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Infections in the head may also spread inferiorly posterior to the esophagus and enter the posterior mediastinum, or it may spread anterior to the trachea and enter the anterior mediastinum. In both males and females, the 1468 musculature described is oriented perpendicular to the perineal membrane, rather than lying in a plane parallel to it. The wall of the thoracic cavity is relatively thin, essentially as thick as its skeleton. A short incision is made in the 5th or 6th intercostal space in the midaxillary line (which is approximately at nipple level). As a result, some flattening of the medial part of the longitudinal arch occurs, along with lateral deviation of the forefoot. The phrenic ampulla, which is seen only radiographically, is the distensible part of the esophagus superior to the diaphragm. Deep to the flexor retinaculum and the origin of the abductor hallucis, the posterior tibial artery divides into medial and lateral plantar arteries, the arteries of the sole of the foot. The branches of the intercostal nerves pass through the pectoral fascia covering the pectoralis major to reach overlying subcutaneous tissue and skin of the breast. Organic pain arising from an organ such as the stomach varies from dull to severe; however, the pain is poorly localized. Movement at the superior tibiofibular joint is impossible without movement at the inferior tibiofibular syndesmosis. This condition, one potentially treatable cause of cognitive impairment, has caused ventriculomegaly (affecting the third and lateral ventricles) with macroscopic preservation of the cortical ribbon. The celiac plexus, surrounding the root of the celiac (arterial) trunk, contains irregular right and left celiac ganglia (approximately 2 cm long) that unite superior and inferior to the celiac trunk. Thus, the parietal pleura generally extends approximately two ribs inferior to the lung. The ampulla receives and holds an accumulating fecal mass until it is expelled during defecation. Each internal carotid artery enters the cranial cavity through the carotid canal in the petrous part of the temporal bone. Thus, much smaller forces of longer duration are transmitted through the skeletal system. Each inferior petrosal sinus runs in a groove between the petrous part of the temporal bone and the basilar part of the occipital bone. The potential or pathological cranial epidural space is not continuous with the spinal epidural space (a natural space occupied by epidural fat and a venous plexus) because the former is external to the periosteum lining the cranium, and the latter is internal to the periosteum covering the vertebrae. Medial to the hilum, the lung root is enclosed within the area of continuity between the parietal and the visceral layers of pleura-the pleural sleeve (mesopneumonium). In this coronal section of hip joint, the acetabular labrum and transverse acetabular ligament, spanning the acetabular notch (and included in the plane of section here), extend the acetabular rim so that a complete socket is formed. The nasopalatine nerve supplies the mucous membrane of the anterior part of the hard palate. The patella provides a bony surface that is able to withstand the compression placed on the quadriceps tendon during kneeling and the friction occurring when the knee is flexed and extended during running. The bulbar conjunctiva is reflected from the sclera onto the deep surface of the eyelid. The extrapelvic distribution of the obturator artery is described with the lower limb (Chapter 7). An anteromedial lobule, deep to the inferolateral lobule, directly lateral to the proximal prostatic urethra. Inferolaterally, finger-like slips, or digitations of the serratus anterior, have a serrated (sawtooth) appearance as they attach to the ribs and interdigitate with the external oblique. The pain may be so intense that the person winces, thus the common term tic (twitch). The anterior skin and subcutaneous tissue have been removed to reveal the deep fascia.

