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Thesuperficial temporal artery is a terminal branch of the external carotid artery erectile dysfunction at age of 20 generic viagra vigour 800 mg mastercard. The temporal branch of the facial nerve runs upwards and forwards to reach the frontalis muscle that it supplies. The posterior auricular branch of the facial nerve lies behind the auricle in the lower part of the temporal region. The zygomaticofacial nerve and the zygomaticotemporal nerve are derived from the zygomatic branch of the maxillary division of the trigeminal nerve. The temporalis is one of the muscles that are responsible for chewing movements (mastication). The term infratemporal fossa is applied to an irregular space lying below the lateral part of the base of the skull. The medial and lateral pterygoid plates arising from the process are intimately related to structures in the fossa. Structures in the fossa (or near it) are exposed by removing the parotid gland and the zygomatic arch. The auriculotemporal nerve passes backwards deep to the neck of the mandible and then turns upwards to enter the temporal region. The masseteric branch of the mandibular nerve passes laterally through the mandibular notch to enter the masseter muscle. The buccal nerve and artery emerging from under the anterior margin of the ramus of the mandible to run forwards on the buccinator muscle. The maxillary artery arises from the external carotid artery just behind the ramus of the mandible. The artery runs forwards deep to the neck of the mandible to enter the infratemporal fossa (38. The upper part of the mandibular nerve lies under cover of the lateral pterygoid muscle. Finally the anterior division continues onto the surface of the buccinator muscle as the buccal nerve. The buccal nerve emerges through the gap between the two heads of the lateral pterygoid. The auriculotemporal nerve which arises by two roots that are separated by the middle meningeal artery (38. The lingual nerve is joined (posteriorly) by the chorda tympani (a branch of the facial nerve). The lingual and inferior alveolar nerves emerge from under the lower border of the lateral pterygoid muscle and descend over the surface of the medial pterygoid. The inferior alveolar nerve is separated from the medial pterygoid muscle by a broad sphenomandibular ligament. The lingual nerve leaves the infratemporal region to pass through the submandibular region on its way to the tongue. The inferior alveolar nerve enters the mandibular canal and passes through it to supply the mandible and the lower teeth. The mylohyoid nerve is given off from the inferior alveolar nerve just before it enters the mandibular canal. The mylohyoid nerve descends into the submandibular region to reach some muscles there. The second component is a gliding movement of the disc (along with the head of the mandible). In wide opening of the mouth the disc glides forwards so that the head of the mandible comes to lie below the articular eminence. Elevates mandible to Branch from anterior division of mandibular close the mouth surfaceof: 2. Helps to open mouth of greater wing of by pulling head of romandibular joint sphenoid bone mandible forwards L 2. Thefasciaisattachedabovetothe(superior)temporalline, and below to the zygomatic arch. In analysing the actions of these muscles it may be remembered that the pull of a muscle is opposite to the directionofitsfibres. The medial and lateral pterygoids of both sides acting together protract the mandible (38. This movement is facilitated by slight rotation of the head of the mandible of the opposite side. The two pterygoid muscles have opposite actions as far as opening and closing of the mouth is concerned. Notethebonesinvolved;(B)Ramusofmandible seen from the medial side to show the insertion of the temporalis Chapter 38 Temporal and Infratemporal Regions 775 38. The lateral pterygoid helps in opening the mouth by pulling the head of the mandible forwards along with the intra-articular disc (as explained above under actions of temporalis). It is a complex joint as its cavity is divided into upper and lower parts by an intra-articular disc. The upper articular surface of the joint is formed by the mandibular fossa of the temporal bone. The inferior articular surface of the joint is formed by the head of the mandible. The lateral part of the capsule is strengthened by the lateral temporomandibular ligament (38.

