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The walls of these compartments are formed by the fascia lata and three fascial intermuscular septa that arise from its deep aspect and attach to the linea aspera of the femur. When the weight is on both feet (A), the pelvis is evenly supported and does not sag. As described by Oelrich (1980), however, the urethral sphincter muscle is not a flat, planar structure, and the only "superior fascia" is the intrinsic fascia of the external urethral sphincter muscle. Lymph from all the superficial inguinal nodes passes via efferent lymph vessels to the external and common iliac, and right and left lumbar (caval/aortic) lymph nodes, draining via lumbar lymphatic trunks to the cisterna chyli and thoracic duct. The components of the medial (dark gray) and lateral (light gray) longitudinal arches are indicated. The relationship of the gallbladder to the duodenum is so intimate that the superior part of the duodenum is usually stained with bile in the cadaver. Its posterior labial nerves (terminal superficial branches of the perineal nerve) supply the labia. The joint capsule ruptures inferiorly and posteriorly, allowing the femoral head to pass 1844 through the tear in the capsule, and over the posterior margin of the acetabulum onto the lateral surface of the ilium, shortening and medial rotating the limb. The internal occipital crest ends in the internal occipital protuberance formed in relationship to the confluence of the sinuses, a merging of dural venous sinuses. The location of the incision also depends on the type of operation, the location of the organ(s) the surgeon wants to reach, bony or cartilaginous boundaries, avoidance of (especially motor) nerves, maintenance of blood supply, and minimizing injury to muscles and fascia of the abdominal wall while aiming for favorable healing. Shown are superficial (A) and deep (B) views of the lateral musculofibrous complex formed by the tensor fasciae latae and gluteus maximus muscles and their shared aponeurotic tendon, the iliotibial tract. Most lymph from these nodes ascends through deep lymphatic vessels to the deep inguinal lymph nodes. The relationships of the flexor tendons to the medial malleolus and sustentaculum tali are shown as they descend the posterolateral aspect of the ankle region and enter the foot. The medial rotation and permanent pronation of the lower limb explain how the knee, unlike the joints superior to it, extends anteriorly and flexes posteriorly, as do the joints inferior to the knee. The greater pelvis (light green) is pelvic by virtue of its bony boundaries but is abdominal in terms of its contents. The interatrial septum separating the atria has an oval, thumbprint-size depression, the oval fossa (L. Most vessels end in the pancreaticosplenic lymph nodes, which lie along the splenic artery. The superior parathyroid glands may be as far superior as the thyroid cartilage, and the inferior glands may be as far inferior as the superior mediastinum. An acutely inflamed appendix, for example, will produce a positive right psoas sign. Reactive microgliosis engages distinct responses by microglial subpopulations after minor central nervous system injury. This ligament converts the groove into a canal, which holds the synovial sheath and tendon of the biceps brachii in place during movements of the glenohumeral joint. The left part of the liver is cut away so that the lesser omentum and omental foramen can be seen. Spasmodic Torticollis 2267 Cervical dystonia (abnormal tonicity of the cervical muscles), commonly known as spasmodic torticollis, usually begins in adulthood. In the superior part of its course, the sciatic nerve passes deep to the gluteus maximus. Dissections are most frequent in young and middleaged adults but also occur in children. The presence of loose connective tissue here accommodates the expansion of the urinary bladder and rectal ampulla as they fill. Sternal Fractures Despite the subcutaneous location of the sternum, sternal fractures are not common. In left cardial (cardiac) angiography, a long, slender catheter is inserted into the artery and passed up the external iliac artery, common iliac artery, and aorta to the left ventricle of the heart. The nodes along the splenic vessels can be excised by removing the spleen, gastrosplenic and splenorenal ligaments, and the body and tail of the pancreas. This union begins during the 1st year, and the halves are fused by the end of the 2nd year. The zygomatic bones articulate with the frontal, sphenoid, and temporal bones and the maxillae.