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Because the branches of the facial nerve are superficial, they are subject to injury by stab and gunshot wounds, cuts, and injury at birth. If the heart stops beating (cardiac arrest) during heart surgery, the surgeon attempts to restart it using internal or openchest heart massage. They have a core of spongy connective tissue containing erectile tissue at their base and many small blood vessels. Motion Sickness the maculae of the membranous labyrinth are primarily static organs, which have small dense particles (otoliths) embedded among hair cells. Dynamic supports involved in maintaining the arches of the foot include: Active (reflexive) bracing action of intrinsic muscles of foot (longitudinal arch). Between the fibrous pericardium and the heart is a "collapsed" sac, the serous pericardium. The generally litigious climate attributing cerebral palsy to obstetric or neonatal paediatric malpractice is based on spurious claims. The median sacral artery represents the caudal end of the embryonic dorsal aorta, which reduced in size as the tail-like caudal eminence of the embryo disappeared. The obturator internus and piriformis are muscles that act on the lower limb but are also components of the pelvic walls. Thus, the major glandular secretions and sperms are delivered to the prostatic urethra. The pelvic girdle is formed by the two hip bones (of the inferior axial 1297 skeleton) anteriorly and laterally and the sacrum (of the axial skeleton) posteriorly. Their long tendons, plus those of the flexors of the digits, also help support the arches of the foot during the stance phase, assisting the intrinsic muscles of the sole. They pass retroperitoneally (posterior to the peritoneum) in an oblique direction, crossing over the ureters and the inferior parts of the external iliac arteries to reach the 1029 deep inguinal rings. Although much smaller than the thyroid cartilage, the cricoid cartilage is thicker and stronger and is the only complete ring of cartilage to encircle any part of the airway. Two to five per cent of the population worldwide are estimated to develop intracranial aneurysms. The venous drainage from the proximal part of the bile duct and the hepatic ducts usually enter the liver directly. The medial surface of the lateral malleolus articulates with the lateral surface of the talus. Determination of the pathological type of stroke is best achieved by early brain imaging, or by autopsy in fatal cases. The manubrium and body of the sternum lie in slightly different planes superior and inferior to their junction, the manubriosternal joint. Inhalation of 500 ppm sulphide causes immediate apnoea, related to hyperpolarization of neurons in the medulla oblongata that control breathing. The soleus is thus an antigravity muscle (the predominant plantarflexor for standing and strolling), which contracts antagonistically but cooperatively (alternately) with the dorsiflexor muscles of the leg to maintain 1725 balance. Because the linea alba transmits only small vessels and nerves to the skin, a median (midline) incision is relatively bloodless and avoids major nerves; however, incisions in some people may reveal abundant and well-vascularized fat. In hypoxaemia, only delivery of O2 is impaired, not removal of products of metabolism. The median part of the upper lip features a tubercle, superior to which is a shallow groove, the philtrum (G. Slowly Progressive Coronary Artery Disease In slow occlusion of a coronary artery, the collateral circulation has time to increase so that adequate perfusion of the myocardium can occur when a 907 potentially ischemic event occurs. Superficial to the outer covering is the deep fascia of the penis (Buck fascia), the continuation of the deep perineal fascia that forms a strong membranous covering for the corpora cavernosa and corpus spongiosum, binding them together. Wrist joint: Motion at the wrist moves the entire hand, making a dynamic contribution to a skill or movement, or allowing it to be stabilized in a particular position to maximize the effectiveness of the hand and fingers in manipulating and holding objects. The posterolateral abdominal wall has been incised between the muscles of the anterolateral abdominal wall and the muscles of the back.

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The extrinsic muscles of the tongue (genioglossus, hyoglossus, styloglossus, and palatoglossus) originate outside the tongue and attach to it. The tentorium cerebelli is attached along the lengths of 1970 the transverse and superior petrosal sinuses (dashed line). The rich nerve supply of the suprarenal glands is from the celiac plexus and abdominopelvic (greater, lesser, and least) splanchnic nerves. The arteries of the scalp supply little blood to the calvaria, which is supplied by the middle meningeal arteries. The upper respiratory passages and alimentary canal in the right 2320 half of a bisected head and neck are shown. Central nervous system apoptosis in human herpes simplex virus and cytomegalovirus encephalitis. Parallel fibers linking two discs resemble those making up the tube-like fibrous layer of the hip joint capsule. The thyrocervical trunk arises from the anterosuperior aspect of the first part of the subclavian artery, near the medial border of the anterior scalene muscle. After entering the femoral triangle, the femoral nerve divides into several branches to the anterior thigh muscles. Deeply, the superior boundaries are formed by the diverging medial and lateral supracondylar lines of the femur. Plantarflexion of the ankle is produced by the muscles in the posterior compartment of the leg (see Table 7. The proximal surface of this disc articulates with the distal aspect of the head of the ulna. Special Sensory (Taste) Peripheral fibers of sensory neurons of the geniculate ganglion are carried by the chorda tympani. Four structures run parallel as they traverse the superior thoracic aperture: trachea, esophagus, left recurrent laryngeal nerve, and thoracic duct. The lateral wall of the infratemporal fossa is formed by the ramus of the mandible. In the depths of the anterior median fissure, alternate sulcal arteries deviate either left or right to supply the corresponding side of the cord. The calcaneal tendon can be easily followed to its attachment to the calcaneal tuberosity, the posterior part of the calcaneus. As stomach cancer becomes more advanced, the lymphogenous dissemination of malignant cells involves the celiac lymph nodes, to which all gastric nodes drain. Consequently, nearly the lower half of the thoracic wall surrounds and protects abdominal rather than thoracic viscera. Position of Appendix A retrocecal appendix extends superiorly toward the right colic flexure and is usually freely mobile. The sciatic nerve usually ends at the superior angle of the popliteal fossa by dividing into the tibial and common fibular nerves. Palmar ligaments of the radio-ulnar, radiocarpal, intercarpal, carpometacarpal, and interphalangeal joints. Excess pressure is placed on the medial aspect of the knee joint, which results in arthrosis (destruction of knee cartilages), and the fibular collateral ligament is overstressed. The reported frequencies of multiple aneurysms in patients with subarachnoid haemorrhage vary from 8. A peritoneal recess, or peritoneal fossa, is a pouch of peritoneum that is formed by a peritoneal fold. The isthmus of the thyroid gland lies immediately inferior to the cricoid cartilage; it extends approximately 1. The characteristic handicap is inability to extend the wrist resulting from paralysis of extensor muscles of the forearm, all of which are innervated by the radial nerve. Consequently, it may be three times stronger than its antagonistic muscle group, the hamstrings. Venous drainage from the brain occurs via cerebral and cerebellar veins that drain to the adjacent dural venous sinuses. The hepatic portal vein and hepatic artery enter the liver via the porta hepatis, where the hepatic ducts exit.