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It is also represented by the lienorenal (or splenorenal) ligament that passes from the hilum to the front of the left kidney erectile dysfunction causes cheap viagra vigour 800 mg online. When the peritoneum lining the posterior surface of the stomach is traced to the greater curvature, it becomes continuous with the anterior (or right) layer of the gastrosplenic ligament. At the hilum of the spleen this layer becomes directly continuous with the right layer of the lienorenal ligament. When the peritoneum lining the anterior surface of the stomach is traced to the greater curvature it becomes continuous with the posterior (or left) layer of the gastrosplenic ligament. At the hilum of the spleen, this layer passes on to the surfaces of the spleen lining (in that order) its gastric impression, the diaphragmatic surface and the renal impression, and thus returns to the hilum. In this way, the spleen comes to be lined all round by peritoneum except at the hilum. The spleen is separated from the diaphragm, from the kidney and from the stomach, by a part of the greater sac of peritoneum. However, the tail of the pancreas passes in the interval between the two layers of the lienorenal ligament and comes into direct contact with splenic tissue. The terminal part of the artery divides into a number of branches that pass through the lienorenal ligament to enter the hilum of the spleen. The splenic artery also gives off the short gastric and left gastroepiploic branches. The spleen receives autonomic nerves that reach it by running along the plexus surrounding the splenic artery. Accessory spleens (splenuneuli) may be present in structures near the organ including the gastrosplenic and lienorenal ligaments, the hilum of the spleen itself, the pancreas, and along the splenic artery. When enlarged considerably (to almost twice its normal size) the spleen projects from under the costal margin and can be felt on palpation of the abdomen. Because of the close relationship of the tail of the pancreas to the hilum of the spleen the former can be injured during splenectomy. Radio-opaque dyes can be introduced into the portal venous system through a needle introduced into the spleen (splenovenography or splenoportography). The technique has now been largely replaced by coeliac angiography during the venous filling phase. The arteries that supply the stomach, the intestines, the liver, the pancreas and the spleen are the ventral branches of the abdominal aorta. The veins draining these organs do not drain directly into the systemic circulation. After passing through the sinusoids of the liver the blood reaches the inferior vena cava through hepatic veins. The coeliac trunk arises from the front of the uppermost part of the abdominal aorta just below the aortic a opening in the diaphragm. On either side, the coeliac trunk is related to the corresponding crus of the diaphragm and to the coeliac ganglion. Chapter 29 Blood Vessels of Stomach, Intestines, Liver, Pancreas and Spleen 585 29. Here it lies in front of the neck of the pancreas and to the left of the bile duct. The gastroduodenal artery also gives off small branches to the stomach, the pancreas, and the duodenum. The right gastroepiploic artery gives branches to the stomach and to the greater omentum. They supply the pancreas, and the duodenum up to the level of the major duodenal papilla. Note that the part of the duodenum above the major duodenal papilla is a derivative of the foregut. It passes to the right behind the hepatic and cystic ducts to reach the gall bladder that it supplies. Several branches are given off to the pancreas, as the artery runs along this organ. Itpassesdownwards,forwardsandtothe right through the gastrosplenic ligament to reach the greater curvature of the stomach. Its area of supply extends cranially up to the middle of the descending part of the duodenum, and caudally tothejunctionoftherighttwo-thirdsandleftone-thirdofthetransversecolon. The artery then crosses in front of the horizontal part of the duodenum to enter the root of the mesentery. The next part of the artery passes in front of the horizontal part of the duodenum. They arise from the left side of the superior mesenteric artery and pass through the mesentery to reach the gut. The ileocolic artery gives off various branches that supply the terminal part of the ileum, the caecum, the appendixandthelowerone-thirdoftheascendingcolon(29. The right colic artery arises from the right side of the superior mesenteric artery at about its middle. Note that the inferior pancreaticoduodenal, right colic and ileocolic branches have a retroperitoneal course(29. The branches given off by the inferior mesenteric artery are the left colic, sigmoid and superior rectal arteries.