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The superficial temporal artery is the smaller terminal branch of the external carotid artery; the other branch is the maxillary artery. Resection may be required to relieve pressure on these structures, which can be performed through a transaxillary approach (incision in axillary fossa or armpit). The three flat abdominal muscles and the 985 formation of the inguinal ligament are demonstrated. The branches of the third part arise just before and within the pterygopalatine fossa. The terminal branches of the arteries of the face anastomose freely (including anastomoses across the midline with their contralateral partners). The nasal septum has a hard (bony) part located deeply (posteriorly) where it is protected and a soft or mobile part located superficially (anteriorly) mostly in the more vulnerable external nose. Five genicular branches of the popliteal artery supply the capsule and 1702 ligaments of the knee joint. Thus, lymph from the stomach and abdominal part of the esophagus drains to the gastric and then celiac lymph nodes. The ischial tuberosity can be felt on deep palpation through the inferior part of the muscle, just superior to the medial part of the gluteal fold. After invading a ganglion, the virus produces a sharp burning pain in the dermatome supplied by the involved nerve. Embryonic blood vessels consist of endothelial cells and pericytes that organize and expand into highly branched conduits. Normally, the sphincter of the pancreatic duct prevents reflux of bile into the pancreatic duct; however, if the hepatopancreatic ampulla is obstructed, the weak pancreatic duct sphincter may be unable to withstand the excessive pressure of the bile in the hepatopancreatic ampulla. Acute pleuritis is marked by sharp, stabbing pain, especially on exertion, such as climbing stairs, when the rate and depth of respiration may be increased even slightly. Klinefelter syndrome is also characterized by small testes and disproportionately long lower limbs (Moore et al. Periventricular white matter may become rarefied, devoid of oligodendroglia and gliotic. Postero-inferior to the medial malleolus, the tibial nerve divides into the medial and lateral plantar nerves. Any change in the volume of the intracranial contents, for example, a brain tumor, an accumulation of ventricular fluid caused by blockage of the cerebral aqueduct. The medial surface of the cerebrum and deeper parts of the brain (diencephalon and brainstem) are shown after bisection of the brain. The pathogenesis of atherosclerosis in the small vessels does not differ substantially from that in larger vessels. Infections of the urethra, and especially of the bladder, are more common in women because the female urethra is short, more distensible, and is open to the exterior through the vestibule of the vagina. Consequences of Cerebrovascular Disorders and Impact on Brain Tissues 137 arterial Spasm Focal ischaemia may develop in the territories of healthy intracerebral arteries, when hypercontraction of the smooth muscle cells reduces the arterial lumen to such a degree that the blood flow is affected. To compensate, the individual leans 1691 away from the unsupported side, raising the pelvis to allow adequate room for the foot to clear the ground as it swings forward. Such deviation occurs especially in females, and its frequency increases with age. The mastoid process of the temporal bone is postero-inferior to the external acoustic meatus opening. The cavity between the layers of the balloon, here filled with air, is analogous to the pleural cavity, although the pleural cavity contains only a thin film of fluid. Bronchoscopy A bronchoscope is an endoscope for inspecting the interior of the tracheobronchial tree. The mediastinum is divided into superior and inferior parts for descriptive purposes. The site of continuity has been referred to as the pericardiacophrenic ligament; however, the fibrous pericardium and central tendon are not separate structures that fused together secondarily, nor are they separable by dissection. Deviation of the heart to the left side primarily affects the right and left sternal lines of pleural reflection, which are asymmetrical. Because the psoas lies along the vertebral column and the iliacus crosses the sacro-iliac joint, disease of the intervertebral and sacro-iliac joints may cause 1279 spasm of the iliopsoas, a protective reflex.