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If the dorsum of the hand is examined with the wrist extended against resistance and the digits abducted, the tendons of the extensor digitorum to the fingers stand out, particularly in thin individuals. Deviation of the trachea from the midline, apparent superficially or radiographically, often signals the presence of a pathological process. The distribution of cardiogenic thromboemboli corresponds relatively closely to the volume of blood each major intracerebral artery receives from the heart. It is opened by a combination of the expanding girth of the belly of the levator veli palatine, as it contracts longitudinally, pushing against one wall and the tensor veli palatini pulling on the other. They pass through the transversus abdominis and internal oblique muscles to supply the external oblique and skin of the anterolateral abdominal wall. Subtotal Pancreatectomy Pancreatectomy, partial or complete surgical removal of the pancreas, is most commonly performed when pancreatic tumors are detected (see "Pancreatic Cancer" below). Fractures of the proximal femur occur at several locations; two examples are transcervical (middle of neck) and intertrochanteric. The deepest fibers of the internal intercostals lie deep to the intercostal vessels and nerves and therefore are somewhat artificially designated as a separate muscle, the innermost intercostals. The popliteus is a thin, triangular muscle that forms the inferior part of the floor of the popliteal fossa. The ligamentum arteriosum is the remnant of the fetal shunt (ductus arteriosus) that bypasses the prefunctional lungs. She then developed a fluid collection in the posterior cervical tissue and aseptic meningitis, prompting wound revision and removal of the soft tissue and Bioglue. Usually this follows a hard blow to the head, and forms an extradural (epidural) hematoma. Patellar Dislocation When the patella is dislocated, it nearly always dislocates laterally. Internal hemorrhoids that prolapse into or through the anal canal are often compressed by the contracted sphincters, impeding blood flow. Some primary care physicians may not have been taught and/or may not realize that the so-called superficial vessels are actually deeply located and that acute thrombosis of the vein is potentially life threatening. Astrocytes show 152 Chapter 2 Vascular Disease, Hypoxia and Related Conditions elongated perivascular foot processes. Internal hemorrhoids result from a breakdown of the muscularis mucosae, a smooth muscle layer deep to the mucosa. The identity of the entrapped cells can be proven by immunostaining for epithelial membrane antigen (h). The posterior auricular and superficial temporal arteries and veins and the great auricular and auriculotemporal nerves provide the circulation and innervation of the external ear. As children get older, the fat is lost, and a normal medial longitudinal arch becomes visible. The left sternal reflection of parietal pleura and anterior border of the left lung deviate from the median plane, circumventing the area where the heart is, lies adjacent to the anterior thoracic wall. The superficial veins have thin walls, no tunica muscularis and no valves, permitting dilation and flow of venous blood in various directions. In addition to sympathetic fibers that pass to blood vessels, sympathetic and parasympathetic fibers are distributed to pancreatic acinar cells and islets. It also prevents anterior displacement of the femur on the tibia or posterior displacement of the tibia on the femur and helps prevent hyperflexion of the knee joint. The two heads of the gastrocnemius muscle have been separated and are being retracted. The inferior hypogastric plexuses are mixed sympathetic and parasympathetic plexuses formed on each side as the hypogastric nerves from the superior hypogastric plexus merge with the pelvic splanchnic nerves. Bursae are membranous sacs lined by a synovial membrane containing a capillary layer of slippery fluid resembling egg white. The posterior layer of the rectus sheath and the peritoneum are then incised to enter the peritoneal cavity. The tentorium cerebelli, the second largest dural infolding, is a wide crescentic septum that separates the occipital lobes of the cerebral hemispheres from the cerebellum. The parasympathetic fibers distributed within the pelvis stimulate contraction of the rectum and bladder for defecation and urination, respectively.