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Through these branches (and through the pharyngeal branches) the vagus supplies muscles of the pharynx erectile dysfunction 37 years old discount viagra vigour 800 mg overnight delivery, soft palate and larynx. The peripheral processes pass through the vagus and its branches to reach the pharynx, larynx, trachea, and oesophagus; and the thoracic and abdominal viscera. According to some authorities some of these fibres terminate in the dorsal nucleus of the vagus. The vagus carries the sensation of taste from the posterior-most part of the tongue and from the epiglottis. Their peripheral processes pass through the superior laryngeal nerve to reach the tongue and epiglottis. Peripheral processes pass through the auricular branch to reach the skin of the auricle. In injury to the superior laryngeal nerve the voice is weak due to paralysis of the cricothyroid muscle. At first there is hoarseness but after some time the opposite cricothyroid muscle compensates for the deficit and hoarseness disappears. Injury to the recurrent laryngeal nerve also leads to hoarseness, but this hoarseness is permanent. On examining the larynx through a laryngoscope it is seen that on the affected side the vocal fold does not move. In cases where the recurrent laryngeal nerve is pressed upon by a tumour it is observed that nerve fibres that supply abductors are lost first. In paralysis of both recurrent laryngeal nerves voice is lost as both vocal folds are immobile. It may be remembered that the left recurrent laryngeal nerve runs part of its course in the thorax. It can be involved in bronchial or oesophageal carcinoma, or in secondary growths in mediastinal lymph nodes. These fibres join the vagus nerve and are distributed through its pharyngeal and laryngeal branches to muscles of the pharynx, soft palate and larynx. The fibres of the spinal part arise from the lateral part of the ventral grey column of the upper five or six cervical segments of the spinal cord. The cranial part of the nerve is attached, by four or five rootlets, to the side of the medulla in the groove between the olive and the inferior cerebellar peduncle. From here the nerve runs laterally to reach the jugular foramen where it is joined by the spinal root (see below). After passing through the jugular foramen the cranial root again separates from the spinal root and merges with the inferior ganglion of the vagus. The fibres of the cranial root of the accessory nerve pass into the pharyngeal and recurrent laryngeal branches of the vagus. It is believed that fibres of the accessory nerve supply all the muscles of the soft palate (except the tensor palati). The spinal part of the accessory nerve is formed by union of a number of rootlets that emerge from the upper five or six cervical segments of the spinal cord. The rootlets emerge along a vertical line midway between the line of attachment of the ventral and dorsal roots of the spinal nerves. The spinal root joins the cranial root within the foramen, but leaves it again on emerging from the foramen. In the neck the spinal accessory nerve first runs backwards and laterally to reach the transverse process of the atlas. It enters the deep surface of the muscle and passing through it emerges at its posterior border (near the middle). The nerve now runs downwards and backwards across the posterior triangle to reach the anterior margin of the trapezius about 5 cm above the clavicle. The spinal part of the accessory nerve supplies the sternocleidomastoid (as it passes through it) and the trapezius (by its terminal branches). Note that these muscles also receive branches from the cervical plexus, but these branches are generally regarded as having only proprioceptive fibres. Between the jugular foramen and the transverse process of the atlas the nerve usually passes posterior to the internal jugular vein. In this part of its course the nerve lies deep to the styloid process and the posterior belly of the digastric muscle. Over the transverse process of the atlas the nerve is crossed by the occipital artery (43. While crossing the posterior triangle of the neck the nerve lies on the levator scapulae (43. The fibres of the accessory nerve are regarded as special visceral efferent as the muscles supplied are derived from branchial arches. Put your hands on the right and left shoulders of the patient and ask him to elevate (shrug) his shoulders. In paralysis, the movement will be weak on one side (due to paralysis of the trapezius). Ask the patient to turn his face to the opposite side (against resistance offered by your hand). In paralysis the movement is weak on the affected side (due to paralysis of the sternocleidomastoid muscle). The neurons that give origin to these fibres are located in the hypoglossal nucleus that is shown in 43. The hypoglossal nerve emerges from the medulla by ten to fifteen rootlets that are attached in the vertical groove separating the pyramid from the olive (43. The hypoglossal nerve leaves the cranial cavity through the hypoglossal canal (or anterior condylar) canal. On emerging at the base of the skull the nerve lies deep (medial) to the internal jugular vein and internal carotid artery.