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A lateral radiograph is made using a lateral projection, with the side of the thorax against the film cassette or X-ray detector and the upper limbs elevated over the head. A localized collection of blood forms between the perichondrium and auricular cartilage, causing distortion of the contours of the auricle. Postsynaptic fibers pass from it by means of cephalic arterial branches to form the internal carotid sympathetic plexus and then enter the cranial cavity. The auriculotemporal nerve and the great auricular nerve, a branch of the cervical plexus composed of fibers from C2 and C3 spinal nerves, innervates the parotid sheath. The anterior free part constituting the majority of the mass of the tongue is the body of the tongue. In running, there is no period of double support; consequently, the time and percentage of the gait cycle represented by the stance phase are reduced. Inferior to the root of the lung, this continuity between parietal and visceral pleura forms the pulmonary ligament, extending between the lung and the mediastinum, immediately anterior to the esophagus. Radial glia serve as neuronal progenitors in all regions of the central nervous system. Branches of the medial and lateral circumflex femoral arteries, branches of the profunda femoris artery, and the artery to the femoral head (a branch of the obturator artery) supply the head and neck of the femur. The abductors and rotators of the thigh attach mainly to the apex of the angle (the greater trochanter) so they are pulling on a lever (the short limb of the L) that is directed more laterally than vertically. The retinaculum is subdivided deeply, forming separate compartments for each tendon of the deep muscle group, as well as for the tibial nerve and posterior tibial artery as they bend around the medial malleolus. The superior (upper) and inferior (lower) eyelids are strengthened by dense bands of connective tissue, the superior and inferior tarsi (singular = tarsus), which form the "skeleton" of the eyelids. The nerve passes postero-inferiorly, within or deep to the investing layer of deep cervical fascia, running on the levator scapulae from which it is separated by the prevertebral layer of fascia. Less commonly, the division of the sciatic nerve occurs as it passes through the greater sciatic foramen. Fractures of the greater trochanter and femoral shaft usually result from direct trauma (direct blows sustained by the bone resulting from falls or being hit) and are most common during the more active years. The brain lacks significant energy reserves and requires a continuous supply of well-oxygenated blood. This relationship explains why a ruptured tubal pregnancy and the resulting peritonitis may be misdiagnosed as acute appendicitis. The pO2 is the pressure that the oxygen would exert in a liquid or gas if it alone occupied the total volume, regardless of other molecules that may be present and irrespective of the total pressure. The auricular surfaces of the synovial joint have irregular but congruent elevations and depressions that interlock. Efferent lymphatic vessels 2334 from the deep cervical nodes join to form the jugular lymphatic trunks, which usually join the thoracic duct on the left side and enter the junction of the internal jugular and subclavian veins (right venous angle) directly or via a short right lymphatic duct on the right. To support the erect bipedal posture better, the 1539 femurs are oblique (directed inferomedially) within the thighs so that when standing, the knees are adjacent and placed directly inferior to the trunk, returning the center of gravity to the vertical lines of the supporting legs and feet. The infrahyoid group of muscles are arranged in two planes: a superficial plane, made up of the sternohyoid and omohyoid, and a deep plane, composed of the sternothyroid and thyrohyoid. However, this is surrounded by a penumbra, a zone of tissue that, although electrically silent, has the capacity to recover if perfusion is restored. The deep bronchopulmonary lymphatic plexus is located in the submucosa of the bronchi and in the peribronchial connective tissue. 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). The five rami unite to form the three trunks of the brachial plexus, which descend inferolaterally through the lateral cervical region. The posterior rami pass posteriorly to supply the muscles of the back and overlying 1266 skin, whereas the anterior rami pass laterally and inferiorly, to supply the skin and muscles of the inferiormost trunk and lower limb. In the extra-oral approach, the needle passes through the mandibular notch of the ramus of the mandible into the infratemporal fossa. It is firmly attached to and indents the anterior vaginal wall centrally and distally. The pericardial sac (and therefore the heart) lies approximately one third to the right of the midsternal line and two thirds to the left (inset).

