5j. The Vagus Nerve

(N. Vagus; Tenth Nerve; Pneumogastric Nerve)

The vagus nerve (Figs. 791, 792, 793) is composed of both motor and sensory fibers, and has a more extensive course and distribution than any of the other cranial nerves, since it passes through the neck and thorax to the abdomen. 1 The vagus is attached by eight or ten filaments to the medulla oblongata in the groove between the olive and the inferior peduncle, below the glossopharyngeal. The sensory fibers arise from the cells of the jugular ganglion and ganglion nodosum of the nerve, and, when traced into the medulla oblongata mostly end by arborizing around the cells of the inferior part of a nucleus which lies beneath the ala cinerea in the lower part of the rhomboid fossa. These are the sympathetic afferent fibers. Some of the sensory fibers of the glossopharyngeal nerve have been seen to end in the upper part of this nucleus. A few of the sensory fibers of the vagus, probably taste fibers, descend in the fasciculus solitarius and end around its cells. The somatic sensory fibers, few in number, from the posterior part of the external auditory meatus and the back of the ear, probably join the spinal tract of the trigeminal as it descends in the medulla. The somatic motor fibers arise from the cells of the nucleus ambiguus, already referred to in connection with the motor root of the glossopharyngeal nerve. 2 The sympathetic efferent fibers, distributed probably as preganglionic fibers to the thoracic and abdominal viscera, i. e., as motor fibers to the bronchial tree, inhibitory fibers to the heart, motor fibers to the esophagus, stomach, small intestine and gall passages, and as secretory fibers to the stomach and pancreas, arise from the dorsal nucleus of the vagus. 3 The filaments of the nerve unite, and form a flat cord, which passes beneath the flocculus to the jugular foramen, through which it leaves the cranium. In emerging through this opening, the vagus is accompanied by and contained in the same sheath of dura mater with the accessory nerve, a septum separating them from the glossopharyngeal which lies in front (Fig. 792). In this situation the vagus presents a well-marked ganglionic enlargement, which is called the jugular ganglion (ganglion of the root); to it the accessory nerve is connected by one or two filaments. After its exit from the jugular foramen the vagus is joined by the cranial portion of the accessory nerve, and enlarges into a second gangliform swelling, called the ganglion nodosum (ganglion of the trunk); through this the fibers of the cranial portion of the accessory pass without interruption, being principally distributed to the pharyngeal and superior laryngeal branches of the vagus, but some of its fibers descend in the trunk of the vagus, to be distributed with the recurrent nerve and probably also with the cardiac nerves. 4 The vagus nerve passes vertically down the neck within the carotid sheath, lying between the internal jugular vein and internal carotid artery as far as the upper border of the thyroid cartilage, and then between the same vein and the common carotid artery to the root of the neck. The further course of the nerve differs on the two sides of the body. 5 On the right side, the nerve passes across the subclavian artery between it and the right innominate vein, and descends by the side of the trachea to the back of the root of the lung, where it spreads out in the posterior pulmonary plexus. From the lower part of this plexus two cords descend on the esophagus, and divide to form, with branches from the opposite nerve, the esophageal plexus. Below, these branches are collected into a single cord, which runs along the back of the esophagus enters the abdomen, and is distributed to the postero-inferior surface of the stomach, joining the left side of the celiac plexus, and sending filaments to the lienal plexus. 6 On the left side, the vagus enters the thorax between the left carotid and subclavian arteries, behind the left innominate vein. It crosses the left side of the arch of the aorta, and descends behind the root of the left lung, forming there the posterior pulmonary plexus. From this it runs along the anterior surface of the esophagus, where it unites with the nerve of the right side in the esophageal plexus, and is continued to the stomach, distributing branches over its anterosuperior surface; some of these extend over the fundus, and others along the lesser curvature. Filaments from these branches enter the lesser omentum, and join the hepatic plexus. 7 The Jugular Ganglion (ganglion jugulare; ganglion of the root) is of a grayish color, spherical in form, about 4 mm. in diameter. 8 Branches of Communication.—This ganglion is connected by several delicate filaments to the cranial portion of the accessory nerve; it also communicates by a twig with the petrous ganglion of the glossopharyngeal, with the facial nerve by means of its auricular branch, and with the sympathetic by means of an ascending filament from the superior cervical ganglion. 9 The Ganglion Nodosum (ganglion of the trunk; inferior ganglion) is cylindrical in form, of a reddish color, and 2.5 cm. in length. Passing through it is the cranial portion of the accessory nerve, which blends with the vagus below the ganglion. 10

Branches of Communication.—This ganglion is connected with the hypoglossal, the superior cervical ganglion of the sympathetic, and the loop between the first and second cervical nerves. 11 Branches of Distribution.—The branches of distribution of the vagus are: 12

In the Jugular Fossa…	Meningeal.
	Auricular.

In the Neck…………	Pharyngeal.
	Superior laryngeal.
	Recurrent.
	Superior cardiac.

In the Thorax……….	Inferior cardiac.
	Anterior bronchial.
	Posterior bronchial.
	Esophageal.

In the Abdomen…….	Gastric.
	Celiac.
	Hepatic.