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Peritoneal Relations the upper one-third of the rectum is covered by peritoneum in front and also on the sides (33 erectile dysfunction doctor lexington ky 800 mg viagra vigour order mastercard. In the male, the peritoneum passes from the front of the rectum to the urinary bladder forming the rectovesical pouch (33. In the female the rectum is related anteriorly to the vagina and the lower part of the uterus (33. In both sexes the upper part of the rectum may be related anteriorly to the sigmoid colon and/or coils of ileum (33. These parts of the intestine may also form lateral relations of the upper part of the rectum. Lower down the lateral walls of the rectum are embraced by the right and left coccygei and the right and left levator ani muscles (33. Supports of the Rectum the rectum is held in place by thickenings of fascia or ligaments. The fascia of Waldeyer connects the posterior aspect of the anorectal junction to the lower part of the sacrum. The lateral rectal ligaments connect the lateral aspect of the rectum to the posterolateral part of the wall of the pelvis (33. Considerable information about the structures surrounding the rectum and anal canal can be obtained, in the living, by palpation with a finger inserted through the anus. The structures that can be felt through the anterior wall of the rectum and anal canal in the male are (from below upwards): a. In the female the main structures in front of the anal canal are the vagina and uterus, but as these are directly accessible for examination (through the vagina) a rectal examination is needed for them only when for some reason a vaginal examination is not desirable. Posteriorly, in both the male and female, the coccyx and the lower part of the sacrum can be felt; and laterally, the ischial spine and ischial tuberosity can be palpated. In addition, an experienced surgeon can recognise abnormalities in surrounding viscera (ovary, uterine tube, ureters, a pelvic appendix) such as inflammation or enlargement. Enlarged internal iliac lymph nodes, abnormalities in the rectovesical or rectouterine pouches, or in the ischiorectal fossae can also be detected. However, it may not be possible to see the upper part of the rectum with a proctoscope. In passing a sigmoidoscope into the rectum the curvatures of the rectum and the presence of transverse folds within it has to be remembered. Spread of a rectal carcinoma is usually slow but it can ultimately invade surrounding structures including a. While the lower part of the rectum is directed downwards and forwards, the anal canal is directed downwards and backwards. The anorectal junction lies at the level of the pelvic diaphragm (formed here by the levator ani muscles). The rectum lies above the pelvic diaphragm in the true pelvis, whereas the anal canal lies below the diaphragm in the perineum. The lower aperture of the anal canal (or anus) is in the form of an anteroposterior slit, the right and left walls being in apposition. Posteriorly, the anal canal is separated from the coccyx by a mass of fibromuscular tissue that is called the anococcygeal ligament (or body). In front of the anal canal there is another similar mass called the perineal body. The perineal body separates the anal canal from the membranous urethra and the bulb of the penis in the male (33. Lateral to the anal canal there is a triangular depression called the ischiorectal fossa. The lower ends of the anal columns are united to each other by short transverse folds of mucous membrane. The anal valves together form a transverse line that runs all round the anal canal. In contrast, the part below the line is derived from a surface depression called the proctodaeum, and its lining epithelium is ectodermal. In early fetal life the two parts are separated by the anal membrane which subsequently disappears. Remnants of this membrane may be present in the form of small projections from the anal valves. The next 15 mm or so of the anal canal is also lined by mucous membrane, but anal columns are not present here. The mucosa has a bluish appearance because of a dense venous plexus that lies between it and the muscle coat. It differs from the upper and middle parts in that it is not lined by mucous membrane, but by skin. The epithelium lining the upper 15 mm of the anal canal is columnar (or stratified columnar); that lining the middle part (pecten) is stratified squamous, but is distinguished from skin in that there are no sebaceous or sweat glands, or hair, in relation to it. The epithelium of the lowest part resembles that of true skin in which sebaceous and sweat glands are present. The Anal Musculature the anal canal is surrounded by a number of sphincters that are as follows (33. The internal anal sphincter is formed by thickening of the circular muscle coat of the gut. When a finger is placed in the anal canal a distinct intersphincteric groove can be palpated between the lower end of the internal sphincter and the upper margin of the subcutaneous external sphincter. In section the subcutaneous part of the external sphincter looks like a transverse band (33.