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The foot is raised as in the push off phase of walking, demonstrating the position of the plantarflexor tendons as they cross the ankle. The sigmoid arteries descend obliquely to the left, where they divide into ascending and descending branches. Because of the deep fascial roof and osseofibrous floor, the fossa is a relatively confined space. Extend your neck as far as possible and run your finger over the laryngeal prominence. Some physicians recommend that men perform a selfexamination of their testicles monthly after puberty and report any testicular or scrotal changes. This specimen shows the granulomatous foreign-body type response and the macrophages containing tiny droplets of eosinophilic Bioglue (arrow); the large central inert blob of Bioglue was homogeneously densely eosinophilic, and visually uninteresting. The fibers of the right crus of the diaphragm decussate (cross one another) inferior to the hiatus, forming a muscular sphincter for the esophagus that constricts it when the diaphragm contracts. The hepatic plexus, the largest derivative of the celiac plexus, accompanies the branches of the hepatic artery to the liver conveying sympathetic and parasympathetic fibers. Therefore, some coordinated movement of a properly fitted 2069 artificial eyeball is possible. Pericytes are recruited as support cells, with concomitant basal lamina production. It bifurcates at the level of the transverse thoracic plane (or sternal angle) into main bronchi, one to each lung, passing inferolaterally to 807 enter the lungs at the hila (singular = hilum). Within the posterior compartment, they typically give rise to muscular branches to the hamstrings and anastomotic branches that ascend or descend to unite with those arising superiorly or inferiorly from the other perforating arteries or the inferior gluteal and popliteal artery. It then runs to the dorsum of the penis, where it runs lateral to the dorsal artery. Squamous Cell Carcinoma of Lip Squamous cell carcinoma (cancer) of the lip usually involves the lower lip. Sometimes, the arch curves over the root of the right lung and passes inferiorly on the right side, forming a right arch of the aorta. It also carries proprioceptive fibers from the muscles it innervates, although the muscles of facial expression include relatively few muscle spindles (mechanoreceptors for muscle stretch), so proprioceptive sensory fibers are fewer than in other motor nerves (Haines, 2013). The inguinal ligament is the thickened, underturned, inferior margin of the aponeurosis of the external oblique, forming a retinaculum that bridges the subinguinal space. The femurs of human females are slightly more oblique than those of males, reflecting the greater width of their pelves. Even total splenectomy usually does not produce serious effects, especially in adults, because most of its functions are assumed by other reticuloendothelial organs. It then supplies the skin on the anterolateral aspect of the leg and divides into the medial and intermediate dorsal cutaneous nerves, which continue across the ankle to supply most of the skin on the dorsum of the foot. When the foot is suddenly and violently inverted, the tuberosity of the 5th metatarsal may be avulsed (torn away) by the tendon of the fibularis brevis muscle. The fleshy part of the muscle contributes primarily to the lateral part of the abdominal wall. The diaphragm curves superiorly into right and left domes; normally, the right dome is higher than the left dome owing to the presence of the liver. The hepatic plexus accompanies the branches of the hepatic artery and hepatic portal vein to the liver. Note the convolutions of the small intestine in situ, encircled on three sides by the large intestine and revealed by elevating the greater omentum. In approximately 20% of people, this branch passes inferior to the angle of the mandible. Because the aponeurosis is a layer of the scalp, independent contraction of the occipital belly retracts the scalp and contraction 1927 of the frontal belly protracts it. Thus, the membrane and ligaments strongly resist the downward pull placed on the fibula by eight of the nine muscles attached to it. The arterial supply of the maxillary sinus is mainly from superior alveolar branches of the maxillary artery. The main movements at these joints are rotation and gliding of the thyroid cartilage, which result in changes in the length of the vocal folds. Myotomes are the segmental innervation of muscle groups and movements of lower limb.