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Distinctive hyperkeratotic cutaneous venous malformations may also occur in these patients. On the left side, the levator palpebrae superioris and superior rectus have been cut and reflected and the orbital fat removed to demonstrate the nerves that traverse the intraconal fat. As a result, 1122 food does not pass easily from the stomach into the duodenum and the stomach becomes overly full, usually resulting in discomfort and vomiting. The operation, usually performed during childhood, removes the prepuce of the clitoris but often also removes part or all of the clitoris and labia minora and may include suturing of the vaginal ostium. The pharyngotympanic tube is a communication between the anterior wall of the tympanic cavity and the lateral wall of the nasopharynx. The free posterior border of the hard palate projects posteriorly in the median plane as the posterior nasal spine. However, its intraperitoneal life is short because it is normally trapped by the fimbriae of the infundibulum of the uterine tube and carried into the ampulla, where it may be fertilized. The notched border is helpful when palpating an enlarged spleen because, when the person takes a deep breath, the notches can often be palpated. Most flexion and adduction occur mainly at the wrist joint, whereas extension and abduction occur primarily at the midcarpal joint. The saphenous nerve is the longest and most widely distributed cutaneous branch of the femoral nerve; it is the only branch to extend beyond the knee. The internal pudendal vessels and the pudendal nerve supply and drain blood from and innervate most of the perineum. It parallels the medial border of the psoas, anterior to the obturator nerve, crossing superior to the superior pubic ramus in close proximity to the femoral vein. The frequent association of fat embolism with underlying life-threatening disease makes it difficult to estimate the prognosis of fat embolism per se. The innervation of the pericardium by the phrenic nerves and the course of these somatic nerves between the heart and the lungs make little sense unless the development of the fibrous pericardium is considered. 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. Passes between first and second layers of plantar muscles and then between medial and middle muscles of first layer Passes between first and second layers ol plantar muscles and then between middle and lateral muscles of first layer Lateral and medial branches of tibial and sural nerves, respectively, over calcaneal tuberosity Penetrate thoracodorsal fascia: course laterally and inferiorly in subcutaneous tissue Emerge from dorsal sacral foramina; directly enter overlying subcutaneous tissue Arise deep to gluteus maxlmus: emerge from beneath inferior border of muscle Terminal branches pierce fascia lata to supply skin of posterior thigh and popliteal fossa. It tends to lower the tissue pH but the drop in pH is not due simply to equimolar H+ and lactate production. This procedure, an intercostal nerve block, is commonly used in patients with rib fractures and sometimes after thoracic surgery. Bones of Foot the bones of the foot include the tarsus, metatarsus, and phalanges. False (vertebrochondral) ribs (8th, 9th, and usually 10th ribs): Their cartilages are connected to the cartilage of the rib above them; thus, their connection with the sternum is indirect. The main pancreatic duct and bile duct usually unite to form the short, dilated hepatopancreatic ampulla (of Vater), which opens into the descending part of the duodenum at the summit of the major duodenal papilla. The thick, central part of the plantar fascia forms the strong plantar aponeurosis, longitudinally arranged bundles of dense fibrous connective tissue 1752 investing the central plantar muscles. The inferior (arcuate) pubic ligament is a thick arch of fibers that connects the inferior aspects of the joint components, rounding off the subpubic angle as it forms the apex of the pubic arch. The anterior, internal surface demonstrates the glenohumeral ligaments, which were incised to open the joint. Even in the absence of a cystocele, weakened support to the vagina or pelvic floor may result in a lack of support of the urethra, which runs in close proximity to (essentially "embedded against") the anterior vaginal wall. Anterior scrotal arteries, terminal branches 1492 of the external pudendal arteries (from the femoral artery), supply the anterior aspect of the scrotum. The combined stress on the epiphysial plates resulting from physical activity and rapid growth may result in irritation and injury of the plates and developing 1566 bone (osteochondrosis).

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The parathyroid glands are usually embedded in the fibrous capsule on the posterior surface of the thyroid gland. The person abducts the thigh without flexion or rotation against straight downward resistance. Multiple supernumerary teeth are rare in individuals with no other associated diseases or syndromes, such as cleft lip or cleft palate or cranial 2143 dysplasia (malformation). The phrenic nerves originate chiefly from the C4 nerve but receive contributions from the C3 and C5 nerves. The most common type of torticollis (wry neck) results from a fibrous tissue tumor (L. Here we shall deal with cellular/molecular mechanisms germane to the consequences of hydrocephalus for the brain and consider some aetiologies, as well as selected animal models that bear on the pathogenesis. Cysts and Hernias of the Processus Vaginalis Indirect inguinal hernias can occur in women; however, they are approximately 20 times more common in men. The posterior wall is then chipped away as needed to open the anterior wall of the pterygopalatine fossa. The close positional relationship of these organs results in sharing of blood vessels, lymphatic vessels, and nerve pathways, in whole or in part. The outer parietal layer lines the peritesticular continuation of the internal spermatic fascia. Large aneurysms also often contain lamellated thrombus, which may seed thromboemboli into distal arteries. The medial view shows the right lateral wall of the nasal cavity, and the lateral view shows the nasal septum. The fleshy