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Somatic Efferent Nuclei Somatic efferent nuclei supply skeletal muscle that is derived (embryologically) from somites does kaiser cover erectile dysfunction drugs buy viagra vigour 800 mg overnight delivery. The oculomotor nucleus is situated in the midbrain (upper part, at the level of the superior colliculus). The nuclei of the two sides form a single complex that lies in the central grey matter, ventral to the aqueduct (43. The trochlear nucleus is situated in the midbrain (lower part, at the level of the inferior colliculus). It lies in the grey matter lining the floor of the fourth ventricle, near the midline (43. It is an elongated column extending into both the open and closed parts of the medulla. Its upper part lies deep to the hypoglossal triangle in the floor of the fourth ventricle. When traced downwards it lies next to the middle line in the central grey matter ventral to the central canal (43. Special Visceral Efferent Nuclei these nuclei supply skeletal muscle derived from branchial arch mesoderm. The motor nucleus of the trigeminal nerve lies in the upper part of the pons, in its dorsal part (43. It forms an elongated column that extends through both the open and closed parts of the medulla (43. It is a composite nucleus and contributes fibres to the glossopharyngeal, vagus and accessory nerves. The nuclei in this column give origin to preganglionic fibres that end in peripheral ganglia. These neurons, preganglionic and postganglionic, form part of the parasympathetic nervous system. They relay in the ciliary ganglion to supply the sphincter pupillae and the ciliaris muscle. The salivatory nuclei (superior and inferior) lie in the pons (dorsal part) just above its junction with the medulla (43. These fibres relay in the submandibular ganglion to supply the sub-mandibular and sublingual salivary glands. Other neurons located near the salivatory nuclei send out fibres that supply the lacrimal gland, after relaying in the pterygopalatine ganglion. Its upper end lies deep to the vagal triangle in the floor of the fourth ventricle. Postganglionic fibres arising in these ganglia run a short course to supply smooth muscle and glands in these viscera. Both these columns are represented by the nucleus of the solitary tract, present in the medulla (43. Like other cranial nerve nuclei in the medulla, the cells of this nucleus form an elongated column extending into both the open and closed parts of the medulla. The nucleus of the solitary tract receives fibres carrying general visceral sensations through the vagus and glossopharyngeal nerves. Fibres of taste (special visceral afferent) carried by the facial, glossopharyngeal and vagus nerves end in the upper part of the nucleus. General Somatic Afferent Nuclei the general somatic afferent column is represented by the sensory nuclei of the trigeminal nerve. The main sensory nucleus lies in the upper part of the pons, lateral to the motor nucleus of the nerve (43. In addition to fibres of the trigeminal nerve, it also receives general somatic sensations carried by the facial, glossopharyngeal and vagus nerves. The mesencephalic nucleus of the trigeminal nerve extends from the upper end of the main sensory nucleus into the midbrain (43. The peripheral processes of these cells are believed to carry proprioceptive impulses from muscles of mastication and possibly also from muscles of the eyeball, face and tongue. The central processes of the neurons in the nucleus probably end in the main sensory nucleus of the trigeminal nerve. These nuclei receive fibres from end organs in the cochlea that are concerned with hearing. The vestibular nuclei lie in the grey matter underlying the lateral part of the floor of the fourth ventricle (43. Arrangement of the columns of cranial nerve nuclei as seen in the embryo 882 Part 5 Head and Neck Schematic view of cranial nerve nuclei projected onto the posterior aspect of the brainstem Chapter 43 Nerves of the Head and Neck 883 Transverse sections through the brainstem to show the position of cranial nerve nuclei. The olfactory (first cranial) nerves are purely sensory and are concerned with smell. The peripheral end organ for smell is the olfactory mucosa that lines the upper and posterior part of the nasal cavity (both on the lateral wall and on the septum). Nerve fibres arising in this mucosa collect to form about twenty bundles that together constitute an olfactory nerve. The fibres of the olfactory nerves are processes of olfactory receptor cells located in the olfactory epithelium. Each cell gives off a short peripheral process directed towards the lumen of the nasal cavity, and a larger central process that passes into the mucosa forming one fibre of the olfactory nerve. These fibres collect to form about twenty bundles that collectively constitute one olfactory nerve. The bundles pass through foramina in the cribriform plate of the ethmoid bone to enter the cranial cavity (anterior cranial fossa) where they terminate in the olfactory bulb (43. Olfactory impulses carried by these fibres pass to other neurons located in the olfactory bulb. From the bulb they pass into the olfactory tract and ultimately end in several small areas located on the inferior surface of the cerebral hemisphere.

