Development Fig 199
A small nodule, the tuberculum impar, is the first evidence of the developing tongue in the floor of the pharynx. This is soon covered over by the lingual swellings, one on each side, derived from the first branchial arch. These fuse in the midline to form the definitive anterior two-thirds of the tongue supplied by V and reinforced by chorda tympani. Posteriorly, this mass meets the copula or hypobranchial eminence , a central swelling in the pharyngeal floor which represents the 2nd, 3rd and...
The parotid gland
This is the largest of the salivary glands, lying wedged between the Internal jugular vein, vagu and sympathetic chair Internal jugular vein, vagu and sympathetic chair Fig. 208 The parotid and its surrounds in a schematic horizontal section the facial nerve is the most superficial of the structures traversing the gland. The line of section is shown in the inset head. external carotid artery and retromandibular vein Fig. 208 The parotid and its surrounds in a schematic horizontal section the...
The ulnar nerve
The ulnar nerve C 7 , 8, T1 Fig. 142 is formed from the medial cord of the plexus. It lies medial to the axillary and brachial artery as far as the middle of the humerus, then pierces the medial intermuscular septum in company with the superior ulnar collateral artery to descend on the anterior face of triceps. It passes behind the medial epicondyle where it can readily be rolled against the bone , to enter the forearm Fig. 122 . Here it descends beneath flexor carpi ulnaris until this muscle...
Segmental anatomy
The gross anatomical division of the liver into a right and left lobe, demarcated by a line passing from the attachment of the falciform ligament on the anterior surface to the fissures for the ligamentum teres and ligamentum venosum on its posterior surface, is simply a gross anatomical descriptive term with no morphological significance. Studies of the distribution of the hepatic blood vessels and ducts have indicated that the true morphological and physiological division of the liver is into...
Developmental abnormalities Fig 86
1 It is common for one or more distally placed arteries to persist aberrant renal arteries and one may even run to the kidney from the common iliac artery. 2 Occasionally the kidney will fail to migrate cranially, resulting in a persistent pelvic kidney. 3 The two metanephric masses may fuse in development, forming a horseshoe kidney linked across the midline. 4 In 1 in 2400 births there is complete failure of development of one kidney congenital absence of the kidney . 5 Congenital polycystic...
The median nerve
The median nerve C6, 7, 8, T1 Fig. 142 arises by the junction of a branch from the medial and another from the lateral cord of the plexus, which unite anterior to the third part of the axillary artery. Continuing along the lateral aspect of the brachial artery, the nerve then crosses superficially occasionally deep to the artery at the mid-humerus to lie on its medial side. The nerve enters the forearm between the heads of pronator teres, the deeper of which separates it from the ulnar artery...
Arterial supply of the intestine
The alimentary tract develops from the fore-, mid- and hind-gut the arterial supply to each is discrete, although anastomosing with its neighbour. The fore-gut comprises stomach and duodenum as far as the entry of the bile duct and is supplied by branches of the coeliac axis which arises from the aorta at T12 vertebral level see Fig. 53 . The mid-gut extends from mid-duodenum to the distal transverse colon and is supplied by the superior mesenteric artery Fig. 66 arising from the aorta at L1....
The veins of the lower limb
Fig. 180 The superficial veins of the lower limb. Fig. 180 The superficial veins of the lower limb. branches run upwards and medially from it to join the great saphenous vein. The small saphenous vein is accompanied by the sural nerve a sensory branch of the tibial nerve Fig. 178a , which may be damaged in operating on varices of this vein. The great long saphenous vein drains the medial part of the venous plexus on the dorsum of the foot and passes upwards immediately in front of the medial...
The radial nerve
Fig. 140 The segmental cutaneous innervation of the body. The radial nerve C5, 6, 7, 8, T1 is the main branch of the posterior cord. Fig. 141 The distribution of the radial nerve. Fig. 141 The distribution of the radial nerve. Lying first behind the axillary artery, it then passes backwards between the long and medial heads of the triceps to lie in the spiral groove on the back of the humerus between the medial and lateral heads of triceps Fig. 141 . The profunda branch of the brachial artery...
Clinical features Cvf
Ludwig's angina is a cellulitis of the floor of the mouth, usually originating from a carious molar tooth. The infection spreads above the mylohyoid oedema forces the tongue upwards and the mylohyoid itself is pushed downwards so that there is swelling both below the chin and within the mouth. There is considerable danger of spread of infection backwards with oedema of the glottis and asphyxia. Drainage is carried out by a deep incision below the mandible which must divide the mylohyoid muscle....