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The intrinsic pathway originates with mitochondrial release of cytochrome c and subsequent stimulation of caspase-3 whereas the extrinsic pathway is initiated by the activation of cell surface death receptors, which belong to the tumour necrosis factor superfamily, by Fas ligand, resulting in the stimulation of caspase-8. The ureter lies posterolateral to the ductus deferens 1366 and enters the posterosuperior angle of the bladder, just superior to the seminal gland. Furthermore, the tarsal and metatarsal bones are arranged in longitudinal and transverse arches passively supported and actively restrained by flexible tendons that add to the weight-bearing capabilities and resiliency of the foot. After entering the perineum via the lesser sciatic foramen, the nerve supplies the obturator internus muscle. Males are especially susceptible to subcutaneous accumulation of fat in the lower anterior abdominal wall. However, the hepatic lobule is a firmly established concept and is useful for descriptive purposes. Most lymph is formed in the perisinusoidal spaces (of Disse) and drains to the deep lymphatics in the surrounding intralobular portal triads. These muscles all have distal attachments on or adjacent to the intertrochanteric crest of the femur. Consequently, a first rib fracture is commonly viewed as a hallmark of severe injury in blunt trauma. The anterior border of the tibia is sharp, subcutaneous, and easily followed distally by palpation from the tibial tuberosity to the medial malleolus. Obliteration of sutures usually begins at the bregma and continues sequentially in the sagittal, coronal, and lambdoid sutures. The vagina lies posterior to the urinary bladder and urethra, the latter projecting along the midline of its inferior anterior wall. It extends from the duodenojejunal junction on the left side of vertebra L2 to the ileocolic junction and the right sacro-iliac joint. Cancer of Larynx the incidence of cancer of the larynx is high in individuals who smoke cigarettes or chew tobacco. The orifices of posterior, middle, and anterior ethmoidal cells open into the superior meatus, middle meatus, and semilunar hiatus, respectively. A medium-size embolus may block an artery supplying a bronchopulmonary segment, producing a pulmonary infarct, an area of necrotic (dead) lung tissue. The terminology used to describe these aqueductal anomalies is inconsistent and often confusing. The pericardium is influenced by movements of the heart and great vessels, the sternum, and the diaphragm. The anterior and superior borders of the spleen 1146 are sharp and often notched, whereas its posterior (medial) end and inferior border are rounded. The easily palpated concave center of the superior border of the manubrium is the jugular notch (suprasternal notch). They frequently occur during motor vehicle accidents and sports, such as skiing and climbing. Usually, movement at the sacro-iliac joint is limited by interlocking of the articulating bones and the sacro-iliac ligaments to slight gliding and rotary movements. Paralysis of Quadriceps A person with paralyzed quadriceps muscles cannot extend the leg against resistance. The left phrenic nerve descends between the left subclavian and left common carotid arteries. The outline of the horizontal fissure of the right lung clearly parallels the 4th rib. Summary of cranial parasympathetic ganglia and related visceral motor and sensory fiber distribution. Abdominal muscles protect and support the viscera most effectively when they are well toned; thus, the well-conditioned adult of normal weight has a flat or scaphoid (lit. An open-book view of the lateral and medial walls of the right side of the nasal cavity is shown.

Syndromes

• Prevent injuries to the face by using standard safety precautions. Most injuries to the face are related to motor vehicle accidents and can be prevented by using seat belts.
• Nerve conduction study with electromyography
• Mouth pain (severe)
• Losing excess weight
• Low red blood cell count (anemia)
• Having a pet that may carry ticks home
• Nail abnormalities
• Osteomalacia
• Brain aneurysm clips
• Do you feel fatigued or tired throughout the day? Does it tend to get worse as the day goes on or stay about the same?

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Cochlear implants are one approach employed to restore sound perception when the hair cells of the spiral organ have been damaged. While standing (especially on one foot), however, the two muscles may cooperate to depress the lateral side of the foot and pull medially on the leg as needed to counteract lateral leaning for balance. Complete section of the optic chiasm reduces peripheral vision and results in bitemporal hemianopsia, the loss of vision of one half of the visual field of both eyes. Before eruption, the developing teeth reside in the alveolar arches as tooth buds. Lymph from the deep tissues of the gluteal region enters the pelvis along the gluteal veins, draining to the superior and inferior gluteal lymph nodes; from them, it passes to the iliac and lateral lumbar (caval/aortic) lymph nodes. The first part of the maxillary artery, the larger of the two end branches of the external carotid, run anteriorly, deep to the neck of the mandible, and then pass deeply between the lateral and the medial pterygoid muscles. The superior part joins the brachial plexus, the nerve plexus supplying the upper limb, and the inferior part becomes the 1st intercostal nerve. The otic capsule is often erroneously illustrated and identified as being the bony labyrinth. Compression of the recurrent laryngeal nerves by an esophageal tumor produces hoarseness. The nerves are derived from the prostatic plexus (mixed sympathetic, parasympathetic, and visceral afferent fibers). Avulsion (tearing away) of the ischial tuberosity at the proximal attachment of the biceps femoris and semitendinosus may result from forcible flexion of the hip with the knee extended. The thin anterolateral walls (appearing disproportionately thick here) are distensible. Stenosis of Internal Carotid Artery At the medial angle of