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Just near its origin from the ophthalmic artery erectile dysfunction 42 buy 800 mg viagra vigour with amex, the lacrimal artery gives off a recurrent meningeal branch that runs backwards to enter the middle cranial fossa through the superior orbital fissure. The lacrimal artery gives off two zygomatic branches that enter canals in the zygomatic bone. Their terminal branches (specially of the anterior artery) enter the nose and supply part of it. The supratrochlear artery is one of the terminal branches of the ophthalmic artery. Each external carotid artery arises from the common carotid at the level of the upper border of the thyroid cartilage (or the level of the disc between the third and fourth cervical vertebrae) (42. It gives off several branches through which it is widely distributed to structures of the head and neck outside the cranial cavity. From its origin, the artery runs upwards and terminates behind the neck of the mandible. Here, it is relatively superficial being covered by skin, superficial and deep fascia and by the anterior margin of the sternocleidomastoid muscle. Scheme to show the branches of the ophthalmic artery Chapter 42 Blood Vessels of Head and Neck 839 Course of central artery of retina Scheme to show the landmarks to which the external carotid artery, and its branches, are related. Above the triangle, the artery lies deep to the posterior belly of the digastric muscle and the parotid gland. The pharynx is separated from the upper part of the artery by the styloid process (and some muscles attached to it) and by the internal carotid artery. In addition to the relations mentioned above the external carotid artery is crossed by several structures that pass superficial or deep to it. The branches of the external carotid artery and their levels of origin are as follows (in order of origin) (42. The ascending pharyngeal artery arises from the deep aspect of the external carotid artery just above its lower end. The superior thyroid artery arises from the front of the external carotid just below the level of the greater cornu of the hyoid bone. The lingual artery arises from the front of the external carotid artery opposite the tip of the greater cornu of the hyoid bone. The facial artery arises from the front of the external carotid a little above the origin of the lingual artery. The occipital artery arises from the back of the external carotid opposite the origin of the facial artery. The posterior auricular artery arises from the back of the external carotid just above the level at which the latter is crossed by the posterior belly of the digastric muscle. The superficial temporal artery and the maxillary artery are terminal branches of the external carotid artery. They begin behind the neck of the mandible, in the substance of the parotid gland. The ascending pharyngeal artery runs upwards to the base of the skull, lying between the pharynx and the internal carotid artery. The superior thyroid artery runs downwards and medially to reach the upper pole of the thyroid gland. The terminal part of the anterior branch runs across the upper part of the isthmus of the gland to anastomose with the artery of the opposite side. The posterior branch runs downwards along the posterior border of the thyroid to anastomose with the inferior thyroid artery. The lingual artery arises from the external carotid artery opposite the tip of the greater cornu of the hyoid bone (42. The first part of the artery lies in the carotid triangle, superficial to the middle constrictor of the pharynx (42. The second part of the artery lies deep to the hyoglossus muscle that separates the artery from the hypoglossal nerve. The third or deep part of the artery runs upwards along the anterior margin of the hyoglossus; and then forwards to the tip of the tongue. The facial artery arises from the external carotid just above the greater cornu of the hyoid bone (42. The artery first runs upwards along the posterior border of the gland and then downwards and forwards between the gland (deep to it) and the medial pterygoid muscle (superficial to it) (42. It reaches the lower border of the mandible at the anterior edge of the masseter (42. Curving round this border the artery runs upwards and forwards across the superficial aspect of the body of the mandible, and across the buccinator muscle to reach the angle of the mouth. It then runs upwards along the side of the nose to reach the medial angle of the palpebral fissure. The tonsillar branch reaches the tonsil by piercing the superior constrictor muscle. The submental artery runs forwards along the lower border of the mandible (over the mylohyoid muscle). This artery arises from the posterior aspect of the external carotid opposite the origin of the facial artery. It runs backwards along the lower border of the posterior belly of the digastric muscle (42. Here, it lies deep to the sternocleidomastoid, the digastric and some other muscles. It then runs medially, and becoming superficial supplies the posterior part of the scalp. The stylomastoid branch enters the stylomastoid foramen to supply the middle ear and related structures. Meningeal branches enter the skull through the jugular foramen and the carotid canal.

