are under 

 the influence of the respiratory movements. During 

 inspiration these vessels become more or less emptied; 

 during expiration they become enlarged and turgid. 

 With greatly impeded breathing they may attain 

 formidable size. Since ether usually causes some 

 respiratory difficulty, it is seldom administered in 

 operations on the neck. The only other veins that 

 are under the influence of the aspiratory power of the 