the eye, an anastomosis occurs between the facial artery, a branch of the external carotid artery, and cutaneous branches of the internal carotid artery. To prevent regeneration of nerve fibers, the sensory root of the trigeminal nerve may be partially cut between the ganglion and the brainstem (rhizotomy). The hernial sac compresses the contents of the femoral canal (loose connective tissue, fat, and lymphatics) and distends the wall of the canal. The inferior alveolar nerve enters the mandibular foramen and passes through the mandibular canal, forming the inferior dental plexus, which sends branches to all mandibular teeth on its side. The arrows indicate transient narrowing of the lumina of the ureters resulting from peristaltic contraction. The skin ligaments also anchor the skin to the underlying deep fascia (plantar aponeurosis), improving the "grip" of the sole. A cholecysto-enteric fistula also permits gas from the gastrointestinal tract to enter the gallbladder, providing a diagnostic radiographic sign. The profunda femoris artery (deep artery of thigh) is the largest branch of the femoral artery and the chief artery to the thigh. The inflammation fades as the affected arteries perforate the dura, at which point the amount of elastic in the arterial wall is also markedly diminished. As they approach the vertebral column, the posterior intercostal veins receive a posterior branch, which accompanies the posterior ramus of the spinal nerve of that level, and an intervertebral vein draining the vertebral venous plexuses associated with the vertebral column. Most (65%) duodenal ulcers occur in the posterior wall of the superior part of the duodenum within 3 cm of the pylorus. Colorectal cancers have different characteristics based on their location within the colon or rectum. The two muscles of the posterior compartment that pass to the toes are crisscrossed-that is, the muscle attaching medially to the great toe (flexor hallucis longus) arises laterally (from the fibula) in the deep subcompartment, and the muscle attaching to the lateral four toes (flexor digitorum longus) arises medially (from the tibia). The medial two thirds of the meatus is bony and lined with thin skin that is continuous with the external layer of the tympanic membrane. The enlarged view of the surface of a block of parenchyma removed from the liver in (B) shows the hexagonal pattern of lobes and the place of (A) within that pattern. The definitive atrium is enlarged by incorporation of most of the embryonic sinus venosus. The ciliary ganglion receives three types of nerve fibers from three separate sources. It has many causes, all of which result in a reduced blood supply to the vital 905 myocardial tissue. It also sends articular branches to the hip and knee joints and provides several cutaneous branches to the anteromedial side of the thigh (Table 7.

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The central artery and vein of the retina traverse the meningeal layers and course in the anterior part of the optic nerve. In these cases, the dorsalis pedis artery is replaced by an extended perforating fibular artery of smaller caliber than the typical dorsalis pedis artery, but running in the same location. Surface Anatomy of Eye and Lacrimal Apparatus For a description of the surface anatomy of the eyelids, see "Surface Anatomy of Face. Later, severe pain in the right lower quadrant results from irritation of the parietal peritoneum lining the posterior abdominal wall (usually formed by the psoas and iliacus muscles in the region of the appendix). Vaginismus Vaginismus is defined as involuntary (reflex) muscle spasms that occur when vaginal penetration is attempted (when perineal muscles are distended). All anatomical structures within the eyeball have a circular or spherical arrangement. Slight movement of the joint occurs during dorsiflexion of the foot as a result of wedging of the trochlea of the talus between the malleoli (see "Articular Surfaces of Ankle Joint" later in this chapter). Little or no trace of the lines of fusion of the primary bones is visible in older adults. The zygomatic bone underlying the prominence and the zygomatic arch, which continues posteriorly, are commonly referred to as the "cheek bone". The nerves of the larynx are the internal and external branches of the superior laryngeal nerve and the inferior laryngeal nerve from the recurrent laryngeal nerve. Laterally: the peritoneal broad ligament flanking the uterine body and the fascial cardinal ligaments on each side of the cervix and vaginal. Reflective of their abdominal origins, lymph from the testes follow a route, independent of the scrotal drainage, along the testicular veins to the intermesenteric portion of the lumbar (caval/aortic) and pre-aortic lymph nodes. The sympathetic innervation that stimulates ejaculation simultaneously causes contraction of the 1376 internal urethral sphincter, to prevent reflux of semen into the bladder. The pectoral girdle is a partial bony ring (incomplete posteriorly) formed by the manubrium of the sternum, the clavicle, and the scapulae. This vein passes inferiorly and superficially in the neck to empty into the subclavian vein. The circumflex femoral arteries encircle the uppermost shaft of the femur and anastomose with each other and other arteries, supplying the thigh muscles and the superior (proximal) end of the femur. The amount of blood and air that accumulates determines the extent of pulmonary collapse. Venous drainage of deep parts of the scalp in the temporal region is through deep temporal veins, which are tributaries of the pterygoid venous plexus. If present, the accessory phrenic nerve lies lateral to the main nerve and descends posterior and sometimes anterior to the subclavian vein. It then penetrates the perineal membrane, ending as the urethra enters the bulb of the penis. Pulmonic regurgitation may be heard through a stethoscope as a heart murmur, an abnormal sound from the heart, produced in this case by damage to the cusps of the pulmonary valve. The remainder of this chapter discusses several of these regions in detail, as well as some deep regions