attachments of the obturator internus muscles cover and thus pad most of the lateral pelvic walls. The hepatic portal vein and hepatic artery enter the liver via the porta hepatis, where the hepatic ducts exit. In this superficial dissection, most of the zygomatic arch and attached masseter, the coronoid process and adjacent parts of the ramus 2092 of the mandible, and the inferior half of the temporal muscle have been removed. The veins follow a similar pattern, flowing retrograde to the arteries, but are more plexiform, including a pampiniform plexus related to the ovary and continuous uterine and vaginal plexuses (collectively, the uterovaginal plexus). Because its anterior surface is subcutaneous, the tibial shaft is the most common site for a compound fracture. These muscles, particularly the serratus posterior superior, have been implicated as a source of chronic pain in myofascial pain syndromes. The lower lip is separated from the mental protuberance (chin) by the mentolabial sulcus. Because the ribs slope inferiorly, their elevation also results in anteroposterior movement of the sternum, especially its inferior end, with slight movement occurring at the manubriosternal joint in young people, in whom this joint has not yet synostosed (united). Paralysis of recurrent laryngeal nerves usually results from cancer of the larynx and thyroid gland and/or from injury during surgery on the thyroid gland, neck, esophagus, heart, and lungs. Superficial Abdominal Reflexes the abdominal wall is the only protection most of the abdominal organs have. They may also form on the plantar 1863 surfaces of the metatarsal heads and the toe tips because they bear extra weight when claw toes are present. The tail of the pancreas lies anterior to the left kidney, where it is closely related to the splenic hilum and the left colic flexure. The inferior epigastric artery arises from the external iliac artery just superior to the inguinal ligament. As a consequence, infection of the pulp cavity may also cause sinusitis, or sinusitis may stimulate nerves entering the teeth and simulate a toothache. Of the neurovascular structures at the apex of the femoral triangle, the two anterior vessels (femoral artery and vein) and the two nerves enter the adductor canal (anterior to adductor longus), and the two posterior vessels (profunda femoris artery and vein) pass deep (posterior) to the adductor longus.

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Lingual Carcinoma A lingual carcinoma in the posterior part of the tongue metastasizes to the superior deep cervical lymph nodes on both sides. On the left, the aorta is related to the left crus of the diaphragm and the left celiac ganglion. Cardiac Referred Pain the heart is insensitive to touch, cutting, cold, and heat; however, ischemia and the accumulation of metabolic products stimulate pain endings in the myocardium. Injury to Tibial Nerve Injury to the tibial nerve is uncommon because of its deep and protected position in the popliteal fossa; however, the nerve may be injured by deep lacerations in the fossa. Injury to nerves of the anterolateral abdominal wall may result in weakening of the muscles. Tricuspid valve (left) spread out, and pulmonary valve (right) showing influence of blood flow in opening and closing of valve. This loss of sensation may annoy the patient, who may not recognize the presence of food on the lip and cheek or feel it within the mouth on the side of the nerve section. Disturbance in the level of consciousness is the most common symptom of head injury. The pubis is divided into a flattened medially placed body and superior and inferior rami that project laterally from the body. Because its fibers are largely of the white, fast-twitch (type 2) variety, contractions of the gastrocnemius produce rapid movements during running and jumping. The esophagus, stomach, and small and large intestines constitute the gastrointestinal tract and are derived from the primordial foregut, midgut, and hindgut. The rectus femoris may be easily observed as a ridge passing down the thigh when the lower limb is raised from the floor while sitting. The intimal arteriosclerotic thickening may alter the haemodynamic stress at sites of arterial bifurcation. Lymphatic vessels from the middle part of the ureter usually drain into the common iliac lymph nodes, whereas vessels from its inferior part drain into the common, external, or internal iliac lymph nodes. Irritation of the parietal pleura may produce local pain or referred pain projected to dermatomes supplied by the same spinal (posterior root) ganglia and segments of the spinal cord. The lesser pelvis is surrounded by the inferior pelvic girdle, which provides the skeletal framework for both the pelvic cavity and the perineum-compartments of the trunk separated by the musculofascial pelvic diaphragm. The patellar ligament, the distal part of the quadriceps femoris tendon, is a strong, thick fibrous band passing from the apex and adjoining margins of the patella to the tibial tuberosity. An infective process develops and spreads through the root canal to the alveolar bone, producing an abscess (peri-apical disease). Surgical Significance of Transverse Pericardial Sinus the transverse pericardial sinus is especially important to cardiac surgeons. Because they fuse, the integrity of the fibrous layer of the joint capsule of the glenohumeral joint is usually compromised when the rotator cuff is injured. Each cavernous body has an outer fibrous covering or capsule, the tunica albuginea. Ascending (fourth) part: short (5 cm) and begins at the left of the L3 vertebra and rises superiorly as far as the superior border of the L2 vertebra. Both right and left brachiocephalic trunks originate from the arch in approximately 1. The aqueduct extends to the posterior surface of the petrous part of the temporal bone, where it opens posterolateral to the internal acoustic meatus. The submandibular duct, approximately 5 cm long, arises from the portion of the gland that lies between the mylohyoid and hyoglossus muscles. The sigmoid colon usually has a long mesentery-the sigmoid mesocolon- and therefore has considerable freedom of movement, especially its middle part (see the Clinical Box "Volvulus of Sigmoid Colon," p.