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The two are held in position by continuity of the periosteum of the rib with the perichondrium of the cartilage does kaiser cover erectile dysfunction drugs purchase viagra vigour 800 mg with visa. The arrow points to the attachment of the superior costotransverse ligament CliniCal Correlation In dislocation of a costochondral joint, a rib separates from its costal cartilage. Chondrosternal Joints these joints are often, less accurately, referred to as sternocostal joints. They are joints between the (medial ends of) 1st and 7th costal cartilages and the sternum. The joint of the first costal cartilage with the manubrium sterni has been described, in the past, as a synchondrosis. However, the costal cartilage is united to the manubrium through a plate of fibrocartilage and is not a typical synchondrosis. The joints between the 2nd and 7th costal cartilages and the sternum are synovial joints. They are strengthened anteriorly and posteriorly by fibres that radiate from the costal cartilage onto the sternum. The cavity of the joint between the 2nd costal cartilage and the sternum is normally divided into upper and lower parts by an intra-articular ligament. Interchondral Joints the 6th to 9th costal cartilages come into contact with one another and form a number of small interchondral synovial joints. The precise nature of the movements is complex and differs in different ribs, but the two fundamental movements to be understood are as follows: 1. The anterior ends of the ribs can move up or down by rotation at the costovertebral and costotransverse joints. In expiration, the anterior ends of the ribs are lower than their posterior ends (17. During inspiration, the anterior end moves upwards in an arc becoming more horizontal. The forward movement of the rib is made possible by an angular movement at the manubriosternal joint. Rotation of ribs on a transverse axis takes place mainly in relation to the upper six ribs. These movements are facilitated by the fact that articular surfaces on the tubercles of these ribs are convex. The second movement of the ribs occurs on an axis that is roughly anteroposterior. During quiet breathing the movements of the ribs described above are produced by intercostal muscles. Elevation of ribs (during inspiration) is produced by the external intercostals, and depression (during expiration) by the internal intercostals, aided by elastic recoil of the thoracic wall. In deep inspiration movements of the ribs are aided by contraction of some muscles attached to the ribs. The scaleni (present in the neck) and the sternocleidomastoid muscles elevate the first rib, while the erector spinae helps expansion of the thorax by reducing the concavity of the thoracic part of the vertebral column. In forced inspiration (against resistance), the scapulae are elevated and fixed by the trapezius, the levator scapulae and the rhomboideus muscles. With the arms fixed (by holding onto a firm object) contraction of the serratus anterior and of the pectoralis major pulls upon the ribs helping expansion of the thorax. In forced expiration (as in patients with asthma), the thorax is compressed by the latissimus dorsi (but the major role is played by abdominal muscles). In infants, the thorax is more nearly circular as a result of which respiration is mostly abdominal. In a condition called emphysema the lungs are dilated, and as a result the thorax can become rounded in section (barrel chest), making respiration much less effective. Deformities seen in the thoracic cage may be congenital or may result from disease. In funnel chest, the front of the chest (in the region of the body of sternum and xiphoid process) is depressed. In pigeon chest, the thorax may project forwards in midline (as is normal in birds). In this chapter, we will consider other structures to be encountered in the thoracic wall. There being twelve ribs on either side, and eleven intercostal spaces between them, we have eleven sets of external and internal intercostal muscles. Each intercostal space extends, posteriorly, up to the superior costotransverse ligaments (extending between the neck of the rib and the transverse process of the vertebra next above it). The internal intercostal muscles do not extend over the entire length of the space: anteriorly they extend right up to the sternum, but posteriorly they end at the level of the angles of the ribs beyond which they are replaced by the posterior intercostal membranes. The external intercostals reach the costotransverse ligaments posteriorly, but they are deficient in front. Between the costal cartilages, they are replaced by the anterior intercostal membranes. The internal intercostal membrane has been removed in the upper space to reveal the underlying external intercostal muscle; (B) Anterior ends of two intercostal spaces viewed from the front. The external intercostal muscle and membrane have been removed in the upper space 354 Part 3 Thorax 18. Costal cartilages (adjoining parts of 4th to 7th) At right angles to external intercostal. On the front Inner surface of adjoining of the thorax fibres run downwards and laterally rib Inner surface of rib two or three intercostal spaces below origin 2nd, 3rd, 4th, 5th and 6th costal cartilages (lower borders and inner surfaces) 1. Upwards and laterally Depresses costal cartilages into which from origin to insertion it is inserted 2. The intercostalis intimi (or innermost intercostal muscle) is seen only in the middle two-fourths of the intercostal space.