not represented on the surface. The gastrocnemius and most of the soleus are removed, leaving only a horseshoe-shaped section of the soleus close to its proximal attachments and the distal part of the calcaneal tendon. Efferent vessels from these nodes form the intestinal lymphatic trunks, which may be single or multiple, and participate in the confluence of lymphatic trunks that gives rise to the thoracic duct. The deep branches passing anteromedially are motor branches, including the roots of the phrenic nerve (to 2244 the diaphragm) and the ansa cervicalis. Distally, the longitudinal bundles of collagen fibers of the aponeurosis divide into five bands that become continuous with the fibrous digital sheaths that enclose the flexor tendons that pass to the toes. Therefore, the foot is not lowered to the ground in a controlled manner after heel strike; instead, the foot slaps the ground suddenly, producing a distinctive "clop" and greatly increasing the shock both received by the forefoot and transmitted up the tibia to the knee. It is divided into anterior recto-uterine (female) or rectovesical (male) spaces and posterior retrorectal (presacral) spaces by the rectosacral (lateral rectal) ligaments, which are the posterior laminae of the hypogastric sheaths. The distal end of the radius and the articular disc of the distal radio-ulnar joint articulate with the proximal row of carpal bones, except for the pisiform. At first, the external laryngeal nerve lies on the inferior pharyngeal constrictor; it then pierces the muscle, contributing to its innervation (with the pharyngeal plexus), and continues to supply the cricothyroid muscle. The phrenic nerves are important because, in addition to their sensory distribution, they provide the sole motor supply to their own half of the diaphragm (see Chapter 4, Thorax, for details).

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Starvation and Rectal Prolapse the fat bodies of the ischio-anal fossae are among the last reserves of fatty tissue to disappear with starvation. Renal Cysts Cysts in the kidney, multiple or solitary, are common findings during ultrasound examinations and dissection of cadavers. Although they are valveless and blood may flow in both directions, flow in the emissary veins is usually away from the brain. The internal pudendal artery, larger in males than in females, passes inferolaterally, anterior to the piriformis muscle and sacral plexus. At irregular intervals, gastric peristalsis pushes the chyme through the pyloric canal and orifice into the small intestine for further mixing, digestion, and absorption. Spread of Pathological Fluids Peritoneal recesses are of clinical importance in connection with the spread of pathological fluids such as pus, a product of inflammation. Full understanding of the features of the right atrium requires an awareness of the development of the heart (see the Clinical Box "Embryology of Right Atrium"). However, there is a communication pathway in females to the exterior of the body through the uterine tubes, uterine cavity, and vagina. The subcostal muscles are variable in size and shape, usually being well developed only in the lower thoracic wall. The most common clinical features are headaches, confusion, memory impairment, hallucinations, seizures and multifocal neurological deficits. Because of the attachment of the ovarian ligaments to the uterus, the ovaries do not relocate to the inguinal region; however, the round ligament passes through the inguinal canal and disperses into the subcutaneous tissue of the anterior labium majus. Observe the nearly equal proximal articular surfaces of the scaphoid and lunate and that the lunate articulates with both the radius and the articular disc. Excess fat accumulation due to overnourishment most commonly involves the subcutaneous fatty layer; however, there may also be excessive depositions of extraperitoneal fat in some types of obesity. The deep palmar arch lies approximately 1 cm proximal to the superficial palmar arch. To visualize the relationship of the pleurae and lungs, push your fist into an underinflated balloon. In addition, because the superior oblique is the primary muscle producing intorsion of the eyeball, the primary muscle producing extorsion (the inferior oblique) is unopposed when the superior oblique is paralyzed. During insertion of a sigmoidoscope, the curvatures of the rectum and its acute flexion at the rectosigmoid junction have to be kept in mind so the patient does not undergo unnecessary discomfort. In addition, superficial and deep branches of the external pudendal arteries supply the penile skin, anastomosing with branches of the internal pudendal arteries. As ventriculomegaly progresses, the ependymal lining of the ventricles is compromised (ependymal cells are largely non-proliferative, see earlier), in particular over the periventricular white matter. Intercostal spaces separate the ribs and their costal cartilages from one another. It becomes increasingly vulnerable with age, especially in females, secondary to osteoporosis. This change in direction is accommodated by the supraventricular crest, which deflects the incoming flow into the main cavity of the ventricle and the outgoing flow into the conus arteriosus toward the pulmonary orifice. If the femoral artery must be ligated, blood can bypass the occlusion through the genicular anastomosis and reach the popliteal artery distal to the ligation. Catenins serve to provide linkage between adherens junctions and the endothelial cytoskeleton. Numerous small sublingual ducts open into the floor of the mouth along the sublingual folds. One of the anterior cerebral arteries is often small in the proximal part of its course; the anterior communicating artery is larger than usual in these individuals. Injections of an anesthetic agent around these branches in the ankle region, anterior to the palpable portion of the fibula, anesthetize the skin on the dorsum of the foot (except the web between and adjacent surfaces of the 1st and 2nd toes) more broadly and effectively than more local injections on the dorsum of the foot for superficial surgery.