Clinical features Iog
Since it contains air, the trachea is more radio-translucent than the neighbouring structures and is seen in posteroanterior and lateral radiographs as a dark area passing downwards, backwards and slightly to the right. In the elderly, calcification of the tracheal rings may be a source of radiological confusion. The trachea may be compressed or displaced by pathological enlargement Superior vena cava Right phrenic nerve Azygos vein Right vagus nerve Trachea Oesophagus Fig. 17 The thoracic part...
Lymph drainage Fig 198
The drainage zones of the mucosa of the tongue can be grouped into three 1 the tip drains to the submental nodes 2 the anterior two-thirds drains to the submental and submandibular nodes and thence to the lower nodes of the deep cervical chain along the carotid sheath 3 the posterior one-third drains to the upper nodes of the deep cervical chain. There is a rich anastomosis across the midline between the lymphatics of the posterior one-third of the tongue so that a tumour on one side readily...
Clinical features Ptf
1 The upper end of the tibial shaft is one of the most common sites for acute osteomyelitis. Fortunately, the capsule of the knee joint is attached closely around the articular surfaces so that the upper extremity of the tibial diaphysis is extracapsular involvement of the knee joint therefore only occurs in the late and neglected case. 2 The shaft of the tibia is subcutaneous and unprotected anteromedially throughout its course and is particularly slender in its lower third. It is not...
Relations of the stomach Fig 52
Anteriorly the abdominal wall, the left costal margin, the diaphragm and the left lobe of the liver. Posteriorly the lesser sac, which separates the stomach from the pancreas, transverse mesocolon, left kidney, left suprarenal, the spleen and the splenic artery. Superiorly the left dome of the diaphragm. The lesser omentum is attached along the lesser curvature of the stomach, the greater omentum along the greater curvature. These omenta contain the vascular and lymphatic supply of the...
A note on growing ends and nutrient foramina in the long bones
The shaft of every long bone bears one or more nutrient foramina which are obliquely placed this obliquity is due to unequal growth at the upper and lower epiphyses. The artery is obviously dragged in the direction of more rapid growth and the direction of slope of entry of the nutrient foramen therefore points away from the more rapid growing end of the bone. The direction of growth of the long bones can be remembered by a little jingle which runs With one exception, the epiphysis of the...
Clinical features Kcm
1 Developmental abnormalities are not uncommon. The nipple may fail to evert and it is important to find out from the patient whether or not an inverted nipple is a recent event or has been present since birth. Supernumerary nipples or even breasts may occur along a vertical 'milk line' a reminder of the line of mammary glands in more primitive mammals on the other hand, the breast on one or both sides may be small or even absent amazia . 2 An abscess of the breast should be opened by a radial...
The duodenum
The duodenum curves in a C around the head of the pancreas and is 10 in 25 cm long. At its origin from the pylorus it is completely covered with peritoneum for about 1in 2.5 cm , but then becomes a retroperitoneal organ, only partially covered by serous membrane. For descriptive purposes, the duodenum is divided into four sections. The first part 2 in 5 cm ascends from the gastroduodenal junction, overlapped by the liver and gall-bladder. Immediately posterior to it lie the portal vein, common...
Paracentesis abdominis
Intraperitoneal fluid collections can be evacuated via a cannula inserted through the abdominal wall. The bladder having been first emptied with a catheter, the cannula is introduced on a trocar either through the midline where the linea alba is relatively bloodless or lateral to McBurney's point where there is no danger of wounding the inferior epigastric vessels . The coils of gut are not in danger in this procedure because they are mobile and are pushed away by the tip of the trocar. These...
The brachial plexus
Axillary nerve Radial nerve Median nerve Axillary nerve Radial nerve Median nerve Fig. 138 Scheme of the brachial plexus. a medial, from the anterior division of the lower trunk a posterior, from the union of all three posterior divisions. The roots lie between the anterior and middle scalene muscles. The trunks traverse the posterior triangle of the neck. The divisions lie behind the clavicle. The cords lie in the axilla. The cords continue distally to form the main nerve trunks of the upper...
The structure of the alimentary canal
The alimentary canal is made up of mucosa demarcated by the muscularis mucosae from the submucosa, the muscle coat and the serosa the last being absent where the gut is extraperitoneal. Middle colic artery Superior mesenteric artery Middle colic artery Superior mesenteric artery Fig. 68 Lymph nodes of the large intestine. Fig. 68 Lymph nodes of the large intestine. The oesophageal mucosa and that of the lower anal canal is stratified squamous elsewhere it is columnar. At the cardio-oesophageal...