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Active contraction of the (voluntary) puborectalis portion is important in maintaining fecal continence immediately after rectal filling or during peristalsis when the rectum is full and the involuntary sphincter muscle is inhibited (relaxed). It is more difficult to achieve watertight anastomoses of 1058 extraperitoneal structures that have an outer adventitial layer, such as the thoracic esophagus. Small cerebral arteries and arterioles may be affected by many other diseases, such as hereditary angiopathies, inflammatory and infective vasculitides and toxic disorders (see later). This patient had a history of hypertension and histology revealed widespread cerebral arteriolosclerosis (arrows) as well as enlargement of perivascular spaces in the cerebral white matter and basal ganglia. The level of the domes of the diaphragm varies according to the phase of respiration (inspiration or expiration). The costal pleura and the peripheral part of the diaphragmatic pleura are supplied by the intercostal nerves. Concurrent fracturing of the zygomatic arches causes the maxillae and zygomatic bones to separate from the rest of the cranium. To count the ribs and intercostal spaces anteriorly, slide the fingers (digits) laterally from the sternal angle onto the 2nd costal cartilage and begin counting the ribs and spaces by moving the fingers from here. Quadratus lumborum: lying adjacent to the transverse processes of the lumbar vertebrae and lateral to superior parts of the psoas major. Fine ducts passing from the superior border of the sublingual gland open on the sublingual fold. Near the apex (the left extremity) of the wedge-shaped liver, the anterior and posterior layers of the left part of the coronary ligament meet to form the left triangular ligament. Dural Origin of Headaches the cranial dura mater is sensitive to pain, especially where it is related to the dural venous sinuses and meningeal arteries. Consequently, surgical pedicle scalp flaps are made so that they remain attached inferiorly to preserve the nerves and vessels, thereby promoting good healing. The deep cervical fascial layers also afford the slipperiness that allows structures in the neck to move and pass over one another without difficulty, for example, when swallowing and turning the head and neck. Calcaneal tendon rupture is probably the most severe acute muscular problem of the leg. A trachea that is compressed enough to affect breathing may require surgical division of the vascular ring. Damage to one or more of the listed spinal cord segments, or to the motor nerve roots arising from them, results in paralysis of the muscles concerned. The perineal muscles provide dynamic support for the uterus by contracting during moments of increased intra-abdominal pressure (sneezing, coughing, etc. To obtain a bloodless surgical operating field for treating complicated hand injuries, it may be necessary to compress the brachial artery and its branches proximal to the elbow. This duct normally disappears, but remnants of epithelium may remain and form a thyroglossal duct cyst at any point along the path of its descent. When stimulation ceases and the diaphragm relaxes, the diaphragm is pushed upward (ascends) by the combined decompression of the viscera and tonus of the muscles of the anterolateral abdominal wall. Venous Return From Leg 1745 A venous plexus deep to the triceps surae is involved in the return of blood from the leg. The innervation of the intermediate part of the urethra is the same as that of the prostatic part: autonomic (efferent) innervation via the prostatic nerve plexus, arising from the inferior hypogastric plexus. The median root is a branch of the celiac plexus, and the lateral roots arise from the lesser and least splanchnic nerves, sometimes with a contribution from the first lumbar ganglion of the sympathetic trunk. Dural border hemorrhage usually follows a hard blow to the head that jerks the brain inside the cranium and injures it. Coronary Atherosclerosis the atherosclerotic process, characterized by lipid deposits in the intima (lining layer) of the coronary arteries, begins during early adulthood and slowly results in stenosis of the lumina of the arteries. Peritoneum: the peritoneum lining the abdominal cavity continues into the pelvic cavity, reflecting onto the superior aspects of most pelvic viscera (only the lengths of the uterine tubes, but not their free ends, are fully intraperitoneal and have a mesentery).