The Meningeal Branch (ramus meningeus; dural branch) is a recurrent filament given off from the jugular ganglion; it is distributed to the dura mater in the posterior fossa of the base of the skull. 13 The Auricular Branch (ramus auricularis; nerve of Arnold) arises from the jugular ganglion, and is joined soon after its origin by a filament from the petrous ganglion of the glossopharyngeal; it passes behind the internal jugular vein, and enters the mastoid canaliculus on the lateral wall of the jugular fossa. Traversing the substance of the temporal bone, it crosses the facial canal about 4 mm. above the stylomastoid foramen, and here it gives off an ascending branch which joins the facial nerve. The nerve reaches the surface by passing through the tympanomastoid fissure between the mastoid process and the tympanic part of the temporal bone, and divides into two branches: one joins the posterior auricular nerve, the other is distributed to the skin of the back of the auricula and to the posterior part of the external acoustic meatus. 14 The Pharyngeal Branch (ramus pharyngeus), the principal motor nerve of the pharynx, arises from the upper part of the ganglion nodosum, and consists principally of filaments from the cranial portion of the accessory nerve. It passes across the internal carotid artery to the upper border of the Constrictor pharyngis medius, where it divides into numerous filaments, which join with branches from the glossopharyngeal, sympathetic, and external laryngeal to form the pharyngeal plexus. From the plexus, branches are distributed to the muscles and mucous membrane of the pharynx and the muscles of the soft palate, except the Tensor veli palatini. A minute filament descends and joins the hypoglossal nerve as it winds around the occipital artery. 15 The Superior Laryngeal Nerve (n. laryngeus superior) larger than the preceding, arises from the middle of the ganglion nodosum and in its course receives a branch from the superior cervical ganglion of the sympathetic. It descends, by the side of the pharynx, behind the internal carotid artery, and divides into two branches, external and internal. 16 The external branch (ramus externus), the smaller, descends on the larynx, beneath the Sternothyreoideus, to supply the Cricothyreoideus. It gives branches to the pharyngeal plexus and the Constrictor pharyngis inferior, and communicates with the superior cardiac nerve, behind the common carotid artery. 17 The internal branch (ramus internus) descends to the hyothyroid membrane, pierces it in company with the superior laryngeal artery, and is distributed to the mucous membrane of the larynx. Of these branches some are distributed to the epiglottis, the base of the tongue, and the epiglottic glands; others pass backward, in the aryepiglottic fold, to supply the mucous membrane surrounding the entrance of the larynx, and that lining the cavity of the larynx as low down as the vocal folds. A filament descends beneath the mucous membrane on the inner surface of the thyroid cartilage and joins the recurrent nerve. 18 The Recurrent Nerve (n. recurrens; inferior or recurrent laryngeal nerve) arises, on the right side, in front of the subclavian artery; winds from before backward around that vessel, and ascends obliquely to the side of the trachea behind the common carotid artery, and either in front of or behind the inferior thyroid artery. On the left side, it arises on the left of the arch of the aorta, and winds below the aorta at the point where the ligamentum arteriosum is attached, and then ascends to the side of the trachea. The nerve on either side ascends in the groove between the trachea and esophagus, passes under the lower border of the Constrictor pharyngis inferior, and enters the larynx behind the articulation of the inferior cornu of the thyroid cartilage with the cricoid; it is distributed to all the muscles of the larynx, excepting the Cricothyreoideus. It communicates with the internal branch of the superior laryngeal nerve, and gives off a few filaments to the mucous membrane of the lower part of the larynx. 19 As the recurrent nerve hooks around the subclavian artery or aorta, it gives off several cardiac filaments to the deep part of the cardiac plexus. As it ascends in the neck it gives off branches, more numerous on the left than on the right side, to the mucous membrane and muscular coat of the esophagus; branches to the mucous membrane and muscular fibers of the trachea; and some pharyngeal filaments to the Constrictor pharyngis inferior. 20 The Superior Cardiac Branches (rami cardiaci superiores; cervical cardiac branches), two or three in number, arise from the vagus, at the upper and lower parts of the neck. 21 The upper branches are small, and communicate with the cardiac branches of the sympathetic. They can be traced to the deep part of the cardiac plexus. 22 The lower branch arises at the root of the neck, just above the first rib. That from the right vagus passes in front or by the side of the innominate artery, and proceeds to the deep part of the cardiac plexus; that from the left runs down across the left side of the arch of the aorta, and joins the superficial part of the cardiac plexus. 23 The Inferior Cardiac Branches (rami cardiaci inferiores; thoracic cardiac branches), on the right side, arise from the trunk of the vagus as it lies by the side of the trachea, and from its recurrent nerve; on the left side from the recurrent nerve only; passing inward, they end in the deep part of the cardiac plexus. 24 The Anterior Bronchial Branches (rami bronchiales anteriores; anterior or ventral pulmonary branches), two or three in number, and of small size, are distributed on the anterior surface of the root of the lung. They join with filaments from the sympathetic, and form the anterior pulmonary plexus. 25 The Posterior Bronchial Branches (rami bronchiales posteriores; posterior or dorsal pulmonary branches), more numerous and larger than the anterior, are distributed on the posterior surface of the root of the lung; they are joined by filaments from the third and fourth (sometimes also from the first and second) thoracic ganglia of the sympathetic trunk, and form the posterior pulmonary plexus. Branches from this plexus accompany the ramifications of the bronchi through the substance of the lung. 26 The Esophageal Branches (rami æsophagei) are given off both above and below the bronchial branches; the lower are numerous and larger than the upper. They form, together with the branches from the opposite nerve, the esophageal plexus. From this plexus filaments are distributed to the back of the pericardium. 27 The Gastric Branches (rami gastrici) are distributed to the stomach. The right vagus forms the posterior gastric plexus on the postero-inferior surface of the stomach and the left the anterior gastric plexus on the antero-superior surface. 28 The Celiac Branches (rami cæliaci) are mainly derived from the right vagus: they join the celiac plexus and through it supply branches to the pancreas, spleen, kidneys, suprarenal bodies, and intestine. 29 The Hepatic Branches (rami hepatici) arise from the left vagus: they join the hepatic plexus and through it are conveyed to the liver. 30

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