The prostatic capsules Fig 88
These are normally two, pathologically three, in number. 1 The true capsule a thin fibrous sheath which surrounds the gland. 2 The false capsule condensed extraperitoneal fascia which continues into the fascia surrounding the bladder and with the fascia of Denonvilliers posteriorly. Between layers 1 and 2 lies the prostatic venous plexus. 3 The pathological capsule when benign 'adenomatous' hypertrophy of the prostate takes place, the normal peripheral part of the gland becomes compressed into...
Large intestine
The large intestine is subdivided, for descriptive purposes, into caecum with the appendix vermiformis ascending colon 5-8 in 12-20 cm transverse colon 18in 45cm Fig. 59 The simple arterial arcades of the jejunum a compared with the complex arcades of the ileum b . Fig. 59 The simple arterial arcades of the jejunum a compared with the complex arcades of the ileum b . descending colon 9-12in 22-30 cm sigmoid colon 5-30 in 12-75 cm , average 15in 37 cm The large bowel may vary considerably in...
Blood supply Tcc
The testicular artery arises from the aorta at the level of the renal vessels. It anastomoses with the artery to the vas, supplying the vas deferens and epi-didymis, which arises from the inferior vesical branch of the internal iliac Fig. 90 Transverse section of the testis. Fig. 90 Transverse section of the testis. artery. This cross-connection means that ligation of the testicular artery is not necessarily followed by testicular atrophy. The pampiniform plexus of veins becomes a single...
The segmental cutaneous supply of the upper limb Fig 140
In spite of this complex interlacing of the nerve roots in the brachial plexus, the skin of the upper limb, as with the skin of the rest of the body, has a perfectly regular segmental nerve supply. This is derived from C4 to T2 which is arranged approximately as follows C4 supplies skin over the shoulder tip C5 radial side of upper arm C6 radial side of forearm C8 ulnar side of forearm T1 ulnar side of upper arm T2 skin of the axilla via its intercostobrachial branch .
The mediastinum
The mediastinum is defined as 'the space which is sandwiched between the two pleural sacs'. For descriptive purposes the mediastinum is divided by a line drawn horizontally from the sternal angle to the lower border of T4 angle of Louis into superior and inferior mediastinum. The inferior mediastinum is further subdivided into the anterior in front of the pericardium, a middle mediastinum containing the pericardium itself with the heart and great vessels, and posterior mediastinum between the...
Clinical features Xot
1 Local irritation of the intercostal nerves by such conditions as Pott's disease of the thoracic vertebrae tuberculosis may give rise to pain which is referred to the front of the chest or abdomen in the region of the peripheral termination of the nerves. 2 Local anaesthesia of an intercostal space is easily produced by infiltration around the intercostal nerve trunk and its collateral branch a procedure known as intercostal nerve block. 3 In a conventional posterolateral thoracotomy e.g. for...
Relations
Lying partly in the neck and partly in the thorax, its relations are anteriorly the isthmus of thyroid gland, inferior thyroid veins, ster-nohyoid and sternothyroid muscles laterally the lobes of thyroid gland and the common carotid artery posteriorly the oesophagus with the recurrent laryngeal nerve lying in the groove between oesophagus and trachea Fig. 16 . In the superior mediastinum its relations are anteriorly commencement of the brachiocephalic innominate artery Fig. 14 The trachea and...
Lymphatic drainage
This is of considerable importance in the spread of breast tumours. The lymph drainage of the breast, as with any other organ, follows the pathway of its blood supply and therefore travels 1 along tributaries of the axillary vessels to axillary lymph nodes 2 along the tributaries of the internal thoracic vessels, piercing pectoralis major to traverse each intercostal space to lymph nodes along the internal mammary chain these also receive lymphatics penetrating along the lateral perforating...
Peritoneal cavity
The endothelial lining of the primitive coelomic cavity of the embryo becomes the thoracic pleura and the abdominal peritoneum. Each is invagi-nated by ingrowing viscera which thus come to be covered by a serous membrane and to be packed snugly into a serous-lined cavity, the visceral and parietal layer respectively. In the male, the peritoneal cavity is completely closed, but in the female it is perforated by the openings of the uterine tubes which constitute a possible pathway of infection...
The muscles of the pelvic floor and perineum
The canal of the bony and ligamentous pelvis is closed by a diaphragm of muscles and fasciae which the rectum, urethra and, in the female, the vagina, must pierce to reach the exterior. The muscles are divided into a the pelvic diaphragm, formed by the levator ani and the coccygeus and b the superficial muscles of the a anterior urogenital perineum and the b posterior anal perineum. Levator ani Fig. 97 is the largest and most important muscle of the pelvic floor. It arises from the posterior...