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Accompanied by the internal pudendal artery, it leaves the pelvis through the greater sciatic foramen between the piriformis and coccygeus muscles. It descends posteromedially into the lesser 1342 pelvis, medial to the external iliac vein and obturator nerve and lateral to the peritoneum. It covers the salpingopharyngeus muscle, which opens the pharyngeal orifice of the pharyngotympanic tube during swallowing. Although most commonly 2298 known for its role as the phonating mechanism for voice production, its most vital function is to guard the air passages, especially during swallowing when it serves as the "sphincter" or "valve" of the lower respiratory tract, thus maintaining a patent airway. Determination of the pathological type of stroke is best achieved by early brain imaging, or by autopsy in fatal cases. Because this fascia has a distinct superior margin, novices dissecting in this area commonly assume when they see the femoral vessels pass deep to this fascia that they are traversing the adductor hiatus. Valvular Heart Disease Disorders involving the valves of the heart disturb the pumping efficiency of the heart. The most important and largest tributary artery is arteria radicularis magna (of Adamkiewicz), which enters the spinal canal at a variable level, between T8 and L2, below which spinal artery blood flow is mainly downward. The arterial supply to the auricle is derived mainly from the posterior auricular and superficial temporal arteries. The most common supernumerary tooth is a mesiodens, which is a malformed, peg-like tooth that occurs between the maxillary central incisor teeth. The pelvis tilts anteriorly at the hip joints when standing (the pubis descends and the sacrum ascends) producing excessive lordosis of the lumbar region. Like the overlying skin, the peritoneum lining the interior of the body wall is sensitive to pressure, pain, heat and cold, and laceration. It then deviates to the left and passes through the esophageal hiatus in the diaphragm at the level of the T10 vertebra, anterior to the aorta. The common nerve supply of the skin and muscles of the wall explains why these spasms occur. The transpyloric plane, extrapolated midway between the superior borders of the manubrium of the sternum and the pubic symphysis (typically the L1 vertebral level), commonly transects the pylorus (the distal, more tubular part of the stomach) when the patient is recumbent (supine or prone). Except for the inferior part of the pancreatic head (including uncinate process), the spleen and pancreas receive blood from the celiac artery. Such an injury may be unnoticed in individuals who do not usually employ a wide range of tone in their speech, but it may be critical to singers or public speakers. In some cases, the abnormal arch, after passing over the root of the right lung, passes posterior to the esophagus to reach its usual position on the left side. Pararectus incisions along the lateral border of the rectus sheath are undesirable because they may cut the nerve supply to the rectus abdominis. This results in elevation and depression movements of the sternal ends of the ribs and sternum in the sagittal plane (pump-handle movement). The transverse facial artery arises from the superficial temporal artery within the parotid gland and crosses the face superficial to the masseter. For those born in the early- and mid20th century, rheumatic fever was a common cause but now accounts for <10% of cases of aortic stenosis. For an overview of superficial and deep lymphatic drainage, see Chapter 1, Overview and Basic Concepts. Ischaemic bowel is a rich source of bacteria and anaerobes characteristically find their way into the blood stream just before death. The proximal third of the line represents this artery as it passes through the femoral triangle, whereas the middle third represents the artery while it is in the adductor canal. Because it supplies all the intrinsic muscles except the cricothyroid, the inferior laryngeal nerve is the primary motor nerve of the larynx. The right ovarian vein ascends to enter the inferior vena cava; the left ovarian vein drains into the left renal vein. The lumbar part of this posterior sheath, extending between the 12th rib and the iliac crest, attaches laterally to the internal oblique and transversus abdominis muscles, as does the rectus sheath. All of these nerves are branches of the sacral plexus and leave the pelvis through the greater sciatic foramen. Its relocation out of the abdomen into the perineum through the inguinal canal accounts for many of the structural features of the region. This is characterized by stenosis of the extracranial and intracranial segments of the internal carotid artery, and the anterior, middle and posterior cerebral arteries.