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The suprarenal cortex derives from mesoderm and secretes corticosteroids and androgens. This dissection shows the posterior aspect of the pharynx and associated structures. Inferiorly, the linea aspera divides into medial and lateral supracondylar lines, which lead to the medial and lateral femoral condyles. Inferiorly, the buccopharyngeal fascia blends with the pretracheal layer of the deep cervical fascia. The right lymphatic duct is formed by the union of the contralateral partners of the ducts that join the termination of the thoracic duct. The auricular surface of the ilium articulates with a corresponding surface of the sacrum to form the sacro-iliac joint. Most lymph from these nodes ascends through deep lymphatic vessels to the deep inguinal lymph nodes. Relapsing and remitting multiple sclerosis: pathology of the newly forming lesion. Perineal muscles: In addition to their bony origins, the voluntary superficial and deep muscles of the perineum are also attached to the perineal membrane (by which they are separated) and the perineal body. Autopsy studies in patients in whom central herniation has been clinically established show backwards and downwards displacement of the mammillary bodies, compression of the pituitary stalk and caudal displacement of the posterior part of the floor of the third ventricle, which comes to lie below the level of the tentorial incisure. Approximately 40% of males with this syndrome have gynecomastia (development of breasts) and small testes. The lateral margin of 1214 each kidney is convex, and the medial margin is concave where the renal sinus and renal pelvis are located. Consequently, when visceral afferent fibers are stimulated by stretching, the bladder contracts reflexively, the internal urethral sphincter relaxes (in males), and urine flows into the urethra. The relationships of the muscles, aponeurotic muscle sheaths, and fascia of the abdominal wall are 1261 demonstrated in transverse section. The bursa of the obturator internus underlies the tendon of the obturator internus. The pyloric part of the stomach empties into the duodenum, duodenal admission being regulated by the pylorus. Pulsations of a large aneurysm can be detected to the left of the midline; the pulsatile mass can be moved easily from side to side. Between the breast and the pectoral fascia is a loose subcutaneous tissue plane or potential space-the retromammary space (bursa). Erectile sinus engorgement during the excitement phase of the sexual response causes an increase in the size and consistency of the clitoris and bulbs of the vestibule of the vagina. Once routinely performed, episiotomies are now markedly less commonly performed in vaginal deliveries in the United States (Gabbe et al. These parts of the large intestine are described with the pelvis in Chapter 6, Pelvis and Perineum. The median umbilical fold extends from the apex of the urinary bladder to the umbilicus and covers the median umbilical ligament, a fibrous remnant of the urachus that joined the apex of the fetal bladder to the umbilicus. The submandibular glands are supplied by presynaptic parasympathetic secretomotor fibers conveyed from the facial nerve to the lingual nerve by the chorda tympani nerve, which synapse with postsynaptic neurons in the submandibular ganglion. The greater omentum has been reflected superiorly, and the small intestine has been retracted to the right side to reveal the mesentery of the small intestine and the transverse mesocolon. All space within the orbits not occupied by these structures is filled with orbital fat; thus, it forms a matrix in which the structures of the orbit are embedded. This oval elevation indicates the level of the head of the fibula and the bifurcation of the popliteal artery into the anterior and posterior tibial arteries. The posterior vagal trunk supplies branches to the anterior and posterior surfaces of the stomach. External spermatic fascia: derived from the external oblique aponeurosis and its investing fascia. The parietal pleura consists of three parts-costal, mediastinal, and diaphragmatic-and the cervical pleura. On each side of the frenulum, a deep lingual vein is visible through the thin mucous membrane. The areola usually darkens during pregnancy and retains the darkened pigmentation thereafter.