The development of the face lips and palate with special reference to their
Around the primitive mouth, or stomodaeum, develop the following 1 the frontonasal process which projects down from the cranium. Two olfactory pits develop in it and rupture into the pharynx to form the nostrils. Definitively, this process forms the nose, the nasal septum, nostril, the philtrum of the upper lip the small midline depression and the premaxilla the V-shaped anterior portion of the upper jaw which usually bears the four incisor teeth 2 the maxillary processes on each side, which...
The asymmetrical
Asymmetry can be due to a variety of causes such as scoliosis, longstanding hip disease e.g. congenital dislocation , poliomyelitis, pelvic frac- Fig. 96 Pelvic variations and abnormalities shown as diagrammatic outlines of the pelvic inlet. Fig. 96 Pelvic variations and abnormalities shown as diagrammatic outlines of the pelvic inlet. ture, congenital abnormality due to thalidomide and the Naegele pelvis which is due to the congenital absence of one wing of the sacrum or its destruction by...
The parathyroid glands Fig 192
These are usually four in number, a superior and inferior on either side however, the numbers vary from two to six. Ninety per cent are in close relationship to the thyroid, 10 are aberrant, the latter invariably being the inferior glands. Fig. 191 The relationship of the recurrent laryngeal nerve to the thyroid gland and the inferior thyroid artery. a The nerve is usually deep to the artery but b may be superficial to it or c pass through its branches. In these diagrams the lateral lobe of the...
The axillary nerve
The axillary circumflex nerve C5, 6 arises from the posterior cord of the Fig. 140 The segmental cutaneous innervation of the body. plexus and winds round the surgical neck of the humerus in company with the posterior circumflex humeral vessels Figs 122, 141 . Its branches are muscular to deltoid and teres minor cutaneous to a palm-sized area of skin over the deltoid. The axillary nerve may be injured in fractures of the humeral neck or in dislocations of the shoulder. This will be followed by...
Peritoneal attachments
The transverse colon and sigmoid are completely peritonealized the former being readily identified by its attachment to the greater omentum . The ascending and descending colon have no mesocolon but adhere directly to the posterior abdominal wall although exceptionally the ascending colon has a mesocolon . The caecum may or may not be completely peritonealized, and the appendix, although usually free within its own mesentery, occasionally lies extraperitoneally behind caecum and ascending colon...
The arches of the foot Fig 172
On standing, the heel and the metatarsal heads are the principal weight-bearing points, but a moment's study of footprints on the wet bathroom floor will show that the lateral margin of the foot and the tips of the phalanges also touch the ground. The bones of the foot are arranged in the form of two longitudinal arches. The medial arch comprises calcaneus, talus, navicular, the three cuneiforms and the three medial metatarsals the apex of this arch is the talus. The lateral arch, which is...
Clinical features Oyg
1 These possible aberrant sites are, of course, of great importance in searching for a parathyroid adenoma in hyperparathyroidism. 2 The parathyroids are usually safe in subtotal thyroidectomy because the posterior rim of the thyroid is preserved. However, they may be Fig. 193 Normal and abnormal sites of the parathyroid glands lateral view . Fig. 193 Normal and abnormal sites of the parathyroid glands lateral view . Fig. 194 The derivatives of the branchial pouches. Note that the inferior...
Clinical features Xpx
1 Minor sepsis and abrasions of the leg are so common that it is usual to find that the inguinal nodes are palpable in perfectly healthy people. 2 Secondary involvement of the inguinal nodes by malignant deposits may be dealt with by block dissection of the groin. This involves removal of the superficial and deep fascial roof of the femoral triangle, the saphenous vein and its tributaries and the fatty and lymphatic contents of the triangle, leaving only the femoral artery, vein and nerve. The...
Surface anatomy and surface markings 1
Be able to identify these landmarks on yourself or the patient Fig. 42 . The xiphoid. The costal margin extends from the 7th costal cartilage at the xiphoid to the tip of the 12 th rib although the latter is often difficult to feel this margin bears a distinct step, which is the tip of the 9 th costal cartilage. The iliac crest ends in front at the anterior superior spine from which the inguinal ligament Poupart's ligament passes downwards and medially to the pubic tubercle. Identify this...
The superficial pulp space of the fingers
The tips of the fingers and thumb are composed entirely of subcutaneous fat broken up and packed between fibrous septa, which pass from the skin down to the periosteum of the terminal phalanx. The tight packing of this compartment is responsible for the severe pain of a 'septic finger' there is little room for the expansion of inflamed and oedematous tissues. The blood vessels to the shaft of the distal phalanx must traverse this space and may become thrombosed in a severe pulp infection with...