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The anterior layer of the coronary ligament is continuous on the left with the right layer of the falciform ligament, and the posterior layer is continuous with the right layer of the lesser omentum. Each participating ramus, except the first, divides into ascending and descending branches that unite with the branches of the adjacent spinal nerve to form the loops. Four or five lymphatic trunks leave the renal hilum and are joined by vessels from the capsule (arrows). This condition, present in approximately 11% of individuals, may cause cecal bascule (folding of the mobile cecum) or, less commonly, cecal volvulus (L. The weight-bearing medial tubercle of the calcaneus on the plantar surface of the foot is broad and large. As the ureters cross the bifurcation of the common iliac artery (or the beginning of the external iliac artery), they pass over the pelvic brim, thus leaving the abdomen and entering the lesser pelvis. As long as this ligament is intact with the clavicle tethered to the coronoid process, the acromion of the scapula cannot be driven inferior to the clavicle. Point tenderness is located at the proximal attachment of the aponeurosis to the medial tubercle of the calcaneus and on the medial surface of this bone. This dissection of the lateral wall of the nasal cavity shows the communications through the lateral wall of the nasal cavity. Lymphatic vessels from the superior part of the ureter may join those from the kidney or pass directly to the lumbar nodes. As the alveolar mucosa approaches the necks of the teeth, it changes in texture and color to become the gingiva proper. The apex of the bladder points toward the superior edge of the pubic symphysis when the bladder is empty. In the mature female, the processus vaginalis has degenerated, but the round ligament persists and passes through the inguinal canal. This open-book view shows the innervation of the lateral wall and septum of the nasal cavity and palate. Oocytes released from the ovaries that enter the tubes of these patients degenerate and are soon absorbed. Normally, most of the processus vaginalis obliterates before birth, except for the distal part that forms the tunica vaginalis of the testis (see Table 5. This defect is the most common form of visual field loss and is often observed in patients with strokes (Swartz, 2014). It lies too far anteriorly to be a strong abductor and thus probably contributes primarily as a synergist or fixator. The posterior vagal trunk supplies branches to the anterior and posterior surfaces of the stomach. The right recurrent laryngeal nerve hooks around the right subclavian 929 artery and ascends between the trachea and esophagus to supply the larynx. The injury is typically experienced as an audible snap during a forceful push off (plantarflexion with the knee extended) followed immediately by sudden calf pain and sudden dorsiflexion of the plantarflexed foot. Indirectly, they can also help depress the mandible, especially when opening the mouth suddenly, against resistance, or when inverted. Weakness of the vastus medialis or vastus lateralis, resulting from arthritis or trauma to the knee joint, can result in abnormal patellar movement and loss of joint stability. In the case of the alimentary tract (large intestine), the pain line does not correlate with the peritoneum; the pain line occurs in the middle of the sigmoid colon. The right heart (blue side) is the pump for the pulmonary circuit; the left heart (red side) is the pump for the systemic circuit. The bone forming the superior part of this 1545 fossa may become thin and translucent, especially in older women with osteoporosis. Hence, space-occupying lesions, such as tumors in the supratentorial compartment, produce increased intracranial pressure, and may cause part of the adjacent temporal lobe of the brain to herniate through the tentorial notch. The pharyngeal tonsil (commonly called the adenoid when enlarged) is in the mucous membrane of the roof and posterior wall of the nasopharynx. The medial plantar nerve, the larger and more anterior of the two terminal branches of the tibial nerve, arises deep to the flexor retinaculum. They have their attachments entirely within the tongue and are not attached to bone. Ileus is accompanied by a severe colicky pain, along with abdominal distension, vomiting, and often fever and dehydration.