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It runs laterally behind the inguinal ligament to reach the anterior superior iliac spine depression and erectile dysfunction causes discount 800 mg viagra vigour. It then passes along the inner lip of the iliac crest, deep to the transversus abdominis muscle. At about the middle of the iliac crest, it pierces the muscle and continues to run backwards between it and the internal oblique. The superficial circumflex iliac artery runs laterally towards the anterior superior iliac spine. The superficial epigastric artery ascends across the inguinal ligament and runs towards the umbilicus. The superficial external pudendal artery runs medially to supply skin over the external genitalia and over the lower part of the abdomen. Branches from the various arteries described above supply muscles in the abdominal wall. The skin of the abdomen is supplied by lateral cutaneous branches arising from intercostal and subcostal arteries; 2. By anterior cutaneous arteries arising from the superior and inferior epigastric arteries. Veins of Anterior Abdominal Wall the veins of the anterior abdominal wall correspond to the arteries described above. The veins that accompany the superficial branches of the femoral artery drain into the long saphenous vein (not into the femoral vein). Lymphatic Drainage of the Anterior Abdominal Wall lymphatic drainage of the Skin 1. The skin above the level of the umbilicus (in front) and above the iliac crest (at the back) drains into the axillary lymph nodes (25. The skin of the anterior abdominal wall below the umbilicus drains into the superficial inguinal lymph nodes. The vessels from the upper part of the abdominal wall travel along the superior epigastric vessels to reach parasternal lymph nodes. The vessels from the lower part of the anterolateral abdominal wall travel along the inferior epigastric and circumflex iliac vessels. Passing through nodes placed along these vessels they reach the external iliac nodes (25. CliniCal Correlation of abdominal wall Lymphatic drainage the lymphatic drainage of the abdominal wall described above is important. Infections or malignancy in relation to the abdominal wall can drain into widely separated lymph nodes. Superficial veins the superficial veins over the anterior abdominal wall are normally inconspicuous. The umbilicus is one of the sites at which tributaries of the portal vein communicate with systemic veins. In case of obstruction to the portal vein, these communications become very prominent and are seen as veins that radiate from the umbilicus. Superficial veins running more or less vertically over the lateral part of the anterior abdominal wall connect tributaries of the lateral thoracic vein with tributaries of the superficial epigastric vein. The superficial epigastric vein joins the great saphenous vein that, in turn, joins the femoral vein. The superficial veins referred to above, therefore, provide channels of communication between the axillary and femoral veins. In case of obstruction to either the superior or inferior vena cava these superficial veins enlarge considerably and serve as alternative channels through which blood can flow one vena cava to the other and thus reach the heart. The direction of blood flow in superficial veins gives a clue to the identity of the blocked vena cava. Typically, the umbilicus lies at the level of the intervertebral disc between vertebral bodies l3 and l4. However, it is not a reliable guide to structures within the abdomen due to variability in its position. The cutaneous nerve supply of the skin at the level of the umbilicus is derived from the tenth intercostal nerve. Early in fetal life the region of the future umbilicus is marked by a large gap in the future abdominal wall. If the duct remains patent, there is a channel through which intestinal contents flow out at the umbilicus (fecal fistula). Sometimes, the vitellointestinal duct may not communicate with the exterior but part of it may remain patent as a diverticulum communicating with the gut. Remnants of the vitellointestinal duct may also give rise to tumours at the umbilicus. The allantoic diverticulum is a tube like structure that is connected, at one end, to the distal part of the embryonic gut (the part called the cloaca). In later development, the cloaca is partitioned into a part that forms the rectum and another part that forms the urinary bladder, and after this partition is established the allantoic diverticulum comes to communicate with the urinary bladder. Normally, the allantoic diverticulum is occluded and forms a fibrous band called the urachus. Occasionally, however the urachus remains patent resulting in a communication between the urinary bladder and the umbilicus (urinary fistula). Meanwhile the gut undergoes rapid growth and the abdomen is unable to accommodate it. As a result, some coils of intestine pass out of the abdomen through the umbilical opening (This is referred to as physiological hernia).

Rocko, 39 years: In the upper lobe of the left lung the apical and posterior segmental bronchi arise by a common stem.

Marius, 61 years: The profunda femoris vessels, and the anterior division of the obturator nerve, lie deep to it.

Daryl, 60 years: The sinus has frontal and parietal tributaries corresponding to those of the artery.

Ashton, 24 years: The first metatarsal bone has a large kidney shaped facet on the proximal surface of its base.