The os innominatum Fig 92
Examine the bone and revise the following structures. The ilium with its iliac crest running between the anterior and posterior superior iliac spines below each of these are the corresponding inferior spines. Well-defined ridges on its lateral surface are the strong muscle markings of the glutei. Its inner aspect bears the large auricular surface which articulates with the sacrum. The iliopectineal line runs forward from the apex of the auricular surface and demarcates the true from the false...
The endopelvic fascia and the pelvic ligaments Fig 107
Pelvic fascia is the term applied to the connective tissue floor of the pelvis covering levator ani and obturator internus. The endopelvic fascia is the extraperitoneal cellular tissue of the uterus the parametrium , vagina, bladder and rectum. Within this endopelvic fascia are three important condensations of connective tissue which sling the pelvic viscera from the pelvic walls. 1 The cardinal ligaments transverse cervical, or Mackenrodt's ligaments , which pass laterally from the cervix and...
Development
The thyroid develops from a bud which pushes out from the floor of the Fig. 190 The descent of the thyroid, showing possible sites of ectopic thyroid tissue or thyroglossal cysts, and also the course of a thyroglossal fistula. The arrow shows the further descent of the thyroid which may take place retrosternally into the superior mediastinum. pharynx this outgrowth then descends to its definitive position in the neck. It normally loses all connection with its origin which is commemorated,...
The thoracic duct Figs 37 213
The cisterna chyli lies between the abdominal aorta and right crus of the diaphragm. It drains lymphatics from the abdomen and the lower limbs, then passes upwards through the aortic opening to become the thoracic duct. This ascends behind the oesophagus, inclines to the left of the oesophagus at the level of T5, then runs upwards behind the carotid sheath, descends over the subclavian artery and drains into the commencement of the left brachiocephalic vein see Fig. 213 . The left jugular,...
The biliary system Fig 75
The right and left hepatic ducts fuse in the porta hepatis to form the common hepatic duct 1.5 in 4 cm . This joins with the cystic duct 1.5 in 4 cm , draining the gall-bladder, to form the common bile duct 4in 10 cm . The common bile duct commences about 1 in 4 cm above the duodenum, then passes behind it to open at a papilla on the medial aspect of the second part of the duodenum. In this course the common duct lies either in a groove in the posterior aspect of the head of the pancreas or is...
The tibiofibular joints
The tibia and fibula are connected by 1 the superior tibiofibular joint, a synovial joint between the head of the fibula and the lateral condyle of the tibia 2 the interosseous membrane, which is crossed by the anterior tibial vessels above and pierced by the perforating branch of the peroneal artery below 3 the inferior tibiofibular joint, a fibrous joint, the only one in the limbs, between the triangular areas of each bone immediately above the ankle joint. The ankle is a hinge joint between...
The axillary artery
The axillary artery commences at the lateral border of the first rib, as a continuation of the subclavian, and ends at the lower border of the axilla i.e. the lower border of teres major to become the brachial artery. It is divided into three parts by pectoralis minor and, apart from its distal extremity, it lies covered by pectoralis major. Above pectoralis minor, the brachial plexus lies above and behind the artery, but, distal to this, the cords of the plexus take up their positions around...
Relations Urz
Anteriorly the pubic symphysis. Superiorly the bladder is covered by peritoneum with coils of small intestine and sigmoid colon lying against it. In the female, the body of the uterus flops against its posterosuperior aspect. Posteriorly in the male the rectum, the termination of the vasa defer-entia and the seminal vesicles in the female, the vagina and the supravaginal part of the cervix. Laterally the levator ani and obturator internus. Fig. 87 a The prostate, seminal vesicles and vasa...
The thyroid gland
The thyroid is made up of Fig. 189 1 the isthmus overlying the 2nd and 3rd rings of the trachea 2 the lateral lobes each extending from the side of the thyroid cartilage downwards to the 6th tracheal ring 3 an inconstant pyramidal lobe projecting upwards from the isthmus, usually on the left side, which represents a remnant of the embryological descent of the thyroid. The gland is enclosed in the pretracheal fascia, covered by the strap muscles and overlapped by the sternocleidomastoids. The...
The gastrointestinal adnexae liver gallbladder and its ducts pancreas and spleen
This is the largest organ in the body. It is related by its domed upper surface to the diaphragm, which separates it from pleura, lungs, pericardium and heart. Its postero-inferior or visceral surface abuts against the abdominal oesophagus, the stomach, duodenum hepatic flexure of colon and the right kidney and suprarenal, as well as carrying the gall-bladder. The liver is divided into a larger right and small left lobe, separated superiorly by the falciform ligament and postero-inferiorly by...